Beginning Again...Rotation 3

Posted by Nina Cimino at Wednesday, September 28, 2011

Another month, another new rotation! I am starting to get used to the fact that for the first one or two days of a new rotation, I feel a little lost and overwhelmed. After the first couple of days though, I find myself settling in and getting a good grasp of what I am doing. I really believe that one of the most beneficial aspects of P4 rotations is learning how to jump into new environments and adept quickly.

This month, I am doing my drug information rotation in medical writing, with a company that produces drug information resources for healthcare professionals. I specifically wanted this drug information rotation because I had worked in a more traditional drug information center during one of my FDA internships. While this rotation is still classified as drug information, it is a unique drug information setting and still allows me to have a new experience.

So now that I am oriented to my new rotation site, I can tell you a little bit about what I do! My preceptor maintains the drug information database for the company, so my rotation partner and I work with him to revise and update drug interaction monographs. We do literature searches to review the available evidence, and incorporate this information into the monograph to ensure that it is complete. In addition to updating the drug interaction monographs, we will also be writing new monographs, presenting journal articles, and working on longitudinal projects.

This rotation is very different from the direct patient care rotations I have had in the previous months, but I think it will be a great experience. I will definitely have an opportunity to brush up on my literature search skills, and these skills will be very important in any practice area where I find myself!

End of PICU

Posted by Amanda at Wednesday, September 28, 2011

That is a picture of my amazing preceptor Dr. Beckman, she taught me so much.

I finished my time in the Pediatric Intensive Care Unit and I am quite sad to go. I will miss all the kids from my unit. I wish I could stay with them. I learned a lot on my rotation. Being in the ICU you get to see a lot of disease states so that was what I liked the most. I get exposed to everything. I learned about typical topics like diabetes and asthma and then I had more complicated topics like bone marrow transplants and organ transplants. I really enjoyed my time in the PICU and it has definitely made me want to do a pediatric residency.

I also would like to note that the nurses that work in the PICU are amazing and that without them the unit would not be able to function.

Feeling the weight of my HIV/AIDS rotation

Posted by Anna Polk at Sunday, September 25, 2011

Rotation 2 has come and gone and I am spending my Sunday afternoon frantically addressing all of the things I put off during the month (like blogging, for example!)  I spent the rotation in Chicago with fellow P4 Jennifer Wang, working at Walgreens inside the Howard Brown Health Center, one of the nation’s largest LGBT healthcare organizations.  Two afternoons a week we would also head down to a free multidisciplinary HIV/AIDS clinic at Mercy Hospital on Chicago’s south side.

Jenn and I arrived on our first day, bright-eyed and bushy-tailed, ready to tackle this new patient population and feeling confident in our knowledge, having memorized all of the drug names that were assigned to us.  We quickly realized, however, that we effectively knew absolutely nothing.  Every night we would race home to start looking up questions that arose during the day and preparing our assignments for the next day.  I didn’t have internet where I was staying (my apologies if I neglected any emails from you!!) so my iPhone and I spent a significant amount of quality time together.  Jenn and I also realized that we were not going to spend a portion of each day shopping and eating great Chicago food like we had originally planned.  

    So what did we accomplish during the month?  Six OTC topic discussions, two presentations to PsyD students, one MTM session apiece, two hours of online continuing education, two pharmaceutical company dinners, one crash course in immunizations, four learning modules with case discussions, six mock patient consultations, four STD consultations and one final exam.  And that was in addition to the day to day work of filling, verifying, counseling patients and attending clinic!  Plus we managed to squeeze in trips to the Field Museum, Museum of Contemporary Art, Shedd Aquarium, Willis Tower, Millennium Park, a Cubs game and an architectural boat tour.  Phew! I am tired just typing that out.  

    All in all, it was a completely exhausting month, but also incredibly rewarding.  I went from knowing very little about the management of HIV to feeling confident counseling patients on all of their different treatment options and helping select a regimen with the highest likelihood for success.  I held an AIDS-induced dementia patient’s hand while she had wound dressings changed.  I helped a patient with a CD4 count of 7 (AIDS diagnosis is <200) administer his Neupogen injections.  I filled a transgendered patient’s first prescriptions that would help her lead the new life she was looking for.  Basically, I solidified my desire to be a patient-centered pharmacist, intimately involved in all aspects of patient care.  

    Well, I could probably write an entire novel about my rotation, but I better end here so I can begin preparing for my Cardiology rotation at Allegiance Hospital in Jackson, MI.  Stay tuned!

Good Bye Rotation 2.

Posted by Matthew Lewis at Thursday, September 22, 2011

Tomorrow's the last day of lung transplant, and Monday I move on to Institutional(think generalist staffing clinical pharmacist) at the VA in Detroit. First, one last bit about L.T. I feel like this rotation confirmed that transplant would be a good field for me, since there are opportunities to influence patient care directly, work as a team with many other types of health professionals, be on the cutting edge of medication therapy as more and more medications are used and developed for transplant patients to alleviate option depletion due to intolerable side effects.

Today I saw one of the patients I helped discharge about a week ago who was readmitted to the hospital. He (I have to use the pronoun to protect his identity due to HIPPA rules) had end stage cystic fibrosis and received two new lungs. I feared that he was admitted for some type of infection, but it looked like he came in due to some anemia (whew, that's a lot less damaging to new lungs). He had color, he wanted to move around and not be stuck in a bed; He didn't look sick any more. This patient recognized me as the pharmacy student who helped him out with understanding his new 21 drug regimen, and was quite thankful about everything we gave to him. He especially loves the medication schedule, since it helps him work out what medications he needs because he's still getting used to it all. His comments and condition made me feel like a graduated pharmacist to know I helped a patient understand their medications to the point of the patient having no issues, no complaints, and say I did a good job. That is something which will be the highlight of any rotation I have.

Now, talking about the VA (Vetran's Affairs) hospital in Detroit, I think I got off to a bad start and I have not even begun. Dear fellow students, if you have never worked for the VA, they require forms two weeks before you start so they can get you set up with a badge and computer access. You may not be told, and even if you are told at some point along the P4 orientation process, you will not be reminded about these forms. My point being, if you have a rotation at any government site, contact the preceptor more than two weeks ahead of time. You'll probably want to do the same for outside the state rotations as well, in case there are any state level papers that must be completed.

On the positive, I am looking forward to this rotation because of the population it serves. I have the utmost respect for people who served our country and they deserve proper care. It's the least I can do for them. This healthcare system is actually socialized medicine, which is something hotly debated in the public right now and I'm going to keep my opinions to myself on the matter. The important point about this health care system is that nowhere else is the balance of efficacy and safety vs. cost effectiveness scrutinized so closely. I will likely have to defend my recommendations with more background, studies, and protocols than in other institutions. I will also have to work within a particular formulary, so my recommendations might be limited to what we can get. This will be a good test to my therapeutic knowledge and will no doubt expand my abilities as a pharmacist.

Hematology/Oncology... intense but great

Posted by Elizabeth Kelly at Thursday, September 22, 2011

First off, I would like to apologize for not blogging sooner, but if the fact that I haven't gotten to it yet says anything about how busy my month has been I don't think anything else can. I was on the hematology/oncology rotation with Dr. Shawna Kraft at UofM Hospital this past month.

I am going to split up the rotation between the first two weeks and the second two weeks.

First two weeks:
The first day was a little overwhelming, I was with another student in my class and the first thing we did was go on rounds and each get assigned 6 patients to work up and be ready to go over and present to Dr. Kraft. I also discovered all the people who can make up a team: an attending, a fellow, a senior resident, two interns (first year residents), two medical students, a pharmacist, and us the two students. It was also really interesting how their was an attending for hematology with a fellow, and then a completely separate attending for oncology, with no fellow. So the team I was on would go with one or the other and then switch with the other team and go with the other attending. Hematology is leukemia and lymphoma patients. Oncology patients were mostly people coming in because they are having symptoms related to their cancer like neutropenic fever (lots of infectious disease), pain (morphine up the wazoo), nausea/vomiting, etc. Hematology is basically considered to be more complicated and that is why they have fellows and not oncology.
And then also on the first day we were given a quiz. I did terrible. I felt like I knew nothing. We were given the quiz at the beginning of the rotation and then we also took it at the end. I actually got a 12/30 the first time and improved to a 24/30 today when I retook it. Hey, it was hard! Anyways...
So, to basically summarize the first two weeks it was the other student and I trying to figure out what was going on with our patients while also attending "boot camp" which was a series of topic discussions lead by the different cancer pharmacists. For example, neutropenic fever, anemia, tumor lysis syndrome, etc. For me at least I was feeling pretty bogged down and not getting anywhere close to the amount of sleep I needed.

Second two weeks:
Everything changed the third week however. The first two I was nervous about talking to the doctors about potential changes and felt like a lowly student. Then an epiphany hit and I was all over them like white on rice. I was making suggestions all over the place, monitoring my patients therapy much closer, and becoming a true member of the team. It was great, I felt so sad leaving them today on my last day. I think they got really used to the other student and I being there to help them with everything they need.
Some examples of the great interventions I felt I made:
- clarified allergies (note: if someone says they had a red face to Keflex, does not mean they have an allergy to penicillins!!)
- thorough counseling on Lantus Solostar
- pain management dosing
- antibiotic dosing
- called a patient's wife to clarify a home regimen.
- and of course much more.
If you notice some of the things I did, its what you will do on any rotation. To the future P4s: become involved as much as possible. Its sad to say, but even though the MD's are super smart and well meaning, they are just as human as you and I, and will make mistakes/not know everything.
The only thing that truly sucked about this rotation was the patients who passed away, or the ones you knew you were sending home to hospice for them to pass away there. There were some really great patients though and by the end of the rotation they were MY patients. I worried about their pain, how their liver function was, or if their vanco trough was going to be therapeutic. It's truly a great population to work with. Also, Dr. Kraft is a great teacher and even though it felt overwhelming at first, the other student and I both learned a lot and I appreciate everything she did for us. I would definitely do this rotation again if given the chance.

They don't call it the Intensive Care Unit for Nothing

Posted by Jenna at Sunday, September 18, 2011

This week was an interesting one for me:

• I played private investigator. A patient came in with SEVERE rhabdomyolysis (muscle breakdown) and for his first 2 days in the ICU nobody could figure it out. Thankfully, his daughter was able to bring in his medications, which gave us some insight & the answers we were looking for.
• I had to identify about 12 pills that were loose in a pill box.
• There were about 6 bottles of medication in a small bag.
• There were about 30 bottles of medication in a huge gift bag.
• I kinda, sorta watched a tracheostomy be placed. I was outside the room but was still kind of observing. Once patients have been vented for ~8-10 days, the team starts considering a trach if the patient isn't able to be weaned off the ventilator.
• I truly felt like part of the team. Starting at the end of my 2nd week, I started to do my work in the ICU, rather than going back to the main pharmacy. Well, the saying 'Out of sight, out of mind' is completely true. When the residents see me on the floor, they actually seek me out to ask questions .. that really makes you feel like part of the team. It's a good feeling!
• I've lost count of how many patients have died in my 3 weeks in the CCMU. It's been about 8. :-(
• I've been having some fleeting thoughts about my interest in psychiatry. I've had 1 & currently have 2 psych patients in the unit. I find this patient population interesting but I also have a lot of empathy for them.
• I saw an autopsy. A young patient who was going to come to the CCMU coded and was unable to be resuscitated so the team wanted to go to the autopsy. The patient didn't have a significant past medical history so no one really knew what happened.
• I have a stronger stomach than I thought. Luckily, it didn't really smell because I think that would've really bothered me.
• The patient was already all cut up when we got there so we were mostly observing the analysis of the organs. 
• Warning - this may be too graphic for some: It's kind of indescribable .. how it feels to be right next to a dead body laying on a table. The head was cut open to remove the brain and the chest was wide open, with pretty much only the ribs and spine remaining. I was able to see the brain, kidneys, liver, & lungs. Sadly, they had already analyzed the heart before we got there so I didn't see that.
• I know what it feels like to truly care about your patients. Now, I've never not cared .. but I just feel so personally invested in my patients' outcomes. On rotations, we're technically not required to follow our patients on the weekends but I haven't been able to stop myself. I feel like I need to know what's going on with my patients.
• For example, the same patient who's medications I went through, is the patient that I've been looking at a lot obsessing over. He had been taking a combination of Simvastatin, Cyclosporine, & Itraconazole .. yikes. His CK (creatinine phosphokinase) levels had been steadily rising to about 120,000 (normal value is <400). We have been waiting for it to start downtrending  (to prove our theory that his rhabdo was drug-induced) and it finally did today! I can't tell you how excited this made me! Dork? Yes of course but I don't care! 

Here's to my last week in the ICU, may it be less eventful than it has been so far!

Eli Lilly

Posted by Eric Zhao at Friday, September 16, 2011

I just witnessed insulin and Alimta® (pemetrexed) being manufactured. That was cool. -Eric

Oncologic Drugs Advisory Committee

Posted by Eric Zhao at Wednesday, September 14, 2011

SILVER SPRING, Maryland - Oncology experts from around the nation gather in the FDA's White Oak Conference Center to evaluate the new drug application for Ferriprox (deferiprone) and to discuss trial design for the development of products to treat patients with non-metastatic prostate cancer. It's 8 o'clock in the morning and the Chair of the Oncologic Drugs Advisory Committee (ODAC) meeting begins the Call to Order for this all-day meeting. The ODAC consists of 13 voting members to review and evaluate safety and efficacy data for oncology drugs and makes recommendations to the Commissioner of Food and Drugs, CDER, and CBER.

Their view:

The Great Room in the White Oak Conference Center
FDA White Oak Campus, Building 31

Meanwhile, in Indianapolis, I park myself in my desk chair, log on to the Lilly corporate system, and break out my headphones. Inside my bag, I pack two caffeinated beverages with my lunch to prepare for today's 8:00 a.m. to 5:00 p.m. meeting. My assignment today consists of analyzing and interpreting how the FDA thinks. Think of it like the industry playing chess against the FDA.

My view:

The closed captioning didn't make sense all day.

Ferriprox (deferiprone) [8:00 a.m. - 12:00 p.m.]

Iron Man's Kryptonite

Submitted by ApoPharma, Inc., deferiprone is proposed for the treatment of patients with transfusional iron overload, when current chelation therapy is inadequate. During the meeting, ApoPharma, Inc. presents their case, and then afterwards, the FDA presents their case (are we in court??). Following this, the public delivers their testimonials and opinions about the magic of deferiprone. Finally, the ODAC answers questions, discusses any issues, and casts a final vote. In this case, they voted 10-2 to support an application for accelerated approval.

Non-Metastatic Prostate Cancer Study Design [1:00 p.m. - 5:00 p.m.]
Currently, there are no products approved for the following indications:

1. Non-metastatic, PSA-only recurrent prostate cancer who have not received androgen deprivation therapy (ADT)
2. Non-metastatic castration resistant prostate cancer (NM-CRPC) who have a rising serum level of prostate-specific antigen (PSA) despite currently receiving ADT

The afternoon session of the ODAC meeting discusses possible patient populations, trial designs, and suitable clinical endpoints for studies intended to support a product for these unmet medical needs. The session begins with an FDA presentation and two speaker presentations for background, and I feel like I'm in lecture again. For the next 3 hours, however, the committee argues about the pros and cons of trial endpoints until they finally hit 5:00 p.m.--with a split conclusion. I'm sure my preceptor is going to loooove this result.

The Food and Drug Administration

FDA stands for Full Day Agenda

Today was definitely a test of endurance, but a great experience nonetheless. I wish I requested a clerkship rotation with the FDA, because after attending this meeting, I realize how valuable that experience would have been. If you're interested in the industry, having been at the FDA will truly give you a leg up. Write that down...

-Eric Zhao

Week 3 in community pharmacy

Posted by Nina Cimino at Wednesday, September 14, 2011

It's really amazing how quickly rotations fly by, and how quickly you adjust to an environment when you're there everyday. So far, both of my rotations have felt overwhelming (in different ways) during my first week, and, by week 3, I've started feeling comfortable in my new environment.

Now that I have been in the community pharmacy for 2 and 1/2 weeks, I'm feeling more comfortable and enjoying it a lot more. I have gotten to know the pharmacists and technicians a lot better, and I really enjoy working with them. I'm lucky to be with people who are used to having students and who are fun to be around. Another thing that has been beneficial, is that the pharmacy staff is now more comfortable with me. Now that the technicians and pharmacists have seen me counsel patients and answer questions effectively, they seem more comfortable referring questions to me. This is great for me, because now I get to spend more time counseling and answering questions, which is my favorite part of community pharmacy!

As I mentioned in my last post, one thing I've been working on this rotation is letting things roll off my back. I've had some patients who are extremely nice and grateful for my help, and I've had others who are extremely rude. I think I'm getting better at taking everything with a grain of salt, and not letting angry patients upset me too much. The technicians have to get used to this too, and they have given me good advice and helped me to not take things too personally. I try to keep in mind that I only see a small snapshot of these patients' lives, and I don't know what else they may be dealing with. Remembering that patients may have a whole lot going on besides whatever brought them to the pharmacy helps me to not take it personally when they get upset with things besides my control (like insurance co-pays).

Transplant with Dr. Park - Part I

Posted by Bernadette at Tuesday, September 13, 2011

As the P4 class is going into the second half of Rotation 2, this will have to be a retrospective look on my first rotation, solid organ transplant with Dr. Park. This rotation is notoriously known as one of the more difficult rotations. From what I gathered from previous students before the start of the rotation, Dr. Park has high expectations and the amount of material needed to prepare for this rotation was, well, endless. Looking back at my experience, both those points were quite true, but while those were reasons why it made the rotation so difficult, they were also the reasons why I liked it and learned so much in my first month. With that said, this was in no way an easy rotation, but in my opinion, one worth trying to get.

Rounds

Now there are things as a P4 you can do to prepare for this rotation, and there are things you simply cannot control. Example of things out of your control: your partner, your team (medical students, residents, fellows, attending, etc.), and your rounding hours. I was not the biggest fan of rounds starting at 5:45 am, but like I said, you can't control it. Surprisingly, when I began to follow and track the progress of my patients, rounds were the most energizing part of the day. The team is actively discussing each patient, and it's the time you start to consider the direction of your patients' therapies - do you continue their current medications, what needs to be added/dropped, etc. Unlike many other types of rounds, these are actually pretty quick and efficient - about an hour and a half for 20-30 patients. This also means you need to be paying attention; if the team is discussing your patient, have in mind their likely problems and how to resolve them, listen to what the team will be doing and start to think about why (there are lot of labs and tests to run, but if you don't know why they're being done or what the expected results will be, just ask!).

Overall, rounds are the best way to stay updated on a patient. Notes in the chart get posted late and aren't as descriptive and helpful as simply talking to a person. If you were the patient, wouldn't you want to just ask rather than read off your medical record? Also, it's the time when you have the opportunity to make your recommendations for your patient. Sometimes you will get asked for recommendations, and while the "look it up" cliche still holds, it does help to be familiar with general guidelines because most decisions are made on the spot about what medications to start/stop. Of course, if you don't know, you don't know - look it up after and if something does need to be changed, tell someone and make it happen.

...to be continued after rotation today!

And Here is Your Box of Medications

Posted by Matthew Lewis at Sunday, September 11, 2011

The plan for Monday is to do our initial medication education for one of our very successful lung transplant patients. I have discharged two patients so far, one new and one who came in with a problem post transplant. They each had such different needs that it is definitely note worthy.

The old transplant patient had to come into have a surgical incision and drainage of the fluid between his lung and chest wall because a Candida albicans infection got so bad it was pushing on his lungs preventing breath. He also developed acute kidney failure due to his anti rejection medication tacrolimus having elevated levels secondary to an interaction with the fluconazole first prescribed to treat the chest infection. Surgery went well and eventually he was educated and discharged in much better shape than he came in. We made a large number of changes to his medications, but the patient and his wife had created their own medication spreadsheet with their own code and notes, so it was just a matter of writing down the new regimen and going over the two new medications (voriconazole for the C. albicans and dapsone to replace Bactrim single strength as PCP prophylaxis). We didn't even give the patient medications since he's a veteran he can go through the VA.

Now, the new transplant patient literally received a box of medications. I thought it was just an exaggeration, but there was a duffel bag inside a box filled with about 20 different pills, three insulins, a blood pressure cuff, diabetes testing supplies, since he had prednisone induced diabetes, there was a nice folder of all the medication guides and receipts, and a few other goodies. How many other pharmacists can claim that they give their patients duffel bags to contain all the patient's meds? However, this medication inundation comes with education to match. We take the time to show the patient every single medication so they can help catch dispensing errors because unintended interactions or wrong dosing can cause kidney damage, liver damage, graft (donated organ) rejection, or maybe even worse things. We also give the patient a schedule on how to take all their medication to avoid drug-drug side effects and help the patient get a grasp on what their new, medication filled lease on life is going to be like.

There is a lot of talk about how pharmacists deserve to be paid for counseling and able to bill insurance for things like medication therapy management. To really show what a pharmacist is capable of and how crucial they are, a transplant pharmacist should be used as an example to insurances and Congress. These pharmacists have to routinely manage patients who usually have 20 or more medications which consist of different dosing times, dosage forms, and will sometimes require interaction management for drugs that must be given together but have known interactions. The pharmacist here also has to make sure medications for multiple co-morbidities (which are a lot of times induced by required anti-rejection medications) are ordered and appropriate while inpatient. On top of that all, the transplant pharmacist must make sure that every medication ordered has a niche in the therapy of the patient because every chance to cut medications protects the patients from adverse reactions, drug interactions, and saves money. Who else can do that with the speed and accuracy of a pharmacist?

Pediatric ICU

Posted by Amanda at Saturday, September 10, 2011

I am now halfway through my pediatric ICU rotation and I have seen so much and learned a lot. My day starts at 7 am. I am usually at the hospital and I look up my patients and make sure everything is good. Rounds begin at 8 am. I go on rounds with my preceptor Elizabeth Beckman, an attending, 3-4 residents, 2 medical students, 2 fellows, and a nurse practitioner. Sometimes a respiratory therapist or dietitian comes also. So as you can imagine there are a lot of us. We do not enter the patients rooms. So we all stand out in the hallway outside and someone will present on the patient. After rounds, I work-up my patients, I check to make sure all the doses are correct because in pediatrics, all the medications are dosed by weight. I look at the indications and make sure they are being used correctly. I then discuss the patients with my preceptor and bring up any changes that need to be made. Afterwards, my preceptor will usually have a topic discussion with me, where she will provide a topic that comes up often in a critical care setting. Some days I attend meetings with the PICU attendings and fellows.

Since I have been in the unit for two weeks, I can appreciate the use of technology. I have seen the use of ventilators which help patients breath. I have also seen the use of a continuous renal replacement therapy machine which works in the place of your kidneys. I have seen the use of an ECMO machine which is used to help blood exchange oxygen.

So I have been in the PICU for two weeks now and I am really starting to develop an interest for it.

TT whaaa??

Posted by Christine Rabah at Friday, September 09, 2011

So before we know it, rotation #1 one is over, and we're 2 weeks into rotation #2. I really enjoyed my Drug Information rotation at Beaumont and will miss all of the people I met there.

I am currently on rotation at Mott in Pediatric Hematology/Oncology with Dr. Erika Howle. I'm not gonna lie, I was terrified going into this rotation. I know next to nothing about peds, let alone pediatric oncology. It was also a big change to just complete a Drug Information rotation that had zero patient interaction to the complete opposite of the spectrum.

My typical day starts off by getting to the hospital around 7-7:30am to check on my patients before rounds at 9. Rounds last about 1.5-2 hours depending on how many patients we have on our service at the moment. Rounds include an attending, 2 interns (1st year residents), 1 senior resident, a fellow, a couple of med students, sometimes a dietician, and us. It's typical to see patients discharged for a few days then come back for chemo, so we follow the same patients throughout the month whenever they are readmitted. Each of our cancer patients are on a certain chemo protocol (as Melanie described a few posts down) which we have to follow. We also have to be very conscious of their supportive therapy (for pain, nausea/vomiting, neutropenic fever, etc) and make sure it's appropriate.

After rounds, my preceptor, fellow pharmacy student, PGY-2 Oncology resident, and myself discuss our patients. We then get some time for lunch, and lastly, attend boot camp. All 5 of the pharmacy students on oncology rotations (whether they are adult or peds) attend "boot camp" topic discussions about different things that can affect cancer patients. As Melanie described below, the first week consisted of topics on pain, nausea/vomiting, and neutropenic fever. During the second week, we talked about anemia, colony stimulating factors, and tumor lysis syndrome.

We also have smaller topic discussion as a peds heme/onc group on common pediatric cancers/heme disorders such as acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), sickle cell disease, the 3 sarcomas (osteosarcoma, rhabdomyosarcoma, Ewing sarcoma), and neuroblastoma. Dr. Howle was sure to give each of us a wide range of patients so we could learn about their diseases. Currently I have a patient with pre-B cell ALL, one with osteosarcoma, and one with TTP. Now, day 1 of this rotation when the team kept throwing around this acronym "TTP", all I could think was "what the heck are they talking about??" Of course, I had to LOOK IT UP!

TTP stands for thrombotic thrombocytopenic purpura. It is a blood disorder that occurs when the body is deficient or lacking (this is rare) a certain enzyme called ADAMST-13, or if the body has developed antibodies to this enzyme. This enzyme breaks down a protein called von Willebrand factor which clumps together with platelets to form blood clots. When you are deficient in this enzyme, all of your platelets are getting stuck to the von Willebrand factor causing tiny blood clots all over your body (and shows up as tiny purple spots under your skin, called purpura), and are not free elsewhere in the body to do their job. This is why patients with this disorder have a very very low platelet count. To fix this, patients get a treatment called plasma exchange where blood is removed, the plasma is separated and the antibodies against the enzyme are removed. More plasma with the enzyme is added and it goes back into the patient's body.

So far, my favorite part of this rotation is getting to see the kids. A couple of them have already stolen my heart. I have also learned more than I ever thought I would about pediatric cancers in just 2 weeks, and am looking forward to learning much more. Previous to this rotation, anything having to do with pediatrics was not on my radar but now it just might be :)

Oh, The Agony of Ambition

Posted by Nicki Baker at Friday, September 09, 2011

Wound Staging...the pleasant cartoon version

(Hang in there, this is a long one...)

I have long been baffled by nurses as a species.  First, I can’t for the life of me understand how a single profession can draw in the most tender, loving individuals and at the same time attract the coarsest, unhappiest people.  What is it about nursing that draws these extremes of personality? 

Second, nursing seems to be one of the most demanding professions in existence, right?  Well, knowing this, what makes a person choose to become a nurse over, say, a physician?  Sure it’s a bit more school, but I can’t imagine it’s more difficult than nursing in the long run and it certainly pays more and garners more respect.  Nursing is an arduous, thankless profession and I’m incredibly grateful that there are people out there not only willing, but wanting to be a part of it. 

Anyway, my respect and admiration for nurses further expanded today after spending the longest half hour of my life with three of them on a wound care visit.  Many of the patients at Select have been bed-ridden for long periods of time, whether from paralysis, acute injury or long-term residence in a nursing facility.  This can cause extreme muscle atrophy, skin break-down and ulceration.  Wounds are one of the reasons that patients are brought to Select and the wound care they receive is outstanding.  A great learning opportunity for an eager student…

So I ran into one of the wound care nurses and asked if I could tag along to observe.  Well sure!  Perfect timing, in fact, the next patient had a good variety of wounds so I could see an assortment of stages and severities in one stop.  Perfect! 

I couldn’t believe what this poor man’s legs looked like when the covers were pulled back.  He is a big guy, probably 260lbs, but his legs were so underused and atrophied that his calves were nearly the thickness of my forearms.  They were purple and had sores on them and his heels were missing areas of skin.  The nurses explained the staging system for wounds and pointed out examples of each on the gentleman while he endured the painful processes of manipulation and wrapping.  By the time we arrived at stage IV (yup, that’s down to the bone) I was glad that I had skipped lunch.  There were also a couple of “unstageable” wounds, meaning there was too much necrotic tissue present to determine the depth of the injury.   I did my best to pay attention and participate by helping measure and photograph the wounds, but I was putting a lot of effort into not gagging or passing out. 

With his leg wrappings replaced, it was time to move north.  The nurses rolled him onto his side and removed the dressings from his bottom and low back.  The wound on his bottom was very clean, but it was difficult for me to bear.  It had been packed with medicated gauze, which, when removed, revealed a softball-sized pocket of absent tissue.  Trying to stay engaged (and conscious), I asked how long it would take a wound like his to heal and was told that if cared for properly, it would take months for the wound to heal and would require daily dressing changes.  If he plans to go home, his wife is in for a lot of work.  It’s hard to imagine anyone but a professional being able to stomach that process, but when I think about it, if it ever came to it, I’m sure I would do it for my boyfriend.  In fact, I guess I’d rather do it myself than have anyone else do it for him.    

The team was pleased with the condition of the wound on his bottom, so they repacked it and moved on to his lower back.  In my opinion, this was the most severe of the three.  It looked like a hole in his back and was about the size of my fist.  One of the nurses explained to me that skin that is pink or orangeish is what we want to see, while black, blue and yellow tissue means trouble.  I’m not sure if anything besides photographing and measuring was done to this wound because I gave in and blurred my eyes while they worked on this last one.  It’s a trick I used as a kid when I didn’t want to watch the scary parts of horror movies but wanted it to look like I was catching every gory scene.  I felt I’d gotten the gist at that point. 

It takes a unique person to be able to do what those nurses do.  They are incredibly tough – able to stomach any injury and determine its severity and what will best allow it to heal, then they perform any debridement and mechanical care needed.  I was simultaneously amazed and appalled.  Not only could I never handle the wound care itself, but the pain that you inflict in the process of cleaning and dressing the wounds is clearly intense.  I realize it’s ultimately what’s best for the patient, but I don’t think I would be able to continue a dressing change while the patient moans and wails in agony.   Again, my esteem, appreciation and bewilderment for nurses have grown. 

So, yes, this was a great learning experience for me and it’s probably a good thing that I didn’t hesitate before asking to tag along, but when I next find myself with spare time on my hands, I will certainly not be donning a gown, pulling on gloves and seeking out the wound care team. 

1st week in CCMU

Posted by Jenna at Tuesday, September 06, 2011

"Bravery is the capacity to perform properly even when scared half to death." ~Omar Bradley

Monday, I met my preceptor, Dr. Alaniz, around 8am. I'm on rotation with one of my classmates, so she and I went up to the cafeteria to talk with him about the rotation. He gave us more detail about the unit and the patients they typically see. Oh yea, and he also started quizzing us right away. I think that made us both scared to death right off the bat. We were able to answer some but most of them left us feeling pretty dumb. After we met with him for about 90 minutes he sent us to start working up 2-4 patients each.

CCMU (critical care medicine unit) is a 20-bed unit with 2 teams. On each team is an attending (the head doctor), a pulmonary fellow (residency graduate undergoing more specialized training), medical residents (3-7 years of training following internship), medical interns (1st year out of medical school), and M3's/M4's (medical students equivalent to P3's/P4's).

We each randomly chose an attending and will be sticking with that team for the entire rotation. Each team is on call every other day (from 6 am to 6 am), meaning that new patients that come in through the ER or are transferred from another floor get picked up (followed by) the team that's on call that day. While it's only a 20-bed unit, Friday we had 28 patients, meaning that some of our patients were in the other ICU's. Monday and Tuesday were so incredibly overwhelming to me. When I was working up my patients, I had to look up what felt like every other word/acronym. I spent so much time trying to figure out what was going on with my patients that literally the only thing I did with their medications was write them down. I hadn't identified why they were taking it, if the dose/timing was appropriate, if there were any drug interactions, etc. Well, crap, that's what I'm supposed to be doing! Add to that the fact that I went on rounds by myself the first 2 days .. I was just a nervous wreck.

The first two nights I barely got 4 hours of sleep/night because my heart was racing, my mind wouldn't turn off, and I was just feeling dumber than ever.

Thursday, I started to feel a bit better. In the afternoon, we had a discussion with our preceptor about sedation, analgesia, & delirium based on an article we had to read. He told us that we both did a great job during the discussion so it was nice to get some positive reinforcement. Also, our PGY-2 Critical Care resident started his CCMU rotation Thursday. It's nice to have a familiar face around!

Wednesday and Friday were also a bit rough on me. Wednesday, I was in the room when a man was told he had a few days to live. He had been hoping that he could die at home but the attending empathetically told him that he would not survive the transport home. It was a very hard conversation to witness and I had to be sure to hold back tears that were building up in my eyes. Sadly, this patient died at the end of the week.. It was unfortunate that he passed before his family from out of town could come say goodbye. He had also requested that his dog be allowed to visit him in the hospital but sadly he passed before the appropriate measures were taken for that to happen (verifying the dog's vaccinations). Friday, I also had to hold back tears. It's hard for me to see people crying/grieving but it's especially hard when I see men crying. A man about my age was visiting his dad with Stage IV cancer that was complicated by an AKI (Acute kidney injury) and from 2 rooms away I could see that he was crying as he held onto his dad's hand. Luckily I didn't lose it but I felt like I was going to. Sadly, that patient also passed.

I know death is a natural part of life but it's also something I don't think I'll ever grow accustomed to. I know medical professionals can't save everyone and don't have super powers .. but I wish they did. I lost two 'young' patients this week and while I never developed a relationship with them, other than following their meds/labs, their deaths have affected me. They were 2 people who still should have had at least 20 more years to spend with their families and friends.

I'm not looking forward to these similar situations over the next 3 weeks but I am looking forward to feeling less lost and confused. There is such a huge learning curve, especially with inpatient rotations. When I was a P1, P2, and P3, I thought P4's knew it all .. but I can tell you from personal experience, that we hardly know a thing. The situations and the complexities of real patients is something we don't learn how to manage in class .. so the learning curve is more of a steep, steep mountain!

FDA!

Posted by Rebecca Lalani at Sunday, September 04, 2011

Day 1 of my only away rotation. I arrived at Baltimore Washington International Airport Sunday morning, excited about the prospect of spending the next 4 weeks working for the FDA! Today was my prep day: I would set up my new digs, buy supplies, stock the fridge and of course, do my pre-rotation research (Go in prepared!) But as I found out upon my arrival at my sublet, even the best laid plans can go awry. My first day in Maryland was marred by the lingering effects of Hurricane Irene that struck the area only the night before. My landlord informed me that the power had been out since the previous night, with restoration nowhere in sight. “It’s daylight” I think as I march towards the closest grocery store and RiteAid location. Much to my chagrin, everything is shutdown. There isn’t a place I can even grab food. Hungry, tired and devoid of even the most basic of necessities, I shuffle my way back to my new place. I hope the power company can accomplish the miracle I’m praying for: I would REALLY appreciate some electricity! I spent the evening sitting in the dark, chatting with my new roommate and although my wishes were eventually fulfilled, it would not come to pass until the following day. So Day 1 of my only away rotation… was spent at home.

Day 2 of my only away rotation. That was much more exciting! I’m in the Office of Compliance under the auspices of Dr. Ilisa Bernstein. I’ve been assigned to work for the nascent Drug Integrity and Security Program, addressing the increasing drug imports that find their way to the American consumer. All rotation students are also given a lecture schedule that involves a variety of topics pertinent to pharmacy at the FDA. As far as my mentors go, I couldn’t have asked for a more supportive group. I’m pleased to report then that I am 2/2 for amazing rotation experiences. Working with Dr. Rozelle Hegeman-Dingle (Pfizer, Medical Outcomes Specialist) during rotation 1 was an absolute delight. With this track record, I’m looking forward to what rotation 3 has to offer!

Out in the community

Posted by Nina Cimino at Sunday, September 04, 2011

A new month, a new rotation! I am no longer in inpatient oncology, and have now moved on to my community rotation. I am at chain retail pharmacy in a "big box" store. The pharmacy is pretty busy (they fill about 300 prescriptions per day!) but so far, I have been happy to see how much counseling and patient interaction still occurs.

During my first week on rotation, one of the things that stood out most me was the layout of the pharmacy. At this pharmacy, the pharmacist's work station is right next to the pick-up window. Increasing the visibility of the pharmacist to patients seems to encourage more patients to ask questions or ask to receive counseling. Also, because the pharmacist can keep an eye on interactions between the technicians and patients at the pick-up window, they are able to step in if necessary (for example, if they hear a patient asking a technician to ring up a bottle of aspirin with their warfarin...a big drug interaction). I have been very impressed with how the layout of the pharmacy seems to be designed to facilitate interactions between pharmacists and patients, rather than keeping the pharmacist back behind a counter and much less accessible. Even though the pharmacy is busy, many the pharmacists know many of the patients by name. I definitely believe that being in a position to interact with each patient helps to establish a trusting relationship!

Another thing that has struck me about community pharmacy is the huge variety in patient interactions I have had. I have worked in various community pharmacy settings for 10 years now, and I was still surprised! While I have been working in community pharmacy for a long time, it has been a while since I have been there all day, every day, and I forgot how hugely different the range of patient encounters can be! All within my first week, I have had patients: hug me because my advice relieved a big worry, tell me the pharmacy staff should be fired for incompetence, thank me for helpful advice about vitamins, and tell me they wanted to speak to someone else because they don't like the sound of my voice. While being able to help patients with their medication questions is very rewarding, being yelled at or talked down to is tough (and something I had gotten used to not dealing with in an inpatient environment). One thing I definitely will learn this rotation is how to just let some things roll of my back.

RoTaTiOn 2 - POH

Posted by Melanie at Friday, September 02, 2011

For my second rotation, I am in Mott Children's Hospital on the pediatric oncology/hematology (POH) unit with preceptor Dr. Erika Howle.

So far, a typical day involves working up the patients I have been assigned, rounding with the team, and attending boot camp. That's right.... boot camp!

Boot camp is a two week long introduction to oncology that takes place for two hours every afternoon. Tuesday = Pain; Wednesday = Nausea/Vomiting; Thursday = Neutropenic Fever. During these sessions, the P4s on POH are joined by the P4s on Adult Hem/Onc and Gyn/Onc. These sessions are very informative and cover topics that are commonly seen on rotation.

Friday I had a topic discussion with my preceptor about Sickle Cell.

I also have to document notes on my patients in TheraDoc, as well as interventions I have been involved with. For this documentation, I am required to become familiar with the protocol that my patients are receiving, which can be found at http://childrensoncologygroup.org/. It is important to become familiar with the protocols so that you are able to make sure the patient is receiving the correct therapy for that day.

For example, the following is a treatment protocol for Hodgkin Lymphoma:

Drug/Dose/BCCA Administration Guideline
DOXOrubicin/25 mg/m2 on days 1 and 15/ IV push
vinBLAStine/ 6 mg/m2 on days 1 and 15/ IV push
Hydrocortisone/ 100 mg on days 1 and 15/ IV in 50 to 100 mL NS over 10 to 15 min
Bleomycin/ 10 units/m2 on days 1 and 15/IV in 50 mL NS over 15 minutes
Dacarbazine/ 375 mg/m2 on days 1 and 15/ IV in 250 to 500 mL NS or D5W over 1 to 2 hr

The protocol will also indicate which toxicities will likey occur with each drug and when therapy might need to be dose adjusted or omitted. For example:

Hepatotoxicity: DOXOrubicin only
Bilirubin (mmol/L) Dose Modification
2-35 100%
35-85 50%
greater than 85 Omit DOXOrubicin. Substitute cyclophosphamide 375 mg/m2

The protocols will also indicate what supportive therapy should be initiated. For example, antiemetics or PCP prophylaxis.

Overall, this week has been challenging, dealing with three unfamiliar subjects: oncology, hematology, and pediatrics. However, I have learned and great deal and even got to observe a bone marrow biopsy!

Caught Up In The Regulations

Posted by Eric Zhao at Friday, September 02, 2011

Once again, I find myself in the pharmaceutical industry (surprise!). This time, however, I am with Eli Lilly and Company...in the Regulatory Affairs Department, no less.

Eli Lilly and Company, Indianapolis, IN

If you remember from my previous adventures, I spent a summer in regulatory affairs at Abbott in Advertising and Promotion. You're probably thinking, what's the point of doing two regulatory affairs positions? I had the same thought, believe me.

What I didn't know was that I would be working on the complete opposite spectrum of the drug development process. At Abbott, I dealt with the regulations after the FDA approved a drug. At Lilly, I deal with the regulations before and during FDA approval. Yup, I'm working with Investigational New Drug (IND) applications and New Drug Applications (NDA).

I'm currently wrapping up a journal club presentation for this upcoming Tuesday on a competitor's newly approved biologic drug and will finish the rest of the clerkship gathering intelligence on a project that's under Double Secret Probation. I wish I could say more, but these industry folk like to keep to themselves.

I'm sure I'll come up with interesting topics to blog about that won't compromise my employment status, but for now, enjoy a picture of Lilly's entrance fountain.

Best,
Eric

Live on the Verge of Death

Posted by Nicki Baker at Thursday, September 01, 2011

I’ve worked at Select Specialty in Ypsilanti a couple of times in the past when I filled in as a technician and I’m excited to be spending my second rotation there. Select is a long-term acute care facility located on the campus of St. Joseph Mercy Hospital and cares for patients with complex medical needs who require an extended hospital stay. Many of them are on ventilators, PEG tube feedings and IV antibiotics. They’re currently at capacity, caring for 36 patients.

I generally start the day by checking INRs for patients on warfarin. Select has a combination of electronic and paper charts, so I can get lab values from the computer but have to go to each patient’s room to check the MAR to be sure they were given the warfarin dose they were supposed to have received the previous evening. Based on the patient’s INR trends, I decide whether to continue them on their current dose or to make a change. Since I’ve been there about a week now, I’m starting to see the impact of the changes I’ve made. It’s really fun and gratifying to see patients become therapeutic or to be moving in the right direction based on decisions I’ve made. I’m also enjoying writing orders for warfarin and lab draws, which pharmacists at Select do per established protocols.

Antibiotic stewardship is another of pharmacy’s responsibilities at Select. Checking culture results and making sure all antibiotics have reasonable stop dates is part of the student’s job. I’m glad that I’m getting a chance to work with antibiotics a bit more since it’s an area I need to improve in.

Working with this population really makes you appreciate your health and the health of your loved ones. A lot of the patients are very old an ill, but some of them are younger and trying to recover from falls, accidents or infections. Many of them will improve and be transferred to a skilled nursing facility, inpatient rehab or even be discharged home, but for others, this will be their last stop. It’s difficult to see some of these people struggle, but even more difficult to watch their families make tough decisions. I guess what these patients are going through could best be described as living on the verge of death.

It appears difficult for physicians to let these patients go, even when it feels like the time has come. It seems to be against their nature, like they're admitting defeat. As healthcare professionals, we've devoted ourselves to preserving and extending life, so being ok with letting a patient pass away feels contrary to what we've been taught.

Still, the respiratory therapists, physicians and PAs, occupational therapists, nurses and pharmacists at Select take great care to do what’s best for patients and families. Some really amazing stories of recovery have come out of this place. A woman who nearly passed away from a terrible case of H1N1 stopped by to visit yesterday. It was obvious that she had a real connection with the staff who cared for her during her stay at Select and she was doing great.

This blog is becoming a blab. More later!