My Job
By general standards, I do not have a “cool” job. When people hear I am a pharmacist, there are four automatic perceptions:
- I make A LOT of money!
- I know detailed information about most drugs.
- I count pills.
- I work in a retail/big box store (Walgreens, CVS, etc).
And although this is too much for Atticus to read and understand, I want to break these four points down between perception and reality.
Perception 1
The first perception is true. By the United States median pay, my compensation is above the national average. I do not believe this will last forever though and within the last ten years, many new pharmacy schools have opened, meaning, more students graduate. These graduates are facing reality: an oversupply of pharmacists and shock from decreased salaries. This article reiterates my opinion of the profession moving into the future. Not only are there too many pharmacists in certain localities, but salaries are decreasing as it is a supply and demand issue. Last year, I saw a posting for a position in Colorado with a starting rate of $35 an hour. Many will say that is a lot of money for a salary. (If one basically doubles an hourly rate and add three zeroes to the end, an annual salary can be estimated (2080 hours worked in a year = 40 hours a week x 52 weeks in a year). This would translate to approximately $73,000 a year. Not only is the cost of living higher in the Colorado area than other places, but another consideration is MANY of these new graduates have loans exceeding $100,000 (and I know of graduates with $200,000 — 300,000+). Several coworkers are utilizing the public service loan forgiveness program as the prospect of ever paying off $200,000+ (with interest) would otherwise burden their monthly financial situation. (This is not just limited to pharmacy, but many other professions: physician, dentist, lawyer, undergraduate/graduate degree, etc.) I am not trying to justify my salary against the student loan debate, but the unfortunate reality is, the pharmacy career has been sold as one with a rewarding financial compensation package, but the truth is, the cost for that reward can be quite high for many seeking a life in this profession.
Perception 2
Perception number 2 is I know everything about most medicines; that I am a drug expert. Under no circumstance is that accurate. I know a good deal of information about the medications I routinely use in everyday practice, but there are many, many drugs out there for which I have very limited, if any knowledge, unless I research the information. From an FDA website, I think this should help give an idea:
There are over 20,000 prescription drug products approved for marketing.
First, based on their wording, I am assuming this does not include the OTC (over the counter) products. (Prescription meaning an order from a licensed practitioner, not an OTC.) No human can retain that much information about so many different products, including names, interactions, pharmacodynamic and kinetic profiles and costs, just to name a few of many data points for a medication. Point is, I feel confident with the medications I use on a daily basis (although I do go back and double check information all the time), but that is a very small subset of the total number of available medications.
Perception 3
Perception number 3: I count pills. This is completely false. I am willing to bet, many pharmacists in the retail setting do not either. That work is likely performed by a technician or an automated machine. As I was preparing this post, I saw an article which confirms my statement. The process for the retail setting is the pharmacist or technician will receive the prescription and enter the details into the patient profile. The prescription is checked against other medications for duplicates or interactions, if applicable, and also processed through insurance to determine if a copay or prior authorization is necessary. The technician or pharmacist will fill the script once those processes are complete and package the prescription for distribution to the patient. Usually, but not always, these medications may come from “stock bottles” in which large quantities of medication are stored (100 – 1,000 count bottles). This is because those prescriptions are for 30 or 90 days, hence the need for higher pill count bottles. This is the opposite of the hospital world where we dispense individual (single) doses of medicines. Take a common cholesterol lowering medication, Lipitor (atorvastatin): in the outpatient world, a bottle of 30 or 90 tablets will be dispensed. In the hospital, the pill is packaged in an individual setting, with a barcode, in which the patient and medication are scanned to ensure “right patient, right medication”. (Not all facilities do this, but many do.) Do errors still happen? Sure, but technology is advancing to try and limit these incorrect scenarios to lessen the chance of patient harm.
Perception 4
The final perception is I work in a retail setting. I have not worked in a retail setting for over 11 years. Initially, after graduating and obtaining my license, I worked in a retail store, Rite Aid, floating between Tennessee and Arkansas. After six months, I had an opportunity to transition to a hospital, specifically, The MED (now known as Regional One Health) in Memphis.
I took that opportunity and never looked back. Several months after starting at The MED, I was asked if I wanted to work in the emergency room as the then current pharmacist was leaving. There was much trepidation and honestly, the prospect was enticing, but I felt I was in over my head. Talk about a training experience: The MED is a Level 1 trauma center, along with a burn center, and high-risk OB service coupled with a neonatal intensive care unit (NICU). (Side note, I was able to see conjoined twins in the NICU before they were transported to Le Bonheur for separation.) We also served a large majority of indigent patients throughout the community, who had many challenges, not just with affording care, but also reading, knowledge and understanding of their medical situation as many had low levels of education. Initially, before graduation, I applied for and did not match in a spot for residency. Hence my work in retail for half a year. But luck has a way of working out and after working at The MED for a while, I was granted an opportunity to complete a “non-traditional residency” to enhance my training, experience and knowledge in pharmacy. Now, one might ask, what exactly does a pharmacist in the emergency room do? I have been asked this question by family and friends and have never been able to explain the answer as most everyone's perception is that of a “retail” pharmacist. I am going to try to with this post. Although this is in not definitive, here is a subset of what a day might involve:
- One of my most basic job functions is a medication reconciliation. I will interview (or review paperwork or call a patient family representative) and ask what medications he or she is taking at home (prescription, OTC, etc.). I will compare it with what is in the hospital system prior to admission (PTA) list for accurate dosage, formulation, addition of new medications or deletions of inaccurate ones. This process, hopefully, ensures that if the patient is admitted, most of the medications ordered are correct. I try to prioritize those with high risk medications: blood thinners, certain cardiac medications and anti-rejection medications to name a few. As an example, Gulf Coast used to perform kidney transplants. These patients would receive the transplant and, if necessary, return to the hospital if there were complications or became sick. What medications the recipient was on depended on the time since the transplant. Having an updated and accurate record of that information is vital as we do not want the anti-rejection medications to be too much or too little in dosage given the sensitivity of the transplanted organ.
Just an example that will make more sense later. - Along with medication reconciliation is verifying medication orders. These are orders for patients who are admitted and what medications will be administered. Just like in retail, a physician or midlevel provider will order a medication. I review the patient’s current medication profile and clinical presentation to make sure it makes medical sense. (An example is a physician orders a blood pressure lowering medication for someone who is already on medicine to RAISE their blood pressure. I will contact the physician and ensure he or she did not mean to order a different medication given the clinical presentation of the patient.) I can do this anywhere I have a computer and access to our electronic health system (although it is vastly easier to be physically at the hospital); I even worked from home when I had COVID in August of 2020. This is not just limited to when I work in the ER, this can also be when I work in the “central” pharmacy. But those orders not only cover the ER, but also the ward patients throughout the hospital.
- But, my primary work environment is the ER. And within it, I have a variety of functions. An example may be a physician wants to send a patient home (non admission), but the blood pressure is elevated. I may be asked how I would adjust or add medications to help achieve a desired blood pressure goal. Again, I review the profile for what might be some options, speak with the patient (assess understanding and competency) and then give a recommendation. This may hold true, but not limited to, someone who is diabetic needing adjustments in therapy prior to visiting a primary or endocrinology doctor.
- Most days, I receive an alert in our electronic health system, which notifies me of a positive culture result of a discharged ER patient. When a patient visits and an infection is suspected, a collection from blood, skin, or urine, etc., may be obtained and sent for analysis. At discharge, the provider prescribes an antibiotic which is presumed to be useful against the suspected organism. Cultures can take a few days to grow for analysis and antibiotic sensitivity, hence there could be a mismatch in the bug/drug combination based on results of the culture. If a mismatch exist, I will decide if a change is warranted or not. I send the recommendation to the physician and he or she will sign off on it. Having pharmacists involved in this process cut our culture follow up times from an average of 2 days to less than 6 hours.
- But, there are other, more exciting, clinical aspects of what I do, especially in the emergency room. Being in the ER, I respond to multiple types of codes. These include CODE STROKES, BLUE (cardiac/pulmonary arrest), and TRAUMA. (We have an actual 'red phone' which is a direct connection to Lee County Dispatch, who calls ahead with these types of codes or other serious events.)
The black one is a two way radio with EMS to give us information about the inbound ambulance's patient. This can help us determine what type of room the patient will need (high level or normal). Sometimes I will be the one to speak with them and record the information on the paper next to the phone. If it is something serious, I let the charge nurse know so patients can be moved if necessary.
As Gulf Coast is the comprehensive stroke center for southwest Florida, we receive ALL EMS stroke alerts. Part of this treatment may involve giving the patient a ‘clot buster’ which will hopefully dissolve the clot. (In addition, the patient may go to the NI (neurointerventional lab) to have the clot removed with a catheter guided wire.)
– To continue, a physician may come by and say, “Room 1 has sepsis; fix them.” What does that mean? It means order the proper medications. First, can the patient tolerate getting fluids and if so, how much? What antibiotics would be best for this patient? How is the blood pressure and what is (are) the best agents to use if say the blood pressure is low but the heart rate is elevated. Will this patient need any additional testing (i.e., a test where we can see if fungus is growing in their blood)? Using these questions as a baseline I start order what I think is the best answers to those questions.
– I may retrieve those fluids, antibiotics and blood pressure medications I ordered and help prepare and hook them up to the patient. It can be invaluable to be an extra set of hands to a busy nurse.
– But, if I am busy with something else and the nurse taking care of the patient with sepsis calls, he or she may ask if multiple medications are compatible, meaning, he or she has limited intravenous (IV) access and needs to administer multiple medications/fluids through maybe one or two IV lines. Usually these patients receive boluses of fluids, multiple antibiotics and potentially one or more 'pressors' (medicines to raise the blood pressure). I will review the medications and using what I know and a few clinical programs, will determine the best way to administer the medications as some medicines cannot be mixed within the same IV line (we call this ‘Y-site compatibility’).
– Speaking of anti-rejection medications, some medications need to be monitored given there is a therapeutic index for what is ideal between not effective, just right and too much.
Pharmacy is usually the group who monitors these types of medications and in cases, depending on the laboratory work, will make adjustments to the dose to ensure that the drug remains in that therapeutic range.
- A drug concentration may be too low in someone and thus we need to load them to achieve a higher concentration in a short amount of time. Think of someone who might be on an anti-seizure medicine. If he or she has not been taking it, subtherapeutic concentrations are likely to the result. I will calculate a loading dose of the medication given certain parameters.
- Conversely of that, if a drug concentration is too high, I may be asked to reverse the effects, if applicable. An example is a blood thinner Coumadin (Warfarin) that has a fairly narrow therapeutic window. But if a patient presents with a brain bleed while on it, it is imperative to try and reverse the effects of the blood thinner as quickly as possible.
- If a CODE BLUE situation occurs, I am usually standing by the code cart (which stores medications and supplies). I may prepare and administer (or hand to the nurse to do so), medications used during resuscitation. There are times, since the defibrillator sits on top of the cart, I may 'shock' the patient to try and ‘reset’ the electrical rhythm of the heart. Rarely, but there have been times, I administered CPR (pumped on someone’s chest) during resuscitation.
- And on top of all that, I precept pharmacy students and residents (those who have graduated pharmacy school and seeking additional training). These individuals are with me for about a month and depending on if he or she is a student or resident, depends on the level of autonomy and supervision. We were all one, but students are generally the hardest as they have limited knowledge and functionality within the acute care setting.
Many people think of a pharmacist and envision someone at a retail store, standing behind a counter, dispensing medications in bottles and counseling patients. Of the approximately 300,000 pharmacists in the profession, I would estimate MAYBE 1 – 2% of that number are working in emergency rooms. This post, albeit very long winded, is a more detailed way to explain what a day is like as a hospital pharmacist, one specifically working in the emergency room. Not every emergency room has one, but more and more each day are placing a pharmacist in the environment, not only for potential cost savings, but also for enhanced drug information and optimized patient care. You may not realize it, but it is not just techs, nurses and doctors taking care of patients. I fully admit my position is a unique one. I was lucky enough to stumble into this position a decade ago. The days can have some monotony with respect to patient presentation, but when there is action, it is that organized chaos which makes my job unlike many others in this world. There are not many who can say he or she educated a patient on a new blood thinner before being discharged, then went to another patient and gave a thrombolytic (clot busting drug), moved to another room to an unresponsive person in cardiac arrest who did not survive despite our best efforts and then went to the trauma bay for an incoming trauma all within 60 minutes of a day. A person's life can change in the blink of an eye. Long days are a reality, but being in this type of environment, I am more appreciative of my health and status in life as I walk out the exit door each day.