20% Mechanically Separated Turkey (Happy Christmas)

“26% turkey, 20% mechanically separated turkey”; such percentages on a tin of meat leave a lot to the imagination and the words ‘mechanically separated’ do little to tempt the taste buds. However, a can of ‘Ye Olde Oak Turkey Roll’ was the best of a mixed bunch of traditional festive offerings in the Kenema supermarket. We did splash out on a tin of Danish ham with a slightly more reassuring meat content of 84%. Once we threw together a few handmade Christmas decorations and crafted a cardboard tree from an old drinks box, our festive plans were complete. Whilst there may be many things we shall miss this Christmas, the simplicity of our preparations and absence of anything resembling a crowded shopping mall is unquestionably refreshing.  

The hospital has sympathetically quietened a little this week and we’ve closed the outpatient department from today through to Boxing Day.  Nevertheless, as with any hospital there are still enough emergencies to keep us in business; unfortunately the increased number of festive travellers and some dangerous road conditions created due to excessive dust and gravel on the half -finished Segbwema –Kenema road have combined to result in a worryingly high number of accidents.

In some ways it has been difficult to get into the festive spirit, but I felt the Christmas atmosphere arrive last week courtesy of some impromptu music in the hospital to help calm a nervous patient.  A young girl was having a procedure performed under local anaesthetic in the operating theatre and had started to become increasingly anxious towards the final stages of her surgery. Fortunately I had my IPod in my bag and we decided to put on some music to help her relax. After a quick search for a ‘Merry Xmas’ album, a stillness descended and we all enjoyed a serene moment of calm and quiet as voices singing ‘Silent Night’ filled the room.

I popped down to the TB ward this morning to see Evelyn and her gang to deliver a food package for the next few days including some fresh beef from the market. Incidentally, we saw the cow from which the meat came being led down through town as we sat having a drink at Victor's bar last night. Although perhaps not quite matured for 21 days, at least we knew it was fresh! (It appears that I’ve come a long way from my vegetarian years as I certainly enjoyed the portion of Daisy the cow which we had for our lunch).

After we re-opened the hospital library we set the student nurses an essay competition on “strategies to reduce the burden of maternal death in their local community” to encourage them to do some research.  Last week we happily began to peruse their entries and I shall end this Christmas Eve by sharing a few of their words of wisdom.  

On the importance of punishing those involved in sex crimes:

“As the saying goes, when the first frog falls into the pit, the others behind will take caution.” (MS)

On the need to work together on health interventions:

“In order to achieve (a reduction in maternal mortality) there must be collective cooperation. That is pregnant women, husbands, neighbours, the youth, the elderly, health workers, drivers and government workers each have a role to play. Their joint contribution in one way or another will help to save lives”. (SK)

On the importance of family planning:

“A father should be encouraged to remember that the community will judge him as much by the health of his children as the number of his children.” (AM)

Happy Christmas!

Magnesium Sulphate, Coke and Other Drugs

Thanks to a generous grant from a UK charity we found ourselves in Freetown a few weeks ago on a ‘drug run’ aiming to initiate a sustainable supply of medicines for the hospital. With 48 million Leones (about £8000) next to me in plastic bags, sitting in a wholesale pharmacy surrounded by packets and plastic containers of several decades of pharmaceutical development, I felt like a child in a toy shop with a year’s worth of pocket money to spend supplemented by a large Christmas bonus. Naturally, as is the way in Africa, it wasn’t quite as simple as turning up with our shopping list, and a number of items on our newly developed formulary were very difficult to locate in Freetown’s almost impenetrable congestion. Adult naso-gastric tubes, thiazide diuretics and blood transfusion bags appeared to be like gold dust. Efforts to secure 100 vials of magnesium sulphate (the precious drug needed to treat seizures in pregnancy that was unavailable on one of my recent night time visits to the ward) involved a “BBC apprentice” style mission consisting of negotiating with the Women’s Centre in Freetown to find their supplier and then abandoning the vehicle and dashing through the stand-still traffic to meet him in a central location for exchange of goods and money before we left town. 

 At some points when rushing around in the suffocating hustle of horns and swarming masses of people that comprise Sierra Leone’s capital city, I wished I had my stethoscope with me. Fortunately, this desire did not come from an unseen medical emergency, but from a craving for that moment of quiet and solitude you get from closing off the outside world as you place a stethoscope in your ears. Perhaps I am not alone in this, but not uncommonly I leave my stethoscope on a patient’s chest for a few seconds longer than is clinically really necessary, just to enjoy that moment of uninterrupted calm, with only the “lub-dup” of the patient’s heart in my ears; in amongst the chaos of hospital life it is possibly the only time when you are rarely interrupted.

Although it has been a significant boost to know that we now have most of the core essential medicines available, the art of medicine is often more complex than finding the right combination of pills. An older woman on the female ward was becoming what one would unkindly refer to as a “heart sink” patient. Each day the observation chart would show everything to be normal, examination was always unremarkable and yet each day she would have a new complaint to tell me about. Although mental health and psychological support are spoken of little here, it was clear that some of her problems may be related to a low mood, not helped by an absence of any visits from family members. I was doubtful that anything from the pharmacy would improve her list of ailments. After a few days of her not leaving the ward or getting out of bed, I decided to bargain with her that if she had a walk outside I would find her a can of coke. ‘You’re all talk and no action pumwee (white person), ’ was her vague reply. However, I was true to my word and went and found a couple of cans of Coca Cola, and she willingly kept up her end of the deal and came and sat with me outside for a drink.  For the first time I saw a glimmer of a smile on her face. In a week that saw me exhausted from not sleeping due to a noisy contractor staying upstairs, half blind from catching a purulent conjunctivitis, and miserable from eating only bread and ‘cheeze balls’ for 5 days after our camping stove malfunctioned and caught fire, I’m not sure whether it was the patient or me who most needed that 10 minute sit on the wall outside the ward in the sunshine with a coke on a Friday morning.

I would be lying if I said that sometimes the daily grind doesn’t get me down and that the tiredness and frustration of seeing the human cost of unmet healthcare need doesn’t upset me, but I know it would be naïve to imagine that I’m the only exhausted worker in the world. This time last year I was working in A&E in London which was an endurance activity in itself. I especially remember a certain sense of despondency on night shifts when colleagues whose shifts started earlier in the day gradually left every couple of hours throughout the night, until 2am when there was only 3 or 4 doctors left working in the department until morning. It wasn’t uncommon, particularly on a Saturday night, for the list of patients on the computer screen waiting to be seen to increase at a faster rate than the team of doctors could cope with, and thus the number of patients breaching the stipulated 4 hour target by the time morning came was sometimes embarrassingly long.  But however bad the night was, there was some comfort in the knowledge that at 8am a healthy brigade of fresh A&E doctors would arrive and within a few hours the department would usually be more respectable; however low you may have felt at 5am, you knew by 10am you’d be at home in bed and someone else would be clearing up the mess. The only difference here is that at 8am nothing changes and there is no cavalry coming over the hill.

Evelyn update: Evelyn came back from the village a couple of weeks ago and so far appears to be making reasonable progress despite the gap in her treatment. Unfortunately she has an ever growing number of patients for company on the TB ward as diagnoses are on the increase, possibly contributed to by problems with continuity of the government’s TB drug supplies.

Tomato update:  Plants are doing ok but since being planted out into old rice bags one or two have fallen by the wayside. Naturally I am suspecting sabotage from my noisy contractor house guest. (Does lack of sleep make you paranoid…?)

To Cut or Not to Cut?

 
As Janna stood over me with a pair of old rusting surgical scissors, previously given to me by a colleague to practice surgical knot tying, I began to consider if, in fact, I really needed a hair cut at all.



The local barber shop

Although I have to confess I have let slip my previous routine of a daily shave before work, my hair was beginning to edge towards a somewhat Neanderthal appearance and I felt both patients and relatives may have a little more confidence in me if I had a trim. I first attempted to have a hair cut not long after we arrived and visited a barber’s shack at the top of the hill outside the hospital gates. The barber’s method of hair dressing was unorthodox to say the least. Instead of using clippers or scissors, he employed an interesting comb-like device into which he placed a razor blade which he used to make repeated small slicing movements hacking away at my hair. After around an hour of painful tugging and the constant feeling that perhaps he hadn’t quite understood what I meant by a ‘tidy up’ I emerged looking probably more dishevelled than I started. Having learnt from this experience, 2 months on I found myself in the Lebanese supermarket in Kenema looking at the two available hair clipper sets; a mains powered one or a slightly cheaper battery powered set.  Anyone that knows my frugal inclination and fondness for a bargain will be unsurprised to hear that I opted for the cheaper version. Predictably, this was the wrong call as when I got back to the hospital I discovered that instead of cutting, the battery powered clippers weakly pulled at the hairs as it glossed over them. And thus I found myself entrusting Janna with the scissors….

Of course in a hospital there are far more serious matters concerning the decision to cut or not. (Incidentally, I am not referring to the widespread practice of an initiation rite performed by secret societies that may affect up to 98% of Sierra Leonean girls and young women; the controversy and depth of secrecy of which means that it is probably appropriate that I only allude to it whilst I reside here).  I am indeed referring to the matter of operations and surgery, which can be a risky business even in the most high tech of healthcare facilities. In my first week here the surgical team performed an operation to the remove a very large football sized fibroid (benign tumour) from a woman. There was much fanfare surrounding this with a line of students queuing up to see the specimen and congratulatory talk of whether this was the biggest fibroid removed in Sierra Leone.  Conversely, there is little excitement or passion for the child slowly dying from preventable anaemia and malnutrition, and there were certainly no trumpets sounding out in celebration after 2 weeks of medical input managed to get a young man with suspected typhoid fever, pulmonary oedema (fluid on the lungs) and kidney failure, a potentially terminal situation, round the corner towards recovery.

Perhaps it is the physical and visceral nature of surgery and operations that maintains the palpable awe that surrounds them and their ability to allow people, whether medical or not, to relate to a visual understanding of the cure of an illness which is seducing. However, one of the most important lessons in any surgical speciality maybe knowing when not to cut; just because something can be done does not mean it should be. Whilst I hope the woman who had the fibroid removed made an informed decision about the possible risks and benefits before choosing to proceed, I imagine there would have been far less back-slapping had a complication arisen, even one requiring relatively simple correctable measures such as oxygen which is not available.

Another increasingly difficult surgical decision concerns whether to carry out a caesarean for a woman in labour. On UK delivery suites there is naturally a relatively low threshold to intervene if there is any suggestion of foetal compromise. However, in rural Sierra Leone, even when accounting for the limitations in how the foetal heart can be monitored, the boundaries are rather different. Subjecting a woman, particularly in her first pregnancy to a caesarean will leave her with a scarred uterus that may well have to endure labour five, six or ten more times, which possibly will occur nowhere near a health facility or near someone trained appropriately to deal with the complications that may arise including rupture of the scar. In addition, the initial operation will have an increased risk of complications due to the very nature of the environment of limited medical resources and expertise that it is taking place in. The consequence of this heightened risk to the mother’s health and life, both in the acute situation and for future pregnancies is that the value placed on trying to save the life of her unborn child through surgical intervention is sadly less than it should have to be.  

Thankfully I have not had too many comments on my new look. At least the difference between a bad haircut and a good hair cut is only 2 weeks; the consequences of an inappropriate operation can be lifelong.

Onc(hocerciasis)ology

When reorganising, de-cob webbing and cleaning the hospital library I pointed to one of the newly labelled sections on cancer and asked one of the first year nursing students, who was helping us, if he knew the meaning of the word “oncology”. Although obviously unsure, to his credit, he gave it some logical thought and said “is it the medical speciality that deals with onchocerciasis?’ (River blindness). Whilst river blindness (a parasitic worm disease transmitted through the bite of black flies)remains endemic in many parts of West Africa, cancer appears something that has little presence both in and out of the hospital. Whilst having the potential to affect anyone, cancer is predominantly a disease of older people and the life expectancy of 48 years in Sierra Leone undoubtedly limits the target age group for many forms of malignancy. Even for those unfortunate enough to be afflicted by the disease, without the facilities of CT scans and laboratories equipped to comprehensively examine tissue biopsies, a definitive diagnosis often remains elusive.

Unlike the valuable “2 week rule” in the UK that ensures patients with a suspected cancer are seen by a specialist within 2 weeks, even a presumptive diagnosis here can take many months. A recent female patient had a ‘mass’ removed from her womb 6 months ago and was told it was probably a cyst or fibroid (benign tumour). She has since attended twice with severe infections, anaemia requiring blood transfusions and a recurrence of her mass. She was referred to Kenema (the nearest government hospital) who subsequently sent her to Freetown. Even without a full set of investigations, her prognosis is questionable.  Without undermining the severity of her illness, sadly, in contrast to other patients who may find themselves in a similar position, she is comparatively fortunate in that her husband has the available finances to be able to take her to Freetown for treatment and pay for hospital bills. A significant proportion of patients I see appear to struggle finding enough money to meet their basic nutritional needs and the uncomfortable reality of having to alter prescribed drug treatment to fit with what money the patient has is a daily occurrence; investigation and treatment in Freetown remains a matter of fantasy for most.

In spite of this, the vocabulary and associated fear of cancer has, to some extent, penetrated even the most rural areas here. I saw a middle-aged (in UK terms, not Sierra Leonean) woman with a hard craggy mass in her breast that she had been observing grow over the last year at home in her village. When we discussed the possible causes of the lump, it was her who volunteered the word tumour and then broke down in tears after I agreed that this was a possibility. I saw her a few weeks later after she returned from Kenema saying that she didn’t have the money to pay for her scan or treatment.

Although, there are perhaps few similarities in the practice of oncology between the UK and Sierra Leone, one risk factor for the development of the disease which appears universally prevalent is alcohol. Not that I wish to do my dear friend Victor (the bar owner) a disservice, for better and for worse alcohol is rooted in daily life and with a 50ml sachet of 43% proof alcohol costing only 500 Leones (around 8 pence) alcoholism is regrettably within reach of even the poorest Sierra Leoneans.  

I hasten to add that our trips to Victor’s bar have become slightly less regular, but this in part due to the frequent evening downpours that dissuade us from venturing down the muddy road. Even if we do squeeze in a drink, we always appear to be trapped in a game of chicken with an impending mass of charcoal grey clouds that ominously approaches us over the ridge at the top of the village, often just as the lids are removed from bottles. The knowledge that you will have to race against the onslaught of a heavy thunderstorm does not make for a particularly relaxing drinking experience!  Although we should be heading towards the ‘dry’ season, the humidity doesn’t appear to be letting up. Even when the rain isn’t torrential there is often a fine mizzle that appears to descend from the skies to the level of your face but be absorbed into the hot dusty air before it has a chance to reach the ground. (How very British, a few months in and we’re back to talking about the weather…)

Incidentally, on the first day of reopening the library we only had one student come in to browse the available literary selection. As in all things, behaviour change takes time. When I was here in 2010 a significant proportion of free malaria nets that were distributed were used to catch fish as people thought this was a more productive use for them. Three years on, thankfully through education, more people use them to sleep under. Hopefully we will increase the library use with time by promoting the benefits of reading.  Thankfully tonight I have just returned from a heartening few hours with a library full of students.

 

Update on Evelyn: When I ventured down one evening to collect her empty pots I was saddened to see her bed empty and the pots stacked neatly on the neighbouring bed. Fortunately one of her fellow TB patients explained to me that she had got fed up of waiting for her TB drugs, supplies of which ran out 10 days ago and decided to venture back to her village to see her family. Frustratingly there is a national problem with the supply of TB drugs in Sierra Leone and daily calls to the district TB coordinator have thus far proved fruitless. Whilst I am thankful that Evelyn now has the strength to travel to see her children, partially treated TB will most probably recur and may be more difficult to manage due to problems with the increasing resistance to drugs.  We have sent word to her village and hope she will return to the hospital soon.

Update on Tomatoes: Doing well. Watering was a problem last week as we were both scared by a fist-sized hairy spider trapped with between the pots in the gap between the shutters and the window but thankfully the creature (George) has now departed. We are exploring the options for planting out but the choices for ‘grow bags’ are a bit limited!

G9 P7 3A

All was not lost and there was really no reason to be upset; after all this was her first pregnancy and she was still young. This was the sentiment expressed by the relatives of an 18 year old girl with eclampsia (seizures) who delivered twins, one of whom had been still born; the other had died two days later. After seven and half months of carrying the twins, it appeared a period of grieving for her losses was not a luxury afforded to her or something that has much place in a society where women expect only a proportion of their pregnancies to have a successful outcome and where surviving pregnancy itself is by no means guaranteed.

On Fridays I see patients sent over from the antenatal clinic run by the two midwives. As with all things in life, medicine is full of abbreviations. In obstetrics G refers to Gravidity (the number of times a woman has been pregnant) and P refers to Parity (the number of times a woman has delivered after 20-24weeks) with pregnancies ending before this time including miscarriage denoted with a “+1 or 2”. For example, a woman pregnant for the 3^rd time with 1 child and 1 previous miscarriage would be noted as G3 P1+1 (a relatively common situation in the UK). One recent patient in clinic came with abbreviation G9 P7 3A. The extra ‘A’ was new to me but I quickly learnt that the midwives used this to convey how many of the patient’s children were still alive. In the UK one assumes that a woman’s children are alive unless anything is written to the contrary. However, here it appears the assumption is that some of your children will have died and the question is how many. So the short abbreviation “G9 P7 3A” in fact represents an untold tragedy whereby  the woman is now pregnant for the ninth time, has given birth to 7 children, only 3 of which are alive. This is not far from average. The human side to such abbreviations is seen readily on the children’s ward. At 6.30pm yesterday, I was called to see a 2 year old who had just been brought in.  Although his mother stated the only problem to be ‘generalised body pain’, one look at the child, who was frantically gasping for breath, indicated his condition was critical. Sadly without the facilities of oxygen or intubation (to breathe for him) he was not long for this world. At 6.58pm there was a new child on the same bed waiting to be seen, the body of the first child had been moved to the end of the ward and wrapped in a sheet, and the father of that first child was having a frank discussion with the nurse in charge about how quickly they could have his corpse for burial. Perhaps the most upsetting aspect is that this is ‘normal’; engrained and expected. There is little interruption to the ward activities; student nurses delicately but quickly cover the bodies of patients that have passed away, nurses continue with their duties and parents continue on with their lives. Sometimes not even tears are shed. At one point last week I was concerned that not even the practical exams for the student nurses that were taking place in the centre of the open ward would be stopped as a man took his last breath. (Thankfully they did decide to have a temporary pause in the proceedings although this was seen as being particularly kind.)  As an outsider I find it difficult to keep the balance between, on one hand, wanting to remain appalled and shocked at the current situation of an almost daily routine of loss of life, but on the other hand, needing not to be so horrified that you cannot function when the next child is carried through the door who needs assessing and treating. I apologise if these ponderings are an outlet to keep that balance in check.



The new shower...

Last month we were in Freetown to visit the medical council. Although our hotel didn’t quite hit the five star mark, it did have a trickle of cold running water from a rusty shower head. To us this was luxury. The simple matter of removing the need for one hand to be occupied with pouring water from a jug to wash improved the ablution experience considerably. Since then I have spent several hours in our ‘bathroom’ in Segbwema trying to construct a ‘shower’ from a 5L plastic container, rope and dental floss; all quality products purchased in ‘Poundland’ before our departure. Those who are acquainted with my DIY skills will be unsurprised to hear that thus far, results have been mixed. A palliative care consultant when teaching on how difficult it is to judge what one person views as “quality of life” once stated to me that quality of life is about how near a person’s expectations are met by the events of their daily life. Whilst a hot shower sounds appealing, when you have no anticipation of any running water, a trickle of cold water from a shower head certainly exceeds expectations and improves your quality of life.  Whilst not wanting to demean the devastation and misery of women in Segbwema who have children still born or who die very young, realising how these events fit with their expectations of pregnancy, child birth and motherhood can perhaps help to understand their perspective on what we, as outsiders, may view as life shattering events and explain the resilience with which they cope. Ultimately, expectations need to be changed but this is neither quick nor simple.



All is not bleak and life here is filled with moments of both enjoyment and humour. I still find it difficult not to conceal a wry smile when male patients seen in clinic do not respond to the translated line of ‘What’s the problem?’ or ‘How can I help?’ but simply stand up and pull down their trousers to reveal enormous hydroceles (swellings around the testicles) the size of large grapefruits. (How childish of me I know...) There is also time to enjoy the simple pleasures of sitting on the steps outside our house drawing with an ever growing gathering of children who have now discovered our supplies of paper and colouring pencils, or walking home down the hill with Amie, the 6 year old granddaughter of one of the nurses who Janna is helping to read, or honing our scrabble skills and successfully placing ‘JUICY’ onto a triple word score (51).  One of the happiest times of the day is early evening when I walk down to the TB ward and see an ever improving Evelyn smiling and enthusiastically returning my wave through the open wooden shutters to the ward.




Shutters of the TB ward

I listened with interest this week on the world service as promising results of trials of a malaria vaccine were publicised. Although such progress is undoubtedly good news, Benjamin Franklin conducted extensive research on electricity in the 18^th century and a few hundred years on the hospital only has the resources and infrastructure to provide electricity less than 10% of the time. I hope it doesn’t take as long to get the malaria vaccine coverage up to this level here.
How fitting, the power has just gone off for the night…..

Baked Bean Curry & Tomato Plants

Even quite a drastic change in environment can soon become normal and life in Segbwema has settled into something almost consisting of a daily routine, even if that routine is one of regular interruptions that mean we are yet to complete our new favourite meal of a baked bean curry in one sitting. This newly discovered feat of gastronomy is made possible courtesy of an overpriced Lebanese shop in Kenema selling imported tins (including baked beans) but it appears that the novel aroma must be a lure for patients as the noise of placing our bowls on the table thus far has been universally swiftly followed by the sound of a student nurse knocking at the door with a new patient’s chart in their hand waiting to be reviewed.



One routine that has proved rewarding is our daily trips with a basket of food to Evelyn on the TB ward. Evelyn is a young woman who arrived at the main hospital several weeks ago. Half blind, emaciated and coughing up blood; she was not a well woman. I am not a fan of descriptions of malnutrition that often try to be colourfully emotive but I can’t imagine this fully grown adult weighed more than 30 kilograms and her arms were not much thicker than broom handles. She was stabilised on the ward and after the diagnosis of Tuberculosis was confirmed she was moved to the TB ward, a separate building situated at the bottom of the hospital compound. Although the separation is designed to limit the spread of the disease, the patients are somewhat isolated and it arguably contributes to any residual stigma.



The TB ward

 Many of the patients appear to improve significantly when their treatment is commenced so I was sadden to see Evelyn looking increasingly weak and frail some days after she had started her medication. Despite my Krio and Mende (the locally spoken languages) only extending to a few words, with the assistance of some signing, she was able to tell me that she had no food and had not been eating. When we returned later that evening with some rice, water and ground nuts she was laying on her bed under a mosquito net supported by wooden sticks and was half asleep. With no particular expectations, Janna returned the next day to pick up the bowl and found a huge smile on Evelyn’s face and possibly the beginnings of a new woman. Like her TB, her malnourishment certainly won’t be cured overnight, and we acknowledge we are by no means a long term solution to her nutrition problems, but at the most basic level having a hot meal inside her certainly helped.  It is reassuring to see that her strength has improved so that now when we go down each day she has carefully washed the bowls and cups and has them stacked ready in the basket.

Life sways between adrenaline filled moments and the benign daily grind. Last night I was traipsing out through the darkness and sheets of rain with my head torch and stethoscope to a pregnant woman with twins who had eclampsia (seizures). However, the previous weekend had been mainly filled up with hours spent washing clothes in buckets, drafting funding applications and labelling new folders for each hospital bed.  So much for the “African dream”; the reality of administrative tasks and household chores appear to be constant throughout the world. Hopefully the new folders will help make the hospital run a little more smoothly, as previously patient notes and drug charts on A4 sheets seemed to be scattered throughout the wards making it difficult on occasions to discern which patient was being treated for what.  It can be challenging to know where to begin with initiatives to improve clinical activities at the hospital, particularly when, at times, even some of the most fundamental ingredients are missing. When I arrived to assess the pregnant lady who had been fitting, there was no catheter available and only two vials of magnesium sulphate, the vital drug which needed to be given every 4 hours to stop any further seizures. (Even these two vials had been personally bought by the midwife.) Perhaps the unexciting hours spent completing funding applications will bear their fruits of a more consistent drug supply and make night time visits to the ward a little less daunting.

 On the first week we arrived I planted some tomato seeds. This was not for any particular symbolic reason, just in the hope that by the time December comes we may have a crop of fresh tomatoes to supplement our diet of baked bean curries. However, as they steadily grow, sitting in their individual coke cans, baked bean tins and empty sachets used for drinking water, they do serve to reflect that in the same way ripe, juicy tomatoes will not appear overnight on the kitchen table, changes and progress at the hospital, however small, will take their time.

Washing Gloves

I stood over the basin in the corner of the operating theatre and washed the blood off my surgical gloves. It was late on a Friday afternoon and we had just finished a caesarean section operation for a lady who had been in labour for 3 days. Normally after surgery you would remove your gloves and gown, dispose of them in the nearest waste bin and wash your hands. Therefore I was a bit puzzled when I was asked to clean my gloves before taking them off. I was soon informed that they would be rinsed further, powdered and then re-used for other clinical activities in the hospital. After a testing few days, one in particular in which 2 adults in comas and 3 convulsing children arrived almost simultaneously, the symbolic washing of a pair of supposedly disposable gloves that had been used only thirty minutes previously to assist the delivery of a new baby somehow summed up the extent of some of the difficulties and resource limitations.

Following the somewhat evident diagnosis of a prolonged obstructed labour the sequence of events necessary to deliver the baby were frustratingly protracted.  Firstly, the small team of theatre staff had to be located, who then had to establish whether surgical equipment used the previous day had been sterilised.  Next, it was necessary for the small generator to be moved to beside the theatre and diesel found to run it to provide power for the operating  theatre lights. The laboratory technician had to be called back to the hospital and finally the patients’ relatives encouraged to donate blood in case of bleeding.  Thankfully after the several hours it took to organise such matters, a foetal heart beat was still heard before going to theatre.

Despite the challenges encountered at the hospital, which at their worst had had me sending my wife Janna out in the middle of the night to buy drugs and drips for patients, there have been some small successes. Both the comatosed patients improved dramatically; one of whom, in retrospect we discovered had taken an overdose of his diabetic medication and simply needed a glucose drip to revive him. The other patient, a young woman,  most likely had cerebral malaria but responded well to intravenous quinine. In addition the three convulsing children were all discharged the following week and both the mother and baby from the caesarean are doing well.

Last weekend we attended a service in memory of the wife of my close friend Victor who sadly died suddenly 2 months ago. Victor is a friendly giant of a Liberian who first moved to Sierra Leone 20 years ago during the troubles in his neighbouring homeland. He is among the most kind-hearted and virtuous people I know, and, given his occupation as the owner of a small ‘bar’ in Segbwema, currently one of the most valuable as he is on hand anytime of the day or night to provide a cold Star beer and a haven outside the hospital compound.  We became good friends 3 years ago and although I did not know his wife well, they were obviously kindred spirits and proud parents to their 4 children, the youngest of whom is now 5. Tragically although they had been together for over a decade they only finally ‘tied the knot’ in a service 2 months before she unexpectedly passed away. With a life expectancy of only 48 years in Sierra Leone, death, even when it is that of a young mother and wife, is an accepted part of life. For a doctor, dealing with patients who do not get better is not uncommon and we become, to a certain extent, desensitised to the trauma of a person dying. Although it may seem insensitive, when I had to confirm the death of a young patient in the night, although I was upset, when I returned to the house I sat down and continued watching ‘How to Lose a Guy in 10 days’ on the laptop (Janna’s choice not mine). For me, the act of listening for a non-existent heart beat was something I have done as a matter of routine both in the UK and in Sierra Leone, but for the patient's family it was devastating and life changing. When I sat in the memorial service for Victor’s wife, even though I was not directly very close to her, this conceivably preventable death of a young mother felt very personal to me and I see the consequences of this to my friend and his family on an almost daily basis.

Victor with his wife and youngest daughter taken in 2010

Although it is necessary to have a certain detachment from the people we look after, sometimes seeing them not solely as patients but as a mother or sister or daughter, both ensures we remain empathetic in our vocation and arguably may allow us to rationalise activities such as sending your “better half” out to the village ‘pharmacy’ in the night for a vial of magic quinine when there is none to be found in the hospital.

Beginnings...

Showering outside in a Sierra Leonean thunderstorm with ‘Original Source’ mint shower gel is certainly refreshing. Somewhat exhausted on Sunday night after another  day  at the hospital I decided to save myself the effort of lugging a bucket of water from the rain water tank to the house to wash and simply stood on the patch of ground outside our front door and let nature and the rainy season do their best to me. It was at this point I thought I’d have a go at jotting a few lines down about our time here so far.

Despite a broken steering rod on the hospital vehicle and the resultant 2 hour delay outside Freetown, our journey to the hospital in Segbwema was smooth in comparison to my first visit to Sierra Leone as a medical student 3 years ago. Although we still had to contend with the unusual city planning that places the airport on the opposite side of a giant river mouth to Freetown, the capital city, at least British Airways successfully delivered us together with our baggage including emergency ‘cuppa soups’, a shortwave radio and a suitcase of medical equipment (unlike Royal Air Maroc who previously lost our bags somewhere between Casablanca and Monrovia…).  The options to cross to Freetown from the airport include a ferry (that has sunk not infrequently), a helicopter (with a dubious safety record) or a day’s drive on an unsealed road. We choose the speed boat on the basis that, given the worst case scenario, we could swim but not fly! Thankfully we remained dry and after a frantic day in Freetown organising the modern day luxuries (or essentials) of mobile phones, internet access and camping gas we departed for Segbwema, a village just over 300km east of Freetown, nearing the border with Liberia.

After two years as a junior doctor in the UK, my wife and I have returned to hopefully spend a year working at Nixon; a small mission hospital that is currently staffed by one doctor and still burdened by consequences of the civil war that ended in 2002. Although undeniably still relatively inexperienced, I hope another pair of clinical hands will be useful. The hospital attempts to provide medical care to a population of 20-30,000 despite having minimal electricity (a few hours fuelled by the generator every other night and on days when operations take place), no oxygen, minimal laboratory support, no x-rays and difficulties with drugs supplies.  And there was me thinking that my prior NHS employer in London had problems…
 

Although not wishing to be over formal, I hope we can keep anyone interested updated on our time here.  I hope you will forgive my poor literary skills and the spelling mistakes that I’m sure will creep in. Although I expect our readers are unlikely to challenge double figures and although I am someone who has only ever flirted with the likes of facebook, I am wary of the implications of documenting anything on-line and thus I hope any critical views expressed are seen within the context of a difficult situation and are not viewed as personal to any parties with interest in the hospital. Of course, where used, patient names are changed.

My first day at work was a long way from my previous experience of NHS inductions with their abundance of power point slides emphasising the importance of closing fire doors. On our way back from introductions with the Paramount Chief at the other end of the village, the current medical doctor passed me in the hospital vehicle on his way to the nearby town of Kenema for a personal matter. This left me as the sole doctor at the hospital with a row of patients calmly sitting on a bench waiting to be seen in outpatients and several wards of men, women and children to muddle through. A World Health Organisation manual usefully helped me stumble through the apparent swathes of malaria, worm infestations and typhoid that seemed relentless. Thankfully the other doctor returned that evening.

The stark realities and very human consequences of trying to practice medicine with limited resources reveal themselves both coldly and bluntly. Imagine a young man brought into the A&E department of a hospital in London. He is sweaty with a fever, breathing rapidly and has a racing pulse rate. His blood pressure is low and his abdomen is distended, rigid and exquisitely tender.  He has been vomiting and has not been to the toilet for ten days. He may have an obstructed and perforated bowel. He needs resuscitation with intravenous fluids, antibiotics, a tube from his nose to his stomach, oxygen, an array of blood tests, x-rays, an urgent CT scan, intensive care, anaesthetic and surgical input and probably emergency surgery.Late one night a man, whose age is not dissimilar to mine, was brought to the ward in the condition just described. He had been deteriorating  at home for over a week and self medicating with local herbs. By the time he had travelled to the hospital he was critical. Unfortunately only the first three treatment items on the wish list above were available to him and he died very soon after arriving. Regrettably, such cases are in no way exceptional.

However, not all patients have such a sad outcome. Of the many sick children with malaria I have seen over my first 2 weeks, one of the first was 18 month old baby Rosaline. She was struggling at 9.00pm in the evening when she was brought to the Children’s ward with convulsions, lethargy and fever. Her conjunctivae and palms were ivory pale from her anaemia and her chest wall was moving up and down very rapidly trying to ventilate her lungs. After advising for the need for urgent blood transfusion and anti-malarials I then had discomfort of witnessing the beginnings of a discussion between relatives regarding whether they had a donor available to give blood or the money to pay for the blood transfusion bag. Although not sustainable, or sensible in the precedent it sets, but with the child in extremis, I loaned the £6 needed to buy the blood bag and giving set. Thankfully one of the relatives had a compatible blood group. The laboratory technician was contacted and within 30 minutes blood donated from the relative was being transfused in to baby Rosaline. Going to sleep that night I knew that, even despite treatment, unfortunately it is not uncommon for such children not to survive.  The next morning I was therefore extremely relieved  to see my patient transformed into a toddler who was revitalized and alert to the extent she could show how terrified of the new ‘pumwee’ (white-person) doctor she was by kicking and screaming at me. As gratitude goes it was somewhat unusual but it certainly left me with a smile.

As the last of the diesel in the generator is burned, our luxurious few hours of power tonight shall soon end and therefore so shall these ramblings.

Ps: The generator has just run out but a trusty head torch will allow me to at least press the 'upload' button.