Who, Pharm.D.

Over the holiday, I began reading one of the William Osler biographies. While reading his inspiring and influential journey, which to this day continues to guide and lead others, I paused to reflect on my own profession. Although I’m searching for the pharmacy equivalent to such influential figures in medicine, our education methods are far more interesting.

Though books and lectures were a component of late 19^th century and early 20^th century medical education, Osler saw them more as tools opposed to staples.  Introducing “clerkships” to medical education in America, students were thrust into practice to study “…individuals – not diseases.”  No doubt, a reflection of the existing education of physicians in other countries during that time, but paving the way for todays education model and future directions (ie, Khan Academy, flipping the classroom, etc).

Pharmacy education on the other hand, lags behind. Specifically, in the amount of practical experience the average pharmacy student accumulates before graduation and the over reliance on lectures and textbooks. Just recently, more focus on pharmacy clerkships was implemented by increasing the required hours of practical experience.  Unfortunately, there are few teachers out there that can accommodate the vast class sizes of today’s schools of pharmacy.  Speaking from personal experience, one is left to either sit in the back of a pharmacy to ‘observe’ inappropriate habits of overwhelmed community pharmacists or be put to work counting and labeling.  Certainly, students with initiative can create their own learning opportunities, seeking volunteer clerkship with faculty, pursuing PGY1 and PGY2 residency, but similarly, the deficiency of opportunities lags behind the need of the students, and the profession.  The figure is in the neighborhood of 1 residency position for every 2 to 3 pharmacy students seeking a residency. Mind you, only about 20% of graduating pharmacists seek residency/post graduate training.

Pharmacy education needs to change, both prior to graduation and post graduation. Through the evolution of medical education led by pioneering figures, medicine itself has advanced remarkably over the past 120 years. Pharmacy education can do the same.  Pharmacy education must do the same. 

Since Doctor Who saved the universe from oblivion on Dec 21^st (…cough, cough…), 2013 provides us, and the years to come, an opportunity to make a difference.  For me it is, among other things, the need for an evolution (perhaps a revolution) of pharmacy education.

“A difference, to be a difference, must make a difference.” –Gertrude Stein

The Pharmacists Role

The recent weather events here in NY and NJ made me admire the efforts of the staff at NYU to evacuate their patients and caused me to reflect on what it was like being part of the evacuation for Irene last year.  The pharmacy department of NYU and all other hospitals in the area worked behind the scenes, away from the news, to ensure each evacuated patient was sent with three days worth of medication.  That’s our role, that’s how we contribute and it’s something to be proud of. So I came back to something I wrote a few months ago, and feel it’s worth sharing my point of view.

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There’s an analogy I like to make that helps identify the role of the pharmacist in the hospital and in the emergency department. However, the analogy does require a prerequisite knowledge of American football. If you think of the medical professionals working in the emergency department as the players on a football team, the physicians are quarterbacks, nurses are the receivers and running backs and PA’s and NP’s are tight ends. But pharmacy, we’re the linemen.  When everyone is doing his or her job well; you’d never know we existed. But without everyone working together as a team, the quarterback gets sacked, the receivers can’t get open, and the running backs get tackled behind the line of scrimmage – medication delays and errors happen.

As pharmacists we must do our part to ensure that patients get the right drug, at the right dose, at the right time. We accomplish this through verification, preparation, compounding, dispensing, administration and monitoring. When we do our job, physicians can narrow their differential, and nurses can assess and provide directed drug therapy and patient care without having to guess. It allows for others to do their jobs better. If we don’t do our job, the risk of harm would jump because others would have to step in to fill our role.  It’s what would happen if Eli Manning tries to block Ray Lewis: the outcome is going to be bad.

Three of the best pharmacists I’ve ever met trained me to be an emergency medicine pharmacist. In the emergency department we remember our role as pharmacists: ensuring that patients get the right drug, at the right dose, at the right time.  That goes for all patients including trauma alerts, MIs, intubations, resuscitations, and the list goes on.  We’re at the bedside anticipating physician orders to make sure the right drug is being used at the right dose and prepared appropriately.  We don’t save the patients, and we won’t ever get the same attention the quarterback does, but that’s ok. I’m proud to be a pharmacist.  Not getting attention comes with the job but when the team wins – when we can deliver the best possible care to the patient – we win too. 

"So you're an EM pharmacist... What is it that do you do?"

I recently had a discussion about what makes a good EM pharmacist.  Below is a great essay by my EM pharmacy resident discussing just that.

Being A Crystal Baller 

Nadia Awad, Pharm.D.

There is one running theme that I have learned to appreciate and embrace since I started my emergency medicine pharmacy residency nearly three months ago. This theme can be summed up in one word: ANTICIPATION.

Why is this important? For me, emergency medicine is unlike any other discipline of medicine that I have practiced in, which makes it all the more challenging and rewarding to experience.

When a patient enters through the doors of the emergency department, very little information is provided at the onset other than what is acutely going on that brought him/her into the ER in the first place. Because that is all we have to go on, we have to quickly assess the patient and make our interventions before the patient deteriorates any further. It is not enough to just have a sound understanding of the pathophysiology and therapeutic management of various diseases. Truly appreciating the nuances and potential downstream effects of the disease state is essential and allows for us to anticipate the course of therapy that may be necessary when providing care to patients in the emergency department. This is a different way that pharmacists can think about and approach the patient; to me, it is almost as if I enter the brain of the physician caring for the patient and see things from their perspective and I can then say to myself, “Well, because X is going on in the patient, they are probably going to need Y and Z, so I’ll get it all ready and ask them about it if the physician does not ask for it first.” The more that the same disease state presents itself over and over across various stages in the different patients that present to the ER, the more experience we can get as pharmacists in anticipating the care we can potentially provide for that patient.

Let me provide a quick example. Take the case of a young trauma patient who has been stabbed in the upper back. As the paramedics wheel the patient into the trauma bay and proceed to tell the trauma surgical team the story of the incident and their interventions while the patient was en route to the hospital in the ambulance, I keep my eyes peeled on the patient looking at the patient’s general appearance and scan for any other obvious injuries. My ears perk up as I hone in on the patient’s vital signs, medications she received prior to arrival, past medical history, current medications, and allergies. I see that the patient is relatively hemodynamically stable, but is writhing in pain and seems to have some difficulty breathing. Stab wounds are definitely going to hurt, so it would not be unreasonable for me to pull a vial of fentanyl from the trauma pack and proceed to draw up and dilute 100 mcg into a 10-mL syringe and label it just in case it is requested. Since sterile knives rarely exist in the home or on the street, I determine that prophylaxis with antibiotics will be necessary to prevent an infection. However, as the paramedic mentions that the patient has an allergy to penicillin, I have to consider alternative agents to provide to the patient, such as vancomycin or clindamycin, and decide which agent would be more feasible to administer. If it is determined that the patient will need to have a chest tube inserted due to the presence of a hemothorax on chest x-ray, I know that she will need to have both pain and any anxiety minimized during the procedure and will want to forget that it ever even happened. I then proceed to flip the top off of the midazolam vial and start drawing up 2 mg of midazolam into a syringe and hand it to the nurse along with the fentanyl that I’ve already drawn up just as the trauma surgeon turns to me and asks, “Can we get 100 mcg of fentanyl and 2 mg of midazolam for the chest tube?”

What I have described emphasizes the theme of anticipation to a great extent, since I am able to predict the things that may be requested from me by the trauma team as I quickly assess the patient upon arrival.

As I continue my residency training in emergency medicine and solidify my understanding of the various diseases that I come to encounter, it is my goal to become better at anticipating the course of action and pharmacotherapeutic interventions necessary for the patients whom I care for. This, I believe, will allow me to become a stronger practitioner in the field. I am grateful for the mentors that I have in the residency program who have already and will continue to guide me along the path towards achieving this goal. For now, I am going to keep chugging away at anticipating more and more and by the end, I will hopefully earn the title of “Crystal Baller.”

“Can we try and take the high road, Though we don't know where it ends; I want to be your Crystal Baller,
I want to show you how it ends.”

-Third Eye Blind

Welcome!

Welcome to the ED PharmD blog!

My name is Craig Cocchio and I am an emergency medicine pharmacist.  I've created this blog to accomplish a few goals.
1- To describe the activities of pharmacists practicing in the emergency department
2- Share the experiences and knowledge of an established emergency medicine pharmacy team
3- Create an open forum for discussion of all things emergency medicine, of course, focusing on medications
4- Complement the various (and excellent) emergency medicine and toxicology blogs out there

I'll reflect these goals by filling the pages and posts of this blog with everything from pharmacy pearls, new and old drug reviews to medication safety musings.

Sincerely,
Craig Cocchio, Pharm.D., BCPS
Clinical Assistant Professor of Pharmacy Practice, Emergency Medicine
Residency Program Director - Emergency Medicine Pharmacy PGY-2
Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey
Robert Wood Johnson University Hospital