Monday, November 28, 2016

Rotation 5 - Pediatric Cardiology

Posted by Brock Jackson at Monday, November 28, 2016

Most likely this will go down as my hardest rotation of the year. It was an absolute change of pace from my previous rotation (Drug Information). On this rotation, I was at Mott’s Women and Children’s Hospital. It was a drastic change from working at a desk from 9-4.
I would describe my typical day as such:
Wake up around 5am, arrive at the hospital and be working up patients by 6:30am. Because I did not have much exposure to pediatric populations before, this portion was a struggle for me. 
Around 10am – noon, we would round on the pediatric cardiology floor.
Around noon-1, lunchtime 
From 1-4pm, I would have a bit of time to work on topic discussions, adjust my SOAP notes from what we did on rounds, and present topics/patients to my preceptor.
The types of patients that I primarily saw had congestive heart failure, atrial septal defects, ventral septal defects, patent ductus arterious, hypoplastic left heart syndrome, Ebstein’s anomaly, pulmonary hypertension, and other congenital heart defects. Our main goal was to help manage their cardiac conditions and prepare them for surgery or to be discharged.
Throughout my time on this rotation, I had to complete about 10 different topic discussions, which kept me quite busy outside of rotation. When I was presenting topics (such as hypoplastic left heart syndrome, plastic bronchitis, protein losing enteropathy), I would often be accompanied by a PG-Y1 or PG-Y2. I would often listen to them present their patients or topics, as well as they would listen to me. This was a great learning opportunity for me. In addition to that, my preceptor (which I enjoyed working with) often asked questions to failure. This method involved asked questions until the person answer them was unable to answer them. This often led to me having to look up many different questions afterwards and answering them the next day. It was certainly something that I was not used to and took time adjusting to not being able to have an answer for everything. As a side note, I do not believe I am a know-it-all or anything close to that. However, it is disheartening to not be able to leave one day with having answered all the questions about a patient or topic completely.
Highlights of the rotation:
Spending time with my preceptor after hours and talking pharmacy and life
Being on rotation during Halloween. We were able to dress up and round with the kids. The children and their parents APPRECIATED this A LOT. For the record, I was a piece of pizza and the team I was with were teenage mutant ninja turtles.
The food – pediatric rotations (from what I now understand) are laden with food. There is literally good food everywhere. My inner foodie was impressed!
The team – I loved working with all of the residents and medical students. These folks were great and were wonderful to spend long hours alongside.
The wins – Seeing sick children is extremely difficult to deal with…I do not think I need to elaborate on that. However, when we have a great outcome, the whole team is ecstatic. From the beginning, we had a patient that I followed who was in dire need of a heart transplant. They struggled with weight gain and adhering to a sodium and fluid restriction. It was a major struggle watching his condition worsen and worsen and the family try to cope with the reality that a new heart may not come. On my second to last day, the entire transplant team rounded with us (usually it is just one or two of them) and they announced that they had accepted a new heart for them! It was incredible!! The whole team rejoiced, the mother cried, the patient was stunned and it made the whole experience that much better. On my last day, I was able to watch the new heart be put in and the circle was complete.

Overall, the experience was grueling but I learned a lot and I made friendships that I treasure to this day!

Rotation 4 – Drug Information at the BIG House!

Posted by Brock Jackson at Monday, November 28, 2016

This rotation presented me with a whole different view of Pharmacy. It was quite unique from the previous rotations that I have had and most likely would experience in later rotations too. On this particular service, we would answer questions from various healthcare providers such as physicians, nurses, pharmacists, etc. The types of questions we answered varied IMMENSELY from one phone call to the next. Often times, we were the last line of help before it was deemed ‘unanswerable.’

My day-to-day on this rotation was extremely manageable. It was a 9-4 service with lunch from either 12-1 or 1-2, depending on when the classmate on rotation wanted to take lunch. Everything on the rotation was laid back. The several preceptors we worked alongside with were mostly familiar faces and all accommodated us well.

How our time was spent:
Everyday we alternated who answered the phone in the morning and afternoon. When you were on phone duty, you had to work up any questions that came through. If none came through, you were able to work on anything else that needed to be worked on. Occasionally, we would be slammed with phone calls (OR POWER OUTAGES!!!) and both my classmate and I would work up questions together.

When we were not working the phones, we were most likely doing the following:

Working on previous drug information questions that we were not able to be complete the day before.

Our drug monographs – This was the big project of the rotation. We each were assigned a specific drug and had to complete a drug monograph on it. I was assigned chloral hydrate. This particular drug is not really used anywhere anymore. It was a major project researching the studies behind this drug and the requested indications that were associated with it being placed on formulary.

Journal club – We each were assigned one day to present a journal article. During this time, we went through EBM concepts with our previous EBM professor.

Random events – side projects that came up, various drug information meetings, etc.

Overall, this rotation was an excellent one. Our main preceptor was ABSOLUTELY fantastic!

Sunday, November 20, 2016

Rotation 3: Pharmacy Administration: Transitioning to a New Perspective

Posted by Emily VanWieren at Sunday, November 20, 2016

First Impressions and a Day in the Life
What does a pharmacist in administration do?? Before this rotation, I had no idea what pharmacists do on a daily basis in this non-traditional role. I quickly learned that a job in administration felt similar to being in leadership for a student organization, something I was familiar with after being president of our chapter of APhA-ASP. My preceptor was in charge of the outpatient pharmacy as well as transitions of care initiatives at the hospital. We attended many meetings with various interdisciplinary professionals working at the hospital to brainstorm new ideas, create action plans, implement new projects, and track progress. Interpersonal and written communication was key in getting a message across and producing the best outcome. I helped interview technicians and pharmacists for positions that were open. I was also assigned various projects analyzing data and creating proposals for funding and restructuring of positions.


Transitions of Care
I became passionate about transitions of care over the course of this rotation. After two inpatient clinical rotations, I understood what happened while patients were in the hospital, but I had no idea what happened when they were discharged to go home. There are many medication errors that happen upon admission and discharge (transitions of care), and pharmacists can play a huge role in reducing these errors and creating a safer experience for patients throughout the whole health care continuum. I was heavily involved in counseling patients on their new medications during my organ transplant rotation, and there was some counseling on new anticoagulants during my internal medicine rotation, but a large majority of patients receive their discharge instructions via paperwork, and sometimes nurse education. One of my major projects was to create a proposal that would encourage more use of student resources to counsel patients being discharged on their medication changes so that patients and their caregivers understand exactly how, why, and when to take their medications. Pharmacists and student pharmacists can and should take ownership in transitions of care due to our vast knowledge of medications and our primary focus on medication use.


Reflections
I thoroughly enjoyed my administration rotation because I felt my skills of interpersonal communication, teamwork, and organization were in line with the day to day activities of a pharmacy administrator. I enjoyed hearing other's perspectives and brainstorming new ideas that would affect a large number of patients. Although I didn't have one-on-one interaction with patients on this rotation, I was surprised by how much I used my clinical knowledge and understanding of pharmacist workflow in order to problem solve and create ideas for large-scale solutions.

Saturday, November 12, 2016

Rotation 5: Community Pharmacy with a Twist

Posted by Millie at Saturday, November 12, 2016

Hey there,

Currently writing this entry on the train back to Ann Arbor from Chicago! Another P4 (Erika) and I just finished our rotation at a specialty community pharmacy that serves a health center with a patient population of primarily LGBTQ individuals and a focus on HIV/AIDS. As Jimmy, another P4 blogger on here, wrote about a few entries back, this rotation provided us with a lot of really great opportunities to practice our patient counseling skills and learn so much about a disease state we don’t really focus on during pharmacy school.

The past 5 weeks have basically been “HIV Bootcamp” where we learned EVERYTHING about the disease state and medications used in prevention and treatment. HIV medications have not only a trade name and generic name, but also a 3-letter code which – for some of the meds – is interestingly enough related to the medicinal chemistry of their mechanism. We discussed at length and were expected to understand the DHHS guidelines for HIV/AIDS and opportunistic infections, as well as the CDC guidelines for pertinent STDs (prevention and treatment). We were both amazed at how much we learned in the span of just 5 weeks!

Typical days at the pharmacy included making pillboxes for patients, utilizing the script processing software, calling patients to remind them of their refills, counseling patients, and of course administering vaccines. On our first day it all seemed unfamiliar and confusing to us, but by the end of the rotation we were able to better understand the workflow and even grow much more comfortable in verifying prescriptions! We spent two afternoons out of the week at an HIV clinic downtown where we were able to meet with patients, discuss their HIV regimens, and assess their other comorbidities. This rotation really helped improve my SOAP note writing and patient counseling skills.

During any time that we had available, we worked on multiple projects, including data for an MTM study, developing a patient case for continuing education, creating a poster for an HIV/STD conference, and giving a presentation on antidepressants in HIV positive patients to an interdisciplinary team. We were also actually able to attend that HIV/STD conference and my favorite seminar during the conference was one on transgender individuals and barriers they face in receiving good health care. If you want to hear about it, definitely contact me and I will tell you all about it!

Overall, this was definitely one of my favorite rotations. Since this rotation fell during the October/November months, Erika and I had additional challenges of not only keeping up with the large work load for this rotation but also completing our PharmD Investigations manuscripts and posters, completing P4 seminar quizzes, and preparing for post-graduate plans. However, I would not trade my experience for anything and I really enjoyed these last 5 weeks (though I am definitely ready for a nap now)! My advice would be to make sure you come into the rotation with a good mindset of working hard and trying to learn as much as you can.


P.S. We also happened to be in Chicago during a very exciting time of when the Cubs won the World Series (streets were packed!), as well as Michigan beating Michigan State in football! J

Monday, October 31, 2016

Rotation 4: Ambulatory Care Like You've Never Seen Before

Posted by Michael Harrison at Monday, October 31, 2016


I spent block four at the Cancer Center at St. Joseph Mercy Hospital (SJMHS).

My preceptor is piloting a new program at SJMHS where each person that is receiving any oral medication to treat cancer is required to speak to a pharmacist about that medication. Oral chemotherapies—while often much more tolerable than the usual intravenous option—are not benign by any stretch of the imagination. More importantly, unlike the IV chemotherapy where the patient is surrounded by healthcare professionals for the duration of their infusion, the pills go home with them. For many of them, there are very real risks associated with exposing other people to the drug and other considerations like what you should/not eat or drink, warning signs for side effects and other complications, and drug-drug interactions that could compromise their treatment.

All of the same items apply for patients new to IV chemotherapy, but the majority of the side effects and management have significant overlap so that is done in a classroom setting. However, there are always little things that a nurse practitioner and I would team up to address afterwards.

These sessions would typically take about an hour (and sometimes much longer!) and after three or four in a day I would try to avoid talking for a while so I wouldn’t lose my voice!

Typical Day

I would typically arrive at SJMHS between 7 and 8 AM. First things first: check in ARIA (the infusion center electronic medical record system) to see if there were any new patients for the day. While most of these were scheduled days or weeks in advance which would give us plenty of time to prepare, there was the occasional last minute addition. The morning was usually project work or counseling, depending on the day, and afternoons were the same dependent on the IV chemotherapy teaching class schedule. Generally, I would be in my car headed home between 4 and 5PM with a smile on my face.

The Work

Working up a patient is less focused on their specific disease and more focused on the drug and the logistics of getting it to the patient on time. A lot of things need to click in to place before the drug is sent to them by the (usually specialty) pharmacy, and a big portion of what I was responsible for was, on top of the usual pharmacist duties, ensuring that our office had all of the information we needed and that all necessary testing was done or scheduled. Based on the drug or drugs they were receiving additional screening (such as hepatitis B, HIV viral load, or an echocardiogram) might be required.

Next would be actually going to meet the patient and their family. I often had groups as large as eight or nine people—and spend the hour or more discussing the information that I had, answering their questions, and if they wanted to continue, collecting their consent form. Most days these counseling sessions would take 3-5 hours on 2-3 days a week.

These sessions have been some of the most fulfilling work that I have done as a student pharmacist. Most of the people I was seeing have only known that they have had cancer for one or two weeks. There is a lot of apprehension and a lot of things are changing very fast—suddenly they need to reevaluate their entire life plan and here I am talking about all the bad things that could happen if they take this medication. I could relate to what this was like—my father was diagnosed with cancer when I was in high-school—and those experiences went a long way towards helping me understand what these people were going through. The relief that each person experienced when they were done speaking with me was something to behold. Many underestimate the power of knowledge and what that can do when you have been preoccupied with so many fear-filled unknowns. Pharmacists make this possible.

Projects

My preceptor more-or-less owns the responsibility for the back-end management of ARIA and as such, we had access to a ton of data and reporting tools for process improvement. I used my programming background to streamline several reporting processes for each of the five clinic sites that will probably save an analyst a full week of work each year (30-45 minutes per report à 10 seconds per report). This is on top of literature searches for various questions like “should we use cryotherapy with doxorubicin infusions” or “is glucarpidase over dialysis cost-effective in managing methotrexate-induced acute kidney injury?”

A major component of these counseling sessions is a set of informational packets built for each drug. The Michigan Oncology Quality Consortium (MOQC) has built a ton of these for the oral chemotherapies that we enhanced for use in our clinic. Part of my job was building these for new drugs and updating old drugs with new data.

Overall Thoughts

Year to date, this has been a blast of a rotation. I sincerely left each day with a smile on my face and an excitement about the next morning. I found the work fascinating, challenging (but manageable), and I made a sincere, visible difference in the lives of so many people. Not to mention, I got to program and use a bit of my technical background as well! You can peer in to the world of specialty pharmacy billing, learn a whole lot about various cancers and their treatments, and a ton of other interesting work besides. I highly recommend this rotation!

Wednesday, October 26, 2016

HIV Alphabet Soup - From ABC to ZDV

Posted by James Shen at Wednesday, October 26, 2016

I was fortunate enough to spend my 3rd rotation in Chicago, IL for an HIV/AIDs community specialty rotation. There is a steep learning curve for this rotation, especially considering the brief amount of time spent covering HIV/AIDs during school. Making sense of the ~300 page DHHS guidelines, and memorizing every detail about each of the various HIV drugs took up way more time than I would like to admit. However, at the end of the rotation, I can definitely say that I had the knowledge, skills, and confidence to be able to counsel and manage a patient’s HIV/AIDs diagnosis and drug regimen.

Typical Weekly Activities
Rotation ran from 9am to 5pm each day. On Mondays, Wednesdays, and Thursdays, we were at a Walgreens located inside the Howard Brown Health Center, which is a clinic that serves a large volume of LGBTQ and underinsured patients. It is an incredibly high volume store, and it can be very overwhelming for someone who has not worked in a community setting before. On my very first day when I walked in, before I even got a chance to introduce myself to my preceptor, I was already asked to administer a Hepatitis B shot to a patient that had just come in! Other than that, our activities at Walgreens varied; we would usually start off the day by preparing patient pillboxes, making calls to patients that were newly started on therapies, and calling patients about ADAP (AIDs Drug Assistance Program) packages. From there, we would meet up with our preceptor to have some topic discussion, ranging from drug mechanism of actions, to STDs, to HIV epidemiology… whatever the topic was, you can be sure to be questioned about every minute detail until you understood it inside and out. We also participated in a large MTM (medication therapy management) project, which means we helped conduct MTM interviews with multiple patients that came in each day. This entailed performing a complete work up of the patient (looking at lab values, vaccination records, drug interactions, etc.) and then talking/counseling the patient about any concerns he or she had. Finally, by the last 1-2 weeks, we were performing typical pharmacist duties, which included verifying orders, checking technician work, counseling patients at the window, etc. The patient population and drug regimens seen at this site are very unique, and each day was definitely something new and exciting.

On Tuesdays and Fridays, we went to Mercy Hospital where we served in one of the clinics alongside with nurses, PAs, doctors, and other hospital staff. This was definitely a unique component of this rotation, as we were able to see patients one on one and counsel them about their HIV regimens and other drug-related concerns. A typical counseling session could involve readiness assessments (whether or not a patient is ready to begin HIV therapy), medication adherence assessments (whether or not a patient is taking their medications appropriately), and initial therapy counseling (helping patients choose a therapy that is right for them). For example, I personally helped a patient make a switch from an outdated HIV regimen to a newer more tolerable regimen simply by educating him on his options, counseling him on the side effects, and helping him choose a regimen that would best fit into his lifestyle. These clinic days were my favorite part of this rotation, and it provides a unique clinical experience that I think other community rotations do not offer.

Other projects
While you are kept busy with the daily day-to-day topic discussions and activities of rotation, we also had side projects that supplemented our experience on this rotation. For example, we helped create an inservice presentation to the psychology residents and externs at Mercy Hospital, where we presented about the pros and cons of various HIV regimens, as well as the differences between PrEP and PEP therapy. Additionally, we helped construct a database for Hepatitis C patients who had visited the clinic, which included information on their labs, treatment regimens, genotypes, etc.

Final thoughts

This was definitely one of my most rewarding rotations, and I feel like I came away with a new wealth of knowledge. The diverse patient population lends to an experience that is very unique, and I was able to learn more about HIV/AIDs then I ever imagined. On top of all of that, Chicago is an absolutely great city to explore and live in for a month. During my free time, I was able to attend a free airshow along the lake, visit Navy Pier, see the Bean at Millennium Park, explore the Field Museum of Natural History, walk through the expansive Chicago Botanic Gardens, ride down the Chicago River on an architectural boat tour, eat a lot of great food at the multitude of restauraunts, and much, much more! I would highly recommend this rotation to anyone looking for a unique community experience. Attached are just a few of many pictures of my experiences.

Chicago Air and Water Show










Chicago Botanic Gardens














 Architectural boat tour


Underneath the bean!



Tuesday, October 25, 2016

Rotation 4: "Give Me the Big Picture"

Posted by Millie at Tuesday, October 25, 2016

My fourth rotation brought Jenn (another P4 blogger on here!) and I to the Surgical ICU. This was both of our first inpatient clinical experiences, so we were in for quite a challenge. I was excited to start seeing what the inpatient world was like.

We found out very quickly that the SICU was a very busy service, and that even though there were only 20 beds, the patients had very complex needs. The rounding team consisted of us, our preceptor or our pharmacy resident, 5 medical residents, 2 medical fellows, 2 medical students, 1 medical attending, and 1 nutrition specialist. As you can probably imagine, we had a huge team! Rounds also took us anywhere from 4 hours to 6 hours, which leads me to my biggest advice to you all which would be to make sure you get some comfortable professional shoes for any inpatient rotation you have. (Side note: carrying a water bottle and eating a small snack right before rounds will also help in the long run!)

I learned quickly that patient presentations in the SICU went “head to toe,” meaning we covered ALL systems: neurology, cardiovascular, pulmonary, gastrointestinal, genitourinary & fluids, electrolytes, and nutrition (GU/FEN), hematology, infectious diseases, endocrine, and musculoskeletal. During our patient presentations to our preceptor, we would cover all of these systems as well, but with a focus on the patient’s medications.

Typical Day
I would arrive about an hour and a half prior to rounds to work up my patients. In the SICU, we had very high “turnover,” meaning we would always be admitting new patients or transferring current ones to the general floor. Although pharmacy students on other services may work up patients at night, we had such a high turnover in the SICU that this wasn’t really possible and it was more appropriate to wait until the morning. This rotation really helped me learn how to work up patients quickly and assess their clinical picture thoroughly, looking at their most pertinent problems.

Jenn and I each covered half the service, though we followed each other’s patients as well. We were able to really strengthen our skills with pharmacokinetic dosing of aminoglycosides and vancomycin, especially considering our patient population was not your typical classroom example and had kinetics that are all over the place (e.g. constantly changing volume of distribution, GI surgeries that impact absorption, renal dysfunction impacting clearance), so we had to really consider the whole patient when making our dosing adjustments. Our patients are also frequently on intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT), which are two major factors to consider when calculating kinetics. I felt very proud towards the end of the rotation when I realized I felt very comfortable managing the vancomycin and aminoglycoside regimen for a patient who was bouncing back and forth between IHD and CRRT – something I could not have imagined at the start of this rotation!

We would go on rounds for multiple hours, then grab a quick bite to eat for lunch, and then follow up with our preceptor and/or pharmacy resident to discuss what happened on rounds and patients. Afterwards we would do a topic discussion, typically about some critical care topic such as sepsis, acute respiratory distress syndrome, or intra-abdominal infections.

Final Thoughts
Surgery is definitely not an area we focus on in pharmacy school, so it can be very overwhelming to work in the SICU. The majority of these patients may be on mechanical ventilators or use nasal cannulas for oxygenation, and they typically have multiple IV lines or drains. I spent the good majority of my time googling EVERYTHING, but I would definitely encourage you to try not to get lost in all the little details of vent settings and lines.

In addition, try to think ahead of the team if possible. Does it seem like the patient needs an antibiotic? Which one would you recommend based on coverage? What dose/frequency? On the other hand, did microbiology lab results come back and the regimen could be de-escalated? Recommend it to the team.

Jerika also wrote a really great blog post (a few posts back from this one) on her experiences with SICU at a different hospital, and I would encourage you to read it! The SICU is definitely a unique environment, and will challenge you to think about and consider a holistic view of the patient.