“RAM is one of those experiences that define you … ” ANDREW CARMICHAEL, 7/24/11

RAM is one of those experiences that define you as a professional. I think this is because you engage a population of people that usually have nowhere else to go, but typically have the most complex disease state management. More often or not, as pharmacy students we live in a bubble of lectures, homework, studying  and day-to-day decompression. We forget that the patients who need us most often do not have the resources to come to our workplace’s doorstep. We also forget, trying to get through our schooling, that the most important lecture we can ever have is patient engagement.

It’s very different to study disease states and how to treat people without a face or life’s complicating problems. It’s also completely different to develop therapy plans when you realize that your hesitations, your nonverbal communication  and your empathy directly impact how a patient receives the information or recommendations you propose. You can have the best therapy plan on the planet, but if you are callous, cold, unconfident or unsure, your patients will pick up on these things just like we do without any other social interaction.

We become excellent practitioners not because we are expansive in breadth in knowledge alone, but because we learn to be empathetic, relaxed, confident and sensitive to our patient’s needs. Often these qualities become more important. RAM is one of the places I have developed these traits, and I try to hone as sharply as possible. It’s worth every mile, hour of lost sleep and uncomfortable night of hot, sticky sleep. If anything, it gives you an appreciation for everything you have and how lucky we are to be the givers and not the receivers.  I also feel like it’s a sad excuse to not spend a little time in such a setting because most of us spend more time watching television, texting/calling/facebooking each other, and doing other nonessential activities than we devote to helping others.

 So many more things crash into focus when you treat patients who often cannot afford their medications, have social and cultural barriers that make counseling difficult, and whose situations are almost never ideal. Things are never as simple in practice as they are outlined in a classroom or a book. You almost never run across best-case scenarios or clearcut answers. RAM helps you make sense of this. It is also is one of the most rewarding things I’ve undertaken. I feel it is our duty not just as community members, but as professionals, to take a couple days out of our schedule to go to those who cannot come to us. We cannot have good health care without engaging in free health care.

There will always be economic divides, but we can help close them a bit, even if only for a couple days, if we go outside ourselves and give our time freely. We also talk constantly about team-based therapy in school and how medicine is going to this model. There is no place where this is truer than at community outreach events such as RAM.

At RAM, you have all the health-care professional specialties working together, instead of in bubbles, to form an integrated form of care, because there are no issues of who gets paid what or whose plan is more important. We come together to give the patient as much as possible. We also learn each other’s strengths and weaknesses and rush to fill in those cracks to form a more seamless plan of care. You also hear the gratitude, the tears of happiness and humility from your patients. I even often hear the phrase, “Thank you for everything you do. This is the best care I’ve ever received.” I also hear, unfortunately, “Thank you for actually spending time with me. My doctor, nurse, pharmacist, etc., does not spend this kind of time with me, and they charge so much money.”

This is my second time at RAM, and my role is much different this year. This year I’m learning to lead my peers to this same great opportunity and trying to develop ways to expand our presence at this event. I try and focus on what things went well, what needs work and which things not to continue or repeat so that next year, when I lead RAM, I can make it a little bit better than the year before and leave another scaffold on which my successor can build and make better after me, as well.

I’m incredibly excited by this prospect, but also very nervous. I want this experience to be as rewarding to others as it has been to me over the last two years. I want my peers to become better professionals. I want to show our communities that pharmacists are willing to go outside of their 9-to-5 work schedules to make sure that their health needs are met. So many of these things will worry me, but they will also focus me to ensure that I put everything I can into making RAM more successful. RAM has been one of the biggest honors I have been given because it has given me the chance to take care of my fellow man without the restrictions of insurance, prestige or management.

Thank you, RAM, for making me a stronger practitioner and a better human being.

Editor’s note: Andrew Carmichael was assistant team leader for VCU School of Pharmacy’s trek to Remote Area Medical 2011 in Wise County, Va.

“After the amazing experience I had last year …” AMANDA KROLL, 7/23/11

After the amazing experience I had last year at RAM, I couldn’t wait to come back again this year.  I have been eagerly awaiting the opportunity for me to get to know more patients, pharmacists, nurses, doctors and other students as we all work together to serve a common cause.  I was truly humbled last year as I went through the different stations that pharmacy was involved in and got to see how we impact the health of the patients we serve.  

This year, my experience at RAM has been just as wonderful as last year.  So far, the best experiences I have had were while I was using the point of care A1C test.  While getting to use the machine was a great hands-on opportunity, it was also a great time for me to talk to and get to know the patients as well as work on my diabetes counseling skills.  During the five minutes it takes to run the A1C test, I was able to educate patients on how to better manage their diabetes, talk to them about what an A1C test is, how to take their diabetes medications and what to do if their blood sugar gets too low. 

One patient didn’t understand why her blood glucose reading on Friday was in the 300s because when she takes it at home it’s always less than 100.  During the counseling session with her, I discovered that she stores her test strips in the refrigerator.  I was able to talk to her about the importance of storing her test strips at room temperature and how this could cause her to get an error in her glucose readings.  She expressed understanding, and I hope that this will have an impact on the management of her diabetes and insulin. 

While the clinical side of the point-of-care testing was a great learning opportunity, the best part was sitting and listening to the patients.  So many of the patients really enjoy being able to share their story and express their gratitude for the services we provide here at RAM.  To me, this is the most rewarding aspect of RAM.  Knowing that I have in some way made an impact on even just a few patients’ health care is an extremely gratifying feeling.

Reflecting back on these two years I have spent at RAM, I feel really lucky to have been able to be a part of the health care provided.  I am really fortunate to be able to sit with the nurses and learn from them, to be able to listen to the pharmacists and better my counseling skills, and to be able to give back to the community and surrounding areas.  I hope to share my experience with other students and encourage them to come in the future, because I know I will!

RxIMPACT: “I am in Washington, D.C. …,” GEETIKA GHANDI, 3/9/11

Thumbnail image for IMG_2777.JPGParticipants in RxIMPACT Legislative Leadership Academy visited five legislators’ offices, including that of Virginia Rep. Eric Cantor (R-7th). 

 

I am in Washington, D.C., with around 130 students from across the nation, participating in the RxIMPACT Legislative Leadership Academy (sponsored by the National Association of Chain Drug Stores).

I am learning how to identify unresolved issues within my community, to research the health-care policy behind the issue and suggest proposals that will bring change for the benefit of my patients. My interest in advocacy issues within our profession started last summer while caring for my father, who is a homebound patient: “Why are pharmacists not involved in home health services?”

As a student pharmacist, it was evident that pharmacists can make a significant difference in the quality of life of those who are homebound and are unable to receive services at the pharmacy. Little did I know that this question would lead me to do intensive research into the issue and make multiple visits to Capitol Hill.

I knew that I had witnessed the need for medication therapy management (MTM) expansion, but going about advocating for it is a skill that I did not have. Since the terms “leadership” and “advocacy” were of interest to me, I registered for a “Leadership and Advocacy” pharmacy elective (Fall 2010) with Dr. Gary Matzke as my course coordinator. The course introduced me to the different aspects of advocacy and taught me how to research and present my topic of advocacy to our legislators. The Legislative Leadership Academy is giving me the opportunity to build upon my advocacy skills learned through Dr. Matzke’s course.

Today’s focus was to learn about the congressional role in policymaking, using tactics to influence policy outcomes, pharmacy policy issues and incorporating advocacy into regular pharmacy practice. Additionally, Dr. Matzke presented on utilizing student opportunities to engage the community. His presentation made me realize that as VCU SOP students, we are in a perfect location to advocate — across the street from the Virginia State Capitol and a couple hours away from Capitol Hill.

“The Remote Area Medical service experience …” LINDSAY SAMUEL, 8/9/10

Lindsay and Erika.jpgRAM reflections

 

The Remote Area Medical (RAM) service experience in Wise, Va., was a defining moment in my pharmacy student career and personal life. I was exposed to many different people, professions, private and public service organizations.  Not only did I gain valuable clinical experience, but I was also able to step outside of my comfort area and touch patients in a variety of ways. 

I chose to apply for a spot on the team because I wanted to honor my family by giving back to those in need.  My parents come from a rural community where they lived below the poverty line.  Their access to health care was very limited, and some aspects of their health status now, especially dental issues, stem from their lack of health care during their childhood. 

There are so many aspects of the RAM trip that I could focus on; however, my time in triage was the most emotional part of the trip.  During the patient interview, I was able to catch a brief glimpse into the patients’ lives that we were serving.  What touched me the most were the faces of the young patients in their twenties that looked so much older and patients that looked malnourished because they could not eat a proper diet without teeth or dentures.

The trip also gave me a chance to interact with different health-care professionals and promote the pharmacy profession.  I enjoyed collaborating with the nurses at triage, counseling patients at the pharmacy and talking with patients at the grandstand about general health promotion and disease prevention.  

After talking to a pharmacy resident from the University of Virginia Health System, I opened myself up to the possibility of pursuing a hospital residency.  From this experience, I personally felt that I had a greater appreciation for the struggles that my family went through when it came to accessing health care.  I also learned the importance of being a voice and advocating for patients that fall through the gaps of the health-care system.  I feel that it is my responsibility now and even more in the future to remember the patients that I met and advocate for policies that support patients in similar situations.  

It is hard for me to put into words the many emotions that I carried away from this trip, and I have a lot of respect for the many volunteers that transformed a county fairground into a positive, patient-centered medical experience.

“When people asked me how my trip to RAM was …” AMANDA KROLL, 8/5/10

RAM reflections

When people ask me how my trip to RAM was, I find it difficult to answer with just one word or emotion.  Words like interesting, exciting, eye-opening and challenging all come to mind.  However, none of these words encompass the true description of my trip to RAM.  The interactions I had with patients and other health-care providers were experiences that I might never have had the opportunity to be a part of, if it weren’t for RAM.   

It was amazing to me how friendly and thankful all of the patients were, even after they had spent hours, or even days, waiting in the heat for their number to be called.  While talking to patients during their medication reconciliation, triage and in the pharmacy, I was able to learn so much about them, their background and their families.  Many people almost broke down into tears telling me why they haven’t been able to see their doctors and take their medications recently and how thankful they were for RAM providing them medical care. 

I usually don’t get a chance to interact with a lot of young children under a medical setting, so it was really a great learning experience to talk to parents and their kids and explain to them the importance of a healthy lifestyle.  The phrase “Don’t blow smoke, blow bubbles” was often used, while handing out soap bubbles, to emphasize to young children the importance of avoiding tobacco.

I was also able to learn so much from the nurses that were volunteering in the triage section.  One nurse that I worked a lot with, Vicky, was so eager to teach me and answer questions that I had, it truly made me feel special and like I was really helping all of the patients.  She showed me how to make sure I was taking someone’s pulse and respirations correctly and the most efficient way to triage patients.  She was so kind and empathetic that it was truly inspiring to me.

Growing up, I have never been exposed to a true medically underserved group of people.  Being able to provide health care to such a large group of people in a short amount of time was not only a great learning experience but also a very humbling one. Listening to the patients talk about many of the hardships they have endured throughout their lives was really upsetting.  However, they still took time out of their lives to travel (up to hundreds of miles) and sleep in their cars overnight to seek health care for themselves and their families.  They realize how important it is to take their medications and get physicals and vision screenings even if they can’t always afford it and were willing to go great lengths to seek out care.

I am so grateful for the opportunity to participate in RAM this year and only hope I can continue to participate in the upcoming years.  RAM provided me with amazing hands-on experience and allowed me to apply many of the things that I learned during my first year in pharmacy school.  Being able to get insight from patients, other pharmacy students, students in other health fields and health care professions all added to this amazing experience.

“When I first heard of RAM …” LOAN CHIN, 8/3/10

Loan.jpgRAM reflections

When I first heard of RAM, it wasn’t through the school or word of mouth. I actually read an article upon entering pharmacy school. When I finished reading about RAM’s efforts and mission statement, I was set on participating.  I have never been to RAM, and this summer was my first experience. RAM stands for Remote Area Medical, and its name in itself reflects exactly what it stands for. RAM provides free medical, dental, vision and pharmacy services in Wise, Va., one of the most inaccessible regions to receive care. So you can imagine an overwhelming number of people who drive hundreds of miles to receive medical and dental services.

The time I spent in RAM was a humbling experience and a constant reminder of the growing gap between those with health care and those who don’t have health care in the United States. Fortunately, I have experience in providing medical relief in third-world countries, but to provide medical relief hours away from my hometown is an eye-opening experience. It really brought me down a notch. It turned something that I heard and knew about into a reality.

RAM offered a myriad of experiences. I developed and enhanced my skill sets in measuring blood pressure, glucose testing, A1C testing, patient counseling and taking pulse and respiratory rates.  I developed and cultivated new relationships among my team members, other professionals and, more importantly, my patients.

On my second day, I met a family who touched me. This family had three children and a niece visiting from afar. While my partner and I were there in the grandstands, we got the opportunity to meet this family. What inspired me most were the children. They showed curiosity, knowledge, concern and insightfulness about health and especially about diabetes since it runs in their family. We spent over an hour teaching them, and it was one of the most rewarding experiences I ever had. This specific moment in my life became a powerful realization that teaching the youth and empowering them with knowledge is the key to any successful outcome, especially when they are enthusiastic about learning.

I am very lucky to be a part of RAM Pharmacy 2010 because of the organization’s efforts. I am also very fortunate that I was one of many people who helped to hold up the image of such an organization that encompasses the perfect example of interdisciplinary professionals working together to achieve optimal patient care and outcomes.

 

“When I originally decided to participate …” DAVID ALLEN, 8/2/10

RAM reflections

When I originally decided to participate in the Remote Area Medical (RAM) project in Wise, Va., I had no idea what I was getting myself into. It turned out to be long, hard days working in the blistering heat, but luckily the amazing people of Wise County and dedicated volunteers turned it into so much more.

Some of the patients that I had the privilege to help waited in line all night and day, yet they still managed to have the most uniquely positive demeanor. During my time in Wise County, I managed to work alongside a variety of health-care professionals and obtain some clinical experience.

The list of people I met in Wise range from some lovable coal miners to Sen. Mark Warner. I can’t think of any other place where a rising P2 would ever be setting up tents with the director of the VDA, the director of DMAS and a longtime lobbyist in one day. Then the next day get the chance to learn the tricks of the trade from some delightfully passionate nurses. Also in this day I had the privilege of meeting my favorite patient of the entire project.

 I first saw Gloria when I was on my way to the grandstands to do medication reconciliation. She had recently broken her hip and was struggling to get from her wheelchair — which was stuck in the gravel — into a golf cart. I ran up to help her and continued to help her along through check-in and triage. When I did end up leaving her in the dental line, she gave me a hug and was actually in tears. I think she struck a personal note with me because she reminded me of when I would help my late grandmother.

My final day in Wise, I spent a large portion of my time following an endodontist, Dr. Sanjay, and an oral surgeon, Dr. Zogby. It was very interesting to see these masters of their craft at work and see the stark differences in their specialties. I first witnessed Dr. Sanjay and his wife both doing root canals side by side, using an electronic depth finder and constantly changing out various drill bits. I next shadowed Dr. Zogby, who was doing full mouth extractions. It was an interesting contrast going from the precision of a root canal to the brute-force nature of pulling teeth with what were essentially pliers, as well as hammer and chisel when necessary. Both men did a great job of explaining what they were doing and managed to make their highly skilled procedures look simple.

After four long days in Wise County, I left with the desire to give back more. In the end, I feel that RAM was one of the most rewarding experiences I’ve ever had, and I look forward to returning next summer. Until then, though, I will take the things I learned and the friends I made with me.

“It almost seems surreal to watch …” AMBER LANAE SMITH, 7/25/10, 8:21 a.m.

Location: Triage

It almost seems surreal to watch as nurses, pharmacists  and volunteers begin to tear down the triage area. For the last three days, I have watched as health professionals from all backgrounds worked together for a common goal — something that to me is the epitome of what we all as humans should strive for — love and support of people. This is not my first year at RAM, but it has definitely made my list of top five favorite moments of service.

For me, this trip didn’t start on Thursday morning at 5a.m. —  instead it started the day Adam Krukas handed over his title of team leader (trust me, those were big shoes to fill)! I had visions in my head for where I wanted to expand our team roles and how I wanted to use our team to create an atmosphere that shows pharmacists are an undeniable asset to the health-care world. With a brain full of ideas and an executive board who was willing to work hard, we set out to make this year’s RAM better than any other year (a feat I believe we accomplished)!

Our emphasis as a team this year focused on two vital areas of health care: health education and smoking cessation. In each of these areas, I feel our team excelled and gave the best they could to arm the patients at RAM with tools that could improve their lives. While some efforts were received with open minds and lots of attention (the game), other efforts were harder to approach because they are never easy topics (smoking cessation). But I firmly believe that in each area, at least one patient gained some asset that will help them succeed.

One area that I feel we had the most success in was the A1c clinic. In this part of the triage, the patients had to wait for five minutes to receive their test results. It was during this time that the pharmacy students were able to devote their efforts to direct patient counseling. Several of us spent long periods of time educating patients on the importance of controlling their blood glucose, and we really got to know our patients.

There were a few patients who I talked with at length about their diabetes and their health care in general. Two patients in particular, my “mountain man” and my “veteran,” reinforced my desire to provide everyone with the best service that I can. I saw my “mountain man” all three days, and together we did everything we could to get his blood glucose to drop (a feat we never accomplished — although he still referred to me as his angel from heaven — a nickname I’m not sure I’m worthy of).

The “veteran” was a giant man (not in weight, but in stature) who had kind, old eyes and a heart of gold. I managed to get this patient a world-class treatment on his mouth and some of the best patient care possible. I followed him through the day and checked in multiple times; each time, he had a huge hug for me (and I’d be lying if I said it didn’t make my whole heart soar when he did).

There are two other aspects of RAM that I feel deserve attention, before I finish. The first being the friends you make with other health professionals, especially the nurses. It is amazing to watch as people come together and work so hard from 5 a.m. until 5 p.m. Some people spent the entire day refusing to eat so that more patients could be seen; others rotated through, caring for their teammates they had just met a few hours before starting.

There were three nurses in particular who I felt gave our pharmacy students the best education they possibly could (Vicki, Carol, and Pam). Each of the nurses was excited to impart their years of experience upon our students and made it fun in the process. (Just ask Derek — his nurse made him think she was crazy and danced for her patients)!

But even more amazing than the nurses was our team for RAM this year. Adam said it perfectly when he said that it is amazing that the VCU School of Pharmacy RAM Team is the only student-run organization (with a wonderful preceptor, of course — Dr. Sisson). And in my personal opinion, we did one heck of a job providing the best care we could this year. It has been an absolute honor and privilege to work with each of the students on my team. Every single one of them has touched my heart in a different way, and I will never be the same again.

How can you put into words the impact that service has upon your life? Each year I strive to give all that I have to people, I expect to leave giving everything I have got to improve each person’s life. And yet at the end of the trip, I find that I take more with me than I feel I could have ever given. Not only do I get the opportunity to leave with new friends, I take home stories that make me laugh or cry (or laugh so hard that I cry), things that gross me out  and, above all, I take home a heart overflowing with a desire to love people that much harder and give them that much more of myself. With gifts like that, how could anyone not want to be a part of RAM?!

Look at my life, look at my choices. I think it’s safe to say that anyone who devotes one weekend to RAM made the right choice.

“There is something completely different …” AMY DEMBOWSKI, 7/25/10, 6:53 a.m.

Location: Triage

There is something completely different about treating a population like the one we are seeing at RAM — whether there should be or not, there simply is.  Here, members of dentistry, nursing, pharmacy, patient advocacy and education work together to fight something greater than any illness or disease.  We fight the inaccessibility to health care that has led so many people to their current state. 

New this year, the pharmacy students have been running stations for point-of-care HbA1C testing, and I have had the opportunity to work here for a large part of this weekend.  These patients have been incredible. Most diagnosed diabetics, they can explain their medications, describe how they do their foot exams regularly  and actually want to understand their A1C values. Unfortunately for others, some have never been told they have diabetes. 

I met an amazing man today, a man who spent over 30 years as the chief manager in a coal mine where he had countless stories of coming to the aid and at times saving his workers following accidents.  But behind his stories and humor was a man worn with age and reliant on free medical treatment — a man who today would be diagnosed with diabetes. Following a blood glucose well into the 300s and an A1C of 9.5, he was a prime example.

As I told him what these values meant and explained to him what diabetes was, I could feel his fear and worry.  I was so thankful to have the time to walk him through the situation and go over what may take place during his trip to the physicians following our discussion. I walked him to the urgent care area, where physicians and medical students see patients with extremely high blood pressures and blood glucose levels. As I left him in their care, I was happy to hear the physician begin his conversation with empathy and patience. He emphasized that diabetes was manageable and described the details of my patient’s future care. 

With that moment, the simplest realization occurred.  At RAM, health-care providers are not just connected by knowledge and clinical skills, we are connected by compassion and a devotion to these patients. We work collectively in a way not seen in many health-care settings presently, yet it feels more comfortable than anything else would. 

When you come to RAM, it is not all about the clinical experience that you will gain, while as students you get plenty.  It is about comforting the fears of patients, hearing the stories from those who just want someone to listen  and playing tag with a 6-year-old who just waited four hours for her mother to see a doctor.  These people are unique, they are incredible, they are grateful, and overall they are in need of whatever we can offer them.  This is one of the most rewarding things I could’ve ever done, and I know I will be a better pharmacist and person for it.

“After running around for most of the day …” ERIKA STIENE, 7/24/10, 2:20 p.m.

Location: Triage

After running around for most of the day yesterday, I spent most of this morning in triage working with an older nurse from U.Va. I’m not going to lie — even though I have been here before, when I first sat down with her I was slightly intimidated. You could tell she knew her stuff and had everything under control, so I definitely didn’t want to be the pharmacy student that got in her way.

Initially she ran the show, but as time went on she felt more comfortable trusting my readings for vitals and took the time to explain to me different conditions or procedures. By the end of the day, instead of me thanking her for all of her help, she was expressing with other nurses how thankful they were to have pharmacy students with them in triage. They explained how nice it was to have a student to clarify drug names, normal doses and indications.

Some of them had never even heard of certain medication these patients use. For example, they had never heard of Suboxone, a medication many of these patients unfortunately use to treat drug addictions. These few comments helped affirm another reason we are at RAM.

With all of these health-care professions in one place, pharmacy can often get lost in the mix. Many people have no idea what skills we possess or are even confused how a pharmacist can help in a setting like RAM. Although not always explicitly recognized, through our involvement in triage, the grandstands and the medical tent, pharmacy students definitely play a helpful role in RAM.