GeNeRaLiSt RoTaTiOn - WeeK OnE

Posted by Melanie at Sunday, August 07, 2011

I am the FIRST EVER student to partake in this (anticoagulation) rotation. It is brand new (still has that new car smell) and I am the only one taking it -- so that makes me the Eve of this rotation.

Eventually, this rotation will go on the REQUIRED ROTATION list and everyone will have to take it.

As a reminder: I am at UMHHC and my preceptor is Dr. Lizzie Engle (yeah, we rock the last name).

Pre-rotation: Complete required materials on CTools course site. This included pharmacokinetic practice, watching anticoagulation videos, and completing the anticoagulation MLearning.

Day 1: Orientation with Drs. Brummond and Kraft. They gave me a basic overview of what I would be doing – rounding with medical teams, managing anticoagulation and kinetics, patient education, daily readings, topic discussions on Tuesdays and Thursdays, leading a journal club, giving a patient case presentation, and giving a topic discussion.
When this was over, I caught up Dr. Engle on rounds. I was given three patients to work up for the rest of the afternoon.

Day 2: I got to rotation two hours before rounds started (rounds start at 8) to work up patients for the team that Dr. Engle had assigned me (she manages 4 teams, each with about ten patients, so she typically oversees 40 patients). My team had 10 people so I looked at labs, medications, and admission/progress notes to get a better understanding of each patient. I look for anticoagulation and vanco/aminoglycoside antibiotics because they require more management from the pharmacist. I am also looking to see whether there are any drug interactions, if the dose is appropriate for kidney function, and if there are any glaring problems (there is not time to do a full workup for each patient, so you are checking to see if there are any safety problems).

I discussed any issues I had spotted with Dr. Engle and then we went on rounds with the team. During rounds, you can find out what is going on with the patient and what the medical teams plans for treatment. You can find out if they plan on continuing antibiotic therapy, if they plan on restarting any medications that were on hold, or if they plan on discharging the patient.

After rounds, I did a more in-depth workup on the patients. I did medication reconciliation to ensure that patients were receiving in-house what they were taking as an outpatient. I looked in treatment guidelines to make sure that patients were on appropriate medications for their condition. And, I followed up on labs (such as INR, aPTT) and made recommendations to preceptor based on these results.

If a patient is being discharged on anticoagulation therapy, it is policy to provide education. Therefore, it was important during rounds to pay attention to what patients were being discharged and if they were going home on anticoags.

Day 3: I rounded with the same team again, so my prerounds consisted of following up on the progress notes and new labs from the patients.

At UMHS a pharmacist is in charge of carry the code pager. We received a code page, and had to respond. There is a drug box that Dr. Engle grabbed and took with us. Inside of it, there are different drugs that may be needed in such a situation (epinephrine, norepinephrine, atropine, vasopressin, etc). A whole team responds and the pharmacist is in charge of assembling the drugs that are necessary. This includes putting together the epinephrine syringes, drawing up the norepinephrine, and making a vasopressin drip. This was a nerve-wracking experience. It takes a lot of discipline to put your nerves to the side and focus on what you are doing to try to perform your tasks quickly and accurately.

Day 4: I took on a new team today. When I got there in the morning, I looked up my new patients and reviewed the patients from the previous day (this meant I was following 19 patients). Dr. Engle started rounds with me, and then she allowed me to finish by myself. At first I was very nervous, but the medical team has been very supportive of letting me round with them, and the attending physician seems just as interested in helping me learn as much as his residents.

There was a topic discussion around noon on diabetes. In order to prepare for this, I had to read three articles and review my therapeutics notes.

Day 5: I rounded with the same team I had on Thursday. Dr. Engle let me round by myself. It wasn’t as bad as I had expected. I just wrote down my concerns/questions prior to rounds, shared them with Dr. Engle, and then addressed them with the team during rounding.

During the afternoon, I picked up a third team that Dr. Engle was managing and started working up the patients.

Week Summary: I learned how to enter notes for anticoagulation, educate patients, answer questions for the team, order INRs, aPTTs, and Vanco troughs, and adjust anticoag dosing based on protocols.

I was also managing a patient with hemophilia A who was on Factor VIII (helixate). In order to manage this patient, Factor VIII levels had to be drawn and monitored so that the dose could be adjusted properly.

Key Points:

1 – During the first couple of days of rotation I was so nervous about getting asked questions. I would get myself so worked up that you could have asked me what my medications were and I wouldn’t have been able to tell you.

Then I realized – you aren’t going to/can't know everything. My preceptor will keep asking me questions until we get to one I don’t know the answer to. There is no point in being on rotation if you don’t learn things you don’t already know. I have learned a lot of information by looking up answers to questions I have gotten this week.

2- Don’t be afraid to ask the medical teams pertinent questions.

Okay, so the medical team can be intimidating; you have the attending who is very knowledgeable and has been practicing for a long time and you have a senior resident who has been out of medical school for a few year, junior residents, and sometimes a medical student. At first, I felt this pressure that I must know everything under the sun about every single drug on the planet so that they wouldn’t think of pharmacy as an inferior field. But, what I have found in this short week of my life, is that they value you as part of the team. So here is what I do:

a) I always introduce myself and make sure it is okay to round with them.
b) I listen to them when they are presenting the patient to see if any of my questions get answered.
c) I carry my computer tablet with me so that I can look up quick answers on the spot. (For example, I have access to labs and sometimes labs come in while we are rounding and I have been able to update the team; I have been able to look up common side effects; and I have been able to look up the generic name of an uncommon drug.)
d) If my questions were not answered, I will ask the team.
e) When we are done rounding, or if I have to leave rounds early, I thank the team for letting me round with them and tell them I will follow up with them if there was a question I could not answer.

A Question I got from the Medical Resident that may be of use to you in the future:

The patient was having fevers of unknown origin and wanted to know if any of his medications could be the cause. This was one I had to get back to her on.

Different articles publish slightly different lists, but here is one that I found (note: I looked at four articles before formulating an answer, ran it by my preceptor, and then got back with the resident):

http://www.mdconsult.com.proxy.lib.umich.edu/das/article/body/271291532-2/jorg=journal&source=&sp=811057&sid=0/N/51761/1.html?issn=0891-5520

If the link doesn’t work for you, you can always look up drug fever and find a list from a journal article.