Our last days in Masindi

Siiba bulungi! (Good day!) This post is brought to you by Autumn & Mike. Autumn will cover Wednesday 11/14, and Mike will cover Thursday 11/15.

Wednesday 11/14/18

Wednesday morning all nine of us hopped into a van and visited Kijujubwa, which is about 45 minutes out into the Masindi district country side. Thus far in our trip, we’ve been to city clinics/hospitals and a town hospital, so Kijujubwa was our opportunity to see medical care on the village level.  Most of Uganda is made up by small villages, so this hospital was meant to show us a true idea of how most Ugandans receive medical attention.

We started at Kijujubwa-Kitara Medical Center (KKMC) which is another private clinic funded by One World Health. This center is rated as a Level 2 medical center, but honestly performs more like a “2.5” (which doesn’t actually exist). The difference between level 2 & 3 are that a level 3 has a ward and is able to host patients overnight. KKMC is open 24 hours a day, so if a patient comes in at midnight with an injury, they will allow them to stay until morning before leaving (hence the “2.5” rating).

The staff in total (between nurses, midwife, a lab tech, and doctors) is only 8 people, and they all live on site. This hospital did not have a pharmacist on staff, but their dispensing room was still impressive. We were told that they must order enough supplies and medicine to last them a month at a time, unlike in the US where most pharmacies have daily deliveries.

The clinic itself had 2 consultation rooms, a lab, dispensing room, and delivery room for childbirth. They averaged about 5 births a month. After going through each of they rooms the doctors showed us their means for garbage/infectious material disposal. Most of their waste was incinerated and the ashes poured into underground pits, but the most interesting disposal method shocked us Uganda first timers. One disposal pit was dedicated to placentas. That’s right I said placentas. It’s biodegradable, so why not!

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After touring the private hospital, we walked down the road to the Kijujubwa government run facility. The two hospitals were honestly like night and day. Right away we could tell that most of the villagers went to the free government hospital instead of the private KKMC. The dispensing room had very little medicine, and they received shipments every 2 months. The delivery room was bigger, and they had free baby vaccine clinics monthly. Even though the facility was in the middle of some upgrades, it was physically still rough around the edges.

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Thursday 11/15/18

On Thursday, we traveled to Masindi-Kitari Medical Clinic with the automatic blood pressure cuffs. Thank you to ASHP, NCPA, PPAG, Rho Chi, and CPFI for donating the automatic blood pressure cuffs! When we arrived we prepared to greet the community drug shop owners to teach them how to take blood pressures with automatic blood cuffs and teach drug shop owners about screening patients medications to make sure they are safe for pregnancy and lactation.

We began by having Dr. Prelewicz take the drug shop owners names and shops that they owned so we could raffle off the blood pressure cuffs and prizes we had at the end. Once we had a decent number of owners, we began the presentation at 10:15am, 15 minutes after our scheduled 10:00am to try to account for those on “Ugandan time” (there were still quite a few that showed up late!). As the drug shop owners filed in, we noticed that they all sat one next to another filling front to back even though they could have spread out through the open room. In the United States, we all would have opted to spread out unless we knew someone we wanted to sit near. In Uganda, people are not afraid to sit near each other, whereas, in the United States, we often prefer as much personal space as possible. Beth and Rubi began the presentation by teaching the drug shop owners about what blood pressure is, the problems high blood pressure could cause, what questions to ask a patient before taking a blood pressure, and how to read a blood pressure result.

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After teaching about blood pressure, we all broke for a morning tea break. After the tea break, we split up the owners and did a hands on teaching session of how to take a blood pressure with an automatic blood pressure cuff. The drug shop owners were very receptive to the teaching, and, specifically, with the owners I was teaching the owners who understood me the first time would teach each other, before I could assist! This was one of the shining examples for me on this trip that showed how strong the Ugandan sense of community is compared to the United States.

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Once the hands-on session was finished, Mayi and Dr. Manning taught the drug shop owners about asking patients if they were pregnant or breastfeeding and what medications they should screen for in patients who are pregnant or breastfeeding. This presentation seemed to us like it was much need, because, when asked, most of the owners did not ask their patients this before dispensing medications. Many of the owners were very excited to learn to do these things because they want their patients to know that they have the patient and her baby’s health in mind. Once the presentation was complete, we raffled off the automatic blood pressure cuffs we had and the gifts we got for the presentation, including our close friend Katy (the chicken). It was difficult giving Katy away, just as it is when any child. It feels like it was only Saturday that Autumn and I carried Katy 3 miles, while he cuddled us. We are glad that we were able to make someone’s Christmas better with Katy’s sacrifice. After the presentation was over, we all ate lunch made with the chickens that Autumn and I helped prepare.

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Late in the afternoon, we had the opportunity to see wild chimpanzees in a Ugandan forest bordering a sugarcane field. We made a 3 miles trek through the muddy, uneven forest filled with streams to see the chimps. We were able to see two chimpanzees trying to court each other and others using tree tops as sofas. We also saw monkeys during the trek and baboons in the road on the drive back! After this busy day, we were all exhausted and retired early.

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Webale, until next time!

-Mike

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When it all works well…

 

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The last two days we have gotten the opportunity to experience the Masindi-Kitara Medical Center (MKMC) that, like the other places we’ve visited, has it’s own unique features. While Wilkes University pharmacy program has had an extensive relationship with MKMC in the past, this year we were given the opportunity for just a short two day visit. Although, MKMC will be hosting the drug shop owner health training that we are running with Janine’s help this Thursday. This clinic is now sponsored by and partnered with an organization in the United States called OneWorld Health. They work to build sustainable health facilities to provide care to patients that’s affordable and appropriate. Year round they have United States physicians and health care workers, including students and residents, to help fill the gaps but also to help train the healthcare workers of Uganda to achieve improvements in global health. Patients at these facilities must pay for services, which then helps employ the physicians and staff.

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A shot of morning services before rounds!

Yesterday, on our first day at MKMC those from OneWorld Health and also the Ugandan staff welcomed us during the morning service. As a Christian facility they start off every morning with this small service that includes prayer but also announcements. I do not consider myself a religious person therefore I usually find myself a bit uncomfortable in this type of setting. The service was much more than praising and thanking god. One of the physicians gave an inspirational spiritual talk about what is it to be kind and help others whenever you are capable and with any and all capacity. The words he spoke were beautiful and touching for me personally and I actually truly enjoyed hearing him speak such words before starting a “work day.” The optimism, faith, and altruism of the Ugandan people shines brighter with each day I spend in this country.

 

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The group as we head off to rounds!

Following the services we had the ability to round with the doctors throughout the two wards, the maternity ward and the general ward. On the first day we met a young woman who was in labor. We all spoke about the tolerance she displayed to her labor pains. She tossed and turned a bit but we barely heard a peep or groan out of her (these patients are not receiving epidurals of any such for the pain as they do in the US). Her beautiful baby girl was born about 1 hour after we left yesterday (rats), but luckily we were able to check in on them today.

 

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Discussing patients with a MKMC medical officer and OneWorld Health physician prior to rounds with the attending physician!

Today we rounded on a mother whom had preeclampsia upon admission last night, which is a potentially dangerous complication of pregnancy caused by high blood pressure in the mother. She birthed her child but her blood pressure was still fluctuating a bit despite being on anti-hypertensives. Our team was able to help correctly dose her anti-hypertensives where now, her Nifedipine IR will be given three times daily with the conclusion that her original twice daily dosing schedule was not sustaining control long enough. Therefore explaining her need for additional pushes of Hydralazine.

 

MKMC10Patients in the general ward could range anywhere from neonates to geriatrics and we were able to see a bit of both and some in between. They spoke of some of the most common cases they see within their facility and two of those we were able to see were patients with Malaria and patients with H.pylori. Uganda has one of the highest rates of malaria in the world and it is not uncommon for residents of the country to contract the disease at least once (often times more than) in their lifetime.

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Mike and I determining correct dosage calculations for our pediatric patient

In the general ward today a few of us rounded on our own before the doctors were ready to begin. Dr. Manning, Autumn, Mike, and I came across a 2.5-month-old baby who had stopped breastfeeding due to respiratory symptoms such as coughing and trouble breathing. We could see in his chart that they were suspecting pneumonia. He was started on Ceftriaxone, Gentamicin, Hydrocortisone (all IV), as well as IV fluids and oxygen. The first thing we asked ourselves, why did they start Gentamicin and why hydrocortisone? The double antibiotic coverage wasn’t necessary and the hydrocortisone did not seem indicated. The second action we took was to calculate the doses of each medication based off the baby’s weight. The good news was nothing was overdosed, but some of the doses seemed a bit off with some room for improvement. Later during rounds, the physician from OneWorld Health supported our thoughts and recommended discontinuing the gentamicin and hydrocortisone. The baby’s oxygen was increased which improved his O2 sat and they put in an order to have an x-ray done to definitely diagnose pneumonia.

In comparison to some of the other clinics and hospitals in Kampala that were government-run, my first impression was that this clinic was beautiful. The facility was tidy and clean. The patient charts were written fairly neat and in a decently organized chronological manner. The patients seemed comfortable and so did their accompanying family members. Despite these obvious physical differences I noticed some gaps and room for improvement. For example, the clinic only had one working ECG machine and one working ultra sound machine. There was also, like the other facilities, no clinical pharmacist or input from pharmacy in patient care which could be very beneficial to patients such as the scenario mentioned above. I admire the achievements they’ve made and continue to make but I truly believe the value of a clinical pharmacist could drive quality patient care even further.

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PharmD student Bethany Chmil in the lab getting a chance to view some malaria slides!

During rounds we took turns escaping in small groups to the lab just to get a taste of what was happening behind the scenes of diagnosing. The lab technician was so wonderful and kind he took us through step-by-step of all his work he was doing. We were able to look at blood smears to identify malaria, we watched him prepare renal tests (SCr, BUN/Urea, and Uric Acid), and also testing plasma for hepatitis B. With the funding of OneWorld Health via machinery and lab equipment they are able to perform just about every basic/vital test we know in the US. Challenges come with low stock of things such as reagents from their suppliers within the country. My time spent in the lab really brought me back to Microbiology and Analytical chemistry during my undergrad career at Kutztown University and also to pharmaceutics lab with Dr. Jacobs during pharmacy school. It’s been 3 years since I’ve used a pipet (YIKES)!

The above images are of blood smears the first being of mild malaria and the second being severe malaria!

While saying our goodbyes to one of the physicians, Dr. Dan, he expressed his desire to have a conversation with all of us about pharmacy practice in the United States. To our surprise he really was not fully informed on our role as pharmacists. He was shocked to hear that a pharmacist must be present in the pharmacy AT ALL TIMES in order to help patients, receive prescriptions, and dispense medications. This is a huge difference from Uganda. In fact, often times the pharmacist is not in the store and it is their technicians and other employees (whom may or may not have accurate medical training), are present in the pharmacy and are dispensing the medications and making recommendations (hence recommendations during our little experiment yesterday). He then posed what I thought was such an interesting question; “do you think the people of Africa do not treat as many chronic conditions as you do in the US (ie diabetes, hypertension, thyroid disorders, etc), because we are healthier or because we just don’t know we are sick?”

I’m sure most people would assume “that’s easy, it’s because they don’t know they are sick due to limited healthcare access.” This may or may not be true. Although many of our patients from the blood pressure screening had very high readings, we’ve made personal observations about diseases such as diabetes, which does not seem nearly as prevalent in Uganda as it does at home. Fruits, vegetables, and home cooked meals in general are much more common and are staples of their diet whereas in The States, buying fast food is much cheaper than whole foods. Some food for thought (pun intended).

It’s really great to see the execution in patient care this clinic upholds when it all works well (most of the time)! I’m hoping these next (and last) 5 days go by veryyyyyy slowly (although I’m really missing my dog son Oliver)! Thanks for reading and happy Tuesday!

-Rubi

A Warm Masindi Welcome!

Hello (again) everyone!

Just for a little bit of clarity, there are two posts in this blog. A blog post by Mayi and a blog post by Katy! And, as always, a few pictures!

Well, I LOVE MASINDI! The people, the children, the animals, the flowers, ahhh everything! On Saturday Rubi, Mike, Dr. Manning, Janine and I (Mayi) went downtown. We did somewhat of an experiment. We created patient cases and went to “drug shops” and pharmacies to see what the workers would recommend us based in the patient case. For example, one case was back pain and the worker recommended aceclofenac, a derivative of diclofenac. She made sure we knew to take it after meals, twice a day, and she also asked if the patient had ulcers. She was not a pharmacist, but she was still trained to ask key questions when recommending an NSAID. I was really impressed to see other nonpharmacological recommendations, such as when we asked to buy Doxycycline they asked “what for” and responded for malaria prophylaxis, she then proceeded to give the correct dose AND to tell us to still sleep under a mosquito net!

After this experiment, we were able to get a deeper understating of medication availability, like birth control. We did not find birth control on the first try so we had to go to a different drug shop. It was a great learning experience. I feel it will be beneficial when we start clinic and rounding tomorrow!

We went to the market after this to buy some “give aways.” Among other things, we got a rooster! YES, a rooster!! We decided to name the cock “Katy.” (Katy Campf, another student on this trip, is “anti-chicken giving” because she is scared of chickens, roosters, and hens). Katy, the chicken, was not very handsome, but he was a good boy! Mike carried him 1.5 miles to Jeannine farm, where she will be kept safe until Wednesday when we give him away.  I am sure he will make a family HAPPY and FULL! Anyways, the market was really cool, lots of beans, fruits, and vegetables. Every little kid calls us “Muzugo” (white traveler)! They get sooooooo happy to see us and to get a wave back from us. It is adorable!

Above is a picture of Dr. Manning, Mike, Rubi, and I (Mayi), at the market!

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Here is Rubi, Katy (the rooster), and I. 

Sunday, we were up bright and early for a blood pressure screening at a church. We got to the church around 7:30 AM! We screened 150 patients, and explained the importance of checking blood pressure, since there are normally no signs of high blood pressure, but it still can be very dangerous. All the people were so eager to learn about their blood pressure even though the line was long and the day was hot. I especially enjoyed playing and educating the children as well as holding them! Additionally, praising to Jesus in the church was amazing. There was so much joy, so much dancing, everyone was smiling. It was a phenomenal experience! Words nor pictures cannot describe our time here.

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Here are some pictures from the blood pressure screening at the church!

-Mayi

WE MADE IT TO MASINDI, but not before we stopped at the Ziwa Rhino Sanctuary! The sanctuary is home to twenty-six wild white rhinos and their main goal is preservation and conversation of the beautiful species. On our trek, we were able to see four rhinos and two of the rhinos were the smallest rhinos in the sanctuary! Although the rhinos were all wonderful, the babies of the sanctuary were my favorite. The youngest baby of the sanctuary was born on August 10th, 2018. She was THE cutest three month old and the overall experience of the sanctuary and the trek was a once in a lifetime experience!

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Katy, Mayi, Beth, Brittany, and Michael take photos of two rhinos inside the Ziwa Rhino Sanctuary!

After a good nights sleep and some settling in, we met with Janine on Saturday and started to create our plan for the day. For those of you who don’t know Janine, she is a missionary in Uganda and she acts as our coordinator while we are in Masindi. She has lived in Uganda for about 10 years and spends her time helping others through her work with her church. Janine came to our morning meeting with a plan: the group was to break up into two teams and go to separate areas of town. Here, we were to approach local pharmacies with a scenario and see what prescription medication they would recommend and ultimately, sell to us. Over the last few weeks, we’ve learned a lot here in Uganda, especially how community pharmacy operates. Their pharmacists and prescription drugs sales do not rely on written prescriptions or instructions from a doctor. The entire prescription process from physician to pharmacist sometimes relies solely on the pharmacist. After clarifying the situation and setting a budget, we started our walk to the outdoor market with Jimmy, the town celebrity. To be fair, Jimmy is another volunteer with the church and helps Jeanine with just about everything, but walking in town with him felt like we were walking around with a celebrity. Everyone we met was welcoming and thanked us for our service and visiting the beautiful country of Uganda. I’ve never felt more comfortable 7,000 miles away from than when I was walking around a busy Ugandan market with Jimmy. BACK TO OUR PROJECT, we visited three pharmacies with the same story and a few random prescription medications to request if we could access them.

SCENARIO: A 56-year old female presents with lower-back pain. The patient has a few drugs allergies, but the most pertinent one is penicillin. What would you recommend?

RANDOM PRESCRIPTION MEDICATIONS: Birth control, doxycycline, meter-dose inhaler

Pharmacy 1: The pharmacist asked the age of the patient and recommended a topical pain reliever (a herbal-combination diclofenac product). The pharmacist demonstrated how to apply the medication, but neglected to ask if there were any drug allergies.

Pharmacy 2: The pharmacist asked the age of the patient and recommended piroxicam and a beta-lactam antibiotic. The pharmacist wrote how many times to take the medication, but when asked why an antibiotic was needed, she stated that it had to be taken with the piroxicam. The pharmacist neglected to ask if there were any drug allergies and did not counsel the patient on what to expect when taking the medication.

Pharmacy 3: At this pharmacy, we particularly asked for birth control and doxycycline for malaria prophylaxis. Both medications were sold to us, but the pharmacist recognized Jimmy and asked if we were the pharmacy team presenting to Masindi district on Wednesday. With that being said, the pharmacist potentially knew our background in medicine and deferred her counseling session to our baseline knowledge.

After our adventures in town, we traveled back to meet with the other team and discuss our experience. My biggest take away from the day was that critical questions were not asked. In the scenario, our patient had a penicillin allergy and was sold a beta-lactam antibiotic. In the drug requests, our patient was sold birth control without asking if she needed counseling. In the drug requests, a patient was given doxycycline without asking if the patient took the medication before and knew about the increased risk of photosensitivity. In community pharmacy, asking questions is essential when trying to provide the best patient care. My experience with the community pharmacies of Masindi has left me feeling a little uneasy, but that’s why we are here on this trip! We are here to help, it’s plain and simple.

On Sunday, our group had an early morning for a blood pressure screening at Jimmy’s church. Jeanine helped coordinate the event and all we needed to do was bring our blood pressure cuffs and our stethoscopes. Jimmy met our group in town and brought us to his church and WOW, were we welcomed with open arms! The people of his church were so accepting of our group and continued to thank us for our service in Uganda. We observed a few minutes of the ceremony before shuffling outside to set up our blood pressure clinic. Before we knew it, we checked over one-hundred and fifty pediatric and adult blood pressures over the course of five hours. The clinic was hectic and required A LOT of coordination and translation, BUT the entire event was a huge success!

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Autumn, Jimmy, and Stacy work together to check the blood pressure of a church parishioner!

The church parishioners could not thank us enough and everyone who required counseling asked appropriate questions! However, my favorite part of the day wasn’t related to the blood pressure screening at all. It was fully related to the people of the church. These people were so grateful to have us present at the church and they were so willing to welcome us and help in anyway that they could. Parishioners volunteered to sit with our groups and translate for those would could not speak English. They volunteered to help others fill out paperwork and explain what the paperwork was for. They even offered to drive our group home from the church to our hotel on their boda-boda (Ugandan motorcycle). The entire morning was humbling and I cannot try and put into words what I felt at the church. Our group has one week left in Uganda and while I’m preparing for the goodbye, I know a piece of my heart will be left in here in Uganda.

-Katy

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Katy and Stacy work together to check the blood pressure of a church parishioner!

Thank you for taking the time to read our blog and we hope you continue to follow us through our last few days in Masindi!

Community……….and changing my mind.

So this is Dana writing this post…..just so that you can tell 🙂

As I reflect on the past three days, I find myself coming back again and again to the concept of community.  I think if there is anything I find on these trips I have taken to Uganda, it is that community is the central and strongest tenant of what we seek out as human beings.  It is what underlies why we do things – as medical professionals, as students, and as teachers.  Let me explain.

Friday of this past week we had the opportunity to tour the Infectious Diseases Institute (IDI) – they are an organization that is supported by Makerere University as well as the CDC and other NGOs in many countries and Uganda.  The work they do there is simply inspiring.  They have a large facility on the Mulago Hospital campus that houses what I can best describe as a fully integrated medical home for HIV care.  They serve over 8,000 patients that travel from all over the country to get there, and they provide free medication, physician visits, prenatal care, pediatric care, psychological and social counseling, lab services, urgent care, and clinics for the various associated conditions such as Cryptococcus and Kaposi Sarcoma.  Additionally the Institute coordinates multiple clinical trials of medications – everything from pharmacokinetic and dynamic studies of how antiretroviral medications interact with other meds to studies of how to best reach certain populations within the community.  It was quite simply mind blowing – I’ve never seen a fully integrated clinic like that in the United States.  It was clear also how grateful Uganda and many African countries are to the PEPFAR program originally instituted by GW Bush for AIDS relief in 2003.  The impact of this program are so so impressive to me – it is really eye opening to understand how much the US has impacted the rest of the world.  And it is changing my opinion of GW Bush as well for instituting it. I’ve had really interesting “ah ha” moments about many things while I’ve been here this trip – many of them things that my liberal political mind finds difficult to square right away.  I don’t want to get controversial, but I’m finally able to see the other side of the concept of socialized medicine, as well as religious involvement and support of medical facilities.  I am always open to new viewpoints but I may be processing these change concepts for a while.  That said – I can also see the power of global community – and making sure medical care is not for profit – things that do fit well with my existing ideology.

We also got to spend part of the day at the part of IDI that deals with initiatives such as Antimicrobial stewardship.  These are huge efforts that are really focused on the world as a global community – preserving antibiotic usefulness for all people by preventing unnecessary use.  The staff talked about the projects for this having to come from the community – not be imposed upon it.  This is the only way it would be accepted.  The amount of effort that these things take is simply mind blowing, and pharmacists in the community in this country are poised to be an integral part of it.

I could speak at length about all the things we’ve done, but Friday night we had to say goodbye to Winnie and David, and it was one of the hardest things I’ve had to do in this trip so far.  They both have accepted all of us and Wilkes University as a whole as part of their community – going out of their way to make sure we were cared for and included. We are all incredibly grateful for Winnie’s mentorship as she has arranged and helped us process all of our pharmacy experiences here.  They have both given of themselves simply because it is the right thing to do, and they hope that it will be passed on.  Often this giving probably came at an inconvenience to them, but it is simply what they do.  I am having a hard time accepting that all of this help can be given so freely, as it is often not at home sometimes.

And finally we have now moved on to Masindi – a place where I instantly felt as if I was back at home (it helps that Janine was literally there greet us as we got out of the car!).  I am excited for this group to experience a place closer to “small town” Uganda, and the community ties that run deep.  It was great to see familiar faces and step back in to familiar spaces.  I hope that we can bring some of our love to this community – we have a week planned that is filled with outreach and support for the pharmacists and medical community here.

Hello friends,

Today is Wednesday, 11/7/18 (HUMP DAYYY!), and this post is a tag team effort between Stacy and Autumn…. starting with Stacy!

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Yesterday (November 6th) Katy, Autumn and I (Stacy) had the pleasure of touring my old stomping grounds, the Uganda Cancer Institute! We met up with a pharmacist named Isaac who showed us the pharmacy area, mixing room, outpatient infusion center, and inpatient wards. Since I last visited 3.5 years ago they have completely finished building the new upper wards. Even with the expansion they were overcrowded. Patients had mattresses in hallways as make shift hospital beds in the solid tumor ward in order to be treated. UCI is the only inpatient cancer hospital in all of Uganda so patients travel far distances in order to be treated. All of the chemotherapy is free to patients since UCI partners with the Ministry of Health. Although it is free, they do not have as many treatment options as we do in the US since they have to stick to a strict budget and very few patients have insurance. It is impossible for them to order high cost drugs such as nivolumab or perform transplants. The pharmacists also have to anticipate the needs well in advance since they only procure drugs quarterly versus daily in the US. Despite all this they are making advancements in other areas such as enrolling more patients into clinical trials through UCI’s affiliation with the Fred Hutch Cancer Center in Seattle. They also now have a UCI mobile bus that goes out to rural areas to screen and educate patients about cervical cancer, one of the most prominent cancers in Uganda.

Isaac and I bonded over our shared love for oncology. We feel a lot of fulfillment from helping patients through some of the hardest times in their lives, but it can be emotionally difficult becoming close to patients and having them not do well. In my opinion, the oncology pharmacists in Uganda are even more vulnerable to stress and career burn out due to the limited number of successful treatments for many cancers. Unfortunately most patients in Uganda present to UCI with advanced disease due to the lack of cancer screenings, inability to travel long distances for treatment, and sometimes fear associated with coming to UCI for treatment.

Later that day we visited a private catholic hospital, Nsambya. Although they don’t have an inpatient oncology unit, they do have an outpatient infusion center. The difference here is patient’s have to pay for all of their care so they only treat about 5 patients a day. Since they have a low volume, they trained their nurses to mix the chemotherapy versus pharmacy techs and pharmacists. Physically this facility looked nicer and more organized than UCI’s outpatient infusion center, but realistically chemotherapy is very expensive so most patients cannot afford to go there. I personally wonder where I would want to be treated if I lived here in Uganda. Many of the leading experts in oncology work at UCI, so although it is crowded I may still decide to go to UCI for the physicians and pharmacy support. Ultimately I think I would have to do more research before deciding.

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The rest of the post is completed by Autumn.

After touring the cancer center pharmacy at Uganda Cancer Institute in the morning, we caught up with the rest of the group for an afternoon tour of Nsambya Hospital. Nsambya is a private, non-profit, catholic missionary hospital. Unlike the government-run Mulago Hospital, patients at Nsambya must pay for all treatment, tests, and medications.

Before touring the hospital campus, Dr. Manning led a presentation on American inpatient pharmacy to the pharmacy interns and some pharmacy staff. Our presenting skills were really put to the test because we had a lot of barriers to overcome while giving the presentation. A sheet taped to a window was used to project onto, the space to sit and view the presentation in the pharmacy was tight and highly trafficked, and a rain storm rolled through, knocking out the power in the middle of the PowerPoint. Nevertheless, we adapted and were still able to continue with a discussion about specialty areas of pharmacy as well as contribute ideas to current problems the pharmacy department is facing. Some of the issues that were brought up were:

  • How to overcome documentation errors or lack of documentation in general?
  • What are some tips for getting the pharmacist involved in rounding?
  • What are some tools that the interns can use to help them assess patients?

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Post presentation and discussion, we went on to a tour of the Nsambya Hospital campus. After spending the past 2 weeks at Mulago Hospital (a free, government run facility), Nsambya was a sight for sore eyes. My first impression was that the hospital was well kept and felt more like a walk through a serenity garden, rather than walking across a hospital courtyard. At Mulago Hospital and other government facilities, you can expect to see family members washing clothes/dishes outside the wards, people sleeping on the ground, and broken sidewalks/roads. Nsambya did not have anything like that. When we asked our guide where the families sleep, since we did not see them sleeping by the patients or outside. We were told that the caregivers have their own dormitories to sleep in while staying at the hospital.

Nsambya had many specialty departments. The Intensive Care Unit and NICU had updated equipment and was quite impressive. While in the maternity ward, we learned that 80% of the births at that hospital were C-Section, and the other 20% of women give birth naturally without any medication (NO EPIDURAL!!). Ugandan women are some tough ladies!

During the tour, we met many different department heads, and each time we were asked to come back and contribute to their ward. The conversations and offers were heart warming, but alas we regretfully had to decline and leave with hope of coming back on our next Ugandan trip.

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Wednesday, Nov. 7th

Wednesday morning we visited another private, non-profit, missionary hospital called Lubaga. We started our tour with viewing their main pharmacy and then an outpatient pharmacy up in the hospital. The main pharmacy was very impressive. There were multiple storage rooms for IV solutions, supplies, and other medications. I jokingly said that I wanted my ashes scattered in their drug storage room because I was that impressed. This was the first hospital that we’ve been to that had a computerized list of the medication in stock. Most other pharmacies use a “stock card” system where they must manually keep track of the quantity on hand.

Pictures taken while seeing Lubago Hospital’s impressive stock rooms.

After ogling over the main inpatient pharmacy, our pharmacist guide, William, took us up to a different building to check out an outpatient pharmacy. He talked with us about common medications they dispense as well as their dispensing process. This was the first time we saw a computerized record database system in a pharmacy. The database was similar to Epic or Cerner that we use back in the states. The pharmacists could receive prescription orders through the system from any place in the hospital. Later on, Dana and Winnie had the chance to speak with the Medical Administrator (head honcho), and they commented on the impressive computer system here. The administrator told them that the pharmacists currently do not have access to view ANY clinical data on the computer database. Meaning that the pharmacists were forced to dispense medications to patients without knowing disease state, test results, lab values, etc. Dana and Winnie strongly advocated for the increased pharmacist access to that data going forward, and the administrator responded positively (THREE CHEERS FOR LITTLE VICTORIES!!).

After touring the rest of the hospital, the sights were similar to those we saw at Nsambyo the day before. The facilities were well cared for and the equipment was updated and modern. This hospital was also ran by a missionary, but they embraced the Ugandan martyrs so much that they dedicated the hospital to them. The hospital campus also had a beautiful cathedral dedicated to the martyr’s and had their story told through the beautiful stained glass windows.

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Before we parted Lubago, our team split into groups and explained some tools that they can use to help them “work-up” a patient before rounding, as well as helping them communicate with doctors and other medical practitioners. We discussed the structure of a SOAP note for pre-rounding methods, “I-ESCAPED-CPR” for evaluating medication appropriateness, as well as “SBAR” for communicating to doctors.

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Mike, Britt, and Katy describing good clinical techniques to Arthur, a Lubago pharmacist intern.

 

When we returned to our homestead at Makerere Guest House, we had a small, informal social with 5 students that some of us had presented to on Monday. We sat outside in the beautiful weather and had casual conversation about their Ugandan backgrounds, pharmacy, and much more. Before we knew it, the sun was almost set and our faces hurt from laughing. “Weebalennyo” to the gentlemen that took time out of their days to come hang out with us & best of luck on future endeavors!

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Tomorrow, Thursday Nov. 8, is our last day in Kampala! Friday morning we leave for Masindi, in the northwest of Uganda. Until then, stay classy America.

-Autumn

 

Let’s split up, gang!

Nkulamusizzah (hello) and happy Monday!

As the title infers, today we all split up into three separate groups to see/accomplish different tasks.


The first group, consisting of Autumn, Dr. Prelewicz, and I (Mike) stayed at Makerere University to teach the students.

Dr. Prelewicz began by teaching the students an introduction to her specialty, oncology. During her lecture, the students had many questions and were very attentive. The students were also very curious how cancer drugs were prepared and handled in the United States versus in Uganda. Dr. Prelewicz also had students draw their own chemo man for the medications she presented, which is a tool to learn the side effects of oncology medications.

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Following Dr. Prelewicz’s presentation, Autumn and I presented on Free Applications for Portable Devices in Medicine, which falls under my interests. We discussed multiple applications that the students could use while they are on rounds or for when they need drug information.

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I had a great time today being able to step into the opposite side of the classroom and being able to teach. Overall, the students were very happy to have us teach in class and we were happy to be there!

-Mike


The second group, consisting of Beth, Brittany, and Rubi, rounded at a mental health clinic at Mulago Hospital.

This morning, I had the opportunity to round with a Community Pharmacist, Derrick, in a mental health clinic with Rubi and Britt. We were definitely a little bit surprised because we thought we would be seeing a lot of mental health related illnesses, but it ended up being mostly orthopedic patients who were admitted due to car accidents. Although the ward was NOT what we anticipated, the experience was highly educational and allowed us to use our clinical knowledge to assess patients. We had the opportunity to see two patients this morning, both of which we spent roughly 45 minutes with. Derrick did a fantastic job of pushing us to use the visual appearance of the patients to initially develop questions to ask. We had no lab values to make any form of a clinical decision with, so our strong counseling skills were necessary in order to best help our patients. Derrick acted as a translator for us and gathered information from either the patient or a family member in order for us to assess the situations. I was honestly surprised at how easily we developed questions that were necessary to understand what our patients were feeling. Both our patients had pain as their primary complaint, so it was clear that Dr. Franko (our pain management professor) prepared us to be capable to assess our patients. A constant theme I know we have all mentioned in our posts is the difference in resources available here. Clinical data and medications are limited, so we are constantly learning from the pharmacists we round with. Derrick told us that he wanted us to “share a leaf” with him. By that, he meant that he wanted us to share with him how we would assess and treat patients in the states. This way he could use our experiences and knowledge to best formulate a plan that is realistic based on the resources available in Uganda. I think we could all agree that it was great to be able to collaborate and learn from each other today.

I wanted to highlight a key difference in the treatment of patients and mental health here in Uganda that was emphasized through today’s endeavors. A unique aspect to the culture of Uganda is how much patients rely on family and their community. The support that Ugandans provide each other with is very heartwarming and makes me sit back and realize how lucky I personally am to have such a strong support system when I am home. The patients are taken care of in the hospitals by both health care providers and family members. When you walk into a ward, you see patient beds tightly packed in order to maximize space. In between the beds, you will find family members camping out on the floors. Food, drinks, clothes, etc are all provided by family. Could you imagine walking into a hospital in America and seeing a patient’s mother and brother sleeping on a hard and dirty floor in order to be there for the patient? That type of support is consistent throughout the various villages in Uganda. Counseling is a HUGE aspect to mental health in the States. We were very surprised by the fact that, in Uganda, most “psych” patients only seek help when the diseases progress to the point where family members feel urged to take a patient to a hospital. Otherwise, the illnesses are combated through the consistent support of family and the community.

Lastly, I wanted to focus on how I felt after reflecting on today. We were really able to feel the impact that pharmacists could have in hospitals here. The first patient we saw today was there with his brother who acted as our primary source to gather information from. At the end of our meeting with him, he thanked us and said “May god be on your side”. The second patient we saw slowly began to develop trust with the four of us. This lead us to not only discussing the primary complaint of pain, but also diving into very deep and personal issues the patient was experiencing. Although we are not qualified to treat the issues he mentioned, it was amazing to see how his trust developed with us. You really do not realize how much your work can impact someone’s day or even life. It is so important to remember to be open-minded and listen to your patient. Spend extra time with your patients and their families. Help them to feel comforted and have someone they can trust. It is easy to get caught up in the stress of work, but putting your patient first and going above and beyond for them is so rewarding. I felt like today really showed me why I wanted to be a healthcare professional in the first place: To help people. You never know who you can impact in a day 🙂

Beth


The third group, consisting of Katy, Dr. Manning, and Mayi, rounded in the pediatric ward at Mulago Hospital.

Today we broke into groups in order to get multiple tasks accomplished. Katy, Dr. Manning, and I met with six pharmacy interns in the pediatric ward. Just to give you a little bit of background, the pharmacist interns here are different than what we consider interns in the USA. In Uganda, they are finished with their pharmacy degree and are then required to practice as a “pharmacist intern” for a year, but they have the ability to verify orders, dispense, and round with other healthcare professionals. In the USA we are all “pharmacy interns” for all 4 years of pharmacy school, but we are under the direct supervision of the pharmacist. The role of the interns here is similar to the role of the pharmacy residents in the USA. Now, back to this morning. Our main goal was to learn from and to teach the interns about rounding with physicians in an inpatient setting. In Uganda, pharmacists are not used to going up to a physician and making a recommendation. Katy and I role played a scenario using the “SBAR” technique (THANK YOU carelab and Dr. Ference). We demonstrated how we go about making a recommendation and the important aspects of using SBAR properly. The interns were really happy to learn this.

Unit 1

Among other things, we discussed the many other roles a pharmacist has. For example, besides medication ordering and dispensing we should also be in the lookout for the proper use of drugs in any capacity. Moreover, we spoke a little bit about the various resources available in the United States and how this makes our profession a bit more manageable. The interns were not aware of the free phone applications available so we told them about the ones we know, however, most of them have an annual fee. On the other hand, I really wanted to help them develop a systematic approach to gather and process information. When looking through the charts it was difficult to figure out if medications were actually given to the patient or if they were just ordered. They rely on the nurses, they assume the nurses gave the proper medication at the proper time, but there is no record of that. This scared me a little bit as we know how often mistakes occur in the USA with AUTOMATED systems, let alone assume a human being is taking care of others properly at all times. I hope they do implement a way to backtrack when medications were given and at what time. Also, pharmacists do not write on the medical charts. I was shocked by this as we document every intervention we make. They said that only physicians write on the charts, but we are hoping to slowly improve the way pharmacy is practiced in Uganda. I pointed out that the weight was very difficult to find in the chart, it was actually located in a separate document. So how are we assuring that all doses are calculated correctly? They did not have an answer which was also scary especially since they are working with the pediatric population. I explained to them the importance of having the weight readily available in order to prevent harm to the patient and make sure the drug does its job! They nodded and seem to be open to the idea. I am extremely happy at how enthusiastic the pharmacists are to learn despite the hardships they have to overcome.

Unit 2

Another big topic was how there is only one pharmacist intern dispensing, verifying orders, and rounding with physicians in the pediatric ward that I will estimate has approximately 50 patients. Having to take care of so many patients makes rounding very difficult. Usually the pharmacist intern will mainly focus in the dispensing of medication. We proposed that they encourage the doctor to ask medication related questions. Additionally, sometimes the government may not pay them for multiple months, and so they are then working to gain more knowledge and to help patients and not for a salary.

All in all, it was a very eye opening experience and I enjoyed every second of it. Not only did I get to spend the morning in the pediatric ward which is where my heart lies, but I also had the opportunity to learn from the Ugandan pharmacists. Noah and Derrick were so eager to learn that they are actually meeting us later today for dinner to discuss more about pharmacy practice in the USA.  I think they are amazing and they are doing an incredible job at taking care of people even when the environment is difficult!

-Mayi


Have a great Monday and Sula balungi (Good night)!

A Friday filled with lots to say!

Friday, November 2nd

One of the things that I personally have been enjoying about Uganda is the relaxed atmosphere- especially when it comes to being on time and scheduling. If you know me, you know that at home I almost always stick to a schedule and I am always on time. Since being in Uganda, I haven’t looked at the schedule once; I wake up and ~go with the flow~

Our morning’s plan changed, as originally we were supposed to wake up and head to Mulago hospital for rounds but instead our morning started out at the Makerere University because the Dean of the pharmacy school was eager to meet all of us!

Upon arrival to the University a pharmacy student had stopped us all to talk. The conversation started with him asking, “what have you found to be the biggest differences between the hospitals in Uganda compared to the United States?” Naturally, one of us had answered about electronics; we have computers and automated systems everywhere, whereas in Uganda everything is done on paper and therefore things may seem less organized and often times untraceable if papers become damaged or lost. The student went on to express his fears about Uganda following into our countries footsteps in the future and electronics becoming emotional barriers between the physician and patients. I think many if not all of us were taken back and a bit defensive when he expressed these feelings. I appreciate the value that this student held in maintaining close patient-clinician relationships although I had to politely disagree. I feel with our advanced systems we are able to stay organized enough to know even more so about our patients using electronic medical records than others may realize.

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Here’s a photo of a patient’s file from one of the wards. Cardboard and tape make the outer covering while the papers inside are held together by string. Often times if the hospital has run out of paper they will find whatever they can to write patient notes.

Our conversation spun off into a more lengthy conversation involving a nearby professor about continuing to bring Wilkes students to Uganda but also to begin bringing the students from Uganda to Wilkes University. We all came to a common conclusion that the biggest issue is cost. I could not get this conversation off my mind the entire day. For those of you who don’t know, our University does not fund this rotation. We’ve all found a way to afford this trip by working our tails off in our internships while also thoroughly completing our 40 hrs/week unpaid APPE rotations, or by taking out an extra loan (ya know, because we all don’t have enough of those already right)?

I’ve been so stuck on this conversation because I don’t think everyone sees the value behind what funding could provide in a program such as this one. We have been identifying similarities, but there are also many differences, especially between a first and third world country’s healthcare system. The Dean at Makerere University had mentioned the increased motivation he notices in many students following our visits each year where we educate them about our system, practice or teach clinical skills, and present lectures. The exact phrase he had used was that we “inspire them to be better.” If we have had that impact on such students in the small time we have spent directly with them (and them on us!!!), then who is to say we can’t have an immense influence on each other if they are also given the opportunity to come to the United States to see pharmacy and medical practice first hand.

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Group shot with the Dean of Makerere University (We were all missing Beth today…don’t worry she’s feeling better now)!

Maybe some of you are thinking, “Why does Rubi feel so strongly about this? Is it that important for others to learn about or from our system hands-on?” My answer is YES. We’re not just here to lend a helping-hand and improve our teaching skills. We are here to make a difference in underdeveloped health system and therefore improve global health, even if it is one step at a time. International travel plays a huge role within our economies and travel is often accompanied by the spread of new or recurrent infectious diseases. This affects EVERYBODY, rich, poor, young, old, far, and wide.

As Americans, we have the power to be leaders in promoting worldwide comprehensive identification and preventative techniques for infectious disease. What is the easiest step to take in perfecting a system such as this? Education. This is a huge part of our trip. Another way? Philanthropy. Moving forward, we all plan to keep this discussion going to hopefully implement a plan to help fund the future of this rotation for American and Ugandan pharmacy students.

In the afternoon we stopped by the Mulago pediatric ward to follow-up on some of our patients. For my group, we followed up on our patient with end stage renal disease who previously had uncontrolled hypertension despite being prescribed five anti-hypertensive medications. The good news, his blood pressures seemed controlled today after our group’s recommendation. The concerning news; the patient’s initial empiric antibiotic therapy (for an unknown infection) with Linezolid was stopped when he became afebrile. Soon after, his fevers returned where he was started on Meropenem. This is where as pharmacy students we questioned, why? Often times in Uganda, because the cost of antibiotics such as Linezolid are too expensive, the patient is not kept on this therapy for the recommended course of treatment, but instead until their fever has subsided. If the fever returns, then they resume the antibiotics, often times trying a new one, with the idea in mind that the first antibiotic had failed. This was a teaching moment. By doing this, we are increasing the risk of antibiotic resistance, which is an issue in Uganda. Increased antibiotic resistance=increased chance of “super bugs”=increased spread of disease=increased risk of global spread of disease!

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Brittany, Autumn, and I looking through our patient’s chart trying to find that missing puzzle piece.

Following this we went to visit a community pharmacy! Some similarities I had noticed; The clinical consultations and services the pharmacist may provide patients is not compensated, inventory is strongly based on demand, if a patient needs a drug that is out of stock the pharmacy will order it for them ASAP, and this pharmacy (like some in the US) organized their liquid and topical medications separate from other oral formulations. Some major differences I had noticed; the pharmacy operates on a cash basis only, herbal medications are dispensed and compounded very often, nurses and clinical officers are employees within the pharmacy as well, medications tend to be brand name only and only some brands are reputable, many medications do not require a prescription, and the other employees within the pharmacy have the ability to make substitutions for medications indicated on the prescription without the pharmacist’s authorization.

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Dr. Manning, Katy and Gonsha the pharmacist selfie in the community pharmacy! 

The most heart-warming part the visit was the long detailed story told by the pharmacist Gonsha. This woman went above the “above and beyond” for a patient in order to make sure he received the appropriate and best treatment. This patient would often come into her pharmacy looking for antibiotics but would not share why. She continued to follow-up with this patient trying to learn more about him and his conditions. It was when he came in with an amputated leg that he finally shared with her that he believed the amputation was due to a diabetes complication. She continued to check his blood sugars for months, which never revealed diabetes. One day she noticed the patient had extreme pallor (an indicator of severe anemia) and when she had expressed her concern he finally revealed that he had a wound on his groin that was so deep his bone and blood vessels were visible to the naked eye. He also revealed that he’s unable to seek medical treatment because it was unaffordable, which is why he had been treating himself with antibiotics and gauze for all this time.

Gonsha created flyers and shared his story all over town and created a donation box at her pharmacy. With this money she personally took the patient to receive proper treatment at Kiruddu; everything from a blood transfusion, effective antibiotics, biopsies, and more. The deep wound was actually a tumor and the patient has since went from losing one liter of blood a day to only 10 millilters (for my non-medical readers, THIS IS HUGE).

Had she not this put in this care and dedication this patient stood zero chance of being alive today. I know I have been lucky enough to work with a pharmacist in my job who would give an arm and a leg for a patient and I wish to practice this way myself. It was amazing to see that this is a common trait seen in many if not in most of those in my future profession despite the country they practice in.

Gonsha spoke to a few of us about her time she had spent in the United States learning about pharmacy. We talked to her about major differences between the systems per usual but what stuck out to me was that she was unable to mention what she deemed as a negative aspect to her experience in the US. She mentioned that in the hospital they would assign her to work on a maximum of four patients at a time. At first she felt that we did not know what taking on a lot of patients felt like as an American pharmacist. She then continued to explain that she learned by taking on only a few patients at a time she noticed that in the United States we not only focus on the patient’s acute issues but also strive to improve and correct the patients chronic conditions as well. “You really look at the patient as a whole, and I really appreciated that.”

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Group shot with Gonsha outside her pharmacy! 

Thank you to those who took the time to read and happy Friday!!!!

Sula Bulungi! (Good night)

Rubi