The Elective Rotation: A Critical Care Hospital Pharmacy Podcast

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The Elective Rotation: A Critical Care Hospital Pharmacy Podcast episodes

August 20, 2015 9: How to talk like a physician and get a physician to listen like a pharmacist verbal communication tips for hospital pharmacists
Show notes at pharmacyjoe.com/episode9. In this episode I’ll discuss how I trained myself to have successful verbal communications with physicians and get my interventions accepted.
14 min
August 20, 2015 9: How To Talk Like A Physician And Get A Physician To Listen Like A Pharmacist - Critical Care Pharmacy Podcast

Today I’m going to pull the curtain back and show you how I trained myself to have successful verbal communications with physicians and get my interventions accepted.

I’ll go over:

* Expected acceptance rates
* First impressions of your conversation
* Planning out your conversation
* What to do when the physician comes to you with a question

Having the right idea on how to care for a patient is only half of the equation.

The way the hospital system is set up, there is one person with the absolute authority to make a decision for the patient: The physician.
As a pharmacist you have unique and expert knowledge in areas that the physician may not.
You may have the best idea in the world for the patient, but in order to make it happen you must convince the physician that it is the best idea. If you don’t communicate your idea well, it may not be accepted.
Recommendation acceptance rate
What should your acceptance rate be? Published data suggests it should be 90% or higher.
92-97%
90%
92%
99%
First impressions are everything
But how do you start off on the right foot when presenting a recommendation?
Get inside the mind of the physician and pay attention to how they think about patients.
Physicians approach patients in a problem-based manner
They are used to case studies and history & physicals.
They may or may not know a patient by name yet - especially if they haven’t seen them yet.
They see many patients (over 20) in a day and may have been in the middle of thinking about a different patient when you talk to them.
The first thing you must do to successfully communicate an idea about a patient to a physician is get the physician to remember/think about the patient!
Here are two different examples:
Incorrect:
I want to talk to you about Jane Doe’s dose of lovenox.
Correct:
I want to talk to you about Jane Doe, the 55 year old female you just admitted with a pulmonary embolism and are treating with lovenox.
Planning out the conversation
Have you ever found yourself stumbling through a conversation with a physician?
You know you are right but are having trouble phrasing to the physician the problem.
14 min
August 17, 2015 8: Empiric antibiotic selection in the adult medical ICU
Show notes at pharmacyjoe.com/episode8. In this episode I’ll discuss empiric antibiotic selection in the adult medical ICU.
14 min
August 17, 2015 8: Empiric Antibiotic Selection in the ICU - Critical Care Pharmacy Podcast

So much of antibiotic selection has to do with local resistance patterns and it cannot be protocolized or generalized without that knowledge.
That said I believe there are some principles of antibiotic selection in the ICU that are worth discussing in general terms. A big shout out to Pharmacist Sokhak & Physician Mary for suggesting this topic. If you would like to suggest a topic for the show please do so here.
Today we will talk about:

* Source identification and control
* Knowing the antibiotic spectrum of activity
* Selecting empiric therapy against likely pathogens
* Renal dose adjustment of initial empiric therapy

Source identification and control
Source identification is generally taken care of by my docs and it is very rare that I find myself adding to the care of the patient in this area. The easy things to look for are:
- Blood cultures
- Urinalysis (>20 WBC/HPF)
- Chest X-Ray (infiltrate)
- Physical exam (belly, skin wound, etc)
Cold steel and the light of day cured many a disease. - William Conway

Your antibiotics aren't going to do much if source control is not obtained. Know the patient management priority and if source control cannot be achieved due to a problem you can help fix - focus on that!
Blood cultures before antibiotics (when possible)
You can blow your nose and clean your glasses with the same tissue, but you better do it in the right order.

Advocate for blood cultures prior to antibiotics, but don't withhold the antibiotics if it looks like blood cultures will not be readily obtained. Surviving Sepsis guidelines recommend no more than a 45 minute delay in antibiotics for the purpose of obtaining blood cultures first.
The rare case where you would run into trouble here is giving antibiotics prior to cultures in a patient that turns out to have endocarditis. If their cultures come back negative because of this they may need 6 weeks of broad spectrum therapy - yikes!
You'll never forget what to look for as far as source identification after watching this video:

Knowing the antibiotic spectrum of activity
I've found it is much easier to learn the rules and then learn the exceptions to the rules when it comes to knowing what drugs cover what bugs.
This section will not be comprehensive but will focus on classes of antibiotics likely to be used as empiric therapy. I encourage you to get information on dosing, mechanism of action, etc... elsewhere. I suggest
14 min
August 13, 2015 7: Seven tips on How to stay current with medical literature - Critical Care Hospital Pharmacy Podcast

Here are my 7 tips for how to stay current with medical literature:
Pharmacist's Letter / Prescriber's Letter
I've been a subscriber to Pharmacist's Letter for over 12 years. They are an unbiased source of current information about new medications and new uses for old medications. Their monthly newsletter is concise and to the point and you can drill deep on their website for more in-depth content. For physicians they create the Prescriber's Letter.
Pubmed alerts on saved searches
I use pubmed alerts to send me daily emails for medications I want immediate knowledge of new developments. Don't overdo this or you will overwhelm yourself. My current searches are for:
1. Dexmedetomidine (to stay on top of new developments)
2. Procalcitonin (still waiting to figure out the best way to use this lab test - it is a "send out" at my institution)
3. Clevidipine (to predict another formulary request)
4. Fospropofol (to predict another formulary request)
Check out this tutorial I made on how to set up a pubmed email alert (you first need to sign up for a free account on pubmed):

Electronic delivery of journal table of contents
You can sign up for electronic table of contents delivery at most journal websites. Don't overwhelm yourself here - stick to a handful of journals (I pick 2).
Utilize your medical librarian
Shout out to Tammy my Medical Librarian - she is an amazing resource! Tammy photocopies and emails me other journal table of contents. Also she sends me articles and news links of interest based on our previous conversations - Wow!
Listen to a podcast
The EMCrit Podcast is my favorite listen right now - what are yours?
Discuss new articles with other healthcare providers
When I find an article that I think would interest a physician colleague of mine - I share it with them. Guess what? They are constantly sharing new articles with me!
Run a journal club
All participants (pharmacists and students) should benefit from attendance at journal club.
Students benefit from learning how to place clinical trial results into the context of clinical practice.
Pharmacists & other Health Care Providers benefit from being exposed to high quality articles they may not have otherwise encountered.
Sign up below to get a free copy of how I structure journal club:

Journal Club Guidelines
8 min
August 13, 2015 7: 7 tips on how to stay current with medical literature
Show notes at pharmacyjoe.com/episode7 In this episode I’ll discuss my 7 tips for how to stay current with medical literature.
8 min
August 11, 2015 6: Alternatives To Phentolamine For Vasopressor Extravasation - Critical Care Hospital Pharmacy Podcast

11/4/15 Update: Phentolamine is available again!
The rest of the post is un-edited, but check with your purchaser to see if you can get phentolamine now.
Another one bites the dust.

Phentolamine is no longer manufactured
Phentolamine has now made ASHP's list of drugs no longer available.
This information is critical to communicate to emergency medicine and critical care practitioners, as the risk:benefit of peripheral vasopressor therapy changes without the availability of this extravasation antidote.
This doesn't change my any port in a storm philosophy of peripheral vasopressor use, but it will make me advocate for the placement of a central line sooner in patients where I see peripheral vasopressor use continuing for more than a few hours.
The alternatives to phentolamine for extravasation from phenylephrine, norepinephrine, epinephrine, dopamine, and dobutamine are:

* Apply heat proximal to site of extravasation.
* Elevation of the site of extravasation.
* Topical nitroglycerin 2%, apply a 1-inch strip to the site of ischemia q8 hrs prn; monitor for hypotension.
* Dilute 1 mg terbutaline in 10 ml NS. Inject locally across symptomatic sites.

The alternatives to phentolamine for extravasation from vasopressin and methylene blue are:

* Apply heat proximal to site of extravasation.
* Elevation of the site of extravasation.
* Topical nitroglycerin 2%, apply a 1-inch strip to the site of ischemia q8 hrs prn; monitor for hypotension.

The alternatives to phentolamine for extravasation from epinephrine autoinjector are:

* Watchful waiting.
* Topical nitroglycerin 2%, apply a 1-inch strip to the site of ischemia q8 hrs prn; monitor for hypotension.
* Dilute 0.5 to 1 mg terbutaline in 1 ml NS. Inject locally across symptomatic sites (it is usually the finger).

Resources:
Excellent review of extravasation from non-cytotoxic drugs
Use of subcutaneous terbutaline to reverse peripheral ischemia

If you like this post, check out my book -
5 min
August 11, 2015 6: Alternatives to phentolamine for vasopressor extravasation
Show notes at pharmacyjoe.com/episode6 In this episode I’ll discuss alternatives to phentolamine.
5 min
August 10, 2015 5: Vasopressors In Shock – A Review for PGY-1 Pharmacy Residents Critical Care Hospital Pharmacy Podcast

In this episode I'll review the vasopressors norepinephrine, vasopressin, epinephrine, dopamine, and phenylephrine.
Fluids, vasopressors, and inotropes are the essential parts of the treatment of shock.
Shock is the syndrome that results when the cardiovascular system fails to maintain adequate tissue perfusion.
The immediate treatment goal for shock is to maintain hemodynamics while the cause can be addressed.
For more details, find my favorite review of vasoactive drugs in shock here.
Before I dive into discussing each vasopressor, I'll talk dosing and administration.
Starting dose
My starting rate always depends on how close the patient is to death. If they are in extremis I will start at the maximum rate and titrate down. If they are stable then I will start at the bottom and work up.
Maximum dose
Maximum doses vary greatly between institutions. It is likely that your hospital has arbitrarily set a maximum dose for each vasopressor.
I wouldn't get too hung up on it as long as there is agreement across disciplines on your institutional max. Maximum doses were invented to be exceeded, so don't be shocked when your doc squeezes the IV bag in while trying to stabilize that young OD patient long enough for ECMO to be started.
Peripheral vs. central line
Any port in a storm.
Let's be realistic. Many patients would suffer organ damage from profound hypotension if you waited for a central line to be placed to give them vasopressors.
If you are using vasopressors in a peripheral line, you should choose a small bore in the largest vein possible. If the need for vasopressors persists, a central line should be placed ASAP.
In a Cochrane review the average infusion duration that resulted in complications was 55 hours. This is especially important given the phentolamine shortage. I wouldn't count on phentolamine alternatives (terbutaline and topical nitro paste) if I were you.
Norepineprine
If you were going to choose one vasopressor to start first in shock of essentially any etiology, norepinephrine would be the one to choose. Sepsis guidelines say to use this first,
10 min
August 10, 2015 5: Vasopressors in shock A review for PGY-1 pharmacy residents
Show notes at pharmacyjoe.com/episode5. In this episode I’ll review the vasopressors norepinephrine, vasopressin, epinephrine, dopamine, and phenylephrine.
10 min

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