Motivation

What is it that motivates us? What motivates us to go to work? What motivates us, or inspires us, to keep going when things are tough?

Because things are very tough here in SL. There are so many barriers which keep nursing and medical staff away from work. Transport (and particularly traffic) is tricky. People work six days and week and the medical officers get no annual leave. Banks are only open 8.30am-3.30pm and there are no ATMs so you have to go during work time. The hospital has lost four medical officers since I started working here in September (there were eight previously so now everyone is unbelievably stretched). Hospital staff is employed centrally by the Ministry of Health and Sanitation so the hospital management currently have no ability to hire the staff it wants or to fire staff members who don’t come to work or are consistently late.

The most difficult thing for me is that children die. Every day. Every day children die. It is so so difficult to keep going and keep positive when children are dying all the time. (Granted that I spend a lot of time in ER and ICU where the sickest children are, and not the general wards where they are getting better).

So I’ve been asking some colleagues what is it that motivates them. What keeps them going when things are so tough?

The staff nurse on ICU is one of the most motivated people I know. She is a pleasure to work with. I asked her what makes her so determined. “I imagine that it’s my child lying there sick, and I think how I would want the nurse to treat my child” was her answer. I think this a lot at home, especially when people are being rude or impatient. And no matter how bad my day has been, it is ALWAYS worse for the patient, and the family.

A student nurse, also incredibly motivated and hard working told me that her mother was a matron and that her mother inspired her. That, and a desire to know more, to learn, to be able to progress in her career and life (and perhaps, sadly, move away from SL, as most of her family are in the States).

Another nurse answered that she enjoys the patients, likes learning about interesting diseases and likes the “instant rush” of being able to help patients and make them better. Another said that she has a sense of duty to be here.

One doctor told me he is motivated by his religion, his faith in God which has led him to help the people of Sierra Leone by training to be a paediatrician and continue working here. He also, very sweetly, said he was inspired by the international staff working here who have come to help his country (it’s always nice to be appreciated so thanks for that Ish!).

Many are motivated by money, or simple survival. The other NGOs have used monetary incentive schemes to encourage nurses to come to work on time, as a top up to their meagre salaries. Many nurses still (unfortunately) try to charge the patients money for certain things.

Others are motivated by career progression and the respect that it brings. It’s a hierarchical society and Respect is a big issue in this culture.

A lot of people (at home) wonder what on earth possessed me to uproot my life, leave my husband and my comforts of home for a year to live in a place like Sierra Leone. And, believe me, I often wonder the same thing myself. So what was it that brought me here? What is it that motivates me? That keeps me going into work every day, when I am not being paid to be here? And what is it that I’m actually doing?

So what brought me here? My parents worked abroad in the Solomon Islands when I was a child. They have always inspired and encouraged me. Eleven years ago I did my student elective in Malawi, and I always always wanted to go back to Africa, to work here and to try to make a difference. I studied parasitology and went to conferences at medical school with the amazing inspiring people who are part of Medsin (Medical Students International Network) and I never ever let go of that dream. My lovely husband has been unbelievably supportive with the whole thing.

And what keeps me going? I suppose the answer is a mixture of all opinions of my colleagues – I find the medicine very interesting, I get a great buzz from being able to help the patients who get better and I try to empathise with the patients – how would I feel if were my relative who was sick, or me? The “its always worse for someone else” guilt. My faith is also very important. And there is always hope for the future – when a child you think is going to die turns the corner, when you see some amazing team work in ER, when the medical students say that they want to do paediatrics. And finally, my colleagues – local staff who keep going despite the odds, and the incredible international staff I work with (you all know who you are).

I still don’t know what I’m doing sometimes, in terms that I often don’t know what I’m achieving or trying to achieve in the long term. (Reducing child and infant mortality in Sierra Leone is the overall VSO goal but I know that’s too big for me to do on my own. And we can go over the Aid Debate in another blog). But at the moment all those things and people that inspire me are going to keep me going. And the difference I’ll make, if any? I’ll answer that at the end of the year.

Mum and Dad’s Visit

I’ve had a lovely few weeks as Mum and Dad braved the “Battle of Lungi” (as my Dad nicknamed it – the epic journey to get to Freetown from the airport in Lungi) to come and visit. It was brilliant having them here and we had a very busy two weeks (punctuated by them having time to swim, chill out and generally do nothing in air-conditioning!).

Burn’s Supper
(Warning - This is the I love IMATT and anyone in a uniform paragraph).

Mum, Dad and I were invited to wonderful IMATT for Burn’s Supper. Dad kindly agreed to play his electronic bagpipes to pipe in the haggis, which was much appreciated by all. I’ve never seen so much haggis, neeps and tatties all on one plate (we also had a starter of prawn bruschetta, a trifle for pudding and biscuits and cheese (REAL cheese – not laughing cow) with coffee!). We also had the usual traditional poetry readings, and a fantastic Immortal Memory and Toast to the Lassies. As usual everyone was incredibly hospitable and a very fine night had by all.

Banana Island
The morning after we went off to Banana Islands. Actually three islands named Dublin, Rickets and Mes Mieux in the shape of a banana. We met lots of people from Freetown and had lots of time to catch up, read, swim in the Atlantic, eat yummy Atlantic fish and “lobster” (its actually crayfish) and drink illicit wine (from the duty free shop in Heathrow). We also got invited to a “Secret Society” meeting with a scary Dancing Devil (strange cultural aspect of SL – no foreign person actually understands these Secret Societies and the people who dress up in strange outfits so they are unidentifiable and dance around to collect money from people). It was quite bizarre – clearly not put on for the tourists – and everyone was drunk on palm wine and Guinness so we retreated back to the guesthouse.

While I was at work decompressing tension pneumothoraces and teaching resuscitation skills, Mum and Dad went to Tacugama Chimp Sanctuary for a night and Bunce Island with Freya and her Mum and godmother. They also got a chance to visit the hospital and appreciate the “interesting” journey we get to make every day (“Interesting” is the word Dad chose to describe SL whenever anyone asked him what he thought of it – which I translated into “crazy, mad, undecipherable, hot, sticky, slow, busy, amazing, friendly, dusty, mad, mad, mad….!)

Makeni and Kabala
The following weekend we took a long drive up-country to visit Makeni and Kabala. We stayed in MJ’s Motel – where David Beckham stayed in SL, no less – and had a good tour of Makeni courtesy of Cheryl. Next day we drove up through some very impressive scenery (mountains appearing out of nowhere!) to Kabala, where we visited Connie and Lavan, two British VSO GPs who’ve just arrived. We had a great wander around the town (too hot and not enough time to go climbing the hills – but I’d love to go back) and for a drink in Choices Restaurant (dubiously named – I don’t think there is much choice in Kabala!) Thanks to all the VSOs for showing us around your towns!

The following week they spent chilling out at Country Lodge and Hamilton Beach and I was mucho impressed with their new-found abilities to get a taxi into town AND back again. It is quite an effort to do ANYTHING here so to do this journey is really quite something.

Celebrations!
In the meantime Sandra picked up seven new oxygen concentrators for the hospital and Mum and Dad had taken out a new water pump with them – meaning we had a celebratory day delivering new gifts (and hopefully in the long term will save more lives with clean hands and a higher FiO2!) We also had some lovely meals out, including a great meal with Cat and the Welbodi’s at Mamba Point!

I realise it is a massive effort to come here and to be here (SL is not set up for tourists in any way, shape or form) so thank you so much for coming and for all the presents you brought out and for all the lovely protein meals, real cheese and the pint of milk!

The X-Ray You Should Never See

Last week I decompressed a tension pneumothorax in a 4 year old boy. This child had been admitted the week before with a week’s history of fever, cough, breathlessness and reduced appetite. His notes document widespread crackles and hepatomegaly and he was treated for severe pneumonia, malaria and then for pulmonary oedema. Three days ago an X-ray was requested. The following day he went off to Connaught Hospital (about 2 miles away from our hospital) with no oxygen and got his x-ray. Yesterday his family picked up the X-ray from Connaught. The medical officer showed me the x-ray – left sided pneumothorax with mediastinal shift. Eeek! This is the proverbial x-ray you should never see, and it was taken a full 24 hours before! Sure enough his signs now fitted the x-ray but amazingly was not haemodynamically compromised. With a somewhat large audience, I decompressed the pneumothorax with the biggest cannula I could find (a blue one!), heard a reassuring “hiss” and attached it to an improvised underwater seal. Clearly this was only going to buy a bit of time and we don’t have proper chest drains, or suction, or underwater seals, or X-Rays, or very much oxygen. The medical officer contacted an NGO hospital (who have access to all the above) and he was transferred there. I was so happy to hear that he has now got a chest drain in situ and is doing much better.

Resuscitation Scenario Training

We held resusc scenario training for the medical officers last week. It was the second time we’ve done this and it was a lot of fun. They really got into the swing of things and stimulated some good discussion about hypoglycaemia, documentation, communication with parents and nursing staff and handover to other medical staff. I had fun being the instructor while the medical officers also (seemed to) enjoy the role-playing. I’ve found that I really enjoy teaching and training medical staff, nursing staff and medical students. There are so many simple things that, if done well, could really make a difference to paediatric care (and child and infant mortality) so I’ve really been keeping to the basics when teaching to try to improve quality of health care. However its one thing telling someone something and another to actually get them to do it when I’m not around….!

Perinatal Morbidity and Mortality Meeting

We held the first ever perinatal morbidity and mortality meeting last week. It was great for the paediatric department (doctors and one SCBU nurse) to meet with the midwives from the maternity hospital (unfortunately no obstetricians could make it). It was very interesting hearing of the problems which the midwives have. No paediatricians attend the deliveries here so midwives do the resuscitation of newborn babies. With current procedures they then need to take the baby to be registered before taking the baby to SCBU or ER! As a result of this meeting and communication between staff, hopefully this will change. The mortality rate in SCBU last month was about 15% (mostly neonatal sepsis, prematurity and HIE). We still have a very long way to go, but it was a start, and a great privilege to be there for the start.

Perinatal Morbidity and Mortality Meeting

We held the first ever perinatal morbidity and mortality meeting last week. It was great for the paediatric department (doctors and one SCBU nurse) to meet with the midwives from the maternity hospital (unfortunately no obstetricians could make it). It was very interesting hearing of the problems which the midwives have. No paediatricians attend the deliveries here so midwives do the resuscitation of newborn babies. With current procedures they then need to take the baby to be registered before taking the baby to SCBU or ER! As a result of this meeting and communication between staff, hopefully this will change. The mortality rate in SCBU last month was about 15% (mostly neonatal sepsis, prematurity and HIE). We still have a very long way to go, but it was a start, and a great privilege to be there for the start.

Sorrow and Joy

Last week I spent most of my time in ER. Patients who are triaged as emergencies come straight to ER to be assessed and receive initial resuscitation and management. Children then tend to stay in ER until they are stabilised before being transferred to ICU or one of the other wards.

We had a great team of nurses on with us last week; experts at cannulation and at telling parents off for waiting until their child was so sick before bringing them in to hospital.

Alas it was a fairly depressing week as many of our patients died. A 2 month old septic baby. Another 2 month old septic baby (whose 3 older siblings had all died before 1 year of age; I felt so desperately sorry for his mother). A 1 year old child with septic burns (she received 24 hours worth of IV fluids in 12 hours – did this make a difference? I wonder. I don’t know).

And finally a 1 year and 1 month old boy (Saloneans say ages in years and months, rather than 13 months as we would say at home) who was malnourished. He was moribund when he arrived – not breathing and heart rate of 30/min. (For non-medical people reading this, these numbers are not good). We started CPR while trying to cannulate. To my amazement, his heart rate improved with CPR alone (no adrenaline was given, although we do have it here) and he started breathing again. We were struggling with access so in went an intra-osseosus line. He received dextrose, and fluids and his perfusion improved markedly and breathing much more regular. (Clearly if this child had been in the UK he would have been ventilated by this point. We manage with fluids and nasal cannula oxygen). There was a clear plan for further IV fluids, antibiotics and antimalarials. I also stood a nurse next to him with instructions to “watch him like a hawk” while I was at a meeting. (There was also another doctor with him). I came back an hour and a bit later to find that the IV fluids had not started, nor had he received his antimalarials or his antibiotics. Why oh why? The IO wouldn’t run the fluids but was fine for giving antibiotics. He never got another line inserted before he died.

It would have taken a miracle for this boy to survive. Usually when children arrest here, I continue CPR for a short time and then withdraw care (none of them have ever responded before in the way that this child did, and there are no PICU facilities available anyway). When he responded to initial resuscitation I really felt we should do everything we possibly could do (simple things like giving fluids, antibiotics and antimalarials). I was shocked that the meds had not been given. There are a multitude of reasons why they had not been given – ER was very busy, nurses coming late to work, the complicated pharmacy system, no one thought to call me, or another doctor, for help, or maybe the nurses and doctor knew anyway – that this child was going to die, so why waste time trying to get a line in him and give his meds when you could be doing something else. I find this so difficult, coming from a place where every life is so precious, and where parents demand that everything that can be done will be done.


Something which did bring me joy last week was a patient called Joy. Critically unwell with cerebral malaria the week before (alternating fitting with being unconscious), her parents had been praying (very loudly, in fact they were drowning out every other noise in the place) for her recovery. She received her medicines. She stopped fitting. She had an LP to exclude meningitis. Her father came to find me the following week. There she was, sitting up, laughing and waving to me. It was magical and brought a tear to my eye. Musu the very dedicated staff nurse on ICU was also delighted to see her recovery.