Adele4

Report of Dr Adèle Beck

MASANGA UK

6 Months Volunteer Position as Medical Doctor: April – October 2017

Main responsibilities

Medical lead of Grace Emergency Unit

In my first month I focussed on initiating a change in note keeping with implementation of folders and file dividers. We observed that many prescribed medications had not been signed for as administered. When asking the nursing staff on duty, they would almost always insist that the medication had been given, but claimed they had not had enough time to sign for it. Alongside the support of the other medical doctors and our matron Sister Gertrude, I have changed the culture around giving and signing for medication. The nurses now understand how essential it is to document clearly and accurately when medication was given or not given. To support this change of practice further, I optimised the drug chart by introducing a section for fluid administration and “once only” (stat) medications (see attachment).

I led and supervised onward training in Early Warning Score of nurses and nurse students. An important area of focus here has been task shifting, transferring a sense of ownership so that initial clinical decision making shifts from senior clinicians and doctors (expat) to local and national Community Health Officers (CHOs) and Surgical Training Programme (STP) students. Through assuming the role of a mentor, I have sought to develop the capacity as decision makers in their own right, rather than simply deferring decisions to the doctor on call. I supported daily teaching ward rounds with CHO/STPs, nurses and nursing students from Masanga nursing college. I guided the CHOs/STPs from a junior position of learning about common and severe medical presentation and executing medical management plans to a senior position where they were leading their own ward rounds and formulating, documenting and implementing their medical management plans tailored to every individual patient.

I encouraged all staff to adopt an ABCDE approach in every assessment of acutely unwell patients supporting a structured approach to problem identification and solving. Their skills, competencies and confidence were assessed with a mini CEX tool supplied by Dr Daniel from Capacare in line with their surgical training programme.

I supplied the unit with Ministry of Health national paediatric emergency guidelines to empower the on call CHO/STP as well as the nurses in first line assessment and treatment of paediatric admissions. The guidelines included: Malaria, Anaemia, Severe Acute Malnutrition (SAM), Fluid Management (maintenance fluids, dehydration and shock in SAM and non SAM patients) (see attachment).

I have created an admission proforma for every HIV inpatient to ensure a systematic approach. This incorporated a screening tool for opportunistic infections and WHO clinical staging (see attachment). This led to a better understanding of the disease and its underlying complications and guided the medical staff in starting the appropriate treatment and prophylactic therapy in light of all the potential diagnosed opportunistic infections and risk of immune reconstitution inflammatory syndrome (IRIS). This guide was reviewed by an associate specialist in Acute Medicine and Infectious Diseases from Derriford Hospital (Dr Parker), as well as a consultant in Infectious Diseases working in Connaught Hospital, (Dr Marta).

To ensure the best possible onward care for any discharged HIV patient, I developed a discharge summary specific to their disease summarising their status, evolution and current management plan (see attachment).

 

Medical Support for the CHO running the Outpatient Department

The collaborative work with the CHOs running the outpatient department and the out-of-hours work with the STPs continued running smoothly alongside the inpatient work and onward training for hospital staff.

 

Teaching for STP students, CHOs, nurses and nurse aids

Alongside providing onward training on daily ward rounds and at the patient’s bedside, I implemented regular teaching sessions for CHO/STPs as well as weekly teaching for all the nurses and nursing aids. The teaching of the nurses was facilitated and supported locally by Matron Sister Gertrude. I based a lot of my teaching on the Ministry of Health and Sanitation (MoHS) & WHO programme ETAT + (Emergency Triage, Assessment and Treatment of the first 24hrs of admission of under 5 year old patients) (see attachment). Regular feedback was collected after most teaching sessions.

I pleased to know that the current UK and Dutch volunteers have taken over the ETAT+ programme and are focussing on getting paediatric and emergency nurses through the programme in view of empowering them with extra knowledge and skills.

 

TB and HIV programme
Some strong foundations have been laid in the last 6 months with the implementing of an HIV admission and discharge document. Initial screening of HIV and TB inpatients in May and June 2017 demonstrated as below.

 

Graph

More work needs to be done to optimise inpatient treatment and outpatient follow up of these patients heavily stigmatised in their communities.

One could consider optimising their screening with geneXpert and transform their care with a dedicated TB/HIV clinic weekly or bimonthly which could be run together with a CHO or trained specialist nurse. Another option to envisage would be an outreach programme to follow up and further support discharged patients in their daily anxieties and challenges concerning their condition. This would arguably be cost-effective, as it would increase drug adherence and appropriate health-seeking behaviours, and therefore reduce HIV-associated complications such as opportunistic infections.

 

Maintaining and building partnerships
I attended one District health Management Team (DHMT) monthly meeting in June 2017 to advocate for our TB patients. At that time, there was a national shortage in quadruple therapy for tuberculosis and this meeting enabled all parties involved in primary and secondary health care of Tonkolili district to share their concerns, experiences and solutions as well as approach the WHO field coordinator and representative for TB in our district directly.
Given the high number of medical inpatients, it was felt that my presence would be more valuable on the hospital grounds rather than at the meetings. This can be reviewed based on clinical, managerial and project needs during medical management meetings and whoever is felt to be most appropriate should be representing Masanga hospital at these meetings.
There are also weekly meetings run by the DMO of Tonkolili district where all NGO parties are invited to take part.

2 weekly report

I introduced fortnightly Medical Management Meetings where every nurse in charge of their respective ward, Sister, Matron, pharmacist in charge, medical doctors and representative of the CHO/STPs are invited to attend and discuss current medical and managerial challenges and ideas. This has lead so far to better communication between different medical team players. We have discussed issues such as inadequate medical equipment supply, medical forms, suboptimal communication between prescriber, dispenser and nurse, as well as onward training for nursing staff, implementing of new guidelines and better documentation.

Minutes were taken by myself and I am happy to forward these if interested.

AKI Audit

There is very poor epidemiological data on Acute Kidney Injury (AKI) from low-income countries. The aim of this project is to determine the incidence, severity, aetiology, and outcomes of community-acquired AKI in Masanga Hospital, Sierra Leone. This project was inspired by a similar project led in Malawi by Dr Rhys Evans (Evans, Rhys D. R. et al. “Incidence, Aetiology and Outcome of Community-Acquired Acute Kidney Injury in Medical Admissions in Malawi.” BMC Nephrology 18 (2017)) and supported by Dr Hunt and Dr Connor via email.

Over a predetermined period of 1 month (4th of September – 4th of October) 52 medical adult and paediatric patients were screened for community acquired AKI on admission. The data is currently being analysed and I will forward the written report to Dr Hunt and Dr Connell when accomplished.

 

Masanga UK House and social activities

I arrived in the Masanga UK house which had already had some basic furnishings put in place by Dr Mei. The bedrooms were clean and comfortable with kingsize beds and good quality mattresses (a rarity in Sierra Leone!). The kitchen and bathroom were clean and we had a small dining table which could fit 6 people at a stretch. With Dr Hunt’s and Dr Forrest’s approval, I bought another table to transform our small dining table into a bigger community table, a shelving unit for the kitchen and 2 sofas + 2 armchairs with coffee table for the lounge. We also have fairy lights and hammocks complementing our living area and outside space. I am proud to say that the UK house has turned into a hub for all the other volunteers and some of our best socialising events have happened in our house! Please see attached photos for a small insight in what is waiting for you next time you’ll be visiting!

Mr Marrah, our contractor was finally paid the remaining 5% as per contract beginning of October.

 

Fundraising         

Together with my partner Tom Siese who was a Global links volunteer paediatrician in Magburaka Hospital, we set up a crowd funding page to provide financial support to patients and their relatives and enhance training resources offered to healthcare staff. £1475 were raised which we used to pay for posters, books and refreshments for teaching sessions. Tom used some of the money to support families in travels to and from Magburaka Government hospital and the remaining funds will go toward the Masanga sponsorship programme for a particular person.

A donation of €3000 was made by the Rotary Schengen-Mondorf Luxembourg to go towards renovation work in Masanga Hospital. This happened following several discussions I had with the honorary Consulate of Sierra Leone in Luxembourg Mme Natty-Stoffel.

https://www.justgiving.com/crowdfunding/tomadele

 

End of placement report/handover

A short face to face handing over of responsibilities, expectations and further scope for development and ongoing improvement was done for Dr Oliver Hamilton in the 3 days of us overlapping.
I do believe that a >/= 2 week period of overlap would be better as there is a lot to take in on clinical but also social level with locals but also expatriates.

This end of placement written report is the first one written in the context of UK volunteers and could be used as a basis for further volunteers.

 

Find below photos of the hospital, the team, Masanga UK house and landscapes around Masanga.

 

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