Cleanliness

Infections are the leading cause of death in children with cancer in Bangladesh.  When children receive chemotherapy, it significantly reduces their ability to fight infections; illnesses which would be mild in a healthy person can be life-threatening.  

Chicken pox is still prevalent in Bangladesh, as there is no universal immunization program, leading to frequent exposure in children with cancer. When a child with cancer develops chicken pox, chemotherapy needs to be stopped, delaying the cancer treatment and increasing the risk of relapse. In these circumstances, I have no choice but to watch, wait, and hope that the child is able to recover. Treatment is limited to support with antibiotics and antiviral medications; we don’t have access to the much more effective (and expensive) treatment which is available in Canada.  (If you needed a reason to get your child vaccinated against chicken pox, hopefully this convinces you!)

Better management and treatment of this vulnerability to infections is a priority for the BSMMU project in Bangladesh, as this could significantly improve survival rates. The good news is that most of the infection prevention interventions are not expensive or technologically complex. Meticulous hand hygiene practices by health care workers, parents and children themselves have the potential to make a big impact. Unfortunately, getting everyone to wash their hands more often is a lot more difficult than it sounds. Even in developed countries, we are still figuring out how to get people to wash their hands when the should. A recent session with the nurses revealed that they know exactly when the SHOULD wash their hands, they just don’t do it! Doctors, it turns out, are even worse.

That is not the only challenge to ensuring hand hygiene is practiced. There have been several times in the past 6 months, when the ward ran out of alcohol based hand sanitizer for weeks!  What is striking is that no one else seemed that concerned; when I asked why this had happened, I was met with ambivalence and shoulder shrugging. I still don’t fully understand what was the reason why we ran out. One of the senior residents tried to convince me that we shouldn’t bother filling up the dispensers more than once per day, as the dispensers will just get empty again quickly because parents will use more cleanser if we refill it more often!

The recent ward cleaning day has been followed up by a program to more closely supervise the activities of the cleaning staff; making sure that they wash the floors several times per day and don’t just sleep all day. We have also undertaken a cockroach eradication program, coupled with much more strict enforcement of rules prohibiting the storage of food on the ward.

Randi, an American volunteer nutritionist, is running a weekly hygiene education session for parents. This session explains the unique risks for children with cancer, emphasizing the importance of hand hygiene, safe food handling practices and avoiding anyone who is sick. We have teamed up with Unilever to provide bars of soap to all parents who attend the session.

Poster explaining the system for where to place different types of waste.  Until recently the cleaners were sorting everything by hand, including  needles!

I recently ordered 100 bottles of this alcohol based hand cleanser.  Every parent will get a bottle when their child is admitted.

The changes are slow and painstaking, but we are making progress.

Playroom Opening Ceremony

The playroom has been up an running for several months.  On Thursday we held a small opening ceremony to officially open the room.  Heather Cruden, Canadian High Commissioner to Bangladesh, attended at the chief guest as well as the Vice Chancellor of BSMMU.

Heather also distributed welcome packs to all the children on the ward.  Thanks to Dr. Loutfi's contribution for sponsoring these!

Here are a few photos from the event as well as a short article which was printed in the Financial Express.


http://www.thefinancialexpress-bd.com/2014/08/08/49309

Handing out welcome packs!

Heather with the medical team from the department.

With the nursing team.

With all of the playroom volunteers!

Toy Distribution for Eid

Here are some photos from yesterday's toy distribution on the ward.  You'll recognize the first little girl as she was given a toy during the an earlier toy distribution in April.  Her name is Jim and she's doing well with her treatment for leukaemia.  She's getting bigger!

All the children received new pillowcases, which are made by a Brittany, a young girl in Australia who had cancer and now make the pillowcases to encourage other kids with cancer! https://www.facebook.com/pillowcases4oncologykids

Playroom!

Play therapy is now happening 2-3 days per week at BSMMU!

The playroom is finally finished!  Last week Gwen decorated the room with beautiful wall stickers, some of which were donated by TinyMe.  Play therapy is now available with volunteers 2-3 times per week!  The kids and parents now understand the routine: remove shoes and wash hands before entering the playroom.

At first we had a lot of tears whenever a child had the leave the playroom as he or she would want to keep the toys, but now everyone seems to better understand the routine. Every couple of months we do distribute gifts of toys to all the children on the ward.  These are toys which are donated and but aren't suitable for the playroom: stuffed toys or those that aren't durable enough for repeated use.

Hot air balloons to brighten the walls.

Putting stickers on the glass doors, so that no one walks into them!

Underwater scene on the ward.

Jungle scene above bed 12.

Vist to Sylhet

This week, as part of the World Child Cancer visit, I also visited Sylhet as this will be another satellite centre.  Afiqul, Karen and I taught a workshop on pediatric cancer and palliative care while we were there.  The visit was very well received and we have invited 2 pediatric junior doctors and 2 nurses from the pediatric ward to come to BSMMU for a 1 month training period when they can work on the children's cancer ward and receive extra training.  At this time there are no pediatric cancer specialisits in Sylhet, there are only pediatricians who are doing some cancer treatment.  This is not ideal as they don't have sufficient specialized knowledge and training.  We hope that this one month training will be the start of more detailed and indepth training to improve the quality of care which is being provided in Sylhet.

Unfortunately we didn't get to visit the ward as our visit was cut short due to flight delays.

Here are some photos from Sylhet.  This was my first time travelling outside of Dhaka in Bangladesh!

Getting off the plane, 2 hours late!

Driving to the hospital, through tea plantations. 

Speaking at the Workshop on Childhood Cancer

Some of the workshop attendees; local paediatricians.

Afiqul making a passionate speech about ensuring that all children with cancer get access to the highest quality treatment available.

Walking back across the runway to board the plane home, also 1 hr late.

Visit to National Institute of Cancer Research and Hospital

Along with the visit to Dhaka Medical College, we visited National Institute of Cancer Research and Hospital (NICRH) to also help launch them as a satellite centre.  Despite the name, this hospital is unfortunately very limited in their ability to treat children's cancer due to the fact that they have only 4 inpatient beds.

They treat mostly patients with solid tumours (as opposed to leukaemia and lymphoma) as these patients don't require hospitalization as often and can receive most of their treatment as outpatients.  Secondly, this hospital has a strong team of cancer surgeons, which is vital for the appropriate treatment of solid tumours.

In general, the treatment of most solid tumours in children involves chemotherapy to shrink the tumour followed by surgery to remove as much of the tumour as possible, followed by more chemotherapy to kill any remaining cancer cells which may not have been removed by the surgery.  Sometimes radiation is also used after surgery.

It's very important for physicians and surgeons to work together for the best chance for cure in these cases.

Unfortunately this doesn't always happen. t recently saw a child with neuroblastoma, a tumour of the nervous system, which is generally located in the abdomen. In this case the child's tumour had spread to the area behind the eye, which is a common place for neuroblastoma to spread. Because there was swelling and protrusion of the eye, the child went to an ophthalmologist, who mistakenly supposed the swelling to be an eye tumour and so removed it. Sadly without chemotherapy and removal of the primary tumour in the abdomen, the child will have no chance of cure. Ultimately, children with this advanced stage of neuroblastoma in Bangladesh, as it is very difficult to treat once the disease is this advanced.

Talking at the Doctors' Morning Meeting at NICRH, Tim is emphasizing the important of coorperation and avoiding 'territorialism'.

Touring the ward with Dr. Olia. Unfortunately the children's beds are on a ward with about 30 adult patients.

More of the ward.

Kids' beds had bright green sheets in honour of our visit.

Visit to Dhaka Medical College

As part of the World Child Cancer project, we are expanding the network of hospitals which treat children's cancer in Bangladesh.  I visited Dhaka Medical College Hospital with a team from World Child Cancer to see their facilities and meet with hospital administrators as part of these efforts.  At this hospital there is a children's cancer ward, with 17 beds as well as 4 newly opened paediatric palliative care beds in the palliative care unit!

Meeting with the director of Dhaka Medical College

On the ward

Spinal tap room.

The ward.  This hospital used to be barracks for the British Army!

Brand new palliative care unit, I'm very jealous.

Play room, staffed by a full time 'play lady'

More about the Picnic

The Canadian Club in Dhaka decided to host this picnic to encourage all of the families who are treating their children to continue, to celebrate the children who have completed therapy and to recognize the contributions of the staff.

We had a barbecue lunch, followed by games, art activities and a clown.  At the end we had a small award ceremony where we thanked all of the hospital staff for their hard work and dedication to helping treat children with cancer. We were very fortunate to have Arif Hafiz, a local professional photographer, who donated his time and abilities to document the event.

I plan to print some of his photos of survivors which will be printed and displayed on the ward at the hospital with a small biography of each child.  These stories and photos will help to encourage families whose children are on treatment to continue, and reinforce the message that cancer is curable. There is still a huge misconception amongst the general public in Bangladesh that cancer is not curable in children.

World Child Cancer Children's Picnic

Today we hosted a picnic for all the families of children with cancer and the staff from the hospital.  There was a barbecue, games, art and a clown!  The kids had a great time.

Here are a few photos from the event.

Getting off the bus outside the Canadian Club. 

Playing on the tennis courts after the rain finished.

Yaun the clown was definitely the highlight!  He is a French clown visiting Dhaka.  I wish he could come visit the ward, but he's leaving in 2 days.

Play room progress

After 3 meeting with the Architect and his team, work has finally begun on the play room.

First there was a meeting with the Junior Architect to discuss the design. Then there was a meeting with the main architect to confirm the plan and negotiate the price.  During this meeting we agreed to a price and a time frame for completing the work. I specifically asked if he needed a cash advance, as this is quite common in Bangladesh, and I was told no.  Five days went by and no work had been done, despite a promise to start immediately. The next day the Junior Architect came to the hospital and told me that in order to start the work, he'll need an advance of $250! Why didn't you tell me this a week ago!  

Yesterday, when the painters finally arrived to start work, the space was still full of junk and furniture.  Furniture which I had been assured would be moved out of the space 2 days ago. The furniture did finally get moved and the painters got to work sanding and priming.

Now my next task, making sure that the glass windows and new sliding door get installed correctly.  Somehow I've become more than just the department's palliative care doctor, I am also construction supervisor!

I'm hoping that the play room will be done before the World Child Cancer team visiting from London arrive next week. At least the walls will be painted!

The play room with the furniture moved out.  Walls are painted.  Now for the new door and windows.  The new door and wall will start from where the painter is standing and will serve to enclose the space and allow it to be locked. The play room needs to be locked except when the play therapy volunteers are present, otherwise it will get dirty and all the toys will be lost.