By: Nandini Puranprashad, Pharm D. Candidate c/o 2013
I’m sitting in a quaint coffee shop in Cherokee, North Carolina, sipping a dirty chai tea with some of my roommates with 1970s music chiming in the background as I write this article and words cannot describe my experiences at this rotation. The most surprising aspect of my ambulatory care rotation at the Cherokee Indian Hospital was how differently pharmacy is practiced in North Carolina. Cherokee Indian Hospital is part of the Indian Health services, a federal health program for American Indians and Alaska natives throughout the country. Cherokee Indian Hospital is a family practice based hospital and clinic located on the Cherokee Indian Reservation in western North Carolina. It serves approximately 14,000 Native Americans across a five county area through a variety of programs funded and operated through both the Indian Health Service and the Tribal Health Delivery System.
The goal of the Cherokee Indian Hospital rotation is to enable students to gain an understanding of clinical, administrative, and technical aspects of Indian Health Service pharmacy and to provide a unique cultural experience. You will be able to experience one week of inpatient pharmacy and three weeks of outpatient pharmacy which consists of four clinics: anticoagulation, medication therapy management, refill by mail, and counseling. You can also request to see the diabetes care clinic and the pain Suboxone® clinic. Students are assigned one project by a pharmacist, most of whom are commissioned officers. Students are there Monday through Friday and alternate between shifts that start at 8:00 am and end at 5:00 pm or start at 9:00 am and end at 6:00 pm, with an hour allocated for a lunch break. On Wednesdays, everyone starts at 10:00 am and the day ends at 6:00 pm. For inpatient pharmacy, students attend rounds at 8:30 am. The hospital is very small and carries only 22 beds, so you cover a maximum of about 10—12 patients a day. Most patients are admitted for substance abuse or alcohol/opioid withdrawal. Students perform medication reconciliation when a patient is admitted and discharged, which consists of counseling the patient on any and all changes made to their meicatio regimen. Students also make all the patients’ intravenous (IV) medications and answer any drug information questions the pharmacy receives.
The outpatients clinics are all primarily managed by students, so be prepared to work as if you are a pharmacist because you have a lot of direct patient contact and there is a lot of independent work. In the anticoagulation clinic, students routinely monitor INRs for patients on warfarin. You see patients one-on-one in a private room, take the patients’ vitals (i.e. blood pressure, pulse, and respiratory rate), go through a list of questions including any changes in diet and exercise, bleeding and bruising, swelling, difficulty breathing, changes in medications, and tobacco and alcohol use. You take note of the patient’s INR for that clinic visit and their previous INRs and use that information to determine how the patient’s warfarin dose should be adjusted if they are not within their goal range; identify the cause of their INR change; make a recommendation to the pharmacist; adjust the patient’s warfarin dose; and schedule their next appointment in one, two, or four weeks. You also counsel the patient on foods that affect warfarin. After all this is done, you document everything that happened during the visit in the electronic health record system (EHR).
For the medication therapy management (MTM) clinic, patients bring in all their medications, students review their medications with them, and align their medications so that they can receive all their medications at the same time. The same process is done for refill by mail where patient’s medications are partialed so they can finish all their medications at the same time, and then the refill by mail kicks in. Every patient interaction is documented in the EHR system. For the counseling clinic, any changes made to a patient’s medication or refills requires counseling. Here is where you have a lot of patient interaction and will get to know the local Cherokee people. You learn of the poverty these people live in and the drug addiction and substance abuse that plague this small nation of people.
In addition to an excellent clinical experience, a rotation at Cherokee Indian Hospital offers a wide variety of outdoor and recreational activities. Being bored is impossible; Cherokee is located next to the Great Smoky Mountains National Park. There are many activities to do throughout the day in Cherokee such as running, hiking trails, the Indian village, enjoying the beautiful Oconaluftee Island Park, tubing, visiting other towns, the Indian museum, exploring waterfalls around the area, storytelling at the bonfire, and gem mining. You are also able to meet and live in free housing with students from other health professions such as medical students, physician assistant, public health, and dentistry. There is truly a southern hospitality present in Cherokee; the people are very welcoming to visitors and willing to share their culture.
By the end of this rotation, I gained tremendous growth in my professional maturity as a pharmacy student and expanded my knowledge base of ambulatory care and patient interaction. One of the nostalgic memories I have of this rotation is the picturesque drive to the hospital, surrounded by a myriad of smokey mountain peaks with the sunshine sparkling through the hazy clouds and illuminating the magnificence of the surrounding mountains. I enjoyed going to the beautiful Oconaluftee Island Park, sitting on a rock by the stream, my feet wading in the water, watching the laughing children playing in the shallow water and smiling parents taking pictures and just admiring the serenity of the park. They say a picture is worth a thousand words; but, the pictures that I took of Cherokee do not do justice to the natural beauty of this land and its rich culture and history. I only hope to return here someday.