Day 9: Special Formulations

There are times that a medication is needed in a route/dose/mixture that isn't available through a manufacturer. Most of them are ordered solutions for pediatric patients.

Today I got to compound sildenafil solution, hydrocortisone solution, enalapril solution, etc. Lots of crushing tablets which required some arm muscles. But I also opened up 50 capsules of ursodiol, which was much easier! 

The pharmacy looked a lot like a chemistry lab, with lots of drugs but also chemical ingredients necessary for a formulation. They don't just make solutions, but also tablets, capsules, suppositories, etc. 

This was a shorter day, but lots of fun!

Day 8: Drug Information/Medication Safety

Today was a different change of pace. About 8 of us (HIPPE students) were together in a conference room and were led through various activities.

First up was Drug Information (DI):
The speaker for the day was the DI pharmacist, who is available in the hospital to answer any and all questions regarding medications. She is usually saved for questions very rare adverse side effects or anything else that a physician and/or pharmacist can't look up right away or cannot find. She emphasized that every pharmacist should be knowledgable of all the ways to look up information. According to her, if you only look at LexiComp for your drug information, you're not optimizing patient care.

We were lead through various books that she has on hand. Here's a glimpse:

This book was HUGE, and claims to have information regarding every single-drug entity available in the U.S. It's a collection of monographs organized by drug class, so you can compare/contrast drugs within the same class, amongst other things. It is very informative; however, it is not good for quick reference or for specific cases in which you would use the books below. 

This book should be on hand in every retail/community pharmacy and family clinic. It's a guide specifically for contraceptives. It can help guide changing from one pill to another, has an overview of side effects, guidelines on missed doses (always a big question!), and more. It's also small, handbook-sized so it can fit in the white coat pockets. 

The pharmacist said that when she was in residency, she was on call some days for 24 hours at a time, and would sleep with this next to her because most of the calls were about drugs and kidney dysfunction. Because most drugs are filtered through the kidney, it's extremely important to take this into account, especially with doses. This book is helpful for pediatric and adult patients. There are lots of tables for quick reference. 

This was an interesting book that focused on just adverse effects caused by medications. It was written by pharmacists, which makes it even better! It doesn't have information about drugs (regarding dose, administration, indications, etc.). It is organized by disease and body systems and focuses on the more severe adverse effects, not every single adverse effect possible. 

We are exposed to this book in lab, so we were familiar with it. It's a reference for if a drug is compatible with a pregnant or lactating woman. It's also available online, which is good (not all books are available online). It also specifies if a drug is compatible in certain trimesters only. 

ImmunoFacts has information regarding vaccines, antibodies, interferons, interleukins, etc. It's organized by class, and has tables inside with dosing schedules for vaccines, etc. A good second source would be the CDC website. 

This is a very interesting book that focuses on toxicology (obviously) regarding drugs, radiation, metals, household products, occupational hazards (i.e., methylene blue, smoke, etc.), nature (i.e., poisonous plants, snake venom, spider venom, etc.). It specifically focuses on antidotes and managing toxic events, such as drug overdoses. We also were introduced to the term "toxicokinetics", which is similar to pharmacokinetics but specifically how your body handles drugs when in a toxic state. 

This book is specifically for managing bacterial, fungal, viral, etc. infections. It's organized by site of infection, and includes a vaccination section. It has primary therapy, and secondary options if the patient has allergy to the antibiotic or has developed resistance. 

Next up was Medication Safety:
The hospital's Medication Safety Officer, Dr. Kayla Hansen, is a pharmacist who specializes in medication safety. She analyzes reported medication errors that happen in the hospital and figures out ways to prevent them by implementing procedural changes and educating.

It seems like something that is obvious, but errors happen every single day, especially in institutions with so much interdisciplinary communication, and patients receive the consequences. More than half of all errors in a hospital are medication-related, and pharmacists have a key role in preventing them throughout the medication use process.

The most interesting fact is that at UNC Hospitals, the most errors are done by nurses, with pharmacists coming in second. HOWEVER, because error reporting is voluntary, this is not by any means comprehensive. What it does mean is that nurses care enough about patient safety that they will even report themselves doing an error. Many are afraid to report errors because of fear of punishment, but without reporting errors, we wouldn't know how to improve. The ultimate goal is to minimize errors to optimize patient care and safety! 

Day 7: Emergency Department

On this day I finally got the opportunity to speak to patients! In the emergency department of UNC Hospitals, there are pharmacy technicians that take medication histories of patients who will be admitted to one of the other floors.

Taking a medication history consists of asking patients what medications they are currently taking, how they are taking it, the dose, etc. You also ask about medication allergies, food allergies, and over-the-counter medications (i.e., vitamins)/herbal supplements. This information is reconciled with what the patient has in his or her profile. This is an essential step in ensuring a patient is on all of the medications he/she needs while in the hospital. Also, it is necessary to have the most updated information to make sure there are no drug/food interactions that can cause harm.

I got to take 3 medication histories, and it was quite a challenge in some cases because, being in the ED, they aren't exactly calm. But it's so important that we have to push through and get all of the necessary information.

It was so great talking to patients today! We have two days in the ED, so I'll have another opportunity later this week!

The Long Journey

I'm 3 days behind in recording my rotations, but I'll get to that later.

Today, a long journey finally came to an end.

After 4 years of rigorous course work...
summers spent being a science camp counselor...
3 years in a research lab...
months spent taking Kaplan MCAT Prep Course...
26 practice MCAT's...
spending thousands applying to medical/osteopathic schools...
an MCAT score below his target...
months spent re-studying and re-taking the MCAT...
getting ready for spring senior finals with a chemistry major...
withdrawing applications to medical/osteopathic schools...
figuring out a new plan of action...
deciding to take a year off...
getting an MCAT score to be proud of...
re-applying to all of the medical/osteopathic schools...
moving to North Carolina...
trying for months to find a job...
having to figure out how to spend time while his girlfriend was busy with school...
making new friends at work...
waiting to hear back from the dozens of schools re-applied...
finally getting that first interview...
finally getting that first acceptance...
getting wait-listed to his top choice...

and waiting... waiting... waiting...

Errol has FINALLY been accepted into UCF College of Medicine! The College promises to be the future of medicine in Florida, with state of the art equipment (it's only 4 years old), progressive teaching styles, and is strategically centered in the middle of hospitals being constructed.

There were so many times Errol felt disappointed, hopeless, and that nothing would ever just go right. I don't know how one person can go through so much stress, disappointment, and uncertainty. But it has been my job to support him through all of the ups and downs. I like to say that I have done so to the best of my ability. He has persevered through numerous trials and tribulations, and he can now say that he is a future MD.

Only thing left is to celebrate! I'll be taking him out to 411 West, which is the closest place I have seen here to Leonardo's 706.

Day 6: Round with a Resident

Today was another great day! I got to round with the PGY2 hematology/oncology pharmacy resident. We spoke to patients who were in the hospital post-bone marrow transplant and/or for complications regarding the transplant.

The medical team consisted of the attending, resident, 2 interns, a 4th year medical student, and the pharmacy resident. Each of the doctors had a few cases each to present to the team. The reason the patient was in the hospital, any issues/complications over the past 24 hours, remarkable lab values, etc. were amongst the topics presented and discussed outside of the patient's room. After the presentation, the team went inside to speak with the patient. The attending was mainly who spoke to the patients.

This was my first experience seeing communication amongst medical professionals, and communication to patients. One of the required readings before the start of pharmacy school was The Anatomy of Hope, which was written by an M.D. to describe the very delicate process of delivery good/bad news to patients. and his experiences with trying to give false hope, being overly optimistic, or even to negative. The different scenarios even had different results in terms of patient outcome. I highly recommend reading it.

But I digress...

There was a large variety of patients that we saw, from ones who could be discharged the next day, to ones where we couldn't give any good or bad news (unchanged progress), and even ones who needed to go to Hospice. The dialogue used by the physicians were very deliberate.

The pharmacy resident provided input when necessary regarding a patient's medication regimen. A lot of things were recommendations in antibiotic regimens (especially vancomycin). Some of the other roles the pharmacy clinical specialist are to answer questions about adverse reactions, recommendations about drug substitutions or dosing, etc. According to the pharmacy resident, one of the things he learned is that sometimes a question can't be answered right away, and that's okay. Most questions asked are about very rare reactions (<10% of cases), but one of the skills we learn in school is how to look up drug information and support decisions based on primary literature (i.e., clinical trials).

Learned so much today! Starting to think maybe I want to do a residency...

On deck for tomorrow: Emergency Department

Day 5: Surgical Services

Today I thought I would observe the pharmacist of the Surgical Services pharmacy satellite. I arrived and watched the pharmacist and technicians catch up on the morning orders. Surgeons stopped by the window asking for bags of normal saline, ephedrine, heparin, etc., to prepare for their morning cases.

Then, I was given scrubs and was informed that I would be watching surgeries!

I saw a total of 3 in a 4-hour span. The first was a skin graft after removing melanoma. I'm glad that was first because this was my first surgical experience. While I don't normally get squeamish and I'm not afraid of needles, I wasn't sure how I would handle this much. But I was fine, and you actually get used to it once you think of the patient as a body you are trying to fix instead of the pain they will probably feel post-anesthesia.

The second was a transurethral resection of the prostate (TURP). I won't go into the gory details, but the surgery lasted about 2 hours. During this case, I mostly stayed with the Certified Registered Nurse Anesthesist (CRNA) and spoke to him about how he sedates patients, maintains sedation, and then wakes them up. There are a combination of infusions used to sedate the patient, relax the muscles, and control blood pressure (which tends to drop). It was interesting to be around so much medicine administration and not have any sort of pharmacist intervention any step of the way. Maybe it's a future niche to be filled?

As the second case finished, it was 11:30AM, and a discussion was scheduled at noon for all of the students. I walked out of the room and there was a Da Vinci surgical robot being used in the hallway. The big screen TV on the wall showed what was happening in a whole separate room. This case was removing a large fibroid from the uterus, and I watched for about 20 minutes. I couldn't believe I got to see such amazing technology being used first hand!

Scheduled for tomorrow: Round with a pharmacy resident - Bone Marrow Transplant

Day 4: Pediatric Pharmacy

Sorry I've gotten behind, I am determined to document this whole month!

I was in the pediatric satellite pharmacy today, and shadowed the pharmacist. What's different about a pediatric pharmacy is that 90% of all the medicines are in liquid formulation. Very different from what I'm used to at CVS!

One of the challenges of pediatrics is that some drugs may not have a liquid formulation. There was an example of one while I was there with phenoxybenzamine. We talked to the Special Formulations pharmacy to see if they would be able to create a new recipe in house.

The pharmacist and I took a walk up to the floor to talk to the nurse taking care of the patient to let them know it would be a few hours for Special Formulations to get the medicine prepared. The nurse said that was fine, and that during rounds it was inquired the onset of action of the medicine, and I looked it up. This was my first experience communication drug information to part of the health care team (that wasn't another pharmacist).

It took some thought to figure out how to convert "The half life of the drug is 24 hours because it is partially excreted in the bile and therefore is subject to enterohepatic recycling" to "The half life of the drug is 24 hours because it gets reabsorbed, so it stays in the patient's system longer".

For tomorrow: Surgical Services Pharmacy

Day 3: Oncology Pharmacy

I was all gowned up today in the clean room for my 8AM-4PM shift. Most clean rooms and IV rooms are in the basement of a hospital, with zero windows. In the Cancer Hospital, however, the whole back wall is open to the vast North Carolina landscape. It's a wonderful atmosphere!

Before lunch, I shadowed the technician and watched him mix bag after bag of chemo- and non-chemotherapy medications. The clean room of the Cancer Hospital takes orders from the oncology inpatient, infusion outpatient clinic, rheumatology, IDS, pediatric floors, solid organ transplant, rheumatology clinic, etc. It was exciting to see all the antineoplastic medications we learned in pharmaceutics and biochemistry. It's so refreshing to see all of the things we learned in just one year being applied in all aspects of the hospital.

After lunch, I shadowed the pharmacist, who happened to be a resident today. A graduate of UNC, he told me all about his path to residency which was good perspective. I learned how to verify IV's, and it is much different from verifying medicines in the community. The only way to check if an IV bag has been made properly is to verify the vial, concentration, correct volume(s) injected into the bags. The volume injected is determined by providing the syringes used marked or pulled out to the point that was drawn up. We also had to verify Body Surface Area (BSA) for each patient, which is used a lot for chemotherapy drugs.

Today was the first opportunity I got to see drugs I learned in class used as therapy. So exciting!!!

On Monday: Pediatric Pharmacy

Day 2: Transitions of Care

Today's main theme was making the transition from hospital inpatient to home outpatient as smooth and beneficial to the patient as possible. There are many times patients go from a hospital bed to discharge with a stack of prescriptions and quite possibly not be able to fill their medications right away due to the state they are in. In addition, he or she may not receive adequate counseling from the community pharmacist because of time issues and lack of knowledge of what happened within the hospital.

UNC Hospitals is therefore trying to improve the issue by launching Carolina Care at Home. Today I shadowed the transitions technician who took me step-by-step through the process. Right now it's still very new; the program launched October 2011 and is slowly being incorporated into various acute adult units, including cardiac intensive care unit, solid organ transplant unit, and hematology/oncology (the newest unit).

Every morning, the technician goes through the list of patients in the units and looks at the prescription insurance the patients have. Currently, the program is not going to enroll self-pay (no insurance) and Medicaid-covered patients. Another goal of the program is to create some revenue for the hospital, because most of the patients that get prescriptions at the hospital are helped with Medical Assistance Programs. By getting fills that are reimbursed by third party payers, it helps the hospital pharmacies too.

Once she has a list of patients with insurance, we go to the floor and see who on the list will be getting discharged. If a patient is getting discharged, we talk to the nurse and ask if he/she will be going home with new medication prescriptions. If so, we speak with the patient.

We got to talk to one patient. She asked him if he would like to fill his first fill (30 days) at the hospital; we would have them delivered to his room and billed by the discharge pharmacist and he would pay his normal copay. The refills would be sent to his home community pharmacy. He accepted enrollment in the program and we talked to the discharge pharmacist about the prescriptions that were being sent to him.

The ultimate goal of Carolina Care at home is to be incorporated into the whole hospital and enrolling 30 patients a day into the program. I feel this was a great experience to see a brand new initiative being implemented in the hospital. Transitions of care is a very crucial part of a patient's overall health!

On deck for tomorrow: Oncology Pharmacy

Day 1: Investigational Drug Services

Yesterday was technically "day 1" but it was just orientation. Today was the first experience we had in the pharmacies of UNC Hospitals.

My shadowing today exposed me to a type of pharmacy I had never heard of before. The Investigational Drug Services (IDS) is a pharmacy that dispenses medications like any other. However, the difference is that it only dispenses drugs that are for patients in clinical trials being conducted by hospital clinicians. There are about 450 trials currently being conducted within all the hospitals. While the pharmacy I was in today was in the Neurosciences Hospital (just by chance because the space was available), there is another one in the Cancer Hospital that specializes in oncology drugs because there are so many new drugs coming out for cancer. Around 150 trials alone are in the Cancer Hospital.

I found it very interesting to observe what happens in a research-oriented pharmacy. Clinical trial protocols are given to the pharmacists of IDS, who order the drugs (some of which aren't on the market yet because they are Phase 2 and 3 drugs, and some which are on the market and are being studied for a different indication), and dispense either placebo or drug based on the particular trial design.

It turns out that trials can get very complicated with many layers of comparisons. I was able to read through at least 10 trial notebooks during my 8AM-2:30PM shift. Some were placebo vs. active drug, some where 2 active drug comparisons, some were placebo vs. brand drug vs. generic drug, etc. Whatever you can imagine, there is probably a study design for it.

I learned a lot from today's experience, and was very excited to see the type of pharmacy that acts as a bridge between bench research and clinical application.

On deck for tomorrow: Transitions of Care

End-of-semester Wrap-Up/H-IPPE Orientation

I can't believe I never posted since March, but this semester was one of the toughest I have experienced. Last week was finals week, and there were 5 finals, 5 days in a row. Four of them were cumulative. It was the most intense week of my life, but I survived.

Final Report Card: 
Pharmaceutics 2 - A
Pharmacodynamics - A
Pharmaceutical Care Lab - A
Introduction to Therapy 1 - B
Biochemistry - B

Overall, I am very pleased! I finally figured out my study groove, and any B's I had were a painful 88%. I worked harder than I ever have before and it paid off! I am excited for next year when we are exposed to more medicinal chemistry and therapy.

My school positions for next year: 
APhA-ASP President/Liaison-Elect
Recruitment Ambassadors Program Secretary-Elect
Pre-Pharmacy Club Secretary

Another project I'll be working on this summer is writing a proposal to start a dual degree program with Masters in Public Health!

Today was also a big day! My Hospital Introductory Pharmacy Practice Experience (H-IPPE) orientation was today. We took a tour of the vast UNC Hospitals and became familiar with the expectations of the month. I feel so lucky to be rotating at UNC Hospitals. I hope that my classmates have the same great experience wherever they are in North Carolina. The class is spread out into various regions of the state, from Wilmington to Asheville. I will definitely update every day to account for my experience! Here is a list of things I will be exposed to:

-Investigational Drugs
-Transitions of Care (inpatient --> outpatient)
-Oncology Pharmacy
-Pediatric Pharmacy
-OR Satellite pharmacy
-Round with Resident (very excited about this!)
-Emergency Department (twice!)
-Drug Information and Medication Safety
-Special Formulations
-Decentral Pharmacist (twice!)
-Inpatient Pharmacist (twice!)
-Controlled Substances
-Sterile Products
-Administration
-Outpatient Pharmacy
-Pharmacy Support Services

We also have 2 projects. One New Drug presentation, and a special formulations assignment where we analyze a drug that is specially made in the pharmacies and if it's more feasible to buy it commercially.

Tomorrow is Investigational Drugs! Cheers to the month :)