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.