For our last trip, UZ and I went to China’s thousand island lake. The weather was supposed to be like last week, rainy and cool, but it turned out much better than expected. In fact, it was sunny and hot the entire time. The trip started at a steep mountain with scenic waterfalls. The view was spectacular, but the hiking was tough in the hot weather. Still, we managed to enjoy taking pictures of the scenery. Our next stop was one of the highlights of the trip. The schedule indicated there would be a river raft ride, which sounded relaxing to UZ when we booked it. We would be riding in bamboo rafts with someone paddling us down a calm river admiring the scenery from a different point of view. At least, that’s what we thought we’d be doing. Still, we put on our flip-flops and emptied our pockets on the bus, leaving behind anything we didn’t want getting wet. We were thankful we did when we realized this was, in fact, a white-water rafting experience. From each reinforced rubber inflatable raft, two tourists paddled the rapids on their own using small wooden paddles and no training, guidance, or experience. The river was shallow and the rapids were small and easy to manage with the equipment we were given; everyone had a blast! But the constant splashing of the rapids and the 4 waterfalls along the way left our clothes completely soaked (in fact, the raft was completely flooded up to our waist for most of the trip). We didn’t bring a camera on this part, but we did purchase a photo of us taken by their crew. I’ll have it scanned when I get home.
After the river raft, we ate dinner with some new friends we made along the way. I tried speaking some Chinese with them, they tried speaking some English, and we all ate, drank (UZ even drank beer!), and relaxed after an exhausting day on tour. Soon after, we were taken to our hotel as the sun was setting. We didn’t expect too much of this hotel, considering the mediocre quality of hotels we were supplied by tour companies in the past. This hotel, however, was another highlight of our trip. The hotel was a house boat, nicely furnished with modern conveniences, and a balcony with a spectacular view. We were able to watch the sun set right outside our room.
Unfortunately the hotel was the last highlight of our trip. The next day had us cruising around the lake on a small cruise liner, which sounded great but the boat was crowded and uncomfortable and the weather was too hot for us to enjoy it much. Still, the lake was pretty and we saw an interesting museum of the art of locksmithing in ancient China.
After we got back from our tour, it was pretty late and we were very hungry. Searching for food, we wound up walking down East Nanjing Road. We hadn’t been there since our first week in China. We were so busy with other places, we forgot to check this spot out at night. It was like the Times Square of Shanghai; every building had a brightly lit billboard and under it a unique store. There was even a multi-story Hershey’s store, similar to the one in NYC complete with smell of chocolate billowing out onto the street from inside. There were a lot more trees obscuring the view than there are in NY, though.
We wound up eating at a familiar restaurant with an unfamiliar menu. Guess what this upscale establishment is?
Its actually Pizza Hut. Many chains we’d consider low-end have adopted a different image in China, as I’ve mentioned with Haggen Dazs and KFC. It wasn’t necessarily the best example of Shanghai food, but it served as a good last dinner in Shanghai for me.
To those of you who have been keeping up with reading my blog; I apologize for how late its been since I last updated, but I have been so busy I couldn’t find time to write! This week included some very interesting aspects of Traditional Chinese Medicine as well as a ton of extra-curriculars to keep us busy in the evening.
This week’s hospital rotations were all about TCM. We visited the TCM pharmacy and outpatient clinics at our hospital, and traveled to a specialized TCM hospital in another part of the city to see acupuncture practiced at the renowned institute. A TCM pharmacy works just like any other: prescriptions are faxed in from upstairs and the medications are selected and set aside for the patient. Prescriptions in this department average over 10 per patient, because there is a theory of synergy in utilizing multiple specific herbs to treat the many symptoms associated with a disease state. The TCM products in the hospital inventory are ordered in bulk from a supplier that is subject to government oversight. The product supplied must contain what its label indicates, or the facility may be shut down. The products in this pharmacy are usually dry, whole ingredients which the patient will boil in a medicine pot at home. There is another aspect to TCM pharmacy in that highly controlled outside facilities will compound, or brew, the TCM product and then seal the liquid in unit-dose plastic bags. This is often used in the inpatient setting, but is occasionally done outpatient at the patient’s request. At the TCM hospital, we were introduced to electro-acupuncture, which UZ tried for back pain related to an uncomfortable mattress. I tried cupping at the TCM department of our hospital as well.
After work, we found something to do almost every night. Tuesday was my birthday, so we had cake at work from Jing’An Bakery (which I will miss dearly) and then went to the Shanghai Museum of History. We saw many artifacts dating back as long as 6000 BC. After the museum, UZ took me to a nearby restaurant where we ate some very delicious, spicy food.
We booked a final trip and were taken out for a surprise dinner by our co-workers, who took us to a wonderful restaurant serving Shanghai-style delicacies. I tried many new foods here and loved every bite. After dinner, they took us out to the local bars, where we saw a variety of different venues and atmospheres on all levels of the same building. We spent most of our time in a Spanish bar drinking Sangria and a pleasantly unfamiliar Spanish beer. We had a great time getting to know our co-workers. Unfortunately, it wasn’t much longer until we said our goodbyes, but we will try to stay in touch via email and instant messengers. We had forgotten our camera the night of the surprise dinner, so no photos were taken there.
Our final day of rotations was spent with Dr. Zheng, an ACPHS professor and Fudan alumni, who just arrived to visit his alma mater. We went to visit the US FDA, located just outside the Jing’An Si district, to learn the role of the FDA in China and get to know the agents and inspectors working in this facility. The FDA has only a handful of agents to inspect all of the clinical trials for US products in China, so they’re kept very busy travelling all over the country. After the trip to the FDA office, we took Dr. Zheng to Huashan hospital for a tour, and then went with the other two ACPHS students to tour Zhongshan hospital. Our final day was followed by a final dinner meeting with all the preceptors, advisors, and students present, including Dr. Zheng and the students traveling to ACPHS next week. UZ and I sat with Zheng Jiao and talked about all of the experiences we’ve had all these weeks in China. Overall, it was a great learning experience and I am glad to have had the opportunity to travel so far and work with such great pharmacists.
Today was our first day of the last week, which will be entirely devoted to Traditional Chinese Medicine. We started the day in the TCM pharmacy, where we spent the morning checking out the process for preparing an order for delivery to the outpatient pharmacy department. The process is similar to any other pharmacy: a prescription is sent down for the patient with a list of 10-20 TCM medications (large therapy combinations are common in TCM) and the pharmacist gathers those items in the proper quantity and sends them out. The herbals here are not like the typical commercial powder packets available in most Chinese pharmacies; the hospital pharmacy carries the full product, to be boiled as a tea. The products are supplied with oversight from the Chinese FDA, which ensures the correct ingredient is in the package. The pharmacy will also outsource the preparation of the herbal remedy to another facility that brews the tea from the ingredients under strict protocol and packages them in unit-dose bags, for an additional fee. I learned a great deal about supplying and preparing TCM therapies in China.
This weekend included a national holiday, Dragon Boat Festival, so we were given Friday off. With this day off, we had a long list of places to see. Zheng Jiao gave us a detailed tour plan of the things we haven't seen yet in Shanghai but should. We started our day by crossing the river to the Lujiazui area, the area across from the Bund. We took the elevator up the Pearl Tower, where we could see a full 360 degree view of the city from one of its tallest buildings. The building also has a “walk of faith” platform, a glass-bottom platform you can walk out onto. There was even a small roller coaster within the tower. After we were done with this attraction, we went to the nearby Shanghai aquarium, which was quite large and filled with under-aquarium tunnels, as well as ecosystems for different regions of the world. We spent much time in this region, and by the time we reached the Shanghai Museum of History, it was closing time. Our next stops took us to various interesting spots including an old French district with a European-style garden and then a few other shopping regions, the last of which we spent a large amount of time in. There, we found many interesting shops and local handcrafts, as well as unique restaurants and lounges.
After our tour around Shanghai, we woke up early Saturday morning to tour Hengdian, the Hollywood of China. Hengdian is a popular location for shooting Chinese movies and TV shows because of the massive full-scale replicas of ancient structures, most notably a full-scale replica of the Forbidden City. After having been to the real Forbidden City in Beijing, I was doubtful that this recreation would be of any interest. I was blown away, however, at how accurate and detailed the fabrication is. Only by very careful observation would you notice that the central walkways are concrete instead of marble and the intricate arches are printed, not hand-painted. On this trip, we also saw a recreation of an early Qin dynasty palace, featured in one of my favorite movies (Hero), an amusement park that’s only open at night with a fantastic light, acrobatic, and pyrotechnic show, and a recreation of a Song dynasty village based off of a painted scroll. We saw a few TV shows being filmed here and there, but no celebrities that we recognized. The trip was two days long, mostly due to the long bus ride (5 hours one way) which prevented us from seeing everything in one day. Monsoon season was going strong this weekend; it rained all day both days of the tour, but fortunately we had good weather on Friday. My shoes were soaked by the time I got to the amusement park, so I had to buy some sandals there, which made the second day much more enjoyable, although I don’t know yet if my shoes will be salvageable. Overall, it was a great weekend despite the weather. Only one more weekend left here in China, I don’t know yet how we’ll top this but we’ll give it our best try.
Today, John personally took us on a tour of another area of Huashan hospital departments. to get there, we took a 10 minute shuttle bus a few blocks over to a different campus of Huashan buildings. Here, they manufacture and test their products. each lot must have a corresponding sample to be stored at the lab in case a problem requires that the sample be tested at a later time. each lot must also be tested for content, concentration, and contamination. The manufacturing facility itself is a large maze with different corridors for specific product types. Dosage form and ingredients both play a role in determining where a product will be manufactured. We also got to see the lab where his research was conducted, although today it was quite empty due to tomorrow’s holiday (Dragon Boat Day).
Yesterday, UZ and I had taken the subway to another part of the city. We crossed the river to the Pearl Tower, which we had seen from the Bund earlier in our trip. We didn’t bring a camera, so we decided not to go up the tower and instead explored the area around it. We started making plans to tour different areas of Shanghai, including the tower and aquarium located in this district. Today, after we got back from the other Huashan departments, John helped us finish up our tour plans. We now have a full day around Shanghai planned for tomorrow.
We toured the emergency medicine pharmacy on Tuesday, which is more similar to our hospital pharmacies back home in size. There is a key difference, though, in the drugs they stock: almost all are IV medications so the focus of the pharmacy is geared more towards preparing IV bags. There is a separate PIVAS here with four work stations. everything is organized assembly-line style to expedite the process. Even here, we can find TCM medications such as an IV TCM used for clotting.
Since we had another seminar on Wednesday, we spend most of Tuesday night working on it. Unfortunately, our internet wasn’t working over at the dorms so we worked from the library instead. We prepared by first liberally applying bug spray, and bringing hot tea and some candy to help the work session last. Overall, our library experience was much better this time, as it was not crowded and the bugs left us alone.
On Wednesday, our presentation went well. We used one of the weekly SOAP note cases from our previous curriculum for the seminar. The particular case involved a patient with Lupus Nephritis, who also had a history of seizures. We were able to use the brand-new guidelines, just published earlier this month, from the American College of Rheumatology (their previous guidelines were published back in 1999). After the presentation, UZ showed our coworkers a video compilation of the photos taken from our Hangzhou trip with them. She made this video in between working on the seminar and set it to a popular Chinese song.
It seems monsoon season has started in this region; it started lightly raining yesterday and it isn’t predicted to stop at all in the upcoming forecast. At least I have my American umbrella, which is quite sturdy compared to the locally available umbrellas. Another ACPHS student purchased one that leaks, causing it to rain within the umbrella. This morning we spent most of our time at at the 8th floor of the main building, which is the designated foreigner outpatient ward. Here, the amenities are comfortable, the décor is modern, and the crowds are thin. It is actually quite quiet in this ward, mainly due to the prices of treatment here. The cost of treatment is approximately 10-fold, however it has the advantage of being empty for patients who are in a hurry as well as the ability to accept appointment scheduling. This floor is used by locals who don’t mind spending the extra money to set up an appointment with their preferred clinician and be treated upon arrival. UZ has detailed the process of seeking treatment in the hospital’s main outpatient ward in her blog. Here, we learned the difference in insurance billing and the process of becoming a pharmacist in China, all very different from America.
After lunch, I made more corrections to the manuscript from last week while UZ worked on our next seminar for this coming Wednesday. I joined her after the manuscript work was finished. This seminar will involve a patient case and a review of the patient’s therapy. After the end of the work-day, we will look into booking our final tours for these next two weekends. We plan on traveling and seeing the other cities despite the likely rain in our forecast.
I have also finally collected the pictures from this past weekend’s trips to the National Clinical Pharmacy Conference and the trip to the mountain and shopping district.
This was to be an interesting yet extremely short day of work, since we were taking off the afternoon to go to the annual conference for Clinical Pharmacists, held this year in the outskirts of Shanghai. Our rotation this morning was in the hospital’s PIVAS (Pharmacy Intra-Venous Admixture Service) where all of the I.V. solutions are prepared for the hospital. Recently, this department has received a significant overhaul and may now be USP 797 compliant, if in the United States. There is a large main anteroom in the center with two compounding rooms on each side, one for chemotherapy and the other for everything else. to enter the compounding room, an individual must wash up and wear full body covers, tasks which are performed in two separate, sealed rooms before finally entering the compounding area (buffer room). To transfer products two and from the compounding room, a cabinet from within the anteroom is used. The anteroom is class 100,000 (ISO 8) while the compounding (buffer) room is class 10,000 (ISO 7) and the workstations (sterile compounding zones) are class 100 (ISO 5). There is one peculiarity I found in this hospital: the actual compounding is handled by nurses while the rest of the work is handled by the pharmacists. This makes more sense when you consider the history of this hospital and pharmacy in China: before the clean rooms were implemented, only a few short years ago, the admixture process was handled by nurses on the floor. These nurses had the most experience and training involving the proper compounding of IV products, not the local pharmacists so it would only make sense that they would be responsible for compounding in the new environment, since they were the ones most experienced in this field.
After seeing the PIVAS, we got ready to take the ~45 minute subway ride to where the conference would be. The conference was held at a large hospital in the outskirts of Shanghai at a building designed for just such an occasion. The building featured many auditoriums and facilities to house crowds of healthcare professionals attending large events. This day, the auditoriums were being used to present cases and studies from competing pharmacy teams from around China. The presentations were quite interesting and informative, and the facility was extremely comfortable. The conference spanned Friday and Saturday, with a reception Friday night at a nearby 5-star hotel. Clinical pharmacists from all over China, all the most influential figures in the field, were in attendance. This would be the 8th annual convention and the 15th year since the inception of Clinical Pharmacy itself in China. Anyone interested was welcome to attend the conference, but only registered guests were allowed at the reception. Zheng Jiao and the director of pharmacy at Huashan hospital generously arranged for me and UZ to attend the reception, which was largely possible due to the director’s position as a host and coordinator of the entire convention. The reception was spectacular, with performances from familiar pharmacists with unexpected talents and speeches from influential individuals punctuated by delicacies from around China. We were very grateful to attend such an event.
After the reception, there was much discussion within our group of clinical pharmacists about where to stay that night. UZ and I had assumed we would be returning to Fudan University’s dorms, so we did not pack any overnight supplies (such as contact lens cases, deodorant, change of clothes, etc) so we reluctantly turned down the available tickets to spend the night at a nearby hotel with our colleagues. We instead planned to meet them the next morning at the subway station and tour the area for the day. When we met them the next morning, we discovered just what we had missed out on: the hotel accidentally overbooked, so they were forced to move to another hotel. They were moved to a 5-star hotel, which included a wrap-around pool and lavish amenities. For the rest of the day, we hiked up a mountain to see a rare building in China: a Catholic Church seated at the peak. when we got to the base, there was a park that we spent the rest of the morning enjoying until lunchtime when we took the bus to an old shopping district, filled with small local shops, ancient buildings, and unique food. The day was very tiring, but didn’t end there: after traveling with our co-workers, UZ and I went to see The Hunger Games, which just came out as a re-release here in China’s theaters. What remains of the weekend now must be spent catching up on cleaning, laundry, and work.
Wednesday morning, I got to see the dermatology department of the Huashan outpatient pharmacy. The department contains many manufacturer tubes and bottles, but a large section of shelves is devoted entirely to hospital-made products as well. As I have mentioned before, this hospital has a manufacturing division where they produce their own creams suspensions and other topicals from bulk basic components. Many preparations are made to treat acne, as well as impetigo and alopecia.
That afternoon, the students here at the clinical pharmacy department had to give a set of case studies for a formal evaluation in front of several key hospital faculty. The atmosphere was intense as pharmacists and doctors challenged the students on highly specific points of drug therapy. Many issues came up in particular with the differential selection of glucocorticoids, which was a troublesome point because there are so many with subtle differences, having to chose one or the other can be quite puzzling.
The next day, we went to the Traditional Chinese Medicine outpatient pharmacy. Here, the hospital carries some of the many herbs and such that have been used for centuries in China. Huashan hospital has a relatively small TCM department, when compared to other hospitals in China of similar size, but they still manage a vast assortment of powders, creams, raw drugs, and even solutions for injection. Most TCM items are intended to be brewed in the same fashion as a tea, and then consumed orally. A growing trend, however, is to isolate one or more “active compounds” in the TCM raw material and use the extract as an injectable drug. The idea is that this may be more efficacious, but safety can be a concern when injecting medications with no clinical safety data. The effects an oral medication may have when taken intravenously are drastically altered in some cases, for example Vancomycin’s main side effects are diarrhea and nausea when taken orally, but it can cause hearing loss and lethal nephrotoxicity when administered intravenously, due largely to differences in absorption and distribution. Without fully understanding even what the oral medication does within the body, it would be difficult for me to recommend any sort of parenteral use of that drug.
After visiting the TCM department, I had a meeting with a colleague of our preceptor, and a fellow author of the manuscript I was helping to revise earlier in the week. This meeting was a sort of language exchange, where we would attempt to learn each other’s languages by conversing with the vocabulary we have, and sharing new terms and phrases with each other. I must admit, his English is far better than my Chinese, which still needs a lot of work. Our intention was to stick to small topics, such as food and travel, but we quickly left this subject to discuss matters more suited towards our interests, mainly education and differences in curriculum and techniques, as well as some economic issues. This quickly fell out of the range of my comfort zone with the foreign language, and perhaps his a bit too, but still I learned a lot from the conversation and appreciate the time and effort that was spent making it happen.