2005年10月

今日の回診は9時からのため、久しぶりに大学の僕の部屋(Gaines Hall)に早めに行き、そろそろ総合医学社から出版される「救急・集中治療」の締め切りが近くなってきたため急性血液浄化法についてPubMedで文献チェックをするが文献数が少ない。しかも日本人ものが多い。僕のUSBメモリーでは認識しないため、次回新しいものを持って行って、再チェックする予定。1028.png

Michaelは6週間の研修を終え、今日はMarieというOSUの4回生と一緒。彼女も6週間のローテーションで各病棟を回っているらしい。背は僕よりも高い。ちなみにこちらのM寸は日本のL寸と同じ。S寸が僕にはちょうどいいがほとんど売っていないので困る。

患者のカルテ(こちらではChartと呼んでいる)を見て、投薬内容をチェックし、PRN(屯服)の服用暦を見て痛み、吐き気などのモニターをする。さらに最新の検査値を診て患者の状態を観察する。そして回診についていって患者の状態を生の目で確認する。これらの作業の繰り返しで、だんだんと仕事が慣れてきた。この病棟ではJoeの存在があるためか、我々、部外者のものがミーティングに参加したり回診に参加したりしても非常に友好的である。この点でも日本の病院とは大違いだ。

今日はJoeとの最後の日なので、今まで聞き逃していたことを全て聞いてきた。彼は「ACCP(臨床薬剤師の学会)には絶対に行かない。行くとすればOncologyやhematologyなどの医学会に行く」と言っていた。僕も薬学系の学会には参加しているが、これは存在感をアピールするためであって、本当の勝負は透析医学界か腎臓学会だと思っている。薬学系の学会だけで自己満足していては「井の中の蛙、大海を知らず」になってしまう。これから薬剤師は臨床系の学会で認められてこそ、存在価値を認められるものではないかと思っている。Oncologyは自分にとって初めて経験する分野だったが、非常にためになった。メールをするように言われたので、帰ってJoeにお礼のメールをする。

1028_2.png今日は早く終わったので帰ってジョギングをし、アパートのジムでウェイトトレーニングをする。3月に帰る頃にはマッチョに変身できることを夢見て(無理かな?)。プールとジャグジーもある。プールは当然冷たかったが、ジャグジーは野外なのに暖かかった。でもちょっと恥ずかしいので入いるのはやめる。その後、Johnとノア君が訪ねてきたので、家から送ってもらったチョロQで一緒に遊ぶ。30日の夜はハロウィンのパーティーがあるが、僕は仮面ライダーのショッカーの格好で行く予定。

 

 

今日、学んだこと:10/20~28

Left shiftはステロイド投与後だけでなく、リツキシマブによってもリンパ球減少が48%に起こるため起こりやすい。

アセトアミノフェンはがん患者の下熱、鎮痛に有効で、胃障害、腎障害を防ぐにはNSAIDよりも優れているが、1回量は325~650mgとし、4時間以上の間隔をあけて1日量4gを超えないようにすること。Percocetと言う5mgオキシコドン+325mgアセトアミノフェンの合剤も市販されている。

Cheotherapy1時間前にステロイドが使われるのは吐き気の予防のため。オンダンセトロン(ゾフラン)なども同時に投与される。

日本では癌領域ではステロイドとしてリンデロンが汎用されるが、こちらではfirst pass effectを受けやすいため注射が使われるくらい。ただし半減期が長いため(デキサメタゾンと同じくらいで、プレドニゾロンよりも長い)小児には使われることが多い。

Trazadoneはserotonin reuptake inhibitor/antagonistでSSRIとは異なる。

スコポラミンパッチはsedationに用いられている。

低分子ヘパリン使用時のApttのtherapeutic rangeは78~120秒。正常値は26~36秒。

INRのtherapeutic rangeは静脈血栓の場合、2.0~3.0にその他の場合は2.5~3.5。正常値は0.9~1.2

重複投与のことをduplicationと言う。

ACE-Iは少量から漸増していくが、米国での使用量はリシノプリルで降圧目的として40mg、鬱血性心不全には80mgまで投与可能である。

キノロンが処方されたときには自動的に「no antacids for 2 hours」のコメントが入る。

シタラビンによる結膜炎予防には1日4回のプレドニゾロンの点眼が行われる。

新しいテトラサイクリンとしてtigecyclineが注目されているがテトラサイクリンのため静菌的。ラプトイシンは殺菌的。

トリアゾラムは健忘amnesiaが問題なため、最近では超短時間方睡眠導入剤としてゾルピデム、ゾピクロンが用いられることが多い。

Today I attended ACCP meeting from 7:00 to 9: PM. What a busy schedule! But all meals were free.

I took a day off, as today’s programs of ACCP were poor. In the morning, I went to the pier to get on the bout of bay side cruise around the San Francisco bay.  Traveling alone was lonely, but I could enjoy bay side cruise, I could see Alcatoraz island, golden gate bridge, bay bridge, and the sky scraper of San Francisco. After the cruise, I ate clam chowder in big bread. It was very tasty. I went to the pier by old fashioned street car. Then I got on the bus and went Japan Center.  Although in San Francisco, I could find Japanese restaurants, the atmosphere of JapanCenter was almost same as Japan. There were some super markets, apparel shops, Kinokuniya book store, and so on. After I enjoyed the atmosphere of Japanese taste, I went the famous secondhand clothes shop named Crossroads, and bought a sweater, a dress shirt, and a cardigan with less than 10 dollars each. I can be able to tolerate the cold winter in Portland. Although San Francisco is a vigor city, but the night of San Francisco seemed to be scarcely, and full of rough natured people, trashes, and beggars. Portland is much more sophisticated and clean. And people are gentle.

Basic training for new clinical faculty and preceptors was held today, on the day before start of ACCP. Although I have a little confidence about listening comprehension about English, It was all Greek to me. I have lost confidence at all. But I could understand the last satellite symposium named “Comprehensive Diabetes management” almost 100%.

At a break, I met Mr. Paul Wong, the director of Kameda general hospital.  And he told me that Japanese education system in pharmacy college is delayed more than Thai. I remembered Myrna told me to complete the reorganization of education system would take about ten years. Today’s lunch and dinner was “Nikoniko-susgi” in front of Hilton hotel. The set of noodles and a bowl was less than 9 dollars. Much cheaper than Portland, and good taste.

I will go to San Francisco to attend ACCP (American College of Clinical Pharmacy) meeting.

But I should meet Myrna at Gains Hall at 9:20 AM, OSU at OHSU campus to go with Legacy Emanuel Hospital before I leave. The reason is to meet Dr.Karl Heisei, the specialist of anticoaguration clinic.

Before I left my apartment, I had already checked the time when I should get on the bus by website of trimet, municipal bus and train service. Although I reached the bus stop, the bus did not come, and there was no time table there. I was worried about breaking promise with Myrna, While I moved to another bus stop, I called Myrna “I can not meet you on time, how should I do.” Myrna said “Don’t worry, call me at 9:15 and I’ll catch you.” Finally I could get the bus of another line and reach downtown of Portland.  After I called Myrna again, and 15 minute after she picked me up. What a relief!.

Meeting with Dr.Heisei and his colleague and also Myrna’s old friend, Pamela J White was successful, and they were very friendly. I promised to see Dr. Heisei at 1:00 PM on October 31th , the I will go anticoaguration clinic of Legacy Emanuel Hospital on afternoon of Monday, Wednesday, Thursday, and full time on Friday. I should be careful that from 31th of October, the summer time would be end, it meant I could sleep one hour more.

After I got off the Myrna’s car, I went to Portland Airport by MAX, the municipal train, to attend ACCP meeting in San Francisco.

Joe advised me that I was careless, as I have forgotten to record the PRN (as needed) prescriptions and how many times the patients the medicines. For the patients with oncology, PRN prescription includes usually pain relief and opioids, that means the pain status of patients can be monitored by the amounts, or the numbers of pain relief and opioids. And sometimes PRN includes medicines for nausea, vomiting , constipattio, or diarrhea  Generally PRN prescriptions are neglected, but it is very important for the patients to check the PRN prescriptions.

While Joe and I were talking about pharmacist’s specialists, he gave me a book about the countermeasure exercise to be the oncology specialist that he wrote. And I asked him to give me his autograph on the book.  Wow! It must be my treasure.

 今日会った人:Erin:Joeの代役の薬剤師白髪交じりのアジア系女性

今日、学んだこと:10/19

化学療法中にはVK欠乏によりINRが低下する症例が多い。これは抗菌薬投与によるVK産生菌の死滅による。

Bandsとはband neutropilのことで、桿状核好中球のこと。

投与中止のことはdiscontinuedという。

使用期限が過ぎた薬物はお金のない人のためのクリニックにあげる

1ポンドのことを1bsとして表す

金曜日に退院のことをHe goes to Friday、入院したままのことをHe goes to stayという

Nurse Practitionerはほぼ内科医と同じ仕事をしている。

薬物療法専門薬剤師の合格率は50~60%と非常に難しい。また更新は7年ごとに行われ生涯教育研修を120時間/7年間必要で200問の試験問題を受けないと更新できない。現在はコンピュータを使った試験となっている。

Factor 8 inhibitorとは血友病のこと。

From today I should wake up at 5: 3O AM. After I had a Dorayaki and milk and immediately went to bus stop.  From 7:00 AM the meeting was started in the doctor’s office of the department of hematology, then discussed about patients. In Us, the hospitarization period is much shorter in Japan. For example, delivery or tonsillectomy is only 1day hospitalization in US, although it takes 7 to 10 days in Japan. So, the symptom of a patient was improved, he or she should leave the hospital. I often heard the conversation between physicians and Joe, just like as follows: “He goes to stay.” or “He goes Friday.”

Here, the department of oncology, PT-INR was often determined, because the patients were usually antibiotics, and the bacterial flora in the colon was destroyed. Then vitamin K was not produced by intestinal bacteria. So, Pt-INR was decreased, Vitamin K was administered.

Here, in OHSU I can always watch the medical records freely.

Tomorrow Joe will be busy with research, so I will go round with Erin from 7:00 AM.

 

今日会った人:Dr.Nichols, Head of hematology of Oncology

今日、学んだこと:10/18

化学療法中にはVK欠乏によりINRが低下する症例が多い。これは抗菌薬投与によるVK産生菌の死滅による。

Bandsとはband neutropilのことで、桿状核好中球のこと。

投与中止のことはdiscontinuedという。

使用期限が過ぎた薬物はお金のない人のためのクリニックにあげる

1ポンドのことを1bsとして表す

金曜日に退院のことをHe goes to Friday、退院したことをHe is gone、入院したままのことをHe goes to stayという。

PCAとはpatent controlled analgesia(鎮痛法)のこと。

Nurse Practitionerはほぼ内科医と同じ仕事をしている。

薬物療法専門薬剤師の合格率は50~60%と非常に難しい。また更新は7年ごとに行われ生涯教育研修を120時間/7年間必要で200問の試験問題を受けないと更新できない。現在はコンピュータを使った試験となっている。

When I got to the hospital ward of the department of oncology, I could not find Dr. Bubalo and Michael, Pharm.D student.  They had gone to the round with 4 hematologists. Almost all patients lost their hair. Anytime Joe was asked about medicationby the hematologist, he can always the appropriate answer. From what I hear, this go around would been carried out from 7 AM to 8 AM for this week. It means I have to wake up at 5:30.  Wow!  Really tough job. 

Today’s lessons were “ventricular arrhythmias” by visiting assistant professor with PhD and “pharmacokinetics” by Sandy. Today’s theme is clearance. In Japan, “pharmacokinetics” appeared to be disliked most by the students, in general. But Sandy‘s lecture is funny and practical. So, almost students enjoyed the lesson. And “pharmacokinetics” was carried out almost every day, because it seemed to be important.

After lunch I returned to Dr. Bubalo’s office, and he told me “Sumio, do you want try to challenge something different?” And I answered “I do not have many experiences in this field, but I would like to try, if I can.” “Then, check the medications, labo data, and vital status of four patients with leukemia and lymphoma”

The way of writing medical record is totally different from Japan. In Japan the amount of dose in prescription was shown as total amount of the day , but in US, the amount of drugs was shown as one dose.  BID does not mean every 12 hours, so if a physician want to direct to the patient to take every 12 hours, he or she should write as 8:00 and 20:00 concretely.  A dose of medicine to be taken only once when the symptom is appeared is shown as PRN. PRN stands for pro re nata, means “as you needed.”  And the brand names are often different from Japan.  The old drugs like hydraladine are still used. Nystatin was often used instead of Fungison syrup, etc.

After Completed my work, I discussed about the patients with Joe just like as folows.

Joe: “Explain, who is first?”

Me: ” Neutrophil’ s percentage is 90%, extremely high in this case. ” 

Joe: “Why do you think? .”

Me: “I think the cause should be predonisolone.”

Joe: “That’s right!”

今日習ったこと;10/17

ステロイド投与によりレフトシフトが顕著になる。

LDHは細胞のturnoverのマーカーになる。そのため白血病のの再発のマーカーとなる?

BCLP: OncologyのSpecialistの薬剤師

BCPS: pharmacotherapyの専門薬剤師

From today I have decided to write my diary in English instead of Japanese, because my speaking ability had never improved after 2 weeks after coming to Portland.

Yesterday and today, I am completely free.  Yesterday, after I completed my diary in Japanese, decided to go shopping to buy a cardigan, because it would be cold here, and when we went the hospital ward, we had to wear dress shirt and necktie under white coat in OHSU.  I checked out whether there are supermarkets that sell apparels near my apartment. But there was nothing in neighbor, and the huge supermarkets are in the suburbs in general, and in down town everything is expensive as department stores.  But as I checked out the guidebook about Portland in Japanese, I found out “Nordstrom rack” that sold unsold goods and dead stocks at the famous department store called “Nordstrom”.  But the cost of the cardigan was almost 100 dollars, the regular price was 200 dollars.  After all I gave up buy cardigan, and buy a down jacket with 60 dollars, the regular price was 150 dollars.  Bus toward my apartment came every 30 min. While I was waiting the bus, I had been often asked by beggars.  I have been always ignore them.

Today, after lunch I went to some huge super markets with John’s family, John, Mayumi and Noah aged around three years old boy.  First I went a huge super market called “Target”, then went to Fred Meyer that was much bigger than neighbor one and sold apparels.  Though I could not find cardigans but I bought a pants, a T shirt, and a light.  Then we went “Uwajimaya” that sells Asian foods, and I bought Yakisoba, Curry, Age, instant Mabodofu, and so on. It was fun to play with Noah.  “Any time I can baby sitter” I said to John’s family, and came home.  There are enough Japanese foods, I will not worry about cuisines any more.

プロフィール

平田純生
平田 純生
Hirata Sumio

趣味は嫁との旅行(都市よりも自然)、映画(泣けるドラマ)、マラソン 、サウナ、ギター
音楽鑑賞(ビートルズ、サイモンとガーファンクル、ジャンゴ・ラインハルト、風、かぐや姫、ナターシャセブン、沢田聖子)
プロ野球観戦(家族みんな広島カープ)。
それと腎臓と薬に夢中です(趣味だと思えば何も辛くなくなります)

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