Rotation 1 and 2: Community and Nontraditional Informatics

Posted by Andrea at Thursday, August 30, 2018


Hi everyone! My name is Andrea Duong and I will be one of the P4s blogging about their APPEs this year. I’m excited to give you a glimpse into the life of P4. Hope you enjoy!

Rotation 1: Community Pharmacy

I was looking forward to this rotation, since I only had experience working in a big chain pharmacy. This rotation was at an independent pharmacy in a small town in Michigan. Typical hours for this rotation were 9am-5pm. My days were spent filling prescriptions, taking phone calls from patients and providers, and counseling patients. Later in the rotation, I became responsible for checking prescriptions (with preceptor supervision). I felt like a real pharmacist with this autonomy! When checking, this new responsibility changed my perspective- I realized that I would soon be working as an independent practitioner and no longer as an intern under the safety net of a preceptor or supervisor. I appreciated that my preceptor also did an extensive review of law with me, which reinforced what I had just learned in the P3 law class. Other activities included reviewing calculations, compounding some simple creams and solutions, reviewing OTC products, and doing one journal club per week.

The staff and patients were so welcoming here. I could tell that my preceptor was very passionate about community pharmacy and learning in a low volume store was the ideal setting for me.

Rotation 2: Nontraditional Pharmacy- Informatics
I was very excited for this rotation, since I am interested in pharmacy informatics. My rotation was at a community hospital in Michigan and my preceptor was responsible for managing the oncology electronic medical record (EMR) system. Oncology is a complex field with numerous types of cancers and constantly evolving drug therapies, so you can imagine keeping the EMR system up to date can be quite challenging! Managing the EMR system includes updating treatment regimens and building new ones, based on clinical studies and guidelines. Treatment regimens typically consist of multiple chemotherapy drugs and supportive care (e.g. antihistamines, anti-emetics, IV fluids, etc). Patients are on a certain number of “cycles”, which include days with drugs and days without. For example, one cycle can be 14 days, with only one day of chemotherapy and 13 days without. These were just some of the variables we had to keep in mind when building regimens in the EMR.

One major project I worked on was building treatment regimens for Rituxan Hycela (rituximab and hyaluronidase human), a subcutaneous formulation that could be used after the first dose of rituximab IV infusion. This would save the patient lots of time, since they would not need to be in the infusion chair for as long. I also evaluated and presented a comparison of the respiratory interleukin agents, wrote a case report, updated patient education for chemotherapy regimens, created an herbal supplement/vitamin reference sheet, and answered drug information questions. Every day was different, which was thrilling for me. It was a mix of meetings, project time, and discussions with my preceptor. Typical hours for this rotation were 8am-4pm. Most of my time was spent at my desk, but I worked in the cubicle next to my preceptor, so we were able to easily bounce ideas off each other.

In this rotation, I further developed written communication skills and analyzed primary literature. We often referred to the National Comprehensive Cancer Network (NCCN) guidelines and analyzed the clinical studies that were referenced. It’s free to make an account on the NCCN website, I recommend checking it out! Oncology was not an interest of mine prior to this rotation, but now I think it’s such an innovative field with a lot of opportunity for pharmacists to help physicians and patients understand the drugs.

Rotation 2 – Solid Organ Transplant: A New Lease on Life

Posted by Emily VanWieren at Sunday, September 18, 2016

Rotation 2 – Solid Organ Transplant

A New Lease on Life

First Impressions

I was super excited to start my first day with the surgical transplant team. There are a multitude of complex medications used in transplant recipients, and I knew there would be a great role for a pharmacist on the team. I wasn’t super excited that rounds start at 6 AM. The first day I set my alarm at 4:15 was painful - I am not a morning person!

There were over twenty people on the surgical transplant team, which turned into a super intimidating herd of white coats blocking the hallways on rounds. The team was inter-disciplinary and consisted of physicians in all ranges of training from attendings on down to fellows, residents, interns, and medical students. There were Physician Assistants, Nurse Practitioners, and also the pharmacist. You could tell the team respected my preceptor because they straightened up when they heard her walking down the hall. She had recommendations on dosing, stopping this drug, starting that one, ordering new labs, and the team accepted the changes she suggested. I was so impressed by all her knowledge of the patients and their medications!

A Day in the Life

The team I was with transplanted livers, kidneys, and pancreases. My typical day consisted of early morning rounds with the surgical transplant team followed by rounds with the nephrologists in the morning and the gastroenterologists in the afternoon. In between rounds, I would look up questions from the medical team and talk to the patients. I interacted with even more interdisciplinary members of the team and I got a full appreciation of all the care that goes into each transplant recipient. There were social workers, nurses, discharge planners, dieticians, and even interpreters for a deaf patient.

My favorite part of this rotation was educating patients on their new medications. There are a lot of new medications transplant patients have to take to suppress their immune system and prevent infections and they have to take them on a very specific schedule. I taught them the names of their medications, why each one is important, when to take them, and when they need to get their blood levels checked. I got to establish relationships with the patients and it was cool to see their new lease on life and how serious they were about taking their medications to keep their new organ.

Megan and I were able to watch a kidney transplant from a living donor to a recipient. We weren't sure how our stomachs would handle it, but we were both so fascinated and didn't feel squeamish at all. The surgeons talked us through the procedures and we were able to see inside a living human's body! It was also cool to see the anesthesiologists in action since they choose, prepare, and administer all of the medications on the spot. It was humbling to see the whole process from donor to recipient and then educating the recipient on their new medications.

Reflections

On this rotation, I learned a lot about transplant medications and many other therapeutic areas such as diabetes, hypertension, and kidney and liver disease. It was very rewarding to be able to make an impact on patients’ lives by teaching them about their medications and how to support their new organ. On my next rotation, one of my patients recognized me and waved me down. She wanted to thank me again and tell me how well she was doing and that she hasn’t missed a dose. I spent many long days at the hospital and sacrificed sleep on this rotation, but it was well worth it to see the full impact of a pharmacist’s role on the medical team.

Rotation 1: Medical Code, ETA: 5 Minutes

Posted by Unknown at Sunday, June 21, 2015

I cannot believe how fast the last 5 weeks have flown by! If you had told me at the beginning of my first rotation that I would feel comfortable treating patients in the emergency room, I would have laughed. The emergency room is a unique experience, whether you're a pharmacist or a physician as you never know what could walk through the door. In fact, at the large hospital I'm doing my rotation at, I was exposed to just about everything you could imagine; whether it was an eye out of its socket (good thing I'm not squeamish!), lithium toxicity, or heart attacks. As I'm sure you're guessing, I was beyond nervous my first day, more so due to the fact that a medical code came into the resuscitation bay just as I walked in the ED satellite pharmacy. Without any hestitation, Dr. Suprat Wilson (my preceptor and leader in emergency pharmacy) and I jumped right in to help a severely hypoglycemic man with a blood glucose of 23, providing the physician with both oral glucose and an amp of dextrose.

Here's a brief run-down of how the ED operates. When patients come through triage, their vitals are taken by a triage nurse. There are a total of 6 modules a patient could be placed into with a transition of care unit reserved for those being admitted. If certain baselines are not met during the triage interview, for example; if the blood pressure is too low, heart rate is too fast, or oxygen saturation is too low, a patient becomes a "medical code," meaning they need attention ASAP. Additionally, if a trauma code comes in via EMS, it will be designated as either TC1 or TC2 based on a patient's mental status. For a trauma code, the surgical team also attends. The ED pharmacist is both integral and essential in providing assistance to the emergency team.

Over the past 5 weeks, I have seen a wide array of medical emergencies. It's amazing to learn about something in the classroom and then see it happen right in front of you. The biggest eye-opener was how fast Narcan works. The patient comes around very quickly. They are often combative due to their "high" being taken away, but that drug can seriously reverse any opiod. I saw gangrene on the foot of an older gentlemen, causing sepsis and beyond vasopressors, fluids, and antibiotics, the only thing we could provide was amputation. Another bubble that burst was the size of gun-shot-wounds. They are not as big or as bloody as you would expect. During any medical code, Dr. Wilson was amazing at asking me to assess the patient and think about why they might be in the ED and what our course of action might be. This skill will undoubtedly help me in my future rotations and career.

One of the biggest aspects of emergency pharmacy is ACLS and Rapid Sequence Intubation. These were two core topic discussions Dr. Wilson and I talked about. In an ACLS code, the pharmacist is responsible for getting together the epinephrine, reminding the physician when another epi is due (1 mg every 3 min!) and is consulted for what life-saving drug to try next. By the end of the rotation, I was running the pharmacy side of ACLS (with supervision of course). I also got to do CPR for the first time - very hard and tiring! Additionally, if a patient has head trauma or needs ventilatory support, there are many pros and cons to which sedating agent and NMBA blocker to use. The pharmacist is utilized for this too. I can tell you, seeing an intubation in person is way different than on Grey's Anatomy - it looks painful!

In addition to working closely during medical codes, I got proficient at dosing heparin, vancomycin, and TPA. I was able to attend "Wildnerness Emergency Medicine Grand Rounds," where rabies, heat stroke, and seafood toxins were described in detail. Did you know that rabies is actually more common in cats, not dogs? I volunteered myself for two midnight shifts as well as my normal day hours and it was interesting to see how a quiet night can turn into the busiest six hours you've ever experienced. Dr. Wilson was very gracious in letting me see any procedure that happened within in the ED. I accompanied patients to CT, saw the effects of procedural sedation (propofol and ketamine), watched a shoulder be popped back into place and even saw a neurosurgeon drill a hole into a car accident's victim head to reduce the intra-cranial pressure.

Overall, this rotation was incredible. Not only was it highly informative, but I truly enjoyed the entire pharmacy and ED staff. I came into the rotation thinking about ED pharmacy as a possible career, but now I am highly considering it.

Stay tuned - next rotation I will be in Washington DC with the Food and Drug Administration!