Room to grow

Sarah Wheeler, on rotation. (Photo by Dan Smith, NCH)

I was both thrilled and daunted to discover my first APPE rotation would be in the emergency department (ED) at Nationwide Children’s Hospital. Emergency medicine pharmacy was my number one specialty of interest entering my final year of school, but with a lack of prior hospital experience, and years since my last significant interaction with children, I knew I was facing a huge learning curve.

One of the first lessons I learned on my rotation was that pediatric pharmacy is unique because the patients aren’t simply smaller versions of adult patients. On one of my first days, I was alarmed by the heart rate of an infant in the mid-100s, thinking she must be distressed. However, I quickly learned that many vital signs have different norms in pediatric patients that fluctuate as they develop. 

Likewise, the way pediatric patients process medications is vastly different than adults. Human growth is non-linear; therefore, distribution, metabolism, and elimination of drugs for pediatric patients are unique, making it important to use age-specific dosing or specialized pediatric formulas for calculating pharmacokinetics. Finally, dosage form is an important consideration for pediatric patients. Most young children are unable to swallow tablets, so taste must be accounted for with any liquids they are prescribed. Occasionally, patients need medications that do not come in kid-friendly dosage forms, which requires compounded medications to meet their needs. 

Ready for anything 

When thinking about an ED, most people envision crisis—code blues or traumas, non-stop action, and possible tragedy. While all of these things happen, “every day is different” is  a more accurate description. 

The ED sees patients with a full range of complaints: from ear infections and rashes to life-threatening infections or injuries. It is important to have familiarity with a wide range of disease states because you are responsible for starting appropriate care prior to patient discharge or hospital admission. I spent a lot of time learning about new disease states, including rare genetic diseases that were not taught during pharmacy school. 

Occasionally, I had to adapt to treating an adult patient with a chronic pediatric disease like Cystic Fibrosis. It was important to be flexible, to know a little bit about a lot of things, to know where to search for answers when I didn’t have them, and to be willing to learn. 

The ED had an ebb and flow of patients each day, and in slow times, I would work on projects or read articles for topic discussions. Other times I would spend hours on back-to-back critical care situations, preparing bedside medications. I learned to stay calm and collected in these situations, as each medication had to be individually prepared as a weight-based dose and stat. Most days were balanced with critical care and less emergent duties, such as providing medication recommendations to the resident physicians. 

There were always problems to solve, ranging from avoiding drug interactions to working through drug shortages, and each day was unique in the challenges it provided. 

Pass it on 

I emerged from my first rotation with a solid foundation of emergency pediatric care, and I could not have done so without the guidance of my preceptor and the pharmacy team. My preceptor demonstrated to me that as a pharmacist, I will not only be engaged in lifelong learning in an ever-changing environment that demands I stay up-to- date and informed, but that I should engage in lifelong teaching. 

On my last week on rotation, an IPPE student joined our team in the ED, and we were participating in a mock trauma session. Inspired by my preceptors and eager to pass on the knowledge I had gained, I walked the student through the pharmacist’s role in the trauma and engaged him in helping prepare the medications. 

Although I was initially intimidated, I grew confidence in both pediatric and critical care. The wide range of problems I encountered prepared me well for my APPE rotations that followed, but I know that in emergency medicine there will always be room to grow. Seeing the impact pharmacists can make  helped fuel my passion for emergency medicine and solidify my desire to pursue residency next year. 

Sarah Wheeler is a final-year PharmD candidate at The Ohio State University College of Pharmacy and Chair of the 2017–18 APhA–ASP Awards Standing Committee.