Even though it has been a whirlwind of a few months for everyone, I’ve managed to finish my second year studying pharmacy at Cardiff University. Yey! Following suit of last year, I’ve done a breakdown of the modules taught which will include any practicals and placements, and how the exams went.
Professional Development
This is a zero credit module the same as first year. We built on the mathematical skills from last year but it was a little more challenging as you had to teach it yourself (I had three different books to help me make sense of it all) but once you understand it, it’s not too bad. I do wish however, that other calculations would be included in the maths exam such as ones relating to ADME.
The other part of this module was placements, which I have discuss in a post from a couple of months ago but to summarise, the placements went down very well for the whole year, especially the chance to shadow a pharmacist working in a GP practice.
Clinical And Professional Pharmacy
I’m afraid I have some bad news for you. This module contains a large chunk of what I KNOW is very important stuff for a pharmacist to know but it’s also terribly boring – health & safety, pharmacy business, NHS regulations, and consumer law. Yawn.
The clinical side is where you start getting stuck into proper community pharmacy stuff – services available and how to consult on a MUR and EHC. The only problem is that you don’t get much of a chance to do role play scenarios which are extremely useful or OSCEs. Therefore, I’d recommend getting into small groups and meet in the library to role play some scenarios that could come up in the OSCE.
You’ll still be doing POP (dispensing) but its focused towards legally and clinically checking prescriptions. There are held by the brilliant teacher practitioners. You’ll be split into groups within your workshop groups and you’ll have 15 minutes to legally and clinically check a prescription before feeding back to the group on any issues you found within the prescription. It can be a lot to get through in a short amount of time, but they are only small prescriptions, saying that, I have never seen a community pharmacist take 15 minutes per prescription to check, and so I’m hoping that in third & fourth year it will become more reflective of what actually happens. At the moment we’re heavily reliant on the BNF and EMC. This type of workshop reflects the ‘practical’ exam that you’ll have in the module but due to COVID-19 we only had a mock in this style.
Unfortunately this year we have no RTS workshops and so going into our mock OSCE was a bit daunting as we had no idea what to expect. All I can say is inhaler technique.
Providing Pharmaceutical Care (PPC) workshops are new to second year and are a chance to apply knowledge learned from other modules to real life settings. They’re held as a whole year group but are still very interactive with the teacher practitioners coming around and menti will obviously be used. You’ll be given a case/scenario and taught how to manage drugs and give advice on them, and use this in a different form each workshop e.g. a respiratory patient is admitted to hospital and so you must guess what’s wrong with them. It won’t be hard, you’re not medic or nursing student, so it’ll be something like an acute exacerbation of COPD (you’ll have the patient history not just a set of symptoms). Then as they have been admitted to hospital, you’ll learn about hospital drug charts and how to read them and then formulate a care plan, something that will come up more in third year so I’m told.
What to expect in the exam – split MCQs full of questions about health psychology, and what’s included in the Health and Safety at Work Act (1974); and the second part containing sort answer questions based on cases seen in community pharmacy such as supply of EHC.
Diseases and Drugs 1
I’m not going to lie, this module is my favourite but also one of the cruellest. This year we covered some of the most common diseases of the human body which included:
Asthma, COPD
Hypertension, high cholesterol, angina, stroke, arrhythmias, chronic heart failure.
Diabetes, hormone hypo and hypersecretion, osteoporosis, glucocorticoids.
Urinary incontinence, contraception, HRT, male health.
Dry eye, conjunctivitis, glaucoma.
Hypersensitivity, vaccines.
You may think that it doesn’t seem like a lot, but in the beginning of the year we were given access to an excel spreadsheet which gave a list of over 100 drugs with columns to give indication, dose, adverse effects, contraindication, monitoring requirements, and counselling requirements. We thought that we had to learn everything.
The COVID-19 pandemic does have its moments, and for me, that moment was during the online exam that we had. Split between MCQ and short answer questions based off case studies I felt prepared – if it was to be anything similar to the first year ‘Human Body Systems’ exam. But oh no. There was one question on side effects, and that one being the obvious dry cough with ACE inhibitors, several on drugs used for liver disease (which I knew, thankfully) and more than I would like to count on pharmacology. Not nice pharmacology ones either, horrible nit-picky ones and oh, before I forget, two on Cystic Fibrosis…that we haven’t even been taught about (insert exasperated crying noises).
Formulation Science
In the series of practicals we start to make our own formulations but many of us seem completely and utterly lost. Sometimes, there is a ‘template’ you can use from previous Pharmacopoeia Monographs but when there isn’t, it becomes a little stressful a few days before the practical workshops where everyone is just adding random preservatives to their mix. There have been a few nice ones such as making calamine lotion in which I was tempted to sneak my phone out cause it was insta-worthy. By using what is called geometric dilution (a very calming process, I might add) I made a light pink mixture and it was just too cute. In the practical exam you will be expected to make two worksheets and then make one product which is doable in the time given but, it needs to be perfect. You can lose a lot of marks very quickly, like 15 marks for putting the wrong expiry date.
The MCQ exam was a little challenging but it would have been a lot worse without my notes. Why do I need to know what a supercritical fluid is? Sometimes in lectures they’ll add an example and tell you ‘it’s an example you don’t need to learn these values’ but they sneakily added them into the MCQs. You definitely need to know details for the module exam – you can’t get away with learning general concepts.
Design And Disposition
It covers a lot of last year’s stuff but in more detail. There’s still some organic chemistry that you need to know but it’s not too bad. ‘Human Drug Metabolism, an Introduction’ by Michael D. Coleman is a book worth dragging yourself to the library to get. You’ll be studying ADME again in second year and it has some really interesting chapters such as why drinking grapefruit is such a big deal and the effects of age on drug metabolism.
Last lecture of PH2112 we covered biologics. This particular lecturer’s research area was the use of natural compounds as drugs and said that marine organisms were a good source of antibacterial and anticancer drugs as it’s a competitive place to live in and so the organisms produce toxins to reduce competition. He was looking into local sponges and found one in particular produced an antibiotic that was more potent than vancomycin, but he had yet to extract sufficient quantities of it to prove and publish – pretty cool right! But it also made me think of home. Menai Bridge on Anglesey is the home of Bangor University’s School of Ocean Sciences, nestled right by the Menai straits. We are always told how extraordinary the waters of the straits are, containing incredible species and so naturally I wondered if the department had looked into pharmacological uses, but alas, no.
The exam is tough and usually, I finish around an hour early in exams, but I barely managed to finish and had no time to look over my answers. It covered pharmacokinetics and dynamic in detail which means that I’ll need to teach myself over the summer to properly catch up.
Overall it has been a tough year even though we have had fewer lectures and more workshops in order to apply what we’ve learned a lot more e.g. making error logs when checking prescriptions, inhaler techniques. I’m both excited and terrified of what is about to happen in third year.
The beef industry has been under scrutiny in the last few years, one example being due to the continuing increase in climate awareness resulting in diet changes towards veganism. Cattle are responsible for the greatest global emissions among livestock with beef the most as compared to dairy. So how is all this emission produced?[i]
Food is broken down by both enzymes and microbes in the ruminant gut. The enzymatic metabolism produces hydrogen gas as a byproduct which is used to form either VFA (energy source) or by the bacteria to produce methane. Changes in diet can change methane emissions which is why the pressure on the beef market to adapt has led to exciting ideas such as that of adding seaweed to cattle diet. It was found that adding just a little of the algae Asparagopsis taxiformis to their diet reduced methane production by up to 95% – consideration needs to be taken as current studies are in vitro. For me this was such an incredible find as usually cattle get such negative press regarding methane emissions but now, with this insight, hopefully things will change. I mean, it’s a long way away from being mass produced and widely available to farmers but there is hope.
Another hit to the UK beef market was due to a new disease outbreak in the 80s which led to widespread culling of cattle and distrust in the beef market. In 1995, UK beef exports reached over £6oo million but by 1998, it had fallen to just £16 million[ii]. The disease commonly known as ‘Mad Cow Disease’ or Bovine Spongiform Encephalopathy (BSE) is a neurodegenerative disease caused by an accumulation of prions – which are misfolded proteins, in the brain and spinal cord. The most common signs were – changes in temperament, tremors, excessive licking[iii]. At this point in time, it was common to feed cattle a meat-and-bone meal in order to increase their protein intake. This means that cattle were eating the remains of their own species. This infected meal was how BSE was transmitted throughout the UK.
It took four years from the first case for this practice to be banned in the UK but the damage was done. The public was told that beef was safe to eat but 5 years later the first zoonotic case of BSE occurred, which caused a variant of Creutzfeldt-Jakob Disease (vCJD) resulting in a total of 144 deaths in the UK with the average age at death being 28. The young ages of death may be due to a higher consumption of infected meat but it is still unclear. The incubation period is thought to be 13 years after which psychiatric symptoms develop then ataxia and dementia[iv]. Currently, there is no treatment available for prionic diseases.
It wasn’t just beef economy that suffered, as new legislations were introduced to improve traceability of cattle movements. Passports were, and still are, issued to everycattle on the holding which must be updated each time, individually, even if the cattle are moved from one holding to another owned by the same farmer[v]. If you don’t have a passport, a source of income becomes difficult as you cannot move the animals from your land during its life and it cannot go into the food chain – which would be a major issue for beef producers[vi]. You may think that farmers can get away with not having passports or not updating them as who’s going to check a couple of boxes full of passports thoroughly? Well, there are inspections and is there are major issues then movement restrictions may be placed on the animals, and payment reductions from subsidy claims.
Side tracking a little, I wanted to know more about what I had heard at home – a subsidy called Single Farm Payments. This name was actually changed a few years ago to become the ‘Basic Payment Scheme’ which is an income support available to farmers [vii]. Farming is a volatile business due to factors ranging from weather to slow price responsiveness of demand and supply where long term financial complication for the producer. In order to help small farms which supply us with something that we cannot live without – food, subsidies are granted.In Wales 56% of farms made a loss or would have without this vital support[viii]. That is a huge percentage to comprehend but it is a subsidy that must be continued in order to have a stable supply chain and affordable food. Without it, there would be fewer small farms, and from what I can image, there would probably be more intensive farming. On the other hand, food production could be reduced resulting in increased food imports.
The subsidy is allocated by hectares and in Wales the rate is between 103.24-125.65 euros per hectare[ix]. In 2016, Wales paid out £224.0 million in BPS but has a gross value added of £457 million[x], which is over double and which is pretty good coming from investing in something that doesn’t make much profit. Its rather similar to what’s happening right now in the UK. The government has introduced many new schemes to protect people and companies during this recession – which is causing government debt, but will hopefully stop the country falling into a depression. My knowledge in economics is non-existent but in a few years when we begin/have recovered from the effects of COVID-19 I would like to try to understand the stance that the government is taking right now in order to avoid problems in the future.
Back to the point, for cattle, the disease has an incubation period of an average of 4-5 years which means that cattle will show no early symptoms and as it is diagnosed through the observation of clinical symptoms, only cases in the later-stage are detected.[xi]Even today, there are no tests available to detect BSE in live cases before onset of symptoms.
So what happened to the infected cattle? They were culled – there is no treatment available for BSE, and even if there was keeping farmed animals is very different from pets. You can pet sit your pet and care for it until it dies, with insurance to cover vet costs, but for farm animals, unfortunately, the only option is to cull. Over 200,000 cattle were slaughtered in the UK due to BSE[xii], not all from confirmed bases but as a precautionary measure and so there was a compulsory cull of cattle born between October 1990 and june 1993x.
Growing up on a farm there is a lot of agricultural terminology flying around but until this blog I realized that I was pretty clueless even in that. I thought that a bull was just any male but it’s a male which breeds, as compared to a castrated male – a steer. And its not just basic terminology that had me baffled – what on earth are all the different types of herds?!
Suckler bred herd is from what I’ve gathered, ‘beef specific herds’ where the mothers are not milked and so they are able to suckle. Dairy bred is where calves are separated from the mother and fed using artificial milk (this is a smell that I SOOO miss. Monologue moment = I remember my dad mixing the powder with warm water and I can just remember the smell, like there’s a bucket of the artificial milk right in front of my nose right now. A thick, sickly sweet smell – lovely.) since the mother is being milked.
I love calves. They’re just so cute. When I was younger I used to climb into the individual pens to be with them. I can’t remember exactly, but I’m pretty sure that our calving season was during the late winter or early spring. There is so much to consider in terms of calving season not just ‘introduce a bull at this time to get calves at this time’. For heifers its important that they are the correct liveweight etc as they are more prone to difficulties while calving and so measures need to be taken to reduce both difficulties and mortality. These include mating with bulls that have good Estimated Breeding Values (EBV) for example, one of the traits include gestation length. A shorter times period means that the calf will be smaller in size resulting in easier calving. These traits need to be carefully balances with calving ease and traits that will be good for the herd and farmer, such as eye muscle area EBV[xiii]– a positive value will mean that the offspring will be muscular – which is advantageous for the farmer when selling. I’ll try and learn more about morbidity and mortality during calving in a later blog.
It’s not just the care before calving that needs to be considered. Calving intervals depend on many factors – those with a poor body condition after first calving will have an anoestrous period of 50-60 days, length of suckling will also dictate anoestrous period[xiv]. I think that this is mainly due to the fact that the heifers are not only growing a calf and producing milk but are also still growing themselves. These factors reduce the mating period, which causes concerns over whether the cow will calve next season.
A finishing herd is the stage prior to slaughter which means that it’s where the cattle gain a sudden increase in weight which can range from 12 months (intensive) to over 20 months (extensive). I think we had an average herd size for dairy when we were in production and now, even though they’re not our sheep and cattle, there are animals in the fields right now and so I don’t agree with the intensive 12 systems where they are fed on concentrates instead of grazing in order to increase the maximize the liveweight before slaughter. In this instance, beef seems, and is really, a much harsher type of agriculture as compared to dairy. You rear to maximize the meat on an animal, year after year, while with dairy you’re with the same herd for much longer…I don’t know, I’m not very good at explaining such things. Saying that, it was interesting to see the typical finishing systems and the weight aims from the different types of herd from MeatPromotion Wales[xv].
A document I read was going on about the different meat that comes from beef cattle and even though since going to University I have seriously expanded my cooking repertoire if you asked me from which area a ‘hock’ or ‘brisket’ came from and what is it best used for, I’d look pretty confused. Maybe that should be added to my growing list of ‘Things I should know but don’t’. It had an easy guide to fat assessment – which would have been helpful a few years ago when I was in Wales YFC. From the guide you could evaluate how much fat was on the animal which would indicate price at slaughter[xvi]from the EUROP classification grid. Lean and muscular cattle result in higher prices as compared to emaciated and obese.
Well, there it is. Took forever and a day and I still feel like I’ve barely skimmed the surface of what I could learn – especially about calving and cattle diseases. Hopefully I’ll manage to link some to future blog posts and squeeze them in.
Until next time.
[i]Food and Agriculture Organization of the United Nations. 2018. Global Livestock Environmental Assessment Model. Available at: http://www.fao.org/gleam/results/en/
[ii]DEFRA. 2014. Detailed figures on the value and volume of UK imports and exports of food, feed and drink by indigeneity, degree of processing and commodity type, from 1988.
[iii]John W. Willesmith for the Food and Agriculture Organization of the United Nations. 1998. Manual on bovine spongiform encephalopathy.
It may shock you to know that pharmacy students get very few placements but thankfully Cardiff University are trying their best to get us some, starting with a week in community pharmacy and two days in a GP practice for second year students.
As I have worked within community pharmacy for a few years now I knew how the pharmacy runs and what to expect. It takes years to figure out the pharmacy but there are other students that had never stepped behind the counter who had to learn the ropes in just five days…good luck. I was allocated Well Pharmacy in Llantwit Major, and I’m naming the pharmacy cause they were absolutely BRILLIANT! I had expected to be on the counter all week, bored out of my mind; but I’ve been so busy and learnt so much it has been incredible.
Volunteering to do something goes a looong way when you’re out on placement. I hate just standing around so I asked if I could date check, which allowed me into the shop team’s good graces throughout the week. Even just being in the shop really made the think about processes within community. I have only worked for one community pharmacy company but seeing how Well pharmacy did things it does make you wonder why everyone isn’t doing it that way.
At home, after items are dispensed, they’re placed in a plastic bag and hung by surname alphabetically, and since this is Wales when it comes to finding John Jones’ prescription it takes about an hour to go through all the ‘J’s. Off Site Dispensing (ODS) was also bought in during the summer and patients regularly complained about the 2-3 plastic bags that they were given each month, with the company saying that plastic was used for confidentiality reasons etc. With Well, it’s a little different. And it just makes perfect sense. All items, including ODS are packaged in paper bags, closed shut with stickers. Then the bag is scanned with a little hand scanner and allocated an an area to live until its picked up e.g. F9 (shelf F, 9throw down). Therefore, when John Jones comes in for his prescription, the staff type his name into the scanner and it tells when exactly where it is, so they only have to shift through like 8 other bags to find his. So beautiful, brings tears to my eyes. Plus, environmentally friendly, unlike plastic bags.
On Wednesday afternoon I was allowed into the dispensary and dispensed away the afternoon. I made a few dispensing errors but the ACT was lovely, and didn’t like condescend me about how I should know better or whatever.
We were given a booklet to complete during our placement and I had thought that I would just be left to fill it in myself but the pharmacist there has been proactive in helping me learn as much as I can, questioning me, making me look up interactions, and allowing me to sit in on consultations.
Before this placement, I was adamant that I was going to avoid a career within community. The daily repetition of checking prescriptions and all the paperwork just…(visibly shivers). I know that I want to become an Independent Prescriber and in my mind I thought that I’d have to specialise in something along the lines of asthma or hypertension but that pharmacist at Well had just qualified as an independent prescriber in contraceptives. This is an area that I have a strong interest in and suddenly a future where I held clinics within community pharmacy seemed not so bad. I was lucky enough to stand in on a consultation of the ‘morning after pill’ supply. The pill cannot just be handed over. Questions must be asked to determine its suitability – how many days have passed since unprotected sex, when their last period was etc. In this particular case a copper coil was more suitable and so they needed to attend a hospital sexual health clinic.
In some rural areas, taking time off work etc in order to wait for hours at a sexual health/contraceptive clinic which may only occur once a week just isn’t as easy option and so observing such a consultation has shown just how much community pharmacists can help with ease of access to services.
The following week I was at a GP practice and it is only recently that pharmacists have infiltrated GP practices. They first began as cluster pharmacists – being shared between a group of surgeries but were quickly snapped up due to practices seeing a huge improvement in the management of medicines. They have quite a varied role and it depends on the skillset of that particular pharmacist.
A new concept that was introduced to me during this placement was that having such a diverse team allowed the practice to triage patients so that they are matched to the healthcare professional which is most qualified/competent for their issue. For example, GP’s were only required to do medicine reconciliation and reviews – something that they (a) don’t have the time for with increased patient lists and pressures, and (b) didn’t know enough about. Introducing a pharmacist for this role meant that GPs can tackle more complicated patients, leaving the independent prescriber pharmacist to sort less complicated cases, and those related specifically to their medications.
As we are an aging population more and more of us will be on medication, which leads to polypharmacy – a patient won’t just be on one blood pressure medication, they may be on three and a statin and they may need something for joint pain and for bone weakness and type 2 diabetes. See how quickly patient end up with a shopping list of drugs? This means that its the pharmacists job to decide what is absolutely necessary for them to be on.
We shadowed a nurse while there and she was absolutely incredible. In pharmacy we are taught things by the book, but in community pharmacy things don’t really work that way. But this nurse did consultations by the book – she gave all the details to the patient, educated patients on signs of sepsis, and gave resources for patients to help them with their condition. Completely blew me away, AND during consultations made time to explain to us the more intricate details and prescribing issues.
Such experiences deeply enhance student education and allow us to see how knowledge gained within workshops and lectures arise within practice and how they are dealt with.
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.
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
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].
Tea & Tablets 