Heading home from Bangladesh.....

To DAT or not to DAT, that is the question!

You can see from the pictures that some diphtheria pseudo membranes are fairly obvious. Nobody would miss that. Many however are far trickier and as doctors we all have different thresholds for what we would treat with DAT - diphtheria anti toxin. We’ve had a couple more significant reactions to the treatment and of course there isn’t an endless supply. Also it’s incredibly time consuming and as a team we can only DAT 3 at once maximum. Interestingly we are seeing less children these days and more adults, particularly working men. This is a worry as this population isn’t vaccinated as the WHO vaccination campaign has so far focussed on the under 15s. Less paediatric patients reassure us that the vaccination programme is working at least and there’s talk of extending it to adults soon. 

This last few days of the trip has been focused on our exit strategy. Our wards are closing and we will no longer give DAT in our centres. The local staff will provide a triage service only and refer potential diphtheria patients on to MSF for treatment. Training them in referral, transfer and triage is the most important aspect of what we are doing now. Both the medical and nursing teams we leave behind are motivated but very junior. My training was fairly straight forward - ABC’s and resuscitation of the sick child. It was well attended. 

We visited an MSF camp today as well as the Malaysian field hospital. Very impressive set ups. We all know that cholera is coming next and facilities are being prepared for this. The mud huts and roads of the refugee camp will become a wash in the monsoon and the threat of typhoons snd hurricanes are always present... the next outbreak is on its way. Interestingly there are still new people arriving. We see them leaving the holding centre with their initial ration pack donated to them to make some sort of life here.

There is a sadness at leaving this place. It’s been an amazing experience. Our team has gelled really well and in these circumstances that doesn’t always happen. We feel to have been part of the local Bangladeshi team too and some of them move on now as we do. And of course we leave the Rohingya. A population of people who wish to live in safety and peace. It is very humbling when you pass a family the apple from your packed lunch and a boy splits it into 9 pieces to share with the entire family. It makes you realise how lucky you are. And yet on the other hand as I leave the dusty streets with children waving goodbye to us I am reminded that whilst they have little of material value, they have family and community and hopefully some healthcare that we have been part of providing. 

From ED research nurse to volunteer in Laos, an inspiring story.

We often say that our skills in Emergency Medicine are transferrable across a number of vocations and different environments. Mia Paderanga, one of our ED research nurses, has certainly put that to the test!

Here's her account of working as a volunteer nurse in Laos.

Words cannot describe the anticipation and the excitement that I felt the moment I landed in Laos. I was in awe seeing the landscape of Laos from my tiny little plane.  I looked down with such amazement at the vastness of the Mekong River carving its way through rich tropical mountains with no concrete buildings in sight.

I'm finally doing it, volunteering as a Nurse in a developing country - the thing I've always dreamed of but somehow never had the courage to do. Now I'm finally here.

I was very fortunate to be given the opportunity to work as a volunteer nurse for the charity, Friends Without a Border (https://fwab.org/). This is a non-governmental organisation dedicated to providing free high-quality health care to children. They run a small Paediatric hospital consisting of a 24 bedded In-patient ward, Outpatient Clinics, a Neonatal ICU, an Operating Theatre and a 24 hour Emergency Department. 

I arrived in the hospital early in the morning, and already a long queue of patients was waiting to be seen in the outpatient clinic. The inpatient ward had no empty beds and in the ED were a couple of critically ill children undergoing resuscitation. There was a feeling of chaos as if I had just entered a battle ground, but behind the entire buzz, there was a sense of calmness from the local team. I noticed a strong sense of teamwork and comradery. Perhaps it is in the culture of Laos to be soft and calm; an admirable trait which everyone seems to have. I was welcomed by everyone with such warmth and a welcoming smile. I automatically felt at ease with the team and it didn't take long for me to feel like I am a valued member.

As a volunteer nurse my main responsibilities are to provide clinical supervision as well as teaching and assisting with patient assessments, and overall patient care. On top of this, we also manage the patient flow of the whole hospital. I won't deny feeling absolutely overwhelmed on my first day. The challenges that this type of work presents are surely different from the ones we face back home however, the highlights are profoundly rewarding. 

As a charity run hospital, I was impressed by how well established the hospital was despite only running for two years.  They have set evidence based protocols and guidelines. They have equipment and supplies of medications that although basic and limited, can be considered quite advanced for the setting. 

The ethos of the hospital is to “treat every child as if they are your own", and this resonates in the attitude and work ethic of the local staff and the volunteers. 

Despite all our efforts to provide the best health care, we face many challenges due to our lack of resources. It is particularly difficult to see a child have a less of a positive outcome simply because we have no access to certain medications, or that we don't have equipment to do diagnostic tests or to provide life support in critical conditions. At times we have had to send patients home with nothing but our sincerest apologies to offer, as we have no other means to further provide treatment. This is heart-breaking especially knowing that in developed countries, these children will have had a completely different outcome. 

Despite this, I have witnessed many patients recover and defy poor prognosis which I can only describe as something short of a miracle.

There is no doubt that the hospital gives many of the Laos children the opportunity and chance in life that they would otherwise have not received. There is a real sense of sincere gratitude from the parents/families of the children we see. A refreshing change from what seems like a growing culture of entitlement often seen in more developed countries. 

One of the most challenging aspects of the job was communicating with both the staff and the families. I knew I needed to adapt my way of communicating in way that is respectful and sensitive to each individual's level of understanding of English. I quickly learned a few common Laos phrases and with some help from the Laos staff, was able to communicate effectively in the best way I could. The families and the children also got a laugh out of my accent and more often than not my mispronunciation of words! However, they are more than appreciative with my efforts to learn their language. And with my broken Lao and strange "phalang" (foreigner) accent the locals are quick to respond “boh pan yang" translating to "no worries"!

Coming here has opened my eyes to different forms of health care and the ability for people to make the most of what they have.

This has truly been a life changing experience for me and one that I will forever remember. I go home with the knowledge that this experience has helped me develop professionally and more importantly I feel I have grown as a person and gained lifelong friends along the way.

I feel grateful for the support and encouragement I received from families, friends and colleagues who made this journey possible.  I am humbled by this experience knowing that in some small way I have contributed in making a difference in this small corner of the world. I strongly encourage others to take the leap and volunteer.                

 

More news from Bangladesh....

I was woken this morning to the call for prayer as usual at 5.30am, managed another 40 winks then up for breakfast and the usual chaotic drive to the clinic. Today was a fairly quiet day, it’s friday the holy day... around 4pm in comes a wee 4 year old who we had already treated two days ago with the anti toxin for diphtheria... she was floppy, very dry and had sats of 99 but a heart rate of 30. I didn’t quite believe it at first but listening in it sounded about right and on a monitor she had flutter waves with regular escape beats. We gave her a fluid bolus and after a lot of phone calls we transferred her to the MSF centre. Realistically they don’t have a lot more equipment than we do and in hindsight we probably should have just kept her. She had bloods with a creatinine of 700 and never produced any urine despite trying frusemide and I just heard that she died yesterday. Very sad and to think how little we were able to do for her and how much expertise would have been available in the UK. I guess this is what humanitarian work is. At least she was comfortable and with her family at the end.

Today we have had a surge of mumps cases. It seems there’s another outbreak. The WHO have vaccinated for measles and rubella but missed the mumps. The local population aren’t vaccinated for mumps and politically it’s seen as inappropriate to provide better care for the refugees than is provided by the government for the local people. Seems crazy! And I wonder how many host locals will end up with mumps.. we’ll see. Trouble is the ‘bull neck’ of diphtheria can look just like bilateral mumps and even the google images use the same photos for both! With no diagnostic facilities this makes deciding who to treat with the toxic horse serum for diphtheria very tricky. We are seeing the face of a changing outbreak every day and are learning and adapting with it. The team really comes together here. The epidemiologists are working hard to track the outbreak, organising data trying to work out what the treatment effects are and how good our case definition is. Hopefully we get it right most of the time.

I had my first 24 hour shift yesterday.. it definitely makes you feel slightly vulnerable when you are left with your buddy in the middle of a refugee camp. The security guys are always available on the phone and it is reassuring to know that the would come running if we needed them. The background noise is quite something with tannoys blaring, tuc tucs honking, people cramped close together and the regular prayer call.. army ration packs keep us going and the thought of a donut handover as the day team arrive. At least we’ve got a kettle now and can make a decent brew (tetley of course).

A walk on the beach later is a real treat. Time to chill out for an afternoon before starting back tomorrow....

Second day back at AA clinic. We are running 3 treatment centres in total and the docs rotate.. it’s been a fairly busy day with 83 triages and 3 anti toxin treatments.. still two to do. Only one clinic stays open at night so we were about to transfer two patients when we were informed of a demonstration of two groups in the camp- the Rohingya who are demonstrating about plans for repatriation back to Myanmar and the Bangladeshi who want their land back.. you can see the difficulties. The refugees have no where to go and their home is not safe. They would rather stay here where there is food, water and health care. The host nation however understandably are not happy. This is a tourist area and farming land has been used for the camp, never mind the influx of disease and the use of precious resources. Even the elephants are protesting with two reported attacks, this was their land too!! 

Either way it was thought not to be safe and we left camp mid afternoon.. no overnight treatment tonight... but at least we are all safe.

I have my 24 hour shift tomorrow... hopefully it will be less eventful..

Rachel x

A letter from Bangladesh.....

One of our fab EdinburghEM Consultants, Rachel, has been deployed to Bangladesh as part of a UKMED team to help in the diphtheria outbreak at the Rohingya refugee camp. Here's an account of the start of her journey....

I have been very fortunate to have been supported by my colleagues in the Emergency Department as well as NHS Lothian who have allowed me to be part of the team supporting this humanitarian effort. Thanks everyone!

The Rohingya are a minority Muslim group who come from Myanmar. They have been forced to leave their country crossing the border into Bangladesh to seek peace and refuge. There are almost a million people in this area, the largest refugee camp in the world. Many of the refugees are children.

In November 2017 the World Health Organisation declared an outbreak of diphtheria, a disease we have not seen for generations in the UK thanks to our extensive vaccination programme. The Rohingya population have not been vaccinated and living in such close quarters here the disease has spread quickly, especially amongst children.

UKMED are a charity supported by DFID and the UK government and they manage the logistics of the UK's Emergency Medical Team. They had already deployed a team to Bangladesh when I was asked if I was available to come for 3 weeks as part of the second wave. The primary team have done an excellent job at working with other aid agencies and have set up 3 clinics with the help of the British fire and rescue services (ISAR) for the treatment of diphtheria.

Day 1 at the diphtheria treatment clinic. After a long journey out and a training day yesterday I left early this morning. We travelled with the primary team to the clinic for an orientation day. The day started as chilly and misty. We arrived after an hour at the clinic to find the local Bangladeshi doctors and nurses providing an excellent initial triage system. Potential patients for admission are discussed with the UK medics and this would be part of my role. The clinic triages up to 100 patients a day. Today we admitted 10 and have given the anti toxin treatment to 3. The is a long, difficult and potentially dangerous process for the patient. It takes approximately five hours for the infusion and requires meticulous care and attention, no fluid pumps here!! Significant reactions are fairly common and two of the three had such reactions today. One experiencing itch and cough and the other breathing difficulties, rash and facial swelling. Difficult decisions have to be made, should we continue with the potentially dangerous infusion or is it not worth the side effects? The first patient, with patience and good nursing care managed to finish her treatment. The second got through most of it with treatment for his reaction to the toxin but towards the end we stopped the infusion considering it too risky. The anti toxin is given to reduce serious airway compromise and also to reduce the long term sequele of myocarditis, neurological deficit and renal disease.

We had two ward rounds looking at lots of throats and deciding who was highly suspicious for the diphtheria pseudo membrane, giving antibiotics and considering the anti toxin.

Wandering around the camp we can see how despite great hardship homes have been constructed from bamboo, toilets look pretty clean and deep water Bohr holes are being dug out. These people clearly have great resilience and appear warm and welcoming.

The day ended with a team meeting to discuss security and our plans for the next two weeks... quite a start, a flavour of what's to come....

Edinburgh EM partnership feasibility visit to Makerere University & Mulago Hospital, Uganda

Background

Uganda is a rapidly developing East African country that has been through a lot over the last 40 years, and yet is now a stable economic hub for the region, and is developing and progressing every day. Over the last 25 years the population has doubled to 39 million people, resulting in a huge strain on the health care system, facilities and resources. Yet despite a crippling burden of emergency medical, surgical and trauma presentations, there are currently no emergency medicine trained physicians in the country.

Sarah Richardson, one of our EM trainees, has had a connection with East Africa for almost a decade having first visited as a medical student. She has spent several extended periods of time living and working in Uganda, and has made a number of connections with staff working in Mulago Hospital, in the country’s capital Kampala. 

Mulago Hospital is the National Referral Hospital for the country, supported by Makerere University, which houses one of the top medical schools in Africa. The staff of the both these facilities have recognised the need for immediate access to triage, diagnosis and treatment of emergencies. And as such emergency medicine has been identified as an area that staff wish to develop, specialise in and use to reduce the morbidity and mortality they see every day. 

Makerere University are now in the final stages of developing a Specialty Programme in Emergency Medicine (MMed EM) and have developed a full local faculty of support. However, due to the lack of the specialists in the country they are looking internationally for support and assistance in how to take emergency medicine forward in their setting and system. 

As a result of 2 years of meetings, discussions and emails, the team from Edinburgh was invited for a feasibility visit to understand the situation in Uganda, and look towards a possible partnership with Makerere. The visiting team comprised of Professor Alasdair Gray, Dr Ed James, Dr Katy Letham and Dr Sarah Richardson. The trip was made possible in part due to funding from the Medic 1 Charitable Trust.

Blog, part 1: Our first few days in Uganda

After landing in Entebbe, the Edinburgh EM team travelled to Jinja, a town by the banks of the beautiful White Nile, to spend the weekend recovering from the long journey and acclimatising to the surroundings. It was the perfect place to spend a few days getting used to being on ‘Africa Time’ – life is fairly laid back and everything happens at a different pace to what we are used to at home.

Monday brought an early start in an attempt to beat the traffic on the road to Kampala. The journey was somewhat hampered by hazardous potholes, speeding matatus (dangerously overcrowded local buses) and, of course, the boda bodas – motorcycle taxi drivers with no respect for road rules, their own lives, or anyone else's for that matter. It was easy to see why major trauma due to road accidents is so common here.

We arrived at Makerere medical school and had our first meeting with Dr Tonny Luggya Stone (an anaesthetist with an interest in trauma who is heading up the MMed programme), Dr Joseph Kalanzi (a local doctor with an interest in EM, soon to be the first student on the MMed) and Susan, who coordinates international education programmes at Makerere.

 
Makerere University Medical School

Makerere University Medical School

 

After a few minutes in Susan’s office, it was clear she was the Liz MacDonald of Makerere – she knows everyone and everything, she made us feel very welcome and she had some wise words about Uganda. She explained that Ugandans are very friendly but talk quietly – visitors often struggle to hear them so we should just ask them to speak up! Instead of ‘yes’ and ‘no’ there is a slight eyebrow raise with a ‘hmm’ noise, or a slight head shake with a similar ‘hmm’ respectively. Good to know for our many upcoming meetings! Susan describes Kampala as organised chaos, which is funny because we often describe our ED using the same words, with the crazy traffic and bodas everywhere. Perhaps this helps prepare people for what they will see on the wards. She warned us to be careful of using our iPhones in public in case they are stolen – just like home then! Susan also warned us about the current small outbreak of Ebola in the neighbouring Democratic Republic of Congo, advising us to ‘be on high alert’ when interacting with patients just in case.

Tonny and Joseph gave us an insight into the issues facing EM in Uganda. While our Royal College is currently celebrating 50 years of EM in the UK, Joseph describes EM in Uganda as ‘0.1 years old’. There is no EM training programme in the country (the only place on the continent it is established is in South Africa) and there are no EM-trained doctors. The A&E at Mulago hospital is run by a combination of orthopaedic and general surgeons. They have many of the challenges that you might expect from working in a resource-poor country, but in particular they struggle with large patient volumes and lots of major trauma.

 
Katy, Alasdair, Joseph and Ed at Makerere Medical school

Katy, Alasdair, Joseph and Ed at Makerere Medical school

 

Our next stop was a visit to A&E at Mulago, where we met the formidable Margaret, the Principal Nursing Manager. She told us ‘like MTN [the mobile phone network in Uganda], I am everywhere and anywhere!’ We discussed triage, training emergency nurses and patient flow. It was beginning to feel a bit familiar. The hospital layout provides other challenges for A&E patients, such as the long journey to the x-ray department which Margaret described as ‘going to London then back to Kampala’! We continued to tour around the rest of the hospital and the inequalities were becoming obvious – there are brand new buildings for the Infectious Diseases Institute and the Cancer Institute (supported by funding from international organisations) while other wards appear almost derelict. It’s clear that the chance do conduct research brings money alongside it – for better buildings, equipment, resources etc. But emergency care remains underfunded and under-resourced.

 
Alasdair and Tonny discuss the layout of the new A&E

Alasdair and Tonny discuss the layout of the new A&E

 

Over lunch with Tonny and Joseph it becomes clear that they have a fantastic vision of where EM in Uganda could go. They are very aware of some of the difficulties that a fledgling EM specialty might face – lack of recognition by other specialties might be a particular issue. Joseph plans to tackle this by embedding himself in the Mulago team, studying locally rather than travelling to another country for EM training and using the time to build relationships with other specialists in the hospital. During lunch a monkey runs right past Prof Gray and we are all reminded that we are in Africa! We’re reminded of the other differences when we discuss common EM presentations. How could you manage a patient with chest pain if you couldn’t access troponin tests, or even an ECG (the one in the A&E is broken)? They have many issues with donated equipment, which often breaks down and can’t be serviced locally. It’s clear that they see our potential collaboration as a chance to share skills and experience, not to donate resources. We’re still not sure exactly what that might look like, but hopefully the rest of the week will give us some inspiration.