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.

Institutional at Karmanos

Posted by Elizabeth Kelly at Friday, April 20, 2012

Well after a month off it was really nice to just ease into things at Karmanos. I have never worked in a hospital and really gained no experience during P3 IPPE so this was a great introduction.
Some of the stuff I did the first two weeks:
1) Shadowed tech/pharmacist in unit dose
2) Investigated the Investigational Drug Service
3) Learned how to do IV's (quite easy actually)
4) Learned how chemos work
5) Went to med safety meetings, etc.
6) Asked lots of law questions - the law exam is coming up!!!

2nd 2 weeks:
1) Rounded with med onc team and gave a presentation on equianalgesic pain dosing
2) Worked in the BMT clinic with 2 P4s from Wayne State - they won't stop talking about how they only have one week left after this and then graduation (totally bragging)
3) Presented on fertility counseling and preservation in female cancer patients to the pharmacy group. It was a 40 minute presentation (but I got away with maybe 30 minutes).

Overall this rotation was a lot of fun. I am looking forward to my last rotation coming up at St. John Hospital and Medical Center in Detroit for Cardiology/Critical Care and then graduation.... 29 days!!!!

Multidisciplinary Oncology

Posted by Eric Zhao at Thursday, December 22, 2011

St. Joseph Mercy Hospital has been my home for the past month, where I rotated with Dr. Carol Yarrington in Ambulatory Care Oncology.

New Oncology Infusion Centers in Canton, MI and Brighton, MI
Patient bays increase privacy and comfort

After brushing up my knowledge on the oncology drugs, therapeutic areas, and side-effect management strategies, I was charged with setting the groundwork for a pilot pharmacy intervention at the Multidisciplinary Oncology Clinic.

The Multidisciplinary Clinic (MDC)
The clinics are held on Monday (head/neck cancer), Tuesday (lung cancer and gastrointestinal cancer), and Friday (breast cancer). In one sitting, a patient can see a nurse navigator (explained below), nurse practitioner, palliative care nurse, physician assistant, medical oncologist, radiation oncologist, and surgeon. What's nice about this initiative is that the patients receive the full spectrum of care in a single trip. Each of the healthcare professionals will individually visit with the patients, rotating between patient rooms. Afterwards, they all convene to discuss their plan for each patient.

The Multidisciplinary Team in the Cancer Care Specialty Center
[Link to Brochure]

Nurse Navigator

The nurse navigator, a rising new concept, serves as the main contact and face of the multidisciplinary clinic. They make sure the patient is acquainted to the clinic by setting up appointments with the healthcare professionals and providing follow-up when needed. Because days can get hectic, these navigators help orient the patient during their treatment visits.

Pharmacy Intervention
Between visits from the healthcare providers, patients may have 30-120 minutes of downtime before the next visit. What a convenient time for pharmacy to step in, interview the patient, and review their medication list! The clinic is mainly focused on the oncology aspect, so there is a lot of room to manage their chronic health concerns. Oftentimes, patients with cancer will try complementary or alternative medications to improve their situation. However, these medications may interact with chemotherapy to reduce their efficacy; for example, some chemotherapy agents rely on creating free radicals to destroy tumor cells, so ingesting a large amount of antioxidants may cause more harm than good.

Green tea, an antioxidant, may negate chemotherapy agents that depend on producing free radicals to destroy the tumor

Future Direction
The multidisciplinary clinic shows a lot of promise, and I hope the clinic continues to pilot the program with the next student. It's a great way for pharmacists to get involved in the multidisciplinary care of oncology patients through a review of not only their chemotherapy regimen, but their maintenance medications too.

Eric Zhao

Hematology/Oncology... intense but great

Posted by Elizabeth Kelly at Thursday, September 22, 2011

First off, I would like to apologize for not blogging sooner, but if the fact that I haven't gotten to it yet says anything about how busy my month has been I don't think anything else can. I was on the hematology/oncology rotation with Dr. Shawna Kraft at UofM Hospital this past month.

I am going to split up the rotation between the first two weeks and the second two weeks.

First two weeks:
The first day was a little overwhelming, I was with another student in my class and the first thing we did was go on rounds and each get assigned 6 patients to work up and be ready to go over and present to Dr. Kraft. I also discovered all the people who can make up a team: an attending, a fellow, a senior resident, two interns (first year residents), two medical students, a pharmacist, and us the two students. It was also really interesting how their was an attending for hematology with a fellow, and then a completely separate attending for oncology, with no fellow. So the team I was on would go with one or the other and then switch with the other team and go with the other attending. Hematology is leukemia and lymphoma patients. Oncology patients were mostly people coming in because they are having symptoms related to their cancer like neutropenic fever (lots of infectious disease), pain (morphine up the wazoo), nausea/vomiting, etc. Hematology is basically considered to be more complicated and that is why they have fellows and not oncology.
And then also on the first day we were given a quiz. I did terrible. I felt like I knew nothing. We were given the quiz at the beginning of the rotation and then we also took it at the end. I actually got a 12/30 the first time and improved to a 24/30 today when I retook it. Hey, it was hard! Anyways...
So, to basically summarize the first two weeks it was the other student and I trying to figure out what was going on with our patients while also attending "boot camp" which was a series of topic discussions lead by the different cancer pharmacists. For example, neutropenic fever, anemia, tumor lysis syndrome, etc. For me at least I was feeling pretty bogged down and not getting anywhere close to the amount of sleep I needed.

Second two weeks:
Everything changed the third week however. The first two I was nervous about talking to the doctors about potential changes and felt like a lowly student. Then an epiphany hit and I was all over them like white on rice. I was making suggestions all over the place, monitoring my patients therapy much closer, and becoming a true member of the team. It was great, I felt so sad leaving them today on my last day. I think they got really used to the other student and I being there to help them with everything they need.
Some examples of the great interventions I felt I made:
- clarified allergies (note: if someone says they had a red face to Keflex, does not mean they have an allergy to penicillins!!)
- thorough counseling on Lantus Solostar
- pain management dosing
- antibiotic dosing
- called a patient's wife to clarify a home regimen.
- and of course much more.
If you notice some of the things I did, its what you will do on any rotation. To the future P4s: become involved as much as possible. Its sad to say, but even though the MD's are super smart and well meaning, they are just as human as you and I, and will make mistakes/not know everything.
The only thing that truly sucked about this rotation was the patients who passed away, or the ones you knew you were sending home to hospice for them to pass away there. There were some really great patients though and by the end of the rotation they were MY patients. I worried about their pain, how their liver function was, or if their vanco trough was going to be therapeutic. It's truly a great population to work with. Also, Dr. Kraft is a great teacher and even though it felt overwhelming at first, the other student and I both learned a lot and I appreciate everything she did for us. I would definitely do this rotation again if given the chance.

The Ups and Downs of Chemo

Posted by Shannon Hough at Tuesday, February 02, 2010

In therapeutics, we learned that we can treat cancers with chemotherapeutic agents. However, they are accompanied by toxic side effects. This month, I had a chance to see first-hand how these drugs affect our patients. This was a lesson in side-effect profiles I will never forget.

Lesson 1: Myelosuppression (decreased blood counts)
Many of the patients that we saw this month were receiving some form of 3+7 (3 days of an anthracycline and 7 days of cytarabine) for a leukemia diagnosis. These patients often became neutropenic (low white blood cells), anemic (low red blood cells), and/or thrombocytopenic (low platelets). Patients who are neutropenic can be at risk for infection, and were monitored very closely for fevers or other symptoms. Patients who have low red blood cells often had very low energy levels that improved when we gave them a blood transfusion. And patients with low platelets often experienced more bruising or bleeding, including nosebleeds. Many times, these effects can be delayed, and the patient can feel great during chemo, and even a few days afterward. It was almost predictive, that when we saw the patient’s blood counts decreasing, their spunk would decline as well. One of my favorite times to see patients was when their counts were recovering and they were excited at the prospect that they had had a successful treatment and would soon be able to go home.

Lesson 2: Cold-Induced Neuropathy
In this case, a patient with colorectal cancer was receiving FOLFOX, a chemotherapy regimen containing oxaliplatin. Certain patients can experience sudden pain when exposed to cold temperatures when receiving oxaliplatin. This can even be triggered by drinking a cold beverage or holding something cold. This is an important side effect to discuss with our patients as this pain can certainly be avoided with adequate education.

Sometimes studying drug side effects can be difficult. There are so many drugs and so many side effects. But as we continue to work as students, we can collect experiences to help our memories along the way.

The Next Step

Posted by Shannon Hough at Saturday, January 16, 2010

January already.

December came and went with the ASHP Midyear Meeting, the holidays

and residency applications. This year's ASHP Midyear Meeting was held in Las Vegas, NV. I attended the meeting in order to learn more about first year (PGY1) residency programs. I could not believe how many people were at the meeting, including the number of pharmacy students looking for residencies. The photo at the right was taken at a student poster session. The majority of people in the room were students! It was a great experience to be at such an impressive meeting.

After weighing all of my options, I decided where I wanted to apply. So I polished up my applications and sent them off. I requested letters of recommendation and transcripts. Most pharmacy residency programs stopped accepting applications in early January. Over the next few months, I hope to receive invitations to interview for a PGY1 placement, and keep my fingers crossed for a good match.

This month, I also started my rotation in inpatient hematology and oncology at the University of Michigan. This rotation is unique in that there are two hematology/oncology teams, each of which sees both types of patients. Each team spends half of the morning rounding with an oncology attending physician, and the other half with a hematology attending physician. I am on one of the teams, and follow all of the patients that one of the physicians on the team sees. So far, I can see a huge role for a pharmacist with these patients. Cancer can change how the liver, kidneys and bone marrow function. Chemotherapy regimens alone have complex, highly individualized toxicities requiring patient-specific therapy. I have had to consider all of these factors in learning about the care of this patient population.

The team that I round with is quite pharmacy friendly. My fellow P-4-parter-in-crime and I reply to many "Hey Pharmacy..." questions from our residents and medical students. The residents often times make changes to the patient medication profiles as we make our recommendations. (Just one more reason we need to be very accurate in our recommendations!) I'm looking forward to learning more about the pharmaceutical care of hematology/oncology patients as the month continues.