APPE Reflection- Surgery

Wow. I’m finally done with my APPE rotations. All that stands between me and my PharmD is a 1-month NAPLEX review course. This rotation was a really good experience. I feel like I learned a lot and was able to help improve patient outcomes.

You might be wondering what in the world a pharmacist or pharmacy student would be doing during a surgery rotation, so let me give you a little insight into what I was doing.

My preceptor and I sat on the surgical floor (near the nurses) and worked through our patients. We dealt with any pre or post-op medication issues or issues relating to a patient’s home medications. We made sure the patients got their antibiotics on time and didn’t get them if they were not needed. We also worked directly with the nursing staff to make sure the patient’s pain was well controlled. The main reason we sit with the nurses and not down in the main pharmacy is so that we can hear everything that goes on and can act fast when something happens.

Every day this month, I looked at about 7-10 patients, went through their medical chart, and completed a whole workup on them. A “whole workup” includes their background, the reason that they were in the hospital, any pertinent lab values, drug allergies, home medication list, current inpatient medication list, etc.

Along with working the patient up, I went to speak with them after their surgeries to make sure that their medication list that we have was correct (i.e. a medication reconciliation) or ask them any questions that we had about their medications.

I also spent a lot of time talking to the nursing staff and the providers to try and get antibiotics corrected or stopped on time or change doses of a patient’s medications.

Overall, this month I have become more confident making recommendations to the providers and talking to patients. I was able to get patients sent home on appropriate antibiotics and stop antibiotics when they were no longer necessary. I feel like I was truly able to make an impact on the care of the patients that I interacted with.

Over the course of the month, I also had 4 topic discussions with my preceptor (Post-operative Nausea and Vomiting, TPN management, Appendicitis, and Septic Joint Infections) and a presentation to the pharmacy staff on Post-Operative Ileus Prevention and Management.

Of course I also helped in several COVID vaccine clinics as well.

I cannot believe that it has already been a year since I started this journey.

I cannot believe that I’m almost a pharmacist. If you know me, you know that I’ve wanted this for as long as I can remember and now its ~6 weeks away (well.. I guess a few months until I’m licensed to practice).

I hope you’ve enjoyed walking through this journey with me.

I’ll keep you all updated on my post-graduate plans, and I’ll continue to blog as a practicing pharmacist.

Once I pass the board exams, be on the lookout for a blog post on helpful study tips!

Stay Golden,

Emily

APPE Reflection: Internal Medicine

Wow… I cannot believe I only have 1 rotation left! This month went by so quickly. This month was a whirlwind in terms of everything happening all at once. I had several post-grad job interviews, and I had a lot going on personally otherwise. However, I feel like I was really able to make a difference for my patients during my Internal Medicine rotation.

I made countless recommendations to providers (primarily changing up insulin regimens and adjusting antibiotics), but one in particular stands out. We had a patient that was in for possible infective colitis (inflammation of the colon caused by bacteria) who subsequently got a new diagnosis of Non-Alcoholic Steatohepatitis (NASH), which is a type of liver disease. He had ascites (fluid buildup in his abdomen due to the liver disease), which increased his risk of a bacterial infection of the inner abdomen called spontaneous bacterial peritonitis, or SBP.

Why this is important is that I have had experience with patients with liver disease and ascites who do develop SBP and actually did a case presentation on a similar patient a few months back. I noticed that his white blood cell count (WBCs) had been trending up and he was on appropriate treatment for colitis. I mentioned to the provider that the patient could now have SBP and that we should consider getting a paracentesis (sample of the ascitic fluid) and possibly switching antibiotics. Once we got the results of the paracentesis, it was noted that the patient did have SBP, so the recommendation to switch antibiotics was accepted. This provider was extremely thankful for my input and this recommendation, which I made during the first week of my rotation, helped me to build a great professional relationship with that provider.

I took part in another mass COVID vaccination event at the beginning of the month.

A lot of this rotation was focused on learning antibiotics, which I really needed. I have always had a hard time keeping antibiotics straight, but now I feel like I understand them a lot better. I also gave a case presentation on bacterial meningitis at the end of the rotation.

Overall, this rotation was a great experience for me, and I am so glad that I got the opportunity to experience it.

Stay Golden,

Emily

APPE Reflection: Oncology

Let’s start this post on a high note… I absolutely loved this rotation! One of my favorites, but honestly, all of my experiences have been amazing. Also, I received both doses of the Pfizer-BioNTech COVID-19 vaccine during this month, so I will briefly be going over that experience.

On this rotation, I spent the month in the Oncology Clinic Pharmacy, where I assisted the pharmacist as well as nurse navigators and providers to ensure exceptional care for our patients. Oncology, if you don’t know, is a fancy word for cancer… or rather oncology is the study of cancer.

I spent some time helping the nurse navigator with educating patients about their new chemotherapy regimen.

On the very first one, I met a patient who I was able to help more than I knew that I could. She was a patient with newly diagnosed breast cancer and had already received surgical intervention and radiation. Through our conversation, I was able to get to know her better and learned that she was really interested in meeting the president of my university, Nido Qubein. She kept mentioning it, and at the end of our discussion, she mentioned it one more time stating “tell Nido I’m here.” After contemplating whether or not it was appropriate to contact him on her behalf and discussing it with my preceptor as well as the nurse navigator that was in the room when the conversation took place, I decided to email him. After he put me in touch with the appropriate person, we were able to get flowers sent to her on his behalf when she was there for her first treatment the next week.

She told me that she was so thankful and that it really made her day.

That is the first time that I felt like I had the opportunity to go above and beyond what is asked of a GOOD pharmacist or pharmacy student and give her something that she would likely not forget.

Some other things that I was able to do is sit in on some of one of the provider’s new patient visits. I got to learn a lot about ways to break bad news to a patient in a way that shows how compassionate you are and how you are truly there to help them the whole way.

I also researched and got answers for questions that providers had for me. I was able to teach them something new. This was a very rewarding process for me.

I spent a lot of my time in the clinic’s pharmacy assisting the pharmacist in being a part of a 2-check verification system. This was a way for the pharmacist to have someone check their calculations, requirements of diluting/mixing the product, and other pertinent patient information to insure that the patient was safe to get their medication that day and that it was made properly.

Another important aspect of my rotation was going through the concise treatment plans of all new patients to insure the therapy was both appropriate and safe and verifying those things with resources available to us.

Also, I participated in a mass COVID-19 vaccination clinic where we vaccinated >1000 patients. Along with that, I occasionally helped the hospital provide vaccinations at their smaller clinics (Here’s an article detailing the mass vaccination clinic).

Overall, I feel like I learned a lot over the course of the month, and I feel much more confident in my ability to understand oncology and various chemotherapeutic regimens.

Moving on, I’d like to talk a bit about my experience with the Pfizer-BioNTech COVID-19 vaccine. I received the 1st dose on January 5th. I didn’t have any side effects from that one. The injection site was a little sore, but it was less than I typically get with my annual influenza vaccine, so it really didn’t bother me at all. I got my 2nd dose on January 22nd (I know that was only 17 days after the first one, but it’s the only day I was able to get it). It is recommended to get the 2nd dose 21 days after the first. Anyways, the side effects that I had with the 2nd dose were severe pain at the injection site and swollen and severely painful axillary/armpit lymph nodes (on the same side) for ~3 days. I also had a mild headache and felt a little nauseous. I understand that my experience was a lot milder than some people, but I just figured I would explain what happened to me.

Anyways… I only have 2 more months of APPE clinical rotations and then I’ll be in my NAPLEX review class for 1 month and then graduation!

Also, I got a job offer!! I’m still waiting for a community residency to get back to me so I haven’t accepted yet, but it really seems like a great opportunity!

I’ll keep you all updated on that process.

Stay Golden,

Emily

APPE Reflection: Entrepreneurship

Originally, my November rotation was supposed to be a medical mission trip to Jamaica. However, because of COVID, the whole thing got cancelled. While I was disappointed at first that I was not able to go on that trip, this rotation was amazing, and I really learned a lot about myself.

This rotation was designed for us to be as independent as possible. We were tasked with creating a new pharmacy product or service. Throughout the whole rotation, we worked on this project and presented it on the last day of rotation. I’d give you my idea, but then you may steal it, and I actually might act on it in the future.

We were also tasked with choosing a book on innovation to read throughout the rotation and come together weekly to discuss what we learned from the book with the other students and our preceptor. I chose “The Innovation Stack” by Jim McKelvey (co-founder of Square credit card readers). This book was a great read and made me think a lot about what it means to be truly innovative in a world where we are trained to copy.

We also each watched an episode of Shark Tank and summarized it to the group. I think this was critical to the process in that we could see how people were really able to sell their products just based on their pitches and how some flopped for the same reason.

Overall, this experience was great and something that I definitely needed since I would like to own my own independent pharmacy in the future. It opened my eyes to the possibilities of creating a new product, business, or service and rolling it out.

I’m excited to finally have a month off of rotations, and I know I’ll be well rested and ready for my Oncology rotation that starts in January.

Stay Safe and Stay Golden,

Emily

APPE Reflection: Ambulatory Care

The rotation that I had over the month of October was my Ambulatory Care rotation. I completed this one at the Naval Medical Center at Camp Lejeune in the Family Medicine Clinic. I spent a lot of time with patients in the clinic, but I would consider this rotation a “blended” Ambulatory Care rotation.

In the mornings for most of the month, I was on the inpatient Family Medicine team doing rounds. During these rounds, I would work with the pharmacist to answer any questions that the medical interns/residents/students had for us about the different patients and their medication regimen. We also pre-rounded on the patients so that we had suggestions of regimen changes ready to go when we met with the team.

For the rest of the day, I was working in the Family Medicine Clinic with my preceptor or another clinical pharmacist to take care of patients. We saw a variety of patients for different chronic conditions such as diabetes, hyperlipidemia, hypertension, and anticoagulation (with Warfarin, for INR checks and regimen changes).

I didn’t really start writing up patient encounters in the electronic medical record (EMR) until the last week and a half. At that point, I wrote up pretty much all of our encounters and had them sent to my preceptor for review before he signed them.

Because I was at a military location, the clinical pharmacists were able to change medication regimens without a collaborative practice agreement. It was really a great experience being able to see the impact of pharmacists on a clinic. It reinforced for me the true value of pharmacists in the clinic environment.

Over the month, I was able to watch 2 eye surgeries and was also able to shadow a variety of different practitioners (NPs, PAs, and Physicians) and see how they interacted with patients.

I’m so thankful for the opportunity, and although the military environment isn’t really for me, I’m confident in the care that they are receiving.

Stay Golden,

Emily

APPE Reflection: Advanced Community & Enhanced Clinical Services

As with any new rotation, I was very nervous going into this one. However, I had an amazing experience. I got to do things during my community rotation that I feel like a lot of people don’t get the chance to do.

What were those things? Lots of clinical services! I worked with several of our Chronic Care Management (CCM) patients and was able to call and check in on them and see how they were doing with their chronic conditions and how they were dealing with COVID. This is a task that I feel not many people relate to pharmacists, but we are in the perfect position to do these types of services! It’s important to check in on these patients and make sure that they do not have  any pressing issues with regards to their medications or their health in general. Pharmacists partner with physicians to provide these services to their patients. Another important clinical service that I was a part of was Medication Therapy Management (MTM). This involves calling patients and making sure their medication regimen is up to date, they are adherent to their medications, and they are not having any unwanted side effects. It’s important to make sure patients are taking the medications as they are prescribed to them. 

I also participated in 4 flu shot clinic days where I was able to give ~200 flu shots to teachers and other government employees. 

Aside from the clinics, I also gave flu shots, shingles shots, pneumonia shots, and tetanus/diphtheria shots in the pharmacy. 

I also did a lot of blister packaging. For those of you who may not know what that is, it’s where the pharmacy packs all of a patients medications in a weekly or monthly pack with the foil backing to so that the patient can see that they did or did not take their medications on a certain day. Not only did I pack them, I was able to check a few that my preceptor packed (to get experience actually acting as the pharmacist) and looked through patient charts to make sure that their medication regimen made sense. I was able to find some areas where the packs could be improved and was able to prevent some medication errors.

I was able to also check a few prescriptions (with my preceptor) to make sure I understand what it’s like to actually be the pharmacist.

Here’s a couple pie charts that show some of the things that I was able to do over this rotation!

August Patient Care Tasks
September Patient Care Tasks

I really, really enjoyed my time at this rotation site, and I’m so excited for my Ambulatory Care rotation next month! 

Stay Golden,

Emily

APPE Reflection: Critical Care

I was very intimidated going into this rotation because it is only my 2nd APPE experience and the CCU is such a fast-paced environment. However, I have learned a lot over this rotation, and I had the best experience I could have imagined. My confidence in making recommendations to providers has increased significantly, and I was able to do a lot of independent learning.

During the first week, I had my first counseling experience of the month. I was able to counsel a patient on a new prescription for warfarin. It was a great experience because there are so many different things to consider when counseling on warfarin (diet, bleed risk, goal INR, etc).

I also had my first ED shift of the month this week and was able to complete several medication histories as well as make calls to pharmacies to gather information/cancel prescriptions that were sent to them by mistake. It is the job of the ED pharmacist to make calls for patients who tested negative for COVID and make sure that they no longer had a fever. I was able to practice with this on week 1.

I witnessed my first rapid sequence intubation during week 1 and was able to assist the pharmacist in drawing up medications to make sure it ran as smoothly as possible.

Week 1 was also where I began rounding every day on the CCU. Every day, I spent half of my shift sitting on the unit by myself and assisting with any medication related questions that the nurses/providers may have. Of course, being a student, I had to report to my preceptor with all of the recommendations that I had to make sure they were appropriate before recommending them to the provider.

Moving on to week 2, I was able to dose a new start vancomycin in a patient and adjust a heparin drip based on the patient’s aPTT level.

Week 2 was also where I had my weekend ED shifts. I completed 7 medication histories, 16 negative COVID callbacks, and another intubation.

The rest of the month was pretty chaotic. I attended 4 rapid responses, 2 codes, rounded on a total of 35 patients, dosed and prepared TPA, and made daily recommendations to providers. I pretty much handled the CCU patients on my own, with verification with my preceptor.

My big projects for the month were to present a case presentation on a COVID patient that had been in the CCU for most of my month long rotation and create a reference sheet on how to treat hypertensive crises.

I also had 1-2 topic discussions a week on critical care topics such as FASTHUGS, Sepsis, the ABCDEF bundle, RSI/NMBA, PADIS, and ACLS.

The hardest part of this rotation was experiencing codes and seeing how intense and emotionally draining they can be.

I have nothing but good experiences to report for this rotation, and I’m so sad to be leaving this hospital until January. I have really connected with the pharmacy staff here and really have started to feel like family. I hope to have as good of an experience during my Ambulatory Care and Community rotations that I have over the next few months.

I will continue to keep you all updated with all of my rotations!

Stay golden,

Emily

APPE Reflection: Advanced Hospital

First things first, I’d like to mention that I am extremely blessed to be granted permission to continue onto my APPE rotations even in the midst of COVID-19.

This was my first APPE rotation, and I can honestly say that I had an amazing experience. It was better than I could ever have expected. I was not only able to see how to complete orders in the pharmacy, I was able to complete a lot of clinical coursework and attend a lot of meetings.

Throughout my first week, I worked on improving my ability to work through the pharmacy system and find important information in the patient chart. I wrote several brief SOAP notes on the patients that I worked up. On Friday of the first week, I did a lot of research on remdesivir and its dosing because we had a COVID positive patient that we were going to start on remdesivir, and it was our first time gaining access to the drug. I helped one of our pharmacy residents put together a protocol on how we were going to administer it and store it, and even helped prepare a folder full of information on the drug to keep in the pharmacy for the pharmacy staff to refer to.

Then, on my second week, I worked in the main pharmacy for 3 of the days. I was able to assist the pharmacist in checking orders in patient charts, checking IV preparations, and checking cart fill to make sure everything was appropriate and given for the right patient. I really learned a lot during this time. Thursday and Friday I spent most of my time working up patient charts. I did some vancomycin kinetic dosing based on trough levels, warfarin dosing based on INR levels, and increasing/decreasing insulin regimens based on patient 24 hour BG levels. One of my biggest passions so far in pharmacy is diabetes management and education, so it was really exciting to actually be able to make recommendations on insulin regimens. I was actually able to document my intervention notes and discuss recommendations with providers.

On week 3, I was able to spend some time shadowing the pharmacy technicians. I really enjoyed this week because it is important to know exactly what the technicians are responsible for in the pharmacy, and the technicians at the hospital that I am doing rotations at are all really sweet and welcoming. I was also able to help compound oral liquids and a few IVs. On Friday, I spent my day in the Emergency Department. Our hospital is fortunate enough to have an ED pharmacist. I was able to help give recommendations to the physicians and research things that I was unsure of. I learned a lot down in the ED and was able to shadow some medication history reviews.

Week 4 involved more clinical work and a presentation. Monday was spent in the ED again doing similar things. I spent Tuesday up on the surgery floor working through new-start TPN dosing and making sure the post-surgery patients had all of their post-surgery medications on their profile. Wednesday-Thursday, I worked on the medical floor and learned a lot about my patients (because I was able to follow them for 2 days). I learned a lot about alcoholic cirrhosis and meningitis. I also gave a presentation on Malignant Hyperthermia on Wednesday afternoon to the pharmacy staff. Friday was my day off to attend my cousin Ben’s wedding.

Throughout the course of the month, I was also able to attend a lot of meetings with my preceptor and other pharmacists. This was very beneficial for me because I was able to see all of the responsibilities that pharmacists may have and the roles they play on a multidisciplinary team. I attended a meeting on the hospital’s metrics, a P&T committee meeting, and an antimicrobial stewardship meeting.

I can honestly say that I learned a lot from this rotation. I learned more than I ever thought would be possible in just 1 month.

I can’t believe I only have 8 more rotations to go! I’m super excited to begin my next APPE rotation, which is an inpatient elective in Critical Care. I’ll make sure to keep track of everything that I do so that I can keep y’all updated!

Until then…

Stay Golden,

Emily

Why Pharmacy?

Everyone thinks that I am crazy because I have wanted to be a pharmacist since I was in the 5th grade, but I have.

Everyone wonders how I came up with that as a career that early in life. How does a 12-year-old want to become a pharmacist? Why would you want to count pills all day? How does that sound appealing?

The truth is, I didn’t make the decision by myself. Honestly, it has always felt like God was leading me in this direction my whole life. All of the pieces of the puzzle have consistently been falling into place.

I have always looked up to my cousin, Laura, who is an amazing pharmacist. Growing up, I saw how much she was able to help her patients. I saw the passion that she had for helping the community, and I wanted that. My dad was always reminding me how much my study habits and personality reminded him of Laura, and that was another reason I felt like I would be perfect for the job.

Some people go through pharmacy school because they know that pharmacists can make a 6-figure salary, but that was never it for me. I am truly passionate about being able to help patients become the healthiest that they can be.

My end goal is to own my own independent pharmacy where I will be able to treat patients how I see fit without the oversight from a corporation. I want to host educational classes for patients and their families to be able to learn about their disease and how to best manage it with lifestyle modifications, not just medication. I want to get patients to their healthiest while making sure they are on the appropriate therapies and they are able to get taken off of therapies that are not working for them or are unnecessary.

I am constantly told that this is a pipe dream and that independent pharmacies are going out of business, but I truly believe that once patients see how I’m willing to treat them, they’ll be excited to start their healthcare journey with me and my team.

I am willing to do whatever it takes to get to this goal because I know that God has called me to this career and to make the community a better place for everyone in it.

No matter how big or small your dream is, it will succeed if it is what you are truly called to do.

Never forget to dream and to shoot for the stars.

Stay Golden,

Emily

Thoughts on COVID-19

Hey y’all! I hope everyone is doing the best to stay safe in this pandemic that we find ourselves in. 2020 has not been kind to us. I am writing this blog post to put into words how I feel about the Coronavirus.

The panic that has ensued in our beloved country is partially reasonable, however, we have become fearful of things that could have been avoided if the media would not blow things out of proportion. Here is what we (rather I) DO know about the virus:

  1. “Coronavirus” is not a new term for us. We, as a society, have seen many strains of this virus through the years. HOWEVER, this is a new, seemingly more deadly, strain of the virus.
  2. Everyone can get infected, but the virus seems to be most deadly for individuals >60 years old or with decreased immune system function (i.e. smokers, cancer patients, HIV/AIDS patients, etc.) If you know any of these people, volunteer your time to go to the store and get them what they need so that they can avoid exposure as much as possible.
  3. The most important things that you can do to avoid getting COVID-19 is wash your hands (if nothing else, make sure you wash your hands before eating ANYTHING), avoid crowded areas, and cover your mouth when you cough/sneeze (by using your elbow, a tissue, or the inside of your shirt).
  4. Healthcare workers and emergency personnel are not immune but have to continue to work to keep everyone safe. Keep that in mind.
  5. Stockpiling excess supplies does not do you any good and takes them away from others who may desperately need them. By the way, if you buy up all of the hand sanitizer/soap, how are people going to wash their hands and prevent the spread? Only keep what you will need.
  6. Cancelling classes, requiring work from home, and cancelling large events may seem like a drastic measure, but the goal is to stop the spread of the virus so that the country can get a better handle on the situation and prevent healthcare system over-saturation.
  7. Most of the information about the life-cycle of the virus is still unknown to the general public. This is an unknown strain, but that doesn’t mean that we cannot do anything about it.

Here are the websites from the CDC and WHO about COVID-19, strategies to prevent transmission, and updates on confirmed cases: https://www.cdc.gov/coronavirus/2019-ncov/index.html https://www.who.int/health-topics/coronavirus

Stay Safe and Stay Golden,

Emily