First Days on the Job

Thursday (6/27) was our first day at the clinic, sort of. The clinic primarily a maternal and childhood clinic. This clinic offers many services including: vaccinations, HIV testing/counseling, OB-GYN, pediatrics, family medicine, dental care and sonograms. The clinic promotes the 5 Star program and IMCI (Integrated Management of Childhood Illness). 

The 5 Star program is for pregnant mothers and infants up to 60 months (5 years old). Each stage of the program awards up to 5 stars to the mother or child. For instance, the mother first enters the program while she is pregnant. She can earn her 5 stars for getting all necessary vaccines, HIV testing/counseling, doing lab work, visiting the doctor six times, and bringing the newborn within 7 days of birth. After birth, the stars are now awarded to the baby during the different stages. The stages are 0-6 months, 7-12 months, 13-23 months, and 2-5 years old. Within each stage the baby is awarded stars for doctors visits, vaccinations, growth and weight progression, breast-feeding, and other age-specific factors. The program is structured in a way that ensures the mother and child are receiving adequate healthcare management from pregnancy to early childhood.  Health literacy remains an area of improvement in the DR.  One of this program’s goal is empowerment of women by progressing health literacy in all mothers.

The 5 Star program

IMCI is a program that was designed by the WHO and UNICEF in 1995 to provide a comprehensive algorithm for the diagnosis and treatment of 5 of most common diseases that cause illness and death in children under 5 years old. These diseases include: pneumonia, diarrhea, malaria, measles and malnutrition. The IMCI aims to improve childhood illness by integrating aspects of nutrition education, vaccinations, and other influential factors including maternal health. The ultimate goal of the program is to reduce mortality, frequency and severity of the illness, by integrating treatment and prevention strategies, to ultimately contribute to the improved health and development of children.

Okay, now that we all understand a little more about the clinic, I can now tell you a little more about what Derek and I have been doing! We live in a 3-bedroom, 2 bathroom house on the grounds of the clinic. The clinic and the guesthouse are surrounded by a 5-foot fence and have a guard on duty 24/7 (that one is for you, Mom!). The house has running water, electricity, WIRELESS internet (thank you to the volunteers who were here a few weeks before us) and ceiling fans. You many have noticed I did not mention air conditioning, but surprisingly the fans keep it fairly cool inside.

Home Sweet Home! The top right picture shows how close our house is to the clinic! We have a full kitchen, cozy living room and quaint dining room! Bottom right is Derek's room complete with a futon and a bright yellow mosquito net! Mosquito net = must have in DR!

We have a roommate! Her name is Liz, she is a recent graduate from Macaulay Honors College at the City College of New York and is participating in a program called the Jeannette K. Watson Fellowship. She arrived June 8^th and is staying for 10 weeks! She is fluent in Spanish and Derek and I are VERY appreciative of it! She has been a great help orienting us to both the clinic and the city of Monte Plata in general. Liz, Abdias (the medical student from Haiti), Derek and I spend a lot of time together, four best friends!

Derek, Liz and I have housekeeper who cooks for us. Her name is Aude and she is a fantastic chef! She has made us a variety of foods and always makes fresh squeezed juices for us! So far, our favorite is her homemade limeade! We are very grateful for her generosity.

Aude prepared two wonderful lunches for us! Top left was chicken with peppers and onions, vegetable salad, brown rice and beans, and a ceviche peppers and onions. Our next lunch was pork chops with peppers and onions, rice, beens,   and fried cauliflower...this was AMAZING! Fruit is abundant here! We always have bananas, mangos, passion fruit, papaya, apples and plantains!

So now for the clinic! As I mentioned before, Thursday was our first day at the clinic, sort of. Derek, Liz and I were up and ready to head over to the clinic at 8am. We were met by Abdias shortly before we left and he informed us that we were to wait at the house for Teresa, the Project Hope coordinator from Santo Domingo. My impression was that she was going to be there shortly, but in reality she came at about lunchtime. So needless to day, our first day at the clinic was not so much in the clinic. When Teresa arrived, she had an American doctor with her. He was interested in volunteering at the Project Hope clinics in the DR.  Teresa gave all of us an introduction to Project Hope and the clinic.

After lunch, Liz and Abdias gave us the official tour of the clinic. It is small, but always bustling with people! After our tour, we met with Dr. Mansueto, a pediatrician.  She began going over the IMCI algorithm with us in great detail. Luckily we had Liz and Abdias to help translate. The algorithm consists of defining the illness, duration, signs and symptoms, classification, treatment, medication, and a follow-up visit. We all ‘roll played’ being the doctor/interviewer and mother/father of the child.  It was surprisingly easy to do. This algorithm was actually designed to be used by anyone, not just a health professional. For instance, a mother can maneuver through it at home to determine the next step in helping her baby, whether it be bring him/her in to see the doctor or to give some acetaminophen to help reduce a fever.

Derek, Liz and I practicing using the IMCI program, Derek was the baby's father. Dr. Mansueto kindly instructed us!

The next day (6/28), we were shown where the clinic stores all of their medications and medical supplies; they call it “the pantry”. It is a large room detached from the clinic filled with medication and boxes of random healthcare products such as tooth paste, mouth wash, facial cleanser, and much more. Each week, a few of the non-medicinal products are selected to go into their “grab bags” which are sold at the pharmacy for a discounted price.

The majority of the medications in the pantry are antibiotics and written in Spanish. But there is a small section of donated medications that are all written in English. Our task for the day was to translate the basic directions and side effects for each of these medications. We made a chart which included the brand and generic names, direction in English and Spanish, common side effects, and any miscellaneous information that we thought was necessary to someone to know about the medication.  We also took it upon ourselves to create a visual aid for ear and eye drop administration similar to other visuals aids that are hung on the walls of the clinic.  Liz was kind enough to help us translate the directions into Spanish.

Creating the English/Spanish medication translation document and some of the medications inside the pantry.

That evening, Liz, Derek and I explored the town. The clinic is about a quarter of a mile outside the main streets of town. The main part of town is filled with people! People were everywhere, walking down the street, shopping, socializing, playing in the park; it was a very happening place on a Friday evening! The main mode of transportation is via motorcycle. They do not wear helmets and they fit as many people as they can on one, including children and infants. It is a bit nerve-racking to see little babies being held on speedy, rickety motorcycle. We saw clothing shops, grocery stores, banks, bancas (equivalent to a lottery shop and are on every street corner), barbershops, ice cream shops, pizzerias, City Hall, churches, murals and lots of stray dogs.

As we explored further and further outside the main streets of the city, you could see the progression of declining wealth. The houses nearest the city proper were concrete, two stories, gated and often had driveways. As we ventured further out, the houses were made out of wood and sheet metal and much smaller. Also many of these homes were off dirt roads that were in bad condition. But the people there seemed happy. They were very friendly, greeted us with a smile and an “hola”, one little girl even said “hi” to us!

Liz, Derek and I adventuring into town!  

On Saturday (6/29), we went for another walk around town, this time exploring the other side. We saw several baseball fields, shops, schools and bancas. We were in search of a real bank, but they appeared to be closed on Saturday, though no hours were posted. While walking, we passed a group of four boys, ages 9-13, and asked them if they like to play baseball and basketball. They told us that they like to play both sports and do karate at the local gymnasium. They were very excited to talk with us…Liz translated, of course! Our walk was cut short as a looming storm that chased us back to the house. It rains here almost every day, but luckily not for too long, showers last anywhere from 10-45 minutes. It is constantly humid and about 85 degrees. My hair really thrives in humidity! (That is a joke for anyone who doesn’t know I have curly, and now really frizzy, hair!)

Exploring more of the city! Pictured are the boys we met outside of the gymnasium. The bottom left is a map of the provinces of the DR painted on the side of a local high school. Bottom right is me standing outside of a local farmacia!

This coming week we will meet with Dana Fitzsimmons, a pharmacist and medical outcomes specialist for Pfizer. Dana spent 4 months between the two Project Hope clinics in 2008. We are excited to meet him! We will let you know what next week has in store for us in our next blog. Until then, adios!

Bienvenidos a Republicana Dominicana!

6/26 Wednesday

Las Americas International Airport in Santo Domingo

After a relatively short flight from Baltimore Washington International (BWI) to Atlanta and then to Santo Domingo, Jillian and I finally landed at Las Americas International Airport.  The many months of anticipation led us to the beautifully picturesque Dominican Republic.  From BWI, our total flight time was 4 and half hours.

The transition and movement through the airports was seamless. Delta has an app for smartphone users that allows you to check in 24 hours before departure. I'm fairly certain there’s nothing my iPhone can't do at this point. I might just wait until the iPhone 10 comes to the market for pure shock value.

As our last meal before our depart for the Dominican, we decided to have some McDonalds breakfast in Atlanta. You can’t get any more American than that, I thought. In the Dominican, I'd prefer to only experience the local food and try to become fully immersed in the culture.  Perhaps I'll get the chance to show off my very average dance moves as well.

My food was not harmed but stolen for the purpose of taking this photo 

Much of our encounters at the airport were with people inquiring about Project Hope.  We took the time to talk a little about Project Hope and their mission of providing medical care to many underserved regions around the world.  At Las Americas International Airport, we were lucky to find a church group on a mission trip from the Washington D.C who were able to help us through acquiring a tourist visa and getting through customs.  The only drama we encountered at any of the airports was verifying we had our passport and boarding pass. I'm fairly certain that I broke my personal record by rechecking about 92 times.  I had read earlier that it was a custom in the Dominican to clap every time a plane lands safely. This was confirmed when a small cheer with applause began as the wheels of the plane struck the ground.

After clearing customs at Las Americas, we were greeted by Project Hope volunteers Emil and Abdias.  We all then hopped aboard a pickup truck for about an hour ride to the guest house.  Our ride back along the coast of Santo Domingo was incredibly scenic with calm clear waters and numerous palms trees. It began to rain heavily as we departed Santo Domingo and drifted inland towards Monte Plata.

Beautiful coastline waters within close proximity to Las Americas International Airport in Santo Domingo

Considering my Spanish is very limited, I’m glad I was able to converse with Abdias in English and more so in French.  He also speaks Spanish and Haitian Creole.  Abdias is a Medical Student from Haiti who is currently studying in the Dominican Republic.  He will be guiding us and assisting us for the duration of our time at the maternal and pediatric family clinic in Monte Plata. Clinica de Salud Materno Infantil Y Familiar Orden de Malta is our clinic assignment.  We might also spend some time in another clinic in Santo Domingo.  

Chief complaints seen here include tropical diseases (such as dengue fever and parasites), diarrhea, and ear/throat infections.

We'll be discussing health literacy with Dr. Dana Fitzsimmons, a pharmacist and a Medical Outcomes Specialist based in Washington D.C from Pfizer presumably next week. He has taken vacation time to spend a week with us in the Dominican. I can't wait to visit the clinic tomorrow and see what challenges lay ahead. Unlike our friends, Arsen and Tom who visited India, we will fortunately not be experiencing much jet lag.  Same day arrival and no time zone difference! Perhaps Jillian will have to do more internal clock adjustments than me since she recently returned from her first rotation in Arizona. The clinic in Monte Plata is situated on the same grounds where we are staying and we are only a 5-10 minute walk from the town.  It’s an 8 to 5 day work day.

Before signing off for today, I want to thank all involved getting our trip together and the Shenandoah University staff for giving me the opportunity to provide service abroad.  It’s an honor to be able to represent ideals of Project Hope and Shenandoah University in this manner. Lastly, I’d also be remiss if I didn't thank the Sweeney family for letting stay the night due to its close proximity to BWI.  They were kind enough to offer me Maryland style crabs as a farewell meal.  In my almost 3 decades of existence, I can say finally that I finally had crab too. Shocking I know. Thanks.

Jillian and I will try to keep everyone informed of experiences here in Monte Plata and elsewhere. Adios for now.

Refu Nenu Welthnanu (Sun 6/23 to Thurs 6/27)

Sunday 6/23:

Today we took it easy for the most part.  Arsen and I have grown a bit tired of visiting temples for religions neither of us practice, so we declined an invitation to attend a temple in Mangalagiri.  After lunch we took a small rest from India and took in Man of Steel in english at a local theater.  The movie was great.  We were taken by surprise when there was an intermission.  The theater used it as an opportunity for more advertisement.  As many people left their seats for a refill on refreshments, others stayed and were peppered with ads for everything from toothpaste to windmills.

After the movie we went back to Lotus for dinner.

Monday 6/24:

Today we had a discussion regarding clinical pharmacy.  Arsen and I were a bit taken back by the discussion as clinical pharmacy is just not practiced in India.  Mr. Nayak had a book and did a lot of reading from it.  He paused at times to get our thoughts regarding our very brief experience in the matter.

Today was perhaps our biggest opportunity to affect change at NRI.  Arsen and I did our best to suggest incremental steps that pharmacy could take to advance the profession towards clinical pharmacy.  We suggested things like prescription labels, expanding the EMR used to allow for chronic drug/disease state management, counseling, and many other things.  The biggest hurdle for pharmacy at NRI is coming to the realization that changes in practice should drive regulation and not the other way around.  I think if NRI staff needs to get a pioneer mentality and forge ahead when their peers may be reluctant to.  When the hospital experiences success, others are likely to follow.

Dasaradh ran me up to Mangalagiri on his motorcycle to check on some clothes I had sent for dry cleaning (apparently I sent a pen through the laundry again).  They aren't ready yet, so we got Mango's instead.  I guess I'll get another bike ride out of the deal too. :)

Dasaradh's Bike

Tuesday 6/25:

Today we got a lesson in Indian civics.  We learned the structure of the healthcare system from the top (cabinet level) officials on down.  At the cabinet level, the Ministries of Health and Family Welfare are combined.  Under that they split off and have separate power structures.  Each state also has programs at that level.

We also discussed the definition and function of hospitals.

In the afternoon session, we found out we would be getting a companion in the evening.  A nurse from California (Laudy) was on her way to spend about a week observing and teaching the nursing staff.

Dasaradh invited Arsen and I to try out his bike on the NRI campus.  We nervously agreed.  I drive a manual transmission back at home, so I'm familiar with how clutches and gears work.  It took a bit to get used to using the clutch with your hand and shifting with your foot though.  After 2 laps, I think I got the hang of it.

Arsen driving Dasaradh's bike

Riding Dasaradh's bike

We met Laudy shortly after returning to our room.  She seems really interested in improving the practice of nursing at NRI.

Wednesday 6/26:

Mr. Nayak was on leave today, so Arsen and I were given free reign of pharmacy.  We spent time in 3 of the 4 pharmacy locations.  We first went through all the drugs at the Operation Theatre Pharmacy and spent time quizzing each other on the MOA's of the sedatives, anesthetics, and reversal agents found here.

We also went down to the Main Pharmacy and Central Stores Pharmacy and did the same.  We would quiz each other on US brands for the generics we found and have taken up a habit of updating a spread sheet of the drugs we forgot or those not available in the US.

Laudy took us out to Lotus tonight.  She said it would most likely be her only trip out during her brief trip as we are scheduled to leave in 2 short days and she didn't want to go out without company.  We also took her out shopping in Vijayawada as she wanted to purchase candies for the nurses who would be attending her lecture tomorrow.

Thursday 6/27:

Refu nenu welthnanu-  Tomorrow I  am going.

We got a few more Telegu terms this morning and solidified our plan of action for tomorrow (departure day).  In addition to Telegu, Mr. Nayak explained some of the cultural and language differences between Telegu (regional language in Andhra Pradesh) and others used in the country such as Hindi and his native language (from Orissa to the north of Andhra Pradesh).

Arsen got a pretty sweet writing sample from him and another pharmacist.  They wrote "My name is ______" in Telegu, Hindi, and Orissa.  It was so cool to see how people separated by such seemingly small distances were so vastly different.  Telegu looks nothing like Orissa when it is written.  I'm sure if Arsen and I were exposed to either language in spoken terms, we would not be able to tell the difference.

After we finished our duties, Arsen, Laudy, Ramesh, Dasaradh, and myself made the 1.5 mile walk up to Mangalagiri and hit the market for more mangos.

I downloaded a pace counter the other day in an attempt to keep track of my hallway walking (I'm craving cardio exercising with all of the carbs I've been eating all month).  With our walk to Mangalagiri, I'm now at 2 straight days over 10,000 steps.

Arsen and I are super pumped to pack and begin our long journey back to the states tomorrow.  I can't wait to kiss the ground outside of Dulles Saturday night.  This whole experience has been a struggle in some senses.  It has been a bit disheartening to see the progress pharmacy hasn't yet made over here.  In other ways it has been incredibly rewarding.  I will return to the US with a newfound gratitude for everything I have been blessed with.

I urge all family and friends who have followed my journey to keep checking this blog for the next stage of Project Hope at the Bernard J. Dunn School of Pharmacy.  Even now, two great friends of mine are in the Dominican Republic preparing to continue their education in the same way Arsen and I have over the past month.  Jillian Sweeney and Derek Etube will be blogging from the Dominican for the next month or so.  I'm sure Arsen will have things to say following this post, but I'm signing off, and leave you in their capable hands.

Tom

P.S.  Tomorrow I will say Eroyu nenu weltnanu-  Today I am going.  

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.

Woops

Arsen pointed out to me that my last entry didn't include anything from our work week.  I swear I wrote it, but at any rate, I guess I'll give a quick summary again:

Monday, June 17th:

Today we spent the morning doing an extensive review of antibiotics.  We ran through everything from B-Lactam drugs to Tetracyclines.

Most of our discussion revolved around mechanism of action, coverage, and adverse events.  In addition to learning, we had the opportunity to teach Mr. Nayak about some of the intricacies in the drugs.  As pharmacy education emphasizes industry and simple dispensing over here, he was unsure why B-lactamase inhibitors such as Clavulanate in Augmentin were used.  Arsen and I explained to him how some microbes secrete enzymes that break down drugs as a mechanism of resistance.  These inhibitors are given with the drug to prevent the bacteria from destroying the medication.

After our review, Mr. Nayak started to quiz us out of the pharmacy license exam prep book that we have talked about earlier.  These questions were a mix of very useful ones for US pharmacists and also ones specific to Indian medications.  There were also many questions about Ayurvedic medicine as this Ayurvedic medicine apparently got it's start in India.

Tuesday, June 18th:

We continued our Q&A regarding antibiotics today.  After a while, we urged Mr. Nayak to include questions from all areas of medicine.

(Really... I promise this section was longer, but 3 days removed makes it a bit difficult to remember)

Wednesday, June 19th:

On Wednesday Mr. Nayak was on leave so we were entrusted to the direction of Mr. Vasu, his 2nd in command.  We spent most of our time in the Inpatient Pharmacy learning the procedure for specialty departments regarding prescriptions.

In the morning during rounds (or at admission), the attending physician makes up the prescriptions each person will need for the entire day in a carbon copy book.  This book is taken to the pharmacy where the original is used to fill the prescriptions and then filed.  The pharmacists make the bills at this time and send them to the discharge center where they are either processed through insurance or the public assistance program, or prepared for cash collection.

The prescription copies are sent back to the ward where the nursing staff double checks the order upon receipt.

It was interesting to see this system work without the complexities of hospitals in the states.  The pharmacists are responsible for 90% of the billing.  The last 10% is the simple act of sending the bill to the company paying for the services.

Sorry for the mixup!!!  Also sorry for the lack of pictures!!!  There are far more reasons to take pictures on Sunday than during the week.  

Sunday Adventures and NRI

Sunday, June 16th

Today we spent all day outside of NRI except for a couple hours of rest in the afternoon.

Our first adventure was to the town of Guntur where our preceptor (Mr. Nayak) lives.  The drive was like most others we've taken in India.  We took highway 5 towards the southwest.  This is the only main artery we've taken by car in India.  Mangalagiri is located conveniently between Vijayawada (where we flew into) and Guntur (near the CHIPS Pharmacy School we visited).

On the road we caught a funny sight.  This collage by Arsen says more about it than either of us could put into words:

Arsen and I have both talked about how interesting the transportation here is.  You can cram as many people as you can fit onto a bicycle, motorcycle, or a 4-in-all and just go.  We have seen bicycles carrying a family of 4 riding down main roads.

Once arriving in Guntur, we picked up Mr. Nayak who directed the driver to stop at 2 local pharmacies.  The first was Apollo Pharmacy.  It's a 24/7 retail chain pharmacy in India.  We didn't spend enough time here to see the way they processed prescriptions or prepared them for dispensing, but we could tell by examining their shelves that they use blister packaging just like NRI does.  This is yet another difference in the practice of pharmacy between the US and India.  In the US, retail pharmacies use stock bottles for as many drugs as possible.

Looking at their shelves, Arsen quickly noticed that multiple drugs are stored in the same bins.  We reflected later during the day how this could lead to dispensing errors.

Arsen outside of Apollo Pharmacy

Down the street a bit from Apollo Pharmacy was MedPlus Pharmacy.  This is another chain pharmacy in India and had much more limited hours than Apollo.

After visiting the two pharmacies, our driver took us to a Hindu Temple along the Krishna River.  This temple was much less crowded than the one we visited last week.  At one point in the temple, a priest takes your monetary donation and rewards you with a spoonful of a very sugary drink.  Instinctively I put out my left hand to receive it (I'm left handed), and was immediately reminded that using your left hand for many things is frowned upon in India as it is apparently traditionally used for less pure actions over here.  If I remember to use my right hand next Sunday, I will consider this rotation a great success.

Arsen at the Temple.  You can see the hospital vehicle we rode in to his right.

Following the temple visit, Arsen and I also visited a museum with archaeological relics.  Many of them were parts of temples or other buildings that have long since fallen.  I  noticed an ancient earring very similar to the ear-gauging ones that have become so popular in the US recently and joked with Dasaradh that it would look good on him.

We also visited a Buddha statue that will be the largest one in India once it is completed.  The statue is under construction both outside and inside.

Arsen in front of the Buddha statue

Arsen, Dasaradh, and myself in fron of the Buddha statue

After lunch in Guntur, we dropped Mr. Nayak at home and returned to NRI for a couple hours to regroup.  I took the time to make a big dent in my 3rd leisure book of the trip.  I think I can get used to this "no more class" thing!

In the evening, Dasaradh, Arsen, and I met our driver again and the 4 of us went to Haailand.  Haailand is a resort/theme park about 10 minutes away from NRI.  The evening admission fee was about $7 for all 4 of us.  We passed some time by looking through pictures of Hindu temples around the region.  It was interesting to see how they changed depending on the country or region they were in.  China had their well known architecture.  India had several styles ranging from the ones we've documented the past 2 Sundays and also several other styles from different regions.  

Welcoming sign to Haailand resort

At Haailand, I was able to get what I consider the best panorama I've ever taken on my iphone.  The view was simply stunning.  In this resort, you seem to forget about all the poverty you see everywhere else in Andhra Pradesh:

Panorama from a building in Haailand Resort

We took in a couple performances from this building.  There were singers, dancers, and acrobats all performing in the small square directly in the center of the panorama shot.  We soon realized that the building directly in fron of us with the green dome would be a better place to see the show, so we relocated there.

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.