Buluba Hospital – September 2019. Report by R. Hoare and C. Groves
Returning to Buluba Hospital with a fellow radiographer, Cassie Groves, our primary focus was to assist in improving the current darkroom facilities, implementing a more robust patient flow to include clinical guidelines, radiographic requests, radiation safety, image production and quality assurance.
After introductions to the old and new team members, we paid our first visit to the x-ray room. With the arrival of the first patient we were able to observe the entire process from the current acquisition practices , film processing and patient departure. We were delighted to see Moses had been joined by a second member of staff in Xray who is a certified Ugandan trained radiographer,called Esther.Upon completion of a 2 year course, Ugandan radiographers independently undertake Ultrasound,MRI,CT, interventional work and plain film radiography.
With no internet available in the visitor accomodation, the evenings were spent reviewing what tools we had between us that could compliment the current services and how best to assist in implementing any changes over the coming weeks.
These changes included implementation of a simple Red dot scheme, patient ID check process, exposure guides including film sizes, what to include on the film and how many views based on the patient being a trauma case or OPD referral. Room cleaning charts, radiographer opinion slips and chemical changing charts were some of missing record keeping required within the xray room.
Implementing record keeping New viewing area layout Wednesday mornings are dedicated times for CPD/CM presentations given by doctors, clinicians, nurses and visiting specialists. Staff are encouraged and expected to attend and are used as a means for hospital staff collaboration. Provided with the opportunity to participate in these sessions we used the time to give presentations on a variety of topics. One of the most commonly mis-understood subjects was radiation protection and personal safety, so these became our first and probably most useful talks.
Several student nurses now felt encouraged enough to bring their patients to the room where we discussed the use of lead coats, patient gonad shields, thyroid shields and the simple act of standing behind the concrete viewing wall during exposures. Qualified nurses led by example and provided impromptu radiation protection advice within their areas of work.
Presentations and practical sessions included: Radiation safety Manual Handling Infection control Anatomy review of the appendicular skeleton Common trauma fractures as seen in X-ray TB affects as seen in chest X-rays. With no radiologist on site we relied on training/interpretation presentations available on-line. The expertise and knowledge of the two senior physicians was greatly appreciated by us.
Radiographer Training. The rainy season took its toll; and on the 5 occasions when the mains power was down, we shared our knowledge on a variety of topics based on requests of the current radiographers and our observations in the x-ray room.
• Radiation protection for staff and accompanying family members.
• Patient ID check protocol review • Imaging of the appendicular skeleton.
• Pediatric and adult chest anatomy including image acquisition and the relevance of inspiration views. • Imaging the shoulder and the importance of the second view.
• Common fractures and how to acquire 2 views without the use of a rotating tube head.
• Normal bony anomalies seen on x-rays • Infection control with a view to TB,leprosy and basic room cleanliness. • Lumbar spine anatomy and imaging. • Implementation of a rudimentary Red dot system
• Skull radiography and positioning.
• Abdominal films and whether an erect or supine should be taken.
• Patient dignity in view of lack of changing gowns and facilities.
• LMP checks and implementation.
Some of the earlier films were of a poor diagnostic quality for a variety of reasons including the current processing method and the shortage of skilled servicing . Access to the specialised engineers and funding resources, as they are, it remains an area for future development.
Manual processing is still the only method available and with limited control over the darkroom temperature , chemical oxidation and film agitation we faced many challenges in standardising the film quality. With chemical purchase costs so high, the chemicals are not replaced as regularly as required and often a small volume of new chemicals is added to the old, as a way of further minimising costs, whilst extending their use. Good communication between the radiographers became evident as exposure factors changed significantly with the mixing of the chemicals, and this impacted on both the processing time and resultant image quality. We devoted our time to creating a more accurate exposure chart, including guidelines for adapting as the chemicals age.
Practical training for skull image acquisition and lateral images of long bones proved challenging however, after long discussions we managed to compensate for the lack of equipment versatility and barring horizontal beam laterals for fractured hips, we were successful. Armed with a second dark room light, replacement bulbs and a donated external ventilation fan, the old viewing/processing transformed into a safer and more work friendly environment.
The hospital generator it is still not capable of maintaining the xray service during power cuts and during this trip we had patients who simply had no choice but to travel 1 ½ hours to the nearest facility. Those without the necessary funds or the need of immediate treatment often opt to do nothing and return home. On one of our sortee’s to the stores department we scoured every crevasse with the mission of finding a radiopaque mattress and immobilisation pads. Following a good clean and quality test film patients can be xrayed in a little more comfort and positioning is much easier for the radiographers.
Ultrasonography is probably the second most utilized diagnostic screening tool, for patients after the laboratory. A noticeable service improvement is the access to the 5-day a week ultrasound service together with the engineering developments allowing the scanner to operate on either the mains or generator power supply. This continuous service is providing support for the clinical decisions made by the doctors in a much more timely fashion. Patients with obstetric complications and general abdominal complaints are the majority of requests given for scans with one in three deliveries being a cesarean birth. Esther spent 90 percent of her time in the ultrasound room due to the high patient volume. One of the challenges discussed was the comprehensive knowledge required to accurately report on scans without access to a radiologist or team member. Fortunately, we were able to provide comprehensive training resources in the form of powerpoint presentations and the gold standard literature used by Sonographers in both Eire and England, which was generously donated by Michelle O’Connor. We found that our limited time and funding meant we were unable to accomplish all of the tasks we wanted to complete. Those included providing an operational outdoor safety light, installation of the erect bucky film holder and erecting the spare viewing box in theatre. The wonderful on site electrician and engineer tasked themselves with completing these jobs in our absence. Moses and Esther were happy to continue with the implementation of a basic Reject analysis program as well as on going student nurse training in radiation safety and manual handling for x-ray patients.
We would like to thank The Rotary Doctor Bank of Great Britain and Ireland for arranging our visit to Buluba and providing all the funding. We would also like to thank all the generous donors who supported our visit, without whom we could and would not have been as successful in our endeavors. Special thanks are likewise due to the many individual staff members in Buluba for their kindness and generosity with a special thanks to Father Joseph (Executive Director) for facilitating our many requests for help.