Community clinical clerkship report


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Community clinical clerkship report

  2. 2. ACKNOWLEDGEMENTS We would like to extend my sincere thanks to Gulu University for the wonderful program of community clerkship, Madi Opei Health Centre IV for hosting and giving us the opportunity to learn more clinical skills. Special thanks go to Ms. Edna Acayo (The In-charge), Mr. Okumu George (Assistant In- charge), the Health Inspector Mr. Bongomin Richard and the entire staff of Madi Opei HC IV. Finally thank the Madi Opei community and community leaders at large for allowing us work with them for the 5 weeks at Madi Opei HC IV. God bless all of you.
  3. 3. ACRONYMS/ ABBREVIATIONS ANC Antenatal Clinic ARI Acute Respiratory Infection ART Anti-Retroviral Therapy BCG Bacillus Calmette Guerin COBERS Community Based Education Research and Service DPT Diptheria Pertussis Tetanus EID Early Infant Diagnosis ETC And So On F/P Family Planning H/C Health Center H/I Health Inspector HSD Health Sub District IPD In Patient Department LC Local Council MCH Maternal Child Health NGO Non-Governmental Organisation OPD Out Patient Department ORS Oral Rehydration Salts SCO Senior Clinical Officer TBA Traditional Birth Attendants
  4. 4. OPERATIONAL DEFINITIONS COBERS Community Based Education Research and Service CTRR HIV Positive result Depo Provera An injectable contraceptive Environmental surrounding Circumference or influences Immunization Rendering immunity Malaria A tropical disease contracted from mosquito bites leading to the presence of protozoal parasites in red blood cells Nutrition The process by which food is ingested and assimilated in the body. Population Number of people living in an area at a particular time Sanitation Use of measures designed to promote health and prevent disease VDRL An antigen test for syphilis
  5. 5. SUMMARY Gulu University situated in Northern Uganda is spearheading community transformation with its motto “for community transformation” and the mission of faculty of medicine “to produce highly competent human resources for health, conduct high quality health research and provide effective community services in order to contribute to a healthy and productive population appropriate for community transformation”. Also through the introduction of community based education research and service (COBERS) sites, the Faculty of Medicine sends fourth year medical students to Health Centre III/IV facilities within Northern Uganda to do community clerkship and have experience with the rural Ugandan setting. Two medical students were sent to each health facility and to Madi Opei Health Centre IV in particular for community clerkship for a period of 5 weeks (April and May 2013). The purpose of community clerkship is to equip the medical students with the clinical skills and to nurture our desire and responsibility to “give back” to the people less fortunate than themselves as they strive to improve population health and transform the communities. The program also allows students to learn and practice community research through the introduction of community based education research and service (COBERS). We were able to attain clinical skills by clerking patients, administering treatment, monitoring the patients, general management of common conditions, making outreaches to communities as well as giving health talks. We also had time at the health facility to carry out the research on “Determinants of First antenatal care visit by pregnant mothers at COBERS sites in Northern Uganda”
  6. 6. BACKGROUND Community clerkship is part of the academic requirement for a medical student to acquire Bachelors of Medicine and Surgery at Gulu University. Its goal is to provide students with the opportunity for practical training and learning in the real world situation while providing the most needed health care services to communities in Northern Uganda. Madi Opei HC IV is found in Central village, Kal Parish, Madi Opei Sub-county, Lamwo County, East of Lamwo district in the Northern part of Uganda It is about 28 miles from Kitgum town along Kitgum Lamwo district-Sudan Road. The total Land area is about mostly covered by undulating plateaus and hills. The vegetation type is savannah grassland. The soil is of alluvial type and in some areas especially in the west, its tropical black soil that is mixture of sand, silt and clay. It experiences tropical climate with moderate rainfall ranging between 500mm-1000mm per annum and the rainfall is convectional in nature. According to the 2002 population census, Madi Opei sub-county had an estimated population of 14,722 people. However the population projection for the year 2010 was 16,695 people. The major social services and infrastructure existing in the sub-county include; 6 government aided primary schools, 1 missionary funded secondary school, 1 health center IV and 1 health Centre II (non-functional) in Okol parish among others.
  7. 7. Economic Activities in the sub-county The population is involved in various social economic activities including peasant farming with a percentage of close to 96%. Women are mainly included in small scale farming, domestic work and small scale agriculture related business. Agriculture receives support from NAADs and NUSAF. Other economic activities include; brick laying, seasonal hunting, firewood selling, rearing domestic animals, small scale business, carpentry and joinery, fishing in river Aringa, lumbering(on small scale), charcoal burning and sale, selling of liqor. Water sources in Madi Opei Sub-county TYPE NUMBER FUNCTIONAL NON-FUNCTIONAL Borehole 58 50 8 Shallow Well 0 0 0 Dams 5 2 3 Springs 0 0 0 Hand-dug Well 0 0 0 Valley Dams 0 0 0 Some villages however don‟t have access to clean water for example Pama village, Okol parish has no single borehole and they are at the moment depending on river Aringa.
  8. 8. MADI OPEI HEALTH CENTRE IV It is the only public health Centre IV in the sub-county. Staffing at the health unit: Human Resource Professional staff Approved staffing Norm Position currently filled Gap(s) Medical Officer 0 01 Senior Clinical officer 1 Senior Nursing officer 01 Public Health Nurse 1 01 Nursing officer(Nursing) 1 01 Nursing officer(Midwifery) 1 01 Nursing officer(psychiatry) 1 Enrolled psychiatric Nurse 01 Enrolled nurse 1 01 Enrolled Midwife 1 01 Nursing Assistant 1 01 Clinical officer 1 Ophthalmic clinical officer 01 Health inspector 1 Public Health Dental officer 01 Laboratory Technician 1
  9. 9. Assistant Entomological officer Assistant Health Educator Anesthetic officer Anesthetic Assistant 02 Theatre Assistant 2 01 Laboratory Assistant 1 Cold chain Assistant Health Assistant Dispenser Sub-total 14 Support staff Account Assistant Stores Assistant 01 Health information Assistant 1 Office typist Driver 01 Askari 1 Porter 01 Cleaner 2 02 Vaccinators 2 Office Attendant Sub-total 6 Total 20
  10. 10. Infrastructure The health unit comprises of the following infrastructure:- Premises  A block which houses OPD, ANC clinic, pharmacy and clinicians‟ offices  A block which houses the triage Centre.  A block which houses in-patient department comprising of three wards, minor theatre and Labour suit and Records room and vaccine and drug store and the Young child Unit on the verandah.  A block which houses the Laboratory.  A block housing the ART clinic and TB clinic  A block housing the theater  A block housing the isolation ward.  2 incinerators  1 placenta pit Others  1 borehole  Ambulance services for obstetrics cases (complications during labour) and other emergencies. Staff Quarters  5 blocks, each has two units and each unit has two rooms for the nursing and other support staffs  one self-contained 2-bed roomed house for the resident doctor and  Semi-permanent Grass-thatched houses (about 19 in number)
  11. 11. Activities carried out at Madi Opei HC IV On arrival at the facility, we were warmly welcomed and escorted to our place of residence formerly occupied by Medicins Sans Frontiers (MSF), which seemed comfortable. We got acquainted with one senior midwife, an enrolled nurse and a nursing assistant with whom we saw the patients over the first few days. During this time, we also got acquainted with our residence and the trading Centre. We underwent orientation in the second week about the general health unit system/activities. We made our duty Rota which we started using from the 2nd week up to the last week, after consultation with the in-charge and the various departmental heads. We rotated in the major departments of Out-patient, In-patient, laboratory, immunization, Maternity and the HIV/AIDS Clinic following a rota we had designed. We generally participated in all the facility programmes but key to note here include: OPD, IPD clerkship/ treatment, family health days, PMTCT follow up for pregnant and lactating mothers and immunization outreach activities. Our outreaches targeted the Villages of Guda in Pobura Parish, Lubiri-wigweng in Pobura parish, Malech in Kal Parish, Central in Kal parish and Kalala in Kal parish. Out-reaches done on Sabbath days were done in collaboration with UNICEF and are named Family Health Days (targeting people from churches and mosques).
  12. 12. Generally the health Centre carries out the following; o General in-patient and out-patient care o Voluntary counseling and testing for HIV o HIV/AIDS care and treatment for children, adolescents, and Adults including ART, septrine prophylaxis, Post Exposure Prophylaxis, etc. o Prevention of mother to child transmission of HIV. o Maternal child health services (ANC deliveries, PNC family planning services) o Immunization o Laboratory services o Therapeutic and supplementary feeding services o Minor surgical procedures including safe male circumcision o Health education o Participated in generating, recording and updating data in appropriate HMIS registers in the health facility Some of the out-reach activities done include. o Immunization o School health programs o Home visits including follow-up of TB patients o VCT, HIV/AIDS and support including ART o Supplementary feeding o Support supervision of lower level health facilities and supervision of VHTs. o Measuring of MUAC to access for malnutrition
  13. 13. Common conditions (According to the hospital records and observation) The top ten disease conditions in the HSD are:- 1- RTI (Upper) 2- Acute diarrhea 3- Skin conditions 4- Pneumonia 5- Intestinal worms 6- Malaria 7- Dysentery 8- Oral conditions 9- Epilepsy 10- Trauma and other miscellaneous conditions Rare conditions 1. Tetanus. 2. Nodding syndrome. 3. Snake bites etc.
  14. 14. ACHIEVEMENTS (OUTPUT) Out-patient department MONTH MALE FEMALE BELOW 5 YEARS TOTAL April 281 544 297 1122 May 211 328 235 774  Conducted health talks on the management of common conditions like use of ORS in treatment of acute diarrhea, use of mosquito nets.  Educated pregnant mothers on the benefits of early enrolment for antenatal care and problems of late attendances  Clerking of patients, carrying out minor surgical procedures like STS, I&D, injections, wound dressing In- patient Department: April 2013 ITEM NUMBER ADMISSIONS 99 REFERRALS 10 DEATHS 0
  15. 15. May 2013 ITEM NUMBER ADMISSIONS 80 REFERRALS 07 DEATHS 0 HIV/AIDS CLINIC report (2012) Number of clients newly enrolled on ART 30 Number of clients who come for septrine refill 640 Number of clients who come for ART refill 261 Number of infants attending EID 57 Number of infants newly enrolled for EID 12 Number of infants transferred from EID to chronic care 3 The HIV/AIDS clinic works separately from the health facility but under the same management. Patients tested and proven to be HIV positive are counseled and eligibility for HAART treatment done by the staff. Some of the measures used are CD4+ counting with machine provided by the government. We were each on the A-clinic for about 5 days and did HIV/AIDS counseling and testing plus administration of drugs.
  16. 16. MATERNITY ANC and Maternity Reports as for march 2013 a) HIV counseling and testing: HIV counseling and testing of new clients 160 Number of pregnant women counseled, tested and received HIV test Total: 150 CTRR: 07 Number of women who knew their HIV serostatus before 1st ANC visit. WHO: 05 b) HAART administration during pregnancy: Number of mothers given AZT + sdNVP for PMTCT in ANC 05 Number of mothers given AZT/3TC + sdNVP in PMTCT in ANC 00 Number of mothers receiving full HAART 02
  17. 17. c) Labour and Intensive care: Total number of deliveries Total: 22 CTRR: 5 Number of women( new clients ) tested during labour and delivery 00 Number of clients who received AZT/3TC and swallowed NEV during labour. 04 Number of clients who swallowed NVP only during labour 03 Number of clients who initiated EBF within 1hr of delivery 07 Number of given NVP suspension at birth 05 d) Post natal care for mothers: Number of women tested and received results during PNC( new clients) 00 Number of women tested HIV positive during ANC 00 Total number of women who received any method of Family planning post-partum 26 Number of HIV positive women who received Family Planning post-partum. 04
  18. 18. Family planning for the month of March; METHOD NUMBER COCs 07 Depo provera 50 Copper T 04 Condoms 11 Implanol 08 Total 80 We conducted normal deliveries in the supervision of nursing officers/mid wife, managed common cases like abortions, Malaria in pregnancy, neonatal septicemia, Anemia in pregnancy, carried out immunization of neonates. Family planning techniques like implants, IUD‟s, Depo provera injection, contraceptive pills and male condoms. We delivered health talks on PMTCT, feeding, malaria prevention. We also vaccinated the mothers against tetanus, examined the mothers. Also distributed folic acid, malaria prophylaxis NB: The above data results are estimates from observation and patient records, and should not be used as references.
  19. 19. IMMUNISATION BCG 28 OPV 60 DPT+HepB+Hib 50 Measles 23 Tetanus 27 Vitamin A 37 Deworming 23 NUTRITION In-patients Therapeutic Care New admission from 19th April to 15th May 2013……………………………….….3 Outpatient therapeutic care Clients under care of OTC from 29th April to 15th May 2013 .......………………….10 THEATRE Major procedures: None Minor procedures: o Debridement and wound care …..……………………… 03 o Incision and Drainage ………………………………..… 04 o Medical male circumcision …………………………..… 00 o Total ……………………………………………………. 07 NB: The above data results are estimates from observation and patient records, and should not be used as references.
  20. 20. ROTATION AT THE HEALTH UNIT We rotated in the different departments for easy work and maximum achievements and switched after two weeks as follows: Weeks 1 and 2 OPD, IPD and ANC Clinic Maternity Weeks 3 and 4 AIDS Clinic, IN-PATIENT and Theatre Other activities for example emergencies, ward-rounds, out-reaches, maternity care and environmental activities were randomly done. Note: We could however freely rotate in any department at any time.
  21. 21. Organization of clinical work at the facility Duration (weeks) Activities Objectives Achievements Hindrances Supervisors 1 Briefing and orientation at the unit. Starting clerkship at the unit. Integration into the system Managing and monitoring of patients Well oriented, and integrated into the unit None Ms. Acayo Edinah (In-Charge) 2 Collect data on social demographic issues. Give health education to mothers about care for children on ward and at OPD on how to prevent common diseases Clerkship and start community out reaches Data was attained Health talks at OPD, ANC, and on ward were given. Well done No outreach due to fuel Site supervisors
  22. 22. 3 Make community visits Active participation in ANC Determine utilization of F/P and MCH services at the unit We had an outreach to Lawiye Dul P/S Family Health days with UNICEF Walking 6Km to and fro to give services Mr. Bongomin Ms. Sharlon and Ms. Miriam 4 Immunisation, HIV/AIDS Counselling and Testing To acquire necessary skills. Well done None Ms. Pasca Note: Any free time was used to collect research done on “Determinants of ANC utilisation by pregnant mothers at COBERS sites Northern Uganda” „Family Health Days‟ every Sunday were done at churches targeting people who have come to attend Sunday services. This is a program going on all health centres under support from UNICEF. Services offered include: Immunisation, vaccination, health talks, family planning and deworming and assessment for malnutrition. Three of these out-reaches were done under supervision.
  23. 23. OUTREACH PROGRAM School Health We carried out an outreach to Lawiye-Dul Primary School and Kwon-Choc P/S where we offer free HIV/AIDS counseling and deworming We conducted a health talk on relevance of Tetanus Toxoid (TT) vaccination to a group of about 30 girls from this school after seeking permission from the school authorities. Common diseases found among the students (from health Centre records) were Malaria, Upper Respiratory Tract Infections, skin fungal infections (ring worms) diarrheal diseases etc. According to our findings, students at Lawiye-Dul school have access to safe drinking water from a borehole but poor sanitation around the school compound. Health promoting activities in the Community We delivered health talks in Malec, Guda and Lubiri villages in Kal parish on environmental health, After doing a survey together with the VHT‟s and community leaders in the villages with special interest in the number of households with pit latrines, number of households with mosquito nets, bushes around homes, hand washing practices .In the event, we briefed them on the findings of the survey. Thereafter we went on to sensitize them on the importance of using mosquito nets, drinking safe and clean water, and use of pit latrines. The session was interactive as we got their views, of which some were right and others we had to correct.
  24. 24. In summary the following activities were conducted;  Sensitization on diarrheal diseases  Demonstration on appropriate hand washing, making tippy taps and latrine covers using cheap and locally available materials.  Finding out and sensitization on prevention of common diseases  Latrine coverage Results of the survey in Guda and Lubiri villages Village Popula tion No of Households Latrine use Latrines under constructions Bathing shelter Drying rack Refuse pit Hand washing Safe water source Lubiri 250 57 23 9 20 25 08 12 02 Guda 165 36 27 5 07 10 04 09 01 Community Diagnosis From the results of the survey in the table above, Lubiri had poor latrine coverage (57 households having 23 latrines). Refuse pits were also few implying that there is poor disposal of wastes. All the above were attributed to overcrowding hence shortage of space. The level of hand washing was low for both Lubiri and Guda possibly because of lack of a safe water source as indicated in the table above. The common conditions found were diarrheal diseases in children, respiratory tract infections, fungal skin infections and reproductive tract infections in women like Vaginal Candidiasis.
  25. 25. RECOMMENDATIONS o It was suggested that the sub county should allocate some land for construction of pit latrines and digging pits for proper waste disposal in Lubiri. o There was need to repair broken down boreholes and construction of protected wells and bore holes. o There was also need to sensitize the community on routine hand washing practices. o In order to curb the common conditions, the community was advised to take every disease condition experienced to the health centre in time and adhere to the treatment. CHALLENGES MET DURING THIS COMMUNITY CLERKSHIP University  Lack of funding and inadequate supervision by the Lecturers.  Poor accommodation at the Centre. Health Centre  Untimely request for drugs and delay in delivery of drugs.  Understaffing leading to work overload.  Inability to conduct outreaches in distant communities due to shortage of means and fuel.  Language barrier that necessitated an assistant to translate most times
  26. 26. WAY FORWARD The health Centre management should consider timely request for drugs and more staffing from the Government. CONCLUSION Community clerkship/ placement provide a great opportunity for medical students to discover what happens beyond the class and town life. We had a wonderful time and interaction with the patients at Madi Opei HC IV which helped us see other determinants of ill-health other than the biology (that is poverty or the socio-economic life of a patient). Reviewed and corrected by: Mr. Bongomin Richard (Health Inspector Madi Opei HC IV) “FOR COMUNITY TRANSFORMATION” Cc. Own copy Cc. Department of Public health Gulu University Cc. Madi Opei Health Centre Cc. Sub-County Chief Madi Opei