A Touching Article Written by a 4PD Clerkship Student

On The Shoulders of Giants
by Jena Koshaish, 4PD Student, St. Pete Campus

It’s 7:55 am and I’m checking a random vancomycin level from one of my patients drawn earlier this morning. The level is 25.5; darn, we over shot! But it’ll be ok because they have pneumonia and acute respiratory failure, we’ll need troughs around 20 to be aggressive. I’ll have to see them first and figure out what happened. I ask myself:

•Are they still on pressors (norepinephrine, vasopressin)?
•They came in septic, how is their renal function?
•What is their urine output?
•Did we draw cultures?
•Is this still empiric therapy or are we dealing with MRSA?

These are just a few of the questions I’ve been trained to ask in the intensive care unit at Lakeland Regional Medical Center.


Working the ICU is one of the most exciting places in the hospital. Usually patients are on several medications, titrated to keep the patient as hemodynamically stable and comfortable as possible while their body recovers from the trauma or illness. Pharmacists play a key role in the ICU by titrating pain and sedation medications, dosing antibiotics, optimizing blood glucose control, renally adjusting medications, monitoring therapeutic outcomes, choosing appropriate therapy for a given patient, ensuring that evidenced based medicine is practiced by referring to guidelines and primary literature to resolve questions, and as a medication expert for nurses and physicians.

During my rotation I had the privilege to work with three amazing critical care pharmacists who pushed me each and every day to expand my knowledge of the commonly used drugs in the ICU. On my first day of the rotation I assisted with CPR during a code. As I walked into the dimly lit room, the patient’s family members were standing in the corner of the room with tears welling in their eyes as their grandmother/mother was dying right in front of them. The patient was intubated and the nurse had already begun chest compressions when I entered the room. My preceptor asked if I was comfortable giving chest compressions, I nodded yes. He took my white coat and I walk toward the patient’s bed. The nurse asked me if I was ready. I thought, ready as I’ll ever be. But I just nodded yes.

She stopped compressions and I quickly aligned my hands, one on top of the other, over the patient’s chest. As I pushed down on her chest, I heard the tubing of the ventilator crackling in her bronchioles and blood was coming up from the ET tube. It was the scariest thing I’ve ever done. After about a minute and a half I asked my preceptor if I could be relieved. Shortly thereafter the physician came into the room with another family member and told us to hold CPR; the patient’s family had signed the DNR. The nurse took her hands off the patient’s chest, the ventilator and pumps were turned off, and most of the staff in the room left. I washed my hands, put my coat back on and followed my preceptor out of the room. It was perhaps the saddest, most thrilling thing I’ve ever witnessed. From then on I knew this would be a very different rotation, but most of all it would be the best rotation I’ve had so far.