Final Days

Tuesday 13^th September 2016. 

The bay is calm this morning; rusty fishing trawlers are floating at anchor dwarfed by ships heading into the estuary towards the East part of town ready to unload their cargo.  I watch from my balcony as a small boat sets out across the water towards the opposite coast line, ferrying passengers over to the airport.  In the street below a dog lies curled up in the shade, protected from the early sun’s rays by the overhanging roof of a nearby wooden shack.   A cockerel crows from the yard next door and a chicken struts past the gate, pecking idly at the ground until it erupts into a flurry of flapping wings, barely escaping the wheels of a passing 4 x 4.   Freetown is waking up, it is my last day and I realise the last time that I will look out over this view.  It is time to head home and say goodbye to the city that has charmed me and tested me in so many ways over the last 12 months.

I arrived last September in the midst of severe flooding, a country still at the tail end of an epidemic and struggling to recover, now hit by further devastation.  The hospital faced a major incident, compounded by a staffing crisis, as many doctors were sent to care for displaced families temporarily sheltered in the National Stadium, where all sport had been suspended for the last twelve months.  The hospital coped that day and continued to provide a vital service to the sick and injured patients, as it had done throughout the epidemic, due to dedicated staff and strong team work.

King’s Sierra Leone Partnership had played a significant part in the Ebola response alongside the Ministry of Health and Sanitation and Connaught Hospital and I admit to being a little in awe of some of my team members and Sierra Leone staff that had demonstrated such dedication and courage at the height of the epidemic.  Even now I get emotional when I listen to them discuss some of their experiences, especially my colleague Marta.  Although my main role was focused on developing the Emergency Department, the small team of clinicians were still providing an on-call rota to cover the hospital’s isolation unit.  I remember the butterflies in my stomach and sweat trickling down my forehead the first time that I went through the decontamination process to remove my personal protective equipment.  I was keen to ensure that I followed each of the 25 steps in the process to the letter.

KSLP A&E Team December 2015: Ling, Hedda and myself

King's House residents October 2015

On November 7^th, the country was declared Ebola free and although it was to flare again subsequently, this was a momentous day in the history of the country and was a reflection of a collaborative effort between the government of Sierra Leone, the healthcare workers and international organisations to contain the disease.  Effective case management, community engagement and strict infection control practices eventually brought the situation under control and has highlighted the precarious and weak nature of the health system.  It is hoped that one of the positive legacies of this terrible period is a focus on health system strengthening and resilience to deal with emergencies.  Work is already underway as part of the President’s Recovery Plan.  It was humbling to be on the streets amongst the crowds that night and a privilege to play a small role in the subsequent recovery process. 

Candle light vigil 7th November 2015

The main component of my role was to assist in development and strengthening of the Emergency Department at Connaught Hospital, the main government referral centre for the country.  This is an ongoing project that King’s have been involved in since 2013 when the partnership began in-country and the first 6 months were spent working with my dedicated colleague Ling.  Funding had been secured through DfID to refurbish the department in partnership with the hospital staff and management and the aim was to transform what had been the original make-shift isolation unit back into a new fit-for-purpose Emergency and Acute admissions unit.  I learnt a great deal from Ling about how to get things done and I have no doubt that the success to date is due to the work that she did with hospital management, ministry and the team in London developing the project.  In addition, she gave me the job so clearly has an eye for talent!

Without doubt, the most difficult aspect of leaving the UK for a year was saying goodbye to my girlfriend and family.  I have always been very independent and was surprised to find myself struggling with the separation in the first few months; I suspect that this was delayed onset emotional maturity and a stronger appreciation of what is important in the long term.  I spent Christmas in Freetown but returned home for a week in January; although brief, this was a significant week in my life as I found that my sister was pregnant with my first niece and I decided to make plans to propose to my girlfriend.  A month later, in the mountainous jungle of the Peninsula National Park above Sierra Leone’s Atlantic Coast, she made me very happy and said yes.

Christmas Day in Freetown

The week of Alice’s visit in February was a welcome respite before the real hard work began. Ling’s departure coincided with the opening of the new Emergency Department and resuscitation room.   It was the first time that I felt real pressure and responsibility to deliver on a major project for the hospital and organisation that would impact on the health of thousands of patients across the city.  In addition to this, we were launching an extended pilot program to provide emergency free health care so that critically ill patients did not have to wait for family to find money and buy vital medication.  As a result of the careful preparation, the actual move and opening went amazingly smoothly and the staff that did all the hard work appeared far less stressed than I did.

 

A few months later, renovations were also complete on the other side of the department and we were able to complete the work by opening the major trauma and surgical admissions unit.  All this work was carried out in conjunction with local partners and it was immensely satisfying to see the department finished and the care of patients improving as a result of system strengthening in coordination with better facilities and environment.  From a personal point of view, I have developed skills in logistics, building design and plumbing that were never covered in medical school and which I feel will be much more useful in future life than knowledge of the life cycle of a tape worm. 

Rather than winding down over the final couple of months, time seems to have accelerated as I have continued to support the Emergency Department as well as pursue other projects including the development of Early Warning Scores for sick patients with my hard-working intensive care colleague Ruth and some trauma strengthening work with the surgical team.  I briefly took on the role of clinical manager of the team for my last month and gained an insight into the challenges of balancing clinical responsibilities with organisational priorities whilst looking out for the wellbeing of team members- a daunting task for which I was pleased to hand over to a reassuringly capable colleague.

The last week has been about saying goodbye and handing over as well as organising a very wet trip to Bunce Island Monument which enabled some reflection on the history and heritage of the city I have spent the last year in.  I am not someone who enjoys public attention or speech making but I have watched many of my good friends and colleagues say their goodbyes over the last year and each time it got a little more emotional as I knew them more and I became aware that my time was approaching.  So I duly stood and said my farewells, to the hospital staff that I had shared so many experiences with and to my King’s colleagues, some old friends and some new enthusiastic team members. 

Crossing the estuary to Bunce Island and one of the island's former slave fortresses, now being reclaimed by the forest

The highlights of my time in Sierra Leone have been forming relationships with the staff and getting to know and work with so many Sierra Leoneans, who have been warm from the start in their reception, welcoming and ever-friendly, despite my limited ability to learn the Krio language.  It is perhaps clichéd, but true none-the-less, to say that they are an inspiration and their dedication to their work in often challenging circumstances will serve as an example to me for the rest of my career.

 

It is too early to adequately reflect on the enormity of what I have learnt and experienced in the last year but I believe that my future will be shaped and impacted positively from my time in Freetown and I hope that I may maintain my links and return one day to see the results of all the re-building and improvement that is occurring in the country currently.  

Finally embracing African lappa in the KSLP office  

Last day at Connaught Hospital with the team

Thursday 15^th September

I look out onto a different estuary, 3000 miles away.  It is a warm day in Liverpool and the Mersey has a calm blue sheen to its surface.  Life continues in Freetown and it is just another day for my colleagues in the hospital.  For me, it’s a new direction, just as exciting but very different.


If the idea of having your own Sierra Leone experience excites you, why not apply to volunteer with the KSLP team. More info is available at http://kslp.org.uk/get-involved/volunteer/  

R&R

The rain had been heavy overnight, waking me from sleep in the early hours.  The skies were now clearing as the sun’s rays poked through broken cloud, still grey and gloomy in parts.  The path through the catholic mission was beginning to dry as the water evaporated from the surrounding mango trees.  I passed young children playing football on the near-by pitch, the air filled with shouts and laughter and a lady greets me warmly as she walks effortlessly up the hill balancing an improbably large basket on her head.  The road into town is still muddy, motorbikes cautiously ploughing through deep brown puddles on the un-made road, passengers eager to avoid getting their shoes wet.  The mist lifts from the nearby Kambui Hills as the mosque begins to empty after morning prayers.

 

I am in Kenema (300 kms from Freetown) for a weekend of rest and relaxation, staying at the National Pastoral Centre, a seminary for trainee priests and haven of tranquillity to counteract the frenetic streets of the capital.  It is almost time to say goodbye to Sierra Leone so I am keen to visit the Eastern province and explore new territory before I head home.  A hike into the hills is cut short as I am unable to find a guide and the trails are still a little treacherous at the height of rainy season.  I opt instead for a cool beer and some time to reflect on some of my trips away from the city over the last twelve months.  Here are some highlights:

Watching a father and son return from a day’s fishing in the remote Turtle Island archipelago, five hours by boat from Freetown

 

Searching for hippos in Outamba-Kilimi National Park, near the Guinea border

Finding one!

Then the journey back to Freetown, an adventure in itself

Amputee football match in Makeni

After the Sierra Leone marathon, Makeni (I managed the 10k and that was enough)

A 3 day epic to the summit of Mount Bintumani

Cockle Point from Tokeh Beach

Sunset fishing, Banana Island

Engagement at Tacugama, Peninsula National Park

Benefits

Today was a bad day.  I noticed her out of the corner of my eye as I walked into the resus room, her back was arched, lifting her torso almost off the bed and her young face was in spasm.  A concerned nurse and house officer stood next to her administering oxygen and blood, watching her heart racing on the cardiac monitor.  She was only 14 years old and desperately sick.  My first thought was that this may be tetanus but on closer inspection, I could find no wound and a blood test had indicated a high concentration of malaria parasites.  Her story of headache, fever and her pale conjunctiva pointed towards the diagnosis of severe malaria and she was now unconscious.  She had been catheterised and a small trickle of black urine had collected in the bottom of the bag.  I looked at the others standing around the bed and their faces said it all, we knew she was in trouble.  Within hours she was gone.

Working in the medical profession, you become accustomed to patients dying and in a country where the average life expectancy is in the 40s, it tends to be a frequent occurrence unfortunately.  It is never easy, however, to watch a child die especially when the cause is potentially preventable.  There is some consolation in the fact that you know you have done your best but there are still days when you question whether what you are doing makes any difference.  So why do we do this?  Many of my colleagues at home were a little bemused when I told them I was heading to Sierra Leone and I am sure that some friends and family thought I was a little off the wall.  I am not entirely certain myself.  In truth, I think it is a combination of factors; the desire to make a contribution and do something worthwhile, to learn and challenge yourself in a new environment; to develop new skills and perhaps a spirit of adventure that urges travel into the unknown.  It is also fair to say that I felt a little burnt out after a decade of working emergency medicine junior doctor rotas and needed a change. 

    

It does involve sacrifice; there are days when I feel exhausted, being away from friends and family is hard at times and I have just missed the birth of my niece.  Some may see it as selfless and others as selfish, I’m sure that I have tested the patience of my fiancé on occasions and I look forward to being reunited soon and meeting my new niece in person .  I have gained a lot from the last year in Sierra Leone and there are many more positives than negatives.  Just last week, for example, supported by several colleagues, we delivered a 5-day course on emergency medicine to the final year medical students.  Spending time with a group of young people that are enthusiastic to learn and eager to develop their skills is immensely rewarding and will hopefully equip them with tips that they can use in their future careers.  Some even expressed the desire to become emergency physicians which is fantastic as the specialty is currently not formally recognised in Sierra Leone; the only way it will develop is through local doctors driving it forward with appropriate support.  I actually spend more time here undertaking service development and conducting training than clinical work but that is not necessarily a bad thing.

The All-Parliamentary Group on Global Health report in 2013 set out the benefits of UK volunteering to low and middle income countries; namely strengthening the capacity of health systems, institutions and professionals.  The caveat is that it must be appropriate, coordinated and geared to the needs of the country or institution in question, with an eye towards sustainable work.  Development work done badly can actually cause more harm through misaligned priorities, time wasting and utilising resources that would be more appropriately directed elsewhere.  This may foster resentment and worsen morale.

The Tropical Health and Education Trust (THET) identifies the key to success as working in partnership.  A successful partnership involves the UK partner being responsive to the overseas country’s needs, establishing a two-way relationship that is mutually beneficial and utilising a multi-disciplinary approach.  The All-Parliamentary Group also described the benefits to UK individuals and organisations in terms of leadership development, sharing innovation whereby UK institutions can learn novel approaches to solutions where resources are limited and improving international relations.

There are many other benefits to health partnerships and global health volunteering, such as improved cultural competence, education and research opportunities and a greater understanding of social and ethnic diversity amongst staff that volunteer.  This certainly echoes my experiences over the last year.  Engaging in global health is government policy and a framework document was published in 2014 which states that development work “should be seen as the norm, not the exception for every health worker’s career.” 

In the last decade, global health has increasingly been a priority to governments around the world following outbreaks such as SARS and H1N1.  This was brought to the fore during the Ebola epidemic and Public Health England’s Global Health Strategy involves improving global health security, responding to outbreaks of international concern, capacity building and strengthening UK global health partnerships.  Since then, the Zika virus has emerged unexpectedly as a new global threat and who knows what is around the corner. 

In conclusion, when done well, working in global health can have many benefits and I would encourage anyone who is keen to learn more and consider getting involved.  Global health is everyone’s concern and in my experience, there are more good days than bad.

New Developments

It has been a turbulent few weeks; the country’s leader has resigned and been replaced, senior politicians have been stabbing each other in the back and the opposition are in turmoil.  The population are divided after a bitter referendum, promises have already been broken and the rest of the continent look on in concern.  The health system is in financial crisis with concerns over sustainability, resources are stretched to the limit and morale is at an all-time low.   Patients are suffering and the staff that care for them are engaged in a battle with the health secretary with no signs of a resolution or solution.  I refer of course, to the UK and not Sierra Leone. 

I have been home for a few weeks, a trip slightly longer than planned, but have left the political turmoil behind and now arrived back in Freetown to experience the full assault of the rainy season. Gone is the dust and in its place, a damp humidity but at least it is slightly cooler now.  The large majority of my time before leaving last month was spent supporting the development of the hospital’s new acute surgical and trauma assessment unit.  This was the second phase of the new A&E development following the opening of the new department in March.  The unit opened while I was away and I am keen to see how it is going.

I was told that the ward had opened in a bit of a hurry when several seriously injured patients arrived simultaneously following a major traffic accident.  The staff had coped admirably and had continued to do so.  The sister and staff nurse in charge have the ward running smoothly, there is a list of responsibilities for each nurse on duty for each shift of the day.  Each bed has a chart on the wall above it with a plan for the patient.

The high dependency bed currently has a patient being monitored and provided with oxygen after admission for a gunshot wound and collapsed lung.  The lung is now re-inflated after placement of a drain and he is improving.  A patient with a significant head injury has just arrived in the trauma resuscitation room after an assault and the staff are assessing him, supported by the medical officer.  The surgical team are reviewing patients admitted overnight after their morning meeting, a man with a suspected perforated ulcer and a child with an infected wound after a snake bite may need to go to theatre.

Some of my colleagues have been conducting training to support the opening of the ward and have worked tirelessly alongside the staff to ensure it functions effectively.  I am thrilled to see how things are progressing and I have realised how important good relationships and team effort are in moving things forward.  Work initially began over 6 months ago and is now complete, the hospital has a new Emergency Department.  This has been in the planning for a while, well before my time and I feel fortunate to have played a part in it. 

It is not only hospital management, doctors and nurses that have contributed, but we have been working alongside builders, biomedical sciences, cleaners, engineers, infection control, hospital stores, maintenance, Ministry of Health and Sanitation as well as the UK Department for International Development.  As a result of everyone’s efforts, the hospital now has a department that is geared to assessing and managing acutely unwell and injured patients, that staff can be proud of and patients can trust.  It is everyone’s responsibility to sustain this good work. 

Vacancies

Storm clouds gather over the city, forks of lightning flash in the night sky and rumbles of thunder roll across the estuary like distant drums, a warning of the approaching rains.  As the dry season comes to an end, the damns remain low and power shortages add frustration to the daily grind; the humming of generators are heard across the city each evening bringing electricity to those that are able to afford fuel.  

As the dry season ends, so too does the first year of the President’s post-Ebola Recovery Programme, launched last July.  The first nine months were focused on getting to and maintaining zero cases, restoring access to basic healthcare, re-opening schools, providing social protection support and revamping the economy.  Many of these objectives have been achieved, some are still a work in progress.  The next phase has begun; the 10 to 24-month period which is about re-invigorating the private sector, creating jobs and improving infrastructure.  There is also a major focus on building a resilient health system.  This will be a herculean task and there are some promising early signs but there is much hard work to be done.  All this also comes at a time when the World Health Organisation has launched the Sustainable Development Goals (SDGs) to end poverty and ensure prosperity for all.  Goal 3 focuses on good health and well-being including universal health coverage and access to quality health services.  Goal 3c specifically aims to “increase health financing and the recruitment, development, training and retention of the health workforce in developing countries”.

Here are a few facts that illustrate the health situation currently.  Sierra Leone has a population of 7 million, sixty percent of whom live below the poverty line, living on less than $1.25 per day with a 40% literacy rate.  According to World Bank data, for every 100,000 live births, 1,360 mothers die of pregnancy related causes in Sierra Leone whereas in the UK the figure is 9.  Similarly, for every 1000 babies born 120 will die before the age of 5.  There has been progress here as the figure was 150 per 1000 four years ago.  In the UK, the child mortality rate is 4 per 1000.  Maternal health is a good indicator of the functioning of the healthcare system as a whole as they are dependent on services from the community level through to specialist care.  Social and cultural factors also play a part in this; gender inequality and education impact on whether a woman is able to seek appropriate antenatal and emergency obstetric care.  Although Sierra Leone is towards the bottom of the UN development rankings, these problems are shared by many other low income countries across Africa and Asia.

The estimated expenditure on health is $86 per capita, of which 60% is met by the patient. In comparison, the UK spends just under $4000.   There are only around 200 doctors in the whole of Sierra Leone and 288 midwives, the majority of whom are based in the Western Area close to the capital. 64% of skilled health worker posts are vacant across the country and there is a major shortage of more highly-skilled nurses.  It is estimated that just under half the workers are currently unsalaried.  This means that not only are they not payed, but many are unregulated. 

Human resources forms one of the WHO core components of health systems and a workforce that is motivated and adequate for the population it serves is an essential part of a health system strengthening strategy.  This blog post stems from my recent attendances at a Health Ministry summit on human resources and the annual West African College of Physicians Scientific Meeting where many of these issues have been highlighted and discussed in depth.  The government and senior medical figures are well aware of what the problems are and are working hard to improve the situation.  

      

So what is the country doing to address some of these problems and what are the potential solutions?  It will be necessary to increase the number of staff on the payroll, training will need to be improved at all levels, across all cadres of health worker and stronger governance and regulatory systems will need to be introduced.  Task shifting, whereby less skilled workers are utilised to provide certain services, will be important in this process.  Community Health Officers are already being trained to conduct surgical procedures in certain health facilities.

Strong leadership will be required and partnership working will be essential to achieve the targets set.  Health workers will also need incentivisation to stay in the system and not leave the country to work elsewhere.  This will not only require adequate remuneration and supervision but also defined career pathways, professional development and the resources and facilities to enable them to do their jobs properly.  Adequate infrastructure is required in terms of clean water, electricity and a supply chain to ensure that clinics can function effectively.  The discrepancy between urban and rural staffing levels will need to be ironed out and recruitment streamlined and decentralised so that workers may be employed more quickly.  

In the last 6 months, a teaching hospital bill has been passed by parliament which will give hospitals like Connaught more autonomy in governance.  They will be able to recruit and manage their own staff and have more independent decision making over how the organisation is run.  Post-graduate medical training is developing; several months ago I mentioned that the hospital had an accreditation visit from the West African College of Surgeons.  This was successful and the hospital is now able to provide basic surgical training.  The long term goal will be to have doctors that are able to complete speciality training without having to work abroad in all the major specialities.

It will take years and significant investment to train the extra health workers required but I have noticed positive changes even in the last nine months.  King’s is in a fortunate and privileged position to be able to contribute to these changes.  By working with the Ministry, teaching hospital and college of medicine and allied health sciences, we are able to contribute towards policy development discussions, training and the support of post-graduate specialisation.  It is a time of great change and transition.  My time here is short and KSLP are currently recruiting for an emergency physician to take my place, I would encourage anyone reading this with the requisite skills to apply and be part of the journey to recovery and prosperity.     

Healthcare workers at Connaught.  Without adequately trained staff, a health system will not function effectively.    

Improvement

Working as a trainee in the UK, my focus had always been on practising medicine to the best of my abilities and to me this meant being a good clinician, making the correct diagnosis and providing effective evidence-based care.  That is what we are taught at medical school and it remains the focus throughout postgraduate training.  There was little emphasis placed on other skills such as teaching, management and service innovation.  Clinical audit was often a tick-box exercise and even if you identified a problem and wanted to make a change, there was not enough time to enact it and as a trainee, we were rarely empowered to have a significant impact.  This is slowly changing, there is a greater emphasis on clinical leadership as a result of widely publicised system failures in the UK and clinicians are being encouraged to re-engage in management.  This makes sense, we practice on the front-line, working with patients every day.  We know what the problems are so we should have a fair idea of how to solve them and improve delivery of care.

When I arrived in Sierra Leone, one of many new concepts that I was introduced to was monitoring and evaluation (M&E) and I spent several hours with my new team composing an M&E framework for the work we would be undertaking.  Although at times it felt a little tedious, it was actually useful in terms of devising a strategy for the year ahead and identifying objectives for research, training and service delivery that we wanted to achieve.  The really challenging part was deciding how we would measure success and deciding what our outcomes would be.  For example, we knew that we wanted to provide training to the nursing staff but how would we demonstrate that we had achieved what we set out to do and how could we determine whether we had been successful.  Results are all important in this business, the problem is that conducting the M&E could be a full-time job in itself.

This led me on to the topic of quality as I thought that a really interesting study would be to demonstrate that the A&E at Connaught is providing quality care to its patients and that this quality is continuously improving due to the work that we are doing alongside the local staff through our various projects.  It would be important for the organisation, positive for the staff and patients would value the service that they are receiving.  As I write this, it sounds very aspirational but I was fresh and full of enthusiasm.  I still believe it is possible eight months on but I am a little more realistic about how much can be achieved in the time I am here.  The challenge is not only in making improvements, but sustaining them and demonstrating that they have been effective, all in a resource constrained environment.

I began with a bit of a review of the literature and also considered UK emergency department quality indicators.  A review of quality measures in resource limited settings published last year in the International Journal of Emergency Medicine identified 180 different indicators of quality while a study set in South Africa using a panel of experts identified 77, of which only one was an outcome measure- that of missed injuries.    A similar process in Canada came to consensus on 48.  It strikes me that there is actually very little consensus at all and it is reassuring that far greater minds than my own have struggled to answer this question.

 

Quality measures are generally divided into structure, process and outcome. Outcome measures are arguably the most important to capture, although the hardest to measure.  For example, given the short time that patients spend in the emergency department, it is difficult to prove that our interventions have a direct impact on mortality.  The first UK quality measure, still with us but increasingly hard to achieve, is the four-hour target.  This has no doubt improved the experience of many patients attending UK A&Es but I have seen some questionable behaviour by departments to achieve this target acting under managerial pressure over the last 10 years- an unintended consequence.

 

Measures that tend to crop up regularly in the literature are time to antibiotics for patients with infection and time to treatment for patients with heart attacks.  In low-income countries such as Sierra Leone, once diagnosed with infection, patients need to buy their antibiotics as well as the cannula and drip for them to be administered.  They may not be able to afford this.  An ECG my not be available to make the diagnosis of a heart attack so most go unrecognised and the only treatment available is aspirin.  There is no formal ambulance service and it would be a long journey indeed to the nearest cardiac catheter lab so patients will present days later, or not at all.

Quality care, according to the Institute of Medicine should be safe, patient-centred, timely, effective, efficient and equitable.  Translating this to what is achievable and what can be measured in low-income settings is a real challenge but we should try our best and bear these factors in mind in whatever projects we undertake.  A lot of work has been put into developing triage at Connaught over the last few years by King’s and the hospital staff.  Taken for granted at home, triage has revolutionised care of sick patients in Freetown and has continued throughout the recent epidemic.  Emergency patients with severe traumatic injuries or life-threatening medical emergencies such as seizures and stroke may have waited hours to be seen in the past – this is not the case now.

I was fortunate to be able to present some of the work conducted on triage and represent the hospital at the International Conference for Emergency Medicine a few weeks ago in South Africa.  During this conference we took part in a consensus meeting to try and refine the list of quality indicators down and I await the final results with interest.  Meanwhile, back in Freetown, the staff are working hard, quality is improving and I have faith that there will be further progress over the next few years.

Triage team hard at work

Setting up for resus training

Quality

Mohamed (not his real name) presented overnight with progressive breathlessness.  He had been seen by the junior doctor on-call who had listened to Mohamed’s chest and heard crackles possibly suggesting some fluid in the lungs.  A diagnosis of heart failure was made and a prescription was written for a diuretic to help shift the fluid off his chest.  Resus had been full, mostly with stable patients and there were no beds available on the admission ward so he was placed on a trolley in the waiting room for the night.  No comment had been made in the notes about his high fever, low oxygen levels or the dangerously low blood pressure recorded on the triage sheet which would suggest an alternative diagnosis of sepsis. 

Because the patient was not in a medical bed, he was not seen on the ward round the following morning and was reviewed several hours later when the diagnosis was changed and appropriate treatment was prescribed.  Fortunately, he had not received the diuretic as he had no money with him to buy the drug, on the flip side he did not get vital antibiotics either.  It is reasonable to say that Mohamed did not receive quality care and may die as a result.  There are a multitude of factors that resulted in his inadequate care.

Before going any further, let me be clear that I am not intending to be critical, I am simply trying to analyse what happened.  Achieving quality care is a challenge in all health systems across the globe and I have encountered many of these issues in the UK.  I have been that junior doctor, in the middle of the night stretched to my limits with little support and have no doubt made diagnostic errors- no one is infallible.  Why was the diagnosis missed?  Maybe the junior doctor did not read the triage sheet, if he did perhaps he did not comprehend the significance of the vital signs recorded.  He may have been tired and over-worked and did not take a thorough history or perform an adequate examination.  If he was tired, it may have been because he had been working during the day in another job as the basic salary is not enough to support his family.  Perhaps he has not been paid.

It is possible that the patient did not give an accurate history and so misled the doctor; this may have been intentional or accidental.  Some patients will conceal a diagnosis of TB or HIV from medical staff and will not disclose the fact that they are currently on treatment or have stopped it for some reason.  They may fear stigmatisation or reprimand.  They have often seen the traditional healer, tried multiple remedies and self-medicated before presenting to hospital too late for cure in order to save money or due to cultural beliefs.

 

The patient was not reviewed by a more experienced doctor overnight; there may not have been a more senior doctor to consult or maybe they were in bed. Because he was not admitted into a bed, he was not reviewed by the nursing staff so his vital signs and deterioration were not identified.  The doctor was therefore not called back to review him.  The beds were full – this could have been a busy shift but perhaps patients were not reviewed on the previous day or the hospital was full so patients could not be transferred.  I could keep going, this is a complex scenario.  The bottom line is that we could have done better for Mohamed.

 

There is certainly no individual to blame in this story, but there are many lessons to be learnt and much to improve upon. It is also unfair to suggest that this reflects standard care in the hospital or to say that this is unique to the setting.  Many of these problems occur in UK hospitals and while systems are more sophisticated and governance stronger at home to minimise adverse events, we do not always achieve good quality care and patients may suffer as a result.  As an example, The Royal College of Emergency Medicine have highlighted that ‘exit block’ leads to excess mortality and this is one of the factors that is contributing to the current crisis in UK emergency medicine.  At the risk of going slightly off topic, I will conclude by saying that achieving quality care is a challenge globally.

 

Resource limitations in Sierra Leone, and many other low-income countries, make delivering quality care extremely difficult and challenging but many basic issues are shared by more developed health systems.  I often get frustrated and these frustrations are shared by my nursing and medical colleagues here – everyone wants to do the best for their patients, it is fundamental to why we enter the profession but after working in prolonged challenging conditions, I can see how morale can dip.  While not directly comparable, the current struggles of UK junior doctors indicate that the grass is certainly not greener at home currently.

Quality care is an international goal although measures of quality may be different depending on the setting and resources available. Quality can mean different things to different people and a health minister’s view of quality may be different to a doctor’s or nurse’s which in turn may have a different focus to that of the patient or their relative.  There are many definitions and no broad consensus on how to measure it but I would argue that it should focus on the experience of the patient as they are at the centre of everything that we do.

Traumas

The security guards had lost control of the situation, a truck had pulled into the courtyard and a man was standing in the back shouting at everyone and no-one in particular, his stance seemed both threatening and desperate at the same time.  A crowd had gathered around the vehicle and the situation felt tense.  There was a cacophony of sounds and it was impossible to establish what was happening; approaching the truck felt like a bad idea though.   I maneuvered gently through the gathered throng and made my way into the triage room to find a scene of devastation.

A woman lay motionless on the stretcher in the centre of the room, two more victims sat either side; one crying out in pain clutching his ribs and one sat quietly with a deep wound across his forehead.  There was another patient still in the back of the truck who had apparently died on the way to hospital.  The triage nurse explained that a lorry had collided with a mini-bus on the outskirts of town and several people had perished at the scene.  The small, brightly coloured mini-buses or poda-podas as they are known here, are a ubiquitous, cheap form of transport seen throughout the city and will squeeze as many as twenty people or more onto cramped, wooden seats that would comfortably fit half that number in what is essentially a large painted, tin can on wheels.  I shuddered at the thought of what the accident site must have looked like. 

It was rapidly evident that nothing could be done for the lady on the stretcher and as I stood beside her, I noticed another body curled quietly in the corner of the room; a boy in his late teens.  A pool of crimson had congealed on the trolley next to his head, the source seemed to be his ear indicating a significant head injury and at first glance I feared that this was another tragedy about to be discovered.  My initial feelings of overwhelming anxiety were suppressed by my determination to gain control over the situation and prevent further harm whilst also attempting to preserve the dignity of those that were beyond help.

The man sitting with the wound across his forehead was talking, lucid and had no neck pain so I was happy for him to stay where he was for the time being.  The triage staff swiftly carried the unconscious young man into the resus room and as they placed him on the bed, he began to vomit what looked distressingly like fresh blood.  The medical officer was also in attendance at this point and he assessed the man with the chest injury in the other available resus bed.  His vital signs were reassuringly normal and after analgesia, he was beginning to calm so I felt less worried; attention focussed back on the young man that was in danger of compromising his airway.  The nurses were doing a fantastic job supporting his neck, suctioning his stomach contents to prevent them entering his lungs and beginning fluid resuscitation.

At one point there were six staff around the bed, efficiently tending to him and after several attempts to get past them to assess the patient, I gave up and stood back.  The patient was now connected to the newly installed monitors, his oxygen levels were improving and the heart rate and blood pressure were stable so it seemed reasonable to get out of their way for the sake of a few minutes.  Fortunately, the family had arrived by this stage and were able to afford the cost of a CT scan and some x-rays.  After a rapid assessment which identified the head injury as the main cause for concern, we were able to transport him to radiology.  A brief review of the scan revealed air within the skull indicating a fracture and some swelling of the brain but to my great relief, no significant bleeding.  There is no neurosurgery capability in the country and a sizeable bleed would almost certainly have been fatal.

There was no point waiting for a radiology report as this would not be available until the following day so the patient was transferred to intensive care, by which time the oxygen and fluid were taking effect and he was a little more responsive.  I returned to A&E just an hour after I had first arrived, the courtyard was an oasis of calm, the crowd had dispersed and the resus was being cleaned.  A medical patient that had collapsed on his return from the bathroom in the middle of the trauma was now safely back in bed and appeared comfortable.

The new A&E department had only been open a week at this stage and I felt proud of the way that the team, nurses especially, had dealt with such a major incident.  The nurses staffing resus are medical nurses and not trained in severe injury management, but they demonstrated that using basic life-saving principles can make a real difference to patient outcome.  I added relatively little to the proceedings and felt confident that the staff would have performed just as well with a similar outcome had I not been present.  This is the aim of what we are trying to achieve and it has taken a lot of hard work by many people to get to this point.  It may be harder still to maintain.

Triage Nurse Samuel

I felt a mixture of emotions; satisfaction that the systems work with tangible results but a profound sorrow for those families that have unexpectedly lost loved ones today.  Trauma is a preventable disease, it is responsible for too much death and disability here and I feel strongly about trying to improve this situation, even if this contribution is on a small scale.  The next phase in the A&E redevelopment is to re-open the trauma ward and begin trauma training, working with the surgical consultants and senior nurses at the hospital.  Having a trauma receiving unit is only one part of the system; emergency surgery capability, blood availability, rehab, data collection and a functional pre-hospital service are just a few other aspects that spring immediately to mind that will need strengthening over time.  Changes at a population level will require funding, political will, legislation change and enforcement of regulations.  From my experiences, ensuring that motorbike riders start wearing helmets again would be a reasonable place to start.



An accident waiting to happen?

Milestones

The entrance doors were unlocked, revealing dark corridors and empty rooms illuminated only by slivers of sunlight stretching out across the bare floor through broken panes of glass.  My eyes struggle to adjust, pupils dilating as I peer into the shadows. It’s humid and I can already feel beads of perspiration forming at the back of my neck.  The tiles have faded after repeated dousing in chlorine and a fine layer of dust has settled to give the ward an eerie, long-abandoned feel.  This was once part of the red zone, a place of fear and tragedy for many, a place where local staff worked alongside foreigners doing the best they could in a period of great uncertainty.  It is now silent, no one has been here for quite some time.

The old Ebola isolation unit

By the time the epidemic reached Freetown, hundreds of cases a day were being diagnosed across the country and the staff at Connaught needed to act fast to establish an Ebola isolation unit in an attempt to contain the virus and protect its healthcare workers.  Prior to the epidemic King’s had a program in place to help strengthen the emergency services at the hospital and had already introduced a triage system to expedite assessment of the sicker patients that presented to the hospital.   The outpatient department was re-branded as the Accident and Emergency unit to re-inforce the need for timely and effective urgent care for the critically ill and injured patients that attend there on a frequent basis.  An emergency that no one expected subsequently swept across the country at alarming speed and the Accident and Emergency ward was transformed into an Ebola holding unit.

In time, a purpose designed isolation unit was established alongside the hospital and the old unit, after decontamination, became redundant and stood empty; a dark reminder of painful recent events.  When I arrived, just over six months ago, we were isolating and managing suspect patients in the new unit.  I had heard some very upsetting accounts from colleagues, from both Freetown and abroad, that were around at the height of the epidemic and I struggled to imagine how challenging the conditions must have been. Before Christmas, it was opened up and I was able to enter inside.  Renovation work would soon be starting on a new A&E Department and I was curious to see what would be required to transform a place where the grief was still tangible into a facility that will aim to revolutionise emergency care for inhabitants of the city and beyond.

During the epidemic, the emphasis of the government and international agencies was focused out of necessity in containing the disease.  This was no doubt to the detriment of other health related issues.  Maternal and child mortality rates increased, surgery throughout the country was suspended and I have seen many HIV and TB patients that defaulted on treatment.  Most health facilities shut down but Connaught remained open, providing a much needed service to those that were sick but not suffering from Ebola.  The A&E, in its temporary facility, continued to deliver essential care at the front door, at great personal risk to the brave staff that served throughout.

We have seen the country declared free of Ebola twice now since I arrived and with recent cases in Guinea, it seems unlikely that the country will never see another case.  The skill and expertise now exists in Sierra Leone to manage the situation and gain control rapidly, the focus is now on re-building and strengthening the health care system.  This is now the main emphasis of the work of King’s at Connaught and of my role in the Emergency Department.  The lasts few months have seen huge steps forward in the delivery of emergency care and much of the credit should be given to my colleague Ling who has worked tirelessly over several years now to develop the A&E in conjunction with the hospital staff and Ministry of Health.   

The end of February saw work complete on the old isolation unit and the new A&E, along with resus and medical admissions units opened to patients.  Equipment and patients were transferred seamlessly, coordinated by Sister Kamara, in under 2 hours and there was impressively no delay or impact on patient care and safety.  Several of the staff came in early of their own volition to prepare the department and I was told off for being late by one irate nurse who had been there since 6am.

A&E Team in the new resus

Ling is now back in the UK and is sorely missed by all the staff she worked with at Connaught, although she has left a strong legacy.  Several high profile figures have visited the department in the last few weeks including the deputy health minister, chief medical officer and chief nurse; all have been impressed.  The staff are revitalised and proud of their new department, they are eager to learn how to use the new facilities and equipment.  We have a new enthusiastic and motivated medical officer and Emergency medicine is enjoying a raised profile in Sierra Leone currently.  I’m sure that this is all having a positive impact on the care of the patients, who seem to be attending in ever increasing numbers. The big challenge now will be to sustain and build on this momentum and ensure that the ministry can support the hospital to develop systems and maintain a supply chain that will keep the acute care facilities functioning effectively for the benefit of the patients.

Resus/High Dependency Before and After

A lot has taken place over six months and a great deal more is to come.  While work has the potential to become all-consuming at times, it is the down-time and the support of those who are close that is important to maintain a sense of balance and perspective.  My personal highlight has been the visit of Alice, who arrived in Freetown last month as my girlfriend and went home as my fiancée.  I was really pleased to be able to share my experiences and show her the highlights of what can be, at times, a beautiful country.  In a place that offers tropical islands and idyllic beaches in abundance, I felt the most appropriate spot for a proposal would be in the jungle surrounded by howling chimpanzees.  Fortunately, my gamble paid off and she agreed to marry me!

Getting High (Part 2)

We were relieved to see Fiona reappear from the crowd after tense negotiations- the village chief wanted to ensure that he got a fair price for us to pass through and we also agreed on a fee for us to stay in the village overnight.  We were allowed to pitch our tents in front of the goat pen and it was midnight when we finally got our heads down.

We were awoken at 5am to an extremely loud call to prayer so used this as an opportunity to get going early and head to the next and final village before the climb, Sinekoro.  This really is the end of the road and even before we could enter, we had to get the villagers to shift a large tree that had recently fallen and blocked the road.  On arrival, we were again summoned to meet with the chief and village elders.  Wooden benches were brought out to the front of his house and we were all invited to sit for negotiations while seemingly all the children in the area gathered round to observe proceedings.  Discussions were less tense this morning and we agreed prices for a guide director, team of porters and a gift for the chief.  A local volunteer porter named Bala, educated in Freetown spoke good English and was able to assist in our efforts.

We packed our equipment, locked the Defender and departed the village accompanied by a gang of excited children as far as the first river crossing, a small makeshift bridge requiring a steady head and good balance.  The route started with several small stream crossing, passing through farmers’ fields and palm plantations scattered with giant termite mounds before entering the forest with the high mountains towering above in the distance.  A short while after entering the canopy, we arrived at camp one and it was after this that the real climb began. 

Setting off from Sinekoro

The ascent from camp one to camp two is around 1000 metres through dense tropical forest so steep in parts that scrambling up using tree roots as hand-holds is required.  In certain sections, there had been recent forest fires and the ground was ankle deep in ash, logs were still smouldering and the heat given off from smoking patches of ground added to the general unpleasantness of the climb.  After several hours at a pace that I was less than comfortable with, we emerged onto a grassy plateau, the other side of which was a shaded camp two, located next to a small stream; the only source of water on the mountain with which to refill empty bottles and to allow us to prepare our dinner for the evening.  Amongst the vital rations, we had brought a bottle of gin and it was a welcome end to the day to watch the sun go down over the surrounding hills sipping a G&T out of a plastic cup while the pasta slowly cooked on our camp fire.  I even briefly forgot that I don’t like gin.

The ascent to Camp 2

The following morning, we filled and chlorinated our bottles from the stream, ensured that the porters were fed and hydrated and set off for the top watched from a distance by a curious, lone deer standing atop a neighbouring ridge.   The park is remote enough that it has been relatively protected from logging and poaching, there is an abundance of wildlife and much of the ancient forest here is original canopy.  It is only another 600m ascent to the summit from camp two over fairly gentle terrain until the final push which involves another short scramble up steep grassy slopes to the exposed rocky plateau that marks the top of the mountain.  

Summit in the background

The summit (1948m) is marked by a rocky cairn and offers a 360-degree panorama over the surrounding hills and forest.  Despite, the fading Harmattan dust, the views were impressive and I think we all had an immense feeling of satisfaction, not just in completing the climb but in actually getting to the mountain in the first place.  As far as we are aware, we are only the third group to climb the mountain this season.

Bala, our porter adding to the summit cairn

We made the descent back to camp two cautiously, this would not be the best time to sprain an ankle, or worse.  After a brief rest, we collected our tents and made the arduous trek back down to Sinekoro.  We arrived in the village at dusk, as the light from the setting sun gave the surrounding fields a golden yellow glow and the locals were making their way home after a hard day tending their crops. After ten hours of walking we were tired, weak-legged and very dirty.  A cold bucket shower felt like heaven and one of the women in the village even kindly prepared our food.  The journey back to Freetown took the entire next day but was uneventful.  We had made it to the high point of West Africa and I was still on a high when we returned home.

A well deserved beer on our return to the village -still slightly cool!