Heather Chui's E- Portfolio

This week I got to go to the cath lab after a patient came in with an ACS. It was really nice to watch the angioplasty and they had the patient to the hospital within 30 minutes of his symptoms!  The cardiology resident explained where the catheter was going and it was really interesting to see it because I will probably never have that experience again Other procedures I got to see was procedural sedation for cardioversion, fracture and a patient who ended up going in cardiac arrest.

All in all, emergency is very different from my previous rotations as I have learned “let go” of trying to solve ALL the DRPs. Most of the time, patients are gone in less than a day. I generally do a medication reconciliation and deal with their chief complaint if it is drug related and antibiotics.

Another thing I have done a lot in this rotation, or more so than others is writing a lot of chart notes. Since the patients all have different MRPs it’s not as simple as tracking finding one or two doctors. The doctors are generally all over the hospital so I have written more notes in this rotation than any of my other rotations. I have to admit I’m still not very “quick” with them but I am getting better.

I just finished week one of my pain clinic/anticoagulation clinic rotation. I’m spending the mornings in the Pain Clinic and the afternoons in the anticoagulation clinic. It’s a bit weird being in two different specialities at a time but so far it’s been working out.

I watched Donna doing two interviews with pain patients and then today I conducted one on my own. I was a little rusty but Donna helped me out. I’m in the process of writing up my assessment and recommendation to the family doctor. Most of the patients who come to the clinic have tried almost every pain medication out there and by the time they get to us, there are fewer and fewer options available. I’m starting to learn about the lidocaine infusion protocol they have started using in some patients.

I’m also a little flustered in the anticoagulation clinic because the first couple of days I wasn’t really sure of the process. But today, I counselled a patient who had a DVT on injecting dalteparin and on warfarin and transferred her warfarin prescription to her community pharmacy. Next week I’m hoping to do a full work up on a patient from start to end (admission to discharge).

So the renal unit it is a complete change of pace from ICU! I’ve worked up a few patients and in general they are pretty stable. The big issue with dialysis patients and their medications is compliance! You can actually tell if someone isn’t taking their TUMS because their phosphate levels go up. Dialysis patients are on an average of 15 medications and evidently med rec is a really important of a renal pharmacist’s job. I’ve found anywhere from 2 to 10 discrepancies so far per patient!

The other thing I’ve noticed (or already knew) is that there isn’t a lot of evidence for many of the medications given to dialysis patients. This makes recommending therapy difficult. For example, there is an HD patient who will require long term prednisone for 6-12 months and the question came up about whether a bisphosphonate is indicated in this situation. In a patient, with a CrCl of > 35 mL/min, a bisphosphonate plus vitamin D and calcium would be indicated if the patient was on steroids for greater than three months and a dose greater of equal to 5 mg of prednisone per day. There are absolutely no bisphosphonate studies done in dialysis patients and the “normal practice” is simply to give alendronate 70 mg q2weeks instead of weekly.

My last week of rotation was spent in the hood at RJH. I got to shadow the technicians the first day.  I ended up making some hydromorphone and bupivicaine epidural bags, vancomycin minibags, clindamycin minibags and cefuroxime minibags as well. It was nice to get the practice in case I ever get called in to mix something when I’m on call. I also requested to be shown how to mix intravitreal vancomycin syringes as I know pharmacists have been called in before in the middle of the night. Since they didn’t have any orders for this, they used expired drug and Dana, one of the technicians talked me through how to mix them. They quite complicated as the solution has to be diluted and filtered but I think I got the hang out of it. Unfortunately, it was a really slow week in terms of chemo orders so I didn’t get a chance to go into the chemo hood.

When I wasn’t mixing I spent the other time working on some learning questions and calculations. One of the questions I had to use the alligation method to solve. I never thought after using that method in first year pharmacy that I would ever have to use it again in real life.  I guess I was wrong!

I just completed my first week in CIVA at VGH. This past week I have shadowed the sterile products pharmacist, attended neonatal TPN rounds, did TPN calculations for neonates and adults, verified TPN orders and shadowed a dietitian for the morning.

A lot of the information was review this week but what I found most useful was learning about neonatal TPN  because it was something I never got to do at RJH. The calculations are a bit more complicated that adult TPN and subsequently it is easier to make mistakes in calculations or when entering the TPN into Abacus. There was an incident when the Na Acetate was entered in Abacus  as “mmol/kg” instead of “mmol/kg” and the baby ended up getting a lot more in the bag than was ordered.

I also reviewed some “TPN theory” with Kim in regards to fat overload syndrome, refeeding syndrome, TPN compatability, etc. Overall, the TPN review helped bring together what I had learned working as a sterile products pharmacist at RJH.