Dear Kidneys, Thanks For Making Urine!

My Solid Organ Transplant rotation ended last week, and I’m really sad to leave it behind. It took me a while to get into the swing of how hospital works and understanding the transplant schedule. The more I work on transplant, the more grateful I am that all of my organs work, and I have started wanting to take very good care of them!! Time for an overview of being a 4th year student on the SOT and at Fairview, I think!

7:15-8:15: Look up your patients and write down all of their over-night lab values and medication changes. I was assigned 4-6 patients to follow at a time (the pharmacist, of course, manages to track all 20+ while I handled this amount).

7:30-9:30: Starting anywhere in that range, the organ transplant teams start rounding. At Fairview they are broken up into 3 smaller teams, Kidney, Liver, and Pancrease+Auto Islet Cells. Each rounding team consists of 1 surgical fellow, 1 NP or PA, the pharmacist, the social worker, sometimes the nutritionist, and any students. While other floors have regularly scheduled rounds (ex: Cystic Fibrosis floor rounds at 9am), these teams round whenever the fellow comes up to the floor and has a chance- they just swing past the pharmacy desk (located in the work room along with the SOT team members) and say, “Kidney is rounding!”. On rounds the team discusses each patient on their service, looking at recent lab values, any changes over night, determining therapy for the coming day (Ex: for a new transplant patient, what should the days cellcept, prednisone, thymoglobulin, and valgancyclovir doses be and is the patient ready to start a CNI? Which CNI?). They then go in the room and chat with the patient, find out how they are doing, if they have any concerns, and do a short physical assessment of breathing and the surgical sight (or other if they are not a new transplant patient). The pharmacist pushes a computer cart during rounds and is able to answer any questions about current or past medication use by the patient, and has access lab values especially infectious disease cultures and sensitivity data, and uses this opportunity to make therapeutic recommendations for initiation/discontinuation, as well as be tied in to understanding the treatment plan for the day. From my observations, the pharmacist was of especial utility to the team in recommending appropriate antibiotic therapy and noticing potential interactions in the proposed antibiotic plan. Each team has only about 2-6 patients on it’s service so rounds are not too long, but as pharmacy attends all the teams (as possible), they can be on rounds for some time.

End of rounds-12: Students have time to dig more deeply into each of the patients they were assigned. I got to read notes back through the entire visit as well as prior admissions, look at all electrolyte trends, analyze immunosupression trough levels, vancomycin trough levels, warfarin and heparin levels, check up on the medication plan for the day and if it followed the protocols, look for drug interactions, etc. I had a wonderful amount of time to do some independent study on things I have forgotten or never knew (Up To Date is such a nice resource!). I tried to also research any conditions in the PMH that I was unfamiliar with and get to know my patients as well as possible- The pharmacist told me, “These are your patients. You have to take responsibility for them.”

12:00-1:00: All Fairview APPE Students attend lunch lecture. Some weeks lectures are provided by Fairview pharmacy faculty members on topics from Hospital Aquired Pneumonia to Diabetic Ketoacidosis, other weeks they are student prepared case presentations. I am one of about 15 students currently at Fairview, and we each take turns presenting a patient of ours to eachother, which means we get a review of a number of topics as well as get to hear about the many services we are each on in the hospital, form ICU to oncology and BMT! I presented a SOT patient last block who had Post Transplant Lymphoproliferative Disorder.

1:00-2:00ish: You have a short time to come back and check up on your pateints one last time to see if anything new has happened – perhaps new ABX cultures have come back or new immunosupression trough levels. Review your patients and be ready to present.

2:00-Leave: Around 2/2:30 the pharmacist would spend time with me. I presented my findings on my patients  with a background if they were new, or just updates if they were not. It took me a while to get the hang of this, but instead of pointing out problems I found, I was asked to present my solutions to the problems I found, including a plan for how to adjust immunosuppresion doses, change blood pressure meds, etc, as well as an assessment of what medication changes had already been made by the providers, why they had changed, and if they seemed appropriate (indicated, appropriate, dosed appropriate and corrected for renal function, etc). Then we would also discuss my “homework” – topics that I was assigned the day before to look-up overnight. I would give a description of what I had found out and the pharmacist spent some time teaching me more on the topic including filling in details I had missed. Everything from IV iron therapies to different antibioitic coverages. Also during these discussions we often found new holes in my knowledge that I was then assigned for the coming evening. At the very end of it all, the pharmacist brought any concerns she had to the PA/NP team members, sometimes having me do so.

On this rotation I also had assigned textbook and article readings, a project to develop index cards on immunosupression drugs and protocols, and helped conduct medication histories. I learned and got to practice managing patient TPN (total parenteral nutrition, aka IV nutrition), adjusting immunosuppression, adjusting vancomycin and aminoglycosides, managing warfarin and heparin, and practicing my knowledge of antibiotic coverage.

While it took me a few weeks to hit my stride (and goodness knows I could have used at least a few more weeks to really get better), I ended up LOVING my time in the SOT. A fascinating patient population. It was amazing to see people who improved dramatically after their transplant, although also an opportunity to see and care for some very very sick people. You never heard so much talk about bowel function and urine in your life! Both of the Fairview transplant pharmacists were wonderful and I learned a lot from them. I still try to bump into them from time to time!!

At the end of 5 weeks of talking about peoples kidneys making urine, I just have to thank mine a little bit and I suggest next time you grumble that you have to get up to pee that you say the same: Dear Kidneys, thanks for making urine!!


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