Sunday, August 21, 2016

Off to the Great Land aka Alaska for Inpatient A - Oncology

Posted by Brock Jackson at Sunday, August 21, 2016

After my first rotation in Health Systems, I thought I was ready for a challenge. This challenge would come in the form of an Inpatient rotation. This particular one was spiced in the manner of Oncology. I knew this was going to be a difficult one. Oncology was one of the harder subjects in both medicinal chemistry and therapeutics.  I ranked this one as one of my top choices in part because of that fact. I thought it would help me build a strong Oncology background, at least enough to make me feel confident before I took the NAPLEX.

Weeks One - Three
This week was more of an introduction to the rotation than anything else. I wasn’t able to start truly working with patients and beginning my experience until I finished my site’s orientation. During this limbo time, I was given a tour of the hospital, met with preceptor and discussed what we/I would like to accomplish during this rotation, met a few other pharmacists and residents that I would be working alongside, and other little activities. Once I was able to start working in patient charts, things picked up in an expedited fashion. Most of my days began at 8am (otherwise it was earlier) and ended around 4:30 (often later). 

Generally speaking, when I arrived, I would take a gander at what patients were coming in the next day and needed to be worked up. I would go through their past medical histories, current medications, and review their chemotherapy regimens. On the next day, I would meet with the patient and go through their medication list, ensuring it was the same as what we had on our medical records. More often than not, there were numerous discrepancies. After figuring out exactly what they were taking, I would go online and look into medications/herbals/OTCS/supplements that I did not know much about. This practice led me to question why patients were on a myriad of herbals and supplements. Many times we would have a conversation about why they were taking what they were taking and it occasionally would end with ‘You know…I am really not sure why I am taking that herb!’ This was extremely frustrating, as looking at the evidence (or lack there of), it made no sense why they were on them. Other times, I would ask and the patient would respond simply with ‘It is for my cancer.’ These responses were always landed me in the doldrums. They typically came from patients that had a Stage IV cancer diagnosis and things were not looking good. Looking into their eyes after asking these questions seemed to last an eternity. A lugrubious feeling often ensued for the remainder of the session.

In between working up patients and speaking with them, various other activities would take place. I had to present my patients, weekly topic discussions, journal club presentations, drug information questions, chemotherapy teaching, attending tumor boards, pediatric rounding, and numerous other things. I will expound on a few of these topics here.

Weekly Topic Discussions – I was required to work on topics that pertain to Oncology patients and present them to either my preceptor or a pharmacist that was free (typically with the PGY-2 resident). Basically, it is a quick and dirty of a specific topic, what it is, how common it is, who is likely to have it, why we care about it, how to treat it, etc. My topics were febrile neutropenia, malignant pleural effusions, spinal cord compression, superior vena cava syndrome, nausea and vomiting, tumor lysis syndrome, extravasation, and hypercalcemia of malignancy. A few of these topics we covered in our therapeutics course. This was a nice refresher but my resident knew how to make them challenging. He typically would have multiple questions along the way (some way off topic) and a challenging one or two at the end that he did not expect me to know. This was generally meant for me to look up and report to him during our next topic discussion or patient work up session.

Tumor Boards – This is where specialists from around the hospital came to discuss tough patient cases (both adult and pediatric). Brain surgeons, pathologists, oncologists, pharmacists, radiation oncologists, general surgeons, etc. would all attend. They would present their particular patients and receive recommendations from the various colleagues who attended. It was always fascinating to watch these because every aspect of their future treatment is considered from a myriad of angles.

Chemotherapy teaching – For patients that were receiving new chemotherapy regimens (that they had never had before), we would go out and teach them about what to expect with their new regimens. We would go over the main toxicities, how to manage them, when to call for help, and field any questions/concerns that they might have had. At first, I just watched them but by the fourth and fifth week, I was going out and leading them.

Weeks 4 and 5
The last two weeks were pretty gut wrenching. Sometime between weeks 3 and 4, we will have our midpoint evaluation. Both my preceptor and I fill out a form we later on discuss in person. This is a time for the preceptor to meet with the student and go over what has been going well, not so well, and everything in between. For my first inpatient experience, I thought I was doing alright and progressing well. Apparently, my primary preceptor did not feel the same way. Upon discussing it, they thought I should be progressing on my work at a much faster pace. This was quite disheartening. However, I did discover that they usually do not take students on until they have had at least one inpatient rotation before (or until around rotation 5 and beyond). For my second rotation, that made me feel a little better. It was also nice to know that they were receptive to the fact that the four pharmacists I was working alongside all had different expectations for presenting patients, topic discussions, chemotherapy teaching etc. Later on, this helped me understand exactly what each preceptor wanted and would ‘grade’ me on.

Honest pearl of wisdom – Think hard on the criticism that you receive. If it is meant to be constructive, you should certainly consider making the appropriate changes.
After my midpoint evaluation, I felt I needed to alter how things were going and I took their criticism to heart. At this point, I knew it would be an uphill battle to finish strong through the remaining weeks. I worked hard on my understanding and presentation of patients. The workload only increased but eventually I was able to catch on and it all just sort’ve clicked. By the last week, I had patients worked up two days in advance, presented multiple topic discussions on the same day, multiple meetings with patients (chemotherapy teachings, medication history), and still was present during rounding and tumor boards. It was a rather dramatic change. I credit this a lot to how my midpoint evaluation went and how I responded to it.

In the end, I ended up being able to hit on all the things that my preceptor wanted me to be able to on a regular basis. This helped alleviate my fears of being absolutely destroyed on my final evaluation. Repeating a rotation is not anything that I am interested in doing moving forward. As it turns out, I ended up doing quite well!

Here are some pictures of my trip…please feel free to ask me anything about them!

Hiking up Flattop Mountain - the weather changed dramatically towards the top

   Fishing on the Upper Kenai River - Landed a couple Sockeye Salmon :)

Gold panning on Crow Creek - I won't be quitting my future job as a pharmacist anytime soon. 

Exit Glacier climbing - Easily one of the highlights of the trip! Hiking up a mountain for about an hour, cutting across onto a glacier and then spending time climbing into moulins. Absolutely incredible!

PS - If you want to see more pictures or hear more about what I did outside of this rotation, please just send me a message. I wanted to keep this as much about the rotation aspect as possible BUT being in Alaska for my weekends was part of the rotation too!

Wednesday, August 10, 2016

Rotation 2: Siiiick, brah! Or, Love at First CABG

Posted by Jerika Nguyen at Wednesday, August 10, 2016

I've been consistently told that after each rotation, as in the Hozier song "Someone New," you'll fall in love just a little ol' little bit every day with some new pharmacy practice area [sic].

That happened for me in the Surgical Intensive Care Unit, or SICU, aptly pronounced as it houses the most critically ill patients in the hospital. I had the awesome opportunity of rotating at a newly dubbed Level 1 Trauma Center in a 20-bed unit comprised of patients from the Trauma Critical Care Service (TCCS) and Cardiothoracic Surgery Service (CTS): trauma surgery, cardiothoracic surgery, neurosurgery, vascular surgery, colorectal surgery, general surgery, otolaryngology, obstetrics, and orthopedic surgery.

Surgery isn't covered in our didactic curriculum, so I started the first day as a total derp (Deer in headlights with Extreme anxiety and Retrograde amnesia of Pharmacology). Thankfully, my preceptor reassured me that every P4 student feels the same way at first, and that I'd learn exponentially more on rotation than I ever did in class.

Pro-tip to avoid being a derp at any inpatient rotation: get familiar with your organization's intranet. Like, be best buds with that guy. An intranet is an electronic and readily available Room of Requirement. My personified conversations with the intranet went something like:

"How's the susceptibility to Bactrim here?"

"Yo, can we get rid of the IV PPI?"
"I got 99 million guidelines and Stress Ulcer Prophylaxis is one."

"Are any of these 14 drugs dialyzable?"

What was a typical day like?
I arrived at 6:30 to work up patients until rounds. Once we had gauged the number and acuity of the patients on the floor that morning, my preceptor and I would round with either TCCS at 9:00 or CTS at 8:45. TCCS is a teaching service that consists of an attending surgical intensivist, surgical critical care fellow, surgical and medical residents, a clinical dietician, a respiratory therapist, nursing, and a clinical pharmacist on rounds, whereas CTS is physician assistant-led. Side note: the health care professionals I worked with are truly impressive. Many of them are nationally renowned in their respective specialties, and the cardiac surgery program here ranks in the top 15 in the nation (among 400+ other hospitals' Consumer Reports' Ratings).

After rounds, which lasted anywhere from an hour to several hours depending on how many patients were on the service, I would often bombard my preceptor with a myriad of questions. Side note: the thing about being curious and wanting to learn is that it'll almost always result in self-assigned drug info questions, which present as both a curse and a blessing in disguise. I encourage you to embrace this curse.

I had 1-2 critical care topic discussions each day with my preceptor before and/or after lunch, which helped keep me on my toes. In the afternoons, I'd re-work up my patients to see what changes were made after rounds and/or any surgeries and give patient presentations to my preceptor.

What neat stuff did you get to see?
Neutropenic enterocolitis, esophageal rupture, necrotizing pancreatitis, aortic dissection, traumatic brain injury, motor vehicle accidents, buzzword buzzword. Also got a bird's eye view of a coronary artery bypass graft (CABG) and saw a lower lobectomy.

What do you wish you knew going into the rotation? How can I prepare? Clinical pearls? Coffee choice? HALP

I finally realized that having a wealth of education as a P4 student isn't necessarily what leads to success. Initially, I was mortified by my extreme deficit of therapeutic knowledge. But while pharmacists need to know a lot of information, they don't necessarily have to memorize every detail of every drug ever made (just most of them, ha!). Pharmacy school can't teach you everything you need to know in 3 years. What it can do is teach you how to think like a pharmacist and how to find the information you need to facilitate patient care.

Something you don't learn from a textbook is how to interact with the medical team to optimize treatment. I've decided that I need to create some sort of cheesy alliteration to help others combat this, and I hereby give you the three C's:
  1. Confidence: You can be incredibly informed on a certain subject and still appear as unintelligent if you're visibly nervous. Some of my battles during this rotation were convincing myself that I actually did know what I was doing and beginning to speak up during rounds. Certainly don't rattle off about something you're not 100% sure about—that's what the "I'll look it up and get back to you" card is for. But speak with conviction, and more people will take heed of your recommendations (even if you're a student who's rounding alone!)
  2. Camaraderie: If you don't get along with the people you work with, team decision-making is going to be as productive as a day in the life of Snorlax. I had the opportunity to talk to PAs, nurses, residents, patients, and their families about things unrelated to work (like Ann Arbor restaurants and mutual desires for caffeine gtts). Walking up to someone, being personable, and making a recommendation face-to-face is much more effective than paging someone in what might be interpreted as a passive-aggressive tone. 
  3. Credibility: You know who you should add to your BFF list along with the intranet? Evidence-based medicine (EBM). EBM is the realest thing you'll use to stay up to date with pharmacy after you've left the classroom. Your recommendations will be more compelling if they're supported by well-designed, peer-reviewed research. Keep up to date with the lit—there's an app for that. 

Actually, instead of using cheesy alliteration, you could probably just refer to Aristotle's Modes of Persuasion. (Man, this is like when 14-year-old you thinks you've come up with a catchy guitar riff and it ends up being a Fratellis song because you've listened to Costello Music religiously).

Anyway, these skills really made me feel like a boss as time went on. For example, when a traumatic brain injury patient was newly admitted, I reviewed the patient's profile and discussed 5 interventions I wanted to make with my preceptor before rounds. Sure enough, all of them had been implemented when I checked the medication administration record (MAR) later that day. *mental self-high five*

Any cool pharm perks?
Someone ALWAYS brought in donuts or brownies or chocolate or D) all of the above to share. I'm not a huge sweets person, but the constant supply of glucose I was exposed to was unreal.

I also lunched and learned so hard. Besides the fact that I got free food each Thursday (heyooo), I saw cool presentations about medical decision making for organ donation, ventilator settings and the importance of checking the ABG (arterial blood gas, not aznbbygurl) and M&Ms. M&Ms (Morbidity and Mortality Conferences) are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The medical team reviews real patient cases involving either poor or unintended outcomes which might have been due to or worsened by error, "near misses" in which an error could have resulted in a poor outcome, or interesting and unique cases. Then, they discuss what went wrong, what could have been done differently, and what can be done to prevent such events from occurring in the future. Super sick stuff.

In addition to my day-to-day activities, I wrote antimicrobial stewardship notes, conducted a journal club, and delivered an in-service about the pharmacologic management of pain, agitation, and delirium in the ICU to the CTS team. Overall, this was a great practice site at which clinical pharmacists work alongside and are respected by their colleagues. I'm pretty stoked for my next direct patient care gig. As Hozier says, "Love with every rotation, the stranger the better." 

Monday, August 8, 2016

Rotation 1 - Health Systems

Posted by Brock Jackson at Monday, August 08, 2016

Hello everyone! 

My name is Brock Jackson. As a fourth year PharmD student, you will go through a series of nine different Advanced Pharmacy Practice Experiences (APPEs for short) rotations. I'll be updating you about my experiences over each rotation along the way. My hope is that you will be able to gain a better understanding of what each rotation entails and my experience within that rotation. 
As a quick aside, PLEASE ask any questions you may have about anything I have written!
For a quick background on myself, my interests in Pharmacy are almost entirely with Independent Community Pharmacy. If I were to go the clinical route, I would go with either an Infectious Diseases or Oncology speciality. Personally, I love to travel and any opportunity that I have that would offer more of that I would probably jump on in a heartbeat (Drug Information Pharmacist on a Cruise Ship would be a dream job but those don't exist, to my knowledge.).

My current rotation list is as follows:

Rotation 1 - Health Systems
Rotation 2 - Inpatient A - Oncology
Rotation 3 - Ambulatory Care - Oncology
Rotation 4 - Drug Information
Rotation 5 - Inpatient A - Pediatric Cardiology
Rotation 6 - National Community Pharmacists Association
Rotation 7 - Off
Rotation 8 - Generalist
Rotation 9 - Community Pharmacy

My typical day during Health Systems begins at about 6am. My daily commute is about an hour. Once I arrive, I prepare to start my day by checking out the patients that are on the Warfarin and the Antimicrobial Stewardship reports. For the Warfarin Report, checking to ensure the doses match the indication and recommending appropriate changes usually takes me about 10-15 minutes. With the Antimicrobial Stewardship, I am checking to see if various cultures and sensitivities are back from the lab. From here, I will see if we can move down from a broad-spectrum antibiotic to a narrow-spectrum antibiotic.

After this, I go up to attend rounds with one of our clinical pharmacists. This usually takes about an hour. I follow up with any questions the team may have and anything I did not understand during the patient presentations. Being my first rotation, there was generally quite a bit that I was looking up on a regular basis.

Following daily rounds, my day typically was never the exact same. I spent a lot of time doing various activities around the hospital.

Here are a few examples of things I did:
  • ·      Representing the Pharmacy department at the county Aging Wellness Fair
  • ·      Working alongside our anticoagulation pharmacist
  • ·      Compounding drug and nutrition products
  • ·      Shadowing dieticians
  • ·      Drug information questions
  • ·      Assisting the Pharmacy technicians in their duties
  • ·      Attending various internal Pharmacy and Nursing meetings
  • ·      Pharmacy-related projects
  • ·      Creating Pharmacy staff educational materials

For the most part, this rotation was laid back. My stress level never went over a 3/10. For a first rotation, this was perfect to wet my feet a little bit. The Pharmacy staff was absolutely incredible to work with over the five weeks I was with them.

PS - I apologize for the timing of my first post. My transition back from Alaska was a bit rougher than I previously expected. 

Monday, August 1, 2016

Rotation 2 - Infectious Diseases at UMHS

Posted by James Shen at Monday, August 01, 2016

I finished up my second rotation with the infectious disease consult service at UMHS, and it was definitely quite the experience. We have an excellent team of infectious disease pharmacists at the University of Michigan, and you will undoubtedly learn more about antibiotics, antifungals, stewardship, and other infectious disease related topics than at any other rotation. Make sure you review your bug-drug list, brush up on your pharmacokinetics, and put on your stewardship hats – because you will be in for a very challenging, yet rewarding rotation!

 Infectious diseases functions primarily as a consult service at UMHS, which means that we have no specific unit to which we are assigned to. Any patients that have complicated infectious cases are referred to our team, where we will review their antimicrobial regimen and determine if any adjustments need to be made. Throughout my time on the service, I was able to see many unique cases, including patients with HIV, mucormycosis fungal infections, gangrenous toes and fingers, gunshot wounds, amputated limbs, and more. Sometimes the infectious causes were obvious, whereas other times I really had to dig deep to find out what the true source of a patient’s infection was.

Morning Routine
A typical day on rotation would start with me working up patients in the morning that were assigned to our particular consult service, which would usually amount to around 15-20 patients per day. Some patients would remain on the service for weeks, and I got to know their cases in-depth as I followed up with them each day, whereas other patients came on the service and were signed off within hours. Once I had a solid grasp on several patients on the service, I would meet up with my preceptor to discuss each of the cases. Sometimes, a topic would come up that would warrant a further topic discussion for the next day, such as the use of linezolid with SSRIs, or the use of carbapenems in patients with penicillin allergies. After going through the patients with my preceptor, we would discuss if any changes needed to be made to their regimen based on their clinical status, culture results, or any other relevant factors. We would then start our afternoon rounds, which typically lasted from 1 pm until 4 pm.

Rounds were typically preceded by something called “Micro-rounds,” where the team would meet in the pathology lab and we would have a brief topic discussion about some microbiology topic. After that, we would head up to the floors to begin our actual patient rounds. The rounding team is large, and it typically consisted of at least one attending physician, an ID fellow, a medical resident, a medical intern, a fourth-year medical student, the fourth-year pharmacy student, and occasionally the ID pharmacist. Prior to entering the patient room, one of the team members would present the patient case to the attending, and we would then have a discussion about what we think needed to be done. Don’t be surprised if the team turns to you and asks for a dosing recommendation during this whole process - the team will take your dosing recommendations very seriously, so make sure you do the proper research beforehand about each of the patients on the service!

What else?
In addition to rounds, I attended various weekly meetings, which included stewardship meetings, weekly reports, and ID grand rounds. The weekly reports were my personal favorite. We would meet early in the morning, and one of the ID fellows or ID physicians would present 2-3 interesting, complex, or unsolved cases from the previous week. It was always interesting to hear the ID team’s thought process as they tried to narrow down a patient’s diagnosis, and discuss all the possible differentials that may be contributing to a patient’s clinical symptoms. I also attended various other meetings on and off throughout the rotation, including an infection control meeting (where we discussed environmental and non-pharmacological ways to reduce infection spread in the hospital), and a P&T committee meeting (where we discussed changing some of our ID guidelines).

Other student responsibilities during this rotation included monitoring patients on restricted antimicrobials (ex: fidaxomicin, meropenem, micafungin), and determining whether or not their use was appropriate. I also participated in ID stewardship, where I assessed patients that had S. aureus bacteremias, C. difficile infections, or HIV infections. Finally, I did a lot of reading of primary literature, and I gained a much better understanding of how to properly interpret, analyze, and critique the literature. I would often be assigned one or two landmark trials per week, and then I would meet up with my preceptor to discuss each of them in depth (ex: statistical analysis, inclusion/exclusion criteria, flaws in study designs, implications for practice, etc.)

 Overall, I learned a lot on this rotation about what it means to be an infectious disease specialist. This was a topic that I greatly enjoyed learning about in therapeutics, and I would highly recommend this for anyone that is interested in learning more about it. Even if you are not interested in pursuing a future career in ID, I think this rotation really gives you a solid foundation that will undoubtedly be useful for any future clinical rotations.

Infectious Diseases - The Big Guns Come to Life

Posted by Jared at Monday, August 01, 2016

After my first rotation in ambulatory care managing patients with mostly hypertension and diabetes, I was doing a bit of a 180 in the clinical sense and jumping into the world of infectious diseases (ID). ID was by far my favorite section in therapeutics during pharmacy school, and I was both excited and nervous for this rotation, as I knew it was going to be a challenging rotation. I had the opportunity to do this at a hospital in Detroit, so I was interested to see how the patient population would affect the type of infections we would see and how these patients would be managed.

A Typical Day
I generally would get into the hospital at around 6:30 AM to work up the patients I was planning on presenting to my preceptor, along with following up on patients I was still following and finishing up my topic discussions. At around 9 AM most days, I would meet with my preceptor and present the two new patients I picked up on our service, do a topic overview of their disease state, present my assessment/plans, and then discuss patients I was still following. Afterwards, I would typically go on rounds for a variable amount of time, which was dependent on the schedule of the attending physician and fellows, as they had different commitments (clinics, didactic, meetings, etc.). Generally, we would round for about a few hours in the morning, then break for either ID Grand Rounds, a lecture, or journal club, and then re-convene in the afternoon and finish rounding, which usually got out anywhere from 5-6 PM.

Of note, ID services are typically consult services, so we would see patients on a number of floors, ranging from the internal medicine floors to ICU, Burn, Neuro ICU, and Surgery. Due to the nature of our service, which typically consisted of the attending physician, two fellows, two to three residents, the clinical pharmacist, and me, we would often get new consults during the day that we would need to address. On average, our service had around 12-15 patients, but could go up to 20-23 patients.

Expectations, Challenges, and Overall Thoughts
As I mentioned earlier, my preceptor required two new patient presentations a day, along with a topic discussion for each patient's disease state.  I also needed to follow all my patients that were previously presented that our service was still following, along with keeping an updated patient list that included the patient's infection, their antibiotic therapy and duration, along with notes about their treatment. Also, if any patients I was following were on aminoglycosides or vancomycin, I was responsible for doing the pharmacokinetic calculations by hand and showing it to my preceptor that morning when discussing dose recommendations. I also had to write a review paper on a topic of interest that could only utilize primary literature as sources (no review articles or textbooks).

Without a doubt, this rotation was a huge challenge on my time management skills. I would initially spend a lot of time both at home and in the hospital working up patients and putting the topic discussions together. My preceptor in particular challenged me to use only primary literature, rather than relying on class notes or textbooks to put these together. This was difficult for me at first, as not every disease state has a nice review or guidelines to go over and synthesize into a succinct presentation. After I ran through most of the common ID disease states (i.e. pneumonia, skin and soft tissue infections, bacteremia), I essentially picked what might be interesting to me or things my preceptor recommended to go over (i.e. tuberculosis, malaria). Often, I was in a time crunch in the morning, but as the rotation went on, I got much more efficient at putting together these topic discussions and working up my patients.

Also, while the topic discussions were time intensive in terms of preparation, it really helped to solidify my therapeutic knowledge. My preceptor was great at asking probing questions and really helping me to understand the reasons behind various concepts (i.e. why is IV drug abuse a risk factor for endocarditis?). Furthermore, the institution I rotated at doses vancomycin differently than what we were taught at UM. Rather than using a nomogram, they targeted AUC (area under the curve). This required me to essentially re-learn vanco PK, but it helped a lot with practicing those equations and solidifying my skills. Due to the nature of Detroit's patient population, I got to see a lot of patients with either MRSA infections or multi-drug resistant infections that required either those big gun agents Dr. Carver has us avoid using in therapeutics (i.e. daptomycin, linezolid) or unconventional combinations. Finally, the questions I got from both my preceptor and the clinical pharmacist that went on rounds daily helped me to understand why we spent so much time learning physiology and med chem by really "connecting the dots" between concepts I didn't think could relate to ID in the first place.

All in all, this was an extremely rewarding experience. I was constantly challenged and pushed to my limits, but I came out of it with a much more solidified therapeutic knowledge base of ID and a greater appreciation for the discipline. A PGY-2 in ID still isn't out of the question for me, but we will see what the rest of the year holds! For now, it's on to community and rotation 3!