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Short Report of Visit to Lira Uganda October 2019 – Team 2

Short Report of Visit to Lira Uganda  October 2019 – Team 2

The teams from Poole Africa Link have been visiting the Hospital in Lira (LRRH) and the new University Hospital and Schools of Midwifery and Public Health,  for 5 years.  Our relationship is now well established.

Since the last visit,  the hospital has become busier,  the Emergency Department is seeing around 100 hundred patients per day and there were around 15 in patients on surgery or medicine.  There are surgical or gynae lists most days and the separate maternity unit is becoming busier

The team consisted of;

Frankie Dormon –  Anaesthetist

Judy Mella – General Surgeon

Freyja Brown – Elderly Care Consultant

Emma Pickard – Theatre Nurse.

During the first week, we were able to arrange ward based and lecture theatre teaching,  Time was spent at  the Regionnal Referral Hospital and the University hospital.  Unfortunately we had the usual difficulties locating the students at times,  with their timetables being constantly changed.

We organised a very successful Safe Surgery course on the Saturday,   partially lecture based teaching and small group scenario/workshop teaching. It was attended by 50 midwifery students and a few of the doctors.   The topics covered included Communication and Teamwork,  Sterility in Theatre,  The WHO checklist, Recognition and Treatment of the Sickest patient.

During the second week we were joined by Carmen Carroll  (Elderly Care consultant in Salisbury)  and Anita Whalley (Occupational Therapy)  They were visiting with a view to exploring what a link between Salisbury Hospital and Lira might look like.

In addition we were joined by Andy Kent,  an Orthopaedic Surgeon from Inverness.  His role was to  support the Internationally Recognised Primary Trauma Care course.

Logistics.

We used Arnold Kamya,  from Tulika tours as usual.  With a second vehicle for the second week as we had effectively 2 teams. We stayed at the same Hotel which is perfectly adequate.

Primary Trauma Care (PTC)

PTC was developed some 20 years ago and has been taught around the world,  in particular in resource poor countries.  The aim of the course is to develop a sustainable training by incorporating a train the trainers element.  This concept was rolled out over 5 years ago,  funded by UK  (The COOL Project)  in Uganda.  Since then the only courses had been run in Gulu and local trainers were difficult to find.

The issue of funding the course is a local challenge. For the first course the funding was provided by Dr Frankie, this is not sustainable.  There is significant printing of  paperwork,  and downloading of resources.  In addition some refreshments are required  for faculty and participants during the day.    The University Skills lab has a good range of equipment and only a few additional items were required.  These have been left for future courses.

The first 2 days we had a mixed faculty of 2 local instructors,  and the 3 UK instructors.  The participants gave excellent feedback and the scores showed that a significant improvement in skills and confidence had been achieved.

We were able to identify 5 participants  who we then trained on the third day, to run their own course on the 4th and 5th day.  The new faculty showed that they were totally capable to run a high quality course.  Again the feedback was excellent and the improvement in knowledge was demonstrated with the scores on the multiple choice.

This course is of value to any health care provider who may be a first responder in a trauma situation which would include the Midwifery students, doctors and clinical officers from Level 4 units.  The burden of trauma is significant in Uganda,  many of the deaths occur before the patients are able to get to a suitable health care facility and therefore it is vital that the skills are taught outside the main referral hospitals.

Other Developments – Anaesthetics

The glostavent anaesthetic machine,  purchased last year,  is now being well used,  There was both Halothane and Isoflurane,  but still no muscle relaxants apart from the short acting suxamethonium.  This makes any major anaesthetic very challenging for both anaesthetist and surgeon. We have created a minimum drug list previously and this aspect of supply needs to be addressed.

There is no ECG monitoring or recording at Lira University.  ECG  monitoring in theatres should be addressed as a matter of urgency

The Lifebox Oximeter was functioning but keeping it charged and ready for use remains a challenge.  There will need to be better systems set up to ensure that equipment that is available, is properly stored and maintained.

Drug Chart

During our last visit we worked hard on the introduction of a drug chart.  This has been  well received.  In addition the Referral Hospital, previously been resistant to using a drug chart,  were now apparently keen to adopt the chart.  We had made plans for a fluid section and a section for intermittent (prn) and one off (stat) treatments to be added and this was successfully integrated with the charts for future use.

Dr Freyja was one of our first physicians in Uganda,  and as well as working on the drug chart,  she was able to focus  on the ward round and how this was able to improve care,  she spent time on teaching the importance of observations and how one should react to  this information when patients show signs of deterioration.

Emma Pickard worked with students and surgeons on the importance of a theatre check list and how to develop a check list that would work for the staff at Lira University. We were able to utilise a white board that had been purchased previously specifically for the check list project,  and created a template for a checklist that the local team felt was appropriate.

Judy Mella has visited lira on several occasions.  She assisted on the PTC course and was hugely inventive with some of the skill station props.  Sourcing  a goat thorax for teaching chest drain insertion and some sheeps bowel to teach the Interns about suturing of bowel.

General Communication

This remain a significant challenge, both between teams from UK and between UK and Lira.  We have endeavoured over the years to plan our teaching well in advance.   Our Lira friends have suggested that full days at the University would be preferable and we had tried to arrange this for this visit. However,  there were several sessions where students did not seem to be aware of the teaching that we were planning and would be at the Referral Hospital,  or having tests.

Salisbury report – awaited.

Summary.

We are seeing the University Hospital developing,  and the introduction of a drug chart has gone very well.  We were pleased to see that the WHO checklist is being used in theatre.. However the equipment that has been delivered to date is woefully inadequate. There are no facilities fort basic ECG monitoring  or to test for Potassium levels. The lab have the most up to date machines,  but no reagents to use it or suitable bottles to collect the samples.  There are 6 brand new incubators in the neonatal unit,  but no disposable equipment or even  oxygen monitoring .

It is impossible to run an anaesthetic service without basic muscle relaxant drugs.

The students are being taught to a high standard and know what is required to practice good medicine but they are unable to apply their training in practice due to lack of resources.

As a charity we can sometimes buy small items of equipment to supplement what is already available.  We cannot bring out vital drugs or disposables in any meaningful volumes. All these items need to be sourced locally to make the University hospital sustainable.

The formal PTC course was a huge success and we proved that the hospital have the necessary space and trainers to continue to run such courses with only minimal support from our charity

Dr Frankie Dormon

Medical lead for Poole Africa Link.