Safari Time! Lions-Lions-Lions!

Posted on April 22, 2017 by kbohan

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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Last Day in Masindi

Posted on April 21, 2017 by kbohan

21 April 2017: A Blog Post by Dr. Manning

Heading over to the clinic this morning, it felt as though I had been doing the same routine for much longer than just the past week. The cool early morning sun and the familiar breakfast and my excitement in seeing the progress of the patients that I had been following over the last days with the students was a comfortable feeling. I could finally read the unfamiliar abbreviations and evaluate the medical therapies in the charts without too many moments of panic trying to quickly supplement my knowledge with the magic of the internet. However, today was also our last day at MKMC, and a day that reminded all of us that we came here to be pushed out of our comfort zone with the hope of both learning and feeling new things.

Today, two patients illustrated best the push and pull of the learning process for me. The first patient is a 10 month old baby boy we had been following for the last several days who came in with a case of chronic diarrhea and dehydration. The mother had told us several times that she had taken the child for admission to the clinic at least 4 times before for his diarrhea, without real improvement. Several days ago, my nutrition instincts hinted to me that despite tweaking the drugs and medical care he had been receiving, the little boy probably had some lactose intolerance that started because of past diarrhea episodes which was not allowing him to fully recover. He was pretty much only drinking milk because his belly hurt so badly. We has suggested withholding milk for 2 days to see what happened, and today we came in to find a smiling and bright little boy as well as a smiling mother! It was the first time in weeks he was without diarrhea. So much improvement for a simple change. We had also educated the mother about other nutritious food for the child and his appetite was good this morning. I felt so so good seeing a good resolution for this family and I felt good about how we were able to contribute to his care and that my learning process had been a benefit to others as well as to me.
However, a different patient quickly reminded me of how much I don’t know and how challenging helping with medicine can be. A seven year old boy had been brought in overnight because of a snake bite – which was likely from a puff adder. His foot and leg were swollen and incredibly painful, and his tears, as we examined him, brought tears to my eyes as well. Although the was receiving supportive care and our team suggested some important changes that will help give him the best chance, when we discussed the cost of antivenin, it became clear just how hard medical decisions in this country can be. A course of antivenin would likely cost the family more than a year’s salary, and it still might not be effective. My heart is still in knots thinking of this little boy – I don’t know what the outcome will be. There wasn’t anything else we could learn, or look up, or suggest that would make the difference a costly drug would.
These two patients demonstrate the huge contrasts that make up this Ugandan learning experience. They both pushed me to think out of the box, and to wrestle with cost and practicality in medicine (over evidence and efficacy) – something that I find most of the time is a peripheral concern in the U.S. (even though it should be a central one). I found myself feeling less clinical and more emotional about these patients than I have in a very long time, not out of pity for their situation but because I could see my son’s eyes in the boys’ eyes, and my heart in the mothers’ as they cared for their children. Despite thousands of miles, different economic situations, countries, and skin colors – we are far far more alike than we are different.  
I have a lot more reflecting to do on my trip to Uganda, which I know will take some time. And tonight, what I can say is all I feel is grateful. Grateful to my students and colleagues on this trip with me who have helped me wrestle with learning, grateful to the medical staff at MKMC for welcoming us so expansively, and most of all, grateful to the patients who allowed me to participate in their stories. I sincerely hope that I can use this experience to give back more than I have received.

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Another Great Day at MKMC

Posted on April 20, 2017 by kbohan

20 April 2017

Today we divided and conquered with our work at MKMC.  The students and Dr. Manning went on Ward Rounds with the Clinical Officer, Vincent, and Dr. Pauling and I helped Janine, the Health Education Missionary, complete a Pharmacy Audit required by the Ministry of Health.  And while the Wilkes-Binghamton Crew was at the MKMC, Dr. Crowe and Dr. Flores headed off to see OneWorld Health’s newest clinic in Uganda in Bulima with the Administrators, Patrick and Baluku.  When we got back together at lunchtime, it was clear that everyone had a fantastic day!  Dr. Manning raved about how well the students have able to learn about the Ugandan diseases and independently work-up patients and present them to the Clinicians.  I wasn’t surprised at her comments. Tristram, Becky and Jess have been wonderful! I’ve seen much growth in knowledge of culture and tropical illnesses as well as growth in their confidence while working in this very different environment and I’ve been very pleased.  The group has gotten along so well together! Tomorrow is their last day of clinical rotation, ever! They will be done with Pharmacy School as of tomorrow and shortly after they return to the USA, they will be graduating and on to their futures- which I’m sure will be immensely successful!  We also had a guest visitor on Rounds today; John, the Makerere Pharmacy student who showed us around Masindi District Hospital yesterday, was able to join them for rounds.  There aren’t many pharmacists in Masindi and when I found out that John was from Masindi and had a job at Masindi District Hospital, I made sure to invite him to MKMC to see the fine work they are doing.  John was able to join us in Masindi last fall as well.  Today I got to introduce him to Daniel, the Regional Director of MKMC, as well as the on-site Administrator, Baluku.  Perhaps in the future when John is a full pharmacist, he may be able to consult with MKMC to help them with their Medication Use.  

Dr. Pauling and I got a chance to learn more about the Pharmacy Dispensing and Drug Storage processes today as we helped Janine with the Pharmacy Audit.  Joyce, the head of the Pharmacy Store (pharmacy drug and laboratory supplies stock) was a great help! We had to keep asking her to pull stock cards so we could double check the supplies on the shelf.  Basically, whenever we found positive results, we listed 1 point on the data collection form. If the procedure wasn’t followed, we had to list “0” points.  Joyce was so happy every time we could give her a “1”!  Although there can still be some improvement, I was impressed with their overall performance and when talking with Janine, I learned the results were extra good because they had definitely improved from the last audit.  

Tomorrow is our last day at MKMC and we will start the morning by providing a CME for the staff.  More about that tomorrow.

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An Intersting Day in Masindi 

Posted on April 19, 2017 by kbohan

19 April 2017

This morning we arrived at Masindi-Kitara Medical Center (MKMC) and started to review our patients before ward rounds but then realized that it was Wednesday, the day MKMC has morning CME sessions (continuing medical education) so we quickly joined the staff for the presentation. Today they were learning about Nosocomial Infections. These are infections that patients sometimes get while in the hospital being treated for something else.  This is something we try very hard to avoid in the USA and it was really interesting to learn this is of concern in Uganda, too.  The topic was led by one of the Public Health Officer.  I loved his teaching style. Apparently he had asked groups of the staff to prepare different sections and called them up one at a time to do their part. He would write the points down on a white board so we could all see them. After all 4 groups presented, he then pulled it altogether and added some additional points. It was a very thorough discussion.

After Ward Rounds, Becky, one of the Wilkes University Students, had the opportunity to teach an elderly Ugandan woman how to use an Inhaler to help her breathe easier.  Teaching inhaler use is almost a daily activity for the pharmacy students at home during their regular clinical rotations but doing this in Uganda was quite a different experience. The woman didn’t speak English and at first, her attendant, said she didn’t speak English either. But, it turns out she understands it well, but just didn’t feel comfortable speaking it. Then the neighboring patient’s attendants got involved in helping to translate and encourage the woman to learn to use the inhaler. In addition, the photos of how to use the inhaler on the package insert were also very helpful.  In the end, the woman was able to demonstrate appropriate inhaler technique and she was really appreciative. With the help of the attendants, she was able to say “Thank you doctor”, which really touched us.

At the end of the day, we got together with John, a 4th year Pharmacy Student at Makerere University whom I have taught in the past. He has a job at Masindi District Hospital and was able to be in town this week so he invited us to come and visit Masindi Hospital.  It was really a pleasure to meet the staff he works with at the hospital. Sister Caningom Frances, the head Nursing Supervisor, welcomed us warmly by saying “You’re most welcome.” First we met with her in her office and signed the Visitors Book. This is a common cultural activity- whenever you visit someone in their business, you are asked to sign the visitors log.  Then Sister Frances gave us a tour of the entire facility. We got to see the Men’s, Women’s, Children’s, and Maternity Wards.  At each location, the nurse in charge welcomed us by saying “you’re most welcome” and was asked by Sister Frances to give us some information about the type of patients there and give us a tour. We were overwhelmed at the warm welcome by all we met.  At the end of the tour, when we were ready to leave, John said “let me give you a push”. This is the custom of walking you to the door and even if you say it isn’t needed, they really want to do it. I think it is a very nice custom!!

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Reflections on Our Masindi Experiences So Far

Posted on April 18, 2017 by kbohan

18 April 2017: A Blog Post By Becky

Today was our second day at Masindi-Kitara Medical Center. We arrived early to check up on the patients we saw yesterday and to look over the charts of patients who were admitted last night. Sadly when it was time for rounds we learned that Dr. Godson was not able to make it in today. Dr. Godson is an amazing doctor and it is a pleasure working with him. He does everything from general medicine to delivering babies. Yesterday when we finished rounding he just decided he had enough time to do a surgery and invited us to shadow.

When the doctor is away the clinical officers take over patient care. Our malaria discussion last night was very insightful and allowed me to better understand the care involved in treating patients with severe malaria. When gathering a medical history from patients at the clinic, you don’t ask if they’ve ever had malaria, you ask how many times they’ve had malaria.  

A group of eight pharmacists can be overwhelming to patients, so part of the team explored the pharmacy and met with staff this morning. I am extremely proud of the ideas that have come out this group. They are really working to prove clinical pharmacy can be an asset here and trying to create a sustainable program to bring students to in the future. We learned that although many students pass through Masindi-Kitara and make great recommendations, once they leave their suggestions are often forgotten. One great idea I heard today was to keep a folder in the guesthouse at the medical center containing the current projects so the next group can choose to continue the last group’s work.  

After lunch we needed to run some errands, including stops at the africell and airtel shops. Something refreshing about being here is that I am not the only one with phone trouble. I am notorious for being phoneless and out of reach, but here in Uganda I am not alone. Since getting our Ugandan SIM cards we have been struggling to understand the process of airtime and purchasing data. I’m not sure what the fee was for, but when we all received the message about re-registering our numbers, we did what was necessary to do so. As I sit in darkness I am reminded that perspective is everything and can appreciate the things we sometimes take for granted such as having reliable electricity.  

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Day 1 at Masindi-Kitara Medical Center

Posted on April 17, 2017 by kbohan

17 April 2017

It was so wonderful to see old friends at the Masindi-Kitara Medical Center (MKMC) this morning and introduce them to my team, as I’ve been working with them since 2012. MKMC is a private, not for profit outpatient clinic and hospital.  They opened their doors to the clinic sometime in late 2010 or early 2011.  It was started by OneWorld Health, a non-profit which has been leading medical mission trips in the Masindi area and beyond for many years, when they decided they wanted to have a more permanent and sustainable presence of healthcare in the area.  The medical care has always been 100% provided by Ugandans with American partners primarily for the business end.  Their mission is to “provide quality affordable health care to people in need”.  It is not a free clinic but provides medical care at very reasonable costs for a large number of the people in the area.  Over the years, it has become self-sustaining for operational expenses from the fees that are charged.  The day to day business end is primarily managed by Ugandans now with an American Director placed in Kampala to manage their USAID grant and oversee larger projects.  

Today we attended ward rounds with Dr. Godson and the students had the chance to see many patients with Malaria. Believe it or not, we hadn’t seen much of this during our patient interactions thus far in Uganda but it is rainy season in Masindi and Malaria is very prevalent at this time of year.  This evening, we all gathered to discuss the disease, led by Dr. Susie Crowe, from ETSU. Since she has 4 years of experience working in Eldoret, Kenya and has seen too numerous to count cases of Malaria, she was the perfect one to lead the discussion.  We also spent time today with Janine, the Health Educator Missionary for the Masindi Diocese of the Church of Uganda.  She was really helpful in orienting the team to MKMC and common illnesses and issues and also was instrumental in helping us all learn more about Malaria during our discussion. She has had it many times and since she lives here permanently, she doesn’t use daily prophylaxis.  For us Americans, Malaria is a frightening disease for good reason as it kills about 430,000 people a year but for most Ugandans, it is simply a common illness for which they may actually only seek care from a pharmacy or drug shop where they just ask for the medicine to treat malaria – no prescription needed.  It is only the inicidences of severe malaria that bring patients to the hospital.  

We are all looking forward to tomorrow and working more with Dr Godson. He is an amazing physician and teacher. It is so cute to watch him with the babies- he seems to have the perfect demeanor with them and they seem to love him. 

MKMC continues to evolve every time I visit here. They now have a radiology clinic with an X-RAY machine and a new ultrasound. They do about 300 ultrasounds per month and about 70 X-RAYS. In terms of the volumes of patients, last month they hit their highest ever and saw more than 1700 patients!  

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Safe Arrival in Masindi with a Stop to See the Rhinos on the Way

Posted on April 16, 2017 by kbohan

16 April 2016: A Blog Post by Jess

Today on this Easter Sunday, we have left Kampala and are on our way to Masindi. Just to recap our time in Kampala, we spent the majority of our time at Nakesero Hospital working with 4 pharmacists that are training to become clinical pharmacists in that hospital or any hospital that would be willing to work with them. Uganda is different in the sense that they underutilize their pharmacists. Many of the pharmacists in Uganda practice in community pharmacy, but it is very different from the US retail pharmacy because the pharmacists don’t actual have to show up to get a paycheck. If the pharmacists don’t work in the community setting they will work in industry, which the majority of the Ugandan pharmacists seek after graduation/internships. Thus, the pharmacists volunteering at Nakesero are community pharmacists and will still get a paycheck even though they’re not at the pharmacy. Kampala was very different then Mbarara. Mbarara is rural where Kampala is very urban. They each have their own positives and negatives and in Kampala they include positives such as everything is conveniently accessible and close in proximity and the shopping and food was AMAZING, which we actively participated in both way too much. On the other hand, the negatives include overpopulation which leads to high traffic no matter where you go, but that’s pretty much it. 

On our way to Masindi we stopped at the Ziwa Rhino Sanctuary. This was a very unique experience because unlike most safaris where you stay in a vehicle and observe the animals the Rhino sanctuary allows you to go on foot, track the rhinos, and watch them from afar. We found a group of them and we got about 20 yards away from them! We even got to see two little rhinos playing with each other. It was the most amazing experience to actually get to see the animals in their natural environment. We had to sign a release form and our tour guide, Edward, warned us if they start running towards you to hide behind a giant tree, but he said it’s very unlikely it will happen. He explained that rhinos are a peaceful animal. They have poor eyesight but they have excellent hearing and smell which allows them to be aware of our presence, but they won’t attack unless they feel threatened. After observing the rhinos for quite sometime we ate lunch, where I tried to order a traditional US Easter meal but that wasn’t an option, went to the gift shop, and then got back in the van to continue our journey to Masindi. 

As we entered Masindi it reminded me very much of Mbarara. It is very rural, which is a relief after the hustle and bustle of the city. We are staying at the New Court View hotel which is so cute because the rooms resemble the traditional Ugandan homes. I look forward to spending my last week in Uganda here. To everyone reading the blog, “Happy Easter! From my Ugandan family to yours! 

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A Day Trip To Jinja

Posted on April 15, 2017 by kbohan

15 April 2016

Today is Saturday and we were off to Jinja at about 8:15am.  Arthur, from Econesttim Safaris Uganda, was our tour guide and I highly recommend him. I’ve known Arthur for years now and he is an excellent guide with a wealth of knowledge about the flora and fauna of Uganda.  He is also a super nice guy and my friend.  On our way to Jinja, after driving about 45min out of Kampala, we went to Ssezibwa Falls. This is a beautiful cultural site with a waterfall.  Then we went on to Jinja, the Source of the Nile River, and took a lovely boat ride in a cute wooden boat and went to the reptile zoo and saw snakes, among other animals, and a large Nile Croccodile. We ended our time in Jinja with a delicious lunch at the Gately Restaurant.  After we returned to Kampala through the huge “jam” (they call a traffic jam, a “jam” for short), which made it seem like it took us double the time to get back than to get to Jinja, we stopped by the craft shops once again. Since we have a new member of our team, we needed to let her check out the wonderful goodies for sale.  And, coincidentally, some of us also bought more stuff….

Tomorrow we head to Masindi for our final week in Uganda! 

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Last Day of Work in Kampala

Posted on April 14, 2017 by kbohan

14 April 2017  

It’s been a fantastic week! For this trip, our time in Kampala was the most “up in the air” of the plans I had made but once again, there was plenty of work to get involved with. It was such perfect timing for us to be able to work with the new Clincial Pharmacists at Nakereso Hospital as they embark on the development of Pharmaceutical Care services. All 4 of The Ugandan Pharmacists were a joy to teach and mentor and they are very capable of carrying on this project. As we reminded them everyday, we urge them to continue to be reliable team members and to show up every day to work on their units. The way they will gain the rapport and respect of the nurses, physicians, and other healthcare worker is to be dedicated to the patients and the healthcare team. We got to know Peterson and Aziiz best and I compliment them on their quick learning and dedication to this project. As we head to Masindi on Sunday, we leave them under the capable leadership of Winnie. 

This afternoon over a delicious Mexican lunch at Que Pasa, we met with Daniel, the Regional Director of OneWorld Health, the group that developed and supports Masindi-Kitara Medical Center, our next stop. It was great to get to know him as he is relatively new in this position. We had an opportunity to talk about their new initiatives and brainstorm about ways we can help this week at the clinic. 

In the late afternoon, my friend, Patrick, who is one of the Ugandan pharmacists who came to study with me in the USA stopped by the Mulago Guest House for a brief visit. Our time in Kampala was limited to just this one week and we’ve been keeping so busy I hadn’t had time to talk with him. I’m so glad he swung by. And I got the treat of meeting one of his sons and we had fun taking selfies. 

This evening I went to meet another friend, Dr Mohammed Lamorde, Head of Prevention, Care, and Treatment Programs for the Infectious Diseases Institute, to talk about the possible phenytoin research project that Winnie and I want to do. His specialty is Pharmacokinetics. We had a great planning session for this project but he also offered me a chance to help develop a training program to teach Ugandan Physicians and Pharmacists about Antimicrobial Stewardship – a topic very dear to my heart. Worldwide Antimicrobial Resistance is growing and if we don’t become stewards of the use of our precious antibiotics, we will soon be at risk for going back to the dark ages before antibiotics were available to treat common infections. Many of the bacteria are now able to resist the killing action of our normal antibiotics. Uganda is not immune to this problem and in fact may be in a worse situation than the Western world, as are many developing countries, due to the easy access to antibiotics without prescriptions at community pharmacies. Addressing outpatient antibiotic use at the community pharmacies level eventually needs to be tackled but the first steps involve training medical practitioners in the government clinics and hospitals. I am so thrilled to be asked to be part of this project!!

Now I am on my way to the airport to pick up Dana Manning, Associate Professor at Wilkes University and one of old colleagues. She’s been wanting to join my Uganda project for years but it is only now that her children are older and she is able to try it out. Let me introduce her to you now. 

Dr. Dana Manning

 My name is Dana Manning, and I am an associate professor of pharmacy practice at Wilkes. This is my first trip to Uganda and I am very excited to be part of this experience for many different reasons. I grew up in Rochester NY, and have lived in Northeast Pennsylvania (NEPA) for almost 20 years now. I came to NEPA to be with my husband Brian, who runs a hundred year old vertically-integrated dairy farm that makes the most amazing ice cream and fresh milk. I have three great children – Julia (13), Charlotte (8), and Eddie (5). We have our own farm as well, where we have horses, beef cattle, alpacas, chickens, turkeys, 4 cats, a dog, and a bunny. In addition to my pharmacy career, I am also a registered dietitian and I love all aspects of food – from the production to the politics of it.  

      I have traveled to Europe and Australia in the past, but it has been a long time since I have travelled out of the country. I have spent the last 15 years of my life building my family and my career, and I am now in a part of my career where I an doing a lot of thinking about how I want to grow and contribute to the broader world. I am a person who believes that everyone could use a little more “vitamin P” – perspective, and “vitamin H” – humility. I am grateful for the opportunity to travel to Uganda and be part of an experience with pharmacy students that opens our eyes to challenges and opportunities in the healthcare world as well as in the broader world. I am also very grateful to my amazing husband and to my parents, who are going to keep my busy family and farm running while I am gone!

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Healthcare Challenges at Mulago Hospital & A Meeting at Makerere School of Pharmacy

Posted on April 13, 2017 by kbohan

13 April 2017

This morning, as the rest of the team went to Nakesero Hospital to continue working with the new clinical pharmacists there, I headed off to meet Winnie at Mulago National Referral Hospital for Neurosurgery Rounds.  Winnie has been working in that ward as a Volunteer Clinical Pharmacist for about the past year and has done an amazing job gaining the rapport of the head Consultant physician and the other physicians.  Today I joined her to observe what she has been doing and to try and help with any drug therapy problems that arose.  I immediately saw how much they depend on her for drug information and recommendations.  One of the big challenges in treating patients with head trauma and/or neurosurgery at Mulago Hospital is the lack of drugs, ability to run basic lab tests, and obtain CT scans and MRI’s. The patient’s family often has to go out and purchase the drugs from a community pharmacy and they may have to go to a private hospital and pay to get a CT or MRI.  One of the big problems Winnie has noticed is that at least 3 people per day go into Status Epilepticus despite being on Phenytoin, a standard drug for prophylaxis.  We are working together to develop a research project to see if it is because the patients aren’t achieving adequate drug levels in their blood. In the USA, we would never consider using this drug if we couldn’t get drug levels but here in Uganda, they use it all the time but have never been able to do drug levels.  This is a drug that if adequate levels aren’t achieved, the patient could have a seizure. If the levels are too high, the patient could exhibit signs of toxicity.  We really need to research the issues because when a drug is being used to prevent seizures, we need to know it will do this. Using it, if the levels aren’t being achieved, is just a waste of a precious resource. Of course, if we find the levels are low, that will lead to another project to see why they are low- is it because the dosing isn’t high enough, or the drug is counterfeit or because the patients may have a genetic variance that causes them to more rapidly metabolize the drug…. But, first things first.

After rounding at the Neurosurgery Unit, Winnie and I went back to Nakesero to meet with the rest of the team. They had an excellent day and since the work was done, we decided to go to lunch.  This afternoon, then, while the women students went to do more shopping, the faculty and one of the students went to Makerere University School of Pharmacy to meet with the Head of the Pharmacy Program, Dr. Kamba, and two other faculty I’ve been working with closely- Professor Richard Odoi and Kalidi.  I wanted to introduce them to Erin, the Binghamton Faculty member on this trip with me who is in training to bring future Binghamton pharmacy students. We are also accompanied on this trip by 2 faculty from East Tennessee State University (ETSU) who are looking for opportunities to develop a Global Health project in Uganda.  It was a great meeting. We were able to consider options for possible collaborative research and also learn more about the beginnings of the pharmacy school here which was started by Professor Odoi in 1988.  He said that the first class was only 10 students and that others at the University were skeptical the program would draw many students but it has been extremely successful and is a very popular program today!  The next step in the pharmacy program is to start a Masters of Science in Pharmaceutical Care (Clinical Pharmacy).  I had helped work on the initial concepts for this new curriculum but Dr. Darowan Akajagbor, previously of D’Youville School of Pharmacy in Buffalo, NY had put it altogether during her Carnegie Fellowship in Uganda in 2015. It is making its way through the Curriculum Process at Makerere University and we hope to see the first class in August 2018.

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