Journey to Masindi via The Equator

Today we were up early for our journey to Masindi. We hadn’t gotten a chance to get to the Equator yet, so I asked our driver to head there first. This was definitely a worthwhile experience but was quite a bit out of our way and made the trip longer. All in all, though, the trip went well. We started out at 7:20 and arrived at the Equator by 9am. After looking in the shops, taking pictures at the Equator monument, and watching the Water Flow experiment (see the video at the bottom of this post), we headed on to Masindi at 10:15. just over 5 hours later we arrived. Instead of a bunch of text today, I’m going to let the images do the talking. Even though we felt like we were on the road quite early, it was clear that Kampala was already bustling with much activity at the variety of produce stands and other stores.

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Last Day in Kampala at Mulago National Referral Hospital

Stacy dispenses medications to a patient under the supervision of Pharmacy Intern, Vivian

Stacy dispenses medications to a patient under the supervision of Pharmacy Intern, Vivian

Today was our last day at Mulago National Hospital as tomorrow morning we head for Masindi at 7am. We have all thoroughly enjoyed our time in Kampala and have made many new friends. It has been a joy to watch the relationships between the US students and the Mulago Pharmacy Interns and Makerere Pharmacy Students grow. They have definitely learned from each other. We have tried to model Pharmaceutical Care (advanced pharmacy practice where pharmacists assist prescribers and patients in managing drug therapy) as we rounded with the medical teams and worked with patients to make sure their drug dosages were correct and directions understood. An example is our interaction with the caregiver (daughter) of a patient at the hospital today. Her mother was just diagnosed with cancer and was constantly moaning while we were in the room. The daughter reported this had gone on all night. It appeared the patient was in serious pain but had no routine pain medication ordered. We went to talk to the medical team and they said that a palliative care consult had been ordered two days ago but when we went to seek out that team, they never received the request to get involved. We explained the situation and they said they’d “take it from there” so we went back to the original team to report our findings. We checked back an hour or so later and sure enough, the patient had been seen by palliative care and now had routine morphine orders and was resting much more comfortably. Lack of communication is not a problem unique to Uganda for sure; even with electronic medical records and our advanced technologies, communication regarding consults can get “lost”. This is just an example of a normal activity that a pharmacist can get involved in- helping to make sure that appropriate medication orders reach the patient.

Jeff and Stacy review a chart with Vivian and discuss the drug therapy regimen

Jeff and Stacy review a chart with Vivian and discuss the drug therapy regimen

Vicky dispenses medication and provides education to a caregiver for one of the patients; notice the beautiful outfit- I thought this woman might have "dressed up" to come to the hospital but I was told that this is her normal, everyday traditional garment.

Vivian dispenses medication and provides education to a caregiver for one of the patients; notice the beautiful outfit- I thought this woman might have “dressed up” to come to the hospital but I was told that this is her normal, everyday traditional garment.

Despite the lack of many drugs and lab tests that are readily available in the US, the Ugandan healthcare providers truly care about their patients and have learned to think “out of the box” and improvise as needed so their patients improve. More than ever I have personally realized that in the US we waste precious medical dollars on unnecessary tests. If we could just learn to listen more carefully to the health stories our patients tell us, we would be able to figure out what is wrong much of the time and streamline the tests we order to confirm diseases. For example, when a patient is clearly improving, is another CBC and BMP (blood count and chemistry tests) really necessary for monitoring and confirming, that “yes” this patient is indeed improving? We should be thinking twice before ordering tests and considering what we will do with the results we get. If the answer is “nothing different than we are doing now”, then is it really necessary? Definitely, care to patients in Uganda could be improved with a constant supply of drugs and testing reagents (no “out of stocks”) but I’m amazed at how well patients are managed under these difficult circumstances. Overall we have been very well received in Kampala; the medical team members seem to really appreciate our input and it appears that the pharmacy interns and students are truly motivated to learn new skills and provide pharmaceutical care. We leave Kampala with plans to see everyone once again on October 14, before we leave Uganda, as it is way too soon to say goodbye.

China-Uganda Friendship Hospital-Naguru with Pharmacist Vicky

China-Uganda Friendship Hospital-Naguru with Pharmacist Vicky

Vicky and KarenBeth outside China-Uganda Friendship Hospital-Naguru (this hospital just opened in 2012)

Vicky and KarenBeth outside China-Uganda Friendship Hospital-Naguru (this hospital just opened in 2012)

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Nikko, Stacy, and Jeff check out the new GeneXpert machinery at Naguru Hospital that can very quickly identify if the TB organism is in a sputum specimen, helping to make the diagnosis sooner to assure appropriate therapy more quickly.

A view of the Pediatric Pharmacy

A view of the Pediatric Pharmacy

Now, on to Masindi and many more adventures. Note: our travel tomorrow is long and we are getting up very early in Masindi on Sunday to conduct our first Blood Pressure screening, so it may not be possible to post tomorrow night- but no worries- I resume as soon as possible.

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Advocating for Pharmaceutical Care for Ugandan Pharmacists

20130926-213754.jpgToday’s work was non-clinical but quite fulfilling all the same. We got a really early start (7am) and attended the annual meeting of the Pharmaceutical Society of Uganda (PSU) for the purpose of administering the Pharmaceutical Care Needs Assessment questionnaire that a Wilkes student and I designed in collaboration with a faulty member at Makerere University School of Pharmacy and the Secretary of the PSU. There are somewhere between 400-600 practicing pharmacists in Uganda and there must have been at least 200 at today’s meeting. The survey results will provide a baseline record of the types of pharmaceutical care activities that are being provided by Ugandan pharmacists today so that we can watch this grow as the collaboration of Wilkes University and D’Youville College with Makerere University and PSU gets off the ground. In addition, we are collecting info about the types of programs pharmacists want to participate in along with the resources they are willing to commit to advanced training.

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This afternoon the students and I went back to Mulago Hospital to give a presentation for about 40 of the Pharmacy Interns. This is something I have them prepare prior to our trip as an educational session for the interns. Jeff discussed the basics of Patient Counseling Skills. Although this a primary focus in US pharmacy schools, at Makerere University, students are exposed to only a few direct interactions with patients.

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Stacy spoke about an advanced form of counseling called Motivational Interviewing. Instead of the pharmacist just giving information to the patient and expecting them to remember it and utilize it, the pharmacist engages the patient in a conversation about their medications and diseases and learns what will motivate the patient so that they can share in the decision-making process.

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Finally, Nikko concluded the first half of the presentation by changing topics and discussing how to utilize free smart phone applications to help the pharmacists improve patient care by providing drug information at the time of service during rounds. Internet enabled phones are becoming as popular and common in Uganda among students and young professionals as they are in the U.S.

During the 2nd part of the presentation, the students gave examples of the types of Pharmaceutical Care activities that they have participated in while on their clinical rotations this year. I ended the talk by providing information about how the Ugandan pharmacists can advance their own training, from being self-motivated to learn on their own to specifically outlining the requirements for their participation in pharmacy residencies or other training in the USA.
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Throughout the entire talk, the interns were actively engaged in our presentation. I was really thrilled to see how many were interested in gaining advanced skills and becoming a more integral part of patient care by directly interacting with patients as well as work on a team with other healthcare providers.
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My Time at the Uganda Cancer Institute by Stacy

I was able to spend my 1st few days in Uganda at the Uganda Cancer Institute working with a pharmacist, pharmacy technicians, doctors, nurses, and medical students. For my first two days there I worked in the outpatient pharmacy with their pharmacy technician Michael. He helped me learn their process for record keeping, medication dispensing, writing chemotherapy orders for the mixing room, and patient counseling. Prescriptions we received varied from chemotherapy to malaria treatment. There was never a point in the day that there was not a line of patients, so it was very busy. Although they have a small selection of medications, everything they fill is free for the patients. If we did not have it in stock, we would send the patient to another pharmacy where they would have to pay for the medicine. I counseled some patients on how to take oral morphine, bowel regimens, and different antibiotics.

On my first day there I also went to a research presentation on cisplatin-induced ototoxicity. It was great to see an example of the research projects their master’s students are completing. In the meeting everyone gave constructive feedback on how to improve her project.

On my third day there I had the opportunity to go into the mixing room and actually make chemotherapy for the inpatient ward and infusion center. In the picture I just got done mixing some cyclosporine for the infusion center. Their pharmacist Benjamin has worked hard to get their chemo room up to high standards, as you can see it looks identical to what we have in the US.

Stacy in Chemo Hood
Later on that day I was able to meet up with Dr. Kayaja and his medical team to finish rounds in the solid tumor inpatient ward. I participated with the medical students to stage a new patient’s cancer and choose her chemotherapy regimen, as well as learn about different patient cases.

On my last day I was able to work with Dr. Victoria in their outpatient clinic. Here I learned a lot about Kaposi’s Sarcoma since about 60% of the patients that came in that day had it. She also had some patients with breast cancer, leukemia, Burkitt’ s lymphoma and Wilm’s tumor. In the clinic I was able to help calculate chemotherapy doses and provide information about side effects. My short time at UGI was a great learning experience. I hope some day to come back to see all of the people I have worked with that have become my friend, learn more, and help to advance patient care.

We brought pill boxes to donate to the Uganda Cancer Institute- Benjamin will use them to dispense medications to the in-patients.

We brought pill boxes to donate to the Uganda Cancer Institute- Benjamin will use them to dispense medications to the in-patients. Pictured: Jeff, Vivian (Mulago Hospital Pharmacy Intern), Stacy, Pharmacist Benjamin, Nikko

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Coffee

We have been really enjoying trying out lots of new restaurants and food on this trip. Kampala is packed full with great places to eat. I’m also really fortunate to have 3 students with me who are not picky eaters and who have been excited to try new places. Tonight we ate at Faze 2. It was delicious and they had live music- a guitarist and a couple of singers. They sang mostly soft American pop music but then also played music we weren’t familiar with. We all agreed we would definitely eat there again!

On Sunday we went shopping at the Craft Markets and had coffee at a really cute coffee shop across the street- 1000 Cups. Below are a few pictures we took- the coffee was mine- a yummy Mocha. I bought some whole beans to bring home and they’ve been filling my room at the guest house with a fantastic odor!

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Our Life in Kampala

This is just going to be a really quick post since it is once again quite late. I can’t believe how busy we are staying and time is really flying by. I thought you all might be interested in seeing a couple of photos of Mulago Hospital Guest House, our living accommodations while in Kampala. We start the day off with a nice breakfast of eggs, toast, fresh fruit (pineapple or bananas), tea or coffee, and fresh passion fruit juice- yummy! We eat in a communal dining room and breakfast is one of the best parts of the day when we can interact with people from all over the world who have also come to Uganda to do work. Some volunteer, some are conducting research and some are pursing part of their medical residencies. The picture below shows Stacy conversing with Megan, an OB-GYN resident from UCSF in California, and Jean, a Nurse Midwife from the UK.

20130923-234903.jpgAfter breakfast we head to the hospital which is a quick 10min walk.

20130923-235243.jpgUpon arrival at the hospital we all report to the units where we have been assigned to work. Lunch break is anywhere between 12-3 and is usually eaten at one of the many canteens around the hospital. Lunch usually consists of rice or potatoes or matoke (mashed banana) with a meat or bean sauce. We are usually done around 5 and then we to home to rest, relax, or work on projects. Dinner is our nightly treat out and we’ve been sampling some of Kampala’s delicious restaurants.

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A Day Trip to Jinja: The Source of the Nile Part 2

After our visit to Ssezibwa Falls yesterday, we headed on to Jinja. There we took a cute wooden boat (the picture is from our boat of another group) with a roof out on the Nile River to the Source of the Nile which is where it meets up with Lake Victoria.

20130922-193644.jpgWe got out of the boat and went over to the sign where a new guide explained how John Hanning Speke, an officer in the British Army, discovered the source of the Nile in 1862. At that time, there was a large waterfall, Rippon Falls, where the Nile met Lake Victoria but when the hydroelectric dam was built in 1954 at Owens Falls to provide electricity to all of Uganda, the waterfall was lost. But if you look carefully it is easy to see where the Nile meets Lake Victoria and causes ripples in the water as the spring below the river flows to the top and causes turbulence.

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After the boat ride we had a delicious lunch at the Sunset Hotel Restaurant in Jinja. I got adventurous and tried the whole Nile Tilapia deep fried- it was quite yummy!

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The final stop was Bujagali Falls. This was a beautiful site overlooking the Nile river. Up until a year or two ago we would have been looking at Waterfalls and rapids, but these were erased when the Bujagali hydroelectric Dam was created to provide more electricity to Uganda. It is sad that the falls are gone and this has significantly adversely impacted tourism and especially rafting, but the electricity was desperately needed. The whole scenario is a difficult one.

On the way to and from Bujagali Falls, we stopped the 4-wheel drive vehicle a few times so the students could interact with the local children and give them some soccer balls that they bought at a store in Kampala. I think this was one of the highlights of the day for them- it is pretty evident from the pictures below.
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On the way home we were all so tired from our wonderful excursion that we sacked out. Lucky for me, I was the one with the camera instead of visa versa.
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A Day Trip to Jinja: The Source of the Nile Part 1

This is going to be a really short post as I can hardly keep my eyes open after our wonderful excursion to Jinja, the source of the Nile River. We had a very friendly and knowledgeable guide, Arthur Akampurira from Econest Tim Tours and Travel. He knew all of the birds and animals and gave us a wealth of historical information about the area. I would definitely use him again! Our first stop was Ssezibwa Falls. Below is a picture of the students with both guides- Arthur our driver and guide for the entire day is on the far left. The guide who led the tour of the falls area is in the middle.

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Aren’t the falls beautiful in this picture of the students and me?

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The last thing I’ll share for today is a 360 video I took of the area surrounding the falls. (If this video doesn’t work, I’ll fix it tomorrow)

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A Night of Music and Dancing: Ndere Troupe Show

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We are on our way to a night out at the Ndere Troupe Show- a lively African Culture, Music, and Dance Show in Kampala. We invited some Makerere University pharmacy students to join us. Pictured in the front row are Nikko, Stacy, and Jeff, and in the back row are Andrew, Hilda, and Ivan. Two other students joined us at the show, Adele, and Linda. We had a great time and the
BBQ buffet was delicious. The dancing is so fast, especially when they “shake their booties” that it is hard to get a good picture. But I like the one below because you can imagine the dancing and see the beautiful and colorful native dress.

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The narrator was quite funny as he told tales and explained the music and dance styles from all over Uganda.

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All of the students joined in the dancing at the end. This picture shows the students dancing with members of the Ndere Troupe at the end. Nikko, Jeff, and Ivan really got into it and it was hard to get a clear picture of them, too, as they, too, can dance fast!

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The last picture is the group at the end minus Andrew. From left to right: Nikko, Hilda, Linda, Adele (I hope I don’t have them reversed), then Jeff, Stacy, and Ivan.

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Volunteering at Mulago National Hospital

We’ve now finished 2 full days of work at Mulago National Hospital and what a rewarding experience it has been. Stacy spent the last two days at the Uganda Cancer Center helping to dispense medications. Today she said the clinic and hospital were so busy she felt she was really needed and was thrilled to be able to jump right in and help counsel the patients coming to the window for medications. She also ran into some cute kids and one that just clung to her leg and wouldn’t let go. Nikko, Jeff, and I worked on the wards at Mulago. They have been able to work closely with the pharmacy interns and help them learn how to use drug information resources to make recommendations about the care of their patients. Most of the interns have smart phones but many aren’t aware of the numerous free and reliable medical apps out there that can help answer questions very quickly. Not only are Stacy, Jeff, and Nikko helping to provide pharmaceutical care and train the interns, but both groups of students are learning about each other’s culture. I’ll let them tell you in later posts more about their activities and what they are learning.

So what have I been doing? I’ve spent the past 2 days rounding on the medical floors with a few different teams of physicians. I’ve leaned so much about how it is possible to make the diagnosis and determine appropriate care even without a lot of tests. I’ve learned that in the USA we probably rely too much on medical tests like fancy scans and lots of blood tests when what we really should be doing more of is listening to what the patient is telling us. But, on the other hand, certainly it would be better for Ugandan healthcare providers to be able to obtain and rely on a few more tests than they have to improve the care of patients. Yesterday and today I was able to jump right in and review the patients’ drug therapy and make recommendation about dosing and appropriate LAN tests. I also had the opportunity to do a spur of the moment lecture on the diagnosis and treatment of anemia right at the bedside of a patient who came in with this condition. I thought what I knew was common knowledge but it turned out that most of the people rounding were medical students just starting their clinical experiences and they were really eager to eat up new knowledge.

So, I don’t have any pictures from Uganda today, so I’ll close with a couple of “Harry Potter” images from the students day in London.

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