The Challenges of Auditing in Africa…

I’ve been working on a couple of audits – one on intravenous cannula and intramuscular injection associated infections and one on prescription and administration of quinine for malaria.

It’s been an interesting process. Clearly we don’t have an electronic method of tracking the medical notes (yet). The medical records clerks give the notes a separate number once they are filed (separate from the number on the notes when the child is admitted – meaning I have had to search through every single medical record to find all the notes I wanted! I think the clerks reckon I am totally barmy. 304 out of 320 notes isn’t bad though. Especially when the electricity goes off at the hospital and you can’t see anything in the windowless room. I have never been in such a dusty medical records room, and there are occasional cockroaches which come crawling out of the notes I’m looking through….

Obviously I’ve been using my computer to go through the data – again having its challenges trying to look through notes to get information in the dark…. and somewhat annoying when the electricity goes off and the computer battery dies (thankfully I’m quite good at remembering to save everything!)

They’ve both been long and laborious but I’m finally getting close to finishing them (I hope!) Hopefully they might make a difference to practice at the hospital. I want to say a massive thanks to Mr T and Abdul in the treatment who have collected all the data for the cannula audit and are working so hard for change to cannula insertion practice.

Aid

Concern, Goal, CRS, IRC, ICRC, VSO, ODI, AGI, HPA, IFAD, Marie Stopes, Oxfam, Mercy Ships, Emergency, USAID, DfID, GIZ, UNDP, Unicef, UNFPA, UNHCR, UNEP, WHO… These are just some of the many UN agencies, NGOs and GOs (non- and governmental organisations) who have a presence in Sierra Leone. I know what most of them stand for, or at least what their logos are (emblazoned across their White Land Cruisers and Land Rovers they are ever identifiable). But what do they all actually do?

Aid in Sierra Leone is all about “capacity building” in a “post-conflict environment”. We’re past the “humanitarian disaster”. Now we focus on “empowerment”, “sustainability”, and “governance.” It’s all woolly enough that it’s difficult to actually measure the “outputs”, “goals” and “indicators” (whatever all that means).

I know a lot of people who are professional development workers. They work their way up the ladder of “volunteer”, “project development assistant”, “project manager” and “country director” attending various “workshops” along the way. All the local staff receive a daily allowance plus food and drink, to attend the workshops. I’ve been at various workshops myself. I’ve even helped to organise one.

There is a massive dependence culture in Sierra Leone. I’ve said before that there are half the number of local doctors working in the hospital compared to when I started here – is that because the Ministry of Health reduced numbers of local doctors as NGOs increase theirs? I see it on an individual level as well as societal. The nurses are constantly telling me how hard working I am. I think “yes I’m trying to show you a good work ethic, trying to help you do your job better, and not just do your work for you….”

It is often asked, “What would happen if all the NGO’s left and aid money stopped?” I expect it would be absolute chaos for a while. Thousands of children would likely die needlessly. Would it be better for Sierra Leone in the long run? I don’t know the answer.

Sometimes “implementation” of aid is questionable. There are some groups who come here for one to two weeks to “do good and save lives” as Sandra put it. There are many terrible incidences when aid has gone badly wrong; food aid being used as a political weapon, or to sustain soldiers and militia during times of war.

Who’s paying for aid? We all know that the British government are stumping up $1.3 billion for the vaccines initiative. I know many people in the UK are wondering why so much money is being spent on the developing world when there are cuts in our own NHS. Perhaps though it’s better investing in development aid than have military intervention when things go wrong? Development aid is almost certainly cheaper. I think its good value for your money. I am costing the UK taxpayer far less by being here than I will be costing them as a paediatric registrar in Oxford. Babies in the neonatal unit in the UK cost thousands of pounds a day. Vaccines cost pennies. And will save many more lives in the long run.

I believe in aid. I wouldn’t be here if I didn’t. Nor would I be quoted as saying so in various British newspapers…. But it’s healthy to have a bit of scepticism and to continue to question what we are all doing here and what we are achieving. I also believe aid is not the answer to Africa’s problems; of course Africa needs to help itself.

So why do I still believe in aid? It’s a Christian value. Moral responsibility. It’s “The Right Thing to Do”. Guilt. The wish to help others more disadvantaged than myself. Everyone is human and I believe we have a responsibility to share our wealth in order to make the world a better place. There are many charities and NGO’s which I think do an amazing job, particularly the ones who work in partnership with the government (e.g. VSO and Welbodi). So I will continue to take my bricks to go building some capacity and hold my stake to advocate for others. At least until I have to cost you more, saving babies back home in Oxford!

Ethical Questions….

In a resource poor setting, it’s one of the most difficult decisions to make. How much time should I spend with one child? There are so many sick children, not enough staff and not enough equipment or drugs. How do I (and the other staff) prioritise which children I (we) spend more time with?

I gravitate towards sicker children because that’s always what I’ve been trained to do. There comes a point though, when I have done everything within my capabilities and within the constraints of the resources. Then it becomes a bit of a waiting game. Will this child get better, or will they deteriorate despite everything we can do? And if they deteriorate to the point where they are gasping – will anything that we do make a difference to the final outcome? Or will it just prolong the inevitable? Are the medication and fluids that I am prescribing killing them just as much as their disease? We can’t monitor electrolytes, there is no potassium to add to fluids and we can’t check gentamicin levels. Will they just die during the night anyway when they are not getting monitored? (On a separate issue – is this why it can be so difficult to motivate the staff to do things at times? – do they know the child will die anyway, so why bother?)

There are many children here who would be ventilated in a (proper) PICU or neonatal unit at home. At what point do I think, nothing I can do here will make any difference –would it be kinder to this child, this family, (and very sadly, a better use of resources) to withdraw care and allow the child to die with dignity?

Yesterday morning when I went into the S-C-B-U one of the babies with presumed septicaemia had deteriorated markedly overnight. He was profoundly jaundiced and had bruising on his body. He was febrile. He had irregular respirations and occasional gasps. His heart rate was good. He was unconscious. After assessing him and checking his blood sugar (which was normal) it seemed that he had a very poor prognosis, given the limitations of our resources. His parents told the nursing staff they wanted to take him home with them. They knew he was really sick and would die quickly without his oxygen and IV dextrose. I don’t know how much longer he would have survived with it. I could understand why they wanted to take him home. His father put a thumb print to sign he was discharging his son against medical advice. They left.

How long should I keep going with resuscitation? Also when I arrived yesterday morning one of the nurses was bagging a baby (this was all going on at the same time). This baby had been admitted yesterday, with a history of meconium aspiration. His saturations were about 60% for most of yesterday. I expect he had PPHN (sorry about the medical chat – translate this as “he was very sick”). Mohammed had been bagging him for about half an hour. He was gasping only intermittently and had made no spontaneous respiratory effort in response to the resuscitation. However, his heart rate was still good. How long should we keep going, knowing that there is no ventilator, no inotropes, no nitric oxide, no ECMO? As it turned out, his pupils were fixed and dilated (i.e. he was brain dead). Mohammed and I decided, after speaking with the relatives that we should stop bagging and allow his heart to stop.

Another baby (it was a busy day!) has been admitted since Thursday. His mother died two days after he was born. She was 18 years old. To be honest I’m amazed the baby survived the weekend. He has presumed septicaemia and “birth asphyxia”. Yesterday he was really sick again. He needed a blood transfusion. His father, the poor man having already lost his girlfriend, was too underweight to donate blood. So I took him back to the blood bank to get some emergency blood (amazing what a white face and a bit of advocacy will do). The father was extremely grateful to me. The baby was still alive today. But deteriorating massively. I spent quite a bit of time going back to review him. But there are 20 something (I haven’t counted) other patients on the ward all needing attention. Five or six admissions (I lost count after a while). None of them quite as sick. Still most of them would be classed as intensive care babies in the UK. But all of them with probably a better chance of survival. What do you do?

I don’t know the answers to these questions. I try to do as much as I can given the limited resources of equipment and personnel and my own limitations in knowledge and skills. For withdrawing care or stopping resuscitation, I use my best judgement at the time; take advice from the nurses and local doctors about what is culturally appropriate. In the UK we would have more fancy tests to help us come to a decision to withdraw care, and professional guidelines aiding the ethical decisions. And I wouldn’t be making the decision by myself.

Baby number three was still alive when I left this afternoon. Despite the terrible prognosis, I haven’t given up hope for him, not yet. I won’t be surprised if he dies during the night. But miracles happen. Sometimes.

“Mi fut he swell”

I woke on Saturday morning after having a lovely night out on Friday for Banke, Theo, Alex and Dorcas’ leaving party. (I even went out dancing – shock and horror!) I pottered around the house for a while, and did some work on my audits. Then I realised there was something wrong with my left foot. It was swollen. I had pitting oedema to my mid-calf. It was surrounding an infection from a mosquito bite, where my sandal strap had been rubbing. Thankfully it wasn’t sore, just a bit uncomfortable. And I didn’t feel unwell. In the evening there was a massive downpour so I ended up walking through rivers of muddy water on my way to meet some friends for dinner (it was worth it – the steak at Madam Posset’s was amazing!). After a consultation with Dr Sandra we agreed that I should take some antibiotics for my infected foot.

Thankfully it didn’t get any worse overnight. Yesterday morning I hobbled down to Congo Cross to buy some antibiotics (yes you can buy them over the counter….) Now, there is no flucloxacillin in the country. Just cloxacillin (which isn’t even in the BNF!). But they didn’t have that in the pharmacy. Nor did they have augmentin (we don’t have augmentin in the hospital but you can get it in many pharmacies). So I settled on ampiclox (a combination of ampicillin and cloxacillin).

I walked quite a lot, although slowly, yesterday afternoon. Today “he don better”. The swelling has gone down and I am no longer hobbling. Turns out ampliclox is pretty good. One of the treatment room nurses offered to dress my wound for me (obviously not impressed at my effort!). The nurses have all said “Oshya” again and told me off for getting bitten and made sure I am sleeping under a bed net at night (I am).

(“Fut” is Krio for leg; so the title of the blog means “My leg is swollen”).

The Special Care Baby Unit

(Apologies in advance for all the medical terminology.)

I’ve now moved on from Outpatients and TFC to the Special Care Baby Unit. Confusingly known as “S-C-B-U” here, it’s a far cry from any neonatal unit I have worked in before. No ventilators, CPAP machines, vapotherm or noisy alarms going off. No blood gas machine, centrifuge, bilirubinometer, blue phototherapy lights. No SHO running around taking blood gases and TPN bloods and going to deliveries. No TPN for that matter. And no potassium to add to the fluids.

What we do have are radiant warmers, oxygen concentrators, bag and masks, NG tubes, IV fluids and antibiotics and mothers who produce the greatest quantities of expressed breast milk I have ever seen.

Most of the admissions are a product of poor or non-existent antenatal and obstetric care so it seems clear that without interventions in these areas we will never reduce neonatal mortality in Sierra Leone. The current inpatient mortality in SCBU is 27% (overall hospital mortality was 13.9% in May).

The pathology is certainly interesting; presumed septicaemia (no blood cultures so I have no idea which bugs), congenital malaria, meningitis (the most turbid looking CSF I have ever seen. It was actually pus. This baby is still alive thankfully), birth asphyxia (a term we no longer use in the UK but is used frequently here) and two cases of neonatal tetanus in the last week.

It is frustrating, knowing that most of these problems are preventable. If these babies’ mothers had received tetanus immunisations during pregnancy, had received antibiotics during labour, had presented earlier in labour to medical care or if the baby had been monitored during labour and born by assisted delivery or caesarean section when fetal distress was identified then these babies would not have the problems that they do. There is little I can do as a paediatrician for many of these babies. Prevention is much better than cure.

Its also here I notice the lack of investigations and equipment the most. Without blood cultures its hard to know how long to continue with antibiotics. I tend to play it safe and probably give them longer than necessary (thereby further contributing to antibiotic resistance…) Neonates is very equipment intensive in the UK. Most of the babies in SCBU here would be ventilated if they were in the UK. You don’t need a blood gas to tell you that. I find it frustrating because I know what can be done. But until we can do basic things well here (e.g. making sure the babies get their medications, get fed regularly, observations done and everyone has good hygiene) there would be no point in having any more advanced equipment.

I am very much enjoying the team spirit in SCBU – something I missed whilst in outpatients. Doctors, nurses, nursing and medical students all on ward rounds together; everyone learning from each other. The house officer and medical students doing lumbar punctures (surrounded by an infestation of flies – no, not the most sterile procedure you’ve ever seen. But when I arrived at ODCH no children were getting LPs at all). The nursing students watching and learning why it so important for babies to receive their antibiotics.

I learned this week that I’m going to work in the neonatal unit when I go back to Oxford. It’ll be a world away from here.

Lessons I have learned – and am still learning

I wrote this list during a time when I was feeling very down about life in Sierra Leone. You’ll be pleased to know I don’t feel down at the moment, in fact I am feeling particularly up! We’re always on a roller-coaster of emotions here. I didn’t post it at the time but it’s good to reflect now I am more positive. Everything on this list is still something I’ve learned and will continue to learn from.
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1) To be grateful for small miracles.
2) That miracles do happen. Occasionally.
3) That this is a country of unbelievable contrasts – where there are beautiful empty beaches but children die every day.
4) That you can’t win every battle.
5) That some battles are worth battling. You need to choose wisely. I’m still trying to acquire that wisdom.
6) To expect nothing, because then the reward will be greater.
7) That I can be angry. Really angry. I’m still learning how to direct that anger efficiently into something positive.
8) To always try to understand the point of view of the other person.
9) My limitations.
10) That, no matter how much time I spend in the hospital, I will never save every child in Sierra Leone.
11) That time off work is very important.
12) That support from friends is invaluable.
13) That I some means of escape, and will leave at the end of the year, but my national colleagues will not.
14) That my family, friends, and health are really really important to me.

The Journey Home

Usually I have a fairly easy (although long) journey home travelling with Sandra and chatting with her. Sometimes she is at a meeting in town so I get public transport home.

This is the journey I have made a few days this week: I leave the hospital and walk along some back roads, past children collecting water from a stand-pipe, a lady selling barbequed corn on the cob and a couple of tailors. I walk past a conglomeration of poda podas on Bombay Street narrowly avoiding falling into an open sewer as I dodge other people walking past. I turn left up Patton Street, and walk past many people selling rice, onions, tomato puree, groundnut paste, pineapples, mangoes, a few more tailors and other people sitting and chatting. Others are selling things from baskets on their heads. Some men call out to me “White girl white girl”, or “baby baby.” I stop to buy some pineapple slices as a snack. I reach the top of Patton St and turn right onto Kissy Road. I have to watch where I’m going in case there are gaps in the pavement! I walk past a health clinic, a furniture store (not a shop as such – all the furniture is out on the street). I get hissed at a few times. I stop to buy some bananas and a mango from the side of the road. Some women call me over to look at some tie-dyed dresses, and I promise I’ll be back there to look again. I constantly hear the sounds of Sierra Leonean music and people shouting out what they are selling.

I keep walking on Kissy Road, past a clothes shop, and a red Royal Mail post box (!), past more people selling fruit, avocadoes and ground nuts, past some beggars and amputees and a man who looks like he might be dead (but he’s not – I’ve seen him there a few times and he is actually just sleeping on the pavement in the middle of the day…) I reach Eastern Police Station where I stop to buy a coconut. The seller machetes off the top so I can drink the milk, then machetes it in half and scoops out the meat. Yum. So refreshing. Eastern Police and the Clocktower are at the meeting points of five roads and is one of the busiest intersections of human and vehicle traffic in Freetown. I see the police somewhat ineffectually trying to control the traffic. I cross over Kissy Road, endangering my life in the process as Okadas speed past. I walk past more street sellers and turn left off Goderich Street onto an alley I can walk up with no vehicle traffic. Past the people selling grilled chicken (it smells so good, I must try it sometime) and popcorn. Past a lady selling “kill driver” biscuits (these are like shortbread and are delicious – but no idea why they are called kill driver biscuits). A man shouts to me “white girl white girl”. He is standing on top of a building and says he “wants a few minutes of my time”. I keep walking.

I walk on up the alley, past more people selling all sorts of stuff. I walk over a bridge; either side is an open rubbish tip. I get hissed at five more times. Some other people call “Oputo” (white person). I walk over a broken pipe, pouring gallons of precious water into the street. I reach Regent Road, where the poda poda stop is. I am lucky; there is an empty poda waiting; the “apprentice” shouting “Abadeen Abadeen”. I confirm I am going to Congo Cross and jump in. So do 21 others, including 3 children. And a live chicken. I am seated in the second row – strategically near the door. I have never managed to get out of a poda in a ladylike fashion so the nearer the door the better. I say “Aftanoon” to the people seated around me. The base of the music booms out from the loudspeakers. The poda does an impressive three point turn – how they don’t hit any of the oncoming traffic I don’t know. The “apprentice” leans out the door as we start moving, collecting more customers. We get stuck in non-moving traffic on Circular Road for about twenty minutes. I am sweating profusely. People call the street sellers to the poda to buy cold water and snacks. Finally, we get going. Around some back streets. Down Campbell Street. Around St John’s roundabout. Past the Youi (?spelling) building (where the Ministry of Health and Sanitation is). We speed over Peace Bridge. So called because the UNAMSIL forces stopped the Rebels here during the war. It’s a dual carriageway and everyone speeds over it. In an overcrowded poda I always worry we will tip as we speed around the corner. Thankfully we don’t and we are on Main Motor Road. I ask the apprentice to “lef me na moks” (let me out at the mosque). I only have to squeeze past on person, rather than the normal four or five. I am still sweating profusely.

I cross the road and head up “Sewer Alley”. I say “Kushe-o” (hello) to the lovely old lady. Some kids rush up to take my hand and say hello. I duck down under the washing line as I say “Kushe-o” to a little boy we call Spiderman and the carpenters. Some children say “Sheena Sheena” to greet me (this is how many people say my name – the other pronunciation is “Sonia”). Mussa at the shop reminds me that I need to bring back two empty bottles of Star. I chat in Krio with Millicent for a few minutes. I turn the corner and wave to the people who are fixing the massive hole in our road. I open the sqeaky gate. It has taken nearly an hour and a half to go about 5km. I am home.

My Fifteen Minutes of Fame

This week I will get my fifteen minutes of fame (probably more like one by the time I’ve been edited!). The BBC were here in SL a couple of weeks ago filming with GAVI (the Global Alliance for Vaccines and Immunisations) about the new vaccines which are being introduced here. Nearly two million children die each year from vaccine-preventable illnesses. Most of these deaths occur in low-income countries. Pneumonia and diarrhoea are the two leading killers, causing nearly 40% of all childhood deaths. (All stats from the GAVI website). It is really exciting that Sierra Leone is one of the first developing countries to introduce vaccines against the most common causes of pneumonia and diarrhoea. Clearly they will make a big difference to child morbidity and mortality in SL in the long run.

Here are the terrible statistics for Sierra Leone. One in eight women dies (over their lifetime) as a result of childbirth. Sierra Leone has the world’s worst indicators for infant mortality (123 deaths per 1000 live births). One in five children dies before their fifth birthday. Sierra Leone ranks 180th out of 182 countries for overall development. There are 2 doctors per 100,000 population (230 in the UK). I know only too well that there is a drastic drastic shortage of well-trained health care workers here.

Enough statistics. Fergus Walsh (BBC health correspondent) and the film crew came on the ward round with me in TFC and chatted with some parents (slightly bizarre as I had seen some of those patients on the ward round already – which the Mums thought was so funny!) After the ward round I was interviewed about my experiences here in SL. I spoke about working with the doctors, nurses and medical students and about the patients we see, and how they are dying from preventable illnesses. I was also interviewed for some papers and had another whole load of photos taken (in addition to the VSO Photographer a few weeks ago).

So my minute of fame will be on either 10th or 13th June (not sure which!) on the BBC news, to coincide with a meeting which GAVI is holding in London on 13th June entitled “Saving Children’s Lives” with the aim of bringing together donors to fund immunisation in the world’s poorest countries.

The Sierra Leonean Cinema

Banke and I went to the cinema yesterday evening. Yes, an actual cinema, in Freetown. It has just opened. We were not quite sure what to expect. Neither of us had been to the cinema for a very long time so we had a childlike sense of excitement as we arrived at the Lagoonda Complex in Aberdeen. It reminded me of how I felt going to the cinema when I was little – there was no cinema in Shetland where I grew up so a trip to the movies was one of my highlights of going on holiday. We giggled our way inside to find the familiar smell of popcorn. Of course we had to buy some. Inside, we were seated in incredibly large and comfortable seats. There was a proper big screen. Like a real cinema. It was also incredibly cold, as I find cinemas at home. There were no trailers and no Orange advert - although they did remind us to switch off our mobile phones. Unfortunately the film (Thor) was a pirated copy so the quality was not so good. It was however a really fun evening, finished off with some drinks with others in a small local bar in Aberdeen.

P.S. While out for drinks we discussed more things with a blatant disregard for health and safety regulations:

1) People on roller-skates holding onto the back of poda podas to get pulled along.
2) People perched on the back of moving lorries only holding onto the door for balance.
3) Loads of people stuffed into the back of open trucks – often standing.
4) Poda podas up-country piled high with luggage – so high they start to lean over to one side.

Oshya

People have been saying “Oshya” to me in the last few days as I’ve not been feeling too well. Oshya (sometimes shortened to “Osh”) is a Krio term to express your concern for someone, to say you’re sorry for them, for their illness, for their loss. I think it’s a really lovely word. It’s a word which just says it all, whatever the circumstance.

I have unfortunately had to say it to many families who have lost a child. Breaking bad news is something that doctors get a lot of training on in the UK; thinking about setting, privacy, confidentiality, body language, empathy, among other things. Much of this training in communication skills stems from the fact that many complaints to the NHS in the UK are regarding problems with communication. But it’s also to do with being human.

Breaking bad news is not really part of the culture here. I often find that the mothers are left purely guessing that their child has died when the doctors and nurses move away from their child to stop resuscitating. I also find that parents sometimes don’t seem to know why their child is in hospital. Many poor mothers get berated for doing something which they probably didn’t even know they were doing wrong. I’ve found this hard to understand because I’m so used to telling parents as much information as possible about their child’s illness and treatment. It’s also been proven that the more educated a mother is, the healthier her children will be.

This lack of communication is something I’ve questioned and challenged, particularly with the medical students. How would they feel if that was their child? How would they want the doctor or nurse to speak to them? Even a simple “Oshya” goes a long way.

I communicate with the mothers as much as my Krio will allow. Communication in a different language and culture can be very difficult; subtle nuances in language can often be lost in translation. Thankfully I always have a nurse and sometimes a student or two on the ward rounds; meaning they can educate the parents on my behalf. In fact, many of them are very good at it; explaining diagnosis, treatment and prognosis. I’ll never change the whole culture but I hope that those nurses and medical students might see the benefits of explaining things to parents and continue when I’ve gone.

Thankfully I’ve started to feel better now. I’ve had ORS, chicken soup and plenty of rest. I even made it out to the tailor (more new clothes!) and the swimming pool today. However I know how grateful I was to hear that little bit of sympathy; that one short word: “Oshya”.