Bittersweet...

Today was our last full day in England.

I thoroughly enjoyed sleeping in! I had managed to do most of my packing yesterday so I was nice and lazy this morning. I've already addressed my eating problem...so typically, I'm the one who is harassing Elise about where our next meal is going to come from, and since Elise has already been feeding me the last two nights to get finish off her food supply (I clearly demolished the food I bought at the last grocery visit within 4 days of buying it) we were left with Elise's candy drawer and a few little snacks for breakfast. I chose to finish off the pretzel M&Ms (Mom- if you're reading this, don't be too disappointed!)

Elise chose to wait so she was pretty hungry for lunch after a couple hours of being awake. For once, I wasn't the one getting huffy about eating! I figured I should get a move on and jump in the shower so that we could go get some lunch!

We got lunch near by our flat and then went by the college to see Dr. Steinke and our two favorite people who also work in the pharmacy practice office (Paula and Sarah) We had a nice chat with Dr. Steinke and the girls before heading downtown to get a little parting gift for Dr. Steinke. We picked out a picture frame with three picture slots. We put in a picture of Elise in one, me in another, and a thank-you note in the middle.

So we met up with Dr. Steinke for dinner at a place called the Didsbury Inn. Believe it or not, I had not eaten a proper fish and chips meal yet. Shame on me. That situation had to be fixed immediately and since Dr. Steinke knew the restaurant well and said they had good fish and chips, we thought it was the perfect choice. I'm slightly jealous of Elise's meal though because as I was perusing the menu I read the most amazing description of a meal. I told her she should order it and thankfully she not only ordered it but also let me have a bite! Most amazing dish ever! I wish I could remember the name but it was a chicken pesto in a flakey crust of some sort with rosemary potatoes and chorizo! AMAZING. If we were here for another day I would take myself right back to that restaurant for that meal!

We came home after dinner and finished packing up the last minute odds and ends...but clearly I didn't do much because as I sit here - I'm still surrounded by numerous chargers/cords/adaptors, my carry-on bag which is not fully packed, shoes, and all my toiletries still in the bathroom!

I don't think it's officially hit me yet that we are leaving. I'm not sure that it will until I'm sitting on the plane...or maybe until they say "ladies and gentlemen, welcome to Washington, D.C, the current time is _____ and the temperature is______." I think my favorite part of that will be the temperature. England-- I've really enjoyed my time here but I'm so over the rain and grey clouds! I'm sure, as murphey's law will have it, the weather in England will perk up as soon as we leave!

What an amazing six weeks this has been. I've learned and been able to experience so much in such a short time. I feel so blessed to have been able to have had this opportunity! And I do not know what I would have done without Elise - my partner in crime! It's hard living with someone 24/7 without wanting to strangle them, but somehow, we make it work. I'm sure secretly she might have wanted to strangle me a few times though! :)

I suppose I should wrap this up as it's already almost 1AM. I'm so looking forward to seeing everyone back home - especially my parents and my best friend (you know who you are) But I will miss my home-away-from home family, the Paynes a great deal, as well as my surrogate parent, Dr. Steinke! So, cheers England! I will definitely be back again.

Next time I come abroad, I'm going to conquer Europe. I have loads of traveling left to do and I cannot wait! For now, it's back to America to finish up my fourth year of rotations (6 more left!!) and then hopefully starting a residency. Hope y'all enjoyed the blog!

Can't wait to use my British phraseology back home! :)  Btw--- I promised my friend Maddy a shout out, so here it is! Hope to see you soon darling!

Dr. Steinke at Dinner showing off his gift

Aseptics & CF Satellite Clinic

Thursday was our last day at Wythenshawe Hospital and our last working day in England! The morning started with aseptics. Probably one of the biggest differences we've noticed between here and the states is the world of aseptics. First, aseptic products can be made on the floor or the wards here and when that occurs, nurses are the ones who make up the product. While the prescription is still clinically checked by a pharmacist, a pharmacist may never actually see the product before it is given to a patient if it is made on the ward. Technically the products that are made on the ward have a 24 hour expiration date but the policy is that they should only be making IV preparations on an as needed basis to be used right away.

Second, the only products that are made in the pharmacy are high risk medications, namely, antibiotics, monoclonal antibodies, and chemo.  They can only make batches of an IV product with licensed drugs.  If a product does not have a label on it (like not an individual patient order) then they can keep it on the floor as stock but if it's for an individual patient then they are not supposed to give it to anyone else if that patient does not end up needing it. It can be in the hospitals best interest to make these batch orders because then the ward already has stock of the drug and typically the expiration is longer (e.g. when they make clarithromycin as a batch the expiration is 49 days but if they make it for an individual patient and label it as such then the expiration is 7 days) Similar to USP 797, they use Quality Control NW to provide guidance on expiration or BUD for products.

Third, the aseptic unit in the pharmacy is not open 24 hours (8-5pm only!) There are three sessions that the technicians work in: 8-10am, 11-1pm, and 1-5pm.

Fourth, there is much more strict adherence to sterility. There are three separate rooms that are used for aseptic preparation with little chamber compartments (hatches) that allow the various supplies (needles, vials, bags, etc) and final product to be transported. They spray all the supplies (even the needles that are wrapped in paper) with isopropyl alcohol and then follow that up by wiping it down with an alcohol wipe which then sits in the hatch on a two minute timer to dry. Also, once a month they do a double settle plating where they test for contamination. Once a week they do 42 settle plates and contact plates plus broth fills; and during each aseptic session they do finger and settle plates. WOW. I think Elise and I's jaws were on the floor when we heard this!

While chemo spikes are used occasionally here, they only have one size spike so they are limited as to what products they can use it with and they still use a needle to draw the product up to put into the bag. They do put chemo in a specialized bag that is bright yellow to identify it as chemo which is something that is similar to what is done in most hospitals in the US.

Almost all IV products at Wythenshawe are made my technicians. There are different levels for the technicians. It starts at Ban 2 and goes all the way up to Ban 8. The level depends on the amount of training and experience you have had.

The MHRA or the Medicines and Healthcare products Regulatory Agency is the government agency which is responsible for ensuring that medicines and medical devices work and are acceptably safe. They typically audit every 8-10 years. This agency is probably the equivalent of the Joint Commission and FDA mixed into one.

Elise and I had a brief meeting in the afternoon with one of the clinical pharmacists we have been working with on the prescribing errors project. We showed him the data that we had compiled and hopefully Elise and I will be putting together a paper on the pilot study that will get turned into a poster.  Only have to make it through the IRB exemption forms....all 7 sections.

The last part of our day was spent in the outpatient CF (cystic fibrosis) satellite clinic. They also have an entire inpatient CF ward that is on the floor below the outpatient clinic. The satellite clinic is relatively new and Elise and I got to meet the woman who developed the business plan for it's creation, Jan. Jan was a huge proponent for pharmacist involvement in a CF's patient outpatient clinic stay. The prescriptions are brought to the pharmacy and the pharmacist fills the meds and brings the prescription directly to the patient's room so they minimize any potentially infection introduction. There are designated clinic days for the patients (e.g. Pseudomonas group 2 meets Thursdays; this is the group that is transmissible - they caught pseudomonas from another person in contrast to group 1 which are patients that are self pseudomonas colonizers) We learned a lot about the treatment options available for the typical infections seen in CF as well as the routine medications used in the UK for adult CF patients. The majority of the medications are similar - one big difference was that they use a lot of theophylline. They also don't use a lot of mucomyst and megace has somewhat fallen out of favor.

Speaking with Jan was really great because she has been working in CF for about 25 years- so she had an incredible amount of expertise in the area! She also has been a huge advocate in the hospital for the CF patients and created an additional role for pharmacists to make a difference!

Elise and I really enjoyed our time at Wythenshawe! We were always doing/seeing something new and with the additional prescribing errors project, the time flew by! The pharmacists we met were awesome and we could not have asked for a more welcoming group of people!

Outside the inpatient pharmacy

Working hard in the hot desk room at Wythenshawe

Medicine Ward Visit

This morning started off on a bit of a rough note. We didn't realize our bus passes expired yesterday so when we tried to get on the bus, the driver let us know about our ignorance. This wouldn't normally be that big of a deal...if you had money on you..however, neither Elise or I had any cash so we had to try and hunt down an ATM machine at 8AM. The first ATM was a bust. The second was a victory! Luckily we didn't have to walk too far to find one! The thing that stinks is that only certain buses come every 5-10 minutes and unfortunately, the bus that takes us to Wythenshawe only comes about every 40 minutes. Again, luckily it was not pouring down raining...just spitting rain..so it was bearable.

Once we got in, we met up with the two pharmacists that we were going to be following. I went on one of the main medical wards with Lisa. None of the patients were new so I just helped with a few medication discharges or TTOs as they call them here. I also looked through a few patient charts, comparing drug treatment to what we might typically do in the states as well as discussed interesting things I noted in patient care with Lisa. For example, one of the patients was pretty complex and was on an anti-depressant that had an interaction with the antibiotic he was on to treat his diabetic foot ulcer so they stopped it; however, this anti-depressant was already a third line option so the psych team did not want to start something else and yet the patient was already experiencing suicidal ideations. I spoke with Lisa about my thoughts on the case and what I thought I would do after reading the background information but it was definitely a tricky one!

Elise and I ended up leaving after lunch to finish up the database/result analysis on the prescribing errors project we've been working on.

Hard to believe that tomorrow is our last day at Wythenshawe and we will be back in the states in 3 days! We're both so thankful to Jodie and Dr. Steinke for arranging this time at Wythenshawe! We've been able to see/do so much in just 9 short days there!

Surgery Ward & Patient Case Presentation

On Tuesday of this week, Elise and I spent the first half of our day following two clinical pharmacists on two different surgery wards. The ward I was on was primarily orthopedic patients. I actually evaluated a patient's medication list for several aspects: administration (patient had an NG tube so their medications had to be suitable for this delivery), renal dose adjustment (patient had poor renal function), and post-MI status (making sure the patient was on the proper medications for this) I also was able to do discharge counseling for a patient which was neat. There were not many new patients so the remainder of the time I spent talking with the pharmacist about various drug changes or orders that he was evaluating for their clinical accuracy.

That afternoon, Elise and I presented our patient cases to a few pharmacists, our preceptor, and pharmacy students. We both put together a powerpoint to show how we would typically present a patient in the states and work through an individual case. I presented on a patient with a suspected meningitis/encephalitis. Part of the presentation was also to highlight the differences in treatment approach between here and the states. One thing that I'm still getting used to is the unit differences for labs. My frame of reference is completely off because I no longer know what an appropriate lab value is with the different units.

Overall I think the presentations we both gave went really well and they enjoyed seeing our step by step process in handling patient cases.

PharmD. Curriculum

Monday morning we flew back into Manchester. We arrived around 730am and hopped on a bus back to our flat. We weren't able to take advantage of the complimentary breakfast at the hostel that morning as it didn't open up until 8am and we had to leave by 4:10AM so Gary was not pleased by the time we arrived at our gate at the airport.  I got a small snack at the airport to hold him over but eating was a top priority when we arrived at the flat.

We had a presentation at the University of Manchester College of Pharmacy that afternoon for faculty and staff members on the PharmD. curriculum and specifically, the curriculum at the University of Kentucky. Elise and I made a hand out on an overview of the courses we take at UK during our three years of didactic learning plus information on our fourth year rotation year, block testing, the pre-pharmacy requirements/coursework and application process. In England, you go straight from A-levels (essentially our high school equivalent age) into university. A-levels are essentially the equivalent of our undergraduate coursework in the states or AP courses in high school. You focus in on a few areas during your A-levels (i.e. biology, chemistry, math) if you're going to do medicine or pharmacy. There is no entrance exam to get into pharmacy school in the UK nor do they have an application process like the one we have in the states for professional programs. Man what I would have given to not have to apply to pharmacy school or to bypass the PCAT!

I think the faculty/staff members were really interested by our curriculum at UK, the way we take our tests, and some of our unique courses (i.e. business management, our clinical lab sequence courses, etc) We tried to convey why we feel UK is such a great place to learn whether it is through the diverse/well rounded learning experience we are provided with that allows us to adapt to the changing profession of pharmacy, the stress on life-long learning or being engaged/involved within the profession, or the integrative nature of the program that teaches us how to communicate and interact with other healthcare professionals.

Our fourth year of rotations is similar to what they call a pre-registration (pre-reg) year; however, instead of experiencing several different types of pharmacy, student pharmacists here are placed in one location only for 12 months. While I think the role of pharmacists is very similar between the states and the UK, the process/training leading up to becoming a pharmacist is actually quite different. I think Elise and I both really enjoyed sharing a little bit about what we do back home and how UK has given us the foundation we need to practice successfully as future pharmacists.

Howth

Rhyming with "both", Howth is in the Northern County of Dublin. It is a quaint little city on the sea and it reminded me a great deal of Newport, Rhode Island.

Elise and I jumped on a Dart (aka metro) to Howth on Sunday morning to explore the city. When we arrived we checked out a few of the local markets. So much food! Gary was going nuts. I couldn't help myself...I had to buy some of this homemade fudge. Best decision I made on that trip!

We spent some time exploring the harbor and checking out the seals (they actually scared me...not like the cute seals you see on TV) Then we set off on a trek to try and get a good view of the city. We kept climbing and climbing the streets thinking that it would level off at some point but it didn't and it didn't seem like there was going to be a break any time soon! With that in mind, we decided to turn around and go back down. We contemplated going through a few people's yards to try and get a picture! Of course as we came to a point where we might be able to get a picture it started to pour down raining and then everything became cloudy. Murphy's Law.

Scary seal

The Howth Harbor

On our climb up

We turned down a different street on our way down and as the rain let up, we noticed several people walking in a certain direction so we decided to follow. We figured if enough people were walking that way then there was probably something to see! We were right. Incredible views!

What do you know...the sun came out!?

There was a "beach" in Howth as well. I say that in quotes because I think people in the UK are confused as to what a beach actually is...but I guess it's similar to those in Rhode Island...very rocky and the water is freezing!

After we left the beach, we walked to a placed called Abbey's Tavern for lunch! And then I had ice cream afterwards because Gary wasn't quite done yet! We were exhausted after walking all day so we jumped back on the dart and headed back to our hostel! We left very early the next morning for Manchester! All in all, fabulous weekend!

"Solange"

Friday evening, Elise and I boarded a flight to Dublin, Ireland! Although, ironically enough, on our way to the airport we met 3 American students from North Carolina who were not only living in the same accommodations as we were but they were also headed to Dublin the next day. We literally have not met any other Americans in our entire time here so it took Elise and I completely by surprise!

Airports here are way more lax when it comes to security as compared to the U.S. We didn't even have to take our shoes off! Initially we were a bit nervous that we were the only ones going to Dublin because the gate was completely empty (they didn't post the gate number until 30 minutes before the flight was taking off so we happened to just guess a gate that was in the right vicinity) but then we noticed a group of people and figured that they had to be going to the same place we were as it was such a late flight! Thankfully we were both paranoid about something going wrong so we got there like 2 hours early.

We arrived in Dublin pretty late on Friday night as our flight was at 11pm out of Manchester. The flight only took 35 minutes..shortest flight of my life. We checked into our hostel and went straight to bed as we were pretty exhausted!

We set off on Saturday morning to do all the touristy things...right after we helped ourselves to the complimentary breakfast at our hostel of course! Again, all I wanted to do was eat while in Dublin. Constantly hungry. I've considered the possibility that I might have a tape worm given the fact I am always hungry like half an hour after eating a meal. I'm getting to the point where I cannot afford to keep up with my eating habits! So in the event that I do in fact have a tape worm, I've given him a name...Gary. So from here on out if I refer to Gary, you know who I'm talking about!

Our adorable little hostel, abbey court

The Liffey River

Our first stop was Trinity College. Gorgeous place. We went in to see the Book of Kells which was such an awesome experience. We were not supposed to take pictures but I may have taken a picture of the Old Library because...well, I just had to. It's stunning! My picture does not do it justice because I was trying to be stealth about it!

The Book of Kells contains a lavishly decorated copy of the four gospels (all in latin) It was been associated with St Colum Cille who founded his principal monastery on the island of Iona. It is thought that the book was probably created around the 9th century by the monks of Iona. It was written by four main scribes. Scribe A who copied St. John's gospel was though to be conservative, generally leaving the decoration of his pages to others. Scribe B used a lot of colored inks and calligraphy. Scribes C and D did the majority of the gospels of Matthew, Mark, and Luke.  The book was sent to Dublin around 1653 for reasons of security through the Cromwellian period and came to Trinity College when Henry Jones became bishop of Meath.

My favorite part was the portion that discussed the Chi Rho page. It is the most celebrated image in the Book of Kells. Chi Rho is the abbreviated Greek form for the name of Christ. This page is filled with visual reminders of the Eucharistic sacrifice and resurrection of Christ.

The Long Room (aka the main chamber of the Old Library) contains 200,000 of the library's oldest books in oak bookcases. Since 1801 the Trinity College Library has had the right to claim a free copy of all British and Irish publications under the relevant copyrights act and has a stock of nearly 3 million volumes housed in a total of eight buildings. One of the dozen or so remaining copies of the 1916 Proclamation of the Irish Republic is also on display! This signalled the start of the Easter Rising when it was read aloud by Patrick Pearse outside the GPO (General post Office) on April 24th, 1916.

They were filming a TV show at Trinity...thus explains the dressed up people!

Outside the front entrance to Trinity

The Long Room

Our next stop was the Dublin Castle! The name "Dublin" actually comes from the Dubhlinn which is "black pool" in English. The Dubhlinn was a sheltered deep dark pool/harbor that joined the Liffey. Now the present Castle's Dubhlinn Garden stands in its place. When the Vikings captured the harbous of Dublin, it was called Dyflinn. Over 250 years, Dyflinn become a wealthy trading and manufacturing center and the largest Viking town in the North Atlantic region. 

Part of the castle bridge where it was filled in

Dubhlinn Garden Entrance

While on tour of the castle we learned that the harp is the symbol of Ireland. The Guinness family actually copy righted the symbol so if you look at the harp on the Guinness bottle, the body faces a different direction than it does on the Ireland coat of arms. There is a huge blue and gold (coat of arms colors) room in the castle called  Saint Patrick's Hall. It's still used today for president inagurations every 7 years.  The room is absolutely stunning!

On our way to the next stop, we saw St. Patricks Cathedral. Such an incredible structure with a really nice park/garden attached.

Next stop....GUINNESS STOREHOUSE!

Arthur Guinness actually signed a 9000 year lease at the storehouse location. Currently, the inner portion of the storehouse is designed as a giant pint glass. On the outer portion are the various floors the feature different things. For example, the first floor is all about the ingredients. 

The ingredients are: barley, hops, yeast, water

The second floor is about the skill of the brewer. This floor introduced the story of Guinness starting with Arthur. The third floor is about brewing (roasting, mashing, boiling, fermentation, and maturation)

The actual ingredients were all displayed on the first floor. Super cool!

A little sampling on the fourth floor!

On the 7th floor (Gravity Bar)- free drink with your ticket purchase!

After the storehouse we went to Temple Bar which is not only the name for an area of Dublin but also a bar. We had dinner right next to the Temple Bar and then went in for a few drinks and actually ended up going pub hopping with some of the locals! It was a really fun night! We learned a bit of Irish that night as well...one of the sayings was "solange", which means "cheers." We also learned that tipping is not an obligation in Ireland (i.e. you do not have to tip on meals, drinks at a bar, cab drivers, etc) We were actually told that they found the tipping culture in America to be ridiculous/absurd. SO WEIRD.