Adult Medicine Rotation: 7 weeks and 1 day left!

Hi all,
This past week I started a new rotation at Flagler hospital in St. Augustine. It is my adult medicine rotation and it is 8 weeks long. This week has definitely been a challenge. This is the longest I will have been away from my family, especially David. I always get really nervous starting new things and not knowing what to expect. So my tummy was in knots all day Sunday when I had to leave and then all the anticipation of having to meet new people and learn new life stories and build quick relationships with so many people. Not to even mention the unknown academic task ahead of me. I felt so unprepared come Monday morning. Well, let's just say it's a good thing I am typing this blog tonight and didn't type yesterday. I think tonight will be alot more positive and optimistic than if I were to have typed yesterday (Yesterday was melt down day at the pharmacy, it was one of THE WORST days I have ever had).

Here's kinda how my week has been going:

I show up Monday at 8 am. Right on time. I met the secretary and was then informed that my preceptor is involved with this antibiotic stewardship program where he rounds with the physicians every morning until around lunch time. I was then instructed to go have a seat in the corner at my new desk and wait on him to be finished. So I wait patiently and finally I meet with my preceptor. He is a very nice man, an incredibly brilliant pharmacist.

Ok, so my instructions for the week were to "play around" with my daily assignments until I can figure it out. Well I'm not the "playing around" with stuff kinda person. I like checklists, study guides, notes, a person to tell me exactly what I need to do and the process to make it correct before I just do something. This really didn't sit well with me and the first part of this week I was feeling so ill toward this rotation. So this was Monday and Tuesday. Now here comes melt down day, Wednesday, dun dun dun. My preceptor arrives in the pharmacy after his rounds and says, ohh by the way I'm leaving in 5 minutes to go out of town and will be gone until Monday. I was like ok so how am I going to learn what I need to do if you don't show me? Then he told me to just "finish playing around" all week and we will spend more time training you next week. Little did I know that the pharmacists working thought that by Wednesday, they were depending on me to get my tasks done for them. And I had no idea. I was just "playing around", as directed by my preceptor. So then when it was crunch time and everything was due, the pharmacists came to me and asked for all the work, and I had nothing. Nada. Now don't get me wrong, they weren't upset with me, just that I hadn't been trained for any of the time I had been there. I was beyond embarrassed, but there was nothing I could have done. When I got off Wednesday, I did not want to go back to that hospital, not one bit.

Today has been a completely different experience! With my preceptor out of town, a pharmacist saw a need to train me and took it upon herself to sit with me all day today and show me what needed to get done. I am so thankful for her.

So now that I know what I will be doing, here is what my days at Flagler Hospital involves:

Daily TPN Monitoring
Daily Antibiotic monitoring, kinetics, and dosing
Daily Anticoagulation monitoring
Weekly Case presentations
2 In Service presentations

So what the heck is all that? So many people think that a pharmacist just puts pills in a bottle, puts a label on it, and gets paid alot of money to do so. I hope that by blogging people can see that our profession is so much more than that.

My tasks explained:

TPNs, or total parenteral nutrition (no, not toilet paper nonsense Aunt Kate) basically means the patient is receiving nutrition by an iv instead of eating food. There are several reasons a patient may not be able to obtain their nutrition by mouth. The TPNs contain many different things and each TPN is individualized to the patient receiving it. The TPN will contain/but not limited to dextrose, lipids, amino acids, vitamins, insulin, and electrolytes like sodium, potassium, chloride, magnesium, and all that. It is the pharmacist's responsibility to determine what and how much of each component should be placed in the patients bag. I am responsible for obtaining all the patients most recent labs (sodium, potassium, magnesium, glucose, etc) and determine what goes in it. And I am doing all this with an old school computer system that is not easy to navigate. After I have determined what needs to be added, removed, increased or decreased, I then get a pharmacist to approve my recommendation and the TPN goes to a technician to be made. Pretty tedious work!

The daily antibiotic monitoring that I am responsible for is pretty frustrating too. I have to assess my patients, which include open heart recovery, medical ICU and surgical ICU, every morning. For each patient I have to check to see what the most recent vancomycin level was, when the last dose was given, whether the patient has a fever or not, what their kidney function is (the medications may worsen kidney function), what their white blood cell count is (if elevated, will indicate an infection), has the microbiology lab submitted any positive cultures so we can narrow our antibiotic coverage to only the bugs we are dealing with, how many days has our patient been receiving antibiotic therapy, and what is the indication, or reason, the patient is getting these iv antibiotics (will tell us the different ranges we want the antibiotic levels in the body to be so we get the effect we are trying to achieve)? And to answer all of these questions, again, I have to navigate this horrible computer system that is so outdated. Once I have obtained all the patient data, I determine the appropriate dose for the patients and make any changes to the doctors orders if they have been prescribed the wrong dose or dosing interval.

My daily anitcoagulation monitoring is pretty easy. These are patients I have to monitor because they are receiving a certain type of medication that puts them at risk for bleeding and having negative effects on their kidney function. So every day I pull up my anticoag patients and look at their most recent platelet counts and creatinine levels (gives me information on kidney function). If levels are missing, I have to order a level for my patients so I know that they are getting the appropriate care and not experiencing any adverse effects from the medications. If their creatinine levels are elevated then I am responsible for renally dose adjusting their medications to help prevent any further complications due to the medications effect on the kidney's.

The weekly cases and presentations will be given to my preceptor and will cover a variety of topics. This week I have been following a pneumonia patient and will present my case on Monday.

Geez we really do earn that Dr. title when we graduate!

So this has been my week. The Lord has carried me through it and I pray that He uses me at Flagler Hospital to be a light to the people around me. I pray that through my initial struggles that the people around me were able to see my perseverance and my being slow to anger and frustration. Pray for me. I miss Dave terribly and it's hard to crawl into an empty bed at night after a hard day. Ok sorry to be rambling, this was a really long blog. If you stayed with me, wow! You are a great friend!