Monday, August 1, 2016

Infectious Diseases - The Big Guns Come to Life

Posted by Jared at Monday, August 01, 2016

After my first rotation in ambulatory care managing patients with mostly hypertension and diabetes, I was doing a bit of a 180 in the clinical sense and jumping into the world of infectious diseases (ID). ID was by far my favorite section in therapeutics during pharmacy school, and I was both excited and nervous for this rotation, as I knew it was going to be a challenging rotation. I had the opportunity to do this at a hospital in Detroit, so I was interested to see how the patient population would affect the type of infections we would see and how these patients would be managed.

A Typical Day
I generally would get into the hospital at around 6:30 AM to work up the patients I was planning on presenting to my preceptor, along with following up on patients I was still following and finishing up my topic discussions. At around 9 AM most days, I would meet with my preceptor and present the two new patients I picked up on our service, do a topic overview of their disease state, present my assessment/plans, and then discuss patients I was still following. Afterwards, I would typically go on rounds for a variable amount of time, which was dependent on the schedule of the attending physician and fellows, as they had different commitments (clinics, didactic, meetings, etc.). Generally, we would round for about a few hours in the morning, then break for either ID Grand Rounds, a lecture, or journal club, and then re-convene in the afternoon and finish rounding, which usually got out anywhere from 5-6 PM.

Of note, ID services are typically consult services, so we would see patients on a number of floors, ranging from the internal medicine floors to ICU, Burn, Neuro ICU, and Surgery. Due to the nature of our service, which typically consisted of the attending physician, two fellows, two to three residents, the clinical pharmacist, and me, we would often get new consults during the day that we would need to address. On average, our service had around 12-15 patients, but could go up to 20-23 patients.

Expectations, Challenges, and Overall Thoughts
As I mentioned earlier, my preceptor required two new patient presentations a day, along with a topic discussion for each patient's disease state.  I also needed to follow all my patients that were previously presented that our service was still following, along with keeping an updated patient list that included the patient's infection, their antibiotic therapy and duration, along with notes about their treatment. Also, if any patients I was following were on aminoglycosides or vancomycin, I was responsible for doing the pharmacokinetic calculations by hand and showing it to my preceptor that morning when discussing dose recommendations. I also had to write a review paper on a topic of interest that could only utilize primary literature as sources (no review articles or textbooks).

Without a doubt, this rotation was a huge challenge on my time management skills. I would initially spend a lot of time both at home and in the hospital working up patients and putting the topic discussions together. My preceptor in particular challenged me to use only primary literature, rather than relying on class notes or textbooks to put these together. This was difficult for me at first, as not every disease state has a nice review or guidelines to go over and synthesize into a succinct presentation. After I ran through most of the common ID disease states (i.e. pneumonia, skin and soft tissue infections, bacteremia), I essentially picked what might be interesting to me or things my preceptor recommended to go over (i.e. tuberculosis, malaria). Often, I was in a time crunch in the morning, but as the rotation went on, I got much more efficient at putting together these topic discussions and working up my patients.

Also, while the topic discussions were time intensive in terms of preparation, it really helped to solidify my therapeutic knowledge. My preceptor was great at asking probing questions and really helping me to understand the reasons behind various concepts (i.e. why is IV drug abuse a risk factor for endocarditis?). Furthermore, the institution I rotated at doses vancomycin differently than what we were taught at UM. Rather than using a nomogram, they targeted AUC (area under the curve). This required me to essentially re-learn vanco PK, but it helped a lot with practicing those equations and solidifying my skills. Due to the nature of Detroit's patient population, I got to see a lot of patients with either MRSA infections or multi-drug resistant infections that required either those big gun agents Dr. Carver has us avoid using in therapeutics (i.e. daptomycin, linezolid) or unconventional combinations. Finally, the questions I got from both my preceptor and the clinical pharmacist that went on rounds daily helped me to understand why we spent so much time learning physiology and med chem by really "connecting the dots" between concepts I didn't think could relate to ID in the first place.

All in all, this was an extremely rewarding experience. I was constantly challenged and pushed to my limits, but I came out of it with a much more solidified therapeutic knowledge base of ID and a greater appreciation for the discipline. A PGY-2 in ID still isn't out of the question for me, but we will see what the rest of the year holds! For now, it's on to community and rotation 3!

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