ADS – Acid/Base Disorders and Introduction to Precepting

Wow! What an excellent day learning how to identify acid-base disorders as well as learning some pearls about precepting. These sessions always show me how much there is to learn.

The session on acid-base disorders showed me the importance of not only sticking to a process, but more importantly, that acid-base disorders are not unique to the ICU setting. It’s interesting to know that acid-base disorders can occur anywhere and there is a quick way to screen for them via typical lab work. For instance, with a basic chemistry and electrolyte panel, there is sufficient information to help identify anion gaps (Na -Cl-bicarb) which can lead to further testing (i.e. a blood gas).

Another takeaway for me was the importance of understanding normal physiology and how circumstances impede our body’s ability to compensate. For example, this can be seen with propofol preventing hyperventilation leading to respiratory acidosis.

The seminar on precepting was not only enjoyable, but also fun and engaging. It helped me identify some key elements to being a strong preceptor:

  1. Open communication with the student. Being clear on expectations and how/when feedback will occur.
  2. Adaptability. This was well demonstrated in our role-playing example where we had to model being a preceptor who was with a challenging student. Although, my goal was to ask a powerful question, I couldn’t proceed and I had to address the main issue before moving forward on the discussion.
  3. Always ask the student to reflect on their own first – it saves time and the student will likely end up stronger as a result.

Venous Thromboembolism Presentation

This presentation was an excellent learning experience and it taught me the value of knowing my objectives prior to beginning a large project. Originally, when I was consolidating the information, I didn’t have a good idea of what I wanted my audience to learn at the end of the 3 hours. This lead to a lot more time spent and a great epiphany ~3 weeks prior to the presentation. Although I was able to adapt my format, a more thorough plan will help with my presentations in the future. Great learning experience though!

Commitment to the Profession

During my pediatric rotation, I conducted a journal club on Croup. The team consisted of active learners in their approach of a journal club. Prior to the presentation, they did their own appraisal of the journal article and saw this as an opportunity to learn about others’ interpretation. It lead to a very lively discussion and each member was interested in helping each other improve their understanding and grow their knowledge.

This experience has shown me that professional commitment is similar to have a resident’s lens…even after residency is complete. There’s a constant strive toward improvement, teaching others and an never-ending drive toward life-long learning.

Leadership vs. Management

During my medication safety and quality rotation, I saw many examples of the differences between management and leadership. In low stress times, the terms may be used interchangeably, but the separation results when there are times of conflict or moments of high stress.

There were times when some comments may have caused most individuals to become defensive or reactive. Amy demonstrated her leadership abilities to myself and her team when she maintained her disposition and chose to focus on the situation and remain diplomatic.

In addition to emotional composure, other traits of a leader were also shown when members of her team would come to her with concerns. She provided support and they worked together to find a solution. This demonstrated one of the core differences with leadership. Whereas a manager may provide a solution, a leader is open-minded and takes an active role in helping their team to grow and adapt to new situations.

Vancomycin Interpretation

I was asked to interpret one of the vancomycin levels on a patient and give a dose recommendation. The patient was admitted with a necrotizing pneumonia/abscess. His cultures were positive for MRSA and MDR pseudomonas for which he was being treated with ceftazidime/tazobactam, metronidazole and vancomycin for a total duration of 6 weeks as per ID. Creatinine = 112 (stable), WBC = 8.8 (stable), and patient was afebrile. During my information gathering, I found that he was on week 4 of his treatment of which he had been switching between vancomycin 500mg q24h (levels = subtherapeutic at ~11) and vancomycin 750mg q24h (levels = supratherapeutic at ~24). His target was between 15-20 as per previous pharmacist notes. When I saw him, his level was 24.2 with vancomycin 750mg q24h – all doses given on time and the level was drawn appropriately. Given the information, a feasible option included vancomycin 500mg q18h; however, I was concerned with missed doses and difficulties on nursing staffing. In addition, the q18h dosing could lead to potentially difficult drug monitoring. Given the severity of his infection, I opted to continue with vancomycin 750mg q24h as the consequences of his untreated infection were worse than the safety profile. When I discussed this patient with my preceptor he agreed that vancomycin 750mg q24h would be the most viable option at this time. This situation showed me that there is often more grey in dosing than black and white. While the patient was supratherapeutic, the harms of having a lower dose would be more detrimental to the patient.

Antibiotics in Pediatrics Presentation

This presentation was conducted to nurses and was a compilation of different questions that nurses had brought to their CNL. It was an enjoyable experience and also showed the differences in lenses between our professions.

For instance, when I went over this presentation with my preceptor; we viewed the PDTM instructions of ampicillin and gentamicin to be simple; however, this resulted in a lively discussion surrounding the specifics of syringe medications and flushes. The conversation was regarding lines, syringe medications and flushes – pieces of which I still don’t understand and the result of which may end up being addressed in a policy. It speaks to the importance of understanding each others’ professions if we are to collaborate on safer practices.

I also received positive feedback with the underlying story within the presentation. Although I could have originally kept the topics separate, the nurses found it more engaging and helped to keep their attention. I will use this information in the future when I’m asked to do in-services.

Journal Club – Croup

This journal club taught me that there are many ways to interpret what is written in an article. For instance, the authors stated that no masking agent was used in compounding the medications. My interpretation was that no masking agent used to cover the original flavor of the compound whereas other attendees thought that this description referred to complete elimination of any flavoring agent. This lead me to understand why guidelines can have different recommendations even though they are based on the same study. It also shows the importance of appraising the article myself and developing my own interpretation.

Another learning point is that I will be a more effective presenter if I take the time to ensure I understand the meaning of a question before responding. Similar to different interpretations of an article, the same can be said about questions. As a facilitator, I can cause confusion if I don’t properly understand the question before answering.

ADS – Fluid Assessment, AKI and CV management

Fluid Assessment:

  1. Check whether the sodium is high or low as this reflects the ICF status
  2. The main ECF assessments are postural changes (lying –> standing) as well as JVP.
  3. Understanding the fundamental concepts will help me apply this information to the different patient populations; although the treatments may be different (e.g. neonatal fluids)


  1. Systemic consequences of AKI can be depicted by the AEIOU acronym. Acidosis, Electrolyte, Intoxications, Overload and Uremia
  2. A important piece of AKI is determining the trend of SCr. The AKI could instead be CKD.
  3. SCr is not always the best indicator or renal function as it is typically delayed by 1-3 days. Therefore, a more reliable monitoring piece is to look at urine output.

Keeping an updated Curriculum Vitae

  1. Opportunities are often time-sensitive. Having an updated CV will help ensure quality.
  2. Gives more details than a resume
  3. Having a CV with a 5 year goal in mind will help me choose activities which are in parallel with my pursuit.

Medication Safety Presentation – Sterile Compounding and Latex Precautions

This rotation and the presentation has shown me a small glimpse into the complexities and discussions happening behind the scenes.

Many patients with latex allergies are admitted to hospitals; however, there is controversy regarding what is considered “best practice” for sterile compounding in these patients. Though rare, some vials have a latex-containing septum which can potentially result in anaphylaxis if coring occurs. While there is a Fraser Health Policy from 2007 which addresses some of the concerns, the Quality Team was approached by frontline staff who wanted more clarity. My presentation focused on the processes of different organizations who have latex procedures in addition to a review of the evidence to help with policy revision.

Doing this presentation helped me to identify many aspects that I will incorporate into future presentations.

  1. Careful planning in the beginning sagesmay help me to understand the context of my presentation and where I would like to focus. For instance, what is the goal of my presentation, who is the target audience and what is the bridge between the background, evidence and my goal. By having a direction or focus, I’m better able to utilize my time and adjust the content appropriately.
  2. An overview of the presentation contents may help the audience to orient themselves and understand the flow
  3. Where possible, the use of pictures helps attendees to better understand the information that is being told verbally.
  4. And…a tip from the audience: depending on the lecture, possibly ask attendees to hold questions until later to help with flow.

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