Report on Team 2 Lira Trip

Report on Lira Trip October 19th – 31st October
This trip was probably more challenging than usual for a number of reasons. It should be the trigger to discuss future trips, their volunteer makeup, their focus and what we should be taking to Lira in our suitcases.
Team
Dr Frankie Dormon – Lead
Dr Peter McEwen – Neonatology Joint Lead.
Freya Roberts – Neonatal Nurse
Jadine Stanford – Senior Nurse ED
Christine A’Barrow – Advanced Care Practitioner ED
Carly Green – Advanced Care Practitioner ED and Community
Antonella DiMeglio – Practice educator ED

Pre Trip Planning:
As we had two clear specialities, we decided to focus on ED and Neonatology. On a previous visit, there was enthusiasm from the Referral Hospital for developing resuscitation skills including defibrillation. To that end, we purchased a defibrillator and were given another. The issue being in Africa that single use pads are expensive and unlikely to be replaced so we wanted to use devices that could use the reusable paddles. These could only be safely introduced with appropriate time on training.
On previous visits Frankie had identified some fantastic practices in the neonatal unit in Mbale. We decided that it would be hugely beneficial for the neonatal team to visit this unit and adopt some of their practices. Immediately before our visit we received a large donation for a CPAP machine, designed for developing countries, which had inbuilt oxygen concentrator and air compressor plus a suitable circuit. This device is also used in Mbale, strengthening the reason for an Mbale visit.
There were a number of issues around transporting these devices, with no time to send via cargo we took the machine in our luggage. Ensuring the airline were aware as far as possible. We also had a letter to confirm that this was a donation from an import point of view.
The team did an amazing job of collecting items to take, we have always taken our full allowance of two 23 kg bags each. Feedback in the past has always left us confident that airway equipment, catheters, dressings, suture equipment, baby clothing, were greatly appreciated. Provided we had a letter from both the UK hospital and Lira University confirming that we were bringing out of date training equipment for nurse training purposes we have never had any issues. .
Frankie had a number of objectives, as lead, including discussing the MOU for the Referral Hospital and probably renewing the MOU for the University, as there is now a Medical School and senior roles have moved on. In addition the University have many more in house lecturers and our focus on teaching the University students should probably be revised. The feedback we have had in the past has always highlighted that scenario and practical training is always greatly appreciated.
Our focus has been on training the University students, with any other opportunities taken during the trip. We are increasingly spending more time at the Referral Hospital, especially since Pasco secured a grant for working with microbiology and the need for more formal relationships was appropriate.

The Trip:
The luggage arrived safely at Entebbe, however at that point we started to have challenges. As we went through the last security area we were approached by a representative from the NDA (National Drug Authority) At this point it became clear that our usual letters of authority were inadequate. A significant amount of our equipment was confiscated and we were informed that we may be able to collect some of it once it had been examined by the Head Office in Kampala which would not be open till Monday around 10.00. We had arrived on a Saturday
It was decided that the team should drive to Lira with Arnold, our driver while I would stay in Kampala till Monday. Peter and Freya could travel down to Mbale on Sunday as planned and Arnold would return to Kampala to collect me on Monday, hopefully with as much equipment as possible. Our main concern was the CPAP machine and the defibrillator which had been purchased from Charity funds.
The drive up to Lira had now been delayed and we also had to get me to a hotel, I stayed at a hotel I had used before, knowing I would at least be safe, have decent food at a reasonable price. The team finally arrived in Lira very late, but safe.
On Sunday afternoon, Peter and Freya went down to Mbale and the team, all new to Lira, were taken around the University and Referral Hospital, for orientation by Cosmas, who has worked with Judy on her breast programme. Clearly not as valuable as the whole team going around. Being a Sunday, the University and its hospital were very quiet.
Sunday was spent by me trying to understand what had changed regarding importing items. I had contacted Professor Jasper and Anna Grace but I just had to wait till Monday.
On Monday morning, Arnold collected me and we went to the NDA office in Kampala. I had received a message that our items would be in Kampala on Monday first thing. This was clearly not the case, it was all still in Entebbe. I had other friends who were coming into Entebbe on the 10.00 flight, so I tried to arrange for them to collect our items without success. However I now had the telephone number of the Minister of Health, and sent her a message, asking for help and advice.
At around 14.00 hrs our items arrived, some still in their suitcases but some in NDA boxes. I met with the Head of the NDA and apologised, showed him my letters and inexplicably everything in the 5 suitcases was released (including the CPAP machine and defibrillator) the items in the boxes were retained. We then had to wait for a formal letter of release and then we could load the van. The bridge across the nile is currently closed which means the three options for driving to Lira are the Western route via Murchison, 120kg longer, the middle route via a small ferry (risk of long delay) or the Eastern route close to Mbale also about 100km longer. The ferry closes at night so we chose the Eastern route.
A storm, terrible traffic and poor roads resulted in the trip taking 10hrs. We arrived exhausted at 01.30 on Tuesday morning. Not ideal.
The additional cost of all the changes was not insignificant.
Arnold extra driving and fuel. $146
Replacement driver for the team $100
Frankie hotel 2 nights $140
Taxi frim Mbale to Lira $130
Team meal driving up to Lira $62
Total £445.86
At last we could get started. The Team had visited the ED on Monday, without any experienced UK team members, shown around by Dr Fred. It had quite an impact. They spent the afternoon teaching Yr 2 and Yr 3 at the University,
Tuesday morning, we started to make proper plans, with appointments at the University and Hospital. Then it was off to our respective areas to start clinical based teaching and more formal lectures. Armed with a lecture timetable. Lectures were allocated by Samson Udho, as Anna Grace was away with family issues.
Peter was able to formally hand over the Baby CPAP machine at the hospital ‘Parliament meeting’ . We were thrilled that the machine had survived the journey, ( the first one being broken by DHL enroute from Devon!!). Then he and Freya set to work to introduce the new CPAP machine, clarifying systems that they have used in the past that delivered some sort of CPAP. Freya had secured a number of breast pumps and now they can start to organize better feeding regimes for the babies. A white board solution, improving communication is in place, hopefully it will still be in place next year. We didn’t invest in a proper white board. The unit is due to change location shortly, maybe the hospital will be prepared to invest in the board, or this may be something we can purchase next visit, if it is being used correctly.
Frankie was hugely disappointed to see that the department is still cluttered with equipment that was purchased for overhead monitoring in the unit, the roof is not strong enough to support it, so it was never installed. There must be around £2million worth of equipment still in packing boxes.
The work in ED was so variable, At the start of their time, they were appalled that patients would have to wait for hours to get any form of treatment, or observations. They felt a white communication board would help, we purchased this, discussed with the ED lead and it was installed at the start of the second week. Teaching was then instigated. Their time was a mixture of big highs, when their white board was being used appropriately and big lows when staff seemed incapable of reacting to dying patients not even being able to provide oxygen. Even fluids are not available in the department, family members have to purchase from the local pharmacy before any treatment can be given. Our team found this environment challenging but they continued to work with enthusiasm and resilience, plus regular debriefs at the hotel, (helped by a Nile beer) We had 4 ED nurses, so they were able to pace themselves and spent some time in other wards to regain their strength!!
Frankie had a number of important meetings, as well as teaching students at the University. Her meeting with Professor Jasper revolved around the confiscated items, and they discussed how Poole Africa Link could help the new Medical School. Our MOU needs to be revised. He confirmed that this should be with Anna Grace. They discussed that the University was slow to develop but progress is being made. The maternity unit now has around 120 deliveries per month, theatres have regular operating lists, staff numbers have increased significantly, there is now a functioning out patient department with medical and surgical clinics. Xray is now available alongside Ultrasound, blood tests are performed on site. However, much more needs to be done to make the hospital a properly functioning, busy unit.
Felister Apili, Head of Maternity at the University, has been accepted at Bournemouth University to complete her PhD. This cannot be done without arranging some funding, and we will help her to explore working in Obstetrics to support herself financially. This arrangement would be hugely valuable to the link, as she would help arrange distance learning.
The lecture programme seemed to be organized, however, students are often not available, or their programme changes, unbeknown to us!! We would phone the group lead each evening before their teaching, but still things seemed to change which is very frustrating. Teaching that was given was hugely well received. Feedback is similar to the past. They love the scenarios and need more time!! This is now collected via a qr code, though paper and qr codes would probably be ideal.
Peter and I had an excellent meeting with Frances Kiweena. He is a Consultant Physician at the Referral Hospital, but also heads up a Research Group. He was interested to hear about our work at the University, as he didn’t seem to be aware of our achievements there and quite rightly felt that our work at the Referral Hospital is difficult to quantify. I have agreed to write a report on the first 10 years at Lira University, which would be useful for all of us. He would like to help us to identify the needs at the Referral Hospital and better focus our work there. I explained that on each trip we had to work with the volunteers we had, and that our objectives would be adjusted to fit with the team make up. A Better focus would probably be best achieved with initiating an MOU with his Research Group, SICRA, which could then lead to an MOU with the Referral Hospital. He has agreed to write a draft which we will then take forward together.
During the second week we ran a one day Trauma course. This had been agreed some 2 months before our arrival, I was hoping that we could get some of the doctors from the referral hospital, but was only able to arrange for the Trauma interns (4) to be invited. The interns at the University Hospital, nine in number were all invited (interns are both doctors and nurses) and the Masters students. We were expecting around 25 attendees. I arranged lunch and soft drinks for them.
Registration was arranged for 08.00 to start at 08.30, however, people arrived slowly and we finally started around 9.00. We only had 15 in the end, but it was well received by those who attended. I was particularly disappointed that none of the interns from the Referral hospital were able to make it.
The following day I was invited to present to the University CPD meeting. I chose to talk about Safety and Human Factors. About 30 people attended in person and a further 10 on line. I think they enjoyed it and it got them thinking. It was interesting to see how the Board Room could be used for combined live and on line presentations.
I met with Tom Otim, the Dean of the Medical School. Next year the medical students will be on the wards and we discussed how we could support their ward based clinical training in small groups at vboth the University Hospital and the Referral Hospital. Hopefullly the \university Hospital will be busier by then.
I visited the University Theatres to watch some surgery. Dr William was doing a difficult splenectomy. He started with a good team brief. The theatre equipment is much better including end Tidal Co2, although no ECG. I found some ECG dots, so that should now be sorted. There was a problem with the muscle relaxant, which had lost its potency as there is no drug fridge. I purchased a fridge for them, it cost $120.00. They were extremely grateful .
There is a new Doctor Anaesthetist, Dr Ayan, she trained in Mbarara and seemed to be very conscientious. She has been joined by another of the BSc Anaesthetists trained in Mbale. Betty has now moved to the Referral Hospital and is far happier. The department is probably now ready to have a senior trainee anaesthetist who would gain some fantastic skills with support.
General Comments
My team were mainly first timers, which made the support they needed more intensive. My arriving 2 days late exacerbated this issue.
I felt that 7 people may not be the ideal number, maybe 6 is enough.
Our objectives matched the team very well, and we were working in very challenging environments. Everybody gave their all.
In future we should probably concentrate on more practical training, more formal courses and less random sessions with different year groups.
We had more than the usual sickness during our trip and I have advised 3 team members to send stool samples to rule out any significant infections.
We used Rwandair, because the Kenya Airways flights were so expensive. The priority should be arriving in the morning and departing in the evening, so that the journey from Lira has a chance of being completed during daylight hours. Rwandair would have been fine, had they not cancelled our return flight. They did however put us up in a nice hotel while we were waiting. This reduced the stress of the delay.
The accounts will follow. But the trip was more expensive than usual as Arnold now has to pay 18% Vat on his services. The hotel however, remains very cost effective.
Other thoughts for the future is trying to identify surgical camps, which could work effectively at the University, which has plenty of capacity and a good operating theatre.

Frankie Dormon
Medical Lead.