Pharmacist in the ED

[njac]

How many of you have worked/interned/rotated through a place with a pharmacist in the ED?

Where I work we have a pharmacist down there every day from 1500-0130. They're ACLS certified so they help with traumas and codes.

If you've worked with one, what were your thoughts as a physician? The EM literature at the moment is very supportive of pharmacists in the ED.

At the moment my interests are headed that direction and I'd like to get feedback from those writing the orders...

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[dchristismi]

I love it. I just started my first attending job, and having them right across the counter is invaluable - even if it's just to doublecheck something (peds esp) - is really, really nice. I've run a couple of major rescus here so far, and being able to yell for whatever I want and know that a pharmacist is managing it is really nice.

My residency program had just implemented them a month or two before I left, and again, they seemed to be a huge asset. In one instance, a colleage was starting amio, and the pharmacist (who was far more anal than we) sat there making sure that at just the right time, the bolus became a drip.

Overall, I'd like to think that it decreases errors, but I don't know that for sure. But so far, I appreciate their addition to the team.

 

[HNS]

I think that any assistance is great. In the ED we are always making quick decisions. If we make a mistake or are unclear on the proper dosing/interaction, the pharmacist being there is invaluable.

 

[Seaglass]

During residency we had them 24 hours a day, they were awesome - worth their weight in gold.

 

[AmoryBlaine]

I have so far worked with clinical pharmacists in the ICU, on the floor, and in the ED. I have yet to meet one that did not contribute meaningfully and copiously to patient care.

Think of all the **** we have to keep in our heads, while the pharmacist focuses on drugs. I mean this as a complete compliment to them. Hell in the ICU when someone said "what day of Zosyn is this?" everyone just looked over towards our awesome pill-pusher and he always knew. With polypharmacy becoming the rule rather than the exception one could argue that pharmacists are a near necessity.

One thing I cannot get behind (w/o seeing it in action) is PharmD participation in codes/traumas. At almost every institution there are about 3x more people in the room than need to be there for any sort of remotely critical patient. Adding another cook to the kitchen -- not my idea of a good idea.

 

[njac]

Good, I'm glad to see your perspectives are in line with what I've seen elsewhere.

My current interests are ICU or ED. I'm happy to see my superiors have made a good impression on this generation of doctors.

AB - on the polypharmacy issue I almost feel that internal medicine/gen surg is where pharmacists may be needed the most. So many comorbidities and home meds (vs ICU where sometimes home meds can be d/c'd in the interim) etc etc. But you're right especially on the abx, days of therapy etc. On my internal med rotation I found several patients who were put on empiric abx 10-14 days ago and when I questioned if they were still needed (private hospital with hospitalist + cards + nephrology, etc) each doc on the case assumed someone else was going to d/c it. Sometimes having a consistent person looking over all the meds everyday can catch stuff like that. Or remember to renally dose things as kidney function declines, etc.

And you certainly have a point about codes. I have seen the chaos at times. That may depend on the institution or severity or who knows. But I agree that too many people causes unnecessary additional chaos and I've witnessed it interfering with patient care (with a very bad outcome)

 

[WakeDoc]

The pharmacist in the codes are actually great. They are like a walking epocrates. Really, how many know the procainamide dose off hand for refract arrhythmias or WPW? Not me, but pharmacy does. This really speeds up stuff happening, and happening correctly, in code situations. For example, 2 nights ago a level I trauma came in...called in (or so we thought) as a 17 year old MVC w/ head injury. Whoops, its actually a 17 month old. While I was scrambling to get the peds airway stuff out (guessing at tube size and blade size mind you), the pharmacist was getting my 5 RSI drugs ready based on my estimated weight. He was a lifesaver. Given that we were expecting an adult trauma, nobody was in peds intubation mode, so everybody but one person forgot atropine. Yep, you guessed it, the pharmacist remembered. It is great to have one person in charge of thinking about dosing of drugs in critical situations where maybe you are busy w/ airway, lines, etc. We are a busy level I center, so don't always have 3 residents in on a code, it might just be you and the RNs, so its a great help to have that pharmD there w/ his drugs, no accudose / RN to slow you down.

 

[McDoc]

I'm at a busy level 1 and the pharmacist is a key player in all of our codes. They push all the drugs. The RN is busy getting the patient on the monitor, establishing a second line whatever. Our pharmacists even do chest compressions when needed. When I am running the codes I really notice if they aren't there.

They also help with all the ordinary stuff like pointing out allergies if missed, reminding us when it is time for a repeat antibiotic dose (we have long boarding times), and knowing what is and isn't on formulary. Great asset to have in the ED.

 

[njac]

so I'm bumping my own thread from a year ago. Still interested in opinions.

I complete my PGY-1 residency the end of June and am planning on pursuing specialized training in EM. Unless the best job in the world were to show up with a ribbon on top.

I am doing my residency at a teaching hospital that does not have an EM Medical Residency. I have found a completely different environment down in the ED compared to where I went to school/worked before. I shouldn't judge too much yet (I've only been down for traumas, and been told this repeatedly) and I start down there for 4 weeks on Monday, but the overall impression is that they really don't care for pharmacy's input and would rather we just stayed away. I'm not sure how much of this is due to the fact that 2/3 of the attendings down there are FM and not board-certified EM.

Regardless, at this point it has guided me to look for positions only at hospitals with an EM program. How do those of you in community practice feel about the pharmacist? There are a couple specialty residencies available that are at community hospitals, but I'm not sure if it's worth my time and effort if I'm going to spend a year getting ignored.

 

[Apollyon]

My individual professional opinion is that any doctor that would reject the advice and assistance of a fellow professional without a separate agenda is a fool. If they themselves are telling you to stay away, do that, and also don't go there with your ill family or friends.

I don't know how many times the pharmacist when I was a resident or at my last job helped me out - it's like having a gunsmith inside the police station. We're dealing with your specialty. It's a no-brainer.

As it is now, I have to remember to remind patients on OCPs to use a different method while on antibiotics. I have to recall not to write for tetracyclines in 10 year old kids so I don't stain their teeth. There's a host of other things that are now added to my plate, not having the pharmacist there.

 

[southerndoc]

We had a pharmacist in the ED during residency. Well, she was assigned to the ED, but didn't work clinically. She was there more for operations stuff (making sure the med recon form was completed, assessing treatment protocols, acting as an ED advocate during the pharmacy P&T meetings, reviewing medication errors, etc.).

 

[roja]

just started this where I am.

I think its great.

 

[Jeff698]

I'd be more than happy to have a pharmD with us in my community department.

We use MedHost for our order entry and it has a WAY over sensitive drug interaction checker. It'll tell me that there is an interaction between two agents but won't tell me what it actually is. It doesn't understand clinical context and certainly can't suggest alternatives. All of which a real pharmacist could do.

Take care,
Jeff

BTW, as big a proponent as I am of EM training for EPs, I doubt this has much to do with the reaction you noticed. I suspect there are docs who are overfull of themselves and their abilities in every specialty.

 

[Arcan57]

Loved having a PharmD in residency, very useful mammals. As an attending in the community, we just added one but their role is less defined. Mostly they've been useful for getting drips quickly (since our nurses are not allowed to make drips).

 

[Arcan57]

Loved having a PharmD in residency, very useful mammals. As an attending in the community, we just added one but their role is less defined. Mostly they've been useful for getting drips quickly (since our nurses are not allowed to make drips).

 

[njac]

Bumping my own thread again. Because I'm awesome like that.

So now I'm more than halfway done that Emergency Medicine specialty residency. Whose department needs one? (sort of kidding. I have a couple options, but you never know what else is out there...)

The pharmacy organizations are really pushing for adding pharmacists to the ED, is that what you all are seeing out there?

 

[Groove]

Bumping my own thread again. Because I'm awesome like that.

So now I'm more than halfway done that Emergency Medicine specialty residency. Whose department needs one? (sort of kidding. I have a couple options, but you never know what else is out there...)

The pharmacy organizations are really pushing for adding pharmacists to the ED, is that what you all are seeing out there?

One of my good friends is a PharmD in an ED and enjoys it from what I hear. We have one in our institution and I can't imagine not having her around in the ED. Invaluable resource.

 

[Greenbbs]

we started with a pharmacist in the ED and i honestly don't know what I'd do without her being there. it's made a world of difference with doing things, as she's gotten to know all of our styles and can readily anticipate what we're doing and what drugs we need. she's actively worked on our sepsis protocols to ensure that drugs are given in a timely fashion, and her usefulness during codes is unbelievable.

it's like our scribes. can't imagine going back to a time without em.

 

[wook]

I've worked at several institutions where they had pharmacists in the ED, and think they are a great part of the team. If I had my druthers, I'd love to have one in my ED all the time.


Thanks.



Wook

 

[KYTNOH]

We usually have two in our ED during the day. One is an attending and there's a resident, either a PGYI doing a clinical pharmacy residency or a PGYII doing an additional year as an Emergency Medicine Pharmacy Resident. I love having them around, especially with antibiotic choices. They are able to provide suggestions on optimal coverage and dosing schedules. They also go ahead and put in all orders needed to follow levels (phenytoin, vanc, etc) once they go inpatient. They draw up all of our meds for codes and RSI as well as mix pressors and other drips at the bedside. One of the best things they do is follow up on ALL of the cultures we obtain in the ED and make sure that whatever antibiotic choice we made will cover it once sensitivities are returned.