Hospital Life

Despite only having had my medical registration for two weeks, I had actually been “working” on Ward 1 for several weeks before that. “Working” meaning doing the ward rounds with the Sierra Leonean medical officer, reviewing patient with them, making management decisions, sending children home. Basically everything apart from actually signing prescriptions and doing procedures.

Having now got my registration I can now (ethically and legally) sign prescriptions and have managed to put in a total of one cannula (the nurses put in most of them, they just get a doctor if they’re struggling).

Ward 1
Ward 1 is for the more “stable” children. There are usually about 50 patients on the ward to see on the round, which is hard work. No one really gets a proper clerk in when they are seen in emergency…. So there is a lot of guesswork going on… The main diagnoses are “severe malaria”, “severe malaria with severe anaemia”, “diarrhoea with severe dehydration” and “severe pneumonia”. Also the occasional sickle cell crisis (accompanied by severe malaria) or “query meningitis”. Also we’ve recently had a measles outbreak. The lack of proper clerk-ins and proper history taking is frustrating. Frustrating also as, without an interpreter, I can’t do a full history (although I can get by with the basics of fever/vomiting/diarrhoea/etc). It would all be a lot easier if they got a proper history taken by whoever sees them first!

There are some great nurses on ward 1 although they’re terribly disorganised. The crazy pharmacy system doesn’t help – the doctor prescribes the medication on one drug chart, the nurses on the ward round copy this onto another bit of paper, which the doctor then signs. The nurses take this to one of two pharmacies and pick up a supply of medication, supposedly to last two days. The parents keep the drugs (and needles and syringes…) in a bag by the child’s bed so you have to check whether they’ve got enough every day. Then when the nurse actually gives the medication they write out a whole new list on a completely separate chart! Its absolutely mad and I have never come across a child yet who has had their full amount of prescribed drugs given to them. Its so sad when we do actually have the drugs here!

FrustrationsLast week I moved onto ICU. Or at least partly moved onto ICU. After we finally finished that ward round (at 2pm – the medical officer was 2 hours late…), Johnny the nurse from ward 1 came to find me and said there was no doctor on ward 1 at all and could I come to see those patients!

(Just to clarify here – I am not on the medical officers’ rota, and the idea is that I am supposed to be working WITH them and not INSTEAD of them (we’re into “sustainable” development here) – there are enough of them to cover a ward each).

It was somewhat soul-destroying and I asked him to triage their sickest patients and take them to ER to be reviewed by a doctor. The following day (a Muslim holiday) I was sure there would be no doctor covering ward 1 so went back there. Although most of the children hadn’t been seen in a shocking 4-5 days (!) thankfully most were fine and I got to send a lot of them home.

With my limited Krio it takes me much longer to see patients than the doctors here (and I’m much more thorough too – although obviously I’m biased!) so the ward rounds are soul-destroyingly long. Its really really hard work being on the wards all the time – its very hot and sweaty. I also have to do something I never have before – to check that the children are actually getting the medical they are prescribed! It’s a bizarre (and really really sad) thing, seeing quinine written up twice a day and finding they haven’t received it for 36+ hours.

I enjoy seeing the individual patients though and get the instant reward of being able to treat them and although the mortality figures are shockingly high I have been involved with a few little miracles, which keeps up the morale.

An Inspiring Afternoon
Last week the Welbodi team directors were here visiting from the UK (The Welbodi Partnership is a UK-based NGO working to improve standards of child health care in ODCH by providing equipment, training and developing the postgraduate paediatric training system). I joined them and one of the SL medical officers (Ish) for a brainstorming session on ideas to reduce child mortality. The mortality rate is currently about 13% for the whole hospital, 34% for SCBU. It was a really inspiring session and brilliant to get Ish’s point of view on everything. He has just passed the first part of his postgraduate exams and he helped to set up Welbodi, along with a British medical student (now ST1 in paeds).

We then went for a wander around the slum behind the hospital. Unbelievably grim it was. Open sewers everywhere, you really had to watch where you put your feet! Houses so tightly packed together, flies and mosquitoes all around. Lots of open fires. Its no wonder we see so much malaria/TB/diarrhoea/burns. We met with the chief and sat with him and a number of others and asked their opinions of the hospital. They had so much to say about the hospital and it was so interesting to hear from them directly. They had concerns that, even though health care is supposed to be free, they were still being asked for bribes by the nursing staff! They also felt they were not treated with respect and their concerns dismissed unless a child was in extremis. It was really interesting (and sad) to hear all their points of view and how vehemently they expressed their opinions. These people were certainly not apathetic about their children’s health and health care!

Some Interesting Stats (pulled from the WHO Sierra Leone Country Cooperation Strategy Paper 2008-2013)
Sierra Leone ranks as the least developed country in the world, based on its 2007 Human Development Report ranking of 177 out of 177 countries. The country is extremely resource poor. With a GDP per capita (PPP) of US$ 700; it ranked 102 out of 108 countries in the Human Poverty Report, with Human Poverty Index (HPI) of 51.72. Nearly half of the working age population engages in subsistence agriculture.

With an under-five mortality rate of 267/1000 live births, Sierra Leone has the highest
under-five mortality in the world, and malaria is the number one cause of deaths. For the entire population, malaria burden is very heavy: malaria cases were more than 500 per 1000 population in 2003 and about 330 per 1000 in 2007. The disease accounted for about half (48%) of all outpatient consultations, and remains a major threat to socioeconomic development. In children under five years, the disease accounted for 50%-60% of all admissions, and about a third of the children may die (case fatality rate of between 16%-33%).

HIV and AIDS are fast becoming threats to social and economic development in Sierra Leone. The national sero-prevalence survey conducted in 2005 estimated a rate of 1.53% compared to 0.9% in 2002. The highest prevalence among women occurred in the 20-24 years age group (2.0%) whereas males between 35-39 years had the highest prevalence (3.5%). Prevalence in urban areas was 2.1% compared to 1.3% in rural areas, and about 47% of the total numbers of infections were new infections.

The burden of tuberculosis is increasing in Sierra Leone. Between 2004 and 2007, the number of registered TB cases in the country almost doubled, in spite of a case detection rate of about 50% (the WHO target is 75%). This is further complicated by the recent emergence of multi-drug resistant tuberculosis (MDR-TB). The TB/HIV co-infection is also an issue of concern: the prevalence of rate TB/HIV co-infection is 11.6%. However, the defaulter rate has been declining and the treatment success rate has increased, from 83% in 2004 to 87% in 2007.

Sierra Leone is ranked as having the highest under-five mortality rate in the world, with almost one out of every three children dying before reaching the age of five.
The trend has not changed significantly in the past eight years. The three main causes of under-five mortality are malaria, diarrhoea and pneumonia and they account for
over a quarter of all childhood deaths. Malnutrition plays a significant role, as 57% of the deaths would not have occurred if the children were not malnourished. Neonatal death accounts for 20% of the overall under-five mortality rate, an indication of poor quality care during labour, delivery, and immediate postnatal period.

Medical Registration - Finally!

So, on Monday I finally got my medical registration. And what a shambles it was!

I left home at 7.30am in the rain and got a taxi to Aberdeen to the VSO office where I was going to meet Theresa (the VSO the health programme manager) at 8.30am (I was there by 8am) to give me and two other new doctors a lift there. Theresa and the driver were there so I suggested that we go to the hotel where the other doctors were to pick them up, seeing as they were en route anyway. It turns out that Theresa had not informed them that she was going to pick them up at 8.30am and one of them was still in bed! Bless him he got up and was ready in about 5 minutes.

So we got going across town, stopping at my flatmate Carole’s office on route because Theresa had bizarrely left the application forms for Tash and Alex there on Friday – without telling Carole or me about this….

We got to the SL Medical and Dental Council Offices, met the lovely Registrar (who had worked in Ramsgate, it turned out) and were told that, despite us having given VSO our documents and photos goodness only knows how many times, the Council had STILL not been given the required number of any of our documents. My CV had somehow gone missing in the process of it all. (In preparation for this, I had taken my USB with me…) The Registrar got very confused by the Latin on my degree certificates… but we eventually persuaded him that they were a medical and science degree!

By then it was evident that Theresa would have to go back to the VSO office to get more photos of everyone, so I went with her. I printed out my CV (again, times 3) while there and personally counted out all the copies of everything before we left.

Back to the Council. In the meantime, Tash and Alex had already been interviewed. It turns out that they then waited for the third British doctor (me) before interviewing the Philipino and Dr from the DRC…. He said it was just a formality and that he knew we were well trained, that there is a fee of $500 but that was not my problem but that the Ministry and VSO would have to fight it out between them, and thank you so much for coming to volunteer in our country. He was one of the nicest people I have met here so far. And he confirmed that, yes, I can now practice, and the bit of paper will follow in two weeks time (I’ll believe that when I see it, but anyway!)

So Tash, Alex and I thought we would head to Bliss for lunch (it was lunchtime by now). We stopped off at my house on route to pick up my laptop so that they could check their email. Bliss is up the road with all the roadworks and it took us a while to get there, only to discover – its closed on Mondays! So we went a bit further away to a place at the beach – also closed on Mondays! We finally found that Mamba Point (the place that does the films on a Tuesday night) was open, so had lunch there…. Which was v nice and well deserved we thought.

The Sierra Leone Medical and Dental Association 36th Annual Congress

Sandra, Fred (the Welbodi doctors) and I were invited to attend the opening ceremony of the SLMDA annual congress. We arrived at the stated time (and found out we had to pay for the privilege of being invited to attend….) and sat around waiting for another hour or so before it actually started…. It was an impressive affair. Loudspeakers boomed out Paul Simon music and we were greeted at the door by my lovely medical students. The seats were covered (as if at a wedding) and there were some impressive decorations at the “top table” where the important people sat (no bride and groom, although the chairperson did keep announcing which young female junior doctors were “available” to the young male junior doctors! )

It was certainly an "interesting cultural experience", as my friend John (an ophthalmologist) put it. The chairperson invited every Old Boy in the Network to stand up and have their own personal round of applause. To be fair, a) there were a few women and b) these are doctors who had gone abroad to do their training and then actually come back to Sierra Leone to work. I was quite surprised to see how many doctors there actually are in SL – although most of them work either in the Ministry of Health in a managerial/public health capacity or work in private practice.

The obligatory drug company sponsorship was ever present – we even got presented with a laptop bag full of leaflets advertising benylin cough mixture, various ACTs (artemisinin combination treatments) and clexane. Also included were a pen and a bottle opener/key ring in one. Sure they’ll come in handy sometime.

We had a number of different talks from various speakers including the registrar of the Medical Council – yes, the one I am supposed to register with, if anyone in either VSO or the Ministry would get around to organising it for me…. He reminded everyone present why it is so important to be registered and why it is also important to renew your registration each year. My thoughts exactly. So it turns out that most of the doctors in the country aren’t officially registered. And yes, they’re still practicing….

A few more talks later and the Congress was officially opened by the Chief Medical Officer, who was standing in for the Minister for Health. There was a musical entertainment on the programme but unfortunately they didn’t turn up…. At the end all the junior doctors who had qualified since 2007 (which included most of our doctors from ODCH) got to stand up and introduce themselves to the rest of the crowd, and get their own applause. Don’t think that would happen at the BMA annual conference somehow!

Bunce Island
A couple of weekends ago all the hospital NGOs (Welbodi, Cap Anamur and VSO) hired a Pelican water taxi and went to visit Bunce Island – where the old slave fort was/still is although very run down. For those of you who have seen the film Amistad – this is the fort that the good old Brits blow up at the end of the film after the abolition of slavery. We had a great journey and then were shown around by the caretaker – in fluent Krio! Luckily Sandra could translate what we couldn’t understand. After a really interesting tour we headed back to the buzzing traffic of Freetown and off to Alex’s at Lumley beach for dinner and drinks.

Weird and Interesting things in FreetownSo the Chinese have decided they are kindly going to make the main road out the west side of Freetown into a dual carriageway. In principle this is a good idea; the traffic is dreadful and the current road is full of potholes. In practice it means they have had to knock down large chunks of walls, buildings, peoples’ front rooms, even a great restaurant has been knocked down! (we are reassured that it will open again soon as the kitchen is still standing!) So now there are piles of rubble all over the place by the road and the West side of Freetown looks like Beirut. Or maybe people in Beirut would say that their city looks like Freetown (meaning I shouldn’t make judgements on places I haven’t been – as so many people make judgements on SL – like thinking there’s still a war going on – which there isn’t and hasn’t been for 8 years!)

I was in a supermarket earlier in the week and saw some imported magazines and newspapers! I stood astonished for a moment, then realised that The Sunday Times was actually from August! And cost the equivalent of £5. I think I’ll make do with the BBC webpage to keep me updated from time to time…

Another weird thing was probably us! Beth (another VSO) is a qualified yoga instructor. She arranged a class for us last Sunday so some of us did yoga on the beach as the sun was going down. It was just so relaxing, but also really funny as we had crowds watching us, and a few people also who joined in!