Resistant H1N1?

Posted by Jody at Sunday, February 20, 2011

I am currently in the SICU (surgical intensive care unit) at the University of Michian Health System with Dr. Pleva.

In the SICU there is never a dull day. There is always something going on, a new critical patient, ECMO or dialysis being started or someone coding. My rotation was in January which meant the flu season was well underway. The third week of rotation there were 5 patients with H1N1 in the unit and by the fourth week, one patient with resistant H1N1. The attending contacted the CDC to receive zanamivir (IV form of Tamiflu), which was still undergoing drug trials.

The unit consists of 20 patients and since I was on rotation with another student from my class, the unit was split down the middle. I was responsible for 10 patients. Needless to say, I was pretty overwhelmed. Last year I took the critical care elective, but I took it pass/fail so it wasn’t high priority on my list. Starting this rotation I felt very under-prepared.

Rounds started at 8:30am and I met with Dr. Pleva before rounds to discuss my patients and any recommendations, so it was necessary to work up patient in the morning before rounds.

What did I focus on when working-up patients? Most patients on the unit had poor renal function. I looked at all medications and determined with they were dosed appropriately. Next, I looked at antibiotics. I assessed what antibiotic regimens the patient was on – is the regimen appropriate, accurate dosing, any cultures/sensitivities, etc. Every day I had recommendations for the medical team. I never felt more involved in patient care.

Other requirements/activities on rotation….

There were topic discussions and journal club, typical of any inpatient rotation, as well as a final presentation at the end of rotation. Dr. Pleva also discussed ICU nutrition and explained how to write TPN orders for patients. I really enjoyed this aspect of the rotation and by the end of the month I was able to accurately write TPN orders.

Bottom line: Rotation in the SICU with Dr. Pleva taught me how to think like a clinical pharmacist. I needed to incorporate patient characteristics and the entire clinical picture in order to determine the appropriate dose for the patient. In the SICU, the majority of patients are obese with renal insufficiency in which Micromedex isn’t sufficient. When you have a patient 500lbs and on dialysis, clinical judgment must be used.

One Ventrical Heart

Posted by Jody at Sunday, February 20, 2011

Is a one-ventrical heart possible? If so, is it functional? Can a person survive with a one-ventrical heart?

These are all the questions I asked myself when I heard this term on the first day of rotation. I was in the PCTU (pediatric cardio/thoracic unit) at the University of Michigan Health System.

I must say the first couple of weeks I was quite lost. I wasn’t that familiar with the physiology of a normal heart, now I needed to learn the physiology of numerous congenital defects. Conditions such as tetrology of fallot (TOF), patent ductus arteriosus (PAD), transposition of the great vessels, hypoplastic right heart syndrome.

The first few weeks I spent most of my time learn various heart defects and how it affects the physiology and hemodynamics. Each morning I arrived at the hospital between 5-5:30am to work-up my patients. It was surprising how much could change over night. After working up my patients I would go to the bedside and look at medication drips and talk with the night nurses. Rounds typically started at 8am and go until roughly 11:30am. Then it was time to work-up my patients again and follow-up with any changes that occurred on rounds since discussion with my preceptor occurred from 3-5pm.

The goal of this rotation was not to master cardiology or pediatrics for that matter. This rotation taught you how to assess the patient, not just looking at the meds or lab values on the computer screen but going to the bedside to assess the patient and the entire clinical picture. I learned how to sift through all the information and determine what’s the most critical data. I understand the importance of staying active on rounds – always asking myself, why was it appropriate their was a change (or no change) in the drug therapy. This rotation taught me valuable skills and insight in how to manage patients in the clinical setting. I was hard work and long hours, but in the end well worth it.

Don't Call Me, I'll Call You

Posted by Jody at Sunday, February 20, 2011

My rotation is Ambulatory Care with an Oncology focus. This rotation is based out of St. Joseph Mercy Hospital Infusion Clinic.

Why is my role in the infusion clinic?

I participated in a program called “First-dose Follow-Up”. This program targeted new patients to the oncology infusion clinic.

Each day I accessed the schedule to determine the new patients being seen that day. I would work-up each new patient, learning past medical history and chemotherapy regimen. When the new patients arrived to the clinic I would perform medication reconciliation and explain how I would be contacting them the following day to make sure they are doing well and if they have any questions or concerns.

The following day I would contact the patient and go through a questionnaire form. This form was created using the Common Terminology Criteria of Adverse Effects (CTCAE) to assess various adverse effects of chemotherapy.

Once I completed the questionnaire I would discuss the patients’ responses with my preceptor and if needed the physicians.

What did I learn and gain from this rotation?

- What are the common chemotherapy regimens for various cancers (breast, colorectal, prostate, lung)

- Anti-emetic regimens

- Adverse effects of chemotherapy agents

- Time-management

- Communication skills

Whether you are extremely interested in oncology or not, this rotation will improve your communication and ability to manage your time. The First-dose Follow-Up program requires you to not only interact with patients but also nurses and physicians. I spoke daily with the nurses before I would perform med rec’s on their patients. During my phone call to the patient there were times where follow-up with the physician was needed because the patient was experiencing significant adverse effects from the chemotherapy. This program also requires that the student adequately plan and manage their time. Each day you are seeing new patients, calling patients from the previous day, completing projects, journal clubs, etc.

Don't think you need to be extremely interested in oncology in order to take this rotation. You will have patient interaction and strengthen communications stills which are key aspects of ambulatory care.

Knowing Drug Use

Posted by Omo at Tuesday, February 15, 2011


I was at the Ann Arbor VA for my drug info rotation. My daily routine revolved around answering questions pertaining to drug use at the VA. I learned about the various primary, secondary and tertiary sources available.
On a daily basis, I took questions from healthcare professionals mostly about off-label medication use. Most times, several drug regimens was tried for a patient but did not work and then a drug with an off-label use was considered. I would then have to find evidence to back up the drug use for that disease state. I came to find out that most times, evidence was based on case reports and rarely on phase II or III clinical trials.
I also had to prepare a drug monograph which is something I had never done before. A drug monograph is a document that specifies the kinds and amounts of ingredients a new drug or class of drugs may contain, the directions for the drug's use, the conditions in which it may be used, and the contraindications to its use. It also includes evidence of drug use and benefits illustrated in phase I, II and III clinical trials. I also prepared a drug bulletin on bioequivalence and generic drugs. It helped with sharpening my pharmacokinetic and pharmacodynamic background.
Finally, at this rotation, I gave a forty minutes in-service presentation on Clostridium difficile. I presented to students and pharmacy staff at the VA. I learned a lot about C difficile as well as novel therapeutic agents for this disease state. Doing an in-service presentation was advantageous because it prepared me for my seminar presentation which I gave about a week later at the college. Presenting to a team of students and staff at the VA prepared me very well for my seminar.
Overall, it was a great experience and a rotation in which I learned so much from.

Institutional Phamacy

Posted by BJ Opong at Tuesday, February 15, 2011

Institutional Blog
My rotation for the month of January was an Institutional rotation at Sinai Grace Hospital in Detroit. Due to some last minute changes I had the pleasure of having my institutional rotation at the same hospital where I work. I was a little uneasy at first because I didn’t want to end up just getting put to work since I knew about the day to day operations of the pharmacy having spent the last 2 years there as an intern.
The rotation ended up being a good one because I was able to see a lot of things on the management side of hospital pharmacy that I was completely unaware of. During the 1st week I was able to work on an audit that was being performed looking at PTT and heparin administration times. The audit looked at when the PTT was sub or supra therapeutic and how long did it take for the pharmacist to respond with a change in the rate of heparin infusion. From this information management will be able to determine where the major problem is and how much needs to be done to correct it. It was very helpful being a part of this audit because it allowed me to see how administration assesses problems to determine how to correct it.
I was also able to attend a couple of medication use evaluation meetings. During these meetings a committee made of pharmacy and nursing personnel discussed the different medication error issues that came up over the past month ranging from IV medications administered after expiration to patients receiving the wrong medication. The errors were all graded based on severity and the committee then discussed what could be done to prevent such errors moving forward. I enjoyed this because it gave me a better appreciation for the level of thought and planning that goes into implementing new safety measures and computer warnings for medications.
The remainder of the rotation was spent shadowing different pharmacists working in various services in the hospital to see what their job entails. I was able to shadow the pharmacists on the general pharmacy services and learn how Vancomycin, Heparin, Coumadin, and Aminoglycosides are dosed on the patient floors. One observation that I made while working on the dosing was that a lot of time gets spent filling out consult forms which can take away from some of the other responsibilities of the pharmacist. The most interesting thing that I was able to see during the rotation was during my day with the OR pharmacist. The pharmacist let me spend a few hours of the morning watching a coronary artery bypass graft. It was nothing like I expected, for some reason I expected the room to be very tense and uptight given the seriousness of the procedure. The doctors and anesthesiologists were very laid back and willing to answer questions. It was great being able to see the procedure and the immediate actions that various medications had on the heart. Also I was able to stand close enough to look down directly into the patient’s chest. One observation I made was that I don’t ever want to be in a position to have my chest opened for surgery. The amount of force and torque they used to open the chest is probably the cause of most of the post surgical pain patients’ experience.

Information Overload? Not quite.

Posted by Tiffany Pfundt at Thursday, February 10, 2011

My January rotation was with Dr. Stephanie Minich at UMHS on the hematology/oncology service. This rotation was jam packed from start to finish with information and activities. I'll break it down by "what I did,"and "what I learned," then finish with a brief evaluation of the rotation.

What I did?

Rounds

Each morning I'd arrive at the hospital around 6:45 am. Prior to rounding with the medical team, I would review my patients' labs, recent test results, and medication lists. Patients' medication lists changed almost daily, so keeping up on the list was an important part of my routine. The team counted on me to have an accurate and up-to-date list for each of my patients. They also looked to me for medication recommendations for anti-emetics, pain relievers, antibiotics, and dosing changes based on blood levels. Since cancer medication management can be so complex, the medical team relies heavily on pharmacy input. Because of this I was able to interact with the team and make several medication therapy recommendations, and they were grateful for my input. Being ready for rounds required a thorough knowledge of each patient, all of their medications, and the ability to anticipate future medication needs of the patients, as well as possible questions from the team. I will say I was not perfect in these areas, but I definitely improved throughout the month. The ability to anticipate questions is a skill I think I will use a lot in the future.

Projects and Presentations

In addition the patient care activities for this rotation, we were also required to present several cancer related topics. Throughout the rotation we had mini cancer topic discussions. For most of the discussions, Dr. Minich taught and we listened. However, when we discussed Hodgkin's and Non-Hodgkin's Lymphoma the students became the discussion leaders. I found this teaching activity very valuable. Teaching a subject requires a deeper understanding of the subject than learning it on your own.

We also had a to present a patient case and topic to all of the oncology pharmacy students and preceptors. The intent of this presentation was to give the other students a brief overview of a topic they may not have encountered. I enjoyed learning about my fellow classmates' experiences and learning about new topics.

Another presentation came in the form of a journal club. The intent of this presentation was to gauge our understanding of the article as well as to test our ability to critically evaluate scientific literature and assess its applicability to everyday practice. My article compared two chemotherapy drugs used to treat chronic myeloid leukemia. The two drugs were very similar, one just seemed to work a little better, at least in short term studies. After I presented the article, Dr. Minich asked me, "so, which drug would you recommend for your patients?" This meant I had to consider the information in the article at a deeper level, not just spit back the author's conclusions. Being able to take book knowledge, or in this case information from the literature, and apply it to clinical situations is what the fourth year (and beyond) is all about!

What I learned?

Obviously, since it was a hematology/oncology rotation I learned about chemotherapy regimens used for various types of cancer. Most of the chemotherapy I learned about was for the treatment of lymphoma and leukemia. I also had a few patients with solid tumor cancers, but those patients rarely received chemotherapy while under our care. In addition to learning about cancer chemotherapy, I also learned about treatment of other cancer related conditions.

For the first week and a half, the oncology students would meet with one of the preceptors to discuss various oncology related topics - they called it Oncology Boot Camp. Topics covered in these sessions included: pain management, anemia, nausea and vomiting prevention, identifying and treating neutropenic fever, monitoring for and managing tumor lysis syndrome, and properly using colony stimulating factors. At times, it felt like I was learning a new language with all the unique terminology that was used.

As I mentioned above, Dr. Minich held her own kind of oncology boot camp. A couple times a week we would meet to discuss specific types of cancer. She tried to cover topics that we wouldn't necessarily be exposed to on the rotation, in addition to ones we did see. The topics we covered were: lung cancer, Hodgkin's Lymphoma, Non-Hodgkin's lymphoma, Chronic Myeloid Leukemia, Acute Myeloid Leukemia, and Multiple Myeloma.

This rotation also included a hefty dose of infectious diseases. Many cancer patients are immunosuppressed, therefore they need to be on prophylactic antiviral, antifungal and antibacterial medications, but not every patient has the same antibiotic needs. Identifying patient specific factors that determine which medications they need is an important part of optimizing their care.

Recap and Evaluation

As you can see, this is not a rotation you can breeze through, nor would you want to. There are too many things to learn and Dr. Minich is an eager and talented teacher. To not be fully engaged during this rotation would be a disservice to yourself. Compared to other rotations, I experienced the greatest gain in professional pride and confidence during this rotation. To sum it up, this rotation was emotionally taxing, therapeutically challenging, and professionally rewarding. I would highly recommend this rotation to anyone interested in cancer, or anyone who wants a well-rounded inpatient experience with lots of opportunity to interact with other healthcare professionals.

Institutionalized

Posted by Jim Stevenson at Wednesday, February 09, 2011

In January, I joined the pharmacists at St. Joseph Mercy in Howell for my institutional rotation. To my surprise, their central pharmacy was not in the basement, but in fact had a skylight – an unheard of addition to the usual pharmacy décor. But it was not just natural sunlight that I was exposed to on rotation – I also gained an understanding of pharmacists’ roles in a small (census ~70) community hospital.
The three pharmacists at St. Joe’s rotated through staffing and clinical roles. The clinical pharmacist attended rounds every morning and handled pharmacokinetic dosing, while the staff pharmacist verified orders, checked compounded medications, and answered drug information questions. As a student, I participated in functions from both roles.
Through this rotation, I gained experience making IVs, checking compounded medications, and checking cart fills. Additionally, I ensured that patients had proper DVT and stress ulcer prophylaxis, proper antimicrobial therapy, and renally adjusted doses. However, the most helpful aspect of this rotation was talking through complex pharmacokinetic dosing situations with the pharmacists. It is one thing to calculate a dose on a pharmacokinetics test in class, and another thing completely to dose a drug to a target steady-state concentration in a patient with fluctuating renal function.