Heather Chui's E- Portfolio

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.

Today I attended a session with Joanne Bains from Infection Control. She gave a powerpoint presentation and here are a few facts that she told us that I never knew before:

–    The chain of infection → infection can be prevented by breaking any link in the chain
–    30% of the population are S.aureus carriers
–    Up to 30% of patients who are infected with Norwalk are asymptomatic (and potentially could be shedding the virus!)
–    1st and 2nd generation cephalosporins and fluroquinolones are the main culprits for causing C.difficile-associated diarrhea at VIHA
–    C.difficile spores can live in the environment for months!
–    Patients who are colonized with C.difficile can excrete spores for months after infection
–    For enteric related organisms (i.e. C.difficile and Norwalk virus) it is recommended to cleanse hands with soap and water rather than alcohol.

• 1/3 of the population are MRSA colonizers and MRSA can live in dust for up to a year!
• Most people don’t wash their hands correctly. We did an experiment where we washed our hands and looked under a special light to see the areas which we “missed”. I discovered that I don’t do a great job of washing my finger tips and my wrists. So I need to remember to take off my watch and to ensure I remember to adequately cleanse my finger tips!
• The proper gowning/gloving/masking procedure
  Entering room: mask → visor (if using) → gown → gloves
• Exiting room: mask +/-visor → gloves → alcohol on hands → gown → alcohol → leave room → remove mask → soap water- Take home message: BE A ROLE MODEL
• Washing hands or using alcohol gel prior to interacting with ALL may remind other staff members to do the same.

I’ve just completed three days of my ID rotation.  I got to sit in on ICU rounds on day 1. It’s like a whole other language! I ended up adjusting a vancomycin dose on a patient growing S.epidermis in his blood who is also on CRRT which I have never done before. Patients on CRRT have an eGFR ~ 30 mL/min so I adjusted it to 15 mg/kg q24h.

I spent two mornings in the microbiology lab shadowing the technicians – one on the urine bench and another on the sputum bench. It was really interesting to see what goes on “behind the scenes” and how stuff actually gets reported on Powerchart.  I amazed to see how they could identify microorganisms simply by the colour or size that grew on the agar!

I was always curious as to how they determined on cultures in Powerchart if  bacteria were (+1, +2, +3 etc). They simply divide the plate into four  and see if there is growth in each quadrant!  For urine cultures they determined the number of CFU per mL simply by “eye-balling” the number of colonies on the plate. It was more subjective than I would have thought.

It was also interesting to note that sometimes mistakes do happen and things get reported incorrectly.  There was one culture that they incorrectly identified as Enterococcus sp. but after double checking it was actually S.aureus!

A few other interesting facts I learned:

* Gram positive cocci in pairs is usually indicative of Streptococcus sp.
* Gram positive cocci in clusters is usually indicative of Staphylacoccus sp.
* Pseudomonas aeroginosa smells like grapes when it grows on agar!
* Proteus mirabilis smells like chocolate cake batter.