My Pharmacy Practice Experience

My name is Trang and I am a PharmD candidate of the UNC Eshelman School of Pharmacy class of 2017. Here you will find stories and daily logs of my introductory and advanced pharmacy practice experiences (IPPE and APPE).

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April 28th, 2017-  The end of April marks the end of my student rotations! Rotations I didn’t blog about include: Internal Medicine (October), Community (November), Diabetes (January), Pediatrics and NICU (March).

I can’t believe this long journey is finally coming to an end. So excited for what’s in store!

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March 17th, 2017- I don’t update for months then BAM, pharmacy school is almost over. Today was Match Day for pharmacy residency! I spent all of February interviewing at residency programs across the state of Florida. I’m so excited to share that I will be completing my PGY1 Pharmacy Practice Residency at Cleveland Clinic Florida! Here are some photos from Match Day aka St. Patrick’s Day! Maybe I’ll continue to write some updates during residency.

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September 2016 - Ambulatory Care at MAHEC (Mountain Area Health Education Center

Brace yourselves, this post is going to summarize my whole month, since I failed to post anything the whole time I was there!

I spent this month on my Ambulatory Care rotation at MAHEC with another student, Karen. Our preceptor is Dr. Irene Park (not for long though, since she got engaged the second week of rotation!).

I absolutely loved this rotation! It mostly consisted of us traveling to the various clinics that Irene covers. We essentially took over Irene’s schedule, and saw her patients. We mostly saw patients for diabetes visits (normal, and gestational), anticoagulation, and annual wellness visits. Irene allowed us to prepare for the visit, and meet with the patients ourselves. We’d then exit to talk it over with Irene, then we’d come back in together to close out the visit. I loved being able to meet individually with patients and actually get to know them! In Ambulatory Care pharmacy, it’s more of a primary care setting, where you’ll get to see the same patients and truly build a relationship with them. I had a some patients that came in 2-3 times during my month there, and I loved being able to catch up with them and see how they’re doing!

Because North Carolina has the CPP (Clinical Pharmacist Practitioner) model, we are able to make changes to the patient’s medication regimen without having to consult with a physician first. The pharmacist and the physician have an “agreement” where the pharmacist is able to make changes and recommendations under her scope of practice. For instance, Irene can make changes to pretty much all chronic disease regimens (such as diabetes, cholesterol, acid reflux, anticoagulation, etc), but she can’t write a script for TamiFlu if the patient is coming in with the flu (in which case they’d meet with a doctor and not a pharmacist anyway).

Now on to Internal Medicine back at Mission Hospital!

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August 31st, 2016

Pregnancy/Lactation Tips - I spent the past three days in the core pharmacy. This is basically where all the medications and IVs are verified, and made or packaged. Today, we had a lot of pregnancies, so I learned a few tips and trips for those who are trying or going to start a family soon:

- For morning sickness, people used to use Zofran (ondansetron) a lot, but recently it's been loosely linked oral clefts and cardiac issues in babies. Doctors may still prescribe it but its up to your/your doctor's discretion if you'd still want to take it. Just something to consider.

- Doctors may also prescribe Diclegis for nausea and vomiting, but it's a very expensive prescription medication and it can be broken down into two inexpensive over the counter medications: doxylamine (Unisom brand name) + Vitamin B6 (pyridoxime). Both are ingredients in Diclegis to help with nausea/vomiting aka Morning Sickness. However, you may not even need the Vitamin B6. Doxylamine itself can help. But if you ever get prescribed any of those expensive meds and want to consider other options just give me a call :) Sometimes doctors have a pattern and routine, especially those have been in practice for a long time so they may not be up to date with the recommendations OR they might not believe them since they're set in their ways. It’s just important to know your options and alternatives.

- Lastly, once you start looking at nipple creams to help with breastfeeding, Lanosinoh brand may be the way to go. There's a bunch of brands for lanolin creams, but Lanosinoh is the most purified version (it's about the same price as the other ones) so it causes less irritation and allergic reactions. Obviously it's different for any women but apparently this one people love!

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My days at Ridgefield. Can I stay in scrubs forever please?

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August 18-20th, 2016 - Ridgefield - Mission’s Packaging facility

Most hospitals will have their packaging, IV and chemotherapy prep, and compounding facility in the basement of the hospital. Mission has their own “Ridgefield” campus where all of this is done. There are also some affiliate hospitals in the Mission Health system in the area that Ridgefield packages for too. In the morning they package maintenance or “stock” medications and send it over to the hospital. This is anything to fill the automated Pyxis machines on the floors, or replenish stock in the pharmacy. Then in the afternoon, they focus on patient specific medications that are to be given later that night. Even though they do most of the preparing at Ridgefield, Mission also has their own in-patient pharmacy where they have a bunch of medications as well (makes sense since Ridgefield closes at 4:30p--where would you get medications that you now need?). It’s definitely very interesting how it’s set up. There are 1-2 pharmacists that work there daily, and upwards of 15 pharmacy technicians working.

Things I learned

- Donnatal contains phenobarbital, which is a schedule IV drug. But Donnatal isn’t considered a controlled substance. Why? The amount of phenobarbital that is in a daily dose of this mix is lower than the amount to be taken for abuse of the drug (+/- 150mg). Even if a patient were to drink a whole bottle of Donnatal in hopes of getting that euphoric/high effect, they would have extreme anti-cholinergic effects (dryness, urinary retention, increased HR, etc). Based on this, Donnatal is considered an “Exempt Prescription Product” by the DEA. This means that although it contains a scheduled medication, it is not considered a scheduled medication because of it’s lower potential for abuse.

- Insulin regular is the only IV insulin. My pharmacist said to know this for boards, but I did some (quick) research, and I’m not sure if it’s accurate today. I’ll have to do more in-depth research later.

- Levothyroxine is T4! “KNOW THIS FOR BOARDS”

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August 17th, 2016 - Emergency Department

I spent the day in the emergency department and I LOVED it. I’ve never had any experience in the ED, so everything was new to me. Some highlights, or things that I learned:

- There are 1-2 pharmacists in the ED at *most* times. I think between 3-6am there is no pharmacist there. They will answer any physicians have about what medications to give the patient, what dosage to give, and how to administer it. They get a lot of obscure questions from the doctors too, like “My patient wants to be discharged on a blue prescription iron pill he took 5 years ago, can you figure that out?” So it’s pretty fun because you can literally be asked anything!

- We had a stroke patient (my first stroke patient! -- not to say it’s a good thing, but it’s very interesting to be able to watch the team work together for these patients), and a lightening strike trauma patient (my first trauma!). It’s incredible how cohesive the pharmacists, doctors, chaplain, xray techs, nurses, and other staff work together during these situations.

- I learned that when Trauma patients come in, they don’t want to waste time figuring out their name, so they’ll put in a default name, describing the type of trauma and what state or county they’re from. It’ll also default the patient to be 100 years old. Within 10-15 minutes all this information will be updated as they get it, but it’s more important to start treating them, than to figure out who they are.

- If an unidentified patient comes in, they’re listed as ‘Doe-”flowername.”’ So they could be listed as Doe-Carnation, until they figure out who the patient is.

- Pharmacists in the ED at Mission Hospital are responsible for following up on patients who had cultures drawn for infectious diseases. So if a patient came in with a fever and lower back pain, we’d probably get urine cultures and blood cultures to see if they have an infection. While we’re waiting for the results, we’d probably start them on “empiric therapy” to cover the bug that we think they may have, and they may be discharged on this empiric therapy. Once we get the results back, we want to narrow the therapy to kill specifically what bug they have. So if they’ve already been discharged and we receive results, the pharmacist will follow-up with the results to make sure the patient is taking the correct antibiotic.

- We aren’t as concerned when patients come in with Group B Strep (we’re more concerned for Group A!). They have a universal suseptibility to Penicillins (or Cephalexin).

- For UTIs, remember to consider renal function for patients. Bactrim (think of age, renal dysfunction, K+), Nitrofurantoin (contraindicated in CrCl<60), meropenem may be too broad, cefazolin may be narrow enough for UTI.

- For stroke patients, we want to give TPA as soon as possible. TPA is tissue plasminogen activator and its a protein involved in breaking down blood clots. It’s administered as 0.9mg/kg. You give a 10% bolus over 1 minute, then give the rest over an hour.

- We had a meth toxicity and subsequently withdrawal patient who was severely agitated. The pharmacist (Nikki) and I discussed which beta blocker we’d want to give him. We’d want to choose something like carvedilol or labetolol for both their anti–alpha-adrenergic and anti–beta-adrenergic effects. Labetalol has also  been shown to safely lower mean arterial pressure in cocaine-positive patients.

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August 16, 2016 - Adv Hospital

Today was my last day in the CTC (Clinical Training Center) during this rotation. I’ve absolutely loved it here! I got to dose a lot of warfarin, vancomycin, vitamin D, phenytoin, and evaluate patient’s medications based on their renal function. It was fun navigating PowerChart (our electronic health records system) and sort of playing detective to figure out what the patient’s needs are. Tomorrow I start my mini-rotations in the hospital. I’ll be heading to the Emergency Department and Ridgefield (which is Mission Hospital’s medication packaging facility) this week.

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Pharmacokinetic dosing for vancomycin - Here is an example of what it looks like to calculate a vancomycin dose for a patient. Note that this is only HALF the work it takes. So basically a doctor or nurse practitioner will call in a consult to either give a recommendation for a first dose or to check to make sure the current dose is appropriate for the patient, then we’ll check the patient labs, and do the calculations!

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August Rotation - Advanced Hospital (@ Mission Hospital)

I started my Advanced Hospital rotation this week. This rotation essentially exposes us to the inter-workings of the hospital, and allows us to learn about most of the roles of a pharmacist in the hospital. I say most only because there are so many areas that a pharmacist can work in, and we simply don’t have enough time to see it all! Most of this rotation is the “non-patient care” part of pharmacy – not to say we aren’t taking care of patients, but we have less face time with patients, and it’s more of the background work. Some of my experiences include kinetics dosing, core pharmacy, metabolic support, cancer center, pharmacy informatics, management, operating room, emergency department and off-site filling facility. Some other experiences that are offered on this rotation that I will not be doing is pediatrics (I have a rotation in this in March, I’m SO excited!), pharmacogenomics, psychology, etc. My preceptor’s name is Jordan. She got her PharmD at UNC, and did her Residency at Mission Hospital!

My first day was awesome! I think part of it was finally doing something real. Not to say my past three months have been a waste, but I haven’t truly put my pharmacy knowledge into good use. I’m spending the first two weeks in the CTC, where I’ll be doing pharmacokinetics dosing. The last two and a half weeks I’ll spend on those mini-rotations.

Pharmacokinetics. What is it? It’s “the clinical application of the principles of drug absorption, distribution, metabolism and excretion to the safe and effective therapeutic management of drugs in an individual patient.” We use patient characteristics (such as age, weight, and lab values) to calculate personalized doses for patients. I’m focusing on dosing aminoglycosides (a class of antibiotics), vancomycin (an antibiotic), warfarin (anticoagulant aka blood thinner), phenytoin (a seizure medication), vitamin D, and occasionally adjusting medications based a patient’s renal function (how well the kidney is doing!). A lot of times doctors will prescribe these medications, and will call in pharmacy to “consult” on them. Then we’ll calculate a dose if it’s a new start, or adjust based on changes if the patient has been on the medication. See, there’s more to a pharmacist than what most people think! We’re doing some hard work in the background :P See above for an example of what some of my notes look like while calculating doses.

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July 30th, 2016 - Med Rec

What I love about Med Rec is that it is sort of detective work. There was one night this week where I was only able to get through one patient since it was a bit more complicated.

He was a 39-year-old white male who presented with chest tightness. He has bipolar disorder, hypertension, hyperlipidemia, COPD, anxiety, depression, panic attacks, PTSD, sleep apnea, chronic back pain, cardiac catheterization in 2011, gastric bypass in 2011, a history of alcohol abuse and smokes. He fractured his 9th rib on July 4th after falling while experiencing chest heaviness/dullness. For the next few days he felt tightness in his chest and nausea multiple times for up to an hour at rest.

Sometimes nurses will have finished a med history, and we’ll back check it then do the med rec. Sometimes the med history hasn’t been done at all so we’ll go ahead and do the med history and rec. In this case, the med history was done by a nurse when the patient came to the emergency department the night before. So the patient was already given medications (based on his home regimen) that first night.

There were 32 medications on the history list that the nurse approved. I went upstairs to talk with the patient to double check everything he is taking at home. I ended up speaking to his wife on the phone, and I went through every single medication with her, confirming the name, strength and frequency. Here are the issues I found when compared to the original med history:

- 3 medications that he is currently taking was not on his list at all.

- 11 medications were marked “prescribed, but not taking,” but actually are no longer prescribed at all.

- 7 medications were marked “still taking, as prescribed,” but they’re no longer prescribed.

- How he was taking some medications were incorrect.

I went back to the computer and updated his med list. I was happy that I was able to clear everything up, and clean out his history. I did the reconciliation and found that the only two medications that they missed giving him in-hospital was his amlodipine 5mg (blood pressure/heart), buspirone 5 mg (anxiety/depression), and propranolol (blood pressure/anxiety). Really out of those three, the one that he really should be given is the buspirone, but I figured I would recommend all three when I speak to the pharmacist.

HOWEVER. PLOT TWIST.

I called to his floor to speak with a nurse about another patient, but she brought up this patient and said she wasn’t sure if the wife was giving us the correct information (since last night the wife told the nurse inconsistent information as well). We called his pharmacy and obtained a “fill list” (which is basically a history of when he filled all of his medications). It looked like there were 7 medications that either he should have run out a few weeks ago, he hasn’t filled since December 2015, or he’s never filled at all.

I went to clarify with him and his wife. I figured that he hasn’t been taking some medications because maybe they can’t afford it (that was the case). His wife was hesitant at first to tell me he wasn’t taking some of the medications, but I assured her that its okay, and we just wanted to clarify so we know what he has been taking so we don’t give him medications he isn’t even taking. So from that, I confirmed that he is no longer taking 3 medications that I had on my list.

One of the medications we were most concerned about was divalproex (bipolar), because he was on a high dose and we had given it to him last night. But if he is no longer taking it, we don’t want to be giving it to him (especially at such a high dose). It turned out that his doctor helped them obtain another 90 day supply through a medication assist program, so that’s why it was not on his fill list.

In summary, I found 6 errors after doing his medication history and reconciliation.

1. Since the nurse had marked the medication list as “final” last night, the doctor gave the patient 3 medications that he is not currently taking. The doxazosin (bipolar/PTSD), ziprasidone (bipolar/mood), and pregabalin (nerve pain). //Update, they discontinued these meds that night after I left!

2. Since these were not on his original history from last night, he wasn’t started on amlodipine, buspirone, or propranolol.

I confirmed my recommendations with the pharmacist, and I noticed the issues and told the nurse (who would tell the MD).

This was definitely one of my more interesting cases, and I’m glad I was able to clarify a few errors!

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Rotation #4 - Medication Reconciliation

I might just keep this and updated it with random clinical pearls and notes from this rotation (mostly for me to remember):

- Metformin should be discontinued if patients are undergoing contrast dye. This includes patients who present with an MI who are undergoing cardiac catheterization. UpToDate notes: Discontinue metformin at the time of or before iodinated contrast imaging procedures in patients with an eGFR between 30 to 60 mL/minute/1.73 m2, in patients with a history of hepatic disease, alcoholism, or heart failure, and/or in patients who will receive intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours following the imaging procedure; metformin may be reinitiated once renal function is stable.

- Five meds to give MI patients: antiplatelet (+/-), statin, beta blocker, ACE/ARB, aspirin.

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July 23, 2016 - Rotation #4 - Medication Reconciliation

I’m back in Asheville to continue the rest of my rotations! July is my longitudinal medication reconciliation rotation. So I’m going into the hospital in the evenings to do medication histories and reconciliations ("med rec”).

This week I had a really great patient! He was an older male, presenting with atrial fibrillation. He underwent catheter ablation, which is a minimally invasive procedure that basically kills tissues in the heart that are causing abnormal electrical impulses. I came in to speak with him and his wife after surgery. This was one of the most refreshing patient experiences I’ve had while doing medical reconciliations. He is a retired science teacher, so we talked about pharmacy and chemistry, and what peaks our interests. Then he told me about random science experiments he would conduct at home, just based on his own curiosity. He was incredibly upbeat and friendly, and knew everything about what medications he is taking, and why he is taking them. We probably chatted for about 15-20 minutes.  It is refreshing because some patients we see don’t want to talk to us, or don’t know anything about their medication which makes it hard for us to do our part in the med rec. Sometimes it is difficult to find out what medications a patient is on if they (or their caregiver) don’t know, because their pharmacy is usually closed by the time I start working. The point of my job is to make sure we are giving them the correct medications in the hospital, based on what they’re taking at home. So there are nights when our med histories go “uncompleted” or “needing follow-up” which makes me a little uneasy since I like to be complete (who doesn’t?)!

Anyway, although the paperwork takes awhile, I do enjoy doing med recs. It gives me the opportunity to speak with patients/nurses/doctors/pharmacists, and navigate the hospital and EHR (electronic health record) system. Working another full week this week. Looking forward to it!

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Tokyo Week 5 - Thursday, June 30, 2016 - Today was Brian’s and my last day on rotation at Keio University! We both gave a final presentation covering the similarities and differences between a pharmacotherapy topic. He presented on Sepsis and I presented on Gestational Diabetes. It is crazy how fast this month flew by! Pictured here are the other exchange students from the University of Iowa and Khon Kaen University in Thailand. Although we only overlapped for two weeks, it was an incredible experience getting to know them, and learning about their curriculum and pharmacy practice in their area. I am so so grateful for this experience. I’m sad to leave! The good thing is, Brian and I are headed to Thailand on a mini-vacation before going back to reality. See you soon for updates on my Advanced Hospital Rotation at Mission Hospital in August!

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Tokyo Week 5 - Wednesday

June 29, 2016 - Today we visited Kawakita Hospital. I didn’t write a blog, and I don’t remember much from it! Keeping this here so I can still recall what hospital we visited on this day. :)

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Tuesday June 28, 2016 - Today we spent the day at Keio University Pharmacy and Japan Self Defense Force hospital. Keio University Pharmacy is basically the pharmacy school’s community pharmacy. It’s attached to the pharmacy school and students spend time there counseling patients and doing point of care testing. We got to help mix bags of Kampo while we were here! The Japan Self Defense Force hospital was awesome! It was state-of-the art, and fully equipped to handle emergency situations (like an earthquake!). It’s built upon 170 seismic shock absorber devices that suspend the hospital and allows it to withstand almost any strength earthquake. The staff said they don’t even feel anything when one strikes. Other than that, they have an intense plan for if there is any emergency. They have a pavilion area for triage, most patient waiting benches can transform into beds, and every room and hall has an extra set of medical outlets so they can add extra beds to that area if needed. We met approximately 15 pharmacists who are still in training, and will be dispersed to different areas in Japan once they finish training. They were all in different aspects of the military: Air force, army, navy, etc. We also got to check out the helipad on the 11th floor. It is equipped with an elevator to take patients down to the ICU/ED. It’s one of two helipads that can hold the weight of military helicopters (forgot how many tons but it was a LOT). Overall it was a great day!

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Tokyo Week 5 - Monday June 27, 2016 - Today we met an incredible pharmacist. Dr. Mikihiro Maeda obtained his Bachelor of Pharmacy and licensure in Japan. He saw the need for more experienced and better educated clinical pharmacists in Japan, so he spent 8 years in the U.S., taking prerequisites at a CC, then obtaining his PharmD at Nova Southeastern University, PGY1 at Temple University, and PGY2 in critical care at the University of Maryland... all while not knowing anyone, learning English, and having to acclimate to the American lifestyle. He now works as the director of clinical pharmacy at a hospital with one of the most developed clinical pharmacy practices in Japan (thanks to him). Hearing his experience and the sacrifices he made to improve pharmacy practice in his country was so inspiring I just had to share it!

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Rotating at St. Marianna’s hospital today was one of my favorite experiences of this trip. We had a thorough tour of pretty much every area in the hospital that a pharmacist is involved in. Brian and I were surprised to find that the Drug Information Center of the hospital was very robust (especially compared to the other hospitals). They use a lot of paper resources since the online references are very expensive, so they had shelves just lined with all the newest books. There was a book series of Drug side effects that Brian and I had never heard of. It was called Meyler’s, and it was 8 volumes! It reminds me back in the day when everyone had their own encyclopedias.

In the dispensing pharmacy, they had this awesome piece of technology that helps pharmacists with verification. In the U.S., in order to verify prescriptions before they are given to the patient/floors, typically the pharmacist will scan the prescription, and the computer will show an image of what the medication should look like. Then, the pharmacist will verify that they match. Here, they have a scanner, where they put the drug on top, then it scans the image of the drug and lets the pharmacist know if it is correct. It was soo cool!

We also sat through a clinical pharmacist meeting, there the pharmacists get together to discuss issues within their wards, and go over a patient case. We also toured the ICU and a few wards. To wrap up the day, we had a discussion with Dr. Maeda about differences in practice between our countries. It was really neat to hear his point of view since he has a lot of experience in both countries.