Sunday, July 24, 2016

Rotation 1: All is fair in Lovenox and Warfarin

Posted by Dana at Sunday, July 24, 2016

Hi, I’m Dana, and I’ll be telling you all about my life this year as I make my way through P4 rotations! Before I get started on talking about my actual rotations, I'd like to share with you some of my goals and interests so you can determine how much you'll get out of my blog posts. During the P1-P3 years of pharmacy school, the topics I most enjoyed learning about were infectious disease and oncology. Then, when I did my intermediate pharmacy practice experience (IPPE) at the VA in Ann Arbor, I saw first-hand the amazing impact that ambulatory care pharmacists have on their patients, and I was really inspired by that, too. At the moment, I’m still working out exactly what I want to do after graduation. I’d love to pursue any and all of the interests I just mentioned, but I’m also trying to keep an open mind and learn as much as I can this year. At this point in time, I'm planning on applying for a general PGY1 residency. 

Whether you're a prospective pharmacy student trying to get a glimpse into life at U of M, or a P1-P3 doing your homework for ranking, I look forward to sharing my journey with you, and I hope I can give you some good insight. J

I completed my first rotation in Ambulatory Care back in June, which was in the Anticoagulation Service at Domino’s Farms here at U of M. The pharmacists and nurses in the Anticoag Service regularly monitor and adjust patients’ anticoagulation therapy. Medications I regularly worked with included warfarin, DOACs (direct oral anticoagulants such as Xarelto and Eliquis), and lovenox.

The pharmacists at this clinic manage a special population of patients who have Left Ventricular Assistant Devices, or LVADs. An LVAD is an implanted device that serves as a pump from the left ventricle to the aorta for patients with late-stage heart failure. They’re pretty cool to learn about, so I’ll link you here and here to some videos if you’re curious. Having an LVAD device puts patients at an especially increased risk for blood clots compared to other patients, and warfarin is the only anticoagulation medication that has been studied in patients with LVADs. Therefore, these patients must be monitored more closely than most. 

Additionally, several of these patients take antiarrhythmic medications such as amiodarone, and must be put on antibiotics fairly frequently for device-associated infections. As we know, several drugs interact with warfarin, so this is another great opportunity for pharmacists!

Typical Day
I got into the office every morning at 8AM. I’d usually start out my day working up patients who were recently discharged from the hospital. After working the patients up and evaluating their anticoagulation therapy, I would talk to my preceptor to discuss and change the plan I devised, and call the patient to talk about their medications and inform them of any special changes or instructions. 

After discharges were done, I would work up patients whose INR levels had come back to the clinic. If the INR level was out of range, I would adjust the patient's warfarin dose appropriately, then determine when I wanted to get their next INR. Doing this on a daily basis not only gave me a solid foundation in warfarin therapy adjustment, but really enhanced my patient communication skills and gave me confidence when speaking with patients. Occasionally, I got the opportunity to evaluate DOAC therapy and develop bridging calendars for patients with upcoming procedures. One day, I even got to communicate to a patient through a translator, which was a very cool experience!

Other Projects & Activities
During the first half of this rotation, my preceptor and I would have regular topic discussions on frequently seen medications, frequently seen drug interactions, general indications for anticoagulation, certain disease states, and more. Preparing for these topic discussions was sometimes time-consuming, but they really helped me build a solid foundation in therapeutic knowledge, and I know that I'll be glad for it on my upcoming rotations. During the second half of the rotation, I got to work on various projects and presentations in the clinic. I did some chart review for all the patients who were admitted to the anticoag service during the month of May in order to evaluate the appropriateness of their therapy. I also had the opportunity to present on crash cart medications to the cardiac rehab team.

For anyone who gets a rotation that involves regularly speaking to patients on the phone, something that really helped me was making a script to read off of so I didn’t get flustered or forget what to say. Warfarin is typically discussed with patients in tablet size – for example “2 tablets on Mondays, Wednesdays, and Fridays, and 1 tablet on all other days.” This can be pretty easy to get backwards when you’re first starting out, so having a script with blank spaces to fill out helped me keep everything straight and remember to get all of the important questions and points into every conversation.

     Final Thoughts:
      This was a good rotation to start with, because it gave me a lot of confidence in interacting with patients, and I also got to really "master" one subset of disease states and medications. If you have a huge interest in ambulatory disease states such as diabetes, hypertension, and hyperlipidemia, this may not be the rotation for you, but I thought it was a great experience. 

     Next Up:
      I'm actually already on my LAST WEEK of rotation 2 right now! I also have my seminar presentation coming up in 2 weeks, so I'll update you guys on both of those things soon.

     Until then, I hope everyone is having a good July! 

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