The Wide World of Drug Information

Posted by Matt at Sunday, October 02, 2011

Another rotation has come and gone and I am left wondering where the time has gone. The last 4 weeks I was working with Dr. Dan Streetman completing my drug information rotation. Dr. Streetman works for Lexi-Comp, a medical software database, as one of the managers of the interactions database. Most of what I was doing entailed looking into drug interactions and writing monographs to be posted on Lexi-Comp. I was never actually at Lexi-Comp though; I actually worked from home during this rotation. I met with my preceptor twice a week to discuss my assignments and talk about upcoming projects. It was a nice break from being at the hospital all day but it took some effort on my part to keep focused at home, especially with a two year old constantly trying to help me on the computer.

This rotation really helped me refine my evidence based medicine skills, something I hadn’t done since my P1 year. I learned how to effectively search on PubMed and critically review an article. Since the rotation was focused on drug interactions I spent many hours interpreting in vitro data. I learned about pharmacokinetic parameters like Ki and IC50. I also got a good refresher on the CYP substrates, inhibitors, and inducers. Some of my assignments were actually uploaded into the Lexi-Comp database, so if you look up the interaction between warfarin and Augmentin you will find one of the monographs that I wrote.

The skills I learned during this rotation will help me during the rest of my life. As a pharmacist it will be important to effectively analyze and interpret medical literature to make the best possible recommendations for my future patients.

Beginning Again...Rotation 3

Posted by Nina Cimino at Wednesday, September 28, 2011

Another month, another new rotation! I am starting to get used to the fact that for the first one or two days of a new rotation, I feel a little lost and overwhelmed. After the first couple of days though, I find myself settling in and getting a good grasp of what I am doing. I really believe that one of the most beneficial aspects of P4 rotations is learning how to jump into new environments and adept quickly.

This month, I am doing my drug information rotation in medical writing, with a company that produces drug information resources for healthcare professionals. I specifically wanted this drug information rotation because I had worked in a more traditional drug information center during one of my FDA internships. While this rotation is still classified as drug information, it is a unique drug information setting and still allows me to have a new experience.

So now that I am oriented to my new rotation site, I can tell you a little bit about what I do! My preceptor maintains the drug information database for the company, so my rotation partner and I work with him to revise and update drug interaction monographs. We do literature searches to review the available evidence, and incorporate this information into the monograph to ensure that it is complete. In addition to updating the drug interaction monographs, we will also be writing new monographs, presenting journal articles, and working on longitudinal projects.

This rotation is very different from the direct patient care rotations I have had in the previous months, but I think it will be a great experience. I will definitely have an opportunity to brush up on my literature search skills, and these skills will be very important in any practice area where I find myself!

End of PICU

Posted by Amanda at Wednesday, September 28, 2011

That is a picture of my amazing preceptor Dr. Beckman, she taught me so much.

I finished my time in the Pediatric Intensive Care Unit and I am quite sad to go. I will miss all the kids from my unit. I wish I could stay with them. I learned a lot on my rotation. Being in the ICU you get to see a lot of disease states so that was what I liked the most. I get exposed to everything. I learned about typical topics like diabetes and asthma and then I had more complicated topics like bone marrow transplants and organ transplants. I really enjoyed my time in the PICU and it has definitely made me want to do a pediatric residency.

I also would like to note that the nurses that work in the PICU are amazing and that without them the unit would not be able to function.

Feeling the weight of my HIV/AIDS rotation

Posted by Anna Polk at Sunday, September 25, 2011

Rotation 2 has come and gone and I am spending my Sunday afternoon frantically addressing all of the things I put off during the month (like blogging, for example!)  I spent the rotation in Chicago with fellow P4 Jennifer Wang, working at Walgreens inside the Howard Brown Health Center, one of the nation’s largest LGBT healthcare organizations.  Two afternoons a week we would also head down to a free multidisciplinary HIV/AIDS clinic at Mercy Hospital on Chicago’s south side.

Jenn and I arrived on our first day, bright-eyed and bushy-tailed, ready to tackle this new patient population and feeling confident in our knowledge, having memorized all of the drug names that were assigned to us.  We quickly realized, however, that we effectively knew absolutely nothing.  Every night we would race home to start looking up questions that arose during the day and preparing our assignments for the next day.  I didn’t have internet where I was staying (my apologies if I neglected any emails from you!!) so my iPhone and I spent a significant amount of quality time together.  Jenn and I also realized that we were not going to spend a portion of each day shopping and eating great Chicago food like we had originally planned.  

    So what did we accomplish during the month?  Six OTC topic discussions, two presentations to PsyD students, one MTM session apiece, two hours of online continuing education, two pharmaceutical company dinners, one crash course in immunizations, four learning modules with case discussions, six mock patient consultations, four STD consultations and one final exam.  And that was in addition to the day to day work of filling, verifying, counseling patients and attending clinic!  Plus we managed to squeeze in trips to the Field Museum, Museum of Contemporary Art, Shedd Aquarium, Willis Tower, Millennium Park, a Cubs game and an architectural boat tour.  Phew! I am tired just typing that out.  

    All in all, it was a completely exhausting month, but also incredibly rewarding.  I went from knowing very little about the management of HIV to feeling confident counseling patients on all of their different treatment options and helping select a regimen with the highest likelihood for success.  I held an AIDS-induced dementia patient’s hand while she had wound dressings changed.  I helped a patient with a CD4 count of 7 (AIDS diagnosis is <200) administer his Neupogen injections.  I filled a transgendered patient’s first prescriptions that would help her lead the new life she was looking for.  Basically, I solidified my desire to be a patient-centered pharmacist, intimately involved in all aspects of patient care.  

    Well, I could probably write an entire novel about my rotation, but I better end here so I can begin preparing for my Cardiology rotation at Allegiance Hospital in Jackson, MI.  Stay tuned!

Good Bye Rotation 2.

Posted by Matthew Lewis at Thursday, September 22, 2011

Tomorrow's the last day of lung transplant, and Monday I move on to Institutional(think generalist staffing clinical pharmacist) at the VA in Detroit. First, one last bit about L.T. I feel like this rotation confirmed that transplant would be a good field for me, since there are opportunities to influence patient care directly, work as a team with many other types of health professionals, be on the cutting edge of medication therapy as more and more medications are used and developed for transplant patients to alleviate option depletion due to intolerable side effects.

Today I saw one of the patients I helped discharge about a week ago who was readmitted to the hospital. He (I have to use the pronoun to protect his identity due to HIPPA rules) had end stage cystic fibrosis and received two new lungs. I feared that he was admitted for some type of infection, but it looked like he came in due to some anemia (whew, that's a lot less damaging to new lungs). He had color, he wanted to move around and not be stuck in a bed; He didn't look sick any more. This patient recognized me as the pharmacy student who helped him out with understanding his new 21 drug regimen, and was quite thankful about everything we gave to him. He especially loves the medication schedule, since it helps him work out what medications he needs because he's still getting used to it all. His comments and condition made me feel like a graduated pharmacist to know I helped a patient understand their medications to the point of the patient having no issues, no complaints, and say I did a good job. That is something which will be the highlight of any rotation I have.

Now, talking about the VA (Vetran's Affairs) hospital in Detroit, I think I got off to a bad start and I have not even begun. Dear fellow students, if you have never worked for the VA, they require forms two weeks before you start so they can get you set up with a badge and computer access. You may not be told, and even if you are told at some point along the P4 orientation process, you will not be reminded about these forms. My point being, if you have a rotation at any government site, contact the preceptor more than two weeks ahead of time. You'll probably want to do the same for outside the state rotations as well, in case there are any state level papers that must be completed.

On the positive, I am looking forward to this rotation because of the population it serves. I have the utmost respect for people who served our country and they deserve proper care. It's the least I can do for them. This healthcare system is actually socialized medicine, which is something hotly debated in the public right now and I'm going to keep my opinions to myself on the matter. The important point about this health care system is that nowhere else is the balance of efficacy and safety vs. cost effectiveness scrutinized so closely. I will likely have to defend my recommendations with more background, studies, and protocols than in other institutions. I will also have to work within a particular formulary, so my recommendations might be limited to what we can get. This will be a good test to my therapeutic knowledge and will no doubt expand my abilities as a pharmacist.

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.

They don't call it the Intensive Care Unit for Nothing

Posted by Jenna at Sunday, September 18, 2011

This week was an interesting one for me:

• I played private investigator. A patient came in with SEVERE rhabdomyolysis (muscle breakdown) and for his first 2 days in the ICU nobody could figure it out. Thankfully, his daughter was able to bring in his medications, which gave us some insight & the answers we were looking for.
• I had to identify about 12 pills that were loose in a pill box.
• There were about 6 bottles of medication in a small bag.
• There were about 30 bottles of medication in a huge gift bag.
• I kinda, sorta watched a tracheostomy be placed. I was outside the room but was still kind of observing. Once patients have been vented for ~8-10 days, the team starts considering a trach if the patient isn't able to be weaned off the ventilator.
• I truly felt like part of the team. Starting at the end of my 2nd week, I started to do my work in the ICU, rather than going back to the main pharmacy. Well, the saying 'Out of sight, out of mind' is completely true. When the residents see me on the floor, they actually seek me out to ask questions .. that really makes you feel like part of the team. It's a good feeling!
• I've lost count of how many patients have died in my 3 weeks in the CCMU. It's been about 8. :-(
• I've been having some fleeting thoughts about my interest in psychiatry. I've had 1 & currently have 2 psych patients in the unit. I find this patient population interesting but I also have a lot of empathy for them.
• I saw an autopsy. A young patient who was going to come to the CCMU coded and was unable to be resuscitated so the team wanted to go to the autopsy. The patient didn't have a significant past medical history so no one really knew what happened.
• I have a stronger stomach than I thought. Luckily, it didn't really smell because I think that would've really bothered me.
• The patient was already all cut up when we got there so we were mostly observing the analysis of the organs. 
• Warning - this may be too graphic for some: It's kind of indescribable .. how it feels to be right next to a dead body laying on a table. The head was cut open to remove the brain and the chest was wide open, with pretty much only the ribs and spine remaining. I was able to see the brain, kidneys, liver, & lungs. Sadly, they had already analyzed the heart before we got there so I didn't see that.
• I know what it feels like to truly care about your patients. Now, I've never not cared .. but I just feel so personally invested in my patients' outcomes. On rotations, we're technically not required to follow our patients on the weekends but I haven't been able to stop myself. I feel like I need to know what's going on with my patients.
• For example, the same patient who's medications I went through, is the patient that I've been looking at a lot obsessing over. He had been taking a combination of Simvastatin, Cyclosporine, & Itraconazole .. yikes. His CK (creatinine phosphokinase) levels had been steadily rising to about 120,000 (normal value is <400). We have been waiting for it to start downtrending  (to prove our theory that his rhabdo was drug-induced) and it finally did today! I can't tell you how excited this made me! Dork? Yes of course but I don't care! 

Here's to my last week in the ICU, may it be less eventful than it has been so far!