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An Ode to the Pharmacist

David Epstein, MD, MS, FAAP stresses the importance of pharmacists in the medical community.

Pharmacists are not just medication dispensing agents.

Their role is so much more than it seems and warrants further explanation to appreciate the full extent of their importance in healthcare. Over the years, I have learned much from my pharmacist colleagues and so appreciate them as a member of the medical team.
My Pediatric Training
When I was a pediatric resident in training, I would order medications for patients on…yes…paper! At that time, there were only paper order sheets to put in orders for admission to the hospital and orders for miscellaneous procedures, services, or medications required for a child’s hospitalization. Computer order entry did not arrive until a number of years later. The orders would be reviewed by the bedside nurse and the hospital pharmacist.
My first exposure to pharmacists was while I was training in the hospital setting. I ordered medications, carefully calculating the dose and frequency under the guidance of my trusty pocket pediatric resource, The Harriet Lane Handbook. Almost all medication dosing in pediatrics is based on weight and some by age as well. The medication doses in pediatrics will vary greatly between patients since there are infants, children, and teenagers of all different sizes. Having a calculator in pediatrics is just as important as having a stethoscope because of the necessary and, sometimes, complicated medication dosing calculations required for every patient admitted to the hospital or seen in the outpatient clinic setting.
Medication Miscalculations
As you may guess, trainees would often make mistakes in medication calculations. The errors would sometimes be caught by the nurses and the common question would be, “do you really want to order this much…insert any medication name here?” or there was an inquiry as to the utility of the medication itself. They would often have a good idea of what was an appropriate dose and use for most medications. But, the ultimate safety net was the pharmacist.
It was not uncommon to receive a page from the pharmacist after the written orders were processed. Yes…a page on a pager. We didn’t have a cellular phone system for the hospital back then. Anyway, the page from the pharmacist often meant that there was an issue with a medication order that was submitted.

“The ultimate safety net was the pharmacist.”

Early in my training, I had less experience and knowledge. I did not know what I didn’t know and was prone to errors myself. I may have forgotten that the patient had an allergy to the medication that I ordered, I may have misplaced a decimal point when writing the number, or I may have used the incorrect dose for the patient’s renal function. All of these miscalculations were caught by the pharmacist, but I didn’t fully appreciate their guidance at the time.
Pharmacists Save The Day
Fast forwarding through my pediatric critical care medicine fellowship and time as an attending in the pediatric intensive care unit, I grew to appreciate the pharmacists in the hospital (and also those in the outpatient setting when I would practice pediatric urgent care). Over the years, I developed a great respect for the administration of medications because of the life-saving medication infusions and other therapeutic treatments that we would use in the pediatric intensive care unit. The medication adjustments that we would need to make because of the use of multiple medications or the various organ system dysfunctions involved were not uncommon.
Nevertheless, there would occasionally be adverse effects from any medication used. I have seen kidney injury from aggressive diuretic use in conjunction with other kidney toxic medications, too much surgical bleeding with the inappropriate dosing of heparin, prolonged paralysis from paralytic agents not being metabolized as quickly due to organ dysfunction, allergic reactions, medications precipitating arrhythmias, and other adverse effects from medications and their interactions. While the intention is to treat and cure patients of their illnesses with various medications, those same medications can cause great harm.
This great harm is often prevented by the attention to detail, knowledge, and experience of the pharmacists. Their knowledge of medication side effects, drug-drug interactions, dosing adjustments for organ dysfunction or particular disease states, and newly released medications is invaluable. Pharmacists are so much more than just medication dispensing agents. Because much of what they do is “behind the scenes”, the public does not realize the full extent of what pharmacists are responsible for and how important they are in healthcare. I cannot express enough how much I appreciate and value them. They are irreplaceable members of the medical team and critical resources, both for inpatient and outpatient medicine. So, what would the world look like without pharmacists? The simple answer…not good!
What are some positive interactions that you have had with pharmacists?

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