Transplant Rotation

Hi all,
A few weeks ago I completed my transplant rotation in Tampa, FL. I've been so busy since returning home (currently on my month off), that today is my first real day of being lazy with a very short to-do list. Just wanted to share some of my experiences from my time in Tampa.

Prior to my rotation starting I was excited that I had a transplant rotation in the hopes of getting to see the more clinical side to pharmacy and maybe even seeing a transplant done. But as I soon found out I would not be in the hospital at all, rather at a specialty community pharmacy near Tampa General Hospital, called BioScrip Pharmacy. BioScrip Pharmacy specializes in HIV, transplant, and other complex conditions. This rotation was actually more of an HIV elective in that we saw and counseled so many more HIV patients than any other. It was a good opportunity to see certain medications that I am not as familiar with dispensing.

There were a few days that my preceptor scheduled me to visit the transplant floor at Tampa General Hospital and also LifeLink (located right next to TGH) so that I could see the entire process that a transplant patient goes through in order to receive their new organ. The following is a little of what I learned and sort of a picture that you can see of what all the journey entails...

For a patient requiring a transplant they first come to LifeLink which is where they will have an entire medical assessment of their current health status and will be approved to be placed on the "waiting list". I was able to sit in on one classes for patients who are trying to get on the waiting list. Its was really kind of cool to come into a big room and see all of the faces of the people waiting for an organ with their loved ones (spouses, siblings, children, and friends) and also so sad to witness the desperation in all of their lives. The class lasted all afternoon for several hours and here is a bit of what I learned.

The United Network of Organ Sharing, also known as UNOS, maintains the national waiting list and keeps all the transplant statistics. The first kidney transplant done was in 1954 and was done in twin brothers. Because they were twins there was no need for immunosuppression therapy (medications that help to decrease the immune response your body may have that would reject the newly transplanted organ). There is also a way to test for matching today that is a simple blood test, however back then they tested for a match by doing a skin graft. If the skin graft did not die then they thought that transplanting an organ might be a success.

So for todays transplant patient they will come to LifeLink for a series of blood works to do crossmatching and such and also a full day of assessments that include (but not limited to) getting the patients weight (transplant surgery has a BMI limit of 35), chest x-rays, ECHO, abdominal CT scan, EKG, doppler, pap smear, mammogram, stress test, and colonoscopy depending on patients age. The transplant patient is not allowed to smoke because of the concerns of not being able to come off of the ventilator after the surgery. After this day of assessments are completed the medical review board will assess all of the medical and financial information and will either approve or reject the patient from being put on the transplant waiting list.

Once the patient is on the waiting list, they do just that. Wait. The average wait time is about 1-2 years depending on what organ you are waiting for and what your blood type is. While you are on the wait list you must call your coordinator to inform them when you are going on vacation, have any change in phone number or contact information, when you get sick or have been taking any antibiotics.

Once an organ comes available, the patient gets a random phone call, may even be in the middle of the night, and will rush safely to the hospital. Just because you get the phone call doesn't mean you get the organ. They call about 2 people to come in at once so it is important to ask whether you are the primary or the secondary person when you are called. Once both patients arrive they do another blood test to check the antibodies for matching and also weigh the patient and assess if they have recently been sick, etc. If the primary patient is unable to receive the organ than they will give it to the secondary patient so the organ is not wasted.

Lets talk about kidney transplants. I learned that when they do a kidney transplant they leave your kidney in you. They just put the healthy kidney in and connect all the goods. So kidney transplant patients could be walking around with anywhere from 3 to 5 (or maybe more) kidneys in them depending upon how many transplants they have received. The surgery for a kidney transplant will last about 3 hours and the patient will stay in the hospital for about 5 to 7 days. It is important to monitor for graft rejection in this time and to ensure that the transplant is a success. I spent a day at Tampa General Hospital on the transplant floor and was able to go in and assess the patients and to help monitor them during their stay at the hospital post transplant. This was a pretty cool day.

Then comes the after care. Transplant patients must be on numerous amounts of medications for a very long period of time (some they may take the rest of their lives) to prevent their body from rejecting the organ that was transplanted. These medications also require blood tests to monitor levels, have some pretty terrible side effects, and may cause infections since they are taking immunosuppresant therapy. And when infections occur, this requires more medications to help treat or prevent the infection. See how all this gets real complicating real quick. So then there is me, on my rotation at BioScrip pharmacy, where the transplant patients come in to to get their medications and I will be counseling them on all these regimens. So it was a pretty cool month but sort of just another community/retail pharmacy setting.

Once I got back home from Tampa, we went to Destin for a week and went to the beach and just relaxed. It was so nice. We celebrated Laurens bday while we were there and then when we got home we celebrated Mirandas with a surprise birthday party. I am so thankful for great friends! I have about 3 more weeks until my next rotation starts so I am really being lazy and it feels so good!



One Big Thing I learned is that if you want to be an organ donor then TELL YOUR FAMILY. Just because it may say so on your drivers license, doesn't mean you will be able to. Your family can override this if they dont know your wishes.

Two Years of Wedded Bliss

Tomorrow, I will have been married to my best friend for 2 years. Wow! These past two years have been amazing. I always heard people say that the first two years of marriage is the hardest but they have been nothing less than great. We didn't even really have the "growing pains" I heard people talk about. We just really like hanging out with each other, talking about everyday things, and learning together. Well more like me learning from dave. He is alot smarter than I am. I am really excited for him to start pharmacy school in a few weeks so I can study with him and review all the stuff I learned a couple of years ago. Anywho, we plan on celebrating the night at Carrabba's. I think we have made this kind of a tradition. The day after our wedding, before we left for the Dominican Republic, we went to Carrabba's and then decided to go last year for our anniversary. So it looks like we will be going tomorrow night for a great dinner!

One thing we recently began doing is reading the Bible through in a year. To be quite honest I have never read the entire Bible all the way through. Our daily readings are in chronological order. So far we have read part of Genesis and then jumped over to Job. I am learning so much and I wish I would have done this sooner. I am learning so much about my Creator, my God, my Savior. He makes Himself so real through His Word and I am learning so much about His character.

Dave and I have also been researching the benefits of juicing. Yes, that's right, juicing. We have watched several documentaries and read up on the topic. It's a great way to consume the appropriate amounts of fruits and vegetables for the day. By juicing, you are able to consume all of the nutrients that the fruits and vegetables have. Whereas when you cook your veggies, you are cooking out all of the good nutrients they have. Fresh juices are a tremendous source of enzymes. In fact, the "freshness" of juice is one of their key features, because enzymes are destroyed by heat. Since fruits and vegetables are juiced raw, the enzymes are still viable when you drink the juice. Also by juicing, it aids in the initial digestion of your food so your body can use the good stuff better and gets absorbed more efficiently. During the juicing process, indigestible fiber is removed and this allows the nutrients that would be "trapped" if eaten as a whole fruit/veggie, to be released when juiced. So instead of getting a small percentage of the nutrients, you get 100% of the nutrients from the food. Today was our first day trying the process and it was actually quite simple. For breakfast we had juiced two apples and 6 carrots. This made about 8-9 ounces of juice for each of us. For lunch we had juiced 2 tomatoes, 4 celery stalks, 2 carrots, and 1 whole cucumber together. This also made about 8 ounces of vegetable juice for the both of us. Its actually really cool and definitely curbs your appetite.

Here is a pic of our juicer:



I have 2 more weeks here in Tampa and then I will be back home. Dave will be heading home in about a week to start preparing for classes and going to orientation in Jacksonville and in Gainesville. Time for him to start jumping through all the UF College of Pharmacy hoops. :) I remember those days :)

Where are you summer?

Hi all,
Thought it was time for a blog. I haven't written one since my last week in St. Augustine over a month ago. I just completed my Adult Medicine Elective at Baptist Hospital in downtown Jacksonville. My preceptor was awesome!! I learned so much from her! I just wanted to post a few things we had learned during the past 4 weeks that I think everyone should know...

- There is a "weight limit" for the birth control patch. Use over this weight will decrease the effectiveness due to varied absorption.
- Depo Provera may make you infertile for life, even after only one injection.
- Viagra is best absorbed with a fatty meal, so go eat a big ole steak!
- What's the new statin available for cholesterol? pitavastatin (Livalo)
- Pantoprazole (Protonix) is now available in granules
- What's the reversal agent for clopidogrel (Plavix)? desmopressin (DDAVP), titrate up based on urinary output
-Can only shock a patient with a rhythm (VF/VT), don't shock a patient in asystole
-Can you give platelets to reverse abciximab (Reopro)? No, because it has a short duration of action
-What's the treatment of hyperkalemia? Regular insulin 0.1 units/kg IV with 50 ml D50W (50% dextrose)
-What's the dose of aspirin in Aggrenox? 25 mg, so it's ok for your patients to keep taking their 81 mg
- What would be the color of the urine if patient is experiencing severe myopathies? pinkish
- Brand name of Vitamin K? Mephyton
- If patient has HIT, don't use heparin to line the tubing
What's the pretreatment for contrast induced nephropathy? Nabicarb, NAC

I also got in to see a surgery during my last week at Baptist. I watched a pancreatic resection surgery. It was similar to a gastric bypass in that they did the Roux en y technique except it was done on the pancreas. I watched from the very beginning when they put the patient to sleep, saw the intubation process, an A line and central line started, and then the stomach cut wide open and splayed everywhere. I was feeling very woozy. I stood with the anesthesiologist for most of the procedure at the head of the patients table. It was neat to see what he did during the surgery, controlling all the medication administrations and learning about all the machines used for monitoring. Surgery is definitely a different world. And definitely not an interest to me, I thought I was going to pass out the whole time!

So, I've just finished up this elective rotation and I am about to head to Tampa for a month for my transplant rotation. This will not be so bad because David gets to come with me. His last day of work was Friday (yesterday) so he will have 3 weeks with me in Tampa before he has to come back and start pharmacy school! It's kind of a weird feeling that we will both be jobless for about a year, but no worries, the Lord will provide for us.

About 10 more months until I graduate (and hopefully pass my boards)! I'm so ready to be a pharmacist already!

Bring It On Home

My work at Flagler Hospital is soon to be done and I will be heading back to Fernandina to be with my family. I have experienced alot here during my time at Flagler. During my second week here, I experienced losing my first patient in the ICU. It was a very difficult thing to experience. For the first week and a half I was involved with the care of my patient. It was the strangest feeling when I came in the next morning and received the news. After this I knew I could not make a career in the critical care setting. Death is too common a theme. It seems like there is a code called daily. Most of them are Code blues where there has been a patient that went into cardiac or respiratory arrest. When I hear them coming over the intercom saying "Code Blue in Room ___", my heart just sinks. I can only think what if it's one of my patients?? And to be quite honest, the first thing I think about is whether or not they know the sweet saving grace of Jesus? It makes me want to be by their bedside sharing the good news instead of being at my computer monitoring their medications. One announcement I love hearing is when a baby is born. The sweetest lullaby comes over the intercom throughout the entire hospital. One day there were twins and they played the lullaby back to back.

During my time at the hospital I attended two P&T meetings (Pharmacy and Therapeutics). This is a meeting of about 10-15 doctors, nurses, and pharmacists. They meet monthly to discuss hospital issues and to come up with solutions to the problems. At one P&T meeting, there was a case presented about a mistake made by a nurse. The nurses that were present at the meeting were very defensive about the the knowledge that they hold. A solution to the problem was to provide educational material to "refresh" the nurses knowledge of pharmacology so they can differentiate on the front lines when something is not right. Well the ladies in the room said "You should not punish us all for one person's mistake of something she should have known once she graduated!" So I quietly sat back and listened to the back and forth discussion. The leader of the group said, "Ok well let me test you on some common nurse pharmacology knowledge and see how much you know since you graduated 20 years ago. Think about Lasix (furosemide, a loop diuretic used often). If the doctor chose to start Gentamicin, an aminoglycoside (also commonly prescribed), based on the pharmacology of these two drugs what would be your concern and what would you monitor in your patient?" I was like dun, dun, dun... you could hear a pin drop. He only wanted the nurses to respond and nobody said a word. In pharmacy world I immediately thought... the patients hearing!!! Because both of these agents together can contribute to ototoxicity or hearing loss. So needless to say I think we can all learn a lesson from here. Not one of us is more perfect than the other and we all have room to refresh our knowledge and learn new things (and old things again).

What else? I have spent the last 3 weeks straight tutoring the secretary so she could take the certification exam to become a certified technician. She took her exam last Friday and passed!!!! I was so proud of her! I will miss her the most!

After completing this rotation, I am terrified of becoming a pharmacist. Most days I feel so inadequate. But I learn more everyday. UF has provided me with a great education and handy tools so I know where to go look up an answer if I don't know it off the top of my head.

But I have learned all I am going to learn here in St. Augustine and it's time to go home.

Dave, get ready to have your snuggle bunny back :) I miss bed time the most :) I love you and thank you for being an AMAZING husband. You are such a wonderful encouragement to me and I am thankful I get to walk through this life with you by my side.

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!

Produce Day!

Thursday has become my new favorite day! I feel like I get a surprise every afternoon when I go pick up our bag of random fresh organic fruits and veggies. Here is what we got this week:



We got a ton of fresh green beans, sweet potatoes, bananas, peaches, apples, mushrooms, cantaloupe, onions, and beets. Yes, beets. I have no idea what I'm going to do with these things yet. I have never cooked beets in my entire life. Let me rephrase that... I have never even ate beets in my entire life. But you know what? What? I'm going to try it!

So we did alot of cooking this past week with everything we got last week. I realized after I blogged last week that the lettuce I said we got was actually kale. Yeah I have never had kale (that I know of) ever before. Here are a few things we fixed:

Kale Chips:
Preheat oven to 350, lay a bunch of kale on cookie sheet, drizzle with olive oil and sprinkle a little salt and bake for 15 minutes. The leaves come out crispy and are a good healthy substitute for potato chips.

Other Kale Ideas:
Mix into any soups. It's very similar to spinach and goes well with alot of different flavors. Also good in salads, especially with a homemade dressing.

Broccoli Soup:
Saute 1 large onion, garlic, salt and pepper until onion is translucent. Add 1 diced potato, bunch of broccoli (frozen or fresh), 2 cups of chicken broth, 2 cups of nonfat milk and bring to boil. Reduce heat and simmer for 15 minutes. Use a hand mixer and blend until smooth.

Baked Potatoes:
Chop potatoes into cubes, chop onion into medium/large pieces, mix in 1 packet of Lipton Onion Soup Mix and bake at temperature listed on soup mix for 40-45 minutes.

Well that's been our week in the kitchen! I will update next week and I may just have a recipe for beets. :)

I'm leaving for St.Augustine Sunday! Not ready for my Adult Medicine rotation at all! I have alot to read up on in 3 days. Night all!

Exciting Times

Hi all,
Thought it is about time to do some blogging. First, I just want to say that David was accepted to the University of Florida College of Pharmacy!!!! He received an email last Friday informing him that he was smart enough and that they wanted him. He will be starting in August and will graduate in 2014 as Dr. David Ashley White, PharmD. I am so proud of him and I am so thankful he is my husband. Since he was not previously a gator fan, he said he would not be a gator until he was finally accepted. So, in preparation for him getting accepted I bought him a gator shirt (I just had a really good feeling he was in since he is such a genius) and hid it under our living room chair. When he got the email I gave him a nice little present. :)



Here's a picture of Dave with his acceptance email and his new gator shirt:


So, what else is new? I finished my first rotation!!! I'm going to miss the VA so much! The people there were awesome and I loved teaching my diabetes, hypertension, and cholesterol clinics. I learned so much from the other physicians and pharmacists I worked with in the wound, GI, mental health, and cardiology clinics. I just wanted to share some things that stuck out in my mind the most. I asked the cardiologist why she picked cardiology as her focus. Her response: "In med school, I knew for sure I didn't want to do GI because rotating throughout the clinics and sitting through colonoscopies, we were always told the air has to go somewhere during the procedure and in the recovery room." I couldn't stop giggling until my second month at the VA I knew exactly what she was talking about. I sat through my first colonoscopy and the patient is just passing gas like crazy! The doc is just chillaxin and acting like its normal. I was mortified! And then I knew exactly why that field was not for her. But if you ever have a colonoscopy, you will have meds that will knock you out and you won't remember a thing! Just a word of advice: Please do the bowel prep just as prescribed. I saw what it looks like (your bowels and large intestine) when patients have a sub-par bowel prep and it's not pretty! Plus you will just be sent home and have to do it all over again!! But on a serious note, these docs are just as important because they are able to detect cancers and so forth. So go get your colonoscopy if you are at that age!! The cardiologist also taught me what the word "Pendulous" means in terms of describing a certain anatomy. During a breast exam, if you have long and flabby breasts, they will describe them as pendulous. hehe, thought that was a funny random fact of the day, especially from a cardiologist. When I went to the wound clinic, I saw so many things I never thought I would see. So many amputations from toes, feet, and legs due to diabetes and smoking! I also got to see a skin graft put on a patients leg that was burned. The doctor was telling me about the company that they get the grafts from and its a very neat story. The company that supplies the VA with skin grafts, Apligraf, had donated all of their grafts to the victims of Sept 11 at no charge and due to this, the company went out of business. After several years a large company came in and got them up and running again. The grafts are made from fetal foreskin and 1 foreskin sample can grow over a football field amount of graft tissue. I'm so amazed at science and technology, its so cool! I don't even think I can type my experiences from the mental health clinic. All I can say is interviewing schizophrenic patients is a rare opportunity and boy was it interesting! So this was my first rotation. I was exposed to so many different things, people and places. I will miss it so much, I kinda got teary eyed when I left today because I didn't really want to leave.

Anything else new? Yes! My aunt and uncle were telling us about this Organic produce co-op that they have been a part of for the past several weeks along with alot of families from our church. Every Thursday they pick up a large bag full of organic grown vegetables and fruit and you get whatever is in the bag for $25. Every week you get a variety of things and it's always different. David and I decided to become a part of it because you can't beat the price and you get so much fresh fruits and veggies! I also thought that since you can't pick or choose what you get every week, we will be getting things that we may not necessarily buy at the grocery store. So we can try some new things that are healthy for us. Here's a picture of what I picked up today from the co-op:


We got a cucumber, asian pears, a pineapple, avocados, new potatoes, big juicy navel oranges, kiwi, huge broccoli florets, snap peas, and a huge head of lettuce! It's so much for so little and it's all organic. I'm so excited to see what we get next Thursday.

Prayer request needed: My next rotation will take me to Flagler hospital in St. Augustine. This is too far for me to make the drive daily so I will be staying with some family friends for 8 weeks. I will be able to come home on the weekends but I don't like that I will be away from David and everybody else for this long. I know everything will be fine but 8 weeks is a long time to be away. But I keep reminding myself that I can do anything for 8 weeks.



Love to you all,
Lindsey