I got to see a patient in Emerg who had a few medications where she was not taking them as they appeared on Pharmanet, and a couple of things where I had to discuss how to proceed with the attending from Family Practice, who was going to admit her. This patient presented with nausea and vomiting, with worsening spinal and left flank pain. Her CT abdo/pelvis showed a renal stone. She had a prior medical Hx of A-fib (CHADS2 = 2), hypertension, T2DM, spinal stenosis (awaiting orthopedics consult), CKD stage 3a, and fatty liver disease. She was on numerous medications, which included:
– Valsartan 160 mg/HCTZ 12.5 mg PO daily, which was discontinued in community
– Nifedipine XR 30 mg PO daily
– Linagliptin 2.5 mg/metformin 1000 mg PO daily (appeared as BID on Pharmanet)
– Warfarin 1, 2, and 4 mg strengths appeared on her Pharmanet, all with the instructions “take one tablet daily”, but I clarified with the patient that her home dose has been 5 mg PO daily for the past month at least (she had tried 5/6 mg daily alternating days, 4/5 as well in the past), and her INR was 2.3 when she came in (therapeutic for her A-fib). Her diet was self-reported to be erratic, so I provided patient education that consistency is key when considering dietary influences on the INR.
The main thing to reconcile on her MedRec, apart from the warfarin, was polypharmacy on part of analgesics for her spinal stenosis. She was taking gabapentin 300 mg PO BID, diclofenac 2.32% (OTC) gel applied PRN + diclofenac 10% (Rx) gel applied PRN (usually both of these used 2x/week), and acetaminophen 325 mg/methocarbamol 400 mg (Robaxacet) i tab PO HS PRN (usually 2x/week), along with past trials of acetaminophen with codeine +/- caffeine. I discussed this with the physician, and we decided on streamlining her analgesics (diclofenac 10% gel, gabapentin 300 mg PO BID with PRN acetaminophen) referring her to the CPAS service (complex pain and addictions) as increasing her gabapentin was not an option by virtue of her decreased renal function and her intolerance to trials of higher dosages (sedation), possible acetaminophen polypharmacy, and definite diclofenac polypharmacy.
Usually I don’t get to delve into the “Internal Medicine” aspects of a case too deeply in Emerg, but this was a good example of dealing with what she acutely came in with (pain), while cleaning up her medications.
Before I could even blink, it’s already seven months through the residency year. I definitely do not feel ready to enter practice without the comforting safety net of a preceptor (and I shouldn’t; there’s so much more to learn and experience)…so this ADS was a bit of an awakening for me. I may be expected to precept students in the next year, along with the rest of my colleagues! Isn’t that scary?
What is comforting is that if I know what makes a good preceptor, I can model myself to be that way too, but it takes practice and commitment. I’ve done teaching and mentoring before, but never in a clinical or pharmaceutical context. Some take-home messages I got:
– Always understand your student has a life outside of their rotation, and even if they’re putting in 110% into the rotation, life happens, and sometimes they’ll slip, and that’s okay.
– Don’t use the sandwich method: it’s insincere and belittles positive feedback.
– Instruct, model, coach, facilitate, repeat.
– My preceptors wrestle with a lot of dilemmas on a daily basis: do I step back and observe? Do I let my resident make this recommendation on their own? Should I give them the answer, or have them find it on their own without compromising patient care?
Excited to get my first student already – and hopeful that I’ll be up to the challenge when the time comes.
On the eve of the new year, I find myself actually apprehensive of this upcoming rotation. Having been off a clinical rotation since early November, and despite great experiences at DPIC and with the Therapeutic Initiative, I still feel out of practice with the process. The mock oral exam was also a kick in the behind for me; I hope that this upcoming rotation will allow me to further hone the tools that I have acquired and also streamline my process.
I’m also quite fond of documentaries, in any shape or form, and I often watch them to relax (my friends think I’m crazy). One such documentary I came across was Emergency Room: Life + Death at VGH, which follows the frenetic, hectic careers of the emergency physicians, nurses, and allied health in the VGH ED. Am I excited? Of course! Those folks are experienced and seasoned; hopefully I can learn a lot from them without getting in their way :D.
Goal #1: Gain a better understanding of the role of the pharmacist in the Emergency Department beyond medication reconciliation. Objectives to meet this goal:
– Complete all medication reconciliation procedure logs by the end of this rotation
– Shadow at least 2 other allied health in the ED, including EMS if possible
Goal #2: Become proficient in condensing information for patient handover from Emergency to ward pharmacist. Objectives to meet this goal:
– Continue to hone process and deliver a patient presentation to preceptor without “jumping” back too often
Goal #3: Be able to provide recommendations on workup and pharmacotherapy for the most common conditions/procedures in the ED, e.g. acute pain, stroke, seizure, ACS, arrhythmias, tox overdoses, sedation. Objectives to meet this goal:
– Quality over quantity: no trying to learn all conditions at once!
– Learn by doing: by week 4 of rotation, be proficient at handling 50% of practicing ED pharmacist patient load
– Be able to distinguish based on clinical presentation and radiological findings, between conditions that may mimic one another or cause one another, such as ischemic stroke and hypoglycemia, or hyponatremia and hypoglycemia causing seizure.
Liver disease was one of those topics that wasn’t really covered during undergrad, yet through furiously reviewing for PEBCs, and encountering patients with hepatitis and alcoholic cirrhosis throughout rotation, I’ve gotten exposure to it at least. However, I found it immensely helpful to get it in ADS format, so that I at least have an approach to managing complications of liver disease.
What I found surprising was that I did not know how much of a medical emergency variceal bleeds can be, and I learned how they come about, how they are diagnosed, and the role of pharmacotherapy (usually only think about this after initial stabilization and emergency care).
What I think will come in handy for my Emergency med clerkship coming up is that usually if patients present with a suspected upper GI bleed and they don’t know if it is variceal or non-variceal, the team will usually start the patient on both octreotide and an IV PPI pending surgery or a scope. The main therapeutic controversy that was discussed was whether to continue beta-blockers in the setting of secondary prevention of variceal bleed with concurrent refractory ascites. Generally, the benefit for beta-blockers in secondary prevention of variceal bleed is so dramatic (NNT = 3-4, NNT = 10 for primary prevention) that leaving a mini-dose of propranolol (10-20 mg daily) will usually be done.
Overall, this was a useful session with a few stimulating discussions through working with the cases that were provided.
One of the things that a residency should equip one with is a baseline competency to precept, or at least a framework to become a preceptor. This online course is intended to accompany the upcoming ADS on precepting on January 12th.
Overall, throughout the course I felt that it was aimed towards individuals who were established in their practice, but I felt that as a resident (a learner), it was interesting to see how our preceptors may have been trained. I found myself going through the modules and doing some self-evaluation in regards to how I am progressing as a learner, and also in how I would precept a student. During this year, I have taken on a TMP-SMX student, and although it is part of our procedure logs to demonstrate skills to a student, and coach a student to perform a skill, it’s inevitable that all of us will become preceptors at some point in the future, so it is beneficial to acquire these useful skills. Before residency, I have had some experience teaching and mentoring mostly through opportunities through music, but pharmacy is unique in that you are supposed to impart a schema to the learner to forge a thought process…very different!
I feel that after completing the course, I do not know how to be a preceptor, yet I know what it takes to be a good one. I also got the sense that being a good preceptor requires being mindful of what a student is looking for in a good preceptor. It is too easy to forget what it was like to be a student (and years from now, what it was like to be a resident!) and with that lose sense of what a thought process would look like for a student/resident who is still honing their process. I got a glimpse into the questions that preceptors must ask themselves every day when working with learners.
Goal #1: Develop a robust process for evaluating the quality of an RCT and whether to proceed with further critical appraisal. Not sure if I developed a process, but I certainly got a detailed overview in what to look out for in critically appraising an RCT, amongst other types of publications such as meta-analyses. We went through an exercise where we were to explain complicated concepts such as composite outcomes or non-inferiority trials in language that a member of the lay public would be able to understand, or the Feynman technique. I found it helped me quite a bit in solidifying the concepts that I reviewed.
Goal #2: Become familiar with various methods by which study authors present statistics and data to influence the reader to come to the same conclusion as the authors. Through attending a couple of Therapeutics Initiative meetings, a didactic session on meta-analyses, and going through elements of an RCT, there were a few ways that we identified where authors present data in order to make it easier to show the result they wanted to. For example, reporting events as event rates and not absolute event numbers can enable the author to not disclose how many participants were included in the final efficacy analysis (e.g. TORCH).
This rotation overall was a good reminder of caveat emptor when it comes to reading trials or meta-analyses…even in a busy clinical practice it is still possible to put on your critical appraisal hat!
It is now time to apply what I learned during EBM week, but through the lens of a pharmacist on a Therapeutics committee. I come in with preconceived notions that this is an extension of EBM week, and I hope to strengthen my critical appraisal skills and bring that to further rotations and my practice.
Goal #1: Develop a robust process for evaluating the quality of an RCT and whether to proceed with further critical appraisal. Objectives to meet this goal:
– Have a flow of 1st aspects to evaluate when approaching an RCT
– Practice: evaluate a ton of RCTs during the two weeks
Goal #2: Become familiar with various methods by which study authors present statistics and data to influence the reader to come to the same conclusion as the authors. Objectives to meet this goal:
– Be able to list sources of bias outlined in the Cochrane handbook
– Be able to explain 2 common methods for statistical analysis for RCTs and the shortcomings with each analysis
Previous residents and colleagues who had undergone a Toxicology rotation told me that it was going to be a packed week. Well, we had 4 days and Dr. Kent managed to pack 5 days’ worth of material into 4! I learned how to manage a variety of toxidromes and specific poisonings (too numerous to name here), but from listening in to the poison phones, to discussing various toxicities pertaining to CNS and CV systems, I now am more confident in assessing the poisoned patient.
Goal #1: Develop an approach to evaluating the poisoned patient: We actually started with this. I will not forget the adage – stabilize always as needed, GI decontaminate if possible, antidote if available, dialyze if necessary. I also will not forget the typical tox panel to order in case of suspected ingestion: CBC, lytes, LFTs, glucose, lactate, serum acetaminophen, salicylates, and serum osmolality.
Goal #2: Become confident in providing triage, and if applicable, recommendations for ingestion a variety of toxins: It was helpful to become familiar with the various toxidromes that may accompany an acute ingestion of a toxic substance. From this and plus a well-taken history, it is possible to determine whether a patient may not be in immediate danger yet require observation (say, acute ingestion of quetiapine 2000 mg), or a patient who may suddenly seize, undergo cardiopulmonary collapse, and require aggressive medical intervention (say, ingestion of bupropion 6000 mg with suicidal intent). This rotation was also a good primer to think about acute stabilization and supportive care for critically ill patients in any care area, from ED to ICU to a general medicine ward.
This session for me was an excellent reminder of what was covered during undergrad, with additional information on management of A-fib in the emergency department – it also was great to review my V-W antiarrhythmic classes. Actually, it made me think of my Toxicology rotation. Certain classes of antiarrhythmics influence certain ion channels in myocytes, which may affect the ECG. I thought back to certain toxicities – sodium channel = prolonged QRS complex, which potassium channel = prolonged QTc interval.
What I found really valuable from this presentation were actually the series of flashcard-like slides, which were a good reminder of the ADRs associated with each of the medications used for rhythm control (flecainide, amiodarone, dronedarone, sotalol). I hope to apply what I learned during this ADS to my upcoming Emergency rotation.
Before attending this session…full disclosure, I had no clue how to manage a patient with hemorrhagic stroke, be it SAH or ICH. I did not have a patient with either of those during my General Medicine rotation (although I did have a patient with a chronic subdural hematoma…completely different). Overall, here are the take home messages that I got:
– SAH (subarachnoid hemorrhages) carry a much higher rate of mortality and are seen more often in younger patients. Beware of the patient who presents to Emerg with a “thunderclap” headache, most often described as “worst of their life”. Nimodipine and pravastatin are used to manage this (although if pt is already on mod-high intensity statin, don’t be the pharmacist who recommends switching to prava…)
– ICH (intracranial hemorrhages) are best managed by controlling the BP, holding all antiplatelets/anticoagulants (reverse PRN), treat seizures, and possibly surgery.
This session was also a good reminder of the acute management of ischemic stroke and options for antiplatelet therapy for secondary prevention, with a good overview of the landmark trials. I especially found a few slides as quite helpful in summarizing large amounts of information – I intend on using those in my future rotations and possibly in practice.