Shreya’s October ’24 Report

Shreya’s October ’24 Report

This was my first trip to Uganda with Poole-Africa Link and I was initially unsure of what to expect. I joined the team later than the others when a space opened up, and it aligned well with my plans to take a 6-month break from Paediatric Training and develop some of my teaching skills as well as other areas of my CV. Meeting with Antoinette in June, a few months prior to the trip, put me at ease, and we discussed goals for our trip. We wanted to deliver teaching based on the ETAT+ course (Emergency Triage Assessment and Treatment) run by the WHO. Prior to flying out, I did most of the online course myself (available to members of the Royal College of Paediatrics and Child Health) and created some PowerPoint presentations to supplement the ones Antoinette already had from previous years. We also talked about doing some teaching on communication skills, basic newborn and paediatric life support. I met the majority of the team face-to-face before flying out and knew immediately we would get on well!

Teaching:

What we achieved:

Our teaching was based across both sites, Lira Regional Referral Hospital and Lira University. The aim was to have a meeting with Sampson (the senior lecturer at Lira University) and Felista (head of department) on the first morning, to create a teaching timetable, because despite Antoinette reaching out in advance, they wanted to meet us in person to discuss the timetable. This year, it was a shame that we were not timetabled for much paediatric teaching at the University. Therefore, we spent the majority of our time at LRRH which meant doing a lot of bedside teaching and then some classroom based teaching in the afternoon. We had a mixed range of students, including nursing students, midwifery students and medical students, as well as the interns.
At Lira University, we taught 2nd year midwifery masters students on paediatric and maternal nutrition, and separately about Newborn infant physical examinations and Congenital abnormalities. At LRRH, we did sessions on blood transfusions (Antoinette), History taking and examination (both), Triage (Antoinette), ABCDE assessment (Shreya), basic paediatric life support (both), paediatric respiratory disease (Antoinette), Newborn life support/helping babies breathe (Shreya), type 1 diabetes and DKA (Antoinette). The bedside teaching was more informal and consisted of teaching about bronchiolitis, neonatal jaundice, croup, CKD/nephrotic syndrome etc.

I noticed a gap in performing regular observations and wanted to do some formal teaching on this, and prepare observations charts, but we were informed by the senior paediatric sister that the Ugandan Government want the observation charts to be online so they will not fund printing of paper observation charts.

What went well/what was challenging:

Most of the students were very enthusiastic and engaging and have given us some fantastic feedback, asking for more sessions and even lifelong mentorship, which shows that our teaching was a success. The bedside teaching worked really well, as it would be during ward rounds, and it was a good opportunity to teach the medical students, although this would vary as it does in the UK, with sometimes 20 students and other times just 2. On one occasion when Antoinette was at the hospital parliament meeting, I went to the paediatric ward on my own, and there was a sick child with severe stridor, so I used this as an opportunity to do some ABCDE emergency teaching with the interns, medical students and nurses, teaching them about assessment and management of croup, after that teaching to the nursing students on how to perform observations as well as how to give an adrenaline nebuliser.

The classroom teaching was well attended, including the Saturday morning session on basic paediatric resuscitation. The difficulty was trying to gather the nursing/midwifery students away from their clinical duties each day, as the ward was poorly staffed and relied heavily on the students. If we did manage to gather a group of students, we had to secure a room in which to teach, which was usually not a problem as we used the NICU board room, but we had to improvise at times, using outdoor spaces or corridors (which would mean compromising on projecting slides) if no indoor classroom space. This worked well for practical teaching like newborn life support, and we could send the slides around after the teaching to the representatives of each year-group (as was asked for in the feedback). If the nursing/midwifery students at LRRH agreed to attend teaching in the afternoon, they would have to compromise on their lunch, which meant they were often hungry, and some of the feedback mentioned providing refreshments which we will keep in mind for the future (budget permitting). And as to be expected in Lira, they were late to every session, so we had to factor that in, and so could not have multiple teaching sessions per afternoon.

We had prepared QR codes for feedback but the students were not familiar with this so I had to send out feedback links after each session to a student representative of each class. This worked fine, but perhaps meant we did not get as many responses as the number of students, as we know contemporaneous feedback is the most useful. Going forward, I would bring printed out versions of the feedback form to hand out to the students, and while this is worse for the environment, the technology did not support the format we had been prepared for.

On the whole, I felt the teaching went well and the students learnt a lot, and I am hopeful we made a real difference. However, I feel we could have better planned our teaching if we some prior knowledge of how many nursing/midwifery/medical students were around on any given day, and their schedule (when they are not in university teaching). However, communicating with Lira University was already challenging, so I think communicating with the various different universities and colleges that the different students were affiliated with would have proven even more challenging. In that aspect, we demonstrated our flexibility and adaptability, having the lectures pre-prepared and downloaded onto a computer, and we would confirm with the students one day in advance what they wanted lectures on.

On reflection, we could have spent more time doing bedside teaching, or teaching practical skills, because I picked up many areas where the nursing students do not get much supervision or support from sisters, and where they could develop, such as learning how to flush with normal saline after giving an IV bolus, doing continuous observations, passing orogastric tubes etc.

My learning experience:

Being in LRRH was a humbling experience working with the incredibly hard working consultants at LRRH whose work was cut out for them, with over 60 inpatients at any one time, and many very sick patients who are referred from community clinics at such late stages of their presentation. We couldn’t help but get involved in patient management. We encountered some challenging situations where Antoinette and I were taking part in resuscitations on the paediatric ward, but there was a lack of equipment: bag-valve masks, correct sized syringes to aspirate nasogastric tubes, insufficient oxygen in the ICU etc. Aside from the lack of equipment, the equipment that was there was disorganised and it was frustrating at times to see that despite having an “emergency tray,” it was not properly stocked, and the equipment was stored in a chaotic way. One of the learning outcomes from a resuscitation was to ensure that a nurse was delegated the task of restocking the emergency tray so it would be easily accessible in an emergency.

I learnt that a lot of the deaths in the country are caused by “local tonsillectomies,” whereby parents of febrile children get their tonsils removed in community clinics as it is believed they are the source of the infection, after which parents take their children home, praying that the tonsillectomy cures their child’s fever, but unfortunately it often results in sepsis or bleeding if it is done in a non-aseptic method, or if it prevents the child from receiving actual life-saving treatment such as antibiotics or anti-malarials. This is something that was discussed at the weekly WHIT meeting that we attended, where statistics of admissions, deaths, issues raised etc were discussed with consultants and senior management, and the previous 3 of 4 of the previous weeks’ deaths were following local tonsillectomies. It was great to see that the doctors at LRRH were making efforts to address this by finding ways of educating the local community, firstly by auditing the number of deaths linked to local tonsillectomies, then sharing the information on the radio, making posters and videos to be spread around the hospital.

I even had the opportunity to observe a visiting paediatric cardiologist from Uganda Heart Institute who offering free cardiac surgeries to patients with congenital heart disease (if eligible) as long as they could make their own way to the hospital! Some of these patients had never seen a cardiologist before so this was fantastic to see.

Conclusion:

Overall, I had a very fruitful trip, with a fantastic team, both from PAL and the Ugandan staff. I learnt a lot about the way they practice medicine in Lira, as well as giving some well- received teaching. Spending a few weeks has shown me where the gaps in learning and practice are, and has given me the motivation to go back and address these gaps in future years, both with regards to teaching as well as quality improvement. Some things that really spring to mind is talking about the importance of drug charts, fluid balance charts and regular observations but I am mindful that I cannot change an entire system, so it would have to start with some behaviour change workshops, perhaps borrowing a psychologist from our iAIMS colleagues! A fantastic trip and I would highly recommend it t