Upama Banerjee
The Global Links programme at the Royal College of Paediatrics and Child Health (RCPCH) offers many different projects across the world. I was open to going anywhere that they felt was suitable for me, and as someone who has always enjoyed Neonates I was placed on the Rwanda Neonatal Care Project (RNCP), a project run by RCPCH Global but funded by UNICEF. I have always wanted to work abroad in a low resource setting so I applied for an RCPCH Global project in my ST5 year. I knew I wanted to go abroad after having had one year as a registrar under my belt, although retrospectively I didn’t think this was essential. Applying for the Out of Programme Experience (OOPE) was a straightforward process, and since you are directly dealing with RCPCH, they are accustomed to providing any relevant letters needed by your deanery for your OOPE.
Applying for the Out of Programme Experience (OOPE) was a straightforward process, and since you are directly dealing with RCPCH, they are accustomed to providing any relevant letters needed by your deanery for your OOPE.
Before leaving, RCPCH Global ran preparation sessions where we were briefed on the project, taught to be instructors for “Helping Babies Breathe” (HBB) and given an amusing session on safety. One key message was: always carry a laminated copy of your passport in your socks! The most important thing was being able to speak to previous volunteers. They provided an insight into what work in Rwanda was like as well as tips on what to pack: key essentials for me being my travel kettle, PG tips, and an 800g Jar of Nutella!
Hospital and work
The RNCP’s key aim was to improve newborn survival. In Rwanda, most deaths in children under 5 are in the first 28 days of life. I was placed in Kibuye Referral Hospital, which is a small hospital next to Lake Kivu. Although there was no such thing as maximum capacity, the neonatal unit had approximately 12 babies spread across the main unit and the ‘KMC’ (Kangaroo Mother Care) unit. My day ran from 7am till about 5pm and typically I spent the morning running ward rounds with the nurses and doctors and then doing clinical work/teaching in the afternoon.
When we first arrived, there was often a propensity to immediately start chest compressions on a flat newborn baby. We therefore spent a lot of our time teaching midwives HBB and creating ‘resus’ areas, focusing on the importance of drying the baby and bag-mask ventilation. As a consequence, newborn resuscitation changed dramatically within a few weeks and many of the midwives we trained became mentors themselves. This empowered them to make sure the resus areas were stocked with the relevant equipment needed. By the end of our placement, the midwives were running simulation sessions for each other.
Newborn resuscitation changed dramatically within a few weeks and many of the midwives we trained became mentors themselves.
Once a week, we had the opportunity to go to health centres to provide teaching – most babies in Rwanda are actually born in health centres rather than in hospital. These can be many miles from the hospital and take a few hours to get to. The nurses working there really enjoyed these training days, particularly the hands-on teaching that we provided as often they would miss out on the teaching provided in the hospital. As I mentioned earlier, it is actually quite cold in Rwanda and one of the biggest issues we were trying to tackle was hypothermia – in particular for preterm babies admitted from the health centre. Simple measures such as drying the baby, a hat, and skin-to-skin can make a big difference. With limited resources, you soon realise that the medicine isn’t complicated but it’s about using what’s there sensibly.
Each RCPCH Global Links project will have its own individual aims and objectives and the ethos is that the work is designed to be sustainable. It is focussed on long term changes and enabling local staff to make changes suitable for them. Most of our time was spent teaching mentors so that they would be able to continue teaching and training others.
Challenges at work
A lot of our work wasn’t clinical and you get quite savvy at DIY. One of the health centres mentioned to us ‘heaters’ that had been donated. It transpired that all the health centres had been donated resuscitaires but none of these had been assembled, so we spent the next few days in store cupboards of various health centres assembling resuscitaires. We certainly had to be creative in other ways too. The unit was tiny, so we had to really think about how we used our space. One of the most frustrating things was with donated stuff – sadly there is no point giving fancy equipment if it can’t be used. We discovered packs of breast pumps, which were thankfully not being used as they would have been a breeding ground for infection.
My 6 months working in Rwanda included some of the best and worst clinical experiences I have had as a doctor. My worst experience was the arrest of a baby due to incorrect NG placement, especially as this is a never event in the UK. I will never forget bagging her with milk coming out of the mouth and nose. Another challenge was managing babies with congenital abnormalities – both from a clinical and social level this posed many difficulties.
Despite the challenges we had many successes, in particular improving how closely babies were monitored which resulted in deteriorating babies being picked up quicker. One of my biggest highlights was when the unit successfully discharged its first baby born under 1kg. I still get very sweet Whatsapp pictures of this little one. This success really made the local team realise how some of the changes they had made in their clinical care were pivotal to the discharge of this baby. By the end of our 6 months, we took a step back and the neonatal nurses had taken over the work we had been doing.
As trainees we have limited exposure to the management side of the work that our consultant colleagues do, but trying to figure out a hospital improvement plan and thinking about factors such as staffing, infrastructure, and budgets were skills that I have also gained from this project.
Travelling in Rwanda
Rwanda, known as the Land of a Thousand Hills, is a remarkably beautiful country. In a nutshell, it has stunning scenery like the Lake District, except it rains more. When anyone thinks of Rwanda, they think of the Rwandan Genocide, and whilst this is a key part of the country’s history, it has so much more to offer. In fact, I found Rwanda to be a very safe country to work in and travel around. One of the biggest benefits of being on the project is you don’t have to work weekends or nights! You have the luxury of switching off and doing some travelling. We spent our weekends canoeing (badly), hiking, shopping, seeing gorillas, and walking in rainforests!
Returning home
I had mixed feelings about coming home. I had left my wonderful husband at home so I was looking forward to coming home, however I was equally sad to be leaving Rwanda behind. I was warned from the beginning that coming back is hard from a work and a personal perspective. I was surprised at how hard I found adjusting back to NHS work after my experiences in Rwanda and the disparities and contrast with working in the NHS. I am hugely grateful for the experience and big thank you to the RCPCH Global team, my wonderful colleagues in Rwanda and the fellow volunteers I worked worth. Thank you to Rachel, Tom, Lizzie, Mandy, Hannah, Providence, Becci, and Laura for all the laughs.
Dr Upama Banerjee, ST6 Paediatrics, Chelsea and Westminster Hospital
This is one article in of a series of articles from PaediatricFOAM covering Out of Programme Experiences (OOPE) that paediatric trainees have done. If you have done an OOPE and would like to write about it, please get in touch by emailing paediatricfoam@gmail.com. You can also visit our PaediatricFOAM guide on OOPEs here.
For information about the RCPCH Global Links programme, please visit https://www.rcpch.ac.uk/get-involved/volunteering/global-links-programme or email global@rcpch.ac.uk