So why would a gallon of milk a day be bad for you?

Posted by Tom Vassas at Monday, July 30, 2012

Well unbeknownst to me, the world seems to move faster than it does on rotation. It's been 5 weeks since my last post and it seemed so hard to just write a blurb about my ambulatory care rotation but that could not do it justice. So here's a little, brief, thesis paper on my time in ambulatory care:

I was at the UM Canton Clinic with Stu Rockafellow, which by fanciful coincedence was only a 5 minute drive from my house (like omg weird right?). We managed patients with both types of diabetes, hypertension, hyperlipidemia and the occiasional asthma patient. 9 times out of 10 it was DM II, and most of the patients were being followed up from a previous in clinic visist or phoned for a quick update. A lot of patients like the phone call to keep them accountable on they're lifestyle and adjust insulin. We would talk to about 4-8 patients on a half day (that's in clinic and phone) and about 14-20 patients on a full day.


The time there was amazing; my days mostly consisted of the night before looking at my patients on schedule for tomorrow and doing brief workups on them. I would look at their PMH and med list, and any other documents about their reasons for seeing us. I would also start filling out intervention checklists we were required to fill for ongoing research based on what we talked to patients about. The day of, I would go over with Dr. Rockafellow the patients and what I wanted to talk to them about. Most of the time it was talking about how lifestyle changes were going, what barriers they were running into, and if we could offer advice or adjust meds to help. New patients required a long med rec and history. Each patient in clinic, new or old, I would still take their BP (which really is fun after 100 or so). After patients I would finish the checklist and complete a care note and start on the next day.

The coolest parts were being able to see any progress with patients. It didn't happen often due to time, but the feeling you get when you talk to a patient, get them to commit to something, they achieve that and you both see the results in their A1c, is just phenomenal. Most patients were very typical, with needing some diet and exercise changes and maybe adding insulin or dosing. There were some shall we say....unique...patients.

The hardest patient was an older gent with cerebral palsy and a diet consisting of 2 gallons of chocolate milk a day. With 5 weeks of seeing him we got him to ride an indoor bike...There isn't much else to that just because he was very resistant to change and one of the many patients who were also depressed. On that note, depression is a truly hard thing to deal with in patients. Those who had it were not only the hardest to work with, but the ones I felt would benefit the most from seeing even tiny changes. Even though we are not counselors, some patients seem to feel much happier and relaxed to talk to us about medicine and health, compared to a nurse or physician.


Unfortunately, this was a rotation where you wish you had another 5 weeks to track the patients, because ambulatory care really is long-term care. Typically very little change can be seen with anyone (especially since an A1c is done q3mo!) and in the mean time it's the report and trust that can change the most.


So next is cardio and I can only hope I'll have enough time to write a few more, but til then I leave you with this:


Watermelon is really sugar water, a garbonzo bean is a chick pea, and just because a cherry is a low-sugar fruit does NOT mean eating 35 at once is ok.


-TV-

Pediatrics: Other people's babies!

Posted by Unknown at Sunday, July 29, 2012

The best thing about working at Mott Children’s hospital is getting to stare at cute children all day without any negative social ramifications.

I know it seems like I’m stating the obvious, but I just have to say—even when they’re sick—these babies are cute. Like, the kind of cute that makes you zone out on rounds for a few seconds. The kind of cute that makes you want to have your own tiny little yawning bundle. Or just run away with other people’s.

DON’T try that at Mott though. Tempting, but you’d go down fast. In addition to being a fun, playful, and colorful environment, Mott is an incredibly safe place for these kids. I forgot my badge once (bad idea) and they not only noticed (more than once); they made me take a new “temporary” photo, and printed me a badge for the day. In other words, I would definitely feel comfortable taking my loved one here. Also, in other words, never forget your badge here. All SORTS of doors you can’t access without it.  

So, these “babies.” Anywhere from about 7 days to 18 years old! My trusty partner in pharmaceutical elegance and swag (Alicia G, if you couldn’t tell from that description) and I covered the PY Gold service, general pediatrics. We would round on these patients every day at 9AM. Working them up involved lots of math; dosing in pediatrics is almost always weight-based. Furthermore, most of the medications would be oral solutions, so you’d have to make sure there was enough of the active ingredient, and then convert the dose into mLs of solution. Rounds were interesting; It was nice getting a picture of everything going on with the patient, and our attending was really good about explaining every step.

The rest of the day involved medication reconciliation, answering drug info questions, practice with order entry, presenting on our patients, and participating in topic discussions and journal clubs. We also followed PMP patients, who were generally in the hospital for months at a time and had extensive drug profiles. We checked all doses and monitored frequency of PRN meds.

One thing I really valued on this rotation was getting familiar with baby/maternal meds and treatment algorithms.  I tried to take this opportunity to learn about drugs in pregnancy, and disease states that are specific to kids. It was pretty much my only opportunity to do so this year!

I also got better at medical lingo from reading a plethora of progress notes:

-          s/p = “status post:” whatever I’m about to say JUST happened to the patient.

-          perioral cyanosis: blue lips!

-          tocolytic: drug used to slow down premature labor. Ex nifedipine.

-          GBS:  Group B Strep. Positive moms are treated with IV ABX prophylactically during labor, so they don’t infect the baby.

-          37/4: baby was born at 37 weeks and 4 days.

-          G3P2 (Gravida 3 Para 2): mom has been pregnant three times, and has two children.

Also, people really care about their kids. When I’d do a med rec, moms and dads generally knew exactly what they’re kid was taking, and were compliant to the best of their ability. When we counseled parents on drugs, they were SO attentive and into it, and asked all sorts of great questions. I don’t think people are as dedicated to their own medication regimens as they are to their kids! It kind of makes sense.

One of my concerns going into this rotation was the prospect of working every day with children that are helpless and sad and sick. It seemed like it would be depressing. I was worried that it would bring me down emotionally. Throughout these 5 weeks, indeed there were very sad cases. It was difficult to be surrounded by children stuck in such unfortunate situations for no apparent reason, at no fault of their own. What surprised me though, is that instead of constantly bringing me down, working with these kids made me a) happy that they were being treated, and generally getting better in terms of their acute problems, and b) thankful every day for the health of myself and my family. Believe it or not, working in peds can actually be uplifting.  A particularly touching moment was when one of our rehab patients, admitted for lower extremity burns, was able to walk again for the first time this week. He was 2 years old and just about the cutest little kid EVER. The entire staff was in the hallway cheering him on. I was so proud.

So, to sum it up, meds and other people's babies. Crying (not you! the babies!) and also playing. And a whole lotta Tylenol! All my P4s: It’s going by quick. I miss you guys. Best of luck on seminars this coming month!

Good-bye Children, Hello B2!

Posted by ayumi :) at Saturday, July 28, 2012

Hello, hello, again! Long time no see?  I wasn't sure if I'll make it out of my first rotation, and I'm sure you were worried for me, too.  However, here I am again, living to talk about completing my first rotation AND since I’m so behind on this blogging business, completing my second rotation as well!  Time flies when you're having fun (or struggling like woah in my case), that's for sure!

I’m going to give you a little summary about how my Peds ID rotation ended up.  I was talking about how scared I was for rotations to begin, and how nervous I was about ID because it was never my forte, and unfortunately it still isn’t.  That said, my learning curve during this rotation was exponential! Really.  I read more articles about pediatric diseases and treatments than I had ever in my life.  I now know what it means to “choose the right drugs for the right bug coverage,” and that “narrow therapy” is always better than “broad therapy.”  These concepts, I kid you not, where some of the basic things we learned in therapeutics, but it was a difficult for me to fully understand why.  Once you can put a patient’s face to an infection, though, things start to make more sense.  I guess it just adds the urgency and seriousness of what we’re dealing with.  It’s like any other concept.  You just have to go through the hands-on process to actually “get” what’s going on. 

I still am not ready to be an ID pharmacist tomorrow; however, I have tons more respect for the ID team that I worked with and my preceptor.  Dr. Klein knows so much!  Everyone who was involved in this rotation are really good at including the student in all the patient discussions and makes you feel like you’re part of the group, well, because you are.  I do wish I had this rotation a little bit later in my rotation series, just so I would be more prepared and know what to expect, but what’s done is done, and I’m never looking back.  Good-bye Mott Hospital, it’s been real!  Oh, and THANK YOU to my fantastic ID team!  If you’re interested in Pediatrics and ID, this would be a good rotation to rank.  Everyone is so knowledgeable and willing to help you learn!

And two days later…  Hello B2!  I’ve graduated from pediatrics and moved on to the bigger and busier hospital, UH.  I spent most of my days in the basement pharmacy, which was good because Michigan summers are crazy thunderstorm-y, and I am not a fan of storms.  If you’re in the basement, there are NO windows, so you can see what ruckus Mother Nature is causing outside.

My second rotation was Nontraditional – Administration with Dr. Kelley.  She’s new, so not a lot of people have had the fantastic opportunity of meeting her just yet.  Of course, I am one of the lucky ones who got to spend five whole weeks with her!  I know, this is a moment where jealousy would be an appropriate emotion.  I’m telling you right now, P3s and below, when it comes to ranking time, even if you don’t think you’re interested in admin, rank Dr. Kelley high!  I really, truly enjoyed working with her!

I’m sure you’re now super curious as to why it was so great, right?  What does a pharmacist in administration do anyways?  Well, since I just finished my 5 weeks, I can answer that!  Dr. Kelley and I were problem solvers, brainstormers, new idea investigators, policy analyzers, ghost busters!  You name, we did it.  We went to a lot of meetings involving different departments and different minds, all focusing on how to make patient care at UMHS better.  I had the pleasure of meeting and working with so many BIG DEAL people! 

Here are some projects I got to work on during my 5 weeks… 1.  Looking at the feasibility of offering the service to flavor medications at our outpatient pharmacy.  2.  Conducting a gap analysis on the hospital’s 340B policy and procedures.  3.  Creating surveys for a new software being implemented at Mott.  4.  Observing and writing a report on the current discharge process.  5.  Creating a flow chart.  6.  Preparing handouts for various meetings.  In addition, we had lots of discussions on leadership, transitions of care, residencies, interviews, etc.  It might sound overwhelming.  I was overwhelmed for the first week or so, just because we never had a standard day.  Everyday was different.  Depending on what kind of person you are, this can be good or bad.  If you like structure and a set schedule, this rotation might be tough, but if you like not knowing what your day’s going to be like and living in the unknown, this rotation is pretty great and exciting.  I was in between the two.  I like knowing the future to a certain extent, so not knowing what kind of projects were going to pop up after each meeting made me a little anxious.  That said, I get bored really easily, but during this rotation I was seldom bored. 

Some tips for those of you who have this rotation in your future…  Don’t worry!  If I can make it through this, anyone can!  The earliest I went into rotation was 7am, usually 8am, so not super early.  Some days are long depending on how many meetings you have, but some days you just get to work on your projects.  I did have it easy because my rotation was in July, and according to Dr. Kelley, a lot of people like having fun in the summer and taking vacations, which means lots of canceled meetings!  I was spoiled.  So all I can say is, GOOD LUCK!  Hope your schedules aren’t too busy…  I tried keeping a to-do list of just rotation projects, and giving myself vague deadlines so if I run into problems, I can ask her whenever she seemed to have time.  She’s pretty hands off, and let’s you figure out a lot of things, so it’s a great opportunity to figure out how you work independently.  Oh, and I loved the fact that I met so many great people!  All my projects involved different groups of people (ACP, 12W Mott, Business director, financial director, Oncology…) so you have a myriad of chances to interact and network with pharmacists and nurses and other staff and hear their stories!  How cool.

Yes, yes, I liked this rotation a lot.  I don’t think I have the personality to be an admin pharmacist, but I’m really glad I had this rotation!  Thank you Dr. Kelley and everyone else in B2!  I’ll come back and visit J

I’m writing all this in transition to my third rotation on the Megabus – Community Rotation – Specialty Pharmacy (HIV/AIDS) in Chicago!  I hear this rotation is intense!  I’m nervous.  On the other hand, I am super excited to be in Chicago in the summer!  I get to live with my best friends for 5 weeks!  Should be a blast and a half! 

Mkk, until next time!  Hopefully you’ll hear from me sooner next time.

Hope your summer is fun-filled!

yours truly,

ayumi 

Pediatric Emergency– A Generalist Approach

Posted by Anna at Friday, July 27, 2012

The end of the second rotation seems abrupt—how has it been 5 weeks already?! I had the privilege of working with the generalist pharmacists in the pediatric emergency department at U of M. I specifically requested a pediatric experience due to the lack of pediatric-focused care in my other rotations. It was an added bonus to be placed in the emergency setting, which is another area I would have had no experience in otherwise.

I was scheduled to be on rotation from 10am to 6pm but often went in from 1pm to 9pm in order to maximize my chances of being on-site when the ED was busy. Although there is no routine day in the ED, I did have some typical tasks I fit in throughout the day.

1.       Patient work-up. Upon arrival and throughout the day, I assessed the patients in the ED. When there were a good number of patients (>9 or so) or several patients with complicated conditions, I would spend time working up the patients and present them to my preceptor. The presentation included basic background information regarding the patient’s medical history and presenting complaint, with a more detailed discussion of what we have done so far regarding treatment, if that treatment was appropriate, and what else I anticipated the patient may require while in the ED. I found myself better able to anticipate the needs of the patient and make treatment choices as the rotation progressed. With the quick turnaround of patients speed was definitely a factor and is something I will continue to work on.

2.       Topic discussion. I was required to put together a brief (1-2 pages) handout for an ED topic discussion with my preceptor once to twice a week. These topics ranged from management of diabetic ketoacidosis to dealing with rabies or venomous bites. I also had the opportunity to meet with other P4 students on the pediatrics generalist rotation to participate in pharmacist-lead discussions about important topics in pediatrics.

3.       Journal clubs & case presentations. This activity also involved the other three fantastic P4 students on the pediatric generalist rotation. The topics were all pediatric-focused, and I learned a lot from my peers and the pharmacists in attendance. In case you’re dying to know, my journal club discussed the use of hypertonic saline in the ED in the management of acute wheezing in preschool children, and my case presentation pertained to a patient undergoing treatment for neutropenic fever in the ED.

4.       Discharge counseling & medication reconciliation. I was able to perform discharge counseling for patients being sent home with new medications—antibiotics being the most common. For patients requiring hospital admission I was responsible for obtaining a medication history and writing up a medication reconciliation note. Overall, these tasks granted me some face-to-face time with the patients and their caregivers and helped me to become more confident and comfortable in my knowledge and communication skills.

5.       Traumas. The pharmacist is responsible for responding to any traumas that come in—and that meant I got to tag along! I will 100% own up to the fact that I was very nervous about this aspect of the rotation due to my low tolerance for blood and such. However, I can happily report I had no fainting spells or other equally embarrassing reactions! This is likely due in part to the scarcity of traumas while I was on-site; I witnessed a trauma usually once to twice a week. Even so, I did have the chance to see the pharmacist in action and understand how her ability to accurately and quickly prepare medications for administration can impact patient care in this setting.

Overall, I believe this was a great rotation. Patients ranged from 2 days to 20 years old, which allowed me the chance to practice both pediatric and adult dosing. I learned a lot about pediatric-specific conditions and medications. I learned about emergency medicine and how to anticipate patient needs. I was forced to become faster at everything. I got to sleep in. I also worked with some fantastic pharmacists who really tried to maximize my learning experience.

Although I will miss the pediatric ED, I now must switch gears and prepare for my community rotation at Meijer!

The inpatient pharmacy at St. Joseph Mercy Hospital in Ann Arbor

Posted by Beejal at Thursday, July 19, 2012

Hi everyone! Here's another long post on day-to-day activities with a little bit of reflection!  Grab yourself a fro-yo and sit yourself down for 20 mins! :) 

I’ve gotten through 4 weeks at St. Joe's, and have gotten a pretty good handle on things.  This is not a stressful rotation, but you really do learn a lot about the staff pharmacist’s role.  You do a lot of multitasking and learn how to be efficient (in case you’ve missed that somewhere along your pharmacy experience)!  I think this might be a more difficult rotation if you haven’t seen the St. Joe’s system, but I had my IPPE at St. Joe's Livingston so things were pretty familiar.

A typical day…

There are some baseline responsibilities that define a P4’s day: F8s, Ancillary carts, ADEs, Duplicates, and ALS bags/boxes.  Dr. West will put out a schedule for which student is covering each responsibility each week (There are usually 2 P4s in the same block).  Some days you could be assigned everything, other days you could have split responsibilities, and a few days you could have no responsibilities.  

F8s are drugs to be checked first thing in the morning at 7:30am, so that the tech can deliver them at 8am.  My understanding is that they are the drugs that a) don’t fit in the pyxis b) are too expensive to stock in the pyxis and/or c) for patients who are day-to-day, ie they could be leaving anytime.  These “Short-Stays” for example could be referring to someone who just delivered a baby.  Ancillary carts have drugs being refilled in the pyxis, and are checked usually between 9 and 10am. 

Sentri7 is St. Joe's equivalent system for UofM’s Theradoc.  It has tabs for different drug alerts, and ADEs and Duplicates are a couple of examples.  ADEs are alerts that are triggered when a renally-eliminated drug is prescribed.  The intern must check out the patient’s CrCl and determine if the dose is appropriate.  There are usually 5-7 pages of patients to go through so this can be tedious; but you learn which drugs to look out for, where to find the information you need about the patient, and common physician prescribing practices.  I’ve seen a lot of these alerts for famotidine, loratadine, gabapentin, allopurinol, certain antibiotics, metoclopramide, and metronidazole.  If you are assigned this, it is your primary responsibility (besides F8s and Ancillaries if you’re assigned to those too) before any other projects are worked on.  Usually the first day you’re assigned this, you won’t even come close to finishing.  You should get through all of them after a few days, so it’s important to identify the poorest renal functions and the highest risk drugs.  Duplicates is also a tab on Sentri7.  This alert is triggered when a patient is prescribed two drugs that can be used for the same indication.  The intern needs to go through the patient’s notes to figure out if this is indeed duplicate therapy, or if the physician intended to use both drugs.  I usually see these for asthma inhalers, MVIs, and famotadine/omeprazole. There are usually no more than 10 duplicates daily, so this is one of the easier responsibilities.

ALS bags and boxes are emergency drug kits that are carried by EMTs.  The technician restocks the boxes, and the interns check for accuracy as the pharmacist.  These are to be checked by 4pm, so this is your last responsibility of the day.  Both P4s will do these every day because it can get overwhelming.  Our record so far is 11 boxes and 12 bags in one day. 

Other projects... 

There are side projects/tasks that we get assigned on a week-by-week basis, as well as a rotation-long project.  My rotation-long project is to look at a list of patients who are readmitted to determine if poor med reconciliation could have caused the readmission.  The patients on the list are those who were taking anticoagulants, so the goal is to determine if pharmacy presence in anticoagulation monitoring and dosing might prevent readmissions.  This requires you to learn about both of the patient’s admissions by reading through all of the notes.  It can be really tedious especially if the patient was admitted for a long time.  This is a project that one intern is assigned during each block, so usually you’re continuing the work of one of your classmates. 

We’ve also learned how St. Joe’s monitors vancomycin and warfarin.  These are both tabs on the Sentri7 system.  Guidelines are generally the same as UofM (because we all follow CHEST), so you’re just getting more comfortable taking on the PK responsibilities. We aren’t assigned these tasks all of the time; only about a week each.

One of the things I found unique to St. Joe's (though I haven’t been to many other hospitals) is the “Huddle.”  Once every shift we have a team meeting where the pharmacy manager goes through announcements, drug shortages, system outages for other locations where we’ll need to help verify orders, and acknowledgements.  During acknowledgements, different people take the time to thank a coworker that has been really helpful lately, stayed flexible to cover open shifts, etc.  Even when I was at St. Joe's Livingston, the general feel was very kind and appreciative.  Nobody’s hard work goes unnoticed, and there are always open lines of communication.

Reflections…

Dr. West wants you to see all parts of the hospital, so I’ve shadowed a technician, a nurse, an IV room pharmacist, and a Medical ICU clinical pharmacist.  The focus is to see the integration of pharmacists in the hospital system.  I like that there is a focus on being independent; I get taught something once and then I’m responsible for that task from that day forward.  All of the pharmacists and technicians are really nice and helpful.  I like feeling like I’m responsible and trusted, and relied upon.  My role has meaning, and I am becoming more confident in what I know (and realizing what I don’t know)!

It’s very cool to see the difference between a big academic institute and a large community teaching hospital.  I would definitely recommend this rotation to all students!

Dipping my toe in the clinical pool

Posted by mariarx at Wednesday, July 18, 2012

So, my first rotation was health system administration with Dr. Brummond. I learned a TON during my 5 weeks with him - but very little of it was clinical. My interactions regarding medications maxed out at "which meds are on shortage and what do we switch to?"

For my 2nd rotation, I am at Providence Park Hospital in Novi, MI with the peds/oncology clinical pharmacist Missy. It's a pretty small hospital, around 200 beds, and has been open for 4 years now. Pharmacists at PPH take on an interesting role, with some duties falling into classic inpatient order verification; while others fall into antibiotic kinetics/anticoagulation monitoring. The great thing about it is all the pharmacists do everything. There is very little split between clinical/order verification roles.

My first week at PPH was spent mostly with technicians - messenger, IV room (where Frank threw me right in), packager, etc. I also got to spend some time with the OV pharmacists and checking orders that came through. I quickly learned to have lexicomp on stand by to look drugs up that I didn't recognize or know the dosing for.

Week 2 was half pharmacist shadowing and half reviewing kinetics. Oh boy, that was a doozy. Being handed a stack of practice cases and an equation sheet took me right back to P3 first semester therapeutics and Dr. Nagel's exam. Going through my practice problems was a test in frustration and insanity. No matter what I tried, I never seemed to get the right number, and man were my peaks and troughs all over the place. After making me suffer for a couple days, my pharmacist handed over the handheld PCs that have the nifty PK calculators on them. Although, I think I'll have to do some kinetics problems every once in a while so that I don't forget it completely. It's somewhat comforting to know that 'real pharmacists' use the same equations we got in class.

Week 3 was probably my favorite. In addition to starting 10 hour shifts (woo 3 day weekend!), I also started ICU rounding. At PPH, the OR/critical care and metabolic support pharmacists split ICU rounding duties. Each day of rounding started off with printing out a rounds summary report of all the ICU patients, and then going through their profiles and MAR compiling the big picture. The first day of rounding, it took me the full 3 hours to go through my patients. During this week I usually had lexicomp, micromedex, Dr. Carvers bug-drug list, wikipedia, google, and dosing nomograms on standby at all times. I was constantly looking things up and writing little notes down. Rounds each day varied from 1 hour to 2.5 hours depending on the intensivist, number of patients, and any unforeseen circumstances that arose. My second day, rounds started an hour late since the doctor was at a code (on a patient that soon joined us in the ICU). The 4 days of ICU rounding were great, and make me even more excited for my ED rotation in October.

This week has been all about antibiotic kinetics and anticoagulation monitoring. Pharmacists at PPH monitor drugs such as vancomycin, aminoglycosides, heparin, warfarin, rivaroxiban, and dabigatran. I got to work up initial doses for these drugs, and then do follow up monitoring for the rest of the week. This is where I really feel the pain of paper charts. PPH is half electronic and half paper. So, each day when we work up coumadin doses, or dose vancomycin or gent we have to then troll through the hospital to find our patient's charts. I haven't had too much trouble with it so far, but I can only imagine the frustration of a floating chart when all you want to do is add a quick note.

Next week (holy crap, I can't believe it's already week 4) I'll be working on TPNs with Maria, the metabolic support pharmacist, spending a day in the OR (I asked my preceptor Missy for blood and guts), and giving my final presentations. My projects for this rotation included making a formulary review document for Exparel, updating chemotherapy drug info sheets, and my journal club topic.

I have really loved my time at Providence Park. The smaller hospital setting might not have the super crazy cases, but for an institutional rotation I have gotten to do a lot of different things. This has definitely been great practice leading up to my generalist rotation which I have next at UM. I also really like the camaraderie among the staff... a lot of the techs, pharmacists, doctors, etc have been with St. John Providence for a long time before moving to the new site; and having such a small staff means you really know everyone. The only thing I won't miss about PPH is the drive - curse you one lane roads!

From Rural ICU to Inner City LGBTQ

Posted by Janis Rood at Monday, July 16, 2012

To cap up my first rotation, Inpatient Clinical - Internal Medicine:
I ended my rotation in Monroe, MI with a week in the ICU.  I really enjoyed this because I had previously no exposure to emergency medicine.  It was a challenge to take 10 to 13 patients on a daily basis, each with at least 10 complexities and go through them thoroughly.  I was able to optimize therapies for a few, uncover an adverse drug reaction in another, and even help out during a "Code Black" and "Code Brown."  On the one hand I miss that rotation because there was really very little extracurricular work, which was nice for a change.  On the other hand, I missed out on being extra stretched, which promotes person growth and development.  To be determined where the proper balance lies in this regard.

My newest rotation: Community practice with Walgreens in Chicago, IL.  Specifically, Mondays, Wednesdays and Thursdays we spend our days at the Howard Brown Clinic which specializes in serving Lesbians, Gays, Bisexual, Transgendered and Questioning (LGBTQ) patients.  On Tuesdays and Fridays we spend our afternoons at the Mercy Hospital Care Program, which serves only HIV/AIDS patients.  The one word that best describes this rotation is intense.  It's intense for many reasons:

1. The learning curve is steep.  Our preceptor grills us on everything from mechanism of actions, medicinal chemistry, pharmacokinetics, metabolism, drug interactions, first, second and third line medications for ANY given drug state, the ins and outs of all laboratory monitoring parameters, and the list goes on.  He doesn't mind if you don't know an answer...once.  However, you better go home and look it up so everyone can talk about it tomorrow.  The first two weeks are spent looking up anything and everything.

2. The range of topics is wide.  We talk about hormones for transgendered patients, antibiotics for opportunistic infections and STDs, OTC topics, etc.  While the focus of this rotation is HIV/AIDS treatment, we cover every part of inner city medical care, in addition to standard care patients.

3. The range of activities is wide.  We counsel on SubQ injections, perform blood pressure screenings, write SOAP notes, do medication histories, count pills, cashier and counsel, follow-up with new patients, create pill boxes, organize public aid deliveries, etc.  Every day we do something different that builds upon what we did the day before.  I feel that all of my brain is being used at all times.  I go home exhausted, but as stated above, I spend the evenings brushing up on old topics and preparing for new ones.

4. We still have projects and presentations.  We have weekly modules to read over, each with special cases to work up.  We've created a slide show and giving a presentation, "HIV 101," to new psych residents.  We're publishing annotated reviews of literature relative to HIV care in a newsletter.  We're creating a special project to improve clinic/pharmacy work.  In short, we always have something larger than daily work to complete.


While this rotation is a ton of work, completely exhausting, and keeps me away from my husband, friends and family, I really enjoy every day.  This is the type of work I want to do.  I love the interplay of community practice with patients from a constantly clinical perspective.  I thrive on daily tasks that I gain satisfaction from completing, yet have longitudinal projects that keep me motivated.  I like the daily variety, the breadth of topics, and the depth of impact we have on each patient.  I have two weeks left, and I am already sad thinking of leaving.  Here's to an amazing rotation that continues to surprise me, expose me, grow me, and prepare me for what's ahead.

Good morning, drug information, this is Kaleena.

Posted by Kaleena Johnson at Thursday, July 05, 2012

My first rotation as a fourth year was in drug information through the University. I won't lie and say I knew this would be a great rotation, I had heard mixed information regarding this rotation but in retrospect I think those comments were not describing this rotation through the University but other drug info rotations.  This was an amazing experience and one that I was lucky enough to have as my first stop.  And to put the icing on the cake, I had this rotation with my roommate Jessica Fong.

At the beginning of this rotation I was extremely wary about my skills in providing drug information and answering, sometimes complicated, questions from our callers. On the first day we received a sheet of paper with most, if not all, of the possible resources we may need on this rotation and later - it's AMAZING!! I will keep that paper with me all through rotations. We received calls from community and hospital pharmacists, physicians, nurses, dentists and patients.  Our services cater to the University of Michigan staff but we take any calls that come through our system but our staff comes first. In answering these calls you become a detective in trying to find the best answer - to me, this was extremely fun. During my 5 weeks, I received many calls that enhanced not only my knowledge of the plethora of resources at our fingertips but it geared me up for the months ahead. Some questions were simple, taking me less than 5 minutes to answer and others were more complicating, taking from several hours to a couple days. I have random knowledge in the back of brain that I am hoping will be helpful in the future.

The preceptors during our rotation were extremely helpful and always available. It is amazing how much time I was able to spend with each of my preceptors - we worked with 4 total but Gundy Sweet was our number one. My friends at other pharmacy schools have told me they don't spend much time with their preceptors and I consider myself lucky that I have had this opportunity. My favorite part of everyday was our morning 'meetings.' This was the time we took every morning to discuss the calls we had received the day before and more often then not, gain insight in how we can better answer a question or find an additional resource. It was a great way to receive input from others that may have dealt with the same question in the past or has some experience in the area. During those meetings, work talk inevitably led into personal talk with many of our mornings spent talking about a certain popular book for women and mothers the world over (hint hint). This was a time I got to know my co-workers and made the environment extremely friendly and easy to work in.

My projects included writing a drug monograph, preparing a 20 minute presentation on that drug and writing an article for the Pharmacy ForUM newsletter. Look for mine in July - it's on saquinavir and the increased risk of arrhythmias. For the drug monograph I had to conduct research on the mechanism and the current use of the drug and determine if the hospital should put it on their formulary. My suggestion will later go in front of the pharmacy and therapeutics committee. Each of these projects were great experiences in areas I am not familiar or comfortable with and they were challenging in that I had to alter my style of writing to fit the situation.  Each will be a great resource come interview time.

I am already on my second rotation at Sanofi-Aventis in Bridgewater, New Jersey. I do not have experience in industry and I'm excited to learn more about what a pharmacist can do. So far I am enjoying this rotation but it is definitely different than I expected.  I will update in a few weeks about my experience here.

From Community...to Surgical ICU

Posted by Jessica Chen at Monday, July 02, 2012

Hello boys and girls, my name is Jessica! :) I'm originally from Los Angeles, California and I'm definitely am missing the beach filled summers of CA right now. Its so humid in Michigan! If you have any questions about anything Michigan/California/etc related, please don't hesitate to email me. Jesschen@umich.edu

My first rotation was a Target in Brighton with Dr. Joe Davis. I would HIGHLY recommend this particular site if you're interest is in community. I have about 6 years of retail experience (from undergrad and during pharmacy school) so Joe (that's what I call him now because we are buddies! haha) let me tailor the rotation to my taste. He suggested I do more leadership and business model rotation type projects. I definitely was excited to try something different! I still did some prescription filling, but in general I mostly counseled on medications, work on mini patient projects, perform blood pressure and diabetes checks, and I also went through the entire pharmacy to learn about EVERY SINGLE DRUG on the shelves. It was very tedious, but it really refreshed my memory. It was a wonderful first rotation and I was sad to leave!

So I went basically from 0 to 100 from community to the surgical intensive care unit (SICU). My preceptor is Dr. Melissa Pleva and so far I'm really enjoying her rotation. Don't get me wrong, the rotation is very CHALLENGING but not impossible. Dr. Pleva is always there to answer my questions and to challenge my pharmaceutical knowledge.

My typical day starts with arriving at the hospital around 6:30-7am depending on how many patients I see on Careweb (UM Hospital's electronic patient charts) the previous night. I work up patients and pay attention to any acute changes over night. From 8-11:30am we round! Rounding consists of the medical team going from one patient to another and talking about the patient's medical problems and why they are in the SICU. Our goal isn't to "cure" the patient, but to get the patient out of the ICU and into the main hospital (also called "floor status"). There is no reason to keep a patient in the ICU for more than necessary...also I was told a day in the SICU costs 5k! so expensive and a waste if its unnecessary. Anyway... back to the team! Our team is made up 1 attending, 2 fellows, 4-5 interns (1st year residents), 2 med students, a dietitian, a pharmacist, and 2 pharmacy students. In all, a HUGE team! Its very intimidating sometimes to even want to make a recommendation.

After rounds, we usually will talk about our patients and Dr. Pleva lets us go for lunch till 1pm. From 1-2pm, we present patients, go over pharmacokinetic dosing, or just other points of clarification that we didn't finish discussing after rounds because we were too hungry :( From 2-4pm, we have topic discussion with other critical care pharmacy students. We have readings assigned to us, and we discuss what we read and why its important in the critical care setting.


There you have it, community and surgical critical care in a nutshell! Now back to those readings for topic discussion....


Keep Cool! :)
- Jessica

What I want to be when I grow up!

Posted by Beejal at Sunday, July 01, 2012

Hi everyone!

Since the last time I wrote, I finished my General Medicine Rotation in block 1.  This post is going to be final remarks about that!  I did want to correct something I wrote in my first blog post though! I forgot to list a rotation! O:-)

Rotation 1: General Medicine (UMHS, Engle)

Rotation 2: Hospital Pharmacy, former “Institutional” (St. Joes Ann Arbor, West)

Rotation 3: Peds Hem/Onc (Mott, Howell)

Rotation 4: Amb Care Cardiology (VA Ann Arbor, Brenner)

Rotation 5: Meijer (Ypsilanti, Tanabe)

Rotation 6: Nontraditional Geriatrics (St. Louis, MO, Levy)

Rotation 7: Critical Care-Cardiac ICU (UMHS, Butler)

Rotation 8: Off

Rotation 9: Drug Information (DMC)

General Med weeks 3-4: I left off last time after finishing 2 weeks on teaching rounds at UMHS.  These next two weeks, I moved on to two “non-rounding” services where you juggle a lot more patients (the most I had was ~22), but you don’t see any of them.  If you see a problem or have a suggestion, you meet with the patient’s Attending physician in a conference room in the afternoon.   I ended up being bored (for lack of a better word) during these services.  I didn’t need to work up patients at home since the rounds were in the afternoon, but I also felt like I didn’t know my patients very well because I wasn't seeing them.  I also missed interacting with the team on rounds, and wasn't fond of looking at a computer screen all day.  So these types of rounds were not my forte, needless to say!

General Med week 5:  This week I had 1 teaching rounds service and 1 “non-rounding” service.  I thought this was the perfect combination.  I had enough change in my day-to-day activities and interacted with enough people to keep me sane.  I very much felt that I can be happy working in this environment forever!  I figured out a system to manage my time effectively and overall felt like a real pharmacist.  I started to catch the problems before my preceptor would ask, question renal dosing when appropriate, do the calculations before being reminded to, set alerts before being reminded to.  I know that my therapeutic knowledge will still need to improve, but I can identify which drugs are alarming to see, where to look the drugs up, and what questions to ask when confirming that these drugs are appropriate for the patient.

Reflections on the added 5^th week to rotations: In this particular rotation, the 5^th week was incredibly useful.  At the end of week 4, I was so scattered and disorganized that I didn’t think this position was for me.  The extra week gave me a chance to get my system figured out, and I felt like I became worlds more independent in those last 5 days.  A new week usually means starting fresh with new patients; I knew exactly what I would do differently with managing the patients and was lucky enough to have an opportunity to try it out (with success, I might add)! 

Reflections on this rotation:  Believe me when I tell you, I loved this rotation!  I have never felt more competent to be a pharmacist at any time during the last 3 years.  Not to say that I’m ready to be out in the world, but I am becoming more comfortable with the idea that I’ll have to be independent in less than a year.  I really do feel that it’s because you see so many different diseases and problems during this rotation.  You learn about the most common things patients come in with, but you also see really weird situations.  You are a jack-of-all-trades, master at none- but that’s what a consult is for! 

Dr. Engle did a great job precepting because she really gave me the freedom to run the show how I wanted to.  This was incredibly difficult at first because I lack the therapeutic knowledge to comfortably assert my opinion, but she was very supportive and encouraging to help me build the confidence.  I definitely learned a lot from all of the other pharmacists as well because when you have a substitute preceptor for the day, they have specific pet peeves too!  I will always look at max doses for zofran (props to Dr. Richards!).  I know now what a fungal ball is (props to Dr. Tupps!).  I quiz patients instead of lecturing for their anticoag education if they’ve been on warfarin for a long time (props to Dr. Harless!).

Alright, to give you all a break from me, I won’t talk about block 2 for another few days at least! 

Happy rotating!

-Beejal

My Levofair with Internal Med

Posted by David Plumley at Sunday, July 01, 2012

I knew that these five week rotations would go fast but I did not realize just how fast until I looked back a few days ago and I always already done with my first rotation.

To say I learned a lot on from Dr.Regal, Charles in charge, and the members of the Medicine Dock team would be an understatement.  Most of my learning came on the fly during rounds.  Once my team members became comfortable with me and confident in my pharmaceutical knowledge they would ask me questions about almost every patient.  Most of the time I would reply with my favorite phrase, "let me look into that and get back to you" and then do some research of my own, as well as discuss the topic with Dr.Regal, in order to come up with the best recommendation.  However sometimes thanks to the knowledge I acquired from therapeutics and the confidence I gained from this rotation I was able to make a recommendation on the spot.  Most of the recommendations I made involved antibiotics (dosing, optimization, duration, and toxicity), anticoag(warfarin dosing, Lovenox bridging, and the occasional Dabigatran), and optimizing chronic therapies.

The therapeutic and medical knowledge I acquired is very important, but maybe more importantly I learned confidence and how to operate with the medical team.  It took some time for me to understand how rounds work and how to best contribute but once I did I was able to participate in my own active learning even more.

The most valuable advice I can give to students getting ready for their clinical rotations would be to pay attention to every patient on rounds, learn from the discussion the team may be having even if you may not be responsible for that patient, look up everything you aren't sure about, and to work with your team.  We have all heard this before during orientation but it is most definitely true.  

One of the most difficult parts of having a clinical rotation first was my unfamiliarity with much of the medical terminology, but by writing everything down and looking it up later I was able to learn more than I thought.

It wasn't all work however.  Many of you might not know this but Dr.Regal is quite the wordsmith and poet.  He shared with us 2 poems he wrote about protecting fluoroquinolones (one of his favorite past times) and ending levofairs and ciproflections.  I will try to get copies of these so I can share them with the world.

Before I finish today I would also like to give you a quick intro to my next rotation.  I started this past Monday at Karmanos Cancer Center located in the Detroit Medical District.  This is an ambulatory care rotation focused on bone marrow transplant.  I am excited for this rotation since I have an interest in oncology/hematology.  My preceptor is Dr. Simon Cronin, the former preceptor of our very own Dr. David Frame, which makes me semi nervous.

So far in my first week I am getting accustomed to the work flow.  I spend most of my day doing med recs, some patient education, and have opportunities to shadow Simon as he works.  The clinic has approximately 2 MDs, 4 NPs, Simon.  The 2 Wayne State students I am partnered with and myself play an important role in searching out drug therapy issues and bringing them to the attention of the other clinicians.

I will update you on how this rotation goes in a few weeks.