Lira report Frankie Dormon 2022

Lira Oct 2022 Report

This was our first trip since Covid struck, so it was with a little trepidation that the team set off. A group of six, I have been several times and generally know what to expect, the other five had not been to Lira though they had a wealth of Africa experience. Pasco, a microbiology consultant had already had experience of Uganda, working in Mbarara some time ago, Luke, a GP has extensive experience in various roles in Africa, Emily and Rosie, the midwives were keen to get stuck in and Ben another Anaesthetist /Paediatrician was ready for whatever came his way. Although I have visited several times before I really did not know what had changed and how much the University Hospital may have developed. As it happened, many of the key players seemed to have changed and so it was back to square one to forge relationships.

The first day was a whistle stop tour of the Lira Regionnal Referral Hospital (LRRH) meeting the new Hospital management team and explaining all over again what we did, despite several emails prior to the visit. We were excited to see that there was a brand-new delivery suite, built by the Japanese and infinitely better than the old crowded dirty building. The wards seemed tidier and more organised and theatres were busy.

It was a disappointment to see the Oxygen plant that was only built about 3 years ago was not functioning, but our general impression was very positive.

In the afternoon we visited the Lira University (LU) site, to try to put together a programme for teaching. Despite several attempts before the visit there was no plan and 10 days before we left, I was asked if we could come 2 weeks later and there were hardly any students. The term dates having been changed due to covid. This is Africa!!

The first day of teaching, we were told we would have Yr 1, although there were only about 20 students, they had some valuable teaching from Ben and Luke, general topics including communication, and patient assessment. Emily and Rosie got stuck in at the LRRH delivery suite. The LU students were nowhere to be seen but plenty of students from other schools had 2 days of wall to wall teaching, scenarios, obstetric emergencies.

The LU hospital are keen to open an HDU but although they had a space and 2 beds, with 3  critical care nurses to staff it, they had not been able to develop any protocols and needed some help. This ended up being my project for the majority of the trip, ably assisted by Ben. I had set up an HDU of sorts in Wau in Southern Sudan some years ago and had taught an HDU course in Lira 3 years ago so had a few ideas and resources. There were a few issues with politics surrounding who would make the decisions but hopefully these were ironed out with some interesting discussions with various parties during the rest of the trip. We have left them with a number of policies and laminated infographics all developed jointly between the nurses and ourselves.

The skills lab at the University has been transformed the best addition being a large screen. It is even easy for me, an IT technophobe to connect my computer to the screen and start teaching. The younger IT experts tell me we could set up a You Tube channel and start distance learning. Watch this space.
We spent much of our time in the skills lab, covering airway, ABCDE assessment and other scenario drills.
The highlight of the trip for the students, was a PROMPT course, practical multidisciplinary obstetric emergency drills. They are always glad to get a certificate!!

On week 2, we saw more of the Yr 3 students, who received a diet of midwifery and anaesthetics. On the Thursday we had an interesting session on malaria and snakes, from Luke, as well as more scenarios. It was heartening to discover that the student midwives are very knowledgeable in a number of subjects, probably at a similar level as the Intern doctors and better informed in midwifery.

Back to the midwives, Emily is particularly experienced in the mental health aspects of mothers and after talking with the students she has unearthed a huge unmet need. I hope that Poole Africa Link will be able to support her with this particular aspect of care in the future. In addition they identified a potentially simple strategy to identify blood loss following birth (PPH) This is a major cause of mortality across the world but the numbers are very high in LMIC. Part of the challenge is estimating the amount of blood loss by just looking at the delivery couch. They wrote a short talk to explain the need and then we bought some scales and buckets to collect the lost blood and weigh it, then hopefully record it and act on those situations where the blood loss is significant. We hope that when we go back this system will be fully embedded and will help to identify those that may need drug intervention at the time, or at least iron tablets after delivery.

Pasco spent the majority of his time at LRRH, he has developed some strong links with the pathology lab and now has a good idea of the processes involved in running the lab. He took part in ward rounds and discussed the use of antibiotics which is a significant problem in Uganda. It is possible to buy almost any antibiotic at the pharmacy without a prescription and antibiotic resistance is a major problem across the country. He has made some good contacts with both the referral hospital and University and hopefully will be able to develop collaborative working across both sites, including teaching.

But how have they fared since our last visit? Clearly covid had disrupted many developments at the University, the local people have less money than before and with the new modern delivery suite at the LRRH, this is preferred to LU, where the delivery suite was quieter. LU charge a fixed fee with maybe small additional fees for blood tests while the LRRH should be free, but they lack supplies and the families have to make several trips to the pharmacy to buy basic supplies, fluids, antibiotics, plastic sheets etc. There is probably little difference in price but the perception is different.

X Ray and Ultrasound are now fully up and running at LU, the theatres are far busier and everything appears well organised.

I was delighted to find that the drug chart we developed before covid is being well used and on our suggestion, they have set up an Infection Control committee.

There are still numerous gaps in vital equipment, the pathology lab at LU can only do the very basic tests and even the LRRH is limited, they cannot currently do blood cultures and histology although there are developments planned.

The HDU needs a number of items, infusion pumps, better ventilators, (they only have a couple of transport ventilators designed during covid, for transfers) suction, an ECG machine, a defibrillator, additional intubation equipment, an air compressor, Flowtron boots for DVT. Etc. a privacy screen between the beds and the hospital will have to broaden the range of blood tests they can perform.

Alongside our trip we saw what Judy Mella has achieved with a grant from UKAid, which she secured just before covid, to set up a breast screening service, based at the hospital and Level 4 units, around Lira. This included training radiographers, nurses and midwives to examine breast lumps, using ultrasound as well as clinical skills. They are able to perform simple procedures and refer patients where they suspect breast cancer. A process for the ongoing management has been set up and while we were there, Judy visited 2 Level 4 units, seeing about 150 patients and finding some 6 cases of breast cancer. If found early enough they will be treatable.

So although we didn’t teach as many students as usual, we achieved different objectives. We hope to be able to make our teaching more focussed in the future, building on the new way of learning, from a distance.

Dr Frankie Dormon