Rotations 4-6: Working from Home, the MICU, and the Off-Rotation/Midyear

Posted by Jared at Thursday, December 29, 2016

Hello everyone! Apologies for the delayed post, but the last couple months have been quite a busy time! I'll summarize my last few rotation experiences below. Heads up, it's quite long!

Rotation 4: Drug Information

My fourth rotation was actually a work-from-home rotation! I worked for a drug company database alongside a fellow P4 student. The projects we were typically responsible for involved various inquiries from customers of the database (typically healthcare professionals) or drug companies asking us to clarify a statement about their drug that was listed in the database. Other times, we would have to look into evidence because a drug company was trying to prove that what we had in the database was false. We also typically looked into drug interactions that might not be present in the database, and wrote up drug monographs for these based on the research we found.

A typical day involved us meeting our preceptor a few times a week at an off-site location to discuss our assignments, what we found, and to discuss new things that came up. Afterwards, we were free to do as we pleased with our schedule, as long as we finished up the tasks given to us and e-mailed our preceptor with updates. This rotation really tests your time-management skills, as you really could slack off given the lack of normal structure. I tended to do many of my projects at night, as it's easier for me to work on projects like that at that time frame due to years of undergrad and pharmacy school studying. However, I really enjoyed this rotation as it helped to beef up my research skills and further interpretation of drug literature and drug labels. I got better experience understanding pharmacokinetic (PK) data and using PubMed, as often my preceptor would find things that neither me or the other student on rotation would find about our respective assignments. We also got the chance to read through foreign drug labels to help write our monographs, and they're quite different in the data that they provide compared to those here in the US!

I also appreciated this rotation, as it gave me time to finish up my PDI. If you're interested in seeing a different side of pharmacy and believe you can handle managing the time on your own, I would highly recommend this rotation! I really learned a lot more about searching strategies and drug interactions. 

Rotation 5: Critical Care - MICU

My fifth rotation brought me back to the hospital for another inpatient rotation, this time in the medical ICU at UMHS. This was actually my first rotation at UMHS, so I was both nervous and excited at the same time. However, this time I had another student with me on rotation, which was a welcome change from my infectious diseases rotation where I was the lone student.

Typical Day:

6 AM: arrive at the hospital to work-up patients.

7:30 AM: table rounds. This is when the night team would typically hand over new admits to the day teams. Also at this time, the attending doctors would typically go over various topics for the residents (i.e. sepsis, sedatives, etc.)

8:30 AM - 11 AM : Rounds. The MICU at UMHS is divided into two teams: Maize and Blue. For students on this rotation, typically one P4 will take each service and pick up all the patients for that service. There's about 20 beds or so (forgot the exact number) on the unit, so typically you'll have 8-12 patients at a time that you have to follow. For most of the time, we would each round with a pharmacist (either my preceptor or the resident on our rotation at the time). 

11 AM - 1 PM: lunch/preparation. Usually after rounds, we would have lunch, prepare for discussing our patients with our preceptor, or look up questions we were asked.

1 PM - 3 PM: At this point, we would meet with our preceptor and the resident to discuss our patients. We would typically go over our patients, discuss their status, and the changes the team made to their drug therapy. Often here, or during rounds, we would get asked what we thought about their changes. We would also discuss a certain topic that was relevant to critical care, such as sedatives, electrolytes/fluids, sepsis, etc. 

In terms of drug therapy, antibiotics were huge in terms of the pharmacist role. In the MICU, the general trend is to just throw a very broad-spectrum regimen as the patients are extremely sick (vancomycin and Zosyn are huge workhorses). We often had to remind the residents or the team that after 3 days, they needed to get ID approval to continue using vancomycin. Also, we would often recommend adjusting the antibiotics based on culture data and whether the patient was getting better/worse. The other big thing we looked for was renal dosing. Often, many of these patients developed AKIs that sometimes required them to go on dialysis or CRRT temporarily. I would always get asked if drugs were adjusted correctly given the renal function, along with when would be best to order levels for vancomycin or aminoglycosides if they were on one.

  

The MICU was challenging to me because the most common problems we saw were of a respiratory nature (i.e. respiratory failure, ARDS, etc). Beyond pneumonia, the presentation and therapies to treat these type of patients were completely foreign. Often, ventilator settings would be the common route for the team to adjust, and I generally had no idea what it meant. After the rotation, I have a better understanding of it, but I would definitely need more exposure to that and another review of the basic concepts. I also got a great refresher of topics we had learned in therapeutics that I personally wasn't great at, such as electrolytes, metabolic acidosis/alkalosis, vasopressors, and sedatives. Sedation strategy was another thing that often came up in the ICU, and I never really thought to think about it until this rotation.

Ultimately, I think a critical care rotation is a terrific experience, and one I would highly recommend. While it's not my favorite area of practice, I think it offers valuable lessons that would be useful in any setting of practice. You really get exposed to a lot of different clinical areas as these patients present as very complex cases, and you learn to prioritize what really needs to be solved now vs. what could be dealt with at a later time. Finally, it also really hits a number of gaps that our curriculum is unable to cover, particularly on the respiratory side of things.

Rotation 6: Off-Rotation / Midyear

Initially, I chose rotation 6 as my off rotation as I wanted to have time to attend Midyear and work on residency applications/letters of intent, as well as go on one last trip before graduation. However, this worked out for me really well for another reason. 

I had the opportunity to represent the College of Pharmacy at the 2016 International Forum of Pharmacy Students in Nanjing, China. This conference was sponsored and held by China Pharmaceutical University, which is one of the schools in China our College of Pharmacy has a partnership with. Here, I was asked to present a project that provided some insight into clinical pharmacy practice in the United States. In this case, I presented my PDI project as a glimpse into the roles of an infectious disease pharmacist in the US. I thought I was only going to be presenting my project in a small sub-forum, but I ended up being selected to present during the opening session in front of the entire conference, which had hundreds of attendees. Undoubtedly, I was nervous as I had just flown in from the US a couple days prior, but it ended up being a really great experience! I also got to meet other great student pharmacists from around the world, many of whom were there due to their connections with the International Pharmaceutical Student Federation (IPSF). Learning the differences in education and pharmacy practice between our respective countries was really interesting. After graduation, I'd like to get involved with the International Pharmaceutical Federation (FIP). After the conference, I had a chance to visit New Zealand, Australia, and Singapore. Needless to say, it was awesome and a perfect way to relax and clear my head before Midyear. Pictures below:

Some of the great student pharmacists I met at the conference in China

Skydiving in Queenstown, New Zealand

 Hiking the Ben Lomond Track: Queenstown, New Zealand

Mrs. Macquarie's Point at Sunset: Sydney, NSW, Australia

The famous Merlion in Singapore

Midyear

For those that don't know, the ASHP Midyear Clinical Meeting is the largest gathering of pharmacists and pharmacy students worldwide each year. It typically happens around the first weekend of December. This year, it happened in Las Vegas. I will quickly mention that I'd recommend not getting back from a trip on the other side of the world and then flying to Vegas a couple days later. I had the worst jetlag I have ever experienced, which caused me to not to sleep well during my time in Vegas, and also took me quite a while to recover from.

Anyway, this meeting is very important for those of you that are pursuing fellowships or residencies. As I plan to go the residency direction after graduation, I don't know too much about the process with pursuing fellowships. All I can say is that it requires scheduling interviews ahead of time through the Personnel Placement Service (PPS) with the companies/fellowships you're interested in. In terms of residencies, Midyear is great because every residency in the country is present in one location for you to ask questions to their residents, preceptors, or program directors, and determine whether or not you want to apply to a program. So, for those of you that are looking for residencies all across the country (like myself), this helps to put faces to programs and answer some questions that weren't possible via simply e-mailing them. However, if you're only interested in Michigan residencies, Midyear might not be necessary for you. The SMSHP Residency Showcase that occurs in October has all of the Michigan residency programs present and allows you to meet the residents / program directors and ask questions there. Anyway, here's some tips from my experiences:

• BE PREPARED. This really can't be overstated. You will hear this all the time in Dr. Kraft's Opportunities class and from anyone you ask about Midyear. Have updated CVs, business cards, etc. While you won't be handing out CVs to most programs, they sometimes will ask for it or provide a place for you to drop it off. I often heard that if they ask for a CV, it's typically a bad thing as there's so many people at Midyear most programs likely won't remember who you are. But, in my case, I went to a couple programs that did take them to help remember who stopped by their booth, and even got asked for one from a residency program director that I had a good conversation with. Also, many programs took business cards as well, possibly another way for them to keep track of who stopped by. 
• Do your program research ahead of time. Prior to Midyear, go to the ASHP Residency Directory. It lists all the accredited ASHP programs by location and program type, along with giving a summary of the program and the links to the program's website for more information. Prior to Midyear, ASHP provides a schedule of when each program is available during the Residency Showcase, along with a map of where their booth is. The Residency Showcase is divided into three sessions: Monday, Tuesday AM, and Tuesday PM. Each program is only present during one of these times, so it's imperative you know which programs you want to talk to, where they're located, and when they're available.
• Prepare questions for each program you want to talk to. From my experience, it didn't seem like you could just walk up to a program and ask them to give you a general overview of the residency. The residency showcase is like a zoo, with a bunch of frantic P4s trying to figure out their futures and many residents would be talking with multiple P4s at a time. With the limited time frame, you really want to get the questions that will make or break a program for you asked and answered. You could certainly listen to other people's questions and then ask something if you think of it on the fly, but it's easier to be prepared. I personally created a general list of questions I could ask most programs, along with specific questions that pertained to the programs I was visiting. 
• Reach out to preceptors, professors, and alumni! Prior to Midyear, I reached out to a lot of people with help in terms of editing my CV, looking at my program list, asking questions about residencies, etc. Everyone at Michigan or those who have graduated from the program are extremely helpful and really want you to succeed. Your preceptors as well can give useful insight, especially if they're at a system you're interested in possibly obtaining a residency at. 

Finally, my last tip in terms of the application process: Ask for transcripts and letters of recommendation ahead of time. Fall grades will come out way too late for them to be sent to programs on time, so I would recommend immediately sending your transcript to PhORCAS once it comes out in November. Also, I would ask for letters of recommendation ahead of Midyear as well. Many preceptors and professors will understand that you may not have your program list finalized until after Midyear. However, it is good to ask them how they would like the references generated. With PhORCAS, you generate a request to your letter writers and can provide extra directions. For most programs, one general reference will suffice. But, if your writer knows someone at the program, sending another request that's more personalized to that program can be beneficial. When submitting the app, you can designate which specific request you want to assign to a program. This might not make much sense now, but it will when you go through the process.

Wow, sorry again for the long post! Hopefully there's helpful advice in there for you, and enjoy the rest of the holidays!

1st week in CCMU

Posted by Jenna at Tuesday, September 06, 2011

"Bravery is the capacity to perform properly even when scared half to death." ~Omar Bradley

Monday, I met my preceptor, Dr. Alaniz, around 8am. I'm on rotation with one of my classmates, so she and I went up to the cafeteria to talk with him about the rotation. He gave us more detail about the unit and the patients they typically see. Oh yea, and he also started quizzing us right away. I think that made us both scared to death right off the bat. We were able to answer some but most of them left us feeling pretty dumb. After we met with him for about 90 minutes he sent us to start working up 2-4 patients each.

CCMU (critical care medicine unit) is a 20-bed unit with 2 teams. On each team is an attending (the head doctor), a pulmonary fellow (residency graduate undergoing more specialized training), medical residents (3-7 years of training following internship), medical interns (1st year out of medical school), and M3's/M4's (medical students equivalent to P3's/P4's).

We each randomly chose an attending and will be sticking with that team for the entire rotation. Each team is on call every other day (from 6 am to 6 am), meaning that new patients that come in through the ER or are transferred from another floor get picked up (followed by) the team that's on call that day. While it's only a 20-bed unit, Friday we had 28 patients, meaning that some of our patients were in the other ICU's. Monday and Tuesday were so incredibly overwhelming to me. When I was working up my patients, I had to look up what felt like every other word/acronym. I spent so much time trying to figure out what was going on with my patients that literally the only thing I did with their medications was write them down. I hadn't identified why they were taking it, if the dose/timing was appropriate, if there were any drug interactions, etc. Well, crap, that's what I'm supposed to be doing! Add to that the fact that I went on rounds by myself the first 2 days .. I was just a nervous wreck.

The first two nights I barely got 4 hours of sleep/night because my heart was racing, my mind wouldn't turn off, and I was just feeling dumber than ever.

Thursday, I started to feel a bit better. In the afternoon, we had a discussion with our preceptor about sedation, analgesia, & delirium based on an article we had to read. He told us that we both did a great job during the discussion so it was nice to get some positive reinforcement. Also, our PGY-2 Critical Care resident started his CCMU rotation Thursday. It's nice to have a familiar face around!

Wednesday and Friday were also a bit rough on me. Wednesday, I was in the room when a man was told he had a few days to live. He had been hoping that he could die at home but the attending empathetically told him that he would not survive the transport home. It was a very hard conversation to witness and I had to be sure to hold back tears that were building up in my eyes. Sadly, this patient died at the end of the week.. It was unfortunate that he passed before his family from out of town could come say goodbye. He had also requested that his dog be allowed to visit him in the hospital but sadly he passed before the appropriate measures were taken for that to happen (verifying the dog's vaccinations). Friday, I also had to hold back tears. It's hard for me to see people crying/grieving but it's especially hard when I see men crying. A man about my age was visiting his dad with Stage IV cancer that was complicated by an AKI (Acute kidney injury) and from 2 rooms away I could see that he was crying as he held onto his dad's hand. Luckily I didn't lose it but I felt like I was going to. Sadly, that patient also passed.

I know death is a natural part of life but it's also something I don't think I'll ever grow accustomed to. I know medical professionals can't save everyone and don't have super powers .. but I wish they did. I lost two 'young' patients this week and while I never developed a relationship with them, other than following their meds/labs, their deaths have affected me. They were 2 people who still should have had at least 20 more years to spend with their families and friends.

I'm not looking forward to these similar situations over the next 3 weeks but I am looking forward to feeling less lost and confused. There is such a huge learning curve, especially with inpatient rotations. When I was a P1, P2, and P3, I thought P4's knew it all .. but I can tell you from personal experience, that we hardly know a thing. The situations and the complexities of real patients is something we don't learn how to manage in class .. so the learning curve is more of a steep, steep mountain!