Out of the Pharmacy Classroom and Into Africa

April 7, 2016:  A Blog Post by Kassi

Casey and Kassi are ready for rounds. They are standing outside of the central pharmacy at Mulago Hospital

Today was the first day that we were split up and it was very interesting. Makenzie and Lauren spent the day at IDI and Casey and I rounded at Mulago Hospital in different wards.

Casey and I started our day rounding with a GI team, which consisted of an attending physician, a few Ugandan residents, an internal medicine resident from Stanford University and some Ugandan nursing students. While rounding on the first patient, the senior resident briefly presented the patient from the paper chart on the patient’s bed and the attending physician completed a physical exam. This patient was discharged from Mulago a week ago after being diagnosed with peptic ulcer disease and sent home on a week’s regimen of amoxicillin, clarithromycin and omeprazole – which is the standard for PUD treatment in Uganda. She was back at Mulago complaining of abdominal pain and itching from allergic dermatitis. During the discussion for the assessment and plan for the patient, the senior resident briefly mentioned the patient’s home medications – an ARV regimen (these are the drugs to treat HIV infection) including and sulfamethoxazole/trimethoprim. The team then moved on to the next patient, but Casey and I wanted to look more into the patient chart. We saw several papers describing the patient’s medications, which included several medications of different classes that were not mentioned at all during rounds. There were no clear indications for most medications we found listed in the patient chart. With translation assistance from Ivan, a pharmacy intern, we asked the patient and her caregiver if she had her medications with her and she presented them to us. She had several small bags full of medications that contained about 8 different antibiotics, various PPIs and H2 antagonists and a completely different ARV regimen than what was presented during rounds. There was an obvious discrepancy between what medications she was being prescribed, what was recorded in her chart, and what she was actually taking at home. Ivan, Casey and I completed basic medication reconciliation and I asked Ivan if he regularly completes med recs with patients. He responded that he doesn’t have the time to work with patients like this all the time, but when he does he simply takes all the medications the patient doesn’t need back to the pharmacy. I also asked Ivan about his contributions to rounds. The pharmacy interns do not pre-round, because they have to balance several different wards rounds with dispensing responsibilities. He stated that he does not usually contribute during rounds unless drugs are specifically mentioned or if he is asked a direct question. He said that physicians have a flow to their rounds, and he doesn’t interrupt so he waits until all of the rounding for the day is finished, and then he will give his comments to a resident. This really opened my eyes to the hierarchy here at Mulago. It can be difficult for the pharmacists’ to contribute to rounds because the physicians expect to be trusted and not questioned. Casey and I explained to Ivan how we round in the USA, and how our contributions to the team are for the benefit of the patient. This patient is a perfect example that there were discrepancies where pharmacy intervention was entirely appropriate and necessary.

Although you can’t see Casey and Kassi well because of the sunshine, you can get an idea of what Mulago Hospital looks like. You will never see patients in our pictures so that their privacy is protected.

After working with this patient, I switched from the GI team to a pediatrics ward with Eunice, another pharmacy intern. It was Eunice’s first day in the ward so a nurse gave us a tour and I joined the pediatric cardiology rounding team. We rounded on a 13-month-old patient who was premature with bronchopulmonary dysplasia and presented to the ward a week ago with RSV bronchiolitis and a possible super imposed bacterial pneumonia. She had been on IV ceftriaxone for a week but was not clinically improving and still had high fevers and she had also developed a new heart murmur. The attending physician suspected that she had an infective Strep endocarditis and wanted the patient switched to meropenem. I’m sure that the pharmacists and physicians reading this probably have questions about that decision. I don’t want to get too much into detail about that specific choice and how ceftriaxone is still an appropriate treatment for Strep endocarditis, but I do want to talk about the meropenem and the supply of antibiotics at Mulago. There are not many antibiotics on formulary here, and there isn’t a consistent supply either. During rounds the physician asked Eunice if we had meropenem in stock in the ward dispensary. There was no meropenem is our ward so we walked to another ward to check their supply, but they were also out. We reported this to the physician and she asked if the mother could go buy the medication elsewhere. It is common at Mulago to have caregivers of patients go buy out of stock medications at a community pharmacy and then return back to the hospital for it to be administered. However, meropenem is expensive and the patient’s family would not be able to afford purchasing it over the counter. The physician then stated that the patient would just have to wait until tomorrow for an antibiotic and hope that meropenem comes in. This astounded me. I could never imagine a physician in the USA not being able to treat a sick child due to the lack of a medication. Whenever I have had to deal with medication shortages, there are always lists created of alternatives until that medication comes back into stock. There was no discussion of alternatives or continuing the ceftriaxone until the meropenem was available. I suggested to the physician that she should continue administering ceftriaxone, but at a different dose, and she agreed to continue that.

Casey and Kassi with Patrick, one of the Pharmacists at Mulago. He’s been making sure we are introduced to the physicians and interns and are all set for rounds and

These experiences have made it clear that more pharmacist intervention is needed at Mulago. I never realized how desperately these basic clinical skills are needed for pharmacists here and how I have taken them for granted. I am excited to continue teaching the pharmacists and pharmacy interns the basic clinical skills we are taught at Wilkes.

Outside the hospital, my Uganda experience has been just as wonderful. The people are very welcoming and friendly. The weather is sunny and beautiful, although it does get humid and my hair doesn’t quite agree with it. We have been eating lunch at various canteens around the hospital campus and we eat the local foods there. After work, we eat at various restaurants and talk with some other medical volunteers staying at the Guest House. My only complaint is the birds that look identical to pterodactyls and apparently are large enough to swoop down and take kittens off the ground. We are really making the most of our time here and I am very excited for the rest of the week at Mulago.

I would love to talk more about these past few days, so if you have any questions or comments about any part of my experience please email me at kassandra.bugg@wilkes.edu.