"New patient resus charlie"

Posted by mariarx at Wednesday, November 28, 2012

Rotation 5 is in the bag! Hard to believe we have now crossed over the halfway point. For 5 weeks, I was in the emergency department pharmacy with Dr. Pam Walker (no relation to Dr. Paul Walker) and her amazing ED team at UMHS. The ED pharmacist has a unique role in that they are staffing the ED satellite by themselves (checking orders, making all the IVs, answering questions) as well as responding and working first line with all traumas/codes that come through the resuscitation bays. By the end of the rotation I was confident in my ability to jump in and do (mostly) all of their tasks, with supervision of course.

To paint a picture for all the readers - the adult ED is MASSIVE. 90+ beds split into 5 areas, and 3 trauma bays for critical patients, plus a psych wing. ED satellite pharmacy? Approximately 1.5 times bigger than my closet. Super tiny. The skills these pharmacists are not lacking are efficiency, space management, and time management.

The rotation started out with me working in the satellite, observing the workflow and getting comfortable being in that setting. The ED is definitely different than being on the floors - always lots of movement and energy. On the first day I got to respond to a trauma code in a resus bay. Pam and I helped the team with a patient that needed to be intubated. The first thing Pam does - leave me alone with the RSI (rapid sequence intubation) box while she runs back to grab etomidate from the satellite. Drawing up a neuromuscular blocker on the fly via shouted out directions was the moment I knew that I had to be on my feet and ready to go for the remainder of my time down there. I LOVED it. Over the course of the rotation I got familiar with antibiotic dosing, checking orders, how to use EPIC and Carelink and Worx simultaneously, and all that is needed in running a satellite by yourself. I also volunteered myself for 2 midnight shifts during the rotation to get a feel for the types of patients that are coming into the ED at 3am versus 3pm. It was not as difficult as I anticipated to be up all night. The 2 red bulls and bowl of candy helped as well. :)

Throughout the rotation I definitely got more comfortable with resus patients, and building up the ED pharmacist mindset of "what will they need next? What is the worst case scenario for this patient and what drugs will they need?" Those are key skills for an ED pharmacist, along with on-the-fly dosing, estimating a patients weight and height for said on-the-fly dosing, and the order to give them in (etomidate BEFORE neuromuscular blocker).  I practiced this by looking at patients who were "expected to arrive" to the ED, looking at the 1 sentence blurb that usually accompanied them, and coming up with a (fake) plan.

Projects for the rotation included topic discussions a few times a week, both one on one with Pam, joining the Cardiac ICU students for their critical care discussions, and leading the topic discussion about ACLS for the ICU P4s. I also worked on automated dispensing machine optimization for the multiple omnicells throughout the ED. Looking for administrative type projects seems to be my M.O. for P4 year.

In the end I really enjoyed the ED pharmacy rotation and would highly recommend it to any future P4s.  A++ would rotate again! For rotation 6, I'm at Meijer pharmacy for my community rotation. If you shop in Ypsilanti come on by and say hello! 

Of waltzes and wits...

Posted by Unknown at Saturday, November 24, 2012

I’m engulfed in the fumes of the pastel green goop I have just smeared all over my hands and wrists. The familiar coolness of the iconic hospital hand sanitizer washes over my skin, which is just beginning to display the telltale signs of the start of a harsh Michigan winter. A stinging sensation briefly causes me to pause and look down—a new paper cut I hadn’t seen, probably obtained just minutes before when I was shuffling through my patient monitoring forms, scrambling to copy down hot-off-the-press bacterial cultures for one of the patients I was about to round on. I welcomed the stinging, and made sure to work the last traces of hand sanitizer into the cut in the few seconds before they vaporized from my now bacteria-free hands.

You see, this procedure is not uncommon on rounds, it’s the protocol—sanitize in, sanitize out—as we visit each and every patient’s room. While this rotation, Infectious Disease with Dr. Carver, was not my first rotation rounding, the precautions meant so much more to me now. I am gaining a new appreciation for the world of the unseen, a world in which—invisible to the naked eye—bacteria specialize in ravaging the lives of perfectly healthy individuals within weeks, days, even hours. I began to slowly see the pages of my therapeutic notes come to life in front of my eyes. I’d find myself thinking, ‘Aha! Cellulitis. So that’s what it looks like!’

But seeing the patients themselves does not actually comprise the bulk of this rotation. Our daily routine begins with us (my colleagues Tony Elias, Mary Lou Chheng, and I) working up our own patients in the morning, where we assess all aspects of a patient’s antibiotic therapy: indication, dose, allergies, cultures and sensitivities, toxicity. I find this part both challenging and enjoyable. As I pore over the pages of Dr. Carver’s infamous bug drug list, I feel like I am engaged in nothing short of a battle of wits, reading an instruction manual listing all the strengths and weaknesses of my opponents, choosing the best strategy to outsmart them. We then meet with Dr. Carver to discuss our patients and make any necessary recommendations to the medical ID consult team. On rounding days we make the recommendations in person, and on non-rounding days we send our recommendations to the team electronically. The remainder of our day involves extensively reviewing with Dr. Carver the ID topics that are pertinent to our patients.

On a personal level, this rotation is also hitting close to home, as I realized the widespread implications of infection. For example, after seeing cases of patients acquiring infections after recent placement of prostheses the knee replacement surgery I had been encouraging my father to consider because of his increasingly intolerable osteoarthritis pain suddenly didn’t seem like such a good idea anymore. I finally understood why he is holding off on surgery as long as he can. Being a physician, he understands the risks of having foreign hardware in the body, a concept I only just began to internalize as a newbie in the healthcare profession.

And thus is my experience with ID so far. ID, which I have come to see as a delicate waltz, sometimes clinicians leading the dance, sometimes the bacteria, one always struggling to gain footing over the other. 

Rotation #5: Generalist (Adult)

Posted by Kristen Gardner at Sunday, November 11, 2012

I just completed my 5 weeks of the general medicine rotation at UMHS. LOVED it! I strongly believe in the decision by the Experiential Training Office to have this be a mandatory rotation for all students for the following reasons: 

1. It allows you to focus on core clinical services: pharmacokinetics, renal dose adjustments, anticoagulation, appropriate antibiotic use, anticoagulation education, and TPN (although this is just picking up in the adult generalist side).

2. It challenges students to handle a high patient load of ~30 patients daily which is nothing considering the generalists cover at least twice that number.

3. You get very familiar with the computer systems used and navigating your resources available. And you learn the documentation procedures.

4. I liked interacting with so many pharmacists and gaining their perspective on a number of things. You have your primary preceptor but other one cover for them and join your talks and are available to answer your questions if needed.



I do not want to reiterate what other students have said about this rotation as their descriptions were very good. So some specifics- I know we all like details! My journal club/topic discussion was on Stribild, a new HIV treatment, and review of HIV/AIDS management. I also delivered a patient case presentation on a patient dx with a pulmonary mold infection, Aspergillus fumigatus, and worsening of heart failure in the context of numerous other complications per normal given we are at UMHS. The preceptors led various topic discussions such as IVIG, geriatrics, pain, C. diff, and infectious disease which were useful.



What I did to stay organized

1. I printed off the patient overview from theradoc (not sure what this is technically called) to have a basic reference of lab values, meds, cx, crcl, age, allergies, etc. I would NOT print one out for every patient daily- just every time a new patient was admitted.

2. I printed off the theradoc roster of patients for each team for which I was responsible. I would write in a few phrases for why the patient was there to help me remember all 30+ patients! I would also write what I wanted to follow (BP, renal function, glucose, Cx (UCx, BCx, etc), pain med use, etc depending on high priority problems and therapy the patient was receiving. On the left side column I would write what my recommendations were or what I wanted to discuss with the attending (for non-rounding services) or the medical team (for rounding services). I would use the bottom to remind myself of what I need to follow-up on before leaving for the day or to keep track of doses given in the case of pharmacokinetic monitoring or pain regimens.

3. I would complete as much documentation as I could as I was going through and working up patients. Documentation includes, new starts, education, and summaries for anticoagulation, goal troughs for vanco, IV vanco/aminoglycoside follow-up, adding/deleting new flags from theradoc, reasons for using restricted antibiotics, pharmacokinetics, heparin drip follow-up, etc.



Common Interventions

1. specific therapy for infections

2. IV --> po switch for antibiotic regimens

3. Metabolic monitoring for patients on antipsychotics

4. Renal dose adjustments

5. Optimizing antibiotic regimens (ABW, frequency)

6. Citalopram --> lexpro switch for elderly patients on high dose citalopram + EKG > 500 + omeprazole 20-40 daily or BID

7. Optimizing pain regimens and adding therapy to prevent constipation

8. Reducing unnecessary use of IV meds

9. Warfarin dosing and scheduling

10. Optimizing enoxaparin dosing

11. Restarting anticoagulation after procedures

I hope you all enjoy this rotation! 

Life with Lexicomp

Posted by Janis Rood at Saturday, November 10, 2012

Rotation 5: Drug Information - Medical Writing

Yes, I just spent the last five weeks working from home in my pajamas.  However, much of my time was not spent medical writing.  In fact, the first week of rotation I really had no clue what I was doing except all my laundry and dishes were done.  This lack of structure was done on purpose as a way for the preceptor to gauge a student's level of ownership with their work.  For me these were very difficult waters to tread.  I had no trouble getting up each morning, working, staying on task, producing good work.  However, I had a tough time figuring out what was expected of me, how to judge my time management skills, how to gauge my progress.  We were given drug-drug interactions that already exist and tasked with finding all new literature regarding them, updating the monographs, and word-smithing the content.  I never felt confident that my approach to searching, evaluation or assimilation were correct.  However, none of this was actually seen so there was no way to receive feedback.  All I turned in was the updated monograph.

I know myself well enough that I am very plan-oriented, and working on random projects without a goal in mind would be five weeks of torture.  After the first week, I finished all my projects and asked to meet with the preceptor.  I explained my frustrations, and he seemed very surprised but extremely open to my needs.  Together we came up with a list of goals and objectives that I wanted to get out of the rotation.  Specifically, I listed all of the ways in which I felt weak in the areas of literature searching, analysis, evaluation and writing.  From that time forward, my preceptor adjusted the projects towards my interests with special attention to my weaknesses.  I was able to fully engage in topics that interested in me, while at the same time strengthening my skills.  We also kept an open feedback dialogue so I could easily chart my progress.

In the end, I am proud of the monographs that I edited and drafted, the databases I produced on natural products, and my overhaul analysis of OATP1B1 literature.  Ultimately, I decided that such a job would not be the best fit me for the following reasons:

1) I am a workaholic.  Working from home, while flexible, means that you never really leave work.  I need the physical separation from my workplace in order to stop working and not feel guilty about it.

2) I need my patients.  I discovered that what gives me the most satisfaction out of my work as a pharmacist is the impact I make on patients.  My work with Lexi supports evidence-based decisions, but is too far removed for my liking.

3) I need a team.  I like working with people and collaborating.  I felt extremely lonely working by myself, yet a little bit of a loser if I spent 8 hours in a coffee shop.  I much prefer to go to work, spend time working with other people in a team, then come home when all is said and done.

Nevertheless, I did come away with specific new insights:

1) I better understand the art of searching for literature, tweaking strategies, evaluating relevance, and compiling results.  I feel confident that given a topic, I could efficiently complete a literature review.

2) I no longer gravitate towards the discussion section or author's conclusion of an article.  It is so easy to do this, to get the point and get out.  However, I found that if I spent the time going through the statistics, teaching myself what they did, and analyzing the results myself, I came away with a much better understanding and could fully critique the author's conclusions.  I feel confident that over time this will get easier and easier, even though the time spent up front is a tad torturous.

3). Concision, concision, concision.  I learned how to create structure and use this to cut down words without losing my message.  Still a work in progress, but much improved.

All in all a good experience, but not my favorite rotation.

AMBUTUTIONALIST: an "institutional" rotation at Spectrum Health

Posted by Anna at Friday, November 09, 2012

I have just completed my rotation at Spectrum Health Butterworth Hospital in Grand Rapids, MI. Although technically an advanced institutional rotation, I feel it would be better classified as an ambu-tutiona-list rotation. This new classification stems from the varied components of this rotation that went beyond the traditional “institutional” requirements by combining ambulatory care, institutional tasks, and generalist activities. A list of some of my experiences better demonstrates this variety:

Ambulatory Care:
- One week at the West Michigan Heart clinic working with pulmonary hypertension and heart failure patients
- Performed medication histories and patient counseling
- Made recommendations to the provider and charted my interactions in the medical record

Institutional:
- Product dispensing and medication order verification
- Patient chart review
- Discharge counseling (Meijer Heart Center)
- Antibiotic pharmacokinetic monitoring
- Developed nurse-directed educational project on QT-prolonging agents in conjunction with nursing
- Two journal club articles and a formal patient case presentation

Generalist:
- One and a half weeks with the medical surgical unit performing patient chart review and work-up for 12 to 16 patients per day
- Rounded with interdisciplinary team and made treatment recommendations when warranted

My hours typically ran from around 7:30-4 (although this varied a bit), and for the most part I worked with a few select pharmacists. My preceptors were clearly dedicated to my education—you could tell they wanted me to be there and that they enjoyed teaching. This specific rotation was only introduced at Spectrum Health this year, and I was their second student. Many of the kinks had been worked out with the previous student (sorry Mary Lou!), and everything flowed much more smoothly for me. Although there were a few of those inevitable days where it felt more like a shadowing experience than a practice experience, overall the preceptors allowed me to be very independent and kept me busy!

I applied for this rotation specifically for the opportunity to see how things were done in a different health system. I personally benefited greatly from being in a different environment, and it provided me a chance to see how another health system is making changes to advance pharmacy practice. I also loved the opportunity to interact with other pharmacy students, as many Ferris State University students have rotations at this site. I was surprised by how inviting the atmosphere was to an “outsider,” and I would highly recommend this site for an institutional rotation!

My next rotation brings me back home to the University of Michigan Health System. For the next six weeks I will be exploring the world of informatics and administration on my “non-traditional” rotation!

ID Stewardship and Drug Info

Posted by Anonymous at Monday, November 05, 2012

Like many of my co-bloggers, I feel that these rotations are quickly passing by without much time to reflect! Here's a quick summary of my last 2 rotation blocks:

Infectious Disease - Antibiotic Stewardship @ UMHS:

This rotation was divided into ~10 day blocks so that we could get experiences in both stewardship and rounding. Throughout the rotation, the mornings began with a topic discussion lead by a preceptor, resident, or student. This served as a comprehensive overview of all important ID topics that we were likely to encounter over the rotation (and was very useful in reinforcing spectrums of activity for the various classes of antibiotics!). My first block was spent with my preceptor on stewardship, where I would preform culture reviews for all patients on restricted antibiotics within the hospital system on a particular service. This helped me become more familiar with the guidelines for use in patients, and get a sense for assessing clinical need for restricted antibiotics that I hadn't learned much about in school. The following two blocks were spent with a pharmacy resident rounding with ID teams. These services ranged between 10-20 patients at any given time, for which I was responsible for working up and assessing their therapy. Mornings were generally spent reviewing charts and discussing possible interventions prior to rounds in the afternoon. Another notable activity on this rotation was helping to create an competency test for staff pharmacists on our guidelines for antibiotic used, based on case scenarios. Overall, I believe this rotation was very useful during my P4 year to reinforce and expand upon the ID we learned in class. I highly recommend ranking an ID rotation!

Drug Information - Medical Writing @ Lexi-Comp:

This rotation was a review in how to review primary literature for updating or creating new drug interaction monographs for Lexi. Even though a majority of work is done remotely, I found this rotation to be very busy! My preceptor would send drug inquiry emails throughout the day for us to look into, in addition to our workups for newly-approved drugs and revisions to existing monographs. This involved fine-tuning primary literature search skills, and working towards making succinct monographs that contained clinically applicable information. Interactions are graded based on the risk of a patient experiencing a clinically significant effect, which sometimes is hard to judge based on limited information available. I believe this was a good exercise in learning to become more decisive in clinical situations by evaluating primary data and extrapolating its meaning in a patient-specific manner. Another rotation-long assignment was to develop monographs for herbal medications, which are currently limited in Lexi. This involved extensive primary literature searches for each type of interaction (i.e. flaxseed and estrogens, flaxseed and hypoglycemics, etc.). Finally, we met with our preceptor to discuss pharmacokinetic and pharmacodynamic interactions for the monographs we were looking into, and also presented a journal club to our group. Again, this rotation was busy but useful in developing my primary literature search and review skills, and learning how to apply this information in the clinical setting.