In March 2020, the Horvath family’s world was flipped upside down. Only 10 days after the first statewide COVID-19 emergency closures were instated, then-8-year-old Colby was diagnosed with B lymphoblastic lymphoma.
This spring, the number of acutely ill COVID-19 patients swelled at Massachusetts General Hospital, prompting the conversion of several units into temporary intensive care units (ICUs). Critical to the patients’ care were medications—not only for potential treatment, but also for the sedation and pain relief needed to cope with mechanical ventilation.
Yet there weren’t enough critical care-trained pharmacists to handle the growing demand.
Help arrived from an unprecedented place: first-year pharmacy residents. Stephanie Seto, PharmD, was the first to volunteer. “It was hard to see our colleagues strained with the large influx of such high-acuity patients,” she says. “I wanted to help if I could.”
The eight residents had been undergoing their typical training they had started after graduating pharmacy school in May 2019, rotating through a different inpatient pharmacy specialty each month. When COVID hit, the five who had previously completed their required ICU rotation volunteered to spend evenings extending their training in the ICUs. The remaining first-year residents were certified to work in the cleanroom—where sterile IV medications are compounded—and assisted with increased operational needs.
Blake Barlow, PharmD, MBA, then in his Introduction to Pharmacy Operations rotation, analyzed drug utilization data each day to share with pharmacy leadership to keep an eye on potential shortages. “The usage of ketamine infusions shot up by 500%, and hydromorphone infusions by 1,000%,” he says. “And when general care units were converted to ICUs, often with only a few days’ notice, we had to completely convert our automated dispensing cabinets to handle the needs of an ICU.”
The residents in the ICUs found themselves adapting to constant changes to drug regimens. “Sometimes there were multiple changes a day,” says Seto. “Because this was a new disease, it was uncharted territory, and departments such as Infectious Diseases and Hematology routinely updated guidelines. Also, it was difficult to maintain sedation and analgesia for these patients, so guidelines were developed with the help of pharmacists to assist in the titration and weaning of these medications. But we were up for the challenge.”
Adds Assistant Director of Pharmacy Laura Meleis, PharmD, MS, BCPS: “While working with the ICU team to optimize a patient’s therapy, the residents, and pharmacists, also had to note the rapidly changing operational aspects associated with impending medication shortages—for example, switching hydromorphone infusions to fentanyl infusions—keep up with new clinical trials and communicate those with the health care team.”
Though there was help at hand, the residents quickly functioned as independent clinical pharmacists. “For a new pharmacist, it can be intimidating verifying your very first medication order, even if it’s just Tylenol,” says Meleis. “For a first-year resident to round in a COVID ICU, provide recommendations to ICU providers to optimize care and verify ICU medications is a big deal.”
One typical function of clinical pharmacists is to staff a code cart during a code, quickly preparing requested medications and recommending other medications that might be needed —a situation made more challenging by COVID, which prevented pharmacists from entering patient rooms or overhearing what was happening, instead left outside to anticipate any possible need.
“This job, which is stressful at baseline, was made all the more challenging by COVID,” says resident Emma Uchida, PharmD, MBA. “But there were resources, including our peers, to help us through.”
Despite the stress, the residents found that their experience reinforced their passion for the field. “I chose pharmacy because I can advocate for patients in a way that’s different from other medical professions,” says Uchida. “This experience reinforced the impact that a pharmacist can have on a team, and the fact that pharmacists play a vital role in optimizing care.”
Adds Seto: “I worked in a unit that had been converted to an ICU, and it was staffed by a wide variety of clinicians. COVID prompted the attitude that we all had to work together and lean on one another in order to take the best care of our patients. It was really inspiring.”
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