Handling COVID-19 As An Emergency Medicine Clinical Pharmacist

Kathryn Samai, PharmD, BCPS, emergency medicine clinical pharmacist at Sarasota Memorial Hospital, discusses how her institution has been handling COVID-19.

Aislinn Antrim: Hi, this is Aislinn Antrim from Pharmacy Times, and today I’m interviewing Dr. Kathryn Samai about COVID-19 and emergency medicine pharmacists. So Dr. Samai, can you just give us an overview of the situation that you’re currently seeing in your hospital?

Kathryn Samai, PharmD, BCPS: So, things are really ramping up right now. We’re starting to see a lot more positive patients and it just really feels like everything is a moving target. Things are changing really quickly—what we’re doing for PPE, treatments, logistics, everything. I think our administrative team and, you know, us on the frontline team, are trying very hard to keep up with this moving target and we’re trying very hard to be really innovative with things. So, trying to see a few chest moves ahead, but it feels like it’s changing so fast. So things are strained here. There’s a really weird dichotomy between the areas that you’d expect to have hig census, like acute care areas, emergency departments, critical care, needing more staff and feeling the pressure of this pandemic. But then you also have a lot of low census areas, so you have the procedural areas, elective surgeries—all those things are being cancelled. So you have this other cohort of colleagues that are trying to flex hours, use paid time off, that are not working as much. So very strange dichotomy between the 2.

Aislinn Antrim: You mentioned PPE—How are you handling shortages? Do you anticipate seeing more, just what is that situation like?

Kathryn Samai, PharmD, BCPS: Yeah, I think right now we’re trying our very best to conserve, so really limiting it to those that need to wear it in areas that it needs to be worn. Our hospital just allowed and approved an OK for home PPE to be worn, but they specifically put a caveat about it being things that you bought that are actually a product. So not like homemade masks from fabrics or something that you made with your sewing machine. So we’re trying, like I said, to get really innovative with things. People are bringing in their own welding masks that have n100- or p100-appropriate filters on them. Our hospital is trying to be really transparent about what we have. As someone on the front lines and not in an administrative team, I feel like I’m getting regular updates about what we have and how to conserve. But I also feel like what I’m supposed to be wearing at any given time has changed a little bit as we determine just how airborne this pathogen is. That’s been kind of scary. I’m just really hoping we don’t get to the point where the shortages are so bad you have to start making the decisions—who gets to wear it, who doesn’t. And I’m hoping there’s some really good innovative solutions in the works or, you know, how some of these companies are starting to change what they would typically do. Like how Ford is trying to make ventilators, like I’m hoping that some of that will ramp up production more and we’ll start to see some PPE come in.

Aislinn Antrim: Absolutely. Are there any drug shortages that you’re anticipating or that you’re already seeing, and what are the effects of those?

Kathryn Samai, PharmD, BCPS: We already have a fentanyl shortage at our institution, and I think this is pretty consistent with what I’m hearing at some other institutions, that these really critically ill patients especially with severe acute respiratory distress syndrome are requiring high amounts of analgosedation, and typically fentanyl is our go-to. Especially in those hemodynamically unstable patients. So that’s been hard to deal with. We’re trying to move toward hydromorphone where we can or other options. But whenever there’s a big shortage of something as important as something like fentanyl for these analgosedations, it’s just a matter of time before other drugs get taxed, right? Because we all start moving toward them. The obvious shortages, we don’t have them right now, but I would anticipate hydrochloroquine, tocilizumab—these targeted therapies that we’re trying to use in these patients. And then, I’m a little nervous, it’s happened in the past, where critical care meds like vasopressors have gone on shortage and we’re using a high amount of those in general, so I think that’s a possibility. And even scarier, the life-saving crash cart meds—so things like epinephrine syringes and those life-saving syringes—that are just so helpful to use in a code. So hopefully that doesn’t happen, but I’m trying to anticipate that it could.

Aislinn Antrim: Are there medication that you’re evaluating for the COVID patients? What are you using and what are you seeing?

Kathryn Samai, PharmD, BCPS: I would say for the mild cases we’re just doing supportive care. I spend most of my time in the emergency department or critical care, so I don’t spend much time on the floors with those less sick patients. So in the critical care, we are using hydroxychloroquine. We are, in select patients, using tocilizumab. We’re trying really hard to get remdesivir approved for either expanded access or a clinical trial at our institution. That’s new news as of yesterday that it’s maybe going to be approved or in the works, so hopefully that’ll be a yes by today at 4:00 pm or tomorrow. Or who knows, that’s how fast things are changing. Yesterday I got the update that we might get it, [and] today I was told by 4:00 pm I might know for sure, hopefully. I guess some other things we’re using—we aren’t using kaletra in our institution right now, just due to limited evidence. Same thing with zinc—it’s being talked about and tossed around, but we aren’t using it. We moved our community acquired pneumonia protocol from azithromycin to doxycycline for coverage. I know some institutions are talking about azithromycin additive effect with the cap/maybe COVID rollouts, etc. In our institution, we were more worried about QTC prolongation, so we switched to doxycycline instead for all those patients because a lot of them come in and it’s a pneumonia and a rule-out COVID at the same time, so we’re just trying to be really proactive about making sure we’re watching out for when those patients will get hydroxychloroquine. And then, of course, in these severe ARDS patients we’re using neuro-muscular blockers, we’re using all the evidence-based vent support, so just everything in our arsenal that we can do.

Aislinn Antrim: Are you seeing some success?

Kathryn Samai, PharmD, BCPS: So far, we have had cases that have resolved, but we’ve also had some sad situations where we see mortalities. It’s all anecdotal at this point, so I really can’t speak to what exactly I feel like is working. So I’m just trying to stay on top of what all the institutions are putting out there as well as what we’re seeing.

Aislinn Antrim: In your role as a pharmacist, have you seen the role changing during the pandemic with different responsibilities?

Kathryn Samai, PharmD, BCPS: I definitely think this is going to be the strangest thing that’s ever happened in my career, and I’ll look back and just remember that this was such a strange time. I feel like up until this point I worked really hard to be at the bedside, really involved in the care of the patient, right next to them. And I feel like right now there’s like this strange movement where I’m having to step back a little bit. I’m trying to conserve PPE, so maybe I don’t have to be bound up in the room at the bedside, but it’s strange to round on your patients and look at them through a glass and that has been like—I have a strong sense of care for my patients still, but it’s so strange and odd to look at them through glass doors. So that’s been interesting. And then another big piece is that we always think of this, as clinical pharmacists, we’re always thinking about logistics. I feel like even more now, every med is not only a final concern, it is a dire logistical one, too. So will this be an extra gown that has to be used and face masks, or can we use extension tubing to run some of the drugs and come outside of the rooms so the nurses don’t have to go in as frequently and titrate. Can we time the meds more closely together so they’re only going in to lessen the number of times verus having to go in at two o’clockfor this and that’s scheduled, five o’clock for this because that’s scheduled. So recently, in our institution, a medication like warfarin used to be scheduled at 5 p.m., but we changed it now to be on time with some of the other administration of meds and a little bit later in the day. That was to reduce the number of exposures to the nurses and then also just conserve PPE.

Aislinn Antrim: What’s your biggest concern? Just of all the things you’re handling, what’s your biggest concern right now?

Kathryn Samai, PharmD, BCPS: I mean, the biggest thing obviously is just making sure we’re well. I think we all want everyone to be well—your loved ones, your co-workers, yourself—and I think what is scariest to me is that we have this small team of highly trained clinical pharmacists in the ER and the ICU, and it seems like it’s only a matter of time until we start getting sick. And what’s going to happen if we’re sick? And do we have enough people to take care of our patients? How do we take care of ourselves? I don’t want to be rounding on my loved ones in the bed, you know, so it’s just, it’s hard. It’s hard to think that there could be a tipping point where we’re starting to get sick and need treatment.

Aislinn Antrim: Do you have any tips for pharmacists with mental health and physical health and taking care of yourself while you’re taking care of your patients?

Kathryn Samai, PharmD, BCPS: So, as a yoga practitioner, I’m really relying very heavily on the practice of yoga and in a few different ways on and off. So I’m trying really hard to eat well, sleep, get a little bit of physical movement. I think an interesting thing, having everything cancelled makes it a little easier. There’s no stress of like, oh, I need to make it to that birthday party, or I need to get out and do this. You’re not doing any of that, you just take care of yourself, eat well, and rest in between these shifts that are so long. And the other big piece that is the yogi perspective, is trying to move from instead of operating in this mindset of scarcity or fear, moving into this mindset of abundance. So I’m trying really hard to think, ‘I’m grateful that I am well right now, I’m grateful that we are coming up with these incredible, creative, and innovative solutions.’ So things I just think I never would have thought of until I was pressed, you know, we’ve been pressed to do it, right? So it’s really cool to see how great minds come together and start finding solutions for these problems that weren’t even a thought in our mind maybe a year ago or six months ago. So that’s big. Just trying to operate in whatever way I can to find little moments of peace and calm, and so remembering to be kind. That’s been a big one for me.