Today’s Date: Sept. 3, 2011
Total Hours to Date: 45 hours
Mentorship Research Journal #3
On Aug. 25, patient rounds with Dr. Gravatt began in the Main Hospital’s prison area, located beneath the main floor. The inmates housed here had been moved from the local jail in order to receive the kind of medical treatment given to the other patients in the hospital. Although I did not have the chance to pass the main gate and go on rounds with the rest of the team, it was interesting to watch the team conduct business as usual from behind the gates. With added distance between me and the team, I could see just how this large group of 10 would appear to the patients and visitors. Afterward, we moved above ground to the emergency room and checked up on a man who suffered from shortness of breath and had initially been thought to have pneumonia. The results of a CT scan on his chest had recently arrived, though, confirming that he did not have pneumonia. The team then ordered a nebulizer for the patient’s asthma, hoping to prevent possible airway inflammation. When used, the nebulizer would release a mist comprising a mixture of oxygen and other compressed gasses, which would be inhaled by the patient and travel into the lungs.
Another patient had come out of a surgery for her heart failure, in which a small metal rod had been inserted into her heart to compensate for her useless right atrium. Dr. Gravatt had to order anticoagulant medication for her. The medication would serve as a blood thinner, decreasing the probability of blood clotting. During our lunch break in the workroom, Dr. Gravatt conducted a short lesson with her two accompanying pharmacy students, discussing the differences between PPN and TPN, two types of nutrition that can be given to a patient with an IV. PPN stands for Peripheral Parenteral Nutrition and is administered in a peripheral IV site in the patient’s arm. TPN stands for Total Parenteral Nutrition and is administered through a central line, which goes through the patient’s chest. This difference in IV placement is due to the fact that PPN, compared to TPN, has a lower osmolarity, or concentration of particles.
On Aug. 26, I was able to observe a dialysis treatment for the first time. This procedure was administered on a patient whose kidneys could not properly filter out the toxins in his body. Dialysis serves as an artificial kidney for the patient, taking out waste and fluid from the bloodstream and replacing them with dialysis fluid, which consists of potassium, sodium, and calcium in concentrations similar to levels that would be found in healthy blood. Dialysis is based on the principles of diffusion — because solutes tend to move from high to low concentrations, dialysis fluid can move across a semi-permeable membrane into the patient’s bloodstream, while blood diffuses into a machine.
The patient’s wife had come to the hospital that day with complaints about the care her husband had been receiving. The atmosphere became quite tense and awkward at this point because of the manner in which she expressed her complaints, coupled with the fact that she directed all of her complaints toward one specific member of the team, insisting that she failed to treat the patient “as a patient” and ultimately disagreeing with all of the treatments given to her husband. She was adamant about moving him to a different hospital. I imagine that these kinds of complaints arise in the hospital from time to time. Furthermore, I was not surprised that these complaints were delivered in such an antagonistic manner, as patients and their families have to deal with a lot of stress while in the hospital.
However, my shadowing with the team allowed me to look at this situation from the physician’s viewpoint rather than the patient’s. I was aware of the amount of time and energy that particular physician had given to the patient, as well as all of the other patients under her care. After getting to know her personality, I truly believed that the physician had a genuine intention to help the patient get better, despite his wife’s opinion. Thus, it was disappointing to watch her work get criticized in this manner. The head physician in the team, however, took responsibility and responded to the woman’s claims with a calm tone as she explained that she would be more than willing to discuss these matters with her, one-on-one, after patient rounds were completed.
When dealing with patients and their families, medical professionals will come across many different kinds of attitudes and personalities, and it is their job to accommodate those differences and stay calm and professional in order to reach an agreement.
I left the hospital and spent the afternoon in VCU’s Ambulatory Care Clinic for the first time, shadowing a pharmacy resident counseling patients in a clinical setting. Both of the patients who came to the Ambulatory Care Clinic that day were diabetic which, I was told, was commonly seen at the clinic. The resident informed me that the first patient of the afternoon was one of her most memorable patients because, at his last visit, she was able to convince him to try injecting insulin to lower his blood sugar. She explained that he had refused at first, but she eventually changed his mind by gradually building trust between the two of them and convincing him that it might be worth trying for the sake of his health.
She stressed the importance of allowing the patient to decide for himself; it was not the pharmacist’s place to force medical treatments on his or her patients. She also described the process of teaching the patient how to inject insulin, underscoring the practice of “back-teaching.” In other words, to ensure that the patient retained the new information, he should be asked to repeat the steps he had learned back to the pharmacist. This way, it will be clear to the pharmacist whether or not the patient truly understands his instructions.
When the first patient arrived, the resident showed me how she checked blood sugar levels by pricking the patient’s finger and reading the result on the meter. The monitor read 417, much higher than his ideal blood sugar level, which would have been around 180. The patient was quite frustrated about not being able to lower his blood sugar despite his insulin injections. After reviewing all of the patient’s medications, a process that required asking the patient how much and how often each of his medications was taken and checking his responses with his records, the resident determined that all of his medication had been taken correctly. She then asked the patient to explain to her how he had been injecting his insulin. After going through the process of “back-teaching” again, she finally determined that the patient had been following the correct procedures. She ultimately decided to increase the patient’s dosage of insulin. She asked the patient to describe to her his daily routines, and she suggested a few small lifestyle changes that could be made to help lower his blood sugar, such as adjustments to diet.
The second patient was not as severely diabetic, so he did not require insulin. He had come because he wanted to know what each of his medications was treating. Thus, this visit mostly comprised going over the patient’s medications and explaining their purposes, as well as updating his prescription. This patient was significantly more knowledgeable in medicine than the first patient, so it was interesting to observe the resident’s change in vocabulary; her explanations became much more thorough and specific. Afterward, she asked the patient to explain the purpose of each of his medications to her to show that he understood. That afternoon, I learned that the clinical setting certainly allowed the pharmacist to form a closer relationship with the patient than the busy, fast-paced hospital setting. Clinics were also less chaotic than hospitals, but the cases seen in the clinic were much tamer than those seen in the hospital.
I returned to the Main Hospital for patient rounds on Sept. 2. I was no longer shadowing Dr. Gravatt, but I did have the opportunity to go on rounds with another pharmacy resident and a couple of pharmacy students. I joined a different medical team and spent the first half of the morning conducting “sitting” rounds, as opposed to the “walking” rounds I had previously been doing with Dr. Gravatt. During sitting rounds, the team congregated in one room and stayed there for the entirety. The medical students reviewed patient cases while the physicians asked questions and made adjustments as necessary. Although sitting rounds was much less tiring than walking rounds, which required me to stay on my feet, I felt that it was a comparatively more tedious, and perhaps less thorough, process because it did not provide the team members with direct access of each patient they were reviewing.
Afterward, the pharmacy resident and the pharmacy students left the other members of the team in order to conduct bedside counseling. A patient required diabetes training and needed to be taught how to inject insulin, a topic with which I had gained familiarity at the Ambulatory Care Clinic a few days before. I found that bedside counseling was very similar to the counseling process in the clinic; the only difference was that the pharmacists had to come to the patient instead of the other way around. Before entering the patient’s room, the resident quickly described the patient’s loquacious nature and affinity to cats so that the students would not begin counseling without some background knowledge of the patient. With this knowledge, the students were more easily able to connect with the patient, build trust between them, and begin counseling.