Friday, June 19, 2015

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.  

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