Patient-Centered Health Care Presentation

During our last week at RFM hospital, Zinhle asked us to do a presentation about health care and pharmacy in the United States.  There were about 30-40 people that came to see our presentation including doctors, nurses, pharmacy technicians, and other hospital staff.  We really wanted to stress the idea of health care collaboration and teamwork to deliver a patient-centered approach.  From what we observed, there is a hierarchy system in which some members of the health care team are scared to speak up to a doctor or someone "above" them.  We began our presentation discussing the major differences in health care between Swaziland and the USA.  Swaziland deals with a lot of acute disease, infection, HIV/AIDS, and tuberculosis.  The USA sees a lot of chronic disease mostly due to lifestyle choices such as smoking and obesity.  We also really focused on tuberculosis treatment because the differences are so big between Swaziland and the USA.  Swaziland does not require as strict protocol for infection control.  They do indeed try to isolate their TB patients, but do not require negative pressure rooms and such strict rules for visitation. 

 

We felt that it was very important to go through the roles of each member of the health care team in attempts to focus on the importance of collaboration.  We discussed differences and similarities between the two countries, especially in regard to education.  For example, pharmacy technicians in Swaziland are much more educated than pharmacy technicians in the USA.  They go through about 2 years of school and have a much bigger role in medication delivery and patient monitoring. 

 

We discussed the two pharmacy practice models including the drug-distribution centered model as well as the patient-centered integrated model.  The health care team at RFM hospital was particularly interested in the advanced technology we use in the USA including the Pyxis machine, bar code medication administration, and electronic prescription processing. 

 

The biggest difference in pharmacy between Swaziland in the US is prescription processing.  In the USA, prescriptions are reviewed several times by the pharmacist and technicians work under their direct supervision.  In Swaziland, a pharmacist is not required to be present for a medication to be dispensed and they do not have as many checks and balances as we do in the US. 

 

Example of prescription processing in the USA

 



Next, we discussed the importance of patient counseling and education.  We believe this is especially important in Swaziland with the low levels of education and access to resources.  The majority of the population is very poor and cannot afford a good education leading to low reading levels and health literacy.  Further, many people live in rural communities and do not have good access to hospitals or health care clinics.  This is why it is so important to educate every single patient when they come to RFM.  We explained verbal and non-verbal communication and how to effectively use the teach-back method in a patient counseling session. 

Finally, we explained our unit-dose distribution system and compared it to their floor stock system.  We explained that the floor stock system was a model we used previously and how we evolved to our current unit-dose model.  We finished our presentation by again stressing the importance of collaboration and how it can improve health outcomes. 

 

We were very thankful for the members of the RFM team who took time out of their busy day to see our presentation.  They were very attentive and seemed very interested in health care in the US. This presentation allowed us not only to suggest improvements in Swazi health care delivery, but also to identify the flaws within our own system.   We learned so much in our brief time at RFM hospital and are so gracious to the patients and staff who made us feel so welcome. 

 



Swaziland Culture

Picture of King Mswati III which is required to be in every official Swazi business

 

Swaziland is a country very rich in culture and tradition.  Most people are very religious and identify as Christians.  They are a polygamous nation and it is not uncommon for males to have several wives.  King Mswati III now has 14 wives with his latest wife being 16 years of age.  We found the Swazi marriage ceremony to be of particular interest.  When a male is interested in marrying a female he picks a group of his closest friends and they negotiate with the bride's family on how many cows the marriage is worth.  The average dowry is about 18 cows per woman.  Every year there is a ceremony called the Umhlanga or "Reed Dance" in which thousands of maidens gather to show homage to the royal family.  It is not uncommon for the king to select a prospective fiancee at this ceremony. 

The traditonal Swazi lives on a homestead.  Instead of traditional housing, where all the rooms are located in one building, they have separate huts with different functions.  Many homesteads do not have running water, plumbing, or electricity.  All meals are cooked over a fire, and the bathroom is usually just a hole in the ground.  Most Swazi's have to walk miles to get drinking water, and bathe by heating water over an open fire and washing their bodies.  The more fortunate people are able to buy large water containers that can hold enough for several months. 

Mothers to Mothers

Yesterday we had the opportunity to travel to the Matsenjeni clinic in southern Swaziland to participate in the mothers2mothers (m2m) program.  M2M helps prevent transmission of HIV from mothers to babies, provides access to medical care for the mothers, and counsels mothers with HIV to overcome social stigma and live positive and productive lives.  Mothers2mothers trains HIV+ women to become “mentor mothers” to other mothers living with HIV offering not only support but also education on ARVs and how to prevent transmission to their child.  Since 2001, this incredible organization has expanded to seven different sub-Saharan African countries with a total of 405 sites.  The m2m program has been highly effective in decreasing the rate of HIV+ babies as well as helping mothers cope with and effectively treat their HIV.

We traveled in a small van through RFM’s Wellness Centre Outreach Program to the Matsenjeni clinic about 2.5 hours away. The Wellness Centre is a clinic through RFM that provides confidential care to healthcare workers and their families for conditions such as HIV/AIDS and tuberculosis.  This week’s topic was disclosure of HIV status to loved ones.  Disclosure is a very important part of living with HIV in that it allows for a support system among loved ones.  M2M encourages the mothers that they should be the only ones who can disclose this information.  However, as you can imagine, this can be incredibly difficult.  Many women are ashamed; frightened by the stigma that will be put on them, or scared that their partners may leave them to care for their children alone. 

One woman in particular shared her struggles in how to inform her child that she had HIV.  She asked the child, “What would you do if you met someone who had HIV?” to which the child responded “I would run away and throw away anything they touched.”  This was very difficult for the mother as she first felt she needed to educate the child and rid him of his ideals before she revealed her status and he thought of her as a “monster.” 

Many problems can come from misleading others about HIV status.  Some people will go as far as hiding their ARV therapy outside, at work, or even at the neighbors to keep loved ones from knowing.  Unknown to the patient, this is more detrimental to them since the medications should be stored in a cool dry environment.  Children in the home especially should not be lied to.   One example was brought up that a mother claimed her ARVs were for headache leading the child to start taking her medication every time he had a headache causing serious complications and adverse effects.   

Another difficultly these mothers are faced with is how to tell an HIV+ child about their infection.  In school, most children are only taught that HIV can be transmitted sexually and that using a condom will completely prevent transmission.  Many children do not understand that they can be born with HIV and cannot grasp why they have this condition when they did nothing “wrong.”  Education and disclosure to a child at a young age is very important before they become sexually active and begin spreading HIV to others.  In instances when HIV status is disclosed to a child in their later years, many become incredibly angry or depressed.  A child who has not grown up being aware of and learning to cope with their condition may have already developed false and difficult to break stigmas.  In very severe cases, it is not unheard of for a child to run away and live on the streets or even commit suicide rather than face their peers. 

The importance of this outreach program is to educate patients and their loved ones and move away from the social stigma that has been placed on HIV/AIDS.  It does not only provide access to care, but also counseling and a strong support system.  M2M has approximately 712 mentor mothers across Africa.  There are currently 57 sites in Swaziland in which 82 mentor mothers work.  M2M pays for transportation of the mentor mothers to different clinics in Swaziland and is able to reach approximately 75% of HIV+ women who are attending prenatal and postnatal clinics throughout the country.  We found this organization to be extremely eye-opening and learned to not judge a book by its cover.  These women brought up many important struggles that we had not even thought of before.  We were very fortunate to be able to hear their stories and were incredibly inspired by their strength. 

 

Pediatric Ward

Today we did rounds in the pediatric ward with Dr. Pawelos Seyoum, a doctor originally from Ethiopia. Many children here are born to HIV+ mothers and have a 30% chance of acquiring HIV if their mothers are not on antiretroviral therapy.  This is why ARTs are so important for the mothers to adhere to as it reduces the child's chance of acquiring HIV perinatally to less than 2%.  A child born to an HIV+ mother cannot be tested for HIV for at least 6 months because they still have the mother's antibodies.  This is noted on the child's chart as being "exposed" but it can not be determined definitively until later in the child's life involving testing at 6, 12, and 18 months.  If the child is negative at 18 months, it can be diagnosed as definitively HIV negative.  All exposed babies are put on Bactrim after 6 weeks of age to reduce the chances of developing opportunistic infections such as PCP, despite their HIV status. 

A common theme we saw in the infants today was gastroenteritis and pneumonia.  The gastroenteritis can be due to the HIV virus, but can also be bacterial.  With the infants that are marked as exposed, it is hard to tell what the source of the gastroenteritis is, thus prophylactic antibiotics are given.  In the case of an HIV+ baby, the protocol is to do symptomatic treatment and rehydration therapy.  In patients with pneumonia, ceftriaxone is the standard of therapy.

 

 

 

One interesting case in particular we saw was a 6 year old girl who had accidentally ingested paraffin, similar to kerosene or gasoline.  She came in with difficulty breathing and cough and her chest x-ray showed infiltrates.  The paraffin had caused a chemical pneumonitis similar to aspiration pneumonia.  The patient could not be treated with activated charcoal as this was not a solid mass, but rather a liquid.  She was given oxygen therapy and IV fluids coupled with antibiotics.  She is doing much better and will probably be discharged tomorrow. 

 

Another case of interest and much confusion was a 12 year old boy with hypertensive encephalopathy.  He was admitted to the ICU in a coma  with active seizures on May 26th with a blood pressure of >160/120 mmHg putting him in a hypertensive emergency.  He was discharged to the pediatric ward after he had come out of his coma.  This was very interesting to us because we usually see primary hypertension in the US and this was a case of secondary hypertension to which the etiology is still unknown.  We did a differential diagnosis ruling out obesity, diabetes, family history, etc.  The patient's joints were also very stiff in his legs and could not be extended without causing him extreme pain.  We believe this could be a (+) Kernig's sign indicative of meningitis which needs to be followed up on.  The patient was also continuously rocking back and forth which could not be explained further.  We believe this may be some type of neurological disturbance or seizure disorder.  The patient was given Captopril and Lasix for his hypertension which has brought the blood pressure down to 148/108 mmHg, which is still uncontrolled.  He was given phenobarbitol and phenytoin in the ICU for his seizures and has not had another charted seizure since his discharge from the ICU.  His HR is 144 bpm and WBC count at 20.4 K which are both elevated above normal.  This is a patient we are interested in investigating further and following up on to see his progress. 

 

The pediatric ward is also home to its own separate malnutrition ward which was started by Dr. Pawelos.  Unlike America where we mostly see malnourishment as obesity, malnourishment in Swaziland usually involves undernutrition defined as weight being <85% of ideal body weight.  There are usually two types of malnutrition seen.  Kwashiorkor involves protein malnutrition usually characterized by swelling in the limbs or abdomen.  Marasmus involves calorie deficiency and is usually characterized by an emaciated-looking child.  Children are usually started on F-75, which is a formula high in carbohydrates which helps with hypoglycemia and poor absorption due to long-standing poor diets.  The patients are then switched to F-100 which is high in protein. 

 

 

We found it somewhat difficult to adjust to the charting system at RFM.  Everything is done by hand and is sometimes hard to read or locate information.  Also, information may be incomplete at times, which makes it a challenge to fully assess a patient’s status.  For example, in the patient with hypertensive encephalopathy, we were informed that a brain CT and lumbar puncture was done, yet we could not find the results of this in the patient’s chart.  Also, the pain in his lower extremities and uncontrolled rocking movement was not noted anywhere in the chart.  Although the charting system may not be up to the standards we are used to, the RFM health care staff does the best they can with limited funding, staff, and resources. 

 

Cabrini Ministry: St. Philip's Mission

 

 

On Friday, we visited the Cabrini Ministry in the Lubombo lowveld of Swaziland.  They are located in a very rural area of Swaziland and help the community that does not have access to hospitals and clinics like we have seen in Manzini.  We were shocked by the conditions in Manzini but it was even more eye-opening to see the conditions at Cabrini Ministry and how much they were able to help with so little resources and medical help. Their focus is on HIV/AIDs and tuberculosis and provide care to over 700 children and housing for 140 orphans.  In addition to children, over 3,000 individuals have recieved care from Cabrini in the past year. Cabrini provides care on site but also sends nurses out into the homesteads to follow up on patients and make access to care more convenient.  This increases drug compliance which is critical for HIV care.  They provide testing, counseling, anti-retroviral and TB drugs, treatment of opportunistic infections, and much more.  Cabrini also has a strong focus on education as they believe this is an important part of overcoming this epidemic and strengthening the community. Please watch the above video as we feel it is a more complete description of the efforts of the Cabrini Ministry.

 

If you are interested in learning more or wish to donate to this incredible non-profit foundation please visit their website through the links provided.  We believe this is an important mission because HIV/AIDs in Swaziland is more prevalant than any country in the world and may very well go down in history as the first time an epidemic has killed off two generations of people.  Sr. Diane and Sr. Barbara have dedicated their lives to serving the people of this community and we believe their mission is truly making an extraordinary difference.  They, as well as the other staff members, have provided hope that would not be possible in the community without them. 

Male Medical Ward and ICU

We began our day by meeting with Zinhle and processing prescriptions when the pharmacy opened.  Zinhle had us verify patient weights to ensure the gentamicin dosing was correct.  We followed up with Dr. Mtjali on renal dialysis in the ICU.  Next, we visited the male medical ward and did rounds with Dr. Gazagne.  It was mostly a tuberculosis ward, as well as some HIV/AIDS patients with opportunistic infections.  It was extremely interesting to finally connect real patients with the topics we have been learning about in school.  Some of these disease states we may not have had the chance to see in the US. This included severe cases of tuberculosis, cryptococcal meningitis, oral candidiasis, as well as many others.  We also got to see a patient on isonaizid who was developing peripheral neuropathy in his right foot.  Dr. Gazagne asked us to reccomend something for a patient on Efavirenz, an HIV medication, who was confused (as this is an adverse effect of this medication) as well as a reccomendation for and HIV patient who had developed a severe case of oral/esophogeal candidiasis (thrush). 

 

In the afternoon, we visited the ICU to check in on our diabetic ketoacidosis patient.  When we arrived they brought in a head trauma patient who had been hit by a car on foot.  This is very common as most Swazi people get around the town by walking.  We were able to see the patient being brought in and mechanically ventilated.  This was a new experience for both of us.  After the patient was stabilized and adequately sedated, we discussed the status of the patient with Dr. Kinsala.  We went through the medications used for this patient.  This included midazolam for sedation, morphine for pain, and dexamethasone for the brain hemorrhage.  The patient’s PaO₂ was less than 60 mmHg at 40 mmHg which helped us determine that the patient was hypoxemic.  We followed up on our DKA patient who had unfortunately not shown any signs of improvement but was stable.  Just like most days here, many family members were waiting outside all day to see their loved ones.

We have also had the opportunity to visit the Central Medical Stores.  This is similar to a warehouse you might see in the US; however they provide medications to all public health facilities throughout Swaziland.  We met with the pharmacist, Brenda, who explained to us their role in Swaziland health care and discussed some of her concerns.  A major problem they are faced with is quality assurance for the medications.  Swaziland does not have any drug manufacturers within their country, and have to order drugs from other countries such as South Africa and India.  She allowed us to look at some drugs they received that were not up to standard.  Some of these included a liquid suspension that was solidified upon arrival, questionable drug ingredients in IV solutions, and inappropriate packaging.  Central Medical Stores does not have the equipment necessary to test the ingredients of the drugs, and is worried that some of the drugs they are sending to pharmacies are counterfeit and may be harmful to patients.  One step they are taking to improve their quality assurance is having manufactures send drug samples prior to purchasing large orders of the drug.  Dr. Schafermeyer spoke with Dynalabs last year, who were interested in partnering with Brenda to send drug testing equipment to Central Medical Stores in Swaziland.  We are going to follow up with Dynalabs to see if this offer still stands, as Brenda expressed great interest in having proper quality assurance equipment.  She gave us a tour of the warehouse, and explained delivery, storage, and procedure.  We will be keeping in contact with Brenda, as she plans to provide us with a list of medications she finds to be most troublesome and counterfeited. 

 

We've been having a fantastic time so far and have already learned so much.  The Swazi people have been very welcoming to us and we have made many friends along the way. 
The weather has been beautiful and we have enjoyed driving through the mountains (despite the terror of driving on the opposite side of the road).

 

 

 

 

One of the local pharmacists named Willie graciously invited into his home to meet his family and enjoy some traditional African food.  They were so kind and very open to answering any questions about pharmacy in Swaziland and were also very interested in pharmacy in the US.  We had great conversation over similarities and differences in not only pharmacy, but the culture as well. 

 

 

 

 

 

Day 2

We started off today by meeting with Zinhle, one of two pharmacists at Raleigh Fitkin Memorial hospital.  We did an overview of some of the patients in the women's public medical ward and then began rounds with Zinhle as well as two pharmacy technician students from SANU.  We went through four different patient charts before visiting the ward and observing their status.  Some of the disease states we observed included common things in America such as diabetes, anemia, dehydration, and electrolyte distubances.  We also observed some less common ailments such as tuberculosis, HIV/AIDS, malnutrition, and opportunistic infections.  The ward is one room and usually holds around 34 people.  The Swazi people must provided their own bedding and food while hospitalized.  The average stay is around 5 days and costs about 60 cents (USD) per day to stay there.  The protocol for tuberculosis is very different in Swaziland due to limited space and funding.  All the tuberculosis patients are stationed in the back of the room, although not isolated; whereas tuberculosis patients in the US follow very strict protocol with negative pressure rooms and complete isolation.  This is troublesome for the hospital as disease can be easily spread to other patients or healthcare workers.  We were required to wear fitted N95 masks while in the ward to help protect us from tuberculosis. 

Next, we visited the ICU, which was more similar to an ICU you may see in a developed country.  In contrast, however, it was still one large room, but the facility and equipment were more up to date and less crowded than the medical wards.  The ICU isn’t used as frequently and there was only one woman staying in the ICU at the time we visited.  She was brought in and diagnosed with Type I diabetes and symptomatic diabetic ketoacidosis.  We were able to observe kussmaul respirations for the first time, which was visibly evident by her quick and heavy breathing.  We were given a chance to look at some of her labs and evaluate her current therapy. 

Our last stop on rounds was to the renal dialysis unit.  Similar to the ICU, it is a newer donated facility with very nice equipment.  A very nice Swazi man allowed us to observe his dialysis and ask questions.  We then proceeded to do clinical research on topics we encountered during rounds and met with Zinhle for discussion.  We finished our day by meeting with Sarah, the director of the pharmacy technician program at SANU to provide her with materials for her upcoming school year.  There was discussion for rotation opportunities for upcoming 6^th year STLCOP students to teach at the university next year.