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.