Getting psyched for Inpatient Psychiatry

Posted by H. Tran at Thursday, December 31, 2015

Rotation 6 for me was Inpatient Psychiatry in a small hospital. I wasn't too sure what to expect, as I've heard stories about the patient population from another classmate who had this rotation, frightening stories, and the lack of an electronic medical record and other technology that led to many medication errors. But as always, I just brought my "A-game" and let the rest unfold from there.

Upon arrival, I had an eerie feeling run through me. I had to press a button that apparently turned on a camera for the receptionist to see and open the door for entry into the building.  It was obvious that security here was a serious issue.

I introduced myself to the receptionist and asked for the pharmacist (my preceptor). While I was waiting, I observed some anxious adults, who appeared to be patients waiting for intake and admission, but my attention was suddenly drawn to a group of people coming out from the hospital hallways for discharge. A set of parents were eagerly waiting for their daughter, and the look of thrill and happiness of both parties after they were reunited was great to see.

My preceptor welcomed me in and introduced me to the facility. She gave me a set of keys that I was to use to get through every set of doors in the hospital, and explained the process needed in case of lost keys and the incident report required to be done. This is unlike hospital I've been trained at as a Wolverine, where we could use our ID badge and just scan in. Here, we use keys. Additionally as she gave me a tour of the facility, she instructed me to look through the small window on the door to the other side in case there was a patient waiting (or hiding) near the door for an opportunity to escape. "Wait 3." She explained to me to wait 3 seconds after the door shuts to ensure that the door has been securely locked before I proceed to my duties. There is a high elopement risk, and the necessary precautions were in place.

My first day already was a thriller. Towards the end of my day I was debriefing information with my preceptor, when suddenly, we hear loud noises as if there was an argument, a slam, and briefly see a shadow swiftly pass about 5 feet behind us as we turn our heads. A patient had just escaped from his unit. Code 5 was repeated throughout the intercom, alerting all staff to be wary and all trained staff to assist in the pursuit and tracking of this patient's AWOL. At this moment, I felt goosebumps rise throughout my arms and legs. (Note: the patient was eventually located, brought to safety and treated appropriately.)

This incident alone made me more aware and more cautious for the entire rotation. Although these patients are mostly on involuntary holds that would usually require pharmacotherapy, it's important to understand what they are going through and what they may be feeling to help them. Part of my role here was to go into the units and interview patients to assess pharmacotherapy. Beyond that, I tried to get an understanding of the patient, what they are going through, how they are feeling, and their perceptions of their medications. Not only did this allow me to develop a connection with the patients and choose the most appropriate agent for them, but it also served as a learning opportunity for me. I got a better understanding of patient's symptoms of psychiatric disorders such as bipolar, schizophrenia and depression, and a better understanding on how specifically their medications are treating their symptoms, and what it is doing for them. Learning from a textbook, PowerPoint lecture slides, and audio recordings from classrooms is different than hearing real stories and perceptions of patient experiences with not just the disorder, but the medication.

Another responsibility I had was to hold weekly groups at different units covering the topic of the week (i.e., depression, bipolar, schizophrenia, detox, etc.). This led to some great conversations, and allowed social workers to assess the progress of the patient. It also allowed me to have greater insight into how the patients felt about their medications and talk about the stigma involved. I also had wonderful opportunities to take their questions, and look up the ones I didn't know to get back to them. Some of the questions were very specific, such as "why does my SSRI cause weight gain?" and others were more general such as "what are the side effects of my risperidone? and "does my gabapentin affect GABA receptors?" Overall, this rotation was very interesting and the groups were informative for both ends.

Some other interesting incidents during this rotation include a code calling for assistance because a patient was actively cutting herself in the hallway (from wrist to elbow on both arms, leaving a very bloody hallway), and a physical altercation that included a person laughing hysterically into another person's face.

It was a very interesting rotation on a patient care standpoint. Another great learning experience was that given its limited resources, it has made me more appreciative of having an EMR and advanced technology to help prevent medication errors. At this site, we did not use a electronic medical records or Pyxis(R) machines. In a way I'm kind of glad to have completed the rotation, and now I'll use winter break and my off rotation to prepare for my next steps in pharmacy.

Rotation 6 - Refigerator Malfunctions, Life on Hold, and Other Stories

Posted by E. Caliman at Sunday, December 20, 2015

I spent Rotation 6 at the University of Michigan's Drug Information Service. This mainly consisted of working on a couple of assigned projects while fielding calls from various U of M practitioners. Some were quick fixes that merely required reading a medication's package insert, while others required consulting multiple resources to discover the answer. Unfortunately, there is not a lot of data out there for some questions and the best answer you can give is "We couldn't find any data on your question. Use clinical judgment".

One of the more frequent types of calls we received were storage conditions of medications requiring refrigeration. In a few instances, we had some malfunctions that allowed the medications to go on excursions outside their specified temperature. This required calling the manufacturer for information on what the stability is outside of the recommended range. This meant spending a lot of time on hold. We learned to dread calling one particular manufacturer because in order to get the information, we need the expiration date and lot number of the affected products, whereas other manufacturers could provide blanket data.

Calling manufacturers for other reasons resulted in substantial hold times. I got used to listening to hold music, which was mostly smooth jazz or classical music, but one manufacturer in particular played country music, which surprised me. One manufacturer I had to call a couple of times had no hold music, so I sat at my computer, listening to silence. The best you can hope for in these instances is that you navigated the menu tree correctly so you wouldn't be transferred all over the place to someone else who would tell you that this was the wrong department and transfer you again.

There were some interesting stories we encountered in the call center. One was involved a patient's medication by a certain manufacturer no longer being approved by his mail-order pharmacy, so we looked into other generic manufacturers, guided by the site of manufacture. Another involved calling a manufacturer for information on an adverse event that limited the functional capabilities of a patient. Finally, another medication had a temperature excursion, but it was in a patient's home. It was a very expensive medication, but thankfully could remain stable for long enough that the patient could finish it.

Our longitudinal projects included filling out Medwatch reports, where you report adverse events to the FDA. We thankfully only had a few to fill out this rotation. It involves going into the patient's electronic medical record and gathering the necessary data for the form. The other project was a drug monograph, a summarizing report on a particular drug. The ones we were assigned were newly approved by the FDA, but were waiting approval to the U of M formulary. This project involved reading the package insert, looking at prices, and reading clinical trials.

This rotation was a bit more laid back, which is nice when you're trying to prepare for the next stages in your career, including job, residency, and fellowship interviews, attending ASHP Midyear, and finalizing your research paper.

Rotation 6: New Patient Resus Bravo

Posted by Emily at Thursday, December 17, 2015

Six rotations down, another Midyear meeting in the books, and Christmas right around the corner!  P4 year sure flies when you're having fun, and I had a great time doing an additional "inpatient" rotation in the adult emergency department at UMHS.

in the ED satellite

This rotation confirmed my interest in emergency medicine pharmacy and as a result, I focused my Midyear Residency Showcase adventure on speaking with programs that have strong EM offerings.  Emergency medicine pharmacists have a variety of responsibilities, and the extent of pharmacy involvement in the ED is hospital dependent.  Some hospitals don't have pharmacists stationed in the ED at all, while others have a well-established pharmacy presence.  At UMHS, ED pharmacists are in charge of verifying orders for patients in the ED, making IVs since there is no designated ED pharmacy technician, managing cardiac arrest and rapid sequence intubation boxes during codes (e.g. predicting what medications the docs are going to ask for before they ask for them, and having the syringe or bag prepped; providing agent and dose recommendations; keeping track of how long a patient will remain sedated and paralyzed based on the sedative and paralytic they were given for intubation, etc.), providing antibiotic recommendations, answering drug information questions, and attending rounds in the emergency critical care center (a sort of mini ICU attached to the ED).  Most of my time was spent in the pharmacy satellite working on projects, topic discussions, and helping with compounding in the IV hood.  But whenever a new patient was brought into the resuscitation bay, a page would go out over the loudspeaker announcing their arrival, and pharmacy would run over to assist.  Not surprisingly, there was no "typical day" in the ER, so here's an overview of how I kept busy during the last six weeks.

What I Saw:

• A variety of overdoses (acetaminophen, alcohol, sertraline, nortriptyline, diphenhydramine, ibuprofen, zolpidem, lorazepam, alprazolam, quetiapine, hydrocodone etc.)
• Several codes/cardiac arrests, which also meant seeing CPR conducted in real life for the first time
• One of the aforementioned cardiac arrest patients being put on extra-corporeal membrane oxygenation (ECMO)
• A handful of motor vehicle accidents (cyclist vs. truck, car vs. tree/telephone pole, car vs. car, etc.)
• Singed nostrils on a patient who had tried to smoke with her nasal cannula still in
• Hypertensive urgency (with a systolic BP of 294)
• Hemorrhagic shock due to GI bleed
• Ischemic strokes
• Dislocated shoulder
• Septic shock
• Severe respiratory distress
• Diabetic ketoacidosis
• A really gnarly leg wound due to a fall in an elderly patient
• Frostbite
• Compound arm fracture

What I Did:

• Helped at codes (twisting together epinephrine syringes, making a bicarb drip, drawing up just-in-case-of-intubation etomidate, handing off meds)
• Verified orders (with supervision)
• Made IVs, including t-PA
• Assessed appropriateness of vancomycin orders and made dose recommendations
• Counseled patients on how to use EpiPens and Combivent inhalers
• Picked up a handful of evening and weekend shifts, and spent some time in the pediatric emergency department in order to get the full ED experience
• Led topic discussions on advanced cardiac life support, rapid sequence intubation, myocardial infarction, urinary tract infection, status epilepticus, appendicitis, diabetic ketoacidosis, burn management, delirium, GI bleed, stroke, sickle cell crisis, phototoxicity, and sexually transmitted infections
• Developed nursing education slides for ED pharmacy bulletin board on details of new Established Status Epilepticus Treatment Trial being conducted at UMHS
• Updated UMHS antidote stocking quota list
• "Precepted" M1 students who were required to shadow a pharmacist as part of their curriculum

ESETT slides for ED pharmacy bulletin board

What I Learned:

• The ED was not as full of blood and guts as I was expecting.  Most of the patients that came in to the resuscitation bays were medicine patients rather than acute trauma patients.  Had I been in a big city like Chicago or Detroit, I would have seen more "penetrative traumas" (e.g. gunshot and stab wounds), but around here we have a lot of elderly patients having heart attacks, strokes, and other accidents - especially during the day shift.
• Heart attack patients can look really asymptomatic.  On TV, people having heart attacks always clutch their chests and collapse.  During this rotation I saw a handful of patients who had been sent to us only because their PCP noticed something off on their EKG; otherwise they looked and felt normal.
• NAC really does smell as awful as we were told it does.

Challenges:

• There are about six different pharmacists who work the day and afternoon shifts in the emergency department, so in addition to my primary preceptor, I would work with two different pharmacists a day and at least five different pharmacists per week during this rotation.  This was tricky just because each pharmacist does things a little bit differently and I had to adapt to make sure I was meeting the expectations of whatever preceptor I happened to be working with at the time.
• The ED at UMHS is a very "feast or famine" environment.  I rarely had a day that was just a steady flow of resus patients.  I would either have days where almost NO new patients came into the resus bays and I would spend all day working on projects and topic discussions, or days when the resus pager was going off every ten minutes.  There never seemed to be a lot of in between, and I would have been grateful for a few more busy days.
• Unfortunately, I also saw a patient die for the first time during this rotation.  

Now I'm looking forward to a couple weeks of break before starting block seven and, even more daunting, residency interviews.  Stay tuned.

Rotation 5- Keeping it Under Control

Posted by E. Caliman at Wednesday, November 18, 2015

Rotation 5 would have to be my favorite rotation so far. I rotated at the FDA with the Controlled Substances Staff, the people who handle concerns with the controlled substances coming through the pipeline as well as the drugs that affect them (ex. naloxone). Every day was something new and I got to do things most pharmacy students would not get to do, such as help my preceptor prepare for the World Health Organization's summit on international drug control and summarize a report requesting Schedule I substances for research. I also helped edit a drug label for a controlled substance that has since been approved and researched a topic of interest to my preceptor and other members of the staff.


One of the great things about the FDA rotation is that you get to go on a lot of field trips. You can go to the Pentagon as well as visit APhA and ASHP headquarters, all of which are in the area. Even though you are assigned to one department, you can attend lectures given by people working in various departments so you learn the broad scope of the FDA. It will force you to manage your time well, as there can be several lectures in a day and you'll have a project or two to work on.


I thoroughly enjoyed my time at the FDA and genuinely did not want to leave (and it's not just because the high was in the 70-80 range at the beginning of November). The people were great and the projects I worked on were very interesting. If you have any remote interest in regulatory affairs, definitely apply to do a rotation or an internship.


If you are lucky enough to be chosen for a rotation, here are some helpful tips I wish I knew before coming to the FDA.

1. Locate which campus you'll be on. Odds are, you'll be at either White Oak or Hillendale, both of which are on the same stretch of road, New Hampshire Ave.

2. If you're driving down from Michigan, bring about $40 in cash for the toll roads, mainly in small bills.

3. When you get here, you should get a SmarTrip card. It's like a pre-paid debit card that allows you to ride the public transportation in the area, including the Metro Rail, Metro Bus, and Montgomery County Bus. It can also be used to pay at parking meters. It will get you $1 off each Metro Rail ride and will serve as your transfer between the above modes of public transportation. There may be some days where you'll be traveling offsite on different field trips, so driving may not make sense. You can pick them up at any of the Metro Rail stations. Starting in 2016, they'll be the only thing you can use for the Metro Rail. Buses and Metro Extra Buses are $1.75 per ride.

4. When dealing with public transportation, there is no "Ride Guide", like we have in Ann Arbor. Each route is published on a separate pamphlet. You can access the website at wmata.com. You'll also note that the buses do not display the route name and number, followed by the destination (ex. Washtenaw, to Ypsilanti). Instead, they just display the route number and the destination.

5. Parking at the FDA is free, but if you're in one of White Oak's parking decks, it may be difficult to find a parking space where a permit is not required, so you may end up on the roof. If you enter the parking deck late enough, you may notice that the attendants have parallel parked some cars that are blocking a row of cars in.

6. Bring reusable shopping bags. There's a 5 cent charge per plastic bag you use when shopping if you use the store's plastic bags. Also, the sales tax is 6% in Maryland, 5.75% in DC.

7. The FDA is very close to the borders of Washington, DC and Virginia, so don't be too surprised if you hear about people commuting from Virginia.

8. Pack warm clothes if you're going from October to March. The highs may still be in the 60-70 range in early October, but in the mornings, it's in the 40-50 range.

9. This one is crucial: email your preceptor to find out when your badging appointment is. You'll have an appointment to get your ID badge, and they won't do that without all of your paperwork. You may experience some backups with the Badging Office. The sooner you can get your badge, the better. On the first day, you'll sign in at a check-in kiosk and get a sticker name tag. When you have this, you have to be escorted everywhere, but with a badge, you don't need an escort.

10. Some days, your preceptor will work from home. They'll tell you what days those are, but they'll likely be around for the first week, unless they're traveling.

Rotation 5: Beyond the Comfort Zone

Posted by Unknown at Sunday, November 08, 2015

My fifth rotation (where is the time going?) was on the pediatrics generalist service.  Emily did an excellent job of summarizing a typical day in her post, which can be found here.  But this rotation was a giant leap outside my comfort zone

I have said from the first day I walked into the College of Pharmacy that I did not want to work with kids.  First, it was that I didn't want to see sick kids, that I didn't think I could emotionally handle it.  Once we had our pediatrics section in therapeutics, I was worried about dosing and the complexity of their medications.  When I was ranking rotations, I purposely ranked all the inpatient adult rotations in a desperate attempt to avoid pediatrics.  However, once I started on rotations and I was trying new things almost daily, I softened up to the idea of trying pediatrics on my generalist.  By the time rotation three rolled around, I desperately wanted a change of pace from the adult world and to diversify my experiences as much as possible.  Luckily, I was assigned to the pediatrics generalist service.

My first day of rotation I was incredibly nervous, because I hardly knew anything about peds.  However, my preceptor and the residents, interns, attendings, and med students were very supportive and helpful, and with their assistance I was able to quickly learn the ropes and learn medication dosing and protocols.  The parents were so grateful that we were there to help, and the kids were usually happy to see us and eager to show us the picture they had painted or tell us about their day.  The hospital was a place where we could help kids feel better and put a smile back on their faces, and it wasn't as hard to handle as I thought it might be.  

While I learned a lot about pediatric medicine, especially unusual conditions like short gut syndrome as well as nutrition, I also learned a lot about appreciating opportunities I may never get again.  For those of you who are ranking rotations, don't close any doors until you've tried something.  While I don't want to specialize in pediatric medicine, I am grateful for this opportunity and I am so glad I elected to do peds rather than another adult rotation because it exposed me to a whole other world of diseases and medications.  I feel I have a more well-rounded education now because of this experience, and I wouldn't trade it for anything.  

Rotation 5: “Cause, baby, now we got bad blood”

Posted by Stephanie Burke at Saturday, November 07, 2015

I was on the inpatient hematology/oncology service this past rotation block. The experience was more than I anticipated! As my first intensive patient care rotation, I was slightly (i.e. terribly) intimidated by the thought of enduring five weeks on such a demanding and challenging service. Fast-forward a bit: I survived! It took quite a bit of adjusting to the therapeutics of the rotation, but by the end, I felt fairly comfortable managing my patients on the floor. I arrived at the hospital early each morning and some days stretched pretty long. My daily routine involved working up patients for the day, rounding with the hematology and oncology teams, following up on patient needs or physician questions, and finally topic discussions with my preceptor and PGY1/2 residents in the afternoon. Overall, it was a well-rounded learning experience.

My favorite part of the rotation was working with hematology patients. I learned the guidelines for managing acute myeloid leukemia patients, lymphoma patients, and patients with neutropenic fever relatively quickly. I always felt on top of the needs of my patients; monitoring their renal function, need for continuation/discontinuation of anticoagulation, antibiotics or antifungal agents, drug levels, etc. I had an impact on the health of my patients, and even if they only had a week or a month more to live, I was going to do everything I could to ensure their last days were comfortable. This was the hard part of heme/onc – many patients did not have much longer to live. I remember my first week on service standing with the medical team in a patient’s room. The patient was dying, completely incoherent and unable to communicate effectively with us. As the attending began the conversation about home hospice care with the patient’s spouse, the spouse appeared okay, taking in this difficult news. Then, he was not doing okay and began to cry. As we all stood in silence with our heads down, the attending comforted the spouse. It was my first dose of reality in the world of the sick and dying. This aspect of the rotation also took some adjustment. Many of our patients were sick and dying. But, as my preceptor reminded me, the patients we saw in the hospital were only a subset of all the hematology and oncology patients outside of the hospital who were doing fine.

This rotation challenged me in many ways. Professionally, it challenged my knowledge and understanding of therapeutics and pathophysiology. Personally, it challenged me to remember that each day is a gift, and even in the toughest of circumstances, one can still find joy and hope. It takes a special person to work on the hematology/oncology service. Some days it was a lot to handle, but if nothing else, remember your patients. Some are fighting for their lives, and you need to do your best to help them in that fight. 

Rotation 5: Compounding Community Pharmacy

Posted by Emily at Thursday, November 05, 2015

I was fortunate to complete my community pharmacy APPE experience in a unique setting: a local, independently owned compounding pharmacy. I wasn't sure what to expect going into this rotation, but what I got was five weeks packed with variety and new experiences.

This rotation site was certainly not your average community pharmacy. According to my preceptor, about 80% of the prescriptions filled here are compounds, while the other 20% are "traditional", commercially available prescription medications. The front of the pharmacy has a small corner for normal OTCs, while the rest of the space is devoted to professional-grade, made in the USA dietary supplements. I had shadowed at this pharmacy as a P1 and ranked it for APPEs knowing that the pharmacy had a complementary and alternative medicine (CAM) leaning. My preceptor was very knowledgeable and walked an interesting line between the world of pharmaceuticals and nutraceuticals. As someone interested in CAM and traditional pharmaceuticals, I found this balance fascinating. It was clear on day one that this unique pharmacy attracts clientele who run the gamut from being heavily skeptical of alternative medicine, to being 100% against pharmaceuticals just because they're pharmaceuticals. My preceptor did an excellent job of presenting balanced information to a patient who was proud to no longer be taking her beta-blocker and was seeking a "natural" alternative for her heart condition. The pharmacist showed that he understood the patient's reticence to use prescription drugs, but explained that beta-blockers are often life-saving and that there was no good nutraceutical alternative. I tried to take this balanced approach in the consults I conducted independently throughout the rotation. I understand being hesitant to take drugs, and I think many people are over-medicated or unnecessarily medicated. But many medications are necessary, and it's the pharmacist's job to help patients make the distinction.

Each day was busy with small projects and tasks that included patient counseling, supplementation consultations, verifying lab calculations, helping to pack compounds into their dispensing receptacles, receiving, transferring, and filling prescriptions, making capsules, working in the sterile lab, fielding drug information requests from patients and practitioners, and administering (preservative free) flu shots.

It was clear from week one that pharmacists in this setting have to do a ton of multi-tasking. I was constantly making mental (and hard copy) to-do lists and shuffling my priorities as new requests, assignments, projects, and tasks arose. Since my preceptor was always running around putting out fires, or on the phone, or checking scripts, or attending to patients, it could be hard to get him to sit still long enough to ask for project guidance. Consequently, the ability to work independently and be self-motivated was huge. I felt more autonomous on this rotation than I have on any other, and since one of my primary P4 year goals is to build autonomy and confidence, this was a satisfying feeling. In fact, I had my most rewarding pharmacy experience to date during this rotation, which came as a result of the pharmacist trusting me (and me feeling confident enough in my abilities) to counsel a patient independently.

During my first week, my preceptor asked if I could stay late (typical rotation hours were 9AM - 5PM) as he'd just gotten off the phone with a patient who was planning to come in at 5:30 and needed to be counseled. She was in her thirties, but had just been diagnosed with type I diabetes that day. No one at the hospital or the chain pharmacy where she picked up her insulin pens and glucometer had shown her how to use them. In fact, she was coming to our pharmacy because the chain pharmacy had failed to dispense the needles that she needed for her insulin pen. My preceptor asked if I felt comfortable counseling her, and I said yes. Finally, a rotation challenge on something I felt well qualified to do! After all, how many times have I had to teach an SPI how to use an insulin pen? (Many times.)

I spent almost an hour with the patient and her dad reviewing and practicing how to use the insulin pens and glucometer. This was easily one of the most positive and rewarding pharmacy experiences I’ve ever had. I felt knowledgeable and confident, and it was clear that the patient truly valued my help. It was so gratifying to see the positive impact I could make as a pharmacist, especially for someone who was probably not having a very good day. When they left, the patient and her dad were very gracious, saying how much they appreciated me taking the time to step through everything slowly and that I was clearly passionate about and good at what I do! I didn’t even mind staying late because it was a great learning opportunity and more importantly, an opportunity to help a patient in need.

Despite this excellent encounter, I don't think community pharmacy is for me. If 80% of the job was encounters like the one I just described, I might feel differently. But from what I've observed, so much of the community pharmacist's energy is consumed with smaller tasks and the daily grind of checking prescriptions, answering phones, and in the case of an independent pharmacy like this one, managing the business and the bottom line. There were certainly aspects of this rotation that I enjoyed, but I'm looking forward to stepping back in to the world of hospital pharmacy with my next rotation in emergency medicine! Stay tuned.