Two Professions at Once: Surgery Generalist

Posted by Unknown at Wednesday, July 27, 2016

After my first rotation at a local community pharmacy I was finally due for my first clinical rotation--generalist. This rotation is required for all University of Michigan pharmacy students and (looking back) a great way to kick off my clinical experiences. A few weeks prior to my assigned block we got a survey asking us to rank which generalist sub-specialty we were most interested in. We could choose between Internal Medicine (pediatric and adult), Surgery, Cardiology, and the pediatric intensive care unit (PICU). Before long, I was assigned to Surgery.

I had no idea what to expect. Surgery (of any type) is not exactly something that we cover in school and while I find it fascinating I had zero practical knowledge about how to manage these people. To be honest, I knew very little about how to manage a 'regular' patient, let alone one that we've gone in to and moved a whole bunch of things around.

Due to the way that preceptor schedules worked out, I spent three weeks with a general surgery unit and the remaining two weeks with a urology surgery unit. The units work a little differently:

A Day In the Life on General Surgery

Arrive at 7 AM to begin working up patients. I live on the south side of campus but the buses come every 10 minutes and there is virtually no traffic. For the general unit there are no formal rounds that pharmacy is a part of (they happen at 5 AM!). As a consequence, we meet with the Physician's Assistants that are doing most of the day-to-day clinical management around 11 AM to discuss our interventions. This meant that I would work up my patients until about 9 or 9:30 AM, then meet with my preceptor. We made a point of staying out in the conference room where the medical team worked to be accessible for drug related questions. We would walk through each patient, each problem, and discuss what information we needed (usually the people who knew were right behind us!) and why, then make recommendations accordingly.

Surgery patients are challenging in that every third word is a strange surgical term or acronym. Down the literature rabbit hole I would go to find out what is going on and determine how their medications might be affected. Regardless of the procedure, the four main areas we focus above and beyond the typical dosing, safety, and interactions are home medications, nutrition (pharmacy owns IV nutrition like TPN and PPN), anti-infectives, and anti-coagulation.

By the time that process was finished it would be 11 AM or so and I would have a dozen things to follow-up with patients and nurses, disease states to look up and apply guidelines or literature to, drug-information questions to research, as well as counseling and education to complete.

Somewhere in there, I would take 20 minutes for lunch before meeting back in the pharmacy for a quick follow-up with my preceptor and discuss our plans before jumping into a one-on-one topic discussions with one of the surgery pharmacists. We covered a wide range of topics from toxicology to common procedures for X, Y, or Z disease state, infectious disease and much, much more.

This would be immediately followed by a student led topic discussion, case presentation, or journal club (we each had an assigned afternoon for each of those three things spread out over the five weeks) that wrapped up the day around 3:30 PM.

A Day in the Life of Urology

Urology works a little differently. They also have general rounds that pharmacy does not participate in directly, but instead have interdisciplinary rounds led by the urology intern/fellow around 8 to 8:30 AM. I would quickly look over my patients beforehand (not a full workup) to see if there were any major, urgent issues to review before briefly meeting with my preceptor to discuss things before heading upstairs to rounds. These are primarily an information gathering session--notes in the electronic medical record can often be a day behind so these allowed us to get up-to-date on the plan and goings-on for each patient in our service. Any major questions we have are answered (and we get a fair number of questions ourselves!) before heading back down to report out. A full workup of each patient follows, along with the same walk-through-each-patient as before, go talk to the team as before, and a dozen things to look up and follow-up on as before.

There is still room for lunch before the afternoon progresses just like before with topic discussions, case presentations, and journal clubs.

In each case, there are usually a handful of things to finish during the evening hours, but never so many that you can't hit the gym, relax a little, get some other work done, and make dinner before getting some rest and doing it again the next day!

--

Now on my last few days, I can safely say that I have learned an enormous amount and that this is a fantastic springboard for my next rotation: infectious disease! See you again soon!

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!

My Levofair with Internal Med

Posted by David Plumley at Sunday, July 01, 2012

I knew that these five week rotations would go fast but I did not realize just how fast until I looked back a few days ago and I always already done with my first rotation.

To say I learned a lot on from Dr.Regal, Charles in charge, and the members of the Medicine Dock team would be an understatement.  Most of my learning came on the fly during rounds.  Once my team members became comfortable with me and confident in my pharmaceutical knowledge they would ask me questions about almost every patient.  Most of the time I would reply with my favorite phrase, "let me look into that and get back to you" and then do some research of my own, as well as discuss the topic with Dr.Regal, in order to come up with the best recommendation.  However sometimes thanks to the knowledge I acquired from therapeutics and the confidence I gained from this rotation I was able to make a recommendation on the spot.  Most of the recommendations I made involved antibiotics (dosing, optimization, duration, and toxicity), anticoag(warfarin dosing, Lovenox bridging, and the occasional Dabigatran), and optimizing chronic therapies.

The therapeutic and medical knowledge I acquired is very important, but maybe more importantly I learned confidence and how to operate with the medical team.  It took some time for me to understand how rounds work and how to best contribute but once I did I was able to participate in my own active learning even more.

The most valuable advice I can give to students getting ready for their clinical rotations would be to pay attention to every patient on rounds, learn from the discussion the team may be having even if you may not be responsible for that patient, look up everything you aren't sure about, and to work with your team.  We have all heard this before during orientation but it is most definitely true.  

One of the most difficult parts of having a clinical rotation first was my unfamiliarity with much of the medical terminology, but by writing everything down and looking it up later I was able to learn more than I thought.

It wasn't all work however.  Many of you might not know this but Dr.Regal is quite the wordsmith and poet.  He shared with us 2 poems he wrote about protecting fluoroquinolones (one of his favorite past times) and ending levofairs and ciproflections.  I will try to get copies of these so I can share them with the world.

Before I finish today I would also like to give you a quick intro to my next rotation.  I started this past Monday at Karmanos Cancer Center located in the Detroit Medical District.  This is an ambulatory care rotation focused on bone marrow transplant.  I am excited for this rotation since I have an interest in oncology/hematology.  My preceptor is Dr. Simon Cronin, the former preceptor of our very own Dr. David Frame, which makes me semi nervous.

So far in my first week I am getting accustomed to the work flow.  I spend most of my day doing med recs, some patient education, and have opportunities to shadow Simon as he works.  The clinic has approximately 2 MDs, 4 NPs, Simon.  The 2 Wayne State students I am partnered with and myself play an important role in searching out drug therapy issues and bringing them to the attention of the other clinicians.

I will update you on how this rotation goes in a few weeks.

Hometown Hospital

Posted by Eric Zhao at Monday, April 30, 2012

Last month, I was with Providence Park Hospital in Novi, MI. If you have the fortunate opportunity to do a rotation in your hometown and live with your parents, do it. Coming home to homecooked meals and some family loving is a nice relief from the Totino's pizza and shenanigans associated with the typical college lifestyle.

Providence Park Hospital, Novi, MI

This was no ordinary institutional rotation, however. Each week had a different theme to provide exposure to the varied aspects of a hospital pharmacist.

Week 1: Made IVs in the clean room, delivered controlled substances, dealt with medication shortages, assessed/restocked inventory, and packaged medications.

Providence's USP 797-compliant Cleanroom

Week 2: Dosed-adjusted for the pharmacokinetics/anticoagulation service. We monitored for aminoglycoside/vancomycin levels and initiated/adjusted heparin, warfarin, dabigatran, fondaparinux, and rivaroxaban doses.

Week 3: Assisted metabolic support services through ordering appropriate parenteral nutrition. Rounded in the intensive-care unit (ICU). This part of the rotation is like a mini critical care rotation!

 ICU Rounds

Week 4: Attended a Pharmacy and Therapeutics meeting at Providence Hospital in Southfield. Gave a journal club presentation on the potential use of rivaroxaban in the treatment of pulmonary embolism. Spent a day in the Operating Room and viewed implementation of a bone-assisted hearing aid, a laparoscopic cholecystectomy, and a hemicolectomy. 

 

Bone-assisted Hearing Aid

 

Hemicolectomy

(I will spare you the graphic photos, but feel free to google it)

All in all, a great rotation that far exceeded my expectations. Highly recommended. A+++! Would rotate again.

Eric Zhao

Staff pharmacist

Posted by Matthew Lewis at Thursday, October 06, 2011

This rotation is all about figuring out what it would be like to be a general staff pharmacist, and it's at the VA (veteran's affairs) if you haven't read my previous post. The first thing that stuck me was where this VA is, which is right next to a college (Wayne State) and several other hospitals (Detroit Medical Center and Karmanos Cancer Institute to name a few) so it's at the heart of a medical complex. I've already done quite a few different things. The life of a staff pharmacist can pretty much be what you want to make it. You could be asked to take charge of the anticoagulation clinic, or make decisions about non-formulary medications. Your job might be to check physician orders and medication fills mostly.

Speaking of checking medications, the hospital inpatient setting employs a tech-check-tech system where properly trained and trusted pharmacy technicians check each other's work for accuracy. You might think it unsafe, but literature has shown that this system is just as accurate as a pharmacist check. tech-check-tech is an up and coming practice which allows pharmacists to get out onto the floor more often and help the medication ordering and administration process, which is where most medication errors occur.

Making IVs was fun, and interesting. You have to scrub in and gown up according to our fairly new industry practice of USP 797 guidelines which dictates how sterile IVs should be made. The actual mixing of the standard IVs isn't hard since most medications aren't toxic to any degree. I did not get the special chemo drug training though, since that is so dangerous even to people who follow the guidelines and have the two pairs of gloves on, the sterile disposable jacket, hair covering, mask, eye protection, mixing hoods with particular airflow and filters put in place among other things (As you can see, there are a lot of things to consider when implimenting USP 797.).

Now I'm just going on rounds and offering suggestions to the team to best manage the medications. Part of the job the pharmacist I round with is to make sure the vancomycin troughs are appropriate, and all the anticoagulation pharmacy follows is done by this pharmacist as well. I've learned quite a bit from that pharmacist as to the real-life application of medications which have narrow therapeutic ranges. In school, we learn with the impression that we can get patients' drug concentrations to the exact middle of our precise desired range, but in real practice there are mistakes as to when patients get lab draws, physicians of varying experience might not take your recommendations, or the patient might not "fit the mold" and metabolize the medication in some super fast or slow manner just to name a few things fighting against a pharmacist trying to get that perfect concentration.

That's what this rotation is all about for now, I'll keep you updated as things change.

Live on the Verge of Death

Posted by Nicki Baker at Thursday, September 01, 2011

I’ve worked at Select Specialty in Ypsilanti a couple of times in the past when I filled in as a technician and I’m excited to be spending my second rotation there. Select is a long-term acute care facility located on the campus of St. Joseph Mercy Hospital and cares for patients with complex medical needs who require an extended hospital stay. Many of them are on ventilators, PEG tube feedings and IV antibiotics. They’re currently at capacity, caring for 36 patients.

I generally start the day by checking INRs for patients on warfarin. Select has a combination of electronic and paper charts, so I can get lab values from the computer but have to go to each patient’s room to check the MAR to be sure they were given the warfarin dose they were supposed to have received the previous evening. Based on the patient’s INR trends, I decide whether to continue them on their current dose or to make a change. Since I’ve been there about a week now, I’m starting to see the impact of the changes I’ve made. It’s really fun and gratifying to see patients become therapeutic or to be moving in the right direction based on decisions I’ve made. I’m also enjoying writing orders for warfarin and lab draws, which pharmacists at Select do per established protocols.

Antibiotic stewardship is another of pharmacy’s responsibilities at Select. Checking culture results and making sure all antibiotics have reasonable stop dates is part of the student’s job. I’m glad that I’m getting a chance to work with antibiotics a bit more since it’s an area I need to improve in.

Working with this population really makes you appreciate your health and the health of your loved ones. A lot of the patients are very old an ill, but some of them are younger and trying to recover from falls, accidents or infections. Many of them will improve and be transferred to a skilled nursing facility, inpatient rehab or even be discharged home, but for others, this will be their last stop. It’s difficult to see some of these people struggle, but even more difficult to watch their families make tough decisions. I guess what these patients are going through could best be described as living on the verge of death.

It appears difficult for physicians to let these patients go, even when it feels like the time has come. It seems to be against their nature, like they're admitting defeat. As healthcare professionals, we've devoted ourselves to preserving and extending life, so being ok with letting a patient pass away feels contrary to what we've been taught.

Still, the respiratory therapists, physicians and PAs, occupational therapists, nurses and pharmacists at Select take great care to do what’s best for patients and families. Some really amazing stories of recovery have come out of this place. A woman who nearly passed away from a terrible case of H1N1 stopped by to visit yesterday. It was obvious that she had a real connection with the staff who cared for her during her stay at Select and she was doing great.

This blog is becoming a blab. More later!