Beth Israel Deaconess Medical Center
Five things I learned during COVID-19 pandemic as a critical care pharmacist: As a recent graduate fresh out of critical care residency training, I never thought I would be getting ready to work in the front line of a national pandemic only a couple of months after the end of my residency training. To be honest, I am not sure any of us thought one day we would be going through what we went through in Massachusetts during the surge of the COVID-19 pandemic (or what some of you are going through right now).
I still remember when during my emergency medicine rotation we were discussing preparedness in chemical/bioterrorism attacks and went through the content of our medication boxes in our “secret hidden” room in the hospital in case of a mass casualty or bioterrorism. As a PGY2 critical resident, I never imagined soon I will be the one having to collaborate on a surge plan for my own institution.
- When please “DON’T Midaz” becomes “please DO Midaz ...” There is strong evidence suggesting that benzodiazepine-based continuous sedation is associated with prolonged duration of mechanical ventilation and increased ICU length of stay. We’ve all been told benzodiazepines are not your friend in the ICU unless you’re treating a seizure! I proudly say before this pandemic I cannot remember the last time any of my vented patients were on a continuous infusion of benzodiazepine in my MICU. But joke’s on me! This pandemic was a different game. Within weeks of the surge, we started getting emails from our purchasing colleagues that propofol supply was becoming scarce, which meant we had to modify our sedation practices from the best practice to the most “available” options. That meant having to decrease the number of intubated patients sedated with propofol, but increasing those sedated with midazolam or a mix of both. I was already receiving patients transferred from other hospitals to us due to a lack of drug availability for keeping them sedated while ventilated. The thought of having to paralyze an intubated patient without proper sedation and pain control is a nightmare for ANY critical care pharmacist, provider, nurse, or human being. This brings me to the next point …
- You’re more than JUST A CLINICAL PHARMACIST!!!!You probably are familiar with the concept of antimicrobial stewardship. But have you heard of sedation stewardship? On a daily basis, to efficiently reallocate our sedative and analgesic medications, all of my amazing critical care pharmacists would individually assess the appropriateness of each patient’s regimen and after clinical rounds actively work with nurses to effectively minimize the amount of sedative and analgesic drugs used for the maximal effect necessary to keep these patients synchronized with the vent. This meant spending a good portion of my day with one-on-one time with my amazing nurses to educate the team on the management of pain, sedation, and, who can forget about delirium in these patients who were alone in the isolation rooms with all the PPEs we had on looking like an astronaut. Your team depends on YOU!
- When you go from being a PHARMacologist to a MIXologist real quick (#respect to all the anesthesiologists). With all the drug shortages that were (is) happening, you quickly learn that you either have to adapt or you will drown in the consequences of your poor management in drug allocation. Yes, I know! A continuous infusion of fentanyl or midazolam is more “convenient” and more “pharmaceutically elegant,” but have you considered having to put a fentanyl patch on your intubated patients to slowly wean them off of the fentanyl drips they have been on for days or having to start giving them intermittent diazepam injections to wean them off of midazolam drip because you HAVE to save the drips for those who need to be paralyzed for severe ARDS during a pandemic? On a daily basis, my colleagues and I were faced with these difficult decisions at various levels in different clinical scenarios. We used our clinical knowledge and experience to come up with alternative drug therapy options that were going on shortage. At my institution, this meant more and more of my intensivists started to show some love to “Special K” and became significantly more comfortable with using ketamine for analgosedation.
- Smizing (aka smiling with your eyes) is an effective method of communication behind masks. COVID-19 has not been easy on any of us physically or emotionally. I think this is an area that as a profession we have more room to grow and learn. I personally don’t remember having a class or lecture during pharmacy school about how to cope with the emotional stress of being a healthcare professional. I think my profession has always been so focused on training me to be a good clinician that it missed the opportunity to teach trainees on how to deal with the death of a patient emotionally or how to not burn out under the pressure of striving to be a perfect clinician. While the number of COVID-19-positive patients has significantly decreased at my institution, I can still hear the vent alarms for all the patients who would all (ironically in a synchronous fashion) experience asynchronous events on their ventilators.While the noise may not seem bothersome at all, you would be surprised by how much stress it would add to the nursing staff or respiratory therapists. That noise meant someone had to gown up to go inside the room to adjust the vent setting or adjust the sedative doses to make the patient more comfortable. More time inside the room meant a higher probability of being in close proximity to a patient with an airborne illness. I will forever remember the images of dying patients in their death beds alone because their loved ones couldn’t be at their bedside for one last time. Did my profession fail me or did I say I fail myself for not knowing or learning about how to deal with the emotional weight of losing numerous patients I was taking care of on a daily basis? The people who kept me sane during this pandemic were all my awesome MICU colleagues from the attendings and nurses to the RTs and environmental lady who made sure my workstation keyboard was double sanitized every morning before I used it and she would smize at me behind her mask every morning, thanking me for being there while I was the one who was internally and utterly thankful for her presence. It is sometimes impossible to expect your body and brain to both function at their maximal capacity. Reach out to a friend or a work buddy and talk it out if you’re overworked and overwhelmed. It might be therapeutic for both of you! (For those unfamiliar with the cultural phenomenon of America’s Next Topic Model, “smizing” is the act of “smiling” with your eyes) .
- You will be surprised by the good things that come out of a pandemic! For my institution, this meant a change in the way we practice at so many levels. We realized the amount of drug waste we created on a daily basis. With all the drug shortages going on, this meant not spiking that bottle of propofol early for “just in case reasons” or being more amenable to alternative therapy options that would require nurses to enter the room less frequently to decrease their exposure time to infected patients. As a clinical pharmacist, I learned to actively think about all the waste I was creating! Did I really need that Q6hr POC glucose for that intubated-but otherwise-healthy patient or was once a day spot-checking glucose on daily labs was enough to stop Q6hr glucose monitoring? As the COVID-19 surge is subsiding in Massachusetts, it is rising in other areas. I want all my colleagues in the hotspot areas to know that you’re not alone in this. Use social media to your advantage. If you need help, seek one. Don’t repeat the same mistakes that we made and learn from our experience. There is light at the end of the tunnel. Next time, before you run to that code blue make sure you have your mask on and you’re properly donned before entering the room. Remember, there is no emergency in a pandemic. Your team and your patients need you! Every morning when I walk to my MICU and see these ventilators on standby, it reminds me of all the hard work and greatest things we accomplished as a TEAM TOGETHER.
Mehrnaz Sadrolashrafi, PharmD, BCCCP, is a critical care clinical pharmacist at Beth Israel Deaconess Medical Center.
Posted April 1, 2021