C’est fini.

This time last year, I didn’t quite understand why the P2-going-on-P3 students were celebrating the end of the semester with so much fanfair.  Didn’t they realize that they still had another 9 months of APPE rotations standing between them and graduation?

Now that I’m in their shoes, I understand completely.  It has been a long 2 years.  68 weeks of didactic coursework, 98 exams, 8 weeks of full-time IPPE rotations.  I thought they were working us hard during our P1 year, loading us with 7 classes per semester (18 credits).  P2 year brought just as many credit hours but more difficult material.  Add additional responsibilities as a leader of student organizations on top of the coursework, and it was just a busy year all around.  I learned to be happy with A- grades, and being on the Dean’s List became a much more elite honor.

P3s always say that the last year goes by very quickly, and I’m glad to hear that.  I’m glad that I will finally get to put all the information I’ve crammed into my skull over the past year into practice.  I’m glad that I will be evaluated based on my overall performance rather than based on a fixed number of examinations.  I’m looking forward to starting new research projects, working in a new setting, and marketing myself as a prospective PGY1 pharmacy resident.

I don’t believe I’ve mentioned it on this blog before, but my current goal is to pursue a PGY1 residency at UMass and then stay on for an additional year as a PGY2 critical care resident.  Ever since a guest speaker from UMass came to my school to speak about critical care pharmacy in the fall of my P1 year, I’ve had a deep conviction that I should devote my career to critical care pharmacy.  I do have a rotation in critical care pharmacy at Baystate, but it is not until February/March of next year, so I asked my mentor, Dr. Fong, whether I could shadow him at the UMass neuro/trauma ICU for a day.  He graciously allowed me to do so.  Here is the reflection I wrote after the shadowing experience:

Initial impression: If nothing else, one thing that I learned today is the importance of wearing a seat belt while driving and a helmet while riding a bicycle.

Overall, though, nothing I saw in the neuro/trauma ICU at UMass today was particularly surprising.  Perhaps my biggest surprise was that although the unit is equipped with portable computers for clinicians to take on rounds, the medical record is not completely electronic, and CPOE has not yet been implemented.  But considering that the UMass NICU had only paper-based medical records when my son was there three years ago, perhaps I shouldn’t have been so surprised to find the neuro/trauma ICU in a state of transition between paper records and electronic records.

I like to compare and contrast the new things I encounter in the classroom or on rotation with my previous experiences at the UMass NICU and the Athol Memorial inpatient floor.  I think I was expecting the role of clinical pharmacists at the UMass intensive care units to somehow be more intense or more sophisticated than the role of the staff pharmacists at Athol Memorial.  In reality, though, what I saw the pharmacists do at UMass was not much different from what I saw pharmacists do at Athol: participate in multidisciplinary rounds, offer pharmacotherapeutic recommendations, approve medication orders, and procure needed drugs.  Granted, the acute medical problems of patients seen at the neuro/trauma ICU were generally much more complex than the problems of the patients at Athol, but when you consider the chronic conditions and comorbidities of many of the patients at Athol, they don’t appear quite so simple in comparison.  The real difference is that because the ICU patients are less stable, there is less room for error.  A small miscalculation can potentially push a patient over the edge.

I know that there is more to the role of a clinical pharmacist than what I saw today: drug-use evaluation programs, drug error management, in-service education, patient drug counseling, CPR team participation, protocol development, and so on.  I saw some of those activities at Athol, but I’m sure that the opportunities for a clinical pharmacist in an ICU setting at a teaching hospital are different from those of a staff pharmacist at a rural hospital.  For example, pharmacists at UMass get to see investigational drugs come through their units, and that’s something that you wouldn’t see at a rural hospital.  As someone with a background in chemical research, I find pharmaceutical research very interesting.  I’d like to be able to participate in research projects throughout my career, and that is probably not something that I would be able to do at a rural hospital.  More of a pharmacist’s time at a rural hospital is devoted to managing the department and performing tasks that might be automated or taken care of by pharmacy technician at a larger institution.  When there are only three pharmacists and one pharmacy technician employed by a hospital, all the pharmacists need to be able to act as a department manager, a clinical pharmacist, and a technician.

One thing I like about clinical pharmacy is that you are able to see the complete clinical presentation and pertinent medical history of a patient.  You have all the information that you need to make sound clinical recommendations, or if you don’t, you can recommend that tests or labs be done to help guide your clinical recommendations.  Ideally, a clinical pharmacist should be in a position to watch a disease progress and/or resolve over a period of days or weeks.  That experience becomes very valuable when you see a similar case in the future and need to make new recommendations.

I also appreciate the fact that clinical pharmacists work in a multidisciplinary team.  It’s mutually beneficial when pharmacists can share their knowledge and experience with other clinicians from varying backgrounds.

I enjoyed observing how a clinical pharmacist works up a patient.  Today, it seemed like we skimmed through patients very quickly, but I know that pre-rounds get easier as you start to see the same disease states over and over again.  You learn what to look for.  Even in my amateur role as a NICU mom, it didn’t take me long to sort out all the common conditions that arise in the preterm infant patient population – RDS, PDA, NEC, hyperbilirubinemia, IVH, ROP, apnea, GERD, hernias, etc.  They’re just common conditions that everyone knows when to expect, how to spot, and how to treat.  Occasionally, the NICU staff gets thrown a curve ball – a rare birth defect, for example.  But from the practitioner’s perspective, I suppose that curve balls just help to keep things interesting.  A good example is the cyclophosphamide/mesna order today – clinicians normally don’t see chemotherapy in the neuro/ICU, so the cyclophosphamide order gave the clinical pharmacist an opportunity to learn more about chemotherapy.

When I talk about potentially working as an ICU pharmacist, most people tell me that they think it would be too depressing to work in such a setting.  My general attitude has been that if I wasn’t traumatized by my son’s 23 days in critical care and 50 days in a step-down unit, I shouldn’t find it upsetting to care for strangers in an ICU.  I have never been completely certain that an ICU would be a good work setting for me, though: How would I react to seeing traumatic injuries?  How would I react in a code call?  How would I react to seeing a patient die?  At this point, I feel pretty confident that traumatic injuries are a non-issue.  I’m just not a squeamish person when it comes to injuries and ventilators.  On the other hand, I’m still not sure about code calls.  After all, the code call during my son’s delivery left me struggling with PTSD for months postpartum.  But at this point, I think that as long as I’m not working in a maternity unit, I’m unlikely to see anything that resembles my son’s delivery closely enough to trigger flashbacks.  What made that code traumatic was the fact that my child was in danger, I had no control over the situation, and it was extremely unexpected.  I doubt that nothing unexpected ever happens in a neuro/trauma ICU, but as a clinician, it shouldn’t be my family member in the unit, and I shouldn’t feel like I have no control over the situation.

Have I digressed?  My goal today really wasn’t to learn everything about the care of neuro/trauma patients or to learn what the role of a clinical pharmacist is.  After all, I’ve spent the past year or so learning what clinical pharmacists do, how they think and solve problems.  I still have a lot more to learn, but the goal today was really to determine whether a critical care unit could be a good place for me to work.  And the verdict is yes, the neuro/trauma ICU is a good place.  It’s a place where clinicians can see diverse and complex patients – patients with neurological issues, trauma and burns, respiratory failure, infections, and pain management issues.  It’s a place where a pharmacist can make a difference both with individual patients and with the procedures and protocols of the unit.  It’s a place where patients can get patched up and be given another chance at life.  Of course, not everyone who comes in gets that second chance, and most people leave with permanent scars of one sort or another.  But still, I think that there is no greater privilege than to be able to help someone when s/he is most in need, and that’s what the ICU staff does every day.

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