Saturday, January 18, 2014

Institutional Rotation, Health Systems at UofM

Posted by Unknown at Saturday, January 18, 2014

Rotation 5 was exciting for multiple reasons.  First, I was looking forward to getting more hospital experience to better prepare me for a residency and gather much needed inpatient experience.  Second, at the conclusion of the rotation, my off rotation began in addition to a few vacations with the family.  

The rotation was mostly procedural, getting a handle on the daily functions of a hospital pharmacist while performing clinical services and fielding clinical questions from the hospital nurses and physicians.  I was placed in the cardiovascular pharmacy (CVC) at UMHS.  Every morning we prepared infusions and dispensed narcotic kits for the anesthesiologists.  It always helps to see the drugs you learn about in therapeutics.  I got to check orders for the CVC patients as well as pre-operative antibiotics making sure they were dosed appropriately and that the team had enough to last the duration of the surgery.

Additionally, I got to spend time in the cancer infusion center which was an experience in itself from making the medications, seeing the cost of one infusion for the patients, and following the nurses to talk to the patients and see the full process.  While I had a little experience making infusions and IV preparations of medications, I got lots of practice between the cancer center and the downstairs B2 main pharmacy at UMHS.  I am quite proud that I still have yet to stab myself with a syringe and was even complimented by the IV tech staff on my aseptic technique!

All in all it was a great experience, met some great pharmacists and am fully ready for my month off to get ready for residency interviews!

Friday, January 10, 2014

Critical Care Catch-up

Posted by Unknown at Friday, January 10, 2014

Whew! P4 year has really been a whirlwind thus far! I wanted to take the time to catch up on some of my blog posts from the last several rotations, so these next couple posts will hopefully bring everyone up to speed on how things have been going so far this year! This post will discuss my 10 solid weeks of critical care rotations, and how things went along the way. Enjoy!

Medical Intensive Care Unit at Sinai-Grace Hospital in Detroit, MI
I was extremely excited to begin my inpatient critical care rotation at Sinai-Grace. As my first inpatient rotation, it was a little intimidating to step onto the unit at first. These adult patients were very different from the pediatric patients I was used to caring for at my job at C.S. Mott Children’s Hospital; many of them had multiple comorbidities and complex diagnoses, and at first I really doubted my ability to care for this type of patient population. My preceptor, Dr. Mark Pangrazzi, had been working on this unit for the past year, directly from his residency training, and had already developed a solid relationship with the physicians and nurses on his team. Though I was a little nervous at first, Dr. Pangrazzi was excellent at easing me into the rotation and ensuring my understanding of the disease states and drugs we use to treat them.

Each day, I would make the 40-minute drive from Ann Arbor to Detroit for rotation, generally arriving by 7am. Dr. Pangrazzi and I were responsible for the two teams that operated in the MICU, which meant that each day we would have to alternate which team we were rounding with. I would spend a little over an hour working up my patients each day, being sure to address any medication-related issues and anticipate any changes that may need to be made during rounds. As time went on, I developed my own relationship with each of the teams and was able to make my own recommendations and round by myself.

I quickly learned that things can change in an instant in the MICU. There were multiple occasions where patients would decompensate; they would be stable one minute and in full-blown cardiac arrest seconds later. During each of these circumstances, quickly and calmly, my preceptor began preparing emergency medications for administration during each code blue. Though I had some experience with emergency drug preparation through my experience as a pharmacy technician, the adrenaline was always pumping just as high as ever. I learned a lot about life-saving measures pharmacists can take to be prepared for these types of situations, and I definitely feel more confident in my ability to be a vital member of a code team after these experiences.

Besides gaining an abundance of clinical knowledge, I also really enjoyed our weekly topic discussions. Some of the things I explored during my rotation included stress ulcer prophylaxis, intensive insulin therapy, COPD exacerbations, and aneurysmal subarachnoid hemorrhage. Additionally, I prepared a journal club presentation for the pharmacists on rapid blood pressure lowering in patients with intracranial hemorrhage. Overall, I really enjoyed this critical care experience and would recommend it to anyone looking for an interesting and challenging rotation!

Pediatric Cardiology at the University of Michigan C.S. Mott Children’s Hospital

While this rotation was probably the most intimidating title on my list of rotations, I was ecstatic to get back to C.S. Mott Children’s Hospital! Coming off of an adult critical care rotation, I was feeling prepared for another challenging critical care experience, this time involving the most delicate of babies. I was familiar with the Pediatric Cardiothoracic Intensive Care Unit, as it was one of the units I worked in during my time as a pharmacy technician. However, over the course of the 5-week rotation, I learned more than I could have imagined about a unit I had worked in for 4 years. I also wasn’t so sure how I felt about cardiology, as it was a pretty difficult subject to comprehend during therapeutics. However, the patients on our service suffered from congenital heart defects, which encompassed a totally different aspect of cardiology that had not been taught in pharmacy school.

Each day started really early, as I usually arrived between 5:15 and 5:30 am to work up my patients for the day. Before rounds each day, not only would I look up the patient’s most recent labs, but I would also talk to each patient’s nurse about overnight events, along with checking each drip pump to see what dose and rate were running for every medication. I would then meet with the team for morning sign off, and check in with my preceptor, Dr. Regine Caruthers, to run any interventions by her before rounds. One of the things I really liked about this rotation was the independence I was given. The very first day of rotation, I was rounding on my own with my team and fielding any questions to Dr. Caruthers. By the middle and end of rotation, I felt comfortable answering a lot of the team’s questions, and Dr. Caruthers would always support and encourage me whenever I lacked confidence.

I was given the time to learn new things at my own pace, and the bi-weekly topic discussions were extremely helpful. Some of the things I researched throughout rotation included Patent Ductus Arteriosus, Tetralogy of Fallot, Transposition of the Great Arteries, infectious endocarditis, and Coarctation of the Aorta. I also looked into Hypoplastic Left Heart Syndrome and the palliative surgeries performed to correct it, as we had several patients who suffered from this on our service. Additionally, there were several heart transplant patients on our service, so it was a great review of transplant drugs in addition to cardiology considerations. I even had the opportunity to help with discharge counseling for one of our transplant patients! Other patient interactions included performing medication reconciliations for new patients that joined our service. I had the opportunity to explore drug dosing in ECMO, monitoring and pharmacokinetics of antibiotics, and (more) participation in code blue emergencies. Though the hours were long, sometimes up to 12-hours each day, they always flew by and I enjoyed every second of it!
I hope you have enjoyed this post, which includes my experiences on some of my most rigorous, but favorite rotations thus far! I just want to remind underclassmen who may be reading this that though some rotations may seem intimidating at first, they may be extremely rewarding in the end. While I had 10 straight weeks of intense critical care rotations, it really helped me to determine where I may want to focus during a potential residency and has helped me to seek out residency programs that are strong in this area. This whole process is about developing you as a clinician, and discovering where your interests may lie and how you can impact patient care. My best advice is to make the most of your P4 year by challenging yourself through interesting rotations. That’s all for now. Look out for another catch-up blog post soon to recount some of my other experiences! 

Wednesday, January 8, 2014

Who You Gonna Call? Drug Info!

Posted by Rachel Lebovic at Wednesday, January 08, 2014

While I don’t want to become a drug information pharmacist, my drug information rotation at the Ann Arbor VA was a worthwhile experience. When any health care professional in the Ann Arbor VA doesn’t know the answer to a medication-related question, they have the opportunity to call the drug information pharmacist (my preceptor, Dr. Ed LaHaie). Most often, the physician, nurse, or pharmacist with the question already looked at a few drug information resources and either couldn’t find the answer or found conflicting information. Then, it was my turn to delve deeper into drug information resources, primary literature, and/or call the manufacturer to try to answer the clinician’s question.

I received a wide variety of questions during my time at the VA. For example, one practitioner asked if losses in word-finding ability have been reported with gabapentin, a medication often used in diabetic neuropathy. A pharmacist called to ask if there were any clinically relevant drug interactions between a patient’s current medications and konjac root, an herbal product reported to lower cholesterol and stimulate weight loss. A physician wondered if alendronate, a medication for osteoporosis, would be absorbed in a patient whose stomach had been surgically removed due to gastric cancer. Yet another clinician asked if there were data to support the use of mifepristone, an abortifacient, in patients with Cushings disease. After responding to these questions and many more, I feel I have a better understanding of which references are best suited to answer different types of questions.

In addition to answering drug information questions, I also wrote a new drug monograph and prepared an hour-long presentation to the pharmacists at the VA. My new drug monograph explained the efficacy and safety of vortioxetine, a new anti-depressant medication. One of the most time-consuming but educational parts of the monograph was the appendix, in which I created a detailed chart comparing the data from eleven clinical trials that studied vortioxetine. The hour-long presentation I created on this rotation was titled, “Update on the Management of Crohn’s Disease.” Since I am interested in teaching pharmacy students as part of my career, I enjoyed the process of researching a topic and developing an engaging presentation that I thought the audience would find useful. I was proud that the pharmacists in the audience seemed interested in the presentation and asked pertinent questions.

Lastly, throughout this rotation I gained insight into some of the administrative roles a drug information pharmacist might have. My preceptor, Dr. LaHaie, approves (or denies) all of the non-formulary drug requests for the Ann Arbor VA. Non-formulary medications are those that are not allowed to be ordered for a patient, unless the patient’s case warrants special approval. I enjoyed discussing some of these non-formulary drug requests with my preceptor because they frequently involved interesting ethical dilemmas. Dr. Lahaie also serves on the Pharmacy and Therapeutics (P&T) Committee and the Drug Shortages Committee at the VA, so I was able to attend these meetings and gain insight into the decisions and work that goes on behind the scenes to determine which medications will be on the formulary and ways to work around drug shortages.

In all, I gained valuable experience during my drug information rotation at the VA. I missed seeing patients and I still think I am better suited for a clinical specialist position on an inpatient multidisciplinary team, but the drug information skills I developed will help me be a better clinical pharmacist.

Monday, January 6, 2014

"Drug Information Service, How Can I Help You?”

Posted by Silu at Monday, January 06, 2014

Happy New Year, everyone! P4s, the mysterious year of graduation is upon us…2014! It has definitely been a busy two months with rotations, the Midyear meeting and residency applications. The past few weeks was a much-needed break. 

I was excited for this rotation at the Drug Information Service at U of M to learn about using resources to their full potential and answering questions from all parts of the health system. In the end, drug information taught me much more than just that.

The student’s responsibilities for this rotation include running the phone- and email-based drug information service, attending P&T and sub-committee meetings at the hospital, two major projects (a drug monograph and another writing project), a newsletter article, and other small assignments that may come up.

Answering questions was my favorite aspect of the rotation. A wide variety of questions came to us, from the outpatient clinics asking for antibiotic selection to UMHS pharmacies in search of compounding recipes and medication formulations to physicians inquiring about potential idiosyncratic drug reactions. UM Drug Information Service has a comprehensive collection of books, online databases, and internal resources…it was definitely a nice privilege having ease of access to these resources. The meetings we attended gave a unique insight into behind-the-scenes operations. It was empowering to see excellent pharmacy representation at both P&T and interdisciplinary committee meetings.

Of all of the duties we were assigned, the projects ended up being the most challenging aspect for me. I felt confident about my ability to complete these assignments well. However, both my projects turned out to be larger in scope than I (or my preceptors) had imagined. My first writing project regarding IV acetaminophen for post-operative pain was complex and had a much sooner deadline than anticipated along with several points of follow-up based on changing circumstances. My monograph of an ophthalmic preparation of an antiviral drug used for a very specific disease also included a cross-country search for an ophthalmic recipe and writing an informed consent. At first, I was surprised by the scope and constantly changing demands of these projects, but realized in the end that this was, after all, real life. For my preceptors, new situations and different opinions can change the direction of their work, just as it did with mine. This challenged my ability to prioritize and manage my time around meetings, assignments, and an unpredictable volume of phone questions. In the end, I appreciated that I was immersed in real work of a drug information pharmacist rather than simplified student work.  

Overall, I am thankful for all I have learned at Drug Information and for the opportunities to make a difference to improve patient care on a different level through the work I accomplished.

Stayed tuned for the next rotation …o wait…I am off! See you in February for community pharmacy.  


Sunday, January 5, 2014

Institutional Rotation at Oakwood Annapolis Hospital

Posted by Patrick at Sunday, January 05, 2014

In many ways, the institutional rotation represents the nuts-and-bolts phase of our P4 inpatient experiences. Over the course of these five weeks, we learn the essentials of order verification and drug distribution. These two skills are important elements that define what pharmacy practice is all about: right drug, right patient, right time.
My particular experience at Oakwood Annapolis helped me to build a foundation in these skills, as well as expose to me to additional, unexpected, practice opportunities. The first week of the rotation was highly structured and centered on drug distribution. Each day focused on a different aspect of the drug delivery process. Days one and two were devoted to Pyxis delivery, packaging, staffing the IV room, and order fulfillment. The time spent in the IV room was a special treat. The sterile compounding conducted in 797 clean rooms at hospitals every day is a critical aspect of modern pharmacy practice and a skill that is very difficult to properly develop in a classroom setting. I was also fortunate to have an excellent teacher.
Most of the remainder of the week was spent with the inpatient pharmacists learning the basics of order verification. We talked about the criteria they examine when they verify “routine” orders as well as the more complex criteria that they use to evaluate more unusual orders. Each and every order is held up to the same high standard to ensure patient safety. I had a million questions and they were patient with each and every one. One of the most interesting takeaways was the magnitude of the differences between Epic based computer system and other software packages. Epic really does do things differently and I’m grateful that I had the chance to work intensely with Epic during this rotation (the University of Michigan Hospital will be making the transition some time in 2014).

The other major experience offered at Oakwood was the opportunity to spend two weeks rounding with the clinical pharmacist in the ICU. It is a quirk of my rotation schedule that I have not yet had the chance to work in a critical care environment and it was a welcome surprise to find that chance on my institutional rotation. The experience was very similar to what I experienced on rounds in my generalist rotation during the prior month, but given the setting, it was a very different set of medications we were working with. Of special note was a concern for dramatically changing renal functions, given the critical condition of these patients. A dose an antibiotic would be appropriate one day, and then way too high the next. Staying on top of the rapidly changing condition of these patients was one of the chief challenges and rewards of working and learning in this environment.

Outside of these primary learning experiences, Oakwood offered a great deal of flexibility to the student to pursue their own pharmacy interests within the context of the hospital. I built a strong relationship with the pharmacy director and we had the chance to have extensive discussions about the challenges facing the pharmacy and how it needs to grow in the coming years. I took on an additional project, communicating updated guidelines to the surgical staff, and I delivered an inservice on the atherosclerotic disease prevention guidelines (cholesterol guidelines) that I feel may have been one of the best presentation I’ve ever given. My five weeks at Oakwood Annapolis were well spent and I thank the staff for helping me to make the experience optimally fit my learning needs.