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.