Experiences involving an international advanced pharmacy practice experience (APPE) rotation in Ecuador: review of prescribing practices and preparation for future trips.

Madison Block, Iulia Vartolomei, Jacque Garza, Amanda Hack, Joshua Burwell, Doctor of Pharmacy Candidates 2016 Shannon Panther, PharmD, BCACP Washington State University College of Pharmacy

Cebadas Comprised of over thirty small communities just south of Riobamba. Families rely on an agriculture economy and continue to remain extremely poor, thus lacking access to basic needs and resources. The closest hospital is two and a half hours away

Retrospective : The population served was largely made up of indigenous Quechua culture, fluent in both Quechua and Spanish. Patients were predominantly children and elderly individuals that work in the fields under constant UV light being the closet to the sun of all the world. Sunglasses are expensive and non-existent.

Leading Diagnosis: Pterygium • Total of 196 people were seen, 13 of those were diagnosed with Pterygium (6.6%) • These patients were given medication and sunglasses to help with the burning,

itching, tearing and dry eye symptoms. Surgery was not provided. • 50 eyewash prescriptions were dispensed. Sunglasses dispensed not reported. • Other commonly dispensed medications: mebendazole, vitamins and ibuprofen • Patients were educated on proper eye care and encouraged to protect from sun.

Prospective: More eye washes, more sunglasses on future trips. Start education on eye health at a younger age, catching it before it develops. Educate about protection from UV.

Alao In the Andes two hours from Riobamba. The road to the village is a rough, single lane road alongside thousand-foot cliffs with washouts, and narrow bridges. The elevation is 12,000 feet with lush vegatation and extraordinary views. The weather is cold and rainy, which provides ideal farming conditions.

Retrospective: The villagers were primarily middle-aged individuals of poor economic status. Farming is the only option for making a living. Their lifestyle is physically taxing because the villagers must travel long distances by foot and often

work in fields along steep hillsides.

Leading Diagnosis: Pain and/or Arthritis • Total of 118 people were seen, 34 of those had Pain/arthritis (28.9%) • These patients were given medications to help with pain and inflammation • 20 acetaminophen and 31 ibuprofen prescriptions were dispensed • Other commonly dispensed medications included: mebendazole, and vitamins • Patients were shown stretches and how to properly lift heavy objects

Prospective: Could provide more emphasis on exercise and appropriate osteo health. Provide education on osteoporosis and hand out more Calcium with Vit. D

Panchancho In the Andes at an elevation of ~14,000 feet. The land is barren. The air is cold, dry, and dusty from the wind and ash from Ecuador’s many active volcanoes. It’s difficult to grow crops without the assistance of a greenhouse, and water is a scarce commodity. Travel is difficult, access to healthcare is obsolete.

Retrospective: Evenly distributed across all age ranges. Although practitioners did not consistently document pregnancy, prenatal vitamins were dispensed more frequently here than any other village, regardless of population size, indicating that there was a higher pregnant and breastfeeding population in this region.

Leading Diagnosis: Pregnancy • Total of 118 people were seen, 14 of those pregnant or breastfeeding (11.9%) • They were given Prenatal vitamins to assist in healthy growth of mom and baby. • 56 -100 ct. bottles of prenatals were dispensed, sunglasses and bandannas given. • Other commonly dispensed medications: mebendazole, and eye washes • Taught patients to use bandannas and sunglasses to protect their eyes and

airways while outside. Educated on health during pregnancy and prevention.

• Prospective: Make education a larger portion of the day. Hand out more condoms and teach on a model how to use. Bring more pre-natal vitamins. Bring an ultrasound machine to check on baby.

Calpi Located south of Riobamba, it was the most developed from an infrastructure and agricultural point of view. People have better access to healthcare and food as they were closer to the city. The main occupation was farming as the climate was ideal. Retrospective: We served 14.5% of the population. Primarily the elderly and children. Calpi had a more advanced economics infrastructure when compared to the other regions, poverty was still prevalent. Residents endured hunger which they tried to cover up by drinking coffee. Children were given coffee for breakfast, just to keep them full until supper, when real food was being served.

Leading Diagnosis: H. Pylori/GERD • Total of 318 people were seen, 44 of those had H. Pylori/GERD (13.8%) • Pharmacy set up a treatment protocol including ranitidine, amoxicillin and

metronidazole. Educated to properly cook foods and get adequate hydration. • Other commonly dispensed medications: mebendazole, vitamins and eye wash

Prospective: To better serve the Calpi in the future, medical missions could provide education about the importance of nutrition especially in growing children along with identifying barriers to accessing better and cheaper food.

Top Diagnosis/ Concerns by Percentage

1. Well Checks (26%) 2. Pain (22%) 3. Arthritis (12%) 4. Pterygium (7.3%) 5. H. Pylori (5.3%) GERD (6.1%)

Conclusion • Limitations include:

• Recording uniformity, and availability of translators • Varying degrees of knowledge base and experience • Having a tight formulary

• All villages lack access to basic healthcare and resources. • Disease states occurred at a similar rate in every village. • There was a larger amount of H. Pylori than expected. • Bring more inventory: (bandanas, sunglasses, and medications) • A larger emphasis on education and a designated translator for that

purpose. 0 20 40 60 80 100 120

Calpi

Cebadas

Panchancho

Alao

Glasses need based off percentage compared across villages

Glasses No glasses Unknown

0

5

10

15

20

25

30

35

Well Check Pain Arthritis Pterygium H. Pylori GERD

Top Diagnoses by percentage

Calpi

Cebadas

Panchancho

Alao

amoxicillin, 45

metronidazole26

fluconazole, 3 ceftriaxone

inj., 2 ciprofloxacin,

6

azithromycin, 13

cephalexin, 5

sulfamethoxazole and

trimethoprim DS, 7

omeprazole, 1

ranitidine, 48 Dispensed Antibiotics