Tuesday, October 26, 2010

"Dark and early" at the Trauma Burn Center

Posted by Zhe Han at Tuesday, October 26, 2010

Last Friday, I completed my first inpatient rotation- Trauma Burn. My main reason for choosing to take this rotation was because of my PharmD investigations project which looks at the use of an anabolic steroid in burn patients. If there's one thing I hear frequently about this rotation, it is "rounds are early". Indeed, rounds are very early; starting at 6am on most days and at 5.30am every Thursday. Hence, before I go to bed the night before, I need to have a good idea of the issues I like to bring up on rounds. On most days, I would arrive ~15 minutes before rounds begin to look up some labs that came back overnight. This is also the time when the intern on-call last night gives report to other interns, so sometimes I can get an idea of what happened to my patients overnight even before rounds begin.

In many ways, this was the hardest rotation I've had so far. Yet, it was also my favorite because I gained so much clinical knowledge and developed a more systematic way of looking at patients. Here are 3 main learning points that I hope to share:

1) Be at where things happen.

When you are on inpatient rotations, try to be on the unit as much as possible. There are "COWs" (computer on wheels) along the hall which you may use to work up your patients. In this way, you see what happen to patients, you hear what interns/residents say, and you get the latest updates. When the interns see you around, they ask you questions (eg. antibiotic dosing). You feel involved and they see you as part of the team.

2) Be ready when you make a recommendation.

Whenever you make a recommendation, give a rationale. If you propose adding a new drug, have the dose ready and be sure you can explain your choice and give your reference (if applicable). By being ready, you sound more credible and that increases the likelihood of your recommendation being accepted.

3) Persistence counts.

If your recommendation is not accepted the first time, keep bringing it up when similar situation arises. I encountered a situation on BICU rounds where the chief resident changed IV ranitidine to PO omeprazole whenever patients were able to tolerate oral medications. The reason being PPIs are "innocuous" and Zegerid can be dissolved in water and be administered easily down a tube. It wasn't until the third time that I bring up this issue that he was willing to listen to my explanation of why the H2RAs are first line for stress ulcer prophylaxis (VAP, C. difficile, etc.) plus ranitidine comes as a liquid. He was convinced! So persistence counts and being able to explain the rationale behind your recommendation counts. Even if your recommendation was never accepted, take it as an opportunity to educate and demonstrate your knowledge!

Monday, October 25, 2010

"Words Can't Bring Me Down"

Posted by Karen at Monday, October 25, 2010

After driving eight hours, I am now sitting at home in St. Louis, Missouri, waiting to start my fourth rotation at Facts and Comparisons. During my drive, I was listening to my Glee CD that I got from my roommate when something sort of inspirational happened-the song “I am beautiful” came on. Most of you have probably heard of this song. I never really paid too much attention to the lyrics until yesterday. When she sang “words can’t bring me down,” it brought up the memory of an unforgettable incident that occurred to me during my second rotation in an outpatient oncology clinic.

As part of my routine work at this clinic, I sat down with patients to go over their medications to make sure that our medication list was reflective of the patients’ most current medications. This process, called medication reconciliation, is an important step in taking care of our patients. Each time a medication reconciliation was performed, I checked to see if there were any clinically significant drug-drug interactions, whether the dosages were correct, and if each of the medications had an appropriate indication. Equally important, I asked my patients if they took any supplements or over-the-counter medications. If my patients were on a pain medication, I would inquire the specifics as to how many pills were taken and how often they took them. In addition, I inquired about how well the pain was being controlled.

One morning, as I sat down near my next patient with whom to conduct a medication reconciliation, I felt an unwelcoming atmosphere from her nonverbal body language. I quickly dismissed this thought and began my usual routine of performing a medication reconciliation. Similar to what I did with other patients, I introduced myself and explained my role. Then, when I asked her “Do you still take drug X?” and “How often do you use this medication?” she abruptly raised her voice and said, “What is the point of asking all these questions?” I was taken aback with this sudden outburst of discontent. I looked to her husband sitting to the left of her, who did not seem perturbed. I re-focused back on her and explained to her the importance for us to have an updated list of all current medications, especially since she was receiving chemotherapy. My explanation did not work. She stated that she would continue this process not because she saw benefits in it, but because it was an educational opportunity for me as a pharmacy student. Feelings of intimidation and the uninvited atmosphere overwhelmed me during these brief few minutes. Seeing that further explanation would be futile, I quickly recollected myself, thought about my original intention of performing a medication reconciliation, and went ahead and continued the interview to make sure that all pertinent questions were answered. Even though this was not the most pleasant interview, I tried not to let her “words bring me down” and maintained my professional demeanor. When we were finished, I politely thanked her for her time.

As I am writing about this incident, my patient’s words and expressions are still clear in my mind. Though it was not a pleasant experience, this is a part of life. Even with the best intentions, people are sometimes wary of your actions. Even I must be guilty of this at times. As health care professionals, we work in a helping industry, and no matter how our patients perceive us, we are here because we want to help others. The lyrics, “words can’t bring me down,” serve as an encouragement and inspiration for me to continue to believe in the work that I do. Looking at this event retrospectively, I am thankful that my patient allowed me to gain this insight and to grow from the experience. When else is a better time to experience setbacks and unpredictable events than now?

Saturday, October 23, 2010

Serving the COMMUNITY

Posted by Omo at Saturday, October 23, 2010

Working at THE Pharmacy, Ypsilanti has been very great and eye-opening experience. Contrary to popular belief, not all community pharmacies work hard to fill and dispense scripts without focusing and addressing direct patient care. I started to make interventions on day 1 of my rotation. For example, a customer complained that her Children’s Multivitamins that she bought at The Pharmacy had black spots. My preceptor (Kiela Samuels, PharmD) brought the situation to my attention and asked that I called the manufacturing company. I did so and the company explained that the vitamins may have been turning black because the product contained iron and iron coming in contact with moisture leads to oxidation and consequentially, to the black spots forming on the vitamin tablets. They offered to send the dissatisfied customer a coupon in the mail for a replacement bottle. I felt accomplished because I learned something new and the customer was also satisfied in the end.
This experience made me pumped to do more and learn more about how I could make a difference at the pharmacy. I performed several blood pressure measurements daily and gave useful recommendations in my first week. I also applied what I learned in my previous rotation to this rotation. I had my inpatient cardiology last month and I learned a lot about meds for cardiovascular diseases so when I saw that a patient with chronic heart failure was on metoprolol IR, I immediately though why not ER as shown in the MERIT and COMET trials. I brought this to the pharmacist’s attention and we had a discussion as to why the patient was not on ER with the patient’s daughter. The feeling of being able to apply my previous learning was elating and this motivated me even more to screen patient profiles and intervene whenever I could.

I got involved in many other things at my rotation. Some of these things include:
1. The Antibiotic Call-Back Program
Everyday, I have a list of patients that I had to call to follow up on how their antibiotics were working for them. As little as it may sound, it makes such a huge difference because these patients appreciate that we are concerned about their health. They also appreciate the effort made to call to check up on them. It helps to build trust and confidence in the pharmacist in the long run and these patients feel more comfortable in confiding in the pharmacist.

2. Constant Med Profile Reviews
We constantly check to see how patients are doing when they get their refills. We also set time out to counsel patients and ensure that they understand why they are taking their meds, what to monitor for and goals to expect upon proper compliance and use of the drug.
3. Compounding
I also got to compound medications at the allergy clinic every Thursday. I got a lot of practice in compounding and can say that I am now proficient in compounding mixtures ☺
4. Teaching
Every Thursdays, I was like a teaching assistant to Dr. Samuels at the Washtenaw Community College. She was involved in teaching students in the certified pharmacy technician’s program. I got to see what it was like from the technician’s view. I really valued this experience because most pharmacists have to work with techs and this experience helped me to see what it was like for them to learn the skill they have to apply in pharmacy.
There is so much more that I can share but overall it was a great experience! You can always email me with questions and I will respond as soon as I can…

Tuesday, October 19, 2010

Drug Interactions- Wading through the data

Posted by Sarah Thiel at Tuesday, October 19, 2010

For my third rotation, I have been working on drug information with LexiComp. My preceptor works specifically on all topics related to drug interactions, including writing the monographs seen in LexiInteract.

It can be crazy to think about, but all those useful resources, such as Micromedex, the Drug Information Handbook, and Facts and Comparisons, all had to be written by somebody.

And while as students we may use those resources on a daily basis, it is easy to take for granted the concise and direct nature of the text and all the long hours put into reading the research that is the foundation for such resources.

One of the most valuable skills all students should take away from their drug information rotation is the ability to critically evaluate literature and to be able to consolidate those tens to possible hundreds of pages of research to a concise but thorough piece of writing.

Critically evaluating and reviewing literature is more than "there were some typos and the funding source could have biased the results". You have to dig so much deeper.

For drug interactions specifically, there are many factors that can influence findings. Many of the cytochrome P450 enzymes are polymorphic, resulting in different phenotypes of enzymes. Medications that are classified as "inhibitors" don't all inhibit to the same degree. Concentrations used for in vitro experiments may not represent concentrations seen in humans. Transporter proteins, both efflux and uptake pumps, can also influence magnitudes of interactions.

Then there is the issue of conflicting results: study A found increased risks of poor outcomes from combination therapy of drugs X and Y, but study B found no difference in risks. Now it's your job to wade through the data, the study design, and yes- even the statistical methods, to understand the possible reasons behind the difference in results. Because what would you tell a physician who is asking you, the pharmacist, if they could put a patient on drug Y who is already on drug X? Clearly, knowing how to critically evaluate the literature and explain it to another person in a concise manner can further make the pharmacist a critical member of the health care team.

So despite the hundreds of hours I've spent running PubMed literature searches, reading primary research, writing and revising interaction monographs, I can be assured that I'll never read a research paper the same way I did prior to this rotation.

Why is everyone talking...

Posted by Sarah Thiel at Tuesday, October 19, 2010

about poop?

Now, I know that many of you will read this and have the same reaction I did. As students, we chose pharmacy over nursing and medicine for various reasons, but for me (especially after I worked as a nurses aid at a nursing home in Germany one summer), I knew I did not want to physically handle or care for patients they way a nurse or physician may be required to, and that included seeing, handling, or discussing "bodily habits".

So what does this topic have to do with pharmacy rotations?

While attending rounds everyday last month on the Bone Marrow Transplant service, it got me wondering why half the time the medical and nursing team was talking about poop. What does poop have to do with being a pharmacist? I mean, I know we learn about constipation and diarrhea in therapeutics, but how much is poop really going to impact my therapeutic plan?

Well, the answer is- A LOT!

Color, consistency, frequency (or lack thereof), volume, and even the smell of excrement can tell you a lot about a bone marrow transplant patient.

First, there are concerns of graft versus host disease (GVHD) in these patients. Simply put, this is when the transplanted stem cells and resultant mature immune cells recognize the patient's body as foreign and begin attacking. The most common sites for this to occur are the skin, liver, and gut. To diagnose and grade GVHD of the gut, stool volume has to be >500ml.

Second, poop can tell you about infections. BMT patients are severely immunocompromised- we just completely whipped out their own immune system and gave them back stem cells that take time to develop into mature immune cells (in the BMT world, thats called engraftment). Therefore, infections of any kind can pose a serious threat to these patients. If the patient is having diarrhea, is it C-Diff? rotavirus? adenovirus? Other potential causes? And if you smell something extremely foul...there's a good chance its C-diff.

Third, poop can tell you about other complications. If there is no poop, does the patient have an illeus? Will they need parenteral nutrition if it doesn't resolve? Or is it just constipation from antiemetic and analgesic medications? If the stool is black and tarry or bright red, that can tell you there is a GI-bleed (upper verses lower respectively).

All of these affect how you treat a patient and your therapeutic plan as a student pharmacist. From pharmacokinetic dosing of immunosuppressants to prevent GVHD, adding steroids or other therapy to treat GVHD of the gut, adding antimicrobial or viral therapies to treat infections, addressing possible GI bleeds, to requesting a nutrition consult, knowing all the gory details about your patient's poop can help you choose the best therapeutic plan for you patient.

So why is everyone talking about poop? Because sometimes in life, crap actually is important.

Tuesday, October 12, 2010

A Part of the Community

Posted by Jim Stevenson at Tuesday, October 12, 2010

This month I am on rotation at an independent retail pharmacy called Warren Sav-Mor Prescriptions. You might be surprised to learn that it is not in Warren, MI but rather on the border of Farmington Hills and West Bloomfield. The Warren part of the pharmacy's name comes from its long history as an independent pharmacy owned an operated by the Warren family. Sav-Mor is a conglomerate of independently owned pharmacies in Michigan. Sav-Mor gives these independent pharmacies some tools, like a computer system and some supplier contracts that allow them to compete against the big corporations.

When I think of an independent pharmacy, I typically think of a low-volume niche type store. That's not how this store is... they fill up to 500 prescriptions on a busy day. During my rotation, I have discussed the business aspect of an independent pharmacy quite a bit with my preceptor. Because he is so involved with the business-side of things, sometimes he will straight-up tell a customer "Look, I buy this at $45 for 30 pills. I'm not even making any money off of this." He's telling the truth, too, and the customers are often more satisfied after hearing that. Both my preceptor and the other main pharmacist at Warren have worked there for more than 20 years: they know retail pharmacy and the business side of it inside and out.

I've seen polls where pharmacists were perceived as one of the most trusted professions in communities. Now I can see it with my own eyes. Of course people get angry when there is disconnect between the prescribers, insurance companies, and pharmacy, but they listen to what the pharmacist has to say. For good reason, too: When I ask some of the customers if they've filled prescriptions there before, some answer "Yes, you must be new. I've been coming here for 20 years now."

Monday, October 4, 2010

Rotation 2: Arrhythmias, Heart Failure, CAD, Hypertension and the list goes on!

Posted by Omo at Monday, October 04, 2010

After going through my cardiology rotation, I can gladly and proudly say that I learned a great deal within the short time span of a month. My rotation was at the University of Michigan Hospital. My typical day involved me waking up at about 5am to work-up my patients then head off to the hospital for early morning rounds. After rounds, we would meet with our preceptor to discuss all the patients that we rounded on, usually focusing on their drug therapy and medication plans. It took me a while to blog about this rotation because I have so much to share so I tried to condense it as best as I could. Feel free to contact me for more info/questions.
Here are a few pertinent things I learned.

1. In dealing with patients, focus on drug therapy!
When rounding with a medical team, it is easy to get sucked into all their recommendations for patients with regards to their drug therapy. Most times, the medical team is right about choosing medications for a patient but they do not always choose the best medication for a specific patient. We are pharmacists in the making and our job is to make sure that every patient is on the best medication for their disease state. These include accounting for drug interactions, therapeutic duplications and disease state. While on my cardiology rotation, I learned to look at each patient’s condition and ensure that they were on all the right medications without being influenced by the medical team’s decision.

2. Don’t sleep on Evidenced Based Medicine (EBM) and Keeping up with Literature!
This rotation provided the opportunity to go through over 100 important journal articles/reviews in cardiology. I was able to connect groundbreaking studies with recommendations for drug therapy. For example, according the 4S Lancet trial, we know that any patient with coronary artery disease (CAD) should be on a statin. I would go through patient’s profile and ensure that they were on a statin and I found myself making an intervention/suggesting a statin to the medical group on more than one occasion. Additionally, if a patient had A-fib, I will be checking to make sure he or she was on warfarin and also ensuring that he or she was followed by an anticoagulation clinic as an outpatient to monitor their INR. These are a few of the interventions I made on a daily basis.

3. Science is always evolving!
Like many other sciences, pharmacy and therapeutics are always changing. To be the best pharmacist you can be to a patient, it is therefore important to stay up-to-date with literature and drug-related issues. My preceptor was a very good role model because he was very current with pharmacy and drug related issues not only pertaining to the field of cardiology. One advice he gave that resonates with me all the time is to continuously educate myself even after graduating from pharmacy school. It is very easy to say that we would try to stay current with the information but when we get out to the work force and have other responsibilities, it is easy to get swamped and forget to keep up with continuous education. This is something I am going to be very conscious of and I advice my fellow students to be conscious of this too!

Overall, the rotation was awesome. I learned a great deal and I am very happy I had it early on in the year because I feel more prepared for my other rotations!!!