My final rotation will be in the clinical teaching unit (CTU). I am excited for the experience of working as the CTU blue team pharmacist. The patients admitted to CTU are generally acutely ill and often have a clinically interesting condition to facilitate the learning of the medical residents and students. My learning goals for this rotation are to explore the pharmacotherapy and therapeutic alternatives for managing conditions such as pericarditis, diabetic ketoacidosis, cirrhosis, acute heart failure, metabolic acidosis and alkalosis. If you have been reading my ePortfolio at all, you’ll know that I generally speak my mind. So here it is: I am so excited for this challenge and learning opportunity that I have butterflies. So wish me well and I will update you soon!
Thyroid stimulating hormone (TSH), plays an important role in thyroid function and consequently metabolic function. It is the most common lab measurement ordered to determine thyroid function (and with low thyroid function, where would you get the energy to make dinner for your sweetheart?).
One of my learning goals was to look at diagnostic tests and their role in medication management. Originally I was thinking of diagnostic imaging however the diagnostic value of TSH measurements in acutely ill patients has resurfaced time and time again during my clinical re-orientation. This was especially true in patients previously diagnosed with hypothyroidism.
On your floor, a patient with previously controlled hypothyroidism was admitted through the ER where a TSH was ordered. The TSH is low however there are no signs or symptoms of clinical hyperthyroidism…at least none that cannot be explained by another mechanism. Do we dose adjust the levothyroxine?
Now, I do not claim to have all the answers to this question but it was helpful for me to create a short write-up and to create a table of how I would approach TSH (and FT4 if available) measurement with what I now know today. This includes patients believed to be euthyroid prior to admission. I would love feedback from others to know how you approach this.
Renal excretion is an important pharmacokinetic parameter for many drugs. Clinical pharmacists carefully monitor patient’s renal function to assess if changes in drug dosing are required to avoid toxicity or maximum efficacy. The kidney do a lot more than excrete drugs, they participate in maintaining fluid and electrolyte balance, acid/base homeostasis, red blood cell production, vitamin production and waste excretion. As kidney function declines into chronic kidney disease (CKD), pharmacotherapy may be employed to partially regulate these homeostatic functions. However, now a patient less able to renally excrete drugs requires a greater number of medications. This is one of the dilemmas that will be addressed during my nephrology rotation. Hemodialysis (HD) may be employed when kidney function declines to a point where medications and life style alone cannot compensate for the loss in filtration. HD also has its limitations and an in-depth understanding of these is required when optimizing drug therapy in these individuals. Something tells me there will be a lot to learn on this rotation.
These are my personal rotation specific goals in addition to those presented on the ROAD document.
- To gain a thorough understanding of common co-morbidities and treatment options in CKD and dialysis patients including but not limited to heart failure, hepatic disease, atrial fibrillation and infection.
- To conduct pharmacokinetic assessment in patients with CKD or on dialysis including vancomycin, aminoglycosides and phenytoin if the opportunity presents.
- To evaluate and form a treatment plan for acid-base disturbances in patients with CKD and on dialysis.
- To evaluate and form a treatment plan for electrolyte disturbances in patients with CKD and on dialysis.
During my 2 weeks on an acute medicine ward at VGH, I had the opportunity to work with patients with a variety of clinically interesting conditions and pharmaceutical care needs. These included infectious diseases such as an abdominal abscess, urosepsis in patient with hypopituitarism and another with complicated cellulitis of the legs. Multi-organ damage was common in this patient group. One who stood out was admitted post-fall with hepatic encephalopathy, liver disease with abdominal ascites, CHF, atrial fibrillation, leg chronic ulcers secondary to venous insufficiency with a historical ADR to furosemide (yes, this was one patient and I will talk about the ADR in more detail in another post).
Throughout these busy weeks (snow and all!) I was able to meet my rotation specific goals with the assistance of my preceptor. The last week included a mock oral exam which I was able to complete in the 2h time period. More than this, I am excited to be back in the residency. I am thrilled to be involved with the interdisciplinary team again with the patient right where the patient belongs, in the center!
Speaking of organ systems and comorbidities, on to nephrology…
I have just completed my ICU rotation and it was a different world altogether! I could write pages about inotropes and vasopressors or the different agents for sedation. I gained a wealth of knowledge and experience in this rotation including interpreting ABGs, including detecting superimposed metabolic acidosis,’ the different mechanisms of shock, cardiogenic, distributive and hypovolemic and assessment of pain and delirium in a critically ill population.
Something else happened that I will not likely forget anytime soon. This is not insignificant considering the fluctuating and dynamic environment of the ICU.
My oral exam was scheduled during this rotation and so, as you can imagine, my mind was also focused on completing a full patient work-up in 2 hours in order to successfully complete my exam and meet this CHPRB standard. Time management and prioritization has been one of my primary goals throughout this year. The residency program and my exceptional preceptors have been reinforcing this and providing me the opportunity to gain the necessary skills and training to meet the challenges.
Back to the point, a patient whose care I had become involved in had extensive coronary disease and renal failure among many things but was smiling while I reviewed his home medications and held my hand with a strong grip before I left. I needed to leave briefly for a Leadership and Management session and could not find the chart to order his home eye drops.
Two hours later, I ran up the stairs to grab the chart before heading home to do some reading. Again the chart was not by the bed. The intensivists was documenting as the patient passed. I acted professionally but my shock was tangible as he was still in his room.
I completely understand the necessity to provide excellent pharmaceutical care in an efficient, step wise approach. This was however, a crystalizing moment for me. I had only been out of ICU 2 hours. The eye drops would not have prevented ventricular fibrillation, he was critically ill and there was nothing that could have been done in this case. However, time is finite and suddenly refining my process for the sake of an exam seemed somewhat trivial. It had to be for the patients. The exam was simply a demonstration of this ability and the process to ensure completeness and competency.
With the rotation and exam complete!
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!