มะม่วง [mango]

Our first day back in Bangkok was wonderful, but we greatly miss our friends at Mahasarakham University already. In our many moments of reminiscing lately, we realized we forgot to blog about one of the most hilarious stories we’ve ever heard! Our friend Prim told a story at our farewell dinner that had us rolling with laughter. Friday morning, she picked up ‘take-away’ pork and rice for breakfast at a local shop and was waiting to cross the street to meet with her research advisor when a monk came up and took her bag of breakfast, since he thought she was crossing the street to make merit by bringing the monk breakfast. Essentially, a monk stole her breakfast!! She had to go back to the store and buy herself another breakfast of pork and rice! As our Thai friends say, 555555.

Back to our life in Bangkok—we decided to name our first day back “Tiger Thursday” in honor of all the sleep we got (tigers sleep 18 hours a day) and the Auburn pharmily reunion we had!  After a long tiger snooze, we finally woke up at 11 AM. We opened the curtains to look out over our awesome view of the hustle and bustle of somewhat smoggy Bangkok while we enjoyed our morning coffee and Cliff Bar (yay America) breakfast in bed. After a few hours of catching up on emails and enjoying very hot showers, we ventured out into the city and found a little side street lined with street cart food vendors and hotels, and decided to pop into a café that had lots of English on the menu for a snack and free WiFi. This ended up being a great choice since our mid-afternoon food and drinks here were delicious. Megan had an amazing mango smoothie and Erin had an espresso frappe. We finally had our first sandwich since we have been in Thailand (over a month!). The cheesey, fresh tomato basil sandwich that we shared really hit the spot! We enjoyed spending the afternoon feeling like we truly lived in Bangkok, just sitting in the city catching up on things we needed to do!  

Breakfast in Bed/View from our Bangkok Hotel

Hanging out in the city for the afternoon

For dinner we met Dr. Kelli Johnson, a 1999 alumna of the Auburn University Harrison School of Pharmacy, at Outback Steakhouse in the Siam Discovery Mall. This was just a short walk away from our hotel. Dr. Johnson is currently a missionary in Bangkok and connected with us via email after seeing our blog posted on Facebook! This was by far the swankiest Outback to which we have ever been. It was on the 6^th floor of the mall and overlooked the house of one of the princesses of Thailand. The food didn’t have quite the same taste as Outback in America, but it was still wonderful to have some steak and potatoes! It was fun to have a War Eagle moment and hear about Dr. Johnson’s pharmacy career in pediatric oncology (a potential interest area for Erin and Megan) and her role as a missionary first in Bolivia and now in Bangkok for the past 2 years working to help women in the sex industry. She is an incredible example of faithfulness to God’s direction for your life! Dr. Johnson was also very gracious and interested in our adventure across Thailand, pharmacy school experience, and pharmacy career plans. We talked together over dinner for almost 4 hours! Being a part of the Auburn family truly is a gift and we are very thankful to have had the opportunity to meet Dr. Johnson!

Dr. Kelli Johnson, HSOP 1999

On Friday morning we woke, grabbed breakfast at the hotel, and ventured on the BTS Skytrain to Bumrungrad International Hospital to learn about their pharmacy practices. We were very excited to see this private hospital where they have several medications that are not available or can only be prescribed by specialists in other areas of Thailand – like carvedilol (Erin’s favorite beta-blocker!). This hospital facility and pharmacy practices were phenomenal and very impressive. Bumrungrad International Hospital is Thailand’s first Joint Commission International Accredited Hospital and serves over 1.1 million patients a year, 520,000 of which are international patients. The facilities include 580 inpatient beds and a 12-story outpatient clinic building providing world-class care to 5,500 patients each day. We met one of the hospital pharmacists, Mr. Pat, in the main hospital lobby, which was 2 floors and elegantly decorated with floral arrangements, an incredible gift shop, and familiar restaurants like Au Bon Pain (brought back meal plan memories for us from our Auburn undergraduate days) and Starbucks.

Main Hospital Building

Lobby

Mr. Pat lead us first to the IPD (inpatient pharmacy department) where pharmacists transcribe and verify orders that are written by physicians and scanned into the computer system and also check the prepared medications before they are sent to patient care units (called wards). This was an impressive area that had a robotic dispensing machine, the Swisslog PillPick System for tablets and a few injectables, as well as an area where sterile preparation was preformed. An IV compounding area for chemotherapy agents was on a separate floor. The IPD utilized the tube system for sending medications to the floor throughout the day and prepared medication carts every evening with medications that patients would need for the next day. There are also two pharmacists responsible for medication reconciliation located in the IPD. The medication reconciliation process at Bumrungrad consists of nurses conducting medication reconciliation by interviewing the patient when they arrive to their room and scanning their findings to the medication reconciliation pharmacists, who then compare to hospital records. This is a newer service that the pharmacy department is offering and a huge area that pharmacists in hospitals across the United States are seeking to be involved in to improve patient care. The IPD pharmacists also participate in the adverse drug reaction (ADR) monitoring, which involves one pharmacist visiting the patient when an ADR is reported to assess whether this event was truly related to a medication. Then the pharmacists contacts the physician, records the findings and a drug allergy alert in the patient chart.  

Automation/Informatics in Action

Inpatient Pharmacy Department

After seeing the IPD, Mr. Pat dropped us off for the next part of the morning at the office of the Pharmacy Practice Specialists (clinical pharmacists) responsible for therapeutic drug monitoring (TDM) and discharge counseling (DC). Ms. Sasiluk provided us with a PowerPoint presentation on their TDM service, which has been offered since 2003. As part of the TDM, two pharmacists work as part of a team with physicians and the laboratory specialists to evaluate the 20 to 30 patients a day who are receiving vancomycin and the aminoglycosides amikacin and gentamicin, as these antibiotics require accurate dosing and careful monitoring. Physicians can also consult the TDM service for other medications such as the anticonvulsants valproic acid and phenytoin.  Each morning the pharmacists utilize a drug monitoring worksheet for each patient and then in the afternoon complete rounds on the wards. We also discussed how these pharmacists make their interventions to physicians and learned that this is similar to practice in the United States where they call the physician to discuss the recommendation, or speak to the face-to-face, or leave a pharmacy note in the patient’s chart. The pharmacists feel that this service works well to decrease adverse drug reactions and maximize efficacy and patient outcomes, but the only downside is that this is not a 24-hour service, as they do not have enough staff to provide such coverage.

Inpatient Pharmacy Consulting Area

PK Monitoring Form

Next we discussed the discharge counseling service. One pharmacy practice specialist is responsible each day for going to specific patients’ bedsides to dispense and counsel the patients on all medications the patient will be taking when they are sent home from the hospital. This service is provided to patients who are receiving anticoagulants (warfarin, apixiban, dabigitran, rivaroxaban) and patients with diabetes mellitus, chronic kidney disease or were admitted for an MI, stroke, or underwent a transplant (mainly kidney tranplants). A nurse can also make a request for other patients and the pharmacist leaves a slip in patients chart to request that the nurse alert them before a patient is sent home. The pharmacist shared that because this is an international hospital, they see patients from all over the world and often the biggest challenge is having an interpreter available who is able to help convey the information to the patient and his/her family. All in all this seemed like a very well run service!

Outside the Outpatient Pharmacy and DI Center in the Main Hospital Building

The Pharmacy Practice Specialist then led us to one of the four ICUs within the hospital. Bumrungrad has 3 adult ICUs, 1 CCU (cardiac care), 1 PICU, and a Level III NICU. There is a satellite pharmacy within one of the adult ICUs, where a pharmacist and technician enter and verify all orders for the ICUs and have stock medication for stat orders. There are two Pharmacy Practice Specialists that remain in ICU 1 and 2 and participate in the interdisciplinary care of these patients. We also learned that there is a satellite pharmacy within the Emergency Department, where a pharmacist is responsible for dispensing activities and assessing adverse drug events. This was the first healthcare facility in Thailand that we have heard of having a satellite pharmacy in the ER and ICU.   

   

Then it was time to walk over to the Outpatient Clinic Building, where we meet with the pharmacist conducting the Anticoagulation Clinic located on the Cardiac floor. A physician refers patients to this clinic and the pharmacist sees about 4 to 10 patients a day and is on call 24 hours a day. This reminded us a lot of the pharmacist-run anticoagulation clinic we have seen within the Veterans Affairs Health System in the United States. The patients taking warfarin (brand name Orafin in Thailand) first come and have their INR taken by a CoaguChek point-of-care INR device at the lab or check on their home CoaguChek and call in to the pharmacist if they are international. The pharmacist then completes a patient assessment of their knowledge of their medication (a pre-test) and then provides patient education and completes a post-test to track the patients understanding. Then the pharmacist is able to adjust the patient’s warfarin based on a protocol and provides each patient with a guidebook and warfarin alert card for the patient to carry. It was interesting to learn that the largest problem pharmacists face at this clinic is patients who have drug interactions with the herbal products so prevalent in Thai and Chinese medicine (ginseng, garlic, ginkho biloba) causing supratherapeutic INR levels.  

Our next visit was to the Medication Therapy Management service within the OPD (outpatient pharmacy department) in the Outpatient Clinic Building. The MTM pharmacist provides education, compliance assessment, and collaborates to resolve any drug-related problems to patients seen at the outpatient clinics who have diabetes mellitus, chronic kidney disease, or take more than 10 medications daily. The pharmacist typically sees at least 10 patients a day and documents all finding on an interdisciplinary note within the patient’s chart. This MTM service was awarded 1^st Prize for Outstanding Poster in 2011 at the International Pharmaceutical Federation for research on the correlation between improvement in patient knowledge and adherence and interaction with an MTM pharmacist.    

Outpatient Building waiting area

Outpatient clinic building

Outpatient clinics

Our last visit of the day was to the Drug Information Center (DIC) located within the Outpatient Pharmacy in the main hospital building. This was a busy time of day and we were thankful the pharmacist took a few minutes to speak to us. The DIC is open for 9AM to 7PM daily and the one pharmacist receives 40 to 50 questions a day via email or phone calls from patients and healthcare staff. The DIC has a 95% success rate of completing a response to a question within 15 minutes. We were impressed! The DIC records each request on a Drug Information Request/Response form in the computer and uses familiar resources to answer their questions such as Lexicomp, Micromedex, and Trissel’s Handbook of Injectable Drugs. We were curious to know where they get information about Thai Traditional Medicines and learned that Mahidol University has a website database for traditional medicines. 

It was wonderful to see the advanced clinical services the pharmacists at Bumrungrad provide. Plus, we adored their smart pharmacist uniforms with teal skirts or dresses and well tailored, embroidered white jackets! It was also neat to learn that pharmacists do not require any additional training prior to obtaining a position at Bumrungrad. They are simply partnered with a senior pharmacist who trains them in their respected area for several months upon starting the job. Also, the pharmacists rotate days of providing dispensing services and clinical services in any area they are trained in. This seems like a great place to practice pharmacy!

On our way back towards the BTS Skytrain from Bumrungrad, we spotted some mango with sticky rice (with the added bonus of coconut milk and peanuts) from a street cart and couldn’t resist! It was so delicious as always, and we felt like such residents of Bangkok when we stopped to eat this on little seats outside the Siam Square shopping area after exiting the Skytrain. When we got to our hotel to take an afternoon break, we decided to eat some substantial food and tried the club sandwich which had intrigued us since our first stay in Bangkok, since one of the ingredients was called red oak. We discovered red oak is a mushroom and loved this chicken sandwich! We were both excited for the surprise slice of avocado on the sandwich too and realized how badly we miss Chipotle.

Just two girls in the big city

In the afternoon we saw our first drops of rain since being in Thailand through our hotel window. The weather has been hot and muggy the past two days, so hopefully this rain will bring us a beautiful day tomorrow for our day-trip we have planned to Ayutthaya. This is the ancient capital of the kingdom of Thailand, also know as the “Venice of the East” in the 1700s. Since we are in the shopping mecca of Bangkok, close to MBK, Siam Square, Siam Centre, and Siam Paragon, we decided to see if we could find a fun new outfit for our tour.  Megan was able to find a great maxi skirt on sale at Workshop in Siam Centre, so we will both be politely dressed for the temples tomorrow. Then we walked over to Siam Paragon, where the more high-end stores are (i.e. Louis Vutton, Maserati cars, Hermes, etc.) We spotted an adorable, fancy teashop called TWG Tea Boutique and the menu had our mouth watering. Erin is an avid tea lover, so we treated ourselves to the most wonderful tea and dessert for dinner! TWG had an extensive and descriptive Tea Book that accompanied the menu. (Note: Erin is a huge nerd and loved pouring over these pages, learning all about the different kinds of tea. If anyone wants to buy it for her...Hi Mom and Dad...she wouldn't complain). For our wonderful and girly teatime, Erin opted for a pot of blue tea called Jasmine Oolong and Megan had a blend of green and blue tea from Thailand called the Secret of Siam. Both were fabulous and we enjoyed tea infused mango crumble, which was served with a wonderful mango and tea ice cream, as well as split 4 melt-in-your mouth macaroons! After a little more window-shopping we headed back home.  We’re excited to pop a bag of popcorn and catch up on the latest episode of Greys Anatomy and fall asleep dreaming of our delicious tea!  

"A reminiscent delight, this alluring tart is filled with fresh mango wedges and a light coconut cream infused with Vanilla Bourbon Tea topped with crumble biscuit and served with a scoop of Alfonso Tea ice cream."

Macaroons!!

Purple: Grand Wedding Tea, Passion Fruit, and Coconut

Black: Napoleon Tea and Caramel

Blue: Vanilla Bourbon Tea and Kaya

Pink: Bain de Roses Tea

Update upon posting blog: Sadly, even though we can access ABC online through the Auburn VPN, the Internet connection isn’t strong enough to load the video. No one spoil this episode for us please!!!