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Paediatric Report from Lira October 2016

Report from Lira 2016

Antoinette McAulay

Background

This was the second team teaching visit to Lira. At the request of the university it was carried out over 4 weeks, with staggered teams mainly staying for 2 weeks. This ensured a prolonged period of teaching, but was complex to arrange, and made it more difficult for team cohesiveness.
The team taught both to the University students in Lira University, and clinical teaching to the the doctors, nurses and nursing students at Lira Regional Referral Hospital (LRRH). Frankie Dorman ran a BASIC course for HDU management assisted by various members of the team. Training for the new medical Interns was also arranged.

University

The University now has 4 years of students studying with the first graduations due to take place in October 2017. Clinical work at the hospital has still not started due to a number of issues, but building work is continuing including both more university lecture theatres and hospital facilities. There is a clear plan agreed with the Ugandan government for a full University Teaching hospital and Medical School, as well as the current faculties of nursing, midwifery and public health.
There were some initial frustrations with university staff during the first few days adjusting the previously agreed teaching plan, and this was not always adhered to. Thus team members would arrive for instance at 8am for a teaching session to find it had been cancelled. There was less local tutor involvement than last year with various of the tutors undertaking post- graduate training. There was some friction evident with NGO tutors. Perhaps as a result of these difficulties which had impacted on the initial weeks of term, some students seemed less engaged with our program, and either did not attend or arrived late. Despite this the vast majority of students were very enthusiastic about our educational input as indeed were the University and NGO tutors.
We had an extremely useful meeting with Professor Jasper and were able to agree a Memorandum of Understanding.

Hospital

The Hospital as previously has few trained doctors. In addition the Interns only arrived in our third week due to national intern strike compounding the workforce issues. Senior trained nurses and midwives were also a scarce resource. Nursing students from 6 different institutions attend LRRH. The impact of this was numerous students on every ward having little clinical guidance or teaching. Many often seemed uncertain what to do, and spent much of their time sitting watching or chatting.
The hospital has beautifully kept grounds and is cleaned on a daily basis, but most of the wards are cramped and in need of significant decor. There seemed usually to be an electricity supply and water available.

Paediatrics

The paediatric service consisted of a Paediatric ward serving the 0-5 year age-group. Older children and teenagers were managed on the adult wards. It had around 40 cots, mainly cramped into a nightingale-style ward. There were also 3 separate rooms for neonates (post discharge from maternity unit) and isolation cases. There was one oxygen concentrator, which was not functioning, but an oxygen cylinder was available. There was one observation machine for oxygen saturations, pulse and BP. There was no current facility for measuring ward blood glucose levels. Few observations were being carried out and there was a shortage of thermometers. There were however hospital notes folders for all patient, with entries made at each ward round. Drug charts and observation charts were kept in the notes and results filed there.

The main conditions seen during out stay were Malaria, anaemia, sickle cell disease, pneumonia, sepsis, asthma and bronchiolitis. Investigations were limited to X-ray, USS, Fbc, lab glucose, malaria screen, urinalysis and HIV testing. Other tests such as routine biochemistry had to be requested in private labs which parent would have to pay for. Cardiac ECHO was being done as part of a USA collaborative research project, but the technicians would also do ECHOs on children on the ward if requested

The senior staff consisted of a Consultant Paediatrician William …, and a Medical Officer James Okello. During the third week of our visit they were joined by 4 new interns taking their first post- qualification job. They were expected to arrange an on-call system for ward cover out of hours. There was a very organised and effective nursing sister called Stella. Sometimes there was one other nurse to help with venepuncture and cannula insertion, but otherwise all nursing staffing during the day were students. Apparently there is a night paediatric nurse who also makes clinical assessments and starts urgent treatment overnight.

Basic drugs such as antibiotics were available on the ward. However by example there was no 10% dextrose or phenobarbitone to treat a fitting neonate, and parents had to be sent to the pharmacy to obtain them first.

The paediatric department also runs the Infant feeding centre for malnutrition. This follows UNICEF guidelines. There were only 4-5 in-patients during out stay as community food supplies were good, but apparently the ward is full during March to May. Numerous student nurses were attached to this ward, as well as one of the new interns, with little to do.

The neonatal unit was also part of the paediatric unit, but I wasn’t aware of the paediatric staff carrying out ward rounds there. One of the paediatric interns was allocated to this ward.

Paediatric (age 0-10 years) clinics occurred daily and were predominately new patients queuing to see a doctor. An adolescent clinic also runs daily (11-19 years). The latter although run in very run-down facilities had an inspirational Nursing Sister who arranged daily health education sessions, and HIV testing before the medical consultation. The work of clinic is being audited, with graphs of results on display.

During our visit the patients in both these clinics were being run by volunteer final year medical students who were awaiting their final results and taking unpaid thee month contracts.

Achievements

1. Alongside the Team, maintaining and developing relationships with the University and LRRH including achieving a Memorandum of Understanding with the University
2. Neonatal resuscitation with Peter McEwan to all University students, and to Interns at LRRH
3. Paediatric resuscitation to Year 4
4. Recognition Triage and Management of the sick child taught at the University and in ward tutorials at the hospital
5. Ward and clinic paediatric teaching to nursing students, doctors, interns and final medical student volunteers.
6. Continued emphasis and teaching on the importance of clinical observations with colleague Ali Ahvee.
7. Organising the visit of our previous South Sudanese paediatric colleague Dr Louis Danga who joined us in helping with ward and university paediatric teaching for a day.
8. Helping Frankie Dormon deliver 3 BASIC course sessions.

Suggestions for next visit
Teaching

  • Yearly update on neonatal, paediatric and adult resuscitation
  • Lunchtime teaching to interns ( as per Poole F1 program)
  • Try to do a Hospital Grand round
  • Clinical teaching to nursing students and Interns on the ward
  • Possible NLS/ ETAT course

Equipment

  • Thermometers, watches, mini-sats to aid teaching and practice
  • Spacers
  • Blood glucose strips
  • Syringe drivers
  • Ecg machine
  • Reusable infant saturation probes

AHM 20/10/16



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