One of the most intense experiences of my cardiovascular rotation was witnessing a 3 x CABG in the OR. Not only did I get to observe the surgery, the anesthesiologist and technician discussed the medications used throughout the procedure. Maintaining tight control of blood pressure, glucose, pH and anticoagulation throughout the process was essential in sustaining hemodynamic stability of the patient and in supporting the delicate homeostasis of vital organs including the brain and kidneys. Medications do not get their fair share of the glory in open-heart surgery but the use of the “heart and lung” machine would not be possible without heparin. This machine is incredible as it minimizes blood loss, controls blood flow and provides an easily accessible source of blood to measure the specific parameters. Anesthetics, inotropes, vasopressors, neuromuscular blockers are a few of the agents employed to facilitate a successful surgery. Oh yes, and a bag of 100mmol/L KCl (nope, no decimal).
The anesthesiologist explained the various structures we were viewing on the ECHO from different planes, what each of these meant, how this was used to measure valvular regurgitation and how the image may differ in a heart with differing pathophysiologies. Once again this visual brought a new life to the reports on powerchart and broadened my understanding of the imaging.
So where does Cinderella fit in? Well, surgery was delayed (on one of the rare occasions I make plans of course *sigh*) and I had permission to leave at any time but there was no way I would miss this. I was rewarded for my patience by witnessing a heart, slowly come back to life. I learned how the ECHO and direct observation was used to assess the capability of the right ventricle to receive blood as the heart resumed its job of pumping blood to the body. I was left with 30mins to make myself presentable for a formal foodie event and it was so worth it! (this is likely an odd place to mention how very much I enjoy eating appies)
This was my final day of a great cardiovascular rotation and a fantastic day to be in residency!
As part of my cardiovascular rotation, I prepared an inservice for the nurses in the out-patient anticoagulant clinic outlining the treatment of acute VTE and extended therapy options. This was in line with one of my rotation goals to provide inter-professional teaching. The team in the anticoagulation clinic is extremely knowledgable and I wanted to demystify any lingering questions. In many cases, these questions revolved around patient inquiries regarding the duration of therapy and the necessity of warfarin bridging (5days total warfarin treatment and 2 consecutive INRs within therapeutic range). The use of fondaparinux in heparin induced thrombocytopenia (HIT) was another hot interest of discussion and I had to exercise caution when explaining how it was the synthetic pentasaccharide sequence of heparin and safer to use in instances of HIT…I have learned that unnecessary jargon is the fastest way to loose an audience especially when interacting with a different health care professional team with a different knowledge base. This inservice gave me a better appreciation for the knowledge relevant to nurses and allowed me to tailor the presentation to the nursing staff on the cardiovascular intensive care unit (CCU).
Unfractionated heparin and some of the IV administered anticoagulants were not agents employed in the outpatient anticoagulant clinic however these were used in various contexts in the CCU setting. These were not addressed in this presentation as it focused on VTE treatment in the out-patient anticoagulant however this presented a learning opportunity which will likely be important in my ICU rotation.
Below are my prepared table for VTE treatment as well as a simplified presentation which allowed me to work through each drug and drug target in hopes the the coagulation cascade would appear less overwhelming.
Acute Treatment of VTE_ Anticoagulant Clinic Therapy Table in the Outpatient ATC_ Clinic Nursing Inservice
Clotting Cascade Supplemental to Anticoagulant Nursing Inservice
One of aspect that I did touch on during the nursing in-services was a little off topic but an issue that I personally feel strongly about. Each of us is responsible for medication safety and I believe the nursing places a key role in preventing medication errors and so more eduction can never hurt. Currently there is a debate between the nomenclature between NOACs (new oral anticoagulants) and DOACs (direct oral anticoagulants) because they are not “new” any more blah, blah…to me these arguments are semantic in nature and I honestly should care more about this, but I don’t (sorry to all my preceptors and mentors that feel differently). To me it gained importance when it became a matter of patient safety. Read the following physician note, quickly jotted down with the best of intentions:
“Stop warfarin, NOAC”
What does this say to you when you read it? 9/10 healthcare practitioners read the same thing. “Stop warfarin, no ac (anticoagulation)” rather that the intended “stop warfarin and begin a NOAC.” I was not directly involved in this patient’s care however I was sad to learn he died shortly in hospital from an embolic stroke. For this reason, I urge others to refer to this class of medications as DOACs if the abbreviation must be made.
On arrival to CCU, the knowledgeable medical resident assessed a patient at high-risk of infection post emergency bowel resection and the decision to continue a short course of antibiotics post-op was made. Unfortunately, the patient had a documented penicillin allergy and there was some debate as to which antibiotics to use. A suggestion put forward was to switch the medication order from metronidazole/cefazolin to metronidazole/ciprofloxacin. The coverage of ciprofloxacin for common skin pathogens such as the Streptococcus spp. and Staphylococcus aureus could have been suboptimal. This was true for some of the common Enterobacteriaceae ssp. associated with post procedure infection. Given the recommended alternatives form Bugs and Drugs for severe penicillin allergies (gentamicin/ metronidazole or gentamicin/clindamycin) and the patient’s eGFR of 36ml/min, some investigation was warranted. After reviewing the chart history, it was discovered the patient received:
Ceftriaxone 1g IV and metronidazole 500mg IV at 08:30 March 16, 2106
Cefazolin 1g IV and metronidazole 500mg IV at 02:00 March 17, 2016
The patient had also tolerate imipenem in hospital on a previous visit.
During the patient interview, she described the allergy as a rash to her arms, chest and abdomen that had emerged within 24hrs of penicillin use in 2006.
On exam, the patient had no signs of rash on her chest, abdomen, back or legs. Given the alternatives, if antibiotic therapy were to continue, the suggested was made that cefazolin 1g IV and metronidazole 500mg IV be continued tid as ordered with careful monitoring for signs of an allergic reaction. The probability of cross reactivity between penicillins and cephalosporins was communicated to the residents, nurses and dispensary pharmacist. Needless to say, I was diligent to monitor closely for signs of an allergic reaction!
This served as a good lesson of where reviewing the patient medication history and a careful allergy assessment was beneficial in ensuring the patient received the most effective and safe medication. It was also an opportunity to demonstrate the utility of a pharmacist as part of the patient care team. A medical resident and a pharmacy resident may have a different approaches to the same problem however by working as a team we were able to determine the most viable option for the patient.
I am happy to report that today was my first day teaching at the warfarin information session in my Cardiology rotation (Tuesdays and Thursdays at 10:00 if you are interested). At this session, one woman diagnosed with atrial fibrillation and her daughter, were my two audience members. This actually turned out quite well as I could tailor the presentation to her specifically. They both had many questions, which I could easily answer. The part that surprised me most was how much I had actually learned from them. They had intelligent, legitimate questions about this new medication and I had answers that they could understand. I have never doubted the key role of a pharmacist in providing medication related education but it reminded me that concepts considered common knowledge in the health care profession and in a busy hospital can often be a black box to patients. So my key reminder here today was to educate, educate, educate. If necessary, educate until the patient cannot even stand the thought of Googling it anymore (Disclaimer: I do not dislike Google at all but accessing accurate information is a rant discussion for a different time and place). As an added bonus, becoming an effective pharmacy educator is one of my residency learning objectives and this was a great opportunity to exercise this. Overall, it was a good experience and I am once again sincerely grateful to the patients for helping me become a better clinician.
Following 2 project weeks that had me at several different locations on the Island, it is now the beginning of my Cardiology rotation. I anticipate it will be challenging and a steep learning curve but one I feel ready for. After meeting with my preceptors, I have developed some specific goals and objectives for this rotation:
Goal 1: To develop and apply knowledge and clinical skills specific to cardiology.
- To develop an understanding of the pathophysiology, risk factors, pharmacological and non-pharmacological treatment of VTE, Afib and valvular heart disease through therapeutic discussions with my preceptor.
- To improve my patient presentation approach to preceptor (ID, HPI, medications and past medical history, etc).
Goal 2: To demonstrate the skills necessary to provide effective direct patient care.
- To develop a system for identifying patients most likely to benefit from a comprehensive pharmaceutical assessment through practice and discussion with my preceptor.
- To clearly identify and prioritize DTPs.
- To practice presenting the treatment alternatives and justifying my recommendations.
- To refine monitoring parameters to include time to expected change, patient specific thresholds to changes in therapy (in terms of efficacy and safety) and frequency of monitoring.
- To gather relevant information in a consistent, systematic fashion using a condensed data collection sheet (20mins).
- To improve my interpretation of diagnostics and imaging by creating a list of unfamiliar terms.
Goal 3: To develop and integrate knowledge to provide direct patient care and medication- and practice-related education.
- To provide pharmaceutical education to patients and non-pharmacy health care professionals through formal teaching sessions to as per rotation schedule.
- To provide pharmaceutical education to patients health care professionals through a nursing inservice.
This is slightly more structured than previous rotations however I believe these are quite attainable during my DPC rotation #4 with two great preceptors to coach, model and facilitate.