The Student Perspective - Avery Hagedorn

I honestly do not even know where to begin. Coming to Kenya, I had such a mixed set of emotions running through my mind. The anxiety was palpable in nearly everything I did the month prior to my departure for this foreign land of which I had little knowledge and knew even less of what to expect. Though we all take the elective course to “prepare” us for what each of us will do here, to be completely honest, it does not prepare us whatsoever for the experience. It is truly a life changing experience that I wish all my classmates were able to experience firsthand. Unless you have been here and seen the wards, one is likely to never understand the difference one person can make.

My first few weeks here were an adjustment period. No doubt about that. I had many days on the wards in my first weeks that were absolutely frustrating. However, as Sonak had prefaced, “if you aren’t frustrated on the wards, then you aren’t trying hard enough”, rang true for me in my first week. I have never, and doubt I ever will feel as overwhelmed as I did my first week here in Eldoret. From anger that my patients weren’t receiving their anti-TB drugs to absolute despair seeing a patient we had just rounded on 20 minutes prior pass, without anyone even so much as batting an eye, my emotions were all over the place. It is such a stark contrast to care in the States. For someone whom has never been exposed to such a system, the differences to the American healthcare system are almost too much to bear. However, I stuck it out and continued to do my best and I am proud to say that it has made me a much better practitioner.

With only two rotations left in the year, we had all been on clinical rotations back in the States. I can easily say, that in the most of resource constrained settings; I had my best clinical rotation of my experiential year. Working with such limited resources places a huge emphasis on proper patient management that is both cost effective and beneficial to patients. It is remarkable to have such freedom in the ability to practice clinical pharmacy (as a student) and manage such a large patient load. I worked tirelessly to manage my patients’ medications, help both physicians, medical students, along pharmacy students learn about the medications used for said disease states, and ensure that they received drugs vital to their care. It is amazing to me personally, to be able to say that I had my best clinical rotation in the most of constrained settings. It speaks volumes to the ability of Sonak, and the passion that most of us bring on this rotation. It is truly amazing to know that me, a single person, can have an impact on so many patients and their outcomes.

The most rewarding experience, however, was noticing my own growth from within as both a practitioner and as a person. I knew that this experience would change who I am, but I had no idea just how it would affect me. I am proud to say that I feel I have grown both my clinical knowledge and compassion, in large part because of Sonak and his wealth of knowledge and his generosity, immensely in just eight short weeks. Sonak personifies what a pharmacist is capable of, and what a pharmacist should be. He works tirelessly to change the face of the Kenyan healthcare system, and gives to patients without ever being asked to do so. He is someone for whom I have the utmost respect and someone I hope to emulate in my own practice.

Prior to this experience, I had no ambitions of ever pursuing a career in “clinical pharmacy”. I still am planning on going into community pharmacy (as many people say its not clinical, I say to them, why can’t it be!); however, I plan on brining clinical work with me, and being a catalyst for change in my own work environment. If my employer will not allow me to practice, as all pharmacists should be able, then I plan on finding an employer that will, or changing my career path. This experience has shown me what a pharmacist is capable of, and how valued we should be in any healthcare setting. I plan on carrying that on wherever my career may take me.

I also feel that I would, at a minimum, like to precept rotation students in my future endeavors. Although I only had a week to do so, I was able to teach the Kenyan pharmacy students the ropes on rounds. It was amazing to see them learning right in front of me, solely based on the knowledge that I shared with them. Giving them a short assignment and seeing them respond with research and then present the topic to me the next day on rounds was remarkable. I am grateful for the opportunity to work with them, and hopefully have taught them along the way.

Other than my time spent rounding on the wards, I truly enjoyed seeing the healthy side of AMPATH and the difference this program makes. On the wards, it is easy to forget that most patients with HIV are now able to lead a normal life, maintain their job, support their families and are such a happy people. The days I spent out at the AMPATH satellite clinics, with the Orphans and Vulnerable Children (OVC), and my day on the AMPATH farm were a welcome sight to know that we are winning the fight here in Kenya. I cannot wait to come back in a few years and see what this program has become. I know that it will be remarkable.

I’ll close on a remark from Sonak made to me on my most depressing day here, and one that I hope everyone who reads this takes to heart. “Don’t let episodes like this prevent you from always trying to do more. Every student who truly invests time into their patients will have these types of experiences. It is how you respond that really determines the type of practitioner you will turn into.” I know what type of practitioner I will be, and I hope that everyone else carries that same attitude with them throughout their time here and throughout their career.

Avery Hagedorn
PharmD Candidate, February 2009

The Student Perspective - Isabel Hagedorn

My time in Kenya is nearing an end. We finished our final ward rounds on Friday with bittersweet emotions. It was a mixture of relief to not have to watch the suffering as well as an overwhelming sense of desperation to stay and help where ever I can.

In a way, my time in Kenya has come full circle. You may remember my frustration I expressed in my early days here, and as I left on my final day my frustration had returned. More so for differing reasons, but the walk home was like déjà vu of my walk home from my first solo day on the ward.

Though my emotions are swirling and I’ve felt tormented at times, I wouldn’t trade a single second of my time here. This trip has helped me to define who I am as a person and as a care giver. It has also taught me who I want to become as I continue on with my education and life. I have learned a great deal about pharmacy but even more about compassion and selfless giving.

All my hours I have spent feeling helpless or useless were forgotten as I was visiting my last patient of the day Friday. He is a young man married with three children under the age of 5. As he lay in our hospital for weeks, a tumor was rapidly growing and closing his airway. Day after day we rounded on him with a casual “ENT consult” and moved on to the next patient. My anger grew until I couldn’t take it anymore. He was hardly able to breathe, eat, or talk. Within a matter of days he would be dead and I couldn’t bear to watch that happen. I found my preceptor to ask for guidance and couldn’t hold back my tears any longer. I was angry for letting myself cry, but I was so exhausted emotionally I didn’t have the strength to stop. To make a long story short, by taking matters into my own hands, I was able help get him scheduled for surgery, reviewed by oncology, and more importantly to give his wife someone to talk to for what she was going through. What felt like endless hours of work were rewarded this week when he was started on chemo and scheduled for radiation with an optimistic chance of survival. I was even able to find him a sponsor to cover the cost of his treatment. As I stopped by to see him before I left, he shook my hand while his wife hugged me and both were sobbing saying countless thank yous. Seeing their gratitude was overwhelming and it helped to confirm why I was here.

Though the culture may be different and difficult at times, the Kenyans are such a beautiful people. Working side by side with them has taught me how to adjust my work style in order to bring out the best in the team. We made some terrible mistakes as a team, but we also made some incredible saves. We will encounter many personalities and work ethics in the future and the most important thing we can do is learn to work together to provide the best care for our patients. This doesn’t mean giving up or slacking, but working longer and harder to accomplish what you are capable of. While here I have learned how to be an advocate for the patient and to not give up when you believe in something – especially when you believe in a patient.

I never knew anger could be such great fuel. When I look back on my time on the wards, the moments I’m most proud of were in response to moments that pushed me professionally and challenged me. Every effect has a cause. Why not use the cause to do great things. I don’t think I’ll soon forget what I have learned here, and I hope I never will. I believe I will be a better care giver in my career because of my experiences. My registrar, Nadia, told me repeatedly through our countless conversations to harden myself to what I was seeing around me so I can provide better care, but I think by doing that I would be letting myself slip. I enjoy the compassion I have for my patients and I intend to carry that on to the states. I think it’s especially important in America to have that drive when it’s becoming more and more about the money. I will always be grateful towards this rotation and the Kenyans for teaching me this. I can’t seem to find the right words for what I want to say, but I think one of my patients said it best when he told me, “we may be a very simple people, but God still smiles on us.”

Isabel Hagedorn, PharmD Candidate
February 2009

The Student Perspective - Lisa Zagroba

Overall I really enjoyed my 8 week rotation in Kenya. This is not to say that there were not challenges along the way, but I do believe everyone that comes here makes a profound impact. It definitely took some adjusting, but after the fist few weeks I felt like I was able to contribute on rounds. We rounded with a team of physicians, nurses, and pharmacists in the Moi Teaching and Referral Hospital (MTRH) wards on a daily basis. This was a good learning environment because there are so many opportunities to use your clinical judgment to impact patient care and educate staff members. I often found myself question physicians about drug regimens, helping fellow pharmacists’ dose medications, educating patients on how to properly use inhalers, and educating nurses about various medications. I really enjoyed getting to work with the vast array of medical personnel from all over the US, Kenya, and other parts of the world. This truly was a global and very uniting experience. Sonak did a great job of helping us adjust and learn from this unique environment. I got to see many different areas including outpatient oncology, the diabetes clinic, and some of the rural clinics. In each of these very different practice settings pharmacists were making an impact.
I also really enjoyed the opportunity to do presentations and complete projects. I assisted in developing antiemetic regimens for chemotherapy treatment, helped make pediatric ARV handouts, and worked with IU medical students to complete a morning report presentation. My favorite project was a presentation about the treatment of chemotherapy induced side effects. This was a good chance for me to review the treatment options, especially since my next rotation is in oncology. This is also an area that I am considering specializing in, so it was very pertinent. It was interesting to see how their oncology program is developing, since it is still in the early stages of organization. It was frustrating, but educational at the same time. They do not even mix the chemotherapy drugs in any kind of a flow hood, just next to an open window.
I think I learned the most at our afternoon topic/ patient case discussions with Sonak and the other pharmacy students. These were great opportunities to learn from each other and better the care of our patients. Plus Sonak did a great job of asking us questions and making it a learning experience. I also enjoyed our fireside chats that related to public health topics. This was a great opportunity to lean more about the world and understand different perspectives. We discussed different topics ranging from the street kids in Eldoret to contrasting the health care systems of the US and Canada. These were good discussions because they involved people with different backgrounds and from different parts of the world.
Lastly, I enjoyed the opportunities to see some of the non-pharmacy related work that is done through AMPATH, such as the Orphans and Vulnerable Children (OVC) program, Sally Test Center, and farming. OVC was a great opportunity to see people helping each other. The stories of these families were amazing and really moved me to want to help. I met a grandmother that was caring for 11 of her grandchildren because two of her daughters had died from AIDS. The organization had helped her find a small one room home for her to live in with her grandchildren. She was incredibly grateful; the experience was very moving. The Sally Test Center was such an enjoyable environment where we could play with the children from the pediatric wards. The kids always greeted you with a smile and were ready to have some fun and forget about the hospital. I also enjoyed learning about the farming initiative, because with out food, the patients ARV regimens would useless. AMPATH tries to look at the big picture when caring for patients. Honestly, adjusting to life here was not as hard as I had expected. I had many opportunities to grow both as a pharmacy student and as an individual. I hope I was able to make as much of an impact here, as I this experience has made on me.

The Student Perspective - Serena Harris

As my first flight, of many, was about to take off I had a mixture of emotions running through my head. This would be my first experience outside of the US for longer than a week and I knew I was about to be immersed in a new culture. Everything would be different from the food and living arrangements to the lack of medical resources and healthcare facilities. I’m happy to say that although I had my worries, this experience has helped me grow both personally as well as professionally.

My experiences at the Moi Teaching and Referral Hospital were very different from any other hospital experiences thus far in my 6 months of rotations. As I walked into the hospital my first day there was a distinct, overwhelming smell that nearly took my breath away. This was only one of the many things I would become accustom to over the next 8 weeks. Multiple patients to a bed, medication not being given, unreliable lab results, and lack of resources were encountered daily. It’s indescribable the feeling you get when you know a patient will soon die because they either don’t have the money to pay for proper treatment or it simply is not yet available here. I sometimes found myself near tears during rounds and frustrated to the point of almost walking out. These were the bad days. The most rewarding experiences came when I improved quality of life for my patients and watched the transformation of the sick into the healthy. Whether it is managing glucose in a newly diagnosed diabetic or changing anticonvulsant medication to control seizures, the potential role of pharmacy in Kenya is immense.

Through my interaction with Kenyan and American physicians and medical students on rounds, it has become clear the effect we can have on patient care when working closely together. The Kenyan interns are often responsible for over 25 patients a day, a truly mind boggling thing once you understand the amount of work required in each patients care. I found my role on the team often changing from typical pharmacy related medication issues to recommending appropriate labs, calling attention to electrolyte disturbances, and addressing untreated medical problems. Purdue pharmacy students have a unique opportunity to truly make a difference in all aspect of patient care. Once you earn the trust of your team, they will look to you as the expert in all things related to medication. I not only recommended dosing, but also specific agents we should use based on patient and disease specifics.

Learning did not end with ward rounds. We had daily patient discussions with Sonak that enhanced not only our medication knowledge, but also our critical thinking skills. We used this opportunity to present difficult patient cases and determine the best management for each patient. Other unique learning opportunities came from our interaction with Kenyan pharmacy students. They made the transition from work in America to Kenya much easier. As I looked down at a treatment sheet for the first time, I had no idea what half of the medications were treating. Disease such as typhoid fever, PCP, malaria, toxoplasmosis, and tuberculosis are a common diagnosis here rather than a rarity. We were able to share our knowledge base with each other and form friendships along the way.
My eight weeks in Kenya have offered much more than just a learning experience.
The opportunity to experience a new culture and meet people from around the world has been amazing. I’ve tried new things and stepped outside my comfort zone. I clearly remember my first time walking through town. I felt like an outsider for the first time in my life. All eyes were on me as I walked through the dirt streets of Eldoret. To my surprise, I was greeted with smiles, waves, and best wishes for the duration of my stay here.

There’s a sense of camaraderie and respect for one another found here that we’re often lacking in the US. I’ve met a lot of amazing people here and I’ll never forget the kindness and generosity they’ve shown me. I’m grateful for all of my experiences in Kenya, the good with the bad. I hope that in some small way my stay in Kenya has made a difference because it sure has left a lasting impression on me!

The Student Perspective - Shauna Santare

After completion of the Kenya rotation, I have been able to better evaluate the impact pharmacists can make to improve patient care. As my first experience with clinical pharmacy and also within any hospital setting, I had to quickly learn to adjust to following many patients with different disease states and following up on their care daily. I gained a lot of experience in multidisciplinary care rounds, which definitely influenced my interest in clinical pharmacy. MTRH was the first opportunity where I have had involvement in important (life or death) patient care decisions and in-depth discussions with physicians. I felt as though my opinion and knowledge were respected, and that confidence boost provided self motivation to continue my efforts.
I enjoyed this rotation for more than the obvious perks of weekend trips, new friendships, and cultural broadening. Reviewing charts may have felt tedious at times, but I learned to filter information for pertinent lab results. This skill is necessary at my new rotation site, where I am “rounding” in a different ward every day of the week and have many more patients.
I felt very intimidated in the beginning of the Kenya rotation because we were immediately thrown into the experience and had to learn to fend for ourselves. Looking back, I realize this was the only way it could be done. As for the rotation itself, I cannot recommend anything to be changed.

The Student Perspective - Tobie Rogers

Before arriving in Kenya, I was very apprehensive about the experiences that I would have. I had heard horror stories about the sights and smells in the hospital. I was also still slightly nervous about the environment that I would be living in, especially after the post-election violence. However, I knew that Purdue would not let us go if we were not going to be safe. The first week or so of rounds, I was very overwhelmed. I was fortunate enough to have rounded on a medical team before; however, I had never covered a patient load of this magnitude. The charting and lab reporting system is very different from what I am accustomed to and made thumbing through the charts somewhat challenging at times. I was also not used to being a member of such a large team, which reached over 20 people occasionally. Fortunately, the sights and smells were not nearly as horrible as I had envisioned them in my head. Eventually, I was able to somewhat adjust to their system and become more at ease with my role. Looking back on the experience, I was able to identify some of the challenges and benefits associated with it.
In the beginning, rounds were very trying for me, in that I often felt useless and unhelpful in many ways. One major barrier was actually hearing the Kenyan medical students and doctors as they tend to be very soft-spoken. This coupled with the fact that I was at the very back of the pack of students made deciphering what was going on very challenging. However, as I began making pharmacological recommendations to the team, I began to earn their respect and a spot nearer to the front. As time passed, I found that the interns would seek me out while they were admitting for recommendations. At the end of my time with my team, I felt I was a very vital member of the team.
Another major frustration stemmed from not knowing which medications were carried by the hospital and the lack of medications available for use. We were given a ‘formulary’ at first, but it was never updated over the course of the rotation. It may be beneficial to actually develop a formulary and printout a list of stock outs either daily or weekly for the entire medical staff including pharmacy, nursing, and medical students and interns. Another alternative for the pharmacy students is to hold a brief meeting every morning to give updates on current medications that are not available. I found often that I was halfway through rounds before it was brought to my attention that a medication was out of stock, which required me to go back through all the treatment sheets to change those medications on the patients that had already been seen.
Finally, the nursing staff is overworked in that there are not enough nurses scheduled to work for the number of patients that are in the hospital on any given day. This leads to less than exceptional care for the patients; which means that medications are often not given appropriately. I feel that it may be beneficial for the pharmacy students to present brief in-services to the nursing staff on a weekly or bi-weekly basis. It is important to discuss the treatment of infections and disease and emphasize the importance of compliance and receiving the medications at the time they are ordered.
Although the rotation was challenging at times, there were positives as well. First, the pharmacy students from Nairobi are a great addition to the medical teams. Their knowledge of the name brand medications and standards of care in Kenya are invaluable to the team. Also, their ability to speak Kiswahili is an added benefit. Communication with patients would have been much more challenging without them. I feel that we learn just as much from them as they learn from us.
This experience also exposes us to various disease states and infections that are not often seen in the United States, offering a great learning experience. I felt that I learned a great deal of information that will help me as I pursue a career in clinical pharmacy. A large amount of information that we were exposed to is applicable while practicing in the United States, while the rest is merely a great learning experience. I also enjoyed venturing to the clinics to work in the pharmacy. It was great to interact with the patients and practice speaking Swahili.
I have been home for a week now and looking back this experience was more than I ever thought that it would be. Although it was frustrating at times, it was also very rewarding. My most memorable experience at the hospital was with an HIV+ woman who was experiencing symptoms associated with zidovudine-induced anemia. I went to the AMPATH pharmacy and switched her zidovudine for stavudine and took it back to her. A few days later, I was standing at the nurse’s station reading charts and she came up to me to tell me that she was feeling better and that she would be going home. She said thank you, shook my hand, and walked away. A week or so later as I was walking through the hallway in the AMPATH clinic, someone grabbed my arm. When I looked down, it was the same woman. She told me that she was there for her follow up and thanked me again for helping her. I felt amazing knowing that I helped someone and made a difference in their life, even if it was only that one person.
I learned a great amount of medical and pharmacy information in the time I was in Kenyathat will help me professionally. However, I also was able to learn a lot about the people of Kenya and its culture through talking to the Kenyans that live and work at IU House and to the pharmacy students from Nairobi. It was definitely an experience that I will not soon forget. My hope is that after graduation, I will be able to go back to work at Moi and visit with the friends that I have made. Who knows, maybe one day I will be the first psychiatric pharmacist in Kenya!! I am quite certain Sonak is counting down the days until my joyous return!!!

The Student Perspective - Alex Fohl

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