Reflection – Total Parenteral Nutrition

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:

  1. Identify if there is an indication to TPN
    1. Surgery progress notes/reports (e.g. length of bowel resected) and imaging often provide the indication for TPN (e.g. anastomotic leak)
      1. 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)
    2. This will also help you identify how to assess when your patient should be off TPN!
      1. 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)
  2. If TPN indicated, assess the risk for refeeding syndrome and nutrition status
  3. Information gathering:
    1. current weight (assess fluid status → is this a dry or wet weight?)
      1. Calculate BMI, IBW and do adjBW if overweight
    2. usual weight at home
    3. weight change
    4. nutrition status
      1. intake during hospital admission
      2. intake prior to hospital admission
      3. signs of muscle wasting
    5. PMHx
      1. hx of organ failure (kidney, liver, cardiac)
      2. diabetes
    6. IV maintenance fluids and replacement fluids
      1. Provides you an idea of their volume status, tolerance to fluids and need for electrolyte replacements
      2. Check how long they have been on it and whether they have been any recent rate changes
    7. IV access
    8. Inputs and outputs
      1. Consider what patient is losing (e.g. diarrhea, vomiting, NG suction output, stoma output, urine output) + insensible losses
      2. Diarrhea → lose bicarb, sodium, chloride
      3. Vomiting → lose chloride
    9. Electrolytes → should get a baseline Mg and PO4 prior to starting TPN
  4. Order any electrolyte replacement orders
    1. TPN changes and starts tonight (reach the wards from VGH at 1830h)
    2. 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

Practical pearls:

  • when changing orders, write delta signs to any change (helps pharmacy identify if there are any unintended mistakes)

Reflection – Leadership

This was my first non-clinical rotation, and I think the timing of this rotation at the half-way mark of my residency is very fitting. It was very eye-opening to see the layers of management and leadership behind ensuring that all the operations, clinical services and strategic plans run smoothly.

Through shadowing Mits, and having discussions and daily reflections with Mits, I had the opportunity to learn and observe about his management and communication styles.

Some clinical pearls I learned were:

  1. Communicating with SBAR

    Prior to this rotation, SBAR was something I had only seen on a nursing communication sheet at MSJ. SBAR stands for Situation, Background, Assessment and Recommendation – it follows a similar order that SOAP does. When addressing a management issue, Mits had me practice how I would explain this particular issue through SBAR and I was also able to observe how Mits used SBAR to explain the same issue to a medical director. One difference between the way I explained SBAR and Mits was that he included parts of the “R” in my “S” to allow the receiving end to understand the purpose of the conversation. I think this tool will be a very systematic and effective way for me to communicate issues to other health care team members and my colleagues.

  2. Communicating with OWTF and using “I” language

    OTFW is communicating by talking about what I observed, what I think, what I feel and want. The order doesn’t have to exactly follow OTFW, but the key is to touch on all of them when bringing up an issue. Communicating with OWTF and using “I” language will help others understand your perspective, communicate in a non-confrontational manner and provide others with the choice of helping you (versus demanding for assistance on the matter).

  3. ADKAR

    Implementing and ensuring successful change requires going through all 5 steps of ADKAR. On my last day, we attended a leadership forum at Burnaby Hospital where managers, coorindators, PCCs, LPNs and executive directors presented and discussed about the health care report card, different initiatives taking place at BH, the successful patient stories and steps to take and are being taken to ensure successful change. This forum was also great example of another communication tip that Mits taught me and that was to ensure that everything communicated does a 360. If there is an issue, ensure that those who brought up the issue are made aware of the status of the issue (e.g. email, verbal communication, interim reports). This forum provided an opportunity for the leaders in BH to provide feedback and input, as well as, ask questions to president of Fraser Health, Michael Marchbank. Overall, it was a great end to my rotation to see ADKAR being applied in practice!

  4. The Donut Model imageskykedry3

    The Donut Model consists of 3 layers – the inner most represents what you can directly affect (e.g. what you can wear)?, the second layer represents what you can influence and the third layer represents what you can’t control (e.g. weather, the past). It is important, in my residency year and the rest of my career, to be aware of these different layers and avoid putting my energy into things I cannot control.





Reflections – Surgery

The following are my objectives for surgery:

  1. Continue to develop a systematic thought process to assessing and managing infectious diseases
  2. Continue to develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)
  3. Continue to develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides and anticoagulation
  4. Develop my ability to effectively manage anti-coagulation (e.g. pre- and post-op management, duration of treatment or prophylaxis)
  5. Continue to develop my ability to write concise and clear chart notes

Another great rotation at RCH! Bruce was incredibly knowledgeable and helped to build my thought process regarding patients in surgery. This rotation definitely gave me a lot of experience with infectious diseases, especially intra-abdominal infections. Bruce also helped schedule a shadowing opportunity for me with one of the antimicrobial stewardship pharmacists. One key thing I will always keep in mind when managing infections is the importance of source control! Unfortunately, I was not able to get any experience with aminoglycosides…but was able to get lots of experience with anticoagulation (e.g. VTE prophylaxis for patients who have abdominal surgery for cancer – requires 28 days of LMWH). Generally, VTE prophylaxis is started on POD 1 with dalteparin if eGFR > 10. With Bruce’s guidance, I was able to write clearer chart notes. Writing concise and clear chart notes will definitely be a goal that I will continue in future rotations.

Reflections – General Medicine

I can’t believe how quickly this rotation flew by! I’m very fortunate to have been able to work with such a supportive preceptor and health care team at the Short Stay Medical Unit (SSMU).

These were my objectives for this rotation:

  1. Develop and strengthen my systematic approach to assess and work up patients
  2. Develop my ability to clearly and concisely document my soap notes and important patient interactions
  3. Develop my ability to effectively perform therapeutic drug monitoring on medications such as vancomycin, aminoglycosides, digoxin and anticoagulation
  4. Develop my ability to practice antimicrobial stewardship (e.g. assessing when therapy can be narrowed, for IV to PO stepdown)

During this rotation, my preceptor helped to build on my approach and when I presented on my patients, he would help map it all out on the whiteboard. This made it easier for me to view my patient as a whole and connect their medications to their indications and medical conditions. The importance of matching medications to medical conditions, vice versa was emphasized with this rotation. Additionally, I feel that I was able to improve on my documentation, especially on my soap notes for therapeutic drug monitoring (e.g. for vancomycin). Unfortunately, I was not able to get much experience with monitoring of digoxin or aminoglycosides. I was able to see various patients with pneumonia, and had more experience assessing for narrowing of therapy and IV to PO stepdown.

Reflection – Pharmacokinetics

For the past week, Dr. Ensom went over pharmacokinetics for vancomycin, aminoglycosides, phenytoin and digoxin, as well as, gave us a brief overview of other drugs that have TDM. On our last day, we also had clinical pharmacists share real-life cases and how to apply pharmacokinetics in real life. The sessions were incredibly useful, especially since I didn’t take the pharmacokinetics electives. During my general medicine rotation, I hope to get more experience with interpreting levels, applying my pharmacokinetic knowledge and writing concise and comprehensive chart-notes/documentations.

Some things I took away from the sessions:

  • For future chart notes on TDM, I will document if possible on: individual pharmacokinetic parameters, population estimates (if clinically useful)
    – check if this is the first or follow-up note
    – write chart notes in bullet points
    – check infusion times, timing of level relative to dose, previous doses and their timing
    – keep in mind that my audience is the health care team and other pharmacists
  • Patient can only be toxic if they are alive!
  • Population estimates are like clothes off the clothing rack. Whenever possible, want to get individual PK parameters

Reflection: Evidence Based Medicine

This was definitely a jam-packed week of statistics and critical appraisal. It was very valuable to have the opportunities to not only learn about the different critical appraisal tools, but also apply and use it for patient cases. Even with the time allotted for us to use the tools, I was not able to finish going over the entire checklist and was able to truly appreciate how long a full and comprehensive critical appraisal can take. The big thing that most of our presenters emphasized was the need to practice, practice practice before you can expect to be efficient in this skill. As residency progresses, I aim to refine this skill as I prepare for my future journal clubs, project and literature searches.


Some points that I took away were:

  • Make evidence synopses! Always question the evidence of what you are recommending or counselling (e.g. no alcohol while taking antibiotics — this belief actually came about because people were dying from STIs and they were still infective while taking ab treatment, and alcohol increased the likelihood they would have more intercourse)
    • Cochrane reviews: as unbiased as you can get, but still have bias
    • Search: drug name meta-analysis systematic review, RCTs
  • Even if it is a small study where SS cannot be achieved (e.g. pilot studies), statistics can still be used to tell you about variance, mean, population size
  • Talking to patients about evidence
    1. Set the stage (WOW Intro: Who you are, Occupation, Why you are here)
    2. Use Framing language
    3. Understand the Patient’s Experience and Expectations
    4. Build partnerships
    5. Explain disease
    *Why they were at risk
    *Disease and symptoms
    *Impact of having that disease and complications
    6. Explain medications
    7. Provide Evidence on Benefit and Risk
    (Benefits, Risks, Characteristics)
    8. Elicit patient’s benefits, values and preferences
    9. Discuss a shared recommendation
    10. Check for understanding and agreement
    11. Talk about follow-up

Helpful Resources:


Reflections – Clinical Orientation

The past 2 weeks passed by so quickly! I’m really thankful that our residency program has a clinical orientation as it allowed me to focus and build on my thought process and systematic approach. I was fortunate to have Mike who was very supportive and knowledgeable. The health care team at SMH worked closely with the pharmacists and were very approachable, which helped to enrich my learning experience

For my reflections, I plan to discuss how I have accomplished my objectives, as well as, make one new objective for each of them.

  1. Use the head-to-toe approach to assess my patients and if time provided, present at least 5 full patient work-ups to my preceptor (i.e. not just reading out the information I have gathered)

    Reflection: I used the head-to-toe approach to gather information and present all of my patients. With each presentation of my patient, I felt more comfortable with the head-to-toe approach and knowing which information was relevant to point out to my preceptor. I need to work on better presenting the progress of my patient in the hospital. In my OEE, I was taught to summarize the progress in one line. While that may work for patients who are newly admitted, for patients who I am encountering part-way through their hospital stay, capturing their progress in one line is challenging. For future patient presentations, I will try to summarize their progress while going through their head-to-toe (e.g. any trends in labs, etc).

    New Objective(s):
    – When presenting my patients, use the head-to-toe approach to summarize my patients’ progress, identify any new issues and highlight relevant trends. Do this for at least 5 more patients.
    – Consistently use the head-to-toe approach when gathering information and assessing all my patients

  2. Conduct at least 1-2 patient interviews in an organized and comprehensive manner
    – Have a list of interview questions ready prior to visiting the patient
    – Prioritize my interview questions in case time with the patient is limited
    – Make sure to also inquire about adherence, community pharmacy, family support, OTCs/herbals/supplements

    Reflection: Initially, my interviews were disorganized as I would jump from one condition to the next. My preceptor taught and provided me with an interview form that allowed me to conduct a proper BPMH and patient interview in an organized manner. I was able to meet my stated objective and always prepared a list of questions prior to visiting my patients. I will definitely not forget the most important question to ask — which is what are my patient’s goals from this hospital admission and expectations of their health care team!

    New Objective(s):
    – Document relevant information from patient interviews in a concise and organized manner in the progress notes
    – Delve further into patients’ responses (e.g. use questionnaires if a patient mentions they have a low mood) and tailor interviews toward my patients’ concerns and needs.

  3. Discuss with my  preceptor and write at least 1 clinical pharmacy note. Observe how my preceptor writes his clinical pharmacy notes and collaborates with other health care professionals and implement them into my practice.

    Reflection: I was able to get more experience writing SOAP notes. My preceptor would help point out situations where pharmacists would document a clinical pharmacy note. My notes tend to be wordy and at times, I would repeat information multiple times in my notes. My preceptor helped coach me on how to write clear, concise and organized notes. Currently, I still feel more comfortable drafting my note and reviewing it with my preceptor before writing it in the chart. Some useful tips were to include information from patient interviews or gather information from the bed-side nurse for the subjective, make sure you are not repeating details, write A/P in point form and always include your monitoring plan!
    FYI — Pharmacists are able to order non-prescription meds, continue medications PTA after verifying with the patient and another resource (e.g. P’net), labs and referrals to clinics.

    New Objective(s):
    – Independently assess the patients’ DRPs and clinical situation, and determine when writing a clinical pharmacy note would be appropriate (e.g. addressing a DTP and suggesting a care plan; discharge counselling; drug level monitoring). Draft up clear, organized and concise pharmacy notes and review with my preceptor prior to documenting it in the chart.
    – Become more comfortable and confident with my documentation skills

  4. Give 1 presentation. Practice my presentation at least 3 times while paying attention to my body language, tone and flow of presentation.

    Reflection: I facilitated a journal club for the first time, which was a great opportunity to brush up on my clinical appraisal skills and review non-inferiority trials. A more detailed reflection can be found in my procedure log. Reviewing it with my preceptor ahead of time helped better prepare me for my journal club and gave me a better idea of what to consider and research further on for future journal clubs.

    New Objective(s):
    – Prepare a cleaner and shorter journal club form
    – Have more questions prepared to facilitate discussion during future journal clubs

  5. Take opportunities to ensure continuity of care (e.g. with discharge counselling, communicating with the community pharmacy)

    Reflection: I was able to do a discharge counselling for a patient who was leaving nicotine replacement patches and a few medication changes. Although I was not able to do much discharge planning as most of my patients were still in the hospital when my clinical orientation ended, my preceptor and I helped prepare patients for discharge in other ways (e.g. asking what patients’ goals upon discharge, writing referrals, contact community pharmacies, medication reconciliations).

    New Objective(s):
    – Perform and document at least 5 discharge counselling during my general medicine rotation. Provide medication calendars and any useful counselling material.
    – Liase with community pharmacists and other appropriate health care professionals, in order to ensure a seamless continuity of care
    – Educate and connect patients with any necessary health resources during discharge (e.g. blister packing, special authority, insurance cards (e.g. Pfizer Strive))

On a random side-note…I recently watched Piper, a Pixar short about an unbelievably adorable little sandpiper bird (squee!) who leaves its nest to find food. I won’t spoil the story, but I found the beginning of Piper’s story to be similar to my start in residency where I’m starting to develop the skills and knowledge to be a clinical pharmacist. So, I’ll end my reflection with a picture of Piper in the beginning of its discovery of the world outside its nest: