Day 4 in Holland

Today is the first day that we did what’s really the purpose of this trip – learn through work the pharmacy profession. We began the day in the Dutch way – dressed up in office wear and cycled on the bike to the pharmacy. It is common to see men in suits or women in pretty dresses on a bicycle here. Being our first time with a handbag and pumps (that kept dropping off jwen’s heels) and since Xfen wasn’t fluent with cycling yet (although she’d improve tremendously after the next few days of training), it was hard to manage the bikes and we had several stops along the way before we finally reached the pharmacy. The journey that usually took 10 minutes probably took us half an hour instead. Each time we had to stop at the traffic junction, it was excruciating since we had to get the bicycles started again. Its a miracle that children who are shorter and smaller than us can manage the tall, big bicycles so well.

As we saw over the next few weeks, cycling around to work, to school, on campus etc was great exercise and a good way to avoid traffic jams. Perhaps Singapore and NUS should consider starting bicycle lanes to ease traffic congestion It’d be a good way to minimize carbon dioxide emission to the enviroment, healthy for the citizens to exercise daily (imagine going up on a bike the slopes of NUS) and we can cut down on all the ERP gantries and perhaps lower the cost of living slightly.

 

The layout of the pharmacy was simple. Starting from the front of the shop, there was an area in front of the counter for customers to wait to be served.

View from the customer’s position

View of the front of the shop from behind the counter.

Behind that is the working counter to pack the medications, print out patient information leaflet (Bijsluieters) and etc.

Directly behind this area is the work space to pack weekly medications for chronic patients who are non-ambulant and can’t make their way to the Pharmacy. It is also the area where cream, suppositories, lotion, capsules are made.

 

Behind this area is the office of the pharmacists, who also serve as the area for the typist to type the prescription, as well as where the staff have their tea break.

 

Further behind lies the corridor which also serves as a kitchen. It is common here to have dish washing machine and this includes the Pharmacy too. The corridor leads to a working space that has a roterstat (recall dosage form design module where we learnt about the different mixing machines) and a clean room where the pharmacists will do small quantity of preparations that require aseptic/sterile environment. It is equipped with a white area to swap clean all the apparatus before they are brought into the sterile environment.

 

Going further down the corridor will finally lead to the store where all the diapers, syringes, needles, bottles etc are stored.

 

On day 1 of work, we began with packing the weekly medication box for the chronic patients who are non-ambulant. This involves opening up blister pack of medications and then sort them out into trays (5 trays, 1 for each day), with 4 subsections (for morning, noon, evening and night) according to the details on the prescription. Like in Singapore, pharmacies in The Netherlands have many steps in place to minimize errors in picking medications.

Each medication in The Netherlands has a registered number printed on the box and this number is reflected on the label sticker. The picker is then required to write down the number on the box of medication beside the label sticker, which is to be pasted on the back of the prescription, and this ensures that the picker sees exactly what he is picking instead of blindly doing it. This will hopefully minimize error.

The pharmacy also has a location system for different drawers on the labels. For example, if the label says L5L10,the picker can just head to the drawer thats arrange in a coordinate fashion. By opening the really long drawers, several medications will be found inside and the picker will have to pick the right medicine. This procedure takes quite a long time as compared to Singapore’s yellow tray system where you can just stick your hand in and pick the medication, without having to rumage through the collection of medicines in each drawer to pick the right one. Perhaps, the slow speed might have been due to us being unfamiliar with where the medicine is.

1 plus point about medicines in ther Netherlands is that they are all packed in boxes of 30 (for a month’s use) and you can just stick the label directly on the box. This minimize the possibility of picking the wrong number of medicines, as in Singapore’s system of taking out the blisters from the boxes and the picker will have to pick them either by strips of 10, 14, 7, 21, 50 or any random number. Furthermore, it reduces the use of ziplock bags as what Singapore does, and hence is more environmentally friendly.

 

Back to packing of the medications for the non-ambulant chronic patients. Each patient has his/her own pillboxes that they leave with the pharmacy. They each have a box containing all the medications that they are on, and the picker will take out the required number of each medicine from that box each week. In a typical pillbox, there are 7 trays for monday to friday (mandag, dinsdag, woensdag, donderdag,vrijdag) and each day has 4 subsections for morning(morgen), afternoon (middag), evening (avond) and night (nacht). The prescription will contain the number and type of pills to pick, and the dosing schedule. The picker will then burst the blister pack and put the pills in the right boxes for the tright time, before sending the boxes for the pharmacists to check. Subsequently, they will be packaged and kept in the cupboard to wait for either patient’s relatives to pick up, or the pharmacy’s ‘courier man’ to bring it to the patients.

Waiting for pharmacist to check before the trays are stacked up, and then packaged, to wait to be collected. All of these medicines are stored in the cupboard by the last names.

 

We spent the rest of Monday doing the picking of medications. Despite the monsterous training in Singapore pharmacies, we were still quite slow, having to decipher the prescription and labels which were in Dutch, familiarize ourselves with the many new medications that are seldom seen in Singapore, learn to use their computer system to check whether medicines are in stock, as well as to locate the medications. Its interesting that most of the rules of validity of a legal prescription ties in pretty much the same in Holland, except that a prescription by email/fax is actually legal here, but not so in Singapore.

All in all, I think we did a good job for our first day at work.

Since everything here was in Dutch, we had to learn the language (and fast!) so that we know what was on the prescriptions (instructions/special precautions) and can paste on relevant warning labels.  Below is a list of Dutch instructions. List is not exhaustive.

 

1. Heel doorslikken, niet kauwen :  Swallow whole. Do not chew.
2. ’s avonds innemen bij de maaltijd: Take in evening with meals
3. Gebruik volgens scheme trombosedienst: Take at the same time as directed
   Bij dit middel GEEN grapefruit sap drinken: Don’t take with grapefruit juice.
4. Zonodig voor de nacht: When necessary at night
5. Pas op met alcohol: Be careful when taken with alcohol
6. Kan het reactievermogen verminderen: May slow reaction. Beware.
7. 1 maal per dag aanbrengen: 1 time a day on skin
8. Bezorgen: medication brought to patient. patient is non-ambulant and can’t come to the store.
9. Huisarts: Doctor
10. apotheek/apotheeker: pharmacy/pharmacist

They really have alot of labels to go along with the medications. Xfen is the sticker collector, and I got influenced by her to collect all the labels too.

 

It was also interesting to see a whole load of medications which we never use in Singapore. For example, in Europe, to thin blood, they use accenocumarol rather than warfarin. Apparently, although warfarin is cheaper, accenocumarol gives a more steady INR reading and hence easier for anticoagulation management.

Interesting things seen/learnt:

1. A person with the name L van Kasteel (Kasteel = castle) could either mean that he used to live in a castle long time ago, or he was a servant of the castle.
2. It is common to have Restless Legs Syndrome in the europe. Adartrel (ropinirol) is used to treat this syndrome, and the catch phase for the product is,”Turn restless legs into restful nights” Apparently this is a neurological disease and 500000 patients are inflicted with this.
   Dosing scheme is as follow:
   Loading dose:  Week 1 day 1-2 0.25 mg
                           Week 1 day 3-7 0.5mg
   Dosing Scheme: Week 2            1.0mg 
                             Week 3             1.5mg 
                             Week 4             2.0mgTo know more about Restless Legs Syndrome,

   Restless legs syndrome (RLS) is a neurological condition that is characterized by the irresistible urge to move the legs. In order for you to be officially diagnosed with RLS, you must meet the criteria described in the four bullets below:

   • You have a strong urge to move your legs which you may not be able to resist. The need to move is often accompanied by uncomfortable sensations. Some words used to describe these sensations include: creeping, itching, pulling, creepy-crawly, tugging, or gnawing.
   • Your RLS symptoms start or become worse when you are resting. The longer you are resting, the greater the chance the symptoms will occur and the more severe they are likely to be.
   • Your RLS symptoms get better when you move your legs. The relief can be complete or only partial but generally starts very soon after starting an activity. Relief persists as long as the motor activity continues.
   • Your RLS symptoms are worse in the evening especially when you are lying down. Activities that bother you at night do not bother you during the day.

   RLS can also cause difficulty in falling or staying asleep which can be one of the chief complaints of the syndrome. A substantial number of people who have RLS also have periodic limb movements of sleep (PLMS). These are jerks that occur every 20 to 30 seconds on and off throughout the night. This can cause partial awakenings that disrupt sleep. Sleep deprivation can seriously impact your work, relationships, and health.

The work culture here is that they have breaks during work, and everyone MUST go for their breaks. There’s one at 10am, and then another one at 3pm and lunch is at 12 or 1. 

We had our first lunch at the work place the Dutch way too. That is, to pack a sandwich, warm it up with the toaster at the work place and make some hot soup in the pantry. Lee gave us an apple each for our vitamin dose.

Our first packed lunch!

After a day of work, we went home to dinner of leftovers from chinese food the day before, with some cauliflowers in tomato sauce whipped up by Rob.