Archive for August, 2009

My Art. ( newly added to the About Me page)

August 31, 2009 at 1:21 pm · Filed under Uncategorized

MY ART. MY PASSION.

my paper house….. ( traditional style japanese house + modern bakery)
– This project started with an idea that I wanted to build a paper house from scrap….These models were based off from pictures I saw on the internet.

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My t-shirt doodle session
– I think that I was in a destructive mode when I first started drawing this ( hence the monsters terrorizing the city), but then I calmed down from drawing for a bit….which led to the addition of a flying girl with a balloon over the city. The back of the shirt shows a long line-up of children waiting to get their balloons so that they may also float over the destructive city. The front of the t-shirt shows an interesting contrast between the peaceful child floating through fluffy clouds vs the destructive city below. I have colored the ballon in red to amplify the difference.This symbolizes the innocence of a child.

I imagine that this is how it is like to be a child. The ugliness is still there, but you just fly above it all. Eventually, the balloon runs out of air and you descend to the city and live as an adult.

FRONT

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BACK

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Day 15- Home IV Program – EVALUATION

August 29, 2009 at 12:30 am · Filed under Objectives, Reflections on Residency & Learning ·Tagged , ,

Today is my last day with the home IV program. I am sad to see it end, but also excited to see what’s to come.

The morning mostly involved filling in the details for the incident report and continuing to work- up a new patient for home IV setup. I tried to do a home iv counselling at the burns & plastics unit as well. This counselling session didn’t go too well and the patient became really agitiated when he realized that he would be hooked to a pump for the entire duration of his therapy.

Mandeep went over the rotation objectives with me once more in the afternoon. I was able to meet all the objectives. For my coming rotations, I must continue to work on the following:

1. Being more confident when talking with my patients

2. being able to identify my own learning needs and to learn how to pursue them

3. continual improvements in my communication skills (ie. think or plan what I’m going to say before I say it)

4. continue to polish upon my basic pharmcology, therapeutics and pathophysiology

Overall, I really enjoyed this rotation and feel that I have gained alot from it. Mandeep was a very motivating preceptor and mentor. 

I want to be a better pharmacist for my patients.

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Day 14- Home IV Program

August 27, 2009 at 7:36 pm · Filed under Presentations, Reflections on Residency & Learning, Useful Sites/Links ·Tagged , , ,

The morning picked up quickly.

A patient had been accidentally discharged before the CADD pump was connected and the home IV counseling was done. The nurse had overlooked the note saying that the patient should be discharged after these tasks were done. Not only so, the nurse also gave to the patient a prescription for a few weeks of pip/taz IV bags that was clipped inside the chart and asked the patient to fill it at a local pharmacy. It is worthy to note that the prescription had a note on it that said, “Not needed- Home IV program will …have meds sent to the clinic.” This created alot of inconvenience and confusion for the patient and his family. Fortunately, we were able to contact the patient’s son, who was able to bring the patient back to the hospital. The down side was that the patient missed his 12 o’clock dose of antibiotic and this dose was given an hour later than scheduled. An incident report was filed regarding this matter. This incident could have easily been avoided if the nurse had checked the notes or if she had contacted the CML, resident or pharmacist for confirmation of discharge.

This afternoon, I did a presentation for the nurses on “Antibiotics- Spectrum of Activity, a review”. I wish I had done better. One of my goals from my midpoint evaluation was to become more confident and concise in my speech. I wish I had done better. Nevertheless, the nurses told me that they found it very helpful. They also brought up some interesting scenarios from real practice during the discussion portion of the presentation. It was interesting to hear things from their point of view and I felt comfort in that they may have benefited from the presentation.

There was a new patient assessment near the end of the day. This assessment brought up an unique assessment factor that had never came up so far during my rotation, the patient’s social history. Because this had never played a big factors in my previous assessment, it became a challenge in learning to weight the importance of recreational drug use and compliance to home iv therapy.

Useful link: http://www.vhpharmsci.com/

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Day 13- Home IV Program

August 26, 2009 at 7:12 pm · Filed under Reflections on Residency & Learning, Topics Discussed ·Tagged , , ,

I finished some of the paperwork needed for a patient discharge tomorrow, so I will be following up with a discharge counsel the following day.

Today is our clinic day and I was able to follow up with one of the patients that I had first met in week 1. I interviewed him for both the safety ( i.e. diarrhea, rash, PICC complications,etc) and efficacy (i.e. fever and chills) of his therapy. I had first met this patient when I was doing a home IV entry assessment, which was followed by a discharge counseling session. The patient was doing well on therapy. His only concern was that it was bothersome to carry around a pump and bag for the last two weeks. He claims that it is contributing to his neck pain, which is complicated with a hx of spondylosis. Fortunately, Mandeep was able to come up with a compromise where the patient would be switched to once a day ceftriaxone ( 30 min by gravity at the nursing clinic). The patient was very satisfy with this alternative. I was impressed by how Mandeep had thought of this alternative and I feel at fault that I had not tried to solve this problem for the patient before hand.

 

FMI: Cephalosporin Didactics :

1st gen:

– most gram +ve and some gram -ve: PECK ( Proteus, e. coli, citrobacter, klebsiella)
– 1st and 2nd gen are not effective against pseudomonas a.
– effective for cellulitis, surgical prophylaxis, URTI 

2nd gen:

– gram +ve and effective against gram-ve: HEN PECK  ( H. influenza, enterobacter, N. meningitis….)
– better against strep pneumonia than 1st gen
– less effective against MSSA than 1st gen
– better against lower respiratory track infection  ( community pneumonia) than 1st gen
– cefoxitin is effective for B. fragilis
 

3rd gen:

– ceftazidime is the only 3rd gen that is effective against pseudomonas
– not effective against B. fragilis 
 

  • strep pneumoniae is generally resistant to penicillin
  • all cephalosporins are cleared renally, the only exception is ceftriaxone, which is cleared hepatically
  • cross sensitivity with penicillin is less than 2%

Academic 1/2 day today:
This afternoon, I saw a ppt that outlined how technician regulation will be enforced in 2010. In one slide, there was a flowchart showing how current techs will have to take an evaluation test, followed by an entry to practice test before getting officially licenced. In the future, we will be having pharmacy assistants ( those who didn’t go through a certified program ) and pharmacy technicians ( those who did go through a certified program). It is uncertain as of yet how their job description at the hospital will differ.

This reminds me of how the entry pharm D in the future may force our current Bachelor pharm to undergo another evaluation test, followed by an entry to practice exam. I can relat to how the older techs must feel…it must be stressful times.

PROJECT

I met up with Karen today, one of the co-investigators for the project. We were able to clarify some of the comments that had been noted on the protocol draft. It looks like we will be doing some final revisions to fine-polish the protocol this week. Our goal is to have the protocol finish by next week, but we will likely need assistance for the statistical analysis portion. Ethics still need to be submitted…..and the site approval form is still in the works…..( not looking forward to this)

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Day 12- Home IV Program

August 25, 2009 at 5:50 pm · Filed under Reflections on Residency & Learning ·Tagged ,

Today, I spent most of the morning trying to complete a out-patient transfer from Vancouver to North Van. There was alot of liaising involve and the situation turned out to be more complicated than I do.

I received another vancomycin level back today. This time, the dose was given late (this required some speculations before the patient’s wife was contacted), so the vanco pre-level came out lower than expected. Nevertheless, the patient is still within the therapeutic range.  This is a perfect scenario where I must always remember to : (1) check if the dose was given on time (2) check if the dose was collected on time

I also spent some time preparing for the clinic day tomorrow where I will be following up with one of the out-patients I met in first week.

The latter part of the day was spent assessing a new patient for entry into the home iv program. This patient didn’t speak fluent English, but I was able to converse with him in Chinese. My only worry is that he would have problems trouble shooting his pump at home.

Presentation Thursday- must prep for the antibiotic review now. Sharon. Out.

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Day 10- Home IV Program

August 21, 2009 at 5:27 pm · Filed under Reflections on Residency & Learning ·Tagged , ,

Plan for this weekend: FINISH revising the project protocol!!!!!!

For now: START on presentation for Thursday

2 successful discharges today! Yay! Both patients were happy to be going home and be with their family again.  The discharge counseling went well. I am learning to become more confident with my counseling and it certainly helps to have a list of items that I plan on addressing with the patient.

There are many integrated parts that need to be done in order for the pt to be discharged. Even if one part is missed, it can lead to a detrimental delay in the patient’s discharge.

PENICILLIN Didactic Discussion:

  • enterococcus: DOC are amox and amp
  • Gram -ve: pip/tazo, amox, amp ( no clox)
  • Staph aureus: clox
  • bacteroide fragilis ( in lower GI):  pip/taz
  • peptostreptococcus ( oral anaerobe): sensitive to pen class
  • Clostridium ( not difficile)( not in GI): pip/taz, amox/clav, pen
  • not for staph epid, MRSA
  • clox: only pen that is not renally eliminated
  • pen class need renal adjustment
  • penicillin may cause seizure , especially for patients with renal impairment

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Day 9- Home IV Program

August 20, 2009 at 6:03 pm · Filed under Reflections on Residency & Learning ·Tagged ,

Today, I followed up on a patient with suspected endocarditis. During my follow-up, I monitored for both safety ( allergy, antibiotic associated diarrhea, PICC line complications, etc) and efficacy of the patient’s therapy. I had first met the patient in the hospital, when I did an assessment of him for the Home IV Program. After setting up the home IV program for him, I followed up with a counseling session on what was going to happen to him as an outpatient, as well as important issues to monitor with his antibiotic therapy.

Yay! Two patients were successfully set up for home IV today ! I am happy that they are happy to be going home. I will be following up with a discussion with the patient/family about their home IV therapy tomorrow.I hope to be more confident, thorough and concise with my counseling tomorrow.

One of my patients was discharged today and I did a counseling session on his medications/home iv therapy. He was very friendly and it was such a pleasure to talk to him. 

Talking to these three patients really made my day.

FMI from C. Difficile discussion today:

  • differentiating between c. difficile and antibiotic associated diarrhea: timing ( late [more than 3 weeks] or early), assay ( definitive)
  • Definition of diarrhea: varies from patient to patient ( ask the patient about the frequency of their normal BM)
  • vanco PO doesn’t affect serum creatinine ( no blood stream absorption); hence, no renal adjustment needed
  • severe cases of C. difficile: high temp, high WBC, colitis, elderly ( oer 70 yo)
  • Factors impt in deciding on therapy: severe/mild c. diff, 1st/ 2nd reoccurance
  • management: (1) stop antibiotic (2) switch to low risk antibiotic  (3) keep hydrated (4) treat with antibiotics ( vanco or metro)
  • expect response in 2 to 4 days// if no response by 5th day or worsen–> reassess
  • PO is more effective than iv
  • it’s a gram positive , spore forming, anaerobe–> reoccurance doesn’t imply resistance necessarily; reinfections are common because of germination of dormant spores that antibiotics are less effective on
  • remember to stop bowel protocol// PPI stop?????
  • macrolides–> increase motility

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Day 8- Home IV Program

August 19, 2009 at 5:24 pm · Filed under Reflections on Residency & Learning ·Tagged ,

Mandeep and I started off the day with a pre-vanco interpretation for one o f our outpatients. In order to assess the level, we looked into the following:

– was the drug at ss?
– drawn on time/ appropriate?
– time when last dose was infused
– target level
– pt status
– adherence- dose given on time?
– Options: keep at present dose? decrease? Increase?
– alternatives: change dosing interval, increase/decrease dose?
– pt’s creatinine level

Based on our assessment, the patient’s dose can be lowered in order to aim for the target levels of 15-20. We will be following up with the patient’s pre-vanco levels again next week.

FMI:

vanco 1/2 life: 7-8 hr
ss: after 5 1/2 lives

 

Mid-point evaluation today. Here are things that I should work on:

1) verbal communication skills (suggestions as per communication area)
2) Becoming more self-directed to meet my learning needs
3) Focussing my readings to relevant areas to meet mylearning objectives and apply them to patient care
4) Improving my basic knowledge on antibiotics and spectrum of activity
5) Improving my basic knowledge of conditions that are prevalent (eg CHF)

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Day 7- Home IV Program

August 18, 2009 at 5:27 pm · Filed under Reflections on Residency & Learning ·Tagged ,

I continued to follow up with some of the patients to see if they would be candidate for the home IV program. 

One of the patients was a suitable candidate for the home IV program and a referral was done for N. Vancouver. Unfortunately, the LGH’s home IV program is at a maximum capacity and they are unable to take in this patient. Because of this set back, the patient is forced to stay in the hospital until next week when a spot may possibly open up. I imagine that the cost of one day of hospital out-weights that of an outpatient; however, resources are limited and I can understand that frustration that people may have with the system.

I followed up with another patient at the clinic today. It was my first chance to present the patient’s case to the physician and it does take some time to adjust to being a licenced healthcare professional now.

Met with Peter for the resident progress meeting. It was nice to see him again and I am comforted to know that there is someone there to support us in the background.

AMG discussion:

  • amikacin is used in patients who are resistant to gent or tobra
  • tobra is more effective for the treatment of pseudomonas than gent
  • gent is cheaper; hence, it is often an automatic substitution for tobra ( except in the case of ICU and bone transplant clinic where pts are at a higher risk for pseudomonas )

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Day 6- Home IV Program

August 17, 2009 at 8:15 pm · Filed under Reflections on Residency & Learning ·Tagged ,

I did a follow up phone call with one of the patients who were discharged today. I had first assessed the patient for the home IV program last week. This was when I first introduced her to the home IV program. After the patient was finalized to be a suitable candidate for the home IV program, I helped with the transit of care by filling out some paperwork for her medication/pump delivery , as well as contacted the transitional care team to faciliate seamless care by the community nurses. A final counselling session on the patient’s pip/taz was conducted prior to discharge. Today’s phone call was mainly to monitor for the patient’s therapy, whether it was safe and effective. I learned that there is a lot of liaising when it comes to seamless care. There are many people involve. In order to make the process seamless, documentation is important. Not only must it be performed, it must also be complete, accurate and on time. At the end, the patient was appreciative of the phone call and I look forward to following up on the next patient.

Today’s didactic topic is osteomyelitis:

  • rifampin is used to help with antibiotic penetration to the prosthetic’s biofilm
  • clox 2 G Q4H is doc for staph aureus ( MSSA) 
  • Ortho patients are harder to treat than osteomyelitis b/c: (1) poor blood circulation with humonal and antibody immunity (2) biofilm on prosthetics protect bacterias and make it hard for antibiotics to penetrate

I continued to follow up with 2 other patients today and I assessed a new patient from N. Van for home IV also. He was very pleasant and it would be a good experience to follow a patient from out of our Vancouver region.

Overall: GOOD DAY. 😀

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