I think this past year has taught me a lot about what it means to be commited to this profession.  I have had the great fortune of working with so many great pharmacists who are actively involved in various aspects of this great profession. 

On a personal level, I think being commited to the profession means taking the time to keep up to date with current practice.  This will become increasingly important as I learn to work independently as a clinical pharmacist.  Pharmacy is a profession of life-long learning that is required to provide the best possible pharmaceutical care to patients. 

In a broader sense, I’m hoping to be able to get involved in the education and development of future pharmacists through mentorship and precepting undergrad SPEP students.  This past year has served as an excellent example of how much the development of pharmacists relies on members of the profession.

As I grow and mature in my career as a pharmacist, I hope to keep an open-mind about the possibilities that pharmacy can provide.

During my second week, we discussed rejection in solid organ transplant as well as a general review of liver transplants.  I also started attending liver rounds where the team discusses upcoming transplants, patients that are post-transplant as well as decide who needs a liver most urgently should a deceased donor come up.  An interesting situation came up at the first meeting I attended as  a liver had become available that weekend and the first 2 patients that were contacted ended up turning the liver down, for reasons that really weren’t justifiable.  This was a concern to the team and they have since re-evaluated the 2 patients for their suitability to be on the transplant list. 

This past week we discussed infectious disease complications in the SOT population and had a good review of anti-fungal agents.  The biggest thing to remember about treating infections in these patients is that they are always considered complicated because of their suppressed immune system.  I always need to remember to check doses and duration of therapy before making any recommendations. 

On Friday, I had a journal club with my preceptor, discussing a meta-analysis that looked at the use of steroid avoidance and withdrawal protocols in renal transplant recipients.  It was an interesting article to read as the use a steroid free protocol in kidney transplants at VGH.  I’ve never reviewed a meta-analysis before so this was a great learning experience.

Some recommendations I’ve made lately:

1-patient with edema and a chronically low sodium was getting many IV meds in large volumes of D5W so I recommended switching them over to NS and minimizing the volume.

2-patient admitted while he waits for his liver transplant did not have his SBP prophylaxis reordered so I asked the fellow to continue it.  He was very happy that I picked up on this as it would be devastating for the patient to develop an infection at this point.

3-patient started emperically on vancomycin over the weekend grew group B strep on blood culture so I recommended to d/c the vanco and keep him just on Pip-tazo (he had other complicated issues as well).  When the patient continued to have no improvement in his WBC and continued spikes in his temp I recommended adding fluconazole 400 mg IV daily in case he had leak after his liver transplant. 

4-recommended stepping IV pip-tazo down to co-trimoxazole to treat a patient’s UTI. The cultures came back indicating E.coli that was sensitive to sulfa. 
Looking forward to my last week on the rotation and the final days of residency!!

On rounds today, I made a few recommendations for dose adjustments in a few of our patients as their kidney function was improving and the doses of their medications were now too low.  I also noticed that one of the patients didn’t get his ASA reordered post-op so I made sure to get that re-started as well.

On Wednesday this week we also had our Residency Presentation Night and it feels really good to have that done and over with.  It was a long day and my poster was one of the last ones to get evaluated but I got to get my presenation over with first which made the rest of the night much more relaxing.  Now all that’s left is to write up a manuscript and hopefully get our project published somewhere.  I’ve really enjoyed working on this project this past year.  It’s the first time I’ve been involved in a research project and while it was definitely a lot of work, I think I learned a lot throughout the process.  The feedback I received about our project on presentation night was all positive and everyone found our results pretty interesting which makes all of the effort worth it.  I have to give a giant thank you to my preceptors throughout the year- Penny Bring, Ruth Tsang and Karen Tulloch.  They have put an incredible amount of time into the project as well and helped me get through all of the edits, submissions, revisions, drafts, protocols, posters and presentations. 

So, only 3 weeks left until it’s all over.  Looking forward to the remainder of my SOT rotation and to life after residency.

Having only lived in Vancouver for just under 2 years, I have not had much experience in the downtown eastside (was told to stay away for the most part).  My experience at the MAT clinic provided me with an eye opening experience of life on that side of town.  Though I was only at the clinic for 3 days, it was definitely interesting to witness what goes on in this clinic.  The pharmacists/nurses/doctors/social workers working at this clinic have developed an amazing rapport with the clients  and have far more patience that I could ever hope to have.  I think the work they are doing at the clinic is very much needed just not sure if I could see myself doing it all day every day. 

Today I presented on a topic that has resurfaced lately in the HIV world with a warning from the FDA and Health Canada.  I reviewed the risk of QTc prolongation associated with the use of protease inhibitors.  The evidence that I was able to find is pretty inconclusive at this point but at the end of the day, PIs are a cornerstone in the treatment of HIV and will continue to be used.  I expressed that they might want to be cautious in patients with risk factors for QTc prolongation and patients already on medications known to prolong the QT interval. 

This afternoon, I will be spending some time on the distribution side of the ambulatory clinic.

I have to say that I knew/remembered basically nothing about HIV before starting this rotation but my preceptors have been very good at reviewing the medications and classes and what to monitor for each of them.  Though I will be far from an expert in this field at the end of this 3 week rotation, I think what I’ve been learning will help me manage HIV patients in an acute setting in terms of particular adverse effects to monitor for and ensuring therapy is not interupted during hospital stays.

Other then project stuff this week, my to do list including something that I should have done quite a while ago now but have just put off.  During my admin shadowing rotation, I was supposed to comment on the difference between management and leadership so here goes.

Management, in my opinion, deals more with ensuring things are getting done.  They’re goal is to assure various tasks and projects are completed appropriately (on time and under budget) and running the day to day activites.  They react to events as they unfold and have pre-set goals they strive to achieve.

Leadership, on the other hand, deals more with the people within an organization.  They motivate employees to work towards a vision and lay the framwork to achieve these visions.  They are proactive in their thinking and planning.  Leaders created an environment that encourages employees to want to come to work and work as part of a team.

One of my patients in the CCU, who has managed to pull through despite the odds stacked against her on a few occassions, had a run of A. fib yesterday.  They were able to get her heart rate under control with IV metoprolol but now the question about anticoagulation has been raised.  She unfortunately has a CHADS-2 score of 5 with a prior history of stroke but we are hesitant to start her on warfarin as she is quite fragile (she only weighs 36 kg) and has been tried on warfarin once in the past which was stopped for an unknown reason.  In this case, I think it’s best to provide the patient and her family with the risks and benefits of treatment and leave the decision up to them.  They have discussed her code status and the plan of care with the patient and family and comfort care seems to be their choice but she seems to be pulling through so who knows what could happen. 

We started discussing the management of dyslipidemia today but ran short on time so we will be continuing on that topic tomorrow.  The new guidelines are definitely much more simpler but dont’ really provide recommendations based on the evidence.  PL’s podcast from his undergrad lecture was a great review of the topic in preparation for the didactic session. 

Interview with SPH tomorrow then oral assessment on Thursday…

Still rounding in the CCU as well as following a few patients on 5A this week.  One of my patients on CCU was intubated and on levophed and seemed more like the patients I was seeing in the ICU on my last rotation.  He came in with rapid atrial flutter and most likely septic shock.  An ECHO revealed a massive thrombus (3x1cm) in his RV so shocking him was out of the question (though he had already been shocked numerous times before he was transfered to SPH.  He was a bit of a mystery but he was eventually transfered to the ICU for further management.  Turns out he had a pretty large PE, which was most likely the cause of his fever (>40 C at times). 

Need to prepare for our heart failure discussion tomorrow and finish up slides for the academic half day on stroke next week.  Busy, busy month.

Just finished rounding in the CCU, much more complicated patients then the ones on 5A.  I didn’t have much time to look at my patient this morning as he was new but I was able to pick out a few drug related issues for rounds and they actually took my recommendations.  The patient was admitted with worsening CHF and was put on hydralazine/nitrate combo.  He was on an ARB PTA but this was not started on admission, presumably because they were worried about his renal function.  The patient has known stage IV CKD and was on maintaining a fairly constant SCr.  My recommendation was to put him back on the ARB at a slightly lower dose and monitor his kidney function.  He was also re-started on his one-alpha that he was on PTA but for some reason he was also started on vitamin D 1000 units daily so they stopped this one as well. 

All in all, good times on cardiology so far.  Still loads of stuff to learn though.

1. To become more familiar with the evidence behind the guidelines and various recommendations.  I think this will come with practice as I work through each patient and through the various didactic sessions with I fan.

2. Focus on presenting patients in a clear and concise way in an effort to prepare for the upcoming oral assessment. 

We had our first topic review yesterday, covering STEMI- a big one in the cardiology world.  I fan worked through the information slowly and divided it up based on whether the patient received a lytic or went for primary PCI.  It was much easier to follow the information when you looked at one patient population at a time.