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PharmDs, docs make right call for patients  by Mary Helen Yarborough Public Relations It’s another hot and hectic afternoon in emergency medicine. A patient is brought in from an aircraft accident while doctors, nurses and technicians scurry quietly to attend to this man and other patients in the Emergency Department (ED).   The constant sound of monitors beeping and softly spoken discussions blend through the maze of rooms that make up the ED.   Dr. Larry Raney discusses a patient's condition with Drs. Sarah Dehoney, left, and Wendy Bullington. Larry Raney, M.D., is the director of MUSC’s Emergency Medicine. His eyes darting at numerous monitoring devices and responding staff, Raney grabs a cup of coffee and takes a sip. He glances up at the patient-tracking board, looks around the nurses' station then his eyes rest on Wendy Bullington, PharmD, and pharmacy resident Sarah Dehoney, PharmD.   “How did I do without them,” Raney said, referring to the pharmacists. “It’s invaluable having a pharmacist in the ED.”   Bullington is a clinical pharmacy specialist in emergency and pulmonary medicine. She also is director of the pharmacotherapy residency program. Two years ago, Bullington established the ED pharmacy program with the help of Joe Mazur, PharmD, clinical pharmacy manager.   “We did not have a pharmacist here in the ED before Wendy,” Raney said. “Joe Mazur called me one day and said, ‘How would you like to have a pharmacist?’ I said, ‘How much will one cost, because we don’t have any money?’ And he said, ‘Nothing.’ So, we got a pharmacist and it’s been great. I call them at least four or five times in a shift.”   The ED has come to rely on the pharmacy program and Bullington, who soon will be on maternity leave. In her place will be her understudy, Dehoney, a second-year pharmacotherapy specialty resident. Dehoney entered MUSC’s pharmacy residency program after earning her PharmD from Texas Tech’s College of Pharmacy in Amarillo, Texas. Having worked with Bullington, her preceptor, Dehoney said she feels she has a much deeper feel for pharmacotherapy.   Dehoney had never considered working in an ED before coming to MUSC. “Wendy asked me to give it a try, and I’m glad I did,” she said. “MUSC has a staff, including the nurses and attendings, that is very pharmacy friendly. The interdisciplinary relationships are good, and decisions are made together. There is a lot of mutual respect here. You walk in the door, and they’re very open to you. The pharmacists here are very active in making pharmacotherapy decisions.”   ED pharmacists generally do not exist in hospitals, though they are a little more common in teaching hospitals, Dehoney said.   Raney said that having a specialized pharmacist to work with has cut precious time and created another layer of quality care assurance.   “Before, when I needed something, I would have to call upstairs to pharmacy,” Raney said. “Most of the time they were busy, though they did all they could. But it’s good to have people here in the ED who understand this field.”   Having a pharmacist has proven critical in a multitude of situations, but one case especially demonstrates how having a pharmacist meant the difference in treatment, Raney said. Case in point Recently, a woman experiencing methadone withdrawal was brought to the ED. She was violently ill from acute withdrawal, which could be fatal for someone with a heart condition.   Methadone is a therapy provided to heroin addicts as part of an overall detoxification therapy. Raney quickly deducted that this woman was not a typical junkie and needed help.   Raney learned that the woman withdrawing from methadone had been taking the drug for dental pain. She had obtained the drug from an acquaintance and unwittingly became addicted. When she discovered the acquaintance was no friend, but a drug pusher, she stopped taking it, which hurled her into full blown withdrawal.   Raney said the case so illuminated the important role that Bullington and the ED pharmacy program have played, that he offered the following story, which he had written in an e-mail to Bullington and shared with other colleagues after the woman was successfully treated in the ED:   “After some discussion, we decided to first treat the patient with IV morphine, titrated to stop the incessant vomiting (she had already received Phenergan, Zofran, and droperidol with no effect), followed by a half-her-usual daily dose of methadone PO. This worked like a charm!” Raney wrote.   In the e-mail, he explained the woman’s background and why this case was so extraordinary.   “This patient had a ‘friend’ who supplied her with a ‘pain pill’ that was the only thing she found that helped her tooth pain.   “Suddenly, after a few weeks, this ‘friend’ started asking her to pay for this pill (she had been getting it for nothing). Three days later, she is in my ED,” Raney wrote.   The woman was taking 40 milligrams of methadone per day, he added. “Her ‘friend’ seemed to know just how long it would take to get her addicted. Scary,” Raney said. “Anyway, I realize she may have been lying to me, but doubted it. I think we came together as a team and made a big difference in one family’s life.”   The ED team, operating on the advice of the pharmacist, administered morphine. “With the first dose of IV morphine, you could see the improvement immediately. With the second, she was perfect and able to take her PO methadone,” he said. The methadone was reintroduced to the woman’s body, but in smaller doses, to help her safely withdraw from the drug.   The Charleston Center, an outpatient detoxification treatment within Charleston Memorial Hospital, normally does not conduct inpatient detoxification for opiate withdrawal, Raney said. But due to the woman’s unique history, Jim Tolley, M.D., director of CMH’s ED, successfully sought an exception for the woman.   “Overall, everyone pulled together and did what is right,” Raney said. “I thank each of you, and this patient has a chance to get rid of the monkey.”     Friday, Sept. 7, 2007 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island Publications at 849-1778, ext. 201.