Solid Organ Transplantation

Wow, it has been almost 15 weeks since I last posted.  I’ve been caught up with my Acute Care Rotations at the University of Minnesota Medical Center – Fairview; it’s been an amazing experience, and I have learned so much!

Let me tell you about one of my 5 week experiences.  I’ll have to post later on the other two… 

Block 7: Solid Organ Transplant
During this rotation I followed patients who were admitted for a kidney, liver, pancreas, or simultaneous kidney-pancreas transplant.  Some patients I followed post-operatively, as they were admitted after a deceased-donor was identified and immediately went into surgery upon arrival to the hospital.  Other patients were admitted a day or two before their planned kidney transplant from a living-donor, either a related-donor or a living-unrelated-undirected kidney.  It always was amazing to think of how selfless and generous a person was to donate a kidney, either to somebody they know OR somebody they don’t know!  Most kidney transplant recipients have been on dialysis for YEARS, so getting a kidney gives them back some freedom and time, as they hopefully won’t need to go for thrice weekly dialysis runs for 4-6 hours. 

A typical day consisted of getting to Unit 7A around 7am, and looking at my patients, collecting lab values and reading progress notes – basically combing through their chart to find any concerns I may have about their medication therapy that I can bring up with the team during daily rounds.  Rounds are organized by the transplanted organ: kidney, pancreas, and liver.  The pancreas team usually covers the simultaneous kidney-pancreas transplant patients.  The team consists of a midlevel provider (Nurse Practitioner, NP, or Physicians Assistant, PA), the Pharmacist, Social Worker, Nurse, Dietician, and the Attending Physician.  Outside of every patient’s room, the team discusses progress the patient is making, plans for the day, and addresses concerns with lab values or medications.  Then the Attending physician, midlevel provider, and nurse enter the room and assess the patient.  After assessing the patient, they leave the room and again huddle around in a circle outside the patient’s room and talk about how the patient is doing and what the plan is; and if I had a concern, this is when I’d bring it up!  Other healthcare providers were always nice and receptive to my suggestions or concerns, and if I was wrong to be concerned about something – they’d take the time to teach me why! 🙂

I learned alot about the managment of patients pre and post transplant, including monitoring improving renal, pancreas and kidney function following transplant, following protocols for inducing immunosuppression, monitoring and modifying immunosuppression regimens according to drug levels, and evaluating the patient on an individualized basis.

This was my first acute care rotation, so it was a STEEP learning curve.  All the drugs that are used frequently on an outpatient side I was pretty familiar with, but IVIG? mycophenolate? sirolimus?  Woah, I had to refresh my memory quite a bit.

One of the coolest things about this rotation was seeing how grateful the patient’s were for receiving a transplant.  I had conversations with new admits when reviewing their Prior-To-Admit medication lists, and some expressed to me their feelings when they received the call about an organ being ready for them.  Some people cried for joy, some were sad, knowing a person had died in order for them to get an organ, some described it as “the best call they had ever recieved.” 

My sister works as a nurse on the transplant floor, and I now have a deeper understanding of how difficult but rewarding her job is.

Thanks for reading! – Heather
Stay tuned for my next post, describing my experience in the Cardivascular ICU…

FYI:
Graduation Countdown: 15 days!!!!
Wedding Count Down: 44 days! 🙂

Pharm.D. Paper and Seminar, check!

I feel like a huge weight has been lifted off my shoulders!  I am now completely finished with my Pharm.D. Paper and Seminar!  There are only 3 rotations and one portfolio submission that stand between me and walking across that stage on May 10th for graduation!!

My classmates and I spent today and yesterday in our old classrooms, Life Science 163 and 165,  presenting the results of our hard work over the past year or more.  Each student had 20 minutes total: 15 minutes to present, followed by a 5 minutes of questions.

It was the first time most of us have been back in the classroom since May 2013!

It was fun to see my classmates and learn from them about topics they’ve been studying for the past year.  It was also fun catching up over a good meal – about a third of our class was at Burrito Union for lunch today – so delicious!

 

Next rotation starts Tuesday.  I’m planning to review some of my notes from the transplant unit of therapy before then…it’s been awhile since I learned about anti-rejection therapy!

 

-Heather

 

Goodbye Winter Break, Hello Fairview!!

I have a little over one more week left to my LAST winter vacation EVER.

Let’s just let that sink in for a minute.

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Ok, so it is sad, but the good news is: I am really excited to get started on my final three rotations!!

My last three rotations will all be at the University of Minnesota Medical Center – Fairview, located on the Minneapolis Campus.  There are 14 students assigned to this facility for blocks 7-9, and we all submitted our top choices for 2 acute care blocks and 1 elective block.  Recently, we found out what areas of the hospital we will be in!

Block 7: Transplant, Floor East 7A
Block 8: Cardiovascular ICU/Cardiology, Floor East 4E
Block 9: Infectious Disease Stewardship

I am really excited as I got all of my top picks!!  Also, my sister, Michelle, works as a nurse on the transplant floor, so I am excited to spend some time with her and learn more about the hard work she does.

 

PharmD IV Presentations will be happening this week, on Monday and Tuesday in Duluth. (The Twin Cities occurs over three days, because they have more students, but students are still only required to be there for two total days).  I present on Wednesday at 10:10 AM, and then after that, there are only those three rotations and a portfolio submission that stand between me and graduation!  🙂

I am excited for the presentations to see my classmates and hear what they have been working on for the past year.  My presentation is titled (just like my paper), “How Pharmacists Can Best Help People With Celiac Disease; A Literature Review.”

 

Here’s a random picture I took (Instagrammed of course)….

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Peace,

Heather

Last few weeks in Deer River!

 

 

Happy New Year!!  With the hustle and bustle of the holiday season I have been neglecting my blogging duties!  Today I am stuck indoors, as the Duluth Police have ordered all unnecessary travel to be avoided due to very very icy roads.  I have already watched a few people struggle to make it to their cars in the parking lot without falling, so I am going to wait it out, watch some football, and blog for all you readers out there 🙂

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Pictured above is the Deer River HealthCare Center, or Deer River Hospital.  Most mornings on my drive in I saw some gorgeous views and sunrises.

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Unit-dosing is pretty standard for most hospitals.   Single doses are packaged in the hospital pharmacy when they are not available commercially, or are too expensive to buy pre-packaged.  I helped out a little bit with this….

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…..or was I just showing off my engagement ring?!!?  The world will never know.

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As you can tell, it’s pretty hard work to get those labels to stick! ;-P

 

 

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I love photographing auxiliary labels, and then instagraming them.  I also believe this makes me more of a pharmacy nerd than I am already.

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This is a photo of my workstation, complete with the festive Merry Christmas sign I made.  I was usually busy working on something, but one day I had a few minutes of free time and was excited for Christmas!

 

I also celebrated my birthday on my 2nd to last day of rotations in Deer River.  My wonderful fiance, Ryan, sent me flowers and a balloon that were delivered to the pharmacy!  The pharmacy staff organized a walking taco bar for lunch, and one of the housekeepers made me a gluten-free cake!  I miss everyone in Deer River, they were all so friendly and fun to work with!

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During my last few weeks I had the incredible opportunity to watch surgeries!  I saw two total knee replacements, one partial knee (unilateral) replacement, a shoulder ligament repair, and colon resection/colostomy.  All the surgeries were extremely interesting to watch from inside the OR, but the colon resection/colostomy made me a little light headed and I had to sit down a few times to keep from fainting.  I had never seen the contents of the abdominal cavity of a living person before, nor had I seen a diseased colon.

The orthopedic surgeries were so interesting!  To replace a whole knee, the surgeon shaves off the bottom of the femur, the top of the fibula, and the back of the knee cap; and then cements the correctly sized metal piece to replace the elements removed!  There is always a product representative in the OR helping the surgeon to pick the correctly sized replacement parts, and I spent a while talking with one of the reps.  I had never knew such a job existed!

 

I also spent time with each of the four surgeons and went over my proposals for updating the antimicrobial prophylaxis prior to/after surgical procedures, according to the 2013 guidelines.  Although I have to admit I was nervous to talk to surgeons, and tell them what they should be doing according to the most recent guidelines, I was thankful for the experience as it greatly improved my communication skills, and confidence in speaking with other healthcare providers.

 

I am super excited for my roommate, Tessa, who has this rotation next year!!  🙂

 

Hope everyone stays safe on the roads out there today!!

– Heather

Baby Fever?!

There have been three adorable babies born recently at the Deer River Memorial Hospital 🙂

I’ve had a chance to see them all, either while walking by the nursery where they preform the hearing test, or while doing discharge medication counseling for the new mommies before they leave the hospital.  One of the pharmacists at the hospital is convinced I have “baby fever” because I always talk about how adorable the babies are, and how it makes me excited to have my own.  Trust me, not ready for that, but excited for it in at least a couple years.

 

Medication counseling is done by the pharmacist for all patients prior to discharge from the hospital.  This is to ensure that patients are aware of the changes made to their medications, the proper way to take their medications, and side effects that may occur.  For new mothers, their medication lists usually include iron supplements and multivitamins, which are pretty straightforward to counsel on.  Iron supplements can cause stomach upset, discolor the stool, and cause constipation – which is a significantly bigger issue for new mothers, as it can be much more painful in the few months immediately post-partum.  This is an important counseling point, so that new mothers can take steps to prevent iron-induced constipation such as drinking plenty of fluids and getting fiber in their diet.

 

Medication counseling for other patients is usually more extensive, and the medication changes can either be minimal, or extensive.  It is nice that the pharmacist is able to provide this counseling while the patient is still in the hospital, where they are usually comfortable in their hospital bed, and willing to talk about their medications.  Sometimes, when patients just get out of the hospital and pick up their medications from a community pharmacy, they are tired, or their pain medications have worn off and they are in pain again, making them less likely to want to talk to a pharmacist about any changes or additions to their medication therapy.

I really enjoy talking with patients, especially the new mommies, so I can see their cute bundles of joy.

 

In other news, I spoke to one of the orthopedic surgeons today about updating the pre-op antimicrobial prophylaxis order set to reflect the current guidelines.  He was very receptive to making the changes, which was basically a dosage increase.  Current guidelines recommend cefazolin 2 grams IV within 60 minutes prior to orthopedic procedures involving implants, and the use of 3 grams if the patient weights more than 120 kg.  Prior to this, the pre-op orders called for cefazolin 1 gram IV for patients less than 80 kg, and 2 grams for those who weigh more than 80 kg.  I presented all of my recommended updates to the Pharmacy and Therapeutics Committee earlier this week, and I need to talk with a few more surgeons and then the physicians at the clinic, before making the changes on the order sets.  It is exciting to be leading this effort!

T-6 days before Turkey Day!! WHOO HOOO

 

– Heather

 

 

 

Rural Rotation Life

Hello my lovely blog readers, long time no see!!  It’s been a while since I’ve written, I’ve been busy getting engaged and starting to plan my wedding 🙂  I will graduate May 10th, and get married on June 7th, and I couldn’t be more excited!!

So where am I at now? I’m in Deer River.  What’s that you say?!! you don’t know where Deer River is??  How could you not know Deer River….it’s the home of the World’s Largest Wild Rice Festival!!  Come on now people, this is Minnesota!

Just kidding.  According to the 2010 census, only 930 people live here, so you probably have never heard of it.  And of course, these facts are completely accurate, as they’re from the reputable source of Wikipedia!  😉  (if I had a dollar for every time I wished I could use wikipedia as a source for something in pharmacy school….)

I asked a nurse at the hospital today how many people live in Deer River, and she said about 1000.  Deer River is about 15 miles west of Grand Rapids, or about 90 miles northwest of Duluth.  It is the site of my one required Rural Rotation.  The rotation I am doing right now is an “Elective – Institutional” and I am still really learning what that means; a mixture of hospital pharmacy and hospital pharmacy administration.

This is my second of five weeks at Deer River Memorial Hospital.  It’s definitely the smallest hospital I’ve seen, but they still do a lot, including total knee and hip replacements.  From what I’ve seen, there has been a hospital census ranging between 2-7 patients.

I have been helping with warfarin dosing, providing warfarin and discharge education to patients, and attending daily discharge planning rounds.  Most of my time so far has gone to looking at pre-operative orders for antimicrobial prophylaxis and making a presentation to propose changes to these orders in order to conform to the most current practice guidelines:

CPG antibiotics for surg

This paper is the biggest source of my information.

I have also learned the proper way to dispose of an expired bag of Lactated Ringers….

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Stab it with some scissors and pour it down the drain!! Awwwwww yeahhh.

My hours are 8-430, with the occasional 7am meeting.  This means I am either on my way to, or at the hospital by sunrise, and just leaving the hospital by sunset.  So although my vitamin D levels are plummeting, I sure am getting some good photo-ops:

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This one has the sunset and the moon in the same frame, and was taken on Hwy 2 between Deer River and Grand Rapids, aka “G*Rock.”

I am staying with my great aunt and uncle, who have provided me with what I think may be the most comfortable bed I’ve ever slept in, and delicious home-cooked meals and desserts 🙂  I am really enjoying their company and hospitality, and I’m thankful for the rural rotation experience for the opportunity to visit with them for five weeks 🙂

Alrighty, time to get back to my second draft of my PharmD 4 Paper….or updating my Pinterest wedding board….

– Heather

PharmD IV Paper + expert procrastination skills = early mornings and late nights

Current time: 5:30 AM.

I’ve been up for over an hour.

I’m trying to put the finishing touches on my PharmD IV paper.

The initial draft was due about a week ago, but I luckily got an extension so I could polish it up a bit before sending it to my content advisor for the first review.

 

What is the PharmD IV Paper, you ask?! It is a research paper you complete between your third and fourth years which demonstrates a lot of the skills you have learned in pharmacy school, including the ability to locate and evaluate literature, and present it in a clinically useful way.  The topic is totally up to you, and you can either design a research study, or do a literature review.

 

Just so you know how good my procrastination skills have become over my 20+ years of education, I’ll share one of my favorite poems:

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In other news, tonight is MPhA Pharmacy Night in Duluth!  I don’t get to see my classmates as often anymore since we aren’t in class everyday, so I am excited to see everyone!

 

Alrighty, back to work…

 

 

Pictures from my ED Pharmacy Rotation!

I had a great time at Mercy Hospital Emergency Department, and learned a ton.  I am sad that the 5 weeks went by so quickly!

On my last few days I took some pictures to share with all you readers, enjoy!

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A picture of the entrance to the ED, with the signs lit up!….then I had to Instagram it, of course! 

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An ambulance in the ED garage.

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My Instagrammed picture of the syringe labels, used to quickly label a drug after it’s drawn up for the few seconds – minutes before it’s administered to a patient.

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The RSI Box includes all the medications that might be needed for Rapid Sequence Intubation.  Medications are used to sedate and then temporarily paralyze the patient for proper placement of the breathing tube.

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One of the “Stab Rooms” (pronounced ‘stabe’) – short for Stabilization.  The cart with blue drawers is the adult crash cart, with all the medications needed to treat a patient in cardiac arrest

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The cart with colorful drawers is the Pediatric Crash Cart, which has supplies and medications needed to treat infants and children.  When the weight of the child is unknown, it is estimated using the Broslow Tape (pictured on the right) which is used like a ruler to measure the length of the child.  Based on their length they fall into a certain color category which corresponds to a specific drawer on the Crash Cart.

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The ER chest pain box has a lot of medications needed for patients who present with chest pain: aspirin, nitroglycerin, heparin, etc.

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Just filling out the Care Board, with Dr. Ervasti (that’s me, in less than a year!)  as the Provider!  hehe

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Probably the best advice for any ER Pharmacist.  KEEP CALM and DO YOUR JOB!  🙂

 

I will miss my preceptors dearly!  Thank you so much for the wonderful experience!!  

Another thing I will miss is the friendly nurses, doctors, technicians, and housekeeping staff who made me feel welcome during my 5 week experience.  Especially the nurse to whom I was known as “minion.”  Everyday I saw this nurse, he greeted me with a head nod and “Hello, minion,” or simply “miniON” with the emphasis on the second half of the word which makes it sound French or something.   It made me laugh every time, thinking about the minions in Despicable Me 2 (great movie), and the fact that this nurse was tall, bald, and somewhat resembled Shrek in a good way….

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Thanks for reading! 

– The Minion 

PS. I got called a minion at my new rotation today….haha, perhaps I will have to make this into a halloween costume.

 

 

 

 

 

Thing’s I’ve seen in the Emergency Room

Over my first 5 days of my Emergency Medicine rotation I have seen quite a few things.

Some of the more gory things I have watched an ED physician do include:
– relocating a dislocated kneecap,
– realignment of shattered wrist bones under sedation

Some of the more scary things I have seen:
– Cardiac arrest
– Intubation
– Anaphylaxis

…..Seeing anaphylaxis in real life was scary.  Knowing that something like a simple bee sting, peanut butter, or seafood can cause a reaction like the one I saw today is alarming.  Knowing that some medications can cause this reaction makes me even more determined to identify and avoid patient drug allergies.

As a pharmacy student, I have been taught the importance of asking about drug allergies, but never has it seemed so important as it did to me when I saw anaphylaxis occurring in real life, in front of me.

 

So what IS anaphylaxis, and how can it be treated before getting emergency medical care?

Anaphylaxis is a life-threatening allergic reaction in which the body goes into a state of shock, making it hard to breath.  If severe enough, the patient has to be intubated and put on a respirator to breath.  People with known allergies may carry around an Epi-Pen, for those times when they accidentally come into contact with an allergen.

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These Epi-Pens deliver a dose of medication that help to open up the airway so the patient can breath better, giving them ample time to get to a hospital for further care.  They are to be injected into the thigh of a person undergoing an allergic reaction, even though the person’s clothing!  If you know somebody with a history of an allergic reaction, encourage them to get an Epi-Pen, and learn how to help them use it if in case they are unable to.

And to all my future Pharmers out there, make sure you ask for drug allergies!  I wouldn’t want to be responsible for causing an anaphylactic reaction, especially after seeing one in real life.

 

 

 

 

 

My First Few days of ER Pharmacy

Today will be my third day in the ER.  You are probably wondering why I am posting this at 11:30 am….well my hours are a bit different than other rotations.  Since the Emergency Room sees the most traffic during the evening hours, most of my days start at 1pm and end at 9:30 pm.  I welcome this change of pace from other rotations, where getting up early is common.  I also appreciate the fact that I am there during the most eventful times, so I have the most opportunities to learn!

Day 1 and 2 were very eventful, and I got to see a number of different critical patients being cared for.  A number of patients required intubation, so I have gotten very familiar with Rapid Sequence Intubation (RSI), and the role of the Pharmacist in these situations.

During a RSI At Mercy Hospital, the pharmacist is in charge of the medications needed to sedate and paralyze the patient for intubation.  All of these medications are dosed based on weight, so the pharmacist has to be sure to know the dosing and be able to calculate things quickly.  There are a few options for sedation and paralyzation that should be selected according to the patient’s reason for needing intubation, lab values, and other medical conditions.  The pharmacist will help the physician to select the most appropriate medication, draw up the correct dose, and pass it along to the ER nurses for administration.

The pharmacists in this situation also ensure that the medications are given in the correct order:  so the patient is sedated BEFORE they are paralyzed for intubation.  Once the patient is paralyzed, they cannot communicate in any way that they are still awake and feeling pain or discomfort, so it is important to make sure the patient is sedated before administering paralytics.

Mercy Hospital is a Level II trauma center, and received this designation in 2010.  This means they have 24 hour care for patients, among other things.  Here is a link to their webpage with a video describing what needed to be done to gain this Level II status:

http://www.allinahealth.org/ahs/news.nsf/newspage/LevelTwoACS

Im excited to continue learning about the roles of Pharmacists in Critical Care!

Thanks for reading!

– Heather