Monday, March 17, 2014

Ambulatory Care – Cardiology Clinic at the Ann Arbor, Veteran’s Affairs Hospital

Posted by Mindy Prasad at Monday, March 17, 2014

Rotation 7
Ambulatory Care – Cardiology Clinic at the Ann Arbor, Veteran’s Affairs Hospital

I was fortunate enough to get one of my top choices for the for the ambulatory care rotation. I had heard from students in previous years that this particular site and preceptor really challenged the student to perform at high levels, and would offer me an excellent experience in how a pharmacist can practice at the top of their license by essentially providing care autonomously in an outpatient setting. This rotation was also supposed to improve my cardiology therapeutic knowledge and force me to practice writing thorough SOAP notes. (SOAP notes are the main written communication tool used in patient care settings of all types and the level of detail varies with the type/scope of services provided). I can definitely say that this rotation lived up to all of my expectations!

Dr. Michael Brenner was my preceptor. He definitely had high standards for SOAP note quality and really helped me develop my writing by allowing me to make any corrections instead of just adjusting them himself. This was a really good way to get a lot of practice in writing. He also allowed me to see patients on my own for a large portion of the rotation. There was always the “staffing” component, of course (patient presenting) in which my recommendations were vetted and challenged by Dr. Brenner.

There are several types of clinics that Dr. Brenner runs and helps out with that provided me a variety of experiences. All are cardiology focused. On Thursdays was the post-discharge heart failure clinic, Monday mornings were the anticoagulation clinic, and the remaining days were general cardiology appointments in which patients were referred for Amiodarone monitoring, resistant hypertension, lipid management, or other cardiology related issues.

The beauty of cardiology is that much of the treatments are guideline driven. This is because there are LOTS (and lots!) of studies and clinical trials related to cardiology topics. There are also a very larger number of patients with cardiac issues. One of the most challenging aspects of this rotation was keeping the guidelines straight and remembering which drugs had evidence for mortality benefits and which drugs offered symptom reduction only. (Being able to cite a particular study when making a recommendation is particularly useful in defending a treatment recommendation to your preceptor.)

In addition to the clinics, Dr. Brenner provides medication education to cardiology patients who are signed up in a special program/class that offers exercise, dietitian care, and of course pharmacist provided medication education among other services. The veterans signed up for the group meet regularly over the course of five or six weeks and participate in a variety of sessions. The group is small and personal and I was fortunate to take part in two classes, the first time teaching about erectile dysfunction treatment options and the second time facilitating a question answer session. It was interesting, to say the least!

Dr. Brenner also provided the opportunity for me to spend a day in the heart catheterization laboratory (cath lab). I observed a left heart cath, a right heart cath, a trans-radial angiography, and the placement of 3 PCIs (percutaneous coronary interventions aka heart stents). This was amazing to see and I was surprised at how “awake” the patients were during the procedures. I also provided comfort to one patient before his cardioconversion and then I was able to actively participate in his conversion. It was impressive to see his heart rate drop from 105 to 83 instantly after 200 Joules of electric current went through him. One of my most memorable experiences of pharmacy school, for sure.  


Overall, this was a challenging yet rewarding experience. The patient population of this clinic was possibly my favorite part of the rotation. Everyone is a veteran and that is reason enough to instill a feeling of deep respect above and beyond the average respect for patients. Just walking down the hallways and saying hello is inspiring. It was really rewarding to be able to see changes in patients when they returned for follow-up appointments. This was a tough rotation but one that I am very grateful to have had. 

Sunday, March 2, 2014

The Pediatric Intensive Care Unit (PICU)

Posted by Mindy Prasad at Sunday, March 02, 2014

Since day 1 of pharmacy school, I had maintained that working with sick children is something I would never do. I've always preferred geriatric (people over 65 years old) populations. Children were out of the question; too difficult to manage their drugs and too upsetting to see sick kids - just not the environment I wanted to be in. But then I had a couple great professors in therapeutics courses who specialize in peds (pediatrics aka children); and then I took the peds pharmacotherapy elective course in P3 year and my opinion gradually shifted – well I at least became open to the idea. One thing I have come to realize as my pharmacy education at the University of Michigan has progressed, is how fortunate we are for the truly high-quality educators we have; and how some faculty will really go out of their way to listen to students’ concerns and offer advice when they are feeling conflicted. But I am starting to ramble, so…

Rotation 5 was in the pediatric intensive care unit (PICU) at Mott Hospital here in Ann Arbor. Dr. Elizabeth Beckman was my preceptor. The PICU had two teams each with attending physicians, fellows, resident physicians, nurse practitioners (NP), and Elizabeth to cover both teams, plus the two of us pharmacy students.  I was lucky to have my classmate and friend, Lydia, on rotation with me. (Challenging rotations are so much better when you are working with a friend and sharing the struggles and the triumphs.) Lydia and I each had our own team and we were responsible for the patients on our teams and attended rounds every morning. On most days we would arrive between 6 and 6:30am to work up our patients and talk to the nurses who were taking care of the patients overnight. Typically there were 8-11 patients on each of our teams, but that number could really vary day-to-day. Rounds would last anywhere from 2 hours to 4 hours depending on the acuity of the patients and the attending’s tendency to teach during rounds. When working up our patients, if we noted medication issues we would share our recommendations with Elizabeth first and then talk with the resident or nurse practitioner for that patient. There was already a very good working relationship established between the physician/NP team and pharmacy so recommendations were generally received well and often accepted without issue. After rounds we would again look over our patients’ profiles and note any changes. Then we would present our patients and have a pediatric-focused topic discussion with Elizabeth. There were also journal club presentations and pharmacy resident or medical resident presentations to attend.

This rotation was a challenge because of the steep learning curve and the patient population involved.  I was as prepared as possible for this rotation as far as coursework was concerned. I had taken both the peds elective and the critical care elective. What I wasn't prepared for, that no coursework could have prepared me for, was the emotional aspect involved in caring for children (and the family) who are in critical condition. For example…..getting to soothe the cries of a toddler by playing with them while the nurse is busy and the parents have taken a much needed rest, is a fun perk to the rotation. However, watching that same child crash onto ECMO (Extra Corporeal Membrane Oxygenation aka lung-bypass-machine) because the child is not effectively breathing on the very next day, is heart breaking. But then, when that same child is well enough to be weaned off ECMO and breathing on their own, and recovering such that the child goes home healthy and happy, well, that’s more rewarding than can be described. There was also a nearly indescribable moment when a different child who had been fighting for their life from an infection for 4 weeks of my rotation, finally had the ventilator tube removed from their throat and woke up enough to ask for pizza….it was amazing.

I left this rotation with a lot more knowledge and an even greater amount of respect for the professionals that treat sick children on a daily basis. Of course the medication dosing is extra complicated with no set doses and there is zero margin for error (children receive weight-based dosing for almost all medications), but also because a PICU in particular is an emotional roller-coaster. It takes a very special person to be a pediatric pharmacist. I had a great experience on this rotation and I really loved being around children, but I realized that I would probably be burned-out quickly from a career in this setting. Maybe my initial thoughts about pediatric pharmacy career options were a little too absolute, but I think I do still prefer the geriatric population if I had to choose a clinical pharmacy career path. 

Here is a special contribution to the blog (and special thanks to Lydia Benitez) to provide a different perspective of this rotation based on Lydia’s experience:

Status asthmaticus is a serious disease event that is frequently seen in the pediatric intensive care unit (PICU). There is a fairly standard treatment algorithm to guide the treatment of a child with status asthmaticus that is tailored to the patient depending on their needs. My experience in the PICU provided me the opportunity to care for multiple patients with status asthmaticus. One particular child’s case really hammered in the importance of intraprofessional communication. While gathering the medication history for a young boy, his mother told me that he was only on a rescue inhaler (albuterol) and had never been prescribed controller medications (inhaled corticosteroids). After contacting the patient’s home pharmacy to gather more information, and I found that he had received multiple courses of antibiotics and steroids from different urgent care facilities in the last year. I also discovered that he had been prescribed a controller inhaler once, but it had never been refilled. With this information, I went back to the medical team and we changed our approach to the situation. Instead of providing the standard training on new inhalers which would be prescribed, we could now focus on addressing specific factors pertinent to this particular child. We discussed the barriers to adherence with the controller medication that had been prescribed in the past, educated the patient and his family about the importance of using controller medications, and worked to ensure the patient had more cohesive care. The medical team contacted the patient’s primary care physician and shared information about the multiple exacerbations and our treatment plan for discharge. We were able to really help this patient by overcoming the immediate crisis and maybe more importantly, reduce the risk of future exacerbations and hospitalizations. By collaborating with the outpatient pharmacy team I was able to acquire information that would otherwise be unknown to our team. In a case where previous medical care was very fragmented, the patient’s community pharmacy of choice was constant, and by collaborating with them we were able to provide personalized care.    

Administration Rotation at the University of Michigan

Posted by Patrick at Sunday, March 02, 2014

I’ve long thought that I had a fair idea of what it meant to be “a busy person.” A glance at the schedules of Dr. Jim Stevenson (UMHS’s Chief Pharmacy Officer) and Dr. John Clark (UMHS’s Director of Pharmacy) overhauled my idea of what I thought “busy” meant. Their days are packed with meetings, generally from 8 am to 5 pm with few or no gaps, except for the occasional 15 or 30 minutes set aside for travel from one meeting to another. In order to have time during the day to “accomplish work,” in the traditional sense, they need to pre-emptively set aside blocks of time explicitly for that purpose. It was clear to me immediately that keeping up with the chaotic schedule of high level administrators was going to be a wild ride.

The rotation is subdivided into three major components: attending relevant meetings that expose the student to new aspects of administrative responsibilities, project time to work on ways to improve processes and advance pharmacy, and job introduction meetings with various other members of the administrative team. The student’s time is split approximately 45%, 45%, and 10% between these components respectively.

I’m proud to have successfully completed several interesting projects. My major project was a cost analysis of the feasibility of bringing some currently outsourced compounded products back into the UMHS fold. I met with a variety of pharmacy team members, gathering the relevant data and expertise, processed the data (in Excel, of course), and moved the project forward to the point where we could make a decision about the status of particular products.

The deepest thing I learned in my five weeks with Dr. Clark and Dr. Stevenson is about the information flow in a large organization and the way that institutional knowledge is distributed. A project of any considerable size requires extensive coordination between many individuals scattered throughout the department. This coordination role, bringing people with the relevant subject matter expertise together, is a key component of what makes an administrator successful.

As we darted from one meeting to the next, and the days turned into weeks, I also began to develop a feel for the deeper processes at work in the life of an administrator. Most accomplishments take place on a much longer time horizon than for front line employees. The question “what projects have I moved forward this month?” is in some ways much more relevant than “what did I accomplish today?” The understanding I gained from my time with Dr. Stevenson and Dr. Clark will inform my experiences in the coming years in any practice environment. 

Saturday, March 1, 2014

Improving Public Health through the Indian Health Service

Posted by Adam Loyson at Saturday, March 01, 2014

I hope you are enjoying a well-deserved spring break! Since last writing about my rotations in the emergency department and at the Food and Drug Administration, I found myself working in a more remote location with the U.S. Indian Health Service (IHS) located in Michigan's Upper Peninsula this past fall. Needless to say, providing health services to such a unique patient population has provided me with an experience that is unlike any of my other rotations!

Reversing health disparities
As an agency within the U.S. Department of Health and Human Services, the IHS provides health services to both American Indians and Alaskan Natives. The IHS was created to advocate for the American Indian people and to improve the access and delivery of their health care to the highest standard possible. Drawing from the past, American Indians and Alaskan Natives have historically experienced poorer health outcomes in comparison to other American populations. Remarkably, these native populations have a lower life expectancy and disproportional amounts of heart disease, pneumonia infection, and diabetes mellitus than individuals from other origins. The IHS is set up to specifically reverse these health discrepancies and focus on elevating the physical, mental, social, and spiritual health of American Indians and  Alaskan Natives.

Making an impact
There are 566 federally recognized American Indian Tribes, and I helped those affiliated with the Chippewa Indian Tribe. The health care services I provided during my rotation originate from an outpatient-like pharmacy that exists within a small tribal hospital. The hospital serves as a one stop shop for patients and includes clinics for mental health, dental, and ambulatory care services.

A day in the IHS outpatient setting consists of counseling patients in a manner similar to community pharmacy practice, interacting with health care providers, and engaging patients in medication therapy management to better understand their compliance and medication use in the outpatient clinics. I definitely considered this rotation to be fascinating based on the extraordinary plethora of opportunities available to make patient care interventions in the uniquely combined community-ambulatory care environment.

Patients who arrive at the clinic commonly cope with multiple disease states, including respiratory (asthma and chronic obstructive pulmonary disease) problems, diabetes, and chronic pain. These patients present great opportunities for pharmacists to determine whether the patients understand why they are taking their medication and know how to use their medical devices.   During my patient interactions, I frequently asked them if they were experiencing any medication-related side effects and if they were making appropriate lifestyle changes. I also evaluated patients for drug–drug interactions, drug diversion, and financial limitations to determine proper drug selection and dose escalation recommendations.

The pharmacists’ work in the outpatient world doesn’t go unnoticed. In my time with the IHS, completing such detailed patient assessments almost always led to improved patient outcomes and drug cost management. In addition, the IHS physicians were always delighted to have a pharmacist participate in interdisciplinary care and evaluate patients for medication-related problems before their primary assessment.

Learning automated pharmacy operations
Aside from the excellent opportunities for face-to-face patient interactions, my IHS site also featured integrated pharmacy automation and pharmacy robotics for drug selection and filling. Because this was my first time seeing these intelligent machines function up close, I was astonished by how much of the pharmacy workflow was simplified. Equipped with barcode technology and a comprehensive drug database, I learned how to partner with the robotic system to ensure the highest level of dispensing accuracy, efficiency, and patient safety. With robotic automation to the rescue, these mechanical systems also helped track drug use and accelerated prescription verification to free up significant time for additional patient interactions.

I was fortunate to have had this IHS rotation under my belt prior to the American Society of Health-System Pharmacists Midyear Clinical Meeting in December. I can confidently say that my counseling skills have improved drastically, as has my therapeutic knowledge set. After working with the American Indian population, I find myself even more curious about pharmacy careers in public health and the opportunities within the United States Public Health Service.

Only time will tell what the future holds for me!