Public Health Brigade

Before our public health brigade officially began, we make the 3 hour rocky bus ride to Zuzurlar to meet the families we would be working with. On a normal day, the ride would be an hour and a half, but since the rock "bridge" we had to cross was flooded over and some of the rocks had been displaced by the rain, we had to forgo the short cut and learn to hold our pee.

Attempting to cross the river.

The community was quiet - minus the 2 little boys we came across shouting and throwing sharp rocks at each other with incredible precision. The community already had their own church and primary school (which consisted of 2 classrooms) and the Architecture Brigade was in the midst of building a secondary school. This was a huge deal because students that want to attend secondary school currently have to take the public bus for hours to reach Tegucigalpa, the capital of Honduras. Students usually are only able to make the trip once a week, and must study on their own the rest of the time.

Our first glimpse of the town of Zuzurlar.

Our projects in Zuzurlar consisted of building a latrine, stove, pila (essentially a large cement block that holds clean water), and cement floors for 2 houses. It was exciting meeting the 2 families - there were a lot of questions asked to get to know the families. What I liked most about the program is that we would be building the projects with the families. As opposed to swooping in with our American ideals and building something for someone else, we were working together with people we were getting to know to building something together.

We split up into 2 groups - one working at each home. My group worked on the home of Daniel and Nancy, newlyweds who had saved enough money to be able to move into a home of their own. The ot
her group worked with a couple with 4 children. During construction, Nancy would boil us organic coffee and Daniel, his little brother, and his brother's friend worked with us on their home.

Photo on left: Daniel and Nancy

Starting from the left with the girl with the green shirt and going clock-wise is Becca, Daniel's brother, Rachel, Vishan, Angelique, and Daniel mixing cement.

With the help of a couple of amazing and very patient masons we finished construction on day 3. The last day we were in the community consisted of the "despedida" or "farewell". We had lunch together and shared our thoughts about the last few days of construction. It was really exciting to see the finished products and that they worked!

Getting our daily doses of irons!

Hello friends!! I took a brief break from Boston in order to return to Ann Arbor for the annual College of Pharmacy Alumni & Friends Golf Scramble. I think that people were a little bit surprised that I would fly back for the event, but I’ve missed it both my previous summers and was always jealous when I heard people talking about what a blast it was. When I was asked to help coordinate the student volunteers for the event, I knew I could easily get out of it, being in Boston and all, but I also knew that I didn’t want to get through my time here without experiencing the golf outing at least once! Therefore, I happily agreed to help out with the event in any way possible.

Golf outing day started bright and early for me. Students were told to arrive at the course at 8 am and I wanted to make sure I was up to speed on what was going on so I could help direct them to where there efforts would be most appreciated. I spent the next couple of hours unloading cars, making sure students were signed up for activities throughout the day and otherwise just ran around like a crazy woman.

There were a few open spots among the golfers so I quickly offered up my services- it had been a long time since my high school golf team days, but I was excited to get back into the swing of it (pun intended)! I ended up on team Pharm Sci with Professors Greg Amidon and Steve Schwendeman and another student, a P3-to-be. We may not have been the most skillful foursome out there (we quickly realized that Prof. Schwendeman’s clubs are older than I am) but I think we definitely had the most fun. We took part in all of the student organization games- a Spelling Bee Challenge, Dizzy Putt-Putt and Beat a Student Golfer, but I think we had the most fun on the Sing Along. If you are good friends with Jenna B, you may be able to get a hold of the video that goes along with this photo- feel free to use it to blackmail me if I ever run for public office!

After the outing there was a dinner and silent auction and plenty of time to mingle with our alumni. People say it all the time, but it really is true- we have the best alumni network in the world! Everyone is so approachable, easy to talk to and supportive. In summary, if you are around next summer I strongly encourage you to attend the golf outing!

Satellite Pharmacy Success

Hello everyone, I am blogging again to describe my internship experience at the University of Michigan Hospital. In my last post, I portrayed my compounding experience in the Clean Room of the central pharmacy department. In this post, I will illustrate my new position of working in the satellite pharmacies, which are located on the individual floors (units) of the hospital.

The satellite pharmacies are an exciting atmosphere to work in. They are the "first line" of contact and solution for most patients who are admitted into the hospital and require pharmaceutical care. Pharmacists who work in the satellites are termed ‘generalists’ and answer inquiries from nurses on a variety of topics ranging from the selection of blood pressure medication to the administration of inhaled oral medication to dosing frequency of heartburn medication to recommendations for patient self-treatment. An environment such as the satellite requires pharmacists to have a broad sense of pharmaceutical knowledge and great communication skills. There isn’t a day of work where the pharmacist doesn't learn something new.

While operating in the satellite, I have held multiple responsibilities that require swift and accurate working skills in order to fulfill patient medication requirements. The first position that I will describe is the so-called “runner”. As the runner, I am responsible for filling oral medication requests that are sent to the satellite pharmacy. This sounds like an easy task but like in retail pharmacy, there are over 2,000 in-house alphabetized medications with 1,000 more uncommonly used medications available through contact with the central pharmacy department. The key here is having an organizational system that works and being able to find the medication in a timely fashion! In addition to filling the correct dose of oral tablets, capsules, liquids, and powders, the runner also compounds liquids into oral syringes for administration. This part of the job can be quite unique because while preparing the pharmaceutical-active medication with an additive to mask the taste, additives, such as syrup, are quite strong smelling and can leave the immediate surrounding smelling like strawberries. After collecting the required oral medications and syringes, they are given to the pharmacist to check for dose and drug accuracy in comparison to the medication request form printed on a stickered label within the satellite pharmacy. Once approved, the pharmacist signs the label and the label is officially placed on the bulk medication to be delivered. The oral medications are combined with IV bags compounded from the satellite’s chemical hood personnel and are then stored into holding bins designated by patient's room numbers.

The runner’s second responsibility is delivering the medications from the holding areas to the correct patient's room or medication holding area on a unit. This involves delivering general patient medications to multiple numerical-coded medication holding rooms on each floor, delivery of narcotics and other controlled medications to Omnicells (computerized medication storage areas requiring user identification), or to patient's rooms (medications that are immediately required such as electrolyte dialysis bags). The runner position is exactly what the title describes: a position in which I get ample exercise by way of medication distribution throughout the hospital.

Another cool opportunity in which I have been able to take part in has been IV piggyback compounding in the satellite. While the same procedure applies as described in my last post (compounding IVPBs in the clean room), the satellite IV-compounding position is considered to be much more spontaneous. It is spontaneous in the fact that the medications that I compound into IV form may change drastically day-to-day based on the hospital’s inpatient population. While one day I might be compounding numerous electrolyte dialysis bags for renal therapy, I might compound many narcotics or insulin the next. Since no one day is the same, working in the satellite IV compounding hood keeps me on my feet and excited for what the rest of the day has to bring. The feeling of accomplishment is also felt when I work in this position. When a patient codes in the hospital, a medication request is sent to the pharmacy requiring sometimes 4, 5, or 6 medications that are required STAT. It is then up to my compounding ability to provide the medications in a quick yet accurate fashion. At the end of the day, I know I have tried my hardest in helping that patient survive.

A unique aspect to IV compounding in satellite pharmacies is the opportunity to compound narcotics. Based on the power of medications such as hydromorphone, fentanyl, and amphetamine, accuracy is of high importance. It is necessary to show the pharmacist all of the narcotic and IV-base syringe volumes I use to compound the narcotic as well as the narcotic waste I do not use. Presenting the pharmacist with the waste is imperative in controlling the use and distribution of the narcotic among the hospital.

In summary, working in UofM hospital’s satellite pharmacy is a great experience in having the opportunity to act as the patient's emergency pharmaceutical responder. While I have explored with you the central pharmacy department's clean room and roles within the satellite pharmacies, I will next be writing about my experience in managing the hospital’s drug inventory. Stay tuned and have a great summer!

Medication use eVAluations at the VA

Yesterday was the first day of summer but my summer internship is more than half way over. My time at the VA has been going quickly. I recently started the biggest project of the summer. I am working on a medication use evaluation (MUE) with three pharmacists and a PGY1 resident. MUE’s are programs designed to improve the medication use process throughout the hospital. The evaluation consists of a review of the prescribing practices of dementia medications (cholinesterase inhibitors and memantine) within the Ann Arbor VA System. Dementia is a disorder characterized by major impairments in learning and memory. Clinically diagnosed dementia is often preceded by a period of gradual cognitive decline referred to as mild cognitive impairment (MCI). Cholinesterase inhibitors or memantine have not shown any benefit in the treatment of MCI. The MUE will verify that patients receiving cholinesterase inhibitors or memantine have a clinical diagnosis of dementia, not MCI. We are doing manual chart reviews of over 500 patients, with each review taking about 15 minutes. I won’t finish this summer but I look forward to hearing the results when the project is finished.

Besides the MUE I have also begun work on a project for the Chief of Dental Services. I am helping her create a presentation on the 25 most common drugs used in VA dental clinics. These include analgesics, antibiotics, local anesthetics, and sedatives. I am creating a handout with information on all of the drugs, including typical doses, indications, and clinical pearls surrounding their use.

Suffice it to say that I have plenty to do every day. The projects I work on have been teaching me a great deal about therapeutics and pharmacy practice in general. I look forward to seeing what comes next during my internship at the VA.

Honduras Medical Brigade

There were 28 of us at the Tegucigalpa airport. 22 undergraduates (most of whom were pre-med), me (the lone grad student), one nurse, one registered nurse, one medical doctor, one opthamologist, and one pharmacist. And something like twenty-two 50lb black body bags of medications and medical supplies.

We took the 1.5 hour bus ride to where we would be staying, a place called Rapaco which just so happened to be the old summer home of a former Honduran president. No big deal.

Hammocks lined the compound at Rapaco.

We spent the first day settling in (28 people to one large room. Needless to say, not a whole lot of sleeping happened) and the next day packing medications with our Honduran pharmacist, Mirelle. We unpacked the 22 black body bags onto shelves organized into types of medications....kids antibiotics, adult cough and cold, derm, etc. We counted out 30 tablets of each medication into hundreds of small zip-lock bags, and repacked the organized meds back into suitcases. It was a long process but we put a little Honduran hip-hop on the CD player and got to work.

Paige and Christina sorting meds.

Our first day of the medical brigade was a little overwhelming. We arrived in the morning to the town of Hoya Grande to hundreds of people waiting in a single-file line standing in the light rain. Some held umbrellas, most didn't, but all stood patiently in line. All day long. With small children. Many without food and water. Most had trekked for hours to get to the small school/church that we turned into our make-shift medical clinic. If only patients at retail pharmacies would wait patiently. For 15 minutes.

The school where we set up the medical clinic.

Students were broken up into groups to work in triage, translate for our doctors, and work in the pharmacy. Naturally, 3 out of the 4 days I was in the pharmacy. It was interesting to see the medications that were prescribed over and over again. Every patient received albendazole to treat parasites and vitamins and most patients also received acetaminophen or ibuprofen. A lot of patients had skin fungi and we also gave out a lot of antibiotic suspensions for kids. Many patients needed natural tears because of the dry and sunburned eyes from working out in the fields all day. Very few patients had chronic diseases such as hypertension, diabetes, or asthma.

Setting up the pharmacy in the community church with our Honduran pharmacist, Mirelle, on the far left. Our pharmacy consisted of plastic bags of medications organized into suitcases.

What was most surprising was the number of children young women already had at such a young age. A 20 year-old woman already had 4 kids. Another was 15 years-old, had an 8-month old daughter, and had just been told she was pregnant again. I wonder how that feels? To be 15 and told that you will be having another child...

Dr. Cederna's table with her student translator, Rikav.

I took a break from the pharmacy for one brigade day and went around shadowing different doctors. During my stint with citología, or gynecology, we saw a patient with a 2cm x 2cm lump in her left breast as well as a cervical polyp. It seemed like a lose-lose situation. If she manages to gather the money necessary to perform the biopsy to determine if she has breast cancer and it is cancer, she wouldn't be able to pay for treatment. According to the patient, what would be the point of learning it was cancer if she wouldn't be able to do anything about it?

As of now, we are communicating with Global Brigades to figure out how to fundraise for this patient to be able to get a biopsy and to treat her cancer if she does have it.

The view on the drive from Rapaco to Hoya Grande.

Most of the other patients had short-term problems that could be immediately treated. All in all, we saw 968 patients in 4 days.

Intern in the ‘ship part 4

I thought I would go outside the box or the pharmacy for my next post. And that is what I did! Two fellow interns and I went to St. Johns Hospital in Detroit for a diabetes fair recently. It was an event to promote the awareness of diabetes and healthy living. We were there to promote our pharmacy stores, our diabetes program, and to give away free stuff. We had a good number of people stop by our table to hear about what our pharmacy has to offer and also to get free stuff. To be honest, we had some cool free stuff. We had pens but also skin lotion, hand sanitizer and pill box holders! This event was definitely a nice change of pace away from the busy pharmacy.

One of our store’s pharmacists gave a talk about controlling blood glucose levels to a group of elderly ladies. It was not a big group but he told us that it was still an effect talk for those who showed up. When one has information and knowledge, one can make better decisions. This is an important part of being a pharmacist from what I have seen in community setting. Drugs and medications can confuse the heck out of people. The pharmacist can turn complex paragraphs about medication into a couple key points for the patient in front of him. Customers do not want to know all the side effect but the two or three ones that could affect them. The other day I advised a customer to stop taking naproxen after she was experiencing an upset stomach and dark urine. I told to see her doctor in the next day or two. I did not save the day but I probably prevented a more serious end result. I am scheduled to do one more outreach event next month, and I am looking forward to it because it certainly made an impact.

A digression

My fourth post. Five more weeks of internship. This summer is disappearing faster than I can type pneumonoultramicroscopicsilicovolcanoconiosis. What's not disappearing is my writer's block. I could write about the data analysis I did to explain how our pharmacy was able to dispense more products than it purchased. (Still haven't figured that one out but the data might have lied, if physical laws hold.) I could describe bedside barcoding and the challenges associated with its implementation. I could outline the reasons the pharmacy department chose to hold off on the wikipedia idea, for now they say. But none of those things is condensing into fine stories in my mind.

Instead, I will talk about the most important lesson I learned this summer. It starts with the importance of taking initiative. My most meaningful assignments to date were the ones I brought onto myself. And not one of the pharmacists the interns had the pleasure of meeting this summer did not go the extra mile. They all went so far beyond their job descriptions that they had to squint, I imagine, to read their job descriptions, and they excelled. The benefits are obvious. That isn't the lesson. The truth is... I'm slowly realizing that what really matters is having free time. Sounds counterintuitive, doesn't it? But without free time, there is no opportunity to take initiative. The goal is always to improve the status quo. What is valuable now will not be valuable forever. A crammed schedule blinds us to what is better and what could be better. Have some idle moments, and they keep our minds fresh and open to new possibilities. They make it possible for us to seize the new opportunities that emerge. The danger is that we never realize our schedules were maxed out until we are idle. Because it's so natural to become wrapped up in our work.

With this revelation, I am restructuring my agenda to include "nothing."

Komoto Healthcare Company

Hi everyone! My name is Natalie Gong and I am proud to say that I will be a P2 this Fall. P1 year was tough, but we made it through! I am spending my summer interning with Komoto Healthcare Company based in California's central valley. This company first began as a small corner drugstore in Delano, CA, which, over the past 30 years has evolved to include two retail pharmacies, a compounding pharmacy, and a home infusion pharmacy. Komoto Healthcare Company is owned by Dr. Brian Komoto, a generous, easy-going, and dedicated pharmacist and entrepreneur. On my first day as an intern, Dr. Komoto told me that the main idea that led him to where he is today is the fact that he was "never afraid to take risks--even if it meant losing a little money here and there--as long as it was beneficial for the patient."

Shortly after it opened in 1981, at the request of a children's hospital, Komoto Pharmacy began compounding suspensions from tablets as heart medications for children. Their success in this endeavor led to the opening of Optimal Compounding in Bakersfield, CA, which specializes in the compounding of unique formulations for veterinary medications, hormone replacement therapies, and hospice medications. In 1990, Dr. Komoto began Integrated Care Services, a home infusion pharmacy in Visalia, CA. The company has continued to expand and shift throughout the years to fit the needs of the changing population throughout the central valley, state, and they even make a few deliveries to outside states. They have broadened their services to include diabetes and asthma therapy management programs as well as immunizations and home medical equipment.

I will be spending the first six weeks of my internship at Optimal Compounding pharmacy in Bakersfield on Monday through Wednesday and at Integrated Care Systems (ICS) in Visalia on Thursdays and Fridays. The following six weeks, I will be at Komoto Pharmacy in Delano on Monday through Wednesday, and at ICS on Thursdays and Fridays.

I actually completed my 3rd week of interning last week and have already learned and experienced so much! I just haven't had time to do any blogging until now. (The 1 hour and 10 min commute both ways to Bakersfield leaves me super exhausted). I just wanted to give you all a (semi) quick introduction...be prepared for a few stories later this week! :) Hope you all are having a great summer!

Until next time,
N

Primary Care: The CCA Way

Hello friends!! There are severe thunderstorms in Boston right now and I’m too scared to venture out for my evening commute, so you all get a blog posting! How lucky! I was going to meet my new friend Danielle, a Nurse Practitioner at Commonwealth Care Alliance (CCA) for dinner, but we shall see what the weather has to say about that!

Speaking of Danielle, though- I had the opportunity to meet her when I went shadowed her on home visits. My boss thought it would be useful for me to see firsthand how we provide care to our members and he was definitely right! Danielle acts as a care manager for her patients, as an integral part of their primary care team. She is responsible for about 20 patients and provides care to them in their homes (be it an apartment, assisted living facility- anywhere). She has the flexibility to schedule her time as she sees fit, enabling her to adjust her appointments as patient acuity dictates. You can see a video of a CCA nurse practitioner visit here.

We started out our day at the Somerville Home, a residential care facility. We met with two of her patients in the nursing station there which allowed for communication with the nursing staff at the facility, giving us some insight into their daily condition. Danielle suspected one of the patients might be under-reporting their pain, but the Somerville Home nurses let us know how she feels throughout the day, allowing Danielle to appropriately adjust her medications. She typically visits her patients once a month, but one of the patients we visited is relatively new to her so she wanted to go back in two weeks to make sure she understands all of her conditions and to help build her relationship with her. It was exciting for me being there, as I was able to provide some drug information relating to which drugs might be causing certain symptoms.

Next, we were off to the Cambridge Hospital as she had admitted one of her patients the day before. She likes to check up on all of her patients when they are in the hospital, to check on them and to communicate with the hospital staff so they are well informed about the patient’s conditions. While there, she spoke with the patient’s nurse, the patient and the patient’s daughter, who is her primary caregiver in the community. She was also able to speak with the case manager to begin her discharge planning for when her condition was sufficiently stabilized. After patient’s are discharged, Danielle makes it a priority to visit them within 48 hours to ensure everything was well coordinated. After our P3 Direct Care IPPE’s, where we performed medication reconciliation, I realized right away what a great idea this is! If anything slips through the cracks during her transition back home, Danielle is able to catch it right away.

Finally, we visited a patient in her apartment. While there, we discovered that she had some piroxicam from several years ago. Danielle and I talked about it with the patient (it was nice to have some knowledge of the drug- it has a very long half-life and is definitely a drug to avoid in the elderly!) and decided to adjust the timing of her other medications and avoid the piroxicam altogether. Had we not been providing care to the patient in her home, however, I think this medication could have been missed, possible leading to a very serious adverse drug reaction.

In summary, I had a great day! It was so fun being out on the road with Danielle, meeting some of our members firsthand. It got my mind going about the possibility of adding a pharmacist to the CCA primary care teams, seeing how useful it was for Danielle and I to discuss the patients’ medications.

UPDATE (since I didn’t actually post this last night): I was able to make it safely to Danielle’s for dinner and we had a wonderful time!

Prescription Drug Print Advertisements

Clearance at last! It only took a month of negotiation, but I can finally put my thoughts on the world wide web. Now, please grab some popcorn while I attempt to entertain you for the next 2 minutes and 14 seconds:

Fellow pharm animals,

Remember pharmacy law? Let’s kick it up a notch. With all these acts and regulations, who can keep up? That’s right. We do. As part of the Regulatory Affairs – Advertising and Promotion division of a large healthcare company in the midwest, we make sure that all promotional materials going out to you (the consumers) and to you (the healthcare professionals) are marketed safely and accurately. This means that ads adequately convey the drug’s labeled indications and do not contain misleading information.

Let’s start with an example of a well-designed print advertisement about the fictional drug, Arbitraer (Source: FDA DDMAC website):

What makes this a good ad?

1. Correctly identifies brand (Arbitraer) and generic (misvastatium) names
2. Accurately claims an FDA-approved indication
3. Appropriately states Arbitraer is given by prescription only
4. Provides “fair balance” about risks and benefits
5. The man on the beach is in the approved age range of the drug
6. Encourages reporting of adverse events to FDA
7. Refers reader to the “Brief Summary” of FDA-approved prescribing information
8. Tells readers to refer to their doctors to discourage self-diagnosis
9. Provides additional sources of drug information

What a beautiful print ad! Here’s an ugly ad of the same drug:

Problems:

1. Cannot use images of children if not approved for this age range
2. This is a false claim that is not supported by well-designed studies
3. Arbitraer is approved for seasonal nasal allergy symptoms, not asthma. Cannot make a claim that it will control asthma symptoms
4. As stated above, claims must be supported by well-designed studies
5. Risk information is in small type size and positioned far away from the benefits. “Fair balance” requirement not met.
6. No “brief summary” about risk information, and no information about reporting adverse events to Medwatch.

In a nutshell, the team I’m working with collaborates with marketing teams to keep all materials in line with the FDA rules and regulations. That’s nice, Eric. What if I don’t want to follow the rules? That’s fine…if you want to get slapped with a Notice of Violation or Warning Letter from the FDA’s Division of Drug Marketing, Advertising, and Communications (DDMAC; pronounced dee-dee-mak). More on those in the next post. Baby steps, my friend.

Eric Zhao

I am currently a summer intern in the Regulatory Affairs Department, and the opinions and positions expressed are my own and don’t necessarily reflect those of Abbott Laboratories.