Getting psyched for Inpatient Psychiatry

Posted by H. Tran at Thursday, December 31, 2015

Rotation 6 for me was Inpatient Psychiatry in a small hospital. I wasn't too sure what to expect, as I've heard stories about the patient population from another classmate who had this rotation, frightening stories, and the lack of an electronic medical record and other technology that led to many medication errors. But as always, I just brought my "A-game" and let the rest unfold from there.

Upon arrival, I had an eerie feeling run through me. I had to press a button that apparently turned on a camera for the receptionist to see and open the door for entry into the building.  It was obvious that security here was a serious issue.

I introduced myself to the receptionist and asked for the pharmacist (my preceptor). While I was waiting, I observed some anxious adults, who appeared to be patients waiting for intake and admission, but my attention was suddenly drawn to a group of people coming out from the hospital hallways for discharge. A set of parents were eagerly waiting for their daughter, and the look of thrill and happiness of both parties after they were reunited was great to see.

My preceptor welcomed me in and introduced me to the facility. She gave me a set of keys that I was to use to get through every set of doors in the hospital, and explained the process needed in case of lost keys and the incident report required to be done. This is unlike hospital I've been trained at as a Wolverine, where we could use our ID badge and just scan in. Here, we use keys. Additionally as she gave me a tour of the facility, she instructed me to look through the small window on the door to the other side in case there was a patient waiting (or hiding) near the door for an opportunity to escape. "Wait 3." She explained to me to wait 3 seconds after the door shuts to ensure that the door has been securely locked before I proceed to my duties. There is a high elopement risk, and the necessary precautions were in place.

My first day already was a thriller. Towards the end of my day I was debriefing information with my preceptor, when suddenly, we hear loud noises as if there was an argument, a slam, and briefly see a shadow swiftly pass about 5 feet behind us as we turn our heads. A patient had just escaped from his unit. Code 5 was repeated throughout the intercom, alerting all staff to be wary and all trained staff to assist in the pursuit and tracking of this patient's AWOL. At this moment, I felt goosebumps rise throughout my arms and legs. (Note: the patient was eventually located, brought to safety and treated appropriately.)

This incident alone made me more aware and more cautious for the entire rotation. Although these patients are mostly on involuntary holds that would usually require pharmacotherapy, it's important to understand what they are going through and what they may be feeling to help them. Part of my role here was to go into the units and interview patients to assess pharmacotherapy. Beyond that, I tried to get an understanding of the patient, what they are going through, how they are feeling, and their perceptions of their medications. Not only did this allow me to develop a connection with the patients and choose the most appropriate agent for them, but it also served as a learning opportunity for me. I got a better understanding of patient's symptoms of psychiatric disorders such as bipolar, schizophrenia and depression, and a better understanding on how specifically their medications are treating their symptoms, and what it is doing for them. Learning from a textbook, PowerPoint lecture slides, and audio recordings from classrooms is different than hearing real stories and perceptions of patient experiences with not just the disorder, but the medication.

Another responsibility I had was to hold weekly groups at different units covering the topic of the week (i.e., depression, bipolar, schizophrenia, detox, etc.). This led to some great conversations, and allowed social workers to assess the progress of the patient. It also allowed me to have greater insight into how the patients felt about their medications and talk about the stigma involved. I also had wonderful opportunities to take their questions, and look up the ones I didn't know to get back to them. Some of the questions were very specific, such as "why does my SSRI cause weight gain?" and others were more general such as "what are the side effects of my risperidone? and "does my gabapentin affect GABA receptors?" Overall, this rotation was very interesting and the groups were informative for both ends.

Some other interesting incidents during this rotation include a code calling for assistance because a patient was actively cutting herself in the hallway (from wrist to elbow on both arms, leaving a very bloody hallway), and a physical altercation that included a person laughing hysterically into another person's face.

It was a very interesting rotation on a patient care standpoint. Another great learning experience was that given its limited resources, it has made me more appreciative of having an EMR and advanced technology to help prevent medication errors. At this site, we did not use a electronic medical records or Pyxis(R) machines. In a way I'm kind of glad to have completed the rotation, and now I'll use winter break and my off rotation to prepare for my next steps in pharmacy.

Rotation 6 - Refigerator Malfunctions, Life on Hold, and Other Stories

Posted by E. Caliman at Sunday, December 20, 2015

I spent Rotation 6 at the University of Michigan's Drug Information Service. This mainly consisted of working on a couple of assigned projects while fielding calls from various U of M practitioners. Some were quick fixes that merely required reading a medication's package insert, while others required consulting multiple resources to discover the answer. Unfortunately, there is not a lot of data out there for some questions and the best answer you can give is "We couldn't find any data on your question. Use clinical judgment".

One of the more frequent types of calls we received were storage conditions of medications requiring refrigeration. In a few instances, we had some malfunctions that allowed the medications to go on excursions outside their specified temperature. This required calling the manufacturer for information on what the stability is outside of the recommended range. This meant spending a lot of time on hold. We learned to dread calling one particular manufacturer because in order to get the information, we need the expiration date and lot number of the affected products, whereas other manufacturers could provide blanket data.

Calling manufacturers for other reasons resulted in substantial hold times. I got used to listening to hold music, which was mostly smooth jazz or classical music, but one manufacturer in particular played country music, which surprised me. One manufacturer I had to call a couple of times had no hold music, so I sat at my computer, listening to silence. The best you can hope for in these instances is that you navigated the menu tree correctly so you wouldn't be transferred all over the place to someone else who would tell you that this was the wrong department and transfer you again.

There were some interesting stories we encountered in the call center. One was involved a patient's medication by a certain manufacturer no longer being approved by his mail-order pharmacy, so we looked into other generic manufacturers, guided by the site of manufacture. Another involved calling a manufacturer for information on an adverse event that limited the functional capabilities of a patient. Finally, another medication had a temperature excursion, but it was in a patient's home. It was a very expensive medication, but thankfully could remain stable for long enough that the patient could finish it.

Our longitudinal projects included filling out Medwatch reports, where you report adverse events to the FDA. We thankfully only had a few to fill out this rotation. It involves going into the patient's electronic medical record and gathering the necessary data for the form. The other project was a drug monograph, a summarizing report on a particular drug. The ones we were assigned were newly approved by the FDA, but were waiting approval to the U of M formulary. This project involved reading the package insert, looking at prices, and reading clinical trials.

This rotation was a bit more laid back, which is nice when you're trying to prepare for the next stages in your career, including job, residency, and fellowship interviews, attending ASHP Midyear, and finalizing your research paper.

Rotation 6: New Patient Resus Bravo

Posted by Emily at Thursday, December 17, 2015

Six rotations down, another Midyear meeting in the books, and Christmas right around the corner!  P4 year sure flies when you're having fun, and I had a great time doing an additional "inpatient" rotation in the adult emergency department at UMHS.

in the ED satellite

This rotation confirmed my interest in emergency medicine pharmacy and as a result, I focused my Midyear Residency Showcase adventure on speaking with programs that have strong EM offerings.  Emergency medicine pharmacists have a variety of responsibilities, and the extent of pharmacy involvement in the ED is hospital dependent.  Some hospitals don't have pharmacists stationed in the ED at all, while others have a well-established pharmacy presence.  At UMHS, ED pharmacists are in charge of verifying orders for patients in the ED, making IVs since there is no designated ED pharmacy technician, managing cardiac arrest and rapid sequence intubation boxes during codes (e.g. predicting what medications the docs are going to ask for before they ask for them, and having the syringe or bag prepped; providing agent and dose recommendations; keeping track of how long a patient will remain sedated and paralyzed based on the sedative and paralytic they were given for intubation, etc.), providing antibiotic recommendations, answering drug information questions, and attending rounds in the emergency critical care center (a sort of mini ICU attached to the ED).  Most of my time was spent in the pharmacy satellite working on projects, topic discussions, and helping with compounding in the IV hood.  But whenever a new patient was brought into the resuscitation bay, a page would go out over the loudspeaker announcing their arrival, and pharmacy would run over to assist.  Not surprisingly, there was no "typical day" in the ER, so here's an overview of how I kept busy during the last six weeks.

What I Saw:

• A variety of overdoses (acetaminophen, alcohol, sertraline, nortriptyline, diphenhydramine, ibuprofen, zolpidem, lorazepam, alprazolam, quetiapine, hydrocodone etc.)
• Several codes/cardiac arrests, which also meant seeing CPR conducted in real life for the first time
• One of the aforementioned cardiac arrest patients being put on extra-corporeal membrane oxygenation (ECMO)
• A handful of motor vehicle accidents (cyclist vs. truck, car vs. tree/telephone pole, car vs. car, etc.)
• Singed nostrils on a patient who had tried to smoke with her nasal cannula still in
• Hypertensive urgency (with a systolic BP of 294)
• Hemorrhagic shock due to GI bleed
• Ischemic strokes
• Dislocated shoulder
• Septic shock
• Severe respiratory distress
• Diabetic ketoacidosis
• A really gnarly leg wound due to a fall in an elderly patient
• Frostbite
• Compound arm fracture

What I Did:

• Helped at codes (twisting together epinephrine syringes, making a bicarb drip, drawing up just-in-case-of-intubation etomidate, handing off meds)
• Verified orders (with supervision)
• Made IVs, including t-PA
• Assessed appropriateness of vancomycin orders and made dose recommendations
• Counseled patients on how to use EpiPens and Combivent inhalers
• Picked up a handful of evening and weekend shifts, and spent some time in the pediatric emergency department in order to get the full ED experience
• Led topic discussions on advanced cardiac life support, rapid sequence intubation, myocardial infarction, urinary tract infection, status epilepticus, appendicitis, diabetic ketoacidosis, burn management, delirium, GI bleed, stroke, sickle cell crisis, phototoxicity, and sexually transmitted infections
• Developed nursing education slides for ED pharmacy bulletin board on details of new Established Status Epilepticus Treatment Trial being conducted at UMHS
• Updated UMHS antidote stocking quota list
• "Precepted" M1 students who were required to shadow a pharmacist as part of their curriculum

ESETT slides for ED pharmacy bulletin board

What I Learned:

• The ED was not as full of blood and guts as I was expecting.  Most of the patients that came in to the resuscitation bays were medicine patients rather than acute trauma patients.  Had I been in a big city like Chicago or Detroit, I would have seen more "penetrative traumas" (e.g. gunshot and stab wounds), but around here we have a lot of elderly patients having heart attacks, strokes, and other accidents - especially during the day shift.
• Heart attack patients can look really asymptomatic.  On TV, people having heart attacks always clutch their chests and collapse.  During this rotation I saw a handful of patients who had been sent to us only because their PCP noticed something off on their EKG; otherwise they looked and felt normal.
• NAC really does smell as awful as we were told it does.

Challenges:

• There are about six different pharmacists who work the day and afternoon shifts in the emergency department, so in addition to my primary preceptor, I would work with two different pharmacists a day and at least five different pharmacists per week during this rotation.  This was tricky just because each pharmacist does things a little bit differently and I had to adapt to make sure I was meeting the expectations of whatever preceptor I happened to be working with at the time.
• The ED at UMHS is a very "feast or famine" environment.  I rarely had a day that was just a steady flow of resus patients.  I would either have days where almost NO new patients came into the resus bays and I would spend all day working on projects and topic discussions, or days when the resus pager was going off every ten minutes.  There never seemed to be a lot of in between, and I would have been grateful for a few more busy days.
• Unfortunately, I also saw a patient die for the first time during this rotation.  

Now I'm looking forward to a couple weeks of break before starting block seven and, even more daunting, residency interviews.  Stay tuned.

Rotation 5- Keeping it Under Control

Posted by E. Caliman at Wednesday, November 18, 2015

Rotation 5 would have to be my favorite rotation so far. I rotated at the FDA with the Controlled Substances Staff, the people who handle concerns with the controlled substances coming through the pipeline as well as the drugs that affect them (ex. naloxone). Every day was something new and I got to do things most pharmacy students would not get to do, such as help my preceptor prepare for the World Health Organization's summit on international drug control and summarize a report requesting Schedule I substances for research. I also helped edit a drug label for a controlled substance that has since been approved and researched a topic of interest to my preceptor and other members of the staff.


One of the great things about the FDA rotation is that you get to go on a lot of field trips. You can go to the Pentagon as well as visit APhA and ASHP headquarters, all of which are in the area. Even though you are assigned to one department, you can attend lectures given by people working in various departments so you learn the broad scope of the FDA. It will force you to manage your time well, as there can be several lectures in a day and you'll have a project or two to work on.


I thoroughly enjoyed my time at the FDA and genuinely did not want to leave (and it's not just because the high was in the 70-80 range at the beginning of November). The people were great and the projects I worked on were very interesting. If you have any remote interest in regulatory affairs, definitely apply to do a rotation or an internship.


If you are lucky enough to be chosen for a rotation, here are some helpful tips I wish I knew before coming to the FDA.

1. Locate which campus you'll be on. Odds are, you'll be at either White Oak or Hillendale, both of which are on the same stretch of road, New Hampshire Ave.

2. If you're driving down from Michigan, bring about $40 in cash for the toll roads, mainly in small bills.

3. When you get here, you should get a SmarTrip card. It's like a pre-paid debit card that allows you to ride the public transportation in the area, including the Metro Rail, Metro Bus, and Montgomery County Bus. It can also be used to pay at parking meters. It will get you $1 off each Metro Rail ride and will serve as your transfer between the above modes of public transportation. There may be some days where you'll be traveling offsite on different field trips, so driving may not make sense. You can pick them up at any of the Metro Rail stations. Starting in 2016, they'll be the only thing you can use for the Metro Rail. Buses and Metro Extra Buses are $1.75 per ride.

4. When dealing with public transportation, there is no "Ride Guide", like we have in Ann Arbor. Each route is published on a separate pamphlet. You can access the website at wmata.com. You'll also note that the buses do not display the route name and number, followed by the destination (ex. Washtenaw, to Ypsilanti). Instead, they just display the route number and the destination.

5. Parking at the FDA is free, but if you're in one of White Oak's parking decks, it may be difficult to find a parking space where a permit is not required, so you may end up on the roof. If you enter the parking deck late enough, you may notice that the attendants have parallel parked some cars that are blocking a row of cars in.

6. Bring reusable shopping bags. There's a 5 cent charge per plastic bag you use when shopping if you use the store's plastic bags. Also, the sales tax is 6% in Maryland, 5.75% in DC.

7. The FDA is very close to the borders of Washington, DC and Virginia, so don't be too surprised if you hear about people commuting from Virginia.

8. Pack warm clothes if you're going from October to March. The highs may still be in the 60-70 range in early October, but in the mornings, it's in the 40-50 range.

9. This one is crucial: email your preceptor to find out when your badging appointment is. You'll have an appointment to get your ID badge, and they won't do that without all of your paperwork. You may experience some backups with the Badging Office. The sooner you can get your badge, the better. On the first day, you'll sign in at a check-in kiosk and get a sticker name tag. When you have this, you have to be escorted everywhere, but with a badge, you don't need an escort.

10. Some days, your preceptor will work from home. They'll tell you what days those are, but they'll likely be around for the first week, unless they're traveling.

Rotation 5: Beyond the Comfort Zone

Posted by Unknown at Sunday, November 08, 2015

My fifth rotation (where is the time going?) was on the pediatrics generalist service.  Emily did an excellent job of summarizing a typical day in her post, which can be found here.  But this rotation was a giant leap outside my comfort zone

I have said from the first day I walked into the College of Pharmacy that I did not want to work with kids.  First, it was that I didn't want to see sick kids, that I didn't think I could emotionally handle it.  Once we had our pediatrics section in therapeutics, I was worried about dosing and the complexity of their medications.  When I was ranking rotations, I purposely ranked all the inpatient adult rotations in a desperate attempt to avoid pediatrics.  However, once I started on rotations and I was trying new things almost daily, I softened up to the idea of trying pediatrics on my generalist.  By the time rotation three rolled around, I desperately wanted a change of pace from the adult world and to diversify my experiences as much as possible.  Luckily, I was assigned to the pediatrics generalist service.

My first day of rotation I was incredibly nervous, because I hardly knew anything about peds.  However, my preceptor and the residents, interns, attendings, and med students were very supportive and helpful, and with their assistance I was able to quickly learn the ropes and learn medication dosing and protocols.  The parents were so grateful that we were there to help, and the kids were usually happy to see us and eager to show us the picture they had painted or tell us about their day.  The hospital was a place where we could help kids feel better and put a smile back on their faces, and it wasn't as hard to handle as I thought it might be.  

While I learned a lot about pediatric medicine, especially unusual conditions like short gut syndrome as well as nutrition, I also learned a lot about appreciating opportunities I may never get again.  For those of you who are ranking rotations, don't close any doors until you've tried something.  While I don't want to specialize in pediatric medicine, I am grateful for this opportunity and I am so glad I elected to do peds rather than another adult rotation because it exposed me to a whole other world of diseases and medications.  I feel I have a more well-rounded education now because of this experience, and I wouldn't trade it for anything.  

Rotation 5: “Cause, baby, now we got bad blood”

Posted by Stephanie Burke at Saturday, November 07, 2015

I was on the inpatient hematology/oncology service this past rotation block. The experience was more than I anticipated! As my first intensive patient care rotation, I was slightly (i.e. terribly) intimidated by the thought of enduring five weeks on such a demanding and challenging service. Fast-forward a bit: I survived! It took quite a bit of adjusting to the therapeutics of the rotation, but by the end, I felt fairly comfortable managing my patients on the floor. I arrived at the hospital early each morning and some days stretched pretty long. My daily routine involved working up patients for the day, rounding with the hematology and oncology teams, following up on patient needs or physician questions, and finally topic discussions with my preceptor and PGY1/2 residents in the afternoon. Overall, it was a well-rounded learning experience.

My favorite part of the rotation was working with hematology patients. I learned the guidelines for managing acute myeloid leukemia patients, lymphoma patients, and patients with neutropenic fever relatively quickly. I always felt on top of the needs of my patients; monitoring their renal function, need for continuation/discontinuation of anticoagulation, antibiotics or antifungal agents, drug levels, etc. I had an impact on the health of my patients, and even if they only had a week or a month more to live, I was going to do everything I could to ensure their last days were comfortable. This was the hard part of heme/onc – many patients did not have much longer to live. I remember my first week on service standing with the medical team in a patient’s room. The patient was dying, completely incoherent and unable to communicate effectively with us. As the attending began the conversation about home hospice care with the patient’s spouse, the spouse appeared okay, taking in this difficult news. Then, he was not doing okay and began to cry. As we all stood in silence with our heads down, the attending comforted the spouse. It was my first dose of reality in the world of the sick and dying. This aspect of the rotation also took some adjustment. Many of our patients were sick and dying. But, as my preceptor reminded me, the patients we saw in the hospital were only a subset of all the hematology and oncology patients outside of the hospital who were doing fine.

This rotation challenged me in many ways. Professionally, it challenged my knowledge and understanding of therapeutics and pathophysiology. Personally, it challenged me to remember that each day is a gift, and even in the toughest of circumstances, one can still find joy and hope. It takes a special person to work on the hematology/oncology service. Some days it was a lot to handle, but if nothing else, remember your patients. Some are fighting for their lives, and you need to do your best to help them in that fight. 

Rotation 5: Compounding Community Pharmacy

Posted by Emily at Thursday, November 05, 2015

I was fortunate to complete my community pharmacy APPE experience in a unique setting: a local, independently owned compounding pharmacy. I wasn't sure what to expect going into this rotation, but what I got was five weeks packed with variety and new experiences.

This rotation site was certainly not your average community pharmacy. According to my preceptor, about 80% of the prescriptions filled here are compounds, while the other 20% are "traditional", commercially available prescription medications. The front of the pharmacy has a small corner for normal OTCs, while the rest of the space is devoted to professional-grade, made in the USA dietary supplements. I had shadowed at this pharmacy as a P1 and ranked it for APPEs knowing that the pharmacy had a complementary and alternative medicine (CAM) leaning. My preceptor was very knowledgeable and walked an interesting line between the world of pharmaceuticals and nutraceuticals. As someone interested in CAM and traditional pharmaceuticals, I found this balance fascinating. It was clear on day one that this unique pharmacy attracts clientele who run the gamut from being heavily skeptical of alternative medicine, to being 100% against pharmaceuticals just because they're pharmaceuticals. My preceptor did an excellent job of presenting balanced information to a patient who was proud to no longer be taking her beta-blocker and was seeking a "natural" alternative for her heart condition. The pharmacist showed that he understood the patient's reticence to use prescription drugs, but explained that beta-blockers are often life-saving and that there was no good nutraceutical alternative. I tried to take this balanced approach in the consults I conducted independently throughout the rotation. I understand being hesitant to take drugs, and I think many people are over-medicated or unnecessarily medicated. But many medications are necessary, and it's the pharmacist's job to help patients make the distinction.

Each day was busy with small projects and tasks that included patient counseling, supplementation consultations, verifying lab calculations, helping to pack compounds into their dispensing receptacles, receiving, transferring, and filling prescriptions, making capsules, working in the sterile lab, fielding drug information requests from patients and practitioners, and administering (preservative free) flu shots.

It was clear from week one that pharmacists in this setting have to do a ton of multi-tasking. I was constantly making mental (and hard copy) to-do lists and shuffling my priorities as new requests, assignments, projects, and tasks arose. Since my preceptor was always running around putting out fires, or on the phone, or checking scripts, or attending to patients, it could be hard to get him to sit still long enough to ask for project guidance. Consequently, the ability to work independently and be self-motivated was huge. I felt more autonomous on this rotation than I have on any other, and since one of my primary P4 year goals is to build autonomy and confidence, this was a satisfying feeling. In fact, I had my most rewarding pharmacy experience to date during this rotation, which came as a result of the pharmacist trusting me (and me feeling confident enough in my abilities) to counsel a patient independently.

During my first week, my preceptor asked if I could stay late (typical rotation hours were 9AM - 5PM) as he'd just gotten off the phone with a patient who was planning to come in at 5:30 and needed to be counseled. She was in her thirties, but had just been diagnosed with type I diabetes that day. No one at the hospital or the chain pharmacy where she picked up her insulin pens and glucometer had shown her how to use them. In fact, she was coming to our pharmacy because the chain pharmacy had failed to dispense the needles that she needed for her insulin pen. My preceptor asked if I felt comfortable counseling her, and I said yes. Finally, a rotation challenge on something I felt well qualified to do! After all, how many times have I had to teach an SPI how to use an insulin pen? (Many times.)

I spent almost an hour with the patient and her dad reviewing and practicing how to use the insulin pens and glucometer. This was easily one of the most positive and rewarding pharmacy experiences I’ve ever had. I felt knowledgeable and confident, and it was clear that the patient truly valued my help. It was so gratifying to see the positive impact I could make as a pharmacist, especially for someone who was probably not having a very good day. When they left, the patient and her dad were very gracious, saying how much they appreciated me taking the time to step through everything slowly and that I was clearly passionate about and good at what I do! I didn’t even mind staying late because it was a great learning opportunity and more importantly, an opportunity to help a patient in need.

Despite this excellent encounter, I don't think community pharmacy is for me. If 80% of the job was encounters like the one I just described, I might feel differently. But from what I've observed, so much of the community pharmacist's energy is consumed with smaller tasks and the daily grind of checking prescriptions, answering phones, and in the case of an independent pharmacy like this one, managing the business and the bottom line. There were certainly aspects of this rotation that I enjoyed, but I'm looking forward to stepping back in to the world of hospital pharmacy with my next rotation in emergency medicine! Stay tuned.

Rotation 4: Alphabet Soup

Posted by Unknown at Sunday, October 11, 2015

ORP, OCC, DMEPA, OGD.  On my first day, while I was waiting to meet my preceptor, a man struck up a conversation with me (apparently I looked lost).  He asked me where I worked, and I spelled it out, Office of Regulatory Policy.  He nodded with recognition: "Oh, ORP! I'm from OSE!"  I guess I looked confused, because he started explaining some of the abbreviations before he had to run to a meeting.  Five weeks later, I still see and hear abbreviations daily that I need to look up.

Working in ORP was completely different from what I expected, but I still absolutely loved it.  I was surprised to learn (although it is somewhat implied in the name) that the office is filled with lawyers. Interacting with lawyers in a healthcare setting is very different from working with other healthcare professionals.  Some of my office's main responsibilities included participating in the development of rules and regulations and responding to citizen petitions (documents individuals, groups, and companies can write to FDA to try to persuade them to change something, such as remove a drug from the market, issue a guidance or rule, or make labeling changes).  In both of these cases, I appreciated having different disciplines working on these projects together.  As a healthcare professional, advice and knowledge I felt was obvious was not always clear to others, and vice versa.  Having multiple experts from a variety of areas allowed for the clearest documents to be released to the general public.

FDA was not all work and no play, however.  I attended nearly daily meetings to learn about all the different departments and met individually with pharmacists from several departments.  I also went on several field trips, including the Bureau of Prisons, American Pharmacists Association, United States Pharmacopeia, and the Pentagon.  Pharmacists are working all over the world in places you would never expect to find them, and hearing about the variety of opportunities available for those looking for a non-traditional path was informative - many jobs I had never considered, or even heard of before!

Overall, this was a fantastic rotation that went by too fast.  I loved the idea that I was affecting pharmacy at a national level by assisting with the creation of various policies.  I have always wanted to effect change on a grander scale than one patient, one pharmacy, or one hospital, and at FDA I was able to accomplish that.  I look forward to hopefully returning one day, but until then, onwards to pediatrics!

Rotation 4- Poison Control-

Posted by E. Caliman at Friday, October 09, 2015

My fourth rotation was also at the Poison Control Center, so I had the same experience as Emily in the post below. I was also surprised that knowing the substance the patient took wasn't particularly critical to treating the patient; many times, you just treat the symptoms as they show up. It still made it interesting to guess the substance when we went over cases. I also learned that not every toxin has an antidote, which leads to treating the patient supportively.

Several of the cases involved acetaminophen (Tylenol) in some form, which is to be expected: it's the most common toxin called into poison control centers and the most common cause of liver failure. Alcohol was also very common, as well as a mixture of illicit substances. On the other hand, we got to handle uncommon cases, such as rattlesnake bites (the only rattlesnake in Michigan is the Massasauga), insulin, and fuzzy caterpillars (not poisonous, but the "fuzz" is actually many tiny spines, so it's like a porcupine). It was interesting to see how certain substances were more common to certain age groups. Another interesting point was that the patient may not be telling you the truth when they tell you what they took. Sometimes, what they say they took and what they actually took look completely different.

This rotation highlighted several things we discussed in the American Pharmacist Association's Generation Rx committee about securing your medications. Even though the focus of the committee is young adults getting into their parents or grandparent's medication cabinets, young children also can get access to them if they're not locked, get past child-resistant caps, and consume medications in spite of the taste. One of the cases I consulted for while on call involved a kid about 2 years old who took some of his parent's medications when they were briefly left unattended. Another problem highlighted was that of household products. Detergent pods are very colorful and appealing to children and their contents are under pressure. If a child bites one, some of the liquid detergent can spray to the back of the throat where it can be swallowed, or worse, inhaled. Chemicals found in the garage are also a problem. Products such as antifreeze and brake fluid have a sweet taste, but can cause renal failure, which means the patient may be put on hemodialysis for life.

Overall, this was a great rotation and I'm considering further studies in toxicology. If nothing else, I can expand my knowledge base to better help my patients.

Rotation 4: The Dose Makes the Poison

Posted by Emily at Friday, October 02, 2015

Despite the clinical nature of this rotation, my experience at the Michigan Poison Center certainly fit its “non-traditional” billing.  Full disclosure: I have been very interested in toxicology since shadowing at this poison center the summer after P1 year (and two more times as a P2), and thus this was the rotation I was most looking forward to.  It definitely lived up to my expectations and has solidified my plan to pursue a clinical toxicology fellowship following completion a PGY1 residency.  Please bear with me while I gush about this rotation.

As I mentioned, this rotation is considered non-traditional as it is geared towards emergency medicine medical residents (aka licensed physicians who have a few years of practice under their belts), although there were a handful of pharmacy residents and medical students on rotation as well.  In total, there were about 25 rotators, so you can imagine that we did not all physically visit and consult on every toxicology patient that passed through the Detroit Medical Center.  Instead, we were divided into four teams who were assigned one day a week to be “on-call”, with the following day designated for team “call backs”.  Additionally, each team was assigned one weekend to be on-call.  This was confusing to me initially because I’m used to traditional rounding which generally occurs at the same time every day with more or less the same group of people.  Consult services, like toxicology, are more flexible and can see patients at any time, day or night.  A typical day at the poison control center looked something like this:

0730-0900 – consults or call backs

On the days my team was on-call, our designated team leader would call the poison center at 0600 to see if there were any patients within the Detroit Medical Center network of hospitals who required a toxicology consultation.  Some days there weren’t any patients, other days there were one or two.  It was up to the team to decide who would see the patient.  I consulted every patient that was available to me to consult, though I always teamed up with the physicians in my group who performed a physical exam, asked follow-up questions of the patient and the patient’s nurses to gain a more complete toxicologic history, and wrote consultation notes for the medical record.

On call-back days, we were required to log into the Toxicall system which is the database that tracks all of the calls that come in through the poison center hotline each day.  From here we returned calls to health care providers who may have consulted the poison center the night before for recommendations regarding a toxic exposure.  As rotators, it was our job to gather as much pertinent information as possible about the patient’s history, as well as their treatment course and most recent labs and vitals.  From there we would consult with the toxicology fellow or attending toxicologists about what additional recommendations for care needed to be made, and then write a SOAP note to log our encounter and recommendations in Toxicall.

0900-1100 – case review

Each morning, the on-call and call back teams would present the cases they had seen.  These were case presentations with a twist, however.  Whenever possible, the toxic substance was withheld so that we could try to guess what it was based on the patient’s presentation, vital signs, and lab findings.  Certain classes of medications have specific toxidromes that can help clinicians narrow down the possible ingestant(s).  For example, sympathomimetics (like bath salts, amphetamines, and cocaine) cause increased blood pressure, heart rate, respiratory rate, and temperature, pupil dilation, CNS activation, sweating, and GI activation like nausea, vomiting, and diarrhea.  Conversely, sedative-hypnotics and opioids cause decreased blood pressure, heart rate, respiratory rate, and CNS depression.  Patients rarely present with a textbook perfect toxidrome, especially if they ingested more than one substance (or even if they’re withdrawing from one substance while overdosing on another).  Toxicology requires a lot of problem-solving and detective work, which made cases my favorite part of the day.  It was just piecing together puzzles all morning!

Of course, it was frustrating when the poison was never elucidated because the patient was intubated and unable to tell us what they took.  I was surprised at how often it didn’t matter what the actual toxic ingestion was.  The toxicologists made treatment recommendations based on the patient’s symptoms, not necessarily based on what the patient claimed to have taken.

Here are some examples of the many and varied toxic ingestions I saw during this rotation: synthetic cannabinoids, lithium, heroin, glipizide, bupropion, acetaminophen, Coricidin, Listerine, antifreeze, quetiapine and cocaine, Dust-Off, a caterpillar, and some chemical called 3FPM that the patient ordered online.  We were also consulted about a Massasauga rattlesnake bite!

1100-1200 – lunch

1200-1400 – lectures, journal club, topic presentations, field trips

The afternoons were devoted to lectures on a wide variety of toxicology topics which were given by the handful of toxicologist attendings who worked at the poison center.  We reviewed everything from acid-base chemistry and acetaminophen toxicity to poisonous mushrooms and venomous spiders.  Each rotator was also required to present a journal club and a topic presentation.  My presentations were on colchicine toxicity and castor bean/ricin poisoning.

We had two field trips during the rotation: one to the Detroit Zoo to learn about venomous snakes, and one to the Michigan State University botanical gardens to learn about poisonous plants.

castor beans from the botanical gardens

autumn crocus, the plant from which colchicine is derived, at the botanical gardens

1400-1600 – review materials, work on projects from home

My major assignment for the rotation was to help develop a protocol for the management of zinc/aluminum phosphide poisoning.  Aluminum phosphide is a rodenticide that’s especially prevalent in agriculture southern Asian nations like India, but can easily be obtained in the US via the internet.  When aluminum phosphide comes in contact with water, it releases phosphine gas which is super toxic because it disrupts mitochondrial function.  When ingested, stomach acid causes an even greater release of phosphine gas.  Not surprisingly, the mortality rate from aluminum phosphide ingestion is very high, and unfortunately there isn’t an antidote.  In addition to being incredibly toxic to the individual who ingested the aluminum phosphide, the patient can off-gas phosphine even post-mortem which puts the healthcare providers caring for these patients at risk.  These patients essentially become HAZMAT problems.  It’s a pretty fascinating issue.  Here’s a link to a news article about a recent case of aluminum phosphide ingestion in New Mexico: http://www.koat.com/news/man-overdoses-vomit-contaminates-taos-hospital/34890148

And now, dear readers, please allow me to list the reasons why I love toxicology and thus loved this rotation:

• Toxicology is a broad specialty because the dose makes the poison, which means that basically anything can be toxic in the right quantities.  This means toxicologists have to be well versed in pharmacology and biochemistry, because toxic ingestions can be household items just as easily as they can be medication related.
• Toxicology is all about SOLVING PUZZLES.  I love this so much.
• Toxic ingestions often have a social component to them that I find very interesting.  For example, lead poisoning is more prevalent in low-income areas because the houses are often older and thus more likely to have been painted with lead paint.  Or parents may be reluctant to admit that their child could have accessed their prescription (or not prescription) medications out of fear that Child Protective Services will be contacted.  These complicated situations add a whole new layer of challenge to the field.
• I am a biologist at heart, and toxicology caters to this because beyond drugs, toxicologists are concerned with poisonous plants and animals too!
• In my opinion, toxicology offers pharmacist a good balance of activities including clinical care, drug information, research, teaching, and administrative duties. 
• Toxicology offers tons of variety because there are always new poisons (see: Tide Pods) and drugs of abuse trends are always changing.  There is always something new to learn.
• Finally, I really love emergency medicine docs.  All of the toxicologists and EM residents who I worked with this month had the most delightfully dry senses of humor on top of being super smart.  It made me excited to come in to rotation every day. 

Long story long, this non-traditional rotation in poison control definitely met my expectations!  I have been working on narrowing down residency options based on what programs also offer toxicology fellowships or at the very least are associated with poison centers and have PGY1 rotations in toxicology.

Warfarin: All Day, Every day!

Posted by Unknown at Saturday, September 05, 2015

It's been 15 weeks and 3 rotations since we started P4 year, which is both incredible and terrifying. My most recent rotation was centered on pharmacy within an ambulatory care setting. I was stationed at an outpatient anticoagulation clinic and the care I was able to provide patients exceeded my expectations. Although I knew going into the rotation that it would be focused on cardiology and blood thinners, I had no idea how immersed in it I would become.

The pharmacists I worked with handle a special, high-risk population of patients who need anticoagulation because they have an LVAD (left ventricular assist device) implanted inside them. These patients need increased monitoring because they are at increased risk to clot. Any foreign substance within the body has the potential to put you at a higher risk for clots as blood will stick to it.

My day usually started by following up with patients who had recently been discharged from the hospital. Although the patient is technically off our service while admitted, we still follow their INRs and report any medication changes. Many times, someone will come home on a new antibiotic that has the potential to affect the INR. About 90% of antibiotics will increase your INR, but nafcillin and rifampin significantly reduce it. In fact, we dealt with a patient who was on a 6 week home course of nafcillin due to MSSA bacteremia. We had to empirically adjust his warfarin dose by doubling it, which is a huge dose change when it comes to warfarin.

I also helped the pharmacist counsel patients who were being started on the new oral anticoagulants termed "DOACs" (direct oral anticoagulant). These include rivaroxaban, apixaban, and dabigatran. They don't need the same kind of monitoring as warfarin does, nor do they require the consistent diet of vitamin K as warfarin, but they are extremely expensive.

Finally, I was able to create "bridging calendars" and provide instructions to patients who had upcoming surgeries. For patients on warfarin, surgeries are tricky as you don't want them to have thin blood during the surgery, but you need to prevent a thromboembolism in the pre-operative period. This is where a low molecular weight heparin such as enoxaparin comes in. They have a much shorter duration of action, which means a patient can take this drug up to the day of surgery while in the interim of stopping the warfarin. Therefore, the warfarin gets out of their system, but they are still protected against clots. The decision if a patient needs bridging is based on their thromboembolism risk classification. High risk patients almost always need bridging and low risk patients almost always don't. However, when it comes to intermediate risk patients, it is based on patient and surgery characteristics. One of my projects while at this rotation was to review the new BRIDGE trial, published in June of 2015 and see how we could apply it at my rotation. Essentially, it showed that bridging for patients with atrial fibrillation in an intermediate risk category is not recommended.

Overall, this rotation taught me a ton about cardiology and pharmacy. I didn't think I was a big cardio girl until I spent all day with it. I know the knowledge I gained about anticoagulants will help me in my future rotations and career.

Rotation 3

Posted by Stephanie Burke at Friday, September 04, 2015

Making the best out of the unexpected

As you know, rotations are learning experiences; they are intended to challenge us, equip us, and shape us as we progress in our pharmacy education. There will be rotations that you are incredibly excited for, and there will be rotations that you are not very excited for. However, even those experiences that are not our favorite are learning opportunities. This is a challenge I faced in my last rotation. It was the one I had been looking forward to the most, but the experience was very different than what I was hoping for, and not necessarily in a positive way. It took me some time to adjust to (or rather, accept) the responsibilities and routine of the rotation. After two weeks of grappling with my disappointment, I finally made the conscious decision to accept my circumstances and focus on the positive aspects of the rotation that I could then further build upon. Following this change in perspective I was able to find more enjoyment in the work that I was doing and I was also able to better engage with those around me.

This is such an important lesson for us, as students, to learn early on. We will all be faced with disappointment or circumstances that cannot easily or readily be changed. However, we must be able to focus our efforts and energy on the things we can learn from – good or bad – and the aspects of the situation that we do enjoy. We will only be hurting ourselves and our own personal growth if we choose to focus on the things we don’t like, or the things that are not going as planned. 

So make the most out of the unexpected!

Rotation 3: Meticulous Minds for Medication Error Prevention

Posted by Emily at Friday, August 28, 2015

Block three brought me to Silver Spring, Maryland (just outside of Washington DC) for a non-traditional rotation experience at the Food and Drug Administration.  This was my first rotation outside of UMHS and my first rotation where I didn’t have a classmate by my side for support.  That was a little nerve-wracking at first, but I’ve learned that putting yourself in slightly uncomfortable situations in unfamiliar environments and adapting as you go is a great way to grow personally and professionally.  The uncomfortable situation is rarely as uncomfortable the next time.

FDA Building 1

It was clear from day one that FDA loves acronyms even more than BMT.  My preceptor’s email signature read something like:

DMEPA|OMEPRM|OSE|CDER|FDA

Translated: I was working in the Division of Medication Error Prevention and Analysis, housed within the Office of Medication Error Prevention and Risk Management, which is part of the Office of Surveillance and Epidemiology within the Center for Drug Evaluation and Research at the Food and Drug Administration.  (Suffice it to say I quickly began referring to my division as DMEPA just like all the other employees.)

DMEPA is full of pharmacist safety evaluators who are responsible for conducting pre- and post-marketing safety reviews of proprietary names, labels, and labeling with the end goal of preventing medication errors.  For example, if a manufacturer proposes a carton design in which the drug strength “200 mg” is too close in proximity to the quantity “100 tablets”, the safety evaluator will recommend separating the numbers physically or graphically to minimize the possibility of a busy pharmacist mistaking “100 tablets” for “100 mg” and contributing to a potential overdose.  Safety evaluators also conduct safety reviews of proposed brand names.  Part of this process involves asking employees to interpret handwritten and verbal prescriptions to see if the name they see/hear could easily be confused with an existing drug name.  I have pretty good penmanship overall, so I struggled to make my handwriting physician-worthy when I was asked to contribute prescription samples for these studies.

I was my preceptor’s first student at FDA, and he explained on the first day that the rotation was going to be more observational and self-directed than my previous clinical experiences.  That was true, but between projects, meetings, field trips, and the extensive student lecture series, I kept busy.  To keep this post from becoming too unwieldy, here are some of the projects I did and meetings/talks I attended in list form:

Projects:

• Summarized the literature on the effect of calendarized blister packaging on adherence
• Created a chart of abuse deterrent formulation opioids
• Conducted a literature search on best practices for standardized chemotherapy order forms (my preceptor works specifically with oncology products
• Presented recent DMEPA interventions aimed at preventing errors with chemotherapy agents

Meetings:

• ISMP monthly conference
•  Human factors study meeting
• DMEPA and OSE “All Hands” staff meetings
• Advisory Committee practice meeting

Student Lecture Examples:

• Office of Prescription Drug Promotion overview
• Orphan Drug Product Development
• United States Public Health Service overview
• CDER Drug Shortage Program
• The Scientific Basis for Drug Control Under the Controlled Substances Act
• Unapproved Drugs
• President’s Emergency Plan for AIDS Relief
• Introduction to OTC Drug Regulation

 Field Trips:

• ASHP headquarters in Bethesda, MD
• Bureau of Prisons in Washington DC
• United States Pharmacopeial Convention in Rockville, MD
• Pentagon tour in Washington DC
• Consumer Product Safety Commission in Rockville, MD  (This experience was not part of the FDA “curriculum”; my awesome preceptor arranged for me to shadow the pharmacologists at the CPSC after I told him about my interest in poison control and prevention.  The CPSC tests all kinds of consumer products, everything from bike helmets to baby cribs, ATVs to mattresses, and everything in between.  The chemists do a lot of work testing products for lead and phthalates.  The coolest part of this experience was getting to tour CPSC’s testing laboratories.  I totally felt like I’d walked onto the set of MythBusters.  You can watch a video tour of the labs here: http://abcnews.go.com/GMA/video/consumer-product-safety-commissions-test-lab-13827984)

ASHP Headquarters

USP Headquarters

Pentagon

Overall, my FDA experience was positive and unique.  It was great to see pharmacists from diverse backgrounds filling these non-traditional roles, and there are TONS of pharmacists at FDA!  Most of the employees seem to enjoy their work and the work environment, and even as a student I felt like I was part of significant work and something important.  I also felt proud to introduce myself as a University of Michigan student.  It’s true that the name demands a certain degree of respect, and I was grateful to be able to represent the COP outside of Michigan.  It also turned out to be a great networking tool.  I met two other Michigan alums on my second day, and that’s not including my preceptor!  One of the alums was a resident at one of the programs I’m considering, and he was more than happy to sit down with me to discuss his experience.  I was also able to network with the other students.  There were about thirty of us in total, representing over 20 different colleges of pharmacy!

While I learned a lot on this rotation about the drug approval process (and got to see firsthand that package inserts don’t just rain down from the heavens), the most important thing I learned is that I am not interested in working at FDA.  I love direct patient care too much to be happy in a job that involves no direct patient care whatsoever.  Perhaps in the future I’ll find myself in a position where taking on a desk job is the right move for me at that time, but for now I am excited at the prospect of pursuing residency and, more immediately, starting another clinical rotation next block at the Michigan Regional Poison Control Center!  Stay tuned.

PS – If you find yourself in the DC metro area for a rotation, be sure to take advantage!  I did all kinds of touristy things in DC on the weekends, and even caught a Tigers/Orioles game at Camden Yards in Baltimore one Friday.

Salk's polio vaccine at the National Museum of American History

Tigers vs. Orioles at Camden Yards

Rotation 3- Community: Still Going Strong

Posted by E. Caliman at Tuesday, August 25, 2015

I'm doing my Community Rotation at a local compounding pharmacy. I enjoyed compounding during P1 year and was interested in it even before starting pharmacy school. After the fungal meningitis outbreak from the New England Compounding Center in 2012, I thought that a community compounding pharmacy would be a nice, slower-paced rotation as compared to a chain community pharmacy.

I was wrong. I was so very wrong.

Compounding pharmacies are very much alive and well, even with piles of restrictions and new regulation. It's likely due to the fact that compounding pharmacies provide patients with medications they can't find at a regular community pharmacy and the personal level of service because many of them have fewer patients.

Slow days here are few and far between. I started off on a week where almost 100 scripts were filled each day. It's always busy. If you're not filling, you're probably tackling the pile of drug information questions patients and doctors call you about, from drug stability of compounded medications, to drug interactions, to helping them navigate insurance issues, since many insurance companies no longer pay for compounded medications.

Naturally, I got to spend time in the compounding lab. The pharmacy can compound capsules, suspensions, topical creams, ointments, lotions, suppositories, as well as sterile products. I got to try a little bit of each. The experience was more automated than I expected (there's a machine that mixes the topicals and you don't fill capsules by hand), but a little more labor intensive than P1 year would have you believe. Even so, I still enjoy compounding and it's still a career option.

Some of my other projects include updating policies and forms, as well as doing research into regulation and new business opportunities. I researched how a pharmacy in the partnership could provide a new service for the county and updated a privacy practice form to reflect that the pharmacy could now text patients with their permission. Overall I had a great experience and am looking forward to the next rotation.

Rotation 2: I'll Take a General Kit, Please

Posted by Unknown at Saturday, August 01, 2015

My entire life I've been terrified of blood, so imagine my shock and horror when I found out I was assigned to the operating room pharmacy for my health system/hospital rotation!  In the first hour of my first day I was handed a syringe of morphine mixed with blood to empty, and thus began my 5-week journey of desensitization.

A typical day kept me constantly moving and looked something like this:

0600 - 0730: Pass out kits
The OR pharmacy had pre-made drug packs containing various narcotics that the CRNAs and doctors could sign out for their patients.  There were kits for ECT, codes, PACU, the medical procedures unit (MPU), and, most popular, kits for general surgery.  Doctors and CRNAs could ask for additional add-ons, such as ketamine or Dilaudid, as well as pick up non-controlled medications, such as Tylenol, Neurontin, and Precedex, and request infusions.  This time was particularly busy, as all 30 ORs had a shotgun start at 7:30.  During this time, we also received several kits that were used overnight, and had to reconcile those with the provider while he or she was standing there.

0730 - 1000: Verify, topic discussions, and LOTS of paperwork
The next 2.5 hours were spent talking about various topics related to anesthesia, opioids, or other OR drugs, verifying the pre-op medications for the next day, and reconciling and completing the returned kit paperwork.  The paperwork could be very tedious at times, as we could have as few as 2 kits returned or as many as 20 or more if there was a weekend or holiday! The paperwork had to be double checked against what was actually returned and against the Omnicell.  Anything returned in syringes had to be refracted to ensure that what was documented to be in the syringe was actually in there.

1030 - 1430: Pharmacy adventure!
Every day I went to a new place to learn about a new area of pharmacy.  On Mondays, I went to the main pharmacy in the children's hospital, where I was able to check prescriptions, participate in cart fill, learn about dosing children, and chemotherapy dosing.  On Tuesdays, I went to the OR in the children's hospital, where I performed very similar tasks to my responsibilities in the adult hospital.  On Wednesdays, I worked with the medication safety officer on a medication use project.  On Thursdays, I went to the Investigational Drug Service and learned how to verify a prescription for a study, how to read a protocol, and how to write guidelines for pharmacists dispensing based on the protocol.  On Fridays, I stayed in the OR and filled pre-op orders for the next day.

One of my favorite days in the OR was a day I never thought would happen: I spent four hours walking in and out of various surgeries and intently watching the procedures.  I walked around with an amazing anesthesiologist, who showed me how she uses all the drugs I had seen coming in and out of the pharmacy every day, which was fascinating.  I was also able to watch a kidney transplant, brain tumor biopsy, ear canal tumor removal, and a prostatectomy using the da Vinci robot.  Watching those surgeries showed me that I had come a long way in those five weeks with regards to my blood sensitivity!

Overall, this was a fantastic rotation and nothing like I expected it to be.  It was a lot of work, but well worth the effort!

Meetings, Meds, and Monographs: Drug Information Rotation

Posted by Stephanie Burke at Friday, July 24, 2015


Already done with rotation 2 – time flies! I had my Drug Information (DI) rotation these past 5 weeks, and I learned a ton! I’ve got a pretty good grasp on where to find information for different types of DI questions. The questions I received ranged anywhere from ‘what are the clinical manifestations that could result following accidental injection of a nasal solution of drug A’ to ‘can drug X be crushed and flushed through a G-tube’ to ‘we have a patient who is allergic to sulfites – can you review the ingredients of the attached list of medications for presence/absence of sulfites?’ Not your typical, everyday stuff, but now I have some familiarity with the types of clinical questions that could arise and where I could look to find information. I consider it a great skill to have acquired early on in my rotation schedule.

In addition to answering phone calls and emails from the inquiring minds of our UM providers and researchers, the DI folk also attend a number of different committee meetings. On this rotation, I went to committee meetings for anesthesia, cancer, pain, inventory, and glycemic control. It’s great having our DI pharmacists present because they bring a solid understanding of the available literature, and the meetings help the DI staff stay up-to-date on new information. My personal favorite was the Glycemic Committee meeting given my interest in diabetes mellitus. There was a monograph presentation on Afrezza, the newer inhaled insulin product, and also a discussion on the concentrated insulins that have been surfacing in recent years. Lots of cool stuff in my opinion!!! My hope is to continue attending these monthly meetings in future rotations when I am back in Ann Arbor (out of area rotation 3). If that is the case, I’m sure you’ll see more fun stuff on that in future posts J

One of my other favorite components of this rotation was the monograph project (or in my case, 3 total monographs!). The monographs I prepared will be presented at future Pharmacy and Therapeutics Committee meetings for consideration for formulary addition. The first drug assigned to me was mifepristone. This is a very interesting (and controversial) medication. Used as an investigational drug since 1985, mifepristone was FDA-approved in 2000 for termination of pregnancy through 49 days gestation. The drug had already been adopted in a number of European and Scandinavian countries prior to its approval in the United States. The brand name for this indication was Mifeprex^TM, produced by Danco Laboratories. Twelve years later, mifepristone was approved for another indication – management of hyperglycemia in patients with impaired glucose tolerance or type 2 diabetes secondary to endogenous Cushing’s syndrome. This brand, Korlym^TM, was produced by Corcept Therapeutics. Same active ingredient, two different brands, indications, and manufacturers. Take a look at the pharmacology of mifepristone to see how it could work for two very different conditions!

The third monograph I wrote was for U-300 glargine (Toujeo^TM). Again related to diabetes, it was of significant interest to me. The clinical trials that Sanofi-Aventis completed showed, overall, that U-300 glargine was non-inferior to Lantus in blood glucose control, and in some cases, produced less nocturnal hypoglycemia. There were no significant differences in adverse effect profiles between the two. The primary concern we see with adding U-300 glargine to formulary is safety. There have absolutely been medical errors when someone draws up the concentrated product thinking it’s the unconcentrated, or a provider fails to correctly calculate the volume needed given the number of units of insulin. Many things could go wrong here when used in the inpatient setting. For those unaware, insulin is a high alert medication, and there must be effective and appropriate protocols in place to ensure safe use of insulin products.

Drug Information was an excellent experience. It challenges you to dig deep into the inquiries that come in, and also to consider all the data you’ve gathered and make a clinical recommendation. The rotation also better familiarizes you with drug information resources which will be invaluable to any type of work that you do.

 

Rotation 2: Prednisone Tastes like Rancid Mints and Other Pearls from Pediatric Generalist

Posted by Emily at Thursday, July 23, 2015

What does a generalist do?  The short answer: everything!

Here's what a typical day looked like on rotation as a pediatric generalist-in-training:

0730-0930 - work up patients at the hospital

On the first day of rotation, my classmate and I were both assigned to a specific pediatric general medicine service that we would continue to follow for the rest of the month.  These services see kids with all different kinds of chief complaints ranging from intractable vomiting to osteomyelitis to febrile seizures to premature babies who are simply admitted for feeding and growth monitoring; basically patients who are too sick to go home but not sick enough to be sent to the PICU or assigned to a specialty service like heme/onc.  Patient duration of stays also varied greatly, so our patient lists changed every morning as our old patients were discharged and new ones were admitted.  This kind of variety is the hallmark of a general service and because of it I gained exposure to an array of disease states and medications that I hadn't previously seen.  We reviewed our patients and recommendations with our preceptor before starting rounds.

0930-1100 - rounding with the medical team

My favorite part of the day!  Pediatric generalist is a teaching service, so my team consisted of an attending physician, medical residents, medical interns, med students, and a dietitian.  I benefited from the attendings' teaching points just as much as the medical students did, and sometimes I was even able to answer the attendings' questions when the medical students couldn't.  (What do we want to monitor with linezolid?  Weekly CBC!)  Rounds was also my opportunity to make recommendations, though because of the fact that these patients tended to be less complicated than, say, my BMT patients last month, and because the medical students and interns were all working to develop their own autonomy, I feel like the generalist pharmacist wasn't as valued/utilized as the specialists pharmacists are during rounds.  Nonetheless, the team DID turn to me with questions from time to time, and I was also able to recommend a few therapeutic interventions of my own. :D

1100-1500 - review patients, do med recs/med histories, do medication teaching, review TPN orders, work on projects, eat lunch

Remember how I said generalists do everything?  Our afternoons were left open for completing the myriad tasks that generalists are responsible for.  We'd review our patients again with our preceptor after rounds to let her know if there were any significant updates, and then we were free to complete medication histories and medication reconciliations for all the patients who had been newly admitted to the floors.  For patients being discharged with new prescriptions for Diastat (diazepam rectal gel for seizure emergencies), EpiPens, or enoxaparin, my classmate and I were available to review proper medication administration technique with parents and families.  We were also tasked with reviewing total parenteral nutrition (TPN) orders to make sure that all changes made to the TPN composition were appropriate based on that morning's labs, and that the changes made were appropriate for each patient's age and weight.  In addition to these patient care activities, we had a handful of projects to complete during our five week rotation block.  These included three informal topic discussions (I presented on perinatal HIV, preeclampsia/eclampsia, and pediatric acetaminophen toxicity), a journal club on a randomized controlled trial of aerosolized versus subcutaneous injection measles vaccine, and a formal patient case presentation on Kawasaki's disease.

1500-1600 - attend topic discussions, journal clubs, and case presentations

The last hour of the day was often devoted to topic discussions led by various pharmacy staff.  Topics included an introduction to pediatric pharmacy, how to properly conduct a medication reconciliation, pediatric emergency services, a pharmacokinetics review, how to verify TPNs, and a discussion of lines and tubes.  But our most fun (and most disgusting) afternoon activity by far was the infamous TASTE TEST.

Many pediatric patients are not able to swallow pills and thus are prescribed liquid medication formulations.  To gain a better understanding of what we're expecting our patients to endure when we recommend a liquid formulation, we participated in a taste test of over twenty different liquid medications.  Armed with bottles of pop and chocolate sauce to cleanse our palates in between each medication, we were given a drop or two of commonly prescribed pediatric drugs (everything from azithromycin to Zofran) on a plastic spoon to sample.  The results ranged from legitimately delicious (amoxicillin) to horrifyingly vile (metronidazole).  Knowing how these medications taste gave me a much greater appreciation of why it can be so difficult for parents to get children to take their medicine.  As a pharmacist, it's easy to say "take 15 mL twice a day" and to stress the importance of completing a full course of therapy, but if a medicine has a completely intolerable taste the kid isn't going to take it no matter how much ice cream she chases it with.  In fact, the day after the taste test, my attending prescribed Bactrim rather than clindamycin for a six month old patient because (aside from being less likely to cause C. diff) Bactrim is MUCH more palatable.  Bactrim tastes like medicinal Kool Aid.  Clinda tastes like sadness.  This is the kind of practical knowledge you can only gain from being out on the front lines, and it’s such a refreshing change after three years of textbooks and lectures.

note sheet and snacks from the liquid medications taste test

Interestingly, three years ago I completed my first P1/P4 shadowing experience while my P4 was on this exact rotation.  In my post-shadowing write up, I said, "I feel connected to the pediatric patient population, but I worry that I lack the emotional fortitude to work within this specialty."  For the most part, this rotation has not been as emotionally demanding as I was expecting it to be.  Most of the kids on a general service are not too sick - not sick enough to be in the PICU, at least.  We also don't see hematology/oncology patients.  In short, most of our kids aren't dying.  That said, I still saw some difficult cases this month, the most striking of which was a seven week old baby boy who was admitted for "non-accidental trauma" (e.g. child abuse).  His x-rays showed more than twenty fractures in various states of healing.  While it was hard to know that such a cute little guy had had such a rough start, it was incredibly rewarding to be a member of the team that was ensuring he would be safe and responsibly cared for in the future.  In fact, I enjoyed working with the kiddos so much that I've added pediatric rotations and PGY2 offerings in pediatrics to my PGY1 residency search list.