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.