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!