LIRA REPORT MAY 2023 S Clark

REPORT by Sarah Clark
29th April – 13th May 2023

Team:
Sarah Clark -Consultant Surgeon (Team Leader)
Peter McEwan – Consultant Neonatologist
Judy Mella – Consultant Surgeon
Camelia Gecse – Senior Theatre Nurse
Laura Flynn – Dietician
Katherine Richards – Paediatric Physiotherapist
Jane Reader – Senior Nurse

Pre-trip Preparations.
The team met twice before departure. The first meeting was useful for everyone to get to know each other. We also discussed what the trip would involve and what to bring (see appendix B for updated list of recommended items). We also discussed team members skills and possible teaching topics. We set up a group WhatsApp group which was invaluable for communications both before and during the trip.
Our second meeting involved packing Kit (see Appendix C for useful items that we have been asked to bring in future), planning the timetable and safer surgery course and checking everyone was up to date with documentation, vaccinations and malaria tablets etc. This was also a social evening which allowed the team to get to know each other better and discuss their worries and expectations about the trip.

Day 1 – Saturday
The team met at my house in Poole at 1pm. Peter had arranged a minivan to transport us to Heathrow and we made very good time. The flight to Kenya was uneventful and after a short stop-over we took our second flight to Uganda. We were successful in getting all of our bags on-board and just scraping through the weight allowance.

Day 2- Sunday
We arrived in Entebbe at 7am. A minor problem in immigration as Peter hadn’t paid for his visa but after being taken off to a little office out the back for half an hour it was sorted. Arnold was waiting for us at the airport and after loading all of the baggage into his van we set off for Lira. We stopped at Kambega for samosas and a beer and saw elephants on the drive up right next to the road as well as a troop of baboons. Arnold’s new green van is very comfortable and Arnold drove us excellently on the quite busy roads, which had improved since my last trip. Quite worried by the overloaded lorries with men perched on the top and the goats and chickens being transported in any which way they could. Never seen people riding such overloaded bicycles, one chap was carrying at least 20 child’s chairs on his! Finally arrived Kanberra at 18:30 after 27 hours of travelling!
Had an interesting meal of purple yam, goat and spinach and all tucked up in bed by 9:30 ready for the next day of orientation and planning.

Day 3 – Monday
Orientation day- I think this day is vital, it allows everyone time to acclimatise and reduces anxiety, especially for those who have not been before. In Uganda it was a public holiday so the university was not running classes.
We went to the university first and looked round where we will be teaching. We then
walked round the university hospital. A&E was working with an HDU of 2 beds which had patients in. We also went to theatre; an emergency operation had taken place overnight. We met Edwin, theatre nurse, who said operations were scheduled tomorrow. No patients on the male ward but 1 on the female ward. Didn’t go in to maternity but antenatal looked like there were patients.
We then went to the referral hospital. It was very busy. There is an amazing new 6-bay maternity unit. We also discovered that medical students now come to Lira and really like it. The
Feeding centre was also busy. There was a ward round underway on the paediatric ICU.

We then went to change money; they will not accept any dollars with tears or marks on them and you get a better exchange rate for large bills.
I managed to geta a Ugandan SIM card for my extra phone, you need to take passport to do this. It was a very long process and didn’t work to start with due to network problems so I had to go back to the shop 2 days later. We decided not to get Sim cards for the whole team as the Wi-Fi worked well at Kanberra and the university allowing us to contact each other via WhatsApp and we all had phones that were working (though expensive to use) in case of emergency.

We bought lunch from a supermarket, rolls, peanut butter and inedible chocolate spread, the yoghurts were a big hit. I wouldn’t recommend this unless no other options as choice very limited and relatively expensive.

We then went back to Kanberra and went through the timetable. I had tried to contact Anna Grace (Dean) prior to our trip to confirm which sessions we were teaching but was unsuccessful. Everyone split into groups to work on teaching sessions and have a plan for Tuesday. You could see everyone’s anxiety levels settle with this time to plan after seeing what the hospitals had and where they would be teaching.

Buffet dinner again, chicken, beef, spinach, cabbage slaw and sweet potatoes. Very good. Everyone very tired so another early night.

Day 4- Tuesday
First day of teaching at the university. Unfortunately, the timetable we had been given wasn’t right. Cami and Jane managed to a session in the morning for year 2 on observations. Peter and Laura did a session in the afternoon for year 3 on nutrition and paediatrics. I met with Felista, head of nursing teaching and we arranged a timetable for the rest of our time. Unfortunately, Anna Grace was away but apparently would be back on Thursday so the aim was to recheck the timetables then. Unfortunately, she didn’t come back during our visit so we did have on-going timetable issues. We had a good chat with the tutors about the course. Mary from Malawi was very engaging. She explained the difference between certificate (lowest), diploma (intermediate) and degree.
Cami and I went to the referral hospital in the afternoon. Met John, anaesthetic practitioner, in theatres who showed us round. There were 4 theatres all running, it was gynaecology day. Also met Alex, head anaesthetic practitioner. We gave the theatre and anaesthetic teams a lot of the kit we had brought with us which they were very grateful for, especially diathermy sets and hernia meshes.
We had to wear covid suits to be shown round theatre which were incredibly hot. Must remember to bring theatre hats, masks, scrubs, shoes for future visits.
I had arranged to meet Dr Onyachi, the hospital director, at 2:30 but unfortunately, he was in Kampala. I emailed him at the end of our trip to thank him for allowing us to teach in the hospital and had a lovely email back from him thanking us for our time. I think he will be happy to have PAL team members again.
Cami and I walked back from the hospital and stopped at the market. Cami arranged to have some theatre scrubs made which would be ready on Thursday.

Day 5 – Wednesday
Peter and I went to the referral hospital. We spent a long time in NICU with the sister in charge. She showed us around. There were lots of babies in incubators. They have had a 700g premature baby survive which is very impressive. They are desperate for CPAP. We gave them some hats; they would like more of the very small ones. They also need baby clothes for prems, booties and scrubs for staff.
Peter discussed a case on the phone with a female ENT surgeon and suggested some nasal drops which may improve the babies breathing.
I went to theatre and met a general surgeon (didn’t get his name), another anaesthetic practitioner and a theatre nurse. Arranged to go back on Monday which is general surgery day, with the hope of going into an operation. Will also do teach for 3 surgical SHOs who want to do MRCS.
Peter and I then went to the paediatric ward which was very busy. We gave them some face masks but the nebulisers we had brought were no good and dint fit their systems.
Laura, Jane and Kat went to the nutrition centre, they were really pleased with the baby scales they gave them. They then went to the University to teach Year 2 nursing skills.
We all came back to Kanberra to prepare more teaching sessions for the next few days.
We went out for dinner at out Car wash, an Indian restaurant with excellent food. You do need to pre-order during the day, which Arnold is happy to arrange.

Day 6- Thursday
I went to the university to do the breast course with Judy. Very worrying at first, we turned up at 8 but no one else until 10:30. When they did arrive it was fantastic. Sister Doreen gave an amazing talk on breast anatomy, physiology and benign breast disease. Phyllis the radiographer also gave a very good talk on Ultra Sound. Sister Philomena was the star of the day with her talk on caring for the patient. We taught them breast FNA which was fun. It was a very long day but very worthwhile -got back to Kanberra exhausted!
Peter, Laura + Kat did neonatal resus teaching with Year 3 and Jane and Camelia did more nursing skills teaching with Year 2.

Day 7- Friday
Another excellent day. Peter and Jane did year 3 neonatal resus in the morning and year 1 in the afternoon. Cami, Judy and I spent the whole day with year 4. We divided them into 2 and did sessions on suturing, local anaesthetic and the WHO checklist. Laura and Kat went to the rehab Centre and came back buzzing. Kat did a lot of work with a small boy who was an amputee. They are both keen to go back as feel they could have a huge impact there.
We all felt we had achieved something. Looking forward to the course tomorrow and then safari.
Daniel Obia has finally got in touch so am trying to arrange to give him the oxygen concentrator parts.

Day 7- Saturday
Safer surgery course
15 students attended which worked well as we only had access to the skills lab as other classes were going on in the classrooms.
All 7 of us took turns. Kat did paediatric pain, consent and leadership, Peter did pulse oximetry, Laura did communication, I did spinal anaesthesia and with Jane ran a practical on caring for patients after spinal anaesthesia and checking the levels of blocks. Judy did a really fun scenario on haemorrhage which brought Jane’s acting skills to the fore. Certificates and nurses’ watches were given to all the students who had really enjoyed the day. Lunch was provided, samosas and soft drinks.

When the course had finished, we went directly to Murchison. We stayed in Vilakazi safari lodge which was organised by Arnold. We had little wooden huts that etched slept 2 people with shower and flushing toilets. The lodge has a small swimming pool which was a real treat. They cooked us a lovely meal and we sat outside on a patio by a large firepit.

Day 8 – Sunday.
We got up early and were ready to leave at 6:30. Entrance to the game park needs to be paid for by credit card. Our entrance to the game park was blocked by an elephant in the road so we knew we were in for a good day! We saw antelope, elephants, giraffes, warthogs and a pride of lions asleep under a tree. We then went on a river cruise up to the falls and saw crocodiles, hippos and plenty of different varieties of birds. The falls were spectacular. When we finished on the boat, we then drove to the top of the falls which you can walk round, very impressive! It was a long day but one we all thoroughly enjoyed. We arrived back at Kanberra about 7pm, tired but very happy. I believe this day off re-energised the team and is essential as it allows people to let off steam and process some of the things, they have seen during the week which can be quite distressing.

Day 9 – Monday
Camelia and I went to spend the day in theatres at the referral hospital. We arrived at 08:00 which was too early for anything to be happening but allowed us time to familiarise ourselves with the set up and meet some more members of staff. There was a delay as there was a shortage of drapes but once this problem had been rectified things moved at a swift pace. They were mainly undertaking hernia repairs. They perform a simple repair and only use meshes for recurrent hernias which is a sensible use of a precious resource. They are not using the WHO checklist and although we talked about it, we were unable to take this further. Instead, we concentrated on counting swabs and instruments and safe handling of sharps. Camelia scrubbed and assisted in an operation. They were all very impressed by how she managed her trolley and the safety measures she employed so we are hopeful they may start to implement them. We put charts on the wall and I acted as circulating nurse, showing the team how to record swabs and needles used and how to perform the counts at the endo of the operation. I also taught some of the surgeons how to perform an Aberdeen knot which is a better way of reducing infection. They picked up the technique very quickly and are keen to continue using it.
At the university Peter + Kat taught paediatrics to year 3 and Jane and Kat did more nursing skills teaching for Year 2 in the afternoon.

Day 10 – Tuesday
I went with Judy to the Kristina clinic to help with an outreach breast clinic. The Kristina clinic is about a 2-hour drive from Lira along terrible roads. However, I was amazed when I arrived at how well set up it was. They have male and female wards and an outpatient clinic. The grounds are beautiful and it is obviously managed extremely well. They had sent out notices to the community about the clinic. Many of the patients had walked long distances the day before and slept outside in preparation for the clinic. The clinic had set up a large marquee to shade the patients whilst they waited and had even laid on a music system. We saw over 70 patients. The majority didn’t have any breast problems but we used the clinic as a breast screening service and all patient had a breast ultrasound. We also diagnosed several hernias, ischaemic heart disease, neurofibromatosis and the radiographer undertook several antenatal scans. By the end of the day all of the patients had been seen and had been reassured regarding their breast health or told where to seek help for other problems.
At the University Kat and Jane spent the day at the rehab centre. Peter and Laura taught Year 3 students in the morning and Camelia and Jane taught Year 2 students in the afternoon.

Day 11 – Wednesday.
Camelia and I returned to theatres on Wednesday morning and spent more time teaching surgical safety. I also did a teaching session on Consent for the surgical SHOs and we went though the WHO check list again. Camelia stayed on in theatres and I went to the University in the afternoon to teach the Masters student. There were only 4 out of 10 present as some were working. I did a session on Breast Cancer which was very well received. Laura + Kat taught the medical students at the feeding centre in the Referral Hospital. Jane went to help Judy with her outreach breast clinic and walked over 6 miles escorting patients!

Day 12 – Thursday.
Unfortunately, gastroenteritis struck some of the team. Kat and Laura were not well enough to teach so I stayed with them at Kanberra. Laura was really quite unwell with a very high temperature. I had some cooling packs with me which were very useful and I would advise taking them again. It would have been useful to be able to give her IV fluids so future teams should consider taking them. Jane and Cami went to the university in the morning to teach year 1 nursing skills. I was supposed to go in the afternoon to do suturing with Year 3 students but didn’t want to leave Laura so Peter went in my place only to find Camelia had taught Jane how to suture and the 2 of theme were happily teaching the students. Judy went to play football with the team that her breast charity sponsors and then those of us who were well enough went to Ottina Wa for a delicious Mexican meal.

Day 13 – Friday
We left Kanberra at 7am as we wanted to have plenty of time to make stops if Laura needed them, she was still very unwell. We stopped at Kambega again for more samosa, it is a really good halfway point on the drive. We then went to a craft market in Kampala which was absolutely fabulous. It was a fantastic place to buy souvenirs and I would recommend future teams try and fit this into their journey- however make sure you have some money left! We arrived at the airport with an hour to spare so stopped at a lovely restaurant which had very good facilities, much needed after a long day travelling. We were slightly worried about whether we would manage to get Laura on the plane as she was still very weak and quite unwell. However, she was amazing and pulled together the last bit of strength to get through the airport and onto the flight to Nairobi. It was a short turn around in Nairobi and the main flight back to England was uneventful. We arrived at Heathrow about 7am Saturday morning where we were met by 3 of our partners who drove us back to Poole.

Appendix A – Useful information

The University.
All classes running well
Difficulties with timetabling
There are 2 good size classrooms with white boards and the skills lab. The skills lab has a new door, the key can be found at the main security gate and needs to be signed in and out or is kept by the caretaker in the office opposite the skills lab. The skills labs has been completely reorganised, very tidy and plenty of equipment including 2 full size mannequins, several babies, plenty of syringes and instruments, very useful to take flip chart paper and Sellotape.
Need to take sutures if want to teach that.

New Masters students – 2-year course, have to have degree and then 2 years of practical experience to be on it – 10 places. They hope to get highly qualified jobs or enter academia, research or teaching.
Skills lab – new key. Kept by the caretaker in office opposite. She works very day including Saturdays. If not, there is a key kept at the main gate by security. Plenty of equipment.
Classes for Masters students doing different subjects are run on Saturdays so only have the skills lab to run a course.

University hospital.
A+E is working with a 2 bed HDU. Theatres running an emergency service. We only managed to make it once and they had been operating overnight. Don’t know what the elective service is like
Wards are open but only 2 patients on the female ward and none on the male ward. Didn’t go to obstetrics. Paediatrics seems to be running quite well.
Generally, very quiet.
New food kiosk so can now get cold drinks, doughnuts and fruit.

Referral Hospital
Seemed to be running well. New 6 bay delivery suite which was very clean and busy.
Theatres also running well. General surgery and gynaecology lists running the days we were there. Also performing emergency caesareans – twins delivered successfully whilst we were there.
Shortage of diathermy. Instruments very old and not very good. Lots of medical and nursing students watching operations and 3 surgical SHOs now employed. Surgeons were generally very welcoming and happy to have us there. Sr Molly in charge, very strict on asepsis but a good person to get on side and facilitate.
There is a brand-new outpatients and A&E department with radiology.
Anaesthetic practitioners as good as ever. Mostly spinal or ketamine anaesthesia. Hernias done under local.

Kanberra
Manager – Bonny, receptionist – Daisy, Bar – Gloria
Very good service as usual. Not everyone had hot water. Buffet dinners very good, especially the fish.

Appendix B – Recommended items to bring

PERSONAL

• HEAD TORCH/TORCH
• CEREAL BARS
• NUTS/SNACKS
• 2X COAT HANGERS
• ANTI-MOSQUITO BANDS
• MALARIA TABLETS
• BITE CREAM
• CLOTHES WASHING LIQUID
• FLIP FLOPS
• TUPPERWARE CONTAINER
• WATER BOTTLE
• PERSONAL MEDICATIONS
• TRAINERS/SANDALS/CLOSED TOE SHOES
• SCRUBS
• LAPTOP/CHARGER/ USB CABLE
• TOILETRIES
• BABY WIPES
• HAND GEL
• FAN
• LONG SLEEVED TOPS
• PAL T-SHIRT
• SUNGLASSES
• SUN CREAM
• SUN HAT
• CAMERA
• CHARGERS
• PHONE/IPAD
• UMBRELLA
• DAY BAG/RUCKSACK
• BATTERY PACK
• KNIFE/FORK/SPOON

GROUP

• BOTTLE OPENER
• CHOPPING BOARD
• SHARP KNIFE
• PAPER/PEN/BLUE TACK/SELLOTAPE
• TEA/COFFE
• SALT
• MARMITE
• NEEDLE & THREAD
• BINNOCULARS
• FLIPCHART PAPER
• EXTENSION CABLE
• PROJECTOR
• SUTURES

• SCRUBS for theatre
• Surgical hats and masks
• Theatre shoes
• Sterile gloves

• Cool Packs
• IV fluids and giving sets

Appendix C – Kit to take

Anaesthetics department

• laryngoscope kits
• portable pulse oximeters
• endotracheal tubes
• nasal prongs and oxygen delivery tubes
• airways
• LMAs
• regulators/oxygen heads
• They would also like teaching on updates in anaesthetics

NICU

• baby hats
• baby clothes
• booties
• sterile gloves
• scrubs

Theatres

• surgical instruments
• diathermy sets including plates
• hernia meshes
• monocryl sutures

Appendix D – Safer Surgery Course Timetable