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Currents in Pharmacy Teaching and Learning 5 (2013) 241–243

Research

The pediatric critical care pharmacist: A student’s perspectiveJoseph M. LaRochelle, PharmDa,b,*, Nicole Rileya, Kelly Chapmana

a Xavier University of Louisiana, College of Pharmacy, New Orleans, LAb Louisiana State University Health Sciences Center, School of Medicine, New Orleans, LA

http://www.pharmacyteaching.com

Abstract

Didactic learning of pharmacy is an essential part of building the foundation of knowledge needed as a pharmacist.Application of that knowledge is essential to optimal patient care. Pharmacy students in their early professional years do not getadequately exposed to the practice of clinical pharmacy and often have a narrow view of the pharmacy profession, especiallypediatrics. Early exposure to clinical pharmacy can help guide students and show first-hand how the curriculum taught in theclassroom is applied and impacts patients’ lives. As second-year pharmacy students, we describe our experiences on a shortclinical shadowing in a Pediatric Intensive Care Unit.r 2013 Elsevier Inc. All rights reserved.

Keywords: Pediatric intensive care; Pediatric pharmacy; Pharmacy student

Introduction

Pediatric patients consist of a significant percentage ofthe population that a pharmacist cares for.1 The activities ofthe pediatric pharmacist in the inpatient care of pediatricpatients are documented for a variety of settings includingcritical care.2–4 Pediatric medication use is commonplace inthe hospital setting, making the role of the pharmacist anessential part of pediatric care.5 The American Academy ofPediatrics has supported the use of pharmacists in theroutine care of pediatric patients.6 Although pediatric careis important for pharmacists, pharmacy students receivelimited pediatric education,7 and there is limited guidanceon pediatric curricula.8,9 Pharmacy students generally areexposed to different pharmacy careers during their first yearof school, however seldom do they have a true under-standing of the role the pharmacist plays in the care ofpatients. Experiencing what a pharmacist does is somethingthat cannot be taught in the classroom. During didactic classwork, students learn about various disease states andmedications used in their treatment, but the content is

– see front matter r 2013 Elsevier Inc. All rights reserv/10.1016/j.cptl.2013.02.006

ng author: Joseph M. LaRochelle, PharmD, Xavierouisiana, College of Pharmacy, 1 Drexel Drive,A 70125.che@xula.edu

primarily limited to the adult population. The majority ofstudents do not get exposed to clinical pediatric care, and ifthis does occur, it is not until later in the professionalprogram. If a school employs a faculty member thatspecializes in pediatrics, students can begin to explorepediatrics as a career through mentoring and advising. Wedescribe a two-day shadowing and mentoring experiencewith second-year pharmacy students and a faculty memberwith a specialty in pediatrics in an 18-bed tertiary caremedical–surgical Pediatric Intensive Care Unit (PICU).

During a pathophysiology course, students study pedia-tric disease states and the differences in the care of pediatricpatients from that of adults. The students approached thefaculty member in charge of this course to arrange a moreformal mentoring relationship and the opportunity toshadow in their clinical setting. Prior to the clinicalexperience, the students reviewed literature on pediatricpharmacy and conducted an interview with a pediatricfaculty member.

Interview

Students: When did you know you wanted to go intopediatrics?

Faculty: Prior to school, I worked at a small hospital as atechnician and was exposed to general pediatrics and

ed.

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neonatal intensive care, but never realized the clinicalaspects associated with the care of those patients. I spentthe majority of my time focusing on adult critical care, as Ihad experience in that area. It was my fourthyear rotationsthat solidified my interest in pediatrics as I was able toexperience the role of the clinical pharmacist in that setting.

Students: Did you have a mentor that exposed you topediatrics?

Faculty: During my first year of pharmacy school, I hadthe opportunity to get to know the pediatric faculty memberand became extremely impressed by her skills as aneducator and as a pharmacist. She helped guide me alongthis path.

Students: Did you have any doubts?Faculty: Absolutely. Although, I was able to experience

pediatrics, I still enjoyed adult critical care and had a hardtime deciding between the two. During my fourth year, Ihad the opportunity to do a rotation in the PICU and then itfinally dawned on me. I didn’t have to choose between adultcritical care and pediatrics. Pediatric patients need criticalcare services and I could simply combine my true interests.That is how my career path began.

Students: What impressed you most about pediatrics?Faculty: One of the basic things one learns about

pediatrics is how different they are from adults in almostevery aspect of pharmacy. This seemed like a hugeopportunity for pharmacists. While on rotations, I was ableto see that the input of the pharmacist is truly valued in thecare of these patients.

Students: Why did you decide to do two residencies inpediatric settings?

Faculty: Because I was so fortunate to decide onpediatric critical care so early in my career, I wanted asmuch training in pediatrics and, in particular, critical care asI could. One of the things that struck me with pediatrics ishow varied the career paths are within the field. The PGY2residency is just labeled pediatrics without a specific sub-specialty focus. Due to the flexibility of my individualprograms, I was able to spend half of my total time incritical care.

Students: What should a student do if they are interestedin pediatrics?

Faculty: I would do a literature search and discovereverything you can about pediatric medication use andclinical pharmacy. It is important to verbalize your intereststo a pediatric practitioner and shadow him/her in a clinicalsetting in order to see what he/she really does.

Student perspective

The false impression of a clinical pharmacist’s lifeworking alone in a quiet, dark, and tense unit, going toeach room making adjustments without involving otherswas quickly changed. The participation and interaction ofthe pharmacist in the unit with other healthcare profes-sionals was impressive. It was clear that the clinical

pediatric pharmacist plays an integral part of the interdisci-plinary healthcare team and that his/her input is valued andhighly sought.

The first day of this experience was eye opening as theteam cared for critically ill children. The decisions made bythe team could mean life or death for someone’s child. Atwo-inch stack of patient medication profiles was reviewedextensively for errors and appropriateness. What appearedto be minute details, such as the appropriate concentrations(depending on the intravenous access of the child), the rateof administration, and the times the medication was givenare essential because an error in any of these could meanclinical consequences for the patient.

After reviewing the medication profiles for accuracy anderrors, it was time to analyze the patient-specific informa-tion and correlate the drug therapy with the patient. Theinformation collected from the patient in the PICU wasenormous, ranging from hourly vital signs and urine outputto extensive laboratory values and physical findings. Corre-lating this wealth of information to the patient’s drugtherapy seemed impossible, but the experienced pharmacistaccomplished this with ease. Two basic questions were thefoundation of the analysis: are the medications making aclinical change in the patient, and does this change affectthe medications. With those two questions in mind, the roleof the pharmacist on the team was clear, as others on theteam do not always have medication therapy at the forefrontof their minds.

Three hours of rounding were intense as the discussionswere above the knowledge level of a typical second-yearpharmacy student. The most interesting part of rounds wasthe discussion of the plan: what the team was going to do toaddress each problem. This was where the impact of theclinical pharmacist was most apparent. The medical teamdevelops a plan and the pharmacist then offers alternativesor addresses issues not discussed. There was an in-depthpharmacotherapeutic discussion as to which option wouldbe best for the patient in achieving the desired clinicaloutcome. The majority of the time the pharmacist’s sugges-tions were implemented by the medical team, showing thetrue value of the pharmacist in the decision-making process.The pediatric intensivist, after debating a tough decision,turned to the pharmacist and asked, ‘‘What do you think weshould do?’’ displaying trust in the pharmacist’s opinion.Students may be able to perform exceptionally on aPharmacology or Therapeutics test, but it was the applica-tion of the knowledge learned in the classroom to thatspecific child that was essential to patient care.

It appeared that the job of the clinical pharmacist wouldbe complete after the majority of the decisions for thepatients were made during rounds; however, this assump-tion was incorrect. In a critical care setting, the status ofeach patient changes constantly and adjustments need to bemade as new clinical information becomes available. In oneinstance, the oncology team needed to perform a bonemarrow aspiration on a three-year-old cancer patient. The

J.M. LaRochelle et al. / Currents in Pharmacy Teaching and Learning 5 (2013) 241–243 243

clinical pharmacist assisted the team in the proper selectionof sedative agents and prepared them for administration.Because the patient was tolerant to the analgesic given, thenormal dosing learned in school was greatly increased forthis patient. This highlighted the lesson that everythinglearned on paper or in a book cannot always be applied toreal-life situations and the rules sometimes have to bestretched. It is through expertise and judgment that the bestclinical decisions for the patient are made, especially inpediatrics where medication studies are sometimes lacking.

A pharmacy student learns much about medication useand therapeutics; however he/she is rarely prepared toaddress the emotional components of patient care. Therewas one little boy with spinal muscular atrophy andrespiratory failure secondary to hospital-acquired pneumo-nia that particularly stood out and made the most impact.The healthcare team had to optimize the medication therapydespite the patient being in both liver and kidney failurestate. The boy’s family knew the clinical outlook was poor,but they put their trust in the team and hoped for a recovery.When the outlook got worse that one particular day, themother of the child sobbed intensely knowing her son had aslim chance of surviving. The pharmacist compassionatelyexplained all the medications and how they were being usedto hopefully achieve a positive outcome for her son.Another aspect of the care a pharmacist provides sometimesinvolves comforting the patient’s families; something that isnot always discussed in the classroom, but must beexperienced. Everything is not always in control and thereis not always a pill for everything. Pharmacy school cannever truly prepare a future pharmacist to observe theemotional drain such a devastating condition can have ona family, nor are pharmacy students often exposed to theseunfortunate circumstances.

Even when sitting in didactic lectures, thoughts of thehealth and status of the children in the PICU wereconstantly occurring because a face could now be placedon the information being learned. The second visit had evenmore of an impact as the discussion about the child whowas clinging to life just two weeks ago, turned to dischargeplanning. Moments like that make the stressful life of aclinical pediatric pharmacist so much more rewarding.

Pharmacy school comes with lots of responsibilities suchas meeting deadlines, learning the top 200 drugs, takingtests, doing presentations, etc. Pharmacy students are often

overwhelmed with drugs, their mechanisms of action, andtrying to put together all the information learned. Theapplication of this knowledge to affect the life of a childwas the most impressive part of this experience. The‘‘useless’’ information that a student sometimes feels istaught in school can one day impact a life or death decisiona pharmacist makes. It is important for a first- or second-year pharmacy student to observe and have this kind ofexperience as early as possible, because it makes everythinglearned in the classroom more applicable. The application ofknowledge that occurred on that one day was more valuablethan any exam taken in the classroom. Our time spent inthe Pediatric Intensive Care Unit gave purpose to ourprofession.

References

1. Haase M, Luedtke S. Assessment of pediatric services incommunity pharmacies. J Pediatr Pharmacol Ther. 2001;6:218–224.

2. Buck ML, Conner JJ, Snipes CJ, et al. Comprehensive pharma-ceutical services for pediatric patients. Am J Hosp Pharm.1993;50:78–84.

3. Condren ME, Haase MR, Leudke SA, et al. Clinical activities ofan academic pediatric pharmacy team. Ann Pharmacother.2004;38:574–578.

4. LaRochelle JM, Ghaly M, Creel AM. Clinical pharmacy facultyinterventions in a pediatric intensive care unit: an eight-monthreview. J Pediatr Pharmacol Ther. 2012;17(3):263–269.

5. Feudtner C, Dai D, Hexem KR, et al. Prevalence of polyphar-macy exposure among hospitalized children in the United States.Arch Pediatr Adolesc Med. 2012;166:9–16.

6. American Academy of Pediatrics Committee on Drugs andCommittee on Hospital Care. Prevention of medication errors inthe pediatric inpatient setting. Pediatrics. 2003;112(2):431–436.

7. Low J, Baldwin J, Greiner G. Pediatric pharmacy education forU.S. entry-level doctor of pharmacy programs. Am J PharmEduc. 1999;63:323–327.

8. Aucoin RG, Buck ML, Dupuis LL, et al. Pediatric pharmaco-therapeutic education: current status and recommendations to fillthe growing need. Pharmacotherapy. 2005;25:1277–1282.

9. Accreditation Council for Pharmacy Education. Accreditationstandards and guidelines for the professional program inpharmacy leading to the Doctor of Pharmacy degree. Accred-itation Council for Pharmacy Education. /http://www.acpe-accredit.org/pdf/FinalS2007Guidelines2.0.pdfS; Accessed January11, 2013.