Complications (Part 2)

Connaught Hospital is the principal government hospital serving Freetown; it provides medical and surgical care to the local population and is a tertiary referral centre for the rest of the country.  There are around 300 beds and the vast majority of admitted patients will pass through the emergency department.  Patients that require admission are often incredibly sick, and the medical staff, many of whom are volunteers often work under challenging circumstances.  I’m constantly impressed by their positivity and eagerness to do the best for their patients, despite the resource limitations and lack of critical infrastructure that exists within the healthcare system to manage the high burden of disease here. 

Malaria is incredibly common; the WHO World Malaria Report quotes a figure of 1.7 million cases in 2013 (in a population of 6 million) with over 4000 deaths.  The prevalence of HIV is quoted as around 1.5% although the hospital prevalence is likely to be higher; many are newly diagnosed when they present with advanced features of the disease, such as disseminated TB and neurological complications such as toxoplasmosis and meningitis.  In addition to the ‘big three’ infectious diseases of TB, HIV and malaria; tetanus is not uncommon and typhoid is a fairly frequent diagnosis, although the diagnostic limitations currently make this a difficult disease to confirm.

I was expecting a high burden of infectious disease in Sierra Leone but I have been surprised by the significant degree of morbidity caused by non-communicable disease, much of which remains undetected and undiagnosed.  Patients are not generally screened for diseases such as hypertension and diabetes and many are often only diagnosed when they present with a complication such as a stroke, heart failure or diabetic coma.

 

The other main group of patients that present frequently to A&E in Connaught are victims of trauma.  Injury accounts for 8% of all deaths in Sierra Leone and the reasons for such a high figure are multi-factorial.  Road traffic collisions are common and vehicle safety often inadequate; it is a rarity to find a public vehicle with functioning seat belts.  Motorbikes weave in and out of traffic on narrow crowded roads, dodging around unwary pedestrians; many riders do not have helmets, let alone protective clothing, and it is a rarity to see their passengers wearing one.

Emergency care is a small, but increasingly important part of the overall picture.  The healthcare system is fragile and vulnerable, as recent experiences have proven.  In 2012, there were only 185 doctors serving the entire country and half the country’s healthcare workers were based in the capital.  This was pre-Ebola.  Poverty is common and the cost of care and hospital admission may bankrupt a family.  In 2010, the government introduced the Free Healthcare Initiative with the aim of reducing maternal and child mortality rates and making progress towards the Millennium Development Goals.  By offering free care to pregnant women, new mothers and children under 5, the country was making progress in improving what were some of the worst mortality rates in the world.  The situation is undoubtedly worse now, however, the country is beginning to look forward again.

The government have updated their Basic Package of Essential Health Services with a focus on recovery and building a resilient health system.  The goal is to provide efficient, cost-effective care that is available to all Sierra Leoneans and it recognises Emergency Care as one of the essential services.  There will be a major focus on maternal and child health but many of these deaths can be prevented by timely and effective emergency care.  Emergency systems strengthening, including pre-hospital care will improve outcomes for acutely sick and injured patients throughout the country but it will take time and effort.

 

Each patient described previously is based on a real case, and each has led to a great deal of reflection on how their outcomes could be improved and how their presentations could be prevented.  It can feel a little overwhelming at times.  I am developing a greater insight into how health systems function in general from my experience here, and gaining an appreciation of how challenging it can be to make changes that will have significant impact.  I have been in Sierra Leone for 3 months now, time is passing quickly and I am still ascending a steep learning curve.  Healthcare is a complicated business! 

Complications (Part 1)

The first patient to arrive in the A&E this morning is clearly frail and unwell, he is only 40 but appears twice his age.  Unable to walk, his skeletal frame is supported by concerned relatives who assist him into the doctors’ office and lower him into a chair.  Even this minimal effort makes him breathless as he holds a cloth to his mouth whilst attempting to control a bout of coughing.  He struggles to speak so his relative does the talking, explaining how he is not eating and has been coughing for several weeks.  He has tried a variety of remedies and medications which have not helped and has tried to hide his illness from friends and family.  Now he is wracked with fever and too ill to manage at home.  His cheeks are hollow and his breathing shallow, he has clearly been unwell for some time and I am concerned that he has presented too late for treatment to tackle the TB and undiagnosed HIV that have ravaged his body.

The next patient is young, in her late teens and has been unwell for a couple of days with headache and fever.  She has deteriorated overnight and is now unconscious and lying on a trolley.  She is wheeled into the doctors’ room from the triage area accompanied by anxious looking relatives who give a history of a rapid progression of her symptoms.  She suddenly cries out and becomes tense as a brief seizure causes her body to spasm.  Her HIV test is negative but her blood sugar is low.  This is rapidly corrected but she remains drowsy.  Some basic investigations are requested but the results are unlikely to be available today so she is treated empirically for meningitis and severe malaria.  There are several other possible diagnoses but these are the most likely and easiest to treat.  As a result of funding initiatives, there are some emergency drugs and fluids available free of charge to critically unwell patients that present to the A&E but most medications need to be purchased by the patient.  The family are sent urgently to buy antibiotics and anti-malarial drugs while a bed is organised for admission.

The A&E is filling up already and a crowd of people now congregate in the courtyard, waiting to see the doctor and two community health officers that are working hard, staffing the department this morning.  The sick patients are effectively prioritised by the triage staff and today there seem to be a lot arriving in quick succession.  A lady in her sixties is carried in by her nephew, she is diabetic and taking medication for hypertension.  She has been unable to walk for 3 days and is not able to move her right arm or leg.  Her blood sugar is high and so is her blood pressure, she has been unable to afford regular medication and now she has had a stroke.  As the family do not have funds to pay for a CT scan, treatment is aimed at blood pressure control and prevention of complications such as pressure sores.  The hospital has an excellent physiotherapist who will aim to help restore some function.

Another emergency case is brought through from triage; a young man has been hit by a car whilst travelling to work on his motorbike.  There is no formal emergency ambulance service in Sierra Leone so he was brought in by his friend in a taxi.  He was not wearing a helmet and has sustained a significant head injury.  There is no neurosurgeon in country and ventilation on intensive care is not available currently.  He is assessed and transferred to the trauma ward for review by the surgical team but his outlook remains uncertain.

By mid-afternoon, the queue is diminishing and the early shift are preparing to go home.  There is one patient left in the triage room; he is a destitute patient with no possessions and no family to care for him.  He has been found in the street having been assaulted and left outside the hospital.  He has multiple wounds and his face is bruised and swollen, we are unable to obtain any information from him as he is agitated and incoherent.  He has no money for treatment, the admissions ward is now full and he certainly cannot be discharged in his current condition.  The sister in charge is able to find some dressings and the nurses try their best to clean him.  We try to locate a surgical bed in the hospital but draw a blank.  I’m really not sure what to do next, there is no easy answer here.

Forty-Two Days: Ebola Free!

9th November 2015

I am the doctor covering the Ebola isolation unit at the hospital today.  All patients that attended the hospital for treatment during the outbreak were screened before entering the grounds.  They have a temperature check from a contactless thermometer and they complete a screening questionnaire that enquires about fever, relevant symptoms and any contact with potential cases of the disease.  If they meet the case definition for Ebola, they are admitted to the isolation unit and are nursed by staff in full personal protective equipment (PPE) until their blood results are available.  All patients are prescribed broad spectrum antibiotics, antimalarial drugs and fluids; oral rehydration therapy if they can drink or intravenous therapy if they are vomiting or too weak to drink. 

Screening continues for the time being and there is one name on the board this morning, a lady who was referred with fever, diarrhoea and vomiting. These are typical symptoms of the disease but at this stage, are much more likely to be due to gastroenteritis.  Over the weekend, on November 7^th, the country achieved a fantastic milestone; it was declared officially free of Ebola by the World Health Organisation (WHO), having reached 42 days (2 incubation periods) since the last patient was discharged from hospital.  The approach to our patient, however, is no less cautious than before as the country observes a ninety-day period of heightened surveillance.

Twelve months ago, the chances of this patient having Ebola would have been much higher and the board would have been full of names.  When I arrived in Sierra Leone, there were a handful of cases still being treated in-country but none had been reported in Freetown for some time.  The previous year, the situation was very different.  The first case was confirmed in the South East of Guinea on 23^rd March 2014.  By May, it had spread to Liberia and crossed the border into Sierra Leone.
 

Although several other countries were affected, it was these three West African nations that bore the brunt of the epidemic with tragic consequences.  It has been well described that the international community was slow to recognise and respond to the epidemic but by August the UN had declared an international public health emergency.  The health systems of the 3 countries were completely overwhelmed by the epidemic and no-one had experience of dealing with such an emergency.  Previous epidemics had been relatively small and contained – this was different.  The virus spread across the country and ,alarmingly, quickly reached Freetown and it’s densely populated urban sprawl. 

At the height of the epidemic, hundreds of cases were being reported on a weekly basis and huge international efforts were mobilised to assist the countries to deal with the epidemic.  It is suspected that over 11,000 people died of the disease.  The Sierra Leone National Ebola Response Centre (NERC) website states that there have been 8704 confirmed cases of which 3589 died in Sierra Leone.  221 of these were health care workers.     The isolation unit at Connaught has treated in the region of 500 positive patients and here too, Ebola has left its mark amongst the staff.

On the evening of November 6^th, we joined a candle lit procession of thousands of people through the streets of the city, ending at The Cotton Tree in the centre of town.  The vigil was held in honour of all the health care workers who had selflessly continued to work in the face of danger and uncertainty to provide care to their patients and ultimately lost their lives to the disease.  It was a lively march, led by a military brass band and while there was much celebration and dancing, there was also an ambience of reflection and a sense of weary relief amongst many in the crowd who have been present, working tirelessly throughout the last 18 months. 

The following day, at a conference in Freetown, the president declared an end to the state of emergency and the WHO representative announced that transmission had been stopped and commended the county for their herculean efforts to contain the virus.

“The strong leadership of the Sierra Leone Government, working with partners from around the globe, mobilized the necessary expertise needed to contain the outbreak... Sierra Leone achieved this milestone through tremendous hard work and commitment while battling the most unprecedented Ebola virus disease outbreak in human history.”

This was achieved through establishing appropriate facilities to manage cases, enforcement of strict infection control policies, setting up safe and dignified burial teams and strong community engagement.

On the evening of November 7^th, King’s held a party in town for the isolation unit staff to recognise their massive contribution towards ‘getting to zero’.  The team of staff include nurses, screeners, surveillance officers, security, cleaners and they are all true heroes that have risked their lives by turning up to work every day throughout the outbreak.  I am in awe of them but they are not the only ones.  There are staff throughout the hospital that also looked after patients, unsure if they would be infected and in total over 35,000 Sierra Leoneans were registered as Ebola response workers.

My patient today is fortunately Ebola negative and well enough to be discharged.  The count remains at zero and the ninety-day surveillance period continues.  Despite this momentous achievement, the country must remain vigilant.  Sierra Leone cannot afford to let its guard down now.

The Province of Freedom

Sierra Leone (Lion Mountains) was named by the Portuguese back in the 1400s on seeing the range of wooded hills that sit back from the coastal beaches lining the length of the Freetown peninsula. The city is situated on the northern tip of the peninsula, Atlantic Ocean to one side and Africa’s largest natural harbour opening from the mouth of the Sierra Leone River, on the other.

The site was chosen in 1787 by the British as a settlement for freed slaves that had become destitute in England as a consequence of the abolition movement.  This tropical idyll was touted as a haven for the new settlers but the reality was somewhat different; conditions were harsh throughout the rainy season and many died as a result of disease and starvation.  This first settlement was actually burnt down by a local ruler but a second attempt to form a colony was made 5 years later in 1792.

This time, the settlers originated from Nova Scotia, freed slaves who had fought for the British during the American Revolution.  The original settlement had been reclaimed by the jungle but the new colonists cleared the forest as far as a giant cotton tree which still stands at what is now one of the busiest junctions in the city, next to the colonial era Courts of Justice building. The conditions were tough for the first inhabitants of the Freetown Colony but through hard work and determination, they began to prosper.  The Sierra Leone Creole people (Krio) went on to establish and populate what is now the capital of the country and shape what was to become a centre for culture and education. 

 

The Cotton Tree

British influence remained, initially in order to shield the town from the demands and taxes of indigenous leaders, but subsequently to intervene in the ongoing trading of slaves whilst also protecting its own trading interests in the region and expanding the protectorate into the hinterland.   The settlement became a Crown Colony in 1808 and went on to become the capital of British West Africa.  Independence arrived in 1961 but transition was far from a smooth process.

During the next 20 years, corruption became commonplace as society and the economy began to break down.  The country endured a series of coups and attempted coups, becoming a republic in 1971 and was a one-party state by 1978.  With a divided society established as a legacy of colonial rule, an unstable government and a marginalised youth, the country was a powder keg ready to ignite.  In 1991, civil war broke out when the Revolutionary United Front (RUF) crossed the border from Liberia and within a year the president had been deposed.  In 1999, Freetown itself was taken for a brief time by rebel forces.  A ceasefire was finally declared in 2002, by which time it was estimated that 50,000 people had been killed in a decade of terrible violence and civilian suffering.

The country slowly started the re-building process; in 2005, the last UN peacekeeping force left the country and a new president was democratically elected in 2007.  The country has a vast array of natural resources; diamonds, titanium and iron ore, bauxite and gold can be found in abundance and foreign investment in these industries, as well as fisheries and agriculture was helping to expand the economy.  Money was being invested in desperately needed infrastructure projects and GDP began to grow.  All this progress came to a dramatic halt, however, in May 2014 when the first case of ebola virus disease was detected.  By September, Freetown was in lock-down and under-siege from a very different type of threat.

Fast forward 12 months, the threat is diminishing, and the city is once again trying to re-build.  People go about their daily business, the streets are crowded with stalls, there is laughing and shouting in equal measure and car horns sound relentlessly in the impatient queues of traffic.  This is a noisy and lively city, from the call to prayer before sunrise to the sound of music well after sunset into the early hours, activity never stops.  Young men play football on the beach, the bars are open and music is playing.  Freetown is a chaotic city but it possesses a welcoming charm and even a certain beauty when viewed from the quiet of the surrounding hills. 

There are many challenges ahead for the government and people of Sierra Leone but I feel privileged to witness the start of what I hope will be a positive new chapter in the turbulent history of this remarkable country.  

Sunrise over Freetown

The city viewed from Leicester Peak

Football on Bureh Beach

Welcome to Freetown

Day 1:  September 16th 2015

The screech of wheels on tarmac and a round of applause from surrounding passengers signals my arrival in Freetown, the capital of Sierra Leone.  Situated in the west of the country on the Atlantic coast, it has a population of around 1 million people and it is where I will be calling home for the next 12 months.

“Welcome to Freetown, the local time is 5:30 in the evening and the current temperature is 25 degrees,” announces the pilot as we taxi to a stop at Lungi Airport.  The humidity makes it feel much warmer and with the country approaching the end of the rainy season, it will only get hotter.  The runway and surrounding vegetation are still damp and it is clear that it has rained heavily today.  On the approach to landing, the coastal rivers appeared swollen and the descent had been turbulent through dense cloud.  I was yet to become aware of the significance of this, however, as I made my way through passport control.

I am relieved to find that my temperature is normal at the screening check point and can proceed to collect my luggage unimpeded.  The quickest route to the city involves a forty-minute journey across the harbour by water taxi and I disembark to find my luggage and Victor, the organisation’s driver, waiting on the jetty holding a sign with my name and a big ‘Welcome’.  So far, so good! 

The rest of the evening passes in a blur as I am introduced to the rest of the King’s team and battle fatigue to remember all the new names and faces of the people that I will be working closely with over the coming months.  I head to bed, oblivious to the terrible tragedy that has taken place in the city during the day.

  

The rain had been persistent and torrential during the day and had wreaked havoc throughout the city causing widespread flooding.  Several deaths had been reported by the following morning and thousands of people have been displaced, having lost their homes and possessions.  The National Stadium is being used as a temporary settlement and the government has advised people to stay at home and not to travel unless on essential business. 

I will be working at Connaught Hospital, the main government referral hospital situated to the east of the city next to Kroo Bay which was one of the areas worse affected by the flooding.  The hospital did not escape from the disaster and its theatre complex was flooded meaning that no surgery could take place.  Despite this, a procession of patients attended the emergency department throughout the morning with a variety of wounds and injuries from minor lacerations to open fractures and more significant trauma, many sent over from the stadium.

Doctors, nurses and ancillary staff throughout the hospital mobilised to provide care to the patients and the Emergency Department became the focal point for triage, assessment and treatment of the wounded.  The hospital matron, emergency team and trauma ward played a vital role in ensuring that all the patients were managed in a timely and efficient fashion.  Pain relief, antibiotics and tetanus injections formed the bulk of treatment and the emergency dressings store for the hospital was exhausted by the end of the day.

Having only arrived in country 12 hours previously, I remained a frustrated spectator to most of the day’s events.  My desire to help and get stuck in was tempered by the fact that I had no knowledge of how the hospital was organised and where equipment was kept.  In fact, by the time I arrived in the early afternoon, most patients had been seen and managed which is a huge testament to the work of the hospital staff that pitched in to help out. 

As the crowds dissipated and the afternoon heat began to settle, thoughts turned to short term problems and longer term solutions, many of which are beyond the remit of the healthcare sector.  The possibility remained of further rain and ongoing casualties over the next few days, cases of malaria were likely to increase and cholera remains a significant concern.  Despite the fact that everyone pulled together to provide fantastic care, it will be important for the hospital to devise a formal major incident plan that can coordinate staff in the future.

I am reassured that this is not a normal day in Freetown but I remain to be convinced that such a phenomenon exists.   If positives can be taken from such an awful day, it is that staff worked hard together to provide vital care and made a significant impact on the outcomes of the people that attended the hospital.  I am humbled by the resilience of the people of Sierra Leone and their ability to remain positive despite all the knocks that the country has taken.  It has been an eventful first 24 hours!