Monday, June 25, 2012

Rotation 1. Check!

Posted by Kristen Gardner at Monday, June 25, 2012

I just completed my first rotation: Institutional or Hospital/Health System!  J

This will be a short blog thanks to Courtney K! I will attempt to elaborate on the excellent overview she provided.

To reiterate, this rotation requires a great work ethic to get a lot out of it. You can do as many extra projects as you want (provided you ask)! It is tempting to do the least amount of work possible- especially transitioning from P3 year/2.5 week break into P4 year. There were so many projects/agenda items I was trying to complete (Pharm.D. final report, Pharm.D. seminar literature search, Leadership Scholars Board of Governor’s project, reviewing therapeutic topics I had forgotten, etc.), it would have been nice to strictly be “on rotation” from 7am-3pm; however, I am glad that I was able to work on extra projects because I learn in the process and now I have even more things to talk about on residency interviews!

Working in the 6th floor satellite was GREAT! As Courtney mentioned, I really started to feel like a real pharmacists verifying orders. I really took ownership of my patients by signing my name to the pages I sent out to the physician and answering phone calls (drug information requests by physicians and nurses and responding to physician pages). Recommendations/concerns I paged on mainly related to antibiotic dosing. Physicians love to start vancomycin 1g q12 hrs for every patient regardless of actual body weight and renal function; therefore, we were always paging on recommendations to modify vanco orders. We paged the clinical specialty pharmacist in ICU (intensive care unit) because one patient was started on traditional dosing (TD) tobramycin (an aminoglycoside), but did not meet any restrictions (basically anything that would alter volume of distribution or renal function, e.g. CrCl <40ml/min, burn patients >20% total body surface area, pregnant patients, obese, meningitis, ped patients, infective endocarditis, ascites, cirrhosis, end stage liver disease (ESLD), anasarca) for single daily dosing (SDD) of aminoglycosides. SDD is great because it provides a high Cmax (aminoglycosides are concentration dependent killing) and you take advantage of the post-antibiotic effect of the drug and allow trough levels to drop low which minimizes risk for toxicities such as ototoxicity and nephrotoxicity. I also happened to catch that the prescribed dose of metformin was incorrect for the patient based on her problem summary list (PSL ) in Careweb when I was trying to find a serum creatinine (SCr) level since metformin is renally eliminated and is contraindicated with higher levels (1.4-1.5; gender specific) due to risk of lactic acidosis.  There were also some pain regimens that would not optimally prescribed. I also learned some great lessons. For example, we paged because we wanted warfarin dosing clarified as they were increasing the dose when the patient’s INR just came back at 3.0 when their goal was 2-3. I overlooked that the patient was also on argatroban which falsely elevates the INR. The pharmacist was not aware of this fact or that the hospital uses chromogenic factor X as a monitoring tool in this scenario. Therefore, I took on the extra project of looking into this and reported back to the pharmacist my findings. It was a great educational opportunity because I corrected a learning deficit not only for me but a lot of other staff involved.

IDS was super fun! That is all I have to say. But, I love research which may bias my positive perspective.

The Clean room was great too because again I was verifying orders! I would verify kits (mostly antibiotics with IV bags containing the proper diluent for the drug) that the technicians put together (to prepare for orders in advance) as well as compounded products. I recommend looking at the actual product first and then reading the label because sometimes reading the label first makes you see things when looking at the product second!  J

I LOVED the administration week. I learned so much interviewing the different staff in administration. It was really interesting to gain their perspectives and it also helped us identify great questions to ask of other programs during interview season. Oh yeah!

Mott is much crazier/busier than 6th floor satellite and because of that I was unable to “drive” and do all the order verification with a pharmacist sitting beside me and checking my work 100% of the time; however, I was able to do enough where I was not terrified of dosing the kiddos. Note: They receive crazy drug information questions all the time and you will definitely be involved in answering these questions. Do not fear because the staff is SO nice in Mott! I was so hopeful that I would be able to attend a code during my week there, but unfortunately, the one code that was called occurred while I was gowned up in the Clean room. Oh well! I also went out with some of the medication managers (the technicians deliver medications to the bedside in the new hospital and there are a few techs dedicated to make sure nursing has all the medications they need- we are being proactive) which was nice because I saw the PICU, NICU, and PCTU. Through visiting these units I learned that I like to see my kiddies healthy vs. intubated with 10 different smart pumps hooked up to them or an ICP monitor. I saw a baby that was 1.5lbs! She was so precious! Projects included helping one of the pharmacists update the IV compounding book and creating a reference for which vaccines contain thiomersal/mercury as a result of a drug information call I took.

I am moving on to my “community” rotation with a Walgreens specialty clinic focusing on HIV/AIDS management at Howard Brown Medical Center in Chicago, IL. I am excited yet nervous because I heard our preceptor is demanding and constantly quizzes you. But, that is a good thing because I need repetition! Plus, I get to share this experience with my well-known study buddy/partner in crime, Janis Rood. Prior to the first day our preceptor asked us to know the generic names, brand names, abbreviations, and preferred/alternative treatment for treatment naïve patients. Check! I have also been reading random other information as well because I am known for going off on tangents during my studies. There is so much to know! Only time will tell what information I am able to retain in this brain of mine.

Also- this is my first time living in a big city! I am sure you will be hearing about interesting stories. For example, today I decided to figure out the “L” or the train in Chicago. That probably would have been fine on any other Sunday besides when the 2012 Pride Parade was being held. I observed many interesting people wearing/not wearing interesting articles of clothing. Unfortunately, these pictures would be inappropriate for this forum!

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