Tuesday, October 2, 2012

"So You're An EM pharmacist...What Is It That You Do?"

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that.

Being A Crystal Baller
Nadia Awad, Pharm.D.

There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.

Why is this important? For me, emergency medicine is unlike any other discipline of medicine that I have practiced in, which makes it all the more challenging and rewarding to experience.

When a patient enters through the doors of the emergency department, very little information is provided at the onset other than what is acutely going on that brought him/her into the ER in the first place. Because that is all we have to go on, we have to quickly assess the patient and make our interventions before the patient deteriorates any further. It is not enough to just have a sound understanding of the pathophysiology and therapeutic management of various diseases. Truly appreciating the nuances and potential downstream effects of the disease state is essential and allows for us to anticipate the course of therapy that may be necessary when providing care to patients in the emergency department. This is a different way that pharmacists can think about and approach the patient; to me, it is almost as if I enter the brain of the physician caring for the patient and see things from their perspective and I can then say to myself, “Well, because X is going on in the patient, they are probably going to need Y and Z, so I’ll get it all ready and ask them about it if the physician does not ask for it first.” The more that the same disease state presents itself over and over across various stages in the different patients that present to the ER, the more experience we can get as pharmacists in anticipating the care we can potentially provide for that patient.

Let me provide a quick example. Take the case of a young trauma patient who has been stabbed in the upper back. As the paramedics wheel the patient into the trauma bay and proceed to tell the trauma surgical team the story of the incident and their interventions while the patient was en route to the hospital in the ambulance, I keep my eyes peeled on the patient looking at the patient’s general appearance and scan for any other obvious injuries. My ears perk up as I hone in on the patient’s vital signs, medications she received prior to arrival, past medical history, current medications, and allergies. I see that the patient is relatively hemodynamically stable, but is writhing in pain and seems to have some difficulty breathing. Stab wounds are definitely going to hurt, so it would not be unreasonable for me to pull a vial of fentanyl from the trauma pack and proceed to draw up and dilute 100 mcg into a 10-mL syringe and label it just in case it is requested. Since sterile knives rarely exist in the home or on the street, I determine that prophylaxis with antibiotics will be necessary to prevent an infection. However, as the paramedic mentions that the patient has an allergy to penicillin, I have to consider alternative agents to provide to the patient, such as vancomycin or clindamycin, and decide which agent would be more feasible to administer. If it is determined that the patient will need to have a chest tube inserted due to the presence of a hemothorax on chest x-ray, I know that she will need to have both pain and any anxiety minimized during the procedure and will want to forget that it ever even happened. I then proceed to flip the top off of the midazolam vial and start drawing up 2 mg of midazolam into a syringe and hand it to the nurse along with the fentanyl that I’ve already drawn up just as the trauma surgeon turns to me and asks, “Can we get 100 mcg of fentanyl and 2 mg of midazolam for the chest tube?”

What I have described emphasizes the theme of anticipation to a great extent, since I am able to predict the things that may be requested from me by the trauma team as I quickly assess the patient upon arrival.

As I continue my residency training in emergency medicine and solidify my understanding of the various diseases that I come to encounter, it is my goal to become better at anticipating the course of action and pharmacotherapeutic interventions necessary for the patients whom I care for. This, I believe, will allow me to become a stronger practitioner in the field. I am grateful for the mentors that I have in the residency program who have already and will continue to guide me along the path towards achieving this goal. For now, I am going to keep chugging away at anticipating more and more and by the end, I will hopefully earn the title of “Crystal Baller.”

“Can we try and take the high road, 
Though we don't know where it ends; 
I want to be your Crystal Baller,

I want to show you how it ends.”
-Third Eye Blind