Teaching: heads you win; tails I lose! (Emma Graham-Clarke)

Emma Graham-Clarke

I have worked in critical care for more years than I care to remember. Despite the heartbreak that you see, the patients who make it — seemingly against all odds — and the strength of the teamwork make it worthwhile.

Critical care continues 24 hours a day, seven days a week, looking after a constant stream of patients with serious illnesses. For the critical care pharmacist, these patients present an array of pharmaceutical challenges. But I don’t work 24/7 so what happens when I am not around? Or, more to the point, how do I enable the other prescribers to make appropriate prescribing decisions when I am absent? This is a particular issue since many of our junior doctors are new to critical care and so have not built up the reservoir of experience that consultants have.

The obvious answer is by teaching, and teaching at the point of prescribing is a great opportunity. This is where I start debating with myself — should I talk the doctors through my thought processes and then let them prescribe? Perhaps, but then I lose out on practising myself. Or do I prescribe and potentially lose out on the chance to teach them? It is a bit of a case of heads you win, tails I lose! I also need to remember that what seems standard practice to me might be something new to the junior doctors.

A case in point was a patient who had been admitted with mediastinitis and had developed atrial fibrillation (AF). Unfortunately after each treatment attempt he would have a short period of sinus rhythm then would drop back into AF. At one stage he was on digoxin and the doctors were contemplating adding in amiodarone. Oh, and the patient had renal impairment. To say my alarm bells were ringing would be an understatement!

The thoughts going through my head included (in no particular order): what is his renal function today; we need to check the digoxin level; how valid will the level be since he hasn’t been on it for long; the dose of digoxin needs to be halved; does he still need digoxin; is amiodarone appropriate; how will the amiodarone be administered?

As I started talking through my concerns, I suddenly realised that the things I’d considered automatically were completely new to the junior doctors. Ten minutes later, after a quick tutorial on digoxin and amiodarone, we decided to stop the digoxin and load with amiodarone — maybe not the tidiest of approaches. But at least the doctors have a bit more knowledge, and if they face a similar situation they’ll be better informed.

Emma Graham-Clarke is consultant pharmacist for critical care at Sandwell and West Birmingham Hospitals NHS Trust