On to the next one...

Posted by Christine Rabah at Thursday, October 27, 2011

Rotation #3 in ambulatory care (AmCare) wrapped up nicely for me. I counseled my very last patient on how to use Lantus. He had never used any type of insulin before, so this was very new to him. I started my consultation by asking him our typical AmCare questions: diet, exercise, blood sugar readings/low sugar reactions, caffeine intake, pain scale, and reviewed all of his medications. When he started telling me about his diet, I knew we were in for a very long visit. Let's just say he and his wife own a particular convenience store, and the food sold there consisted of his whole diet. Uh oh. That's about the LAST thing we want to hear from a patient with diabetes.

Needless to say, he got a TON of diabetic diet counseling. This consisted of talking about the plate method (half of your plate should be veggies, a quarter should be protein no larger than the palm of your hand, and the other quarter should be carbs no larger than your fist size). We also talked to him about how to check food labels for carb values, and counseled him on how many carbs to aim for with meals and snacks. While gathering his dietary information, I learned that whenever he gets low sugar reactions, he would eat a doughnut or candy bar. This is the last thing you want your patients to eat in these situations! So I had to counsel him on this too: that it's best to drink either juice or milk, or take 2-3 glucose tablets.

He walked away that day with a lot of information to process, so let's hope after our counseling (*fingers crossed!*) he started making major changes to become healthier.

Currently I am on my Institutional Pharmacy rotation at St. Joe's. I have never worked in an inpatient hospital pharmacy before, so I am way out of my comfort zone. They have me doing a TON of things here. My daily activities include checking orders called "F-8's" (mainly bulkier products that can't fit in the Pyxis machines), monitoring patients on warfarin (Coumadin) and/or enoxaparin (Lovenox), adverse drug event (ADE) report screening, checking patients' own meds, and checking ALS kits and A Packs.

What does all of this mean? I'll explain a little, since I didn't know before Monday, either.

When monitoring patients on warfarin, I check their INR, daily, to see if they are within therapeutic range for their specific indication. (INR stands for International Normalized Ratio, which measures the time it takes for blood to clot and compares it to an average). For patients with atrial fibrillation (a.k.a. most of my patients) their INR goal is between 2-3. I check what dose of warfarin they are taking, and make recommendations on what to do with their dose if their INR is not within goal. Later in the day, I meet with the pharmacist who is designated that day to monitor these patients and talk to him/her about my recommendations. If anything needs to be done, we will contact the physician. With enoxaparin, I check their renal function and indication for use and make sure their dose is appropriate.

Adverse Drug Experience (ADE) reports print out daily, and usually are a flag for patients with renal dysfunction and I check if the doses of their medications are appropriate. With these, I have to calculate their creatinine clearance and decide if any changes need to be made. There usually aren't too many reports I need to act on, but I have had a couple where patients with high serum creatinine levels were on Metformin, or were on antibiotic doses too high for their renal function. In these cases, I notify one of the staff pharmacists.

Checking patient's own meds (POM) consists of me printing a report of patients who refuse to take certain medications provided by the hospital and prefer to take their own from home. Here's where patient interaction comes in. I review their profiles to see what meds they brought, then visit them in their rooms to talk about their medication, check what they have compared to what was entered in their medication administration record (MAR), and put a "POM" sticker on it so nurses know that pharmacy has checked and okay-ed the patient's home medication.

Lastly, I check the ALS kits and A Packs. These are the medication bags/boxes that are on ambulances, so making sure everything is where it should be is imperative. I'm not gonna lie and say I didn't feel a little pressure here :) The most important thing to watch with this is that none of the medications are expired, everything is in its designated area, and there are the correct amounts of each med.

This rotation has definitely been very interesting so far, mainly because it's all very new to me. I think I'm getting the hang of it, though :)