On the Hotline
LOH Chin Siew is a pharmacist at the Drug & Poison Information Centre at Singapore General Hospital.
A doctor calls from the Accident and Emergency Department of a hospital. An unconscious man has just been brought in by ambulance. His friend told the doctor the man drank liquid from a bottle about an hour ago and lost consciousness shortly thereafter. The patient has a lot of secretions from his mouth, he has pinhole pupils, and his leg muscles are twitching.
The symptoms suggest poisoning with an organophosphate insecticide. I advise the doctor to give the patient atropine and pralidoxime, which are antidotes for this type of poisoning, and to manage the patient’s airway, breathing and circulation. I know that with this treatment, he has an excellent chance for full recovery.
I spend a good part of each day on the phone, both with doctors and with worried people calling our 24-hour hotline.
A doctor from the hospital calls and asks if there is any drug interaction between cyclosporin, which the patient has been taking for some time, and levofloxacin, which he wants to prescribe for a week. (A modest increase in cyclosporin levels may occur, so I advise him to monitor the cyclosporin levels during treatment with levofloxacin). Another doctor asks if any dose adjustment is required for the medicine meropenem in a patient with impaired renal function. (I recommend a dose of 2g once a day, instead of the usual 2g three times a day, because meropenem is cleared to a significant extent by the kidney.) A young doctor calls and asks if the antidote N-acetylcysteine should be started in a 21-year old, lady weighing 50kg, who took 30 tablets of paracetamol 2 hours ago. ( I tell him yes, after calculating that this amount exceeds the dose that is considered toxic.)
A young mother of a two-year-old boy, who has accidentally given him a double-dose of antihistamine, calls in a state of anxiety. I start the conversation by telling her to stay calm, that all will be well, as I calculate the dose per kilogram of antihistamine. Very quickly I can reassure her that her baby will be fine, although he may experience some drowsiness. Another mother calls to check if she needs to bring her 1-year old child to hospital after she caught him eating silica beads. (I tell her no, as long as he is not choking, since the beads are non-toxic and will pass through his digestive system.) A young lady who is 10 weeks pregnant calls to check if she can take paracetamol. (I tell her she can take moderate amounts and only when necessary.)
I always follow up on my cases to make sure our advice has had a good result.
We don't just talk on the phone at the centre. It is also a place of learning. We have no formal training in managing poisons at the National University of Singapore, where I studied. Therefore we must learn on the job. After I graduated with a Bachelor of Pharmacy in 2003 and completed a 9-month internship at Singapore General Hospital, I immediately started on-the-job training at the Drug and Poison Information Centre, which was set up the same year. I continue to learn, but now I am also a teacher.
If there are students rotating on our service, I spend time discussing therapeutics and drug information skills with them. Sometimes I make presentations on new drugs to the students or hospital's other pharmacists.
Although much of our work has to do with trying to save lives one by one, prevention is a core function of our job. We do it through communications and awareness raising for healthcare professionals and the public. This July, the Drug & Poison Information Centre will hold its first public forum -- “Poisonings, Drug Allergies & Side Effects of Medicines” -- at the National Library. We hope many people will come.
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