Posted by Tiffany Pfundt at Monday, November 29, 2010

For my institutional rotation I chose a hospital close to home: Genesys Regional Medical Center in Grand Blanc. It wasn't the most exciting rotation I've had, but I think that can be said of most Institutional rotations. I managed to learn a lot, so I count it as a win!

Week One

I spent my first week shadowing various technicians around the hospital. Each day I worked with technicians in different areas of the pharmacy department. I learned how to receive and take care of drugs from the supplier, refill Pyxis machines, fill orders for medications not in the Pyxis, stock the clean room, prepare sterile products, and manage inventory. This week helped further my appreciation for technicians and the vital role they play in safe medication distribution.

Week Two

The second week I shadowed several pharmacists. The first two days I watched pharmacists enter orders into the computer. Genesys is currently developing Computerized Physician Order Entry (CPOE) software, but it won't be ready until next year. I also helped check IVs and unit dose medications after technicians prepared them. Then I went to one of the satellite pharmacies and worked with a pharmacist there. I finished up the week with the ICU pharmacist who does rounds twice a day with doctors in the ICU.

Week Three

I spent the third week on the fourth floor working with clinical pharmacists. I helped dose and choose appropriate antibiotics, adjust medications based on patients' renal function, and dose Coumadin. Even though I was in the same place all week, I worked with a different pharmacist every day. I liked working with different pharmacists; it allowed me to see and compare the pharmacists' different styles in action.

Week Four

The last week I got to work with several clinical specialists. I worked with the infectious diseases pharmacist, operating room pharmacist, and ICU pharmacist again. While with the OR pharmacist I was able to sit in on an open heart surgery. I thought the first four hours were very cool, then my feet started to hurt and looking at a beating heart wasn't that exciting anymore. That is when I decided it is good I didn't become a surgeon. I never realized the heart torqued so much when it beat - very educational. To finish up the month, I gave an in-service to the department about Lantus and Levemir. The hospital had recently decided to only use Levemir as their basal insulin product. I enjoyed the project as it helped me brush up on my diabetes material.

For anyone who lives in this area, or who doesn't mind a quick trip up US 23, I recommend the rotation. As you can see, my four weeks included a good mix of observational and hands-on experiences.

Caring for the Critically Ill

Posted by BJ Opong at Monday, November 29, 2010

I spent the month of November at Sinai Grace Hospital a place that I am very familiar with. I also intern at Sinai so I was very familiar with the surroundings and the staff, which made the month all the more enjoyable. My time at Sinai would be spent in the ICU’s dealing with critically ill patients. From the beginning I was told that to work in the ICU you have to look at it a lot differently than the general hospital population.

First, I had to realize that these were the sickest of the sick within the hospital and some of my patients were not going to make it. Secondly, I learned the goal of the ICU, which is to get the patient out of the ICU as fast as possible, the longer a patient remains in the ICU mortality increases. This differs from general hospital practice because you are to treat the patient’s main complaint or admitting problem. In the ICU the common admitting cause was shock secondary to pulmonary edema from pneumonia. This would develop while in the hospital or sometimes present to the ED with. More than any other problem pneumonia was most commonly seen in ICU patients. Pneumonia is so common in the ICU that any patient who presents with a spike in temperature or WBC and shows some sign of infiltrates on the CXR are treated empirically until sputum cultures return.

The ICU pharmacist we worked with throughout the month was also on the CODE team. His responsibility was to be present when a code blue (adult emergency) is called, and administer medications from the crash cart. The pharmacist would deliver the recommended doses of Epinephrine or Atropine as needed. During our first week we were fortunate to be present for a code blue. The room was filled with over 12 people of various medical disciplines trying to resuscitate the patient. Over 40 minutes later the patient unfortunately expired. It was a very gripping first experience at a code that I learned a lot from and will never forget.

By and large this has been my most enjoyable rotation to date. I think I enjoyed the ICU because of the fast pace that the teams work, and in part to the style of critical thinking that goes into determining the treatment plan for some very dangerous and rare conditions. While I was in the ICU I was able to learn about a lot of different and new treatment modalities. I would recommend that anyone who enjoys the fast paced work environment spend time in the ICU.

Pharmacy Beyond "the Right Drug for the Right Patient at the Right Time"

Posted by Zhe Han at Sunday, November 21, 2010

This month, I traveled to the East coast and completed my fourth rotation at the US corporate headquarter of Sanofi- Aventis, located in Bridgewater, NJ. Although I have decided on a residency route during my first rotation, I was still very excited about this experience because the pharmaceutical industry is one aspect of pharmacy that I knew very little about so I really looked forward to gaining a good overview of the various roles pharmacists can have in this setting.

The department that I was in is called "Health Policy and Strategic Advocacy". If you aren't sure what this department does, you are not alone since I had no clue of what to expect when I began my rotation 4 weeks ago. So what is strategic advocacy? Here is an exact quote from my final presentation last Friday: "strategic advocacy is important because by cultivating impactful partnerships with influential players, the company can have a greater voice in changes that affect how well its products do on the market". In a nutshell, people in the advocacy department work closely with patient, provider, payer and quality groups to influence health policies that are beneficial to the company's products. For my final presentation, I focused on oncology and identified the top 10 groups which I think Sanofi- Aventis should work with (eg. ASCO, NCCN, National Business Group on Health, etc.). My project challenged me to think about pharmacy in relations to public policies.

During this rotation, I also had opportunities to meet one-on-one with fellows in other departments such as Medical Information, Health Outcome Research, Evidence Based Medicine, Marketing, Clinical Development, Translational Research, and Regulatory Affairs. These meetings gave me a very broad understanding of different roles pharmacists can have and how pharmacists' clinical training can still be valuable even in the industry. I certainly recommend this rotation to anyone who is curious to learn about the industry. An appreciation for how the industry conducts trials, markets its products, and communicates information to providers and consumers can be very helpful in other practice settings.

????!!!

Posted by Salem at Saturday, November 20, 2010

I have spent the first half of November on rotation in the Drug Information Center at Ann Arbor’s Veterans Affairs hospital.

When VA staff members have medication questions they call the Drug Information Center. It is my job to provide answers to their questions. In a time when everyone on the medical team carries a handheld PDA full of downloaded drug information resources, the questions that make it all the way to me are the obscurest of the obscure. Questions like:

??!How do you prevent bortezomib-induced hypotension in a patient receiving hemodialysis??!

and

??!Is there any evidence for using minocycline to treat panitumumab-induced dermatologic toxicity??!

The great thing about the drug information center is that so many excellent drug information resources are readily available. They have some of my personal favorites; Lexi-comp, Micromedex, Facts & Comparisons, PubMed with full text access, Trissel’s and plenty of conversion and compatibility charts. So when I get puzzling questions like these I am able to find the answers if they are out there.

Most of the questions people ask do not require immediate responses, so I am usually given plenty of time to come up with thorough answers. It’s a great way to help out in caring for patients, in a mellow environment. I can see how drug information would be an attractive field for the pharmacist who is interested in research and caring for hospitalized patients, but wants to avoid the hustle and bustle of the floor.

Ghana International Rotation

Posted by BJ Opong at Saturday, November 13, 2010

I have traveled to Ghana several times in the past with my family, and this experience was vastly different from the others. The first and most notable difference was that this was not a vacation and that I would be working at Komfo Anokye Teaching Hospital (KATH). Although I had traveled to Ghana several times prior, I had my first ride on a Trotro. This was by far the new experience outside of KATH that I will remember the most. I had always wondered how the Trotro system works and how you would know where each Trotro was headed, now I know. It was a bit of an adventure the first time I had to wait at Tech Junction with close to 50 other people waiting to head into town. The moment the Trotro pulled up and the doors opened there was a mad dash to the doors to be one of the 12 fortunate people who had a seat, and avoid having to wait another 20-30 minutes for the next one. Although we ended up taking a droppin the rest of our time in Ghana, the Trotro experience is one that I will always remember due to its authenticity to Ghana.

My experience at KATH was just as memorable. KATH on appearance seemed very different from the hospitals I had experienced in the past. As the saying goes “appearances are only skin deep”. As we began to round with the pharmacists and the clinicians, I realized that a lot of the same types of patient and administration issues were present. KATH services a lot of patients in a very resource-constrained facility. Although the budgets may be different hospitals everywhere are faced with the burden of trying to deliver the patient the best care possible, while keeping their costs down. The issue of medications that are too expensive for the patient to afford arise often in the US and similar to here it is up to the pharmacist to determine an alternative medication that has similar efficacy that the patient can afford. Some similar patient issues that I encountered were patients who were non-compliant when it comes to regularly taking their insulin or other medications. It was up to the pharmacist and other health personnel to try to convince the patient of the importance of compliance and how properly taking the medication would lead to less hospital visits.

Another similarity that I was surprised to find is that both Hypertension and Diabetes are very common disease states. I believe that the diet plays a large part in the prevalence of diabetes in Ghana. The diet is filled with dishes heavy on carbohydrates and low on green leafy vegetables. These posse a large problem when attempting to counsel patients on their diabetes and lifestyle changes that needed to be made to improve or slow the progression of the disease. Patients with Hypertension often came to the hospital with very high initial blood pressures. The pharmacists attributed this to patients’ unwillingness to receive frequent check ups. By the time the patients come to the hospital the condition had worsened and would take longer to stabilize. Both of these conditions and issues often occur in the US as well.

Some of the differences that I noticed immediately while on the wards were the prevalence of different infectious diseases. Disease states such as malaria, enteric fever, tuberculosis and schistosomiasis are things we read about but only if we are lucky would we ever encounter it in the hospital. Another disease state that I had never even heard about but is endemic to the area was Buruli Ulcers. I was very surprised to learn of how common it was, so much that the World Health Organization sends a lot of resources and support to help prevent the spread.

I have truly enjoyed this trip to Ghana and getting to experience the country from a new perspective. Being a Ghanaian-American this trip has opened my eyes to some of the woes of the health care system and limited access to resources, be it health based literature or actual medications.

Committed to Mental Health

Posted by Jim Stevenson at Sunday, November 07, 2010

My current rotation is at Pine Rest Christian Mental Health Services in Grand Rapids, MI. It's a psychiatric inpatient unit, meaning the patients are a potential danger to themselves or others. Needless to say, the interesting patients are one of the best parts of the rotation.

I've seen most of the major psychiatric conditions, and many times patients have more than one diagnosis. I've seen patients hospitalized for major depression, bipolar disorder, schizophrenia, mood disorders, substance abuse, eating disorders, and post-traumatic stress disorder. Some of patients with psychoses are very insistent that what they perceive is real, while others have very good insight that what they are experiencing is a symptom of their disease.

Aside from the interesting patients, there are some other perks to the rotation. There is only one clinical pharmacist for the entire facility, so I get to participate on all pharmacy consults. That also means that he is the lone pharmacotherapy expert on the team and his opinion is well-valued.

In terms of pharmacotherapy, I am learning a lot. Because of the long-term nature of these conditions, stopping therapy is not an option (and is often not legal due to court orders). As a result, psychiatry is one area where we do try to treat side effects with additional medications. It's also an area where different drug forms are of high value. For example, decanoate injectable forms of drugs are useful because they allow us to achieve therapeutic levels with monthly or every two week injections as opposed to daily oral therapy. In a patient that has compliance issues, this is a great option. We also turn to liquid or orally-disintegrating tablets in certain patients that have been known to hide a tablet under their tongue to spit it out later. This is sometimes an issue in paranoid or manic patients.

So far, I've really enjoyed my rotation at Pine Rest. The patients are interesting. The medication therapy is interesting. I also feel that the facility is run in a very safe and humane way. If you're interested in psychiatry and have a place to stay in Grand Rapids, I can certainly give this rotation my recommendation.