Rotation 4: Alphabet Soup

Posted by Unknown at Sunday, October 11, 2015

ORP, OCC, DMEPA, OGD.  On my first day, while I was waiting to meet my preceptor, a man struck up a conversation with me (apparently I looked lost).  He asked me where I worked, and I spelled it out, Office of Regulatory Policy.  He nodded with recognition: "Oh, ORP! I'm from OSE!"  I guess I looked confused, because he started explaining some of the abbreviations before he had to run to a meeting.  Five weeks later, I still see and hear abbreviations daily that I need to look up.

Working in ORP was completely different from what I expected, but I still absolutely loved it.  I was surprised to learn (although it is somewhat implied in the name) that the office is filled with lawyers. Interacting with lawyers in a healthcare setting is very different from working with other healthcare professionals.  Some of my office's main responsibilities included participating in the development of rules and regulations and responding to citizen petitions (documents individuals, groups, and companies can write to FDA to try to persuade them to change something, such as remove a drug from the market, issue a guidance or rule, or make labeling changes).  In both of these cases, I appreciated having different disciplines working on these projects together.  As a healthcare professional, advice and knowledge I felt was obvious was not always clear to others, and vice versa.  Having multiple experts from a variety of areas allowed for the clearest documents to be released to the general public.

FDA was not all work and no play, however.  I attended nearly daily meetings to learn about all the different departments and met individually with pharmacists from several departments.  I also went on several field trips, including the Bureau of Prisons, American Pharmacists Association, United States Pharmacopeia, and the Pentagon.  Pharmacists are working all over the world in places you would never expect to find them, and hearing about the variety of opportunities available for those looking for a non-traditional path was informative - many jobs I had never considered, or even heard of before!

Overall, this was a fantastic rotation that went by too fast.  I loved the idea that I was affecting pharmacy at a national level by assisting with the creation of various policies.  I have always wanted to effect change on a grander scale than one patient, one pharmacy, or one hospital, and at FDA I was able to accomplish that.  I look forward to hopefully returning one day, but until then, onwards to pediatrics!

Rotation 4- Poison Control-

Posted by E. Caliman at Friday, October 09, 2015

My fourth rotation was also at the Poison Control Center, so I had the same experience as Emily in the post below. I was also surprised that knowing the substance the patient took wasn't particularly critical to treating the patient; many times, you just treat the symptoms as they show up. It still made it interesting to guess the substance when we went over cases. I also learned that not every toxin has an antidote, which leads to treating the patient supportively.

Several of the cases involved acetaminophen (Tylenol) in some form, which is to be expected: it's the most common toxin called into poison control centers and the most common cause of liver failure. Alcohol was also very common, as well as a mixture of illicit substances. On the other hand, we got to handle uncommon cases, such as rattlesnake bites (the only rattlesnake in Michigan is the Massasauga), insulin, and fuzzy caterpillars (not poisonous, but the "fuzz" is actually many tiny spines, so it's like a porcupine). It was interesting to see how certain substances were more common to certain age groups. Another interesting point was that the patient may not be telling you the truth when they tell you what they took. Sometimes, what they say they took and what they actually took look completely different.

This rotation highlighted several things we discussed in the American Pharmacist Association's Generation Rx committee about securing your medications. Even though the focus of the committee is young adults getting into their parents or grandparent's medication cabinets, young children also can get access to them if they're not locked, get past child-resistant caps, and consume medications in spite of the taste. One of the cases I consulted for while on call involved a kid about 2 years old who took some of his parent's medications when they were briefly left unattended. Another problem highlighted was that of household products. Detergent pods are very colorful and appealing to children and their contents are under pressure. If a child bites one, some of the liquid detergent can spray to the back of the throat where it can be swallowed, or worse, inhaled. Chemicals found in the garage are also a problem. Products such as antifreeze and brake fluid have a sweet taste, but can cause renal failure, which means the patient may be put on hemodialysis for life.

Overall, this was a great rotation and I'm considering further studies in toxicology. If nothing else, I can expand my knowledge base to better help my patients.

Rotation 4: The Dose Makes the Poison

Posted by Emily at Friday, October 02, 2015

Despite the clinical nature of this rotation, my experience at the Michigan Poison Center certainly fit its “non-traditional” billing.  Full disclosure: I have been very interested in toxicology since shadowing at this poison center the summer after P1 year (and two more times as a P2), and thus this was the rotation I was most looking forward to.  It definitely lived up to my expectations and has solidified my plan to pursue a clinical toxicology fellowship following completion a PGY1 residency.  Please bear with me while I gush about this rotation.

As I mentioned, this rotation is considered non-traditional as it is geared towards emergency medicine medical residents (aka licensed physicians who have a few years of practice under their belts), although there were a handful of pharmacy residents and medical students on rotation as well.  In total, there were about 25 rotators, so you can imagine that we did not all physically visit and consult on every toxicology patient that passed through the Detroit Medical Center.  Instead, we were divided into four teams who were assigned one day a week to be “on-call”, with the following day designated for team “call backs”.  Additionally, each team was assigned one weekend to be on-call.  This was confusing to me initially because I’m used to traditional rounding which generally occurs at the same time every day with more or less the same group of people.  Consult services, like toxicology, are more flexible and can see patients at any time, day or night.  A typical day at the poison control center looked something like this:

0730-0900 – consults or call backs

On the days my team was on-call, our designated team leader would call the poison center at 0600 to see if there were any patients within the Detroit Medical Center network of hospitals who required a toxicology consultation.  Some days there weren’t any patients, other days there were one or two.  It was up to the team to decide who would see the patient.  I consulted every patient that was available to me to consult, though I always teamed up with the physicians in my group who performed a physical exam, asked follow-up questions of the patient and the patient’s nurses to gain a more complete toxicologic history, and wrote consultation notes for the medical record.

On call-back days, we were required to log into the Toxicall system which is the database that tracks all of the calls that come in through the poison center hotline each day.  From here we returned calls to health care providers who may have consulted the poison center the night before for recommendations regarding a toxic exposure.  As rotators, it was our job to gather as much pertinent information as possible about the patient’s history, as well as their treatment course and most recent labs and vitals.  From there we would consult with the toxicology fellow or attending toxicologists about what additional recommendations for care needed to be made, and then write a SOAP note to log our encounter and recommendations in Toxicall.

0900-1100 – case review

Each morning, the on-call and call back teams would present the cases they had seen.  These were case presentations with a twist, however.  Whenever possible, the toxic substance was withheld so that we could try to guess what it was based on the patient’s presentation, vital signs, and lab findings.  Certain classes of medications have specific toxidromes that can help clinicians narrow down the possible ingestant(s).  For example, sympathomimetics (like bath salts, amphetamines, and cocaine) cause increased blood pressure, heart rate, respiratory rate, and temperature, pupil dilation, CNS activation, sweating, and GI activation like nausea, vomiting, and diarrhea.  Conversely, sedative-hypnotics and opioids cause decreased blood pressure, heart rate, respiratory rate, and CNS depression.  Patients rarely present with a textbook perfect toxidrome, especially if they ingested more than one substance (or even if they’re withdrawing from one substance while overdosing on another).  Toxicology requires a lot of problem-solving and detective work, which made cases my favorite part of the day.  It was just piecing together puzzles all morning!

Of course, it was frustrating when the poison was never elucidated because the patient was intubated and unable to tell us what they took.  I was surprised at how often it didn’t matter what the actual toxic ingestion was.  The toxicologists made treatment recommendations based on the patient’s symptoms, not necessarily based on what the patient claimed to have taken.

Here are some examples of the many and varied toxic ingestions I saw during this rotation: synthetic cannabinoids, lithium, heroin, glipizide, bupropion, acetaminophen, Coricidin, Listerine, antifreeze, quetiapine and cocaine, Dust-Off, a caterpillar, and some chemical called 3FPM that the patient ordered online.  We were also consulted about a Massasauga rattlesnake bite!

1100-1200 – lunch

1200-1400 – lectures, journal club, topic presentations, field trips

The afternoons were devoted to lectures on a wide variety of toxicology topics which were given by the handful of toxicologist attendings who worked at the poison center.  We reviewed everything from acid-base chemistry and acetaminophen toxicity to poisonous mushrooms and venomous spiders.  Each rotator was also required to present a journal club and a topic presentation.  My presentations were on colchicine toxicity and castor bean/ricin poisoning.

We had two field trips during the rotation: one to the Detroit Zoo to learn about venomous snakes, and one to the Michigan State University botanical gardens to learn about poisonous plants.

castor beans from the botanical gardens

autumn crocus, the plant from which colchicine is derived, at the botanical gardens

1400-1600 – review materials, work on projects from home

My major assignment for the rotation was to help develop a protocol for the management of zinc/aluminum phosphide poisoning.  Aluminum phosphide is a rodenticide that’s especially prevalent in agriculture southern Asian nations like India, but can easily be obtained in the US via the internet.  When aluminum phosphide comes in contact with water, it releases phosphine gas which is super toxic because it disrupts mitochondrial function.  When ingested, stomach acid causes an even greater release of phosphine gas.  Not surprisingly, the mortality rate from aluminum phosphide ingestion is very high, and unfortunately there isn’t an antidote.  In addition to being incredibly toxic to the individual who ingested the aluminum phosphide, the patient can off-gas phosphine even post-mortem which puts the healthcare providers caring for these patients at risk.  These patients essentially become HAZMAT problems.  It’s a pretty fascinating issue.  Here’s a link to a news article about a recent case of aluminum phosphide ingestion in New Mexico: http://www.koat.com/news/man-overdoses-vomit-contaminates-taos-hospital/34890148

And now, dear readers, please allow me to list the reasons why I love toxicology and thus loved this rotation:

• Toxicology is a broad specialty because the dose makes the poison, which means that basically anything can be toxic in the right quantities.  This means toxicologists have to be well versed in pharmacology and biochemistry, because toxic ingestions can be household items just as easily as they can be medication related.
• Toxicology is all about SOLVING PUZZLES.  I love this so much.
• Toxic ingestions often have a social component to them that I find very interesting.  For example, lead poisoning is more prevalent in low-income areas because the houses are often older and thus more likely to have been painted with lead paint.  Or parents may be reluctant to admit that their child could have accessed their prescription (or not prescription) medications out of fear that Child Protective Services will be contacted.  These complicated situations add a whole new layer of challenge to the field.
• I am a biologist at heart, and toxicology caters to this because beyond drugs, toxicologists are concerned with poisonous plants and animals too!
• In my opinion, toxicology offers pharmacist a good balance of activities including clinical care, drug information, research, teaching, and administrative duties. 
• Toxicology offers tons of variety because there are always new poisons (see: Tide Pods) and drugs of abuse trends are always changing.  There is always something new to learn.
• Finally, I really love emergency medicine docs.  All of the toxicologists and EM residents who I worked with this month had the most delightfully dry senses of humor on top of being super smart.  It made me excited to come in to rotation every day. 

Long story long, this non-traditional rotation in poison control definitely met my expectations!  I have been working on narrowing down residency options based on what programs also offer toxicology fellowships or at the very least are associated with poison centers and have PGY1 rotations in toxicology.

Warfarin: All Day, Every day!

Posted by Unknown at Saturday, September 05, 2015

It's been 15 weeks and 3 rotations since we started P4 year, which is both incredible and terrifying. My most recent rotation was centered on pharmacy within an ambulatory care setting. I was stationed at an outpatient anticoagulation clinic and the care I was able to provide patients exceeded my expectations. Although I knew going into the rotation that it would be focused on cardiology and blood thinners, I had no idea how immersed in it I would become.

The pharmacists I worked with handle a special, high-risk population of patients who need anticoagulation because they have an LVAD (left ventricular assist device) implanted inside them. These patients need increased monitoring because they are at increased risk to clot. Any foreign substance within the body has the potential to put you at a higher risk for clots as blood will stick to it.

My day usually started by following up with patients who had recently been discharged from the hospital. Although the patient is technically off our service while admitted, we still follow their INRs and report any medication changes. Many times, someone will come home on a new antibiotic that has the potential to affect the INR. About 90% of antibiotics will increase your INR, but nafcillin and rifampin significantly reduce it. In fact, we dealt with a patient who was on a 6 week home course of nafcillin due to MSSA bacteremia. We had to empirically adjust his warfarin dose by doubling it, which is a huge dose change when it comes to warfarin.

I also helped the pharmacist counsel patients who were being started on the new oral anticoagulants termed "DOACs" (direct oral anticoagulant). These include rivaroxaban, apixaban, and dabigatran. They don't need the same kind of monitoring as warfarin does, nor do they require the consistent diet of vitamin K as warfarin, but they are extremely expensive.

Finally, I was able to create "bridging calendars" and provide instructions to patients who had upcoming surgeries. For patients on warfarin, surgeries are tricky as you don't want them to have thin blood during the surgery, but you need to prevent a thromboembolism in the pre-operative period. This is where a low molecular weight heparin such as enoxaparin comes in. They have a much shorter duration of action, which means a patient can take this drug up to the day of surgery while in the interim of stopping the warfarin. Therefore, the warfarin gets out of their system, but they are still protected against clots. The decision if a patient needs bridging is based on their thromboembolism risk classification. High risk patients almost always need bridging and low risk patients almost always don't. However, when it comes to intermediate risk patients, it is based on patient and surgery characteristics. One of my projects while at this rotation was to review the new BRIDGE trial, published in June of 2015 and see how we could apply it at my rotation. Essentially, it showed that bridging for patients with atrial fibrillation in an intermediate risk category is not recommended.

Overall, this rotation taught me a ton about cardiology and pharmacy. I didn't think I was a big cardio girl until I spent all day with it. I know the knowledge I gained about anticoagulants will help me in my future rotations and career.

Rotation 3

Posted by Stephanie Burke at Friday, September 04, 2015

Making the best out of the unexpected

As you know, rotations are learning experiences; they are intended to challenge us, equip us, and shape us as we progress in our pharmacy education. There will be rotations that you are incredibly excited for, and there will be rotations that you are not very excited for. However, even those experiences that are not our favorite are learning opportunities. This is a challenge I faced in my last rotation. It was the one I had been looking forward to the most, but the experience was very different than what I was hoping for, and not necessarily in a positive way. It took me some time to adjust to (or rather, accept) the responsibilities and routine of the rotation. After two weeks of grappling with my disappointment, I finally made the conscious decision to accept my circumstances and focus on the positive aspects of the rotation that I could then further build upon. Following this change in perspective I was able to find more enjoyment in the work that I was doing and I was also able to better engage with those around me.

This is such an important lesson for us, as students, to learn early on. We will all be faced with disappointment or circumstances that cannot easily or readily be changed. However, we must be able to focus our efforts and energy on the things we can learn from – good or bad – and the aspects of the situation that we do enjoy. We will only be hurting ourselves and our own personal growth if we choose to focus on the things we don’t like, or the things that are not going as planned. 

So make the most out of the unexpected!

Rotation 3: Meticulous Minds for Medication Error Prevention

Posted by Emily at Friday, August 28, 2015

Block three brought me to Silver Spring, Maryland (just outside of Washington DC) for a non-traditional rotation experience at the Food and Drug Administration.  This was my first rotation outside of UMHS and my first rotation where I didn’t have a classmate by my side for support.  That was a little nerve-wracking at first, but I’ve learned that putting yourself in slightly uncomfortable situations in unfamiliar environments and adapting as you go is a great way to grow personally and professionally.  The uncomfortable situation is rarely as uncomfortable the next time.

FDA Building 1

It was clear from day one that FDA loves acronyms even more than BMT.  My preceptor’s email signature read something like:

DMEPA|OMEPRM|OSE|CDER|FDA

Translated: I was working in the Division of Medication Error Prevention and Analysis, housed within the Office of Medication Error Prevention and Risk Management, which is part of the Office of Surveillance and Epidemiology within the Center for Drug Evaluation and Research at the Food and Drug Administration.  (Suffice it to say I quickly began referring to my division as DMEPA just like all the other employees.)

DMEPA is full of pharmacist safety evaluators who are responsible for conducting pre- and post-marketing safety reviews of proprietary names, labels, and labeling with the end goal of preventing medication errors.  For example, if a manufacturer proposes a carton design in which the drug strength “200 mg” is too close in proximity to the quantity “100 tablets”, the safety evaluator will recommend separating the numbers physically or graphically to minimize the possibility of a busy pharmacist mistaking “100 tablets” for “100 mg” and contributing to a potential overdose.  Safety evaluators also conduct safety reviews of proposed brand names.  Part of this process involves asking employees to interpret handwritten and verbal prescriptions to see if the name they see/hear could easily be confused with an existing drug name.  I have pretty good penmanship overall, so I struggled to make my handwriting physician-worthy when I was asked to contribute prescription samples for these studies.

I was my preceptor’s first student at FDA, and he explained on the first day that the rotation was going to be more observational and self-directed than my previous clinical experiences.  That was true, but between projects, meetings, field trips, and the extensive student lecture series, I kept busy.  To keep this post from becoming too unwieldy, here are some of the projects I did and meetings/talks I attended in list form:

Projects:

• Summarized the literature on the effect of calendarized blister packaging on adherence
• Created a chart of abuse deterrent formulation opioids
• Conducted a literature search on best practices for standardized chemotherapy order forms (my preceptor works specifically with oncology products
• Presented recent DMEPA interventions aimed at preventing errors with chemotherapy agents

Meetings:

• ISMP monthly conference
•  Human factors study meeting
• DMEPA and OSE “All Hands” staff meetings
• Advisory Committee practice meeting

Student Lecture Examples:

• Office of Prescription Drug Promotion overview
• Orphan Drug Product Development
• United States Public Health Service overview
• CDER Drug Shortage Program
• The Scientific Basis for Drug Control Under the Controlled Substances Act
• Unapproved Drugs
• President’s Emergency Plan for AIDS Relief
• Introduction to OTC Drug Regulation

 Field Trips:

• ASHP headquarters in Bethesda, MD
• Bureau of Prisons in Washington DC
• United States Pharmacopeial Convention in Rockville, MD
• Pentagon tour in Washington DC
• Consumer Product Safety Commission in Rockville, MD  (This experience was not part of the FDA “curriculum”; my awesome preceptor arranged for me to shadow the pharmacologists at the CPSC after I told him about my interest in poison control and prevention.  The CPSC tests all kinds of consumer products, everything from bike helmets to baby cribs, ATVs to mattresses, and everything in between.  The chemists do a lot of work testing products for lead and phthalates.  The coolest part of this experience was getting to tour CPSC’s testing laboratories.  I totally felt like I’d walked onto the set of MythBusters.  You can watch a video tour of the labs here: http://abcnews.go.com/GMA/video/consumer-product-safety-commissions-test-lab-13827984)

ASHP Headquarters

USP Headquarters

Pentagon

Overall, my FDA experience was positive and unique.  It was great to see pharmacists from diverse backgrounds filling these non-traditional roles, and there are TONS of pharmacists at FDA!  Most of the employees seem to enjoy their work and the work environment, and even as a student I felt like I was part of significant work and something important.  I also felt proud to introduce myself as a University of Michigan student.  It’s true that the name demands a certain degree of respect, and I was grateful to be able to represent the COP outside of Michigan.  It also turned out to be a great networking tool.  I met two other Michigan alums on my second day, and that’s not including my preceptor!  One of the alums was a resident at one of the programs I’m considering, and he was more than happy to sit down with me to discuss his experience.  I was also able to network with the other students.  There were about thirty of us in total, representing over 20 different colleges of pharmacy!

While I learned a lot on this rotation about the drug approval process (and got to see firsthand that package inserts don’t just rain down from the heavens), the most important thing I learned is that I am not interested in working at FDA.  I love direct patient care too much to be happy in a job that involves no direct patient care whatsoever.  Perhaps in the future I’ll find myself in a position where taking on a desk job is the right move for me at that time, but for now I am excited at the prospect of pursuing residency and, more immediately, starting another clinical rotation next block at the Michigan Regional Poison Control Center!  Stay tuned.

PS – If you find yourself in the DC metro area for a rotation, be sure to take advantage!  I did all kinds of touristy things in DC on the weekends, and even caught a Tigers/Orioles game at Camden Yards in Baltimore one Friday.

Salk's polio vaccine at the National Museum of American History

Tigers vs. Orioles at Camden Yards

Rotation 3- Community: Still Going Strong

Posted by E. Caliman at Tuesday, August 25, 2015

I'm doing my Community Rotation at a local compounding pharmacy. I enjoyed compounding during P1 year and was interested in it even before starting pharmacy school. After the fungal meningitis outbreak from the New England Compounding Center in 2012, I thought that a community compounding pharmacy would be a nice, slower-paced rotation as compared to a chain community pharmacy.

I was wrong. I was so very wrong.

Compounding pharmacies are very much alive and well, even with piles of restrictions and new regulation. It's likely due to the fact that compounding pharmacies provide patients with medications they can't find at a regular community pharmacy and the personal level of service because many of them have fewer patients.

Slow days here are few and far between. I started off on a week where almost 100 scripts were filled each day. It's always busy. If you're not filling, you're probably tackling the pile of drug information questions patients and doctors call you about, from drug stability of compounded medications, to drug interactions, to helping them navigate insurance issues, since many insurance companies no longer pay for compounded medications.

Naturally, I got to spend time in the compounding lab. The pharmacy can compound capsules, suspensions, topical creams, ointments, lotions, suppositories, as well as sterile products. I got to try a little bit of each. The experience was more automated than I expected (there's a machine that mixes the topicals and you don't fill capsules by hand), but a little more labor intensive than P1 year would have you believe. Even so, I still enjoy compounding and it's still a career option.

Some of my other projects include updating policies and forms, as well as doing research into regulation and new business opportunities. I researched how a pharmacy in the partnership could provide a new service for the county and updated a privacy practice form to reflect that the pharmacy could now text patients with their permission. Overall I had a great experience and am looking forward to the next rotation.