P4 Rotations/Clerkships Survival Guide/Tips

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PharmaCgirl

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I searched but did not find a forum that discusses this topic for pharmacy students...

Does anyone have any P4 Rotation/Clerkship Survival Tips?

Things that you wish you knew while on rotation, things you recommend reviewing or having in your white coat, books/survival guides/manuals you personally recommend to have for rotations (especially things that we want to keep very handy on rounds, etc.), tips or lifesavers for projects/journal clubs/presentations that you did on rotation....anything helpful basically (things I should make/buy/have in my lab coat)....websites/quick reference guides..ETC
 
just know lovenox dosing and that's half the battle
 
nnguyenc said:
just know lovenox dosing and that's half the battle
Click to expand...

Are you serious?

I think knowing when to use lovenox and the disease state, ADR and indications of Lovenox is more important.

How hard is 1mg/kg SC q12h or 1.5mg/kg SC q24 or for renally compromised pt, 1mg/kg sc q24h for treatment and 40mg SC q24h or 30mg SC q12h for prophylaxis???
 
UpToDate is awesome...

Other than that...just know everything about your patients, have a calculator handy, if you can get lexicomp or epocrates...you're golden.
 
he's partially right. I didn't do a straight anti-coag rotation. Instead I battled anticoag on my internal med, ID, ER, ADMIN, hem/onc, and MICU rotations. I bet I'll see it next month on cards, too!

So the only months where I didn't directly do anticoag were Drug Info and Tox.

Obviously get a copy of Sanford. It isn't the end all, but it's good to have.
 
njac said:
Obviously get a copy of Sanford. It isn't the end all, but it's good to have.
Click to expand...

Yea, I agree you should get this book. I hated it though...I could never navigate through it fast enough. I ended up just using our own hospital guidelines religiously. Good to have regardless, I guess. If you don't use it...makes a good doorstop.
 
the 2009 is a really pretty chartreuse, too.

Good for color coordinating!!
 
njac said:
Obviously get a copy of Sanford.
Click to expand...

Ditto. $12-ish and worth it.

In my pockets I had my PDA with Lexi-Comp Complete (among other things) which I didn't use all the time, a Sanford guide, a pen, a highlighter, a 3x5 spiral notecard book where I'd jot down my own notes and dosings and tables and such, hand sanitizer, an English-Spanish quick reference pocket guide for medical terms and directions, and chapstick.

Know how to do literature searches. When you're asked to provide information to back up your answers, "because DiPiro said so" and "that's what we were taught two years ago in class" don't cut it.

I would always do a quick review of relevant material the weekend before I started a new rotation.

And lastly, especially if you are wanting to do post-graduate anything (i.e., residency or fellowship) keep your CV updated as you go. There's nothing like trying to remember what you did on a rotation 6 months ago. And, be active on your rotations; don't just passively wait to be told what to do. If you can assist with implementing some sort of change in therapy or practice, speak up. 🙂
 
njac said:
the 2009 is a really pretty chartreuse, too.

Good for color coordinating!!
Click to expand...


Chartreuse jigs are awesome. It fools many crappie and I'm gearing to go slay em. I would've been out fishin tonight but we got a nasty cold front. The last hurrah of the oldman winter.
 
Glycerin said:
Ditto. $12-ish and worth it.

In my pockets I had my PDA with Lexi-Comp Complete (among other things) which I didn't use all the time, a Sanford guide, a pen, a highlighter, a 3x5 spiral notecard book where I'd jot down my own notes and dosings and tables and such, hand sanitizer, an English-Spanish quick reference pocket guide for medical terms and directions, and chapstick.

Know how to do literature searches. When you're asked to provide information to back up your answers, "because DiPiro said so" and "that's what we were taught two years ago in class" don't cut it.

I would always do a quick review of relevant material the weekend before I started a new rotation.

And lastly, especially if you are wanting to do post-graduate anything (i.e., residency or fellowship) keep your CV updated as you go. There's nothing like trying to remember what you did on a rotation 6 months ago. And, be active on your rotations; don't just passively wait to be told what to do. If you can assist with implementing some sort of change in therapy or practice, speak up. 🙂
Click to expand...

Bah... Sanford is too commercially biased. Make sure you get a copy of the hospital's antibiogram and study it and understand the resistance pattern and understand which antibiotic works for different bugs.
 
ItsOverZyvox said:
Make sure you get a copy of the hospital's antibiogram and study it and understand the resistance pattern and understand which antibiotic works for different bugs.
Click to expand...

That, too. I had my institution's antibiogram for the last two years in my pocket as well.

Sanford isn't a bad reference. It isn't the end all be all, though, but it's also still nice to have.
 
Gum for that after coffee breath. And granola bars...for rounds that never end.
 
Glycerin said:
That, too. I had my institution's antibiogram for the last two years in my pocket as well.

Sanford isn't a bad reference. It isn't the end all be all, though, but it's also still nice to have.
Click to expand...


yeah? But you know how to read it?
 
aboveliquidice said:
Your anti-establishment tendencies are scary sometimes - you may indeed be WVU version 1.0
Click to expand...

You will one day appreciate my tendencies. In fact, you may be right behind WVU....he was a lot like you when he was a student. But he's coming around. He just doesn't know it as well.
 
Glycerin said:
The percentages are percentages of enterobacter susceptibilities to each antibiotic at that institution.
Click to expand...


But what does it mean? Why 100% for cefotetan but only 89% for Ceftriaxone? And how could cefotetan have a higher susceptibility than Imipenem?
 
ItsOverZyvox said:
You will one day appreciate my tendencies. In fact, you may be right behind WVU....he was a lot like you when he was a student. But he's coming around. He just doesn't know it as well.
Click to expand...

The jury is still out :meanie:

To the question...

Is it a trend in use = Ceftriaxone going for most susceptible bugs, imi for broad coverage prior to culture and Cefotetan being reserved for use with anaerobes???

I really have no idea
 
I mean, what can you deduce from looking at an Antibiogram.

I'll give you an example what I do. I first look at the Ps.A panel for the drug of choice. Then I look at the Enterococcus Faecalis and Faecium against Vanc and Linezolid. Then I look at the enterbacter speices to assess their ESBL rates. This gives me an understanding of their resistance pattern and the appropriate ABX regimen for different infection and likely pathogens.
 
ItsOverZyvox said:
But what does it mean? Why 100% for cefotetan but only 89% for Ceftriaxone? And how could cefotetan have a higher susceptibility than Imipenem?
Click to expand...

It means enterobacter is 100% susceptible to cefotetan, since there's been no bacterial mutation so far to overcome the drug's effects or the cefotetan isn't used there as often versus the other drugs (and likely so, since I haven't seen cefotetan used regularly in years). Cefotetan probably has a higher % since imipenem's been added to the water at every institution.
 
I'll go one step further. Let's say they had 100 isolates of E.faecium with 90% Vanc susceptibility and 98% Linezolid susceptibility.

Then we can deduce that there were 10 VRE isolates and 2 LRVRE. But you realize institution goes through eleventy million dollars worth of Linezolid. Then we know Pfizer rep has been busy.

So you, glycerin the resident, can politely remind that resident who's writing for linezolid for MRSA say..."hey, we had 2 cases of LRVRE last year yet we've only had 10 cases of VRE." "At the same time we have not seen a VRSA here so... why don't you let me dose that Vanco for you instead of using Linezolid?"
 
ItsOverZyvox said:
Chartreuse jigs are awesome. It fools many crappie and I'm gearing to go slay em. I would've been out fishin tonight but we got a nasty cold front. The last hurrah of the oldman winter.
Click to expand...

I know! I had a snow day in the MICU today - I'm housesitting in the mountains and my exit on the Interstate was closed.

One hospital I rotated through did not make their antibiogram available. They didn't want the doctors to know it (other than the ID docs) and were afraid it would influence drug reps.
 
Glycerin said:
It means enterobacter is 100% susceptible to cefotetan, since there's been no bacterial mutation so far to overcome the drug's effects or the cefotetan isn't used there as often versus the other drugs (and likely so, since I haven't seen cefotetan used regularly in years). Cefotetan probably has a higher % since imipenem's been added to the water at every institution. :rolls eyes:
Click to expand...


No. Absolutely not. ESBL does not breakdown cephamycin (cefoxitin & cefotetan) in-vitro..hence cefotetan usually shows a very high susceptibility on an antibiogram but don't you dare recommend it for in vivo treatment. And no..enterbacter species can develope Carbapenemase which breaks down imipenem. However, ceftriaxone susceptibility may be a better indication of the ESBL prevalence of that institution therefore imipenem would be a better choice than Cefotetan or Cefoxitin.
 
njac said:
I know! I had a snow day in the MICU today - I'm housesitting in the mountains and my exit on the Interstate was closed.

One hospital I rotated through did not make their antibiogram available. They didn't want the doctors to know it (other than the ID docs) and were afraid it would influence drug reps.
Click to expand...


Actually, I guarded my antibiogram from reps but had it available to docs. Physicians were instructed to not give it out. Then again, drug reps were banned from my hospital so...
 
ItsOverZyvox said:
No. Absolutely not. ESBL does not breakdown cephamycin (cefoxitin & cefotetan) in-vitro..hence cefotetan usually shows a very high susceptibility on an antibiogram but don't you dare recommend it for in vivo treatment. And no..enterbacter species can develope Carbapenemase which breaks down imipenem. However, ceftriaxone susceptibility may be a better indication of the ESBL prevalence of that institution therefore imipenem would be a better choice than Cefotetan or Cefoxitin.
Click to expand...

And I'd erased the rolls eyes icon I'd originally had at the end of that because since I changed browsers from IE to Mozilla, I can't click on them, and I have to manually type in my smileys. I was being a bit facetious.

Here, I can type in meanie. :meanie:
 
ItsOverZyvox said:
I'll go one step further. Let's say they had 100 isolates of E.faecium with 90% Vanc susceptibility and 98% Linezolid susceptibility.

Then we can deduce that there were 10 VRE isolates and 2 LRVRE. But you realize institution goes through eleventy million dollars worth of Linezolid. Then we know Pfizer rep has been busy.

So you, glycerin the resident, can politely remind that resident who's writing for linezolid for MRSA say..."hey, we had 2 cases of LRVRE last year yet we've only had 10 cases of VRE." "At the same time we have not seen a VRSA here so... why don't you let me dose that Vanco for you instead of using Linezolid?"
Click to expand...

I was definitely not thinking monetary...
 
ItsOverZyvox said:
No. Absolutely not. ESBL does not breakdown cephamycin (cefoxitin & cefotetan) in-vitro..hence cefotetan usually shows a very high susceptibility on an antibiogram but don't you dare recommend it for in vivo treatment. And no..enterbacter species can develope Carbapenemase which breaks down imipenem. However, ceftriaxone susceptibility may be a better indication of the ESBL prevalence of that institution therefore imipenem would be a better choice than Cefotetan or Cefoxitin.
Click to expand...

but Ceftriaxone susceptibility is still >80% so you can empirically use Ceftriaxone empirically for suspected enterobacter.
 
What I'm trying to say is antibiogram is a great tool at face value. But it becomes more valuable once you take it a part, analyze it, and memorize it. It's one of the best way to influence prescribing and also improve ABX tx at your facility.
 
njac said:
but Ceftriaxone susceptibility is still >80% so you can empirically use Ceftriaxone empirically for suspected enterobacter.
Click to expand...


Absolutely. And you should reserve penems for ESBL or PS. A if Zosyn is resistant.
 
so I took today off, and I work tomorrow night.

I miss my patients and my team! I'm considering going in tomorrow. But that would mean I would be at the hospital from 0630-2330... I really want to know what happened to a couple people who came in on Thursday.

Oh god, I'm totally going to be one of those people who gets too involved at work.
 
When I say Enterobacter, I'm also referring to Citorbacter, Acinetobacter, & Klebsiella... and of course E.Coli and PS. A.

Acinetobacters are getting nasty...
 
ItsOverZyvox said:
Absolutely. And you should reserve penems for ESBL or PS. A if Zosyn is resistant.
Click to expand...

so it's a good thing I have limited experience with the penems. 👍 We do have one guy on it for an ESBL Klebsiella bacteremia, and another lady went on Meropenem this week for a Klebsiella pna that was just. not. resolving. on Zosyn. Curious to see where she goes too.
 
njac said:
so I took today off, and I work tomorrow night.

I miss my patients and my team! I'm considering going in tomorrow. But that would mean I would be at the hospital from 0630-2330... I really want to know what happened to a couple people who came in on Thursday.

Oh god, I'm totally going to be one of those people who gets too involved at work.
Click to expand...


You're a dork.
 
ItsOverZyvox said:
When I say Enterobacter, I'm also referring to Citorbacter, Acinetobacter, & Klebsiella... and of course E.Coli and PS. A.

Acinetobacters are getting nasty...
Click to expand...

I interviewed somewhere with a pan-resistant Acinetobacter in their burn center. 😱 Collistin was an essential part of their therapy. They'd had the CDC in to help find sources and everything.
 
Glycerin said:
And I'd erased the rolls eyes icon I'd originally had at the end of that because since I changed browsers from IE to Mozilla, I can't click on them, and I have to manually type in my smileys. I was being a bit facetious.

Here, I can type in meanie. :meanie:
Click to expand...


Now you've lost it!
 
njac said:
I interviewed somewhere with a pan-resistant Acinetobacter in their burn center. 😱 Collistin was an essential part of their therapy. They'd had the CDC in to help find sources and everything.
Click to expand...


Gram Neg resistance scares me...


While the rest of the world are worried about MRSA.. geesh..my saliva can kill MRSA.
 
aboveliquidice said:
The jury is still out :meanie:

To the question...

Is it a trend in use = Ceftriaxone going for most susceptible bugs, imi for broad coverage prior to culture and Cefotetan being reserved for use with anaerobes???

I really have no idea
Click to expand...

what do you think about what you just wrote after having read everything on this thread?
 
ItsOverZyvox said:
You should.
Click to expand...

but how much is thinking about money too much. Working in a county hospital I'm aware of the costs of things. I had one preceptor tell me not to worry about it.

For example: Had a guy come in Thurs night (aforementioned above) who basically we don't know what's wrong with him. Some ascites and a little more difficulty breathing - but he didn't feel that bad, his sister made him come to the ER. MICU declined until his lactate came back at >12.

By the time we came in at 6 he was tubed and on pressors and looking very not good. They put him on Zosyn/Vanco.

I felt like I had a good argument for Ceftriaxone/Metronidazole - no pseudomonas risk and a possible GI somethingorother. And cheaper.
Their argument is "he's so sick and he's not going to live 24 hours".
 
njac said:
but how much is thinking about money too much. Working in a county hospital I'm aware of the costs of things. I had one preceptor tell me not to worry about it.

For example: Had a guy come in Thurs night (aforementioned above) who basically we don't know what's wrong with him. Some ascites and a little more difficulty breathing - but he didn't feel that bad, his sister made him come to the ER. MICU declined until his lactate came back at >12.

By the time we came in at 6 he was tubed and on pressors and looking very not good. They put him on Zosyn/Vanco.

I felt like I had a good argument for Ceftriaxone/Metronidazole - no pseudomonas risk and a possible GI somethingorother. And cheaper.
Their argument is "he's so sick and he's not going to live 24 hours".
Click to expand...

When you deny appropriate therapy knowing what you're recommending is solely based on cost and inappropriate, then you're thinking about money is too much. I like ceftriaxone/metronidazole combination. But it depends on the setting. For a tertiary institution, you may have to go with a penem or pip-tazo for intra-ab infection. Again, ESBL is the concern.
 
ItsOverZyvox said:
When you deny appropriate therapy knowing what you're recommending is solely based on cost and inappropriate, then you're thinking about money is too much. I like ceftriaxone/metronidazole combination. But it depends on the setting. For a tertiary institution, you may have to go with a penem or pip-tazo for intra-ab infection. Again, ESBL is the concern.
Click to expand...

yeah but no medical history - this would be a community acquired bug.

He had a little bacteria on his UA but the culture hadn't come back yet when I left Thursday. I'm very curious to see what was going on there. Super nice guy with a super nice family too 😕
 
ItsOverZyvox said:
what do you think about what you just wrote after having read everything on this thread?
Click to expand...

I was aware of ESBLs... I was thinking that the usage of said medications was indicative of the resistance profile. Its the real world application part that I was missing. I would have felt comfortable using either one of the Cefs for enterobacter - but leaning towards ceftriaxone, Cefotetan was only discussed "in class" for use with anaerobes (along with cefoxitin).

I feel like a little fish, swimming in the same pond as Glycerin and Njac. Ask me again after christmas - when I have 4 hospital rotations under my belt 😉

~above~
 
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