Non-Trauma Emergency (NTE)

Posted by BJ Opong at Tuesday, September 28, 2010

When I first learned that I had the non-trauma emergency rotation I was excited because I knew I was going to see all sorts of interesting things. The more I thought about it I became more and more uncertain of what I was going to experience because I had no clue as to what exactly was a non-trauma emergency. To put it as concise and simple as I can its really any kind of Gastrointestinal surgery that needs to be performed immediately. The best example I can give is someone has appendicitis and needs an appendectomy immediately; they would be placed on the NTE service.

When this rotation first started the adjustment that I was most concerned with was not learning all the various surgical procedures and treatments. I was concerned with how my body would adjust to having to be at the hospital and ready to go at 5:30am some days earlier. I have never had to be up so early for an entire month, but after the 1^st week I can say I hardly even noticed the time.

The thing I enjoyed the most about this rotation was that 90% of what we were doing was completely new which required a lot of on the spot learning. It also gave me the opportunity to better acquaint myself with the anatomy of the GI system. I’m sure your wondering what exactly the pharmacist does on an NTE rotation so let me begin.

We would arrive at 5:30 or 5:45 to round with the NTE surgical team which consisted of 3 residents, 2 Physician Assistants, a few medical students, and the pharmacy staff consisting of Dr. Kraft, Jason, and myself. While rounding we would discuss the clinical plan for patients with problems ranging from Appendicitis, Pancreatitis, Choledolithiasis, Fistulas and Ostomys. The team would discuss the the best surgical plan, medication plan and even the best nutrition plan for the patients. I was pleasantly surprised at how often the team would look to the pharmacist for information about various medications and nutrition in the patient. Total Parenteral Nutrition (TPN) is a very important aspect of a patients care plan if they want to recover. I realized that a lot of times when patients have GI issues they are incapable of consuming there nutrition by mouth so it must be administered IV. It is up to the pharmacist to make sure that the patient receives the right amount of fluids, protein, carbohydrates, lipids, and electrolytes to restore their health, because a large majority is malnourished. Nutrition happens to be a good indicator at the likely hood of having a successful surgical procedure. Patients with very poor nutrition status were sometimes withheld from surgery to improve there nutrition to increase they chances of recovery post surgery. All in all this was a very beneficial and informative rotation. I learned a great deal about GI surgical, and infection issues.

Call Me Beep Me if you Wanna Reach Me...

Posted by Alex at Tuesday, September 28, 2010

Rotation #3 for me is drug information at U of M. Today I worked the call center and had some interesting calls....

A nurse practitioner (NP) called explaining how a patient reacted to spironolactone with rash and hives. She was wondering if the patient could be switched to eplerenone, which is also an aldosterone antagonist. The NP had concerns about cross-reactivity between the 2 agents. Patient can tolerate furosemide, and also has a sulfa allergy.

So I proceeded to search Micromedex, Lexi-Comp and PubMed to find any information about aldosterone and eplerenone cross-reactivity. No mention about cross-reactivity. Then I recalled the patient has sulfa allergy so decided to search that term in the monographs of the 2 drugs. I saw spironolactone has metabolites containing sulfur...so then I thought, "OH! that's why the patient had a reaction" Then...I proceeded to look at Goodman & Gilman to look at the STRUCTURES of aldosterone and eplerenone. Turns out aldosterone contains a sulfur atom, and eplerenone does not. I discussed my findings with my preceptor and we came to the conclusion that switching from aldosterone to eplerenone should be safe.

So what's the point of my story?

My knowledge gained from the medicinal chemistry courses actually came to use! In my formal write up to the NP, I was tempted to be a geek and write about the "sulfur moiety of the chemical structure"...but I just stood with saying "sulfur atom in the structure."

To be honest, I was intimidated at first to take phone calls to answer drug information questions mainly from other health professionals. However, I am finding it fun because people call asking for your advice. I research the question asked, then I follow up, and the caller is really grateful for the help...it's a great feeling to be a great source of information. I am also learning things I don't think I would otherwise know. For example, I learned today that the Fluvirin vaccine is stable in 77 degrees fahrenheit for up to 72 hours after 1 excursion. Pretty random, huh?

Posted by Shelley Ling at Monday, September 27, 2010

I have always appreciated the importance of research and how it translates to the standard of care at the bedside. A PharmD Investigations Project, which gives pharmacy students research experience, is a unique component of the U-M PharmD program. We get to pick an area of interest and to conduct a guided research project, from writing a proposal, to doing the actual project, and then presenting it in a seminar setting. Students also have the option of presenting a therapeutic topic for their seminar if they so choose.

I had the pleasure of working with Dr. Stringer for my project. It is focused on a rare but potentially fatal pediatric condition known as plastic bronchitis. Its hallmark symptom is the formation of thick, rubbery, bronchial casts that take the shape of the airways where they are formed (see photograph). My project is on supporting the use of inhaled tissue plasminogen activator, a fibrinolytic approved for myocardial infarctions and strokes, in this patient population. Dr. Stringer has challenged me to think about research topics critically as well as given me great advice on presenting a research topic.

As the first student to present my PharmD seminar in my class, I felt stressed about the limited time to prepare. In response to my nervousness, Dr. Stringer said, "We are going to set the bar high!" and "I will do everything I can to make sure you do great on your seminar." Both comments were very reassuring. I delivered my seminar successfully on September 24. In retrospect, I could have prepared a little more for the Q&A session. Here are some tips I can offer anyone who is presenting a seminar for the first time.

1. Start preparing as early as possible. If you have a rotation that is less demanding, start now! It will take longer than you think.
2. Think of your seminar as telling a story. Give your audience enough details to understand the material. But also remember to keep it "simple and stupid."
3. State off the bat why your topic is important, so your audience know why they should pay attention to you.
4. Keep your slides simple. Try to follow the "7 (words across) by 7 (rows down) Rule." Your slides are just a tool that supplements your verbal presentation, not take the place of it.
   
5. Practice, practice, and practice. Use tone of voice, pauses, and choice of words to inspire your audience and keep them interested.
6. Use visuals. We are all visual creatures and a picture is worth a thousand words.
7. Preparing for anticipated questions will make you less nervous during the Q&A session!
8. Choose an advisor whose work habits match yours. I am very happy and very fortunate to have an advisor who is very attentive to my areas of improvement and is patient enough to teach and guide me. I could not have completed this seminar successfully without her.
   

The Wonderful World of Warfarin

Posted by Salem at Sunday, September 26, 2010

I spent the month of September in the transitional anticoagulation clinic at Sparrow hospital in Lansing.

I liked anticoag. It was a good mix of the outpatient and inpatient settings.

I spent the first half of each day in the clinic, seeing patients who had recently been hospitalized at Sparrow with new prescriptions for Coumadin. I read their INR, spoke with them about the importance of adherence, and we discussed Coumadin’s most common drug and food interactions during 15 minute appointments.

Since the patients were just getting started with Coumadin, we saw them frequently to make dose adjustments. It did not take long to get to know everyone who was a patient at the clinic.

I spent the second half of each day speaking with patients who were still hospitalized and ready to be discharged with new Coumadin prescriptions. I discussed Coumadin and low-molecular weight heparin with each new patient for about an hour, and they often had many questions. I remember being pretty nervous the first time I had to run one of these counseling sessions on my own. By the end of September the long sessions were my favorite part of the day.

I have always worked in inpatient pharmacy so being able to interact with the people I was taking care of was a new experience. It was rewarding being able to see patients’ health improve from week-to-week and knowing that I was contributing to that improvement.

In the CUB Unit

Posted by Alex at Saturday, September 25, 2010

This past month I was at Allegiance Health for my inpatient cardiology rotation. I spent my time at the CUB (cardiovascular universal bed) unit monitoring patients from the time they have open heart surgery until discharge. To get a better understanding of what patients go through, I was given the opportunity to observe a CABG (coronary artery bypass graft) and aortic valve replacement surgeries! I thought I would pass out from seeing all the blood and organs, but was able to keep my cool.

As I reflect back, some thoughts that stick out in my mind:

(1) P-care discussion sessions linked with Institutional & Community IPPE: Extremely valuable! In these discussion classes we are assigned to work up patients and give patient presentations. All those long hours I spent last year working up patients has paid off. Working up patients on P4 rotations is nothing new since I got good practice during P3 year

(2) You still need to know everything! Although I was doing a cardio rotation, non-cardio issues arose such as delirium and aminoglycosides dosing

(3) Utilize your fellow health team members- Sometimes you cannot get the full picture by reading charts and looking at drug orders. My preceptor emphasized to me that talking to nurses and asking them about patients' status can make your job much easier

(4) Try extremely hard to have most of your PharmD investigations project complete prior to P4 rotations- Rotations are busy...on top of your tasks during the day on site, you also have to work on presentations for rotation pretty much each week. Such workload gets done when you get home from a 7-10 hour day at rotation. This past month I have been working on my P680 Seminar as well, which is a huge presentation you give 4th year on a topic you have to research extensively. At least have your data collection and analysis for PharmD investigations project complete since it's 1 less thing to worry about.

After completing this rotation, I feel like I have further developed my clinical skills. My mind automatically clicks what drugs and important lab values to look for in a patient undergoing cardiac surgery. I have also identified areas in which I need improvement. For future rotations I hope to work on these weaknesses and better fine tune my skills.

Help me help you

Posted by Jim Stevenson at Wednesday, September 22, 2010

My second rotation is in ambulatory care with Dr. Stu Rockafellow. When seeing the day to day services he provides, an outsider probably would not realize he's a pharmacist. That's the beauty of ambulatory care pharmacy - there is no dispensing, just the optimization of the care for the patient.

This is how it works: There are a number of primary care physicians at the two clinics where Dr. Rockafellow staffs. When they have a patient that requires extended management of diabetes, hypertension, hyperlipidemia, or asthma, they refer them for an appointment with Dr. Rockafellow. At their first appointment with the pharmacist, the pharmacist reconciles their medication lists and learns more about their lifestyle choices (diet, exercise, alcohol, etc). At subsequent appointments, the pharmacist interprets updated lab values (A1c, blood pressure, electrolytes, etc) and adjusts medications accordingly. A huge part of the service is also encouraging better lifestyle choices to the patient.

Instead of pushing the patient toward these decisions with paternalistic lecturing, the pharmacist has the patient make specific, achievable self-management goals (eg walk 3x weekly for 30 min) to help the patient meet their disease-state related goal (A1c <7 etc). If a patient is unable to exercise intensely, we'll either focus on diet or have the patient make a small, achievable exercise goal and work from there. In this way, the patient has a big say in his/her preferences for treatment.

Dr. Rockafellow also has a collaborative practice agreement, allowing him to adjust medications related to diabetes, HTN, and hyperlipidemia. If a patient is above his/her blood pressure goal and has reached his/her lifestyle goals, Dr. Rockafellow can increase their lisinopril dose and order a potassium level to be evaluated a week later at follow-up.

There's a ton of one-on-one patient interaction in ambulatory care, and most of the patients seem to really enjoy having a health care provider listen to them for once and individualize their care. The long-term follow-up that many patients require also builds bonds between the patient and pharmacist with all the repeat visits. If you're known for your rapport with patients and your ability to formulate an individualized plan for a patient, you were born for ambulatory care pharmacy.

The Great (Medical) Communicator

Posted by Tiffany Pfundt at Tuesday, September 14, 2010

No, I am not talking about Reagan, I'm talking about me. This month I am at Arbor Communications for my Drug Info rotation. Arbor Communications is a medical communications company located here in Ann Arbor. Once again I lucked out in terms of rotation selection. As with my first rotation, this rotation picked me, instead of the other way around. As a result, I am spending September as a pseudo-medical writer...and I like it.

What is medical communication?

Arbor Communication does project work with major national and international pharmaceutical companies. Projects include:

• Content development: publications for peer-reviewed journals; abstracts and posters for scientific congresses; presentations and slide kits; live, print, and web-based communications and activities.
• Advocacy development
• Meetings and Events: Advisory board meetings, stakeholder meetings, speaker training, web conferences, and more

On my first day, I met with my preceptor and we went over the outline for the entire month. One of the first things she told me was that during my last week I was going to have to do a presentation in front of the whole company (yikes!). Although, I am not one who minds presentations, giving one in front of an entire company seemed scary. She must have noticed my blood pressure rise because that's when she noted the company has 30 or so employees and only 5 of those employees are onsite.

The rest of week one was spent learning about the company and medical communications in general. Each student that rotates at Arbor interviews various employees. These interviews are geared toward helping the student gain an understanding of how the entire company operates. Knowing how the entire company operates has allowed me to perform my job better. Most of the projects I have worked on fall into the "content development" category, which is not uncommon for medical writers with scientific backgrounds.

Rotation perks:

• Easy commute
• My OWN office - complete with name plate
• Endless supply of coffee
• Independent working environment
• Close proximity to Main Street eateries

We all know that P4 year is a chance to take what we've learned in the classroom and apply it to the real world. It's a chance to solidify our therapeutic knowledge and act like real pharmacists. Just as importantly as that, P4 year is an opportunity to evaluate various working environments. We can evaluate each rotation in a way that helps us decide what we want to do when we grow up. One of the most important discoveries I have made during rotations thus far is that I like project based work. This is a discovery that has shaped the way I am approaching my career hunt.

HIV in Cali

Posted by Jody at Tuesday, September 07, 2010

I am in my second rotation in California and the East Bay AIDS center (EBAC). This rotation is my community rotation but it’s far from “retail” pharmacy.

My first week at EBAC flew by fast. On my first day I was given an overview of the pharmacy and the clinic as a whole. My preceptor explain how EBAC developed and how she acquired a position in this specialty. She discussed the patient population and explained how I would not be able to counsel patients until she thought I was ready to handle this patient population. At first I didn’t fully comprehend her statement, “handle this patient population.” We have been counseling in school, internships and our IPPEs – how am I not ready? When I started reading the patients’ charts I finally understood. Some of the patients have a history of (or currently going through) domestic violence, prostitution, homelessness, and drug addiction. Of course this isn’t every patient, but I realized why my preceptor was caution with students counseling.

The entire first week I reviewed patient charts and learned the different classes of HIV medications. I was given a list of 10 patients. My preceptor made sure to include all types of patients since their experiences and how they acquired HIV is very different. My list of patients included males, females, youth and MTFs (male to female). At EBAC the charts are not electronic and some patients have up to five separate charts because they have been a patient for so many years. One of my patients only had three charts and when stacked together it was bigger than Diprio! At the end of the week I presented on this patient and condensing 3 charts into a 15min patient presentation was difficult and frustrating. But with three more patient presentations to ago I’m sure things will get easier.

Now, that I have the basics covered for HIV I’m looking forward to counseling and interacting with the patients at the clinic.

Posted by Jody at Sunday, September 05, 2010

My second rotation is out-of-state in Oakland, CA. I have no friends or family to stay with, but I was partnered with another student. Out-of-state rotations can definitely put a dent in your budget, especially if you also have to find your own housing. My recommendation is to travel with another classmate (or two) to help cut costs. If the rotation doesn’t list this information then ask– more times than not the preceptors are very accommodating and will allow two students.

TIPS for out-of-state rotations (when you are NOT staying with friends/family)

- Housing

o Ask your preceptor: They live in the area and should be able to either help you find a place or offer suggestions.

o Criag’s list: You may be able to find cheap sublets fully furnished

o Hotels: (extended stay or regular) This is what my classmate and I did.

§ Call and speak with the manager directly

· Student pricing/discount? You are staying at least 28 days. My classmate and I were able to get over $1,000 off our entire stay.

· Ask are accommodations: free internet, fridge, microwave

- Transportation (to and from the rotation site)

o Talk with your preceptor:

§ Ask about public transportation

§ Public transportation: (things to think about)

· Look up the routes, does it run often, when does it start/stop, weekend routes

· Prices, you will be taking it twice a day

· Is your hotel/apartment near the station/stop (Trust me, in the morning you want to be very close to the pick-up point)

o Bringing your own car or renting

§ After speaking with other students, if a car is necessary it’s best to bring your own car (and cheaper too).

Hope this was helpful. If you have questions, just ask!