Gary’s May 25 Report

25 . 06 . 2025

Gary’s May 25 Report

My Personal Observations

I was very lucky to be part of a very strong team and achieved more than I would have expected because of the commitment of each person. The varied experience of the team worked to our advantage not only in the delivery of clinical service but also in teaching the students, nurses and doctors.

I felt the work I did in the Referral Hospital was valued by the staff there, and I think that I could have achieved more if I had focused my efforts here rather than at the University. I was surprised by how few patients and staff there were at the University Hospital and learned that the interns there had recently been removed due to the lack of patients who attended. When we visited the ED, there were no patients and a solitary nurse.

Several of the teaching sessions I did at the University were poorly attended despite the leads for the students being fully aware of our proposed timetable. Part of the reason for this was that many of the students were having exams in May, so they needed to concentrate on personal learning. I also wasn’t sure how relevant our teaching was in respect of what they were being tested on/ exposed to clinically.

For example, we delivered a session on arrhythmias and defibrillation, yet they did not have a defibrillator, nor was it their clinical experience to need to resuscitate any patient in cardiac arrest. For one 2-hour session, we had to wait 1 hour for more students to teach and ended up with an audience of only 3.

This said, all the students we taught were enthusiastic about learning, demonstrated a good knowledge base and were very grateful for the teaching we delivered. The skills lab at the University was an ideal learning environment as the room was large and had a reasonable array of equipment.

Teaching students and staff in the Referral Hospital, on the other hand, was more challenging as informal bedside teaching that I did was at the bedside or at the nursing station. I felt conflicted in this environment to teach versus help with clinical work. For example, whilst I was doing a teaching on how to assess if a patient had lacerated a tendon in the hand, a patient nearby was groaning in discomfort – should I continue teaching or see the patient? I could give several other examples where the patient’s clinical need was more important than delivering bedside teaching.

It made me wonder whether bedside teaching should only be done on patients in the Emergency Department who had already been treated. On review, however, many patients hadn’t been seen by any clinician at all or if they had, it had only been by an intern who was waiting to present their plan of action to a senior. To me, bedside teaching within the ED became a luxury – something to be done only once all the patients had been seen and sorted.

As a senior doctor, I felt very responsible for the care of the ED patient, as juniors often weren’t clear on what needed to be done or were uncertain of the diagnosis. However, I felt limited in what I could do for these patients and the clinical staff because:

a) I could not communicate directly with the patient or their family, as many did not speak English;
b) I was conscious that I did not have a work permit, so legally I could not assess/treat patients on my own;
c) I did not feel that I had a clinical role as I was not considered part of the clinical team, even by the juniors (often I was not listened to by the intern when providing advice)

I felt particularly vulnerable when I arrived at 8 am in the ED as I was the only doctor at that time and quickly learned that the ED doctors left at 1 am and that all subsequent patients who attended were assessed, diagnosed and managed by the nursing team. This team usually consisted of a trained nurse and 5 or 6 student nurses/midwives! There was no clear-cut time at which either the nursing or medical teams were expected to arrive!

One morning, I arrived to find the nurse instructing 3 student nurses on how to pass an NG tube on a middle-aged patient that she’d diagnosed with bowel obstruction. I then felt obliged to assess the patient,t only to find no one knew how to communicate with the patient as no one knew her particular language. On another morning, I found 2 Major Trauma patients who had been seen at midnight by an intern, and a plan had been made, but nothing had happened. One was in a coma with obvious facial and head injuries, and the other needed a deep wound review. The first patient obviously needed a CT scan of her brain, so I went to the Radiology building (when I finally found it) and explained that the request had been made some 8 hours previously. They informed me that it wasn’t requested as urgent and that the patient hadn’t paid for the scan. I spent the morning trying to get this done and learned:

a) How poor their communication can be
b) that there did not seem to be a clear way of knowing what patients did and did not have to pay for
c) that there did not seem to be any sense of urgency where you might expect it

The Patients

The patients in the Referral Hospital were grateful that we were simply present.

I had several relatives use hand signals to say thank you, even though I was simply asking a nurse or doctor about their relative. One afternoon, outside the ED, a 3-year-old girl suddenly approached me, took my hand and knelt down whilst bowing her head in respect, whilst her mother simply smiled.

Often, I felt like an impostor as I wasn’t actually delivering any clinical care.

The Staff

In the ED, they were all hardworking and keen to help and made us feel very welcome. However, there were very few trained nurses, and the bulk of the nursing workforce was students. After the nurses did their brief handover, there did not appear to be any structure to which patients were being seen/treated. If something did need doing, several of the students did it as a large group.

With regards to the Medical team, almost all the doctors I saw were interns who were clerking patients and producing treatment plans. The seniors who were designated as Senior House Officers did a ward round in the morning and then again in the evening. These ward rounds were quite brief. The interns were very grateful that I was there, but were a little confused that I wasn’t actually assessing or treating patients.

I only saw a Consultant in the ED twice in my whole stay. I tried but failed to meet the Head of ED and was not sure what physical presence he provided.

The PAL Team

I got to know each member of the team very well, and it was for me the best part of the trip. Everyone was clearly committed to teaching and effecting change in their respective area. I felt we supported each other, and I was particularly grateful that everyone (albeit not at the same time) wanted to come with me to the chaos of ED, even though it wasn’t their forte. We all got on so well in the evenings, the bars, the safari and the long car/plane journeys – I could not have wished for a better team.

The team, however, was not complete without Arnold and Brian. They were exceptional: reliable, punctual, committed to ensuring all our needs were met, good fun yet hardworking, with a sound knowledge of the local population, and very flexible. Arnold was keen to help us despite having his dominant arm in a sling for all of the tri,p which showed his unfailing commitment to PAL.

Achievements

With help, I numbered all the trolleys/beds TWICE!
I encouraged the nurses to write the names and plans of the patients on the whiteboard, and even after we left, this is still ongoing
Informal and formal teaching sessions

Objectives not achieved

I had hoped to teach focused ultrasound in the Emergency Department, but quickly realised that this was not appropriate as basic examination skills often gave the diagnosis. I was put in touch with a Sonographer who kindly lent me a portable USS which I did take to the ED so I believe it could be taught in the future when more basic needs of the patients are met first.

I had hoped to deliver a wound management workshop, but unfortunately did not find the time in our busy schedule to do this.

The Timetable

We had a very full timetable from the outset and met several people in important positions in the beginning. The timetable was developed each evening by Frankie and was split between the |University and the Referral hospital. On the first day, we toured each Dept and found one or 2 nurses who wanted specific things to be taught, but other than this, the formal teaching was decided on an ad hoc basis.

I wonder if we could have spent more time asking the students what they wanted to learn, especially given that they were having exams that month.

The Hotel

The hotel was very good and I felt safe and looked after. The staff were very good at accommodating our needs and providing refreshments and lovely food. The dining area was large and allowed us to plan the following day’s activities together, up late into the night. The internet service wasn’t very good in the rooms, which was a bit disappointing as I had to go outside to speak to my family.

Downtime

Frankie had arranged for us to go out on several evenings, and her recommendations were very good. We enjoyed each other’s company more being out, and really needed it to refresh after seeing some horrendous cases in the hospital.

Visiting the Lira market was a great opportunity to see how the people of Lira worked and the things they did. Buying “prints” to then have them made into items of clothing was a highlight for me.

My personal recommendations

I saw little value in going to the University Hospital other than to deliver skills-based teaching, and would suggest the focus should be on trying to improve care within the Referral Hospital.
It would be really helpful if PAL could arrange to have a dedicated room to do formal teaching in the Referral Hospital in advance, eg either a morning or afternoon block (if only for 2 hours)
For those going for the first time, I would recommend they immerse themselves in their clinical area for a few days and try and see and understand the problems of the staff working there. I didn’t feel comfortable trying to impose changes on my first day, but felt pressured to do so.
Should we consider moving the date for PAL visits earlier in the year to avoid the clash with the students’ exams?
It would be useful to have a Lira hospital document that clarified what the Referral Hospital patients paid for and what they didn’t. Knowledge of this may help us think of alternative treatments/tests patients need when teaching.
I would benefit from knowing the staffing and shift patterns of the various areas in the hospital beforehand. This would help me understand whom I might meet and when. It would also help me understand my position within their team.
Should we be trying to maintain WhatsApp links with the clinical/nurse leads in our respective areas so they feel we are continually interested in developing things- you may already be doing this.
Could we get them to tell us what they need in advance? Several times I went to the private pharmacies to get a kit that they had that was broken, eg a bit of a nebuliser, glucose meter sticks.
I think there should be a limit on how far into the evening you prepare things. I got really tired when these sessions went on after dinner.
I would recommend allowing individuals to determine their own timetable. I felt I knew what needed to be done, but was distracted by doing some of the University sessions. I would envisage that this would include asking another person or 2 to join you, and certainly it was good to do an entire joint team workshop.
I feel that a packed lunch made by the hotel would be ideal for lunches, eg a sandwich and a piece of fruit. I never felt I really ate healthily at lunchtime, as I ate a cereal bar and/or something I had taken from the breakfast menu. I think it would be useful to know how much this would cost.
Would it be possible to further build relationships with the nursing staff there by having them do attachments with us in the UK?
The Safari was excellent and a much-needed break, so I would certainly advocate keeping this in the Program

Summary

Overall, I enjoyed the trip far more than I thought I would. We got on so well as a team in and out of work, so I felt supported all the time. The poor conditions of the Referral Hospital were an eye-opener and I was surprised how quickly I normalised their care in my mind. I felt privileged to be there and valued by the patients and the staff despite doing so little hands-on care. I am very grateful to the Poole Africa Link team for giving me this unique opportunity to help others less fortunate than ourselves.