VA Ambulatory Care: Cardiology

Posted by Beejal at Wednesday, October 31, 2012

Hello everyone!

It’s been 2 months since I’ve posted, but rest-assured that it was intentional!  My block 4 rotation was Cardiology at the VA with Dr. Brenner.  Krystal already posted a blog about it, and her descriptions mirrored what I would say to the T!  I encourage you to read her September post before reading mine.  Hopefully my post will be supplemental to hers with some added challenges I faced.  I will also speak to the impact this rotation had on my block 5 rotation (why I waited to post!)!  First, here’s a short summary of my experience at the VA! (My definition of “short” ha).

Summary

While it is very true that everyone has a different experience with Dr. Brenner, the topic discussions, anticoagulation responsibilities, and types of patients you see are very similar to students prior.  My topic discussions were done TIW over the first 3 weeks, then BIW thereafter :).  He wants you to know everything about the topic you’re presenting.  Like Krystal noted, when you give a topic discussion he will not allow you to read your handout; he wants you to know it and just use it as a reference.

I saw my first patient on day 4 of rotation.  I was nervous, but I ended up doing great with patient interactions- it’s the therapeutics that I lacked! (Naturally!)   As with topic discussions, Dr. Brenner wants you to know everything cardiology-related about your patient when you work them up.  The patients that are referred to his clinic are ones that are difficult to manage.  You will rarely see a patient in this clinic who simply has hypertension and is well-controlled with first line therapies.  His referrals tend to need more investigation.   

When working up patients, you have to know which medications have ever been tried for all of the patient’s cardiac conditions (not just the condition the patient is being referred for).  You should know what happened with each medication and why they are on their specific regimen.  Even if atorvastatin was used 8 years ago and the patient is now taking rosuvastatin, you should know when and why they were switched, and if they ever experienced muscle pain or had elevated CPK levels.  You should know their last ECHO and ECG results, whether they had a CABG or stent placed (when and what kind), and what other conditions may be related or may impact their cardiac conditions (kidney injury, BPH, etc).  Specific to hypertension, you should be able to use home blood pressure readings and serum aldosterone and renin levels to drive therapy changes.  Specific to heart failure, you should be able to probe the patient to determine how well controlled they are, and if they are on the verge of an exacerbation.  Many of these patients are older so you should always be mindful of orthostatic hypotension, dizziness, and chest pain.  You really learn how to assess a patient from every cardiology disease state inside and out.  Finally, you write SOAP notes for every patient you see.  He knows how valuable this is, and he challenges you so that you have an easier time in residency. 

Specific challenges

Besides re-learning topics like hypertension, heart failure, dyslipidemia, and arrhythmias in a short amount of time, the biggest challenge was being comfortable making therapy changes.  For example, in one of my patients with multiple cardiac problems, we changed 2 medications and discontinued 3 medications.  This was the first time I realized the extent of the impact we can make in an ambulatory care setting, and the relevance of having prescribing abilities.

The other challenge was entering my appointments not knowing what I was going to recommend.  All your recommendations change once you talk to the patient!  You find out what symptoms are really bothering them, and what their home blood pressure and heart rate readings are.  You also generally don’t have lab values back until the middle of the appointment, so you cannot assess dose changes or abnormal lab values ahead of time.  If lab values return when you get to that portion of the appointment, you think out loud through each value, explain to the patient what the significance is, and inform them of whether they have met their goals.   Based on their lab values and their signs/symptoms, you make a recommendation for what the next step should be.  The only way to prepare for these interviews is to have different plans for if A happens, B happens, C happens, and D happens.  More than likely neither A, B, C, nor D will happen!

Cardiology is the field I had always considered for a residency.  This rotation reminded me of how much I enjoy it!  I have my favorite topics (heart failure, post-ACS, and anticoagulation) and ones I’m not so fond of (hypertension, arrhythmias).  Despite having an “interest-bias,” I am now comfortable and confident in most (if not all) of the topics that we discussed. 

Reflections

Impact on my community pharmacy rotation at Meijer:  I consider myself to be proficient in assessing a patient’s cardiology regimen.  Dr. Brenner challenged me to know my therapeutics very well, and I am truly thankful.  Knowledge of heart medications is very important to any practice of pharmacy.  I am blown away with how much I have retained, and how spot-on I can be with patient profile reviews in the community setting.  I even gave a hypertension topic discussion to the P2 IPPE student and my preceptor during this rotation!  Again, I can’t describe enough how relevant cardiology is in pharmacy practice, and how much I learned during Dr. Brenner’s VA cardiology rotation. 

Time management:  I was fortunate to have 3 clinical rotations before the Mid Year meeting, and now I have a better direction for my future. This, however, was very overwhelming.  Having this cardiology rotation immediately after Peds Hem/Onc left me burnt out.  When I added my seminar presentation to this, I was working all day, every day … including weekends… for 10 weeks.  This is something to mentally prepare yourself for when you have a series of inpatient rotations.  P4s always say how busy they are, but it’s a different kind of busy.  I now know what they mean!  The best way I can think of to describe it:  you have real responsibilities as a P4- it’s not just about showing up, it’s about being prepared.  You get out of your rotations what you make of them.  Be mentally prepared to work hard during your inpatient rotations, and keep up!

Rotation 4: Nuclear Medicine

Posted by Alison Van Kampen at Sunday, October 28, 2012

My fourth rotation this year was at Covance Laboratories in Madison, WI.  This was a unique experience because I not only learned a lot about nuclear medicine but also about Phase 1 research.  I spent the majority of my time at the Clinical Research Unit where they primarily conduct research in humans examining the AME properties of new products.

In this setting I was able to observe how radio-labeling is used to detect drug serum concentrations, route of administration, route of excretion, and length of time that the medication is in the body.  The role of the pharmacists in this setting was primarily drug preparation, determining if and how client specifications could be met, and participating in meetings with clients for quality assurance.  The pharmacists also were responsible for ensuring equipment integrity and that all staff were knowledgeable and followed standard operating procedures.  

I learn a lot about how phase 1 research is carried out, about imaging studies, precautions that are taken during preparations with radioactive or "hot" material, and why and how these products are used.  While I was there I primarily attended client meetings with my preceptor, observed preparations, helped with equipment qualification, worked on projects, and went on "field trips."  

Client meetings were interesting because I was able to see all the work that goes into setting up research.  Several times each week, a company with a new product that is currently working with or may work with Covance on a study, will have a teleconference with employees at Covance.  This meeting can be anything from going into great detail about how the study will be conducted (number of participants, types of participants, route of administration, special monitoring, etc) to periodic checks during a study for quality assurance.

The preparation was different for each study and so each presented it's own challenges.  Each study needed to have a mock preparation that was evaluated for appropriate strength, purity, and contamination.  They prepared sterile and non-sterile as well as "hot" (radioactive) and "cold" (non-radioactive) products.  Products were prepared on regular lab benches, in vertical flow hoods, and in ISO class 5 glove boxes, which, by the way, are very difficult to use. Just putting on the three pairs of gloves was  very difficult on it's own, let alone try to avoid contaminating the products.  I also did a qualification of two of the pipettes.  Twice a year they need to check all of their equipment to ensure that it is working properly and is accurate.  This was a way that I could learn and contribute to the clinic, and I am proud to say that I was able to pass both of the pipettes, which is more difficult that it sounds.

I was also given some small and large projects to work on during the rotation.  The main projects that I worked on were two journal clubs that were related to nuclear medicine and that I presented to the pharmacists, medication coordinators, and the physicians working at the clinic.  I also had two other presentations to give which were related to some of the work being done at the clinic.  One presentation was on appropriate aseptic technique using non-sterile product and the other was a large project about vaccines, specifically influenza vaccine produced in tobacco plants. This second project I found to be especially interesting and was comparable to a second seminar presentation.  So even though this was a lot of work, I now have two projects that I can possibly present, should it be required in any future interviews.  Not a bad deal. :)  I also had a few small projects like calculating the amount of hot and cold drug needed for a study, calculating how much radioactivity each patient would receive per dose, and looking up information on different radioactive products.

Finally I was sent on "field trips." The field trips were day trips to nuclear pharmacies so I could see how radio-labeled products were used in imaging and treatment of certain disease states. This was really cool when I visited the University of Wisconsin Hospital and saw not only how they prepared the products but all the imaging equipment and even where they were able to create radioactive particles in their cyclotron.  I know sounds like a mad science project and that is what it looked like too, but it was really neat.

Last thing, Madison is a really cool city.  There are a lot of fun things to do there and even though the rotation has a lot of projects, you get time to work on them during the day and can still spend time enjoying the city.  Cool things to do include going to the free zoo, Saturday farmers market, Wisconsin football games, trails near Picnic Point, lots of bars and restaurants down town Madison, and you must try cheese curds, delicious.  Overall, this was a pretty good rotation, very different and very interesting.

Rotation #4: Pediatrics Infectious Disease

Posted by Kristen Gardner at Saturday, October 27, 2012

Overview

• This rotation was an inpatient clinical rotation specializing in pediatrics infectious disease
• I was on this rotation with another student- always helpful!
• The medical team is smaller than others with an attending, 3rd year fellow ( --> PGY-6), 1st year medical resident, 4th year medical student from Wayne State, me and my classmate, and Dr. Klein the clinical pharmacist
• I appreciated the smaller team and focusing on 1-3 patients/day for my first clinical rotation then following them through their stay

What did I see?

• OSTEOMYELITIS
• Septic arthritis
• Complicated pneumonia cases with abscess development in the lungs
• Tracheitis
• UTIs (especially with patients who had neurogenic bladder)
• Culture negative sepsis
• Meningitis
• Fungemia and bacteremia
• Mold peritonitis
• OTHERS!

What did I do?

• Worked up patients
• patient load/week ~8 patients but this varied depending on how many consults we had for the week
• Had patient discussion with my preceptor every day for 1-2 hours
• Rounding with the pediatrics/infectious disease consult team
• Attended the Pediatrics Infectious Disease weekly case conference every Thursday
• Attend journal club for the above group
• Presented an overview of antifungal agents to the above group
• Delivered 4 topic discussions on shunt infections, community acquired pneumonia in infants and children, infective endocarditis, antibiotic lock therapy
• Normally students attend daily microrounds in the pathology department where they learn about a new  test everyday. We did not attend.

Common drugs

• VANCOMYCIN
• Zosyn, Unasyn, ceftriaxone, Bactrim, clindamycin, 
• Amphotericin B and Ambisome (lipid version of ampho B), voriconazole, micafungin
• PCP prophylaxis drugs such as bactrim, dapsone, atovaquone, pentamidine
• Know differences between these such as efficacy (e.g. incidence of recurrence, resolution of infection), fluid requirement, dose adjustments, side effect profile)

Tips

• BE READY TO REPEAT DETAILS
• Describe their fever curve (how many fevers, how long were they febrile, is it getting better/worse)
• Have their vent setting changed or need for nasal cannula (if relevant such as with tracheitis, pneumonia, etc)
• For pharmacokinetics know when doses were given (date and time), time of last dose, when and where level was drawn from, what is their goal peak and trough. Consider many factors when interpreting levels!
• Know all info about cultures obtained (where, when, preliminary/final result, how (e.g. wound swab, blood draw, heel stick; this may signify if positive culture with Staphlococcus epidermidis or coagulase negative microorganism is a contaminate) especially in relation to antibiotics administered to patient. For example, if culture is negative, is there really no bug or no bug because antibiotics were being given
• Be proactive; anticipate questions and follow your patients closely! Know what to keep an eye out for!
• Consider colonization vs. infection (sometimes this is difficult!)
• LISTEN to the team even for your other classmates
• ASK your classmates for help! If someone had a PICU rotation, ask about dialysis dosing! If someone has had a psychiatry rotation- ask them for information first! This saves you time and builds skills you will use as a pharmacist. You cannot be at the top of your game for every specialty and disease state. It is impossible.
• HAVE FUN! Sing kids happy birthday, play with them in their room, and learn to French braid hair if that is all they keep asking for
• Check the medical administration record (MAR) to see if the kids are throwing up from antibiotics (If so, there will be comments. You may use this information to recommend adjusting the frequency or dose an antibiotic such as clindamycin)
• Take INITIATIVE and follow-up with your preceptor on questions posed to which you did not know the answer. They may not hold you accountable for this by asking you later but it demonstrates motivation and prompt follow-through.
• Be familiar with common labs values of neonates, infants, children
• Be familiar with our restricted antibiotics and protocols and hold the medical team accountable for these

Common Interventions

• Reminding the medical teams of some of out institutions/unit specific antibiotic resistance patterns (hint: use the UMHS antibiogram)
• Adjusting antibiotic dosages- either increase or decrease dose
• Pharmacokinetic monitoring/adjustments with vancomycin and aminoglycosides
• Antibiotic regimens for IV -> po switches
• Antibiotics regimens IV inpatient à IV outpatient (for when a patient is on a q6hr regimen inpatient as this is difficult to adhere to as an outpatient)
• Recommending labs: basic metabolic panel, renal labs (SCr/BUN), LFTs, voriconazole trough level
• Providing pharmacokinetic knowledge to the medical team (oral bioavailability, protein binding, renal excretion, antibiotic coverage). 
• Medical students have limited knowledge about antibiotics. I consider ID an ESSENTIAL niche for pharmacists. 
• You will very likely use this information on every rotation.

Fun Facts

• For antifungals we monitor voriconazole, posaconazole, itraconazole, and flucytosine levels at UMHS
• Sign of voriconazole toxicity (level > 5) is when patient is having visual disturbances or hallucinations
• There are many different formulations of amphotericin B (non-lipid and lipid with 3 different lipid formulations)
• Voriconazole and echinocandins (e.g. micafungin) do not appreciably accumulate in the urine and cannot use to strictly treat candiduria
• fluconazole has NO mold coverage, only yeast; all candida spp. may not be sensitive to fluconazole
• when adjusting vancomycin and aminoglycoside levels- try to cap modifications at 30% dose change or frequency change. Do not do both at once.
• Do not forget about fosfomycin and its coverage spectrum! This treatment can be VERY useful!
• Ciprofloxacin has a narrower spectrum vs. levofloxacin
• For community acquired pneumonia (CAP) in children < 5yo, you do not need to empirically cover for atypical pathogens UNLESS they are strongly suspected based on the clinical presentation
• Always embrace antibiotic stewardship and use the antibiotic with the most narrow spectrum, even when choosing on empiric therapy
• Ambisome does not share the nephrotoxicity risk of amphotericin B
• voriconazole IV formulation has a vehicle (a cyclodextrin) that is eliminated slower then the drug --> we try to minimize use to 2 weeks or else the vehicle can cause nephrotoxicity
• triazoles can cause a transient transaminitis that usually manifests after 7-10 days of treatment--> baseline LFTs needed and follow-up in 1 week to assess. D/C if 5x upper normal limit

What was difficult?

• It was my first clinical rotation, and I am way too curious of a student. Therefore, it was hard for me to make myself prioritize (even though I knew what I had to do, I would get side tracked). But, exhaustion is a great motivator.
• We are a consult team; therefore, we may get PICU patients who have been in the hospital since birth! Initially, I felt overwhelmed in these cases because there was so much data in the medical chart. Hint: graphing results in Carelink is your best friend to visualize trends and figure out their baseline values. Read the ADMIN note, prog note/reason for consult, and go from there.

Do I recommend this rotation? YES! It is a great way to get a dose of two worlds: infectious disease and pediatrics. The little kiddies are challenging! Dr. Klein is extremely respected by the medical team and is very knowledgeable. She is always available for questions and responds to pages quickly. She holds a final jeopardy at the end of the rotation. I was somewhat anxious about this but it was really fun! If you paid attention on rotation it is a breeze!

Amb Care and Cardiology

Posted by Courtney K at Sunday, October 14, 2012

Hello all,

I apologize for the delay in this post, P4 year really picked up all of a sudden and we're now HALF WAY DONE!! Here's a recap of my last 2 rotations:

Rotation 3
My ambulatory care rotation with Dr. Wells has been my favorite one so far! I hadn't really considered amb care as a possible career for me prior to this rotation, but my experiences on this rotation have made me think more seriously about it. I was on this amb care rotation during the big switch to the MiChart computer system, so that changed my experience a little bit in the following ways:

-I got to see how health care professionals handle a big switch in technology. This put many employees outside their comfort zone and it was quite an adjustment for them. Luckily there were "super MiChart users" available all day for the first few weeks of the change and they were able to troubleshoot a lot of the problems.
-As a student, I had read-only access to MiChart (so i could no longer write notes in the medical record like we can with Careweb). I was still able to access MiChart to get all the patient information I needed, such as lab values, medication lists, and notes from past encounters. The main difference for me was that I now had to email my visit notes to Dr. Wells instead of forwarding them through Careweb.
-My patient load was smaller (50-75% of normal) to allow for the adjustment to MiChart. On average I had between 6 and 8 patients for a morning in clinic, and normally this would be doubled.

My responsibilities for this rotation included:
-working up each clinic patient ahead of time and discussing with Dr. Wells. This means having multiple plans ready to go depending on if the patient's blood sugar and blood pressures are improving, staying the same, getting worse and based on how their diet/exercise is going.
-interviewing and assessing patients during their visits
-insulin teaching and diabetic foot exams
-writing up notes of the encounter
-4 topic discussions (diabetes, hypertension, lipids, diet/exercise)
-2 journal clubs
-1 patient case presentation

The large majority of the patients I saw had uncontrolled diabetes so they are referred to the clinical pharmacist by one of the primary care physicians to help get their sugars under control. Dr. Wells has a collaborative practice agreement with each of the physicians at the clinic so she is able to prescribe new medications and make any dose changes she wants to for their diabetes, hypertension and hyperlipidemia management. She has a great relationship with all of the staff and they really value the work she does. Seeing the big impact that pharmacists can make in chronic disease management was really awesome to see and be a part of. I learned so much on this rotation and feel much more confident about managing diabetes, blood pressure and lipids. I learned something new from each patient I talked to and one of my favorite things was following up with patients I had already met with and seeing them improve throughout my 5 weeks. This rotation was also a good lead in to my first inpatient clinical rotation at U of M.

Rotation 4
Cardiology with Dr. Pogue was my first inpatient clinical rotation of the year. I was really nervous and excited to finally have a clinical rotation that involved rounding with the medical team. Luckily, this rotation didn't throw us straight into rounding the first day, which I appreciated. And I wasn't alone either- I had my partners in crime, Dave and Edwin on the other 2 cardiology teams and Corrine on heart failure. The first 2 weeks we worked on our own to get familiar with the patients on our team, and our responsibilities for the rotation which included medication reconciliation on each patient, anticoagulation management, educating all patients on anticoagulation meds, and pharmacokinetics for vanco/aminoglycosides. Once we figured out how to get all of these things accomplished, we through rounding into the mix. When rounding started, my schedule looked like this:

7am- arrive at the hospital and work up any new patients, follow-up on labs and med changes for current patients and formulate my recommendations for rounds
8-8:30am- Rounding with the team. My team consisted of 2 medical students, 1-3 interns, 1 resident, and the attending physician. This could take anywhere from 2-4 hours, depending on the number of patients and how complicated they are. One particularly long day when my team had admitted 7 new patients over night we rounded until about 1 pm. Needless to say I was STARVING and forgot a snack that day. *Note-ALWAYS keep a snack in the pocket of your white coat.
12/12:30pm- Follow-up on any questions/issues that came up on rounds ("Let me look that up and get back to you" was my go-to phrase), and check-in with Dr. Pogue on any issues that needed attention before our afternoon meeting. Then I'd eat a quick lunch and make my way through med recs and warfarin educations. Rounding in the morning helped me to prioritize my work, because I would have a good idea of which patients were having procedures done that day, when patients would be going home, etc. This was especially important for patients new to warfarin because we had to make sure that the team knew who was going to manage them outpatient (PCP, UMHS anticoag service, other) and make sure that they had coverage for enoxaparin if they were being sent home on bridging. One of the main goals of the pharmacy managed anticoag service is to ensure safe transitions of care and making sure everyone is clear on who will be monitoring and when the next INR check will be. For patient's being sent home on new medications for antiplatelet therapy (clopidogrel, ticagrelor, prasugrel) we also worked to make sure these drugs would be covered by their insurance and if not, work with the patient to get them started in assistance programs.
2-3pm- meet with Dr. Pogue to go over patients, recommendations, and follow-up on any other issues that have come up throughout the day. We also did afternoon topic discussions, 8 total throughout the rotation. The topic discussions that I lead were on hypertension and arrhythmias. The discussions covered background of the disease state, classes of meds used to treat (MOA, DDIs, PK/PD, side effects), and a summary of assigned primary literature and clinical applications. Cardiology is very evidence based and there are a LOT of studies. One day my attending brought up the HOPE trial on rounds and I actually knew what he was talking about because we had just talked about it in our topic discussion.
4:30-5pm- leave for the day and get ready to do it all again. This rotation was a lot of work, but very worthwhile. On days that my team was admitting I would work up new patients from home in the evening in hopes of saving time in the morning. Even then, sometimes I would only have time for a brief look at a patient before rounds. Topic discussions also took a lot of time outside of rotation to prepare.

One of my favorite aspects of the rotation was all the patient educating I got to do. The most unique counseling experience I had was a warfarin education with a hearing impaired patient. I had to call and schedule an appointment with the hospital's interpreter service and an interpreter met me at the room so I could go through the education points with him. The patient was already pretty familiar with anticoagulation so that made my job easier, but it was a great experience nonetheless.

This was a really great clinical rotation. Each patient had very complex medical history and many of them were transferred to U of M from outside hospitals because of their high risk status or for special procedures. I saw a wide range of disease states from acute coronary syndrome, pulmonary hypertension, endocarditis, heart failure exacerbation, atrial fibrillation, pulmonary embolism, digital ischemia, and the list goes on. I learned so much from rounding and topic discussions and one of the biggest lessons I learned was how much I still don't know. The cardiology pharmacists all know SO MUCH and can rattle off study results, half lives, and max rates/doses without batting an eye. This rotation solidified my decision to want to do a PGY1 residency because if I can learn this much in a 5 week rotation, think of how much I'll learn in a whole extra year!

How did October get here so quickly?

Posted by Janis Rood at Saturday, October 13, 2012

Rotation #5: Lexicomp Medical Writing

It's hard to believe that we are already on to the fifth rotation.  This time around I get to stay at home with Lexicomp.  I will be honest and say that it has been a difficult transition.  I prefer the hustle and bustle of teamwork and patient interaction.  I like leaving my house with a purpose, then coming home when the work is done.  None of that happens now.  I feel a little lonely at home, but you can't beat waking up, having no commute, and working in your pajamas.  So what am I actually doing?  Well, my preceptor maintains the drug interaction database.  He has assigned me three drug interaction monographs.  My job is to perform literature searches checking the most recently published data and editing the monographs for wording and content.  I've had to dig for interest in these projects and find new things to learn and ways to challenge myself.  So far I've learned how entertain myself for 8 hours while being productive, how to tweak out the best lit searches, and dig deeper into the clinical pharmacology of common drugs like beta-blockers and calcium channel blockers.  Up next week is a review of stats and study design.

Now to what I did for the third and fourth rotations.

Rotation #3: Institutional at UMHS

This rotation was split up by week.  Week 1 I worked in the Investigational Drug Services with Rivka Siden.  She has amazing amounts of energy and insight into the research process.  This week consisted of understanding the intricate process of dispensing investigational drugs, all of the documentation involved, 9 assigned readings with discussions, preparing dispensing guidelines for an investigational drug and completing an audit.  The hours were very nice, an 8 to 4:30 work day with breaks and lunches.  Week 2 was admin week.  This week I worked with the other three P4s on rotation with me on various projects, including: a CE presentation for technicians on medication safety, revamping the APPE evaluation process for institutional experiences, and revamping the IPPE experience with relevant readings, checklist activities, and additional sites.  We also had scheduled meetings throughout the week with different administrators, asking questions, hearing their stories, and hearing different perspectives on the administrative side of pharmacy.  We were able to finish all of our projects on the job, so nothing came home with me.  Definitely a good exercise in efficient team work.  Week 3 I was in the clean room, checking prescriptions, putting together batches, ordering batches, going on runs, and generally being part of the team.  Week 4 I was in the eight floor satellite pharmacy checking prescriptions, following chemotherapy protocols, investigating the Clinical Home Page, and making interventions as needed to any orders than came through.  Week 5 I was in the Central Pharmacy working with drug shortages, PacMed, and any interesting projects that came up.  The major challenge from this rotation was staying challenged.  To do this I set daily goals.  I asked myself, what about this practice site have I not experienced yet?  What do I not know?  Who do I not know?  I took it on myself to fill in these gaps every day.  I also adopted the motto "No job too small."  I was willing to do anything that the team needed me to do.  I found that  by doing this, I learned a lot about little details that can slip through the cracks, never got bored, and built a strong rapport with a large pool of technicians.  I came away with a sense of satisfaction, knowing I had gotten the most out of a less-challenging rotation.

Rotation #4: Generalist at UMHS

A generalist pharmacist is a hybrid between staff pharmacist, reviewing orders as they come through, and clinical pharmacist, working up patients and rounding with medical teams.  I was assigned to Dr. Andrew Lucarotti for a preceptor.  He graduated recently from the UM COP (2011), which made it easy for him to help me with the transition from student to practitioner.  The focus of our service was renal dosing, anticoagulation, and antibiotic stewardship, dosing and monitoring.  My general routine was as follows: 1) arrive at the 5th floor satellite pharmacy between 6:30/6:45 and work up my morning patients, 2) go over my findings with my preceptor before rounds, 3) round with the medical team (around 8 am), making my recommendations as we went, 4) report back to my preceptor after rounds the updates on patients and recommendations taken, 5) make any notes on my interventions, 6) educate patients on anticoagulation meds and log my notes, 7) work up my afternoon patients, 8) go over my findings with my preceptor before rounds, 9) meet with my physician on afternoon rounds at 1:30, 10) report back to my preceptor, 11) make any notes on my recommendations, and 12) attend or give a topic discussion, case presentation or journal club from 2:30 to 3:30.  I will describe what each of these things entailed:
1) I worked up my patients by doing the following things: reading CareWeb H&P notes, checking renal dosing, spot checking DDIs, precursory med rec, checking appropriateness of all antibiotics and their doses, monitoring INR, PTT, drug levels and coordinating timing of drawing levels and pharmacokinetic calculations.  I started out with 3 patients on day 1, and by the end of week 1 took on anywhere from 10 to 15 patients.
2) I presented what changes, levels or results I discovered.  We compared our work, confirmed my recommendations and sent me off to rounds.  This process helped to build my confidence in working up patients and making recommendations.  By the end my recommendations were mostly the same as his and I even found things he didn't.
3) Rounds could be sitting in a room and just talking through each patient with the medical team, working in your recommendations as each patient came up.  Other possibilities were walking from room to room, visiting and discussing each patient.  This took anywhere from 1 to 3 hours depending on the attending physician.  Some teams loved me and wouldn't make any changes without my advice.  Other teams tolerated my advice and made my recommended changes if they agreed.
4) Reporting back did not take too long, but helped me to work through the times when my recommendations were not taken and discuss the role of a pharmacists.
5) Making notes was very important.  It meant that anyone who touched that patient or worked them up could follow the trail of what had already been done and what still yet needed to be done.  At times this was laborious, but over time you could see the way your work impacted a patient.  Very cool indeed.
6) Educating patients was one of my favorite things.  We had standard education forms that we brought to each patient on warfarin, Lovenox or dabigatran.  Some patients didn't really want to talk with you, but most really appreciated your insight and asked lots of questions.  I found this to be really rewarding.
7) This was much like what happened in step 1), with another 10 to 15 patients.  This meant a total of 20 to 30 patients in total.  The first day working everybody up is hard (each week you move to a new service).  You miss stuff and don't get through everybody.  But by Wednesday you've got the whole of it worked through and things are a little smoother.
7.5) Please note that no lunch is in here.  We often ate lunch at the computer working patients up.
8) This is much the same as step 2).
9) Afternoon rounds were very different from the morning.  We meet with only the physician in a little conference room between 1:30 and 2.  Often times they don't show up.  Either you find them in another office or just page them with any recommendations that are critical.  Not as exciting as morning rounds, but a good experience in resistance and triaging recommendations.
10) This is much the same as step 4).  I want to note here that he did accompany us a few times, but let us be as independent as we wanted.  I appreciated this.
11) Again, much like 5).
12) The first week the different pharmacists gave topic discussions on anything from pneumonia to geriatric consideration to pain management.  Very interesting.  Each student was also assigned a topic discussion, journal club and case presentation.  These were staggered throughout the last four weeks, always in the 5th floor satellite pharmacy, always from 2:30 to 3:30.

I was almost always done with my work by then and could go home.  However, as discussed in a previous blog, I knew I wanted to get the most out of this rotation, so I asked my preceptor to assign extra homework, since you never had to work patients up at home.  Over the five weeks I completed the following projects: hypertensive emergency and urgency topic discussion, APAP overdose topic discussion, ECMO topic discussion, LVAD topic discussion, therapeutic drug monitoring chart, Top 100 renal dosing/side effects chart, pulmonary hypertension topic discussion, and a total patient review and work-up.  I appreciated the added challenge and learned so much from this rotation.  The areas in which I grew the most would be coumadin management and pharmacokinetics.  I hope to continue to grow in antibiotic stewardship.

That's all for now.  Stay tuned for more on Lexicomp and Rotation #6: Teaching Skills at Washtenaw Community College.

AmbCare Cancer Style

Posted by mariarx at Wednesday, October 10, 2012

Hello everyone! We're almost at the half-way point of P4 year! Time is really flying by, and I am hitting my rotation groove full force now.

Rotation 4 placed me at St. Joseph Mercy Hospital for my ambulatory care practice experience. This is a unique site in that it is an oncology outpatient practice. I was slightly terrified of doing a cancer rotation, but my time with Dr. Carol Yarrington was been great.

My rotation duties were 3-fold: I spent time in the multidisciplinary clinic, the infusion center, and doing project/answering questions work.

Multidisciplinary clinic (MDC)

Recent COP grad, Eric Zhao, gave a really great breakdown of the MDC model during his time last year... so I'll let you read what he had to say about it HERE. To add my 2 cents, I enjoyed my time in the clinic. They aren't really used to having a pharmacist around, so it took a couple weeks for the oncologists to warm up to my presence and respond positively to my feedback about patients. There was one patient who did not really need much intervention on my part, just someone to sit with her while waiting for the doc and talk about her new diagnosis.

First Dose Follow-up

A pharmacy intervention that I was able to bring back to life while on rotation was first dose follow-up (FDFU). This is a service for all patients who are either new to the infusion center or are getting a new/different chemo regimen. I would find these new patients on my non-clinic days and arrange a time to meet with them during their visit in the infusion center in order to figure out the best time to call them the next day. My FDFU phone calls consisted primarily of symptom assessment, as well as being the middle person between the patient and the oncologist when their symptoms needed intervention in order to be managed. I had one patient who had been hiccuping for around 6 solid hours and did not think that it was related to his chemotherapy - definitely an intervention opportunity. A lot of patients really enjoyed talking about how much they enjoy the clinic and all the health care professionals they met with. Go St. Joes!

Project Work

During my non-clinic hours, I spent the majority of my time working on project stuff. Carol fields questions day in and day out, and she would occasionally throw some of them at me! Some of the other things I worked on included a formulary review update, doing research on herbal supplements and their drug interactions for patients interested in trying them, and other random stuff.

My big project for the rotation fit right into my management interests. On my first day, we had a patient coming into the clinic to undergo desensitization because her chemo drug was thought to have caused a massive rash during her previous cycle. The patient ended up having a skin test done first to confirm the nature of the reaction. The clinicians, oncologists, and Carol were able to come up with a test - however, this scenario also made it very clear that the health system does not have a policy in place for this. That's where I came in. Throughout the rotation I gathered literature about skin testing and desensitization, presented it to a multidisciplinary P&T committee, and finally wrote 2 protocols on the topics. I felt like this project was something actually relevant and useful to the department. I love that kind of work!

Overall, I liked my time at St. Joes. Carol was very open and receptive to my interests as well as getting any exposure I wanted to the oncology department, workflow, and staff. The people at St. Joes are wonderful, very patient, and willing to listen to students.