Practicing pharmacy at Moi Teaching and Referral Hospital in Eldoret, Kenya revealed a health system highly influenced by pharmacists and demonstrated effective management of patients in a resource-constrained setting. The past two months have re-enforced the difference a pharmacist can make in patient care. MTRH has made a permanent impression on how I will practice pharmacy in America and has demonstrated the positive impact pharmacy can have on patient care regardless of the setting.
Moi Teaching and Referral Hospital currently has a number of outpatient clinics (cardiology, diabetes and oncology) to accommodate the follow-up of patients. Doctors are involved in the clinics, but the pharmacists take significant responsibility in ensuring patients understand their medication regimen and monitor their own therapy. The pharmacists act as the first line in the clinics, and they defer complicated patients to the doctors and ensure the doctors agree with the assessments of routine patients.
During our rotation, we assessed the need of an anticoagulation clinic in Eldoret based on a chart review of cardiology clinic patients. Currently, patients are being anticoagulated in the hospital and either sent home on a dose which will hopefully maintain a therapeutic INR or they are sent home without any anticoagulation at all. Most patients are sent home without any anticoagulation because there is no means to reliably monitor the patient’s INR due to the lack of resources and funds. Kenyan patients also lack a regular diet which may result in alterations in their INR. The anticoagulation clinic we are setting up will help to manage patients on their anticoagulation medications and may eventually yield an opportunity to establish a valve replacement clinic within the hospital.
Something that really surprised me during this rotation was the condition of the wards. Upon walking into the hospital the smell nearly takes your breath away and no one breaths through their nose for the rest of the day. Proceeding down to the Nyayo wards, the men’s ward is to the left and the women’s ward is to the right. Each ward is divided into six cubes with each cube holding eight beds. Normally there are two patients to a bed with their heads facing in opposite directions. There is no identification for these patients, and I do not know how the nurses ensure that the correct patient receives the correct medication. There are times when I am not sure we are talking about the correct patient when we are holding the patient’s files during rounds. The condition of the wards really surprised me, but patients do receive their medications and improve.
AMPATH is very impressive and it is hard to imagine that it started in 2003. Currently, it is an integrated and established department for Moi Teaching and Referral Hospital. AMPATH has helped so many patients and doctors in the hospital refer patients regularly to AMPATH. This is an excellent example of the influence pharmacists can have in the practice of medicine with some determination and effort. I know there were a lot of people that told professor Mamlin this would be too daunting of a task, but his confidence in his abilities remained strong and currently AMPATH is a reality.
The experience I will remember most regarding my clinical experiences in Kenya revolve around a little girl who presented with an exacerbation of sickle cell anemia. She may have been eight years of age, but weighed only 25 kg. She was in so much pain she winced every time we touched her stomach or moved her. She refused to talk to us or even smile. Her father, a man suffering from the effects of polio since birth, remained at his daughter’s side day and night. Family remaining at the patient’s bedside for the duration of their stay is a common occurrence in Kenya. Although there are visiting hours, patients are permitted to have one family member present at all times. This often proves useful during rounds because the patient’s representative is able to update us on the patient’s status over the night better than the nurses. The patient’s representatives act as the patient’s primary caretakers while they are in the hospital. After a couple days in the hospital, we realized that our patient with sickle cell disease was not receiving the medications we were requesting. After talking to the nurses and the pharmacy multiple times, we were able to get our patient the care she required. After a couple of days, she made a full recovery and became a very happy young lady once again. Her father was so thankful her daughter was back in good health again, he shook my hand every time he saw me in the streets. Seeing our patient smile as she walked out of the wards has left a permanent impression on my patient care.
The practice of pharmacy in Kenya demonstrated the importance of pharmacists taking an active role in the care of patients. Pharmacists have established multiple clinics to patients’ needs and work directly with patients during follow-up visits once they are discharged from the hospital. From this experience, I have a thorough understanding of the common tropical diseases present in Kenya (ISS, malaria, tuberculosis, PCP, cryptococcal meningitis and toxoplasmosis), but I also understand the importance of pharmacists establishing themselves as active participants in patient care both in the hospital and in the community. If patients can be effectively managed in the resource-constrained society of Eldoret, Kenya, patients can be effectively managed anywhere in America, but pharmacists have to become essential to the practice of medicine.
Alex Fohl
PharmD Candidate, May 2009
