H-IPPE: OR Satellite Pharmacy

My favorite day of the H-IPPE rotation was the OR Satellite.  In think it was pretty much everyone's

favorite day.  After filling a couple Pyxis machines on the floor, I was to observe a KIDNEY TRANSPLANT!!! The patient's sister was in the next OR having a kidney removed, while I followed the CRNA as we brought the recipient back to get ready.  While the actual surgery primarily involves gross anatomy, the general anesthesia delivers a complex protocol of drugs to ensure that the patient cannot feel, cannot move and cannot remember. The anesthetic process begins in the Pre-Care area as the patient says good-bye to family and friends (and apparently takes pictures with the nurses).  While different for different patients and certain surgeries, the general protocol for patient induction includes:

1.     Midazolam - the sedative relaxes the patient and is given in the pre-care area. Working almost immediately, the patient is not unconscious but also will not remember anything about heading into the OR.

2.     Fentanyl - the narcotic pain killer helps to make sure the patient does not feel anything. This is given after the patient has been transferred to the surgical table.

3.     Lidocaine - the local anesthetic prevents the burning sensation upon the administration of the next medication.

4.     Propofol - the general anesthetic helps keep the patient unconscious for the entire surgery. It is a milky, white emulsion.  If you did not know, propofol was the agent that killed Michael Jackson

5.     Succinylcholine - the paralytic makes sure the patient cannot move while the surgeon operates.

During the actual surgery, the surgeon goes to work opening up the patient.  While the kidneys are in the back of your body, the new kidney will be placed in the front.  The surgeon must first get through a lot of tissue which involved cauterizing the incisions.  I won't soon forget the smell of burning flesh.  Once he reaches the kidney, he must disconnect all the pipes to and from the kidney to be refitted for the sister's kidney.  Meanwhile, the CRNA continues to monitor the patient's vital signs - adjusting knobs on the ventilator and providing a small electric shock to check for paralysis.  Soon the sister's kidney is brought in from next door in a large silver bowl.  When the surgeon finishes detaching the original kidney, he moves to a separate table to inspect, clean and prepare the new organ.  But when he goes to the other table, the patient is still there.  Opened up with clamps and things sticking out of her!    Sadly, this was the point that I had to leave to go to a meeting.  The surgery would last for another few hours, but I would not be back in time.  

Overall the process of renal transplant was amazing.  The amount of drugs pumped into a patient for induction, maintaining, and waking is incredible.  I witnessed about 7 or 8 medication, with several on the table in case of emergencies.  If anything else was needed, a Pyxis machine was available with a healthy stock of medications.  That kind of concerned me.  The nurse could grab just about anything, the doctor could order anything at any time.  But there was not form of pharmacist verification with any of it.  The OR seemed like the Wild West, where the laws of pharmacy were no longer valid.  There was a phone to call a pharmacist if there was a question, but it was completely up to the nurse and the surgeon.  I am by no means questioning their abilities, but it seemed odd after learning about order verification and other steps to avoid medication errors.

After returning from my meeting, I spent time with the OR pharmacist.  They actually rotate from the Inpatient Pharmacy up to the OR on some kind of schedule.  Which makes sense, you definitely need someone who knows with IVs in an OR.  Strangely, no pharmacists are in the satellite for the evening or night shift.  There are technicians, but if something needs to be verified, they must call or travel down to the CIP.  When I sat with him, the pharmacist was busy verifying the antibiotics for the next day's operations.  When patients prepare for surgery, they are given a prophylactic administration of antibiotics. The most important surgical complication comes from post-operative infection. Different surgical areas must prepare for different types of microbes. Upper body surgeons are concerned about Gram-positive bacteria like Staph and Strep. They tend to order ceFAZolin. Lower body and GI surgeons encounter more Gram-negative bacteria. Interestingly, urologist typically order levofloxacin.

Anyways, he went through the each patient to make sure that the antibiotic matches up with the type of surgery. Instead of memorizing the antibiotics, UNC has prepared a list of common orders for every category and other criteria. For some medicines, the pharmacist must check renal function by calculating CrCl using a common equation (CrCl=(140-age)/SCr). Levofloxacin and Meropenem were most commonly ordered and checked for renal function. Gentamycin was much more difficult to dose as it is based on the patient's ideal weight determined through a complicated equation. The surgeons commonly only use the patient's actual weight, but the pharmacist must change the dose. If gentamycin is dosed incorrectly for extended periods, it can result in ototoxicity (hearing loss).

As you can tell from the length of this post, I really enjoyed this day.  I learned a lot from observing the CRNA and sitting with the pharmacist.  Who wouldn't enjoy a kidney transplant?  To me, the OR seemed like an open opportunity.  More than just short staffing problems, but about the verification process of surgical medication.  The pharmacist could have more of a role during surgery.  They may not need to be in the actual room, but there could be a place for more aggressive involvement.  Hospitals perform hundreds of surgeries a day.  I feel like the OR could be a possible frontier in the future of pharmacy.

TED Talk Tuesday: Matt Cutts

Have you wanted to try something new or change something old about your life?  Matt Cutts tells TED to try anything, anything at all for 30 days.  It can be as simple as cutting sugar or caffeine to writing novels and biking to work.  All you need is 30 days.

What would you do for 30 days?

H-IPPE: Pediatric Behavioral Health

1 in 13 kids take psych meds

My first clinical specialist day paired me with the pediatric resident during his behavioral health month.  When our preceptors asked us if their was any particular area we wanted to see as a specialty, I asked for anything dealing with the brain.  I enjoy neuroscience and found it to be my favorite section in my Anatomy class to teacher.  So I figured that it would be interesting - mental illnesses, Alzheimer's,
Parkinson's, etc.  I was not disappointed with my day in pediatric behavioral health.

We started the morning by talking about a few basic things like introductions, the layout of the ward, how the rounds would work and then went up to the pediatric psychiatric unit.  The doctors, residents, nurses, and their teachers piled into a very small room to discuss the 10 children on the ward for the day.  These were some serious 9-13 year olds who had been through more than most people in their 30s.  These kids were diagnosed with MDD, ADHD, ODD, Mood D/O with symptoms of SIB, SI, HI taking various amounts of Prozac, Lexapro, Concerta.  Some stay in the unit for a few days, but others had been there for a month.  The Hospital School addresses their education needs while they are in the hospital and the teachers work closely with the doctors.  The Hospital teachers would contact the home school for information and IEPs - pretty much every kid had one.  Parents would come during visiting hours with a pass, but generally the kids cannot leave the floor.  

We talked about their medication treatments, but mostly these kids required intense therapy and behavioral plans.  To treat the younger kids the doctors prefer hugs to drugs.  As a pharmacist, we sometimes forget that and go straight to medications.  But let's not forget that these kids are on some serious prescriptions.  Fluoxetine and escitalopram (SSRIs) were the favorites for depression.  Agitated patients would also recieve ropinarole, a 2nd gen antipsychotic).  But then the agitation could be due to the ADHD requiring a stimulant.  Even if the patient was on only 2-3 drugs, there was a lot to consider in matching the medication to indication and achieving therapeutic doses.  For another point, you don't want to open the door to greater abuse in young children by prescribing long-term benzodiazapem.  Pediatric dosing for neuro-drugs was different as well.  Usually, the doctor titrated up from the lowest dose available until reaching an effective point.  Not only are these kids growing, their brains continue to develop as well.

Unfortunately, I had to leave for a meeting before actually meeting with the kids and families.  They had left for the Hospital School when we came out of our meeting.  The resident showed me the other areas on the floor for adolescents and eating disorders.  I learned a lot during this day and was actually able to talk about this more due to my education background.  As a subspecialty, Pediatric Behavioral Health would be incredibly interesting, but potentially devastating.  I was glad to experience it.  At any rate, almost every pharmacist will dispense psychiatric drugs to pediatric patients.  One in 13 children take some kind of psych med in the US.  It is important to see the most extreme cases to understand the others.

Alphabet Soup Notes:
MDD - Major Depressive Disorder
ADHD - Attention-Deficit with Hyperactivity Disorder
ODD - Oppositional Defiant Disorder
Mood D/O - Mood Disorder
SIB - Self-Injurous Behavior
SI - Suicidal Ideation
HI - Homicidal Ideation
IEP - Individualized Education Plan

The McMap of the US

At the start of a class, I would put up this picture:

The description would have been removed and I would offer extra credit test points to the first person that could tell me what this picture represented.  They came up with a lot of answers - the US, cities in the US, cell phone towers, Facebook users, and on and on.  Eventually, someone would get it right - every McDonald's in the contiguous United States.  Wow!

That is a lot of McDonald'ses.  They are everywhere.  I really like the brighter spots that show you the locations of cities.  You can see Raleigh-Durham, Greensboro, and Charlotte pretty clearly.  Stephen Von Worley constructed this map in 2009 to demonstrate the our collective proximity to the fast-food chain.  To be clear, the map has actually changed since then.  Von Worley also determined the McFarthurest spot - the place on the map furtherest from any McDonald's.  If you ever visit Glad Valley, South Dakota, you would have to drive about 145 miles to buy a Big Mac!

Saving Money at the Drug Store

Looking for a simple way to save some money.  Stop buying brand name drugs.  The generic versions required by law to be identical to the more famous names.  Why spend extra money just on a name?  Hospitals save money by only providing generics, unless they have to.  Medicaid and Medicare save money by requiring generics if possible. If they can do it, so can you.  This is a not-so-secret strategy employed by doctors, pharmacists and nurses when they go to the drug store.

Let's look at an example from the Walgreen's website.  Pain is the number one reason people buy medicines.  They head to Walgreen's for some Advil.  You can buy a bottle of 200 Advil tablets for $15.99.  That comes out to about 8 cents per tablet.  Not a bad price if you think about it.

But Advil is just the brand name that Pfizer gives to the drug ibuprofen.  The pain reliever and fever reducer was developed in 1961 as an alternative to aspirin.  McNeil Consumer Healthcare also produces a version of ibuprofen known as Motrin.  All three names work the same, because all three are the same thing - ibuprofen.  As a non-steroidal anti-inflammatory drug (NSAID), ibuprofen interrupts the inflammation process (by blocking the COX enzyme) which reduces swelling and pain.  Any tablet that contains ibuprofen works exactly the same way.

So let's head back to the pain aisle of Walgreens.  They sell a bottle of Walgreen's ibuprofen in the generic form as well.  It's the same thing and works the same way, so how much.  A bottle of 1000 generic tablets costs $19.99 or 2 cents per tablet.  Advil (8 cents) is literally 4x more expensive that a product that does the exact same thing.  So why do people by the Advil instead of generic ibuprofen?  Mostly advertising and not understanding drug names.  I think there maybe some kind of placebo effect as well.  If I pay more for this name brand it should work better.  But it doesn't and Pfizer counts on the majority of people not to know such things.

This can save you a lot of money in the long run.  Assume you took 12 ibuprofen everyday for one year- which you shouldn't because you will probably end up with an ulcer.  Buying Advil will cost you $350 over that year.  The generic tables will come to an astounding total of $88.  It really adds up fast.  So save some money, buy generics!

H-IPPE: Sterile Products Area

Of all our locations during the IPPE month, the Sterile Products Area (SPA) worried me the most.  We would be required to fill IV bags with medicines that would go to an actual patient in the hospital.  Sure we learned and demonstrated aseptic technique during the lab class, but this was real.  Messing up in here could lead to an infection in the patient or overdose or underdose.  There are a lot of ways to be wrong when filling IV bags or syringes.

Going into the room was just as predicted.  No ties or jewelry. Put on the bonnet, face mask and shoe covers.  After a thorough hand/forearm washing, you don the gown and step into the sterile area.  Apply some alcohol to your hands in case you missed anything and put on the special, tight, sterile gloves.  Oh and some more alcohol.  Essentially, in the SPA the answer is always alcohol.  Now you are ready to get to work.

After collecting a long list of medication orders, you fill a table with the appropriate drug and bag.  Then you start filling.  Now at the table, more aseptic procedures prevent contamination.  In lab, we worked with a horizontal air flow.  Nothing should get in between the filter and their products.  In this hospital, we had a vertical air flow, so nothing should be above the needle or bags.  This includes your hands.  Clean your area with some alcohol, spray your gloved hands, and the ports on the vials and bags.  Now you are ready to stick a needle into the vial.  After withdrawing the correct amount, inject that into the IV bag of normal saline or dextrose.  At all times, remember the air flow comes from above.  If you accidentally pass over the bag, spray the port with some alcohol.  Finally, cap your needle and put into the sharps container.  Place the label on the bag and hand it off to the pharmacist.

I was really nervous for the first couple of bags, but I had no problems and started to move along.  We did some reconstitutions by adding sterile water for injection into a vial of dry powder before putting it into the bag.  We used a transfer needle which squeezes the bag's fluid into the vial, mixes the solution and passes the medicine into the bag.  Everything was moving along until my partner had a major accident.  While I was dutifully removing air bubbles from the syringe, a rather large needle went flying past my face along with a few choice words.  She had accidentally stuck herself in the thumb.  Before I could turn around, she was gone.  There wasn't much I could do other than clean up the area and finish my batch.  I felt really bad for her.

All of that was before lunch.  After our lunch meeting, I came back to the SPA to work with the pharmacist.  We checked the bags that the technicians (including me) filled.  You check the contents of the bag, the drug from the vial and the volume from the syringe.  Everything must match up to the order before putting your legal initials on the label.  We went to the nutrition area to check the TPN (total parenteral nutrition) for the patients that can't eat.  A lot of products do into a yellow fluid to provide calories, carbs, proteins and fats to an unconscious patient - also a lot for babies in the NICU.

Some IPPE students that the other hospitals throughout the state spent an entire week in the IV room.  We worked in the SPA for one morning, about 3 hours.  I would have liked more time to fill IV bags and use the aseptic technique we worked on.  But I don't know what I would have wanted to give up more time there.  The SPA technique is complicated, but a simple checklist helps prevent you from missing anything that might hurt a patient.  I believe I would be comfortable as a pharmacist in the IV area.  You have to know a lot about compatibility between the drug and the fluid.  A lot can go wrong in the area, but you definitely use a lot of the knowledge you accumulate in pharmacy school.

TED Talk Tuesday: Pamela Meyer

According to Dr. House, Everybody Lies!  Everybody.  They may be lies to make people feel better, but that doesn't make them any less untrue.  But then again, I don't think that I would want to live in a run down Chicago with a faction of Candor either.  So if we everyone is a potential liar, then we should be able to spot the truth from the lies.  Pamela Meyer shows us the tell tale signs of deception in this TED talk.

Enjoy!

H-IPPE: Special Formulations

I spent a day in Special Formulations area tucked into a small corner in the back of the Central Inpatient Pharmacy.  This was one of the days I looked forward to the most for the IPPE.  I ACTUALLY enjoy compounding because it is more like old school pharmacy (as the chemist or apothecary).  Most medications come straight from the manufacturer as a pill, but some have to be prepared into an IV bag or oral syringe.  Compounding changes a manufactured product into something else.  This is where the mortar and pestle of the pharmacy come from, and they had a huge mortar.

During our short tour, I realized that it pretty much looked just like my chemical storerooms in the high schools but with a variety of drugs instead of salts, vinegars and aluminum foil.  Also the graduated cylinders and beakers were much larger.  I only got through two compounds today, while my preceptor whizzed through almost 10.  Though She has been a tech at UNC for over 20 years and before that she was a pharmacist in Peru.  Very nice lady and super helpful.  Here's what our IPPE students got to make during our month:

• Nimodipine - Comes in capsules that must be punctured and drained to create an oral solution patients with feeding tubes. Indicated for Subarachnoid Hemmorage
• Vancomycin - Injectable, lypholized that must be reconstituted (with Sterile Water for Injection) and mixed with Ora-Sweet and Sterile Water for Irrigation to create an oral solution. Indicated for bacterial infection
• Mafenide - Yellowish powder that must be added to 1L of Sterile Water for Irrigation. Indicated to prevent infections in burn patients.
• Magic Mouthwash - A mixture that contains nystatin, diphenhyrdamine and sterile water. Indicated for oral candidiasis
• Ursodiol - Comes in capsules that must be unscrewed and finely ground and mixed in a mortar. Indicated for the treatment of primary biliary cirrhosis

For some reason, many of my classmates dislike compounding.  It is just like cooking.  You follow a recipe, except that you have to accurately record the ingredients that you use (Amount, Name, Manufacturer, Lot Number, and Expiration Date).  Some pharmacies focus entirely on compounding and ship out to local hospitals.  But also, some compounding pharmacies have found trouble with their products and over stepping their bounds (that is a post for another day).  If you like baking or you enjoyed chemistry labs, you would have enjoyed a day with Special Formulations. 

I Hate These Word Crimes

"Weird Al" Yankovic returns with an awesome parody of Blurred Lines.  The American language has devolved into text-speak and emojis.  Weird Al takes on every complaint about language in this video that will probably show up in every English class across the country.  I mean ... these grammer mistakes literally makes my head explode and I definitely LOLed at it's message.

Enjoy!

Be A Man

While I coached high school football, the school board became attached to a 1970's football player turned coach and pastor, Joe Ehrmann.  His son played for Wake Forest and since he was around a lot, he would come and speak to us ...  a lot.  He spoke at a Faculty Meeting, School Coaches Meeting, County Coaches Meeting, and a Youth Camp.  Every coach in the county was given the book Season of Life, by Jeffrey Marx about Ehrmann's successes as player and coach of Gilman High School.  Recently, Joe sat down with NPR's All Things Considered to talk about what it means to be a man.

Coaches have an enormous power to mold young men, and women, through their high school career.  During those four years, a scrawny 14-year-old boy develops into an 18-year-old man about to head out into the world.  No doubt that at some point, every male has heard the phrase, "Be a Man".  But mostly, no one ever explains what that means.  Joe Ehrmann believes that the old view of masculinity revolved around three basic lies - Athletic Ability, Sexual Conquest and Economic Success.  Your manliness is essentially on a scale based on these three attributes.  Instead, Joe argues, manhood should be about your capacity to love and your commitment to a cause.  We should be building relationships instead of walls.

Joe Ehrmann gives a great talk and I urge to to listen to the NPR link or to check out the book.

H-IPPE: Clinical Generalist

Clinical generalists work on the floor within the medical team

During our experience, each student had at least one evening shift and mine was on the Clinical Generalist day.  As opposed to a distribution pharmacist in the inpatient pharmacy, the clinical generalist works on the floor with a specific service.  The major responsibility of the clinical generalist is to verify the medication orders put into the computer by the doctors.  Most was accomplished sitting at a desk in the crowded work area.  Using EPIC, she kept up with the new orders on her floor, but they also watched hospital wide to quickly verify high-priority orders.

Because I was on the evening shift, there really wasn't much to see other than order verification.  She went incredibly fast clicking away as they came in.  Several warnings would pop up on orders that she would override.  She explained that our clinical judgement allows us to get past some warnings when the benefits outweigh the risks.  Some medications are hazardous with serious potential complications, but if it cures an infection quickly, it would be worth it.  A few times, the clinical generalist calculated Creatinine Clearance (CrCl) to determine a patient's kidney function which would result in an adjustment of the dosage.  Had I seen a day shift, my experience would have included rounding with the medical team as the generalist makes dosage suggestions.

Usually, a clinical generalist completed one year of residency training.  I enjoyed the experience and would not mind falling into that type of position.  While I may not know all the clinical information yet, you do seem to work towards the peak of your certification making judgement calls and having a potentially active role in patient care on the floor.  Nurses would stop by and ask questions or we would search out doctors to make suggestions. Most importantly, the clinical generalist on the floor helps catch medication errors and optimize patient care.

TED Talk Tuesday: Ric Elias

Ric Elias was a passenger on the fateful flight that left NYC only to be landed in the Hudson River.  He talks to TED with the clarity that can only be revealed when the pilot comes over the intercom and says, "Brace for impact".

Enjoy!

H-IPPE: Central Outpatient Pharmacy

My rotation day with the Central Outpatient Pharmacy marked my first occasion behind a pharmacy counter.  Having never worked in a pharmacy before, I appreciated seeing this opportunity. Outpatient pharmacy is a hybrid, a mixture of retail and hospital pharmacy. In many respects, the COP acts as any retail, community pharmacy, but there remain numerous differences. They require payment, cash or insurance, and they generally have a quick turn around time. But the COP can only fill prescriptions from prescriber affiliated with the hospital and will not accept transfer prescriptions from an outside pharmacy. Most customers are patients being discharged from the hospital on their way out. 

Many of the pharmacists previously worked at CVS or other retailers before coming to the COP.  That was part of the manager's plan to decrease the wait times for the patients.  Apparently a year ago, patients waited for an hour, while now they are in and out in 20 minutes.  The pharmacist that I spoke to was really happy with his choice to leave retail and come to the COP.  There may have been a major pay cut, but greater quality of life - including less weekends and an actual lunch hour.  It is a lot easier to help the patients because they are attached to the hospital network and can view the entire hospital record for a patient and determine the indication.  Knowing the indication can help with verifying a medication's dosage, especially for pediatrics.  For all pediatric prescriptions, they must recalculate the dosage strength.  This requires the child's weight in kilograms and the indication - both readily available in the COP, not at a local retailer.  

As a public hospital devoted to all North Carolina residents, the COP has a pharmacy assistance program for those that cannot pay.  Some have $4 copays or even zero.  Many patients come from 2-4 hours away to receive their heavily discounted drugs, which is why the hospital is pioneering a mail order program.  Before a patient qualifies for the assistance program, the COP will fill any order for 14 days.  When they come back with the forms and are accepted they will fill the remainder of the order.

Even though I may not know what I want to do in the end of the PharmD program, this was one that I definitely felt comfortable with.  I hear the stories about working in retail and the difficulty of getting into a clinical position, but this sits firmly in the middle.  You help patients on their transition from the hospital to home and you get to use more of your clinical knowledge to help.  I would have no problem working in an outpatient pharmacy after this experience.

Be a Good One

If you are going to do something, be the best at it.  Doesn't matter what it is, try your hardest.  You may not become the best, but you will get better.  You will find where your talent lies and potentially impress the right people to get you where you want to be.

This is Rule #2

HIPPE: Carolina Care at Home

Of my three days with the Med Transition Specialists, I spent one day with another subset of the group called Carolina Care at Home (CC@H).  While med histories dealt with people through the admission into the hospital, this group works with the discharge of patients.  Essentially, CC@H extends the Central Outpatient pharmacy into a bedside delivery service before patients leave the hospital.  There are benefits for both parties.  The patient doesn't have to stop at a local pharmacy on the way home to pick up prescriptions, and the hospital generates revenue from the sales.

We started early in the morning by checking the eligibility of the patients about to be discharged from the hospital.  Because there are only four members of this group, they focus on patients with insurance instead of self-pay.  After identifying potential customers, we went through the floors to offer them the service.  After watching the person I was shadowing a few times, I felt comfortable enough to give it a go.  I walked into a patient's room a little nervous, but prepared.  The 26-year-old patient was alone in his room watching TV when we entered.  I asked if he would be interested in bedside delivery, but I didn't get much feedback from him.  I kind of freaked out that I was bad at this and every patient would respond to me in the same way.  After leaving, a nurse let us know that he had the mental capacity of a 5-year-old and probably didn't understand what we were saying.  When we spoke to his guardian later that morning, I noticed that the patient was watching Sesame Street on the TV.  Fortunately, not all of the patient encounters turned out that way.  In fact, pretty much everyone I spoke to was eager to have the meds delivered before leaving the hospital - except one patient that received free medications on the military base.  Of any day on the HIPPE rotation, I spoke to the most patients with the CC@H.

After a patient agreed to CC@H, we would fax their prescriptions down to the Central Outpatient Pharmacy and let them know something was coming.  The popular service could easily overwhelm the staff down there in their little corner of the COP, so it would not be surprising for a 2 hour turn around.  When we went through the floors of her service area, we headed down to the COP to pick up the orders and take them back up to the rooms.  After we left, a pharmacist in the COP would call the patient's room, counsel them on the medications, and collect their payment over credit card.  If the patient paid in cash, we brought up the meds, took their money to the pharmacy, and brought their change back up to the room.  There was a lot of walking done on this day.  Actually, because I have a FitBit I can tell exactly how much walking was done - 14,000 steps for over 5 miles.  For this job, comfortable shoes are a must.

Overall, the Carolina Care at Home initiative is a great program.  The pharmacy can reach out to a hospital full of confined customers.  Patients can receive what they need before leaving and head straight home.  I don't know if other hospitals have a similar program, but if I end up in one that doesn't I will attempt to start it.  Transitions of care is a hot topic in the health care field.  This can earn money from the hospital and help prevent patients from readmission.  Win-Win.

H-IPPE: Transitions of Care

Spurred by the Affordable Care Act, hospitals have turned their focus to reducing hospital readmission rates.  Medicare will no longer reimburse hospitals if a patient is readmitted to the hospital within a month of their discharge.  To prevent these readmissions, hospitals take great interest in the transitions of care - admission, transfers, and discharges - for at-risk patients.  High-risk patients are determined by

This patient is high-risk for readmission and
needs medication review and reconciliation.

age, comorbidities, multiple medications, and economic status.  Once a patient is identified, the Med Transition Specialists come into play to collect a complete and accurate Medication History.  On this team, we spent three days during our rotation.  Though all the IPPE's had different experiences, I enjoyed my time interacting with patients and feeling like I had an impact on their admission to the hospital.

Medication histories are generally taken by the nurses when a patient has been admitted.  A lot of the time, the nurse can just copy and paste from their medical records.  But time and again, this has shown to lead to inaccuracies and missed medications.  Nurses have huge responsibilites in caring for the patient, the pharmacy department is best suited to taking care of a patient's medications.  So at UNC and other hospitals, a team of pharmacy technicians review the collected histories which a pharmacist checks off for medication errors or duplications of therapy.

Unfortunately, the Med history team at UNC only consists of four technicians for the entire hospital.  The means that they must focus on the high or moderate risk patients when collecting patient histories.  The process was relatively simple.

1. Print off the Medications Prior to Admissions from EPIC (computer system)
2. Call the pharmacy if listed in their records to get their last refills (dates and quantities)
3. Interview the patient to confirm which medications their are taking (and how)
4. Make notes in EPIC regarding med use in records.

A person could probably get through 10 a day depending on the patients.  Some interviews take longer when a patient talkative or lonely.  Sometimes, their wrong pharmacy is listed or the person uses multiple pharmacies  Some drug lists are longer - 15 or more medications.  Over my days, we found a patient taking two medicines for the same condition, not taking enough (to make the expensive medicine last longer), taking too much (if some is good), or not taking their medicines at all (unpleasant side effects).

In the end, I found the people interesting and enjoyed working on real patients.  Med Histories are important to provide the doctor with a full background of the patient before coming into the hospital.  Later during the month, I wound up on pediatric rounds for patients if cystic fibrosis.  The medical team had a long debate about what the kid was taking at home and how much we should give them while in the hospital.  Since Med Transitions only have 4 technicians, they can't get everywhere.  Perhaps the automation of the pharmacies will open up technicians to move to roles of taking med histories through out the hospital.  I know that the focus is on high-risk medicare patients, but all patients are at some risk when they transition from one place to another.  And pharmacists are the best suited members of the medical team to oversee those transitions.

TED Talk Tuesday: Keith Barry

Keith Barry describes himself as a mentalist.  He steps onto the TED stage to perform some brain magic in one of my favorite videos of all time.  Magic is mastery of the human brain, and Keith Barry is a grand master.  I showed this one to every class, mostly to get them interested in TED.

After showing this in class, I learned some of the techniques.  I tried teaching this kids how to read someone's mind and here is one to try.  Have a partner pick a number 1 to 20.  Start counting from one and carefully watch their pupils.  While there face may not react when you get to the number, their pupils will never lie.  When you see them change, that should be the number.  The change is subtle and it clearly takes years of practice to master.  Notice that Keith performs the feat with letters to determine the ex-boyfriend's name.  Small reactions and experienced guessing gets him to the right answer.

Enjoy and see if you can figure out the Coke bottle trick!