Surviving ED Pharmacy 101

If you know anything about the emergency department (ED), it can get crazy. Pharmacists are some of the smartest people out there, and they often come across many different types of medical information but sometimes it’s hard to keep track of everything that you’re reading and bookmarking online. Based on a request, below are some bookmarks that I’d recommend for any emergency medicine pharmacist entering this realm.  Whether you’re working with your team or just studying on your own, these resources can save you time and help answer questions quickly.

Paid Resources

This depends if your hospital or school provides access because some may not. In order of most used to least used, these are the resources I use at my hospital. 

  • Lexicomp – I use this to double check:
    • Drug interactions (ie. can olanzapine IM be given with a benzo IV? – No, due to risk excessive sedation and hypotension) 
    • IV compatibility (i.e. can norepinephrine be Y-sited with vasopressin because the patient only has one IV line? – Yes it can)
    • Drug identification (i.e when a patient brings their home medication and nobody knows what it is, you can search to see all the different manufacturers)
    • Policies – All our hospital policies are centralized in Lexicomp but this may vary per hospital. 
    • Doses, administrations, expirations, indications, Briggs (to check if a drug is safe for pregnant patients) etc are available in the search bar. 
  • UpToDate – The most comprehensive resource in my opinion. I like UpToDate because it provides everything from updated recent studies to algorithms that you can use to reference when discussing treatment with evidence-based-medicine. 
  • MicroMedex – I consider this a simpler version of UpToDate. It describes disease state management and gives a simple list of drug options for each treatment. I prefer UpToDate because it includes primary research but sometimes I use MicroMedex to get a quick snapshot summary. 

Free Resources

  • Creatinine Clearance – you will be calculating this literally every day because almost every antibiotic is renally cleared. I’ve done it so much that I can already do this equation in my head.
  • CHEM7 labs – you have seen these values from school. Noting a major change in lab values can alter each drug therapy. 
  • MDCalc – has a decent ANC calculator, corrected calcium (I memorized this in pharmacy school), an other helpful calculators including Alteplase TPA that I use for every stroke code.
  • Steroid Conversion – I mostly use this to convert the creams and ointments since we don’t have every formulation in hospital.
  • Opioid Conversion – Fun fact: the least to worst opioids for QTC prolongation/arrhythmia is morphine and buprenorphine < oxycodone and tramadol < methadone being the worst.
  • Antibiotic Coverage – a great little pocket guide you can use to quickly reference which antibiotic covers what.
  • GlobalRPh – this website has a lot of helpful calculators including vancomycin AUC, aminoglycoside, NSAID selection if patient has a GI bleed (celexicob), and more useful tools.
  • Other random calculators: acetylcysteine for liver poisoning/failure. It’s typically a treatment of three IV bags, it smells, but when you see a patient with AMS and a 1,700 ALT level, you might see this order for damage reversal.
  • Can it be crushed? – This is the Handbook of Enteral Feeding that can be useful if you have a patient who can’t take medications orally and has a G-tube. I control + F and see if certain medications can be crushed.
  • Pubmed – for the specific case studies, unique patient/drug situations, when guidelines don’t have the answer, Pubmed is there.
  • PharmGuides – you’re here! A centralized database of clinical guidelines.

Other resources should be provided by your hospital. Every hospital is different in what they would allow in the ED based on management decisions and policies.

  • IV Push list 
  • IV Drip list
  • Heparin IV Dosing and Monitoring Policy
  • Electrolyte Replacement Policies (Potassium, Phosphate, Sodium, etc)
  • An inventory list of what your ED hospital has – knowing where everything is, shortages, and alternatives helps tremendously. It should be constantly changing and optimized.
  • … and other resources your hospital provides. If they have an antibiotic renal dosing chart, monitoring chart, etc, might as well use them!

Typical workflow

In the emergency department, patients arrive with a medical problem and get registered into the electronic medical record by the front desk. They are then prioritized by their level of emergency to be seen by a doctor which may be an attending, PA, or medical resident. A stroke patient will be seen before a patient with back pain. A patient with a gunshot wound will have the entire ED team attending to the patient to stabilize them before seeing the patient with a UTI. As you can imagine, the ED staff can be physically and mentally worn out on a daily basis and why the wait time can be up to 6-8 hours.

Your job as a pharmacist is to help out where you can in profiling medications, ensuring safety and efficacy of drug therapy, preparing IV medications, having knowledge of what medications are available for which disease, their locations and availability in the hospital to reduce delay of treatment.

As medication orders are entered by the doctors, you review their medications, verify the correct dose, administration, timing, quantity, indication, etc. After you verify/release the medication, the nurse will dispense from the automated dispensing cabinet (ADC) and administer it to the patient. If it’s not in the ADC, it’s your responsibility to locate the medication from other satellites for the patient or suggest an alternative. If the medication order is not correct for any reason, you’d reach out to the doctor to adjust the order. The ED work dynamic is my favorite because the doctors, nurses, technicians, EVS, registration, and security are located in close proximity so it’s easy to walk over and directly communicate about anything. 

Depending on how many patients you’re handling, there’s only so much time you can give each patient to review their medications. The ED is fast paced. There are moments where I am the only pharmacist for 200 patients so I have to work relatively fast and have decent knowledge of each disease state and medications. When I review patient information, I focus on their principle problem (why they are here), glance at key information* and check their medications** before verifying. 

*Key information I glance at: age, allergy, creatinine, vitals, main problem, comorbidities, pregnancy status if female <45 years old, QTc if a QTc medication is ordered, etc depending on the patient
**Examples of what I check before verifying: medication duplication, timing of medication, appropriateness for the issue (indication or bacterial coverage), dose doesn’t pass the maximum allowed, what line (central vs peripheral) patient has inserted and ensuring the IV drug runs at a safe rate to avoid extravasation, CrCl dosing is accurate, drug levels to make sure they don’t reach toxicity, home medications, proper use of guidelines, etc

Everyone has their own method towards profiling orders depending on their work style, environment, how many patients they’re handling, how meticulous they want to be, etc. My method may not work for every scenario or individual or satellite, therefore be mindful that there is always room for adjustment and improvement. 

To Students: Unfortunately writing all those SOAPnotes is not reflective of reality. It helps you organize your thoughts and knowledge but you are not writing SOAPs in real life. Imagine taking 30 minutes writing up one patient and you have 200 total, you’d never be able to finish and your patients would probably be waiting 40 hours for their medication. 

With that being said, take the time in pharmacy school to build that foundational knowledge but don’t feel stressed. All those CrCl cutoffs, drug interactions, drug treatment regimens, etc are accessible online in reality. The only time you’ll need to memorize this much information is in school. Strengthen your peripheral memory now because you’ll never know when you will apply that knowledge in reality. By the time you get to the real world, you will be fully equipped as long as you know where to look and find answers. Hopefully this article helps you get some perspective of what to expect working as an EM pharmacist. Good luck!

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