It's chilly up north (of Sierra Leone)

I'm now waiting in a first class lounge at Euston. The ticket was pretty cheap, so I decided to upgrade. I've never been in first class before so I thought what the heck. I'm waiting for Myroslava to come for a coffee. She's a friend from Canada, met her in Uganda, who's here studying for a Masters in Public Health at the London School of Hygiene and Tropical Medicine - lucky! 

Yesterday's ferry experience certainly wasn't as bad as I'd been preparing for. The usual guys running around you, trying to get commission and tips. The truck that I was getting a lift from only just squeezed onto the ferry deck! The vehicles were packed so close, that two trucks were leaning against each other. I ditched the truck, fearing I wouldn't get to the airport in time as they had a big load of cassava flour to drop off on the way.

I had a barrage of phone calls from friends in Sierra Leone, wishing me farewell which was really nice. I expect them to be 'flashing' (giving missed calls) me on my UK number soon enough. 

Airport faff went mostly very smoothly, even when it transpired that I had overstayed in the country! Oops... my fault really. I was meant to get my passport re-stamped after a month. I'd overstayed by a month! Kinda lucky that I'd learned a bit of Krio, to the surprise of many, and had that meant I'd been put in their good books. They let me off. The lady who was going through my passport recognised me apparently. I just pretended to know her too! She asked for 'a little something' for letting me off, but I said I had nothing but 500 Leones (about 10p). 

The cold cabin on the plane helped to prepare me for the chilliness that refreshed me when I stepped off the plane this morning. Sort of welcome, but at the same time, reminding me of all the layers that I'll have to wear from now.

Adventure. All the way to the end.

I'm sat in a truck on it's way to pick up a shipment of yellow fever
vaccines at the airport. I had so much time to spare at the ferry
port, I couldn't resist trying to hitch a ride for the 15 miles to the
airport on the other side!

Tamba the driver has agreed to the lift for free because he likes
medical people, and he says it's a medical truck. Telling people
you're a student doctor gets you favours at times :) The truck's not
that medical looking. Looks more like a goat transporter or something.

Next to the ferry which we're about to drive on to is a huge rusting
hulk of an old ferry being dismantled. The harbour is full of rusting
relics, consigned to a slow watery decay. They could really do with a
ship building industry here. There's a fantastic deep water harbour.

I met a doctor just now. Private and proud. I couldn't believe some of
the shit he was coming out with! Botswana's HIV problem is due to anti
retroviral medication... What a load of crap. High prevalences in a
country that uses so much medicine that treats HIV?! Had he thought
about it, he'd have realised there were so many people with HIV
because they hadn't died yet (thanks to the medicine)! Conspiracy my
arse.

--
Sent from my mobile device

James Chan
--
e: james.chan.uk@gmail.com
t: +44 (0)7886 237 501
b: jamesonelective.blogspot.com

Last day

There are less than 24 hours until my flight leaves the ground. I hope I'm on there when it takes off.

The airport is situated across a huge river mouth from Freetown. It's 187km by road which takes about 5 hours. Bear in mind my flight takes 6 to reach Heathrow.

Options left:

• Pelican water taxi
• Last time made me feel horrendously nauseous. I've become more susceptible to motion sickness these days. 
• Too expensive at $40
• Takes an hour
• I can try to swim if it sinks
• Helicopter
• It'd be pretty cool
• Expensive at $70
• Takes less than 30 minutes
• I can't fly if it crashes
• Ferry
• Tickets start at 1000Le (20 pence)
• Danger of muggings and theft
• No lifejackets
• It's rusty
• It'll take about 2 hours, but will 2 hours for me to get to the ferry terminus
• It may or may not run on schedule

In the last few days, I've wound down the time spent in the hospital, and really concentrated on writing up my research. I'm quite happy about what I've got. I had a chance to present the findings to a meeting of health NGOs, and Amnesty International who'd just released a (locally) controversial report on maternal mortality and was met with some raised eyebrows and good questions. It was interesting insight into the NGO world - I find it so interesting!

I spent a good few hours yesterday saying bye to everyone I would miss (some not so much) in Kamakwie. Being in Freetown now really made me realise how lucky I was to be able to live in a rural community, with fresh air, and people who had time to form relationships with. I sometimes felt rude being short with people, but you just have to if you want to do a research project. People will always come knocking at your door to just come in and sit down... and watch you work, or they'd sit in relative silence.

A quick once-around the hospital made me smile. The kid in bed P15 was doing better. The 1-and-a-bit year old had come in with a fever, haemoglobin of around 5g/dL (quite low) and had developed very congested lungs at some point too. He had several convulsions on the day of admission. I made sure he got oxygen therapy (two 30 minute sessions per day), and helped him to loosen his sputum and encouraged him to cough by rolling him onto his side. After 3 days, his chest had cleared and was breathing and breastfeeding fine! Only thing was I suspect he had cerebral malaria. He was a bit rigid, and had poor head control, and had that look in his eyes. He may have ended up with a cerebral palsy and possibly epilepsy as a result of cerebral malaria. But he's alive. I saw so many children die from respiratory failure. Nobody before I encouraged it, put children on oxygen. There's one oxygen concentrator in the theatre which can be used when the generator's on so it's limited, but available. First line treatment is antibiotics and antimalarials. Frankly, I don't consider this to be a good standard even with the resources available.

I've done a lot of thinking whilst here, but not enough blogging so I'll continue to write a bit on here even though I'll be back in the UK soon... ugh, 5th year beckons. Not feeling up to it. At least I can be happy to boast I don't have to fill in the dastardly MTAS form for jobs.

Final few things before bed... I think I'll take the ferry.

Things I'll miss:

• The sound of intense downpours and thunderstorms directly overhead - awesome!
• The sound of chirruping insects at night
• New friends
• Groundnuts!
• Red soil
• Doing things by torch/candle light
• No electricity
• Bucket showers
• The handshake
• The wrist shake
• Avoiding emails
• Trying to carry things on my head

Things I won't miss:

• Black ants biting all the way up my leg
• Tripping on big rocks and roots at night
• My dodgy bed and mattress (and a bad back)
• Over genial greetings
• Having to accept food every time it's offered to you
• Expressions of disbelief/horror that I'm not religious 
• 'You're not Christian, so you're Muslim?'
• 'No'
• 'But you believe in God, right?'
• 'Err, not exactly'
• 'So what do you believe in?'
• Taking malaria prophylaxis
• Humidity

About a week to go

With a week to go until I return to Freetown, things are winding down here in Kamakwie. I've been stressing a bit about writing up my research project, and trying to find enough time to be down at the hospital. It feels like I have to be there, as there are so few (trained) people to just keep an eye on the patients!

Ramadan finished last week, culminating in the Rama Jam at the community hall. It was a bare hall, full of sweaty dancing people, lit with a single strip light, music was provided by a local DJ playing Salone dance music. I'll bring some of it back home, it's very catchy!

The end of Ramadan means the food sellers make more business during the day and can get to bed earlier. My regular 'Kukri' (cookery) lady was very happy and made a special soup to celebrate. Here, soup is sloshed over rice and is usually made with fish. I tried some of the special stuff made with various animal organs (oops). I left most of the stuff that I thought once carried stuff out of a body, and just ate the rice.

I've learned a lot about providing healthcare in a resource-poor area, and a bit of medicine too. It's been kinda nice to fall into a routine of morning ward rounds with Dr Tom, Solomon the Community Health Officer student, the occasional American nurse, and the nurses and nursing aides that work at the hospital. Ward rounds pass through the obstetrics, paeds, mens and womens wards and include a pass through the Alpha Project ward for malnourished children. Afternoon clinic starts at 2 and sees minor cases and the odd patient who we deem ill enough to admit. We get by in Krio, with Solomon doing most of the translating, sometimes needing extra interpreters to speak in some of the other local languages. It's the lack of information provided on the patients' records cards that make in confusing though. They have a funny system of having 2 sets of cards (one for inpatient, one for outpatient although some are mixed). One example of inadequate organisation of healthcare.

In the past few weeks, various people have approached me asking for support for school fees. I get the feeling that people are giving me the bags of groundnuts to sweeten me up in a way. I don't blame them for trying, but I really don't have that much to give away! I get into this problem thinking that it's not fair that only a few receive support, and it's those who are lucky enough to have contacts with foreigners and can already speak English.

I may have found something to help support though. A few nights ago, I met a few people from a local youth cooperative who have just organised themselves to run an agricultural project, and plan on other socially constructive projects. I designed a logo for them and have given some advice on budgeting, strategic planning for the future, and some generic 'how to run an organisation' type stuff that I know. They have plans to build up funds to help themselves through higher education, and to create hardship loans for members who fall ill etc. It's quite inspiring to see the local community organise itself to attempt to provide for themselves, to fill in the gaps that the state's supposed to provide - social security and employment opportunities. I set up an email account for them, it's a little strange to see people struggling to find their way around a computer keyboard, let alone use the Internet. I take it for granted that most people in the UK are computer literate and have the skills to use the Internet and get access to all that stuff out there.

Looking forward to coming back home now. I feel as though I've not really spent to much time with family! But it's straight into 5th year, and it's going to be a tough final year. If all goes well, it's less than a year to go until I start work as a doctor... uh oh.

Outamba Kilimi National Park

Last weekend I went to the Outamba Kilimi National Park with a Dutch
medical student friend, Feia, and two of the Health Unlimited field
officers, Samuel and Alusine. The park's about an hour and a half
north of Kamakwie by motorbike. We were all worried about Samuel as he
had raging malaria!

We'd hoped for hippos but everyone said that they all move away from
the river in rainy season. But the canoe ride was fun! Good work out
paddling against the strong current, and happily whiled away the time
singing row row row your boat :) Certainly not quite as fun as the
rafting on the Nile last year!

The whole tourist set up was burned by the rebels during the war. The
decaying stone ruins look reminiscent of the temples at Angkor Wat.
Not because of its architecture, but the way the nooks and crannies
were occupied by plants and green mossy stuff. The replacement tourist
huts were built using DFID (Department for International Development
from the UK), and were all partially submerged in a flash flood a few
days earlier... Uh oh.

We were the second lot of visitors in 2 months as the rainy season
makes the ferry crossing difficult and the roads are fairly jarring.
Plus, the animals all bugger off. In the dry season, one can
supposedly see hippos, elephants, chimps, all sorts of monkeys,
crocodiles, and a hell of a lot of other visiting ex pat tourists from
Freetown. We did come across monkeys at the camp who took to throwing
things down at us from the trees!

There used to be more animals according to Daio, the park ranger. Many
were killed by the rebels for bushmeat, an activity which has now
continued. The consumption of monkey meat is the best theory we have
about the origin of HIV. I wonder what other nasties await us.

--
James Chan
--
e: james.chan.uk@gmail.com
t: +44 (0)7886 237 501
b: jamesonelective.blogspot.com

A bit medic-ed out

Wowser! I’m really feeling quite burned out after this week. It’s been pretty non-stop, with 8.30 ward rounds lasting until 11.30, clinics from 2pm to 5pm, then I’m back in the evenings to keep an eye on the kids mostly. Not finding much time for blogging, finishing my research, or just relaxing. I’m finding that I’m craving a cold bottle of coke each day to get me through the day! Ugh oh…

I’m learning a lot, and there’s a lot more to learn. And not just pure medicine either. As with any patient, clinical and medical science aren’t the only toolboxes used to treat people. The social, cultural, and physical environments play a large role in the treatment of any patient, but over here, they’re very different from the UK.

I’ve seen a lot of very sick young children. 4 have died this week in the hospital. A few things I’ve picked up:

Children are generally at the bottom of the pecking order when it comes to the food. Men eat the best bits, cos they ‘work the hardest’. Malnutrition is widespread and an be very severe, making children more susceptible to disease and reducing chances of survival. This is the ‘hungry season’ when people don’t have a lot of stored food/money available, and food is expensive. Many people eat only 1 or 2 meals a day.

When sick, many patients will first try the local medicine (I haven’t managed to coin a phrase that doesn’t sound like I’m trying to mock it). This is cheaper than going to the hospital. Everything must be paid for here (thank you NHS/‘socialised medicine’). Patients’ families are generally very shy about disclosing use of the local native medicine, or ‘country medicine’. They have denied its use despite seeing the remnants of herbs smeared on the patients. This may be because healthcare staff scald them about using it, embarrass them, and adopt a very ‘told-you-so’ attitude.
So, patients are often delayed.

The management of healthcare: you can’t blame poverty for everything. I’ve seen that there can be miscommunications, mistakes, and poor organisation. There are no drug charts by the bedside, no whiteboards to give ‘at-a-glance’ views of patients, and there are very real language barriers (Krio, English [British and American], Limba, Temne, Susu, Fullah, uncommunicative). Patients’ records are basically small index cards, leaving little room for expanding on histories, and making clear procedures that have been ordered etc.

There are a lot of things that can be done that require little money, but could make a big difference in morale, efficiency and communication – all vital for safety and healthcare delivery. You can’t just throw medicines, equipment, doctors and nurses at people and hope for the best. There have to be good systems in place that can make full use of all resources for patients’ safety (first do no harm), and for effective treatment.

There are reasons why many of those seemingly straight-forward things aren’t in place. In the past, local wannabe doctors used to come to the hospital, look at drug charts/patients records, and remember how they were treated, so that they can treat patients illegally outside of the hospital. Emergency drugs are locked away, and access given only to very few people – not because they want to make life difficult for emergency patients in the middle of the night, but because they will be stolen and sold. Sometimes by healthcare staff who make a pittance and want to boost their salary.

I promise a less medicy entry next.

Hospital

I started work in the hospital on Monday, and as expected, in the ward
round was tiring in the humidity, and was tough for me to get back
into thinking medicine. After so many weeks of real medicine, I'd
forgotten most of it!

Many things made it different from a ward round in the UK. Of course,
it's still the doctor trailing his team around the patients, checking
on their latest test results and routine examinations, but with
interpreters, and what I felt was a lack of a warm bed-side manner at
times – hard due to the language barrier and sheer number of patients
to get through. Because of that, I made an extra effort to smile at
the sometimes nervous, often scared-looking patients, and greet them
good morning.

There are 5 wards: paediatrics, obstetrics, men's medical, men's
surgical, women's, and there's an extra little Alpha Project room for
malnourished kids. There's one operating theatre, a lab that can do
quite a few tests, a non-functioning X-ray machine, and certainly no
canteen facilities (patients often go for days without food due to
lack of funds or family to help prepare it). No food = poor recovery.
This is something that is often forgotten by medics I think – basics.
At 5pm, after the outpatient clinic (which is like a GP surgery), the
doctor, the student Community Health Officer (Solomon), and I were
called to see a little baby boy, CJ, who was in acute respiratory
distress. He was gasping for air, not alert and quite limp. He was
previously admitted with a haemoglobin of 2.7g/dL. A kid of his age
would be classed as anaemic if his haemoglobin was below 9.5g/dL For
those who don't know, haemoglobin is what carried oxygen around inside
red blood cells. When you don't have enough haemoglobin, we call it
anaemic. 2.7g/dL was said to be "incompatible with life" according to
the doctor. We were not sure why he was struggling to breathe, we
thought it most likely mucous from a chest infection. His lungs
sounded like they were full of water.

A is for airway

I gave him a jaw thrust to open the airway as much as possible, to
make every gasp of air as worthwhile as possible. Surprisingly, some
staff hadn't heard of a jaw thrust before.

B is for breathing

Normally, he'd be given oxygen – a lot of it – but no oxygen is
available here. No oxygen concentrator, no oxygen tanks. Oxygen is the
first thing you think of in managing any patient. We took him for
nebulised bronchodilator therapy (vapourised medicine to open his air
tubes as much as possible). There's no electricity in the wards, so we
had to do this in the lab. His oxygen saturations (the proportion of
haemoglobin in your blood carrying oxygen) had gone from 80 to 97 from
this alone.

C is for circulation

He'd been transfused with donated blood already, but no test was
called for to have his haemoglobin checked again. Even if he had 100%
saturated haemoglobin, and he only had a quarter of the normal level
of haemoglobin, he may as well have bled ¾ of his blood away – there's
just not enough oxygen going around his exhausted body.
(His post-transfusion haemoglobin wasn't checked at all.)
DEFG is for don't ever forget glucose.

Well, we forgot glucose. Actually, I'm not sure if we did or not,
because I don't think we have the equipment to test for it.
I asked the ex-pat American nurses to do some physiotherapy to clear
some of what I thought to be mucous out of his lungs. Blood started
coming out of his nose instead, and we then thought he had pulmonary
oedema. Fluid from his blood leaking into his lungs causing him to
effectively drown. Some of the expert local nurses managed to
cannulate his hand (put a tiny tube into his vein) so we could give IV
furosemide (a medicine to make his kidneys drain fluid from his body).
He pissed pretty much straight away, and was saturating at 100%.
Breathing was laboured, but seemed much better.

I agreed to come back at 7pm to give him nubulised saline treatment,
to help him breathe better with humidified air, and again at 9pm,
whilst the generator was still on.

At 7, he did a lot better, and mum was OK.

At 8, doctor check on him, said he was doing good.

At 9, I came back to find him a lot worse, mum sobbing. As babies do,
they seem fine for ages, then they suddenly everything crashes. He was
breathing faster, shallower (probably extremely acidotic), cold hands
and feet. I called the doctor to bring the equipment to check his
saturations. I did a jaw thrust for a good while, then tried to help
clear fluid out of his lungs.

He went limp in my hands. I lay him on the bed, mother started
wailing. No pulse, called for the nurse, and I started CPR.
Before the doctor arrived, he was pronounced dead at 9.09pm.
I've never had to deal with death like this before, and never done CPR
on a baby before.

I comforted the mum, but nothing I said could help her now. The family
live far away, out of phone reception, so it maybe that the mother
will have to carry him back herself.

So much more could've been done. All those things that you learn about
in medical school… but a lot of those tools aren't available.