Who Wants to Live Forever?

In 1986, the rock band Queen asked a simple question, "Who wants to live forever?"  Everyone has asked that question, and Dr. Elizabeth Blackburn and her team won a Noble Prize in pursuit of that discovery.  They found an answer the the biological cause of aging: telomeres.  Jalees Rehman wrote an extensive piece on the topic on SciAm's blog page.

Telomeres protect the ends of our chromosomes

Not long after the discovery of telomeres and their enzyme, telomerase, people began dreaming of a magical elixir of life to reverse aging.  Aging is, unfortunately, a very natural process.  As cells live, they because damaged due to various forms of stress and attack.  To survive, they must reproduce to make more cells.  This requires the replication of the genome.  DNA synthesis splits open the double helix and copies the unpaired nucleotides to produce an identical strand.  Well, almost identical.  The ends of the chromosomes get a little bit difficult and some parts of the ends don't get copied.  The best analogy is the ends of a string.  The ends fray the longer it gets used.  So how do you protect the ends?  Shoe laces have plastic covers called aglets, and your DNA has a telomere.  The telomere is noncoding DNA at the end of a chromosome.  A little bit of the telomere frays away every time the cell divides.  This determines the lifespan of the cell.  Once the telomere erodes away, important coding genes become damaged and the cell must die.  The accumulation of this type of death is called aging.

Dr. Blackburn learned that a sample of DNA can provide enough information to learn about a person's health.  People with longer telomeres were biologically younger, even if not chronologically.  Those with short telomeres were three times more likely to have cancer.  Cancer cells have activated telomerase that repairs the vanishing telomeres producing a cell that never dies.  Cancers cause problems because they have too much telomerase.  Every cell has telomeres, but not every cell has telomerase.  This is so that cells can naturally die out of the way, but cancer messes that system up.

So having too little telomeres can cause the problems of aging.  Too much telomerase can cause the problems of cancer.  Then the healthiest has to be right in the middle.  So their might not be a magic potion to reverse aging and rebuild our telomeres.  At least not without significant risks.  Instead, have have to protect the telomeres we have.  Reduce the stress we put on our cells and let them live out their full potential.  You won't live forever, but you might make it a long time.  Besides, who wants to live forever?

LLWS Coach Inspires His Losing Team

What do you say to kids after they lose?  After the lose in the Little League World Series?  On National TV?  David Belisle's post-game speech to his team might be one of the best things you will see in a while.  A lot of bad is happening in the world - from Iraq to Missouri.  But this is some much needed good.


I played sports from Kindergarten to College - basketball, football, wrestling and more.  I was a coach for 7 seasons.  I love competition and I absolutely hate to lose.  This guy puts it the right way.  No this doesn't mean to always be proud of losing.  But when you play the right way, do the right thing and put all your effort and intensity into the game, sometimes you still lose.  If you Play Hard, Play Smart, Play Together, you can be proud.  This speech reminds me why America loves our sports.  Why athletes are more likely to be hired than non-athletes.  We want people that work hard, people that can come together, and people that can learn from their losses.

TED Talk Tuesday: Charlie Todd

Charlie Todd does improv in New York City.  In one of my favorites, he talks about the shared experience of the absurd.  People doing weird things in public just for the amusement of others.  Which is very different from doing weird things just for your own amusement.  The most important thing is that it is all in good fun.

Enjoy!

Your Skin Through UV

In our therapy class, we are talking about dermatology.  Our first SOAP note, due Wednesday, is about skin care and sunburns.  Most of the damage caused to our skin comes from Ultraviolet Radiation.  UV rays come in three flavors - UVA (aging), UVB (burning), and UVC (blocked by ozone layer).  To protect yourself from burning, aging, and potential skin cancer, everyone should use sunscreen.  The fairer your skin, the higher the Sunburn Protection Factor (SPF) should be.

The video below will show you why.  We have ultraviolet cameras now which can show you what your skin actually looks like.  Thomas Leverit took a UV camera into a park to show people their skin.  The more freckles that appear the more damage had been done.  Look at the kid's skin compared to everyone else.  BUT most importantly, stay until the end and see the effect of sunscreen on the camera.  You will not be disappointed.

Fall PY2 Week 1

Classes have officially begun on a new school year!  The PharmD program always begins a week earlier than the rest of the university, but then we also finish earlier too.  As expected, this was a week of introductions.  But any excitement for the new year was quelled by a family trauma.

Augi had a ruff week

To start the week, I had an afternoon meeting of CAPS leaders.  Deciding to get to campus early and work a little in the library, I took the dogs out for their last pee break about 10 am.  After a few moments of running around like normal, Augi got a weird look on his face.  He stopped moving and stood in place.  I had to tug on him to get up the stairs and into the house.  I thought he was going to throw up or have a problem on the other end.  He didn't respond to any commands or even his name.  He just laid down struggling to breathe through his very white mouth.  I called the vet who told me to go to the emergency vet immediately.

Getting a collapsing Augi into the back of an SUV was not easy, but he was in the emergency room within 30 minutes of showing signs of shock - white gums, cold ears and limbs, unresponsive.  He did not care about any of the people in the waiting room.  And the nurse had to put him on a gurney to take him back.  The scariest part was signing a sheet to authorize CPR on a dog, which is $600 and has a 10% success rate.  The vets in the emergency room did a great job though.  He was hooked up to fluids immediately and started getting some tests done.  He started getting fluid in his abdomen and had low platelets and high ALT.  Augi was in Acute Liver Failure.  The cause is still unknown.  Maybe a mushroom or some kind of infection.  But thanks to the staff at the Vet Specialty Hospital of Durham, Augi is back at home after 3 days in the ICU.  We are still worried about him and giving him a wide assortment of medications.  Most importantly though, he is home again.

So a lot of my enthusiasm for the beginning of classes was diverted toward worrying about Augi and Emily.  But I did have some excitement and learned a lot in just three days.

Monday - No classes yet.  
We had a CAPS Leaders Meeting at 1 pm, which I was late to.  My main role that day was to take the pictures of the leaders.  Sounds easy, but for some reason I am missing quite a few people.  Some of my spare time this week was spent updating the CAPS website.

Tuesday - Official first day of classes.
Our first class of the day begins at a lazy 9 am - two hours of Drug Literature.  After some introductions, the Drug Information Specialist at UNC Hospitals began the first of three classes.  This is all about how to handle requests for information from doctors, nurses, or patients about a medication.  Most important message - understand the question.  All requests fit into some kind of category - Interactions, Reactions, Compatibility, etc.  Knowing what kind of question you have lets to pick the right resource and tailor your response.  Remember, an expert is not someone that knows all the answers, but the most efficient way of reaching it.

After Drug Lit, we were introduced to Medicinal Chemistry.  The professor went over the syllabus and that class ended in about 15 minutes.  After lunch we met with Pharmacotherapy.  Our first unit is dermatology and we jumped right in.  We had to review 100 slides before class to be ready to go over the first set of cases.  Not to bad.  Remember to moisturize, moisturize, moisturize.

Wednesday
During registration I chose the Wednesday morning lab.  I like it.  We met the professors in charge of the class, and then headed to our groups.  My group was very quiet, but efficient.  I think I decided I am ready to take the lead in the small section.  I want to assert myself and answer questions.  Taking the backseat just gets you through.  For the agenda, we took a quiz (23/25) and went over the drugs for next week's quiz.  For compounding today, we made a hydrocortisone semisolid in what looks like a deodorant stick.  The process was more complicated than I expected.  We used beeswax as the stiffening agent, which had to be melted.  No problem there until you remove the heat.  Beeswax cools incredibly quickly, even when mixed with mineral oil and hydrocortisone.  I cannot guarantee that my compound will pass inspection this time around.  I may be going back to redo it in a couple weeks.

After lunch, we had Pharmacokinetics.  As another introductory class, the professor explained the course and his travels over the summer.  Mostly he was making time until the Dean showed up for the second hour.  The Dean talked about the tragedy of a professor that was murdered over the summer just off campus and the changes to the school.

Thursday
The courses are a repeat of Tuesday's schedule, but we did more work.  In Drug Lit, we went over the Tertiary Sources for Drug Information.  These are the textbooks or databases that we all search online.  I have two booked marked on my computer.  There are some resources that are specific to certain questions, especially IV drugs or Pregnancy questions.  Essentially, a tertiary source provides a summary of the research available.  Some are more detailed and others are more specialized.  It is just important to know where to look for what information.

MedChem had one of my favorite professors reviewing some terms.  Autocoids are signaling molecules that usually send information over a short distance.  They usually activate a GPCR (G-Protein Coupled Receptor).  All of this was covered last year in Biochem and Therapy.

Dermatology was very similar to the previous class.  This time we talked a lot about fungal infections like dandruff and an allergic reaction to codeine.  The answers are fairly similar.  If it itches, take diphenhydramine (Benadryll).  If it is inflammed, a steroid should work (hydrocortisone, triamcinolone).  Always check the vehicle that carries the drug.  Creams, ointments, and lotions are not all the same thing.  Apparently, general practitioners only pick the right vehicle 50% of the time (they aren't dermatologists).  This is where the pharmacist can intervene and make sure the patient gets the right combination.

Friday - NO Classes
Friday is my day off.  Well, off is a relative term.  I hope to write my weekly update on Fridays.  And then I have a lot of work to do for the next week.  We already have our first SOAP Note due next week.  SOAP Notes are a patient case that we have to analyze and make recommendations for treatment options.  This one is about dermatology so I am sure moisturize will be one of the answers.

Before I Fall to Pieces

Here's the British band Razorlight with their 2006 song, Before I Fall to Pieces.  This song includes perhaps my favorite lyric of all time.

Now I'm just waiting for something that might never come 

If it's a million to one shot I'll make sure I'm one.

Enjoy!

Robin Williams Gathering Rosebuds

Robin Williams died this week.  He had a unique wit that allowed him to perform amazing feats of improv.  But as we now know he had his demons.  Still, his work will live on forever.  As an actor he showed incredible range.  One of his best was Dead Poet's Society.  In the clip that follows, Robin Williams plays a new teacher with his class.  His lesson is to see the people of the past as just like us - with ambitions, dreams, and hormones.  We should appreciate those that came before us and learn from their successes and failures.  Use this short time on Earth to do as much good as possible.  Mork, the Genie, Popeye, and on an on made people happy.

Gather ye rosebuds while ye may, 
Old time is still a-flying: And this same flower that smiles to-day To-morrow will be dying.

TED Talk Tuesday: Richard St. John

Everyone wants to become successful, but how do you stay successful?  Richard St. John tells a quick story of building, collapsing and rebuilding.  Success is a continuous process that doesn't end once you reach the top.  Other people want to get there and will keep improving themselves, so you have to keep improving yourself.  It's not good enough to graduate with a PharmD, you have to keep educating yourself and updating the newest drugs.

Michael Jordan was the greatest basketball player of all time.  His success came from athletic ability AND intense, continuous practice.  How many times do we see a champion team fall apart the next season?  Michael Jordan and the Bulls didn't fall into that trap they continually improved and stayed ahead of the NBA.  What's true in sport is true in life.  Champions, winners, and other successful people who stay on top keep improving themselves through practice, through education, through passion.

H-IPPE: Remaining Rotations

With classes starting tomorrow, I have run out of time going over my month-long rotations.  These sites were just as interesting and I enjoyed them as well.

Pharmacy Administration
On this day, I followed my Resident to all of her meetings.  UNC offers a two-year Pharmacy Administration residency with a Master's degree and a teaching certificate.  The wonderful ladies in charge of our month were both at the end of their second years.  My Wednesday morning started with a huddle with the Investigational Drug Service followed by a meeting about where the money goes.  IDS is not expected to make money, but somewhere the money that researchers pay for the service had been lumped in with other pharmacy accounts.  After that, we went to the opposite side of the hospital to observe an interview and a meeting about transitioning into a management role.  My favorite part about the last meeting was the source of her ideas - The Carolina Way by Dean Smith.

Central Inpatient Pharmacy
I was excited about the inpatient day because at the end of the month I would start working there.  This was a great introduction to where I would be spending every third weekend.  I won't say much here because I have a much greater experience in the department now that I am employed.  My rotation day started with a trip through the hospital filling Pyxis machines with patient-specific medications- take out expired meds and put in new.  Fairly simple.  When we returned I worked with the pharmacist checking medications that were being dispensed.

Controlled Substances
Also in the CIP, the controlled substances people deal exclusively with the list of drugs that require special supervision - opiates, benzodiazepines and viagra.  This day began with a trip around the hospital filling Pyxis machines with controlled substances = take out expired meds and put in new (sounds familiar).  We restocked the locked cabinets after a trip to the supply room.  The main difference here is that the numbers are taken very seriously.  If there is ever a situation in which there are less of a drug than expected, they have to contact the hospital police who investigate the missing med.  The Pyxis machines keep track of who signs in and the number of medication recorded in the machines.  When the number is off they contact the person before and the person after the number changes.  Usually it is just an accident, but it can have serious consequences - termination and criminal charges.  They take this area seriously.

Infectious Disease Consult
My second residency day was a short time with the Infectious Diseases consult.  In a hospital infections are incredibly serious.  A lot of those infections begin in the hospital - surgery opens up your first line of defense.  The consult group double checks the patients with an infection.  They help with diagnosis and identify the correct antibiotic or antiviral to treat.  There were some interesting cases-  HIV-patients starting chemotherapy or someone coming back from overseas with a case of malaria.  I am really interested in microbial stewardship.  The pharmacist can play a huge role in the hospital managing antibiotics.

Pediatric Satellite
Pediatric pharmacy scares a lot of potential pharmacists.  People seem distressed by the additional math involved in calculated doses for a wide range of patients.  They could be 3-kg newborn or an obese 16-year old.  The dose must be accurate in every case which means calculation.  Also, kids have a different metabolism and that can mean different standards from adults.  Working in Peds generally requires two-years of residency.  Kids also present another problem - they don't like taking pills.  The Peds satellite fills a ton of oral syringes.  In this case, you have to consider the taste.  I tasted several of the medications for an iron supplement that felt like a bloody mouth to cherry- or bubble gum-flavored meds.  I also went on rounds with the respiratory group in the Children's Hospital.  They have a large population of kids with Cystic Fibrosis.  Having taught about CF for many years, I was interested in meeting some of the kids and seeing how they are treated.

Oncology Satellite
My afternoon in the Cancer Hospital was similar to my day in the Sterile Products Area.   Primarily, the technicians fill IV bags for the Infusion Clinics.  In this case though, everything is hazardous.  They work in a sterile room but they don't use open needles.  They have a special needle system to prevent sticks.  I was most interested in the names of the drugs - it was essentially a list of Biochem presentations.

With that, I believe I have finished all of the rotations through the Hospital-IPPE.  Tomorrow, PY2 begins with Drug Literature and Pharmacotherapy.  Then I have to give up my short lab coat of rotations for the long, OSHA-approved lab coat of the PCL.  The first year was great, and I only expect more for the second.

Last Day of Summer

My summer break has reached its final day.  This weekend I go to work at the Hospital before a CAPS meeting on Monday and the first day of classes on Tuesday.  Surprisingly, I accomplished a lot during this unexpected break.  The plan was to work at the hospital during the weekdays during the months of June and July, but too many new full time technicians were starting that they moved me to my weekend schedule.  That meant a lot of free time for the entirety of July.

Chivalry returned to BBC America on Sunday Nights

I know that I shouldn't complain, but I was worried that I would go a little crazy.  Usually my summers are filled with football practices and planning for the next year.  Not anymore.  I have no control over the requirements for this year.   I really did not want to revert to a month of TV watching, so I turned to more constructive ideas.  The closet under the stairs got shelves for better organization.  The guest bathroom was quarterrounded and the master bathroom received two shelves in a completed wasted space.  Our screened in porch now has carpet and a dinner table.  The cats litter box was concealed inside a table looking box.  I also kept the house very clean - which I think my wife will miss the most.

There was some TV watching though - Under the Dome, The Musketeers, Orange is the New Black,
and the World Cup.  I went to seen Dawn of the Planet of the Apes and read The Patriot Games and Allegiant.  The Hobbit was on HBO yesterday.  While I did a lot of work, I did get plenty of relaxation in.  Of course some relaxation isn't so relaxing.  I took the dogs on a lot of walks and Charlie, the black lab, pulls incessantly.  I tried to train them without going to someone.  It helped a little, but he can still be annoying.  Running also fits into the relaxing but not so much category.

But all that is behind me now.  It might have been better not to have worked at the hospital so I could get more done at home.  Then again, I could have used the experience.  Next Tuesday begins Pharmaceutical Year #2.  I met several PY1s at the social led by CAPS leaders at McAllister's.  The all seemed excited about starting their journey, like I was last year.  While I began the semester with a combination eagerness, anxiety and worry that I made a life-altering mistake for my family, PY2 begins with confidence and yet more excitement.  They say PY2 is the hardest year of pharmacy school - tons of material and an exam every week.  Clearly they weren't a high school football coach with an "exam" every week.  I am not worried about this semester, but I might feel differently in a month.  We do have a quiz on the first day of lab and an assignment has already been completed.  Before I know it, it will be December.  I will try to keep writing throughout the semester but I might miss a day here or there.  I should have plenty of material for a weekly update on PY2.  Here is a look at our classes for the Fall Semester:

1. Drug Literature
2. Medicinal Chemistry
3. Pharmacokinetics
4. Pharmacotherapy - GI, Respiratory, Dermatology
5. Pharmaceutical Care Lab #3

Getting a Cavity Filled

Anesthetic injection to the Trigeminal Nerve

So, I had to get a cavity filled yesterday.  Not too much fun, but I did figure out that I can learn from it.  If I asked you what drug they give you to numb you up, I am sure that you would all know the answer - Novocaine.  Right?  Nope.  Apparently, dentists have not used Novocaine for about 30 years.  The answer that we all seem to know is wrong.  Novocaine is the brand name for procaine a synthetic cocaine from 100 years ago.  Unfortunately, a lot of people had allergic reactions to the drug and dentists search for a new choice.

This post started because I asked the technician what the drug was that I would be injected with.  Of course, I then told her that I was in pharmacy school.  I have learned that whenever a nurse or technician learns that you are in pharmacy school, the very next thing they will say is how much they hated their pharmacology class.  Every time, guaranteed.  Moving on.

Articaine - Dental Amide

The dental assistant said that it wasn't novocaine but instead Sceptocaine.  Unfamiliar with the name, I figured it was just a specific brand of Novocaine (which I later learned is itself a brand name).  Sceptocaine is a combination of 4% articaine and 1:100,000 epinephrine that was approved by the FDA in 2000.  For the nerve block to perform a tooth filling, the dentist injects 0.5 to 3.4 mL under the mucous in the back of your mouth near the trigeminal nerve.  The articaine blocks our pain receptors by altering the action potential threshold for the nerves in the area.  A much greater stimulus is needed for a response, which doesn't come.  The epinephrine constricts the surrounding blood vessels to prevent the absorption of articaine into the blood stream and keeps the tissue concentration high.

There aren't a lot of problems with articaine, but allergies to sulfites can be an issue.  This is only for submucousal injects as accidental intravenous injection could lead to serious problems.  As the dentist tells you, you will lose all sensation in the area for several hours.  It will come back.  It took over four hours before I regained all my senses in the area.  The dentist also tells you not to eat anything while drug is working because you might bite your lip, check or tongue.   So when you go to get that next cavity filled, remember that you are not getting Novocaine anymore.  Dentists now give articaine in the form of Sceptocaine or Orabloc.

H-IPPE: OR Satellite Pharmacy

My favorite day of the H-IPPE rotation was the OR Satellite.  In think it was pretty much everyone's

favorite day.  After filling a couple Pyxis machines on the floor, I was to observe a KIDNEY TRANSPLANT!!! The patient's sister was in the next OR having a kidney removed, while I followed the CRNA as we brought the recipient back to get ready.  While the actual surgery primarily involves gross anatomy, the general anesthesia delivers a complex protocol of drugs to ensure that the patient cannot feel, cannot move and cannot remember. The anesthetic process begins in the Pre-Care area as the patient says good-bye to family and friends (and apparently takes pictures with the nurses).  While different for different patients and certain surgeries, the general protocol for patient induction includes:

1.     Midazolam - the sedative relaxes the patient and is given in the pre-care area. Working almost immediately, the patient is not unconscious but also will not remember anything about heading into the OR.

2.     Fentanyl - the narcotic pain killer helps to make sure the patient does not feel anything. This is given after the patient has been transferred to the surgical table.

3.     Lidocaine - the local anesthetic prevents the burning sensation upon the administration of the next medication.

4.     Propofol - the general anesthetic helps keep the patient unconscious for the entire surgery. It is a milky, white emulsion.  If you did not know, propofol was the agent that killed Michael Jackson

5.     Succinylcholine - the paralytic makes sure the patient cannot move while the surgeon operates.

During the actual surgery, the surgeon goes to work opening up the patient.  While the kidneys are in the back of your body, the new kidney will be placed in the front.  The surgeon must first get through a lot of tissue which involved cauterizing the incisions.  I won't soon forget the smell of burning flesh.  Once he reaches the kidney, he must disconnect all the pipes to and from the kidney to be refitted for the sister's kidney.  Meanwhile, the CRNA continues to monitor the patient's vital signs - adjusting knobs on the ventilator and providing a small electric shock to check for paralysis.  Soon the sister's kidney is brought in from next door in a large silver bowl.  When the surgeon finishes detaching the original kidney, he moves to a separate table to inspect, clean and prepare the new organ.  But when he goes to the other table, the patient is still there.  Opened up with clamps and things sticking out of her!    Sadly, this was the point that I had to leave to go to a meeting.  The surgery would last for another few hours, but I would not be back in time.  

Overall the process of renal transplant was amazing.  The amount of drugs pumped into a patient for induction, maintaining, and waking is incredible.  I witnessed about 7 or 8 medication, with several on the table in case of emergencies.  If anything else was needed, a Pyxis machine was available with a healthy stock of medications.  That kind of concerned me.  The nurse could grab just about anything, the doctor could order anything at any time.  But there was not form of pharmacist verification with any of it.  The OR seemed like the Wild West, where the laws of pharmacy were no longer valid.  There was a phone to call a pharmacist if there was a question, but it was completely up to the nurse and the surgeon.  I am by no means questioning their abilities, but it seemed odd after learning about order verification and other steps to avoid medication errors.

After returning from my meeting, I spent time with the OR pharmacist.  They actually rotate from the Inpatient Pharmacy up to the OR on some kind of schedule.  Which makes sense, you definitely need someone who knows with IVs in an OR.  Strangely, no pharmacists are in the satellite for the evening or night shift.  There are technicians, but if something needs to be verified, they must call or travel down to the CIP.  When I sat with him, the pharmacist was busy verifying the antibiotics for the next day's operations.  When patients prepare for surgery, they are given a prophylactic administration of antibiotics. The most important surgical complication comes from post-operative infection. Different surgical areas must prepare for different types of microbes. Upper body surgeons are concerned about Gram-positive bacteria like Staph and Strep. They tend to order ceFAZolin. Lower body and GI surgeons encounter more Gram-negative bacteria. Interestingly, urologist typically order levofloxacin.

Anyways, he went through the each patient to make sure that the antibiotic matches up with the type of surgery. Instead of memorizing the antibiotics, UNC has prepared a list of common orders for every category and other criteria. For some medicines, the pharmacist must check renal function by calculating CrCl using a common equation (CrCl=(140-age)/SCr). Levofloxacin and Meropenem were most commonly ordered and checked for renal function. Gentamycin was much more difficult to dose as it is based on the patient's ideal weight determined through a complicated equation. The surgeons commonly only use the patient's actual weight, but the pharmacist must change the dose. If gentamycin is dosed incorrectly for extended periods, it can result in ototoxicity (hearing loss).

As you can tell from the length of this post, I really enjoyed this day.  I learned a lot from observing the CRNA and sitting with the pharmacist.  Who wouldn't enjoy a kidney transplant?  To me, the OR seemed like an open opportunity.  More than just short staffing problems, but about the verification process of surgical medication.  The pharmacist could have more of a role during surgery.  They may not need to be in the actual room, but there could be a place for more aggressive involvement.  Hospitals perform hundreds of surgeries a day.  I feel like the OR could be a possible frontier in the future of pharmacy.

TED Talk Tuesday: Matt Cutts

Have you wanted to try something new or change something old about your life?  Matt Cutts tells TED to try anything, anything at all for 30 days.  It can be as simple as cutting sugar or caffeine to writing novels and biking to work.  All you need is 30 days.

What would you do for 30 days?

H-IPPE: Pediatric Behavioral Health

1 in 13 kids take psych meds

My first clinical specialist day paired me with the pediatric resident during his behavioral health month.  When our preceptors asked us if their was any particular area we wanted to see as a specialty, I asked for anything dealing with the brain.  I enjoy neuroscience and found it to be my favorite section in my Anatomy class to teacher.  So I figured that it would be interesting - mental illnesses, Alzheimer's,
Parkinson's, etc.  I was not disappointed with my day in pediatric behavioral health.

We started the morning by talking about a few basic things like introductions, the layout of the ward, how the rounds would work and then went up to the pediatric psychiatric unit.  The doctors, residents, nurses, and their teachers piled into a very small room to discuss the 10 children on the ward for the day.  These were some serious 9-13 year olds who had been through more than most people in their 30s.  These kids were diagnosed with MDD, ADHD, ODD, Mood D/O with symptoms of SIB, SI, HI taking various amounts of Prozac, Lexapro, Concerta.  Some stay in the unit for a few days, but others had been there for a month.  The Hospital School addresses their education needs while they are in the hospital and the teachers work closely with the doctors.  The Hospital teachers would contact the home school for information and IEPs - pretty much every kid had one.  Parents would come during visiting hours with a pass, but generally the kids cannot leave the floor.  

We talked about their medication treatments, but mostly these kids required intense therapy and behavioral plans.  To treat the younger kids the doctors prefer hugs to drugs.  As a pharmacist, we sometimes forget that and go straight to medications.  But let's not forget that these kids are on some serious prescriptions.  Fluoxetine and escitalopram (SSRIs) were the favorites for depression.  Agitated patients would also recieve ropinarole, a 2nd gen antipsychotic).  But then the agitation could be due to the ADHD requiring a stimulant.  Even if the patient was on only 2-3 drugs, there was a lot to consider in matching the medication to indication and achieving therapeutic doses.  For another point, you don't want to open the door to greater abuse in young children by prescribing long-term benzodiazapem.  Pediatric dosing for neuro-drugs was different as well.  Usually, the doctor titrated up from the lowest dose available until reaching an effective point.  Not only are these kids growing, their brains continue to develop as well.

Unfortunately, I had to leave for a meeting before actually meeting with the kids and families.  They had left for the Hospital School when we came out of our meeting.  The resident showed me the other areas on the floor for adolescents and eating disorders.  I learned a lot during this day and was actually able to talk about this more due to my education background.  As a subspecialty, Pediatric Behavioral Health would be incredibly interesting, but potentially devastating.  I was glad to experience it.  At any rate, almost every pharmacist will dispense psychiatric drugs to pediatric patients.  One in 13 children take some kind of psych med in the US.  It is important to see the most extreme cases to understand the others.

Alphabet Soup Notes:
MDD - Major Depressive Disorder
ADHD - Attention-Deficit with Hyperactivity Disorder
ODD - Oppositional Defiant Disorder
Mood D/O - Mood Disorder
SIB - Self-Injurous Behavior
SI - Suicidal Ideation
HI - Homicidal Ideation
IEP - Individualized Education Plan