5 Year Review

Tallinding Chldren’s Health Centre (on behalf of TCHC) FIVE YEAR REVIEW

Independent Review of clinical practice at Tallinding Children’s Health Centre (TCHC) on behalf of the TCHCharity 

Conducted by Clare Westwood:

DipHe (Adult Nursing).                                                     ​Huddersfield University​

BSc (Hons) Adult nursing​​​​                                       ​       Huddersfield University

PG Cert. – Acutely Ill Patient​​​​​                                          Huddersfield University​

Level 5 – Supporting Learning in Practice (SLI)                ​Huddersfield Univeristy

Level 5 – Clinical Respiratory Management ​                    Teeside University​

MSc – None Medical Prescribing​​​​                                    Huddersfield University

MSc – Trainee Advanced Clinical Practitioner

(to be completed 2019)​​​                                                   Huddersfield University

 

Background

Tallinding Children’s Health Centre (TCHC) is located in the heart of Serrekunda in The Gambia, West Africa and provides vital, often life-saving treatments to patients from the surrounding areas. Patients who come to the Centre for urgent medical treatment often do so from as far away as 10km.

TCHC is open to anyone from Monday to Friday 8-6pm and Saturday 8-1pm. The TCHCentre has a waiting area for patients, reception area, pharmacy dispensing area, two nurses’ consultation rooms, one treatment / clinic room, one lab room, 1 small 4 bedded ward for patients needing intravenous fluids and treatment, a manager’s office and staff room.

Staff

The Centre is run by Manager Sheikh Tijan Touray (TJ) who works tirelessly to keep the Centre open. As the Centre subsidises children, balancing the books is often a struggle.

The clinical assessment, diagnosis, management and medication prescriptions of new and existing patients are all carried out by two fantastic male nurses, Lamin Njie, 35 years of age who acts as the Centre’s clinical lead and Chernor Jallow, 30 years of age.

Diagnostic laboratory testing via blood films, to confirm diagnoses of Malaria, caused by Plasmodium Falciparum, in addition to anaemia and infection, are carried out by two lab technicians Lamin Cessay and Ebrima Sundu

Distribution of medication to the patients within the Centre, is controlled by Awa Gaye and is assisted by a Pharmacy volunteer, Mariama Kinteh.

Reception: Jaianaba Ba and reception volunteer Mariama Kambi.

Cleaner:  Mariama

Caretaker of the health centre: Ebrima Badjie

Clinical Practice

Patients who attended the Centre on the two half days were both new patients and reviews of existing patients.

Age ranges from two weeks old to mid-sixties (national life expectancy in The Gambia <70 years).

The main presentations in children were:

  • Malaria (children and adult) ​(Tropical Disease)
  • Respiratory problems such as chest infection / pnuemonia (children)              (Respiratory)
  • Ear infections​ (Ears, Nose and Throat ENT)
  • Fungal infections ​(Dermatology)
  • Worms  ​​​(Gastroenterolgy)
  • Tooth abcess           (Dentistry)
  • Cicumcision​​ (Surgery)
  • Abdominal tumour ​(Surgery)
  • Scabies ​     ​(Dermatology)
  • Skin wounds ​(Minor Injuries)

Main presentations in adults were:

  • Malaria​           (Tropical Disease)
  • Hypertension (HTN​(Cardiovascular)
  • Gastritis​           ​(Gastoenterology)
  • Reflux​               ​(Gastroenterolgy)
  • Foreign body in ea. ​(ENT)
  • Post operative wound care / dressing change from Peritonitis (carried out at Banjul hospital)​         ​(Post surgical)

Other conditions regularly treated at TCHC are:

  • Asthma
  • Diabetes
  • Coronary Heart Disease

The nurses treat adult, paediatric patients and both medical and surgical patients, which is unheard of in the UK. Their ability to treat all types of patients confidently and accurately without any medical input from doctors is hardly believable.

In the UK, all the patients seen would have some input from specialists in the field (annotated right column in brackets). This is done completely independently by the nurses at TCHC.

Both Lamin and Chernor work to The Gambian government guidelines and the British National Forumlary (BNF) from 2007.They are aware of national policy drivers for implementation of health care, and restrictions and barriers to these.

Their assessment, diagnosis and management of the patient is very similar to those in the UK. The key difference being that the majority of patients treated are sick due to tropical disease and poverty.

As such, some assessments, carried out routinely in the UK are not completed in The Gambia such as risk stratification for acute coronary syndrome and venous thrombo-embolism.

The large volume of patients, the limited number of staff and limited resources mean that both Lamin and Chernor have to be confident in their diagnosis and treatment plans.

In the rainy season, the nurse can see 90 – 100 patients in a day (50 each)

During the dry season, the nurses’ clinic can see 40 – 60 patients in a day (20-30 each).

The patient registration book at reception indicated on Tuesday 28th November 2108 that patient 115,651 registered that morning. As the Centre opened in September 2013, that represents a footfall of 66 patients per day based on a 7 day week.

Demographic

Day 1

  • Children over 2 years 46%
  • Adults​​​​      30%
  • Children under 2 year’s​ 24%

Day 2

  • Adults​​​     ​ 70%
  • Children over 2​​     20%
  • Children under 2​           10%

Equipment

  1. Stethoscope– to listen to chests and heart sounds

Case Study:

3 year old boy presented with his mum with general lethargy, increased respiration rate and decreased eating and drinking.

Using the stethoscope, diminished breath sounds and creps all over the lung fields were detected.

The diagnosis was pneumonia and Lamin the nurse used intravenous antibiotics in order to maximise efficacy.

The boy was discharged with a prescription of oral antibiotics and vitamins and asked to come back for a review at the end of the week.

  1. Pulse Oximeter– to check saturation of oxygen and heart rate


Case Study:

A 4 year old girl presented with her mum with increased lethargy, generalised body pains and a cough in addition to reduced oral intake.

Using the pulse oximeter, the girls heart rate was much higher than normal.

Diganosis was chest infection.

Lamin the nurse prescribed oral antibiotics and vitamins and again was asked to come back in a week for a review.

  1. Blood Pressure (BP) machine– to monitor BP

Case Study:

60 year old gentleman presented as a review with Hypertension (HTN)

His previous reading had been 148/101 and Lamin had given health promotion advice to this patient to alter his diet, take regular exercise rather than initiate medication as a first line of treatment.

Using the blood pressure cuff on the review, the patients reading had reduced to 111/90 which was a dramatic improvement.

The patient was surprised to see such a reduction and Lamin the nurse praised and continued to encourage him to maintain healthy changes.

Phone torches

Staff use their phone torches to examine ears, nose and throat – no otoscope working at the clinic

Case Study 1:

A six year old boy presented with painful right ear, intermittent fever and decreased appetite.

Using the phone torch, Lamin examined the left ear canal which had a build up of wax and right ear was red and swollen inside.

Diagnosis of ear infection was made.

Prescription of Gentamycin ears drops (antibiotics for ears) was made

The patient was advised to have the left ear irrigated in order to reduce the wax present. 

The patient was to be reviewed in a week.

Case Study 2:

Lamin’s daughter’s teacher attended with hearing problems and pain in right ear.

On inspection Lamin suspected a foreign body and so sent the patient to the treatment room.

Ebrima the lab technician irrigated the ear using sterile water and ear syringe. The ear was blocked with an insect.

After the treatment the patient could hear again.

No further treatment required.

Case Study 3:

12 year old boy presented with toothache and swollen left lower jaw.

He had been to the dentist for an extraction but was unable to do so due to infection.

The patient attended and using the torch on the phone was able to clearly see redness and swelling in the boy’s jaw.

Antibiotics were prescribed and the patient was advised to come back for a review after the antibiotics had finished.

Dressings:

Post surgical patients often come with their own dressings:

Case Study 1:

2 week old baby born with abdominal tumour was kept in Banjul hospital from birth. After investigations and scans ruled out any abnormality within the abdominal cavity or involvement with vital organs, the baby was discharged with Silver alignate dressings both antibacterial and healing. The nurses were responsible for changing the dressings and giving mum advice on aftercare. 

Sadly the baby died a week later in Banjul hospital.

Case Study 2:

39 year old teacher, was rushed into Banjul hospital with acute abdominal pains and suspected Peritonitis.

He was operated on and discharged to the care of TCHC for daily dressings. This patient presented with a 30cm post surgical scar, held with vicryl sutures and covered with Hyperfix.

The wound was cleaned using forceps and cotton wool soaked in Betadine solution and protected with Hyperfix dressing.The patient was encouraged to take analgesia such as Paracetamol.

In the UK this patient would have been off work for a minimum of 1 month; this teacher was back to work after 4 days in order to provide for his family.

Both Lamin and Chernor are able to use other assessments such as palmar anaemia and conjunctival palor in assessing anaemic state of patients within the clinic which can be helpful in deciding whether to proceed to a blood film for the patient.

They both have excellent knowledge in spotting the ‘sick child’ such as intercostal recession, nasal flaring. They are both capable of appropriately ordering and interpreting diagnostic tests such as:

  • Urinalysis – ​​testing of urine;
  • HCG – ​pregnancy testing;
  • Blood Films – Malaria and Aaemia testing

​​These tests are an essential part of the work at TCHC especially in the rainy season when Malaria is more prevalent.  Plasmodium Falciparum is the main parasite seen in Sub Saharan Africa which causes Malaria in the Gambia.

Blood Film Testing – Using blood films and microscope

This is currently how suspected Malaria is confirmed at TCHC and nurses can obtain a result in approximately 5 minutes.

However, the microscope currently used needs electricity and parts are faulty so lab technicians have occasionally had electric shocks from this.  There is another microscope which cannot be used as is too dangerous.

The technicians are able to say how advanced the Malaria is, based on their knowledge of signs and symptoms of Malaria and underpinned by pictoral life cycle of Plasmodium Falciparum. Unfortunately, the blood films have to be washed in bleach every evening and re-used … TCHC has not had new slides for 5 years.

I was able to witness for myself Malaria parasites on blood films and is a learned process through standard operating procedures.

Other devices are available to diagnose Malaria such as Rapid Diagnostic Tests (RDTS) in this part of Sub Saharan Africa.

There are pros and cons of both methods:

  

Blood Film

  

RDT

  

Pros

  

Cons

  

Pros

  

Cons

  

Able to highlight other conditions, ie. Anaemia and infections

  

Equipment inappropriate

  

No electricity required

  

Expensive

  

High accuracy rate in determining main parasite in Malaria ‘Plasmodium Falciparum’

  

Needs more training than RDT

  

Anybody can use with SOP

(standard operating procedure)

  

Can give false results if not kept safe prior to use (? Needs refrigerating)

  

Fast

  

 

  

Fast

  

Can misdiagnose as purley a ‘line’ like a pregnancy test.

      

 

  

Results disappear if not read within certain length of time.

Health Promotion

I witnessed really positive evidence of health promotion with nearly all patients the nurses saw at the clinic.

Smoking (amongst women) is relatively unheard of, and due to religious beliefs, consumption of alcohol does not have a great impact on health in general.  However, high illiteracy rates amongst older population, cultural beliefs handed down from generations such as fertility trees and Maraboo (witch doctor) can be barriers to effective care.

Lifestyle advice such as:

Diet, low salt and low fat have been discussed on my visit. Hypertension is one of the biggest problems with older age population and nurses actively discuss this.

Discussion around increased oral intake witnessed as many Gambians do not drink very much and can present with dehydration, and can complicated such conditions as chest infection and malaria.

Problems still persist in the Gambia with patients adhering to advice from nurses, clinics and ministry of health (MOH) in use of malarial nets and not going out at night. After discussion with nurses at TCHC, it would appear that some patients refuse to believe this advice and some know the risks but do not comply.

The nurses both try their best to educate the population of patients and do this well. 

Qualifications

Lamin Njie was asked to come and work at TCHC by TJ the manager three years ago.

He has completed private nurse training at Sibnor Health Centre equivalent to State Enrolled Nurse (SEN).

He has gained an advanced Diploma in Information Management Systems.

His goal is to achieve a BSc in Nursing in the Gambia, and had applied to colleges in USA and UK prior to this being a qualification offered in the Gambia after 2004.

He has now registered on BSc In Medicine and Midwifery starting in January 2019 and has been awarded the Bendon Bursary by the TCHCharity to assist him with academic finances.

Chernor Jallow came to TCHC as a volunteer in 2013 and after acquiring HND in nursing in the Gambia came back on the payroll as a qualified nurse.  After applying to the local university to study a BSc., he was awarded the Bendon  Bursary by the TCHCharity to assist him with academic finances.

This semester he is studying:

  • Human functional anatomy (2)
  • Principles of Epidemiology
  • Biostatistics for Public Health Practice
  • Microbiology
  • Waste Management

Professionalism, Work Ethic and Attitude

I have never encountered such caring, selfless, community spirited nursing in my career.  Both Lamin and Chernor are a shining example of what can be achieved.  They both receive phone calls from patients within the community outside working hours and arrange for them to come into TCHC for assessment.

Being able to provide a quality service to all members of the community is extremely important to ALL staff at TCHC, indeed they regard each other as ‘family’. Staff have interchangeable roles which in situations such as illness and holiday makes the running of the centre much easier enabling Lamin and Chernor to have protected role whilst still provide the service.

They work in extremely difficult circumstances in a country where national spending on health has decreased below the recommended national amount set my Ministry of Health.The costs for treatment at the centre are:

  • Consultation … ​​​​100 Dalasi     ​​​£1.50
  • Blood Film or Hb …​ ​50 Dalasi​​​ £0.75
  • Blood Sugar … ​​​​       100 Dalasi     ​​​£1.50
  • Urine test​​​ …   ​100 Dalasi     ​​£1.50
  • Pregancy test​​ …. ​100 Dalasi ​​​£1.50

This means that, there is no budget for medication so desperately needed by TCHC to treat their patients. Both Lamin and Chernor bring in medication, such as intravenous antibiotics, to treat really sick patients with infections and intravenous fluids to treat dehydrated patients. Their regular oral medications which they would use daily are:

  1. Paracetamol 500mg – 1g​​​ …to treat myalgia caused by Malaria and other infections
  2. Co-Trimoxazole 4/800mg … to treat infections
  3. Metronidazole 500mg … to treat infections
  4. Mebendazole 100mg