The Best of Both Worlds: Emergency Medicine and FDA

Posted by Adam Loyson at Thursday, December 26, 2013

The last time I wrote to you I described my rotation in critical care, where I provided medication management to patients with a wide variety of medical conditions. I thoroughly enjoyed my experience but little did I know, my rotation experiences were about to get supercharged! In my next rotation, I found myself providing pharmacy services to anyone and everyone who entered the emergency department (ED) doors in a large academic teaching hospital.

It was time to grab the ropes quickly for this APPE rotation because each second of faster patient care initiation could very well be a second closer to saving a life. Shortly after this ED rotation, I entered the world of nontraditional pharmacy practice with a rotation at the FDA.

Breadth of learning opportunities

To my surprise, the ED is comparable to a health care superhighway with patients continuously seen and treated by multiple health care members. Patients are evaluated for the imaginable (animal bites and dehydration) to  the unimaginable (automobile accidents and occupational hazards).With the American Heart Association’s adult cardiac arrest algorithms committed to memory, I regularly participated with the emergency response team of physicians and nurses by preparing necessary drug dosages before they were needed and seamlessly relaying communications to the clinical pharmacist. With airway control and adequate respiration a priority in the management of any seriously ill or injured person, I also assisted in the proper selection and use of paralytic and sedating drug agents to aid in tracheal intubation.

There is nothing like coming right out of the gate on rotation and making an immediate impact in patient care. Staying current with disease management practices, I performed daily appraisals of clinical reviews and topic research on drug overdose/toxicology, trauma-burn, pain management, infectious disease, and cardiology.

Sky is the limit

Although providing high levels of care to patients in critical condition through a team-based approach was a priority in the ED, I also created in-service nursing education on vaccinations, an orientation manual for new ED pharmacists, and standardized the ED’s medication supply chain.

Don’t let this fool you though; there were also plentiful opportunities for patient interactions . In a profession focused on advocacy and provider status, there is nothing better than being one of the first professionals to enter a patient’s room, greeting them, and letting them know that a pharmacist is there to help them.

Navigating the unknown

After an exciting experience in emergency medicine, my next rotation brought me to the country’s heart of drug regulation at the FDA in Washington, DC. I was responsible for reporting to the Office of Compliance within the Center of Drug Evaluation and Research.

During my rotation, students were invited to participate in an extensive daily seminar series to assist with learning how the FDA works. Along with the 20 other students on rotation, I learned about the FDA’s involvement in the revolving drug approval process; the FDA’s role in adverse event review and analysis; and the presence of counterfeit drugs and other supply chain risks. What makes the FDA unique is the combination of employed civilian employees and United States Public Health Service (USPHS) personnel. In working with USPHS staff at the FDA, I learned much more about federal pharmacy opportunities post-graduation and was encouraged to apply.

Influential impact

My specific project at the FDA focused on the review of inspections of compounding pharmacies.  Currently, the FDA does not know how many licensed community pharmacies are actually engaged in activities that more closely resemble the manufacturing of drug products. and  has written warning letters to firms whose practices appear to exceed the scope of pharmacy compounding as outlined in the Federal Food, Drug, and Cosmetic Act of 1938., However, many of these firms believe that their practices fall under the compounding and drug product safety exemptions outlined in the Food and Drug Administration Modernization Act of 1997.

With the recent New England Compounding Center’s meningitis outbreak, the project I chose for my rotation included the review of existing pharmacy compounding inspection documents and recurrent citations (FDA Form 483). I believe the FDA could use my research in the immediate future to support portions of a current U. S. Senate bill that was recently passed by the U.S. House of Representatives, called the Drug Quality and Security Act, which focuses on compounding pharmacy regulations.

Box of chocolates

Overall, I greatly appreciate the vast hands-on involvement while working in emergency medicine and with the FDA. My career goals for the future are slowly coming together with the increased knowledge from these two rotations. Forrest Gump had it down when he said that life is like a box of chocolates and that you never know what you’re going to get. Reflecting on APPE rotations, you never know what great experiences will come your way. Bring on the next rotation!

Hail to the Little Victors: Pediatric Oncology at Mott Children’s Hospital

Posted by Rachel Lebovic at Monday, November 18, 2013

If I told you that my pediatric hematology/oncology (peds hem/onc) rotation was my favorite rotation to date and it confirmed that I want to pursue a career in oncology, you might think, “who could ever want to work with children dying of cancer?” While this area of expertise is certainly not for everyone, I will try to use the rest of this blog post to explain why I am eager to work as a clinical pharmacist specialist in oncology (and possibly even pediatric oncology) in the future.

First, the daily routine on rotation. On most days, I would arrive at Mott Children’s Hospital between 7-7:30am to work up my patients before meeting with my preceptor around 8:15-8:30am to discuss the interventions we wanted to make on rounds. Rounds started at 9am and lasted anywhere from 2-4 hours. Then, I would eat lunch and meet with my preceptor to talk more thoroughly about each patient, discuss what happened on rounds, and determine our plan for follow-up, monitoring, or counseling needed that afternoon. After handling any patient care issues, we would go down to the cafeteria for topic discussions and case presentations. I was very fortunate that my preceptor, Dr. Erika Howle, would take hours out of her busy day to help her students learn. The first week of rotation was a little crazy because we prepared one chemotherapy topic discussion and one supportive care topic discussion every day. In my opinion, the craziness of the first week was well worth it because it allowed me to start contributing to the peds hem/onc team almost immediately. Throughout the remaining four weeks, our topic discussions focused on different disease states, such as leukemias (ALL, AML), lymphomas, neuroblastoma, sarcomas, and sickle cell disease. At the end of the day, I would follow-up with the hem/onc team regarding any medication-related patient problems and look at any new patients before heading home to prepare for the next day’s topic discussion.

This schedule was fairly constant with the exception of Wednesdays. In fact, Wednesdays on the peds hem/onc service are so different that they are colloquially known as “Wacky Wednesdays.” On Wednesdays, the peds hem/onc department holds several meetings. At 7am there is an immunoheme conference where an attending, the oncology fellows, and others discuss complex cases involving immunology. At the 9am meeting, all of the peds hem/onc attendings and the current inpatient care team of a nurse practitioner, interns (1^st year medical residents), a senior resident, medical students, the pharmacist, and pharmacy students all meet to discuss current complex oncology cases. I loved listening to all of the experienced practitioners discuss the benefits and risks of different options for each patient – especially if I was helping care for that patient. Then, we started rounds at 10am and stopped for the tumor board meeting at noon. Tumor board is a joint meeting between the peds surgeons and peds hem/onc team. The practitioners look at scans then decide if a patient can go to surgery to have their tumor resected or if they need more chemotherapy to shrink the tumor before surgery is a viable option. After the conclusion of tumor board the team would finish rounds and address any patient issues the remainder of the afternoon.

In my spare time, I worked with a resident, another P4, and a pharmacist on a special project. After Mott Children’s Hospital heard about a hospital in Brazil that covers its chemotherapy with superhero-themed chemotherapy covers, we decided to pursue a similar project at Mott. Here is a video with our inspiration: http://www.youtube.com/watch?v=KC2y3s-MCMs. We contacted the hospital in Brazil, a plastics company, Disney, and others to start figuring out how to implement a similar chemotherapy cover program. I know this project will take a long time to be fully implemented, but I can’t wait to see how the kids like the chemo covers once they arrive!

Another special experience on the peds hem/onc service came on Halloween. Many members of the inpatient care teams in the hospital dressed up, and the hem/onc team was no exception. On rounds that morning, we had Mary Poppins, an Incredible, a bunny, two witches, Snow White, and a fairy!

Besides special fun projects and dressing up on Halloween, one of the big plusses to the peds hem/onc service is the tremendous impact you can have on patient care. An example of the interventions that I made on this rotation included changing a PPI to an H2RA (one type of acid suppressor to another) to avoid a drug interaction with a chemotherapy agent.  I was also able to adjust anti-nausea, pain, and bowel regimens to make patients more comfortable and help the team dose/monitor/adjust antibiotics to treat infections and neutropenic fever. Furthermore, I followed which chemotherapy agents each patient was to receive each day, made sure they were clinically able to receive the medication based on their blood counts, communicated to the inpatient pharmacy about which patients were going to receive chemo, and answered any questions the families had about the chemotherapy agents. Another plus to working with the peds hem/onc service is the continuity of care in an inpatient setting. Since many children require several rounds of inpatient chemotherapy, practitioners get to know the patients and their families.

In my mind, I can’t change that these children were diagnosed with cancer, but I can try to help them achieve their goals of care – whether they are cure, comfort, and/or palliation. I can help these kids just be kids, and that is an amazing feeling. Furthermore, the other members of the inpatient team rely heavily on pharmacy due to the specialty medications used in this patient population, which made me feel like a valuable member of the team. Yes, there are some patients who lose their battle with cancer, but in most cases the survival rates are actually much higher in children than adults, so there are fewer sad stories than you might think. Lastly, it is really rewarding to adjust patients’ medications to help them live more comfortably, especially if their goals are palliative.

Have I convinced you yet? It’s okay if peds hem/onc isn’t for you, but if you were skeptical, maybe now you won’t think I’m as crazy for loving this rotation and pursuing a career in oncology (and likely pediatric oncology) pharmacy.

Inpatient Psychiatry at Pine Rest Christian Mental Health Services

Posted by Silu at Thursday, November 14, 2013

What do you call an alligator wearing a vest?

…An investigator!

This and many other jokes brought to you by one of the psychiatrists I shadowed on a weekly basis, who told a corny joke Q 15 min while seeing patients. Welcome to the inpatient psychiatry rotation at Pine Rest.

A little bit of background information about this site, Pine Rest Christian Mental Health Services based in Grand Rapids is one of five largest mental health service providers in the nation and has over a 100 year history. Pine Rest not only has a 170-bed psychiatric hospital, but has several clinics in western Michigan and offers a number of unique behavioral health services.

The inpatient psych rotation at Pine Rest is definitely a unique one. Unlike typical inpatient rotations, I did not follow one group or one service of patients, since my preceptor, Dr. Kevin Furmaga, is the only pharmacist at the hospital. He works mostly on a consultation basis and receives requests from psychiatrists mainly for highly specialized or treatment-resistant cases. However, I did have numerous opportunities for patient care through attending multidisciplinary treatment team meetings, shadowing psychiatrists and following up with recommendations and questions, and interviewing patients for consultation.

I also taught a medication education class twice a week to patients in different units, as a part of the schedule/programming for patients during their stay. We discussed the classes of commonly-used psychiatric medications and answered questions for the patients. This was one of my favorite parts of the rotation. Though the material was the same each time, each class was very different depending on the patients there, and I gained a great deal of insight about their attitudes/perceptions about medications and treatment.

Besides patient care and teaching responsibilities, I also worked on a number of projects including (but not limited to) giving short topic presentations at treatment team meetings, creating a resource/guideline for therapeutic drug monitoring, and writing a drug monograph for formulary review for the P&T Committee.

This was definitely one of my favorite rotations to date. I learned so much more about not only psychiatric medications (oh yes, Dr. Furmaga will give you a personal lecture/review on psychopharmacology), but the complex spectrum of care that goes into mental health, including different types of behavioral and group therapy and even electroconvulsive therapy (ECT). I saw how, in a short period of time, a patient’s demeanor and mental status can change completely with treatment and also, unfortunately, patients who have had trials of over 17 medications with no response.

Overall, I'd recommend this rotation for anyone who is even a little bit interested in psychiatry. Dr. Furmaga is an excellent preceptor who is knowledgeable and well-respected. He is also flexible and will work with you on special requests you may have for the rotation. Be prepared to be work hard, manage your time wisely, and look for opportunities to learn in addition to or building on the ones already provided, but have fun and take advantage of your time there as a student. 

Sadly, this rotation marks the last of my clinical rotations. Looking forward to different experiences in drug information, community, and teaching skills for the next few rotations, but will definitely miss seeing patients!

-Silu

Rotation 4: Industry - Catalyst Regulatory Services, LLC, Dexter, MI

Posted by Jennifer at Thursday, October 31, 2013

After having 3 hospital rotations, I was excited to begin my fourth pharmacy rotation in the industry setting at Catalyst Regulatory Services, LLC.  Right from the start, Catalyst welcomed me into their team!

Catalyst is a consulting company that provides regulatory strategy and operational assistance to pharmaceutical companies large and small.  The president of the company is Mark Ammann, Pharm.D., and my preceptor, Anita Fereshetian, R.Ph., MS, is a regulatory director on the management team.  The Catalyst management team consists of a regulatory operations manager and senior consultants, many of whom are pharmacists and have had extensive industry experience at various pharmaceutical companies.  Catalyst also has a widespread consultant staff.

In a nut shell, biotechnology and pharmaceutical companies contract out to Catalyst for guidance with regulatory issues.  Catalyst assists with strategy development, submission of orphan applications, investigational new drug applications, new drug applications, and much more!  Catalyst composes submissions that are sent not only to the FDA but also to the EMA and other international regulatory bodies.  While on rotation, I was considered to be part of the drug development team in two specific pharmaceutical companies for which I was working on projects.

In the beginning of my rotation, I learned about Regulatory Affairs, clinical research, the Prescription Drug User Fee Act (PDUFA), and rare diseases and orphan drugs.  Mark, Anita, and others regularly had didactic discussions with me about these topics and more.  They were glad to have these talks and answered any questions that I had! As various topics arose during my rotation, there were often FDA guidances from which I was able to gather specific information and then discuss with my preceptor Anita.  I became a pro at navigating the FDA and EMA websites as well as clinicaltrials.gov to investigate planned, current, or even completed clinical trials.

I worked on some fascinating projects while at Catalyst!  Most notably, I was the lead author for an orphan application and drafted a protocol synopsis for a phase II study.  I learned in depth about a specific disease state and the current treatments for the disease, including current marketed therapies and investigational new therapies.  These were long-term projects that I worked on for the majority of my rotation, and it was rewarding to finish them on time before my rotation ended!

During my time at Catalyst, I observed several skills and attributes that I think are essential when working in Regulatory Affairs, and I was able to improve upon these skills while on rotation:
Ability to work independently and with a team – I worked on projects independently for some of the time, but I regularly discussed these projects with my preceptor Anita.  Even though self-sufficiency for working on projects is needed, it is very important to be able to work well with others.  For example, I worked with several other people from different divisions of a pharmaceutical company as well.
Time management – Many documents are time-sensitive.  Also, if a company has a goal deadline for a submission, a Regulatory Affairs professional needs to do his or her best to complete their work within that timeframe.
Detail-oriented – There are specific pieces of information that should be included in submission documents in order to obtain approval from the FDA or another regulatory body.
Critical thinking – Understanding the FDA guidances and figuring out how to construct submissions is vital.  Also, understanding the clinical data that supports the submission document is important.
Passion – As with any career, it is important to enjoy what you do!

A highlight of my rotation is that I was able to observe and contribute to team development and committee meetings with Catalyst and pharmaceutical companies, most notably preparation meetings for a pre-IND FDA meeting. There are different types of FDA meetings (A, B, C), and I was very fortunate that Catalyst invited me to attend a pre-IND meeting (type B) at the FDA in Silver Spring, Maryland!  It was terrific to learn first-hand how to prepare for and carry out a meeting with officials from the FDA.  It is very important to know exactly what topics to discuss at the meeting since time is limited.  Additionally, clear and effective communication is vital.

I learned so much about pharmaceutical industry while at Catalyst, not only through reading FDA guidances and working on projects but mainly by talking to people at Catalyst and other pharmaceutical companies about their career paths in industry.  They were all more than happy to share their experiences with me.  There are many wonderful career opportunities for pharmacists in the pharmaceutical industry!

Rotation 3: Pediatric General Medicine - C.S. Mott Children's Hospital, Ann Arbor, MI

Posted by Jennifer at Thursday, October 31, 2013

This rotation was different than my first two rotations in that all of my patients were pediatric patients.  Their ages ranged from only a few days old to late teens.  I did not have much previous experience with pediatrics, so I was very glad to have this rotation!

Daily routine:

0730-0830: I began the day with pre-rounding.  To me, the goal of pre-rounding is to understand the patient’s medical history and current status, think of recommendations to improve the patient’s medication regimen, and anticipate questions the team may have during rounds.  Recommended pediatric doses are often stated in mg/kg or mcg/kg, so it took some time to become accustomed to determining correct dosages for patients. 

Some questions I would be thinking about during this time:
What are the medications treating?
Are those the correct dosages, or do they need to be adjusted?
What should I be monitoring for (renal function, side effects, etc.)?
What changes to the medication regimen might the team be thinking about (IV to oral, increase or decrease in dosage, change to a different medication altogether)?
Can this medication be administered through a G-tube or J-tube?
Are there any home medications which are not listed on the inpatient medication list?

0830 - 0900: Present and discuss my patients with my preceptor and finalize recommendations for the team.  I actually worked with several different preceptors, and they all helped me to improve my therapeutic skills.

0900 - 1000/1100: Round with the team, which consisted of the attending physician, an intern, two residents, three medical students, the nurse, and myself.

1000/1100: Follow-up with any questions from rounds, complete medication reconciliations, track lab values for patients on total parenteral nutrition (TPN) and review the TPN orders. 
1330: Meet with my preceptor to verify TPN orders.
1400 - 1500: Finish medication reconciliations.
1500 - 1600: A variety of topic discussions, case presentations, and journal clubs would occur during this time.
1600: Complete any unfinished work.

It was quite a busy rotation, as you can see from the above daily schedule, but worth every minute of it!  The rounding team was very receptive to my recommendations and valued pharmacy contributions.  If treatment questions arose during rounds that required some research, I gladly would investigate and report back to the team.  I learned about many disease states that I had never heard of before and their recommended treatments! 

Rotation 2: Health System/Hospital - Providence Park Hospital, Novi, MI

Posted by Jennifer at Wednesday, October 30, 2013

I was able to experience many different aspects of hospital pharmacy while at Providence Park.  Each day was filled with different activities, so here I have organized my experiences by week.  The pharmacy staff was very welcoming, gladly allowing me to participate in pharmacy tasks!

Week 1: During this time, I was able to orient myself with the pharmacy department.  I spent time learning how they keep track of controlled substances and how they purchase medications and deal with medication shortages.  I worked in the clean room for a day and made IVs, worked in unit dose and packaging, and shadowed some of the pharmacists to see how they verified medication orders.

Weeks 2-3: Here, I focused on kinetics and anticoagulation.  The hospital has paper forms the pharmacists use to keep track of certain antimicrobials and anticoagulant medications.  I was able to look at patient profiles and discuss medication adjustments with my preceptor. 

Week 4: I began attending ICU rounds during week 4.  Before rounds, I would “pre-round,” meaning that I worked-up patients before rounds.  The rounding team consisted of the attending physician, two nurses, a dietician, the pharmacist, and me.  Since it was a smaller group compared to the larger rounding team at my previous rotation, it was easier to have team discussions here.  After rounds I would discuss my patients with my preceptor, much like my first rotation.  I learned a great deal about a variety of disease states. 

During week 4, I attended a Pharmacy and Therapeutics Committee meeting, summarized pertinent updates, and presented the minutes to the rest of the pharmacy staff.  I also gave a presentation to nurses, pharmacists, and pharmacy technicians, titled Prevention and Treatment of Opioid-induced and Immobilization-related Constipation.

Week 5: I attended ICU rounds during the week and also began working with the metabolic support pharmacist and hospital dietician for adjusting parenteral nutrition for patients. During week 5, I was able to observe two procedures in the operating room.  The staff kindly explained their tasks and answered any questions that I had about the operations.  I had never seen an operation before, so it was an interesting experience!  Throughout my rotation I also worked on projects, such as analyzing proton pump inhibitor usage in the hospital and adding information to hospital oncology guides for specific medications. 

I enjoyed the variety of projects and activities with this rotation and the fact that I was able to work with people from different departments in the hospital (nurses, physicians, dieticians).  The pharmacy staff here is friendly and work so well together that they are more like a pharmacy family.  I’m thankful for my time spent at Providence Park Hospital!       

Rotation 1: Adult Surgery - University of Michigan Hospital, Ann Arbor, MI

Posted by Jennifer at Wednesday, October 30, 2013

This was an ideal rotation to begin P4 year since it encompassed many disease states.  The main therapeutic areas I encountered were anticoagulation, infectious diseases, hypertension, diabetes mellitus, pain management, and total parenteral nutrition.  I learned a great deal while on this surgery service!

Daily routine:

0530/0600: Rounds started bright and early with the surgery team!  The exact start time of rounds would vary each day between 0530 and 0600.  Each morning I would be ready for any questions that might arise, with my white coat pockets filled with a few reference books, a calculator, and handy notes that I had organized.  The team was quite large and consisted of the attending physician, three to five medical residents, two physician assistants, three medical students, myself and another pharmacy student.  It was great to be part of the teamwork on rounds, with healthcare professionals from different departments working together to optimize patient care. 

0700/0730: I would work-up my patients after rounds.  By “work-up,” I mean that I would look at the patient’s profile in the computer system, gather information, and assess the patient’s treatment regimen.  I would check the doses, drug-drug interactions, and think of recommendations for optimizing the medication regimen.  The most challenging part of this rotation was forming a plan for the next steps in the patient’s care.

1200/1300: My classmate and I with would meet with our preceptor at this time.  We would present our patient cases and describe our plans for the patient (examples: dose adjustments, medication changes).  Our preceptor would ask us questions not only about the medications and disease states but also about the types of surgeries, which mainly involved the intra-abdominal area.  The Whipple procedure, ileus, fistula, anastomosis, esophagojejunostomy, and total gastrectomy were just some of the many terms with which I became familiar!  After discussion with our preceptor, we talked with the physician assistants about our recommendations.  Counseling patients before discharge about new medications, which were often anticoagulants, was another great way I was able to contribute to patient care. 

During this time, topic discussions also were held two days each week about subjects such as nutrition support and surgical prophylaxis.  My fellow classmate and I would read articles and prepare summary handouts.  These discussions were very useful because we would use this information when monitoring our patients.

This rotation was challenging and extremely rewarding.  Teamwork, time management, and efficiency were skills that I further sharpened while on the adult surgery service. Even with the early morning rounds, I am glad to have had this experience!

Dare to Fare in Critical Care

Posted by Adam Loyson at Sunday, October 20, 2013

Since writing about my nephrology rotation in the outpatient/inpatient dialysis unit setting, I am now concluding a rotation in critical care at a small private hospital. This new chapter of my APPE experience has been truly amazing, calling upon every bit of my pharmaceutical knowledge to save patient lives.

Detective work

With my new-found confidence growing from just one rotation under my belt, I was up for a new challenge. Enter the critical care arena. Becoming oriented to the intensive care unit (ICU) brought many new opportunities. Starting from day one, I found myself judiciously evaluating the complex clinical status and pharmacotherapy of the patients I was following. I also began participating in multidisciplinary patient rounds for the first time.  Intimidated, yes; but I was determined to make a difference.

Patients arriving to the ICU from the emergency department were often diagnosed with numerous disease states, frequently more than I could count with two hands. These patients required intricate care, with physicians often asking the pharmacist and me for our advice on the direction, agent selection, dosing, and duration of pharmaceutical care. With such inquiries, I quickly found myself becoming a supersluth in researching and recommending solutions from cardiovascular, respiratory, neural, metabolic, infectious disease, and gastrointestinal disease state guidelines. 

Endless opportunities

An exceptionally neat aspect about rotating in the ICU is the sheer number of interventions you can make as a student pharmacist. On a daily basis, I was involved in developing pharmacokinetic and therapeutic plans for patients receiving antibiotics (e.g., aminoglycosides and vancomycin) and anticoagulants (e.g., heparins and warfarin). I often encountered patients that required antibiotics for their recent onset of pneumonia, medications to convert their heart arrhythmia, or electrolyte supplementation. In these situations, I was able to educate the new medical residents about the appropriate agents, medicinal algorithms, and patient monitoring parameters to use.

In contrast to my last rotation in the dialysis unit, many patients in the ICU arrived with multi-organ failure. With elevated levels of acuity, many patients were prescribed complex medication regiments as inpatients.  Thus, I was able to answer many questions from nurses about drug interactions and intravenous line compatibility.

Evidence-based

The multidisciplinary team of physicians, dieticians, respiratory therapists, and nurses often consulted pharmacy services and inquired about the evidence behind particular therapies or signs of drug toxicity. My ICU experience  served as an excellent opportunity for gathering drug information, permitting me to evaluate literature sources for strength and relevance for the individual patients I covered.

For example, a patient was referred to the hospital and admitted into the ICU after taking four pills of diphenhydramine instead of one to help her fall asleep. The patient presented to the hospital with abnormal muscular spasms. After performing a quick search of the literature and contacting poison control, I recommended that an antimuscarinic agent be given for treatment.

Another pharmacy service that I participated in was the monitoring of per-protocol medication administration and assuring that standardized procedures were being met on a consistent basis based on patient care quality indicators. Such indicators that pharmacy would oversee include appropriate administration of a thrombolytic agent during a stroke, a benzodiazepine during alcohol withdrawal, or venous thromboembolism/gastrointestinal stress ulcer prophylaxis for patients during their ICU stay. Interventions were made if any practices were not in agreement with Joint Commission criterion or Medicare reimbursement models.

Continuous learning

Rounding out my rotation experience, I am happy that I have been exposed to the continually revolving care of ICU patients and the treatment of their medical conditions. Whether it is sepsis, hypertensive crisis, drug overdose, or acute coronary syndrome, I can assure you that I have learned substantially from the medication management in the critically ill patient population.  I recommend the ICU experience for any student pharmacists that are interested in challenging themselves and participating in a coordinated team to treat the extremes of human disease and ensuing ethical and social dilemmas.

Needless to say, this rotation has been a great opportunity to help me review for the pharmacy licensing exam!

Rotation 4 - Medication Safety

Posted by Unknown at Saturday, October 12, 2013

               With my rotations finally taking me back to Ann Arbor, I had the chance to get back into my school/life balance groove which I had finally perfected by the end of P3 year in Ann Arbor.  I recently started with a triathlon coach who has thus far kept my honest about training and injury free.  The increased training regimen made my mornings a bit earlier but it was well worth it.  Thankfully, this rotation with Dr. Ciarkowski, the adult medication safety officer, started at 8AM which allowed for my early morning wake up swim at 6AM.

                While this rotation was not as clinical or therapeutic heavy as others on my list, I learned so much regarding pharmacy practice, administration, safety, and communication skills in the process.  During my rotation, I saw first-hand the implementation of Alaris smart pumps and all the policies and training that were required to implement such a system.  In addition to the numerous training and policy meetings, I was a part of a root cause analysis meetings, pre-P&T medication-safety meetings, pediatric medication-safety meetings among many others.  I analyzed the 2012 data of pharmacy related medication errors and developed and presented an executive summary of strategies to implement that could greatly cut down and eliminate pharmacy related errors using systems such as widespread DoseEdge®, PharmTrace® among other strategies.

                In addition to going over medication safety topics and philosophies to prevent and address medication errors, Dr. Ciarkowski and I had the chance to talk at great length about what makes a pharmacist effective including career planning.   During numerous meetings, I observed how Dr. Ciarkowski interacted with numerous other health professionals and the strategies implemented to empower others and achieve pharmacy and safety goals.  By getting the right people together and not forcing change on any group, he allowed critical thinking and problem solving by the group as a whole to occur and create a group solution which gained multidisciplinary buy-in increasing the chance for success. 

                I gained far more than I initially thought from this rotation and enjoyed every day of it.  I even got some extra exercise walking outside to each meeting on a daily basis.  Next, I head to the Health System rotation at UMHS to bring my medication safety perspective to the actual process of medication management itself.  Already half-way done with rotations!

Rotation 3 – Learning to Pronounce Dexmedetomidine - Sparrow ICU

Posted by Unknown at Saturday, October 12, 2013

It seems like just yesterday I was strolling into the basement pharmacy admin offices for my first rotation at Sparrow (Drug Information) not 2 months prior.  Immediately, I knew this rotation was different and my vast community experience was going to be of little help.  Thankfully, due to Dr. Carver’s infectious disease teachings, I at least had ID information down, but I was in for a learning curve as I began my critical care rotation.

The first week, I was able to get my feet wet by having a chance to take part and help the unit-based pharmacist perform their daily kinetic and renal dosing services they provide for their patients.  Recently, Sparrow moved the pharmacists into a unit-based model getting the pharmacist out on the floor to answer questions and work more closely with the healthcare team to provide care for their patients.  Every day it seemed I was learning a new topic and was doing my best to sponge up the information regarding pressor therapy, how much, how long, how to withdrawal therapy, what to monitor, DVT prophylaxis, stress ulcer prophylaxis, evidence based delirium treatment and pain control among many others.  This ICU rotation has been my most busy and frustrating rotation to date, but it has been the most valuable and if I could have gone another week, I would have jumped at the chance.

By the second week, I had my first rounding experience and was excessively nervous looking back on it.  To be that close to the medical decisions being made for the patient with the chance and expectation to contribute and double check therapy for the residents was an amazing experience.  Although out of my element and really only hitting stride on what to look for in ICU patients toward the last two weeks, it really opened my eyes to hospital practice and how valuable the pharmacists are to the inpatient team and the impact they can have on patient care. While I made a few mistakes presenting patient’s to my preceptor, each mistake gave me more perspective and made look forward to coming back the next day to do better, learn more, and be the medication resource for the rounding team.  

It was tough, but I wouldn’t have wanted any other rotation instead….. except maybe a generalist rotation first!  While my stay in Lansing for the Summer was great, rotations 4 and 5 take me back to Ann Arbor  where my Pharm.D investigation and seminar await.

Rotation 2 – From the Largest Retail Chain to the Smallest Independent Community Pharmacy

Posted by Unknown at Saturday, October 12, 2013

After getting my feet wet in my Drug Information rotation 1, I took my newfound confidence to Grass Lake Michigan.  Turns out I had a good idea where it was as I recently raced a triathlon there the week before.  But I had no idea there was a pharmacy in Grass Lake and I almost missed it even with my phone telling me where to go. 
Upon my first day, I was warmly greeted by some of the nicest staff I have had the pleasure of working with.  My retail experience has been with Meijer for the past 5 years where on a daily basis we would complain about our state of the art computer system which seemed to crash all too often.  At Grass Lake it felt as if I had gone back in time nearly three-four years as many of their records were still paper and without a barcoding system which I had become all too dependent on at Meijer.  While they may not have had the multi-million dollar systems, they made up for it in patient care. 
After the first week I already began to recognize and know many of the patients coming through the door.  I had the opportunity to provide MTM services, participate in the final check and essentially run the pharmacy for lack of a better example.  A truly amazing community experience in addition to the managerial aspect behind the scenes which I had never seen as a tech or intern at Meijer.

Once it was all over and my gas bill of travel had taken its toll, I left with a new appreciation of the challenges facing independent pharmacies as well as the incredible, individualized patient care that one is able to provide in a small town independent pharmacy setting.  However, just as fast as it started, rotation 2 was over and I was headed 180 degrees in the other direction starting my first day in the Sparrow ICU.

Pediatric General Medicine: A Whole New World

Posted by Silu at Wednesday, October 09, 2013

Hi everyone. Rotation 4 has ended and so has 50% of P4 year. Siri tells me there are 199 days from today until graduation! Ah!

For this rotation, I was at UMHS Mott Children’s Hospital for pediatric general medicine. This is considered the “Inpatient A – Generalist” rotation that all UM students have to complete at a UM hospital, having the choice of either adult (University Hospital) or peds (Mott Hospital). I had no prior interest in pediatrics, and, up until a few weeks before the rotation started, I had no intention to choose peds. After some consideration, I changed my mind for the following reasons: 1) several of my rotations were adult internal medicine/general medicine-related, and I wanted to add some variety 2) quite a few residencies programs I looked at had mandatory pediatric rotations, 3) this was my last chance to learn about a special population of patients as a student!

The Mott General Medicine rotation has three main components: 1) rounding with a pediatric general medical team, 2) monitoring total parental nutrition (TPN), and 3) medication reconciliation. A typical day began between 7 and 7:30am, when I would arrive before rounds to work up my patients. This was followed by rounds (usually 1.5-2 hours) and TPN monitoring. In the afternoon, we often had topic discussions with the preceptor or would meet with the other Mott pharmacists and P4 students for presentations and discussions. In between, we would follow up with tasks and questions from rounds and complete med recs for newly admitted patients.

In the beginning, I felt like I entered another world. I Googled and Up-to-Dated every other disease state and wrote down everything I didn’t have time to look up to research later…which was always more than I expected. In the end, I enjoyed this rotation much more than I thought and learned a great deal, not only in terms of therapeutic knowledge, but also of unique challenges in pediatrics for which pharmacists can intervene. For example, since most young children cannot swallow pills, their medications must be in liquid form. It is up to the pharmacist to ensure the patient is able to obtain the liquid medication after discharge by confirming its commercial availability or notifying the team if certain medications need to be specially compounded.

Overall, I enjoyed this rotation for the continuity of seeing patients day-to-day, being a valued part of an interdisciplinary team and the challenge of using creativity and critical thinking to resolve special issues related to pediatrics. The hardest part of the rotation was balancing a full patient load with several other responsibilities, but it was a good learning experience in time management and productivity. In the end, I am glad I chose to experience pediatric pharmacy and feel more confident in working with kids. I’d recommend choosing Mott for the generalist rotation to anyone who is remotely thinking about it…you won’t regret it!  (Bonus? Beautiful view of Ann Arbor from the 12^th floor every day!) 

Ambulatory Care at the Canton Health Center

Posted by Patrick at Tuesday, October 08, 2013

At its core, ambulatory care pharmacy is about building relationships between a pharmacist and patient and meeting regularly to discuss specific problems and optimize the use of the patient’s medications. Sometimes these meetings are over the phone, and other times they visit the clinic; it’s generally up to the patient as to their preference. In the ambulatory care setting, we listen to the patient’s story, study the objective lab values, optimize dosing, and provide a substantial amount of motivational interviewing to help patients achieve their lifestyle goals (usually diet and exercise counseling for diabetes).

 

The contours of potential areas of focus are clearly spelled out in the collaborative practice agreement with oversight physicians. At the Canton Health Center, Dr. Rockafellow mostly manages diabetic patients, some hypertension patients, a few hyperlipidemia patients, and an occasional patient who is referred for polypharmacy (on such a large number of medications they their care requires active management).

This particular clinic operates 3 half days per week, from 9 a.m. to 1 p.m. with a full day from 9 a.m. to 5 p.m. on Tuesdays, with an average of six to ten appointments per day, though some days can be much higher (I’m pretty sure my busiest day was 16 patients, though most of these were shorter phone visits). By continuing to work with the same patients every few weeks, we have the chance to work on long-term goals in concert.  We can monitor their home glucose readings every week or every other week and make sure they are taking the optimal dose of insulin. We can also use this same data to help patients make connections between their diet and their diabetes control.

My patient load grew by the day until, by the end of the third week, I was managing all of the clinic visits and upwards of half of the phone visits. Regardless of how the schedule appears in advance, one scheduling change (for example, a patient arrives late, or has additional important topics to discuss that takes a bit longer than the appointed time) has the potential to turn a well-oiled morning into a scramble. After my first full clinic day overflowed all reasonable time constraints, I learned the importance of keeping one eye on the clock as well as a collection of techniques to move the conversation forward efficiently.

 

The best experiences were when the patients surprised you. One week a patient might not be open to making any lifestyle changes, but after listening to them and beginning to build a trusting relationship, it is amazing what changes one can see. On more than one occasion, I had a reluctant patient open up their lifestyle and independently identify possible changes. One thing I learned from this was that it’s not necessary to make every change at once. It’s largely unfeasible and it is certainly overwhelming for patients. Instead, it’s usually appropriate to work with them to find feasible targets for change build toward a more holistic approach week by week. In my view, this is one of the greatest advantages of ambulatory care pharmacy, an enormous opportunity for the profession to improve patient care in the future, and a possible career path for myself  as I gear up for graduation. It would be hard to imagine a better ambulatory care pharmacy practice experience than the one I had. 

Rotation 4: Health System/Hospital Pharmacy at St. Joseph Mercy Hospital

Posted by Rachel Lebovic at Sunday, October 06, 2013

I can’t say that I was looking forward to the health system/hospital (otherwise known as “institutional”) rotation, but at least it was nice to be back at St. Joe’s. All of the pharmacy staff there are so welcoming! I had my P3 institutional rotation at St. Joe’s last spring, and this fall I was assigned to St. Joe’s for my P4 institutional rotation. There were some pros and cons to having both of my institutional rotations in the same hospital. Pros included already being familiar with the computer systems, layout of the pharmacy, etc. Cons included seeing the same system twice instead seeing how different health system pharmacies function, as well as already completing many of the special activities that P4s usually complete on this rotation (such as “buddying” with a nurse for a few hours). At least the intention of the experience was different – the P3 experience was focused on teaching you how to do the work of the pharmacy technicians, while the P4 experience is focused on teaching you how to function as a pharmacist.

A typical day went something like this:

7:30am – check “F8s.” The term F8 comes from an old computer system in which you pushed the F8 key to perform this task. The task consists of checking 24-hour supplies of a specific medication for a specific patient that doesn’t get stocked in the Pyxis machines on the patient’s floor. My job was to verify that the medication in the Ziploc bag matched what was on the label, and that there was the correct quantity to last the patient 24 hours.

9:00am – check the ancillary cart. Unlike the F8s that are for specific patients, the ancillary cart contains medications that are going to be stocked on a floor, then can be used for any patient when the medication is ordered. My job was to check that each product matched the product that was requested by each floor.

Remainder of the morning – Sentri 7 renal dose adjustments and therapeutic duplications. St. Joe’s has a computer system called Sentri 7 that pulls in patient information from their charting program and helps pharmacists know where to focus their attention. For example, Sentri 7 helps pharmacists focus on anticoagulation, antimicrobial stewardship, renal dose adjustments, and many more clinical tasks. The P4 students are responsible for the renal dose adjustments and the therapeutic duplications. In the renal dose adjustment section, for each patient I would see which of their medications are renally dose-adjusted, calculate their creatinine clearance (an estimate of their renal function), then make sure the patient’s medications are dosed appropriately. If they were, I would document that in the system. If not, I would contact a pharmacist or physician treating that patient and ask them if they could adjust the dose to be appropriate for the patient’s kidney function. Most of the medications that needed dose adjustments were antibiotics. For the therapeutic duplications, I would see what medications Sentri 7 thought were duplicates, look in the patient’s chart to see if they were actually receiving both medications, determine if the patient had a need for both medications, then contact the physician if I thought one of the medications should be discontinued.

Early afternoon – patient’s own meds. Most of the time the hospital provides all of the medications a patient takes in the hospital, but sometimes, a patient wants to take a medication they bring in from home. Many of these medications are inhalers, birth control packs, or unique/expensive medications that the hospital doesn’t have on its formulary. In this case, the physician would write an order for a “patient’s own med” and I would go to the patient’s room, verify that it was the correct medication, then label the medication with a barcode so the nurse could scan it when the patient took the medication.

Late afternoon – ALS boxes and bags. Ambulances carry boxes and bags full of medications to administer to patients on their way to the hospital. When the patient arrives at the hospital, the used box or bag gets dropped off at the hospital to be replenished, and the ambulance takes a fully stocked box or bag that the pharmacy staff members already refilled. As a P3, I refilled the bags and boxes in the manner that a technician does. Now, as a P4, I checked the bags and boxes and added the controlled substances in the manner that a pharmacist does.

Other projects I worked on during gaps in my daily routine included a journal club presentation and an audit. The audit assessed discrepancies in patients’ medication lists from their primary care physician and their hospital discharge papers, before and after St. Joe’s hired four med historians to perform medication histories when patients are admitted to the hospital. We found that the med historians decreased the number of discrepancies between the patients’ medication lists with the addition of the med historians, although the discrepancies were not eliminated completely.

Other special activities I completed throughout this rotation included rounding with two residents, reviewing patient profiles, performing anticoagulation assessments and antimicrobial stewardship reviews, discussing IVà PO (oral) medication conversions, verifying orders that are part of order sets, and answering drug information questions.

My most rewarding experience this rotation came when one resident had a patient with HIV on his service. Since I recently completed an HIV rotation, the resident asked if I would mind looking at the patient’s HIV therapy to make sure it was appropriate. When I looked at the patient’s profile, I noticed the patient’s HIV medications did not compose a logical regimen. It appeared that the physician had ordered a medication called “Intelence” instead of a medication called “Isentress.” While these medications sound very similar, they are from two different classes of antiretrovirals. I paged the physician to ask if he meant to order the other medication, and he said he did and he would update the order. I was very proud that my knowledge of medications led to a significant improvement in patient care!

Overall, I am much more interested in being a clinical pharmacy specialist than working in the institutional setting doing drug distribution and verifying orders, but I understand why this rotation is important. The pharmacy needs to get the right drug to the right patient at the right time before pharmacists can be involved in more clinical work.