HYMR1

Wednesday, December 30, 2015

A Leap of Faith: My Clinical Sabbatical in Pediatric Pharmacy

When we reach the end of any year, it is generally a time for personal reflection. We reflect on major milestones that we have achieved, which includes moments that have defined us as well as moments that may have temporarily broken us, but we managed to pick ourselves up and keep running. During these times, we set out to accomplish any list of goals for the coming year, knowing in the back of our minds that there may be challenges that may face along the way.

For me, this year was certainly an interesting one, full of a few unexpected twists and turns in a professional capacity, and I have definitely learned and grown as an individual and as a pharmacist in more ways than one.

One of the ways in which this year will remain a memorable one for me is that for nearly three-quarters of it, I did not practice as an emergency medicine pharmacist.

This is not meant to be some sort of big revelation. If anyone had asked me at any point during the year, I would have provided the honest truth about the nature of my clinical practice; and I did when I was posed that very question throughout the year.

Towards the very beginning of 2015, I came to the realization that I simply needed to be challenged again. It was not that I disliked my joint gig of practicing as an emergency medicine pharmacist and clinical assistant professor; if anything, I appreciated most of what it had to offer. But I grew restless, and I was itching to do something new – and in a sense, something that required me to exercise my brain a bit. I also feared that I was becoming too comfortable with what I knew and applied in practice in the emergency department, and I felt that there was more for me to learn.

Granted, I realized that at that point, I was still relatively fresh out of residency training (just shy two years at the time) and some readers may believe that this should have been the time where I made the most of it, especially having a career in academia. I did everything by the book (and then some), and I was on the fast track to the inevitable in the climb toward the top of the beckoning ivory tower. And I knew that I was not confusing this with burnout; the timing was just not consistent, and if anything, it was the complete opposite; I was enthused to strengthen my clinical practice.

It was a difficult decision for me to make, but I knew I had to trust my gut feeling and take the next steps.


And so I did. An opportunity opened up at the institution where I completed my two years of post-graduate training – but it was in pediatric pharmacy. Pediatrics was not a completely foreign specialty to me; I trained in pediatrics for nearly two months as a PGY-1 pharmacy resident (one required rotation, and one elective rotation), and I had a positive experience on these rotations. In fact, I determined that pediatrics came in as a strong second after my first love in emergency medicine. However, I did come to terms with the fact that this would be a completely different experience, given that I would be the pharmacist (not trainee) covering the pediatric hospital, which consists of a multitude of units, including general pediatrics, pediatric intensive care, and neonatal intensive care.

One of the reasons that I chose pediatrics was that I wanted to gain some more practical hands-on experience in being part of the multidisciplinary team taking care of sick pediatric patients. From my previous experiences in emergency medicine, whenever we received word that we had a pediatric patient who would be coming to us requiring resuscitation, the room would swell with about two to three times more clinicians relative to an adult resuscitation, the chaos is outstanding (to say the least), and as the pharmacist in the room, there is a certain degree of comfort that is highly desired with dosing medications for these patients, as most are weight-based. One has to be at ease in recognizing concentrations of medications and safe methods for dilution, let alone identifying the rationale for said therapies, and with everything else that is happening simultaneously, it can be quite a harrying experience. I knew that if I ever had the opportunity to practice in emergency medicine again, I wanted to make sure that I knew exactly what to do and what to anticipate when a sick pediatric patient came in through the doors of the emergency department.

When I started my new position, it was quite a steep learning curve. I treated my experience as a second specialty residency, where I was my own program director, learning everything from the basics to the advanced level of clinical practice within the specialty of pediatrics. The pharmacists who trained me in pediatrics were stellar, and when it was time for me to practice solo, I also took it upon myself to read as much as I could on my own time anything that I could get my hands on related to pediatric pharmacotherapy. This is where my experiences in self-directed learning, including my engagement in #FOAMed, really came in quite handy, as I had already been doing so for a number of years. This was especially true at times when I managed a patient with a disease state that was uncommon where we instituted pharmacotherapies based on evidence that may not have been completely black and white. Of course, I was drawn to topics related to pediatric emergency medicine and critical care, and I thrived when I took care of those patients, and better yet, during those times when I was summoned to the emergency department for assistance in taking care of acutely ill pediatric patients.

During my practice in pediatric pharmacy, I noted that there were many similarities to my own experiences from the emergency department, and many of the skills and clinical acumen that I developed within emergency medicine could be applied to pediatrics. For instance, I was accustomed to taking care of patients of a wide range of disease states of varying acuities in the emergency department, and this was something that I encountered on a daily basis within pediatrics. There were weeks where my patients ranged in age and weight from 23 weeks, 300 g (yes, 300 g) to 18 years, 120 kg. In addition, as the emergency department can be a highly stressful environment with patient volume and acuity, my evenings in pediatrics were that same way at times, especially when caring for patients in the pediatric intensive care unit. However, my pharmacy technicians often told me that even if it was that way, I never lost my 'cool' (substituted for another four-letter word that starts with ‘s’ and ends with ‘t’), which helped some during some of those challenging evenings. Again, this was a skill that I gained after practicing in the emergency department that made its way into my practice in pediatric pharmacy.

At times, it was strange to gain a handle on the fact that much of how we care for patients in the emergency department can set the tone of how patients are managed in the inpatient unit. But it really is the case, and communication is key, especially in this vulnerable population of patients. My colleagues in the emergency department and pediatrics and my attending physicians and nurses in the pediatric intensive care unit would often provide me with a heads up related to a patient who would be reaching us at some point during the evening. Regardless of how ill and complicated the patient may have been, those evenings for me went along quite smoothly, especially when information was communicated in a timely and appropriate manner.

One thing that I never fully appreciated about pediatrics until I practiced in the specialty is that these patients are very resilient. There were times that I honestly thought that some of the patients that I was managing in the intensive care units would not make it; yet somehow, not only would they make it through the next day, but they would also turn around and improve significantly to the point of being transferred to the general pediatric floor or better yet, discharged home. Not to say that it was all peachy, as I did have patients who did not make it. Those experiences were the hardest for me to face emotionally, especially when we exhausted all of our resources in attempts to resuscitate these patients; witnessing the team having to break the news to caregivers and other family members and their reactions was extremely difficult.

My experience in pediatric pharmacy was invaluable, and I am grateful that I had the opportunity to practice in the specialty. However, even as I was fully engaged and truly enjoyed my time in pediatric pharmacy, I knew that in my heart of hearts, I belonged in emergency medicine. While I was gaining and absorbing all the information and knowledge that I could related to pediatric pharmacy as it directly affected the care of my patients on a day-to-day basis, I was simultaneously still ensuring that I was keeping up to date with the latest literature in emergency medicine. I was hopeful that I would practice emergency medicine again at some point in the future. And so when an unexpected series of musical chairs took place in the emergency department at my institution and a position for an emergency medicine pharmacist became available, I knew that I could not not pursue it. I took the plunge, and threw my name in the ring, formally applied, interviewed, waited for a bit for the decision, and was offered the position a short time later, which I heartily accepted (I will admit that I cried tears of joy when I learned the news).

I started back in the emergency department a couple of short weeks ago, and even just in this time alone, I can truly say that I have achieved my goal of being able to anticipate the needs of sick pediatric patients in our emergency department in addition to our adult patients. In some ways, it seems odd to me that transitioning back to the emergency department after not practicing for some time feels like riding a bicycle, but perhaps this is because I made an effort to continue to learn and grow as a practitioner.

My ten-month clinical sabbatical of sorts in pediatric pharmacy, though risky, was one of the best decisions that I have made for my career, and I am glad that I did it. Although I may not have been too far along in my own career, being a formal learner again was a fulfilling and worthwhile experience. Do I recommend it? It certainly may not be for everyone, but depending on the timing and circumstances, it may be an experience worth pursuing mid-career as a means of gaining a new skill set and knowledge base in a different specialty. As a result of this entire experience, I appreciate my chosen specialty of emergency medicine more so than ever, and I have a renewed sense of purpose and drive in my clinical practice as an emergency medicine pharmacist, knowing now that there are ways that I can be more mindful of pediatrics within emergency medicine.

I am happy that I am practicing again in the emergency department. As to what the future holds, time will tell. I am taking it one day at a time, making sure that I thoroughly enjoy every bit of it along the way.

Wednesday, December 23, 2015

Top 10 Posts of 2015

2015 was such a great year at EMPharmD with so many new authors proividing amazing content.

I encourage any readers who have a great idea for a blog topic or want to write a post yourself to submit it to myself or Nadia for review. As you can see below, some of the best content is from guest authors!

Here are the top 10 posts from this past year.

Three Reasons Not to Prescribe Tramadol
Matthew DeLaney, MD, FACEP, FAAEM (@MDeLaneyMD)
Assistant Professor of Emergency Medicine
Assistant Medical Director
University of Alabama at Birmingham


Steroids and Strep Throat
Meghan E. Groth, Pharm.D., BCPS (@EMpharmgirl)
Emergency Medicine Pharmacy Clinician
The University of Vermont Medical Center
Nadia Awad, Pharm.D., BCPS (@Nadia_EMPharmD)
Emergency Medicine Pharmacist
Robert Wood Johnson University Hospital
New Brunswick, New Jersey


Emily Richards, PharmD (@EmilyPharmD)
Pharmacy Practice Resident (PGY1)
Banner - University Medical Center Phoenix
Phoenix, Arizona
 &
Mark Culver, PharmD, BCPS (@EMdruggist)
Emergency Medicine Pharmacist
Banner - University Medical Center Phoenix
Phoenix, Arizona

Use Pantoprazole Intermittently and Cancel the Infusion for Upper GI Bleed
Mark Culver, PharmD, BCPS (@EMdruggist)
Emergency Medicine Pharmacist
Banner - University Medical Center Phoenix
Phoenix, Arizona
Craig Cocchio, Pharm.D., BCPS (@iEMPharmD)
Clinical Pharmacist, Emergency Medicine
Trinity Mother Frances Hospital
Tyler, Texas
 


Kyle DeWitt, Pharm.D., BCPS (@EmergPharm)

Emergency Medicine Pharmacy Clinician
The University of Vermont Medical Center
 
Craig Cocchio, Pharm.D., BCPS (@iEMPharmD)
Clinical Pharmacist, Emergency Medicine
Trinity Mother Frances Hospital
Tyler, Texas
Maria Cardinale, PharmD, BCPS
Clinical Pharmacy Specialist, Critical Care
Clinical Assistant Professor, Rutgers, The State University of New Jersey

Inspiring Change Through Social Media: Our Moral Responsibility in 140 Characters or Less
Nadia Awad, Pharm.D., BCPS (@Nadia_EMPharmD)
Emergency Medicine Pharmacist
Robert Wood Johnson University Hospital
New Brunswick, New Jersey

Wednesday, December 16, 2015

Sugammadex, revisited

Sugammadex (I call it Suggs) is a selective muscle relaxant-binding agent. As a result of its chemical structure, modified cyclodextrin compound with a hydrophilic outer surface and a lipophilic central cavity, sugammadex encapsulates both rocuronium and vecuronium.  This encapsulation creates a concentration gradient by which rocuronium or vecuronium leaves the neuromuscular junction for the plasma and then subsequently bound by sugammadex (think DigiFab).  The result is a dramatically shortened duration of effect of rocuronium or vecuronium.  At a typical surgical reversal dose of 4 mg/kg the median time to reach train of four ratio of 0.9 is 2.4 minutes after rocuronium or 3.4 minutes for vecuronium compared to 49 minutes using neostigmine. 

In the emergency department, the use of a drug like this would open up the possibility of freely using rocuronium for paralysis after induction of anesthesia for intubation, putting succinylcholine out to pasture. But it’s not that simple. The Gas Exchange blog said it best: “If sugammadex is the answer what is the question?”

In this awesome post, Dr. Jolley describes several different reasonable situations where suggs could be used. The two I think best apply to emergency medicine are pre-planned reversal of rocuronium (patients with neuromuscular disorders; and patients with severe pulmonary disease with limited reserve) and unplanned rocuronium reversal (unexpected difficult airway / can’t intubate, can’t ventilate situations).  The latter, I would imagine, would be the hot topic surrounding its use in the ED given the potential to put succinylcholine out to pasture.

Real world practice is going to be different compared to the controlled setting of an investigational study in an OR. A study of elective surgical adult patients who required induction and paralysis were randomized to rocuronium+suggs or succinylcholine alone to compare the time from start of administration of rocuronium or succinylcholine to recovery of T1 to 10% of the baseline value. Suggs was administered to the rocuronium group 3 minutes after the start of the rocuronium bolus. In this OR setting, rocuronium+suggs compared to succinylcholine alone recovery from paralysis (T1 10%, and T1 90%) was significantly faster with rocuronium+suggs.  This difference was 2.7 (mean rocuronium+suggs 4.4 min vs succinylcholine 7.1 min) minutes faster to T1 10%.  But (as pointed out in the Gas Exchange blog as well) this is a controlled setting. If there is a situation where rocuronium needs to be reversed, that decision is made when the prevailing issue is discovered. In other words, not before a RSI attempt. Therefore, once a complication is discovered, suggs ordered, mixed (5-8 vials or so for a 16 mg/kg dose) and administered, that difference of 2.7 minutes is gone and succinylcholine would have worn off on its own. The better question is what is that situation where rocuronium must be emergently reversed in a critical airway patient setting? I am no expert in airway management, I am simply the pharmacist at the bedside, however if a patient needs to be intubated / needs an airway, if you revers the rocuronium paralysis… they STILL need an airway. Supraglottic airways or cric procedures may benefit from lingering paralysis.

So where does sugammadex fit into clinical practice? In critical airway management, perhaps the role is not as great as once thought.

There is more to the argument, of course. 1) While the above study used train of four analysis for a marker of neuromuscular function recovery, patient oriented outcomes (shorter vent time, LOS, mortality) have not been studied. Another expensive drug with nothing but surrogate markers to go on. 2) Cost. Probably a lot. Probably not worth it. 3) Patients with GFR < 30. The drug may accumulate since it is cleared by the kidneys. This could mean an attempt at re-paralysis with roc/vec would not be effective or reduced efficacy. The RESUS ME blog pointed out a published case where this occurred. 4) Allergic reactions. Reported in the literature and the possible culprit for the FDA reluctance to approve.

The problem is the same as with Praxbind or Kcentra. It is hard to justify not having it on hand. The case where it might help a patient is probably a rare one, but it would be a nice drug to have on hand for those n=1 situations.

Controlling widespread use will be a challenge. I’m certain OR staff will request it with the same argument as IV acetaminophen – it will shorten PACU times, and get patients out faster. Just like with IV APAP, that argument hasn’t been supported, and the cost has been a significant issue.

The story of suggs continues to unfold.

I would love to hear the experience from our colleagues from the rest of the world where this has been available.

Monday, December 7, 2015

EM PharmD at ASHP Midyear 2015

We want to meet you!

I'd love to hear from any readers or followers at Midyear. Or just stop by to say hi.

On Tuesday I will be at the PM residency showcase at the Trinity Mother Frances Hospital PGY 1 booth (6221).

Later that day, blog contributor Adam Spaulding and myself will be speaking about the evolution of the indications for ketamine in the emergency department at 4:15 in room 293.

Wednesday come check out the EM pearls seen hosted by Nadia Awad and feasting pearls by awesome EM pharmacist from all over.

That is if you behave and not consume too many hurricanes.

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