Throughout my residency and especially, as I approach the next step in my career of being a full-fledged clinical pharmacist, this is a question that I find myself thinking about more and more…And for me, the answer is rooted in a saying that I frequently heard in 2nd year lab from Colleen – which is to be comfortable being uncomfortable.
Commitment to the profession is synonymous to being committed to growth. And committing to continually self-reflecting and challenging myself to be a better clinician tomorrow than I was today will be bumpy, uncomfortable but undoubtedly rewarding. At the end of my residency, I can probably write out lists of things that I still don’t know and areas that I need to improve in…and it’s going to be easy for me to feel overwhelmed by the steep learning curve ahead of me. To avoid this, I will need to frequently remind myself to break things down into little steps, to not be deterred by future setbacks, to connect with other pharmacists for support and advice, and to actively put myself in situations that will support my growth as a clinical pharmacist.
How I will strive to commit to my profession in the next year:
- Self-reflecting. Each time I encounter a setback or achieved an objective I have set, I will document and reflect on the situation. What did I do well? What could I have done better? So what? What now? How could I work to improve on this (e.g. efficiency)? What goals should I set and when should I hold myself accountable to them?
- Learning, Discussing, Teaching. The beauty of residency – and one of the many reasons, if presented with the choice again, I will always choose to do residency – is that it provides both the luxury of time and support to learn, discuss and ultimately teach yourself by applying your knowledge to real patients. When practicing on my own, I will work to train myself to continue to be an active learner…whether that may be by, re-visiting trials I have forgotten, critically appraising evidence and assessing how it applies to my practice, teaching myself and others about different topics.
- Broadening the scope of pharmacy. My commitment to the profession should not be limited to just the hours I have been scheduled to work. While this will be difficult to do in the next year, I will aim to become more involved in different aspects of pharmacy…for example, by regularly applying physical assessment skills, being more involved in CSHP and strengthening my teaching and precepting skills.
Lastly, I’ll end my post with a Pixar short that I found utterly adorable and very relatable during my year of residency:
Last presentation in residency! My topic was on Sodium Polystyrene Sulfonate and the evidence surrounding its efficacy and safety. This topic came from one of the emergency medicine doctors who was concerned with its use in emergency due to its association with intestinal necrosis and the limited evidence surrounding its efficacy. My presentation can be found here: KayexalatePresentation_May2017
Areas of improvement:
- With the help of my preceptor, I was able to improve on and work on the flow of my presentation. Some things for me to keep in mind for future presentations are to: step away from my presentation and assess if the flow would make sense for someone listening to the presentation for the first time, as well as, make sure that the evidence ties in with my approach, recommendations and summary at the end.
- Initially, my presentation was very content-heavy. It is important to regularly ask myself what I want my audience to take away from the presentation and limit any extraneous information. As discussed with my preceptor, keeping my presentation clear and concise will help reduce any pressure to speak fast. See next point.
- Keeping myself at an easy to follow pace and loud volume has been a continuous work in progress. I wish I could say that I have succeeded in doing so at the end of residency as this has been my goal for every presentation…I feel like I definitely improved on my pace in the first half of my presentation but started going faster in the second half. Hopefully, one day! I will try to embrace any opportunity to do presentations or public speaking post-residency and continue to work on pacing myself and speaking in a loud and clear voice.
- Especially when going over content-heavy slides (e.g. trials, literature review), emphasizing and bringing home key points both visually and verbally will help keep my audience engaged. I will avoid reciting information off the slide and work on highllighting key points and summarizing them concisely.
Last rotation of residency! It is absolutely crazy how time has flown this past year. I am super excited for emergency, but am also nervous about whether I would be able to handle things “on the fly”.
My learning objectives are:
- Apply my knowledge from sodium/fluid balance to appropriate patients
- Have a systematic approach to addressing hyponatremia and hypernatremia
- Describe and build a systematic approach to Advanced Cardiac Life Support, Stroke, Toxicology and/or other commonly seen conditions in the ER
- Perform at least 2 physical assessments per week and interpret my findings to my preceptor
- Consistently state patient-specific goals of therapy when discussing my patients to my preceptor
- Overall, continuing to build my thought process and approach so that I am able to efficiently triage and work up patients in the ER setting
- Aim to have less reliance on paper and be more proactive to address issues in a timely manner
- Improve on ability to concisely document in a timely manner
- Speak at an easy to follow pace and volume for my presentation
I really enjoyed this rotation at SPH and learned so much from Linda and the rest of the team on how to manage total parenteral nutrition. During this week, the team also had a new gastroenterology fellow and dietitian intern starting and it was a nice experience to be learning and working together with them!
With the help of Linda, I was able to build on a systematic approach to working up and assessing patients for TPN:
- Identify if there is an indication to TPN
- Surgery progress notes/reports (e.g. length of bowel resected) and imaging often provide the indication for TPN (e.g. anastomotic leak)
- Generally don’t give “pre-operative TPN”, but there are exceptions to this (e.g. had a patient who lost ~20kg over the last yr and surgery wanted pre-op TPN for malnutrition)
- This will also help you identify how to assess when your patient should be off TPN!
- Generally ideally would like to see pts tolerate solid foods for 24 hours prior to coming off TPN…generally TPN → PO intake and if can’t tolerate PO → EN (unless in ICU, generally don’t go from TPN → EN)
- If TPN indicated, assess the risk for refeeding syndrome and nutrition status
- Information gathering:
- current weight (assess fluid status → is this a dry or wet weight?)
- Calculate BMI, IBW and do adjBW if overweight
- usual weight at home
- weight change
- nutrition status
- intake during hospital admission
- intake prior to hospital admission
- signs of muscle wasting
- hx of organ failure (kidney, liver, cardiac)
- IV maintenance fluids and replacement fluids
- Provides you an idea of their volume status, tolerance to fluids and need for electrolyte replacements
- Check how long they have been on it and whether they have been any recent rate changes
- IV access
- Inputs and outputs
- Consider what patient is losing (e.g. diarrhea, vomiting, NG suction output, stoma output, urine output) + insensible losses
- Diarrhea → lose bicarb, sodium, chloride
- Vomiting → lose chloride
- Electrolytes → should get a baseline Mg and PO4 prior to starting TPN
- Order any electrolyte replacement orders
- TPN changes and starts tonight (reach the wards from VGH at 1830h)
- Electrolyte replacements would be given prior to TPN start
General monitoring parameters:
- Main Labs: Na, K, Ca, Phos, Mg, urea, sCr, glucose
- Other labs: bicarb, Cl, alb, prealbumin, LFTs
- Weights today and then q Mon + Th
- Ins and outs
- Can choose to order strict ins and outs – good to specify if want to record PO intake even if you specify “strict”
- If no ins and outs → checking with patient to get a sense of that (e.g. frequency and volume of diarrhea, vomiting, etc.)
- Calorie counts if progressing with diet
- Plan with diet (decided by surgery)
- Plan with surgery
- s/s associated with indication for TPN → e.g. vomiting, presence of gas, abdominal discomfort, tolerance to PO intake
- when changing orders, write delta signs to any change (helps pharmacy identify if there are any unintended mistakes)
I will be heading to St. Paul’s Hospital for a week of TPN! From our recent ADS on TPN, I’m expecting that this will be a very valuable, rewarding and challenging rotation. The following are my learning objectives:
- Competently evaluate the nutritional status of a patient. Determine the appropriate form of nutrition and set monitoring parameters to help determine when it is:
(1) no longer necessary, or
(2) appropriate to taper off TPN and transition to PO intake
(3) appropriate to taper off TPN and transition to EN
- Describe the available formulations and their differences/similarities.
- Competently and safely order electrolyte replacements for patients on TPN, and create an appropriate monitoring plan for them
- Describe how to approach TPN in patients with metabolic disorders (e.g. metabolic alkalosis, metabolic acidosis)
- Describe the different delivery methods and determine which is most appropriate in a given patient
- Describe commonly used equations and calculators and understand when and how to use them
- Describe the role of pharmacists in managing TPN
The following are the rotation manual’s learning objectives:
- Evaluate the nutritional status of a given patient.
- Determine the most appropriate form of the nutrition support required, if any.
- Estimate protein and caloric requirements of a patient based on the disease state.
- Design a suitable parenteral nutrition formulation for a given patient, allowing for compounding limitations of the pharmacy department, and medical conditions of the patient.
- Monitor nutrition support for potential metabolic, infectious, or technical complications, and recommend appropriate TPN formula adjustments to better meet nutritional needs or to prevent adverse effects.
- Identify altered nutrient requirements due to concomitant medications or drug-nutrient interactions.
- Demonstrate competence in discussing the pathophysiology, clinical features, and management of the following disease states/processes:
- Protein-energy malnutrition
- Refeeding syndrome
- Overfeeding from parenteral nutrition
During my ambulatory cardiology rotation, I presented on two topics to the interprofessional teams at JPOSC.
#1: Journal Club: FOURIER_Evolocumab (2017)
For this journal club, I had created brief summaries of relevant trials and a supplementary appendix at the end. Some things that I could improve on is having a more in-depth discussion comparing the different statin doses in other trials, and making more references to the appendix as necessary. My pace was quite fast for some of my audience members and for my future presentations, I will aim to slow my pace down and check in about my pace and volume with my audience. It was great to have other health care professionals at the journal club and to learn how this study was relevant to their practice.
#2: Beta-blockers and COPD
I really enjoyed working on this presentation as it was based on a question from a RN during one of the cardiac clinic appointments and seems to be a question that I will likely encounter in my future practice. It was challenging to figure out how to present this topic to a group of different health care professionals. I think I could work more on explaining my trial critique slides in more layman’s terms and using less jargon. Once again…pace is definitely a recurrent struggle for me during presentations. During my presentation, I had checked in with my audience regarding my pace and thought there weren’t any issues…but I definitely need to work on regularly checking in with them to make sure that I am still going at an appropriate pace, especially if people are coming into the presentation part-way. Another thing to incorporate into my future presentations is to provide more time (suggested 5-7 secs) when asking my audience if they have any questions, as well as, to always discuss if I agree/partly agree or disagree to a study’s conclusion and why.
ID: 83 yo female with refractory hypertension (on multiple antihypertensives with SBP ~170)
- Has subclinical hypothyroidism which is being treated with levothyroxine (?link to refractory hypertension)
- Primary hypothyroidism is characterized by a high serum thyroid-stimulating hormone (TSH) concentration and a low serum free thyroxine (T4) concentration
- Subclinical hypothyroidism is defined biochemically as a normal free T4 concentration in the presence of an elevated TSH concentration. Secondary (central) hypothyroidism is characterized by a low serum T4 concentration and a serum TSH concentration that is not appropriately elevated
Primary hypothyroidism: 95%
- TSH high, serum free T4 is low; subclinical (TSH high, serum free T4 normal)
- Chronic autoimmune/lymphocytic (Hashimoto’s) thyroiditis: most common cause of hypothyroidism. Mainly older women. Anti-TPO (thyroid peroxidase) antibodies present in 75% of cases.
- Iatrogenic: radioiodine, external Neck radiation, thyroidectomy
- Iodine: deficiency (urine iodone <45 mcg/d) or excess
- Drugs: rifampin, carbamazepine, phenobarbital, phenytoin, valproate, estrogen, cholestyramine, sucralfate, FeSO4, AlOH, CaCO3, lithium, interferon alpha, sunitinib, PPI? coffee?. Numerous mechanisms.
- Infiltrative diseases: hemochromatosis, scleroderma, leukemia, tuberculosis, PCP
- Presence of high serum concentrations of abs to thyroid peroxidase (TPO) and thyroglobulin
- Do not routinely measure TPO abs in patients with primary overt hypothyroidism because almost all have chronic autoimmune thyroiditis – can be measured in subclinical hypothyroidism to predict likelihood of progression to permanent overt hypothyroidism
Secondary hypothyroidism: <1 %
- TSH deficiency
- Pituitary necrosis (eg. Sheehan’s syndrome), trauma, pituitary tumors
- Treat with Thyrotropin (TSH, Thyrogen). Usually also need to replace other pituitary hormones.
Tertiary (central) hypothyroidism: <1%
- TRH deficiency
- Hypothalamic damage from tumors, trauma, radiation therapy, or infiltrative diseases.
- Treat with Protirelin (TRH, Relefact TRH). Usually also need to replace other pituitary hormones.
In hypothyroidism caused by hypothalamic or pituitary disease, TSH secretion does not increase appropriately as T4 secretion falls. As a result, the symptoms and the serum free T4 value must be used to make the diagnosis. Thus, we measure both serum TSH and free T4 if pituitary or hypothalamic disease is suspected (eg, a young woman with amenorrhea and fatigue)
Hypothalamus — TRH –> Anterior Pituitary — TSH –> Thyroid Gland
Signs and symptoms:
||Fatigue, weakness, paresthesia, depression, cognitive dysfunction, decreased hearing, slow speech
||Periorbital edema, tongue enlargement
||Dyspnea on exertion, pleural effusion, sleep apnea
||Bradycardia, diastolic hypertension, pericardial effusion, nonpitting edema (severe hypo), ↑ risk of CVD (HF, CHD, stroke, lipids)
||Constipation, decreased taste
||Menorrhagia, pubertal delay, galactorrhea, hyperprolactinemia
||Weight gain, ↑ LDL, ↑ total cholesterol
||Hyponatremia (rare, only in severe), normochromic, normocytic hypoproliferative anemia
||Growth delay, myalgia, cramps, weakness, bradykinesia, carpal tunnel syndrome
||Dry, coarse skin, eczema thinning of hair, loss of eyebrows, cold sensitivity, brittle nails
The clearance of many drugs, including antiepileptic, anticoagulant, hypnotic and opioid drugs, is decreased in hypothyroidism. Thus, drug toxicity may occur if drug dose is not reduced. In addition, drugs that are administered at effective doses in patients who are hypothyroid may become less effective during T4 replacement.
Goal: Normalize TSH, T4, T3 + eliminate S&Sx.
- Synthetic Levothyroxine (T4):
- Young healthy adults: Start “full replacement dose”: 1.6 mcg/kg/d (50-200ug/d)
- ELDERLY: Start 50 mcg/d; may be 1 μg/kg/d in elderly (50-100 μg/d).
- CAD: Start 12.5-25 μg/d and monitor for angina.
- 12.5-25 mcg/d dosage adjustments. Initiate with T4 monotherapy.
- T4+T3 not superior to T4 alone on body weight, lipids, symptoms, cognition, QOL.
- IV formulation available (500μg/vial = $125)
Do you treat in subclinical hypothyroidism?:
- TSH > 10 mU/L: treat to prevent progression to overt hypothyroidism
- data linking subclinical hypothyroidism with atherosclerosis and myocardial infarction and the increased risk of progression to overt hypothyroidism
- supported by ATA, AACE, European thyroid association guidelines
- TSH 7-9.9 mU/L: treat most under age 65-70 yo d/t association of increased CV mortality in younger patients. ?benefit in older patients and concerns of safety in older pts (↑ risk of exacerbation and induction of angina and CAD)
TSH ULN-6.9mU/L: treat <65 to 70 who have sxs suggestive of hypothyroidism. Consider if high titers of anti-TPO abs, and patients with goiter. For older patients, these levels of TSH may be age-appropriate.
- Infertility or attempting pregnancy: suggest initiating T4 replacement (TSH values above 1st trimester-specific normal reference range with normal free T4)
- Re-measure TSH 4-8 weeks after initiation or dose change.
- Questionable role for fT4, no role for T3 in routine monitoring.
- TSH annually once stable & when conditions change.
- Avoid chronically low TSH even if asymptomatic due to osteoporosis risk (TSH <0.1 to 3.6 x ↑ in hip fracture risk & 4.5 x ↑ in vertebral fracture risk vs. normal TSH in women >65 y/o. [Ann Intern Med 2001;134:561-568, BMJ 2011;342:d2238].)
- NOTES: Targeting lower half of TSH range no better than upper half w.r.t. Sx, QOL, cognition. [JCEM 2006:91: 2624 –2630].
- Factors possibly requiring UPWARD dosage adjustment: worsened thyroid function, pregnancy, hi-fiber diet, concurrent rifampin, carbamazepine, phenobarbital, phenytoin, estrogen, cholestyramine, sucralfate, FeSO4, AlOH, CaCO3, lithium, nephrotic syndrome
- ASSESS ADHERENCE (most common reason)
- Factors possibly requiring DOWNWARD dosage adjustment: nephrotic syndrome, weight loss, androgen therapy.
Primary Hypothyroidism & Pregnancy:
- Screening in normal healthy women: no consensus.
- Recommendations range from screen all women before pregnancy (AACE) to screen only if high-risk (family history or goiter).
- TREAT with T4 if TSH > ~4 mU/L.
- If not on T4 therapy prior to pregnancy, no consensus about optimal initial dose. Some have suggested 1.2-1.4 mcg/kg/d initially. A retrospective study showed T4 50mcg/d (avg) was associated with reduced pregnancy loss and increased preterm delivery, preeclampsia, gestational diabetes.
- Women with pre-existing primary hypothyroidism: Counsel women with primary hypothyroidism before pregnancy. If already on T4 before detecting pregnancy: Increase L-thyroxine intake by 20-30% immediately + contact caregivers urgently. [e.g. take an extra L- thyroxine dose twice weekly beginning immediately]
- MONITORING: TSH ~q4 weeks until ~20 weeks, and at least once ~30 weeks. T4 requirements go up as early as 4-6 weeks of pregnancy, and increase through weeks 16-20, then plateau until delivery. 50 and 85% of LT4-treated hypothyroid women need a dose increase during pregnancy. Target TSH: 0.4-2.5 mU/L throughout pregnancy. Return to preconception T4 dose following delivery, TSH @ 6 weeks.
Considering patient’s refractory hypertension which is uncontrolled on multiple antihypertensives, trialing treatment of subclinical hypothyroidism to manage hypertension is appropriate (go low and slow).