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Our second week of rotation at Mahasarakham University has been filled with opportunities to share experiences through presentations and tours, as well as few exciting and unexpected experiences!  We started the week off with a trip back to Khon Kaen, the largest city in the province and just an hour drive away. The faculty of pharmacy has its own 15 passenger van that shuttles us to and from our off-campus activities. We spent Monday in Khon Kaen observing the pharmacy practices at the larger regional hospital, Khon Kaen Hospital. There are 13 regions in Thailand, and Khon Kaen is the center of region 7. As a regional hospital, it is operated under the Ministry of Public Health. There is also a hospital in Khon Kaen affiliated with Khon Kaen University that is operated under the Ministry of Education. We were graciously greeted by Dr. Silaruks, an administrator in the Department of Pharmacy and Drug Information Specialist, and explored each of the 7 pharmacy units within this hospital system. The first pharmacy unit we visited was the outpatient pharmacy located in the front of the hospital. There was a large patient waiting area outside of the pharmacy where patients wait for their prescriptions and to have laboratory tests conducted. Nearly every seat was filled including the separate reserved sections for monks since Mondays are one of their busiest days. There are 3 pharmacists working at time, one to enter prescriptions, one to check the prescriptions after they have been prepared and labeled by the technicians, and one to provide the medication and counseling to the patient. The pharmacists have access to patient labs through the computer system and a unique dispensing procedure where the medication is placed a specific color coded bag that has the appropriated pre-printed counseling instructions.  This outpatient pharmacy stocks 2,665 items (including generic Crestor!) and dispenses 812 prescriptions a day, with the most commonly dispensed medications being antibiotics, diabetic medications, and medications to manage chronic kidney disease.

Outpatient Pharmacy

Next we walked back through the hospital past large open courtyards filled with a pond, beautiful landscaping, and waiting family members to the large pharmacy wing of the hospital, which filled 6 floors! The pharmacy department has much more space than we are used to seeing in our American hospitals. We stopped at the inpatient pharmacy on the first floor, where pharmacists and assistants were busy preparing the 10 medication carts that would go to a designated ward (floor/unit). Each cart contained bed-specific drawers; the medications for a designated patient are put in the drawer that corresponds to their bed. Just around the corner from the inpatient pharmacy was the discharge pharmacy, where medications are prepared for the patient to take home with them, as well as stat medication orders that are sent to the wards every 15 minutes, narcotic medications, and CPR boxes.

                   Outpatient Pharmacy in Hospital                             Medication carts for wards

                   Hospital Courtyard                                                      Overflow beds in hallways

Then we were able to venture to the wards to see patient care firsthand. Khon Kaen Hospital contains 867 beds and has an occupancy rate of 120%, with some wards that only have 30 beds caring for 60 patients.  Patients also line the hallways waiting in beds. The ICU, containing 8 beds and 2 isolation rooms was our first stop. Here the ratio of nurse to patient is 1:2 (side note: nurses here still wear adorable hats of which we are big fans). Only the sickest of the sick are treated here since there is such limited room, often patients are placed on the ventilator are treated on general wards do to overcrowding. Directly connected to the ICU was the CCU (cardiac care unit), since this is the regional hospital all patients requiring cardiac catheterizations both emergent and elective must come to this hospital. The CCU contained 12 beds and had a fixed stock medication box and emergency cart. Then we visited the general adult wards, which are divided into 2 male and 2 female units. We witnessed a medical team composed of an attending physician, a medical resident, a medical intern, and medical students rounding on 1 of their 20 patients. In this ward typically 1 nurse serves 7 patients. Khon Kaen Hospital does have clinical pharmacists who are present on the wards to assist the physicians in medical decisions and offers a 3-month rotation to pharmacy students in general medicine. A few of our Thai friends will be at Khon Kaen Hospital later this year!

                                        

Next we ventured to see our 3^rd pharmacy unit affiliated with Khon Kaen Hospital, the Nong Wang Primary Care Unit, which serves 100,100 patients in the proximity. This was similar to the primary care unit we visited in Maha Sarakham Province last week, where patients wait to see the physician each morning, then the medications are ordered by computer and the pharmacist checks the order for safety and accuracy and provides the patient with the medication and counseling. Every household that visits this primary care unit as a Family Folder, and all of the members of the household’s medical records are kept in one folder. The patient can also visit the Thai traditional medical clinic here. We also enjoyed seeing the food models that nurses use to educate diabetic patients on portion size and sugar content.

Then it was back to Khon Kaen Hospital where the pharmacy department provided us with a wonderful lunch from Pizza Hut. We enjoyed having bread and cheese for the first time since America, but opted not to eat our pizza the Thai way of squeezing ketchup or chili paste on top! Then we visited the compounding unit on the 3^rd floor of the pharmacy wing, where pharmacists prepare total parenteral nutrition for 15 patients a day and vaccinations for children including Hepatitis B and BCG (Bacillus Calmette-Guerin which is for tuberculosis). Also in the wing is the cytotoxic pharmacy service, where chemotherapy is prepared in 2 hoods. Khon Kaen Hospital was the first medical care center in Thailand to have a separate area for chemotherapy preparation. It was built in 1980, and many pharmacists will come to this hospital to be trained in chemotherapy preparation techniques.

The day finished on the 4^th floor of the hospital where the pharmacy administration, drug information and inventory services are conducted. We learned a few more interesting things about pharmacy in Thailand, such as their drug procurement process (no distributors, each hospital orders directly from manufacturers), and then gave our presentation on Clinical Pharmacy in the United States to the group of pharmacy students, the director of pharmacy and medical information services, and the clinical pharmacists responsible for both the adult male and female wards. This presentation was a collaboration between the Tennessee and Auburn students and stimulated conversation about how clinical pharmacists are trained in the United States and how to ensure pharmacists are a part of interdisciplinary practice models. At Khon Kaen Hospital, pharmacists do not participate in interdisciplinary rounding and this is something they could potentially implement in the future. At the end of our day we placed a picture from our visit and a thank you note in the visitors notebook. It was fun to flip back through the pages and see the familiar faces of Dr. Phillip Lee, while he was a student at the University of Tennessee, and HSOP’s own Dr. Jessica Pantanella and Dr. Zach Hung who did their rotation at Mahasarakham University last year! We also graciously received Papada animals, made from Isan cloth, as gifts. They are adorable!!

After arriving back in Maha Sarakham we grabbed a few snacks and coffee frappes at the small market and worked on our upcoming presentations and travel plans to Chiang Mai in our wonderful and comfy elephant pants since it has been chillier lately. The temperature in Maha Sarkham is getting to 54°F at night with crisp mornings, but warming up to a bright sunny and 75°F in the afternoon. 

Tuesday was another fantastic day! In the morning we met with Thai students and Dr. Phayom for a session on the healthcare system and pharmacy practice in the United States and Japan. Airi and Risa, from Showa University in Japan, presented first and did an outstanding job sharing about the universal healthcare system in Japan. We enjoyed seeing the Japanese insurance card, which is the same throughout the entire country and contains pertinent information such as their blood type and organ donation choice. Another unique and exciting feature we learned about Japanese pharmacy practice is their newly implemented Medicine Notebook. A Japanese patient can pick from many cute cover designs and pharmacists use this notebook to record patient allergies, medical conditions, and medication records. Pharmacists can be reimbursed for evaluating the patient’s medication therapy using this notebook each time a patient comes to the pharmacy.  Next Hannah, Camellia, Erin, and Megan delivered our presentation on the United States. Go team USA! We enjoyed the conversation that developed from these presentations, allowing for great discussion again on the challenge of developing interdisciplinary practice in all 3 countries. It was interesting too that the Thai students were particularly interested in community pharmacy practice in the United States, wondering about our drive-thru pharmacies (there is not even drive-thru fast food in Thailand!), how much time pharmacists are able to spend with a patient, and comparison of OTC products. For example pseudoephedrine is illegal in Thailand, while Voltaren gel is OTC!  

We were all hungry after our 3-hour morning session and headed to the University Restaurant for lunch of Pad Thai for Erin and Pad See Ew for Megan, followed with the universally beloved dessert…the ice cream cone. Lunch held even more memorable discussions. We finally created a name for the mix of Thai and English we have begun to speak as our Thai speaking skills have expanded – we now speak THAILISH :) Also since the kitchen was out of chicken we had to order pork. The word for pork in Thailand is ‘moo’, but cows say moo in the US, right?! This lead to us asking what the noise for a cow is in Thailand and they say more of a ‘maaa’ sound. Who knew animal noises weren’t universal? Even their dog and pig noises are different, but the cats ‘meow‘ seems to be used worldwide!

In the afternoon our van chauffeured us to our first community pharmacy experience in Thailand. We visited the first branch of the University Pharmacy in downtown Maha Sarakham run by the Faculty of Pharmacy at Mahasarakham University, which reminded us of the AUPCC (Auburn University Pharmaceutical Care Center), as it had unique patient care initiatives, such as screening booths set up outside the pharmacy to screen patients for asthma, depression, diabetes mellitus, hypertension, sexually transmitted diseases, and smoking cessation. Smoking cessation is a huge area for pharmacists in Thailand, and most community pharmacies are equipped with carbon monoxide monitors to help follow-up and counsel patients. Pharmacists can also dispense nortriptyline for patients that smoke more than 10 cigarettes a day (similar to our use of bupropion, but they don’t need a prescription!) This community pharmacy is special because it was the first pharmacy in Thailand to try to join the National Health Insurance network as a primary care clinic, but it was not successful. National Health Insurance only pays for patients to see doctors at the primary care clinic. Medication purchased at a community pharmacy is not covered under the national care plan. However, the University Community Pharmacy does store HTN and Diabetes medications for the Primary Care Unit affiliated with the University to help decrease crowds at the PCU. These medications are stored separately from the medications the pharmacy dispenses and insurance does cover these.

We noted a few vast differences from the typical community pharmacy in America including set up and the pharmacist’s role. The pharmacy only contained medical items and herbal remedies, there were no extra retail products and the variety of OTC products was also much more extensive. There are also no restrictions as to what medications (OTC and behind the counter) can be dispensed to children, whereas in America we often refer children younger than 4 to a doctor’s office. It was neat to discuss with the pharmacist how in community pharmacies they do not require a prescription for what they consider common diseases, such as an infection! This means a pharmacist is able to interview a patient, diagnose their infection and dispense an antibiotic in the pharmacy without the patient or pharmacist consulting a physician for a prescription. A prescription is required for chronic conditions, like hypertension though! The community pharmacist stated that his favorite part of his job was the huge role that he played in healthcare and felt that he used more clinical judgment and had more patient interactions than many acute care pharmacists.

The way home was filled with some fun stops, first at a Thai sweets shop. Megan was excited to finally try the Thai treat, which is her Thai nickname – Kao Mao. It is a ball of sticky rice covered in sweet green sauce made from pandan leaves! Then we dropped by the Thai post office to mail a postcard to Megan’s grandmother who loves to receive snail mail!

Our dinner Tuesday night was the BEST so far! Even the name of the restaurant we ate at was perfect, in English it translated to ‘share with friends’. One of our sweet Thai friends, Tony, had remembered from a conversation that we mentioned we wanted to have the delicious mango and sticky rice dessert we had during our time at Ao Nang beach and also wanted to try massaman curry, so he went the day before and asked the restaurant owners to prepare these for our group for dinner! We enjoyed a delicious dinner that had lots of the local staple sticky rice! For our entrée we had a variety of options: massaman curry, a sweet and sour fish dish, and a fresh broccoli and shrimp dish. We both thought the massaman curry, a southern Thai dish, lived up to its hype with its tender chicken and great flavor of coconut undertones. Our dessert of mango and sweet sticky rice and sticky rice with egg custard was wonderful. Even more exciting was that while we were eating, we looked out to the street and saw a BABY ELEPHANT walking by! Of course we rushed outside squealing with joy and oogeled over the elephants adorable smile and the chance to be so close to this wonderful creature. What a fun reminder of the unexpected joys that each day holds and of the Zeek family bedtime prayer to thank God for all the things He gives our eyes to see! 

Wednesday morning was a break from rotation, but our time was filled with our first dorm laundry adventure since our on-campus days at Auburn. It was a success with 10 baht coins and small bottle of Tide! There are no dryers in Thailand, so our laundry air-dried in creative hanging spots across our dorm room! We then had a fantastic afternoon presenting our clinical rotation experiences to about 50 4^th year pharmacy students at school. We described our curriculum at Auburn, detailed our rotation experiences, and gave candy to students who answered our fun facts Auburn questions. They loved learning to say War Eagle and our coordinating orange and blue outfits were a hit! We enjoyed hearing about the curriculum and 3 semesters of rotations at the University of Tennessee College of Pharmacy, and also about Showa University in Japan. In Japan they complete only 2 clinical rotations for a total of 23 weeks during their 5^th year and spend their entire 6^th year studying for the national board exam, which only 60% of pharmacy students in the nation pass – whew!  After the presentation we broke out into small groups where the students were able to ask us more one-on-one questions.  Not all the students were able to fully understand English, so we were very impressed when two of our host students, Boss and Fern, were able to listen to our answer to the questions in English, immediately comprehend a new concept, and then translate our answers for Thai peers! Have we mentioned how wonderful our Thai host students are?!

Wednesday evening was filled with more delicious foods and fun times. Our Thai hosts have a weekly English language class, taught by Arnie, a professor from the Philippines. We loved meeting her and she has agreed to let us teach English class next week. This week we joined their English class and decided to have class at an adorable outdoor coffee shop. We loved our mint mocha frappes and honey toast covered in fruit with a side of ice cream and whipped cream. The pretty fruit presentation on the toast reminded us a lot of our favorite breakfast spot in Auburn, Big Blue Bagel! Mint, one of our sweet Thai hosts, treated us to the honey toast with the money she won today in a patient counseling competition in English. Our other hosts Beau and Best also placed in the patient counseling competition in Thai!

Thursday morning we jumped back in the van and spent the day at the local Maha Sarakham Hospital. We received a warm welcome from the head of each unit within the pharmacy department and a great presentation about the hospital and its pharmacy services. This is a 525 bed hospital, usually running an occupancy rate close to 100%. The most common conditions patients are treated for at this hospital are senile cataracts, acute appendicitis, diarrhea, bacteremia, and acute renal failure. 35 pharmacists serve within the outpatient pharmacy, inpatient pharmacy, drug information center, manufacturing area, and primary care unit. We were able to visit each of these facilities. Particularly interesting to us was the manufacturing area, which is where sterile preparation is preformed as well as preparation of non-sterile products such as emollient cream, since the pharmacy can make these more cost-effectively than purchasing from the manufacturer. We also learned that drug procurement is a big deal at this hospital too, with only one large order placed a month from each manufacturer. Like the United States, the most expensive drugs are antibiotics, but unlike the United States the most expensive chronic medication is generic atorvastatin! The hospital spends 100-200 million Baht each year ($6.5 million) on medication.

After visiting each pharmacy department, we visited the floors where we saw the Tuberculosis Clinic that is held every Thursday. Here, patients were seated in a waiting area wearing masks and when their name was called they would see the pharmacist first, followed by the physician, then the pharmacist again for dispensing of pre-bagged 8 medication regimen and counseling. It was interesting to learn about the medication regimen and role of the pharmacist in the care of patients with tuberculosis, as this is a disease rarely seen in the United States. Directly next to the Tuberculosis Clinic waiting area was the warfarin clinic, open 3 days a week and patients will again see the pharmacist for an interview, then the physician, and then the pharmacist again for medication counseling. Maha Sarakham Hospital employs a Pharmaceutical Care Pharmacist whose role is to follow all patients in the hospital on warfarin therapy to monitor for drug interactions, adverse drug reactions, and provide counseling, similar to many of our warfarin counseling programs in US hospitals, which we have participated in during our P4 rotations. Fun fact: they only have warfarin 3mg tablets at Maha Sarakham hospital and use great sheets with visual pictures of the warfarin tablets a patient should take each day, so that the patient can easily determine their dose and cross off the day to help with compliance. 

Warfarin Counseling Sheets

Our visit to Maha Sarakham hospital ended with a tour of the Semi-ICU where patients who are in slight critical condition are treated. After seeing this unit, we had a discussion with the professors of pharmacy and student pharmacists from Mahasarakham University who are doing a rotation at the hospital. We enjoyed the students sharing their patient cases today, ranging from hyperkalemia and pneumonia to secondary prevention after an ischemic stoke. We were able to discuss together therapy choices and potential medication recommendations they could make to the physician with whom they were rounding. We both really enjoyed using our clinical practice skills and collaborating to improve patient care of Thai patients.

Thursday afternoon has been very girly! Our Thai friends, Mint and Fern, took Erin and Hannah to a local salon where they 4 all got gorgeous haircuts! Megan of course came along for the experience. The Thai hairdressers were very fun and gave wonderful head massages while they washed hair and gave fabulous hairstyles for only $8! Erin thinks this may be one of her best haircuts yet! Then we tracked down a measuring tape at the local community pharmacy to take our own measurements for our bridesmaids dresses for our dear friends upcoming weddings. The plan for the rest of today is to bike to the nearby small market for to grab some take-away dinner to eat and work on our Journal Club and Role Play projects for next week! We’re hoping to get a good nights rest before our 6:30am wake-up tomorrow for a trip to special temple that is only accessible by boat and our weekend adventure hiking/camping trip in Phu Kradueng National Park. Stay tuned for our weekend adventures!