Thursday, December 20, 2012

What is an Administration – Technology Systems rotation?

Posted by Anna at Thursday, December 20, 2012

This was a common question I received after informing people the title of my nontraditional rotation. After completing this rotation, I finally have a good answer!

The rotation was an administrative rotation within the context of the technology systems used in a hospital. These different systems include automated medication packaging, automated dispensing cabinets, and automated inventory management, to name a few. I worked under a pharmacist responsible for understanding the various systems, and who uses their capabilities and the data they collect to improve efficiency and safety within the health system.

My rotation followed a similar format to the other administrative rotations discussed by my colleagues already. However, I also spent the first week or so working with pharmacy technicians and actually using the technology. This included receiving medications from the order, picking medications for delivery, and going on runs to stock automated dispensing cabinets. This was not my favorite part of the rotation; however, it was important I understood how the systems worked in order to interpret the data they generated.

My day can easily be summarized into two main tasks: meetings and projects. I attended meetings that covered the administrative side of things (management/operations, policy review, and Joint Commission preparation) and those more specific to supporting the technology systems (purchasing/contracting, drug shortages, and quality improvement). Projects I completed include:
-          Review of pharmacy technician medication kit filling records to determine utilization of extra technician hours
-          Assessment of stock out data from Omnicells and recommendations for how to meet goals
-          Creation of a new database to store controlled substance research prescriber information
-          Collection of data and development of a timeline for implementation of consolidating purchasing of a product for the health system
-          Review of medication usage and current par levels in Omnicells and recommended changes
-          Evaluation of usage of bulk compounded products by outpatient areas
All of these projects involved ridiculous amounts of data which I had to sift through and make sense of. As a result, I became intimately acquainted with pivot tables.

I am very happy with my selection for a nontraditional rotation. I learned a lot about the administrative side of hospital pharmacy, and I better understand the challenges faced in this environment. This rotation taught me that how we get the drug to the patient is just as important as choosing the right drug. After this experience, I would be very open to an administrative position in the future.

This concludes my very last rotation at the University of Michigan hospitals—sad!!! Starting in January I test my winter driving skills (if we ever get a winter) as I venture out to Detroit’s Sinai-Grace Hospital for an Infectious Disease rotation!

Wednesday, November 28, 2012

"New patient resus charlie"

Posted by mariarx at Wednesday, November 28, 2012

Rotation 5 is in the bag! Hard to believe we have now crossed over the halfway point. For 5 weeks, I was in the emergency department pharmacy with Dr. Pam Walker (no relation to Dr. Paul Walker) and her amazing ED team at UMHS. The ED pharmacist has a unique role in that they are staffing the ED satellite by themselves (checking orders, making all the IVs, answering questions) as well as responding and working first line with all traumas/codes that come through the resuscitation bays. By the end of the rotation I was confident in my ability to jump in and do (mostly) all of their tasks, with supervision of course.

To paint a picture for all the readers - the adult ED is MASSIVE. 90+ beds split into 5 areas, and 3 trauma bays for critical patients, plus a psych wing. ED satellite pharmacy? Approximately 1.5 times bigger than my closet. Super tiny. The skills these pharmacists are not lacking are efficiency, space management, and time management.

The rotation started out with me working in the satellite, observing the workflow and getting comfortable being in that setting. The ED is definitely different than being on the floors - always lots of movement and energy. On the first day I got to respond to a trauma code in a resus bay. Pam and I helped the team with a patient that needed to be intubated. The first thing Pam does - leave me alone with the RSI (rapid sequence intubation) box while she runs back to grab etomidate from the satellite. Drawing up a neuromuscular blocker on the fly via shouted out directions was the moment I knew that I had to be on my feet and ready to go for the remainder of my time down there. I LOVED it. Over the course of the rotation I got familiar with antibiotic dosing, checking orders, how to use EPIC and Carelink and Worx simultaneously, and all that is needed in running a satellite by yourself. I also volunteered myself for 2 midnight shifts during the rotation to get a feel for the types of patients that are coming into the ED at 3am versus 3pm. It was not as difficult as I anticipated to be up all night. The 2 red bulls and bowl of candy helped as well. :)

Throughout the rotation I definitely got more comfortable with resus patients, and building up the ED pharmacist mindset of "what will they need next? What is the worst case scenario for this patient and what drugs will they need?" Those are key skills for an ED pharmacist, along with on-the-fly dosing, estimating a patients weight and height for said on-the-fly dosing, and the order to give them in (etomidate BEFORE neuromuscular blocker).  I practiced this by looking at patients who were "expected to arrive" to the ED, looking at the 1 sentence blurb that usually accompanied them, and coming up with a (fake) plan.

Projects for the rotation included topic discussions a few times a week, both one on one with Pam, joining the Cardiac ICU students for their critical care discussions, and leading the topic discussion about ACLS for the ICU P4s. I also worked on automated dispensing machine optimization for the multiple omnicells throughout the ED. Looking for administrative type projects seems to be my M.O. for P4 year.

In the end I really enjoyed the ED pharmacy rotation and would highly recommend it to any future P4s.  A++ would rotate again! For rotation 6, I'm at Meijer pharmacy for my community rotation. If you shop in Ypsilanti come on by and say hello! 

Saturday, November 24, 2012

Of waltzes and wits...

Posted by Unknown at Saturday, November 24, 2012

I’m engulfed in the fumes of the pastel green goop I have just smeared all over my hands and wrists. The familiar coolness of the iconic hospital hand sanitizer washes over my skin, which is just beginning to display the telltale signs of the start of a harsh Michigan winter. A stinging sensation briefly causes me to pause and look down—a new paper cut I hadn’t seen, probably obtained just minutes before when I was shuffling through my patient monitoring forms, scrambling to copy down hot-off-the-press bacterial cultures for one of the patients I was about to round on. I welcomed the stinging, and made sure to work the last traces of hand sanitizer into the cut in the few seconds before they vaporized from my now bacteria-free hands.

You see, this procedure is not uncommon on rounds, it’s the protocol—sanitize in, sanitize out—as we visit each and every patient’s room. While this rotation, Infectious Disease with Dr. Carver, was not my first rotation rounding, the precautions meant so much more to me now. I am gaining a new appreciation for the world of the unseen, a world in which—invisible to the naked eye—bacteria specialize in ravaging the lives of perfectly healthy individuals within weeks, days, even hours. I began to slowly see the pages of my therapeutic notes come to life in front of my eyes. I’d find myself thinking, ‘Aha! Cellulitis. So that’s what it looks like!’

But seeing the patients themselves does not actually comprise the bulk of this rotation. Our daily routine begins with us (my colleagues Tony Elias, Mary Lou Chheng, and I) working up our own patients in the morning, where we assess all aspects of a patient’s antibiotic therapy: indication, dose, allergies, cultures and sensitivities, toxicity. I find this part both challenging and enjoyable. As I pore over the pages of Dr. Carver’s infamous bug drug list, I feel like I am engaged in nothing short of a battle of wits, reading an instruction manual listing all the strengths and weaknesses of my opponents, choosing the best strategy to outsmart them. We then meet with Dr. Carver to discuss our patients and make any necessary recommendations to the medical ID consult team. On rounding days we make the recommendations in person, and on non-rounding days we send our recommendations to the team electronically. The remainder of our day involves extensively reviewing with Dr. Carver the ID topics that are pertinent to our patients.

On a personal level, this rotation is also hitting close to home, as I realized the widespread implications of infection. For example, after seeing cases of patients acquiring infections after recent placement of prostheses the knee replacement surgery I had been encouraging my father to consider because of his increasingly intolerable osteoarthritis pain suddenly didn’t seem like such a good idea anymore. I finally understood why he is holding off on surgery as long as he can. Being a physician, he understands the risks of having foreign hardware in the body, a concept I only just began to internalize as a newbie in the healthcare profession.

And thus is my experience with ID so far. ID, which I have come to see as a delicate waltz, sometimes clinicians leading the dance, sometimes the bacteria, one always struggling to gain footing over the other. 

Sunday, November 11, 2012

Rotation #5: Generalist (Adult)

Posted by Kristen Gardner at Sunday, November 11, 2012

I just completed my 5 weeks of the general medicine rotation at UMHS. LOVED it! I strongly believe in the decision by the Experiential Training Office to have this be a mandatory rotation for all students for the following reasons: 

1. It allows you to focus on core clinical services: pharmacokinetics, renal dose adjustments, anticoagulation, appropriate antibiotic use, anticoagulation education, and TPN (although this is just picking up in the adult generalist side).

2. It challenges students to handle a high patient load of ~30 patients daily which is nothing considering the generalists cover at least twice that number.

3. You get very familiar with the computer systems used and navigating your resources available. And you learn the documentation procedures.

4. I liked interacting with so many pharmacists and gaining their perspective on a number of things. You have your primary preceptor but other one cover for them and join your talks and are available to answer your questions if needed.

I do not want to reiterate what other students have said about this rotation as their descriptions were very good. So some specifics- I know we all like details! My journal club/topic discussion was on Stribild, a new HIV treatment, and review of HIV/AIDS management. I also delivered a patient case presentation on a patient dx with a pulmonary mold infection, Aspergillus fumigatus, and worsening of heart failure in the context of numerous other complications per normal given we are at UMHS. The preceptors led various topic discussions such as IVIG, geriatrics, pain, C. diff, and infectious disease which were useful.

What I did to stay organized

1. I printed off the patient overview from theradoc (not sure what this is technically called) to have a basic reference of lab values, meds, cx, crcl, age, allergies, etc. I would NOT print one out for every patient daily- just every time a new patient was admitted.

2. I printed off the theradoc roster of patients for each team for which I was responsible. I would write in a few phrases for why the patient was there to help me remember all 30+ patients! I would also write what I wanted to follow (BP, renal function, glucose, Cx (UCx, BCx, etc), pain med use, etc depending on high priority problems and therapy the patient was receiving. On the left side column I would write what my recommendations were or what I wanted to discuss with the attending (for non-rounding services) or the medical team (for rounding services). I would use the bottom to remind myself of what I need to follow-up on before leaving for the day or to keep track of doses given in the case of pharmacokinetic monitoring or pain regimens.

3. I would complete as much documentation as I could as I was going through and working up patients. Documentation includes, new starts, education, and summaries for anticoagulation, goal troughs for vanco, IV vanco/aminoglycoside follow-up, adding/deleting new flags from theradoc, reasons for using restricted antibiotics, pharmacokinetics, heparin drip follow-up, etc.

Common Interventions

1. specific therapy for infections

2. IV --> po switch for antibiotic regimens

3. Metabolic monitoring for patients on antipsychotics

4. Renal dose adjustments

5. Optimizing antibiotic regimens (ABW, frequency)

6. Citalopram --> lexpro switch for elderly patients on high dose citalopram + EKG > 500 + omeprazole 20-40 daily or BID

7. Optimizing pain regimens and adding therapy to prevent constipation

8. Reducing unnecessary use of IV meds

9. Warfarin dosing and scheduling

10. Optimizing enoxaparin dosing

11. Restarting anticoagulation after procedures

I hope you all enjoy this rotation! 

Saturday, November 10, 2012

Life with Lexicomp

Posted by Janis Rood at Saturday, November 10, 2012

Rotation 5: Drug Information - Medical Writing

Yes, I just spent the last five weeks working from home in my pajamas.  However, much of my time was not spent medical writing.  In fact, the first week of rotation I really had no clue what I was doing except all my laundry and dishes were done.  This lack of structure was done on purpose as a way for the preceptor to gauge a student's level of ownership with their work.  For me these were very difficult waters to tread.  I had no trouble getting up each morning, working, staying on task, producing good work.  However, I had a tough time figuring out what was expected of me, how to judge my time management skills, how to gauge my progress.  We were given drug-drug interactions that already exist and tasked with finding all new literature regarding them, updating the monographs, and word-smithing the content.  I never felt confident that my approach to searching, evaluation or assimilation were correct.  However, none of this was actually seen so there was no way to receive feedback.  All I turned in was the updated monograph.

I know myself well enough that I am very plan-oriented, and working on random projects without a goal in mind would be five weeks of torture.  After the first week, I finished all my projects and asked to meet with the preceptor.  I explained my frustrations, and he seemed very surprised but extremely open to my needs.  Together we came up with a list of goals and objectives that I wanted to get out of the rotation.  Specifically, I listed all of the ways in which I felt weak in the areas of literature searching, analysis, evaluation and writing.  From that time forward, my preceptor adjusted the projects towards my interests with special attention to my weaknesses.  I was able to fully engage in topics that interested in me, while at the same time strengthening my skills.  We also kept an open feedback dialogue so I could easily chart my progress.

In the end, I am proud of the monographs that I edited and drafted, the databases I produced on natural products, and my overhaul analysis of OATP1B1 literature.  Ultimately, I decided that such a job would not be the best fit me for the following reasons:

1) I am a workaholic.  Working from home, while flexible, means that you never really leave work.  I need the physical separation from my workplace in order to stop working and not feel guilty about it.

2) I need my patients.  I discovered that what gives me the most satisfaction out of my work as a pharmacist is the impact I make on patients.  My work with Lexi supports evidence-based decisions, but is too far removed for my liking.

3) I need a team.  I like working with people and collaborating.  I felt extremely lonely working by myself, yet a little bit of a loser if I spent 8 hours in a coffee shop.  I much prefer to go to work, spend time working with other people in a team, then come home when all is said and done.

Nevertheless, I did come away with specific new insights:

1) I better understand the art of searching for literature, tweaking strategies, evaluating relevance, and compiling results.  I feel confident that given a topic, I could efficiently complete a literature review.

2) I no longer gravitate towards the discussion section or author's conclusion of an article.  It is so easy to do this, to get the point and get out.  However, I found that if I spent the time going through the statistics, teaching myself what they did, and analyzing the results myself, I came away with a much better understanding and could fully critique the author's conclusions.  I feel confident that over time this will get easier and easier, even though the time spent up front is a tad torturous.

3). Concision, concision, concision.  I learned how to create structure and use this to cut down words without losing my message.  Still a work in progress, but much improved.

All in all a good experience, but not my favorite rotation.

Friday, November 9, 2012

AMBUTUTIONALIST: an "institutional" rotation at Spectrum Health

Posted by Anna at Friday, November 09, 2012

I have just completed my rotation at Spectrum Health Butterworth Hospital in Grand Rapids, MI. Although technically an advanced institutional rotation, I feel it would be better classified as an ambu-tutiona-list rotation. This new classification stems from the varied components of this rotation that went beyond the traditional “institutional” requirements by combining ambulatory care, institutional tasks, and generalist activities. A list of some of my experiences better demonstrates this variety:

Ambulatory Care:
One week at the West Michigan Heart clinic working with pulmonary hypertension and heart failure patients
- Performed medication histories and patient counseling
- Made recommendations to the provider and charted my interactions in the medical record

- Product dispensing and medication order verification
- Patient chart review
- Discharge counseling (Meijer Heart Center)
- Antibiotic pharmacokinetic monitoring
- Developed nurse-directed educational project on QT-prolonging agents in conjunction with nursing
- Two journal club articles and a formal patient case presentation

One and a half weeks with the medical surgical unit performing patient chart review and work-up for 12 to 16 patients per day
- Rounded with interdisciplinary team and made treatment recommendations when warranted

My hours typically ran from around 7:30-4 (although this varied a bit), and for the most part I worked with a few select pharmacists. My preceptors were clearly dedicated to my education—you could tell they wanted me to be there and that they enjoyed teaching. This specific rotation was only introduced at Spectrum Health this year, and I was their second student. Many of the kinks had been worked out with the previous student (sorry Mary Lou!), and everything flowed much more smoothly for me. Although there were a few of those inevitable days where it felt more like a shadowing experience than a practice experience, overall the preceptors allowed me to be very independent and kept me busy!

I applied for this rotation specifically for the opportunity to see how things were done in a different health system. I personally benefited greatly from being in a different environment, and it provided me a chance to see how another health system is making changes to advance pharmacy practice. I also loved the opportunity to interact with other pharmacy students, as many Ferris State University students have rotations at this site. I was surprised by how inviting the atmosphere was to an “outsider,” and I would highly recommend this site for an institutional rotation!

My next rotation brings me back home to the University of Michigan Health System. For the next six weeks I will be exploring the world of informatics and administration on my “non-traditional” rotation!

Monday, November 5, 2012

ID Stewardship and Drug Info

Posted by Anonymous at Monday, November 05, 2012

Like many of my co-bloggers, I feel that these rotations are quickly passing by without much time to reflect! Here's a quick summary of my last 2 rotation blocks:

Infectious Disease - Antibiotic Stewardship @ UMHS:

This rotation was divided into ~10 day blocks so that we could get experiences in both stewardship and rounding. Throughout the rotation, the mornings began with a topic discussion lead by a preceptor, resident, or student. This served as a comprehensive overview of all important ID topics that we were likely to encounter over the rotation (and was very useful in reinforcing spectrums of activity for the various classes of antibiotics!). My first block was spent with my preceptor on stewardship, where I would preform culture reviews for all patients on restricted antibiotics within the hospital system on a particular service. This helped me become more familiar with the guidelines for use in patients, and get a sense for assessing clinical need for restricted antibiotics that I hadn't learned much about in school. The following two blocks were spent with a pharmacy resident rounding with ID teams. These services ranged between 10-20 patients at any given time, for which I was responsible for working up and assessing their therapy. Mornings were generally spent reviewing charts and discussing possible interventions prior to rounds in the afternoon. Another notable activity on this rotation was helping to create an competency test for staff pharmacists on our guidelines for antibiotic used, based on case scenarios. Overall, I believe this rotation was very useful during my P4 year to reinforce and expand upon the ID we learned in class. I highly recommend ranking an ID rotation!

Drug Information - Medical Writing @ Lexi-Comp:

This rotation was a review in how to review primary literature for updating or creating new drug interaction monographs for Lexi. Even though a majority of work is done remotely, I found this rotation to be very busy! My preceptor would send drug inquiry emails throughout the day for us to look into, in addition to our workups for newly-approved drugs and revisions to existing monographs. This involved fine-tuning primary literature search skills, and working towards making succinct monographs that contained clinically applicable information. Interactions are graded based on the risk of a patient experiencing a clinically significant effect, which sometimes is hard to judge based on limited information available. I believe this was a good exercise in learning to become more decisive in clinical situations by evaluating primary data and extrapolating its meaning in a patient-specific manner. Another rotation-long assignment was to develop monographs for herbal medications, which are currently limited in Lexi. This involved extensive primary literature searches for each type of interaction (i.e. flaxseed and estrogens, flaxseed and hypoglycemics, etc.). Finally, we met with our preceptor to discuss pharmacokinetic and pharmacodynamic interactions for the monographs we were looking into, and also presented a journal club to our group. Again, this rotation was busy but useful in developing my primary literature search and review skills, and learning how to apply this information in the clinical setting.

Wednesday, October 31, 2012

VA Ambulatory Care: Cardiology

Posted by Beejal at Wednesday, October 31, 2012

Hello everyone!

It’s been 2 months since I’ve posted, but rest-assured that it was intentional!  My block 4 rotation was Cardiology at the VA with Dr. Brenner.  Krystal already posted a blog about it, and her descriptions mirrored what I would say to the T!  I encourage you to read her September post before reading mine.  Hopefully my post will be supplemental to hers with some added challenges I faced.  I will also speak to the impact this rotation had on my block 5 rotation (why I waited to post!)!  First, here’s a short summary of my experience at the VA! (My definition of “short” ha).

While it is very true that everyone has a different experience with Dr. Brenner, the topic discussions, anticoagulation responsibilities, and types of patients you see are very similar to students prior.  My topic discussions were done TIW over the first 3 weeks, then BIW thereafter :).  He wants you to know everything about the topic you’re presenting.  Like Krystal noted, when you give a topic discussion he will not allow you to read your handout; he wants you to know it and just use it as a reference.

I saw my first patient on day 4 of rotation.  I was nervous, but I ended up doing great with patient interactions- it’s the therapeutics that I lacked! (Naturally!)   As with topic discussions, Dr. Brenner wants you to know everything cardiology-related about your patient when you work them up.  The patients that are referred to his clinic are ones that are difficult to manage.  You will rarely see a patient in this clinic who simply has hypertension and is well-controlled with first line therapies.  His referrals tend to need more investigation.   

When working up patients, you have to know which medications have ever been tried for all of the patient’s cardiac conditions (not just the condition the patient is being referred for).  You should know what happened with each medication and why they are on their specific regimen.  Even if atorvastatin was used 8 years ago and the patient is now taking rosuvastatin, you should know when and why they were switched, and if they ever experienced muscle pain or had elevated CPK levels.  You should know their last ECHO and ECG results, whether they had a CABG or stent placed (when and what kind), and what other conditions may be related or may impact their cardiac conditions (kidney injury, BPH, etc).  Specific to hypertension, you should be able to use home blood pressure readings and serum aldosterone and renin levels to drive therapy changes.  Specific to heart failure, you should be able to probe the patient to determine how well controlled they are, and if they are on the verge of an exacerbation.  Many of these patients are older so you should always be mindful of orthostatic hypotension, dizziness, and chest pain.  You really learn how to assess a patient from every cardiology disease state inside and out.  Finally, you write SOAP notes for every patient you see.  He knows how valuable this is, and he challenges you so that you have an easier time in residency. 

Specific challenges
Besides re-learning topics like hypertension, heart failure, dyslipidemia, and arrhythmias in a short amount of time, the biggest challenge was being comfortable making therapy changes.  For example, in one of my patients with multiple cardiac problems, we changed 2 medications and discontinued 3 medications.  This was the first time I realized the extent of the impact we can make in an ambulatory care setting, and the relevance of having prescribing abilities.

The other challenge was entering my appointments not knowing what I was going to recommend.  All your recommendations change once you talk to the patient!  You find out what symptoms are really bothering them, and what their home blood pressure and heart rate readings are.  You also generally don’t have lab values back until the middle of the appointment, so you cannot assess dose changes or abnormal lab values ahead of time.  If lab values return when you get to that portion of the appointment, you think out loud through each value, explain to the patient what the significance is, and inform them of whether they have met their goals.   Based on their lab values and their signs/symptoms, you make a recommendation for what the next step should be.  The only way to prepare for these interviews is to have different plans for if A happens, B happens, C happens, and D happens.  More than likely neither A, B, C, nor D will happen!

Cardiology is the field I had always considered for a residency.  This rotation reminded me of how much I enjoy it!  I have my favorite topics (heart failure, post-ACS, and anticoagulation) and ones I’m not so fond of (hypertension, arrhythmias).  Despite having an “interest-bias,” I am now comfortable and confident in most (if not all) of the topics that we discussed. 

Impact on my community pharmacy rotation at Meijer:  I consider myself to be proficient in assessing a patient’s cardiology regimen.  Dr. Brenner challenged me to know my therapeutics very well, and I am truly thankful.  Knowledge of heart medications is very important to any practice of pharmacy.  I am blown away with how much I have retained, and how spot-on I can be with patient profile reviews in the community setting.  I even gave a hypertension topic discussion to the P2 IPPE student and my preceptor during this rotation!  Again, I can’t describe enough how relevant cardiology is in pharmacy practice, and how much I learned during Dr. Brenner’s VA cardiology rotation. 

Time management:  I was fortunate to have 3 clinical rotations before the Mid Year meeting, and now I have a better direction for my future. This, however, was very overwhelming.  Having this cardiology rotation immediately after Peds Hem/Onc left me burnt out.  When I added my seminar presentation to this, I was working all day, every day … including weekends… for 10 weeks.  This is something to mentally prepare yourself for when you have a series of inpatient rotations.  P4s always say how busy they are, but it’s a different kind of busy.  I now know what they mean!  The best way I can think of to describe it:  you have real responsibilities as a P4- it’s not just about showing up, it’s about being prepared.  You get out of your rotations what you make of them.  Be mentally prepared to work hard during your inpatient rotations, and keep up!

Sunday, October 28, 2012

Rotation 4: Nuclear Medicine

Posted by Alison Van Kampen at Sunday, October 28, 2012

My fourth rotation this year was at Covance Laboratories in Madison, WI.  This was a unique experience because I not only learned a lot about nuclear medicine but also about Phase 1 research.  I spent the majority of my time at the Clinical Research Unit where they primarily conduct research in humans examining the AME properties of new products.

In this setting I was able to observe how radio-labeling is used to detect drug serum concentrations, route of administration, route of excretion, and length of time that the medication is in the body.  The role of the pharmacists in this setting was primarily drug preparation, determining if and how client specifications could be met, and participating in meetings with clients for quality assurance.  The pharmacists also were responsible for ensuring equipment integrity and that all staff were knowledgeable and followed standard operating procedures.  

I learn a lot about how phase 1 research is carried out, about imaging studies, precautions that are taken during preparations with radioactive or "hot" material, and why and how these products are used.  While I was there I primarily attended client meetings with my preceptor, observed preparations, helped with equipment qualification, worked on projects, and went on "field trips."  

Client meetings were interesting because I was able to see all the work that goes into setting up research.  Several times each week, a company with a new product that is currently working with or may work with Covance on a study, will have a teleconference with employees at Covance.  This meeting can be anything from going into great detail about how the study will be conducted (number of participants, types of participants, route of administration, special monitoring, etc) to periodic checks during a study for quality assurance.

The preparation was different for each study and so each presented it's own challenges.  Each study needed to have a mock preparation that was evaluated for appropriate strength, purity, and contamination.  They prepared sterile and non-sterile as well as "hot" (radioactive) and "cold" (non-radioactive) products.  Products were prepared on regular lab benches, in vertical flow hoods, and in ISO class 5 glove boxes, which, by the way, are very difficult to use. Just putting on the three pairs of gloves was  very difficult on it's own, let alone try to avoid contaminating the products.  I also did a qualification of two of the pipettes.  Twice a year they need to check all of their equipment to ensure that it is working properly and is accurate.  This was a way that I could learn and contribute to the clinic, and I am proud to say that I was able to pass both of the pipettes, which is more difficult that it sounds.

I was also given some small and large projects to work on during the rotation.  The main projects that I worked on were two journal clubs that were related to nuclear medicine and that I presented to the pharmacists, medication coordinators, and the physicians working at the clinic.  I also had two other presentations to give which were related to some of the work being done at the clinic.  One presentation was on appropriate aseptic technique using non-sterile product and the other was a large project about vaccines, specifically influenza vaccine produced in tobacco plants. This second project I found to be especially interesting and was comparable to a second seminar presentation.  So even though this was a lot of work, I now have two projects that I can possibly present, should it be required in any future interviews.  Not a bad deal. :)  I also had a few small projects like calculating the amount of hot and cold drug needed for a study, calculating how much radioactivity each patient would receive per dose, and looking up information on different radioactive products.

Finally I was sent on "field trips." The field trips were day trips to nuclear pharmacies so I could see how radio-labeled products were used in imaging and treatment of certain disease states. This was really cool when I visited the University of Wisconsin Hospital and saw not only how they prepared the products but all the imaging equipment and even where they were able to create radioactive particles in their cyclotron.  I know sounds like a mad science project and that is what it looked like too, but it was really neat.

Last thing, Madison is a really cool city.  There are a lot of fun things to do there and even though the rotation has a lot of projects, you get time to work on them during the day and can still spend time enjoying the city.  Cool things to do include going to the free zoo, Saturday farmers market, Wisconsin football games, trails near Picnic Point, lots of bars and restaurants down town Madison, and you must try cheese curds, delicious.  Overall, this was a pretty good rotation, very different and very interesting.

Saturday, October 27, 2012

Rotation #4: Pediatrics Infectious Disease

Posted by Kristen Gardner at Saturday, October 27, 2012

  • This rotation was an inpatient clinical rotation specializing in pediatrics infectious disease
  • I was on this rotation with another student- always helpful!
  • The medical team is smaller than others with an attending, 3rd year fellow ( --> PGY-6), 1st year medical resident, 4th year medical student from Wayne State, me and my classmate, and Dr. Klein the clinical pharmacist
    • I appreciated the smaller team and focusing on 1-3 patients/day for my first clinical rotation then following them through their stay

What did I see?
  • Septic arthritis
  • Complicated pneumonia cases with abscess development in the lungs
  • Tracheitis
  • UTIs (especially with patients who had neurogenic bladder)
  • Culture negative sepsis
  • Meningitis
  • Fungemia and bacteremia
  • Mold peritonitis

What did I do?
  • Worked up patients
    • patient load/week ~8 patients but this varied depending on how many consults we had for the week
  • Had patient discussion with my preceptor every day for 1-2 hours
  • Rounding with the pediatrics/infectious disease consult team
  • Attended the Pediatrics Infectious Disease weekly case conference every Thursday
  • Attend journal club for the above group
  • Presented an overview of antifungal agents to the above group
  • Delivered 4 topic discussions on shunt infections, community acquired pneumonia in infants and children, infective endocarditis, antibiotic lock therapy
  • Normally students attend daily microrounds in the pathology department where they learn about a new  test everyday. We did not attend.

Common drugs
  • Zosyn, Unasyn, ceftriaxone, Bactrim, clindamycin, 
  • Amphotericin B and Ambisome (lipid version of ampho B), voriconazole, micafungin
  • PCP prophylaxis drugs such as bactrim, dapsone, atovaquone, pentamidine
    • Know differences between these such as efficacy (e.g. incidence of recurrence, resolution of infection), fluid requirement, dose adjustments, side effect profile)

    • Describe their fever curve (how many fevers, how long were they febrile, is it getting better/worse)
    • Have their vent setting changed or need for nasal cannula (if relevant such as with tracheitis, pneumonia, etc)
    • For pharmacokinetics know when doses were given (date and time), time of last dose, when and where level was drawn from, what is their goal peak and trough. Consider many factors when interpreting levels!
    • Know all info about cultures obtained (where, when, preliminary/final result, how (e.g. wound swab, blood draw, heel stick; this may signify if positive culture with Staphlococcus epidermidis or coagulase negative microorganism is a contaminate) especially in relation to antibiotics administered to patient. For example, if culture is negative, is there really no bug or no bug because antibiotics were being given
  • Be proactive; anticipate questions and follow your patients closely! Know what to keep an eye out for!
  • Consider colonization vs. infection (sometimes this is difficult!)
  • LISTEN to the team even for your other classmates
  • ASK your classmates for help! If someone had a PICU rotation, ask about dialysis dosing! If someone has had a psychiatry rotation- ask them for information first! This saves you time and builds skills you will use as a pharmacist. You cannot be at the top of your game for every specialty and disease state. It is impossible.
  • HAVE FUN! Sing kids happy birthday, play with them in their room, and learn to French braid hair if that is all they keep asking for
  • Check the medical administration record (MAR) to see if the kids are throwing up from antibiotics (If so, there will be comments. You may use this information to recommend adjusting the frequency or dose an antibiotic such as clindamycin)
  • Take INITIATIVE and follow-up with your preceptor on questions posed to which you did not know the answer. They may not hold you accountable for this by asking you later but it demonstrates motivation and prompt follow-through.
  • Be familiar with common labs values of neonates, infants, children
  • Be familiar with our restricted antibiotics and protocols and hold the medical team accountable for these

Common Interventions
  • Reminding the medical teams of some of out institutions/unit specific antibiotic resistance patterns (hint: use the UMHS antibiogram)
  • Adjusting antibiotic dosages- either increase or decrease dose
  • Pharmacokinetic monitoring/adjustments with vancomycin and aminoglycosides
  • Antibiotic regimens for IV -> po switches
  • Antibiotics regimens IV inpatient à IV outpatient (for when a patient is on a q6hr regimen inpatient as this is difficult to adhere to as an outpatient)
  • Recommending labs: basic metabolic panel, renal labs (SCr/BUN), LFTs, voriconazole trough level
  • Providing pharmacokinetic knowledge to the medical team (oral bioavailability, protein binding, renal excretion, antibiotic coverage). 
    • Medical students have limited knowledge about antibiotics. I consider ID an ESSENTIAL niche for pharmacists. 
    • You will very likely use this information on every rotation.

Fun Facts
  • For antifungals we monitor voriconazole, posaconazole, itraconazole, and flucytosine levels at UMHS
    • Sign of voriconazole toxicity (level > 5) is when patient is having visual disturbances or hallucinations
  • There are many different formulations of amphotericin B (non-lipid and lipid with 3 different lipid formulations)
  • Voriconazole and echinocandins (e.g. micafungin) do not appreciably accumulate in the urine and cannot use to strictly treat candiduria
  • fluconazole has NO mold coverage, only yeast; all candida spp. may not be sensitive to fluconazole
  • when adjusting vancomycin and aminoglycoside levels- try to cap modifications at 30% dose change or frequency change. Do not do both at once.
  • Do not forget about fosfomycin and its coverage spectrum! This treatment can be VERY useful!
  • Ciprofloxacin has a narrower spectrum vs. levofloxacin
  • For community acquired pneumonia (CAP) in children < 5yo, you do not need to empirically cover for atypical pathogens UNLESS they are strongly suspected based on the clinical presentation
  • Always embrace antibiotic stewardship and use the antibiotic with the most narrow spectrum, even when choosing on empiric therapy
  • Ambisome does not share the nephrotoxicity risk of amphotericin B
  • voriconazole IV formulation has a vehicle (a cyclodextrin) that is eliminated slower then the drug --> we try to minimize use to 2 weeks or else the vehicle can cause nephrotoxicity
  • triazoles can cause a transient transaminitis that usually manifests after 7-10 days of treatment--> baseline LFTs needed and follow-up in 1 week to assess. D/C if 5x upper normal limit

What was difficult?
  • It was my first clinical rotation, and I am way too curious of a student. Therefore, it was hard for me to make myself prioritize (even though I knew what I had to do, I would get side tracked). But, exhaustion is a great motivator.
  • We are a consult team; therefore, we may get PICU patients who have been in the hospital since birth! Initially, I felt overwhelmed in these cases because there was so much data in the medical chart. Hint: graphing results in Carelink is your best friend to visualize trends and figure out their baseline values. Read the ADMIN note, prog note/reason for consult, and go from there.

Do I recommend this rotation? YES! It is a great way to get a dose of two worlds: infectious disease and pediatrics. The little kiddies are challenging! Dr. Klein is extremely respected by the medical team and is very knowledgeable. She is always available for questions and responds to pages quickly. She holds a final jeopardy at the end of the rotation. I was somewhat anxious about this but it was really fun! If you paid attention on rotation it is a breeze!