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Reality vs. Expectation: Being an Emergency Department Pharmacist (GOT Version)

In my opinion, Emergency Medicine (EM) is one of the most dynamic and exciting practice environments for a pharmacist. Emergency medicine is also a very rapidly growing specialty in pharmacy as shown in the 2014 AJHP Pharmacy Practice Survey where 16.4% of hospitals responded to have pharmacists staffed in the Emergency Department (ED) up from 6.8% in 2008. This growth is creating many job opportunities for new and experienced clinicians alike, and it is also driving many students to seek out learning experiences in the ED as well.

When it comes to reality versus expectation, everyone has a preconceived notion of what working in an ED is like. Some expect it to be like the television drama, ER, with constant excitement, passion, and mystery. Others expect it to be like MASH, comraderous frontline medicine always on the verge of disaster. In reality, both of these examples are hilariously inaccurate and true at the same time.

Of the many unrealistic expectations about the ED, one of the most insidious I continue to encounter over and over again with my students and residents, is fear. The fear of inadequacy, the fear that you won’t be able to handle working in the ED, and the fear that you won’t live up to expectations. So if we are talking about reality versus expectation, let’s start there…

1. The ED is too scary and I can’t handle the pressure

Over and over again my students and residents start day one in the ED with some version of the line, “I’m nervous I’m not gonna know what to do [in an emergency].” I usually reply with something like,”of course you won’t know what to do, that’s why you’re here.” The point I eventually get to is that the weight of the entire ED does not rest on their shoulders alone.

Working in the ED is to be part of a team, sometimes a slightly dysfunctional team, but a team none-the-less. There is in incredible wealth of combined knowledge and experience in the ED and in the worst possible scenarios everyone will come together to contribute what they can to try to save a life. I tell my students that if they want to step back and learn, they can, the team will still take care of the patient. If they want to jump in and run the code cart or help with chest compressions, sure it won’t be easy the first time, but they have prepared for this and someone will back them up if need be.

When it comes down to it, it’s less a lack of knowledge and more lack of confidence in their own capabilities that really scares people. Confidence will only come with practice and sometimes you just have to jump in with both feet.  My best advice is don’t take things personally and keep your cool, sometimes people get a little snappy with the rush of adrenaline, and that is normal human nature; all you can do is stay cool, stay observant, and do your best.

2. ED staff doesn’t want pharmacy there

I am incredibly spoiled. I have basically worked in the ED for my entire career as a pharmacist and I have forgotten what it feels like to be yelled at over the phone. A great part about working in the ED is that you are physically there, face-to-face, with the team. You make connections, you gain the trust of your coworkers, and it makes all the difference. Once someone understands how much you have to offer and how much easier you make their job, they won’t let you leave!

Another great part about being a pharmacist in the ED is that everyone thinks you have magical powers. To others, every question that they ask the ED pharmacist, be it medication related or not, gets magically answered almost immediately. The truth is, obviously, that I don’t know everything, but I am really really good at finding answers fast. That brings me to my next point…

3. There’s too much stuff to know

When I was finishing up pharmacy school, I did not want to specialize because no single field interested me enough to focus primarily on that. It was by pure luck that I ended up working in the ED and for me it was the perfect fit. Emergency Medicine Pharmacy is more of a specialty of skills than it is knowledge. Many of the ways you go about practicing pharmacy in the ED is different than anywhere else. The thought processes, the rationale, and the goals are all unique to EM and require a great deal of practice and experience to perfect.

On the other hand the knowledge base needed could not be more broad. How can you remember how to take care of anything that could come through the door, be it a bruise or gunshot, a cold or ebola? The answer is, you can’t. But here is where those skills come in; you review the case, take what you know, look up what you don’t, and make the most educated decision possible. Do that over and over again, and the whole process gets tighter and faster, but you will never know everything. The best clinicians never forget that.

4. The ED is always crazy

In reality the ED is 95% run of the mill clinical pharmacy accentuated by 5% intense high acuity situations. Admittedly I work in a relatively busy ED with moderate acuity, so my ED is not the craziest. There are certainly more high action trauma centers in the city, but we have an exceptionally complex patient population. Most nights I play de-facto antimicrobial stewardship pharmacist mixed in with a little cardiologist, neurologist, and anesthesiologist.

Many people think that the ED is all blood guts and action, but most of the time it just chest pain and headaches and STDs. Not to say that that stuff isn’t interesting because there is never a night that goes by where I am not challenged to solve a number of complex clinical scenarios, and that’s where the long term satisfaction comes from. Sometimes I get lucky and encounter really unique clinical case which allows me to feel all “Dr. Housey.”

While the high energy stuff is interesting, when you can solve a complex problem and help the patient, that’s the real good stuff.

Bonus point

There is one unfortunate reality that is all too common in the ED (and in healthcare in general) and that is learned complacency. Due to stress, disappointment, and disillusionment it is very easy to slowly care less and less about what you do. The worst manifestation of this is when you stop looking at your patients as people. The truth is, it takes a great deal of personal strength to keep your sights clear and remember that you got into healthcare to be a caregiver. Not to document, not to just get through your shift, not to have disputes with co-workers but to make another human being better than they were before they met you.

Very few individuals can keep that truth clear throughout their career and I have so much respect for the nurse or doctor or pharmacist who always cares for each patient with the same attitude as if it were their first. For the rest of us, the best we can do is to remind ourselves every so often that our patients are our mothers, fathers, sisters, brothers, sons, and daughters.

This article was originally posted on (sans Game of Thrones gifs)

Robert Pugliese