Rotation 1: Medical Code, ETA: 5 Minutes

Posted by Unknown at Sunday, June 21, 2015

I cannot believe how fast the last 5 weeks have flown by! If you had told me at the beginning of my first rotation that I would feel comfortable treating patients in the emergency room, I would have laughed. The emergency room is a unique experience, whether you're a pharmacist or a physician as you never know what could walk through the door. In fact, at the large hospital I'm doing my rotation at, I was exposed to just about everything you could imagine; whether it was an eye out of its socket (good thing I'm not squeamish!), lithium toxicity, or heart attacks. As I'm sure you're guessing, I was beyond nervous my first day, more so due to the fact that a medical code came into the resuscitation bay just as I walked in the ED satellite pharmacy. Without any hestitation, Dr. Suprat Wilson (my preceptor and leader in emergency pharmacy) and I jumped right in to help a severely hypoglycemic man with a blood glucose of 23, providing the physician with both oral glucose and an amp of dextrose.

Here's a brief run-down of how the ED operates. When patients come through triage, their vitals are taken by a triage nurse. There are a total of 6 modules a patient could be placed into with a transition of care unit reserved for those being admitted. If certain baselines are not met during the triage interview, for example; if the blood pressure is too low, heart rate is too fast, or oxygen saturation is too low, a patient becomes a "medical code," meaning they need attention ASAP. Additionally, if a trauma code comes in via EMS, it will be designated as either TC1 or TC2 based on a patient's mental status. For a trauma code, the surgical team also attends. The ED pharmacist is both integral and essential in providing assistance to the emergency team.

Over the past 5 weeks, I have seen a wide array of medical emergencies. It's amazing to learn about something in the classroom and then see it happen right in front of you. The biggest eye-opener was how fast Narcan works. The patient comes around very quickly. They are often combative due to their "high" being taken away, but that drug can seriously reverse any opiod. I saw gangrene on the foot of an older gentlemen, causing sepsis and beyond vasopressors, fluids, and antibiotics, the only thing we could provide was amputation. Another bubble that burst was the size of gun-shot-wounds. They are not as big or as bloody as you would expect. During any medical code, Dr. Wilson was amazing at asking me to assess the patient and think about why they might be in the ED and what our course of action might be. This skill will undoubtedly help me in my future rotations and career.

One of the biggest aspects of emergency pharmacy is ACLS and Rapid Sequence Intubation. These were two core topic discussions Dr. Wilson and I talked about. In an ACLS code, the pharmacist is responsible for getting together the epinephrine, reminding the physician when another epi is due (1 mg every 3 min!) and is consulted for what life-saving drug to try next. By the end of the rotation, I was running the pharmacy side of ACLS (with supervision of course). I also got to do CPR for the first time - very hard and tiring! Additionally, if a patient has head trauma or needs ventilatory support, there are many pros and cons to which sedating agent and NMBA blocker to use. The pharmacist is utilized for this too. I can tell you, seeing an intubation in person is way different than on Grey's Anatomy - it looks painful!

In addition to working closely during medical codes, I got proficient at dosing heparin, vancomycin, and TPA. I was able to attend "Wildnerness Emergency Medicine Grand Rounds," where rabies, heat stroke, and seafood toxins were described in detail. Did you know that rabies is actually more common in cats, not dogs? I volunteered myself for two midnight shifts as well as my normal day hours and it was interesting to see how a quiet night can turn into the busiest six hours you've ever experienced. Dr. Wilson was very gracious in letting me see any procedure that happened within in the ED. I accompanied patients to CT, saw the effects of procedural sedation (propofol and ketamine), watched a shoulder be popped back into place and even saw a neurosurgeon drill a hole into a car accident's victim head to reduce the intra-cranial pressure.

Overall, this rotation was incredible. Not only was it highly informative, but I truly enjoyed the entire pharmacy and ED staff. I came into the rotation thinking about ED pharmacy as a possible career, but now I am highly considering it.

Stay tuned - next rotation I will be in Washington DC with the Food and Drug Administration!

Rotation 1: Maximizing Patient Interactions in Community Pharmacy!

Posted by Unknown at Sunday, June 21, 2015

Going into my rotations, I can't say that I was extremely excited about having my Community Practice APPE at a chain retail pharmacy. I've worked retail for about 2 years prior and thought that I have seen everything community pharmacy has to offer. However, after spending the past five weeks with my awesome preceptor Alan, I have a renewed appreciation for community practice and the importance of building patient-pharmacist relationships.

A Positive Role Model
Alan is a fantastic preceptor and great role model for pharmacists. You really see that he wants to make a difference in community pharmacy and improve the lives of his patients. Alan handles the Medication Therapy Management (MTM) at the store and he frequently assist other stores with their MTM cases. Alan always takes the extra effort to assess patient's management of their disease states and providing extra counseling for lifestyle modifications and adverse effect prevention.You really see the trust patients have for Alan and all the patient-pharmacist relationships he built over the years was truly inspiring to see. Alan is also a great teacher, frequently spending one-on-one time with me to improve my patient counseling skills and review therapeutic topics. He really takes what I want out of this rotation into consideration when planning projects and activities and I feel like I'm learning something new from him everyday.

Maximizing Patient Interaction
My primary goal for this rotation is to improve my communication skills with patients. If there are any counseling opportunities or if patients had questions for the pharmacist, I would always be the first person to speak with the patient. Alan would also have me frequently walk the OTC aisles to look for patients in need of OTC recommendation. I was initially quite overwhelmed by the amount of patient interaction, as communication skills have never been my strong point. However, Alan allowed me practice counseling with him for the Top 100 drugs, and I began to realize the importance of translating the drug information into patient friendly terms so that the patient will not be scared or overwhelmed. After a couple weeks into it, I felt much more confident in my abilities to counsel patients.
.
MTM in Action
One of my main responsibility in this rotation is to assist Alan with MTM and Comprehensive Medication Reviews (CMR). I had the opportunity to take part in four CMRs, both in person and on the phone. Alan would have me work up the patient the day prior to CMR, which consists of recording every drug the patient is on, assess adherence, gap in therapy, and assessment of patient's disease state. I would also call the physician's office to address any problems we identified during the CMR. MTM is a very progressive service for community pharmacy, as it improves patient safety, saves costs, and allows for more clinical roles for community pharmacists.

A Change in Perspective 
Prior to this rotation, I had some major preconceived bias regarding community practice. I thought that it was a stagnant field of pharmacy full of jaded and cynical pharmacists. I could not have been more wrong. With MTM, I caught a glimpse of the potential and possibilities for the future of community pharmacy, and as long as there are pharmacists like Alan, community pharmacy could really become an important cornerstone of healthcare.

Thanks for reading my experiences with rotation one. Moving onto Emergency Medicine for rotation two!

Rotation 1: Real World, Real Patients, Real Experiences

Posted by Stephanie Burke at Friday, June 19, 2015

When I started my first rotation – Hospital/Health-System – I was full of energy and excitement for the learning experiences ahead of me. They put me to work on projects right away, and my days went by quickly; almost too quickly! I made educational materials for nurses, pharmacy staff, and patients; compiled information on new drugs to be considered for formulary; and attended a variety of meetings. The focus of my rotation was more on processes, protocols, and operations, but I did have the opportunity to participate in some clinical and patient care activities. These activities primarily consisted of reviewing patient profiles for appropriate medication use and making recommendations to the physicians when necessary. While I enjoyed all the project work I was doing, it was two patient cases that really gave me my first dose of reality as a (to-be) practicing pharmacist.

To provide a frame of reference, my hospital was very small (88 beds). The type of services offered were not as many as a large, bustling hospital like UM. For example, this hospital did not have an infectious diseases team, endocrinologists, or a psych unit. A patient requiring these services was sent to one of the System’s other hospitals that did have that particular specialty. Bottom line, it was a very different experience than UM. For those of you who know me, I have type 1 diabetes and I am very passionate about the care of people with diabetes. The two patient cases that stood out to me were two individuals with uncontrolled diabetes. The first patient, an older gentleman with type 2, came in week four of my rotation, and I spent a good 1.5 hrs working up his profile, getting all the data and information I needed. (*To note, this health system did not have EMR, so not all notes were electronic) The patient’s blood sugars were all over the place, going as high as 500 and as low as 40. His insulin regimens followed a similar trend. After finally coming up with a possible insulin regimen for the patient, the pharmacist took me to the floor so I could speak with the physician. And, the physician said he had discharged him that day. I was so upset. His blood sugars were not well-controlled and his insulin regimens were not stable. After a week in the hospital due to DKA (and some SOB), he didn’t seem to be much better than when he came in. However, there was nothing I, or the pharmacist, could do at that point. Seeing my frustration, the pharmacist said “welcome to the real world.” It took me a good portion of the day to recover from my disappointment and feeling that more could’ve been done for the patient.

The following week, on my second-to-last-day of rotation, I came across another diabetes case. This one was a 22-year old (35 kg) type 1 patient with three admissions in the last month and a half, all largely due to diabetes. When I looked at his initial med list, I noticed that he was not receiving any basal insulin. Then I noticed his 35 kg (yes, 35) body weight. I dove deeper into his profile and discovered that he has gone weeks (not sure how!) without insulin because he had no insurance and could not afford it. Now his multiple admissions made sense. There was not too much information to work from on his electronic profile, so I went upstairs to speak with the patient directly. After introducing myself and telling him that I also had type 1 diabetes, I sat down and we had a 15 minute conversation about diabetes, his life, etc. He had no friends or family, no insurance, no place to stay, and he thought he was going to lose his job at a factory because he could hardly stand anymore due to what sounded like neuropathy in his calves and ankles. So there I sat, listening to this young man’s troubled life and impossible circumstances. Thankfully, the social worker was able to get him on Medicaid and gave him information for a local clinic that serviced individuals with minimal or no insurance. But would he really utilize either resource? He said he had been on Medicaid before. He was not at all hostile to me; he was quiet, but he participated in the conversation with me. He just seemed exhausted by his circumstances.

It’s challenging to be the provider of a patient you can only do so much for. But it also makes me wonder how far my responsibility and obligation as a health care provider extends. I do not have a good answer to this question. I suppose it’s a balance of fighting the fights you can win and accepting the fights you cannot.  

Rotation 1: The Infamous Stay-At-Home Rotation

Posted by Unknown at Thursday, June 18, 2015

My first rotation was drug information.  I’d heard a lot about this rotation, so I was very excited to begin!  I was at a company that provides clinical information for users, and my focus was primarily on drug-drug interactions.

A Typical Day

I started the rotation mostly editing existing monographs and performing quality assurance on monographs that had not updated recently, but I gradually took on more responsibility and began writing more new monographs.  Requests for new monographs generally came from internal (other departments) or external questions, updated product labeling with new interactions, or articles that my preceptor or I happened to stumble across when researching another topic.  Two or three times a week, my preceptor, the other P4 on my rotation, and I would meet at a coffee shop (yum!) to talk about our work, discuss therapeutic topics and the drugs we were working on, research and writing strategies, and talk about life as a pharmacist.

I Didn't Just Write for 25 Days Straight

I didn’t just sit at home writing all day.  We had a Journal Club midway through the rotation, which was my first JC experience.  I also had the opportunity to poke around a little in the informatics side of the company and see where my monographs went once I finished writing them.  I was also able to work on a few pharmacogenomics projects and give recommendations based on my research, which I eventually wrote into a very different type of monograph.  In addition, I worked on a rotation-long project categorizing drugs based on levels of evidence.

Dusting off the MedChem

I unexpectedly found myself constantly challenged finding mechanisms of action, drug metabolic routes, and using this information to figure out how two drugs interacted with each other.  Some interactions were fairly obvious or were spelled out in a study or drug label, but others were not as clear and needed to be deciphered based on studies with other drugs or in vitro studies.  A few interactions had no evidence whatsoever, and the mechanism was left as “unclear, but the following mechanisms have been ruled out.”  I learned a lot about how drugs could interact, even in the strangest, most roundabout ways.

A lot of what this rotation boiled down to was writing, research, and coffee, which are three things I’m very fond of.  However, there were also many non-writing opportunities, and I was challenged in ways I didn’t expect to be challenged, most notably utilizing all of the medicinal chemistry I had tucked away in my brain a few years back.  If you like to write, I would highly recommend this rotation! 

Rotation 1: The Gospel According to Frame

Posted by Emily at Wednesday, June 17, 2015

My first rotation was something of a baptism by fire as I was assigned to the adult bone marrow transplant service at a large health center with Dr. David Frame.  As you can imagine, bone marrow transplant patients are a complicated population, so walking into the hospital on the first day was equal parts terrifying and exciting.  The first week was overwhelming as my two fellow rotation-mates and I learned to navigate the (abbreviation-filled) world of BMT.  For example, a typical progress note for a BMT patient might start something like this:

XY is a 40 yo male w/ AML in CR1 s/p 3+7 (idarubicin/ara-C) and s/p 3 cycles HiDAC followed by FluBu4 conditioning for MUD allo PBSCT on 5/1/15.  Admitted for intractable N/V/D with concern for GVHD.

Translation:  XY is a 40 year old male with acute myeloid leukemia in his first complete remission status post a chemotherapy course consisting of 3 days of idarubicin and 7 days of cytarabine, as well as three cycles of high-dose intermittent cytarabine, followed by four days of fludarabine and busulfan as preparatory conditioning for a matched unrelated donor allogenic peripheral blood stem cell transplant on 5/1/15.  Admitted for intractable nausea, vomiting, and diarrhea with concern for graft-versus-host disease.

Phew!  Fortunately, Dr. Frame gave us a high-level overview of the tenants of BMT on our first day.  There are two main types of bone marrow transplant: autologous and allogenic.

Autologous transplants are simply rescue therapy for patients who require incredibly high doses of chemotherapy to treat their blood cancer.  The patient's own hematopoietic stem cells are harvested and stored, the patient is given a course of high-dose chemotherapy that essentially wipes out their entire immune system because the regimens are so myelosuppressive, and then those stored stem cells are reinfused into the patient to save them from the toxicity of the chemo they received.

Allogenic transplants are a little bit more magical, as Dr. Frame put it.  In allogenic transplant, a patient's immune system is wiped out ("ablated") by high-dose chemotherapy, and then replaced with stem cells from a donor.  The idea is that the new immune system from the donor will recognize the patient's cancer cells as foreign and attack them, with the goal of getting rid of the cancer all together.  However, allogenic transplants are a careful balancing act because while we want the new cells to attack the cancer, we don't want them to attack the rest of the body.  Unfortunately, this is a relatively common occurrence in allogenic BMT referred to as "graft-versus-host disease" or GVHD.  Thus, allo patients are placed on immunosuppressive regimens including medications that are often used in solid organ transplant like tacrolimus or cyclosporine, mycophenolate, sirolimus, and/or steroids in order to prevent GVHD.

GVHD is a big concern for allo patients, but infection is a major issue for all BMT patients, especially immediately following transplant when patients' white blood cell and neutrophil counts essentially drop to zero.  Thus, all patients are placed prophylactically on an antibiotic, an antiviral, and an antifungal.     

The learning curve was steep, but I started to speak the language of BMT and feel more comfortable after those initial two weeks.  A typical day on this rotation looked something like this:

0630-0800 - work up patients at home 

I was never very clear on what it meant to "work up" patients before starting this rotation.  It's a phrase we hear thrown around a lot during pharmacy school, and it simply refers to following your patients' progress, monitoring their lab values, and most importantly, combing through their drug therapy to make sure all medications and doses are appropriate.  "Working up" a patient means developing a pharmacist care plan, complete with assessment of each issue and your plan to address and monitor the problem.  Patient work ups are the core of clinical pharmacy practice and are crucial if you want to meaningfully contribute to patient care during rounds.  I developed my own monitoring form specific for this rotation, since most BMT patients receive similar infectious disease prophylactic regimens, nausea and vomiting regimens, pain regimens, etc.  Having a service-specific form helped me to be more efficient as I increased my patient load.

0900-1200 - rounding with the medical team

The team was made up of an attending physician, "physician extenders" like physicians assistants and nurse practitioners who took rotating ownership of a fraction of the patients, a discharge planner, a registered dietician, and of course - the pharmacist!  Rounds generally lasted anywhere from two to four hours depending on the attending physician and the number of patients on the floor on any given day.  We would visit each patient's room as a group, and after the NP or PA presented an update of the patient's condition and problems that needed to be addressed, we would all go in to speak with the patient in person.  Rounding was not as high pressure as I expected it to be.  While Dr. Frame (and everyone else on the team!) loved to quiz us, they were all very understanding of the fact that we are still students and this was only our first rotation.

It was also very cool to see Dr. Frame's genius in action.  The team - including the attending physicians - frequently turned to him for recommendations and explanations as to why a certain medication/regimen/dose was preferable to another.  BMT is a very guideline-driven service.  Because Dr. Frame helped to write/overhaul so many of the BMT treatment guidelines here based on the best available evidence, and because the medical team trusts his knowledge so much, one of the physicians referred to these protocols as "The Gospel According to Frame".  To me, this exemplified the pivotal role pharmacists play in providing patient care of the highest quality.  Even patients knew Dr. Frame as "the drug guy" or "that pharmacist I was telling you about", and this was because Dr. Frame treats every patient with as much care and attention to detail as if they were his own family member - and he encouraged us to do the same.  I hope to one day inspire that same level of confidence and appreciation from my patients as Dr. Frame does from his.

1300-1500 - patient and topic discussion with Dr. Frame and/or Dr. Benitez, the PGY1 resident who was on rotation with us this month

Topics included management of chemotherapy-induced nausea and vomiting, posterior reversible encephalopathy syndrome (or PRES, a serious side effect of the immunosuppressant tacrolimus), Clostridium difficile infections, pain management, graft-versus-host disease, cytomegalovirus, neutropenic fever, pharmacokinetics, management of fungal infections in immunocompromised patients, respiratory syncytial virus, engraftment syndrome, and more!

evening - read journal articles, prepare answers to questions that came up during topic discussion, work on nursing in-service project

My nursing in-service was on the anti-emetic drug dronabinol, a synthetic form of THC.

My favorite part of this rotation by far was the way Dr. Frame pushed us to really THINK.  He told us on the first day that he didn't care if we became bone marrow transplant experts; he was more interested in us learning how to think like pharmacists, to reason our way to appropriate recommendations, and to always ask WHY.  Every day on rotation was full of puzzles needing to be solved, and I had so much fun striving to really think every puzzle through mechanistically.  I used to think that Dr. Frame was some kind of pharmacy wizard who just magically knew everything.  But I quickly realized that he's not so much a pharmacy wizard as a pharmacy super sleuth who uses logic (and half-lives!) rather than magic to be so good at what he does.  (Even if allo transplants are a little bit magical.)

Overall, this was a fantastic, highly recommended rotation experience.  It solidified my interest in pursuing residency, and helped me to realize that I probably know more than I give myself credit for.  I'm looking forward to diving into my next rotation - pediatric generalist - ready to continue building my skills and my confidence!

Superman, Spiderman, and Captain American washing the windows at Mott