Monday, November 18, 2013

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

Posted by Rachel Lebovic at Monday, November 18, 2013

If I told you that my pediatric hematology/oncology (peds hem/onc) rotation was my favorite rotation to date and it confirmed that I want to pursue a career in oncology, you might think, “who could ever want to work with children dying of cancer?” While this area of expertise is certainly not for everyone, I will try to use the rest of this blog post to explain why I am eager to work as a clinical pharmacist specialist in oncology (and possibly even pediatric oncology) in the future.
First, the daily routine on rotation. On most days, I would arrive at Mott Children’s Hospital between 7-7:30am to work up my patients before meeting with my preceptor around 8:15-8:30am to discuss the interventions we wanted to make on rounds. Rounds started at 9am and lasted anywhere from 2-4 hours. Then, I would eat lunch and meet with my preceptor to talk more thoroughly about each patient, discuss what happened on rounds, and determine our plan for follow-up, monitoring, or counseling needed that afternoon. After handling any patient care issues, we would go down to the cafeteria for topic discussions and case presentations. I was very fortunate that my preceptor, Dr. Erika Howle, would take hours out of her busy day to help her students learn. The first week of rotation was a little crazy because we prepared one chemotherapy topic discussion and one supportive care topic discussion every day. In my opinion, the craziness of the first week was well worth it because it allowed me to start contributing to the peds hem/onc team almost immediately. Throughout the remaining four weeks, our topic discussions focused on different disease states, such as leukemias (ALL, AML), lymphomas, neuroblastoma, sarcomas, and sickle cell disease. At the end of the day, I would follow-up with the hem/onc team regarding any medication-related patient problems and look at any new patients before heading home to prepare for the next day’s topic discussion.
This schedule was fairly constant with the exception of Wednesdays. In fact, Wednesdays on the peds hem/onc service are so different that they are colloquially known as “Wacky Wednesdays.” On Wednesdays, the peds hem/onc department holds several meetings. At 7am there is an immunoheme conference where an attending, the oncology fellows, and others discuss complex cases involving immunology. At the 9am meeting, all of the peds hem/onc attendings and the current inpatient care team of a nurse practitioner, interns (1st year medical residents), a senior resident, medical students, the pharmacist, and pharmacy students all meet to discuss current complex oncology cases. I loved listening to all of the experienced practitioners discuss the benefits and risks of different options for each patient – especially if I was helping care for that patient. Then, we started rounds at 10am and stopped for the tumor board meeting at noon. Tumor board is a joint meeting between the peds surgeons and peds hem/onc team. The practitioners look at scans then decide if a patient can go to surgery to have their tumor resected or if they need more chemotherapy to shrink the tumor before surgery is a viable option. After the conclusion of tumor board the team would finish rounds and address any patient issues the remainder of the afternoon.
In my spare time, I worked with a resident, another P4, and a pharmacist on a special project. After Mott Children’s Hospital heard about a hospital in Brazil that covers its chemotherapy with superhero-themed chemotherapy covers, we decided to pursue a similar project at Mott. Here is a video with our inspiration: We contacted the hospital in Brazil, a plastics company, Disney, and others to start figuring out how to implement a similar chemotherapy cover program. I know this project will take a long time to be fully implemented, but I can’t wait to see how the kids like the chemo covers once they arrive!
Another special experience on the peds hem/onc service came on Halloween. Many members of the inpatient care teams in the hospital dressed up, and the hem/onc team was no exception. On rounds that morning, we had Mary Poppins, an Incredible, a bunny, two witches, Snow White, and a fairy!
Besides special fun projects and dressing up on Halloween, one of the big plusses to the peds hem/onc service is the tremendous impact you can have on patient care. An example of the interventions that I made on this rotation included changing a PPI to an H2RA (one type of acid suppressor to another) to avoid a drug interaction with a chemotherapy agent.  I was also able to adjust anti-nausea, pain, and bowel regimens to make patients more comfortable and help the team dose/monitor/adjust antibiotics to treat infections and neutropenic fever. Furthermore, I followed which chemotherapy agents each patient was to receive each day, made sure they were clinically able to receive the medication based on their blood counts, communicated to the inpatient pharmacy about which patients were going to receive chemo, and answered any questions the families had about the chemotherapy agents. Another plus to working with the peds hem/onc service is the continuity of care in an inpatient setting. Since many children require several rounds of inpatient chemotherapy, practitioners get to know the patients and their families.
In my mind, I can’t change that these children were diagnosed with cancer, but I can try to help them achieve their goals of care – whether they are cure, comfort, and/or palliation. I can help these kids just be kids, and that is an amazing feeling. Furthermore, the other members of the inpatient team rely heavily on pharmacy due to the specialty medications used in this patient population, which made me feel like a valuable member of the team. Yes, there are some patients who lose their battle with cancer, but in most cases the survival rates are actually much higher in children than adults, so there are fewer sad stories than you might think. Lastly, it is really rewarding to adjust patients’ medications to help them live more comfortably, especially if their goals are palliative.
Have I convinced you yet? It’s okay if peds hem/onc isn’t for you, but if you were skeptical, maybe now you won’t think I’m as crazy for loving this rotation and pursuing a career in oncology (and likely pediatric oncology) pharmacy.

Thursday, November 14, 2013

Inpatient Psychiatry at Pine Rest Christian Mental Health Services

Posted by Silu at Thursday, November 14, 2013

What do you call an alligator wearing a vest?

…An investigator!

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

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

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

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

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

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

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

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