Thursday, July 23, 2015

Rotation 2: Prednisone Tastes like Rancid Mints and Other Pearls from Pediatric Generalist

Posted by Emily at Thursday, July 23, 2015

What does a generalist do?  The short answer: everything!

Here's what a typical day looked like on rotation as a pediatric generalist-in-training:

0730-0930 - work up patients at the hospital
On the first day of rotation, my classmate and I were both assigned to a specific pediatric general medicine service that we would continue to follow for the rest of the month.  These services see kids with all different kinds of chief complaints ranging from intractable vomiting to osteomyelitis to febrile seizures to premature babies who are simply admitted for feeding and growth monitoring; basically patients who are too sick to go home but not sick enough to be sent to the PICU or assigned to a specialty service like heme/onc.  Patient duration of stays also varied greatly, so our patient lists changed every morning as our old patients were discharged and new ones were admitted.  This kind of variety is the hallmark of a general service and because of it I gained exposure to an array of disease states and medications that I hadn't previously seen.  We reviewed our patients and recommendations with our preceptor before starting rounds.

0930-1100 - rounding with the medical team
My favorite part of the day!  Pediatric generalist is a teaching service, so my team consisted of an attending physician, medical residents, medical interns, med students, and a dietitian.  I benefited from the attendings' teaching points just as much as the medical students did, and sometimes I was even able to answer the attendings' questions when the medical students couldn't.  (What do we want to monitor with linezolid?  Weekly CBC!)  Rounds was also my opportunity to make recommendations, though because of the fact that these patients tended to be less complicated than, say, my BMT patients last month, and because the medical students and interns were all working to develop their own autonomy, I feel like the generalist pharmacist wasn't as valued/utilized as the specialists pharmacists are during rounds.  Nonetheless, the team DID turn to me with questions from time to time, and I was also able to recommend a few therapeutic interventions of my own. :D

1100-1500 - review patients, do med recs/med histories, do medication teaching, review TPN orders, work on projects, eat lunch
Remember how I said generalists do everything?  Our afternoons were left open for completing the myriad tasks that generalists are responsible for.  We'd review our patients again with our preceptor after rounds to let her know if there were any significant updates, and then we were free to complete medication histories and medication reconciliations for all the patients who had been newly admitted to the floors.  For patients being discharged with new prescriptions for Diastat (diazepam rectal gel for seizure emergencies), EpiPens, or enoxaparin, my classmate and I were available to review proper medication administration technique with parents and families.  We were also tasked with reviewing total parenteral nutrition (TPN) orders to make sure that all changes made to the TPN composition were appropriate based on that morning's labs, and that the changes made were appropriate for each patient's age and weight.  In addition to these patient care activities, we had a handful of projects to complete during our five week rotation block.  These included three informal topic discussions (I presented on perinatal HIV, preeclampsia/eclampsia, and pediatric acetaminophen toxicity), a journal club on a randomized controlled trial of aerosolized versus subcutaneous injection measles vaccine, and a formal patient case presentation on Kawasaki's disease.

1500-1600 - attend topic discussions, journal clubs, and case presentations
The last hour of the day was often devoted to topic discussions led by various pharmacy staff.  Topics included an introduction to pediatric pharmacy, how to properly conduct a medication reconciliation, pediatric emergency services, a pharmacokinetics review, how to verify TPNs, and a discussion of lines and tubes.  But our most fun (and most disgusting) afternoon activity by far was the infamous TASTE TEST.

Many pediatric patients are not able to swallow pills and thus are prescribed liquid medication formulations.  To gain a better understanding of what we're expecting our patients to endure when we recommend a liquid formulation, we participated in a taste test of over twenty different liquid medications.  Armed with bottles of pop and chocolate sauce to cleanse our palates in between each medication, we were given a drop or two of commonly prescribed pediatric drugs (everything from azithromycin to Zofran) on a plastic spoon to sample.  The results ranged from legitimately delicious (amoxicillin) to horrifyingly vile (metronidazole).  Knowing how these medications taste gave me a much greater appreciation of why it can be so difficult for parents to get children to take their medicine.  As a pharmacist, it's easy to say "take 15 mL twice a day" and to stress the importance of completing a full course of therapy, but if a medicine has a completely intolerable taste the kid isn't going to take it no matter how much ice cream she chases it with.  In fact, the day after the taste test, my attending prescribed Bactrim rather than clindamycin for a six month old patient because (aside from being less likely to cause C. diff) Bactrim is MUCH more palatable.  Bactrim tastes like medicinal Kool Aid.  Clinda tastes like sadness.  This is the kind of practical knowledge you can only gain from being out on the front lines, and it’s such a refreshing change after three years of textbooks and lectures.

note sheet and snacks from the liquid medications taste test

Interestingly, three years ago I completed my first P1/P4 shadowing experience while my P4 was on this exact rotation.  In my post-shadowing write up, I said, "I feel connected to the pediatric patient population, but I worry that I lack the emotional fortitude to work within this specialty."  For the most part, this rotation has not been as emotionally demanding as I was expecting it to be.  Most of the kids on a general service are not too sick - not sick enough to be in the PICU, at least.  We also don't see hematology/oncology patients.  In short, most of our kids aren't dying.  That said, I still saw some difficult cases this month, the most striking of which was a seven week old baby boy who was admitted for "non-accidental trauma" (e.g. child abuse).  His x-rays showed more than twenty fractures in various states of healing.  While it was hard to know that such a cute little guy had had such a rough start, it was incredibly rewarding to be a member of the team that was ensuring he would be safe and responsibly cared for in the future.  In fact, I enjoyed working with the kiddos so much that I've added pediatric rotations and PGY2 offerings in pediatrics to my PGY1 residency search list.

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