March Madness with the Medicineheads

Posted by mariarx at Tuesday, March 26, 2013

Internal medicine - where specialists go to die. Ok, maybe not die, but definitely expand readily available therapeutic knowledge.

Rotation 8 had me back at UMHS for internal medicine with Dr. Regal. I know the saying is "jack of all trades and master of none" but this does not apply to Dr. Regal. He is more master of all trades. It's kind of scary sometimes. Internal medicine stretched my immediate memory of random bits of drug information, ways of getting the team to follow my recommendations, and not falling asleep on rounds after not having slept well.

Walking circles on rounds
My day usually started with working up patients. On a good day I only had 4-5 patients... bad days had me around 14-16 patients. I would check out doses, indications, labs, relevant drug levels, and their past medical history/reason for hospital stay.

The medical team (shout out Med Dock!) really utilized having a (future) pharmacist on hand to help with dosing and drug selection. I loved working with them, and I really felt useful and a major part of the team. I also felt like a butcher sometimes, chopping down options I knew weren't ideal before they got to Carelink. I'm looking at you, fluoroquinolones. I was also responsible for anticoagulation monitoring, teaching, and documenting. Any time a patient was started on warfarin, LMWH, or UFH we had to be on it. Warfarin INR monitoring is a fickle thing, especially with the bazillion drug interactions you have to look out for. We had a few interesting anticoagulation patients including someone with antiphospholipid antibody syndrome. Quite the tongue twister.

The Bench Test
One thing I heard about, and was scared of, coming in was the idea of the Bench Test. Dr. Regal wants to know how much we've crammed and retained through 5 weeks; and that comes in the form of a written and oral exam. The stack of articles looks pretty daunting, but it's not so scary once you find yourself actually using the information and giving references to justify recommendations to the team. I'd say the worst part was the oral exam - sitting at a table watching Dr. Regal scratch notes down while you're trying to recall a tiny detail from one article that is at the edge of your memory. But, I survived!

The End
On the first day Dr. Regal said that his rotation is built to prepare P4s for the intensity of residency training. As daunting as that was I'm grateful for it. I think I'm a bit less scared about the next 2 years knowing that I can do well in a clinical setting and that I have been prepared by a great clinical pharmacist.

To future P4s - Dr. Regal's rotation sounds scary, but isn't in the end. Start practicing your jokes!

The 8 week slump... let's go back to community

Posted by mariarx at Wednesday, February 20, 2013

Wow am I behind in blogging. Having a 6 week off block full of residency applications, interview prep, and lots of traveling really made me lose track of time and I sadly neglected my blogging.

I last left off with the end of rotation 5, Emergency Medicine at UMHS. Rotation 6 saw me at Meijer Pharmacy for my community rotation block. I do have a fair amount of community experience, and my preceptor Alan Tanabe definitely took that into consideration in planning out my time with him.

Alan is a great preceptor who is an example of the difference community pharmacists can make. He does a lot of MTM and medication review interviews, in-store A1C and cholesterol checks, and a LOT of patient counseling. The pharmacists at the Meijer store in Ypsilanti are pretty vigilant about making sure they fix gaps in medication therapies and working with their patients about medication costs, side effects, and OTC recommendations.

As a P4 my time was primarily spent doing patient counseling. Alan would have me walk through the aisles looking for those people standing in front of a huge shelf of medications with a confused look on their face. By my second week I got pretty good at knowing where most things were in the aisles. I would also spend time in the pharmacy, counseling on any new medications being dispensed, answering questions, and calling doctor offices to make changes to therapies. I had the chance to sit in on medication review meetings with Alan and his MTM patients as well. Seeing the trust the patients have in their pharmacist was great! I also put together a poster about tylenol/acetaminophen and pamphlets about tylenol, and OTC cough and cold products. These I presented in my final week.

I know hospital pharmacy is a growing field, and one I hope to pursue, but it was nice being back in the trenches talking to patients regularly, and being an advocate for them when things got confusing and difficult. My time there was fun and interesting; the pharmacists and technicians working there are a great team.

I haven't decided if I want to write about Midyear/residency yet... I know a lot of my classmates went through the process and last years group wrote a bunch too. If anyone is interested in experiences about midyear and PPS for residency purposes, the administration programs in particular, then I'll write something up. Till next time!

"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! 

AmbCare Cancer Style

Posted by mariarx at Wednesday, October 10, 2012

Hello everyone! We're almost at the half-way point of P4 year! Time is really flying by, and I am hitting my rotation groove full force now.

Rotation 4 placed me at St. Joseph Mercy Hospital for my ambulatory care practice experience. This is a unique site in that it is an oncology outpatient practice. I was slightly terrified of doing a cancer rotation, but my time with Dr. Carol Yarrington was been great.

My rotation duties were 3-fold: I spent time in the multidisciplinary clinic, the infusion center, and doing project/answering questions work.

Multidisciplinary clinic (MDC)

Recent COP grad, Eric Zhao, gave a really great breakdown of the MDC model during his time last year... so I'll let you read what he had to say about it HERE. To add my 2 cents, I enjoyed my time in the clinic. They aren't really used to having a pharmacist around, so it took a couple weeks for the oncologists to warm up to my presence and respond positively to my feedback about patients. There was one patient who did not really need much intervention on my part, just someone to sit with her while waiting for the doc and talk about her new diagnosis.

First Dose Follow-up

A pharmacy intervention that I was able to bring back to life while on rotation was first dose follow-up (FDFU). This is a service for all patients who are either new to the infusion center or are getting a new/different chemo regimen. I would find these new patients on my non-clinic days and arrange a time to meet with them during their visit in the infusion center in order to figure out the best time to call them the next day. My FDFU phone calls consisted primarily of symptom assessment, as well as being the middle person between the patient and the oncologist when their symptoms needed intervention in order to be managed. I had one patient who had been hiccuping for around 6 solid hours and did not think that it was related to his chemotherapy - definitely an intervention opportunity. A lot of patients really enjoyed talking about how much they enjoy the clinic and all the health care professionals they met with. Go St. Joes!

Project Work

During my non-clinic hours, I spent the majority of my time working on project stuff. Carol fields questions day in and day out, and she would occasionally throw some of them at me! Some of the other things I worked on included a formulary review update, doing research on herbal supplements and their drug interactions for patients interested in trying them, and other random stuff.

My big project for the rotation fit right into my management interests. On my first day, we had a patient coming into the clinic to undergo desensitization because her chemo drug was thought to have caused a massive rash during her previous cycle. The patient ended up having a skin test done first to confirm the nature of the reaction. The clinicians, oncologists, and Carol were able to come up with a test - however, this scenario also made it very clear that the health system does not have a policy in place for this. That's where I came in. Throughout the rotation I gathered literature about skin testing and desensitization, presented it to a multidisciplinary P&T committee, and finally wrote 2 protocols on the topics. I felt like this project was something actually relevant and useful to the department. I love that kind of work!

Overall, I liked my time at St. Joes. Carol was very open and receptive to my interests as well as getting any exposure I wanted to the oncology department, workflow, and staff. The people at St. Joes are wonderful, very patient, and willing to listen to students.

Adventures in Babysitting -errr, Pediatrics!

Posted by mariarx at Tuesday, September 04, 2012

Oh man, I can't believe it's already rotation 4! The quiet summers of empty Ann Arbor are gone... soon we'll be entrenched in computer turf wars with the P3s on their direct care IPPEs. Before we get too far into rotation 4, I wanted to look back at my adventures in peds.

Our PY team. I like to think I'm the girl with the gold viking helmet hanging on for dear life.

The generalist rotation, new and required this year, gives you the option of working on the adult (UH) side or the pediatric (Mott) side. I decided to take the plunge and go with peds. Who doesn't love kids? Me. But I did like working with their meds. My mom would be so proud. 

My day on the generalist rotation started with rounds prep. On any given day we had between 2-6 patients admitted to the PY (pediatric gold) team. That isn't a lot of patients... until you realize the work that goes into peds dosing, indications, etc. For each patient I tried to get a good idea of their problems and what all their diagnoses meant (helloooo Google), their dosing regimens, weight based dosing, daily maxes for the medications, indications, and any alternatives that I may be asked about. Safe to say my monitoring form looked like a rainbow in trying to keep all the info divided. My preceptor, Jenny Hlubocky, was really good at giving pointers for keeping everything straight and reminding me to focus on the drugs and not get lost in the world of googling mowat-wilson disease.

One aspect of peds drugs and dosing that I didn't really think about before this rotation was the taste of oral meds. Unfortunately, tiny mouths and esophagi are not made for swallowing tablets - which is where solutions come into play. Doing the taste test with Dr. Streetman and the medical students was really fun, even if I did get a headache from all the random drugs we tasted. Note to the public: linezolid, clindamycin, MVIs, and iron taste GROSS; and chocolate syrup is Dr. Streetman's gift to little kids everywhere. 

After rounds my partner-in-crime Vince and I would go over our patients with Jenny, maybe work on orders for our services, and then have the afternoon to do individual work. Besides our general PY patients, we also worked up the rehab patients in Mott. These patients are usually in the hospital for a really long time (and have a really long MAR), so we would make sure that doses were appropriate and make recommendations for cleaning up the med list - such as getting rid of PRN meds that hadn't been used in a while. 

Our final patient interaction component was med reconciliation. I feel like I spent the majority of my afternoon work hours trying to find parents to speak with about their kids medications... the laws of not speaking to minors alone make medrecing quite the difficult task. 

Besides patient interactions and monitoring, we also had some mini-projects and 2 bigger presentations. Mini-projects consisted of topic discussions about things that may have come up in our talks about patients or just interesting topics in the world of peds. In the effort to bring my own interests into the pediatric world, I ended up presenting my journal club and larger topic discussion about pharmacy administration and its role in the inpatient stay and discharge. Dr. Brummond and Dr. Kelley would be proud (I think). 

Overall, I'm really glad I picked the pediatric side of the generalist rotation. I don't have any other peds rotations on the horizon so this was a good adventure to have. My 4th rotation is ambulatory care in oncology... you'll hear about that soon enough if I make it out alive. Till next time, keep saving lives fellow P4s! 

Dipping my toe in the clinical pool

Posted by mariarx at Wednesday, July 18, 2012

So, my first rotation was health system administration with Dr. Brummond. I learned a TON during my 5 weeks with him - but very little of it was clinical. My interactions regarding medications maxed out at "which meds are on shortage and what do we switch to?"

For my 2nd rotation, I am at Providence Park Hospital in Novi, MI with the peds/oncology clinical pharmacist Missy. It's a pretty small hospital, around 200 beds, and has been open for 4 years now. Pharmacists at PPH take on an interesting role, with some duties falling into classic inpatient order verification; while others fall into antibiotic kinetics/anticoagulation monitoring. The great thing about it is all the pharmacists do everything. There is very little split between clinical/order verification roles.

My first week at PPH was spent mostly with technicians - messenger, IV room (where Frank threw me right in), packager, etc. I also got to spend some time with the OV pharmacists and checking orders that came through. I quickly learned to have lexicomp on stand by to look drugs up that I didn't recognize or know the dosing for.

Week 2 was half pharmacist shadowing and half reviewing kinetics. Oh boy, that was a doozy. Being handed a stack of practice cases and an equation sheet took me right back to P3 first semester therapeutics and Dr. Nagel's exam. Going through my practice problems was a test in frustration and insanity. No matter what I tried, I never seemed to get the right number, and man were my peaks and troughs all over the place. After making me suffer for a couple days, my pharmacist handed over the handheld PCs that have the nifty PK calculators on them. Although, I think I'll have to do some kinetics problems every once in a while so that I don't forget it completely. It's somewhat comforting to know that 'real pharmacists' use the same equations we got in class.

Week 3 was probably my favorite. In addition to starting 10 hour shifts (woo 3 day weekend!), I also started ICU rounding. At PPH, the OR/critical care and metabolic support pharmacists split ICU rounding duties. Each day of rounding started off with printing out a rounds summary report of all the ICU patients, and then going through their profiles and MAR compiling the big picture. The first day of rounding, it took me the full 3 hours to go through my patients. During this week I usually had lexicomp, micromedex, Dr. Carvers bug-drug list, wikipedia, google, and dosing nomograms on standby at all times. I was constantly looking things up and writing little notes down. Rounds each day varied from 1 hour to 2.5 hours depending on the intensivist, number of patients, and any unforeseen circumstances that arose. My second day, rounds started an hour late since the doctor was at a code (on a patient that soon joined us in the ICU). The 4 days of ICU rounding were great, and make me even more excited for my ED rotation in October.

This week has been all about antibiotic kinetics and anticoagulation monitoring. Pharmacists at PPH monitor drugs such as vancomycin, aminoglycosides, heparin, warfarin, rivaroxiban, and dabigatran. I got to work up initial doses for these drugs, and then do follow up monitoring for the rest of the week. This is where I really feel the pain of paper charts. PPH is half electronic and half paper. So, each day when we work up coumadin doses, or dose vancomycin or gent we have to then troll through the hospital to find our patient's charts. I haven't had too much trouble with it so far, but I can only imagine the frustration of a floating chart when all you want to do is add a quick note.

Next week (holy crap, I can't believe it's already week 4) I'll be working on TPNs with Maria, the metabolic support pharmacist, spending a day in the OR (I asked my preceptor Missy for blood and guts), and giving my final presentations. My projects for this rotation included making a formulary review document for Exparel, updating chemotherapy drug info sheets, and my journal club topic.

I have really loved my time at Providence Park. The smaller hospital setting might not have the super crazy cases, but for an institutional rotation I have gotten to do a lot of different things. This has definitely been great practice leading up to my generalist rotation which I have next at UM. I also really like the camaraderie among the staff... a lot of the techs, pharmacists, doctors, etc have been with St. John Providence for a long time before moving to the new site; and having such a small staff means you really know everyone. The only thing I won't miss about PPH is the drive - curse you one lane roads!

Putting healthcare on a diet: Toyota Production System

Posted by mariarx at Tuesday, June 12, 2012

Looking at the title you might be asking yourself "what in the hell do cars have to do with hospitals?" Our answer to you is - let's get lean.

Lean thinking is a concept derived from Toyota and how they work. The company has successfully integrated ideas such as worker responsibility, problem solving, just in time production, and inventory management to maximize quality and profits. The process of taking these concepts from car manufacturing to health systems was fairly simple - applying these will be the real battle. UMHS has committed to getting all of its health care providers thinking and acting lean. Assistant Directors Phil Brummond, Lindsey Kelley, fellow admin blogger Tom and I, attended the LEAN workshop in hopes of solving the pharmacy departments most perplexing problems. During the workshop we realized that every department has problems, and the lean problem solving process could really help give everyone a place to start and map out WHY problems are present.

The first 2 days of the lean workshop involved a highly technological simulation of emergency department workflow... we got to spend 4 rounds playing with lego patients, running around a conference room, and rolling dice. Each round, interspersed with lectures and discussion, added an extra layer of lean. We started with sheer chaos, with teams only finishing 3-4 patients in a 10 minute round. By the last round, our teams had finished 15 patients with time to spare. All of this was accomplished by implementing lean processes one round at a time.

Now you could be asking, "guys... how the heck do you take a lego and dice game and make it work in the real world?" I wish I had the answers. The lean workshop didn't give us a map to find the answers to all of our problems. But, it did give us the boyscout tools needed to navigate through the swamps, deserts, and forests of UMHS. By bringing these tools back to the pharmacy department and teaching others how to use them for themselves, we can (slowly) get to the root of a lot of the problems plaguing the department. Making people really examine every step of their routine and workflow - to look for how things should be done, and not how they've been done in the past - is the real goal of this workshop. One of the most profound things I learned was that you cannot MAKE people change, you need them to WANT to change. Given the power and opportunity, health care personnel will makes the changes needed to get more out of their job while also making it more fun, easier, and less stressful.

We learned a lot at the lean workshop and came back to the hospital with a lot to think about and consider. For now, we take it one step at a time and try and lay some groundwork in the last 2 weeks of rotation for the future. I want to be the person who writes their name in the wet cement of the future, even though I may not be around for it to dry.

Maria & -TV-

Meetings, meetings everyday...

Posted by mariarx at Saturday, May 26, 2012

Week one of rotation one is done. Woo!

If I've learned one thing in my first week on the UMHHC Administration rotation, it is how to eat on the go. Running around the hospital from 0800 - 1700 with no break on day 1 was pretty overwhelming. Nothing like learning to swim by being thrown right in the pool. Besides the long day, I got the opportunity to see a full range of administrative task meetings - RFP presentations, team meetings, pharmacy practice rollout and planning.  My second trial by fire happened on days 2-4 since my preceptor, Dr. Brummond, was in the land of Badgers and I was braving meetings on my own. Most meetings have consisted of taking notes (about medication safety, pharmacy operations, IT, drug shortages, Joint Commission) and then looking up all the terms that I'm not familiar with.

Besides meetings with my preceptor, other administrators, and various pharmacy teams; this rotation includes a 5-week (or more) long project. Thanks to fellow blogger, Andre Harvin, the admin team has a database of over 6.5 million points about medication dispensing in the hospital. My job will be to compile a workload analysis; one of many projects that will be done with the data. The past day has been spent fiddling around with Microsoft Access and googling tutorials. Thank the internet for "Access for Dummies." Also, it stinks that Access isn't available on macs. Boo!

I hope to also use the next 4 weeks to work on my leadership skills, hone in what I need to get done for residency applications, and maybe even create a hospital glossary. I think that's all I have for now.... I'm sure the next 4 weeks will be a great roller coaster, and I'll keep everyone posted!