Report for the Period April 2014 to Oct 2015

Cwm Taf PONTHospital Group

Report for the period April 2014 to Oct 2015

Introduction

Over the course of the last year, Cwm Taf PONT Hospital group have managed to initiate, organise, fund, and complete a number of projects in Mbale Regional Referral Hospital (RRH) with the aim of improving healthcare for the people of the region. The link established between Mbale RRH and the Royal Glamorgan Hospital, Llantrisant has been strengthened. New team members have been recruited who have proved proactive, particularly in fund raising activities. The presence of long term volunteers from the UK (Dr Adam Hewitt Smith and his wife Cathy Burgeoine – the former an anaesthetist, the latter a paediatrician) in Mbale has meant that projects initiated during the Hospital Group’s visit in November 2014 have gained continuity and subsequently completion.

Secretary of the Cwm Taf PONT Hospital Group – Mrs Karen Vaughan

Members - Karen Price / Karen Vaughan / Nadia Bhal /Peter Evans / Teresa Levett / Sarah Morton Hetal Tejura/ Sean Watermeyer / Richard Roberts / Rob Salter / Elizabeth Bruen / Dr Adam Hewitt Smith

Honorary Members – Mr Howard Smith

Treasurer – Mr Geoff Herbert

Visits

The PONT Cwm Taf health care team visited Mbale between 22th November and 29th November 2014 and comprised of three Obstetric and Gynaecology consultants (Mr Sean Watermeyer (SRW) / Mr Hetal Tejura (HT) / Mr Roger Neuberg (RN)) and 1 Senior Midwife (Sister Karen Price (KP)). In addition, we were joined by 3 General Practitioners (Dr Jonathan Finnegan / Dr Kate Jackson / Dr Ibiyinka Osoba). Due to illness and family commitments a number of intending volunteers were unable to make the visit on this occasion. The Health care team were also joined by Mr Howard Smith, a PONT engineer who was instrumental in the manufacture of a new Obstetric Theatre trolley and transfer sheet in the PONT Mbale workshops in Uganda whilst we were visiting.

Sister Karen Price / Dr Kate Jackson / Dr Roger Neuberg / Mr Sean Watermeyer / Dr Jonathan Finnegan / Mr Hatel Tejura / Dr Ibiyinka Osoba / Pastor Apollo – pictured in Mbale). Mr Howard Smith was taking the photograph.

Projects during this visit

1. Vital Signs Monitors:

In the previous years of PONT Cwm Taf visits, vital signs monitors had been provided and training given. These monitors provide (i) Monitoring of blood pressure (ii) Monitoring of oxygen saturations (iii) Continuous monitoring of pulse and are invaluable and life saving in antenatal intrapartum / postnatal care. Three further monitors were provided (courtesy of clinical engineering, RGH) and training given.

Mr Tejura giving instruction to Antenatal Clinic Nurses in Mbale RRH

1. Vacuum Extraction (Ventouse - Kiwi) Project:

During previous visits to Mbale we found that women were either undergoing normal vaginal delivery or caesarean section, but no assisted vaginal deliveries in the form of ventouse or forceps were being conducted. In the UK approximately 5-10% of all deliveries are assisted vaginal deliveries. This negates the need for caesarean section, with its attendant risks of increased blood loss, infection, anaesthetic complications, and uterine (womb) rupture in subsequent pregnancies. This is particularly important in Uganda since the average woman is likely to have multiple pregnancies and births. One of the most common reasons for emergency obstetric operations in Mbale was for a ruptured uterus following previous caesarean section, which invariably resulted in fetal death and often in maternal death. We introduced the “Kiwi” (ventouse) to Mbale and surrounding health centres during our visit in November 2011 following funding from the Sir Halley Stuart Trust and further in 2012. Subsequent initial data collection suggested that 2-3% of all deliveries were being carried out by ventouse. The Kiwi vacuum extraction proved to be successful in achieving deliveries that would otherwise likely result in caesarean section. However, at £25 per unit this was not sustainable long term. During 2013 / 2014 the kiwi devices were depleted and vacuum extraction delivery markedly reduced. Therefore, during the November 2014 visit, with funding from Welsh Assembly Government, we provided two long term reusable vacuum extraction devices. Training was given to the interns and senior midwives on these devices and audit of use has been agreed by Dr Hewitt Smith.

1. Lighting Project:

We had previously reported (report for WAG 2012) that there are frequent power cuts in Mbale and the surrounding area. Hence in 2012, solar powered lamps were provided for the some of the health centres and one for the hospital. Following on from this, we learned that with regard to the RRH, often the generator failed for a number of reasons. There were anecdotal reports of the use of lighting from mobile phones to complete a caesarean section in the middle of the night when the power failed. To address this, two rechargeable battery powered surgical light units (with some funding from WAG) were provided for the obstetric theatre in RRH. The bulbs have a life of 20,000 hours, and the batteries 4-6 hours of life before requiring recharge. The company (Albertwaschle) from which the units were purchased included 2 extra spare batteries. It is hoped that this will ensure less hazardous obstetric procedures in the middle of the night.

a Surgical Headlamp Unit

Feedback from Uganda regarding the surgical headlamps is very good, hence a recent email (30/12/14) from Dr Hewitt Smith read,

“Power/Headlights -We are just in the middle of an audit of power outages to better understand the delays in starting the generator. I was working on christmas eve and the power went so we had to finish a c/s by headlamp. They are excellent for the surgeons but i was resuscitating the baby by phone light!!!!”

1. Bladder Care Project in Labouring Women

The team provided approximately 600 catheters for use in the RRH labour ward and to community midwives. This was accompanied by training on the importance of their use in labour. Sometimes a full bladder with urinary retention can be a cause of an obstructed labour. In addition poor bladder care both intra-partum and post-partum can lead to irreparable bladder damage and even fistula formation.

Example of catheters

1. Provision of Patient Trolley / Transfer Sheet for Labour Ward Theatre

During our visit in 2012, it was evident that there was a need for a further a recovery trolley / transfer sheet to transfer postoperative patients (post caesarean section) back to postnatal ward. Therefore with funding kindly provided by Mrs Jan Gethin (previous PONT hospital group secretary). Mr Howard Smith (Engineer and PONT Trustee) commissioned the PONT workshop in Mbale to manufacture a new trolley for the labour ward. In addition, Sister Terri Levett (Theatre Sister at RGH) provided an example of a theatre transfer sheet, which was then duplicated at workshops in Mbale for use in Obstetric Theatre, RRH.

Howard with Dr Fred Bisso following delivery of the Trolley to RRH

1. Teaching Programme – During the visit in Nov 2014 -The Hospital based team (Mr Hatel Tejura / Mr Sean Watermeyer) held 2 training afternoons in the board room at RRH for midwives and doctors in which vacuum extraction was taught as well as obstetric emergencies (postpartum haemorrhage / antepartum haemorrhage / breech presentation / pre-eclampsia / shoulder dystocia). We utilised a “Mama Natalie” manikin (funded by Welsh Assembly Government) for demonstration purposes.

Midwifery / Obstetric (Sister Karen Price / Mr Roger Neuberg) carried teaching Midwives / TBRAs (Traditional Birth Referral Attendants) in Obstetric emergencies and the benefits of breast feeding in both hospital and the community setting . In addition, teaching on bladder care and provision of catheters was carried out.

Projects for the Provision of Anaesthesia Services within RRH

(i) Anecdotal reports and then a brief audit (2013/2014) of practice highlighted that sometimes obstetric patients were waiting significant time for an emergency procedure because of lack of anaesthetic officers (AO), particularly out of hours. There were 2 reasons for this. Firstly, there are no on-call rooms for AO at night and therefore they often depart home at night only to be called back in the event of an emergency - there are often significant time delays in them returning with poor communication and poor transport facilities. To solve this the PONT Cwm Taf Hospital team in conjunction with MRRH / local builders and Dr Hewitt Smith directed plans for the building of 2 en-suite anaesthetic on-call rooms with a small office in close proximity to the labour ward were subsequently been drawn up. The plans were accepted by the local office of the Municipal Engineer. The Hospital Director (Dr Ben Wanume) was delighted and agreed that if PONT financed the project then the hospital would ensure that these rooms were for use only of the anaesthetic department of the RRH. The RRH also agreed to oversee the building in conjunction with Dr Adam Hewitt Smith (long term volunteer). Below is a copy of the plans for the on-call rooms:

The AO on-call rooms have subsequently been completed and are now fully functional, providing a long term and sustainable solution to enable more timely anaesthetic service at night. The project required co-ordination of the PONT Cwm Taf hospital group with our Ugandan colleagues. Mention is made in particular of Mr Geoff Herbert who organised finance transactions, Dr Adam Hewitt Smith, Dr Fred Bisso and James Wasagami (Human Resources manager at RRH).

The completion of the above building in such close proximity to labour ward will hopefully provide a long term and sustainable solution to enable more timely anaesthetic service at night.

(ii)Anaesthesiologist Accommodation – Attraction of a Ugandan anaesthetist to come and work in Mbale RRH has proved difficult for a number of reasons – poor government remuneration, lack of private practice (viz Kampala) to supplement income being two major perceived obstacles. The presence of an anaesthetic Doctor working within the hospital was seen to have a number of key advantages. A good anaesthetic service was considered to be crucial to developing not only obstetric services within RRH, but also all surgical specialities, as well as A&E, which without anaesthetic services would be rendered impotent. Once appointed, an anaesthetist working within RRH could not only provide a drive to develop services, but the opportunity for training of anaesthetic interns and anaesthetic Officers. This would attract medical personnel to Mbale which in turn would increase and improve not only anaesthetic services and the number of medical staff able to give anaesthesia, but also by extrapolation improve all surgical / A&E disciplines capability.

Therefore, after careful discussion with our Ugandan Colleagues, It was agreed that the Cwm Taf PONT hospital group would fund the building of residence within the RRH hospital grounds for an anaesthetist and his family to live rent free whilst the anaesthetist remained working at RRH, Mbale. The RRH board agreed to the use of its land for the building project and further agreed that the building would be held in perpetuity for the above stated use.

The Project is now nearing completion and huge thanks go to Dr Adam Hewitt Smith for being PONT’s eyes and ears on the ground and liaising with RRH management / builders /planners etc. Thanks also to Mr Geoff Hebert for his facilitation of financial transactions to enable the project.

The Anaesthetic Accommodation in RRH, Mbale (Sep 2015)

(iii) Training of an Anaesthetic Officer – The Cwm Taf PONT Hospital group are currently funding the training of an Anaesthetic Officer –

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Fund Raising Schemes

1. Pennies from Heaven – from Staff employed by the Cwm Taf University Health Board

1. PONT Ball

Organised by Dr Nadia Bhal

1. Voluntary contributions

Exchange visits

1.Sarah Hoyle has put a bid in for a further clinical engineering student to come from Mbale to the RGH for further training. The Clinical Engineering Department at RGH have agreed to this, and the Health Board have sanctioned the cost of accommodation and food for the 2-3 week placement. We await the outcome of the bid

2.Plans for a team visit in Nov 2016 are being collated