Potatoes, Patients, Data Collection, and Meetings

Wednesday, 13 June 2018

I slept really well last night and enjoyed getting up a little later and the delicious breakfast at the guest house. I always love the fried potatoes and onions they make in Uganda. They call these “Irish Potatoes” as opposed to the other common potato which is called a “Sweet Potato”. Actually, if someone wants the Irish potatoes which are normal white potatoes, they may say “I’ll have some Irish.” If a Ugandan came to the USA and asked for sweet potatoes they would be in for a big surprise. In Uganda, sweet potatoes aren’t orange and they aren’t very sweet. They look basically like a peeled russet potato and they are gray when cooked. In the USA, sweet potatoes are orange on the inside and are more sweet than the Ugandan version.

Today we planned on spending most of the day recording data from the patient charts but we made a stop by the Neurosurgery ward first, and the head consultant, head Neurosurgeon, insisted we help out on rounds. He was doing teaching rounds this morning, called Major Ward Rounds, and he and the other surgeons have come to rely on Winnie’s expertise in terms of making sure the patients are receiving the drugs that are ordered and making recommendations about antibiotics and other therapies. A Global Health student for Western Canada also joined us for rounds. She is here for her Global Health Program but is interested in pursuing a pharmacy degree so Winnie is going to let her observe. Rounds were quite interesting and I saw very quickly why they rely on Winnie. Many of the patients had drug issues. One major issue is that the Neurosurgery ward has very few drugs. Most of the patients had to send family to purchase their medications at the local pharmacies. And when they can’t afford them, they go without. Winnie always looks at the actual drug products and asks how the patient is taking it. In one instance, the pharmacy labeled the medication envelope (they don’t put the tables in vials as we do in the States) with “phenytoin 250mg – 1X1” but clearly the capsules in the envelope were labeled phenytoin 100mg. The 1X1 means the patient is to take 1 capsule once a day. But, the doctor’s order in the chart read “phenytoin” 300mg OD. This means the doctor wanted the patient to have 300mg which would be 3 capsules of 100mg and these should be taken once daily. How did the pharmacy get it so wrong? Well, probably because most drugs are dispensed by non-Pharmacists. Although a Pharmacist must be the supervisor of the store, they do no need to be present to dispense drugs. Much of the time, non-medically trained people are hired and trained on the job to dispense the drugs. For a country (USA) where you can’t even open a pharmacy if the Pharmacist is not present, this is just a bit scary. It is fortunate the patient didn’t have seizures because he was only taking 1/3 of the required dose. Winnie spoke to the patient’s family member and changed the directions on the envelope and explained the correct dosage. In another situation, Winnie was asked to recommend and dose an antibiotic for an infant, and in another we recommended discontinuation of an antibiotic when infection was no longer present.

We finally made it to the records room and spent a couple of hours collecting data. In the afternoon, we went to the Pharmaceutical Society of Uganda (PSU) offices for an Education Committee Meeting. I was invited to attend to discuss the USA PharmD Program. This committee has been tasked with making a recommendation about whether Uganda should develop a PharmD program and they’ve been talking to Pharmacists trained in these types of programs all over the world. They had a Pharmacist trained in Algeria these who spoke about his program and some others. It was so interesting that despite the common name, these programs all different. I also explained to them about how our Continuing Education programs to maintain our licensure works. They have a requirement that all Pharmacists complete programs yearly but there are not specific numbers of credits or hours right now. Most of the time, they do this as part of the annual general pharmacy meeting of the PSU.

Arthur and KarenBeth

This evening a friend stopped by the guest house to visit. I met Arthur, my regular tour guide of EconestTim Tours and Travel Uganda, back in either 2011 or 2012. He was eating lunch at The New Court View Hotel in Masindi. I sat near him and we started to talk. He told me about his tour company and how he got started. I liked him right away but didn’t have need for a tour guide at that time. I kept his card and reached out to him the next year. Who would have ever guessed that 6 years later we’d would still be working together and developed a friendship. He has taken me and my students on numerous safaris and trips to Jinja. He has great knowledge of all things cultural in Uganda as well as flora and fauna. I highly recommend his tour company. Plus his vehicles are great!!

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Getting Down to Business

Tuesday, 12 June 2018

This morning my day started very early.  Winnie had a meeting with the Executive Director of the Mulago Hospital scheduled for 7am to discuss the severe antimicrobial resistance problem they are having right now and to present some solutions that the Infectious Diseases Institute (IDI) can help with. I was waiting for her promptly at 6:45am but it turns out she got pulled over this morning by the traffic police on a routine check of having the correct and in-date driver’s permit. She had hers but the stop took a long time and when you don’t beat the morning traffic, you get stuck in what’s called a really bad “jam” (traffic jam). It can then take you an hour to go a couple of miles. These routine traffic stops are just one of the regular obstacles people deal with around here.  It is meant to help make the roads safer but ends up delaying everyone.  Anyway, things worked out, as they tend to do, and when we reached the appointment, the Executive Director was just arriving—he probably got stuck in the “jam”, too. He listened to Winnie and my ideas carefully and agreed with the Infection Control procedures we suggested and said to write them up so he could approve them.

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A waterless hand soap station donated by the Duke Neurosurgery Team for a research project.  The sign explains in the local language of the central district, Luganda, the importance of hand washing and infection control.

This will allow IDI to come in and do a full work-up to find the source of contamination, if possible, and stop the spread. This will involve taking cultures from the healthcare practitioners and also swabbing and culturing equipment and beds, etc, on the wards.  They will also perform disinfection procedures.  One basic issue is that the bed linens are not washed and sterilized by the hospital. The patient’s family members have to wash them and re-make the beds. And they certainly aren’t sterilized. Also, something as simple as waterless soap stations or sinks with running water for hand washing in between patients that we take for granted in the USA is something that is not standard in Uganda.  Old facilities just weren’t created with sinks near the patients and even though there are some waterless soap stations on the walls, they were donated from a Duke University project and many of them are now empty. The hospital doesn’t have the funds to make this sustainable.

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Professor Richard Odoi and KarenBeth

We then headed over, through the traffic, to Makerere University Pharmacy School where I was reunited with Professor Richard Odoi. It was so good to see him!  He has been collaborating with me from the beginning and my first research project assessing the water, health and sanitation endeavors of The Water Trust in Masindi, Uganda back in 2011.  We actually started our conversations via email back in early 2010, maybe even 2009.  Anyway, this trip I have brought a memorandum of understanding to formalize our relationship, Binghamton University and Makerere University. He will be taking it to the Dean of the College of Health Sciences for signing.  We also discussed possible next steps in the Pharmaceutical Care Research and hope to develop another project for next summer.

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This is how many of the medical records are filed. No electronic records here!

Finally, we made it back to Mulago Hospital where we spent the rest of the day going through the paper medical records of the neurosurgery patients we need for the Phenytoin Study.  We found many challenges. First, the charts are not organized well but somehow the medical record staff know what they are doing.  They brought out this huge duffle-type bag (white bag in the photo) and it was labeled “neurosurgery”.  But, the charts were just stuffed in there in no particular order. It took about 5 of us to sort through them to find the patients that qualified for our study. They needed to be adults 18 years of age or older, they needed to have had neurosurgery, and they needed to be ordered Phenytoin.

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The large white bag had neurosurgery charts piled in there in no particular order. The pharmacy student standing next to me is Sara, one of Dr. Melanie Nicol’s APPE students who is being precepted by Winnie.

Then we found out that the charts of the patients who had died were kept in a separate location and to pull those, we needed to hunt for an inpatient record number. Unlike in the USA where everyone gets 1 medical record number that stays with them their whole life, these patients get a new number every time they are admitted and old records are not pulled routinely to see what happened to the patient on the previous visit. We had to go to the neurosurgery ward to look through the ledger books to find more patients.  We met with the head nurse, called the “Matron”, and other nurses who dropped everything to help us find the correct ledgers and explained the codes.  We were then told that there may be more charts in the outpatient clinic, so tomorrow morning, the first order of business it to go there to look for more records.  The picture above gives you an idea of what the records room looks like. There are some files on shelves but they are just stuffed in there.  It’s a little bit crazy.  But I have to compliment the medical records staff. They know where to find what they need. It is kind of like my Dad’s old workshop. When you walked in there it looked like a bomb blew up but just ask him where something was, and he knew just where to go get it.

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It’s Good to be Back in Kampala!

Monday, 11 June 2018

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Entebbe Airport Guest House

I’m in Kampala now! I had a wonderful night and breakfast at the Entebbe Airport Guest House last night. I awoke to sunshine and beautiful gardens. After eating a delicious plate of fresh fruit- papaya and watermelon- and freshly squeeze passion fruit juice, eggs and bacon, yes, I said bacon, I awaited the arrival of my driver, Haji.

We left Entebbe around 10:30am and reached Kampala in about an hour later. I was surprised to see that the new Airport Road is kind of open for business. It made the drive so much faster. The reason I said “kind of” is because it will be a toll road and the ability to charge tolls isn’t quite finished. I was amazed at how similar it looks to American toll roads. There is even a service plaza for easy access on the road. But although it isn’t officially open, no one is preventing cars from driving on it. It was a bit scary at times, though, because cars get confused about what direction to go on it. There are actually 2 one-way roads—one to the airport and one to Kampala.  Luckily, there is very little traffic and Haji just scooted out of the way when a car came towards us head on in our lane.  We reached Kampala without incident and I checked in to my Kampala hotel: The Mulago Guest House. I really like the staff here and the rooms are clean and safe.  It is also very close walking distance to the hospital where I will be spending a lot of time. It is a benefit not to have to walk across town on the busy, traffic-jam filled roads.

Winnie came to meet me for lunch and right away she noticed the Executive Medical Director of Mulago National Referral Hospital was having lunch and brought me over to meet him. We spoke briefly, but in those few minutes he had nothing but great things to say about Winnie’s pharmaceutical care work in the Neurosurgery Ward and he spoke longingly of having many more clinical pharmacists working at the hospital. The main issue is lack of advanced training for pharmacists in Uganda. The only degree offered now is the Bachelors of Pharmacy and that does not provide enough clinical training for the provision of advanced pharmaceutical care.  I have helped to develop and teach pharmaceutical care skills in the Bachelors program but it is still basically just an introduction. The entry level pharmacy degree in the USA evolved to become the Doctor of Pharmacy degree 15 years ago. Beginning with the graduates in 2003, every pharmacy program offers a Doctor of Pharmacy degree.  Much study and debate went on before this was enacted but the decision was out of necessity—the USA healthcare system really needed pharmacists that could provide advanced medication management and work as an integral part of the healthcare team to help improve patient outcomes and ensure safer and more effective medication use overall. The desire of such a level of practice in Uganda is present—many pharmacists, especially the newer trained pharmacists, aspire to directly impact patient care and make lasting improvements in the healthcare of Ugandans. But, the training opportunities just aren’t available quite yet.  This is something I want to explore more. The answer, at least for most Ugandans, isn’t for them to go out of country to enroll in a Pharm.D program. There are very few of these outside of the USA and those in the USA are impossibly expensive for a Ugandan. I’m not sure they really need a full PharmD education. Their undergraduate degree is quite extensive in terms of pharmacology (how drugs work in the body) and pharmaceutics (how to make drugs into products patients can take like tablets…). In fact, I am always impressed at the level of knowledge of the Bachelors students.  They just need more therapeutics (how to use drugs to treat diseases in patients), drug information skills (how to find evidence-based medical information at the point of care), and lots of hands-on mentoring while they practice their skills with real patients.  This may require a couple of years of training, but not to have them repeat courses and take a full 4-year Doctor of Pharmacy degree.

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A typical Ugandan meal of rice and beans, meat sauce, greens, and pumpkin (yellow squash-towards back) and matoke (in front-mashed banana)- yummy!

After lunch, Winnie took me over to meet with the staff of the International Students Office at Makerere University Medical School. This is the office that arranges and supervises medical, nursing, and pharmacy students and residents who come from all over the world to learn while working with medical practitioners in Uganda.  It was nice to be warmly greeted and meet up with Susan and Phionah again. They remembered me from my past visits. Part of my goals for this visit to Uganda, in addition to the research, is to investigate possible opportunities for Binghamton Pharmacy Students.  After talking with Susan and Phionah, I can definitely see there are numerous possibilities.

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Winnie, Susan, KarenBeth, Phionah at International Students Office, Makerere Medical School

I decided to call it a day a bit early so I can hopefully, get a really good and long night’s sleep to ward off any remaining jet lag.  Today I have felt very well—just a bit tired. Greeting so many people I know already kept me going. Good night for now. I will be up super early for a 7am meeting with the Executive Medical Director of Mulago. I’m accompanying Winnie and a pharmacist from the Infectious Diseases Institute to a meeting about what can be done about the horrible situation of antimicrobial resistance here.

I enjoyed watching these monkeys play around my balcony this afternoon. They are cute but I can’t get any really good pictures because I’d have to open the glass doors and they would come right into the room through the grating.

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Arrival in Uganda!

Sunday, 10 June 2018

I have arrived in Entebbe—tired and looking as though I’ve traveled halfway across the world, but very happy to be here safely. The fragrant air is filled with Uganda smells—wood fires cooking rice and beans mixed with gasoline. It’s a bit humid and sticky, around 71F, but once you settle down after hauling luggage and an terribly heavy backpack around, it does feel cooler, especially in the dark of night. As I write this it is 1:45am and I’m settled at my lovely guest house for the night after having taken a beautiful shower!

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Sleeping under a mosquito net makes me feel like I’m a princess!

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The rain shower in this bathroom felt heavenly after 29 hours of air travel!

We had a bit of a delay at the gate in Amsterdam. We had boarded the plane and the engines had been turned on when an engineer noted a fuel leak in one of them. It was thought to be repairable and so we were kept on the plane while the work was done. Twenty minutes turned into 2.5hrs before we actually took off. Fortunately the plane wasn’t too hot, water was provided, and I fell fast asleep during most of that extra time. We finally got in the air and the flight was relatively smooth and uneventful. We arrived in Entebbe about 1.5 hr after our scheduled arrival of 10:20 so we were able to make up 1hr of time. I’m so glad I made arrangements to stay in Entebbe overnight. My friend and driver , Haji, will pick me up I’m the morning to go into Kampala.

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On My Way To Uganda!

Saturday June 9, 2018

21DE05CA-D584-4340-9EC7-DC019700622CI’m finally at the airport awaiting my first flight on this 26 & 1/2 hour journey to Uganda. No matter how early I begin my packing process, I always seem to have last minute, critical issues to attend to and today was no exception. I needed to get money (cash) to take with me to Uganda and when I got it out of the ATM machine last night I knew I would have to go to the bank today to work with a teller to get it changed into large bills- $50’s- that were dated 2006 or more recent and had no marks or tears. If you bring bills that are old or aren’t perfect, the money will be rejected- it has happened to me before, even when I thought I’d done ok with the bills. But usually I’m able to get what I need from the bank. The teller just looks through their cash drawer and finds the bills that will work. Well the new bank I’m using doesn’t have cash drawers anymore. They just get the money out of what is basically an indoor ATM machine. They can’t pick and choose from among the bills. Plus I apparently chose the busiest time on a Saturday morning. The teller was very nice and helpful, though, and after a few tries of getting money out of the machine, we came up with clean good bills. When I got home and sorted through the money and double-checked the amount, I came out $10 high. What had gone wrong? Both my husband and I checked and counted the money over and over again and wracked our brains to figure out how this could have happened. We worried that I’d done something wrong at the bank. Finally we decided to go to the bank to let the teller know the problem. She again was quite busy but took my contact info and said she’d call me later when she counted her drawer. Luckily if she was short, she could just debit my account without filing a complaint since I’d brought it to her attention. So that task done we headed to the airport. As I got out of the car I noticed a $50 bill on the floor. What!!!! Now I wondered if I was $60 over instead of just $10??? Well, at least the bank teller was calling me back soon and I could explain. So I checked in and settled down to wait and calm myself after this morning of running around like a crazy person. As I mentally prepared for this trip my phone rang- the bank teller. Guess what? Her count was even- I did not take more money than I was due! What a relief. So in the end, instead of being $10 up I’m actually $60 up. This was easier to figure out. My husband was holding the money and probably added in 3 $20 bills by accident. So now he has donated to my trip! Ha! Ha! Well that is much better than causing bank fraud. Whew! They are calling my fight soon. I’m looking forward to a wonderful trip! Stay tuned for more adventures…

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Returning to Uganda: 3 Days To Go!

Wednesday, June 6, 2018

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KarenBeth and Winnie at Makerere University School of Pharmacy

Greetings!  I have good news—I’m on my way back to Uganda this weekend for my 12th trip!  I know it’s been over a year since I’ve written but my friends and students in Uganda are never far from my thoughts. I’ll be coming by myself, no pharmacy students this trip, to conduct research with a faculty colleague from Makerere University in the Neurosurgery Ward of Mulago National Referral Hospital.  Winnie Nambatya is a clinical pharmacist who received her Bachelor’s of Pharmacy degree from a university in Cuba. I met her years ago when she was working with the Pharmaceutical Society of Uganda (PSU) to promote clinical pharmacy and pharmaceutical care. She eventually went to a university in South Africa for her Masters of Clinical Pharmacy degree and now she teaches at Makerere and works with the physicians and nurses in the Neurosurgery Ward to ensure safe and effective medication use. Through her experiences, she has noticed that patients may not be getting optimal results from a drug that is being used to prevent seizures in neurosurgery patients called Phenytoin. This is a drug commonly used throughout the world but in the high-income countries, therapy with this drug is always monitored by obtaining drug blood levels, which is called therapeutic drug monitoring (TDM). By using TDM, we can make sure the drug concentration is high enough to prevent seizures but not too high as to cause adverse effects.  Unfortunately, TDM is expensive and not possible in most developing countries, like Uganda. Our goal with this research is to conduct a retrospective medical chart review to systematically characterize the use of Phenytoin at Mulago to learn how the drug is being administered and how the patients are responding. Obtaining this baseline data will help us develop a plan to optimize the therapy with Phenytoin to achieve the best patient outcomes.

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Professor Richard Odoi, Kalidi, and KarenBeth at Makerere University School of Pharmacy

In addition to research, during this trip, I’m hoping to catch up with many friends and colleagues. I’ve found a few old photos of some of them.  As always, I look forward to sharing my journey with you so stay tuned…

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Patrick, one of the Ugandan pharmacists who came to the USA to study with me, KarenBeth, in 2013

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KarenBeth with Peter, a Pharmacy faculty member at MUST in Mbarara at his own pharmacy. His wife, Connie, is also pictured.is wife

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KarenBeth and Dr. Godson at Masindi-Kitara Medical Center (MKMC)

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Janine, a health education missionary for the Church of Uganda, and KarenBeth at MKMC

For those new to the blog, here is a brief synopsis:

I am a pharmacy faculty member with a passion to use my knowledge and skills to help others. My initial foray to Uganda was for the purpose of helping to assess the water, health and sanitation project of an NGO, The Water Trust, in Masindi, Uganda in summer 2011.  Even before that trip, I began to collaborate with Professor Richard Odoi at Makerere University School of Pharmacy to develop a global health experience for advanced pharmacy students in Uganda. I always wanted this project to be sustainable and as beneficial to Uganda as to me and my American pharmacy students. Working with Professor Odoi over these past 7 years and with the help of a Fulbright Specialist Grant in 2014, I have been able to assist in the development and implementation of new curriculum to teach pharmaceutical care to Bachelor’s of Pharmacy students. We also conceived the plan to develop a Masters of Clinical Pharmacy program which is in the curriculum approval process at Makerere University. (The draft of this curriculum was developed by Dr. Darowan Akajagbor, a prior faculty member at D’Youville School of Pharmacy.)  Over the past 7 years I have also been able to conduct pharmaceutical care conferences in Mbarara, at the Mbarara University of Science and Technology (MUST) and for pharmacists of the Pharmaceutical Society of Uganda.  Simultaneous to my work in the pharmacy education system in Uganda, my students and I have also work with the medical staff of Masindi-Kitara Health Center (MKMC) in rural Uganda to improve the safe use of medications. MKMC is part of OneWorld Health, an NGO in Charleston, SC, who works with communities in Uganda and Nicaragua to develop sustainable healthcare facilities. My students and I attend multidisciplinary patient rounds with the MKMC providers, look up the answers to drug information questions, and prepare educational presentations to provide continuing development. The following key blog posts would be a good way to learn more about my endeavors:

https://pharmacyclassintoafrica.com/2015/10/20/spreading-the-news-about-advancing-pharmacy-practice-in-uganda/  (examples of presentations about my previous work- includes research posters)

 

https://pharmacyclassintoafrica.com/2017/04/13/healthcare-challenges-at-mulago-hospital-a-meeting-at-makerere-school-of-pharmacy/  (this post talks more about the concerns regarding the use of Phenytoin)

 

https://pharmacyclassintoafrica.com/2016/05/02/ponderings-at-the-end-of-my-9th-trip-to-uganda/ (a blog post that highlights the multifaceted nature of the healthcare challenges in Uganda)

 

 

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Safari Time! Lions-Lions-Lions!

22 April 2017

As I write this post, I’m super envious of the group that went to Murchison Falls National Park today! They saw lions on their first game drive!! At the last minute, Dr Manning was able to accompany the 3 Wilkes Pharmacy students, instead of traveling home with Dr. Pauling and me, and right about now I’m guessing she is saying this was a fantastic decision!  The photos are compliments of the tour guide, Arthur, from Econesttim Tours and Safari Uganda.  Enjoy some of the wildlife they saw today. I’m hoping they send me more photos tomorrow. (He told me these are photos of 4 different lions.)

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