Hillary B: 00:20 In this episode, you’ll hear from an ER pharmacist who shares what life is like in the emergency room. This is a fast paced think on your feet type of environment and one where pharmacy could play a major role in advising on high cost medications and implementing programs such as opioid stewardship. All right, so today we have a special guest on the talk to your pharmacist podcast. Our guest Justin Griner, who is an emergency department pharmacist at regional one in Memphis, Tennessee. He’s an assistant professor for clinical pharmacy and translational science at Ut College of pharmacy. He received his BA in English literature and a BS in biology from the University of Memphis and his PharmD from the University of Tennessee college of Pharmacy after completing his PGY one residency at Methodist University in Memphis. He has served as preceptors for the ED rotation for both the PGY one and PGY two residents of regional one. He is a co-founder and co-chair of the opioid stewardship committee at regional one and is a faculty advisor for the Memphis chapter of APhA’s generation X. He’s a member of Shelby county’s opioid education and prevention work group and is active in the Tennessee Pharmacists Association and the Tennessee Society of Health Systems Pharmacy. Justin, welcome to the talk to your pharmacist podcast.
Justin Griner: 02:20 Thanks Hillary.
Hillary B: 02:22 Well thanks for being a guest. And now that our listeners have heard a little bit about your background, maybe you can fill in any gaps from that intro and maybe share a little bit about your personal life.
Justin Griner: 02:34 Sure. I guess most important thing about me, uh, two things. Uh, I am uh, the husband of Katie and the father of Elizabeth. So those are the two things I’m most proud of certainly in my life. So you, you mentioned I have a bachelor’s in English lit and a bachelor’s in biology. Uh, you didn’t mention that sort of, there was a gap in between those two degrees where I was sort of wandering the wilderness for a little while deciding what I wanted to do with my life. So, uh, sort of in that gap, I did a few different things. I had my own radio show on a, an am radio station in middle Tennessee called the morning show with Justin g, which is if anyone remembers it, hopefully it’s remembered fondly somewhere. I wasn’t a minister, associate minister in a small church. I worked as a research technician in the Department of developmental neurobiology at Saint Jude in Memphis. And uh, I was also a pharmacy technician and that pharmacy technician is what led me down the road to eventually I’m pursuing my Pharm d and a, the position where I’m at today, but all of these different experiences, I’ve certainly had a major impact in my life and have added some variety to my life. I guess that I wouldn’t have otherwise. Normally had.
Hillary B: 03:55 Certainly a lot of interesting skills too that you’ve picked up along the way I’m sure. Set the scene for our audience regional one. Tell us a little bit more about that because it is a major level one trauma center.
Justin Griner: 04:13 Sure. So Regional One is located in Memphis, Tennessee. I work in the Elvis Presley trauma center at regional one. Named for obviously our Memphis most famous citizen of all time, Elvis. We are the only adult level one trauma center in, in Memphis and in western Tennessee and within about a 150 mile radius. So we serve northern Mississippi, eastern Arkansas, a little bit of southern Missouri and obviously West Tennessee. So the most severe traumas in that area that 150 mile radius come to us. So we see a lot of severe traumas and that’s what are our specialty is at Regional One.
Hillary B: 05:00 For those who may remember the Med, that’s the same thing, correct?
Justin Griner: 05:07 That is correct. That we, for many, many years, we are, we’re known as the Med and a too, too many old timers. And to too many people in the community, we will always be the med. But, um, which is, it’s something we’re proud of because at the med, many lives were saved. But we are, we are now known as regional one and, and we do a lot of things that regional one besides trauma, uh, we’re, we have a newborn center, which is, uh, which is world renowned basically. We have a burn center and on and on and on. But, uh, but my area of practice is in the trauma emergency department.
Hillary B: 05:46 Yeah. Well, so Justin, I don’t think we have talked about emergency medicine on the podcast yet, so it’s exciting to be able to have you share your story., How did you decide to go into emergency medicine and a little bit more about what that is. I remember when I was a student and a resident, um, emergency medicine wasn’t one of my favorite rotations. Partly of course because there was always some thing exciting or oftentimes there was something interesting to learn. A lot of times, you know, you had some downtime but because my preceptor was just so dynamic and such an awesome teacher, she had been, she had established her practice site there for about 20 or 25 years. So a lot to learn from her. But Justin, share a little bit about what it’s like to be an ED or trauma pharmacist. Speaking of education, are you aware of the 2014 drug disposal of controlled substances ruling that regards safe disposal of unused medications? Well, we’re lucky to have RxDestroyer sponsoring the talk to your pharmacist podcast. RxDestroyer – Ready to use chemical drug disposal systems are safe, easy and affordable products which protect the environment and can save thousands in fines to get more information on products, training and medication waste compliance. Check out www.rxdestroyer.com/talk to your pharmacist.
Justin Griner: 07:23 So, so my, Regional One, we are a little bit unique in that we have, uh, we have several different ERs. We have a trauma, er, we have a medicine, er, we have a labor and delivery er, when you have a Bernie are, so I’m in my areas of practice or specifically the medicine Er and the trauma er and I, I covered both those areas. So think switch sort of between very mundane, very routine. I’m, I’m tapping on my computer for a while and then suddenly there’s what we call a shock trauma. That happens. So a severe trauma comes in and a multidisciplinary team sort of converges on all together in this, uh, in this room, a shock trauma bay where a patient has been stabilized and being triaged to determine where they need to go next. Um, whether it be a CT scan or the operating room or you know, hopefully they’re not as injured as badly as our initial, uh, the initial assessment indicated they’ll go just to the emergency department.
Justin Griner: 08:29 So, uh, so it goes from sometimes very tedious almost, uh, you know, just your normal pharmacist duties of reviewing medications of, of determining is is this medication appropriate for this patient to literally you’re in a room with somebody who is, is on the teetering between life and death and yeah, somehow it has severe traumatic injuries and, but once that’s over it’s over and you go back to to whatever thing you were doing for a few minutes or for a few hours or whatever. So it’s interesting how quickly it goes from sort of routine to very interesting. Back to routine.
Hillary B: 09:17 Yeah. And would you say Justin, are there any particular seasons or maybe time of day or anything where there might may be more traumas or emergency room visits than others?
Justin Griner: 09:32 So yeah, on the trauma side, traditionally the warmer weather months, the summer months are what we call trauma season. That it doesn’t always completely hold true. But you know, in the warmer weather months you have more people outside riding motorcycles, riding four wheelers, doing outdoor things that you may be injured doing that you wouldn’t be doing in really cold weather typically. So, um, that certainly plays into it. But on the, on the medicine side of things, sometimes when we’re busier in the colder weather months, because you know, right now we’re sort of being hit by or second wave of flu this year for example, and just all your cold weather complaints of colds and uh, and flu and different kinds of cold weather sicknesses. So, uh, hopefully there’s a balance between the two, so, so we’re not overwhelmed, but sometimes, uh, you know, sometimes it’s, we’re crazy busy on the medicine side and on the trauma side and, and just, you know, there’s a lot going on in the Er at any given.
Hillary B: 10:42 Absolutely. So, you know, or even things like medication reconciliation part of your role or is that, you know, something that, that you all do at, in the ER at Regional One.
Justin Griner: 11:00 It’s something that is part of my role. So we don’t reach retreat routinely do it for every patient in the Er in the Er. But we do it for patients where it’s going to make a major impact on their care and either in the Er or a post admission if they get admitted to the hospital. So that’s just how our system works. Other ers that is a major responsibility that you are pharmacists and it is a, it’s an important responsibility in the setting where I practice, but we try to, um, trying to use our time in the best way possible by by narrowing it down to the patients for whom we, we think that’s going to make the biggest impact.
Hillary B: 11:47 Sure. And uh, what would you say are some of the biggest opportunities for in the
Justin Griner: 11:54 80 [inaudible] there’s so many things going on in the Er that it’s just you have to, sometimes I just have to sit back and say, what can I have the biggest impact on there? Almost always things I could have impact on if I had the time to do all the things. Some of them are much bigger impact than others. Um, on the trauma side, for example, uh, a major issue is patients who are on anticoagulation prior to arrival. Uh, you know, especially elderly patients who are on Coumadin or Xarelto or apixaban or Plavix, so on and so on. And so if someone comes in, especially with the, uh, bleed, like a brain bleed and they’re on one of these medications, there’s not a lot of time to, um, you know, in the Er, time is, is very, uh, it’s a very precious commodity. We don’t, we don’t have hours and hours oftentimes to make decisions, especially on the trauma side.
Justin Griner: 13:01 We have minutes. So trying to determine appropriate reversal strategies for these patients, do they need to be reversed? Uh, you know, is it appropriate if it is, what’s the appropriate agent, what’s the appropriate dose? And then, um, so, and in my setting, I don’t really have the luxury of, you know, coming up with a plan and then letting someone else implement it. So, for example, if we need to reverse a patient with a bleed who’s on Xarelto and we need to use the, uh, our reversal agent, we once we, you know, have converted with the trauma team and we’ve made the decision that we’re going to go forward with it, we’re going to do this, then, you know, I, I get the dose set up and then I’m headed to the main pharmacy to help. I get the medication prepared as quickly as possible and then to the patient as quickly as possible for administration.
Justin Griner: 13:54 So, uh, we’re especially for urgent things like that, I’m sort of involved in every step of that process, but, but some of those medications are, you know, many, many, many thousands of dollars. There’s a new medication that’s just been approved by the FDA called index, which is the, there are two doses, a low dose and high dose. The low dose a price is what they publicly announced his $25,000 per dose, the high dose, which will be used in some situations, this $50,000 per dose. So you can see if you could, you know, make an impact and, uh, you know, help help the team determine that this medication in this instance isn’t appropriate or is appropriate. It wouldn’t take too many of those interventions to, uh, to make a big financial impact and to, you know, to pay for a pharmacist salary in the Ed for, you know, for example. So, so that’s just, I mean, that’s just one that we do, but, you know, it’s a place where you can make a pretty large impact both on the patients, uh, care and, uh, financial and
Hillary B: 15:00 Absolutely. Thanks for, for sharing more on that. Your schedule is a seven on seven off. And are there two ER pharmacists at Regional One or, or how many pharmacists are down there?
Justin Griner: 15:18 Yeah, we have two in the, during the day, uh, to cover the daytime hours. And we actually have an overnight pharmacist in the Ed who’s going to be starting in about a month. So, so we’re, we’re expanding our footprint in the Ed at regional one pharmacy is, so we’re excited about it.
Hillary B: 15:36 Awesome. And so Justin, uh, a lot of times, uh, and the er, we also see a lot of opioid, uh, issues, you know, maybe some overdoses and things like that. And then, um, in your bio you mentioned that you guys have started an opioid stewardship committee, which I’m sure a lot of the listeners have heard about. Anti microbial stewardship committees. Bet, bet this new movement towards opioid stewardship is a, something to address the Ibw I did to make that we’re all seeing across the country. Can you tell us a little bit more about what that looks like?
Justin Griner: 16:19 Sure. I’ve been working in that, in the Edd for approximately five years and not long after I started we started seeing an uptake in patients who presented with some sort of opioid overdose. And it’s become a very routine thing now to see a patient who presents a, either someone drops him off at the, at the front door of the quote unquote friend, uh, after they’ve overdosed and we have to try to revive them or they’re picked up by the police or by the empties and the ambulance services, uh, and given narcan in route after opioid overdose. So that’s unfortunately a commonplace occurrence, almost an everyday occurrence. So we have tried to make some inroads into combating that, although from the emergency department setting, that’s difficult for someone who’s already addicted to these substances. Uh, we, you know, we tried to make an impact by helping them get to some sort of treatment facility, but often people who’ve been reversed from an overdose or that’s, they’re less concerned about getting to treatment at that point, then they are getting out of that withdrawal state that they’d been pushed into by receiving narcan.
Justin Griner: 17:38 And then they’re just worried about trying to get their next fix basically. I mean, that’s sort of the reality. So we’ve done a few things that we’ve been working on it for, for at least a couple of years. We started providing, take home a narcan kits to patients who present with overdose directly from the Er. So now there was a study that came out recently that said prescriptions for Narcan, a written in the Er have about a 1% fill rate. So we are, you know, we have tried to, to bypass that by putting it directly into their hands, ideally into the hands of a family or friend, family member or friend who can actually administer that. But, but that’s, that was one step that we took. Uh, we have, um, been involved with the Tennessee Hospital Association, uh, in a pilot project that several hospitals around the state of taking part in over the past year to, uh, to reduce our opioid use in the Ed with the thought that the fewer opioids that you’re exposed to as a patient, the less likely you are to become a dependent and then ultimately addicted to opioids.
Justin Griner: 18:48 So that’s something that over the past, uh, past year, we’ve reduced our opioid use in the Ed by, uh, approximately 20%, uh, using other agents, uh, for, uh, conditions where that’s appropriate, that are non opioids, but there’s still provide pain relief. And so out of these different efforts, uh, myself and one of our er physicians with the support of our er medical director, you know, have just sort of been building on that. And then ultimately, uh, we started, uh, a system wide committee, an opioid, what we initially just call it an opioid committee, more to give information to the rest of the system, uh, and the providers and different healthcare professionals in the system, just information about opioids. And, and it’s sort of grown now too. And especially now with some joint commission requirements that have just been enacted. That committee has now ultimately grown into a, a system wide stewardship committee where we’re trying to make an impact, um, much like we have in the Er, the throughout the system and providing alternative treatments, uh, to opioids for pain, for pain, uh, for certain conditions.
Justin Griner: 20:00 Now, that doesn’t mean if you come in with a major trauma and you’re, you have an open fracture, we’re going to give you Tylenol because that would not be in, that would not be appropriate. But opioids certainly have their role in a acute pain. But we are trying to on a system wide level, uh, to provide alternatives and, and reduce our opioid footprint, uh, in every aspect of the hospital. And there are some areas where that’s just not feasible, at least with the current, you know, science and information that we have. Opioids are still the, the most appropriate treatment for some conditions, but, but that’s how we’re addressing it as on the system level. So it’s grown from a few small steps in the Er to a, to system wide level of, of addressing and using data, uh, to, to see what areas are there certain providers, are there certain services that, that use more opioids and others and just providing that information to them. Because sometimes once people and providers can see that information and realize that their peers are able to treat the same conditions with, with fewer opioids and treat them appropriately, that’s all it takes to sort of nudge them in, in the, what we think of as the right direction away from opioids and try and other, uh, equally efficacious treatment modalities.
Hillary B: 21:27 Yeah, that is really impressive that, that you’ve grown that out of the ed where, I mean, that’s just so appropriate because you, you probably are seeing a lot of patients with, you know, that have overdoses as you mentioned, and that, that probably present with, with drug seeking behavior. Um, and so you’re, you know, a lot of of patients probably had been discharged on opioids, you know, making that narcan program widely available and, and that this is a really started as a pharmacy led initiative. That’s, that’s really impressive. Um, great work that you all are doing. Um,
Justin Griner: 22:09 but I do want to say that this was only possible through the support of, uh, of our er physicians that, uh, that I’ve been working with. And, uh, you know, by working together with them, uh, you know, just like on the, on when traumas come in, it’s a team effort and it’s exactly the same thing with the opioids. That it’s not something that that pharmacy you’re or I myself could do all by myself. I just want to make that clear that it is, it has to be a team effort for it to work. And I just appreciate everyone on our team recognizing the importance of this and, and working together.
Hillary B: 22:45 Um, and you know, that type of, of collaboration building and, and teamwork, um, is how awesome things like this or accomplish. And uh, the humble, uh, you know, kind of mentality to it goes a long way. Uh, so Justin, um, another thing that you’re involved with is a social media. So you moderate a Facebook group that has, remind me how many, how many Tennessee pharmacists are all involved in, in that, in that group.
Justin Griner: 23:23 Approximately 500. A pharmacist who are directly in members of the group.
Hillary B: 23:29 Yeah. Awesome. And, uh, and just tell a little bit more about kind of what that group is and you know, how long have you been been doing it? And, um, you know, I’m a member of the group and, and I’m always keeping up to date on all across the state you’ve got, even though you’re based in Memphis, which is what about an eight hour drive away from, um, from Knoxville and the other corner of this day, you still are, you know, sharing that information, uh, across the statewide?
Justin Griner: 24:08 Yeah, I mean, he’s an extremely long state, uh, which I’m reminded of whenever I head up to the eastern corner. Um, I’m a Tennessee by birth, uh, and basically live my entire life in Tennessee. And, uh, about three years ago I was just thinking there’s, there’s not a lot of great resources for news about pharmacy and healthcare on, uh, on the local, like state and local level, especially for pharmacists, you know, are specifically for pharmacist. There’s a lot of information on a national level that’s out there and about sort of the big, big picture. But as we think about, you know, like what’s with food and with other things about what’s going on locally, that I sort of was interested in in that on a local level and how we could get some of that information to our pharmacist. Because I have friends who are pharmacists in middle Tennessee, east Tennessee and everywhere in between or across the CSLC.
Justin Griner: 25:10 And, and I’m also, I’m just very interested in, in these sorts of things myself. So I’m always sort of digging around and reading stuff from, you know, whether it’s the new sentinel in Knoxville or the Tennessee in the Nashville or commercial appeal or daily Memphian here in Memphis. Now I’m just sort of doing this already. So I started sharing some of this information that I’ve found with, with a few friends. You start out with just a handful of people that I thought might be interested in. Uh, it’s grown to about 500 pharmacists, uh, and uh, several of them are involved in involved in the colleges of pharmacy on an administration level or they’re involved with the pharmacist association. I’m ration level or were different, different things like that. So, uh, I, I hope it’s helpful. I want it to spread information, but also just something I’m interested in general is how pharmacy is portrayed in the media, both positively and negatively.
Justin Griner: 26:08 And, uh, it’s, it’s interesting how it can be either one, just depending on the, how the, what the story’s about and how, how the, the news media wants to, to spin the story. I’m not, I don’t, uh, I, I appreciate what the news media does and I feel like it’s an essential piece of our, uh, of our system, the role that they fulfill. But sometimes there are inaccurate stories that get posted and put out there. Some of them putting pharmacists in a bad light. And we’ve had multiple stories, uh, from our group, uh, multiple media reports that members, the group have gone to that media site directly. Uh, you know, usually it’s up there if it’s on their home, uh, home town or home city. Did they take any initiative to go out there and get the story correct it. And that’s happened multiple times. So that’s something that I’m proud of and that I was hoping to accomplish through this group, besides just spreading information, uh, helping to, uh, to advance the role and the cause of pharmacy in, in the state of Tennessee. Yes.
Hillary B: 27:13 Yeah. Well, I love that point that you brought up about how pharmacy is portrayed because a, you’re essentially creating a watchdog, you know, just looking out for the profession and, and uh, because we do have to, to make sure that our images is portrayed in the right way. And I think that there are great campaigns that are being released right now. A one kind of spearheaded by a ACP is pharmacists for healthier lives. And it’s a PR campaign to educate really, you know, mom’s a, as kind of the drivers of their family’s health, but to educate about all of the different things that pharmacists can do. And so, um, for you and for others in the state of Tennessee to be on the lookout for how information is shared about pharmacy and make sure that there are no inaccuracies, um, that’s, that’s a great service to the profession. Um, and just to kind of create something, you know, from the ground level and watch it grow is awesome. Love to hear if others have things like that. And there are others in other states across the country, but it’s been really impressive to see that grow here in Tennessee. So Justin, as our final question, what is some advice that you would share with your younger self or for other pharmacists who are just getting started in their careers?
Justin Griner: 28:42 Well, I guess for my younger self, I would tell myself to take some more biology classes when I was getting my English lit degree, that would have saved me a little time down the road. But I dunno, it’s a, it’s easy to, to look back and, and, and see what look like mistakes. But then a couple of years down the road say, Oh, this led me to a really great place. So I mean, one piece of advice is if you are not happy with, with what you’re doing, then then find a way to change it. It may not happen immediately and it may take a lot of work. But, um, you know, I honestly, when I was an English major, you know, I took science for a while. Science for dummies. I took the easiest science class as I could because I just never saw myself in, in that sort of setting.
Justin Griner: 29:33 But when I decided that that’s what I wanted to pursue and uh, and put my nose to the grindstone, it was something I was able to accomplish. So, uh, you know, four or younger pharmacists, I feel like the job market currently maybe a little tight, and it may be pharmacy, may look a little different over the next few years in a currently does, but hopefully that it will look, it’ll look better. Uh, it’ll be, uh, a profession that we can even be more proud of, but it’s going to take work and it’s going to take, uh, taking the initiative, uh, ourselves to, to push programs and projects that are gonna make a real difference in the labs or are patients. And I think that if, if our colleagues in our medical colleagues, our nursing colleagues, our uh, other health care colleagues, administrators and our systems, whether that’s out and healthcare system or if it’s in a community setting and you’re part of a chain pharmacist, there’s always room for, for growth. Uh, it’s just you have to be sometimes willing to look a little bit outside the box and then to be willing to put in some work to make that happen. That’s great advice. And you know, if you don’t like something then change it. You just have to put in the work to be able to date that.
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