Post SEP - Munich!

What better a way to end our SEP than with a MAGNIFICENT post-SEP tour!

Our first stop from the Netherlands was Munich, Germany!

It took us a 9 hour train ride from Groningen to Munich with 2 transfers. Our post-SEP tour began with a bang when we woke up 45mins late :P

Yeah, it was quite freaky. Our train was around 630am and we woke up at 550am. Hee! Thank goodness Tessa was there to give us a lift to our train station. Well, we made rushed like crazy but we made it.

The next bad thing that happened to us was that we couldn't find any seats for our 2nd and 3rd trains :( That was like, a total of 6hrs..... Well, if you're using the Eurail pass, always remember to reserve seats on popular long-haul routes.

Well, no matter, we got there in the end.

The blog post isn't going to be in chronological order, but in terms of what was most memorable at our stay in Munich.

Without a doubt, it had to be the...

...

...

BEER!!!

Yes, omg. From a beer-hater to a beer-lover, that's the kind of transformation a trip to Munich could do to you. (not forgetting also that, a 0.5L beer costs about the same as a 0.3L coke at a restaurant)

We had lots of good food in Munich too (I guess cos it was our first stop and we had plenty of money :) ) so here are pictures of Bavarian / German food :D

A combination platter of 3 sausages, sauerkraut (some salty cabbage) and a liver dumpling!

Maggie's pasta. The mushrooms were delicious!!!

My ugly hair.

"Noodle-pudding"

Maggie and I were curious how to make a pudding out of noodle, but it turned out to be like this --- hmmm. Like bread pudding. Disappointing but very nice anyway.


Next, is a very IMPORTANT part of our stay in Munich that complemented the BEER. It's the BEER GARDENS!!!!!!!!!!


In summer, all over Munich are these magnificent beer gardens where everyone just gather to have beer. It's kindda same as beer houses, except that it's open-air. The best thing about the beer gardens are the atmosphere. At these places, you'll NEVER feel as tho drinking is a vice.

There's just a very healthy, relaxed chilled out atmosphere. I mean, people bring their pet dogs and all. And of course, lots of good beer :D

I'm proud to say, in our 5 short days, we visited three of their major beer gardens, including the largest one!!

The Hirschgarten

This is supposedly the biggest of them all. Sitting capacity of 8000 people! Like what a big MERRY bunch!

The truck carrying the beer mugs :)

With the "beer-men"

Absolut Beer.

Maggie likes the beer better than her apple soda, can u believe it???

Our dinner at the Hirshgarten. A platter of Bavarian duck, pork kunckle and something else I can't remember now. The potato-looking-thing is not mashed potatoes but potato dumpling. It's a cross between potato and the glutinous rice dumpling, no kidding.

Veal steak in mushroom sauce. Absolutely YUMMMMY.

(You should have already noticed by now that if you are a beer and meat lover just like me, you really ought to be in EUROPE. :) )

Next up, at another beer garden! I can't remember what this is called, but it's in the centre of a market. Pity.

The third beer garden - The Chinesischer Turm

Shit. Check out how fat my face has become after all those beers by the fifth day in Munich.

Other beer garden related photos that I'm too lazy to sort. Bottomline is.... when you visit Germany, don't miss Munich. When you are at Munich, don't miss the beer gardens. When you are at the beer gardens, miss the beer and U really ought to be shot.

Queing orderly for their beers. How can beer possibly be a bad thing????

Check out the expanse of the beer garden!

Lastly, our hostel at Munich. Wombat's City Hostel. I'd give it 4 stars!!!



We slept in a all girls' dorm for the last three nights... Bad choice.

Honestly, my advice would be that, sleeping in a mixed dorm is better. Cos guys are ALOT quieter and they don't take 2hrs to wash up.

It's the beer, I swear.

Natrena Project, and many thanks =)

The last bit about work! In our second week of attachment, Eli (the nice pharmacist who kindly arranged our appointments and guided us in our tasks) presented our with a current case and asked us how we will solve the problem. A four week old patient has tachycardia and need propafenone HCl for his condition. It comes as a intravenous solution in a 20ml vial, but his parents wish to bring him home so the drug is needed in an oral dosage form.

This is the drug, brand name Rytmonorm

There is one big problem - the solution is painfully bitter, one of the most bitter drug solution that exist, and there is no way the infant can consume it without spitting it out. So our task is to mask the taste and document our findings. And taste it to make sure it's palatable and suitable for an infant's consumption.

So we were given droppers and small cups for mixing and tasting

We tried syrup, salt, jam, peanut butter, milk and peace juice. Salt gave a precipitation, the rest results in inadequate taste masking. Then we tried the artificial sweetener found in the tea room and Prof Uges' office - Natrena. It is in tablet dispensed from a dispenser, and contains aspartame, saccharin, cyclamate, acesulfame-K and neohesperidine.

Natrena dispenser

However, only aspartame is proven to be safe for infants and approved by FDA. So we had to call the manufacturer and ask for the percentage of each component in the product. Eli always have to answer the call for us first because they always speak Dutch unless they are told that we are Singaporean or Asian =)

And we found out that only Natrena crystal powder contains only aspartame. So we went to a supermarket near the hospital and bought a bottle to begin our experiment...

Mxing Natrena crystal powder with propafenone HCl solution

Each dose is 5.14ml, and we used the maximum safe dose of 40mg/kg/day of aspartame, which equal to 1000mg of Natrena crystal powder per dose (4 doses daily). It was mixing a large volume of artificial sweetener with a low volume of solution!

The bitter taste was still present, and we have got pharmacists and staff at the lab to try the taste and give us comments. Still, it was the best result we can get, bitter still, but possible to consume. We compiled the evidence from FDA and the Natrena website, did the calculations, and sent the document with the formula to the relevant staff.

The next week, we saw the big Natrena bottle in the production department, and the formula was actually followed and doses for 2 weeks were made for the infant. We were very very glad that the formula helped the infant, and that he is now able to go home and take the medication orally after the taste masking.

We are very grateful to be given real current cases to work on, and that all the staff take our comments and plans seriously when they are supported by research and data from references. It wasn't just a practice, where mistakes were corrected by the tutor. We are very glad to be given the responsiblilty and trust in handling cases and solving problems, and our proposals implemented. UMCG is a truly academic learning hospital, the real current cases gave us very much inspirations, and we felt the trust and encouragement from the seniors and professionals.

Thank you for respecting our comments and work and taking them seriously, despite us being students and not yet licensed professionals. We will truly remember this learning journey of ours, and hope to guide our juniors in similar ways in the future.

Thank you Prof Uges, Eli, Bao mu, Prof Freylink, Hans, and everyone at the lab, production and distribution department who has helped us in one way or another. Please let us know if you are visiting Singapore or other parts of Asia by emailing us or dropping a comment in the blog! We'll be more than happy to show you around, like how all of you have been very nice to us in Groningen.

Thank you once again, for this wonderful learning journey and exchange programme of ours. We look forward to seeing you again in the near future =)

Last week at work - Distribution Department

Distribution is the heart of the pharmacy in the hospital, where medications are distributed to their relevant departments, where drugs are label and stored, where medications are ordered from pharmaceutical companies and where continuous supply of medications to the wards are ensured.

This is where very commonly used drugs are stored, for example, paracetamol.

These portable scanners are brought to wards for pharmacy assistants to record what is required to be supplied to the wards. The scanners are then brought to the distribution department to verify quantity of drugs needed, and indicates where they can be obtained.

The required medications are then collected from the racks, and packed into boxes like the one in the bottom left hand corner of the photograph to be sent to the wards. Each rack is label in running order, like a library.

This is where less frequently used drugs are stored.

The medications are first sorted out and counted, and the identity and quantity of the items are checked against the supply form obtained from the system on a daily basis. Expiry dates are also noted and checked.

The barcode at the top right hand corner of forms corresponding to each medication is scanned...

... by the scanner at the bottom right hand corner, whose information will be transmitted into the computer system.

Name of medication and quantity received will be showed on the screen, and pharmacy assistants check against the medication boxes and their order forms.

The shelves then turn to where the particular medication is to be stored, and pharmacy assistants pull out the rack to place the medications to be stored.

This computerized storage system greatly reduce manual work, human error and increase efficiency greatly. Pharmacy assistants perform the daily routine, and pharmacist are notified when special cases arise, for example, when a rare medication is requested, or when the pharmacy assistants face problems and need to consult a pharmacist.

We're back home!

We've arrived in Singapore as of last Friday!

Our holiday in Munich, Berlin & Prague had been extremely enjoyable.... ...! Despite the feeling of being lost and slightly overwhelmed by the catching up of work we missed in the first week of school, it was more than worth it!

I know our blog has described activities only up to Week 3 in Groningen! Haha! That's because we're always lagging by one week in blogging and after we left UMCG after 4 weeks, we didn't have free internet access to blog anymore, so we didn't.

But it will be up, soon! I will not forget why I set up the blog in the first place ... ... To share our experiences but more importantly get people interested in SEP! So, late we are but finish it we must!

And of course, we would like to share very much with people like Nicole, Gwylim, Bao Mu, Tessa & everyone else we had met over there what we did then & a little bit on what we're up to now.

So... ... ... patience! It will be up :D

Third week of attachment - Production

University Medical Centre of Groningen has its own production department, which produces medications for their patients under certain circumstances:

1. When the drug or formulation needed is not available in The Netherlands and Europe

2. Orphan drugs - too few patients need the medication and there are no pharma companies

producing it

3. Pediatric medication - no commerical products with the desirable dosing

4. Cytostatic drugs which are unsafe to produce in the wards

5. Diagnostics - tracers e.g. isotopes

6. Drugs for trials - pharma companies may not want to produce the drug and the placebo

Ok enough of the facts. Presenting to you the production area of the hospital!

On the left is the big tank that produces water for injection (WFI), which is monitored 24 hours to control quality of the water. On the right are some bottles used for different products.

The production area follows Good Manufacturing Practice (GMP) rules closely. The sign shows BLACK ZONE in Dutch, where labcoat must be worn.

See, I wore my coat!

And Mandy pretends that she hasnt got hers on :)

Tank for washing of bottles before they are filled. WFI is used for the washing and the water is filtered. Notice the filter housing which is connected to the tube.

Still in the Black zone... autoclave for terminally sterilzed products!

Some equipment are sterilized here too. The autoclave operates uni-directionally, things go in here and come out from the door on the opposite side of the autoclave, to avoid contamination.

And the pharmacy assistant really opened the autoclave like this! Of course he was much more professional :)

Mad-ny at the control panel of the filling line. Don't push the button!

Ok let's get to work. Personnel have to gown up in a GREY zone to enter the clean room or sterile production area. A Grey zone is also used to transport materials from the black zone into the white zone:

Here is one of the platforms used to transport materials. GRIJZE ZONE is of course, GREY ZONE in Dutch.

And we enter into the WHITE ZONE...

Where a pharmacy assistant is at work! Notice her overall suit, hairnet and mask. Plant shoes are also worn in the sterile preparation area. The fume hood has laminar air flow which constantly blow air out (towards the technician) so as not to contaminate the product.

The white infusion fluid on the right is total parenteral nutrition that is produced here. The white colour is brought about by the lipids present in the infusion.

This shows the sterile production area, where infusions and eyedrops are produced.

By the way, the clocks in the production area are always one hour late in summer as the staff have not adjusted them after daylight saving last October. It should be 9.46am already!

Compounding tank in the sterile production area, where large volumes of solutions are mixed for filling into bottles or ampoules.

The ampoule man :)

He fine tuned the ampoule machine according to their sizes, fill volume, positions, etc. The ampoules are supplied sealed, the machine melts the mouth to open it, fill, and seal is by twisting like what we did at the lab. Of course many times faster, hence the product is exposed for only seconds and chance of contamination is very low!

The galenicals are produced here! Products include tablets, capsules, suppositories, solutions, syrups, ointments, creams, i.e. everything that's non-sterile.

The tablet coating machines

Visual inspection station, where products and labels are checked before release.

There are large scale production and production for individual patients. Large scale production is not so large, maybe 20 to thousand bottles, but some products have been in production for many years in the hospital and the hospital would not function like how it does now without the medications produced here.