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."