From burnout in emergency medicine (EM), to the benefit of intramuscular (IM) epinephrine versus IV in treating out-of-hospital cardiac arrest, to initiating a seamless path for critical care transport to the ICU, this roundup highlights three presentations from the Emergency Medicine Pearls session at the ASHP Midyear 2024 Clinical Meeting & Exhibition, in New Orleans.

Preventing Burnout in EM Pharmacy
Pharmacists working in EM are especially vulnerable to burnout and compassion fatigue due to a heavy workload, long shifts and constant pressure to multitask (J Am Coll Clin Pharm 2020;3[8]:1423-1433), said Kristin Buechler, PharmD, BCCCP, a clinical informatics pharmacy specialist with First Databank Inc. Prior to her current position, she worked as an EM pharmacist.

“Burnout is a psychological response to chronic workplace stress,” Dr. Buechler emphasized. “It’s characterized by a state of general exhaustion, lack of motivation and detachment from work.”
A related, but distinct, challenge to burnout is compassion fatigue. “Unlike burnout, compassion fatigue is more closely tied to the emotional toll of witnessing patient suffering and can emerge suddenly, adding another layer of complexity to healthcare professionals’ well-being,” Dr. Buechler said. Compassion fatigue comprises two elements: burnout plus secondary dramatic stress. “Both conditions impact pharmacists’ emotional well-being, but the key difference is that compassion fatigue stems directly from trauma exposure,” she explained.
Pharmacy learners, including students and residents, are at high risk for burnout, which can set them up for potential failure, Dr. Buechler said. Although exposure to unsettling events may become less frequent, the emotional challenges they face can lead to stress early in their career. “While these challenges can feel overwhelming, there are solutions through self-care, emotional boundaries and workplace support systems,” she said.
Building resilience is key for career longevity in EM pharmacy, according to Dr. Buechler. “We’ve seen that learners with higher resilience levels experience lower rates of burnout and handle clinical uncertainty better,” she said. “Therefore, wellness programs that promote self-management strategies, critical reflection and community building are crucial for preventing burnout among our EM learners.”
She added that organizational support is also essential. “Institutions can help by providing flexible work arrangements, family support resources and access to counseling services,” Dr. Buechler said. “Another critical element is burnout recognition training, which helps staff identify the signs of burnout early. Much like diagnosing a health condition, if the signs aren’t recognized, the opportunity for intervention can be missed.”

IM Epinephrine an Alternative For Out-of-Hospital Cardiac Arrest

Most cardiac arrest responders working in rural areas are trained only in basic life support, according to Jennifer Esch, PharmD, MBA, BCPS, an EM pharmacist at Aurora BayCare Medical Center, in Green Bay, Wis. Although urban areas, she noted, typically have highly trained EMS personnel, rural locations rely on volunteer personnel and are not staffed by paramedics.
“Therefore, responders in rural areas are restricted by their training, or lack thereof,” she said. “But what if there was another option available? Nonmedical personnel use intramuscular epinephrine for anaphylaxis. Why can’t it be used for patients experiencing out-of-hospital cardiac arrest?”
In her presentation, Dr. Esch evaluated the use of IM epinephrine in patients with out-of-hospital cardiac arrest. “Rural EMS personnel are unable to administer medication to patients via IV,” she said. “[Intramuscular] epinephrine could be an acceptable alternative to IV in specific situations.”
She cited a 2021 feasibility study that examined a 5-mg IM epinephrine dose injected into the lateral thigh. The IM group received the first epinephrine dose on average of 5.9 versus 8.6 minutes in the IV/intraosseous group study (Resusc Plus 2021;7:1-7). In 2024, researchers tested survival (Resuscitation 2024;201:1-8) using the same EMS service and found decreased time to first injection with IM (4.3 vs. 7.8 minutes), Dr. Esch said, although she acknowledged the study’s small sample size.
“Furthermore, researchers observed positive neurological outcomes in patients,” she noted. This specifically refers to cerebral performance category scores, which measure neurologic outcomes after cardiac arrest. “We haven’t seen that in other epinephrine studies on cardiac arrest. This is one of the first studies to show this.”

Pharmacists Key to Navigating Critical Care Transport to ICU

The initiation of critical care frequently happens before patients are admitted to the ICU, according to Alyson Esteves, PharmD, BCCCP, BCPS, a clinical pharmacy supervisor for critical care and EM at Dartmouth-Hitchcock Medical Center, in Lebanon, N.H.
Dr. Esteves discussed opportunities for pharmacist intervention in critical care transport to improve ICU outcomes. “The prehospital time frame is often characterized by frequent transitions, which creates a high-risk environment,” she said. “This is further complicated by diagnostic uncertainty, as well as the task of patient stabilization.”
Critical care transport includes ground and air support, she noted, and crew members have diverse medical backgrounds, ranging from RNs to EMS, aiding a variety of patient populations.
To better comprehend the integration of pharmacists into critical care transport, Dr. Esteves stressed the importance of understanding transport duration. “At my institution, transport times are upwards of 80 minutes, which is relatively long and poses tremendous responsibility for crews,” she said. “They’re intubating patients, starting mechanical ventilation and initiating sedation.” At the same time, these crews are faced with many challenges, she said, including noise, small spaces, and limited resources of personnel, medications and diagnostic tools.
Pharmacists focus on therapeutic momentum, a reluctance to withdraw therapy when it is no longer needed or unsupported by evidence, Dr. Esteves explained, but most of their attention is focused on outbound inappropriate continuation of medications. “We need to think about inbound therapeutic momentum as well,” she said.
Dr. Esteves cited a cohort study where researchers aimed to categorize deep sedation in the emergency department, and it revealed that 52.8% of patients were deeply sedated. “This actually continued for most ICU patients on day 1, with 53.8% of them continuing to be deeply sedated,” she said. “This contributed to a longer length of stay as well as mortality [Crit Care Med 2019:47(11):1539-1548].
“Therefore, why should critical care transport be viewed differently? We see high rates of deep sedation, ranging from 41% to 92% in critical care transport, high reliance on benzodiazepine usage at 30% to 50% and high rates of continuation of deep sedation to the initial phases of ICU, upwards of 85%.”
She emphasized that EM and critical care pharmacists should consider how they can make a difference within critical care transport associated with their respective hospitals.
“One suggestion is to evaluate individual practices and trends in the prehospital care environment,” Dr. Esteves said. “My key takeaway is that deep sedation is linked with worse outcomes in critically ill patients. Clinical pharmacists, however, can make an impact on care in the prehospital and critical care treatment stage.”
This article is from the March 2025 print issue.