Tuesday, October 25, 2016

Rotation 4: "Give Me the Big Picture"

Posted by Millie at Tuesday, October 25, 2016

My fourth rotation brought Jenn (another P4 blogger on here!) and I to the Surgical ICU. This was both of our first inpatient clinical experiences, so we were in for quite a challenge. I was excited to start seeing what the inpatient world was like.

We found out very quickly that the SICU was a very busy service, and that even though there were only 20 beds, the patients had very complex needs. The rounding team consisted of us, our preceptor or our pharmacy resident, 5 medical residents, 2 medical fellows, 2 medical students, 1 medical attending, and 1 nutrition specialist. As you can probably imagine, we had a huge team! Rounds also took us anywhere from 4 hours to 6 hours, which leads me to my biggest advice to you all which would be to make sure you get some comfortable professional shoes for any inpatient rotation you have. (Side note: carrying a water bottle and eating a small snack right before rounds will also help in the long run!)

I learned quickly that patient presentations in the SICU went “head to toe,” meaning we covered ALL systems: neurology, cardiovascular, pulmonary, gastrointestinal, genitourinary & fluids, electrolytes, and nutrition (GU/FEN), hematology, infectious diseases, endocrine, and musculoskeletal. During our patient presentations to our preceptor, we would cover all of these systems as well, but with a focus on the patient’s medications.

Typical Day
I would arrive about an hour and a half prior to rounds to work up my patients. In the SICU, we had very high “turnover,” meaning we would always be admitting new patients or transferring current ones to the general floor. Although pharmacy students on other services may work up patients at night, we had such a high turnover in the SICU that this wasn’t really possible and it was more appropriate to wait until the morning. This rotation really helped me learn how to work up patients quickly and assess their clinical picture thoroughly, looking at their most pertinent problems.

Jenn and I each covered half the service, though we followed each other’s patients as well. We were able to really strengthen our skills with pharmacokinetic dosing of aminoglycosides and vancomycin, especially considering our patient population was not your typical classroom example and had kinetics that are all over the place (e.g. constantly changing volume of distribution, GI surgeries that impact absorption, renal dysfunction impacting clearance), so we had to really consider the whole patient when making our dosing adjustments. Our patients are also frequently on intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT), which are two major factors to consider when calculating kinetics. I felt very proud towards the end of the rotation when I realized I felt very comfortable managing the vancomycin and aminoglycoside regimen for a patient who was bouncing back and forth between IHD and CRRT – something I could not have imagined at the start of this rotation!

We would go on rounds for multiple hours, then grab a quick bite to eat for lunch, and then follow up with our preceptor and/or pharmacy resident to discuss what happened on rounds and patients. Afterwards we would do a topic discussion, typically about some critical care topic such as sepsis, acute respiratory distress syndrome, or intra-abdominal infections.

Final Thoughts
Surgery is definitely not an area we focus on in pharmacy school, so it can be very overwhelming to work in the SICU. The majority of these patients may be on mechanical ventilators or use nasal cannulas for oxygenation, and they typically have multiple IV lines or drains. I spent the good majority of my time googling EVERYTHING, but I would definitely encourage you to try not to get lost in all the little details of vent settings and lines.

In addition, try to think ahead of the team if possible. Does it seem like the patient needs an antibiotic? Which one would you recommend based on coverage? What dose/frequency? On the other hand, did microbiology lab results come back and the regimen could be de-escalated? Recommend it to the team.

Jerika also wrote a really great blog post (a few posts back from this one) on her experiences with SICU at a different hospital, and I would encourage you to read it! The SICU is definitely a unique environment, and will challenge you to think about and consider a holistic view of the patient.

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