Hail to the Little Victors: Pediatric Oncology at Mott Children’s Hospital

Posted by Rachel Lebovic at Monday, November 18, 2013

If I told you that my pediatric hematology/oncology (peds hem/onc) rotation was my favorite rotation to date and it confirmed that I want to pursue a career in oncology, you might think, “who could ever want to work with children dying of cancer?” While this area of expertise is certainly not for everyone, I will try to use the rest of this blog post to explain why I am eager to work as a clinical pharmacist specialist in oncology (and possibly even pediatric oncology) in the future.

First, the daily routine on rotation. On most days, I would arrive at Mott Children’s Hospital between 7-7:30am to work up my patients before meeting with my preceptor around 8:15-8:30am to discuss the interventions we wanted to make on rounds. Rounds started at 9am and lasted anywhere from 2-4 hours. Then, I would eat lunch and meet with my preceptor to talk more thoroughly about each patient, discuss what happened on rounds, and determine our plan for follow-up, monitoring, or counseling needed that afternoon. After handling any patient care issues, we would go down to the cafeteria for topic discussions and case presentations. I was very fortunate that my preceptor, Dr. Erika Howle, would take hours out of her busy day to help her students learn. The first week of rotation was a little crazy because we prepared one chemotherapy topic discussion and one supportive care topic discussion every day. In my opinion, the craziness of the first week was well worth it because it allowed me to start contributing to the peds hem/onc team almost immediately. Throughout the remaining four weeks, our topic discussions focused on different disease states, such as leukemias (ALL, AML), lymphomas, neuroblastoma, sarcomas, and sickle cell disease. At the end of the day, I would follow-up with the hem/onc team regarding any medication-related patient problems and look at any new patients before heading home to prepare for the next day’s topic discussion.

This schedule was fairly constant with the exception of Wednesdays. In fact, Wednesdays on the peds hem/onc service are so different that they are colloquially known as “Wacky Wednesdays.” On Wednesdays, the peds hem/onc department holds several meetings. At 7am there is an immunoheme conference where an attending, the oncology fellows, and others discuss complex cases involving immunology. At the 9am meeting, all of the peds hem/onc attendings and the current inpatient care team of a nurse practitioner, interns (1^st year medical residents), a senior resident, medical students, the pharmacist, and pharmacy students all meet to discuss current complex oncology cases. I loved listening to all of the experienced practitioners discuss the benefits and risks of different options for each patient – especially if I was helping care for that patient. Then, we started rounds at 10am and stopped for the tumor board meeting at noon. Tumor board is a joint meeting between the peds surgeons and peds hem/onc team. The practitioners look at scans then decide if a patient can go to surgery to have their tumor resected or if they need more chemotherapy to shrink the tumor before surgery is a viable option. After the conclusion of tumor board the team would finish rounds and address any patient issues the remainder of the afternoon.

In my spare time, I worked with a resident, another P4, and a pharmacist on a special project. After Mott Children’s Hospital heard about a hospital in Brazil that covers its chemotherapy with superhero-themed chemotherapy covers, we decided to pursue a similar project at Mott. Here is a video with our inspiration: http://www.youtube.com/watch?v=KC2y3s-MCMs. We contacted the hospital in Brazil, a plastics company, Disney, and others to start figuring out how to implement a similar chemotherapy cover program. I know this project will take a long time to be fully implemented, but I can’t wait to see how the kids like the chemo covers once they arrive!

Another special experience on the peds hem/onc service came on Halloween. Many members of the inpatient care teams in the hospital dressed up, and the hem/onc team was no exception. On rounds that morning, we had Mary Poppins, an Incredible, a bunny, two witches, Snow White, and a fairy!

Besides special fun projects and dressing up on Halloween, one of the big plusses to the peds hem/onc service is the tremendous impact you can have on patient care. An example of the interventions that I made on this rotation included changing a PPI to an H2RA (one type of acid suppressor to another) to avoid a drug interaction with a chemotherapy agent.  I was also able to adjust anti-nausea, pain, and bowel regimens to make patients more comfortable and help the team dose/monitor/adjust antibiotics to treat infections and neutropenic fever. Furthermore, I followed which chemotherapy agents each patient was to receive each day, made sure they were clinically able to receive the medication based on their blood counts, communicated to the inpatient pharmacy about which patients were going to receive chemo, and answered any questions the families had about the chemotherapy agents. Another plus to working with the peds hem/onc service is the continuity of care in an inpatient setting. Since many children require several rounds of inpatient chemotherapy, practitioners get to know the patients and their families.

In my mind, I can’t change that these children were diagnosed with cancer, but I can try to help them achieve their goals of care – whether they are cure, comfort, and/or palliation. I can help these kids just be kids, and that is an amazing feeling. Furthermore, the other members of the inpatient team rely heavily on pharmacy due to the specialty medications used in this patient population, which made me feel like a valuable member of the team. Yes, there are some patients who lose their battle with cancer, but in most cases the survival rates are actually much higher in children than adults, so there are fewer sad stories than you might think. Lastly, it is really rewarding to adjust patients’ medications to help them live more comfortably, especially if their goals are palliative.

Have I convinced you yet? It’s okay if peds hem/onc isn’t for you, but if you were skeptical, maybe now you won’t think I’m as crazy for loving this rotation and pursuing a career in oncology (and likely pediatric oncology) pharmacy.

Inpatient Psychiatry at Pine Rest Christian Mental Health Services

Posted by Silu at Thursday, November 14, 2013

What do you call an alligator wearing a vest?

…An investigator!

This and many other jokes brought to you by one of the psychiatrists I shadowed on a weekly basis, who told a corny joke Q 15 min while seeing patients. Welcome to the inpatient psychiatry rotation at Pine Rest.

A little bit of background information about this site, Pine Rest Christian Mental Health Services based in Grand Rapids is one of five largest mental health service providers in the nation and has over a 100 year history. Pine Rest not only has a 170-bed psychiatric hospital, but has several clinics in western Michigan and offers a number of unique behavioral health services.

The inpatient psych rotation at Pine Rest is definitely a unique one. Unlike typical inpatient rotations, I did not follow one group or one service of patients, since my preceptor, Dr. Kevin Furmaga, is the only pharmacist at the hospital. He works mostly on a consultation basis and receives requests from psychiatrists mainly for highly specialized or treatment-resistant cases. However, I did have numerous opportunities for patient care through attending multidisciplinary treatment team meetings, shadowing psychiatrists and following up with recommendations and questions, and interviewing patients for consultation.

I also taught a medication education class twice a week to patients in different units, as a part of the schedule/programming for patients during their stay. We discussed the classes of commonly-used psychiatric medications and answered questions for the patients. This was one of my favorite parts of the rotation. Though the material was the same each time, each class was very different depending on the patients there, and I gained a great deal of insight about their attitudes/perceptions about medications and treatment.

Besides patient care and teaching responsibilities, I also worked on a number of projects including (but not limited to) giving short topic presentations at treatment team meetings, creating a resource/guideline for therapeutic drug monitoring, and writing a drug monograph for formulary review for the P&T Committee.

This was definitely one of my favorite rotations to date. I learned so much more about not only psychiatric medications (oh yes, Dr. Furmaga will give you a personal lecture/review on psychopharmacology), but the complex spectrum of care that goes into mental health, including different types of behavioral and group therapy and even electroconvulsive therapy (ECT). I saw how, in a short period of time, a patient’s demeanor and mental status can change completely with treatment and also, unfortunately, patients who have had trials of over 17 medications with no response.

Overall, I'd recommend this rotation for anyone who is even a little bit interested in psychiatry. Dr. Furmaga is an excellent preceptor who is knowledgeable and well-respected. He is also flexible and will work with you on special requests you may have for the rotation. Be prepared to be work hard, manage your time wisely, and look for opportunities to learn in addition to or building on the ones already provided, but have fun and take advantage of your time there as a student. 

Sadly, this rotation marks the last of my clinical rotations. Looking forward to different experiences in drug information, community, and teaching skills for the next few rotations, but will definitely miss seeing patients!

-Silu

Rotation 4: Industry - Catalyst Regulatory Services, LLC, Dexter, MI

Posted by Jennifer at Thursday, October 31, 2013

After having 3 hospital rotations, I was excited to begin my fourth pharmacy rotation in the industry setting at Catalyst Regulatory Services, LLC.  Right from the start, Catalyst welcomed me into their team!

Catalyst is a consulting company that provides regulatory strategy and operational assistance to pharmaceutical companies large and small.  The president of the company is Mark Ammann, Pharm.D., and my preceptor, Anita Fereshetian, R.Ph., MS, is a regulatory director on the management team.  The Catalyst management team consists of a regulatory operations manager and senior consultants, many of whom are pharmacists and have had extensive industry experience at various pharmaceutical companies.  Catalyst also has a widespread consultant staff.

In a nut shell, biotechnology and pharmaceutical companies contract out to Catalyst for guidance with regulatory issues.  Catalyst assists with strategy development, submission of orphan applications, investigational new drug applications, new drug applications, and much more!  Catalyst composes submissions that are sent not only to the FDA but also to the EMA and other international regulatory bodies.  While on rotation, I was considered to be part of the drug development team in two specific pharmaceutical companies for which I was working on projects.

In the beginning of my rotation, I learned about Regulatory Affairs, clinical research, the Prescription Drug User Fee Act (PDUFA), and rare diseases and orphan drugs.  Mark, Anita, and others regularly had didactic discussions with me about these topics and more.  They were glad to have these talks and answered any questions that I had! As various topics arose during my rotation, there were often FDA guidances from which I was able to gather specific information and then discuss with my preceptor Anita.  I became a pro at navigating the FDA and EMA websites as well as clinicaltrials.gov to investigate planned, current, or even completed clinical trials.

I worked on some fascinating projects while at Catalyst!  Most notably, I was the lead author for an orphan application and drafted a protocol synopsis for a phase II study.  I learned in depth about a specific disease state and the current treatments for the disease, including current marketed therapies and investigational new therapies.  These were long-term projects that I worked on for the majority of my rotation, and it was rewarding to finish them on time before my rotation ended!

During my time at Catalyst, I observed several skills and attributes that I think are essential when working in Regulatory Affairs, and I was able to improve upon these skills while on rotation:
Ability to work independently and with a team – I worked on projects independently for some of the time, but I regularly discussed these projects with my preceptor Anita.  Even though self-sufficiency for working on projects is needed, it is very important to be able to work well with others.  For example, I worked with several other people from different divisions of a pharmaceutical company as well.
Time management – Many documents are time-sensitive.  Also, if a company has a goal deadline for a submission, a Regulatory Affairs professional needs to do his or her best to complete their work within that timeframe.
Detail-oriented – There are specific pieces of information that should be included in submission documents in order to obtain approval from the FDA or another regulatory body.
Critical thinking – Understanding the FDA guidances and figuring out how to construct submissions is vital.  Also, understanding the clinical data that supports the submission document is important.
Passion – As with any career, it is important to enjoy what you do!

A highlight of my rotation is that I was able to observe and contribute to team development and committee meetings with Catalyst and pharmaceutical companies, most notably preparation meetings for a pre-IND FDA meeting. There are different types of FDA meetings (A, B, C), and I was very fortunate that Catalyst invited me to attend a pre-IND meeting (type B) at the FDA in Silver Spring, Maryland!  It was terrific to learn first-hand how to prepare for and carry out a meeting with officials from the FDA.  It is very important to know exactly what topics to discuss at the meeting since time is limited.  Additionally, clear and effective communication is vital.

I learned so much about pharmaceutical industry while at Catalyst, not only through reading FDA guidances and working on projects but mainly by talking to people at Catalyst and other pharmaceutical companies about their career paths in industry.  They were all more than happy to share their experiences with me.  There are many wonderful career opportunities for pharmacists in the pharmaceutical industry!

Rotation 3: Pediatric General Medicine - C.S. Mott Children's Hospital, Ann Arbor, MI

Posted by Jennifer at Thursday, October 31, 2013

This rotation was different than my first two rotations in that all of my patients were pediatric patients.  Their ages ranged from only a few days old to late teens.  I did not have much previous experience with pediatrics, so I was very glad to have this rotation!

Daily routine:

0730-0830: I began the day with pre-rounding.  To me, the goal of pre-rounding is to understand the patient’s medical history and current status, think of recommendations to improve the patient’s medication regimen, and anticipate questions the team may have during rounds.  Recommended pediatric doses are often stated in mg/kg or mcg/kg, so it took some time to become accustomed to determining correct dosages for patients. 

Some questions I would be thinking about during this time:
What are the medications treating?
Are those the correct dosages, or do they need to be adjusted?
What should I be monitoring for (renal function, side effects, etc.)?
What changes to the medication regimen might the team be thinking about (IV to oral, increase or decrease in dosage, change to a different medication altogether)?
Can this medication be administered through a G-tube or J-tube?
Are there any home medications which are not listed on the inpatient medication list?

0830 - 0900: Present and discuss my patients with my preceptor and finalize recommendations for the team.  I actually worked with several different preceptors, and they all helped me to improve my therapeutic skills.

0900 - 1000/1100: Round with the team, which consisted of the attending physician, an intern, two residents, three medical students, the nurse, and myself.

1000/1100: Follow-up with any questions from rounds, complete medication reconciliations, track lab values for patients on total parenteral nutrition (TPN) and review the TPN orders. 
1330: Meet with my preceptor to verify TPN orders.
1400 - 1500: Finish medication reconciliations.
1500 - 1600: A variety of topic discussions, case presentations, and journal clubs would occur during this time.
1600: Complete any unfinished work.

It was quite a busy rotation, as you can see from the above daily schedule, but worth every minute of it!  The rounding team was very receptive to my recommendations and valued pharmacy contributions.  If treatment questions arose during rounds that required some research, I gladly would investigate and report back to the team.  I learned about many disease states that I had never heard of before and their recommended treatments! 

Rotation 2: Health System/Hospital - Providence Park Hospital, Novi, MI

Posted by Jennifer at Wednesday, October 30, 2013

I was able to experience many different aspects of hospital pharmacy while at Providence Park.  Each day was filled with different activities, so here I have organized my experiences by week.  The pharmacy staff was very welcoming, gladly allowing me to participate in pharmacy tasks!

Week 1: During this time, I was able to orient myself with the pharmacy department.  I spent time learning how they keep track of controlled substances and how they purchase medications and deal with medication shortages.  I worked in the clean room for a day and made IVs, worked in unit dose and packaging, and shadowed some of the pharmacists to see how they verified medication orders.

Weeks 2-3: Here, I focused on kinetics and anticoagulation.  The hospital has paper forms the pharmacists use to keep track of certain antimicrobials and anticoagulant medications.  I was able to look at patient profiles and discuss medication adjustments with my preceptor. 

Week 4: I began attending ICU rounds during week 4.  Before rounds, I would “pre-round,” meaning that I worked-up patients before rounds.  The rounding team consisted of the attending physician, two nurses, a dietician, the pharmacist, and me.  Since it was a smaller group compared to the larger rounding team at my previous rotation, it was easier to have team discussions here.  After rounds I would discuss my patients with my preceptor, much like my first rotation.  I learned a great deal about a variety of disease states. 

During week 4, I attended a Pharmacy and Therapeutics Committee meeting, summarized pertinent updates, and presented the minutes to the rest of the pharmacy staff.  I also gave a presentation to nurses, pharmacists, and pharmacy technicians, titled Prevention and Treatment of Opioid-induced and Immobilization-related Constipation.

Week 5: I attended ICU rounds during the week and also began working with the metabolic support pharmacist and hospital dietician for adjusting parenteral nutrition for patients. During week 5, I was able to observe two procedures in the operating room.  The staff kindly explained their tasks and answered any questions that I had about the operations.  I had never seen an operation before, so it was an interesting experience!  Throughout my rotation I also worked on projects, such as analyzing proton pump inhibitor usage in the hospital and adding information to hospital oncology guides for specific medications. 

I enjoyed the variety of projects and activities with this rotation and the fact that I was able to work with people from different departments in the hospital (nurses, physicians, dieticians).  The pharmacy staff here is friendly and work so well together that they are more like a pharmacy family.  I’m thankful for my time spent at Providence Park Hospital!       

Rotation 1: Adult Surgery - University of Michigan Hospital, Ann Arbor, MI

Posted by Jennifer at Wednesday, October 30, 2013

This was an ideal rotation to begin P4 year since it encompassed many disease states.  The main therapeutic areas I encountered were anticoagulation, infectious diseases, hypertension, diabetes mellitus, pain management, and total parenteral nutrition.  I learned a great deal while on this surgery service!

Daily routine:

0530/0600: Rounds started bright and early with the surgery team!  The exact start time of rounds would vary each day between 0530 and 0600.  Each morning I would be ready for any questions that might arise, with my white coat pockets filled with a few reference books, a calculator, and handy notes that I had organized.  The team was quite large and consisted of the attending physician, three to five medical residents, two physician assistants, three medical students, myself and another pharmacy student.  It was great to be part of the teamwork on rounds, with healthcare professionals from different departments working together to optimize patient care. 

0700/0730: I would work-up my patients after rounds.  By “work-up,” I mean that I would look at the patient’s profile in the computer system, gather information, and assess the patient’s treatment regimen.  I would check the doses, drug-drug interactions, and think of recommendations for optimizing the medication regimen.  The most challenging part of this rotation was forming a plan for the next steps in the patient’s care.

1200/1300: My classmate and I with would meet with our preceptor at this time.  We would present our patient cases and describe our plans for the patient (examples: dose adjustments, medication changes).  Our preceptor would ask us questions not only about the medications and disease states but also about the types of surgeries, which mainly involved the intra-abdominal area.  The Whipple procedure, ileus, fistula, anastomosis, esophagojejunostomy, and total gastrectomy were just some of the many terms with which I became familiar!  After discussion with our preceptor, we talked with the physician assistants about our recommendations.  Counseling patients before discharge about new medications, which were often anticoagulants, was another great way I was able to contribute to patient care. 

During this time, topic discussions also were held two days each week about subjects such as nutrition support and surgical prophylaxis.  My fellow classmate and I would read articles and prepare summary handouts.  These discussions were very useful because we would use this information when monitoring our patients.

This rotation was challenging and extremely rewarding.  Teamwork, time management, and efficiency were skills that I further sharpened while on the adult surgery service. Even with the early morning rounds, I am glad to have had this experience!

Dare to Fare in Critical Care

Posted by Adam Loyson at Sunday, October 20, 2013

Since writing about my nephrology rotation in the outpatient/inpatient dialysis unit setting, I am now concluding a rotation in critical care at a small private hospital. This new chapter of my APPE experience has been truly amazing, calling upon every bit of my pharmaceutical knowledge to save patient lives.

Detective work

With my new-found confidence growing from just one rotation under my belt, I was up for a new challenge. Enter the critical care arena. Becoming oriented to the intensive care unit (ICU) brought many new opportunities. Starting from day one, I found myself judiciously evaluating the complex clinical status and pharmacotherapy of the patients I was following. I also began participating in multidisciplinary patient rounds for the first time.  Intimidated, yes; but I was determined to make a difference.

Patients arriving to the ICU from the emergency department were often diagnosed with numerous disease states, frequently more than I could count with two hands. These patients required intricate care, with physicians often asking the pharmacist and me for our advice on the direction, agent selection, dosing, and duration of pharmaceutical care. With such inquiries, I quickly found myself becoming a supersluth in researching and recommending solutions from cardiovascular, respiratory, neural, metabolic, infectious disease, and gastrointestinal disease state guidelines. 

Endless opportunities

An exceptionally neat aspect about rotating in the ICU is the sheer number of interventions you can make as a student pharmacist. On a daily basis, I was involved in developing pharmacokinetic and therapeutic plans for patients receiving antibiotics (e.g., aminoglycosides and vancomycin) and anticoagulants (e.g., heparins and warfarin). I often encountered patients that required antibiotics for their recent onset of pneumonia, medications to convert their heart arrhythmia, or electrolyte supplementation. In these situations, I was able to educate the new medical residents about the appropriate agents, medicinal algorithms, and patient monitoring parameters to use.

In contrast to my last rotation in the dialysis unit, many patients in the ICU arrived with multi-organ failure. With elevated levels of acuity, many patients were prescribed complex medication regiments as inpatients.  Thus, I was able to answer many questions from nurses about drug interactions and intravenous line compatibility.

Evidence-based

The multidisciplinary team of physicians, dieticians, respiratory therapists, and nurses often consulted pharmacy services and inquired about the evidence behind particular therapies or signs of drug toxicity. My ICU experience  served as an excellent opportunity for gathering drug information, permitting me to evaluate literature sources for strength and relevance for the individual patients I covered.

For example, a patient was referred to the hospital and admitted into the ICU after taking four pills of diphenhydramine instead of one to help her fall asleep. The patient presented to the hospital with abnormal muscular spasms. After performing a quick search of the literature and contacting poison control, I recommended that an antimuscarinic agent be given for treatment.

Another pharmacy service that I participated in was the monitoring of per-protocol medication administration and assuring that standardized procedures were being met on a consistent basis based on patient care quality indicators. Such indicators that pharmacy would oversee include appropriate administration of a thrombolytic agent during a stroke, a benzodiazepine during alcohol withdrawal, or venous thromboembolism/gastrointestinal stress ulcer prophylaxis for patients during their ICU stay. Interventions were made if any practices were not in agreement with Joint Commission criterion or Medicare reimbursement models.

Continuous learning

Rounding out my rotation experience, I am happy that I have been exposed to the continually revolving care of ICU patients and the treatment of their medical conditions. Whether it is sepsis, hypertensive crisis, drug overdose, or acute coronary syndrome, I can assure you that I have learned substantially from the medication management in the critically ill patient population.  I recommend the ICU experience for any student pharmacists that are interested in challenging themselves and participating in a coordinated team to treat the extremes of human disease and ensuing ethical and social dilemmas.

Needless to say, this rotation has been a great opportunity to help me review for the pharmacy licensing exam!