After completing medical foundation training (F1+F2) in the UK, I spent 4 months volunteering at Kamuli Mission Hospital between April and August 2015. My girlfriend, who is a teacher, also volunteered at nearby secondary school St John Bosco. I divided my time approximately equally between clinical work and quality improvement projects.
During the working day, I would usually conduct a round on the medical or paediatric wards, and assist with the jobs accrued. There was always help and advice available from one of the other doctors if required.
I was surprised to find the main case-load in adult medicine relating to diabetes, heart failure, asthma and other non-communicable diseases. We recognised a great scope and enthusiasm at KMH for improvement of the management of these cases, both in an acute and long-term perspective. This informed our decision to focus a lot of time towards quality improvement projects, such as teaching and guideline development. Additionally, mental health is under-managed in Uganda, and cases of deliberate self-harm and attempted suicide are routine.
In paediatrics, the vast majority of cases were suffering from either malaria, pneumonia +/- sepsis or severe diarrhoeal disease, or a combination of all four. Acute severe malnutrition was also a frequent presentation, but these cases were usually transferred to a regional malnutrition centre.
I made it clear with KMH that I would not work beyond my capabilities, and opted out of on-call duties as this would largely consist of managing obstetric and surgical emergencies in theatre. The rest of my clinical time was spent assessing urgent and emergency cases in the out-patient department.
Triage and the Emergency Room
The vast majority of patients are seen in the outpatient department and either managed by the clinical officers there, or admitted to a ward. At the time of our arrival, patients were seen mostly in time-order regardless of urgency (excluding some of the more obvious emergency cases). Cases can vary from something as commonplace as reflux, to cases of major trauma.
We worked to develop a functioning triage system to categorise both adults and children in terms of priority, and use this to guide initial management. For the emergency cases, we set up a dedicated ‘Emergency Room’ equipped with kit and medications to manage acute presentations. Prior to this, patients had mostly been sent directly to wards or to the laboratory, which could negatively impact on their outcome.
With the triage system and emergency room set up, we arranged a number of teaching sessions for KMH staff and students to familiarise them with the new concepts.
With nursing and midwifery students doing a lot of the work in OPD, including managing the triage desk, we spent a lot of time training them to effectively assess and triage adults and children, running sessions and scenarios at Kamuli Nursing and Midwifery School.
I think one of the most effective interventions was the development of clinical protocols. With collaboration from the KMH staff (including doctors, clinical officers and pharmacists), and utilising the most up to date recommendations, Claire and I developed a number of guidelines for the management of some of the most common acute and chronic conditions seen in KMH, including management of convulsions, acute and chronic asthma, hypertension and heart failure. Aimed mainly for use by the clinical officers in OPD, they focused on ensuring appropriate initial management, consistent prescribing and appropriate follow-up arrangements. The full guidelines are available on request through the Kamuli Friends website.
After a month of working at KMH, I’d identified frequent incidents of patients requiring transfer to alternative hospitals due to lack of blood products at KMH, and incidents of patients having received blood products despite no indication for transfusion. To formally assess this problem, I ran an audit of transfusion practices at KMH. Using the hospital’s transfusion records, I collected information from the previous 31 days, recording number of transfusions, pre-transfusion Hb, indication given for transfusion, and information regarding supply shortages. I compared this data with guidelines from the WHO and Uganda Clinical Guidelines to clarify recommendations and assess current practices. Collaborating with KMH staff, I developed a basic guideline for transfusion, highlighting recommended indications and Hb levels. This has been implemented on all wards, in OPD and the laboratory. I would recommend that a future volunteer re-analyse KMH’s transfusion data to complete the audit cycle and assess for improvement in practices.
I really value the time I spent at KMH. I was able to tailor my visit to focus on my interests, namely adult and paediatric medicine, as well as develop skills in teaching and quality improvement. Although at times frustrating, I found myself to be very motivated by the challenges faced at KMH, and I hope to one day return to the hospital.