Tuesday, September 29, 2009

The Hope for Change in Los Pajarillos

Posted by Mary Liu at Tuesday, September 29, 2009

It’s been a little over a month since I left Honduras. Now that I’m back to the fast-paced life of rotations and hopping from city to city, I immediately notice the blatant disparities between my current lifestyle and those people in Los Pajarillos, Honduras. #1, I drive a car to rotations, while they walk 2 hours down and up a mountain to go to and from work. #2, I went from DC to Ann Arbor to San Diego to Calabasas just this past weekend, while many of them have never left their village, let alone visited a metropolis. #3, I have dined out an inordinate amount this past month in DC, while they make their own food from scratch daily. #4, I constantly use my Blackberry to go on the Internet or connect with people, while the entire village lives without electricity. It’s disturbing witnessing myself slip right back into my old lifestyle even after I was exposed to something as eye-opening as this experience.

To go back to the beginning, I had decided to go on this trip with a friend of mine, Sheerali. We wanted to get out into the world to show what we were made of. After all, we were in school for so long and seeing only the four walls of a classroom or the library can make you a little antsy. Most importantly, we wanted to step out of our Ann Arbor bubble and challenge ourselves, using the tools we have gained from school and life experiences, in a completely foreign environment. We were aware of the Honduras Medical Brigade, which several pharmacy students always participate in every year. But we were seeking a more dynamic interaction with people in the community, where we would not be limited to the walls of a pharmacy dispensing medication. The Honduras Public Health Brigade had just started its first year here at Michigan, so Sheerali and I decided to join.

The Brigade seemed perfect for us, except for the fact that neither of us remembered any Spanish from our high school years. And speaking from experience, it’s not like riding a bike. The language doesn’t instantaneously come back to you once you’re in a country full of Spanish-speaking people. So I intended to borrow Spanish tapes, like Rosetta Stone, thinking I could go from non-speaking to fluent in a few weeks. I even brought my old Spanish notes from high school and my little English-Spanish translator. It turns out that what you learn from reading text on sheets of paper and electronic devices can only take you so far, especially when the electronic device stops working once you arrive in the country. I ultimately relearned Spanish while speaking with the children who attended the 1-classroom school in Los Pajarillos.

At first glance, this classroom looked like any other classroom in the states. It had desks, chairs, workbooks, and drawings on the wall made by the students. But once the students entered, you noticed the difference immediately. Forty to 50 children rushed in, boys and girls ranging in age from four to 13 years old. Some walked in without shoes. None carried book bags. And there was only one teacher for the entire school. But, somehow, it all worked. The children had bright smiles on their faces, eager to learn.

The first day we went to the school, we handed out yellow toothbrushes to each child. We also taught them a song that went to the tune of “Mary Had A Little Lamb”:

Cepillense los dientes, los dientes, los dientes

Cepillense los dientes, dos veces al dia.

Si no lo hacen, tendran dolor, tendran dolor, tendran dolor

Si no lo hacen, tendran dolor, recuerde los cuidarte.

We quickly realized, however, that the kids weren’t familiar with “Mary Had A Little Lamb” when they started singing the song to the tune of “Frère Jacques” instead. Whatever works, right? After we lectured on the importance of brushing your teeth daily, we took the kids outside around the pila and practiced brushing teeth. The kids must have thought it was a competition, because they brushed vigorously for well over five minutes, until white foam bubbled out of their mouths and dripped down to the ground. When it was time to wash up, all the kids fought for the faucet. Some even went inside the pila to wash up. They tucked their toothbrushes in their pockets as we went onto our next activity: freeze tag. The brigaders were the “bad guys”: plaque, gingivitis, missing teeth, illness, etc. If a child was tagged, he could only be saved when tapped by a toothbrush from one of the designated “good guys”, which were one of the children we chose to rescue fellow classmates. We went back a second day to teach the children about wound care. Ultimately, we hope that we got an important message across about health and hygiene to the children. Understandably, one lesson may not change their behavior, but repetition of this lesson from their teacher may.

Our main work was to focus on helping a family that was chosen by the Basic Sanitation Committee (CSB) to build structures vital to good sanitation practices: a latrine (toilet), pila (sink), stove, and concrete floors. With only eight people in our group (seven females, one male) in our Brigade Team, and the majority of us with no prior woodworking experience, our work was cut out for us. Thanks to Habitat for Humanity, a few of us had some experience using tools. I was dubbed a pro with the hammer. Unfortunately, that skill was only limited to hammering nails straight down and at no other angle whatsoever. Sam discovered that cutting metal wasn’t her forte, but bending and breaking it was. Sheerali found a knack for the saw, and thank goodness for Andrew, who was a jack-of-all-trades. We all pitched in to mix cement, gravel, and dirt to form the concrete floors. I focused on building the latrine for the rest of the week, which required woodwork, brick-laying, melting plastic, and cutting aluminum and metal. After completing the final touches on it, I had the honor of testing it out.

The family, as I mentioned before, was chosen by the CSB. This committee was formed in June 2009 by members of the community who voiced concerns about the overall health and hygiene in their area. They created a survey which inquired each household about their living conditions, with specific questions such as “Do they have concrete floors?”, “Do they have a latrine?”, and “Do they use their latrine?”. After latrines fill up, a family has to dig another hole to hold the waste. Not everyone digs another hole, but instead, uses a neighbor’s latrine or goes out in the bushes. Recognizing that people who fail to meet the aforementioned criteria can damage their own health as well as the health of the entire community, the CSB goes out to each household once a month to follow up on each family’s progress.

This particular family consisted of husband Santos Velasquez, wife Maria Cardona, Maria’s sister Yoni (age 14), and children Deinis (age 10), Yosos (age seven), Milis (age 4), and Garis (age 2). Their “extended” family included a hen with her chicks, two doggitos, a mule, and one scrawny, orange cat. The cat was famished, dirty, and surrounded by mosquitos when we first saw him. I felt as if it was my duty to fatten this cat up by the time I left. I was even tempted to smuggle it back to the states with me. Sure enough, as the days went by, the cat looked healthier, cleaner, and cared for. On our last day working on the house, I started worrying about what would happen to the cat after we left. Who would feed him? Where would he get his food from? Would he ever reach a healthy weight? These questions triggered larger questions about the family and community. Would the amount of toothpaste, soap, and shoes be sufficient for one family? Would the children at the school still remember to brush their teeth daily?

I left Los Pajarillos with conflicting thoughts: a sense of accomplishment for the hard work we had done, but also a sense of urgency for all of the work that lies ahead. My goal is to return to communities like Los Pajarillos to implement improvements in health that are sustainable.

Change, whether for an entire community or just for a single individual like myself, doesn’t happen overnight. It takes hard work and a conscious effort to improve your life and those around you. But, as long as you make the effort and have the patience to see it through, a change is possible, and well worth it.

Friday, September 25, 2009

Sue Come or Ella. Say what?

Posted by Shannon Hough at Friday, September 25, 2009

As a consult team, the pediatric infectious disease team sees many patients with complex infectious illnesses. Additionally, as a tertiary care center, Mott Children’s Hospital treats children with complicated medical problems. This month, many of the young patients we've seen were under some variety of precautions invoked by infection control. As a result, we would have to wear gloves or masks/gowns in order to enter the patient rooms.

Johnny was not one of those kids. He was being hospitalized for an infection in a central line. (Central lines are catheters used to deliver long-term IV medications into a central vein.) When we rounded, he was not usually in his room. He was running around the floor playing video games or hanging out in the playroom. This was not typical of the patients we had been seeing all month.

As with most patients with infections, Johnny was placed on empiric antibiotics that would treat the infections he was likely to have. Many times this includes multiple medications. Once we knew what pathogen was causing Johnny’s infection, we would be able to tailor his therapy specifically. A few days later, the microbiology lab informed our team that it was able to grow a bacteria from Johnny’s blood, but was not able to identify the gram negative rods. The bacteria was eventually identified by the State Department of Health as a species of Tsukamurella (pronounced: Sue-Come-Or-Ella). My immediate reaction was "What in the world is Tsukamurella?"

Even if I knew every single thing I had been taught in pharmacy school (which I don’t), I would have no idea how to treat a Tsukamurella infection. In this case, I did what any good pharmacist would do: I LOOKED IT UP! That's one of the things that makes the field of pharmacy so exciting. New bugs, drugs, and diseases are always being discovered. Treatment guidelines change. Thus, it is possible that the treatment protocols we learn in school today will not offer the best solutions a few years from now. But no matter what the advances in the medical sciences may be, knowing how to use investigative resources, and possessing a drive for lifelong learning are qualities that define a good pharmacist.

Image from: http://surgery.med.umich.edu/pediatric/clinical/patient_content/a-m/broviac_placement.shtml)

Keeping A Cool Head

Posted by Kendra Yum at Friday, September 25, 2009

Today started out like most other mornings in the Surgical Intensive Care Unit (SICU) at University Hospital. My classmate, Karen, and I arrived early to review patients’ medical profiles. We then discussed our findings of medication-related issues with our preceptor, a clinical pharmacist in critical care and nutrition support. At 8 a.m., we joined the rest of the SICU team, made up of residents, medical students, nurses, a dietitian, pharmacists, and an attending physician. With the group assembled, we began the morning rounds.

On rounds, we stopped at each patient’s bedside on the unit. The team was huddled around a patient with all of us scribbling notes as we listened to an update of the patient’s status.

Suddenly, an overhead alarm began to beep in rapid succession. Team members stopped writing and looked at each other. Then we heard someone cry out: “We have a code in room number 20!”

The entire team rushed toward room #20. Karen and I looked at one another, each gauging the other's response as we accompanied the group. A code blue had been initiated, meaning that a patient was in cardiac arrest.

The team of doctors and nurses instantly gowned up and surrounded the patient to perform defibrillation and apply chest compressions (CPR). My preceptor immediately pulled open the medication drawer of the crash cart and began rapidly assembling syringes of epinephrine and atropine, so that they were ready for use, on command. (A crash cart is a set of trays/drawers/shelves on wheels used in hospital emergency rooms and containing the tools and drugs needed to treat a person in or near cardiac arrest.)

The attending physician called for multiple doses of epinephrine, followed by a bolus of amiodarone. The room was abuzz and bustling as commands were shouted across the room. The tension in was palpable, and remained that way until the patient's heartbeat stabilized.

After the crisis, our preceptor described the role of a pharmacist during a code blue and the pharmacist's responsibility for monitoring the correct administration of medications during emergency response.

Easier said than done... Experiencing the code today demonstrated how overwhelming an emergency response could be. The literal life-and-death urgency of an emergency situation could easily overwhelm clear and rational thought, and interfere with informed decision-making, including decisions about medication use. As a pharmacist responding to a code blue I could see the absolute need to keep a cool head in a heated crisis. Hopefully, I’ll get there.

Tuesday, September 15, 2009

They don't teach you THIS in pharmacy school!

Posted by Jeffrey Huang at Tuesday, September 15, 2009

I am only just at the midpoint evaluation for this rotation and Al Knaak at Village Pharmacy has already completely turned my perception of retail pharmacy upside down. I came into the rotation thinking that though I would still work hard, there would only be a slim chance I would consider a career in community pharmacy. Now, the idea of a small, independent pharmacy near the beaches of Kona, Hawaii doesn’t seem so bad of an idea! If I could duplicate the business model and work ethic of the team that Al has in place at this store, life would be pretty great – that also includes the flip-flops and boardshorts into work, of course.

First off, Al loves his patients – he knows 90% of them all by name, and they all know his. His pharmacy is completely patient-focused – the staff prides themselves on the unique services they provide for the patients free of charge. In fact, a project that is required for the rotation is to challenge the P4 student to formulate a service plan and pitch it to Al and the other pharmacist, ultimately with the hopes to implement the service at the pharmacy.

I’m becoming proficient at MTM’s (Medication Therapy Management) for the unique patients Al selects, a pro at doctor office calls (3 hours straight today), and wowing the staff with my spatula skills for compounding. I enjoy each morning when we review a new patient case, and I am always impressed with how knowledgeable Al is in areas that can only come from years of practicing experience. He loves sharing all the tidbits where “they don’t teach you this in pharmacy school” and I enjoy picking his brain whenever I get the chance.

The Village Pharmacy community rotation is definitely a great opportunity to learn. Al makes a lot of effort and dedicates specific times during the day to teach and engage his students. It is clear that Al loves his job as a pharmacist – I am trying to make the most out of my time with him and know I will finish this rotation with a newfound appreciation for community pharmacy.

Saturday, September 12, 2009

Hi!!! Bye!!!

Posted by Shannon Hough at Saturday, September 12, 2009

My second rotation is at the C.S.Mott Children's Hospital at the University of Michigan, in pediatric infectious diseases. I really like kids, so I was unsure of how I would feel about seeing sick kids. The first day of rotation we rounded in the afternoon. Our team of eight had a small patient load for the day and was able to spend a long time discussing each patient before we went up to see them. After making a plan for each patient, the eight of us piled into an elevator. I was a little bit nervous, as it was my first time actually rounding and being part of the team. As the elevator doors opened on the seventh floor, we were greeted by a three year-old girl, dressed in a maize and blue cheer costume, complete with very cute pigtails. She waved "HI!!" and "BYE!!" to each person getting in and out of the elevator. As the whole team smiled, and waved "hi!" and "bye!" in return, and I couldn't help but think that this was going to be a fun rotation.

Pediatrics really does have fun moments. Even while delivering a sad plan to a patient and family about a prolonged hospital stay, the team still took the time to talk to the child about whatever seemed to interest them. We've heard about Webkins, Dora the Explorer, dinosaurs you name it.

Besides all of the fun, so far this month I have also really taken a dive into anti-infective therapy. Most of the patients we have seen have unidentified infections, and are quite complicated. It has been a challenge to appropriately select and follow the medications on these patients and contribute to the team.

Thursday, September 10, 2009

Don't get too comfortable

Posted by Akin at Thursday, September 10, 2009

I think I am one of the few students who for the first two rotations is doing them both at inpatient rotation sites within the University of Michigan Health System. During my first rotation, the patients were adults with cancer. This month, I am doing pediatrics at Mott Children’s Hospital. Knowing that I was going to remain at UMHS and feeling good about my last rotation, I figured I would just be able to pick up where I left off. But my transition from adult to pediatrics is certainly a transition worth blogging about.

Aside from getting used to weight-based pediatric dosing, unfamiliar pediatric-specific disease states, and different lab values that I need to pay even more attention to, I also must rebuild my comfort level all over again. The clinical rounding team includes four medical students and three residents, which is a change from the smaller PA service I grew accustomed to. With such a large team, finding a niche and knowing when it is appropriate to speak up is another new challenge. I hope to learn a great deal in the next few weeks.

With all this in mind, I guess if I had to give myself advice for the next few months, I would tell myself not to get too comfortable with each rotation. The school year is just beginning, but I now anticipate a dynamic year full of transitions and adjustments. From month to month, I’ll be changing more than just my daily monitoring form. I’ll be placed into foreign environments outside of the haven of the College of Pharmacy classrooms and into hospitals, clinics, and offices. Our preceptors may put us in situations where we are on our own, fending for ourselves amongst medical doctors and residents. We may sink, we may swim, but regardless of the outcome, we will gain some sort of insight. And by the time we gain any sort of confidence, it’ll be time to move on to the next experience.

My preceptor told me last Friday that most pharmacists don’t get comfortable until about a year of working on a service (not including residency/ fellowship/ or other advanced training.) This made me think of Michigan's Head Football Coach, Rich Rodriguez. The football team is off to a good start and the young team is looking much more comfortable on the gridiron after a rough year in 2008. So I am going to start thinking about my early career right now like I do the University of Michigan football team. The next few years are going to be a time of transition, but I will be winning Rose Bowls and national championships before you know it.

Wednesday, September 2, 2009

The Compromise

Posted by Akin at Wednesday, September 02, 2009

My adult heme/onc rotation ended last week, but I thoroughly enjoyed the experience and would like to further comment on my time there.

I worked on a PA service which was composed of an attending physician, four physician assistants (PAs), and a clinical pharmacist. I generally woke up around 6 a.m. and worked on patients' therapeutic plans at home. Other times, I would develop patients' medication therapy plans in the hospital. I would then meet with my preceptor (Shawna Kraft, PharmD'06, PharmRes'07 and '08), at 8:30 a.m. to review any recommendations that I might have thought of before patient rounds at 9 a.m. Approximately half of my recommendations were vetoed or tweaked by my preceptor and the rest were OK'd meaning I could recommend an intervention during rounds, if it hadn’t already been changed, and later on document the change.

Little did I know that my preceptor would be giving me a summary of all the interventions I made on the last day of rotation, during my final evaluation. As it turns out, I made 20 clinical interventions, 26 patient care alerts, and four drug monitoring notes. I also saved the hospital $94.77! So I’m writing a letter to the University of Michigan Health System. This is how it starts. Let me know what you think:

“To whom it may concern,
I am a P4 student who just finished a clinical pharmacy rotation in the hematology/oncology department. As you know, the clinical pharmacist plays a vital role not only in ensuring appropriate medication therapy, but also in various other services including reducing health care costs. With all this being said, I think it’s important that you know that in the month of August, I saved the hospital $94.77. Let’s keep in mind that this is an underestimation as I may have forgotten to document some my interventions. As a poor student, I believe I’m entitled to at least some of this money. I think half is a fair compromise. Please make a check out to me for $47.39...”

But seriously, it feels good to have a summary of all the clinical interventions that I was a part of for the past month. Perhaps I can also say that I helped our clinical team to prolong a few lives or at least helped to make a patient or two (many of whom were terminal) feel a bit more comfortable in their waning days. This was the most rewarding part of my August experience.

Tuesday, September 1, 2009

Rotation Interim - 55th IPSF World Congress, Bali Indonesia

Posted by Jeffrey Huang at Tuesday, September 01, 2009

International Pharmaceutical Students’ Federation (IPSF)

To give a little background on IPSF, my first involvement with the federation began last summer with its Student Exchange Program in Prague, Czech Republic where I worked in a local community pharmacy. I learned about the role a pharmacist played in the Czech health care system and the similarities and differences of their system compared to our own. Immediately following the exchange, I attended the 54th IPSF World Congress in Cluj-Napoca, Romania in which pharmacy students from over 30 countries were represented. The theme of the Congress revolved around counterfeit medications, where speakers from around the world traveled to conduct workshops, symposiums, and lectured on the growing problem. It also was fascinating to hear about the ways in which my student colleagues were involved in global health issues, and how their roles compared and contrasted with my own.

I returned home with a great desire to become more involved with IPSF and began applying for leadership positions in the federation. Whereas I began the 2009-2010 academic year the University of Michigan College of Pharmacy IPSF chapter liaison, I was recently appointed the Regional Relations Officer (RRO) for the Pan-American Region Office (PARO) of IPSF. In my new role, I promote IPSF throughout the North, Central, and South American regions, recruit new country memberships, as well encourage the involvement of existing IPSF members.

55th IPSF World Congress, Bali Indonesia

August 3-13, 2009

Rotation Interim

When the secretary general of IPSF, Mary Poon, asked me if I would be willing to serve on the federation's motions committee, I had just arrived in Bali after a 35-hour commute from Detroit , baggage still in hand. I blinked. “Yeah. I guess so. Sure.”

What I did not realize was that being on the motions committee for the general assembly was a huge responsibility, adding, as it did, about 30 hours of work on top of my responsibilities as the PARO RRO. I was already responsible for holding a two-and-a-half-hour workshop for the attending members of PARO helping to lead a discussion regarding the future of IPSF; and was later told that because the PARO chairperson was unable to attend the congress, I would be responsible for presenting the PARO annual report to the general assembly. This was going to be a challenge as I was only appointed to my position a few months previous.

Of course, everything works out in the end! Although my friends from the 54th IPSF World Congress were stumped at my reasoning in choosing to take on a much bigger workload this year, I was still able to find a balance between work and play. With the motions committee [photo below], Pedro Lucas (Portugal), Jin Chiong (Singapore), and I were able to work with the IPSF executive on pressing issues, such as the IPSF Membership status of Taiwan, in coordination with UNESCO regulations. My PARO workshop went great. We were able to map out a plan to strengthen our region and provide more value for our existing member countries. I helped lead a group of students that included representatives from Canada, Indonesia, Malaysia, and the Czech Republic on sensitive issues surrounding IPSF. My annual report to the general assembly gave a brief summary of the year and focused on the future of PARO, as discussed in the earlier workshop. Even with my added responsibilities, I was able to take off a full day for surfing; a Balinese massage; and roaming the local markets in Kuta with my international friends. All I had to sacrifice was (a lot of) sleep!

On a side note, here are two funny observations I would like to share:

Much of Asia, including Indonesia, cut their foods cut into smaller pieces as part of their dining culture. In contrast, Europeans almost always eat with a knife (right hand) and fork (left hand). So when there was only a spoon and fork on the table during the Congress meals, almost all the European students replaced the knife with a spoon to help them eat.

Also, students from around the world are generally taught British-English in their foreign language curriculum. Interestingly, they told me they really dislike this because they find British-English more difficult to understand than American-English. And British-English is not as applicable to Hollywood media as is its American counterpart. So even though the American accent is often ridiculed as sounding overly nasal, the foreign students I met claimed that the American accent is much easier to understand.

The Congress was a great experience, one that I look forward to each year. It’s amazing to meet students from around the globe — Kenya, Iran, Slovenia, Australia, the Czech Republic, Finland, Indonesia, and many more nations as well. Our commonality is pharmacy, but when you hear just how diverse pharmacy practice is around the world, every conversation becomes an educational experience.

I really hope to keep alive my ties with the students of IPSF and am determined to find a way to focus my pharmacy career endeavors on an international level. I would also like to thank the College of Pharmacy and newly established Center for Global Health in providing support to attend the conference. Viva la Pharmacie!