Mmmmm Barium!

Mondays.

Like most of last week, I started my shift 6:15 this morning. The hospital census was low, so the R.D.'s had a light case load. After doing a few follow-ups and reviewing our TPN patients, I was able to go to the pharmacy lab and see just how these TPN bags are put together. Keith, a pharmacist at Moore, walked me through the process from the point of receiving the faxed TPN order from the R.D. to the bag's delivery to the patient. Basically, the TPN order is received, the pharmacist plugs the formula into a computer (the computer automatically notifies the user if the volume won't physically fit into the bag, or if the Ca and/or PO4 levels are such that precipitate will occur, etc), and a sterile, empty bag will be connected to a compounder (that the computer communicates with) and fills the bag with the correct ratio of dextrose, clinisol (AA mixture) and saline solution. 3-in-1 bags are not used at Moore, so a standard lipid formula is administered to the patient via a different pump and is not incorporated into the TPN bag. This is done as a safety precaution, so that if precipitate occured in the bag, it would not be masked by the lipid mixture. The pharmacist went so far as to inject some Ca into a bottle of NaPO4 so that I could see the chemical reaction and the milky precipitate form. After the TPN bag is filled by the compounder, a technician injects each of the electrolytes and the multivitamin component into the bag with a seringe. At this point, the bag is finally ready for delivery!

I also had the opportunity to observe a modified barium swallow test facilitated by a speech pathologist. Watching the x-ray capture the bolus gliding past the pharynx and epiglottis was fascinating! I helped the speech pathologist set up for the test; she had a line of cups filled with various consistency nectars, juices, puddings and solids, placed in order from thinnest to thickest. One of the cups was filled solely with a white creamy Barium mixture. The patient was instructed to take a good swallow of each of the samples. The lovely lady who had to take the test sat in her wheelchair and politely expressed how she was very hungry and wanted to eat fried chicken (she had been on a pureed diet for some time). The speech pathologist smiled and told her she'd have to wait to see how she did on the test. Well, that poor lady was so hungry she scarfed down the first few samples just fine, and when she got to the full-on barium sample cup, she downed that too! The speech pathologist said it was the first time she saw someone drink it up so willingly. Even the lady's daughter behind the protective radiation window was laughing at the situation! (In the end, the kind lady was advanced to a Dysphagia Level II diet, but we assured her that with time, she'll be able to eat her fried chicken just fine).