Wednesday, December 3, 2014

APPE #3 - Pharmacy Rotation in Ambulatory Care: Anticoagulation and MTM Clinic

So I'm a little behind in updating my blog with my 4th year pharmacy rotation experiences. 

It feels like I just started 4th year, but I am already on rotation 4 of 6.
And let me tell ya....I'm ready for a brrrreak. Good thing a 2 week Christmas Break is coming and that my next block after that is my vacation block, which means 6 weeks with no rotations! By that time, I will only have 2 more to go and then graduation (May 22nd). And  hopefully my last 2 rotations are going to be a little bit easier. Thank the Lord that I am almost done with all of my brain-crunching, critical-thinking-skills-requiring ones.

So going back to APPE ROTATION #3, with which I got done in mid-November.

By the way, here are the links to posts about all of my rotations so far:

The rotation site was Advocate Health Center or Advocate Medical Group (I still don't know what the difference is and why they use two different names)...which is part of a very large health system network throughout Chicago. In addition to multiple Advocate clinics, there are also 4 large Advocate hospitals around here. My current NICU/Peds rotation is at an Advocate hospital as well (same parent company).

So within this Advocate Health Center site, the pharmacists run what's properly called "The Advocate Anticoagulation and Medication Therapy Management Clinic" or in street language "The Coumadin Clinic." I'm sure some of you have heard of coumadin clinics...or at least of the drug coumadin (warfarin).

So as you can tell by the lengthy name of the clinic, there are 2 major components of care that these ambulatory care pharmacists specialize in: 1) the Anticoagulation part and 2) the Medication Therapy Management Part aka MTM

Most of our patients that came in were there for warfarin management. Managing warfarin is a very delicate and tricky business and it definitely not a drug that a doctor can just put a patient on and never worry about it again. It is a blood thinner drug and it has a very narrow therapeutic spectrum and so it is very important that patients are on the proper dose. If they're underdosed, they're at risk for clots, heart attacks, strokes. If they're overdosed, they're at risk for bleeding. And unfortunately, there is not a standard dose that will work for everyone. The actual milligram dose (ex 1mg, 2mg, 5mg, 10mg) tells us nothing by itself. The only way to see if the patient is on a proper dose, within the therapeutic range, is to measure the patient's INR (Internalized Normalized Ratio), which tells us how fast the blood clots, or how "thin" the blood is. Again, blood too thick = more risk of clots that can get stuck in the veins, or travel to the brain, lungs, or heart (stroke, pulmonary embolism, heart attack, respectively). Blood too thick = does not clot = more easy bleeding that will not stop. The most dangerous is GI bleeding (aka gastric or intestinal hemorrhage)  and brain bleeding (aka intracranial hemorrhage). So we have to constantly remind and counsel our patients to immediately report signs/symptoms of bloody or dark stools, vomiting that looks like coffee grounds, and to go to call their MD or go the ER if they bump their head hard. The other tricky business about warfarin is the fact that it has a million drug-drug interactions and another million food-drug interactions. So at these visits, when patients come to get their INR, our job is to ask them what changes in medications, foods, and alcohol intake they had, whether they noticed any new symptoms of bleeding or bruising, etc. 

 Wow, I got a little carried away (LOL).  Enough pharmaceutical education here.  

Apart from thoroughly educating the patients, we had to take their INR test and based on the result we got, adjust (or not adjust, if INR normal) their warfarin dose.

<-- This is the INR testing device. You just put a drop of blood on a test strip, kind of like with diabetic glucose testing.

Now, the non-anticoagulation part of this rotation was Medication Therapy Management (MTM - a buzz word in the pharmacy world nowadays).  Doctors would refer their patients to see the pharmacists at the med management clinic if patients were on multiple diabetic meds, or multiple blood pressure or heart failure meds and their disease states still weren't controlled (their blood sugars and pressures were still outrageous and dangerous). So we optimize their medication therapy regimen and follow up with them frequently. 

But we don't just play with meds. We're very big on lifestyle changes. We first and foremost educate patients about how to change their lifestyle habits to improve their diabetes and blood pressure control. We talk to them about diet, exercise, and quitting smoking. Specifically for diabetes, we teach them food portion control, and methods such as carb counting. When we place patients on medications that can cause hypoglycemia (low blood sugar) such as insulin (usually only happens when you skip a meal), we make sure they know the symptoms of hypoglycemia  and how they can tell they're having an episode and what to do to treat the episode.

Of course, for persons with pre-diabetes, we teach them to recognize symptoms of high blood glucose (picture below).

On my rotation, I met all kinds of patients.
patients that were nice
patients that were indifferent
patients that were grateful
patients that were ungrateful
patients that had a terrible attitude
patients that were easy
patients that were complicated
patients that raised my blood pressure and heart rate SANCTIFIED ME  

In the end, all of the difficult patients I had, I offered them up for my sanctification, like a good Catholic would, haha! So it all worked out. I didn't take anything personally.

And on my last day, I saved someone's life! Well, I called an ambulance and they saved her life. But it was still my intervention! (If she would not have come in, she would have probably suffered a hemorrhagic stroke and/or some serious organ damage from a hypertensive emergency). Now that's what I want to do when I grow up: save lives (instead of destroying it, like some medical professionals who bought into the culture of death, do).

And of course as always, there were plenty of lovely (sarcasm) projects for me to complete over the course of the rotation.

Working on my patient case presentation late at night. It was on Crohn's Disease.

And this is one of the power point slides from my presentation.

 (yes I leave you with pictures of inflamed intestines)

And for a sneak peak of my current rotation, read my latest 7 Quick Takes post, where I explained what I do and why it makes me sooooo fired up and excited!

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