Fun in Holland??

I've visited Amsterdam, Utrecht, den Haag and Limburg (south Nederlands) on my weekends here. Amsterdam was amazing and it's too bad that most people only think of coffeeshops and the red light district when you mention this great city. It is rich with history and culture, and, of course, beautiful architecture. I was lucky enough to have my own personal tour guide that could tell me about the canals and city walls - when they were built and why.

I was also taken to den Haag which is where the royal family lives. I saw the parliament buildings, browsed the flea market, went to the MC Escher museum, walked down the street with the posh shops for the royal family and finished the day with a walk on the beach of the North Sea. I think this is where I would live if I had to live in Holland.

Vorden finally got a little exciting this past week with their annual festival. It's a small scale county-fair with rides and games and a beer tent with a band. I've been going the past few nights and meeting a lot of cool and fun people. I even got to hang out with one of the bands and they played a few American songs for me (Nirvana and AC/DC) - pretty cool!

So, all-in-all, I've had a great time in the Netherlands. I finished up my last week in the pharmacy yesterday and said good-bye to all my new friends. Tomorrow I start my own holiday, finally. I'm taking the train from Paris to Rome and stopping at Genoa and Florence for a couple days along the way. Three days in Paris and five days in Rome should be enough to see everything worth seeing I think. I'm doing a wine tasting tour in Tuscany and a tour on a Vespa through the Chianti region while I'm in Florence.

I will try and post a few pictures here and there when an internet cafe pops up if you would like to see a little bit of France and Italy. Hope all is well back home.

This is a picture of a tank that somehow makes sterile IV medications. I'm not quite sure how it works except that all of the different parts of the IV are placed inside the tank and the machine selects the correct volumes of each and mixes them. Again, I have no idea if the meds are placed in certain compartments or filled somewhere else and piped into the tank. It was being explained to me in very simple English - the language barrier was a little hard to overcome in this small village hospital. Once the IV is mixed, it is sent through a pipe that runs up the wall, across the ceiling and into the next room's sterile hood where it is filled into a bag and labeled. I couldn't witness the process because this hospital is being renovated and all of their IVs and chemo are being shipped from a larger hospital 30 km away.

This was one of the main differences I could see from the few inpatient pharmacies I've seen in America. Otherwise, it runs pretty much the same way other small hospital pharmacies are run. They have med closets on all of the units that contain most of the fast movers most patients use. If the patient requires a med that the closet doesn't contain, an order is sent to the pharmacy. They fill a weeks worth of the particular medication and place it in a bin marked with the room number of the patient.

One other thing I found interesting is that the entire patient chart is sent to the pharmacy for the orders to be input. Each hour, someone drops off charts and retrieves new charts with new orders - I don't think that would ever happen in a US hospital. They also didn't have a pharmacist present. Pharmacy assistants (that have four years of education in pharmacy) run the entire pharmacy. A pharmacist is supposed to be there, however, for at least a couple hours but just like pharmacies in the US, budgets are getting tight in the Netherlands as well.

Holland has its own symbol that represents an apotheek. Patrons can walk by and see the image of a man with his tongue sticking out and know that they can get medicine there. I've seen them in all of the pharmacies I've visited and the two apotheeks I was in today are no exception. I went to Soest with the Mediq Quality Manager, which is a fancy name for inspector, and watched how he makes apotheekers sweat while reviewing the Apotheek Handbook and looking for any offenses. The handbook contains Mediq policies and procedures as well as future goals the pharmacists makes to prove that they are trying to improve their pharmacy services. The regulations are quite similar to our board of pharmacy in OR - fire extinguisher, opioids have a locking drawer (even though they never lock it), clean room for sterile compounding, emergency exits, training, etc. The goals are reviewed and ways in which they are being implemented and evaluated are discussed. The goal of one of the pharmacies was to make their home delivery process more consistant and efficient by collaborating with her best driver and coming up with one procedure that every driver must follow.

The main problem that occured with both stores is how they deal with patient complaints. There is a new database in which complaints are handled and the assistants are doing it the old way using a paper format. Mediq wants everyone to use the computer forms in order to track the most common errors and complaints. The system they use is actually really cool - they can graph complaints of one store and see how they compare to the other stores. They also use the same system to log customer surveys and stores are graded against the average. Stores can get a grade of 1-4 with 4 being the "gold standard." I was told that most stores in this region were between a 3 and 4. Bart, the inspector, told me that of all the questions asked about the pharmacy, Mediq grades them based on the answers to the professionalism and courtesy questions. I should have asked what the other questions were.

On Saturday I took the train to Utrecht and met three students from Holland and two other exchange students - one from Barcelona and one from Lisbon. They took us on a tour of the Dome church (the tallest structure in Holland) and we went on a boat ride on the canal that runs through the center of the city. We also went shopping, which I'm not going to be doing much more of since tax is 19%!

There are only two pharmacy schools in Holland and one of them is for pharmaceutical/biological sciences where most students go on to work in research facilities or industry. The other is more like our program and they go on to work in community or hospital pharmacies. Everyone that applies to either program gets in - they've never had more students than available seats. Tuition in Holland is a flat rate of 1600 euro (about $2250) and this doesn't go to the university, it goes to a student board that keeps track of all students. The government will give students 200 euro per year and if they get good grades (points) and go to class on time, this becomes a gift they don't have to pay back.

The other students got wide-eyed when I told them that we take a test every-other week. They only have one test at the end of the year. But they saw the value in having a test more often and said that it would be good if their school changed the way they tested. It would make the students focus and study harder instead of cramming the two weeks before the test. Otherwise, they learn pretty much the same things we learn - with less emphasis on the clinical aspect. They focus more on the sciences - pharmacology, biochemistry, etc. They also have to work for one year with another pharmacist before they can work alone - kind of like an internship except they can get paid.

I wish I had more time to talk with them about their experiences with pharmacy. They were more curious about America - not only the pharmacy program and profession itself, but about American life. They think that it's exactly how they see it from TV shows like Gossip Girl and the OC and movies like American Pie. Kind of scary...

Opioids

To answer Rudy's question about narcotics, they are not regulated by a governing body like the DEA. They are not categorized as schedules I-V like in the US; they're not categorized at all. It's the pharmacists' responsibility to regulate their opioid inventory and make sure they are kept safe and being used appropriately. If a physician prescribes an opioid and Mariet notices that the patient hasn't been on an NSAID, she will call and ask why they haven't tried it first. Their narcotic of choice is morphine but they also use everything else we do except Vicodin and Percocet - at least not in Vorden. Mariet counts these drugs once per month to make sure the inventory is correct and if it is off, she needs to find out why and fix it. It is rarely wrong and usually a result of a computer error. If she cannot not account for her narcotic count being wrong or if she discovers someone is stealing/using it, which has never happened in her pharmacy, she tells the region inspector. She also reports physicians that are prescribing too many narcotics to the inspector and an investigation is started. Next week I'm spending a day traveling with the inspector and will have more information about their role in pharmacy.

A Day in the Life of a Village Physician

Today I spent my time with Dr Albers who is one of the General Practitioners for Vorden, his wife Esther is the other. I walked into the brightly lit waiting room and was introduced to the staff that consisted of two secretaries and an assistant whose role is diabetes manager. The room where he performs patient exams doubles as his office and at this point I was really curious to see how the consultations play out in rural Holland. He briefly outlined the complaint of our first visit as tendonitis in the upper groin area in which he prescribed anti-inflammatories for two weeks prior. He guessed she was back for a visit because it wasn't going well. He retrieved her from the waiting area and explained my presence. A women in her early 60's firmly shook my hand t introduce herself and sat in one of the chairs next to his desk. They then had a discussion, in Dutch, about her complaint. I could follow the conversation somewhat but was kind of surprised when she stood up and took her pants off, with no qualms whatsoever, and pointed to the exact area that hurt. He asked her to lay on the table and started to palpate her upper, inner thigh - with no gloves on - to assess it properly. The pain was along her femoral artery and he was worried that it might be an abdominal hernia so he referred her for an ultrasound at the hospital, typed a brief note about the visit and we were ready for the next patient.

They do not employ a nurse or medical assistant that escorts the patient to a room, obtains height, weight and vitals and reviews medication lists, allergies, medical history, etc. The visit is only focused on the complaint and the physician types his note, writes prescriptions and referrals and fills out the lab envelopes himself all within approximately 10 minutes. The next two hours mimic the first appointment except for the emergency visit in which a 73 yr old man fell 2.5 meters (about 8 feet) off of a ladder and secured a gaping 20 cm cut that was bleeding profusely on his right, lateral lower calf (his lower leg, not his livestock). Dr Albers cleaned the wound and placed stitches on the ends and right in the middle leaving the rest open because it was a very dirty cut and he wanted the 'dirt' to work its way out and lower the chance of infection. He prescribed Doxy and sent him on is way with a follow up next week.

After lunch he performed a minor surgery - removing skin tags with possible melanoma - and then I accompanied him on his home visits. This is his favorite part of the day - driving out to the country and visiting patients in their homes. He believes it is better than seeing them in his office. He explained how people are more open and that family members can help by remembering things the patient forgot or giving their point of view on the situation. Everyone was very welcoming to me and one of them even spoke in English so I could understand even though she wasn't completely confident about it.

One of the beautiful farm houses we visited was the widower of the nephew of the famous artist MC Escher. She even had the original "Day and Night" piece hanging in her living area. She told me a story about how Mick Jagger called Mr Escher to ask if he could use his artwork for an album cover and the artist told him "No." Very cool!!

To end my day, we attended a palliative care meeting with a consultation group in which Dr Albers and Mariet (my host) are members. They recieve calls from nurses and other physicians for advice on euthenasia and terminal sedation. These are two different kinds of care and both are legal here with certain requirements. Terminal sedation can be used when a patient's life expectancy is less than one week and all other treatment options have been exhausted. They use midazolam and a high dose narcotic, usually morphine. This group reviews cases that have been consulted on and discuss the outcome to see how they can make the process more efficient and make sure it's within the laws.

I know this entry if very long, but I had an amazing day and wanted to share! Tomorrow I'm back in the pharmacy reviewing the medication lists of patients in the nursing home and finish inputting new insurance formularies for the month of July - yes they change monthly. Now, I'm off to water the plants and flowers with Annelie and practice my Dutch. Doei!!

Mediq Apotheek

I work at a Mediq Apotheek which is a chain pharmacy in Holland. They do about 350 prescriptions (or recipes they call them) per day. The way prescriptions are processed is pretty much the same as in the US. One major difference is how their medications are stored. Instead of having shelves of bottles filled with tablets that we have to pour and count, they have rows of drawers that contain boxes of 28 or 30, 60 and 90 unit dosed meds (which the picture is showing).

Another difference is that Holland has pharmacy assistants that have four years of education in pharmacy. Two assistants can check a prescription before it is dispensed to the patient and they are allowed to counsel. There is only one pharmacist per pharmacy that acts mainly as a medication manager. In this community, all of the pharmacies work closely with the physicians, hospitals, long-term care facilities and other pharmacies to manage the patients meds. If a patient goes to a different pharmacy, other than Mediq, their previous pharmacy must fax the new pharmacy the patients dossier or profile before any medicine can be dispensed. It's the pharmacists responsibility to update the profiles from discharge orders and make sure all dosages and meds are ordered correctly.

The other main job of the pharmacist is to check the "signals" every day. Any time the computer flags the inputter with interactions, duplications or filled too soon, it goes on a list that has to be investigated by the pharmacist. This is part of what I did today. I checked all the signals - and there are lot more than you'd think! It was also very difficult since it's all in Dutch, but I managed - most of the drugs are the same just spelled a little different. You have to put in an explanation of how you fixed the problem, whether it's "called physician and changed med" or "directions changed to bid from qday" or "will counsel patient,"etc.

I also checked in and put away the order and helped fill a little, so they are putting me to work. But I don't mind at all and am so happy to be here! I'm just sad I can't counsel patients because most of the older clients don't speak/understand English. The language barrier isn't ideal but could be worse and the one assistant that speaks the best English is leaving today :( She is in the picture.