Wednesday, August 31, 2011

Critical Care in a Comic?

Posted by Jenna at Wednesday, August 31, 2011

"Sun Protection Cartoons and Comics." CartoonStock - Cartoon Pictures, Political Cartoons, Animations. Web. 31 Aug. 2011

I think I might know what a fish out of water feels like!!

What day is it?

Posted by Matthew Lewis at Wednesday, August 31, 2011

It is hard to believe it's Wednesday already and the first half of the first week of the second rotation is done. As I suspected, I am very familiar with lung transplant issues due to my PharmD project, which is finding out if an anti T-cell drug (antithymoglobulin) has a good risk vs. benefit ratio. I am loving this rotation! It feels great to actually know something about the medications and the patient population, instead of neonatal patients and issues.

However, this rotation started off with lots of work and patients. The expected learning curve is shorter, since we are now all rotation pros, having been on the scene for the lengthy time of four weeks at a previous site. I have already gotten assigned an in-service presentation, did a medication class overview, with another one on the way, got assigned a larger topic on infection protocols, and had four patients. Okay, you might not think four is a lot, but when you consider most of these patients are going home on 20+ medications,multilayered comorbidities, and need extreme education, it becomes a lot. In fact, transplant pharmacists educate everybody because anti-rejection medications like Prograf and Cellcept have severe side effects like nephrotoxicity and debilitating diarrhea which must be managed with appropriate dosing and therapeutic choices. I'm happy here though despite the work load. This is going to be great, but it's going to fly by.

Tuesday, August 30, 2011

Looking Back on Rotation 1

Posted by Nina Cimino at Tuesday, August 30, 2011

With my first rotation behind me now, I am so happy to look back at all the great experiences I had in such a short amount of time. Aside from rounding by myself during my last week, I also got a chance to practice my presentation skills while completing my long-term projects.

First, I presented at journal club. Journal club is held during the lunch hour, and is attended by the pharmacists and pharmacy students in the hospital. For my presentation, I reviewed and critiqued an article which reported the results of a phase 3 study on a new oncology drug. The drug, ipilimumab, had been recently been approved by the FDA and added to the hospital formulary, so it was important that the pharmacists be aware of it. After I went through the article and my critique, my preceptor and the other pharmacists asked me questions they had about the drug and its clinical applications. This experience was a really good chance for me to practice my evidence based medicine skills, and also to practice speaking in front of a group. Since I plan to pursue a residency post-graduation, I was happy to get practice in all of these areas!

My second presentation was a nursing in-service, during which I presented information about a new oncology drug to the nurses working in the outpatient infusion center. I put together a poster and handouts that could be left in the infusion center, so that all the nurses could review the information. One thing I enjoyed about this presentation was that because all nurses were oncology specialists, they were all very interested in the information about the new drug.

I will miss all the great people I had an opportunity to work with on this rotation, but I am so happy with the learning experience I had! I learned more in 4 weeks than I ever thought I would, and I already am starting to feel more confident in my abilities as a pharmacy professional.

Rotation 1 - Internal Medicine

Posted by Matt at Tuesday, August 30, 2011

As many of you know I spent my first rotation walking around the hospital with a cane. I hurt my back during a softball game earlier in the summer and I still hadn’t recuperated by the time rotation one began. As you can probably guess I was the receiving end of many House, MD references. Despite my physical handicap I truly enjoyed my first rotation.

My rotation was internal medicine with Dr. Regal, known by many as the poet pharmacist. I feel like I learned more clinical skills in 4 weeks than in a semester of therapeutics. When you can relate pharmaceutical information to an actual person that you interact with, it has a way of staying with you. The first few weeks were intimidating, but over time I began to feel more comfortable.

The rotation consisted of daily rounds with the team (attending physician, senior medical resident, two interns, and a medical student), patient work-ups, and educational sessions with Dr. Regal every afternoon. Every 4 days the team would be “on call” which meant that new patients were added to the service. That meant that every 4 days we would receive 8-10 new patients to work up. The patients ranged from heroin addicts with endocarditis to acute renal failure patients requiring dialysis. At one point we had so many patients on hemodialysis that we filled over half the beds on the 7A dialysis unit. I also spent a great deal of time following INR’s and warfarin dosing. I had the opportunity to counsel every patient that was receiving warfarin in the hospital on diet, compliance, monitoring, and side effects.

If you like a variety of cases, renal dosing, and warfarin monitoring then this rotation is for you. I feel fortunate to have started with a rotation that allowed me to experience what clinical pharmacy is all about.

Monday, August 29, 2011

Final days at Aastrom

Posted by Amanda at Monday, August 29, 2011

So I finished my rotation at Aastrom Biosciences and I was sad to leave. I learned a lot while I was there. You don't realize how much communications goes on between drug development companies and the FDA.

I was able to sit in on a meeting with an investor where they spoke to the leaders of Aastrom and they asked questions about the product to determine if it would be a good investment.

My last week at Aastrom, I did a lunch-and-learn presentation on heart transplants. This was relevant to Aastrom because the biologic they are producing is geared towards the treatment of dilated cardiomyopathy. And if dilated cardiomyopathy is not treated, it can lead to a heart transplant. I learned a lot about heart transplants for my presentation. It has also helped me realize the importance of certain medications because in the end they can save patients millions of dollars in future treatments.

I learned from my time at Aastrom that there is a lot of paper work involved with drug development, from the information they submit to the FDA to the information that is collected from the trial sites.

This rotation has definitely sparked my interest in drug development. It helped me realize how important drug development companies are and that they are not as evil as others sometimes make them out to be.

Bernie Marini and the Deathly Infections: A Tale of Mudbloods and Unicorns

Posted by Bernie Marini at Monday, August 29, 2011

I know what you're thinking - How did Bernie get so lucky to have a rotation at Hogwarts School of Pharmacy? Although that would explain why I've been so busy and haven't posted yet, I'm not actually enrolled at Hogwarts and my preceptor is not Dumbledore (Dr. Frame is way smarter). However, I have just completed my first rotation with Dr. Frame at the Bone Marrow Transplant unit at U of M, and my rotation has had some strange similarities to the epic series that we've grown up with. If you're not a Harry Potter fan (shame on you), you're probably lost at this point, so I apologize, but... at least you have a good idea of how I felt on the first day of rotation.

Before you start reading about the magic abundant within the world of BMT, I have to drop some knowledge on you. This blew my mind the first day: Although this is the "bone marrow transplant" rotation, they rarely harvest stem cells from the bone marrow these days. That's right, no large needles or painful procedures like you see in the movies. Instead, donor stem cells are obtained from peripheral blood via leukapheresis. To increase the number of circulating stem cells for collection, donors are given agents such as G-CSF, GM-CSF, plerixafor or chemotherapy (typically Cytoxan - obviously this would only be done in autologous transplants) to mobilize the stem cells. The process of donating stem cells is relatively painless, which is why you should join the Be The Match Registry® and save someone's life today!


Yes, Mudbloods, or "MUDs" are a common term in the world of BMT. MUDs are not muggle-born wizards and witches as you've learned from the Harry Potter movies, but are Matched Unrelated Donors, which is one of the four main types of hematopoetic stem cell transplants (HSCTs):

1. Matched Unrelated Donors (MUDs): As the term implies, these stem cells are obtained from non-relatives who are matched at the major HLA antigens (typically they look at HLA-A, B, C, Dq, and Dr). Each person has two alleles for each HLA locus, so the degree of matching is typically reported as a fraction out of 10. If a donor is a 10/10 match for all of these HLA alleles, they are a good candidate for serving as a donor for that particular patient. However, there are many minor antigens, and because the donor and recipient are unrelated, there is a higher incidence of graft-versus-host-disease in these patients, even in 10/10 matches. Simply, GVHD occurs when donor T-cells react to host antigens and mount an immune response against the host. Acute GVHD commonly manifests in the skin, liver and GI tract.

2. Matched Related Donors (MRDs): These transplants are also matched at HLA alleles, and there is less incidence of GVHD, as there will be a better match at the minor antigens, owing to the fact that the host and donor are related. There are also mismatched related donors, but I don't think I need to explain this one.

3. Double Cords: Umbilical Cord-blood transplants are the final type of allogeneic transplant. Cord blood transplants are unique, because patients are actually given stem cells derived from two non-identical umbilical cords. Interestingly, only one cord actually engrafts and "wins out"; however, giving two cords (and a higher number of stem cells) may shorten the time to engraftment and improve outcomes.

4. Autogeneic transplants, or "Autos": The previous three transplant types were allogeneic (donor and host are non-identical) transplants. The primary reason for performing an allogenic transplant is to obtain the seemingly magical "graft-versus-tumor" effect (the donor immune system attacking the tumor in the host). Autogeneic (donor and host are genetically identical) transplants, on the other hand, are performed so that patients can receive very high doses of chemotherapy that would normally completely ablate a persons bone marrow and result in death. Instead, stem cells are harvested, the patient is given super-high-dose chemotherapy, and the stem cells are put back into the patient to rescue them.

The Deathly Infections

In HSCT, the patient's bone marrow is completely wiped out. Thus, patients are neutropenic and without a functional immune system for a significant amount of time post-transplant. As you would expect, infections are very common and can be deadly:

1. Viral Infections: Patients are at an increased risk for reactivation of latent virus and de novo viral infections. Common viral infections in HSCT patients include CMV, HSV, VZV, HHV6 and BK virus. Treatment for these infections often involves antivirals with serious side effects, including ganciclovir, cidofovir, foscarnet, and many others.

2. Fungal Infections: These can be particularly deadly, especially if not treated right away. Usual suspects include candida, aspergillus, MUCOR (coolest name ever, this fungus is bad-news-bears!), and fusarium. On a CT, you would typically see a "halo sign", because invasive fungal infections such as aspergillus love to invade the surrounding vasculature and the "halo sign" you see is actually the bleeding around the fungal nodule.

3. Bacterial Infections: Besides the usual suspects in febrile neutropenia - coagulase-negative staph is the most common - we have seen some very unusual infections on the unit this month. We've had an acid-fast, non-mycobacterial infection (possibly nocardia!) and C-Difficile sepsis!


Because our last day was Garret's birthday, Dr. Frame made us a Unicorn cake! Why a unicorn cake you ask? Well, my daughter had her 4th birthday party this month, and it was a "Unicorn" party. We were toying with the idea of making Garret a unicorn cake for his birthday as well, but didn't have the artistic ability to do it. It's a good thing Dr. Frame, besides being a tremendous preceptor, is also an expert cake decorator.

Well, that's all I've got for the amazing world of HSCT. If you have any questions, drop them in the comments section, and I'll be happy to answer (Although I don't think I've ever seen a single comment in any of the P4 blog posts). It's been a difficult but rewarding month. As a BMT pharmacist, you truly have to be an expert in EVERYTHING - ID, Heme/Onc, you name it. However, the success stories are truly amazing. Many of the nurses on the unit wear shirts that say "BMT: Believe in the Miracle of Transplant." However, in the spirit of the Harry Potter series, they should read "BMT: Believe in the Magic of Transplant"

Friday, August 26, 2011

Nontraditional- Home Infusions

Posted by Anna Polk at Friday, August 26, 2011

I spent my first rotation at HomeMed in Ann Arbor. It was a last minute addition after some trouble with my originally scheduled rotation (I didn’t find out where I would be going until orientation). In the end, though, I couldn’t be happier about the way things worked out!

I really had no idea what to expect, but I came to realize that no two days are ever the same in Home Infusions! One day you could be waiting on all of your patients to see if they were going to discharge and the next they could suddenly discharge all at once and you’d have to scramble to get their orders ready. Your plan for the day could quickly change with the addition of a new referral or changes in your existing patients so you definitely have to be flexible.

The bulk of the patients serviced by HomeMed are on an extended course of IV antibiotics, TPN or chemotherapy. There are a few other therapies as well- such as IVIG. I didn’t realize how much clinical work was involved in Home Infusions. When a patient is initially referred, we do an initial assessment and we create care plans for the patient. If the ordering physician requested lab work to be done we follow up on the results and make assessments for any required therapy changes. It was such great practice for learning what needs to be monitored and how often.

Finally, I learned how important communication is between all of the different healthcare providers! A HomeMed order is usually handled by the ordering physician, the discharge planner, someone who verifies their insurance, the pharmacist, technicians to create their labels and supply lists and then more technicians to compound the order, pickers and packers in the warehouse and then it goes out for delivery. Great care has to be taken to ensure that nothing falls through the cracks! There are also nurses involved at the cancer center, nurses who train the patients while they are inpatients and nurses who go out to the patients’ homes for administration.

So- one down and eight to go! Next up is my community HIV/AIDS rotation in Chicago- I’m actually about to go pack right now!

Wednesday, August 24, 2011

Well, that was fun.

Posted by Matthew Lewis at Wednesday, August 24, 2011

My NICU rotation is all but wrapped up, and I learned a great deal about being a clinical pharmacist. Yes, there was drug information learned like pharmacokinetics of caffeine or proper medication selection with neonatal abstinence syndrome (that's when mothers have to go through methadone withdrawal or a child was exposed to illicit drugs). More so on this rotation, I learned process. How to go about researching, writing, and organizing a topic presentation. How to figure out what to expect when you initiate drug therapy and which of those results have a clinically significant meaning. My preceptor is incredibly knowledgeable about her specialty, especially since she has been with neonatal medicine close to when it really became its own branch of medicine. To fully appreciate that fact, consider that now we just give a baby caffeine to help it remember to breathe. My preceptor started her career shortly after they abandoned mechanical bed shakers.

However, this is all drawing to a close. By Friday night, the first rotation will be done and gone. Due to my desired career path, it will be a very long time before I need to drudge up the medication lessons I learned here. The process lessons I learned, like how to investigate and build the patient's story, I will take with me to my next rotation, which is transplant pharmacy.

Transplant pharmacy rotation is one of fields of pharmacy I am highly interested in going into,and I ranked this rotation very highly. Where I knew next to nothing about neonatal intensive care medications, I come into this rotation with a decent background. Although we were hardly taught about transplant medications in class, my pharmD research project is in this area and my summer workplace supplies transplant meds to patients, so I have a better knowledge on these than my average classmate. I am also glad to be back into working with adults, since I can talk to them and my classwork applies to this population more.

In other news around pharmacy school, we had our first seminar session where we learned a little bit about the P1-P4 mentoring program and then had an info session on the APhA pharmacy convention, commonly called Midyear. I can't wait for both of these things to start. The mentoring will allow me to help somebody have an easier time in pharmacy and really get their new career going. Midyear will help me get my own career going. It's scary and exciting at the same time.

P.S. Sorry about the lack of pictures. It turned out to not be an option after all. Have to respect patient and family privacy!

Sunday, August 21, 2011

Go Time

Posted by Nina Cimino at Sunday, August 21, 2011

I'm getting ready for my last week on the oncology unit, and in my preceptor's words, it's my "go time". That means that this week, I'm on my own with rounds. Typically, my preceptor and I round together with the physician and nurse practitioner each morning, and while they have come to rely on me more, they often default to asking my preceptor's opinion. My preceptor wants me to have the experience of rounding without her, so that the physician and nurse practitioner will direct their questions to me. Of course, my preceptor will still be on the unit, so if I run into a question I need help with, I can go to her for help.

To help prepare myself for rounds and my case discussions with my preceptor each week, I have been doing a lot of reading. Typically, I look for clinical practice guidelines for specific disease states, such as lung cancer or endometrial cancer. Review articles are really helpful as well, especially for getting a general idea of the disease and the approach to treatment. Other times, my reading will be focused on a new drug that has been recently approved, or supportive care measures for some the common chemotherapy adverse effects.

One thing that has been surprising to me is the amount of internal medicine knowledge that is applied in an oncology unit. For example, many of the adverse effects patients experience, like nausea or diarrhea, need to be treated separately from the cancer itself. Also, because so many patients become immunocompromised after chemotherapy, infection prophylaxis and treatment is a HUGE concern! Often times, we can't even focus on treating a patient's cancer until their other medical issues have been stabilized. This makes for a lot of drug therapy concerns to keep up with, but it is a great way to learn!

Saturday, August 20, 2011

Shots, Shots, Shots!

Posted by Jenna at Saturday, August 20, 2011

Yep, you read that right! Tuesday afternoon at rotation we did syringe shooters during a quiet time. Now, don't go turning in Jay or I to Dr. Mason or the Michigan Board of Pharmacy yet, hear me out!!

What we did was a taste test with common liquid pediatric medications. It's important to know what these medications taste like so that you can flavor them, if possible, or give parents advice on how to mask the taste for their kids. Smell is also an important factor, which is sometimes overlooked. Who wants to drink something that smells disgusting?! 

Here are some quick notes on the samples:

Tastes okay, not great, but smells pretty bad. This is an antibiotic where flavoring would be helpful go help mask the smell.
Well, of course this tastes (and smells) good since it's pure sugar!! It smells like cake batter and tastes like a thick frosting.
Bactrim (cherry & grape)
Horrible after taste! A great suggestion is to coat the tongue before and after giving the dose. Chocolate syrup is a favorite and helps block some of the after taste.
Bad after taste!
Contains alcohol and is just plain nasty!
Prenisolone sodium
Tastes okay, no real after taste. [Prednisone is nasty from what I've heard/read - you always want to give PrednisoLONE]
Ferrous Sulfate
Have you ever wondered what sucking on a penny would taste like? Yea, me neither.. But, you're in luck! Tasting liquid iron will give you a pretty good idea of what I imagine a penny tastes like! And the taste just doesn't seem to go away .. nasty!

Don't worry .. if you don't end up on an IPPE or APPE with a super cool pharmacist like I did, the pediatrics elective will now have a taste-testing component. Every pharmacist should have an idea of what liquid medications taste like. 

Thursday, August 18, 2011

Almost done with 3 weeks!

Posted by Elizabeth Kelly at Thursday, August 18, 2011

So I am now pretty much done with my 3rd week of Peds ID. And I have learned ALOT. I have gotten to see some pretty interesting cases such as meningitis, a child with mystery rashes, appendicitis, infection post motor vehicle accident, etc. etc. I have learned how to work up these patients so much more efficiently than I ever thought I would be able to. This has definitely been a great start to rotations. I highly recommend taking Dr. Klein's rotation because not only do you get to see many different cases, but we actually get to use our knowledge! Dr. Klein has us doing these topic discussions twice a week and they may be a slight pain in the butt to prepare, but how much I learn by presenting them to her twice a week is ridiculous. I did one on bacterial meningitis earlier this week and the very next day we have a kid on service with meningitis. I was all over that one!
I haven't really made any big recommendations. I almost did once with making a drug switch but the doctors had already done it before me. But that's ok, because as long as the patient gets appropriate treatment is most important. I have answered some questions right that the medical fellows didn't know the answer to so that makes me feel pretty good! Anyways... this is probably my last post for this rotation... will be back with oncology with Dr. Kraft next month!

Sunday, August 14, 2011

This is not therapeutics class

Posted by Nina Cimino at Sunday, August 14, 2011

Having completed the second week of my inpatient oncology rotation, I feel like I have already gained a lot of insight about what it means to transition from a student to a professional. Being on rotation with my preceptor has taught me a TON about oncology so far, and I still have tons more to learn! Aside from actual oncology pharmacy, I have also been learning a lot about the "real world" of pharmacy, and I think that has been just as valuable for me.

First of all, the past week started off pretty tough, because two of the unit's patients passed away. This is a very sad and all too often occurrence on an oncology unit, and it taught me a lot about the different ways in which healthcare professionals provide care. Unfortunately, there is only so much that medicine can do, and it is important to still be there for patients and their families to provide them with the best supportive care and comfort possible, even when treatment options run out. Seeing how my preceptor and the rest of the medical team deals with these issues taught me a lot about the kind of caring professional I want to be.

And remember evidence-based medicine class from P1 year? It's back. On Wednesday, I went to a tumor board meeting with my preceptor, which is a meeting where the medical oncologists, radiation oncologists, surgeons, clinical trials pharmacists, and oncology pharmacist discuss specific patient cases. There, physicians can choose to present a patient to the rest of the healthcare professionals present in order to receive opinions and insights from others about the best course of treatment for the patient. These cases are usually tricky or unique in some way, which is why the physician is seeking other input. It was really interesting to hear all the discussion going on in this meeting and all the different opinions! And EBM is back in a big way, because the results of clinical trials drive care in oncology. So, a lot of discussion focuses on whether a particular patient can be considered similar to a study population (and therefore could possibly be treated the same way and get similar results). While the results and conclusions of a clinical trial may provide great knowledge to healthcare providers, deciding how to best apply that new knowledge is often a very complicated question.

Friday, August 12, 2011

Community Service

Posted by Eric Zhao at Friday, August 12, 2011

Ahh yes, the community rotation. Many of you already know the rigors of a retail pharmacy, so I will spare you the redundancy. FYI, I am rotating at a medium-volume pharmacy that I won't name (due to their corporate policies; again, I know...). Ask me in person if you want details.

Immediately after walking in, I knew why many patients decide to stay loyal to this pharmacy. The team here prides itself on efficiency and rapport. The pharmacists and techs all know the patients by name and have an all-around jolly good time joking around and causing all sorts of shenanigans. This is, of course, while maintaining patient safety and filling scripts accurately.

In this post, I will go over an awesome prescription software feature and the monthly health fair.

The Four-Point Check
In the workflow, this pharmacy software includes a "four-point check" where the pharmacy checks the 1) patient name, 2) drug, 3) strength, and 4) directions, because these are where errors can have the most impact. Then it goes into technician filling and another final check by the pharmacist before being verified.

Four-Point Verification before Filling

I've worked at three different retail pharmacies before and this procedure is new to me. If the other chains aren't doing this, then I suggest they man up before someone gets hurt.

Health Fair
It's a Saturday morning and I graciously volunteered to help out at the monthly health fair. The topics vary each month and this health fair tested for blood pressure, blood glucose, and vision.

Blood Pressure Testing Machine

Blood Glucose Monitor

Snellen Chart for Vision

Amsler Grid
(Normal Vision)

Amsler Grid
(As seen by a person with age-related macular degeneration)

We spent a good four hours utilizing our pharmacy knowledge to analyze results and encourage people to make lifestyle changes. And, because I know you care, here are my results:

Blood Pressure: 133/89
Blood Glucose (post-prandial): 110
Vision: 20/30 with glasses
Amsler Grid: No macular degeneration!

My BP is a bit high for my liking, but I'm still at goal (<140/90). I blame the economy. I'm happy with a glucose of 110 (post-prandial! AKA "After eating" for the lay person). Looks like I need to upgrade my glasses though...but I don't have macular degeneration! I'll wait until I'm over 50 y/o for that one, thanks.

Until next time, cheers!
-Eric Zhao

Monday, August 8, 2011

Diving into Oncolgy

Posted by Nina Cimino at Monday, August 08, 2011

After the first week of my first rotation, I cannot believe how much I'm learning! I'm spending the month rotating with the inpatient clinical pharmacy specialist in an oncology unit in a community teaching hospital. A typical day goes like this: I get to the hospital in the morning, usually about 2-2.5 hours prior to rounds. For those first few hours, I go through the charts of the patients I've been assigned by my preceptor to catch up on what happened with each patient overnight. I look at things like their lab tests, any new medications that have been started, and nursing notes to get an idea of how the patient is doing overall. My goal is to know what's going on with the patients so I can be ready for rounds. One thing I've noticed on rounds is that if I'm better prepared and can answer the team's questions about a patient's medications right away, they seem to trust me more with other questions as they come up.

During rounds I visit the patient rooms with my preceptor, and either the nurse practitioner or physician, or both. This is also my chance to ask any questions about the patients, or to make any recommendations for the patient (only after I've discussed them with my preceptor, of course!).

After rounds I work up my patients, going through each of their medical problems and any updates. If I have time, I can research disease states that my patients have, or work on some of my long term projects (journal club, newsletter article, nursing in-service, or topic discussions). Later in the afternoon, I present my patients and their updates to my preceptor, so we have a chance to discuss any recommendations that may need to be made. Twice a week, we also have topic discussions about different oncology disease states.

So far, this rotation has been very challenging, but also extremely rewarding. While at times the amount of information I need to learn is overwhelming, it's also rewarding to know that each day I have the opportunity to have a positive impact on my patients.

Sunday, August 7, 2011

First Week at Aastrom Biosciences

Posted by Amanda at Sunday, August 07, 2011

So I have finished the first week of my first rotation. YAY!!! This week has been pretty busy. Aastrom Biosciences is a pharmaceutical development company that focuses on biologics. They are currently using autologous cell therapy called ixmyelocel-T. They are currently working on study trials to get it approved for use in Critical Limb Ischemia and Dilated Cardiomyopathy.

The cool thing about Aastrom is that since it is such a small company, all the manufacturing and tests are done in the building where I work. The building is part of Domino Farms.

My first week has involved a lot of meetings and reading a LOT of papers.

So far I really like it here, the environment is very relaxed and the people here seem to be really happy.

GeNeRaLiSt RoTaTiOn - WeeK OnE

Posted by Melanie at Sunday, August 07, 2011

I am the FIRST EVER student to partake in this (anticoagulation) rotation. It is brand new (still has that new car smell) and I am the only one taking it -- so that makes me the Eve of this rotation.

Eventually, this rotation will go on the REQUIRED ROTATION list and everyone will have to take it.

As a reminder: I am at UMHHC and my preceptor is Dr. Lizzie Engle (yeah, we rock the last name).

Pre-rotation: Complete required materials on CTools course site. This included pharmacokinetic practice, watching anticoagulation videos, and completing the anticoagulation MLearning.

Day 1: Orientation with Drs. Brummond and Kraft. They gave me a basic overview of what I would be doing – rounding with medical teams, managing anticoagulation and kinetics, patient education, daily readings, topic discussions on Tuesdays and Thursdays, leading a journal club, giving a patient case presentation, and giving a topic discussion.
When this was over, I caught up Dr. Engle on rounds. I was given three patients to work up for the rest of the afternoon.

Day 2: I got to rotation two hours before rounds started (rounds start at 8) to work up patients for the team that Dr. Engle had assigned me (she manages 4 teams, each with about ten patients, so she typically oversees 40 patients). My team had 10 people so I looked at labs, medications, and admission/progress notes to get a better understanding of each patient. I look for anticoagulation and vanco/aminoglycoside antibiotics because they require more management from the pharmacist. I am also looking to see whether there are any drug interactions, if the dose is appropriate for kidney function, and if there are any glaring problems (there is not time to do a full workup for each patient, so you are checking to see if there are any safety problems).

I discussed any issues I had spotted with Dr. Engle and then we went on rounds with the team. During rounds, you can find out what is going on with the patient and what the medical teams plans for treatment. You can find out if they plan on continuing antibiotic therapy, if they plan on restarting any medications that were on hold, or if they plan on discharging the patient.

After rounds, I did a more in-depth workup on the patients. I did medication reconciliation to ensure that patients were receiving in-house what they were taking as an outpatient. I looked in treatment guidelines to make sure that patients were on appropriate medications for their condition. And, I followed up on labs (such as INR, aPTT) and made recommendations to preceptor based on these results.

If a patient is being discharged on anticoagulation therapy, it is policy to provide education. Therefore, it was important during rounds to pay attention to what patients were being discharged and if they were going home on anticoags.

Day 3: I rounded with the same team again, so my prerounds consisted of following up on the progress notes and new labs from the patients.

At UMHS a pharmacist is in charge of carry the code pager. We received a code page, and had to respond. There is a drug box that Dr. Engle grabbed and took with us. Inside of it, there are different drugs that may be needed in such a situation (epinephrine, norepinephrine, atropine, vasopressin, etc). A whole team responds and the pharmacist is in charge of assembling the drugs that are necessary. This includes putting together the epinephrine syringes, drawing up the norepinephrine, and making a vasopressin drip. This was a nerve-wracking experience. It takes a lot of discipline to put your nerves to the side and focus on what you are doing to try to perform your tasks quickly and accurately.

Day 4: I took on a new team today. When I got there in the morning, I looked up my new patients and reviewed the patients from the previous day (this meant I was following 19 patients). Dr. Engle started rounds with me, and then she allowed me to finish by myself. At first I was very nervous, but the medical team has been very supportive of letting me round with them, and the attending physician seems just as interested in helping me learn as much as his residents.

There was a topic discussion around noon on diabetes. In order to prepare for this, I had to read three articles and review my therapeutics notes.

Day 5: I rounded with the same team I had on Thursday. Dr. Engle let me round by myself. It wasn’t as bad as I had expected. I just wrote down my concerns/questions prior to rounds, shared them with Dr. Engle, and then addressed them with the team during rounding.

During the afternoon, I picked up a third team that Dr. Engle was managing and started working up the patients.

Week Summary: I learned how to enter notes for anticoagulation, educate patients, answer questions for the team, order INRs, aPTTs, and Vanco troughs, and adjust anticoag dosing based on protocols.

I was also managing a patient with hemophilia A who was on Factor VIII (helixate). In order to manage this patient, Factor VIII levels had to be drawn and monitored so that the dose could be adjusted properly.

Key Points:

1 – During the first couple of days of rotation I was so nervous about getting asked questions. I would get myself so worked up that you could have asked me what my medications were and I wouldn’t have been able to tell you.

Then I realized – you aren’t going to/can't know everything. My preceptor will keep asking me questions until we get to one I don’t know the answer to. There is no point in being on rotation if you don’t learn things you don’t already know. I have learned a lot of information by looking up answers to questions I have gotten this week.

2- Don’t be afraid to ask the medical teams pertinent questions.

Okay, so the medical team can be intimidating; you have the attending who is very knowledgeable and has been practicing for a long time and you have a senior resident who has been out of medical school for a few year, junior residents, and sometimes a medical student. At first, I felt this pressure that I must know everything under the sun about every single drug on the planet so that they wouldn’t think of pharmacy as an inferior field. But, what I have found in this short week of my life, is that they value you as part of the team. So here is what I do:

a) I always introduce myself and make sure it is okay to round with them.
b) I listen to them when they are presenting the patient to see if any of my questions get answered.
c) I carry my computer tablet with me so that I can look up quick answers on the spot. (For example, I have access to labs and sometimes labs come in while we are rounding and I have been able to update the team; I have been able to look up common side effects; and I have been able to look up the generic name of an uncommon drug.)
d) If my questions were not answered, I will ask the team.
e) When we are done rounding, or if I have to leave rounds early, I thank the team for letting me round with them and tell them I will follow up with them if there was a question I could not answer.

A Question I got from the Medical Resident that may be of use to you in the future:

The patient was having fevers of unknown origin and wanted to know if any of his medications could be the cause. This was one I had to get back to her on.

Different articles publish slightly different lists, but here is one that I found (note: I looked at four articles before formulating an answer, ran it by my preceptor, and then got back with the resident):

If the link doesn’t work for you, you can always look up drug fever and find a list from a journal article.


Posted by Matthew Lewis at Sunday, August 07, 2011

As you all have probably seen from other posts, our first week is done. That leaves three to go on this rotation. My actual site is the Neonatal Intensive Care Unit(NICU), and in terms of what a pharmacy student can contribute here, it is a lot of "I'll look that up and get back to you." We have protocols for everything on the NICU, and if something falls outside of that, we have to have a ton of evidence to support our recommendation. Then, we only go by a conservative approach. Nobody wants to cause something terrible to happen to these kids because of something we did. As a side note, in the NICU, our job is to make sure the medications don't hurt the kids through interactions or something and our second job is to get the drugs off as quickly (while appropriate) as possible.

However, I still did get some questions. My favorite was "Where is loperamide (Immodium) absorbed?" I definitely had to look that one up, and since the doc, Alan, was at his clinicals, I told him before rounds the next morning. Alan thanked me and then when it came to that particular patient he said, "Matt did some research into where [loperamide] works. Matt, if you would tell the team your answer." I must've looked shocked for a moment because Alan apologized later for not letting me know he was going to ask me to report to the team. Getting back to the story, I quickly recovered and repeated the answer I found from my research and the team's discussion continued. I was quite proud of my answer and was able to present it in a way that was professional and medically appropriate. I think that was my first real test as a P4 and I passed it.

Moving forward to today, I visited the NICU, just to see if there were any new patients for my partner, Kim, and me. I only got two, just a set of twins, which you see pretty often in the NICU. Usually, whatever happens to one twin has an impact on the other which nets them both in the unit. Kim, however, got five thanks to a set of triplets, one transfer in, and one born today. Slowly, we are picking up all the new patients that come into the unit. However, since it was Sunday, the attending (head honcho) doctor, Dr. Donn, was quite surprised to see me. When briefly asked what I was doing there on a Sunday, it was one of the interns who responded "Dedication." Hey, these are my patients too and not only do I want to represent pharmacy well, I want to know what's going on with my little guys and gals.

I'll try to get some pictures, since I do want to make it clear how sick and tiny these patients are. In the mean time, just think that a five pound bag of oranges is about how heavy these kids are (sometimes that five pounds is twice what a patient will weigh) and they could probably fit in the bag itself.

Friday, August 5, 2011

Lessons from Community

Posted by Jenna at Friday, August 05, 2011

My first rotation is at Hometown Pharmacy in Manchester with Dr. Jay Demski. To be honest, I don't feel comfortable in this setting, so I was nervous. I feel like I lack OTC knowledge (be thankful for the new curriculum!) and knowledge of important counseling points because I've worked in the hospital setting for the past 3 years.

Manchester is a very small, but very active, community and Hometown Pharmacy is the only pharmacy in town. Along with a pharmacy there is a little store, as well as a rented out floral shop. I have a new friend there, Petals, an adorable dog who loves that I share my breakfast with her (Multigrain Cheerios, if you're curious)!

The script count can vary from 40 (Saturdays) - 150 or more. It's not high volume but it does have hectic times and provides a unique experience. It's an ideal pharmacy for students without a lot of retail experience (or if you want to work with a great pharmacist!) because there are slow times where the pharmacist is all yours for questions!

Important Life Lessons
1. You are NOT the earth's gift to pharmacy! Be a TEAM player.
Don't be one of those people, you know the ones who think that they are above other employees/technicians. This past week I faced the shelves, which included everything from OTC's to batteries and toilet paper, and helped order Hallmark cards. Not exactly 'pharmacy intern' duties but I offered to do these things during slow times and I think it was very much appreciated. I did it all with a smile on my face too.
Don't act (or feel, for that matter) that any task is below you. Get over yourself!

2. It's inevitable - There are days when you're going to feel like an idiot.
I don't know about you but there aren't many things worse than feeling like an incompetent fool. Admittedly, I am very hard on myself. I get frustrated with how much I feel like I don't know and I hate when I know that I've learned something but can't dig out that information from my brain. The example that comes to mind is when a patient (who happened to be an MD) asked me about his prescription for Mobic. He saw that I was a student and so he thought he'd quiz me. So here he is standing right in front of me, the pharmacist is standing right next to me, and I'm standing there dumbfounded. CRAP (or some other more profane word), I said to myself, what in the world is this drug and why can't I remember it?!!? I was a combination of panicked, embarrassed, and mad at myself because nothing was coming to mind, other then the fact that it sounded familiar. So after what seemed like the longest 30 seconds of my life, the pharmacist said to me 'It's an NSAID,' so then I said to the doctor (feeling totally defeated) 'Uhh .. take it with food.' There are going to be MANY more of these instances and I need to learn how to deal with them better.
Acknowledge that you can't know everything, no matter how much you prepare. Come up with an action plan to help fill in your knowledge deficits. [This weekend I will be making what I hope will be a fabulous chart on the Top 200 drugs - their counseling points, dosage range, brand name, etc.]

Overall, it was a great first week of rotation and what I think is an ideal rotation to ease into life as a P4 on rotation! I can't wait to see what the next 3 weeks have in store for me.

Week 1 = DONE!

Posted by Christine Rabah at Friday, August 05, 2011

So the first week is over! It really flew by.

My first rotation is Drug Information at Beaumont Hospital in Royal Oak with Dr. Mark Lutz. My first day, a Wayne State LAPP student took myself (the only UM student) and a couple of other Wayne students on a tour of the hospital then dropped us off to our respective preceptors. I am doing my rotation along with a PGY-1 resident (Beaumont has 6 PGY-1 residents this year!). The first thing my preceptor did on Monday for both of us was refresh our memory on what references are used for what types of questions. It was a lengthy, but much needed review. EBM P1 year, anyone? :)

My preceptor gave us a few projects that we would be working on this month, including a calendar with draft and final due dates and meetings & conferences I have to attend. This rotation requires me to do the following:

1. answer drug related questions in the DI call center (duh!)
2. create a new drug monograph on a new antiplatet drug called Ticagrelor (Brilinta) for Beaumont's Medication Management Committee (a.k.a P&T) to review and consider adding to formulary when it's available. This will also be presented to the Cardiology Clinical SubCommittee for review
3. conduct a journal club presentation on the article of my choice in front of other pharmacy students and pharmacists (Beaumont has a system for this where you are reviewed by 4 people just to get feedback on how you did, which is nice)
4. an Institute for Safe Medication Practices (ISMP) newsletter review, and how those issue impact Beaumont
5. an FDA MedWatch Safety Alert on Dronedarone (Multaq) and how this issue impacts Beaumont
6. and lastly, I have to update Beaumont's extemporaneous compounding recipes for 6 different drugs I was given (dantrolene, demeclocycline, enalapril, hydrocortisone, lansoprazole, and verapamil)

This rotation is very independent- I split half of the day in the DI call center with the resident so we both get a chance to answer any questions. When I'm not there, I'm working on my projects. I've already had a chance to attend a meeting with the Formulary Management SubCommittee.

The DI call center doesn't get a high volume of calls. but I have already gotten a couple of interesting ones. One call was a nurse from the anesthesia dept asking if her patient was having surgery in 2 days, should she stop taking her Arava (leflunomide)? As students, what is our typical go-to resource? MICROMEDEX! My preceptor wanted me to shy away from that (even though it is a great source) and try others. After checking a few sources (including Beaumont's Pre-Anesthesia Guidelines that show what drugs need to be stopped and how long prior to surgery), I came to the conclusion that the patient could continue taking her medication like normal.

I won't be posting much on this particular rotation since I basically covered everything I'm doing, but as soon as I get that off-the-wall question, you will all hear about it :)

Pop quiz! How many mEq of potassium are in a banana? (Yep, I really got a call from a physican about this. He was laughing too, which slightly made me feel like I was being punked)

Answer: 11 :)


First week of rotation... wow

Posted by Elizabeth Kelly at Friday, August 05, 2011

So, this first week of rotation has flown by. My very first P4 rotation is with Dr. Klein on Pediatrics Infectious Diseases. I was really scared last week especially because I had to study up on my bug-drug lists, review immunizations, go over pharmacokinetics, etc. etc. Plus, I had another certain blogger who will remain nameless, but lets just say she may have been the very first blogger from the class of 2012 to put something up, but anyways... she scared me to death acting like I had to know EVERYTHING. However, this week has went really well. A few highlights:
Monday: Got to rotation at 9:30 (yay!) and had an orientation with Dr. Klein who then in the afternoon had to fly out to Washington D.C. for a conference and pretty much was leaving the other student and I on our own. She left us with a topic presentation to prepare for Thursday, pharmacokinetics problems for Friday and each one patient to work up to start with. Not bad huh?
Tuesday/Wednesday: first day of us rounding! Met the fellows and attending and rounded on a couple of different children each day. It is really interesting the different situations you will see in pediatrics and how everything is just "slightly" different from adult patients. For example, dosing, different drugs, etc.
Thursday: met back up with Dr. Klein and performed my case presentation on Stevens Johnson Syndrome. I have to say that when the PGY2 residents came in to give the P4s their recommendations about rotation during orientation they said to be really prepared and practice as much as possible the presentations and everything. I think I did pretty well on mine and Dr. Klein even acted like I was OVER prepared. To me... never a bad thing. We also went to a pediatrics ID meeting in the afternoon where different cases the doctors wanted input on were discussed.
I have to say so far I am really enjoying this rotation and putting in a lot of good work.