OT Pharmacy, IHC, NRI

Thursday 6-20

Tom and I learned more about the daily activities of the Operation Theatre (OT) pharmacy, which is located on the second floor of the hospital and at the entrance of OT (surgeries) department. OT pharmacy was the smallest of NRI pharmacies. People entering the OT department were required to take off their shoes, and we followed the rule. The staff was composed of three pharmacists that worked barefoot. This pharmacy offered a variety of anesthesia drugs, IV fluids, number of suturing materials and other surgical and disposable items. We noted that the hospital pharmacy was responsible for the provision of surgical materials. The OT pharmacy has two serving windows: one facing outside the OT department, and the other located inside the department were the OT staff/technicians brought orders and received items faster. When pharmacists received an order brought by an OT technician, they gathered the requested products, billed the patient and gave the products requested to the technician. The same process applied when patient brought an order, but in this case, it was a cash transaction instead of credit. As pointed in my previous blog entries, pharmacy here was about dispensing and assuring proper stock levels.

The pharmacy served about 10 OT in that department, and we were told that an average of 40 surgeries were performed daily. The OT pharmacy was opened from 8:30 am to 7:00 pm. In case of emergency, when products were needed from this pharmacy during closing hours, a pharmacist from the Main pharmacy (opened 24 hours/7days) could retrieve those items from the OT pharmacy, and contact the pharmacist in charge if further information were needed.

OT pharmacy staff. From left to right: Mrs. Dirya, Padma and Sujaynya

We spent the afternoon at the main pharmacy reviewing local and general anesthesia drugs. We did not return to the OT pharmacy because the power was down and it would have been very hot up there since that pharmacy had two fans to cool the room and no air conditioning. Consequently, the PIC suggested that we discussed the drugs in the main pharmacy which had two air conditioning units.

Friday, 6-21

Mr. Nayak arranged a visit at a drug manufacturing facility located in Vijayawada, approximately 30 minutes away from the NRI Academy of Science. We wanted to explore further the role of pharmacists in the industry, since it was an important avenue for graduates in India. International Health Care Limited (IHC) was the name of the company. IHC offered a variety of drugs including poultry, veterinary healthcare products. They also specialized in the designing and manufacturing of several pharmaceutical products used in human health. IHC was affiliated with P.V.S. Group.

First, we stopped by in the main office, which was at a separate location to talk with the founder chairman and managing director of the company.

He received us courteously, and at the end of our discussion, he told us we were welcome anytime to visit the facilities. Unfortunately, there was no manufacturing of drugs for human use at that time, and it might take about two weeks to start new batches, the time to distribute the previous ones. Therefore, we visited two manufacturing facilities that produced mainly poultry and veterinary products.

When we arrived at the first location, it was hard to say the staff was expecting us. After few phone calls, they gathered people that would help with the tour.We visited their stock, granulation, compression, and coating rooms as well as their quality control department. The staff literally showed us every room, and gave us a brief description of machines or equipments that they operated. The facility was separated in sections. For instance, it had sections for beta-lactum, non-beta lactum products. They manufactured multiple dosage forms including tablets, capsules, ointments, dry-powders and oral liquids. The sterilization of the water was performed on the last floor of the building.

I learned that pharmacists were employed in the production department as they knew drugs well and they were familiar with the production process and the equipments used. In the quality control department, employees had master in chemistry. There were three checks during the manufacturing process. Imported active ingredients were examined first. Second, during the production, a sample would be also checked. Third, quality control analyses were performed on the final product. During our visit, we also notice many workers that were probably technicians who were packing or attaching labels to products.

Manufacturing facility 1 

Packaging of blisters 

Tom looking at the packaging equipment 

Tom, thumb up with IHC liquid formulation

At the second location, the general manager of operations was a pharmacist and close friend of Mr. Nayak. There, we met the chemist that came up with formulations of more than a thousand of their products. He was particularly humble. They gave us a tour of their new and old facilities, both were running. They had a microbiology department that grew about 58 strains of microorganisms including bacteria, fungi and yeasts. Those strains were not for sale but they were added, as excipients, to their products to increase their effects in the body.

Manufacturing facility 2

Tom in IHC bacteria culture room 

Operation Manager Office. Chairman and general Manager in the portrait, Operation Manager,  Chemist, and Arsen

In the afternoon, we looked up some important points about bacteria at the main pharmacy. Mr. Nayak was particularly busy that afternoon managing the pharmacy.

Saturday 6-22

We went back to the OT pharmacy, yet it was busy, and only one pharmacist was handling all the activities. Consequently, Mr. Nayak decided it was a good time to look at the hospital sterilization center, and see how it functioned.

We went back to the OT pharmacy after visiting the sterilization center. There were then two pharmacists, and the workload had greatly decreased by the time we arrived. Mr. Nayak, showed us the indent process through the online system. In addition, he emphasized on reports run to appreciate stock level and drug movement.

In the afternoon, we went shopping in Vijayawada market since some shops were closed on Sundays, and it was our last weekend in India. Most items were exceptionally affordable in the shops our guide showed us.

Main Pharmacy, IP Pharmacy & Tragic Event

Thursday,  6-13

 Tom and I spent the morning and the afternoon at the NRI main pharmacy. We continued the review of the pharmacology of drugs and applicable diseases using an Indian pharmacy exam preparation book. Mr. Nayak insisted on diseases such as malaria, tuberculosis and several helminth infections. We also brushed antibiotics and their side effects. He promised he would set up a meeting with a malaria specialist in the hospital, so we can obtain more information on that subject. We covered as well drug sources, toxicities, and some antidotes. He briefly mentioned route to administration since it was partially discussed previously.

The pharmacy was busy, and noisy as usual. Mr. Nayak had to handle his regular PIC tasks while going over items on our agenda. At times, it was hard to follow him in this unsettled environment, yet we did our best to stay focus by actively participating in the discussion.

Their return/resale policy was a bit hard for us to swallow at first. Outpatients could return their unused drugs for cash. Most drugs were accepted, provided patients had their receipts. Vaccines and drugs that required to be conserved in the refrigerator were not eligible. Newly discharged patients could return unused IV fluids, injections, and full tablets in their original boxes. The PIC told us most patients served at the hospital were relatively poor, and they could not afford to keep their unused drugs. The returned drugs would be put back to the shelves and resold. The PIC was aware of storage requirements and drug stability, yet the system was set to accommodate the realities of the population served by the hospital. 

Friday 6-14

The PIC took us to the IP pharmacy and gave Tom and I additional explanations on indents.  Drugs were dispensed only to health care professionals The IP pharmacy was small compared to the Main pharmacy, and it had three dispensing windows. The staff was composed of females only. There was no doubt women were predominant at the NRI pharmacy. There was no IV room. The PIC told us there was no need of IV pharmacists or compounding area because industries supplied needed products readily. The IP pharmacy had not air conditioning, and was relying on ceiling fans to cool the area. At our remark about the storage conditions, since it was relatively hot and humid, the PIC told us the management was working on providing a better storage environment (an air conditioning unit was recently added to the main pharmacy). Tom and I were exceedingly curious about the handling and dosing of vancomycin and aminoglycosides, and whether levels were obtained  for possible adjustment since these roles were typically clinical pharmacists’ responsibilities. Nayak did not know if those drug levels were checked or not. Tom and I took our time to explain further importance of the clinical role of pharmacists and the general structure of pharmacy in the US.

NRI IP Pharmacy

Tom showing Mr. Nayak dosage adjustment of Imipenem and Cilastating based on creatinine clearance 

At the Main pharmacy, the PIC stressed again the importance of physician and how as pharmacists, they abstained to question physician decisions. We continued our review of antidotes. Meanwhile, it was interesting to note that when pharmacists were unable read or recognize drugs on a prescription, after concerting with the PIC, the prescription was sent back to the physician who wrote it for clarifications. They would not dispense a drug based on their guessing abilities.

In the afternoon, we continued reviewing. The topics were drug- drug interactions, drug-food interactions, and drug- induced diseases. We mentioned also the difference between drug abuse, addiction, dependence and misuse.

Saturday 6-15

Our routine was disrupted by a sad event that happened at the NRI Academy of Science. It appeared that a student committed suicide on Friday evening, and relatives were not informed on time as they learned the sad news from another student. Consequently, as we heard, a protest started at the entrance of the hospital since the body was kept for investigation at the Casualties department. The PIC told us employees had to enter the facility using the side entrance because the main entrance was blocked. He joined us later, and said he wanted us to stay in our rooms as people were shouting outside.

Later on, the PIC went to confirm our meeting with a physician to discuss about malaria treatment in their facilities.

We met the physician at the outpatient general medicine department. He was very helpful. He stated that physicians mostly relied on clinical signs and symptoms to empirically treat malaria since the lab tests or test kits used were not sensitive. He added that intermittent fevers, chills, headaches along with splenomagaly and anemia were common in their malaria cases. He mentioned drugs used for treatments, and confirmed that chloroquine was not prescribed anymore because of resistance. In addition, they refrained using quinine because of it caused pronounced side effects and required close patient monitoring. Combination therapy was used. Pramiquine was prescribed for 14 days for relapse prevention.  He affirmed that he had not seen any severe side effects caused by the drug therapy.

We also talked about handling poisonous cases. For specific circumstances, a literature review would be conducted or their National Poison Center would be contacted.

In addition, we covered the different type of tuberculosis and their treatments. Tom and I used this opportunity to ask him if level of vancomycin were checked. He was not sure, since  he worked in the outpatient department. However, he stated that renal impaired patients were dose according to guidelines. Then, we inquired his view on the role of pharmacist.  He said pharmacist could have a larger role in this hospital. He was aware of clinical importance of pharmacists. He mentioned that when he was in United Kingdom, pharmacists were the ones who helped with proper drug dosage, side effects, drug interactions and literature reviews.

In the afternoon, we returned to the Main pharmacy where the PIC showed us prescriptions from different departments. We talked about required information that needed to be on those prescriptions.

There was no more protest. We were told it was resolved, and 10 lacs would be disbursed to the family of the student.

Hindu Temple, Shopping in Vijayawada, CHIPS, and NRI

Sunday June 9th

Today Dasaradh and a driver took us to explore the city of Vijayawada.

Our first stop was a local Hindu Temple.  The driver took us to a gate where we paid the 30 rupee entrance fee and then drove us up to the top of a small mountain overlooking the river.  Two views stood out in my mind.  The first was the view of the river.  It was absolutely gorgeous.  I wish I had thought of taking a picture, but I was quickly distracted by the second view.  The parking lot was sheer chaos.  If you think driving in india is bad, you should see parking in india.  Cars, buses, bicycles, mopeds, and motorcycles were all pointed in various directions jockeying for the best parking spot or exit position.  Pedestrians also littered the area which made the parking experience much more difficult.

The driver dumped us off as close to the entrance as possible.  I was grateful for this because the ground was incredibly hot in the mid morning sun, and we had to remove our shoes in accordance with Hindu tradition.  Dasaradh guided Arsen and I through the market area.  This consisted of a few small shops hugging the cliff that was part of the mountain.  The shopkeepers sold everything from food to trinkets that could be offered up to the priest for some sort of sacrifice or donation.

This visit was probably the most isolated I've felt in the country.  The shopkeepers kept trying to pull Arsen and I aside, noticing that we were different from the rest of the crowd.  Furthermore, (after paying an additional 100 rupees each), I was heckled by the priests who greeted worshipers who looked at me and playfully demanded "US dollar, US dollar!"  All of the locals got a kick out of it and many smiled or laughed at me.  This particular temple was absolutely packed.  People stood closer than shoulder to shoulder and had to wiggle their way through the line.  This is a cultural thing that Arsen and I have noted several times during our trip.  Everybody rushed to the boarding line as soon as boarding was announced on each of our flights.  Everybody picking up drugs at the pharmacy crowds the windows, and now everybody is extremely urgent to get into the temple.  After finally getting to the front of the line, worshipers touched the floor at the entrance, walked into a small room, deposited 10 more rupees as they said an extremely quick prayer, and exited quickly.

I reflected that I could never worship in such a way.  Everything felt so rushed.  I could barely collect my own thoughts let alone try to speak to God.  Anyways, I did my best to pray a non-denominational prayer for peace around the world and exited as those before me had.

After leaving the temple, we stopped downtown to get a Mango smoothie and do a bit of shopping.  As we tried to return to the car, Arsen was approached by 2 women with children trying to beg him for money.  They wouldn't even let him close the car door!  The driver wound up getting out of the car and confronting the women until they left.

We made a bee-line back to NRI where we had a late lunch.  Later in the evening, we went to Lotus.  Lotus is a local restaurant with exceptional food at very low prices.  Arsen, Dasaradh, our driver, and myself all ate for under $20 US.

Monday June 10th:

Today Arsen and I returned to CHIPS to finish some of our analytical work in the morning.  We completed HPLC and also worked with the UV Spectrophotometer for a bit.

During the afternoon, we were reassigned to the pharmacology department.  In this department they do animal experiments to determine the efficacy of drugs.  I didn't take any pictures because I was somewhat uncomfortable during the encounter.  Let's face it.  CHIPS isn't on the cutting edge of drug development.  The effects of diuretics, antidepressants, sedatives, and other drugs they were using are well known.  I didn't see any merit in subjecting a poor animal to needle sticks to see how Lasix administration made them pee more.

This may have been our last visit to CHIPS.  Sometimes with the language barrier it is hard to tell what our preceptor has planned for us.

Tuesday June 11th:

This morning we met with Dr. Raju Mantena.  Dr. Mantena is the secretary for NRI and spent 30 years practicing medicine in St. Louis, MO.  He looked over our itinerary and suggested some modifications. He also did a much better job of explaining the differences in pharmacy between the US and India to our preceptor without the language barrier that Arsen and I often face.  We are hoping that some more clinical opportunities come out of our short meeting.

After departing Dr. Mantena's office, we headed back to the Main Pharmacy at the ground level.  I swear you need ADHD to function in this setting.  There are 6 dot-matrix printers that make a sound so old it's almost foreign to me, 6 pharmacists acting as tellers (making the bills, checking the work of those who retrieve medications from the shelves, etc), another 4 or 5 pharmacists retrieving medications, and a phone that rings incessantly.  It is nearly impossible to focus on what Mr. Nayak is saying.  But we soldiered on, and eventually were given the opportunity to complete the task of creating bills for transactions.  The drug stock is far too extensive for Arsen and I to have mastered yet (all the different brand names, etc) so we were not asked to retrieve medications to prepare orders.

Before lunch, Mr. Nayak took Arsen and I to a small room on the ground floor where bulk IV fluids are kept.  I noted some of the IV fluids are supposed to be stored below 30 Celsius (which the room wasn't).  This is kind of a trend here with the warm weather, so I often wonder about drug stability in this hospital.

In the afternoon Arsen and I continued to shadow pharmacy staff and were showed how to generate a few more reports through the software system.  The pharmacists decided to start teaching us Telegu (the native language in Andhra Pradesh) so our first word is Bonara (sp) which means "How are you?"  When we got back to our room, Dasaradh decided to jump in and help and assigned us "Bonchesear" (sp) which means "Lunch".

Wednesday June 12th

Today was rather uneventful.  We spent more time at the NRI Main Pharmacy which is open 24/7 and serves both inpatient and outpatient visitors.

Mr. Nayak showed us a prep book used by Indian pharmacists in advance of their license exam.  We went through a few sections and refreshed ourselves on the latin abbreviations used in pharmacy.  We also did a brief and unfocused pharmacology review.  Mr. Nayak was impressed with our level of pharmacology knowledge.  Between Arsen and myself, we may have only missed one mechanism of action in the list of drugs we spoke about.

At night, Dasaradh took us to the roof of the NRI hospital building.  I wish my iphone picked up the lighting better, because the view was spectacular.  Under the veil of dark, the poverty of the country disappears and you can see how truly beautiful this part of India is and the potential it has if it can emerge from the 3rd world.

I'm having some trouble today synching my photos from my phone to my macbook.  Once I get that sorted out, I will edit this post to include some.  

Pharmaceutics & Pharmaceutical analysis!

Thursday, 6/6

Our preceptor previously arranged a visit of the Chebrolu Hanumaiah Institute of Pharmaceutical Sciences (CHIPS), which is affiliated with the NRI Academy of Science General Hospital. He wanted us to appreciate the pharmacy curriculum offered in India. The CHIPS is located at 45 minutes drive from the hospital. Tom and I were excited to visit a pharmacy school in India.

 Our ride to the college left us somehow sick to the stomach. I felt like I was in a racing car game or roller coaster ride even though we were not going that fast. I had to brace myself for most part of the trip. In addition, one had to hear the honk almost continuously. The norm was to honk to warn other road users. One could read at the back of most trucks “ Horn, Please” or “ Blow Horn”. Moreover, there was a major highway in construction, which was adding more congestion to the regular traffic at some intersections.

The CHIPS was a prominent red/pink building in the area. At our arrival, we were introduced to the Principal of the institution. He was remarkably courteous. It was then decided that Tom and I would learn and make tablets after the tour of the school. The principal designated a staff for that purpose. Because students were either preparing or taking their exams, we could not spend time with them. We visited their pharmaceutical labs, instruments’ labs, museum, library, computer lab, classrooms, botanical garden and animals used for research. The facility had a significant number of laboratories, which was impressive. Students are required to attend classes in the morning (Monday-Saturday) for lectures and labs were mandatory in the afternoon for practice on subjects discussed in the morning. The emphasis of the pharmacy education was on chemistry and pharmaceuticals since the aim was mainly to prepare students for the industry, which was a prominent market for new graduates compared to community or hospital pharmacy.

Chebrolu Hanumaiah Institute of Pharmaceutical Sciences, view from the botanical garden 

CHIPS

Indian God of Medicine, in the middle of CHIPS museum 

Degrees offered by CHIPS included a Bachelor in Pharmacy (B. Pharm), a Master or post-graduate (PG) in Pharmaceutics or in Pharmaceutical Analysis, and recently a Pharm D. Since therapeutics were only offered to Pharm D students, the majority of pharmacists would lack associated skills. Hence, pharmacy was more about dispensing and inventorying and had less clinical emphasis. Another interesting fact: the Pharm D program was launched to fulfill the ambition of students that wanted to practice pharmacy outside of India, hence in developed countries! A pharmacy practice lab was under construction on the fourth floor, which is dedicated entirely to Pharm D program. The lab under construction depicted a typical retail pharmacy setting with a dispensing area, a counseling area and a seminar area.

 CHIPs is research oriented. An average of 152 research papers are published yearly. I included some numbers to give an idea on the cost of obtaining a degree in pharmacy at this institution. For example, the B Pharm degree would cost about 120,000 rupees (30,000 rupees / year *4 years). The master would require 100,000 rupees per year for two years, and the Pharm D would necessitate 95,000 rupees per year for six years (570,000 rupees total).  The staff mentioned that the cost of their institution was reasonably affordable. At the current currency exchange rates, it would cost about $10,000 to obtain a Pharm D at CHIPS!

We enjoyed our lunch in their guess room in company of three faculty members and our preceptor. Then, Tom and I received a brief, yet useful description of the methods and steps used for compounding tablets. Next, we put the information into practice to make parecetamol (acetaminophen) tablets in the lab.  We used the wet granulation method. I would be happy to provide the full description of the process we used if anyone is interested.

Weighting paracetamol

Group picture. Instructors: far right/left

Friday 6/7

We went back to CHIPS to test the tablets we made the previous day to check if they had the properties required by the Indian Pharmacopeia (IP). According to the IP, five tests were mandatory: weight variation, friability, disintegration, dissolution, and uniformity content. Added to these five evaluations, there was a non-required test to measure the hardness of the tablet, which was relatively associated with the friability of the product. We performed, under the staff supervision, the weight variation and friability tests for both tablets we made previously and tablets that were commercialized. Then, we conducted the disintegration test for the commercialized tablets, and saw the dissolution test process.

Tom, weight variation test

Tom, friability test

Performing hardness test on paracetamol tablet

After the dissolution test, we stepped into the instrumental analysis lab. This lab was well equipped and maintained just as previous lab we visited. The only difference was the running air conditioning, and the presence of reserve batteries to assure uninterrupted experiences in case of power failure (power goes off several times a day; so far, I cannot recall a day without power failure, yet it does not last long). There, the staff clarified the basics of pharmaceutical analysis. The instructor did a great job reviewing with us the qualitative and quantitative analysis. The instrumental analysis was greatly detailed. We also talked about spectroscopy, chromatography (especially high performance liquid chromatography- HPLC) and magnetic resonance

Then, it was time for practice.

First, we made each a pellet of a non-steroidal anti-inflammatory drug called numesulide (not approved in the US), and performed a FT IR (Fourier Transform InfraRed). This analysis can be used to determine the quality/ purity of a sample based on it absorption and transmission of an infrared radiation.

making of the pellet for the FTIR

Tom, applying pressure on the mixture of drug and KBr to form a pellet

My pellet! 

Tom, placing pellet into a holder for FTIR

Second, we started working on the HPLC, but we could not finish because it was time for us to leave. We will go back on Monday and maybe Tuesday to complete the HPLC and expand our knowledge in the pharmaceutical analysis.

Saturday 6/8

We spent our day in the main pharmacy. We worked with our second preceptor because the PIC was on leave of absence that day. We learned about their report system. He showed us where to find the report section on the main pharmacy interface. He demonstrated how to create, or retrieve indents, as well as how to run several reports. Meanwhile, we discussed about cash, corporate, and credit billings. We observed the routine transactions at the dispensing counters, and we tried to familiarize ourselves with drugs in their inventory.

Sunday through Wednesday (June 2- June 5)

Sunday June 2nd:
Sunday the hospital is mostly closed except for the ER and the main floor pharmacy.  Arsen and I spent most of the day trying in vain to catch up with jet lag.  We were still trying to sleep on EST, but were fed on India time.  We wound up napping through the day and eating what I now refer to as our "3 round (the shape I will be in when I return to the states) meals" in between.

We tried to avoid the heat as much as we could, but ventured out in the evening before dinner to walk the grounds and get some pictures.  I continue to be struck by the poverty and the developing nature of this country.  The roads are poorly maintained, all parking is on gravel or dirt, and there is open water of some sort (it sure smells like sewage to me) flowing along the grounds to the municipal system.

Most of the pictures we took Arsen has already posted (front of the hospital and college, main floor pharmacy, etc), but I'll add a few more:

Arsen in front of the main pharmacy

As we returned to our room, we were met in the stairwell by a young man (probably about our age) who had an uncle in the hospital for stent placement.  He kept apologizing saying his English wasn't good, so I tried to explain to him that it's much better than my Telugu!  I have always been surprised by the presence of people here not directly receiving care.  The culture appears to be extremely family centered.  Children, parents, and extended families all come to the hospital to support the sick.

We were met by our excellent wait staff Dasaradh at the foyer leading into the guest wing.  I didn't think about taking pictures of our living quarters at the time, so I will do it later in the week.

Arsen with Dasaradh in the foyer.  Our wing is the doorway seen in the left window.

Myself in front of the Guest Wing

Monday June 3rd:
Today we spent time in the central pharmacy reviewing how drugs are ordered and inventory is managed.  It was interesting to see the level of communication that occurred between each of the 3 satellite pharmacies (Inpatient, Operation Theatre, and Main Pharmacy) with the central or "Main stores" pharmacy that supported them.  No dispensing occurs from Main Stores.  It is more of a drug storage room with a high focus on cost reduction (vendor selection) and inventory management via perpetual electronic monitoring of all four pharmacy locations.

When a drug is short at the satellite pharmacy, it must communicate this shortage with the central or Main Stores pharmacy.  The central pharmacy then can either resupply the pharmacy from stock on hand, order the medication or device through various vendors, or direct the transfer of the goods between the satellites themselves.

We got to witness a vendor dropping off medications and helped the pharmacy staff to check them in (lot #, expiration date, package size, drug name and strength, etc).  None of this is done by barcode, leaving a potential for error.  As noted in other posts several times, this country is still developing and the hospital can probably not yet afford this technology.  The pharmacy staff must take diligent care to check orders and requisitions by hand and then input them into the system.  It was valuable to see inventory handled without the barcoding.  It gave me a new found appreciation for the technologies I have enjoyed in my brief retail experience and also in IPPE hospital settings.

We also spent some time in the Medical Records department.  This is the department is responsible for keeping and maintaining the documents for patient visits.  None of this data (aside from the visit number) is recorded electronically in the patient's chart yet, so Medical Records plays a vital role in hospital function.  The director is intimately aware of the goings on at the hospital, and could recite statistics about average daily admissions for most of the wards and superspecialties for both inpatient and outpatient visits.  Roughly 6,000 patients visit the hospital outpatient departments daily.  The number for inpatient visits are much lower (around 300 or so).

At Medical Records we learned about AAROGYASRI.  This is the equivalent of Medicaid in the Andhra Pradesh region.  Patients below the poverty line receive care for free.  It is payed for by the Andhra Pradesh regional government (capital in Hyderabad) and has become a model for other provincial governments in India.  It has also attracted citizens from other regions to come for care at Andhra Pradesh hospitals.

After being dismissed to our quarters for lunch and rest, we spent some time at A.R.T. or Antiretroviral Therapy.  This department is the HIV department of the hospital.  Most HIV cases are HIV-1 in the region.  Patients are given their medications for free to increase compliance as much as possible.  This is done through a partnership with an AIDS program sponsored by the national government in New Delhi.  All AIDS patient data is sent to this foundation in New Delhi.  The A.R.T. department has its own pharmacist working there.  The primary roles of the pharmacist are to conduct pill counts of old medication bottles to assess adherence, and to dispense the new bottles as ordered by the physician.  We will be spending more time at A.R.T. either tomorrow or Wednesday.

Tuesday June 4th:

We started our day back in the Main Stores pharmacy at ground level.  As on our tour and for a few minutes yesterday, we were encouraged by Mr. Nayak to familiarize ourselves with some of the drug stock.  We went through most oral preparations on our tour and yesterday.  Today we focused on eye and ear products, topicals, etc as well as drugs that have to be stored in controlled climates.  Many of the generic drugs are familiar, but their brand names are not.

Here are some examples:

Piperacillin/Tazobactam- Zosyn in the US, Tazomac in India

Pantoprazole- Protonix in the US, Pantop in India

Mometasone- Nasonex in the US, Metaspray in India

I could probably spend a full week going through the Main Pharmacy Stores just observing the differences in branding between the US and India.  Augmentin, Carafate, Lovenox, Diprivan, Tri-Pak, and countless other medications are branded differently in India.  What's worse is some Medications have multiple brand names.  This occurs because drug manufacturers are allowed to brand generic drugs for their own for sale in India.  Doctors write in brand name only, which is a potential for further confusion.

Azithromycin- Azimen 250 and Azibact 250 in India
Z-Pak in US

After spending some time with the drug stock, we discussed the role of the P&T committee or Pharmacy and Therapeutics Committee.  The role of P&T is much the same as it is in the US.  Formulary management and inventory control are the central responsibilities. Mr. Nayak was kind enough to give us a copy of the P&T's ultimate output:

NRI Hospital Formulary

In the afternoon we spent time in the Main Pharmacy discussing some miscellaneous things.  The big thing I continue to take away from this trip is the different roles of pharmacists between the US and India.  There is no monitoring of drug interactions by pharmacists.  Patients are barely counseled in speech or writing.   Pharmacy is strictly dispensing here at NRI.  Labels aren't even printed.  We have discussed this as a product of under regulation of the profession.

Wednesday, June 5th.  

Today was easily the most fun day I've had since arriving at NRI.  We spent very little time in the hospital this morning, and instead spent it at the college down the street.  The rain this morning provided a welcome relief from the heat, so we decided to take advantage of the bearable weather and walk.

We spent time in 4 of the college's departments.  There were cadavers at the anatomy lab which a few students were examining in preparation of their upcoming exams.  We also spent time in the physiology department (they separate the two in their curriculum unlike our IBHS curriculum at Shenandoah), biochemistry, and pharmacology.

The faculty members seemed pleased to have visitors since so few students were present in the building.  We interacted with around 10 faculty members.

The fun of the day occurred in the pharmacology department.  The lab technicians were eager to show us just about every experiment in their curriculum.  We watched as they conducted qualitative experiments to show the presence of alkaloid drugs (Belladonna, Vinca-alkaloids, Ergot-alkaloids, some opioids, etc) and glycopeptides like digoxin.  These tests would allow a practitioner to rule out (or in) suspected overdoses.

The test tube to the far left in the first row shows the Molisch Test for the presence of glycopeptides.  The white, green, and brown preciptates are Mayer's, Hager's, and Wagner's tests respectively.  They test for the presence of alkaloid drugs.

The Pharmacology Department also had an extensive museum with posters of mechanisms of action and various other aspects of pharmaceutics, pharmacokinetics, and pharmacology:

Example of a poster in the pharmacology museum. HIV Drugs

In the next room, the lab technicians showed us various ways that medical students test the efficacy of drugs.  Animal model experiments were present for everything from depression and memory drugs to diuretics, pain medications, and muscle dexterity:

Plus Maze for antidepressant drugs.  Animals exposed to effective antidepressants should spend more time exposed to light instead of in the dark places.

This test is for diuretic drugs.  Animals are placed in the top and given food and water.  Urine output is measured at the bottom before and after diuretic administration.

The staff at the pharmacology department was great.  They worked well as a team showing us their experiments both in vitro and in vivo.

Arsen, NRI Pharmacology lab technicians, myself, and Mr. Nayak (our preceptor)

The grounds at the NRI Academy of Science Medical College are fantastic.  As with the hospital, most everything is open to the air.  This facility is roughly 5 floors arranged in a box, with a nice garden in the middle.  The student and faculty wings flank the box, which is used only for academics.

Garden at NRI Medical College

I'll let Arsen fill any holes I left.  I know he has a ton more pictures.  We decided to fall into a routine of me updating on the first half of the week in one big batch and him following later in the week with the second half.

Tomorrow (Thursday) we travel roughly 50km to the Chebrolu Hanumaiah Institute of Pharmaceutical Sciences.  This college is one of the few in India to offer a PharmD program and the first in Andhra Pradesh.  Maybe I'll be able to grab a video clip of the driving on the way over.  Trust me.  It's exactly like what you see if you google "driving in India."

Saturday, June 1st: NRI Academy of Science

Tom and I enjoyed our first breakfast ever at the NRI Academy General Hospital at 8 am sharp. I was still sleepy then since I woke up around 2 am that morning and went back to bed around 6. We devoured a delicious meal, high in carbohydrate composed of tea with milk, deep fried pastries, Indian flat bread, and samba soup.

Breakfast

Tom, 1st Indian breakfast experience!

At 9 AM, the medical administrator came to our room, and escorted us to the Superintendent of the hospital. The Superintendent affirmed that we were welcomed in their facilities. He told us not to hesitate to contact him if needed. The medical administrator showed us his office as well. Then, we went down to the lobby where the main pharmacy is located to meet the pharmacist in charge, who is also our preceptor. Next, they drove us to the medical college where we meet the Treasurer of the Medical College. He told us that he was from Chicago, and gave us a quick run down of their activities and requested that a cellular phone be provided to us in case we need assistance.

NRI  Medical College

They drove us back to the general hospital where the PIC gave us the tour of the entire hospital, including a thorough visit of the four pharmacy entities that operate in the hospital.

The Main (outpatient) pharmacy is located on the ground floor, right at the entrance of the hospital, and is opened 24 hours a day, 7 days a week! 

Main Pharmacy, NRI General Hospital

The Central pharmacy is situated on the first floor, yet at the back of the hospital. The Central pharmacy replenishes inventories of other pharmacies and wards at their requests, and is responsible ordering and receiving shipments. The inpatient (IP) pharmacy and the operation theatre (OT) pharmacy are both located on the second floor. The IP pharmacy serves hospitalized patients while OT pharmacy supplies only surgery related equipments and drugs to the OT department of the hospital.

The PIC discussed each pharmacy work schedule, staffing, storage requirements and licensure. He personally accompanied us to several departments in the hospital to learn about their functions and their links to pharmacy. Tom and I had to opportunity to ask questions and talk to many physicians or nurses in charge.

We visited all the 5 levels of the hospital. A lot of walking and climbing of stairs were involved as the elevators were reserved for physicians and critically ill patients.

We will be working Monday to Saturday, and off Sundays.

Tom and I were ecstatic to realize that the Internet was installed in our room by the time we returned.

Our typical lunch /dinner  (flat bread, curry, soup + rice and Indian yogurt)

Travel Summary: Dulles, VA to Vijayawada, India (May 29th to 31st)

May 29^th.

The journey was about to start!  I arrived at Washington Dulles International Airport about two hours before the 10 hours flight to Istanbul. I checked my luggage, received my boarding passes and went through the TSA control. Everything went  swimmingly. Then, I met Tom in the restaurant facing our boarding stand. Our seats in the airplane were far apart. The flight was not as exhausting as I was expecting it to be, aside the crying of a baby during almost the entire flight.

May 30^th

The view of Istanbul, Turkey from the airplane was mesmerizing. In contrast, their airport or precisely the waiting area did not impress me, and was well congested. We even saw a group of people openly drinking alcohol near the boarding area. The airport had an old fashioned appearance.

The flight from Istanbul to New Delhi went well apart of a child crying incessantly, again. The served meal was tasty. I met an old gentleman in the plane. He was fluent in French yet he could not understand any English. I ended up being his “interpreter” during the flight. I helped him order his meal as well. He was grateful, and it was a pleasure to me conversing with him in French.

May 31^st 

We landed at the Indira Gandhi International Airport around 4 AM, and the temperature outside was well over 30 º C. However, we did not feel it because we stayed inside the whole time. Their airport was clean, gigantic, and modern. We found our baggage ok.

Tom and I exchanged our US dollars to Indian Rupees. Then, we walked to the other side of the airport to access the local airplane transfer zone. It was interesting to come across a pharmacy chain in the airport, which led me to talk to the pharmacist. He told me they offer general medications, and patients do not need prescriptions to buy their products. It was a bit intriguing to find that a medical clinic incorporated in the airport facilities.

There was a striking military presence at the airport. Travelers were checked many times. I felt much secured. Then, we encountered a self-motivated “entrepreneur”. We were in line at the entrance of the domestic transfer area of the airport when this young airport employee approached us and asked us where we were going . He asked for our boarding tickets and passports and cut the line to go talk to the officer checking passenger’s papers. I was a bit uncomfortable. He rushed us through other checkpoints even though we told him we had enough time before our next flight. We finally stopped at the food court, since we had plenty of time before our next flight to Hyderabad. He made 500 Ruppies (a bit less than $10) that morning.

We went back to the shopping area for Tom to purchase a charger for his Samsung Tablet before we headed back to the food court. I had a McSpicy Paneer meal, which I was told was very popular in India. I did not regret it. It is definitely a sandwich of choice if aspiring for something different than the chicken or the beef at McDonald’s.  As the time permitted, we visited several stores in the airport until we were tired and decided to proceed to our terminal. There, we found relaxing seats, which is often rare in most airports. We lied down comfortably for about an hour trying to recover before our next flight to Hyderabad. 

      Tom enjoying the relaxing seat (New Delhi, India)

My seat in the airplane was a bit too rigid to provide needed coziness compared to the previous flights. I was not able to close my eyes even though the jet lag was kicking in seriously. On the bright side, I had a window seat for a great view of the town from the air, friendly passengers to talk to, and no crying children around.

We were pretty tired by the time we reached Hyderabad. The transfer time (230 minutes) felt like an eternity to me. The sequel of lack of sleep was getting unbearable. I was so tired I found myself going into deep sleep repeatedly while seating on a rigid chair.

I slept most of the 50 min flight to Vijayawada. A heat wave filled with humidity welcomed us . The transfer bus had no AC, yet the ride was short. Vijayawada has a very small airport and old looking compared to Hyderabad. Anyway, I was happy to be on the ground, and that we recuperated our luggage without any trouble. I was even more delighted to see our welcoming staff.

Tom provided a vivid description of our ride from the airport to the NIR Academy. 

It is fascinating to realize that activities were going smoothly in this apparent chaotic picture that we witnessed riding through the towns.

Tom and I will be staying at the NRI Academy of Sciences General Hospital.

NIR Academy of Sciences General Hospital, front right side

NIR Academy of Sciences General Hospital, front left side 

 

Tom, front right side of the General Hospital

Arsen, front right side of the General Hospital