Tag: interdisciplinary

Cardiogenic Shock and Microteaching that Cuts like a Knife

Cardiogenic Shock and Microteaching that Cuts like a Knife

Rounds in a teaching hospital take different forms, but in addition to taking care of patients, the purpose is to demonstrate and learn.  Sometimes the experience is enthralling and truly enlightening, and sometimes it’s tedious and awkward.  The balance often depends on the approach of the attending.

After we walked around the hospital to see a few patients, we decided to head to the conference room to finish our rounds.  It hadn’t been a good morning.  Our attending had been critisizing the residents on their note-writing skills, unrealistic differential diagnoses, untimely completion of tasks, etc.  He was upset by a patient who took a downturn, later to find out he suspected it was his order for a beta-blocker that sent her into cardiogenic shock…worsened kidney function, ischemic bowel, respiratory failure, and so on.  I wish I could say this event was the only reason he cut the interns with such belittling precision, carving out descriptors like “apathetic” and “ignorant” across their foreheads, but it wasn’t.  This was his usual game, at least in the early days of each week-long tour on the inpatient service.  Usually by Thursday or Friday, he’d give himself permission to be gracious.

I have a pretty good relationship with this particular attending, at least that’s what he wants to believe.  No matter how much he protests, I’m older and more experienced at acute care internal medicine than him.  I don’t mean that I have all his knowledge (although I have the pharmacy-equivalent of training). I don’t pretend to be an expert in diagnosis or physical findings or significance of subjective evidence, but he pretends to be an expert in pharmacology, and on rare occasions he turns to me to confirm that his micro-teaching is correct.  It’s when he doesn’t defer to me, in those moments when he confuses his arrogance for competence, that he often relays inaccurate information. 

He explains to the team how on another patient because she stopped dialysis a month ago, her serum levels of digoxin increased causing her current bradycardia.  Well, actually, no, that’s not it.  Digoxin is not removed by dialysis.  That part of her history is unconnected.  Or how fentanyl is a partial opioid agonist, and that is the reason it’s not a good sedative in intubated elderly patients.  Sorry, it’s a pure agonist, and one doesn’t have anything to do with the other.

How am I supposed to correct these inaccuracies when it’s very possible that my forehead is next?  I imagine my carvings would be “insubordinate” and “irrelevant.”  Picking my battles and picking the right time is always key.  Today most certainly would not be the day.

Today was, in fact, the day.

While walking across the hospital out of the ICU, he offered his elbow to engage in a little Wizard of Oz reenactment, sans yellow brick road.  We talked. We discussed alternative etiologies to our dying patient.  We bonded a little, as he respected me enough to ask my opinion and consider my responses.  Truth is, he knows my strengths, those beyond the scope of the typical pharmacist, those that come with a love of learning and analyzing.  Training.  And experience.

I took that moment in the hallway, away from the others to engage in what I wanted to be an edifying conversation.  “Did you know that fentanyl is not a partial/mixed agonist?”  I continued, hoping that additional information might knock the misconception loose, “It doesn’t have a ceiling analgesic dose.  Partial agonists do.”

He listened, cocked his head, and murmured, “Why did I think that?  What was I thinking of?  Hmmm…”

Then his phone rang.  And that was the end of our micro-lesson.  

Rounds continued a few minutes later around a table. The brief moments of serenity and humanity in the hallway had dissipated.  The repetitive clicking of his pen as the intern presented a clunky assessment and plan for her patient further revealed the mercurial essence of this man.  He was waiting to wield his cutting words while distracting everyone from the intern’s presentation. At that moment, my heart dropped in disappointment at this display.  I think we were all done learning for the day. 

Poop Queen

Poop Queen

I didn’t see it coming , but poop has become a frequent focus in my career…and life.  Gastroenterologists and parents who change poopy diapers probably think the same thing or scoff at my confession, but I’ve unwittingly assumed it as a soapbox matter because there’s a hole in our understanding.

It probably all started back in residency when I rounded with a particular group of young doctors in the hospital.  The physicians in their first and second year of residency created a hazing-type of award called the “Golden Finger”.  A chart drawn on the white board outlined every intern’s name next to a series of columns that denoted certain procedures they regularly performed on patients.  They marked every procedure they squeezed out, but only one column resulted in a trophy, the digital rectal exam (DRE).  Also used for prostate exams, the DRE can be used to manually disimpact the poop chute of a constipated patient.  I doubt it’s pleasant for either patient or doctor.

On the other end of the pooping spectrum is diarrhea, and it can be bad.  In hospitals especially, the spread of Clostridium difficile (C. dif) is as feared as the plague or an impending ice storm, although an ice storm would smell better.  As a resident I presented an educational session over lunch to hospital staff about C. dif.  Antibiotics and stomach acid suppressants can sometimes be just as harmful as they are helpful and lead to outbreaks of C. dif colitis.  The poop is watery and it is frequent.  Washing hands with soap and water and bleaching surfaces are the best preventative measures against its spread.  The best treatment?  Fecal transplants.  It’s a thing.

There’s a fluffier side, albeit just as informative.  A little show called Scrubs immortalized the importance of poop in a song.  It’s not just the fact that the bowel moves or not, but it’s the condition and contents of the poop that expose your darkest secrets.

Runners talk a lot about poop.  There are port-a-potties available on running routes for that very reason.  While urination may be the primary goal for some—some runners just let that go—poop can’t be freely and inconspicuously dropped.  One needs privacy and a pot, or at least a hole.  One time I ate fettuccine alfredo the night before a long run.  I thought carb-loading would be beneficial.  What I didn’t count on was the effect of the deliciously creamy fat in my meal.  After my 8 miles the next morning, I almost did not clear the 15-minute drive home to release my belly angst.

Now it seems that much of my job as a clinical pharmacist is to teach the importance, methods, and mechanisms of keeping things flowing.  Here are a words of wisdom I float to young doctors and those wishing to become more proficient in the cathartic arts:

  • Drug-induced constipation is predictable, therefore, mostly preventable or at least manageable (i.e. if you prescribe a med that causes constipation, you should also prescribe a stool softener and/or laxative, lifestyle modifications/exercise, fiber, and water).
  • Constipation is much easier and less expensive to prevent than it is to treat (i.e. once constipation is present, you’ve already lost the battle; time to bring out the big, unpleasant guns).
  • If constipation has been going on for days, the best route to treat is from underneath (i.e. suppository or enema).
  • If you consult a gastroenterologist for constipation, they will almost always choose the most expensive (albeit, sometimes the most effective) treatment (i.e. potential wasted resources).
  • There are no real evidence-based guidelines for constipation. The patient population and causes of constipation are so heterogeneous (i.e. varied) that a one-size-fits-all approach (or saying one type of treatment is “ineffective”) does not work.
  • Common sense and experience go a long way. Start with your least expensive agents first.  Match the cause of the constipation with the mechanism of action of the bowel regimen.  Maximize doses, routes, and frequencies.  Then, move up the cost ladder.  Then, consult gastroenterology.

Many days my recommendations for bowel regimens pass like this:

“Mr. A is on Norco® PRN [as needed], but he’s taking it 3-4 times a day and has nothing ordered for his bowels.  Can we add docusate scheduled once daily at least?  And maybe senna PRN?  If our attending [physician] prefers Miralax, that’s okay, too.  Just need something scheduled.”

“I was checking Ms. B’s recorded bowel movements, and she’s had none for 5 days.  We started her on diltiazem for her a. fib, and that is known to cause constipation.  She’s also been taking TUMs.  Can we add some scheduled docusate and a one-time bisacodyl suppository?”

Although these seem like rather immaterial propositions and for a seemingly an innocuous illness like constipation, you wouldn’t want to wait until the patient gets a small bowel obstruction and has to be decompressed with a nasogastric tube or until we have to give a $150 one-time injection in hopes to get things moving…or better yet, put in for a gastroenterology consult.

Recommending bowel regimens is akin to a mother reminding a child to flush the toilet after use.  It seems like a minor thing in the hospital, especially when a patient is there for severe pneumonia or a myocardial infarction, but it’s a necessary thing.  Bowels don’t shut off just because there are more life-threatening matters at hand.

I have acquiesced to the fact that this will just be part of my job.  I review medications and look for missing pieces, offending pieces, interacting pieces, and so on.  Who better than me to be on the lookout?  They (the young doctors) know it, too, and I have been crowned the Poop Queen.  I will preside over my kingdom from my throne, if I must.

The Personality of a Hospital

The Personality of a Hospital

The first hospital I worked in after residency was an academic medical center.  It was a hospital located just outside the city limits of a major metropolis that held at least 10 large hospitals, ranging from community to research-oriented, teaching and non-teaching, university-affiliated and non-university affiliated.  There were other hospitals, too, small and medium, specialty, for veterans or native people, etc, etc.  The reason I make all of these distinctions?  They all have different feels, different personalities.  
Now, an academic (or university-affiliated) hospital typically employs a lot of teachers, researchers, and learners.  They teem with teams that are about the size of a junior varsity basketball team, many times clogging the hallways outside of patient rooms or crowded around a computer at the nurses’ station.  All are clamoring for understanding and knowledge of not only diseases and medicine but also of approaches and behaviors.  

I grew up in a small, rural town (population ~ 10,000) and never really knew if I would leave it, but as I progressed through my education, the collective ambition of my encouragers propelled me to see more than what my small town or state could offer.  Away I went to one of America’s 5 largest cities.  Of course there were cultural, economic, and atmospheric differences, but I was up to the challenge.  What does “up to the challenge” even mean, anyways?  Must one be successful at the challenge or just blissfully ignorant of the difficulties that lie ahead?

Aside from the personality of a city, I was excited for the bustling nature of a self-contained powerhouse that makes up an academic medical center.  I generally expected to be intimidated just by being there—not many people with an education have an inferiority complex, but I did.  I do.  There were commanding people, knowledgeable people, good teachers, condescending professionals, good attitudes, and bad attitudes.  This is everywhere though.  

My naiveté, that I would be embraced and utilized to the very limits of my professional knowledge, training, and expertise was quickly injured.  I didn’t give up, though.  I was told I’d have to prove myself, make myself an asset that they would soon see they could not live without.  The thing about academic medical centers, knowledge and expertise are commonplace.  I was commonplace.  I was disposable.  I was also young and not as experienced.  It showed, I’m sure.  The truth was that what I offered wasn’t appreciated, to put it politely. 

Perhaps I could win on a social level.  I learned and begrudgingly accepted that it’s not really what you know; it’s who you know.  And it’s not what you say, it’s how you say it.  I chose to say it with donut holes.  That worked for the few hours we were in rounds and maybe for a few precious minutes when I had to page the resident later to give a recommendation on a patient, but it was fleeting.

Every day when I ventured across the hospital to a meeting, to the cafeteria for lunch, or to the coffee stand for an afternoon break, I’d cross paths with the physicians I’d rounded with that morning.  My hopeful eyes would search for contact, I’d prepare my smile and turn my head slightly in their direction…but nothing.  No acknowledgement.  We’d be the only two people in the hallway for 40 or 50 feet, and their eyes that were once straight ahead, searched the floor.  I clearly had done something wrong, I hadn’t charmed them, hadn’t impressed them with my expertise.  My clothes weren’t fancy enough, my sense of humor wasn’t funny enough, I wasn’t pretty enough. 

It took me a long time to figure it out.  Some of my colleagues were more successful at crossing the invisible line.  They had traits that were deemed more attractive or at least local.  I was an alien.  I didn’t belong.  I began to accept it.  At some point I became more confident in my professional abilities and started not to care as much.  I had surpassed the limits of knowledge and had gained experience that none of the residents and many of the attending physicians had.  I vacillated between bitterness and graciousness when considering their snubbing of me.      

Alas, the time had come for me to move on.  Things always have a way of working out for me at the right time, after a lesson has been learned or the next situation has been readied.  After a small, but very meaningful pit stop, my home started calling.  A job back in my home state, the only position I would have accepted, came open.  It was time for a new personality.

The new hospital I went to had a simple rule for its employees:  Make eye contact and say ‘hello’.  I was no longer an alien.  Everyone smiles and is helpful.  It’s not a large, academic medical center, but it is a teaching hospital.  I don’t have to bribe people with sugar anymore.  In fact the food I brought in the early days didn’t impress anyone, but I didn’t need it to attain a level of respect and acceptance.  Acceptance both as a professional and as a person came simply because I was there, doing my job.  I won’t discount my earlier job because it did teach me.  It provided me an invaluable experience.      

Comparing and contrasting the two hospitals is a ready-made tale of the golden rule and loving your neighbor.  Both hospitals are affiliated with the same religious order—both have a motto that implores its professionals to heal and to treat others, both their body and spirit, as Jesus did.  I laugh at the torture I endured, tearing myself apart and doubting my abilities, my personality, and my looks, when it wasn’t my personality that needed inspection.  

The personality of a hospital has many influencers–the people, the administration, the culture of the surrounding people.  My personality was influenced by the first hospital, and my life suffered.  I had to learn to be myself again and what God intended for me, and eventually, the right hospital found me.