Rotation 4: Ambulatory Care Like You've Never Seen Before

Posted by Unknown at Monday, October 31, 2016

I spent block four at the Cancer Center at St. Joseph Mercy Hospital (SJMHS).

My preceptor is piloting a new program at SJMHS where each person that is receiving any oral medication to treat cancer is required to speak to a pharmacist about that medication. Oral chemotherapies—while often much more tolerable than the usual intravenous option—are not benign by any stretch of the imagination. More importantly, unlike the IV chemotherapy where the patient is surrounded by healthcare professionals for the duration of their infusion, the pills go home with them. For many of them, there are very real risks associated with exposing other people to the drug and other considerations like what you should/not eat or drink, warning signs for side effects and other complications, and drug-drug interactions that could compromise their treatment.

All of the same items apply for patients new to IV chemotherapy, but the majority of the side effects and management have significant overlap so that is done in a classroom setting. However, there are always little things that a nurse practitioner and I would team up to address afterwards.

These sessions would typically take about an hour (and sometimes much longer!) and after three or four in a day I would try to avoid talking for a while so I wouldn’t lose my voice!

Typical Day

I would typically arrive at SJMHS between 7 and 8 AM. First things first: check in ARIA (the infusion center electronic medical record system) to see if there were any new patients for the day. While most of these were scheduled days or weeks in advance which would give us plenty of time to prepare, there was the occasional last minute addition. The morning was usually project work or counseling, depending on the day, and afternoons were the same dependent on the IV chemotherapy teaching class schedule. Generally, I would be in my car headed home between 4 and 5PM with a smile on my face.

The Work

Working up a patient is less focused on their specific disease and more focused on the drug and the logistics of getting it to the patient on time. A lot of things need to click in to place before the drug is sent to them by the (usually specialty) pharmacy, and a big portion of what I was responsible for was, on top of the usual pharmacist duties, ensuring that our office had all of the information we needed and that all necessary testing was done or scheduled. Based on the drug or drugs they were receiving additional screening (such as hepatitis B, HIV viral load, or an echocardiogram) might be required.

Next would be actually going to meet the patient and their family. I often had groups as large as eight or nine people—and spend the hour or more discussing the information that I had, answering their questions, and if they wanted to continue, collecting their consent form. Most days these counseling sessions would take 3-5 hours on 2-3 days a week.

These sessions have been some of the most fulfilling work that I have done as a student pharmacist. Most of the people I was seeing have only known that they have had cancer for one or two weeks. There is a lot of apprehension and a lot of things are changing very fast—suddenly they need to reevaluate their entire life plan and here I am talking about all the bad things that could happen if they take this medication. I could relate to what this was like—my father was diagnosed with cancer when I was in high-school—and those experiences went a long way towards helping me understand what these people were going through. The relief that each person experienced when they were done speaking with me was something to behold. Many underestimate the power of knowledge and what that can do when you have been preoccupied with so many fear-filled unknowns. Pharmacists make this possible.

Projects

My preceptor more-or-less owns the responsibility for the back-end management of ARIA and as such, we had access to a ton of data and reporting tools for process improvement. I used my programming background to streamline several reporting processes for each of the five clinic sites that will probably save an analyst a full week of work each year (30-45 minutes per report à 10 seconds per report). This is on top of literature searches for various questions like “should we use cryotherapy with doxorubicin infusions” or “is glucarpidase over dialysis cost-effective in managing methotrexate-induced acute kidney injury?”

A major component of these counseling sessions is a set of informational packets built for each drug. The Michigan Oncology Quality Consortium (MOQC) has built a ton of these for the oral chemotherapies that we enhanced for use in our clinic. Part of my job was building these for new drugs and updating old drugs with new data.

Overall Thoughts

Year to date, this has been a blast of a rotation. I sincerely left each day with a smile on my face and an excitement about the next morning. I found the work fascinating, challenging (but manageable), and I made a sincere, visible difference in the lives of so many people. Not to mention, I got to program and use a bit of my technical background as well! You can peer in to the world of specialty pharmacy billing, learn a whole lot about various cancers and their treatments, and a ton of other interesting work besides. I highly recommend this rotation!

HIV Alphabet Soup - From ABC to ZDV

Posted by James Shen at Wednesday, October 26, 2016

I was fortunate enough to spend my 3^rd rotation in Chicago, IL for an HIV/AIDs community specialty rotation. There is a steep learning curve for this rotation, especially considering the brief amount of time spent covering HIV/AIDs during school. Making sense of the ~300 page DHHS guidelines, and memorizing every detail about each of the various HIV drugs took up way more time than I would like to admit. However, at the end of the rotation, I can definitely say that I had the knowledge, skills, and confidence to be able to counsel and manage a patient’s HIV/AIDs diagnosis and drug regimen.

Typical Weekly Activities

Rotation ran from 9am to 5pm each day. On Mondays, Wednesdays, and Thursdays, we were at a Walgreens located inside the Howard Brown Health Center, which is a clinic that serves a large volume of LGBTQ and underinsured patients. It is an incredibly high volume store, and it can be very overwhelming for someone who has not worked in a community setting before. On my very first day when I walked in, before I even got a chance to introduce myself to my preceptor, I was already asked to administer a Hepatitis B shot to a patient that had just come in! Other than that, our activities at Walgreens varied; we would usually start off the day by preparing patient pillboxes, making calls to patients that were newly started on therapies, and calling patients about ADAP (AIDs Drug Assistance Program) packages. From there, we would meet up with our preceptor to have some topic discussion, ranging from drug mechanism of actions, to STDs, to HIV epidemiology… whatever the topic was, you can be sure to be questioned about every minute detail until you understood it inside and out. We also participated in a large MTM (medication therapy management) project, which means we helped conduct MTM interviews with multiple patients that came in each day. This entailed performing a complete work up of the patient (looking at lab values, vaccination records, drug interactions, etc.) and then talking/counseling the patient about any concerns he or she had. Finally, by the last 1-2 weeks, we were performing typical pharmacist duties, which included verifying orders, checking technician work, counseling patients at the window, etc. The patient population and drug regimens seen at this site are very unique, and each day was definitely something new and exciting.

On Tuesdays and Fridays, we went to Mercy Hospital where we served in one of the clinics alongside with nurses, PAs, doctors, and other hospital staff. This was definitely a unique component of this rotation, as we were able to see patients one on one and counsel them about their HIV regimens and other drug-related concerns. A typical counseling session could involve readiness assessments (whether or not a patient is ready to begin HIV therapy), medication adherence assessments (whether or not a patient is taking their medications appropriately), and initial therapy counseling (helping patients choose a therapy that is right for them). For example, I personally helped a patient make a switch from an outdated HIV regimen to a newer more tolerable regimen simply by educating him on his options, counseling him on the side effects, and helping him choose a regimen that would best fit into his lifestyle. These clinic days were my favorite part of this rotation, and it provides a unique clinical experience that I think other community rotations do not offer.

Other projects

While you are kept busy with the daily day-to-day topic discussions and activities of rotation, we also had side projects that supplemented our experience on this rotation. For example, we helped create an inservice presentation to the psychology residents and externs at Mercy Hospital, where we presented about the pros and cons of various HIV regimens, as well as the differences between PrEP and PEP therapy. Additionally, we helped construct a database for Hepatitis C patients who had visited the clinic, which included information on their labs, treatment regimens, genotypes, etc.

Final thoughts

This was definitely one of my most rewarding rotations, and I feel like I came away with a new wealth of knowledge. The diverse patient population lends to an experience that is very unique, and I was able to learn more about HIV/AIDs then I ever imagined. On top of all of that, Chicago is an absolutely great city to explore and live in for a month. During my free time, I was able to attend a free airshow along the lake, visit Navy Pier, see the Bean at Millennium Park, explore the Field Museum of Natural History, walk through the expansive Chicago Botanic Gardens, ride down the Chicago River on an architectural boat tour, eat a lot of great food at the multitude of restauraunts, and much, much more! I would highly recommend this rotation to anyone looking for a unique community experience. Attached are just a few of many pictures of my experiences.

Chicago Air and Water Show

Chicago Botanic Gardens

 Architectural boat tour

Underneath the bean!

Rotation 4: "Give Me the Big Picture"

Posted by Millie at Tuesday, October 25, 2016

My fourth rotation brought Jenn (another P4 blogger on here!) and I to the Surgical ICU. This was both of our first inpatient clinical experiences, so we were in for quite a challenge. I was excited to start seeing what the inpatient world was like.

We found out very quickly that the SICU was a very busy service, and that even though there were only 20 beds, the patients had very complex needs. The rounding team consisted of us, our preceptor or our pharmacy resident, 5 medical residents, 2 medical fellows, 2 medical students, 1 medical attending, and 1 nutrition specialist. As you can probably imagine, we had a huge team! Rounds also took us anywhere from 4 hours to 6 hours, which leads me to my biggest advice to you all which would be to make sure you get some comfortable professional shoes for any inpatient rotation you have. (Side note: carrying a water bottle and eating a small snack right before rounds will also help in the long run!)

I learned quickly that patient presentations in the SICU went “head to toe,” meaning we covered ALL systems: neurology, cardiovascular, pulmonary, gastrointestinal, genitourinary & fluids, electrolytes, and nutrition (GU/FEN), hematology, infectious diseases, endocrine, and musculoskeletal. During our patient presentations to our preceptor, we would cover all of these systems as well, but with a focus on the patient’s medications.

Typical Day

I would arrive about an hour and a half prior to rounds to work up my patients. In the SICU, we had very high “turnover,” meaning we would always be admitting new patients or transferring current ones to the general floor. Although pharmacy students on other services may work up patients at night, we had such a high turnover in the SICU that this wasn’t really possible and it was more appropriate to wait until the morning. This rotation really helped me learn how to work up patients quickly and assess their clinical picture thoroughly, looking at their most pertinent problems.

Jenn and I each covered half the service, though we followed each other’s patients as well. We were able to really strengthen our skills with pharmacokinetic dosing of aminoglycosides and vancomycin, especially considering our patient population was not your typical classroom example and had kinetics that are all over the place (e.g. constantly changing volume of distribution, GI surgeries that impact absorption, renal dysfunction impacting clearance), so we had to really consider the whole patient when making our dosing adjustments. Our patients are also frequently on intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT), which are two major factors to consider when calculating kinetics. I felt very proud towards the end of the rotation when I realized I felt very comfortable managing the vancomycin and aminoglycoside regimen for a patient who was bouncing back and forth between IHD and CRRT – something I could not have imagined at the start of this rotation!

We would go on rounds for multiple hours, then grab a quick bite to eat for lunch, and then follow up with our preceptor and/or pharmacy resident to discuss what happened on rounds and patients. Afterwards we would do a topic discussion, typically about some critical care topic such as sepsis, acute respiratory distress syndrome, or intra-abdominal infections.

Final Thoughts

Surgery is definitely not an area we focus on in pharmacy school, so it can be very overwhelming to work in the SICU. The majority of these patients may be on mechanical ventilators or use nasal cannulas for oxygenation, and they typically have multiple IV lines or drains. I spent the good majority of my time googling EVERYTHING, but I would definitely encourage you to try not to get lost in all the little details of vent settings and lines.

In addition, try to think ahead of the team if possible. Does it seem like the patient needs an antibiotic? Which one would you recommend based on coverage? What dose/frequency? On the other hand, did microbiology lab results come back and the regimen could be de-escalated? Recommend it to the team.

Jerika also wrote a really great blog post (a few posts back from this one) on her experiences with SICU at a different hospital, and I would encourage you to read it! The SICU is definitely a unique environment, and will challenge you to think about and consider a holistic view of the patient.