First Day at Mulago National Referral Hospital

29 September 2016

All ready to get to Ward Rounds at Mulago Hospital. The pharmacist in the middle is Winnie, whom I've known and worked with for years. She is teaching the Pharmaceutical Care Skills Lab this year.

All ready to get to Ward Rounds at Mulago Hospital. The pharmacist in the middle is Winnie, whom I’ve known and worked with for years. She is teaching the Pharmaceutical Care Skills Lab this year.

Today was our first full day in Kampala and we participated in Pharmacy Rounds with some of the 4th Year Makerere University Pharmacy Students.  We saw a patient in the Neurosurgery Ward as well as patients in the Pediatrics Ward. All had very complicated situations and our role was to try and find out if any of the disease states or issues could be caused by any of the medications that the patients were taking.  The medical charts are all handwritten and are in quite disarray and the first thing we needed to do was to put the chart in chronological order so we could start to review the patient’s data.  The few Physicians we interacted with were very glad for any recommendations we could offer.

Overall, though, the situation at Mulago regarding the availability of drugs and healthcare personnel right now is really horrible.  Normally, the bulk of the work and patient care is given by the Nursing, Medical and Pharmacy Interns. These students all have graduated from University and then spend their next year doing a mandatory Internship. But, right now there is a dispute between the Government and the Interns because they have significantly decreased their pay and thus they are taking the Government to court and are not working at all right now. In fact, they haven’t had Interns in the hospital since about at least July, maybe even since before that. The old salary was 800,000 shillings/month (about $235/month) and now they want to pay them only 600,000 shillings (about $177/month). That is only $1.10 per hour. And these are the people who deliver all of the basic healthcare to the thousands of patients at the hospital and outpatient clinics. The other current issue, which isn’t a new one, is that many drugs are not available. It is so bad right now that most of the patients have to go purchase their own drugs at the local pharmacies and bring them back to the hospital so they can be treated. This includes IV medicines as well. The hospital has been out of the workhorse antibiotic, Ceftriaxone, for the past 2 weeks and oral Amoxicillin for the past 3 weeks.  I was told that Ceftriaxone came in last Friday but it still hadn’t been brought to the patient units and pharmacies yet even though today is almost a week since the supply was delivered, but “hopefully” that would happen today. The reason for this is that there are no Pharmacy Interns to do the grunt work of going to the storeroom (called simply “the store” here) to pick up the medications. So the Stores staff will have to eventually deliver the drugs to the rest of the hospital. There is no doubt that patients have gotten worse and even died due to the lack of medications right now, but although it sounds super terrible to me and the students, this is the “state of normal business” here in Uganda. It is actually pretty sad that most healthcare practitioners don’t get overly upset about this. They have learned to do the best that they can do given the situation. Although the Government-provided healthcare is supposed to be free, in many cases it is really not at all free. When drugs aren’t there, the patients must go and purchase it. When they can’t afford it and can’t raise money from family and friend then patients die- seems like a really high price to me…..

OK, I don’t want to end this post with a bad flavor in your mouths. Sometimes it is easy to get frustrated and I sure gave my friend, Winnie, a Ugandan Pharmacist whom I’ve known since 2012, an earful this afternoon about how much worse the situation seemed today than ever in the past. But as I was talking with her I realized that the situation isn’t really much worse, it is just that I am becoming more and more familiar to those I work with and the more experiences I have here, the more I am privy to the “real” situation. People don’t hide the situation as much as may to one-time visitors because they can’t begin to understand the “behind-the-scenes” stories. It is easy to just to the conclusion that healthcare in Uganda is horrific and think poorly about the country. But, my experience helps me to put the situation into perspective. I encourage my friends to be extremely candid with me because I know nothing can get better until we know the full extent of the situation. And despite the given the situation, most people do get better-this is really amazing. The healthcare system here certainly could be better, but it could be a whole lot worse. The healthcare workers here are under great stress now with the lack of all of the Interns that usually help out, but those practitioners that are here are extremely dedicated to their patients. They are doing the best they can and many patients are helped and get better. As I’ve said before, we just need to keep things in perspective and try to keep on keeping on and improving the situation one step at a time.

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Greeted By Monkeys As We Settle Into our Rooms Back in Kampala, Uganda

28 September 2016

A Blog Post by Mike

A Fond Farewell to our new friends in Mbarara (Pictured left to right: Jennie, Dr. Bohan, Derrick, Mike, Emily, Nick, Noah)

A Fond Farewell to our new friends in Mbarara (Pictured left to right: Jennie, Dr. Bohan, Derrick, Mike, Emily, Nick, Noah)

It has been another busy few days. Yesterday we finished up our time Mbarara. We were only there for two days but we had a great time interacting with the students at Mbarara University. All of the students we spoke with were very eager to learn and had lots of great questions as we rounded together in the morning. Our afternoon session was a presentation by Dr. Bohan that focused on improving medication safety. Judging by the reaction of the audience, many of them had seen some of the issues that were discussed and were able to more fully appreciate the need for improvement in this area.

Our evening session was a great opportunity for us and some of the pharmacy students to meet in non-clinical, non-academic setting, relax and get to know each other a better. We talked, played games, and laughed often. There was one rule for the evening- NO pharmacy talk! This was a great rule which I think we could benefit from should we enact it at get-togethers back home. It really helped us avoid focusing on the one thing we all knew we had in common and to find other topics for us to bond over.

This morning was bittersweet as Noah and Derrick came by to see us off. I was happy to have the chance to see them and thank them again for inviting us down to work with them and the other students at Mbarara University. Our drive back to Kampala was lovely and punctuated by one stop off for a couple of quick photos as we had one foot in spring and one in fall at the equator.

A visit to the Equator

A visit to the Equator

We checked back into the Mulago Guest House near the hospital where we will rounding and working with students for the next couple of weeks. As nice as it has been to travel and see lots of Uganda, it is nice to know that we will be staying in once place for a while. We had a nice little greeting committee all set up on my balcony. This playful troop decided to hang out on my balcony. I quickly realized that some of the smaller ones would be able to climb through the metal grate and I shut the glass doors as soon as I could. It was fun to watch the monkeys wrestle and play from only a few inches away. They seemed as interested in us as we were in them.dscn7641 dscn7646 dscn7647 dscn7653 dscn7660 dscn7669 dscn7678

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Another Rewarding Day with Faculty and Students At Mbarara University School of Pharmacy

27 September 2016

A Blog Post by Emily

A beautiful morning in Mbarara at the Acacia Hotel

A beautiful morning in Mbarara at the Acacia Hotel

First I would like to expand on Dr. Bohan’s post from yesterday. Nick and I were assigned to the psychiatric ward, which was different than a psychiatric ward in America. The most of the patients can roam around freely and the privacy is very limited which is common throughout Uganda. The first patient that we met in the ward was a middle-aged gentleman that we met Sunday evening while we were touring the hospital. He approached our group and demanding, “you people from America! Greet me” so we obliged and asked how he was. Yesterday when we entered the ward that say gentleman greeted all of us with a “Hi, how are you?” he then joined us on rounds pretending to be a part of the team. The first patient that was presented was a woman diagnosed with HIV induced psychosis. In America we do not see this very often because HIV is not as prevalent and is typically better controlled due to easier access to medications. Our last patient was a young man who was having some type of psychotic episode. He was walking around taking things such as papers or notebooks from the pharmacy students and the other patients. He also stood on a bed and tried to climb over a half a wall. Eventually, the first gentlemen came over and sat the psychotic patient down. He sat for a few minutes before getting up and going outside to scream into the windows. This is a very unfortunate case that will hopefully be helped by the pharmaceutical management by the pharmacy students (who are geniuses by the way). After we debriefed, we had some time to exchange contact information and talk to the pharmacy students about how pharmacy is different in America. One of the biggest differences is that in Uganda community pharmacies do not have to have a pharmacist working to be open. Therefore, the pharmacists can work only a few hours a day. In America, pharmacists work 10-13 hour shifts. I think America should adopt this model (haha).

The American Team from Wilkes University and Binghamton University with the 3rd Year Pharmacy Students At Mbarara University before ward rounds

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A tour of the hospital pharmacy. Note how few drugs they have. There are not many options for therapy.

Today was our second day at the Mbarara University Pharmacy School and we rounded with the 3rd year pharmacy students in the general ward and as with yesterday we split into small groups. The students presented a patient to us and then we discussed what we would like to do with the patient.

Debriefing with the 3rd year students after ward rounds.

Debriefing with the 3rd year students after ward rounds.

Mike and I had a group of students in the male general ward and we saw a patient with hypertension, diabetes, dyslipidemia, peptic ulcer disease, and diabetic peripheral neuropathy. This was a very good patient to go over because there were so many disease states to discuss. We introduced the idea of using the side effect of one drug to treat other symptoms such as using metformin to help with constipation. The students knew so much about each disease state and the drug managements. They reminded me a lot about things that I had forgotten or didn’t know. Like I said, they are so intelligent and passionate for pharmacy. After rounds, like yesterday, we debriefed and reflected on our experiences.

Waiting for Grand Rounds to start in the Pharmacology Lecture Theater

Waiting for Grand Rounds to start in the Pharmacology Lecture Theater

Later Dr. Bohan presented about medication safety to the Grand Rounds. Medical and pharmacy students attended. The medical students expressed interest in talking with the pharmacy students during rounds to get medication recommendations from them. I think that all the students enjoyed our presentations and input in the ward rounds. I hope that they have learned from me as much as I have learned from them.

Dr. Bohan presenting the talk on Safe Medication Use

Dr. Bohan presenting the talk on Safe Medication Use

The group of participants talk with each other during the discussion part and they they shared their conversations

The group of participants talk with each other during the discussion part and they they shared their conversations

Dr. Bohan with Peter, one of the faculty, and Professor Jennie, the Department Head of Pharmacy

Dr. Bohan with Peter, one of the faculty, and Professor Jennie, the Department Head of Pharmacy

I have had a great time in Mbarara and can only hope to have the same experience as we head back to Kampala tomorrow (hopefully with less lizards).

Mike, standing, and Nick, with gloves, extracting a lizard from the girls room in Kampala

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A Wonderful Experience working with Mbarara University Pharmacy Students

26 September 2016

This is the flyer announcing our presentations

This is the flyer announcing our presentations

Today was the first day of the Mbarara University Pharmacy Students Association 7th Annual Conference to which we were invited to speak and participate on ward rounds with the Pharmacy Students.

img_8857 img_8869It was an absolutely wonderful and exciting day for both us and the MUST students. I am so filled with inspiration from their youthful exuberance and passion to improve patient care through the provision of pharmaceutical care.  They say we have encouraged and inspired them but truly, the feeling is mutual! We started out the day with a morning filled with presentations by me and the Wilkes pharmacy students. We all made our talks interactive so the students got a chance to practice the skills we were teaching them. I think they had a lot of fun with the role-play activities where they had to pretend to be patients and pharmacists and interact with each other as they should do with real patients on the hospital wards. When you just talk about how to interview a patient to learn what drugs they are taking or to assess their symptoms of illness, it seems rather simple. They realized when they practiced with each other that doing it for real is a lot different than writing the steps on paper. I think practicing gave them more confidence when we went into the wards for rounds in the afternoon. img_8876We Americans all split up and took small groups of the 4th year pharmacy students to the different wards. The students had found patients to assess ahead of time and presented them to us. We then worked together to determine the patients drug therapy problems and came up with solutions we could recommend to the Clinicians. At the end we went into a room to debrief the whole experience and this was basically like a verbal reflection of what they had learned. Each student arose and talked about what they learned from the rounds and the whole day’s event. Our time here has definitely been helpful for the MUST students as well as for our own personal growth.  Tomorrow we will continue the program with more ward rounds in the morning with the 3rd year students and I will present Grand Rounds to all of the healthcare profession students here at Mbarara Regional Referral Hospital.

Debriefing Ward Rounds

Debriefing Ward Rounds

The 4th year students and us after ward rounds

The 4th year students and us after ward rounds

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A Warm Welcome to Mbarara By New Friends

25 September 2016

Emily, Nick, Robert, Jennie, Mike, Derrick, Noah

After a long day of travel we arrived safely to Mbarara. Despite being hot and tired, our spirits were lifted upon receiving warm greetings and smiles by the 2 Mbarara University Pharmacy students who have worked hard to arrange this opportunity, Derrick and Noah.  We’ve enjoyed several hours of socialization and a long tour of the University and Hospital. We also have met up with another pharmacist from the USA, Robert, who is a Clinical Pharmacist for the University of Minnesota. He was here in Uganda for other business but had found out about my project from my blog. When it turned out that our trips would overlap we arranged to meet. He will be in Uganda periodically and would like to figure out if there is a way he can help out with using his pharmacy skills in some way.  I am so glad to have met him!! It’s so funny how the people you need to meet somehow cross your paths without any planning. We are not sure yet how we might work together to improve safe medication use and pharmacy practice in Uganda, but at least we have started the conversations.  

The Poster for My Grand Rounds Presentation

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Thoughts About Cultural & A Wonderful Last Day in Masindi, Uganda

23 September 2016

A Blog Post by Jennie

Dr. Godson with Mike, Emily, Dr. Bohan, Jennie, and Nick

Dr. Godson with Mike, Emily, Dr. Bohan, Jennie, and Nick

Yesterday, the other students and I had a very impactful cultural experience at the clinic. The other students and I were standing outside of the clinic ward with a group of Ugandan men. Only one of them spoke English. The other students and I were talking to each other in English and the men were talking to each other in their local language. It quickly became clear to the other students and I that the men were most likely talking about us. Eventually, the man who spoke English told us that he and the other men had a “crazy” question for us. They wanted to know if they could see our hands. We of course agreed and held out our hands. The men were so fascinated by the white color of our skin. They held our hands, flipped them over, pinched them, and inspected them. I don’t know for sure but I would assume that they wanted to see if there was anything different about our hands and skin compared to theirs. We were able to communicate with them that we really did not believe that there was anything different between us and the men as people besides our skin color. We are all people and that is all that matters. The men also wanted to know about marriage in the USA. They wanted to know if an American woman would be allowed to marry a Ugandan man and if she would move to Uganda. We were able to explain that this would be possible and that in the United States, interracial marriage is accepted by many people. Our translator then went on to say that he wished he could someday move the United States and that he wished he could be white like us someday. This statement really shocked all of us. We immediately replied that we felt that we are the same as them and that our white skin does not make us any better than they.

When we are at the clinic I feel that we are a bit of a spectacle to the patients and their caregivers. We are a group of five white people in white coats furiously taking notes while working with the doctors and nurses during rounds. Since many of the patients and caregivers do not speak English, we cannot easily communicate with them who we are and why we are there. I think that this often leads to misunderstanding between us and the patients and caregivers and probably makes the patients and caregivers feel uncomfortable. When we walk into the clinic ward in the morning, we can usually feel the stares of everyone in the room. The unexpected interaction that we had with these men was very important for us as we were able to establish a relationship of understanding with them. I hope that the bond we created with these men is now one of trust and made them feel more comfortable with our presence.

The group with Sam, our Masindi driver whom we love!

The group with Sam, our Masindi driver whom we love!

Today was our last day in Masindi at the Masindi Kitara Clinic. We have had a wonderful time here and have learned so much. We are excited to move on to the next leg of our trip but will miss all of the staff at the clinic and at our hotel.

Nick presents about Scorpion stings because we had a patient who got one and had a bad skin reaction- otherwise she was ok

Nick presents about Scorpion stings because we had a patient who got one and had a bad skin reaction- otherwise she was ok

We began our morning by giving a CME to the medical staff at Masindi Kitara Clinic. CME stands for Continuing Medical Education and occurs once a week at the clinic. We based our CME on questions and patient cases we had encountered.

Mike presented on management of breast engorgement after stillbirth and he also talked about some antibiotics

Mike presented on management of breast engorgement after stillbirth and he also talked about some antibiotics

The staff seemed to be very pleased with the information that we provided them with. They commented that they really appreciated how we made the presentation very relevant to what they see at the clinic on a regular basis. The head physician, Dr. Godson, even made a request to the staff that they follow a format similar to our presentation when giving CME presentations in the future.

Jennie presents information about how to treat Amitraz, a pesticide, poisoning- we had a patient who had an accidental ingestion

Jennie presents information about how to treat Amitraz, a pesticide, poisoning- we had a patient who had an accidental ingestion

Emily finished the CME by presenting the requested topic of seizures- she is waving her arms in this picture as she demonstrates what Myoclonic seizures look like

Emily finished the CME by presenting the requested topic of seizures- she is waving her arms in this picture as she demonstrates what Myoclonic seizures look like

Later in the afternoon, we stopped by the baby clinic. This clinic is held every Friday. Mothers bring their babies to the clinic to receive all of their childhood immunizations. We were able to watch the nurses do their work for a while. However, the clinic was very busy today and we did not want to be in their way so we moved on to watch Dr. Godson perform a surgery. Some of us have watched surgeries in the USA before and it was very interesting to note the differences between the way surgery is performed in the USA versus how it is performed in Uganda. We really appreciated Dr. Godson welcoming us into his OR and teaching us a bit about surgery in Uganda.surgery-at-mkmc
After we were done at clinic, our driver, Sam, picked us up and took us for a drive to a beautiful overlook. From the overlook you could see the town of Masindi and the surrounding mountains. Enjoy the pictures!

You can tell the view was beautiful by the students all taking pictures (my phone couldn't get a good picture)

You can tell the view was beautiful by the students all taking pictures (my phone couldn’t get a good picture)

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A Visit to TASO 

22 September 2016

It was another great day of learning at the Masindi Kitara Medical Center. The students and I talked to several patients to learn more about their disease states and provide education about their medications. This had to be done through the help of another person to translate since the nurse wasn’t available to help us. But it only took a few minutes for this process to become pretty natural. At first, though, we were asking the patient if he could speak English and he was speaking back in Runyoro that he didn’t understand us and that was a bit comical. But then they found another patient’s brother who could do the translation and it ended up being a really informative conversation. I think the students learned another good cultural lesson which I think they will share at some point. Tonight, though we are all busy working on presentations. The students are giving a CME (continuing medical education) talk tomorrow for the entire clinic staff and I’m working on my presentations for the MUST conference in Mbarara at the Pharmacy School for next Monday and Tuesday. So I’m going to let the photos do the talking about our visit to TASO this afternoon. (The AIDS Support Organization). Those below show the TASO Drama team singing and dancing with songs that encourage adherence to HIV medicines and hoping for a world that is HIV-free. They also did a skit in the local language that encouraged people to tell their loved ones and support each other when someone has HIV and to take their medication. The rest of the photos are of some of the different areas of the TASO facility. 

Jennie, Nick, Mike, Emily are enjoying the TASO show

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