Pharmacists’ Responses in Medical Emergencies Highlight Need for Provider Status

Pharmacists, pharmacy technicians, and pharmacy students from all over the world gathered together for the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in December 2023.¹ The meeting included clinical and professional development educational session, networking events, a chance to meet up with old friends, and a chance to meet new friends.¹

Like everything, however, the ASHP Midyear Clinical Meeting came to an end. The many attendees went their separate ways, catching crowded flights home.

But for some, the journey ended up longer than expected.

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After the meeting, some passengers found themselves with a connecting flight from Los Angeles, California, to Detroit, Michigan, approximately 4 to 5 hours. The passengers included Michael Liu, PharmD, MBA, BCCCP, BCNSP, BCPS, an assistant dean of clinical and professional affairs practice experience at Touro College of Pharmacy.² Everything on the flight to Michigan proceeded as normal, until the latter half of the flight, with approximately 1 hour left, according to Liu. At this time, flight attendants needed a health care provider. Liu waited approximately 10 to 15 seconds, and when no one else responded he knew he had to “step up to the plate.”

“I knew that I had to do something, given the lack of response from anyone,” Liu said in an interview with Pharmacy Times. “That was exactly what was on my mind. It was kind of a fight or flight response.”

In hospital settings, pharmacists and other health care providers have resources, equipment, and support readily accessible. However, on an aircraft or other public settings, these tools might not necessarily be available, or in this case, may be unusable.

Flight attendants contacted air traffic control, and Liu assessed the patient’s pulse and respiratory rate using an auscultatory. He found a low respiratory rate at approximately 8 breaths per minute and a weak pulse. When assessing the patient’s mental status, he noticed that the patient’s consciousness drifted in and out. He checked their verbal motor and ocular responses via various stimuli, and the patient had an airway somewhat intact, according to Liu. He determined hypoxemia as the cause, due to a bluish skin tint, as far as he could tell with the limited resources. He found no signs of stroke present.

Liu said he directed the flight attendant to bring all the medical equipment to the patient to optimize the environment. There was no pulse oximeter on board, and the blood pressure cuff did not work. Based on the available equipment and assessment, he used the portable oxygen tank in the flight.

“If I were to think of the 3 most important aspects in order, it’s really first, activate the emergency response system, whether that is 911 or a code, if you're in a hospital. The second really [is] assess the ABCs ­–airway, breathing, circulation– and last, but not least, ensure the environment around you is optimized for the patient's clinical outcomes,” Liu said in the interview with Pharmacy Times.

This was not the first time pharmacists have jumped into action after an ASHP Midyear Clinical Meeting. After the 2022 meeting, pharmacists Andrew Vassallo, PharmD; Krishna Shah, PharmD; Andy Hui, PharmD; and Rafay Ali, PharmD, joined Sylvia Narciso, PharmD, MS, BS, to care for a patient in need on a flight from Las Vegas, Nevada to Newark, New Jersey.³

About 40 minutes after takeoff, flight attendants called for a medical professional, to which Narciso responded that she was a pharmacist. The patient appeared to have a small seizure, but the patient was stable, with no feelings of confusion or feeling “off,” and required minimal attention by the time Narciso assessed them. Approximately 30 to 45 minutes later, Narciso said the patient made their way up the aisle.

Narciso said in an interview with Pharmacy Times, “I remember thinking, he's going to fall. I just thought to myself, he's going to fall, and as he's coming towards us, because he was trying to get to the bathroom in the back of the plane, he ends up falling over and as he fell over, he hit his head on the plane.”

On instinct, Narciso stood up, asking for a doctor or a physician’s assistant, and then headed to the patient, turning them on their side in case of vomiting. Narciso’s instinct proved to be right, as the patient did vomit and, at this point, was completely out of it, she said. Her and her makeshift team of other pharmacy professionals asked questions to evaluate medical history, as they would if this event happened in a hospital setting. They assessed the patient’s mental status, evaluated the patient for concussion, and even conducted tests based on equipment available on the plane, including a smart watch’s electrocardiogram feature. The patient had low oxygen levels, so like Liu, Narciso and the other professionals used oxygen tanks and monitored his pulse. She identified hypoxemia as the cause, as far as she could tell.

But it wasn’t necessarily instinct that drove Narciso­–she found herself leaning on her training and education from the pharmacy profession. As a clinical pharmacy specialist in the emergency room, there are many aspects to her job. She attends emergency codes, attends any stroke alerts, prevents medication errors, and consults the providing physician on dosages and medications, including assisting with the titration of medications. The clinical pharmacy specialist is one of many health care professionals serving as support staff during cardiopulmonary resuscitation (CPR).

“These are all things that we take into the real world, and even in this case, all of that training, all of that education, can be utilized in any kind of scenario where there could be a medical emergency,” Narciso said in the Pharmacy Times interview.

She added that most pharmacy schools teach basic life support courses that are required to be an immunizer. For her position as an emergency medicine pharmacist, she also took an advanced cardiac life support course to hone her skills. She said anyone with an interest in pursuing a career in emergency medicine must recognize the importance of training. Additionally, she said ASHP offers certification programs in emergency medicine and recommends that to anyone who has an interest.

Further, she added that there’s also a board certification offered by the organization that is relatively new and a good way to brush up on skills specific to emergency medicine. Liu added that a CPR re-certification through the American Heart Association or other organization helps pharmacists continue to practice as immunizers. He also recommended that pharmacists in a clinical setting should go to the emergency department to observe in order to be more comfortable in emergency situations. Joining organizations like ASHP or any at the local level help in emergency medicine, according to Narciso.

“We must respond head-on because you might be the only health care provider around. You might be the only one, and your engagement can make a difference for the patient. It could be as something as mundane [and] minute as getting the patient back on their feet, or in this case, it can make the difference between life and death,” Liu added in the Pharmacy Times interview.

Perhaps the most important role in emergency situations that pharmacists play comes down to being the drug experts. Narciso said that getting medical background and drug information is one of the most crucial steps during an emergency. This can tell a lot about the patient’s medical history or can help identify any drug-drug interactions that did, or could, take place before and during treatment. After that, Narciso said the rest of a pharmacist’s training and education helps optimize the best patient care plan the situation and availability of equipment calls for.

“I also think it’s really important, in general, to support the passage of provider status legislation for pharmacists. Once we recognize pharmacists as health care providers, this actually allows patients more access to health care services,” Narciso concluded in the interview. “There [are] probably more pharmacists that are accessible than there are our primary care providers. To be able to utilize our knowledge and our skill set, and to be able to get the recognition for it, . . . I feel like there'll be more access [to care] and it'll be better for patients overall.”

In both cases, thanks to the pharmacists’ quick action, the patients were okay and able to continue with their journeys home.

References

1. American Society of Health-System Pharmacists. Midyear 2023. 2024. Accessed January 23, 2024. https://midyear.ashp.org/

2. Traynor K. Pharmacist Takes the Lead During Inflight Medical Emergency. ASHP News Center. January 12, 2023. Accessed January 23, 2024. https://news.ashp.org/News/ashp-news/2024/01/12/pharmacist-takes-the-lead-during-inflight-medical-emergency

3. Inserro A. Flight Home From Pharmacy Conference Holds More Surprises With Medical Emergency. December 9, 2022. Accessed January 23, 2024. https://www.ajmc.com/view/flight-home-from-pharmacy-conference-holds-more-surprises-with-medical-emergency