Report Lira October 2016 Medicine
Lira Trip Medicine October 2016
This trip was organised by Poole Africa Link, a charity linked to Poole Hospital which has been running for 10 years now. Initially, the charity was linked to a hospital in South Sudan, but due to ongoing tribal conflicts, the situation is now unsafe. As a result, the charity have been making contacts with Lira Regional Referrals Hospital and Lira University.
Lira Regional Referrals Hospital is a high volume referral hospital, with 346 bed capacity, covering medical, surgical, orthopaedic, obstetric/gynaecology, child and neonatal services. The hospital is supported by the USAID programme, and has a well run HIV outpatient facility. The hospital serves a population of around 408,000 people.
I am a speciality trainee in Geriatric Medicine. My work day to day is with patients over the age of 80, usually with complex medical needs. However, one of the practical aspects of my job, and a part I particularly relish, is taking a pragmatic view of situations, and tailoring treatments to fit the individual patient. I am a Medical Education Fellow for Wessex Deanery, and am keenly interested in medical education at all levels. I am also an Advanced Life Support Instructor. I was very grateful to be given this opportunity to teach in a very different setting to my usual practice.
Objectives for the trip
- Teach ABCDE management of unwell patients
- Basic observation and documentation teaching
- SBAR communication, team approach
- Teach sessions on BASIC course
- Lead sessions, small groups, clinical skills demonstrations/teaching
- Aid in set up of ITU
- Teaching on BASIC course
- Facilitate small groups in organization/set up of ITU
- Lead sessions, small groups, clinical skills demonstrations/teaching
- Bedside teaching/in hospital teaching
- Involvement in writing blog
- Assist in writing final report
The trip was something of a voyage into the unknown. I wrote my objectives with some difficulty, as it was hard to envisage exactly what I would be doing – and I was aware that plans would probably change and evolve as we became more involved in the work of the hospital.
My clinical time at the hospital was spent mainly on the Female Medical Ward. This is a 26 bedded ward which admits patients from the age of 6years up. There are two doctors who cover the ward and are allocated daily ward rounds. There is one nurse per shift. During my time on the ward, there were many student nurses from the nursing schools around the hospital – anything up to 20 allocated students per shift.
The ward is laid out in a ‘Nightingale ward’ style. Patients are cared for by their families/friends who provide bedding, support with activities of daily living and food. Patients with nasogastric (NG) tubes will be fed through the NG tube by their family on food made by the family, for example porridge. Families remain present with their relatives throughout the day.
There are no curtains between bedspaces and there is little privacy on the wards. Occasionally the student nurses would hold up sheets as a screen for patients having bedbaths, etc. During the ‘laying out’ of a body, some screens were partially put round a bed, but not at the sides of the bed. Various family members as well as other patients relatives were stood at the bedside for this.
During my time observing, student nurses on the ward would do once daily observations for patients, with some variation in the documentation of these observations. Observation charts are available on the ward, but rarely used. Some of the student nurses were unsure of how to fill these charts in.
The student nurses also clean the ward in the morning, help with drawing up of intravenous medications, and set up intravenous fluids. They will cannulate, and carry out venepuncture.
There is little supervision for these students, as the ratio is often 1 nurse: 20 students.
Diseases encountered in Lira were vastly different from the cases I usually work with in England. Something I found particularly challenging was the number of children on the ward. During my time in Lira, I saw many young children, mostly from age 6-12. The conditions seen in children included malaria & complications thereof (particularly anaemia); sickle cell crisis; infectious disease (including pneumonia, infective endocarditis, meningitis); and chronic disease such as asthma and type one diabetes.
In adults, the HIV prevalence rate is extremely high, around 70%. As a result, much of the pathology seen was related to immunosuppression; for example cryptococcal meningitis, oral candidiasis and malnutrition.
Infectious disease was a common cause for admission, with TB, cholecystitis and infectious diarrhoea being some of the cases seen. Patients also presented with complications of relatively simple conditions; for example, stroke and CCF related to untreated hypertension, as well as severe asthma exacerbation related to anaemia. These cases struck me as particularly interesting, as early intervention with appropriate medication could have reduced the admission rate with these complications.
The students on the ward were all very enthusiastic about any teaching offered. I spent my time on the ward on a ‘teaching ward round’ in the morning. This involved seeing each patient, and selecting a particular issue on which to teach. Initially, this started as simple management common to all patients – for example regular observations and the documentation of these observations within the notes. Basic teaching was extremely rewarding, and students often put these teaching sessions into practice with good effect. One example involved teaching half of the students on the ward about measuring oxygen saturations (something that most of the students had not seen before). We discussed ‘normal’ oxygen levels, and conditions that might affect oxygenation. It was a great pleasure to see one of the students who had heard this teaching then take the other students who had not been with us, and teach them about oxygen saturations – and really highlighted the key point of our trip, sustainability.
Staff and students both reported informally that they felt there was not enough supervision for the students on the ward. The students appreciated any teaching and supervision offered, and were seen to develop their own clinical practice following input. Staff reported that the volume of students meant they struggled to supervise and support students. They felt there were some inefficiencies, for example, with so many students, they often could not recall who had been asked to do which jobs, and so were unable to monitor their own wards effectively.
University based teaching & Lira University students
Due to time constraints, I was only able to teach at the university for one session. This was teaching Basic Life Support to the Fourth Year group. Teaching involved 26 students and covered cardiopulmonary resuscitation, airway manoeuvres and adjuncts, and effective ventilation. The session ended with a discussion on the appropriateness of cardiopulmonary resuscitation, as well as the difficulty of stopping resuscitation once it has begun. We discussed reversible causes (the 4 H’s and 4 T’s) and the concept of futility. This was a very interesting conversation as the students experience varied considerably.
During my time in the hospital, I was able to spend some time with a group of the University students. They had all clerked a patient on the ward, and so we were able to review each patient, allow them the chance to present their case and discuss management and ongoing care. This is something I find particularly useful, as it ensures students are thinking beyond the basic care of patients. I was very impressed with the students’ knowledge and ability to formulate a management plan.
BASIC course teaching
I was involved in the running of the BASIC DHS course. This course is designed specifically for developing healthcare systems, and was being run in Lira Regional Referral Hospital with a view to aiding the set up of their Intensive Care Unit. The course covers a wide range of topics, from cardiorespiratory physiology, through medical emergencies, shock and sepsis, to trauma, obstetric emergencies and team work/communication.
A specific aim of the course we were running was to aid in the develop and planning of the intensive care ward. As a result, we included some facilitated sessions to discuss patients that would be appropriate for intensive care support; the type of interventions the hospital was expecting from the ITU, and practical matters such as the equipment required and staffing levels needed.
Our teaching sessions ran from 1400-1600 each day (with a catch up session beforehand when we would review any prior lecture as requested by course members). Around 15 people attended daily; a mixture of nursing staff, clinical and medical officers. Sessions were well received, and it was noted early on that small groups tended to attract the most participation and discussion.
Due to staffing levels, we were unable to run the BASIC course as intended (an intensive four day course), and so the course was divided into daily sessions of two hours. Within reason, we stayed true to the schedule provided by the course.
One of the particularly important learning points made within the course was that of a systematic ‘ABCDE’ approach to patients. This was well received and rapidly became grounded in the participants approach to patients. The use of SBAR communication tool was also introduced with good effect.
Some of the biggest challenges came with running the BASIC course. In the first instance, ensuring staff were able to attend was often difficult. There is limited staffing in the hospital and we were aware that by asking for daily attendance, medical and nursing staff often struggled to leave their clinical area in a timely fashion. In the future, running an intensive four day course may improve attendance, but would need to be carefully planned to ensure sufficient staffing remains on the wards.
An early issue came with the lack of BASIC manuals for the course participants. Due to shipping delays, these were not available until the end of the first week, which meant the staff were unable to do the precourse reading and test. This meant extra lectures/teaching had to be included to ensure the course made sense and people were able to participate in group discussions and teaching.
Staff attending the course. The course was advertised by word of mouth. The staff who attended were all motivated and keen to be involved. All agreed about the importance of setting up an ITU in Lira. However, we did receive feedback from the participants that as the ITU was not running, the course learning would not be put into practice, and so there were concerns that staff would forget the learning from the course. We agreed that this was a challenge, but that this course was probably instrumental in ensuring Lira Hospital would be able to staff their ITU- and so would continue to be used, perhaps following a refresher course in the future.
A further challenge related to the staffing was that often the senior clinicians were unable to attend. As these members of staff were likely to be instrumental in the set up and overseeing of the ITU, these were felt to be a group we needed to gain access to in the future. This may be best achieved by a formal BASIC course being run over the standard four day course.
Suggestions for development
Greater supervision for students on placements on the wards, either by reduction in numbers of students per ward per shift, or with dedicated trainers (for example, from their respective nursing schools) to supervise and support students.
Training for the students in use of observation charts and need for regular observations
A formal BASIC course to be run as part of preparation for opening of the ITU in Lira Hospital
Provision for the Lifebox course to be run – perhaps as a collaborative between the different nursing schools
This trip was an excellent educational opportunity and I was very grateful to have been given the chance to visit Lira. Teaching was extremely well received and time spent on the wards allowed practical informal education sessions to be delivered with resultant change in clinical practice.