Day in the OR

As I mentioned in the previous post, every single neonate on the PSICU service had some form of congenital heart disease that required surgery within days of birth.  After speaking with my preceptor and my cousin who is an anesthesiologist at NTUH, I was given the unique opportunity of observing a pediatric cardiac surgery of one of the patients on my service!  

The patient was born with Tetralogy of Fallot, which involves four defects of the heart and blood vessels:  ventricular septal defect, overriding aorta, right ventricular hypertrophy, and narrowing of pulmonary outflow.  Surgery is necessary because the condition causes low oxygen in the blood and can lead to cyanosis.  

The image above is of the cardiopulmonary bypass, which essentially takes over the function of the heart and lungs during surgery.  

Pre-made trays of medications put together by the pharmacy for surgery.

These pre-made trays was a system developed to minimize medication errors during surgery. 

I felt very anxious as I watched the surgeons work on the tiny heart of patient.  Each and every maneuver had to be so precise.  It was a bit unsettling to see that the HR was zero during the surgery.  However, it was almost miraculous to see the heart start beating after the surgeons reconnected the heart to its blood vessels.  Now it was time to manage my patient postoperatively!

PSICU: first day

One rotation down, one to go!  After three weeks in Family Medicine, I switched over to the Pediatric Surgical Intensive Care Unit (PSICU).  This would be a new experience for me in two respects:  this would be my first peds rotation AND my first ICU rotation.  I was introduced to my new preceptor, who went over the expectations and objectives.  One of the main differences between ICU and Family Medicine that I noticed right off the bat was, ICU pharmacists at NTUH attend daily rounds with the physicians.  Every morning at 8:30 am, I would be joining in on rounds with my pharmacist.  I would also have the opportunity to attend an outpatient infectious disease clinic with an ID physician as well as a day doing pediatric compounding.  

Following orientation, my preceptor provided me some handouts on pediatric dosing.  Since I have had very limited exposure to pediatric patients, it was difficult for me to compare NTUH and the U.S.  From what I saw, they appeared to use many of the same resources, one of them being the Pediatric Handbook.  Dosing would be mostly weight-based, which I would have to get used to.  In addition, many of the normal ranges for lab values, blood pressure, heart rate that I was so familiar with, would all be different!  

Looking at the patient list for my service, I noticed that every single patient had a heart problem.  It turns out that this service, being a surgical ICU, dealt most of the time with neonates with congenital heart problems.  As a result, the focus of pharmacy on this type of service would not be treatment and resolution of disease states, but rather, post-operative management of patients.  Needless to say, it's going to be an interesting experience the next three weeks!

My home for the next three weeks.

A view from the 14th floor of the pediatric hospital.  

Geriatrics Interdisciplinary Team Meeting

One of my favorite parts of the Family Medicine was the weekly Geriatrics Interdisciplinary Team Meetings.  Every Tuesday, instead of morning meeting, we attended a meeting with various healthcare professionals including medical residents, nurses, physicians, dietitians, physical therapists, social workers, and clinical psychologists.  It was the most complete interdisciplinary team that I had ever seen.  The meeting began with a medical resident presenting a patient case.  On this particular day, the patient case revolved around an elderly gentleman with an ileus.  After presenting the chief complaint, history of present illness, relevant labs and imaging, and medications, the resident passed the case on to the other health care professionals to comment on.

It was exciting to see so many different specialties contributing their expertise on the patient case:
Pharmacist: did not make any changes to the medications, but recommended monitoring of renal function and electrolytes due to the patient being on diuretics
Physical Therapy:  assessed the patient's day to day progress in terms of mobility
Social Worker:  commented on the patient's living situation at home prior to admission, relatives that could be potential caretakers, and discharge plans
Clinical Psychologist:  assessed the patient's understanding of reality and discussed with family members about the patient's mental state at his age
Attending Physician:  chimed in with relevant questions from time to time

Once all of the different specialties made their comments, the resident presented the current literature on the topic discussion, which this week was, the treatment of ileus.  Usually, the resident presented it by going over the literature, and then comparing it with the course of therapy they chose to go with at NTUH.  At the end, the attending physician provided closing comments and additional points.

Although there are rarely situations in which there is enough time and resources to devote to one patient case such as this, I do think that it stresses the importance of looking at a problem from different perspectives.  Every health care professional brought up points that the other professions would not have considered otherwise.  The concept of a healthcare team in improving patient care is at work here and it would be great to see more of it.

Here is a photo of the resident going over imaging during the meeting.

Joint Commission International

In the United States, many hospitals and health organizations are accredited by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).  Depending on the state, accreditation may be required for licensure and other government reimbursement programs such as Medicaid in California.  NTUH is accredited by the Joint Commission International (JCI), a not-for-profit affiliate of the JCAHO established about 15 years ago.  Similar to U.S. hospitals., NTUH undergoes inspections by JCI every three years for accreditation.  The overall objective of these inspections is to assess their level of performance compared to healthcare organizations around the world and to ensure they are on par with a certain standard established internationally.  Additionally, these inspections push the hospital to find ways to continually improve their quality of care, medical ethics, patient safety, evidence-based medicine, and many other aspects.

During my time at NTUH, the hospital staff was in the process of preparing for the next upcoming inspection.  My UDD preceptor was on the hospital committee in charge of this preparation for JCI.  She said that NTUH is one of the only hospitals in Taiwan that is currently accredited by JCI.  Although it is not required for licensure as it is in California, NTUH wants to stay on the same level as the leading healthcare organizations in the world.  When I went to the floors with my pharmacist, she noted many operational details that could still be improved upon before the inspection ie leaving charts out in view of the public, hospital staff not sanitizing hands before and after entering patient rooms.  All of these inspections and accreditation processes, though grueling from a day to day standpoint, are the best way for health care organizations to continually improve their quality of care and increase their standards.  In the end, it all goes towards serving one population: the patient.

EMR Terminology

Chinese	Pinyin	English
處方	chǔ fāng	prescription
急診	jí zhěn	emergency
病人	bìng rén	patient
過敏紀錄	guò mǐng jì lù	allergies
身高	shēn gāo	height
體重	tǐ zhòng	weight
血壓	xiě yā	blood pressure
住院醫師	zhù yuàn yī shī	resident physician
主治醫師	zhǔ zhī yī shī	attending physician
主訴	zhǔ sù	chief complaint
病史	bìng shǐ	history of present illness
身體檢查	shēn tǐ jiǎn chá	physical exam
影像報告	yǐng xiàng bào gào	imaging report
病理報告	bìng lǐng bào gào	pathology report
抗生素	kàng shēng sù	antibiotics
抗生素感受性報告	kàng shēng sù gǎn shòu bào gào	antibiogram
洗腎	xǐ shèn	dialysis
門診	mén zhěn	outpatient
診斷	zhěn duàn	diagnosis
檢驗報告	jiǎn yàn bào gào	labs

Patient Presentation--Acute Pyelonephritis

At the end of my first week, my preceptor had me present a patient to her and the pharmacist assigned to the Family Medicine service.  The case a chose was among the patients I had been following throughout the week.  

ID: 55 year old female

CC: Fever x 6 days

HPI: 

Date	Note
Before 8/5	Patient visited outpatient clinic for lower abdominal pain and dysuria. She was given an oral antibiotic for a suspected UTI
8/5	Patient developed a subjective fever.
8/7	She went to the ER, WBC 18650 with left shift (Seg 91.2%), UA:  pyuria (WBC >100), sent home on cephalexin
8/9	She returned to the ER, WBC 11070 with left shift (Seg 89.7), UA: pyuria (WBC 20-35).  Renal ECHO revealed parenchymal renal disease.  Admitted for further evaluation and management.

PMH:

  

Hyperlipidemia

Medication List (8/15):

Acetaminophen 500 mg 1 Tablet PO q6h PRN

Cefuroxime Sodium 1500 mg IV q8h                  

NaCl 500 mL IF QD

Acyclovir Cream 5% 

Magnesium Oxide 250 mg 2 Tablets PO TID

Bisacodyl 10 mg 2 pills qod PRN

sennoside A+B calcium 12.5 mg 2 Tablets PO PRN

Allergies: NKDA

Physical Exam:

Unremarkable

VS:  BP: 126/76    T: 36.6     P: 68   RR: 19       Ht : 156cm   Wt : 67kg       BMI:27.5kg/m2

Labs:     WBC 8.18   RBC 4.92        Hgb 10.2         Hct 31.6      Plts 378           BUN 15.6     

SCr 0.7        AST 47            ALT 52            Na 137        K 5.0                LDL 115           

Tg 146         HDL 26           T. Chol 174     

Problem List:

1.     UTI

2.     Hyperlipidemia

1.  Acute pyelonephritis
S/O	Subjective	Dysuria and frequent urination for several days
	Objective	1.      Febrile since 8/5 2.      Left CVA tenderness 3.      Leukocytosis (WBC 11070)+left shift (Seg: 89.7%) 4.      UA:  pyuria WBC 20-35, proteinuria (200), WBC esterase, bacteria (3+) 5.      Urine culture:  Enterococcus species, colony count 1000/ml
A	1.      Likely pathogens for pyelonephritis:  Escherichia coli (75 to 95 %), with occasional other species of Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae, and Staphylococcus saprophyticus. 2.     Women with pyelonephritis requiring hospitalization should be initially treated with IV antimicrobial therapy:  ·         Fluoroquinolone ·          aminoglycoside ±ampicillin ·         extended-spectrum cephalosporin or extended-spectrum penicillin ± aminoglycoside ·         carbapenem Regimen should be based on local resistance data and susceptibility results. -Cefuroxime 1500 mg IV q8h (8/11—) 3.      Antibiotics should be administered for at least 10 to 14 days. 4.      Standard definition of positive urine culture is ≥105CFU/ml together with pyuria. 5.      Though guidelines recommend the usage of extended-spectrum cephalosporins, given that the colony count is low and patient is clinically improving ie UA, the antimicrobial therapy is adequate.
P	Goal	·         Clear infection ·         Relieve dysuria, frequency of urination ·          Restore WBC to normal ·          Restore UA to normal
	Monitoring	·       Urine analysis ·       Signs and symptoms of infection:  leukocytosis, fever ·       Side effects of medications ·       Renal function

2.  Hyperlipidemia
S/O	Subjective	Nil
	Objective	8/11/2011:  LDL-C:  135 8/13/2012: ·        TG: 146 ·        T-CHO:  174 ·        LDL-C:  115 ·        HDL-C:  26
A	·          Previously on Mevalotin 40 mg PO qHS ·          10-Year Risk by Total Framingham Point Score:  2% ·          ATP III LDL goal is <130 mg/dL ·          Initiation of treatment now is not necessary
P	Monitoring	·        Lipid panel
	Goal	LDL-C<130 mg/dL

Case Discussion

At first, I felt the approach to the treatment of UTI's in Taiwan, and infections in general, was very similar to that of the U.S. However, as I looked at more patients and spoke with my preceptor, I found that the treatment strategies are actually different.  In the case of pyelonephritis, this patient would be classified as a complicated UTI and would require a broad spectrum cephalosporin ie at least a 3rd generation to treat the likely pathogens.  However, I've seen many cases similar to this where they have treated with 1st and 2nd generation cephalosporins.  My preceptor noted that the physicians are, for the most part, aware of the IDSA guidelines and recommendations, however they utilize it literally as a guideline and do not follow it as closely as the U.S. does.  In addition, I noticed many cases where antibiotic changes are made without any rhyme or reason, except that the patient spiked a fever.  The scenario is usually a patient spiking a fever while on an antibiotic regimen.  The antibiotic is switched to another class without regard for whether there was any additional microorganism coverage.  I feel that in the area of infectious diseases, pharmacists have many opportunities to make interventions.