Rotation 3: Health System/Hospital

Posted by Josephine at Saturday, November 18, 2017

Hi Everyone,

I's been very busy recently (with the secondary projects of P4 year - finishing up the PharmD Investigations Project with a polished manuscript, and completing the P4 Seminar). It truly feels good to be done. But as a result of being busy I haven't been able to post about rotations, so I'll start with 3 now.

Block 3: Institutional/Health System/Hospital Rotation @ a local community-based teaching hospital
During this rotation, I was very fortunate to have a variety of responsibilities. The preceptor is very organized and open to feedback. I rotated through the various duties on a 4-day schedule with three other P4 students (2 from Michigan including myself, 1 from the University of Toledo, 1 from Midwestern):

• Verification duties:
• Unverified Orders Monitor (UVOM) - sitting in the central pharmacy and helping them clear the orders that have either already been given or have been discontinued
• Anesthesia Trays
• Pyxis Cart Refills
• ACS Boxes and A-Packs
• Patient Counseling:
• Discharge counseling on Orthopedic Surgery patients
• Anticcoagulation counseling on new-starts (rivaroxaban, apixaban, dabigatran)
• Miscellaneous:
• Constantly checking MedMined (the pharmacy's surveillance system) to assess the clinical significance of each alert and determine potential interventions (renal dose adjustments, duplicate medications, adverse effects)
• Answering random DI questions

In addition to the above duties, I also was able to shadow several times (Emergency Department, Nursing, SICU, MICU, IV room). The preceptor is curious about your interests and works very hard to set up opportunities in that area. I also was required to present a journal club with all of the other P4 students rotating at this hospital (so there were about 10 students in the room). In addition, ther were miscellaneous other presentations to attend: student presentations, pharmacy presentations to nursing, as well as noon conferences for doctors (free food!)

Overall, this rotation was rather relaxing (compared to what I imagine an inpatient rotation would be like). The day was generally 7:30 AM - 4 PM (with 30 minutes for lunch). I never took work home and was not able to access the medical record from home anyway. The preceptors at this institution are very friendly and eager to teach. 

Besides all of this, the rotation was made the most enjoyable by the people! (ie: the other pharmacy students). As I said there were 3 other P4's with me (as well as a P3 from Toledo completing a 2-week IPPE). Honestly, the 5 of us had a lot of fun together, going through all the responsibilities and learning about each others' respective pharmacy schools and various interests. We would eat lunch together everyday and sometimes even hang out after rotation (I'm still in touch with one of the Toledo students even now). I think it could have been easy to simply go through all of our responsibilties without exchanging a word. But this rotation shows me that it's this camaderie-building relationship that truly makes work enjoyable (also, best way to network!). 

(See next post for Rotation 4 details)

Rotation 2: I'll Take a General Kit, Please

Posted by Unknown at Saturday, August 01, 2015

My entire life I've been terrified of blood, so imagine my shock and horror when I found out I was assigned to the operating room pharmacy for my health system/hospital rotation!  In the first hour of my first day I was handed a syringe of morphine mixed with blood to empty, and thus began my 5-week journey of desensitization.

A typical day kept me constantly moving and looked something like this:

0600 - 0730: Pass out kits
The OR pharmacy had pre-made drug packs containing various narcotics that the CRNAs and doctors could sign out for their patients.  There were kits for ECT, codes, PACU, the medical procedures unit (MPU), and, most popular, kits for general surgery.  Doctors and CRNAs could ask for additional add-ons, such as ketamine or Dilaudid, as well as pick up non-controlled medications, such as Tylenol, Neurontin, and Precedex, and request infusions.  This time was particularly busy, as all 30 ORs had a shotgun start at 7:30.  During this time, we also received several kits that were used overnight, and had to reconcile those with the provider while he or she was standing there.

0730 - 1000: Verify, topic discussions, and LOTS of paperwork
The next 2.5 hours were spent talking about various topics related to anesthesia, opioids, or other OR drugs, verifying the pre-op medications for the next day, and reconciling and completing the returned kit paperwork.  The paperwork could be very tedious at times, as we could have as few as 2 kits returned or as many as 20 or more if there was a weekend or holiday! The paperwork had to be double checked against what was actually returned and against the Omnicell.  Anything returned in syringes had to be refracted to ensure that what was documented to be in the syringe was actually in there.

1030 - 1430: Pharmacy adventure!
Every day I went to a new place to learn about a new area of pharmacy.  On Mondays, I went to the main pharmacy in the children's hospital, where I was able to check prescriptions, participate in cart fill, learn about dosing children, and chemotherapy dosing.  On Tuesdays, I went to the OR in the children's hospital, where I performed very similar tasks to my responsibilities in the adult hospital.  On Wednesdays, I worked with the medication safety officer on a medication use project.  On Thursdays, I went to the Investigational Drug Service and learned how to verify a prescription for a study, how to read a protocol, and how to write guidelines for pharmacists dispensing based on the protocol.  On Fridays, I stayed in the OR and filled pre-op orders for the next day.

One of my favorite days in the OR was a day I never thought would happen: I spent four hours walking in and out of various surgeries and intently watching the procedures.  I walked around with an amazing anesthesiologist, who showed me how she uses all the drugs I had seen coming in and out of the pharmacy every day, which was fascinating.  I was also able to watch a kidney transplant, brain tumor biopsy, ear canal tumor removal, and a prostatectomy using the da Vinci robot.  Watching those surgeries showed me that I had come a long way in those five weeks with regards to my blood sensitivity!

Overall, this was a fantastic rotation and nothing like I expected it to be.  It was a lot of work, but well worth the effort!

Rotation 4: Health System/Hospital Pharmacy at St. Joseph Mercy Hospital

Posted by Rachel Lebovic at Sunday, October 06, 2013

I can’t say that I was looking forward to the health system/hospital (otherwise known as “institutional”) rotation, but at least it was nice to be back at St. Joe’s. All of the pharmacy staff there are so welcoming! I had my P3 institutional rotation at St. Joe’s last spring, and this fall I was assigned to St. Joe’s for my P4 institutional rotation. There were some pros and cons to having both of my institutional rotations in the same hospital. Pros included already being familiar with the computer systems, layout of the pharmacy, etc. Cons included seeing the same system twice instead seeing how different health system pharmacies function, as well as already completing many of the special activities that P4s usually complete on this rotation (such as “buddying” with a nurse for a few hours). At least the intention of the experience was different – the P3 experience was focused on teaching you how to do the work of the pharmacy technicians, while the P4 experience is focused on teaching you how to function as a pharmacist.

A typical day went something like this:

7:30am – check “F8s.” The term F8 comes from an old computer system in which you pushed the F8 key to perform this task. The task consists of checking 24-hour supplies of a specific medication for a specific patient that doesn’t get stocked in the Pyxis machines on the patient’s floor. My job was to verify that the medication in the Ziploc bag matched what was on the label, and that there was the correct quantity to last the patient 24 hours.

9:00am – check the ancillary cart. Unlike the F8s that are for specific patients, the ancillary cart contains medications that are going to be stocked on a floor, then can be used for any patient when the medication is ordered. My job was to check that each product matched the product that was requested by each floor.

Remainder of the morning – Sentri 7 renal dose adjustments and therapeutic duplications. St. Joe’s has a computer system called Sentri 7 that pulls in patient information from their charting program and helps pharmacists know where to focus their attention. For example, Sentri 7 helps pharmacists focus on anticoagulation, antimicrobial stewardship, renal dose adjustments, and many more clinical tasks. The P4 students are responsible for the renal dose adjustments and the therapeutic duplications. In the renal dose adjustment section, for each patient I would see which of their medications are renally dose-adjusted, calculate their creatinine clearance (an estimate of their renal function), then make sure the patient’s medications are dosed appropriately. If they were, I would document that in the system. If not, I would contact a pharmacist or physician treating that patient and ask them if they could adjust the dose to be appropriate for the patient’s kidney function. Most of the medications that needed dose adjustments were antibiotics. For the therapeutic duplications, I would see what medications Sentri 7 thought were duplicates, look in the patient’s chart to see if they were actually receiving both medications, determine if the patient had a need for both medications, then contact the physician if I thought one of the medications should be discontinued.

Early afternoon – patient’s own meds. Most of the time the hospital provides all of the medications a patient takes in the hospital, but sometimes, a patient wants to take a medication they bring in from home. Many of these medications are inhalers, birth control packs, or unique/expensive medications that the hospital doesn’t have on its formulary. In this case, the physician would write an order for a “patient’s own med” and I would go to the patient’s room, verify that it was the correct medication, then label the medication with a barcode so the nurse could scan it when the patient took the medication.

Late afternoon – ALS boxes and bags. Ambulances carry boxes and bags full of medications to administer to patients on their way to the hospital. When the patient arrives at the hospital, the used box or bag gets dropped off at the hospital to be replenished, and the ambulance takes a fully stocked box or bag that the pharmacy staff members already refilled. As a P3, I refilled the bags and boxes in the manner that a technician does. Now, as a P4, I checked the bags and boxes and added the controlled substances in the manner that a pharmacist does.

Other projects I worked on during gaps in my daily routine included a journal club presentation and an audit. The audit assessed discrepancies in patients’ medication lists from their primary care physician and their hospital discharge papers, before and after St. Joe’s hired four med historians to perform medication histories when patients are admitted to the hospital. We found that the med historians decreased the number of discrepancies between the patients’ medication lists with the addition of the med historians, although the discrepancies were not eliminated completely.

Other special activities I completed throughout this rotation included rounding with two residents, reviewing patient profiles, performing anticoagulation assessments and antimicrobial stewardship reviews, discussing IVà PO (oral) medication conversions, verifying orders that are part of order sets, and answering drug information questions.

My most rewarding experience this rotation came when one resident had a patient with HIV on his service. Since I recently completed an HIV rotation, the resident asked if I would mind looking at the patient’s HIV therapy to make sure it was appropriate. When I looked at the patient’s profile, I noticed the patient’s HIV medications did not compose a logical regimen. It appeared that the physician had ordered a medication called “Intelence” instead of a medication called “Isentress.” While these medications sound very similar, they are from two different classes of antiretrovirals. I paged the physician to ask if he meant to order the other medication, and he said he did and he would update the order. I was very proud that my knowledge of medications led to a significant improvement in patient care!

Overall, I am much more interested in being a clinical pharmacy specialist than working in the institutional setting doing drug distribution and verifying orders, but I understand why this rotation is important. The pharmacy needs to get the right drug to the right patient at the right time before pharmacists can be involved in more clinical work.

Institutionalized, hehe.

Posted by Michelle at Sunday, February 17, 2013

Hi all! I am woefully behind on blogging, so this entry is reaching back a bit to my block 4 rotation, which was institutional pharmacy at St Joseph Mercy in Ann Arbor. All my rotations have been great, so I don’t want to miss telling you about them! More entries to come in the future as my life craziness level falls just a bit. :)

 

So, back to St. Joe. Institutional rotation is a little bit less glamorous than some rotations like ID or transplant or critical care. Nevertheless, it is very important, because the activities you do on institutional rotation are building blocks and basics of much of the pharmacy world, the meat and potatoes if you will.

A typical day was as follows:

1. Arrive at 7:30 AM, check cartfill. “Cartfill” is essentially all of the unit dose medications needed by patients in the next 24 hours that are not available in on-floor medicine cabinets like Pyxis or Omnicell. While an overwhelming percentage of medication doses may be available in Pyxis, the 5% that are not can add up to a lot, especially in a large hospital. These all need to be hand-picked in the main pharmacy, checked by a pharmacist, and sent up to the floors.

2. Perform renal dose adjustments and resolve duplicate medications. St. Joe identifies renally dosed medications and potential duplicate medications by computer program. It was the task of fellow student Kristin Lee and I to make sure renally eliminated medications (mainly antibiotics, but a few others), were dosed correctly according to each patient’s calculated creatinine clearance. Duplicate medications mainly consisted of proton-pump-inhibitors with H2-blockers, and heparin with certain other anticoagulants. In many cases, especially in the first category, there is no reason for a patient to be using both PPIs and H2 blockers. By identifying which duplicate med should be discontinued, Kristin and I helped reduce unnecessary medication use.

3. Huddle: This was the daily pharmacy department meeting that occurred mid-morning. We went over important information for the day. Daily trivia questions were asked as a fun diversion; Kristin and I performed masterfully in this arena. ;)

4. Patient’s own meds: After lunch, we performed “Patient’s Own Meds”, which meant going up to the floors and barcoding medications that patients had brought in from home and were using in the hospital. This allows nursing able to scan the medications in and record their use in the MAR. It is also a patient safety measure; we needed to certify that the medications are what the patient says they are, and that they are not expired, adulterated etc.
5. Paramedic boxes: After completing Patient’s Own Meds, we had to check paramedic boxes. Each time a medication box is broken open for an ambulance visit, it must be refilled and checked by pharmacy before it can be sent out on another run. It was our responsibility to check the boxes filled by pharmacy techs; in a large hospital, this meant a lot of checking!
6. Other: There were many other activities that I participated in, although not necessarily on a daily basis. During this rotation I was responsible for completing a Medication Use Evaluation (IV midazolam) and a journal club. Kristin and I also spent a couple days in the IV room with the checking pharmacist and the TPN pharmacist, in addition to attending Grand Rounds lectures once per week. We shadowed a nurse, answered drug info questions, and occasionally did some compounding.

 

Finally, the best part of this rotation, you ask? If you are someone who *lives* for patient interaction, this rotation does not necessarily cater to you, simply due to the nature of the duties. But, dear reader, there is opportunity everywhere. On very last day of rotation, I went up to visit a patient for Patient’s Own Meds. When I walked into the room to ask about this particular woman’s seizure meds, she seemed rather upset, and I ended up talking to her for more than a half hour. She was pretty anxious and concerned about several things: some architectural components of the bathroom, the struggles she had with making sure she had her own specified generic brand of seizure drugs, problems with frequent reactions to drugs etc. I was able to talk to her and listen to her concerns, as well as explain some of the details of the difference between generic and branded medications and the differences between drug allergies and drug intolerances/side effects. When I left, her mood was much improved, and she said that while she still wanted to voice some concerns via our patient feedback pathway, she would be sure to note that PHARMACY DID A GREAT JOB! I was so proud to be part of this patient’s good experience at our hospital! Taking time to really listen to patients will always improve results for everyone. :) :)

AMBUTUTIONALIST: an "institutional" rotation at Spectrum Health

Posted by Anna at Friday, November 09, 2012

I have just completed my rotation at Spectrum Health Butterworth Hospital in Grand Rapids, MI. Although technically an advanced institutional rotation, I feel it would be better classified as an ambu-tutiona-list rotation. This new classification stems from the varied components of this rotation that went beyond the traditional “institutional” requirements by combining ambulatory care, institutional tasks, and generalist activities. A list of some of my experiences better demonstrates this variety:

Ambulatory Care:
- One week at the West Michigan Heart clinic working with pulmonary hypertension and heart failure patients
- Performed medication histories and patient counseling
- Made recommendations to the provider and charted my interactions in the medical record

Institutional:
- Product dispensing and medication order verification
- Patient chart review
- Discharge counseling (Meijer Heart Center)
- Antibiotic pharmacokinetic monitoring
- Developed nurse-directed educational project on QT-prolonging agents in conjunction with nursing
- Two journal club articles and a formal patient case presentation

Generalist:
- One and a half weeks with the medical surgical unit performing patient chart review and work-up for 12 to 16 patients per day
- Rounded with interdisciplinary team and made treatment recommendations when warranted

My hours typically ran from around 7:30-4 (although this varied a bit), and for the most part I worked with a few select pharmacists. My preceptors were clearly dedicated to my education—you could tell they wanted me to be there and that they enjoyed teaching. This specific rotation was only introduced at Spectrum Health this year, and I was their second student. Many of the kinks had been worked out with the previous student (sorry Mary Lou!), and everything flowed much more smoothly for me. Although there were a few of those inevitable days where it felt more like a shadowing experience than a practice experience, overall the preceptors allowed me to be very independent and kept me busy!

I applied for this rotation specifically for the opportunity to see how things were done in a different health system. I personally benefited greatly from being in a different environment, and it provided me a chance to see how another health system is making changes to advance pharmacy practice. I also loved the opportunity to interact with other pharmacy students, as many Ferris State University students have rotations at this site. I was surprised by how inviting the atmosphere was to an “outsider,” and I would highly recommend this site for an institutional rotation!

My next rotation brings me back home to the University of Michigan Health System. For the next six weeks I will be exploring the world of informatics and administration on my “non-traditional” rotation!

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!

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

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!!!!

iNsTiTuTiOnAL RoTaTiOn

Posted by Melanie at Monday, December 05, 2011

I am currently on my institutional rotation at UMHHC with Ms. Kathy Kinsey.

This is a very diverse rotation spent in different areas on the hospital.

My first week was spent designing a CE program for pharmacy technicians on aseptic technique and preventing hospital acquired infections with my fellow fourth years (there are four of us). We designed a Powerpoint presentation and recorded some skits showing improper technique and then included videos illustrating proper technique.

The second week was spent on the 6th floor satellite pharmacy. Here, I got to verify orders, serve as the final check for products being dispensed, draw up oral liquids, go on cart fill runs with the technicians, and calculate drug desensitization dilutions.

This week, I am in IDS - the Investigational Drug Services department. Today I completed an IDS training module, learned about eResearch (the website where drug protocols are submitted for approval), read an article about the development and funding on an IDS service (published in AJHP in 1987 by UMMC when the IDS service was just beginning), and learned about Dispensing Guidelines. One of my assignments this week is to develop a Dispensing Guideline for one of the new studies. Over the course of the week, I will learn about IDS and its functions.

Next week I will be in the clean room.

In addition to these activities, I will give a patient case presentation and meet with various administrators throughout the course of the rotation to learn more about their roles and responsibilities.

Toto, we're not in Kansas anymore!!

Posted by Jenna at Sunday, November 06, 2011

My fourth rotation is my institutional rotation at Henry Ford Wyandotte. Institutional rotation is classically the rotation that people wish would be eliminated because a lot of them unfortunately turn out to be a huge waste of time. After coming off such a high from my last rotation, this rotation honestly seemed horrible at first. I wanted my babies back, I wanted my preceptor back, I wanted Mott back. In case you haven't realized, I love Mott! As a side (& dorky) note, whenever I used to walk into UMHS or Mott, I would get goosebumps. Why? Because I knew that great, revolutionary things were happening within their walls. It would be my dream to work at Mott, if I don't end up moving to warmer weather! Anyway, I digress.


Wyandotte is ~350 beds and takes me 50-55 minutes to get to each day. It reminds me a lot of the hospital system that I worked at at home. Paper charts, paper orders .. no real rounds, less pharmacist interaction with other HCP's. Not a fan. Granted, I will fully admit that training at a tertiary academic medical campus like UofM completely spoils us. Pharmacy (and medicine) is not as advanced or collaborative at many hospitals but having rotations and shadowing experiences at UofM makes you (or at least me, anyway) want that level of practice. 


Wyandotte is probably THE friendliest atmosphere, though! Everybody knows everybody and if they don't know you they try to get to know you. My first trip to the coffee shop yielded a 'Welcome to Wyandotte, I've never seen you before, tell me about yourself.' That, and by the third day of me getting my morning coffee, the barista knew my order. That's one of the ways to my heart .. knowing my coffee order. It's the little things, I tell ya!


Everyone in the pharmacy is really nice as well. They're a lot of fun as well. So far, I've mostly been working on projects, including:
          * MAR Reconciliation ~ Comparing the written orders from the previous 24 hours to the patient's daily MAR (medication administration record). This was to check that pharmacy entered/deleted orders correctly to ensure the paper MAR had the correct drugs, doses, & frequency/timing. 
          * Clostridium difficile infection rate ~ Collected patient antibiotic data to determine if specific antibiotics were implicated in their increase in C. diff and to determine if their C. diff treatment/duration was appropriate. 
          * Brilinta (ticagrelor) ~ Antiplatelet drug approved by the FDA in July. I did ~15 minute inservice to the pharmacists to explain the drug and it's major trial (PLATO).
          * Neonatal Umbilical Catheters & Common Neonatal Medications ~ Wyandotte has a 'feeders & growers' NICU, meaning the babies aren't sick, they just need to gain some weight. Like many people, their pharmacists tend to be hesitant about entering orders for the babies so I'm working on an inservice that will hopefully help ease some of these fears. I will probably also make a pocket reference card for them. 


Time is flying by, plain & simple. Yes, I'm excited to graduate and move on to the next chapter of my life .. but I wish time would slow down a bit. I'm starting to get pretty frazzled .. okay really frazzled. My to-do list grows daily and things aren't really getting crossed off of it. In the next few weeks I have a few looming deadlines and still a lot of work to put in to meet them. Midyear is also fast approaching and while I did a ton of research this summer, I feel like I need to get myself more prepared & fast!

From the D to DC, from the Bedside to the Benchtop

Posted by Bernie Marini at Wednesday, October 12, 2011

Wow. These last two months have been a whirlwind. I've been so busy that I haven't posted in a while, so I'll try to summarize two months of rotation into one blogpost. Hard to accomplish? Probably. But the Detroit Lions are 5-0, the Tigers are clawing to stay alive in the ALCS, and the Wolverines are undefeated. I'd say anything's possible at this point (haha! See what I did there...).

CABG Patch Kids
My second rotation was my institutional rotation at the Detroit Medical Center - Sinai Grace. Institutional rotations typically have a bad rap for being boring. However, this was certainly not the case. Because I had also completed my Institutional IPPE at the same site, they were extremely flexible with allowing me to see basically anything that I wanted - within reason, of course. (That's one rotation tip for any P3's, 2's, 1's, 0's (is that pre-pharmacy?). If you want to do something on rotation, just ask. They will likely say yes. If you are not getting everything you want out of your rotation, tell them. They will likely accommodate you.)

Because Sinai-Grace is well known for having an extremely busy and exciting emergency room (for students, not so much for patients), I decided to shadow and help the ER pharmacist for a couple of days. Because the ER is typically slower in the mornings, and I wanted to get the full Sinai-Grace ER experience, I started around 10 AM and left at 1 AM. That's almost two full shifts! I was really tired the next day, but it was truly an awesome experience (again, for me it was great. For the patients... eh, probably not an ideal Friday night).

Another great experience I had on rotation was when I spent the day in the OR. For a good chunk of the day, I was able to hang out with the anesthesiology residents and watch a coronary artery bypass graft, or CABG. It's truly an amazing surgery. Several surgeons work simultaneously; it's like a well-choreographed dance, but with scalpels. The heart is chemically stopped to allow the surgeons to operate on the heart and a cardiopulmonary bypass machine (or a "heart-lung machine") takes over. Clearly, the institutional rotation at Sinai-Grace is anything but boring.

Au Bon Pain? Or "Oh Bone Pain"!

For my third, and current rotation, I am at the National Cancer Institute (NCI; part of the NIH) in Bethesda, MD, just outside of our nation's capital.

Julie and I outside of the ASHP headquarters in Bethesda

My initial impression of the NIH campus in Bethesda: WOW... I was seriously blown away on my first day as I strolled nervously past the National Library of Medicine (yes, that NLM - the world's largest medical library... i.e. PubMed!) towards the clinical center (where NCI patients are treated). The size of the NIH medical campus in Bethesda is about the size of UM's central campus. The clinical center is nearly as big as UM's University Hospital. And every patient is a cancer patient.

The National Library of Medicine

My rotation at the NCI is unique in that it combines elements of research with some clinical experiences. Every Monday, I get to shadow an oncology fellow in the clinic. Every patient in the clinic is on a clinical trial, so patients are monitored closely for recurrence of disease and toxicity from the treatments. The lab that I am working in primarily studies prostate cancer, the leading cancer in men and the second highest cause of cancer-related death in men. The lab studies everything from the pharmacogenomics of cancer to molecular biology to the pharmacokinetics of anticancer agents. I've worked in a lab in undergrad at UM, but I've never experienced research that is so closely related to what is happening clinically.

Let me clarify this with an example. When a patient comes into the clinic with an unexpected side effect or toxicity, serum samples are sent to the lab, where analytical chemists and other researchers can determine drug concentrations using HPLC and Mass Spectroscopy (Oh no... time to dig out those Medchem notes!) to find out if the patient's drug levels were outside of the normal range. If they were, new questions arise. Is there a genetic polymorphism affecting the way that patients are metabolizing the drug? Is there an interaction with another agent? Can we modify the structure of the agent to minimize toxicity and maximize efficacy? These are just some of the ways that clinical trials "at the bedside" at the NCI make their way back "to the benchtop", or vice versa.

As you can see from the lack of me blogging this month (and answering emails...), this rotation has kept me extremely busy. I'm currently writing a review article on bony metastases in prostate cancer. When I'm not in the lab doing benchtop research, or working on my review article, I can usually be found in the coffee shop studying for the oral quizzes my preceptor gives me every Friday on a different cancer. The name of this coffee shop is "Au bon pain", which apparently means something like "place of good bread" in French. I don't speak French, so for me, it sounds ironically like "Oh bone pain..."

The rotation at the NCI has been an amazing and emotional experience so far. Seeing patients and their families deal with the struggles of cancer can be overwhelming. When my wife was diagnosed and treated for a glioblastoma in 2009, we needed all of the support we could get. Walking through the clinical center, seeing patients and their families stay strong throughout difficult times truly puts things into perspective. The worries of everyday life that usually circulate in my head - "I hope I do well on my quiz", "I wish I had known that answer on rounds", or "I really hope I get a residency" - seem small in comparison to their worries and concerns. It makes me think about how lucky I truly am. I am lucky because my wife is healthy right now... My family is healthy... I am healthy... Many people are not this lucky, and experiences like this remind me not to take life for granted and to "not sweat the small stuff", as my Mom always says.

Sometimes you've got to have a little fun!

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.

Institutionalized

Posted by Jim Stevenson at Wednesday, February 09, 2011

In January, I joined the pharmacists at St. Joseph Mercy in Howell for my institutional rotation. To my surprise, their central pharmacy was not in the basement, but in fact had a skylight – an unheard of addition to the usual pharmacy décor. But it was not just natural sunlight that I was exposed to on rotation – I also gained an understanding of pharmacists’ roles in a small (census ~70) community hospital.
The three pharmacists at St. Joe’s rotated through staffing and clinical roles. The clinical pharmacist attended rounds every morning and handled pharmacokinetic dosing, while the staff pharmacist verified orders, checked compounded medications, and answered drug information questions. As a student, I participated in functions from both roles.
Through this rotation, I gained experience making IVs, checking compounded medications, and checking cart fills. Additionally, I ensured that patients had proper DVT and stress ulcer prophylaxis, proper antimicrobial therapy, and renally adjusted doses. However, the most helpful aspect of this rotation was talking through complex pharmacokinetic dosing situations with the pharmacists. It is one thing to calculate a dose on a pharmacokinetics test in class, and another thing completely to dose a drug to a target steady-state concentration in a patient with fluctuating renal function.