First Year Pharmacy Course Modules

First year is finally over and so, here I am, giving those of you who are thinking about applying to a pharmacy course, or have already applied, a little insight into life as a first year pharmacy student.

PH1000

This is a non-examinable module that must be passed in order to progress to the second year and consists of calculations and a placement.

  • Calculations

A few workshops which include homework, and then a test at the beginning of December. The two books recommended are ‘Practical Pharmaceutical Calculations’ by Bonner & Wright; and ‘Introduction to Pharmaceutical Calculations’ by Rees, Smith, & Watson. Before you think, that’s quite a lot to get through if we only get ~4 workshops, well, you only go through the first few chapters in your first year. It’s not too bad but make sure you revise and fully understand how to work through problems.

  • Placements

We were the first year to undergo placements at Cardiff and Vale Hospitals and I’m afraid to say we were misled on what we would be doing. We were under the impression that we were shadowing a pharmacist for 2 hours every 3 weeks for 9 sessions. As quite a few of us had experience within community pharmacy, this would have been an incredible opportunity to become familiar with hospital prescriptions, common drugs, etc. 

However, this was not the case.

The staff were unsure of what we were supposed to be doing and so in pairs, we would sit in an elderly care ward for two hours talking to the patients. The patients were reluctant to speak with us leading to long awkward pauses in dragging conversations. This was of no fault of their own – our placements had been scheduled to that we would see patients immediately after their lunch and would cut across visiting hours. Most patients just wanted to rest, sleep, or have some peace and quiet.

At the end of each placement we had to you complete a reflection page on a site called ‘Mahara’. The reflection was based on what you had learned that session – talking to patients does not constitute as ‘learning’ which meant that we had to be ‘imaginative’ in our reflections. Each short reflection must also linked to the skills used, e.g. ‘Talking to a patient who had experienced a fall which had shaken their confidence’ This page could be linked to actively listens, provides clear and accurate information to patients, and exhibits suitable levels of confidence when communicating.

An example of a reflection:

https://www.pharmacyregulation.org/sites/default/files/example_records_for_revalidation_for_pharmacy_professionals.pdf

Tip – complete a Mahara entry straight after each placement otherwise a) the sessions will blur into one and you’ll have forgotten what you did and b) you’ll spend three days doing Mahara right before the deadline. Don’t put yourself through it. Just don’t.

PH1121

This is quite a ‘waffly’ module which gives on overview of the drug development process. The January exam contributes to 80% of module grade, and the other 20% comes from a presentation on a plant which has medicinal properties. Our assigned plant was ‘Rawolfina serpentina’.  The presentation is delivered in front of the whole year and considering this fact, it was marked quite harshly. 

* Don’t forget about the practical that you did in this module – it is examinable material!

https://bestpractice.bmj.com/topics/en-gb/337 describes paracetamol overdose which is covered in the module. The paracetamol overwose workshop was fun since the lecturers had set up a hospital bed with one of the taking robot dummies which would suddenly start groaning and seizing.

PH1122

This module was probably my favourite as made me feel like as had finally enrolled on a pharmacy course. The main part of this module of the RTS workshops (Responding to Symptoms). In the first year there is an RTS session roughly every two weeks which focuses on OTC conditions and treatments. To get the most out of the workshop you will need to do some pre-reading, which is just to read (+ learn if you haven’t had any experience in community) a chapter from Rutter (2017) Community Pharmacy: Symptoms, Diagnosis and Treatment. This is a great book and is available as an ebook from Cardiff University Library.

At the end of each workshop you will work in pairs or threes to complete OSCE style questions – one patient, one pharmacist and one marker.

Something that I liked about the workshops is that if you speak Welsh, they will place you on a table with other Welsh speaking students. Arriving in Cardiff I thought that I would be speaking Welsh everyday like I did at home, but I found that very little Welsh was spoken. When you go shopping, the person at the till usually doesn’t speak welsh, and very few of your lecturers do (which was a big change from secondary school where all my teachers spoke Welsh). Therefore, these workshops were a lovely way to feel at home.

Close to the end of the year you will have a workshop led by OSCE actors. Seeing a ‘Communication’ workshop in my timetable filled me with dread and thought that it would be a waste of time. That workshop was one of the most important workshops that I have been to. It is held after the mock OSCE and they will pick up things that students did during the mock.  For example, they showed how we knocked on the door, walked in, head down, sat down, then introduced ourselves (guilty). It looked hilarious when they acted out what we did and they gave us lots of tips of how to speak to patients. The actual OSCE was nice and a bit more realistic as compared to the workshops. In the workshops you get a set of symptoms, you diagnose and treat. Community pharmacy doesn’t work like that – you get patients asking for a certain medication, or they want to know which one is the best, therefore you need to know the effectiveness of medications.

Top tip: MAKE NOTECARDS. I rarely used notecards in A level, but in this particular module it’s a great way to test your self on the treatments and referral criteria for OTC conditions.

  • Clinical Knowledge Summaries (NICE)
  • ‘Community Pharmacy: symptoms, diagnosis and treatment’ is the go-to book for this unit. Everything you need to know is in it.
  • Non-prescription Medicines by Nathan, A. 2010. I didn’t know about this book until recently, and by that I mean after the exam…I love know how medications work not just ‘this is the condition and this is the drug used to treat it’ and the book explains how the drug acts within the body to target that condition.

The ‘POP’ classes are useful which gives you an introduction to dispensing such as how to check the legality of a prescription, and how to label. However, for those of you who are planning on doing a community pharmacy placement in the summer, in reality, dispensing is quite different.

The exam was quite straightforward, especially since I had experience within community pharmacy. I always go into an exam expecting the worse and so had expected scenarios where patients had a long list of medications that they’re on with multiple interactions, but in fact, only a few were on other medications and they were also quite obvious ones.

PH1123

This is the module that will probably make you re-think why you’re on a pharmacy course. The practicals involve making and spreading agar plates, looking at the type of bacteria growing etc. and it just doesn’t feel like what you signed up for.

The first assessment you will have in the MPharm course is in this module. The assessment is released in three parts and so I suggest you do them as soon as you get them, other wise you’ll find yourself trying to do it the week before and finding out that its actually not that easy. It is a series of questions, and each has a word limit. I found this difficult as 25 words is not enough to answer a question. 

  • Oxford Handbook of Infections Diseases and Microbiology, Chapter 2, Antibiotics.

For the first year you don’t need to know the names of most drugs (which is great as in one of the first microbiology lectures there’s a few slides with just names of antibiotics and you’re a bit like ‘do I need to know this?’). However, you do need to know the names of antivirals and antifungals.

Towards the end of the module you are taught Glycolysis + Krebs Cycle, and oxidative phosphorylation in more detail which is quite interesting. This leads to my next point – there is a lot of detail in the module which needs to be learned for the multiple choice exam and it can make you feel annoyed as maybe one MCQ will come up on e.g. the whole of glycolysis and Krebs which took you a whole day to learn.

PH1124

This was another of my favourites as it gives a more in-depth look that the human body.

The module is graded through an exam and essay. I always expect the worse and so I thought that they’d give us something really sciency as an essay topic but its quite nice and vague e.g. healthy eating, smoking, etc. They also give you PLENTY of time to write the essay with about a month and a half over Christmas for the first draft, and a month for the second draft.

Useful books and website which apply to all units:

Unit 1 is self taught and covers basic principles such as the position of the body.

Unit 2 – Nervous, Integument, and Skeletal System. Some of the NS parts have been covered in A Level such as the action potential. This is one of the heaviest units, as you come across so many terms that you’ve never heard of before. This means that it will take you ages to learn and so I’ve gathered a few things that might help.

  • Cranial Nerves – you need to remember their names and a little about them. I struggled to remember the order so I made a sort of story/sequence in my head.

I’d point to my nose (olfactory), then eyes (optic) then bridge of my nose (oculomotor), ear (trochlear). Now here’s the story. I imagine I’m walking down the street in a beautiful low cut dress which shows of a beautiful necklace which has three gemstones in it (trigeminal). Someone notices the expensive gems and they attempt to abduct me (abducens). I struggle and I get punched in the face (facial) which causes my hearing to go all skew iff (vestibulocochlear). I retaliate hitting them in the chin, causing them to bite their own tongue (glossopharyngeal) and they start choking (vagus). They fall to the ground, landing on their back (spinal accessory) and I walk away, not before I stick my tongue out at them (hypoglossal) like the mature adult I am.

For whether or not they are sensory/motor/both, our lecturer used the following sentence – some say marry money, but my brother says big brains matter most.

https://bmc.med.utoronto.ca/cranialnerves/

https://www.orthobullets.com/basic-science/9009/fracture-healing

Unit 3 – Cardiovascular and Respiratory introduces some complex pathways such as intracellular signaling which comes up in a few different modules and units and so I’d recommend spending some time to learn the basics (https://en.wikipedia.org/wiki/Second_messenger_system).

It covers topics such as blood pressure, control of cardiac contraction (which I found very complicated and did not learn. Inotropy, chronotrophy, and lusitropy mechanisms involve secondary messengers), cardiac action potentials, haemostasis, gas exchange.

http://www.frca.co.uk/article.aspx?articleid=100096

For both unit 2 & 3 I’d recommend trying to read the chapter the night before just so you can begin to get your head around it.

Unit 4: GI system was quite a new unit for all of us as only digestion is covered in A level. It doesn’t go into that much detail so it’s a relatively short unit.

Unit 5: Immune System. This was another difficult one and the lecturer may be unaware of how little immunology we had done previously. Some parts are quite nice such as the cells involved in immune responses but again has quite a few new terminology that you need to grasp. I remember sitting in the lecture about the classical complement pathway and none of us had any idea what was going on. The lecture kept saying different variation of numbers and letters such as C4b2a and how that is the C3 convertase which forms the C5 convertase C4b2b3b. You could feel the confusion in the room and everyone was looking at each other wondering if they were the only one that didn’t understand. They weren’t. However, if you make a poster flow chart the complement system becomes much easier to understand and learn.

Unit 6: Endocrine – a very interesting unit which covers things like the hypothalamic-pituitary axis and insulin/glucagon.

Unit 7: Kidney and Urinary system– short unit which mostly recaps A level stuff.

Unit 8: Reproductive Hormones – again covers A level work.

This exam was quite nice and was composed of MCQs and eight 5 mark questions. I had expected the long answer questions to be very scientific such as ‘describe muscle contraction’ where I had to give all this terminology, but it was quite nice.

PH1125

For this module I would recommend you to bring your A Level notes with you to University as it covers many of the same concepts including organic reactions, acidity, kinetics, and isomerism. Towards the end of the year they organize workshops which give you a chance to work though exam style questions. I found them very useful but in the end the exam was still very difficult.

Overall:

  • They print off handouts – buying a printer was useless as I could just go to the library to get my notes printed.
  • Exams are different to A Level – most are multiple choice and the questions are not designed to trick you. They will be straightforward such as ‘Describe…’
  • I typed up my notes and expended on some concepts that I didn’t understand. I highly recommend making your own notes, even if it is very time consuming as at the end of the year you will have a 40 page (back to back) display folder of PH1124 notes to study instead of ~2 lever arch files worth of handouts.
  • I have uploaded my flashcards for PH1124 under the name MTFarm on Quizlet (MPharm1).
  • No past papers (with the exception of PH1125) which means that you may be going into your exam blind.

Hope it helps.

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Pharmacy Placement in the Philippines, part 2

NICU

It 5:30 in the morning on a Monday, my second week here. I’ve just had my breakfast and it’s still chucking it down. Most of us were up during the night due to the torrential rain and thunder and so my 5am alarm didn’t sound quite so ghastly. Its weird to think that waking up at 5am seems like a normal time to get up…oh how times have changed.

NICU shift starts at 7am and the first task is to deliver medications to the NICU. Before going into the NICU other HCP must have the relevant PPE – mask, gown, slippers, and a hair net. Something that I have noticed is that in the PHP their paper-trail is excellent. In the pharmacy, outgoing NICU meds are recorded, and meds received by the NICU are recorded when entering. The powders for injections are prepared in the NICU by the pharmacist (it just means that the pharmacists fills an injection with a diluent and adds it to the vial).

When you think of babies you think pink and pudgy and laughing their little heads off but in the NICU it’s a different story. I have only seen NICU babies on Greys Anatomy, and I knew that they were going to be small and scrawny but nothing prepares you to see it in real life. They are premature with a low birth weight and have big chunky masks covering their faces helping them to breathe. It can be uncomfortable at times to be in there, however, medicine and nursing students love it there since they spend more than just a few minutes there, allowing them to sit back and cuddle babies all day.

On return to the pharmacy I was allowed to help with producing the daily charge slips, which records the medications given to the baby and the price. I was shown how to calculate the price and I was actually correct!!!

I also observed the pharmacist making doses. Let me explain. I don’t think this is done in the UK, but in the PHP, especially with NICU meds, capsules can be split to make smaller doses. The capsules are opened and the powder is poured onto a glass plate. It is then split evenly to produce whichever strength the baby requires and each dose is packed in a little tissue paper square. e.g. 3 capsules of 50mg Tramadol was used to make 6 packets of 25 mg Tramadol. There was another instance where a capsule (or a few capsules, I don’t remember) was used to make twenty smaller doses. Its so stressful as its not an accurate method and it takes everything you have not to shout ‘STOP!’ and rush to get weighing scales. This however, is a great learning opportunity to discover how other countries who have fewer resources cope with not having that range of drug strengths as we do have in the UK.

We then went back the the NICU after the doctor had completed her rounds to review the charts and amend the pharmacy records so that new medication can be added and old ones can be removed. The medications for the next day was prepared and I was allowed to label them (with small post it notes instead of actual printed labels – this also didn’t stress me out at all…).

In the main dispensary, medications are not checked (as most of the staff are qualified pharmacists) and so when I labelled the incorrect medication it was terrifying as there is no safety net there for you like there is at home. It was also an issue later on in the day when I helped out by dispensing medications and putting them in boxes for different wards. The slip that you are given is the typical doctors handwriting and so I had to be a right pain and ask that each item was, as other wise I might as well have just picked the first drug that I saw with that began with that letter. It wasn’t easy either to differentiate between vials and tablets on the list. This is a key difference between the UK and the PHP as prescriptions or labels or whatever have to be specific – paracetamol in community can be in tablets, caplets, capsule, suspension, or suppository. It probably wouldn’t be suppository but with tablets/capsules/suspension you have to make sure that you’re giving the patient the right formulation, therefore prescriptions have to be specific.

During the evening we went to a place called Merimart which was a strange experience. One of the girls is originally from the PHP and so knew about cheap places such as this one. I was bored and decided to tag along. Its weird cause its like a huge, relatively modern shopping center which is quite maze like. But the stores there aren’t your normal shopping center stores. Most of the spaces are occupied by small businesses selling counterfeit products, and they all tend to sell the same things. There was a power outage while we were there and all the little shops put on lamps. It was quite an experience. I was tempted to buy a Cath Kidston purse which matched the bag I had with me, but if felt wrong, like it was betraying the original. Sounds strange but its how I felt.

AMS

Today I became a shadow to a pharmacist in the Antimicrobial Stewardship team which was responsible for the OBS & GYNAE wards. Their job is similar to that of unit dose pharmacists, as they go through all patients notes, but they focus on the antibiotics prescribed.

If a doctor needs to prescribe an antibiotic they must fill out a form which allows them to give seven days worth of antibiotics from their list of ‘monitored antibiotics’. If they need an antibiotic from the ‘restricted list’ that form must be approved by a member of the Infectious Disease team. They must record patient details, the drug and dosing regimen, and the indication for use. This means prophylactic / empiric / definitive, along with some other points and results. As WV is a tertiary hospital most of their patients are referrals (with the exception of ER and outpatient referrals) and so patients have already had empirical (broad spectrum) antibiotics and require a culture & sensitivity test so that they could have definitive antimicrobials.

If they require more than 7 days there is a similar form they must fill in which the doctor must state any previous antimicrobial therapy the patient has had and the relevant microbiological results.

AMS pharmacists are also allowed to complete ‘dose optimization’ forms which means that they can advise the doctor to increase or decrease the dose depending on the lab results.

? Should we give antibiotics as a prophylaxis in this day and age with the rise of resistance and fewer new antibiotics produced?

?Why have AMS pharmacists? It basically means that you have two clinical pharmacists per ward and so a waste of resource.

OB & GYN

The obstetrics ward accommodated 45 patients, but as the hospital has a no refusal policy it has over 90 patients. Half of the beds hold uncomplicated normal births which means that beds are for up to 5 babies – not for the mothers to have a rest. Mefenamic acid (NSAID) and co-amoxiclav 625mg was a standard procedure after a normal vaginal birth here. The volume of antibiotics given was strange, but as I had not observed obstetric practices at home I had nothing to compare it to. However, now that I am home and have access to the internet I have found that WHO does not recommend routine antibiotic prophylaxis – why is it standard treatment in Iloilo then?

A quarter of the ward was for Caesarean sections and the last quarter for complicated cases, mostly eclamptic patients. It was disenheartening to hear that the c-section mothers would share beds so that two babies would have a bed and the mothers would sit. Meaning that they would not have proper rest after their ordeal to recover. The lest section was occupied by preeclamptic patients.

MATERNAL MORTALITY

Maternal mortality rate (MMR) per 100 000 live births was 114 in 2015 (1) – to put this into perspective the MMR of the UK is 9 deaths. Why is the Philippines well above the worldwide average of MMR?

  • Only 84% of births are attended by HCP, with only 65% of women from the poorest quantile (2) ’why? Giving birth is free in the UK, pay in the PHP. “In the Philippines, in addition to Administrative Order 2008–0029 articulating policies for delivery by an SBA in a health facility, some local government units have issued local ordinances banning home births; some have imposed fines on women delivering at home, or on the birth attendant, or both.”(3)this means that women may opt for traditional birth attendants which are usually older women within the community which assist during delivery.  This may sound like a much friendlier birthing situation as compared to hospitals but the risk of such practices severely outweigh their benefits. Yes, they are substantially cheaper then going to the hospital, but the hilots have no formal training (4). The study really shocked me because it showed the practices of the respondents – such as having a poor performance in referring mothers for complications, and for the encouragement of immunization.
  • Poor reproductive education & unavailability of contraceptives  = “unplanned pregnancies & unsafe abortions?
  • Once again, my point of reference is Grey’s Anatomy and so I thought that oxytocin was used only to induce labour, but is also used to reduce postpartum haemorrhage. Oxytocin is recommended by WHO for all births which explains why I saw it in most charts (if not all, I don’t remember!).

? How does oxytocin work to prevent haemorrhages?

Obstetrics have their own section of the hospital with a family planning clinic, OB-OPD (out patient department), their own ER, and something quite incredible – a human milk bank. Patients and staff are recommended to donate milk to the bank, which is then pasteurized and given to NICU and c section babies.

  • Why do c-section mother struggle to produce milk?
  • Does the implementation of a human milk bank improve NICU outcomes? 

It reduced neonatal mortality and significantly increased exclusive breastfeeding rate from 34% to 74% post implementation (5).

  • ? What does this mean? This coincides with WHO guidelines which recommends breastfeeding but it does not necessarily mean improved outcomes – human milk (both the mother’s and pasteuised has fewer nutrition and so there is slower growth in neonates as compared to formula (6) this is an area that id love to do more research on, especially since going to many supermarkets in Iloilo where they have a special designated area for formula (similar to how we have a pharmacy area in some large supermarkets in the UK).

A few of the WTW students have had placements within obstetrics and what you hear from them is quite harrowing. I understand that it’s a a different culture and that we’re supposed to be open minded but when you hear such stories it’s difficult not to judge. In the UK deliveries can take time but here mothers are rushed (this was something I had noticed while flicking through charts – most mothers had been given oxytocin). There are no epidurals and mothers are not allowed to scream while giving birth. If the baby takes too long then, I’m not sure what it’s called, but some sort of chest compressions are given to push the baby out. I have also heard from students that they do not wait for the baby’s shoulders to get out, they kind of just pull at the head.

CONTRACEPTIVES

Condom use rate is low in both the UK (7) and the PHP (8) which is surprising considering that sexual health classes within schools in the UK only talk about male condoms from what I can remember – not about the pill which has the highest rate in both countries.

? What percentage of males within heterosexual relationships are willing to use a condom?

? Why is the use of the pill so high?

HIV/AIDS

HIV cases have dramatically increased, but what is the cause? Since males who have sex with males make up the largest proportion of HIV cases, a study on HIV prevalence gives light on the behaviours regarding safe sex (9):

  • 85% of males having sex with males (MSM) have never been tested = low testing rates.
  • Low condom use rate – 41% did not use condom during last anal sex and 64% had multiple sex partners. Looking at both of these statistics is shows that the risk of transmission becomes much higher due to poor barrier use – if individuals do not use barrier methods and have had more than one partners in the past 12 months and do not get tested for HIV then surely transmission risk is high?

In response the the HIV epidemic, the PHP have a target that 90% of those who are living with HIV should be on anti-retroviral therapy (ART) by 2020 (8), currently only 32% of PLHIV receive ART. Just think about that. Nearly 70% of people who live with the stigmatized virus are receiving no treatment. Why is this happening?!

ONCOLOGY

At Cardiff University were are lucky enough to have an aseptic suite – I have not been allowed in yet, hopefully I will within the second year. The oncology department of the hospital does not have one and it nearly gave me a heart attack. I know that having an aseptic suite is expensive and so I wasn’t expecting a huge suite but I definitely didn’t expect what I saw. I have to admit it is a genius move and excellent use of resources but still, kinda shocking. 

Their aseptics unit is a NICU incubator that has been adapted to become a laminar flow unit.

Like I said. Nearly had a heart attack.

The lack of funding for such basic resources is clear within oncology and I have to applaud whoever came up with the idea as without such contraption chemotherapy would not be a possibility for patients at the hospital.

I was allowed to observe a doctor give chemo to a small child. I was so excited that I could see a spinal tap being performed that I shocked myself as as I heard the child screaming, I had forgotten that these are actual patients, not just cases used to learn about. 

BORACAY HERE WE COME!

I had a 4am start but since I’m so used to waking up at 5 here, waking up an hour earlier was like ‘yeah whatever’.  We had rented two vans (1000 pesos each, return) to take us to Boracay and we reached there at around midday. We had to stop a couple of times as everyone had suddenly become travel sick. Its quite amusing being among med and nursing students as the second anyone is ill its like an OSCE. They want to know how exactly you feel, if you already tried so and so anti-sickness tablets…ah okay what about these ones?

The second part of the journey was via boat to Boracay itself. I was quite queasy at this point but the sea breeze made it all okay, plus it was only a short ride of like 20 minutes. The sea is this beautiful blue that no only exists in travel magazines and it kind of makes all the queasiness go away. 

We were greeted there and was taken via a mini electric jeepney (how environmentally friendly!) to our hotel which was called the Turtle Inn. It’s super cheap, especially with four of us in the room, allowing us to spend more on shopping and activities. There’s like a little terrace outside of the rooms which have deck chairs and a table where you have your breakfast. The hotel is quite small but the staff are so lovely and you get a complimentary drink when you arrive.

Packing tips – bikini and rash guard clothes (many people just wear the rash clothes out and about), dry bag.

If you do need to buy anything there are plenty of bikinis and beach wear shops around (even a CROCS shop!) there are lots of cheap souvenir stalls but make sure that you go around them first to get a good price instead of just buying things at the first stall you see. I didn’t realize but you can haggle at these stalls and a friend got 500 pesos off her purchase which is CRAZY! I’m way too scared to haggle plus it feels sort of rude – imagine going to TESCOs and haggling at the till for your groceries.

One of the things that I love about Boracay is that all the shops and restaurants are lined up at the beach and there are so many different cuisines available. We don’t have that much choice of cuisines where I live and we don’t have take aways at home so I joked that if I had the metabolism for it I’d do a ‘food crawl’ of Boracay instead of a pub crawl.

We settled for a Japanese restaurant called HAMA for supper and this was the first time I had had proper Japanese food – I wasn’t to only one inexperienced with chopsticks but we managed it. I had chicken udon teppan which was AMAZING. The second I got back to the hotel I was looking up recipes for when I got home. I try to collect recipes from restaurants so that when I go back to University I have lots of things to try my hand at.

I couldn’t sleep and so banished myself from the bed for a mini yoga session outside. Doing yoga on a gritty balcony wasn’t quite what I had in mind but maybe one day I’ll manage to go to the beach on a warm morning once I’m home and do some sunrise yoga. 

Breakfast was included in the price of our room – it isn’t much just either eggs or pancakes just its good enough.

We went island hopping which cost about 600 pesos. You stop after a couple of minutes to snorkel and most of us went in without life jackets. That was a mistake. The second I was in the water I found it hard to breathe. Thought that I was just a bit nervous since I hadn’t been swimming for years ad that I would breathe normally once I got used to it. Yeah…no. I think maybe three or four of us got caught up in the tide and I was trying to swim back but my breathing was reallyfast and shallow (I think that’s what’s called hyperventilating? Could have been a panic attack, who knows) and I felt like I was going no where – each stroke I took toward the tide went over my head and pushed me five back. I’m sure I looked pretty bad as one of the girls was like ‘are you okay? I’ll go get a life jacket for you’ and rushed off. So yeah, fun times.

! If you can afford it, get a GoPro. Two of the girls had bought one in Iloilo for the trip and the resulting photos and film was amazing! 

We then stopped at this beach which was a great opportunity for a photo shoot, had lunch, another snorkel and split up once we got back to the beach. I had opted for just plain old sunbathing – my stomach was feeling the effect of the boat and getting thrown about on an inflatable being dragged by a speed boat would have ended me.

I haven’t had much experience with sunbathing – when I’m abroad I’m always rushing around all the sights and so when people warn you that you need to reapply suncream often, I obviously didn’t think that that rule applied to me.

That night I looked pretty bad. It looked like someone had punched me where my zygomatic bone was, my stomach was red (and was red for the following three weeks) and I had tan lines on my shoulders.

We’re all talking about how we’re going to miss it, and the non-humid heat, and the white sands and the clear water. I completely understand why it’s a popular honeymoon destination.

The road taken to and from Boracay it terrible. Winding roads with half of the journey on bumpy surfaces due to so much construction going on. We were speeding away (going quite fast which was a bit worrying), getting thrown when a collective feeling went through everyone – something was not right in the front. We pulled over at a café. One of the girls in the front had lied, staying that we all needed a pit stop to refresh – she had seen the driver nodding off and instead of saying that he needed to stop, just sped up.

CLINICAL PEDIATRICS

I woke up at 5am since pedia rotation starts at 7am. Its weird since when I’m at home I absolutely hate getting up early, but here I am bouncing out of bed at 5am.

Disaster struck.

Clinical pedia doesn’t start until 9am so now I’m floating around the pharmacy for two hours. Could have had two whole hours extra of sleep.

The pharmacist in charge of pedia is also responsible for the neonatal unit, ASU, and MICU. In neonatal some of the common admitting causes were:

  • Meconium aspiration,
  • Neonatal sepsis,
  • Neonatal pneumonia,
  • Respiratory Distress Syndrome,
  • Neonatal jaundice – In a big posh medical term it’s known as hyperbilirubinaemia. If you break the word down, you’ll find that essentially its when there is an increased level of bilirubin protein in the blood.In the neonatal unit I saw a teeny tiny baby undergoing phototherapy. I had always thought that jaundice was just something that happened to preemies due to underdeveloped livers but actually it’s a lot more complicated – it can be caused by quite a few different conditions and its something that I’m desperate to read more about. This was a difficult ward for me to observe as in one tiny ward, roughly 25 ill babies and their parents were squished in like sardines in a tin. There was barely any room for me to walk around and so if anything happened to one of the babies and they needed urgent attention, there would be some delay. Hospitals need space.

There was also no permanent nurse observing the babies – only their parents. Unqualified parents. One parent was manually bagging their baby. They looked so small and scrawny, some with cotton wool over their eyes.

UNICEF found that the PHP have a 15% preterm birth rate (10), which is 7.5% in the UK (11). Prematurity was found, also by UNICEF to be the highest cause of neonatal mortality at 32.7%.  Even though I am not a baby person I find neonatology incredibly interesting and so my ‘light reading’ during lunch at the supermarket next to the hospital tended to be WHO recommendation documents – a good one to look up if you do decide to do a placement in the neonatal unit is the ‘WHO recommendations on interventions to improve preterm birth outcomes’ as it can tell you whether or not they recommend a course of action depending on the quality of the evidence they reviewed.

Placement tip for clueless first years – make spider diagrams during ward rounds. Grab a patient’s notes after the pharmacist gone through it, state the admitting diagnosis and then add the drugs used to treat it. Keep adding drugs to the diagram form different patients and when you have the time you can look up the drugs and how they work.

Since passing the dengue ward on induction day I have wanted to know more about this neglected tropical disease. Learning about this condition is relevant for my community pharmacy learning due to travel advice and vaccination services offered.  Malaria is commonly talked about and so the general public is aware of mosquito bite preventions but advice on dengue is lacking – maybe due to its lack of chemoprophylaxis or that its not often seen in popular UK destinations – Europe and North America. As we were not allowed into the dengue ward I didn’t think I would encounter any cases but turns out, in the pedia ward dengue is prevalent – more so during the rainy season when I visited due to more stagnant water around for mosquitoes to breed. I have learnt of the disease’s forms – dengue and dengue haemorrhagic fever/dengue shock syndrome, and how it is treated here in the PHP – with only IV fluids as it turns out.

Other conditions seen in this ward were febrile seizures (which are caused by fever) and pneumonia.

As the pharmacist was taking inventory of the drugs in pedia I tagged along with two other WTW students who were accompanying a doctor on her rounds. I was only able to stay for three patients but the last one really hit me. A child had, what us in the UK call advanced, retinoblastoma but the doctor said that this is a common sight and they can me much worse (common meaning that they see a few advanced cases come in). Look it up and you’ll see how bad it was for this child. In the UK someone would have called social services or something but nothing could have been done here in the PHP and it was all because the lack of money. The child was going to die.

I didn’t realize that medical ICU was a thing and I was expecting a room full of comatose patients, but that may be the surgical ICU. It’s a small unit with only 5 beds in total and were occupied by severe dengue patients. I was also expecting a large stroke unit it since this is a tertiary hospital but it was composed of only three beds. The country’s major health problem keeps popping up all over the hospital and this ward was no exception – hemorrhaging stroke secondary to uncontrolled hypertension.

ORTHOPEDICS

Hash browns and scrambled egg for breakfast – literally the best. I waited for an hour and a half for the pharmacist to come and fetch me before someone told me that the GEOS ward pharmacist was busy and didn’t want a shadow that day. Super. 

However, it did means that I got to choose which department I went to and chose ortho. The pharmacist I was with was SUPER lovely and covered two wards – the Santa Monica ward which was for female Medicare and the orthopaedic ward.

The first ward we went to was the Santa Monica ward which is a small ward of about maybe 15 beds? Don’t really remember how many. Some conditions of the ward were – cardiovascular disease, alcoholic liver disease, chronic kidney disease, anaemia.

We then went to ortho which had roughly 45 patients and is a ward definitely worth doing a whole 9-5 shift in.  It’s a great ward if you like being busy and on the go but to get the most out of it I think you need to know some stuff like classification of fractures and anaesthesic drugs. There’s a lot of broken bones (obviously) and I actually made a tally chart while going through the charts and found that just under half of the patients in the ward were there due to fractures secondary to a vehicular accident. That’s crazy. But it does make sense since the roads here are a bit crazy and many people have motorbikes. When you get off the jeepney to go back home you have to cross quite a busy junction and since my road safety is abysmal I fit in with the pedestrian culture. There is no traffic lights or pedestrian crossings which means that you just have to walk across the busy junction and hope that everyone stops for you.

ICU & GENERAL

7am start with an AMS pharmacist. We started off at St Vincent ward which had only 11 patients. Role of the AMS pharmacist is the reduce error in antibiotic usage such as if there is a missed dose at the ward they must follow it up to find out why. Each ward has a daily census of patients which has the total number of patients and the number of any transfers or admissions.

Our next stop was the MICU and she explained that since they have no infectious ICU so they would only accept infectious cases such as pulmonary TB after 2 weeks of antibiotics and pneumonia after 3 days of antibiotics.

The Acute Stroke Unit is one of two departments which are allowed to administer Actilyse (generic = alteplase), the other being the ER. They called it the wonder drug as within 24 hours it is able to reverse some of the effects caused by the stroke.

We then went to the male medical ward which was situated in one of their shiny new buildings. It had four different sections – renal, gastrointestinal, cardiovascular, and other. It had a total of 56 patients. Cases seen – acute haemorrhaging stroke, hypertensive CVD, alcoholic liver disease, anaemia, hypovolemic shock.  There were a lot of nurses around and the second I sat down ready to flip through some charts I was bombarded with questions like ‘Do you know David Beckham?’ or if I had seen any of the Royals and if I like Robert Pattinson and Tom Holland (the answer is yes, obviously, who doesn’t?)

SICU was the next ward. I didn’t get to see many of the charts (not that they had many patients). And lastly St Jude’s ward which is their psychiatric ward. They had security at the entrance and there were posters listing all the things you couldn’t take in like iced tea and chocolate. The nurses station had bars on the window, patients had no mattress and the bed frame had holes in the side in case the patients needed to be tied up. Patients also had to have a family member or career present at all times during their stay (except for three allocated slots where they could leave for an hour to have food etc). I didn’t get to spend much time in this ward (as there were no antibiotics prescribed) but it seemed like an outdated way to teat patients with mental illnesses – it was something that I expected in a Victorian asylum with no comfort or anything to suggest that they were anything but prisoners.

ER & ONCOLOGY

7am start at the ER today. I’m not sure what I expected to be honest but it wasn’t this. The ER was overwhelmingly busy. There is no place to turn and if there was an emergency they would be wasting valuable time trying to move patients to get to the one in need of assistance. The ER has its own little satellite pharmacy and the pharmacist goes around the ER checking what drugs everyone has – the patient or their guardian I responsible for keeping the drugs safe and they are not kept in the nurses station like every other ward.

This was my first time in an ER and I always though that an ER was kind of like a sorting office. Patients come in get treated and then are either admitted to another ward or discharged. But in this ER it didn’t seem like the case as the pharmacist was ticking patients and drugs off her list – the list that she had made yesterday morning.

I have been open minded about the hospital here in the PHP but just an hour in the ER was shocking and it makes you so frustrated since you can’t do anything or help and you’re just stuck there like a little ball of anger.

I say an hour as the pharmacist who’s in charge of the students here was like ‘come back to oncology today’ and swapped me with another student. I saw four chemotherapy patients today and sat there for hour staring at the floor – fun times. The oncology section is made up of three rooms – a consultation room, chemo room, and a room with two beds in. 

We were also told that privacy regarding patients was different to as seen at home and I saw this during my two days in oncology. In the UK, even in community pharmacy, there is a private consultation room for patients to discuss matters but in oncology there was one consultation room where a patient would be talking to the doctor and there would be patients sitting right behind them, waiting for their turn. 

As I have only completed my first year I had no idea about types of cancers or drugs used but it was the department that I got to do some pretty cool things for a first year student. I was allowed to assist in preparing chemotherapy pre-medications such as ondansetron and dexamethasone! 

BBQ was awesome yet again and stuffed myself on roast potatoes, crispy shrimp, and a whole load of pineapple and a large chunk of pineapple upside down cake.

The kareoke was quite funny as they decided to split us up into four teams and the losing team would have to try balot. The guy who normally mess around actually took it seriously as, I quote, “they threatened me with duck foetus, I’m going to take it seriously”. No one can remember if it’s duck or chicken embryo. Nasty.

HOME

Flight is at six so it’s a long day of doing nothing. I had lunch at Jollybee’s cause rice and gravy is just about the best food combination ever.

I’m just sitting with two of the girls, waiting. It’s currently raining, not too bad but I’ll miss it since it’s not cold rain like at home and it’s quite calming to watch.

There was a lot of traffic on the way to the airport and it started to absolutely chuck it down. We were worried that our flight would be delayed as other airlines had cancelled flights but we were lucky. There was a huge queue for Qatar airlines at Manila but a travel tip for you – if you already have your boarding pass (and you will since it’s a return flight) you can go to the online check in queue which was way shorter. Asking someone for help at the airport saved us probably over an hour.

Its 4:15 in the morning – about to land in Doha. At home I don’t notice light pollution but when you’re in the air it looks quite magnificent, an ethereal orange hue around the city.  Half eight in the morning and I’m bored. Few hours to go before my flight. Something that I love about DOHA airport is how healthy it is. Smoothies, fruit, fresh juices, and wraps the size of burritos. They had a Del Monte café – why can’t we have this many healthy options in the UK???

And that’s the end. To say that its been a life changing experience has been an understatement. If you would have seem me throughout my school year, I would have been the least likely to go to the other side of the world, by myself, for a placement. Its been an absolute dream and I’ve learnt so much – from tropical medicine to the culture over there, and I’ve met some amazing people from many different backgrounds.

Take a leap of faith and maybe you’ll find out that even though you’re on the other side of the world there are other students just like you – who want to travel, and try new things, and learn. You won’t be alone.

References

  • WHO. Maternal mortality in 1990-2015, Philippines. Date unknown [12.08.2019]
  • UNICEF. Maternal and Newborn health Coverage Database. 2018 [accessed 12.08.2019]
  • WHO. Maternal Health Care: policies technical Standards and Service Accessibility in Eight Countries in the Western Pacific Region. 2018. [accessed 26/08/2019].
  • Maghuyop-Butalid R, Mayo N, Polangi H. Prolife and birthing practices of Marananoiudshfk traditional bith attendants. 2015. Int j women’s health
  • Adhisivam, B. Impact of human milk banking on neonatal mortality, necrotizing enterocolitis, and exclusive breastfeeding – experience from a tertiary care teaching hospital, south India. The Journal of Maternal-Fetal & Neonatal Medicine. 2019;32(6). Available from: https://www-tandfonline-com.abc.cardiff.ac.uk/doi/full/10.1080/14767058.2017.1395012
  • Boyd C, Quigley M, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systemic review and meta-analysis. BMJ. 2007;92:169-175. Available from: https://fn.bmj.com/content/92/3/F169
  • Statista Research Department. Prevalence of contraceptive use in the United Kingdom and Europe from 1970 to 2030.  Statista, 2016 [accessed 10/08/2019] Available from: https://www.statista.com/statistics/663186/contraceptive-use-in-the-united-kingdom-europe/
  • Senate Economic Planning Office. Contraceptive use in the Philippines at a glance. 2013.
  • Epidemology Bureau. Qualitative study on the drivers and barriers to condom use, HIV testing, and access to social hygiene clinic services among males who have sex with males. Department of health, Philippines 2015.
  • UNICEF. Maternal and Newborn Health Disparities. Philippines. date unknown [accessed 20/08/2019].
  • NICE. NICE Guidance: Preterm labour and birth. [accessed 10/08/2019] Available from: https://www.nice.org.uk/guidance/ng25/chapter/context

Pharmacy Placement in the Philippines

University for me was a chance to start again, to be that adventurous individual my younger self hoped I could be. I know that after graduating I wouldn’t have the same chance as I would have had during university to explore and learn simultaneously and therefore, every summer I hope to learn, not just about healthcare, but about culture, language, art. I want to grow.

This is summer No1, and this is a blog detailing my three weeks at a hospital in Iloilo in the Philippines.

I thought I’d have been more nervous considering that this was to be my first international flight, and that I would be flying by myself. There were no queues at Manchester and I was checked in and parted with my bumblebee yellow suitcase quickly. We had a slight delay before take off which worried me as I had only a short layover at Doha. I had a row of seats to myself and so you would have thought that as it was an overnight flight I would have taken the chance to sleep. But no, my brain refuses to sleep while travelling so for most of the 8 hour flight I was in a circular state of state of slowly nodding off before my brain sent alarm bells ringing and I was then suddenly awake. Even though I didn’t sleep I had a lovely flight and didn’t realize why people despised long-haul flights so much.

Let me just give you some advice, you need at least two hours of a layoverif you have a connecting flight. The plane landed and I had managed to conceal myself among first class passengers and so got the first shuttle from the plane to the terminal. There was someone waiting with placard to direct me to the transfers desk. Impatiently waited to get through security and then asked someone which gate I was supposed to be. The reply? You need to run to the gate…they just announced the last call for passengers. I had to run…actually runthrough Doha airport and only just managed to get on my next flight to Manila.

This 10 hour flight made me realize why people hated long-haul. Some guy had stolen my window seat and so I was squished in the middle seat unable to stretch my legs or sit cross legged.  It was a NIGHTMARE.

 – If you have the time and money I would recommend breaking up the long haul flight so you can spend a few days somewhere extraordinary and explore.

I arrived in Manila and had a few hours to spare before my last flight to Iloilo. You can either take a shuttle bus (which is free but comes at irregular times during the night) or take a taxi to change terminals. I took the shuttle bus and it was lucky that I did. When I arrived at the Work The World house they explained that a student had paid 5000 pesos for a taxi to change terminals – it should have been a maximum of 500! If you do take a taxi, ask them to put the meter thing on, and if they refuse, don’t get in.

Sunday 23/06/2019

Last time I slept was Thursday night in the UK. Its now Sunday and I’m finally in the Philippines which is +8 GMT. The change in time zones, infrequent meal times, and anti-travel sickness tablets have messed my body up. My brain is of cotton and my GI system is wrecked – I’m either starving, constipated, or have eaten too much. I don’t even know. My stomach kills.

I arrived Iloilo in the early morning at 7am and it’s 29 degrees here. I was greeted at the airport by one of the main WTW house staff and we took a taxi to the house where I was given breakfast and a quick tour. One of the things that I noticed while in the taxi was how different the infrastructure was compared to the UK – they had brand new modern buildings right next to homes of rusty corrugated iron sheets.

I had a small nap but then stayed up until late to avoid jet lag. Breakfast is served at 6am on weekdays and supper at 6:30. I shared a room with 5 other girls and we were lucky that they had just installed air conditioning in. Bunks are covered in mosquito nets and the bathroom is spacious. We were the only room on that floor of the house and so had a lounge area outside it basically to ourselves which had a couple of sofas.

Monday

I miss the quietness of home. A house nearby was playing loud music when I managed to fall asleep and it was still on when I woke up. Also, effing birds I’m telling you, do they actually sleep? Shrieking throughout the night. One guy said that he was ready to roast the cockerel that kept waking him up at ungodly hours.

7:30 start where they took us newbies on a Jeepney to the hospital for an introductory presentation and tour. We were then back on a Jeepney and toured some local sights such as a church, a tourist shop, a small museum of the history of Iloilo, and the Department of Tourism to get information on where to visit during the weekends. During our Jeepney ride one of the staff stopped at a street food stall and bought us all one of these, well, I’m not quite sure what they were. They were a 

sort of mix between pancakes and Welsh cakes with a little cheese for filling.They were delicious. 

We then had Philippino food at a restaurant where they take all the newbies each week and we were not disappointed. Mango smoothies become the obsession of the WTW students and I tried things such as crispy aubergine. For someone who is quite fussy it’s absolutely lovely and there is something for everyone. Garlic rice was a group favourite.

Tuesday 

This was my first day of placement at the pharmacy and I was allowed to decide on my schedule for the next three weeks. Unlike medicine or nursing where you must complete at least one week in each department, in pharmacy you can choose just do one day in an area. This is both a blessing and a cause for headaches – you are exposed to multiple departments within a short space of time (yey!) but if you’re like me and want to know everything about everything it means that the planned ‘crash course in hospital pharmacy’ was about to get a little more intensive (not yey).

  • Most of the pharmacy team are actually pharmacists with very few technicians.
  • Most of the drugs dispensed here are ampules and vials.
  • Daily prescriptions are dispensed – in the Philippines if an inpatient needs medication they must take a prescription (which has meds which will cover the next 24 hours) to the pharmacy to receive it. Only emergency drugs are given in the wards. There are advantages to daily prescriptions such as less waste but it does seem very time consuming to dispense items such as antihypertensive drugs daily – drugs that they will need for years instead just a few days.

CDs are kept in locked drawers instead of safes that are used in community and I was astounded by the fact that in the PHP Diazepam 5mg is classified as a controlled drug! In the UK it is a community fast mover!

To understand the health system I’ve read a few documents published by the Department of Health. Here are a few things that I’ve learned:

They don’t mess around when it comes to objectives – they aim high. A little too high maybe. One document states that one of their visions is that ‘Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040’ (1). From what I have seen, if they manage this, it will be a miracle. Access to healthcare is a problem due to (a) a high proportion of out-of-pocket spending in healthcare, and (b) getting HCP to remote areas.

Out-of-pocket spending has contributed to over half of the current health expenditure of the Philippines, and the largest component of this way of financing was from the poorest individuals. This statistic is quite a…confusing one. The introduction of a ‘Sin Tax’ in 2012 meant that in only one year $1.2 billion was raised and split 80% to PhilHealth and 20% to the DOH. All this money should have been reflected in reducing the OOP expenditure but the value has barely decreased. 49.7% of the OOP financing was spent on medicines (2) which led to the implementation of the Generics Act and the Cheaper Medicines Act.

The high OOP spending posed a financial risk for already impoverished families and was tackled through the introduction of schemes such as ‘No Balance Billing’ (NBB). This scheme prevents hospitals from charging patients anything above what will be reimbursed by PhilHealth (2).  However, there are criteria that need to be met to be eligible for NBB – patients must have no means of income or an income which is insufficient to care for a family, if they are a sponsored patient, domestic workers, or senior citizens (3).

In 2016/17, the NHS cost £144.3bn (4), alcohol duties raised £11.6bn (5) and tobacco £9.1bn (6). The soft drinks levy is expected to raise £240 million – which is both good and bad in a health expenditure point of view (7), good as it caused 50% of manufacturers to reduce the sugar content of affected drinks, but this reduces the money received. However, if the UK were to propose a more widespread sugar tax which would include processed foods and sweets, how much would it raise andcould it be the future of NHS funding?

Access to healthcare is being tackled by deployment programs such as Doctors to the Barrios Program (DTTBP), Nurse Deployment Projects (NDP) and Rural Health Midwives Placement Program (RHMPP).

            In 1998, DTTB was launched by the DOH to try to redistribute healthcare so that it would benefit the rural population. Doctors would be sent for a period of two years to areas and afterwards they had the choice to stay if the desired to. However, their absorption into local area meant they they would receive less salary compared to their urban counterparts, and could be a reason as to why only 18% of the cohort chooses to stay (8). Leonardia et al (2012) found that among the participants the most important factor when deciding whether to stay or not was whether they had support from the local government – e.g. for infrastructure and supplies. Out of those who stayed, many left stating reasons such as they wanted to be with family or they left for career development. We have a similar problem in North Wales – a lack of community pharmacists. Two of the busiest branches that I know of have no permanent pharmacist and rely on locums – some which travel from areas such as Manchester in England (taking them a few hours to get here) and this lack of stability affects the whole team – many locums are not qualified to offer services such as smoking cessation or MURs, and paper work is left uncompleted.

Wednesday

Uneventful day at the main dispensary but I did notice something that I wish we had within community pharmacy in the UK. On a patients’ medication record it will state the patients admitting diagnosis – as quite a few pharmacy students have part-time jobs within community pharmacies it would be a great way for students to begin connecting to dots between diseases and drugs.

We all finished early and went to Guimaras island. Its just across the water from Iloilo and we crossed on one of those boats that you think you’ll only see in Thailand or something, kind of like a wooden catamaran.

We got there and all five of us squished into a little trike to get to Alobijod Cove. It was cloudy but warm there and it wasn’t humid like in Iloilo so we swam and pretended as though we were in a photo shoot. On the way back we stopped at a place called Pit Stop and had mango pizza (not nice, not sure if I actually like mango) and mango spaghetti – the spaghetti itself is not made of mango as I had thought but its just a mango sauce which tasted similar to sweet and sour.

Thursday & Friday

I was assigned to the Malasakit section of the main dispensary. I had no idea what Malasakit was and the main pharmacist of that section was more than happy to give a detailed explanation of what it was and the role of the pharmacy in the program. She was brilliant.  

The Malasakit section patients are usually from the outpatient clinic and they bring their prescription to the counter where the pharmacist will price the items. In the UK, the drug tariff is online but here they just print off a copy each month that has all the medications they have in stock. The patients/family members then go to the Malasakit center, bring back the prescription where they make a charge slip, dispense and release the medication. For inpatients, they give 24 hours worth of medication while for outpatients it’s 30 days.

  • Does visiting the outpatient doctors improve medication adherence? 
  • Does the PHP have GPs or just outpatient clinics?
  • Botika ng Barangay vs pharmacy.
  • Services offered by community pharmacists.

As you can see, I have a few unanswered questions and the internet is not always the best place to learn about culture. If you are planning on going to Iloilo and are interested in everything as I am, you could try get some experience within a community pharmacy. There are three pharmacies lined up opposite to the hospital entrance so I don’t think it would be too difficult.

She showed me booklet which had a tally of all the medications they dispensed and explains what each of the Malasakit fast movers were used for. One item that stood out was the rabies vaccine. Before going to the PHP my knowledge of rabies was probably the same as the general public – if you get bitten by an animal, go to the GP to get a shot or otherwise you might start foaming at the mouth.

Most were post-exposure prophylaxis and this item was a Malasakit fast mover – hence why they had an entire fridge dedicated to the vaccine!

The continuous augmentation of Animal Bite Treatment Centers (ABTCs) has led to the steady decline of human rabies cases from 455 in 1998 (10) to 150 in 2018 (11). The rate of infection has also decreased – the number of bites have increased but cases have decreased, which means that the centers have been able grant more of the population access to treatment.

  • Animal Bite Pharmacological Treatment

PRE-EXPOSURE PROPHYLAXIS (PrEP) – as 51% of animal bites occur in children under 15 (9) the Philippines vaccinate all school children living in endemic areas.

RABIES IMMUNOGLOBULIN (RIG) is injected into and around the wound and so acts quickly to neutralize the viral antigens there.  It is made from components of human blood plasma – plasma is not collected in the UK due to the blood transmitted CJD that occurred in the late 90s and so is imported.

’What is Creutzfeldt-Jakob disease?

Immunoglobulins are in a worldwide shortage from what I gather but in the Philippines the use of both the RIG and vaccine is more common than just the vaccine itself with 17.2% of bites treated with only the vaccine, but 72.9% with the vaccine in addition to ERIG (9) – ERIG is the equine derivative.

POST-EXPOSURE PROPHYLAXIS (PEP) is given intramuscularly to the upper arm or into the thigh for younger children. The problem with vaccinations is that require more than one dose – non-immunized individuals will require four doses, and so completion rate is low at 59% in 2017 (9). This is strange as as of 2016, the government funds all doses of the vaccine and of the one RIG dose. Economic effect of non-completion of rabies vaccine?

Reading recommendation’The Green Book, chapter 27: Rabies.

  • What is being done to reduce the number of bites?

Anti-Rabies Act of 2007 led to ’mass vaccination of dogs, database of registered & vaccinated dogs, impounding of stray dogs, education campaigns, and the provision of free PrEP to school children in high incidence areas.

The majority of Malasakit fast movers were related to cardiovascular issues e.g. amlodipine and captopril for hypertension, atorvastatin for hyperlipidaemia, clopidogrel for the prevention of atherothrombotic events. This pattern of dispensed drugs is reflected in the country’s leading causes of morbidity (#2 = hypertension) and mortality (#1 = ischaemic heart disease) (1).

The hospital relies heavily on old fashioned paper documenting which can make it feel as though you are in an office and not a pharmacy at times. Pharmacists usually spend most of the afternoon updating the pharmacy record to that it matches the ward record. The hospital is currently updating and expanding in order to accommodate the large intake of patients. However, if they were to invest in a centralized electronic system I believe it would change the status of pharmacists from secretaries to clinicians and allow them to fulfill their role and improve patient outcomes.

Thursday

Thursday is BBQ night at the WTW house. Their BBQ is suprisingly different to the UK and is so much better. Crispy shrimp will now be a requirement on every BBQ menu in our house.

On karaoke night, beware of individuals who will put all star by smash mouth on repeat and sing the ‘and they don’t stop coming’ remix. I mean its funny but gets annoying the third time round.

One of the external doors of the pharmacy has a poster raising awareness of counterfeit drugs. WHO found that 10% of drugs in low and middle income countries are falsified (12), and the Pharmaceutical Security Institute found that 193 of 673 pharmaceutical crime incidents occurred in the Philippines (13). The majority of sources originated from Pakistan – why? However, the poster isn’t just something that warns patients of some far away danger that occurs to a minority of individuals – falsified OTC drugs are being locally manufactured.

  • Labels are not printed and applied to drug boxes as they are in the UK which means that pharmacists trust patients to decipher and understand the doctor’s orders. This trust is a stark difference between the culture in the UK – why is medication culture different? Is there more respect for HCP there or do they just care more about their health?

Weekend- I visited the Iloilo Museum of Contemporary Art which was an experience that pleasantly surprised me. ‘Modern’ art is not usually to my taste but the paintings and sculptures interested me.  One of my favourites was a sculpture by Daniel Dela Cruz titled Off With Her Headwhich was a depiction of a scene from Alice’s Adventures in Wonderland.

I had lunch at Nicolette which is this really cute bakery and cafe at SM city. They had a counter full of bread and pastries and they had this amazing idea where they had unbaked filled rolls on display, which meant that you could wait a bit and have them fresh and warm. Lovely and unbelievably cute.

Week one down, two more to go. I hope you found it interesting and please read my next post for the second part of my trip.

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  • Philippine Health Insurance Corporation. PhilHealth Circular 2017-0006. Strengthening the Implementation of the No Blanace Billing Policy (Revision 1) 2017 [accessed 20/07/2019]
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  • Office for Budget Responsibility. Tobacco duties. London: Office for Budget Responsibility; date unknown [updated 07/05/2019]. Available from:  https://obr.uk/forecasts-in-depth/tax-by-tax-spend-by-spend/tobacco-duties/
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  • Leonardia J, Prytherch H, Ronquillo K, Nodora R, Ruppel A. Assessment of factors influencing retention in the Philippine National Rural physical Deploymet Program. BMC Health Serv Res. 2012; 12: 411. doi: https://doi.org/10.1186/1472-6963-12-411
  • Quiambao B. Perspectives on Rabies mAb Development: Example from Academic experience. US FDA Workshop on Rabies mAb July 17, 2017; Maryland.
  • Health Intelligence Service. Field Health Service Information System : Annual 1998. Manila: Department of Health.
  • Epidemiology Bureau. Field Health Services Information System : Annual Report 2018. Manila : Department of Health.
  • World Health Organisation. Substandard and falsified medical products.. Geneva: World Health Organisation; 2018 [accessed 09/08/2019].  Available from: https://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products
  • UNODC. Transnational Organized Crime in Southeast Asia: Evolution, Growth and Impact. Vienna: United Nations Office on Drugs and Crime;2019 [accessed 09/08/2019].

A Quick Guide to Community Pharmacy Placements

I have worked as an MCA at a small community pharmacy for the past three years, working Saturdays and holidays. Here are a few things that I have learned that may, or may not, be useful for a pharmacy student who is undertaking their first placement at a community pharmacy.

SHOP FLOOR

  • First thing that I do is to make the shop floor presentable, such as brushing the mat and bringing stock to the front of the shelves.
  • Community pharmacies can be busy and short staffed and so date checking the shop tends not to be their first priority. Knowing that there is a student on the way they may ask you to date check OTC and P medications. All of them.
  • When collecting prescriptions from patients either write ‘W’ in the corner of their prescription if they are waiting for it, or ‘CB’ if they are calling back for it.
  • You will be asked to retrieve dispensed prescriptions from the area that they are kept. You will get flustered when you can’t find a prescription – don’t worry. There are many places a prescription may be kept – on the shelf, on the owing shelf (Æan item may not have been in stock and so an ‘owing’ label is given to the customer so that they remember to collect the rest of their prescription), blister packs may be kept separately, delivery shelf, or they may have a batch prescription. When giving the items to the customers, ask for their name and address – you would be surprised how many ‘John Jones’ there are so its important to give them the right prescription!

êA batch prescription is where 6 months of prescriptions are kept in the pharmacy, meaning that the customer doesn’t need to re-order their prescription every month.

  • Be aware of the services offered at that pharmacy – smoking cessation, travel vaccinations, MUR, blood pressure measuring, morning after pill, etc.  If there is a locum pharmacist in that day, make sure to ask them if they offer those services, as sometimes only the regular pharmacist will.

êMUR – ‘Medicines Use reviews’ are annual consultations between a customer and pharmacist. 

https://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/Pharmacy/MUR%20Guidance.pdf

Target groups include:those on high risk medicines such as anticoagulants, those prescribed respiratory drugs such as theophylline, and those on 6+ medications.

Aim is to increase adherence to medication through making sure that they understand what they are taking for what condition and that they are complying with the dosing regimen. If they have any issues e.g. they forget to take their medication as they may be on 8+ different drugs, then the pharmacist can help by showing them weekly pill boxes or the blister pack scheme.

êweekly pill boxes are organized by the patients (or family members) so that it is easier for them to take their medication. Blister packs are made up in the pharmacy and as they are time consuming not everyone is eligible.

The pharmacy is given a fee of £28 per MUR are are allowed to claim for 400 MURs a year, therefore it is a good source of income for branches.

  • Depending on where your placement will be the amount of addicts will significantly vary. They will tell you their name and maybe tell you that they have a ‘daily pick-up’ or methadone. I have not yet been allowed into the CD safe and so I don’t know much about this. The pharmacist will either make up the methadone then and there if they have only a few addicts, or they will be made a week in advance due to the large number of patients. While they wait they may ask for 1ml or 2ml packs. When I first started working at a community pharmacy I had no ideawhat these were. This is part of the needle exchange scheme which helps to reduce transmission of blood-borne viruses etc. Its quite a strange feeling knowing that they are about to be given methadone as a treatment for addiction but at the same time you are supplying them with needles so they can inject themselves. Not giving them needles won’t stop them from taking illicit drugs, but it promotes safer injecting practices. You need to make a note of their gender, initials, date of birth, and what you supplied them on a form or directly input it into the computer.

OTC tips:

  • CODEINE & DIPHENHYDRAMINE

During your first year of a pharmacy course, or MCA training for that matter, they don’t tell you on how to deal with addicts. From my experience, the two most common drugs that you need to watch out for is codeine and diphenhydramine. I will use codeine as an example.

A patient will come in with perfectly reasonable set of symptoms (back ache; toothache and dentist is closed/appointment in the next few days) and will ask for co-codamol. I have had someone come in complaining of a migraine, they had ‘tried everything but only co-codamol works’. I had recommended sumatriptan and explained that it was specifically for migraine sufferers, they ignored me and repeated that only co-codamol works. What you have learned at University has no effect on some customers – you are younger, inexperienced, and have no authority. You need to be able to develop a way of persuading customers that you know what you’re talking about. If you say co-codamol won’t help them then they need to respect you and take that advice seriously.

You can get staff who will just hand over Nytol and Solpadeine and so the customers get used to getting what they want which means that when you turn up with your WWHAM questions they will get defensive – ‘I usually get them. Why can’t I have them now?’, ‘I’ll just go to the chemist down the road then’. It can make you feel quite powerless when you KNOW what they don’t really need these medications and you just have to hand them over.

Therefore, ask the pharmacist or look online on how to look out for potential addicts and what you can do. 

  • Ask the WWHAM questions and remember the common interactions (decongestants with anti-hypertensives, fluconazole with anticoagulants, etc).
  • Its been a long day and you just want to sit down and have a bit of a break while the shop is quiet. Don’t. Hoover and then mop every 2-3 days and don’t wait for someone to ask you to do it. You’ll be exhausted but you’ll quickly gain a good reputation for being a hard worker.

DISPENSARY

  • Deliveries arrive twice daily, with the largest arriving in the morning. If a pharmacy dispenses ~400 prescriptions daily then the items need to be replenished daily, meaning that there are A LOT of boxes. The good thing is that quite a few will be ‘fast movers’. These are common medications regularly dispensed such as aspirin, atorvastatin, omeprazole, etc. Fast movers are kept above the dispensing benches so that they are easily and quickly reached.
  • Different branches have different ways to organizing stock but they all follow the general pattern. Drawers are labelled A-Z but there are exceptions. These include a contraceptives drawer, antibiotics, eyes & ears, HRT (which does not stand for ‘heart’ as I had originally thought). Creams and painkillers will also have a separate designated place.
  • Make sure that you keep the right strength in the right place e.g. some medications will be on the ‘fast movers’ shelves and in the drawers, but will have different strengths.
  • If you don’t know where a common or obscure drug goes just ask. Don’t just plonk it where you think its supposed to be.

The dispensing process:

In the first year of University they showed us how to label and dispense (electronically) but the process is quite different to what actually happens. (in Wales anyway).

  1. Prescriptions arrive in large bundles from the surgery (sometimes multiple surgeries) at ~1pm.
  2. They are then sorted into three categories: 1-2 items, 3-5 items, and 6+. They are then sorted alphabetically, making it easier to find a prescription when someone phones in to see if their prescription is there or not.
  3. Legality check – a community pharmacy prescription must indlude: age, DOB (if under 12), name, address, written in indelible ink or typed, prescriptions are valid for 6 months (28 days for CD), signed + dated by prescriber, name and contact details of prescriber.
  4. They are labelled – at University you manually type everything in and have to list all the warnings. Yeah…that’s not how it works. You scan the prescription, it comes up on the screen, and if it’s the same as the previous prescription dispensed for that individual then you can just print out the labels – no warnings included (which doesn’t stress me out at all…).
  5. Dispensing – retrieving the required medication, sticking the correct label on, and signing it. Dispensing large prescriptions can SERIOUSLY confuse you. The phone is ringing, there’s a queue in the shop and you have to stop and help, and you can bet that there will be at least one awkward item on the prescription. I enclose examples:

The prescription asks for 6 zopiclone 7.5mg tablets so you have to ‘split’ the pack = take the tablets you need out and put them in a blank cardboard box, and them squiggle on the split pack so that other know that its not a full one.

Cyanocalabalamin is requested for 84 tablets and they come in tubs of 50 tablets to you have to take a full one (and usually lots of split packs) to make up the 34 left and place in a tiny brown bottle.

The packs that have been used a split must also be placed in the basket containing the items, so that the ACT or pharmacist checking your work knows exactly whats in there.

Stock – may lines are out of stock for a few weeks or months. Migraleve has been out of stock for at least a few months, in December, naproxen was out of stock causing customers to get quite annoyed, There are currently issues with getting HRT and nifedipine in particular.

  • The prescription is checked by a pharmacist or ACT (you will make mistakes, im telling you now).
  • Items are bagged and hung on the shelf ready to be collected.

At the end of the day you may be asked to count all the scripts collected, then count the items on the script.

Why choose Cardiff University?

As MPharm is an accredited course with no optional modules to choose from the choice of Universty depended on grades needed and factors other than the course. Cardiff University Pharmacy required AAB-ABB with a B required in Chemistry.  I didn’t achieve the grades needed but they allowed me onto the course – which may be due to a strong personal statement with experience in community pharmacy.

Things that makes Cardiff stand out:

  • Cardiff university offer free language learning lessons for students which take place weekly or a a week crash course. I’m thinking of applying for a course next year and there will probably be a blog about it in a few months.
  • Global Opportunities provide students with opportunities abroad for students as part of their degree or during the summer. They also offer grants to fund your time abroad – I have a seperatre post on this as I applied and received a grant to help pay for my time in the phillippines.
  • Paid Summer internships offered by each department.
  • The pharmacy department gets emails from local pharmacies about part time job opportunities.
  • Maths support available.
  • Give it a go scheme during freshers which allows you to try your hand at clubs and societies before joining.
  • SU organizes trips throughout the year to places such as Stonehenge, Oxford, Cambridge, St Fagans, Christmas markets, etc.
  • Jobshop advertises part time jobs such as during the rugby or on open days.
  • Skills Development service – courses and session on transferable skills such as dealing with exam stress/anxiety, leadership, communication.
  • Mentoring Scheme – all first years in the pharmacy course (I’m not sure how many in other courses) are allocated a student mentor which is a student from the years above to help with the transition to university life. It also means that you can apply to be a mentor in the subsequent years and is a hugely popular.

CARDIFF

Cardiff is a lovely city and for someone who has moved there from a farm in the countryside its not a scary jump. There are plenty of ways to get around the city from buses to bikes. NextBike is a bike rental company that has stations all around Cardiff and is a popular choice for students due to Cardiff being a relatively flat area and it having and many cycle paths. During my first year I resided at Talybont Court which has a cycle path going right behind it leading to the city centre and is right next to Pontcanna Fields. Recently I have started jogging in the morning and Pontcanna fields/Bute parks is the perfect place for an early morning run for absolute beginners – flat, great views along the river to distract you, and very few people to see you sweating and red in the face after a minute of jogging! Having a park on your doorstep is also a good break during exam season when you want a break and a bit of sun.

The city has something for everyone – clubs and pubs for the outgoing fresher, a trip to the opera at the millennium centre, a workout day with gyms spread out around or a bike ride to ICE arena wales for a shaky first time ice skating…and lets for forget the rugby.

TALYBONT COURT

I moved into my room at Talybont court on the earliest possible day and thought that everyone else would be doing the same, but I spent 2 days by myself in the flat meaning that just because that’s the ‘moving in’ date, you don’t have to go there that day. The accommodation only allows visitors a 45 minute window to drop things off – and this is the rule throughout the year. If you have parents coming to see you during the year then be prepared to have an annoyed voice at the intercom telling you that they can’t stay for long. However, if they want to avoid paying ridiculus amount that multistory car parks overnight then they can leave their can in the Talybont North car park for a £1 if there is space.

Talybont Court is one of the most sought after accommodations at Cardiff University and for good reason – its spacious, clean, and comfy.

  • Kitchen – everyone gets a cupboard under the counter, and a wall cupboard, a shelf in the fridge and in the freezer. 

Something that I definitely don’t regret is buying flat plastic boxes. They can be placed under the bed. Before going down my parents had brought a whole box of storecupboard foods – pasta, pasta sauce, curry jars, tins of soup etc and it realy does help and saves you some money.

Pyrex Casserole dish (small) its great for making spag bol, meatballs, oven baked risotto. You can just leave stuff in the oven to cook and get on with your work.

Small tiered steamer – get healthy and get your 5 a day veggies.

The bedroom is spacious – a single bed, bedside cabinet, a huge desk, wardrobe, and a 3 drawer chest (x2 – a small one as part of the desk for stationary etc and a larger one for clothes), wall storage area for all your files, and has an en-suite. I’d recommend an investment in a god thick matress topper – I have always struggled to sleep in beds other than my own (which includes hotels) but getting one has allowed me to sleep easily. In the warmer months it gets quite hot in the room, and cold in the winter so id also recommend a duo duvet (which has two duvets which you can attach together allowing you to be cool in the summer but toasty in winter)

  • Make sure that you have enough files – you’d be surprised at how quickly they fill up, especially if your course prints off the lecture slides for you.
  • A printer isn’t necessary if lecture slides are printed off for you as you have printers in the library and in your course building.
  • Bring a small extension cable just in case.

There is no TV in the flat so either bring your own (remember to get a TV license) or get a subscription to Amazon prime, Netflix, or nowtv for your ipad.

Talybont is right next to tesco Extra which is where I make my weekly shop or you could opt for Lidl on the way from from your uni building.