Wednesday, September 28, 2016

Rotation 3 - Specialty Pharmacy

Posted by Jared at Wednesday, September 28, 2016

My third rotation brought me to the community site for a specialty pharmacy up in Flint, MI. I was really excited for this rotation, as I have interned in the community setting since P1 year, and I felt this would bring a new angle to it.

When I walked in the first day, I was honestly shocked at the manpower this pharmacy had. There were 3-4 pharmacists + the pharmacist-in-charge (PIC) working at the same time, along with roughly 20-30 technicians (I honestly don't know the exact number, but there were a lot) working on various things (i.e. processing, register, counting, shipping, inventory, etc.). Coming from pharmacies where the norm is one pharmacist and a few techs, this was certainly like sticker shock to me.

Typical Day

The other P4 on rotation from Ferris State and I would usually arrive in the morning at 9 AM. We would generally start by doing doctor calls and following on problems that the pharmacists or techs wanted us to resolve. Afterwards, we would do a number of different things. We might help out in the pharmacy with answering phones, counseling patients, answering questions, or practice verifying prescriptions. We would have a half hour break for lunch, and then essentially doing similar things until I left for the day at 5.

Sprinkled throughout the rotation, I would work on various projects, topic discussions, along with shadow different parts of the pharmacy and ask questions. It was interesting to me that interns at this site had office space, so it allowed me to get away from the busy, loud environment of the pharmacy and gave me some quiet time to get away. Also, we did immunizations and MTM sessions as well! I would also often tell patients that were getting controls or narcotics about issues we had filling them. These often involved warnings about how we might not fill them in the future for whatever reason, or if we were denying them because they had filled too many of these types of prescriptions at too many pharmacies. I certainly had a lot of interesting interactions from these encounters.

Overall Thoughts

Having a community background from interning, I was a bit nervous in general about how this was going to go. I had heard horror stories from previous P4s and different classmates about how many people on their community APPE just get stuck doing tech work because it's too busy for them to really talk with their preceptor and learn. Luckily, this site was nothing like that at all. My preceptor really tailored the rotation to things that he felt would help me the most in terms of learning. Due to the nature of the site, I was exposed to a lot of specialty drugs I had not really heard of in the past. From this, I was able to learn different regulations that go into being able to dispense these medications, along with the limited amount of pharmacies nationwide that are able to dispense them.

Also, my preceptor didn't have us do any typical tech work at all (counting/processing), which I was really thankful for. The topic discussions we did really helped me to revisit OTC medications, which I honestly hadn't dealt with since P1 year. I also got much stronger at my counseling skills, due to the sheer number of questions we fielded either from prescribers, nurses, or patients. Furthermore, my projects I did were really tailored to what I was interested in looking at. For example, I did a topic discussion on Hepatitis C and a presentation on transitions of care and the potential role community pharmacy could play. Finally, I was able to go to the company's corporate headquarters for a few days and shadow different people to get a further sense of what specialty pharmacy is really like, along with their daily operations on a national level.

Ultimately, I think this rotation was really fantastic. I'd highly recommend it if you have previous community experience and want to see a different side to things. The pharmacists and techs are great and really emphasize student learning, as they almost always ask a student to deal with the problem first if we're capable of doing so. However, I will say that if you have never worked community before, I would almost recommend going to a larger chain, as I feel everyone needs the experience of counting a lot of medications, along with processing insurance to really get a comprehensive community experience. Due to my site's system, along with some of the complex, expensive medications that might have to be billed, I don't know that P4s would necessarily be able to jump in and deal with insurance, as it would really interrupt the site's workflow.

Tuesday, September 27, 2016

Rotation #3 - Ambulatory Care Oncology

Posted by Brock Jackson at Tuesday, September 27, 2016

On this particular rotation, it was certainly a mix of emotions. While there were certainly some low points, the high ones outweighed those by a wide margin.

This rotation was not nearly as complicated as the others and I was able to establish a routine from nearly the end of the first week. I’ll break down how my days generally went based on the day of the week.

Monday – Most of my time Monday was spent preparing for Tuesday-Thursday patient interactions. Working up patients, presenting them, and answering various drug information questions took up a majority of my time here.

Tuesday – In the morning, I would continue to work up patients, wrap up drug information questions, and work on special projects. In the afternoon, we had our biweekly chemotherapy teaching sessions. Myself and nurse would go through various IV chemotherapy regimens with patients that were going to receive them. We would go through what their regimen was, what days it was on, how it was administered, other medications that came with it, side effects that are common, side effects that are specific to their chemotherapy, and field a variety of other questions. These sessions typically had 10-16 people in them (family and friends could attend too) and lasted on average 3-4 hours.

Wednesday – In the morning, I had my oral chemotherapy patients come in for chemotherapy teaching. We typically had three, one-hour block sessions set in the morning. Patients typically came with one to two other people and we would sit in our library and go over their chemotherapy regimen. These regimens were a bit different than the IV ones. These were all taken at home, and aside from laboratory monitoring, they did not come in to see us again (barring side effects). These sessions typically did last the entire hour. We went a lot more in depth on how to manage side effects and what to do if they experience them in these sessions compared to the IV chemotherapy teaching sessions (in my opinion).

Thursday – This day was pretty much a clone of what I did on Tuesday. Often times, we would have patients rescheduled onto different days and this often led to last minute work up of patients on Thursdays, prior to our IV chemotherapy sessions.

Friday – If patients had been scheduled for next week, I would work them up first. Otherwise, I would be working on special projects, drug information questions, and patient education materials.

Random special events
-        Shadowing nursing during various procedures and administrations (IP chemotherapy (Fascinating), IV Iron, bone marrow draws, etc.)
-        Inspecting chemotherapy rooms for compliance
-        Journal clubs
-        P & T committee meetings

What I was doing when I was not working up patients or chemotherapy teaching:
      Patient education materials – At the institution that I was at, we made up most of our patient education materials. These were tough to make because you often times had to go through the clinical trials of the oncology drug in question, look at the adverse events reported (and all the other information), and create them based off of that. I wish I could provide a sample here but they are institution-specific and I cannot. Sadly, words will not do justice to what goes into these but they were tough to create and took up quite a bit of time.
      Drug information questions – LOTS of drug information questions. They mostly centered around herbal medications and supplements. I cannot tell you how many of these I answered. Often times, patients would be on several of them at once. It became extremely difficult to manage drug-drug interactions and safety in general with patients being on numerous medications, oncology regimens, and anything else they were taking. I recall one patient being on over twenty different prescription + over-the-counter products, while taking ~7-8 different herbal medications and supplements. This did not include their oncology regimen.

      Overall, I had an absolutely wonderful experience on this rotation!

Sunday, September 18, 2016

Rotation 2 – Solid Organ Transplant: A New Lease on Life

Posted by Emily VanWieren at Sunday, September 18, 2016

Rotation 2 – Solid Organ Transplant
A New Lease on Life
First Impressions
I was super excited to start my first day with the surgical transplant team. There are a multitude of complex medications used in transplant recipients, and I knew there would be a great role for a pharmacist on the team. I wasn’t super excited that rounds start at 6 AM. The first day I set my alarm at 4:15 was painful - I am not a morning person!

There were over twenty people on the surgical transplant team, which turned into a super intimidating herd of white coats blocking the hallways on rounds. The team was inter-disciplinary and consisted of physicians in all ranges of training from attendings on down to fellows, residents, interns, and medical students. There were Physician Assistants, Nurse Practitioners, and also the pharmacist. You could tell the team respected my preceptor because they straightened up when they heard her walking down the hall. She had recommendations on dosing, stopping this drug, starting that one, ordering new labs, and the team accepted the changes she suggested. I was so impressed by all her knowledge of the patients and their medications!

A Day in the Life
The team I was with transplanted livers, kidneys, and pancreases. My typical day consisted of early morning rounds with the surgical transplant team followed by rounds with the nephrologists in the morning and the gastroenterologists in the afternoon. In between rounds, I would look up questions from the medical team and talk to the patients. I interacted with even more interdisciplinary members of the team and I got a full appreciation of all the care that goes into each transplant recipient. There were social workers, nurses, discharge planners, dieticians, and even interpreters for a deaf patient.

My favorite part of this rotation was educating patients on their new medications. There are a lot of new medications transplant patients have to take to suppress their immune system and prevent infections and they have to take them on a very specific schedule. I taught them the names of their medications, why each one is important, when to take them, and when they need to get their blood levels checked. I got to establish relationships with the patients and it was cool to see their new lease on life and how serious they were about taking their medications to keep their new organ.

Megan and I were able to watch a kidney transplant from a living donor to a recipient. We weren't sure how our stomachs would handle it, but we were both so fascinated and didn't feel squeamish at all. The surgeons talked us through the procedures and we were able to see inside a living human's body! It was also cool to see the anesthesiologists in action since they choose, prepare, and administer all of the medications on the spot. It was humbling to see the whole process from donor to recipient and then educating the recipient on their new medications.


On this rotation, I learned a lot about transplant medications and many other therapeutic areas such as diabetes, hypertension, and kidney and liver disease. It was very rewarding to be able to make an impact on patients’ lives by teaching them about their medications and how to support their new organ. On my next rotation, one of my patients recognized me and waved me down. She wanted to thank me again and tell me how well she was doing and that she hasn’t missed a dose. I spent many long days at the hospital and sacrificed sleep on this rotation, but it was well worth it to see the full impact of a pharmacist’s role on the medical team.

Sunday, August 21, 2016

Off to the Great Land aka Alaska for Inpatient A - Oncology

Posted by Brock Jackson at Sunday, August 21, 2016

After my first rotation in Health Systems, I thought I was ready for a challenge. This challenge would come in the form of an Inpatient rotation. This particular one was spiced in the manner of Oncology. I knew this was going to be a difficult one. Oncology was one of the harder subjects in both medicinal chemistry and therapeutics.  I ranked this one as one of my top choices in part because of that fact. I thought it would help me build a strong Oncology background, at least enough to make me feel confident before I took the NAPLEX.

Weeks One - Three
This week was more of an introduction to the rotation than anything else. I wasn’t able to start truly working with patients and beginning my experience until I finished my site’s orientation. During this limbo time, I was given a tour of the hospital, met with preceptor and discussed what we/I would like to accomplish during this rotation, met a few other pharmacists and residents that I would be working alongside, and other little activities. Once I was able to start working in patient charts, things picked up in an expedited fashion. Most of my days began at 8am (otherwise it was earlier) and ended around 4:30 (often later). 

Generally speaking, when I arrived, I would take a gander at what patients were coming in the next day and needed to be worked up. I would go through their past medical histories, current medications, and review their chemotherapy regimens. On the next day, I would meet with the patient and go through their medication list, ensuring it was the same as what we had on our medical records. More often than not, there were numerous discrepancies. After figuring out exactly what they were taking, I would go online and look into medications/herbals/OTCS/supplements that I did not know much about. This practice led me to question why patients were on a myriad of herbals and supplements. Many times we would have a conversation about why they were taking what they were taking and it occasionally would end with ‘You know…I am really not sure why I am taking that herb!’ This was extremely frustrating, as looking at the evidence (or lack there of), it made no sense why they were on them. Other times, I would ask and the patient would respond simply with ‘It is for my cancer.’ These responses were always landed me in the doldrums. They typically came from patients that had a Stage IV cancer diagnosis and things were not looking good. Looking into their eyes after asking these questions seemed to last an eternity. A lugrubious feeling often ensued for the remainder of the session.

In between working up patients and speaking with them, various other activities would take place. I had to present my patients, weekly topic discussions, journal club presentations, drug information questions, chemotherapy teaching, attending tumor boards, pediatric rounding, and numerous other things. I will expound on a few of these topics here.

Weekly Topic Discussions – I was required to work on topics that pertain to Oncology patients and present them to either my preceptor or a pharmacist that was free (typically with the PGY-2 resident). Basically, it is a quick and dirty of a specific topic, what it is, how common it is, who is likely to have it, why we care about it, how to treat it, etc. My topics were febrile neutropenia, malignant pleural effusions, spinal cord compression, superior vena cava syndrome, nausea and vomiting, tumor lysis syndrome, extravasation, and hypercalcemia of malignancy. A few of these topics we covered in our therapeutics course. This was a nice refresher but my resident knew how to make them challenging. He typically would have multiple questions along the way (some way off topic) and a challenging one or two at the end that he did not expect me to know. This was generally meant for me to look up and report to him during our next topic discussion or patient work up session.

Tumor Boards – This is where specialists from around the hospital came to discuss tough patient cases (both adult and pediatric). Brain surgeons, pathologists, oncologists, pharmacists, radiation oncologists, general surgeons, etc. would all attend. They would present their particular patients and receive recommendations from the various colleagues who attended. It was always fascinating to watch these because every aspect of their future treatment is considered from a myriad of angles.

Chemotherapy teaching – For patients that were receiving new chemotherapy regimens (that they had never had before), we would go out and teach them about what to expect with their new regimens. We would go over the main toxicities, how to manage them, when to call for help, and field any questions/concerns that they might have had. At first, I just watched them but by the fourth and fifth week, I was going out and leading them.

Weeks 4 and 5
The last two weeks were pretty gut wrenching. Sometime between weeks 3 and 4, we will have our midpoint evaluation. Both my preceptor and I fill out a form we later on discuss in person. This is a time for the preceptor to meet with the student and go over what has been going well, not so well, and everything in between. For my first inpatient experience, I thought I was doing alright and progressing well. Apparently, my primary preceptor did not feel the same way. Upon discussing it, they thought I should be progressing on my work at a much faster pace. This was quite disheartening. However, I did discover that they usually do not take students on until they have had at least one inpatient rotation before (or until around rotation 5 and beyond). For my second rotation, that made me feel a little better. It was also nice to know that they were receptive to the fact that the four pharmacists I was working alongside all had different expectations for presenting patients, topic discussions, chemotherapy teaching etc. Later on, this helped me understand exactly what each preceptor wanted and would ‘grade’ me on.

Honest pearl of wisdom – Think hard on the criticism that you receive. If it is meant to be constructive, you should certainly consider making the appropriate changes.
After my midpoint evaluation, I felt I needed to alter how things were going and I took their criticism to heart. At this point, I knew it would be an uphill battle to finish strong through the remaining weeks. I worked hard on my understanding and presentation of patients. The workload only increased but eventually I was able to catch on and it all just sort’ve clicked. By the last week, I had patients worked up two days in advance, presented multiple topic discussions on the same day, multiple meetings with patients (chemotherapy teachings, medication history), and still was present during rounding and tumor boards. It was a rather dramatic change. I credit this a lot to how my midpoint evaluation went and how I responded to it.

In the end, I ended up being able to hit on all the things that my preceptor wanted me to be able to on a regular basis. This helped alleviate my fears of being absolutely destroyed on my final evaluation. Repeating a rotation is not anything that I am interested in doing moving forward. As it turns out, I ended up doing quite well!

Here are some pictures of my trip…please feel free to ask me anything about them!

Hiking up Flattop Mountain - the weather changed dramatically towards the top

   Fishing on the Upper Kenai River - Landed a couple Sockeye Salmon :)

Gold panning on Crow Creek - I won't be quitting my future job as a pharmacist anytime soon. 

Exit Glacier climbing - Easily one of the highlights of the trip! Hiking up a mountain for about an hour, cutting across onto a glacier and then spending time climbing into moulins. Absolutely incredible!

PS - If you want to see more pictures or hear more about what I did outside of this rotation, please just send me a message. I wanted to keep this as much about the rotation aspect as possible BUT being in Alaska for my weekends was part of the rotation too!

Wednesday, August 10, 2016

Rotation 2: Siiiick, brah! Or, Love at First CABG

Posted by Jerika Nguyen at Wednesday, August 10, 2016

I've been consistently told that after each rotation, as in the Hozier song "Someone New," you'll fall in love just a little ol' little bit every day with some new pharmacy practice area [sic].

That happened for me in the Surgical Intensive Care Unit, or SICU, aptly pronounced as it houses the most critically ill patients in the hospital. I had the awesome opportunity of rotating at a newly dubbed Level 1 Trauma Center in a 20-bed unit comprised of patients from the Trauma Critical Care Service (TCCS) and Cardiothoracic Surgery Service (CTS): trauma surgery, cardiothoracic surgery, neurosurgery, vascular surgery, colorectal surgery, general surgery, otolaryngology, obstetrics, and orthopedic surgery.

Surgery isn't covered in our didactic curriculum, so I started the first day as a total derp (Deer in headlights with Extreme anxiety and Retrograde amnesia of Pharmacology). Thankfully, my preceptor reassured me that every P4 student feels the same way at first, and that I'd learn exponentially more on rotation than I ever did in class.

Pro-tip to avoid being a derp at any inpatient rotation: get familiar with your organization's intranet. Like, be best buds with that guy. An intranet is an electronic and readily available Room of Requirement. My personified conversations with the intranet went something like:

"How's the susceptibility to Bactrim here?"

"Yo, can we get rid of the IV PPI?"
"I got 99 million guidelines and Stress Ulcer Prophylaxis is one."

"Are any of these 14 drugs dialyzable?"

What was a typical day like?
I arrived at 6:30 to work up patients until rounds. Once we had gauged the number and acuity of the patients on the floor that morning, my preceptor and I would round with either TCCS at 9:00 or CTS at 8:45. TCCS is a teaching service that consists of an attending surgical intensivist, surgical critical care fellow, surgical and medical residents, a clinical dietician, a respiratory therapist, nursing, and a clinical pharmacist on rounds, whereas CTS is physician assistant-led. Side note: the health care professionals I worked with are truly impressive. Many of them are nationally renowned in their respective specialties, and the cardiac surgery program here ranks in the top 15 in the nation (among 400+ other hospitals' Consumer Reports' Ratings).

After rounds, which lasted anywhere from an hour to several hours depending on how many patients were on the service, I would often bombard my preceptor with a myriad of questions. Side note: the thing about being curious and wanting to learn is that it'll almost always result in self-assigned drug info questions, which present as both a curse and a blessing in disguise. I encourage you to embrace this curse.

I had 1-2 critical care topic discussions each day with my preceptor before and/or after lunch, which helped keep me on my toes. In the afternoons, I'd re-work up my patients to see what changes were made after rounds and/or any surgeries and give patient presentations to my preceptor.

What neat stuff did you get to see?
Neutropenic enterocolitis, esophageal rupture, necrotizing pancreatitis, aortic dissection, traumatic brain injury, motor vehicle accidents, buzzword buzzword. Also got a bird's eye view of a coronary artery bypass graft (CABG) and saw a lower lobectomy.

What do you wish you knew going into the rotation? How can I prepare? Clinical pearls? Coffee choice? HALP

I finally realized that having a wealth of education as a P4 student isn't necessarily what leads to success. Initially, I was mortified by my extreme deficit of therapeutic knowledge. But while pharmacists need to know a lot of information, they don't necessarily have to memorize every detail of every drug ever made (just most of them, ha!). Pharmacy school can't teach you everything you need to know in 3 years. What it can do is teach you how to think like a pharmacist and how to find the information you need to facilitate patient care.

Something you don't learn from a textbook is how to interact with the medical team to optimize treatment. I've decided that I need to create some sort of cheesy alliteration to help others combat this, and I hereby give you the three C's:
  1. Confidence: You can be incredibly informed on a certain subject and still appear as unintelligent if you're visibly nervous. Some of my battles during this rotation were convincing myself that I actually did know what I was doing and beginning to speak up during rounds. Certainly don't rattle off about something you're not 100% sure about—that's what the "I'll look it up and get back to you" card is for. But speak with conviction, and more people will take heed of your recommendations (even if you're a student who's rounding alone!)
  2. Camaraderie: If you don't get along with the people you work with, team decision-making is going to be as productive as a day in the life of Snorlax. I had the opportunity to talk to PAs, nurses, residents, patients, and their families about things unrelated to work (like Ann Arbor restaurants and mutual desires for caffeine gtts). Walking up to someone, being personable, and making a recommendation face-to-face is much more effective than paging someone in what might be interpreted as a passive-aggressive tone. 
  3. Credibility: You know who you should add to your BFF list along with the intranet? Evidence-based medicine (EBM). EBM is the realest thing you'll use to stay up to date with pharmacy after you've left the classroom. Your recommendations will be more compelling if they're supported by well-designed, peer-reviewed research. Keep up to date with the lit—there's an app for that. 

Actually, instead of using cheesy alliteration, you could probably just refer to Aristotle's Modes of Persuasion. (Man, this is like when 14-year-old you thinks you've come up with a catchy guitar riff and it ends up being a Fratellis song because you've listened to Costello Music religiously).

Anyway, these skills really made me feel like a boss as time went on. For example, when a traumatic brain injury patient was newly admitted, I reviewed the patient's profile and discussed 5 interventions I wanted to make with my preceptor before rounds. Sure enough, all of them had been implemented when I checked the medication administration record (MAR) later that day. *mental self-high five*

Any cool pharm perks?
Someone ALWAYS brought in donuts or brownies or chocolate or D) all of the above to share. I'm not a huge sweets person, but the constant supply of glucose I was exposed to was unreal.

I also lunched and learned so hard. Besides the fact that I got free food each Thursday (heyooo), I saw cool presentations about medical decision making for organ donation, ventilator settings and the importance of checking the ABG (arterial blood gas, not aznbbygurl) and M&Ms. M&Ms (Morbidity and Mortality Conferences) are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The medical team reviews real patient cases involving either poor or unintended outcomes which might have been due to or worsened by error, "near misses" in which an error could have resulted in a poor outcome, or interesting and unique cases. Then, they discuss what went wrong, what could have been done differently, and what can be done to prevent such events from occurring in the future. Super sick stuff.

In addition to my day-to-day activities, I wrote antimicrobial stewardship notes, conducted a journal club, and delivered an in-service about the pharmacologic management of pain, agitation, and delirium in the ICU to the CTS team. Overall, this was a great practice site at which clinical pharmacists work alongside and are respected by their colleagues. I'm pretty stoked for my next direct patient care gig. As Hozier says, "Love with every rotation, the stranger the better." 

Monday, August 8, 2016

Rotation 1 - Health Systems

Posted by Brock Jackson at Monday, August 08, 2016

Hello everyone! 

My name is Brock Jackson. As a fourth year PharmD student, you will go through a series of nine different Advanced Pharmacy Practice Experiences (APPEs for short) rotations. I'll be updating you about my experiences over each rotation along the way. My hope is that you will be able to gain a better understanding of what each rotation entails and my experience within that rotation. 
As a quick aside, PLEASE ask any questions you may have about anything I have written!
For a quick background on myself, my interests in Pharmacy are almost entirely with Independent Community Pharmacy. If I were to go the clinical route, I would go with either an Infectious Diseases or Oncology speciality. Personally, I love to travel and any opportunity that I have that would offer more of that I would probably jump on in a heartbeat (Drug Information Pharmacist on a Cruise Ship would be a dream job but those don't exist, to my knowledge.).

My current rotation list is as follows:

Rotation 1 - Health Systems
Rotation 2 - Inpatient A - Oncology
Rotation 3 - Ambulatory Care - Oncology
Rotation 4 - Drug Information
Rotation 5 - Inpatient A - Pediatric Cardiology
Rotation 6 - National Community Pharmacists Association
Rotation 7 - Off
Rotation 8 - Generalist
Rotation 9 - Community Pharmacy

My typical day during Health Systems begins at about 6am. My daily commute is about an hour. Once I arrive, I prepare to start my day by checking out the patients that are on the Warfarin and the Antimicrobial Stewardship reports. For the Warfarin Report, checking to ensure the doses match the indication and recommending appropriate changes usually takes me about 10-15 minutes. With the Antimicrobial Stewardship, I am checking to see if various cultures and sensitivities are back from the lab. From here, I will see if we can move down from a broad-spectrum antibiotic to a narrow-spectrum antibiotic.

After this, I go up to attend rounds with one of our clinical pharmacists. This usually takes about an hour. I follow up with any questions the team may have and anything I did not understand during the patient presentations. Being my first rotation, there was generally quite a bit that I was looking up on a regular basis.

Following daily rounds, my day typically was never the exact same. I spent a lot of time doing various activities around the hospital.

Here are a few examples of things I did:
  • ·      Representing the Pharmacy department at the county Aging Wellness Fair
  • ·      Working alongside our anticoagulation pharmacist
  • ·      Compounding drug and nutrition products
  • ·      Shadowing dieticians
  • ·      Drug information questions
  • ·      Assisting the Pharmacy technicians in their duties
  • ·      Attending various internal Pharmacy and Nursing meetings
  • ·      Pharmacy-related projects
  • ·      Creating Pharmacy staff educational materials

For the most part, this rotation was laid back. My stress level never went over a 3/10. For a first rotation, this was perfect to wet my feet a little bit. The Pharmacy staff was absolutely incredible to work with over the five weeks I was with them.

PS - I apologize for the timing of my first post. My transition back from Alaska was a bit rougher than I previously expected.