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