Toxicology Rotation
Posted on: December 6, 2009
Objectives
Upon completion of the one-week Toxicology rotation, the pharmacy resident should be able to:
1. Demonstrate knowledge of available toxicologic resources and ability to retrieve toxicologic
information.
2. Discuss the toxicity, pathophysiology and therapy of common overdoses and poisons.
3. Demonstrate the ability to obtain a pertinent history regarding a poisoning exposure.
4. Demonstrate skills necessary to evaluate the potential severity of a poisoning exposure.
We spent last week at BC Poison Control in Vancouver. It was a nice change from our clinical rotations and project work! We didn’t actually get to answer any phone calls but we got to listen in on some. There is a wide variety of callers. Anything from ER physicians with multi-drug over dose questions to the lay public. There were scenarios that apparently happen all the time that I would have never guessed. For example:
1) People getting crazy glue in their eye
2) Drinking industrial solvents (accidentally) because someone had poured it into a water/pop bottle!
3) People drinking the hand sanitizers in the hospitals (Isogel) to get drunk.
We spent most of the week working up paper cases for common overdoses (acetaminophen, salicylates, TCAs, CCBs, alcohols). We learned the “process” of assessing an overdose patient (stabilization or ABCs, history and PE exam, decontamination, antidote administration if indicated, enhancing elimination and monitor and supportive care). It was a good introduction and I am happy I now have a bit of background before I do my ICU and emergency rotations next year.
Today we had a therapeutic session with Curtis Harder. We critically appraised an article which basically developped the Hartford Nomogram for once daily aminoglycoside dosing. This nomogram was something I remember being discussed during school but when we actually went back to look at the literature it’s actually not validated! It was also only studied in 20 patients. The average age was 43 and doens’t apply to many patients in Victoria at least who might be on aminoglycosides. The good thing is that most pharmacists at VIHA don’t use the nomogram but rather their “clinical judgement” to adjust once daily aminoglycosides. I also didn’t know that the risk of nephrotoxicity increases after ~ 5-7 days as it takes time for ATN to occur. This correlates with a study rise in SCr.
Pediatrics Rotation – Wrapup!
Posted on: November 20, 2009
Last day on Pediatrics today! The rotation seemed to fly by. I really enjoyed working with the team of residents, MSIs and nurses. I had a lot of questions dosing and choice of drug therapy and it was nice to give my input. I ended up looking up most of the questions because I didn’t know a lot of answers. Here are a few things I took away from the rotation:
1) A lot of therapies are initiated without any real evidence. Unfortunately, there aren’t a lot of well done RCTs in the pediatric population so we have to work with what we have. An example is giving PPIs for pediatric GERD.
2) Getting children to take meds can be a challenge. I had multiple encounters where I had to convince patients to take their liquid antibiotics. Cefuroxime suspension is very bitter and most children don’t like it. The taste of it is also difficult to mask in yogurt or apple sauce.
3) Meticulously checking all doses! Normally I am able to look at a drug regimen (in adults) and know whether it’s an “appropriate” dose or not but with pediatrics you have to checking all doses based on mg/kg dosing.
I also presented a case on a contreversial topic: the use of prophylactic antibiotics in children. I had a hard time putting it together and worked really hard to make it interesting for the audience. Afterward, I got some great feedback so the hard work paid off I guess! Here is a copy of my slides: pedscasepresentation
Pediatrics – Week 2
Posted on: November 6, 2009
This week I got to spend a morning in the CF clinic. The clinic is staffed with a multi-disciplinary team (doctor, pharmacist, dietitian, nurse, physiotherapist) and I got to follow a patient all morning. Unfortunately, this patient had to be admitted due to an exacerbation secondary to influenza so now I am following him as an inpatient. There aren’t a lot of “DRPs” per se with this patient because he is so closely followed in the clinic but I am learning a lot about CF medications.
I am also getting to know the nurses, residents and MSIs very well. They are asking questions and I am getting more comfortable making my recommendations. I hope to find an interesting patient to use for my case presentation over the next few days and I need to work on developping better monitoring plans (as per my midpoint evaluation with Greg).
Journal Club – Pediatrics
Posted on: November 3, 2009
Today I lead a journal club on the use of lansoprazole vs placebo in the treatment of symptomatic GERD in infants. Interestly enough, the study showed that there was no difference in “crying episodes” post feedings. Apparently, it is common practice to prescribe PPIs in infants who have regurgitation/crying/fussiness even though there is no evidence of benefit! Here is a copy of my one page summary: Pediatric Journal Club Handout
Pediatrics – Week 1
Posted on: October 31, 2009
Objectives: Pediatric Rotation
I just finished my first week on the pediatric ward at VGH. I admit it is a totally different world and I no longer can work up patients as quickly as I did in internal medicine and geriatrics. My first patient had multiple complicated disease states such as seizures, hypertension, GERD and short bowel syndrome. I’ve had to do a lot of reading because we did not get a lot of exposure to pediatrics during school.
The H1N1 flu is also a bit of a concern on the ward. There has been a few patients who have been admitted with flu-like symptoms and any patient who is influenza A positive gets put on Tamiflu. To get H1N1 confirmation, we have been sending the samples to Vancouver (BCCDC) and this usually takes ~ 1 week. However, starting Monday the labs in Victoria should be able to run the tests.
I’m faciliating a journal club on Tuesday so I will post a copy of my handout after it is done!
Internal Medicine – Final Week
Posted on: October 16, 2009
On Wednesday, I faciliated a journal club on an article which compared varenicline to transdermal NRT for smoking cessation. We had VGH teleconference but we were having technical difficulties and unfortuantely the JC did not flow quite as well as I would have liked. They were having trouble hearing our discussion so we ended up repeating comments multiple times. Here is a copy of my handout: JChandout.
An interesting patient I had this week was a 69 year old patient admitted with acute HF exacerbation. He also had atrial fibrillation and is on warfarin for stroke prophylaxis. His INR was 5 on admission (but was not bleeding) and is also taking clopidogrel due to a history of TIAs. The senior resident wanted to continue dalteparin 5000 units daily for VTE prophylaxis. But I was concerned with an increased bleeding risk and the patient was technically already protected from VTE due to his “supra-therapeutic INR”. After a long discussion, the resident reluctantly agreed to stop the dalteparin. I have had doctors refuse to take my recommendations in the past but I was genuinely concerned that the patient would have a severe bleed if we did not intervene.
Internal Medicine – Week 3
Posted on: October 10, 2009
I presented my case presentation on the use of glucocorticoids in the treatment of alcoholic hepatitis this week. It did not go as well as I had hoped. But I received some constructive feedback that will help me make changes to it before I present it in Vancouver. Here is a copy of my presentation: slides.
I am also feeling more comfortable speaking up during rounds and I am finding that the residents are calling me more often to ask questions. There were a few instances where the attending and the senior resident did not agree with me but I don’t regret giving them my opinion! For instance, there is no evidence that one PPI is clinically more effective than the other and the attending believes esomeprazole is more potent and therefore “more effective” than the other PPIs.
Internal Medicine – Week 2
Posted on: October 2, 2009
The first half of my rotation has flown by! I am feeling more comfortable bringing up issues in rounds and the medical students and residents have been coming to ask me questions so it makes me feel useful! I also realized howimportant it is to do a prior medication reconciliation. I found 8 discrepancies in one of my patients today. The doctor always thought Pharmanet was very “accurate” . I explained to her that it is almost never the case and medications dispensed through BCCA, OTCs, etc are never recorded on pharmanet.
I am adjusting to the different atmosphere (compared to Geriatrics). Patients sometimes are discharged after 1-2 days so it’s hard to fix all their DRPs in such a short time span. I have phoned the family doctor and also the patient’s community pharmacy in some cases to ensure certain issues are dealt with after discharge.
Internal Medicine – Week one
Posted on: September 25, 2009
The first week of internal medicine is a big adjustment for me. Especially coming from geriatrics, where patients were more stable and were admitted for more than a week. The great thing about this rotation is that I get to “tag team” with Evelyn. She overlaps with me for 3 weeks. We have been interviewing patients together and bouncing ideas of each other. A summary of my first week:
1) Daily rounds: We attend rounds every morning with the CTU team which consists of the senior attending, the junior attending, the senior resident, junior residents and MSIs. I have spent a lot of time looking up things we discuss in rounds because many times I admit I have no idea what they talking about.
2) Alcoholic liver disease: for some reason almost half the patients on the unit were admiited with liver failure secondary to alcoholism. I am learning so much about liver disease and my case presentation will be dealing with the use of corticosteroids in the treatment of acute alcoholic hepatitis.
3) Non-inferiority trials: Evelyn, Sean and I spent 2 hours in his office trying to figure out the statistics behind a non-inferiority trial that Evelyn was doing for her journal club. Although, I am still not as comfortable with them as I am with RCTs. I have a much better understanding of them. Specifically, how a statement about superiority and non-inferiority can be stated and when it cannot.
4) Expectations: This week has been overwhelming for me, not in the sense that I have a lot of patients but in the sense that I realized how much I don’t know. I had a long discussion with Sean about this and we both agreed that I have to come to terms with the fact that I am not going to know everything about all the disease states and treatments that I come across. I have spoken with colleagues and friends who have done a residency and it’s nice to know they shared similar experiences. This will be an on-going internal battle throughout my residency but my goal is not to let it stress me out too much or to put a damper on what I will learn.
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