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!

Getting High (Part 1)

I experience a feeling of freedom and release as we leave the busy, dusty streets of the city behind.  The peninsula road is now familiar ground as we pass through the town of Hastings with its now quiet airstrip, followed by the bustling suburb of Waterloo, weaving through roadside stalls and dodging the unpredictable moves of the okada motorbikes.  Beyond these old Krio settlements lies the route that leads out of the Western Area and into the provinces.  I am excited to explore new territory as this will only be the second time I have ventured beyond the peninsula, but I am also nervous about the unknown road ahead.

We are on our way to Mount Bintumani in the remote Loma National Park. The peak takes its name from the female spirit that is said to live there and at just under 2000m, Bintumani is the tallest mountain in West Africa.  We are a team of six and my housemate Ruth has kindly let us borrow her Landrover Defender for the expedition, organised by my colleague Fiona.  Once out of the city, the roads are quiet and in surprisingly good condition.  We make good progress through the Western Area, passing through large expanses of open countryside and the occasional roadside village.  Every now and then, a burnt out abandoned vehicle or a mangled barrier, serve as a reminder that these roads are fast and dangerous and great concentration is required at all times when driving here.

The Team

We stop briefly for lunch in Makeni, the capital of the North and 130km from Freetown.  It is a busy transport hub linking the north with the diamond mining districts in the Eastern Province and has benefited financially in recent years from investment by iron-ore mining companies.  There is a police check point a couple of miles out of town and this is where we encountered our first problem of the trip.  Our vehicle was pulled over and I was asked to get out.  I was approached by an angry immigration official who stated that he had signalled for us to stop in Makeni but claimed that I had ignored him.  In reality, he was not wearing a uniform and I had not noticed him.  He had flagged down a passing motorbike and chased us to the check point, risking his life in the process apparently!  In addition, the attending police officers discovered several other minor offences that we were guilty of. 

Following prolonged discussions and profuse apologies on my part, I was let off with a reprimand and a friendly warning.  We shook hands, he offered me his card in case there were further issues on the journey and the police waved us off, looking bemused as to why we would wish to travel such a distance just to walk up a big hill.

After a further couple of hours driving through scorching heat to the music of Fleetwood Mac and the late David Bowie, we reached Kabala; a small, pretty town situated beneath the imposing cliff face of Gbawuria Hill. It is the gateway to the Wara Wara hills and centre for cattle rearing in the north of the country.  For us, it was a place to rehydrate and was also the end of the tarmac road.  From Kabala to the Loma Mountains and Bintumani, there is a dirt track negotiable only by 4x4 vehicles, motorbikes or by walking which was definitely not an appealing option as there was still another fifty kilometers or so to go. 

Kabala Centre

We drove on through increasingly scenic terrain; lush green, tropical forest covering rolling hills punctuated by small villages with names such as Koinadugu, Momoria Badela and, my favourite, Binty Moria.  Children ran out to greet us from small thatched dwellings as we passed through; waving hands and shouts of hello accompanied the rumble of the Defender’s tyres on the baking red earth beneath us.  The sun was beginning to set as we reached the Seli River, about 30 meters wide and still flowing fairly fast, it would be an impossible proposition in the wet season.  A narrow, precarious rope and vine bridge spans the river just downstream from the vehicle crossing point, this offers the villagers a life-line to the outside world but the only way to get the Landrover across will be to ford the river.  As it is not my vehicle, I admit to being a little dubious about the prospect.  The options are to do a risk assessment and carry on, or to turn back and walk.

After some debate, we decide that the river is low enough to take the Defender across and Lamin, our guide, who seems confident, volunteers to take over the driving.  With hearts in mouths, we traverse the river and pull out onto the steep bank on the opposite side seemingly all in one piece.  The dirt road then turns into a poorly maintained track, so steep in parts that even the Landrover struggled with the gradient and we had to get out to allow the vehicle to get up the hills on more than one occasion.  By this stage it was well and truly dark and we were a long way from anywhere.  We discussed pitching our tents next to the track or even sleeping in the vehicle for the night but decide to continue on in the hope of coming across a village.

Bridge across the Seli River

It is past ten and we have been driving for 12 hours when we finally glimpse a light through the trees and the forest opens into a clearing.  With much relief we arrive in the isolated village of Banda Kefalia, a small settlement of a few hundred people.  They don’t see many vehicles here so there is a lot of excitement when we arrive, the villagers surround the vehicle and we begin to get the impression that some people in the village are less than happy to see us.  Lamin takes Fiona to speak to the village chief and they disappear off into the crowd.  Forty minutes later, they have not returned and we become concerned that there may be a problem.

Back to Work

My visit home to the UK was brief and hectic but I was pleased to be able to spend valuable time with my nearest and dearest.  Those I did not get to see; I hope will be understanding.  I have exchanged a chilly Liverpool for a humid Freetown where there is a temperature difference of 30 degrees and I am trying, but failing to re-acclimatise to the heat.  The sun has set and it is dark as I make my way down the jetty to board the sea-coach.  Children, still playing on the beach below, shout hello as I pass and the lights of the city glimmer in the distance across the harbour.   An hour later, I arrive at my rented house in Murray-town to find it like the Marie Celeste.  The lights are out, there is no power in the neighbourhood and the water tanks are empty. 

Life here is now settling into more of a routine, the novelty of the commute to work through near stationary traffic is wearing off and on occasion, I admit to struggling a little to climb out from under my mosquito net at 0630 in the morning when my alarm goes off.  Living and working here can be testing at times and I have developed more of an appreciation for the freedom and luxuries that we take for granted at home.  I am also acutely aware that compared to most people in Sierra Leone, we still have it good and I also accept that I will never be a morning person, no matter which country I wake up in.

Monday starts at a frenetic pace, a procession of sick patients arrive at the A&E; we admit a lady in septic shock, barely breathing into the last medical bed.  The next lady is in coma, she is not known to be diabetic but her blood sugar is over 30 and she is severely dehydrated.  The nurses administer insulin and fluid in the corridor while we wait for a bed.  The triage staff are dealing with a patient that has had a stroke with a blood pressure above 200 mmHg and one of the community health officers is assessing another patient with possible heart failure.  It continues past two in the afternoon and I sneak out to do some teaching with our new family medicine doctor who is on placement with us for a month.  I am called back twice in the following hour for opinions on two patients, the first is a man with an enlarged tender liver who likely has an abscess, the second presents with hiccups and turns out to have bowel obstruction due to a massive inguinal hernia.

I rush over to the hospital board room for a meeting with a delegation from the West African College of Surgeons.  They are on an accreditation visit to assess whether Connaught hospital can provide specialty surgical training.  Currently, if doctors wish to pursue specialty training to become a registrar and consultant, they must train abroad and this contributes to the brain-drain from which the country suffers.  I don’t have time to change and arrive a little dishevelled.  I feel a little under-dressed in my scrubs as I look around the table to see all the surgeons dressed in suits.  Fortunately, I don’t think this will have too much impact on the outcome of the decision.  The panel members have spent the day with the hospital consultants inspecting the facilities and will give their report in the next few weeks.  The hospital has come through many tough times over the years and it would be a fantastic boost for the dedicated team of surgeons here if they are given a positive verdict.

   

I then manage to catch up with a couple of my colleagues to discuss a course that we are hoping to run.  King’s have helped the hospital to introduce an early warning score to identify unwell and deteriorating patients on the intensive care and medical admissions wards.  We are now aiming to organise a pilot course that trains nurses, doctors and community health officers how to assess and manage these sick patients with the view to reducing hospital mortality.

   

The final event of the day is a Skype link to a medal ceremony in London for the UK staff that worked with King’s Sierra Leone Partnership during the Ebola outbreak.  The partnership was established by the King’s Centre for Global Health and has been in-country since 2013.  The aim is to help strengthen the health system by working alongside the hospital, College of Medicine and Ministry of Health.  When Ebola broke out, the organisation remained in Sierra Leone and played a major role in helping the country to contain the epidemic.  Despite this being an evening of celebration, it is not the end of the story unfortunately.  A 22-year-old girl that died last week tested positive for Ebola and a relative has subsequently also been diagnosed with the disease.  The organisation continues to support the health system here and one of its many roles will be to assist the country in the containment and eradication of this stubborn virus.  I'm ready for the weekend and it’s only Monday.

Celebrations

Happy New Year!  The festive season is drawing to a close and 2016 is now upon us.  Twelve months previously, I could not have imagined that I would be spending Christmas 2015 in Sierra Leone but the journey of life takes some unexpected turns.  My best present from Santa this year was the Christmas rota; for the first time in a decade, I had been given Christmas Day and New Year’s Eve off work.  How ironic that family and loved ones are thousands of miles away.  The wonders of modern communication make contact easier but a patchy Skype chat is not the same as sitting round the same table or sharing a kiss under the mistletoe -options here are much less appealing!;-).  

 

I look forward to catching up with everyone at home later this month, most especially my girlfriend Alice.  There is a great crowd of people here, however, and I thought that I would focus this post on what has been going on in excursions away from the hospital over the last couple of weeks.  To stick with the Emergency Medicine theme though, it’s based on ABCDE.

       

A is for Adventure

Picket Hill, at just under 900m elevation, is the highest point of the Peninsula Mountain range.  My house-mate and I decided to tackle this after Boxing Day as part of a group of six with a couple of guides to lead us to the top.  We set out from a small village of a few dwellings on the east of the range at the end of a dusty bumpy track, only negotiable by 4-wheel drive vehicles.  The trail took us quickly into jungle, past several settlements established in the early 1900s which have now been abandoned and reclaimed by the forest and up through dense vegetation towards the summit. 

The path was overgrown in several places and required clearing with machetes but after 3 hours we reached the top.  The view is a little hazy at this time of year as the Harmattan, a dust-laden wind blows across the country from the Sahara into the Gulf of Guinea, but it is still possible to feel a dramatic sense of elevation looking across the wooden hills that descend to the coastal region and meet the Atlantic Ocean.   

Clearing the way to the top of Picket Hill

B is for Beaches

In stark contrast to the UK, there has been no rain here for well over a month now as we enter the dry season.  In the dry season, the most popular destination in Freetown is the beach and Sierra Leone is home to some of the most pristine in the world.  Lumley beach, perhaps the least pristine due to its location, is a two-mile stretch of sand on the western aspect of the city.  It is fairly quiet in the mornings, aside from the occasional early morning stroller and the fishermen dragging in their nets but by most afternoons over the holiday season, thousands of revellers descend to dance, play football, bathe and generally have a good time.

Working down the peninsula the beaches get gradually more spectacular from Lakka and it’s freshly caught lobsters, through the white sands of Tokeh down to Bureh and its mountainous jungle back-drop, the best place to catch a wave on this section of coast.  A trip to the beach makes being away at Christmas a little easier to manage. 

Fishermen on Lumley Beach

Lobster at Lakka

C is for Carnival

The majority religion in Sierra Leone is Islam with a significant Christian minority.  The constitution provides for freedom of religion and there is a religious tolerance and harmony between faiths here that is seldom found amongst other nations in the region.  Whatever the faith, Christmas is a time to celebrate here and carnivals have been held regularly across the city.

Streets have been decked with decorative bunting, small stages set up for performers and loud speakers rigged to play everything from local pop to Justin Bieber, from the early evening into the ‘wee wee hours’ as one banner stated.  Needless to say, I have been impressing the locals with my dance moves on more than one occasion.

D is for Dinner

There were 14 of us present for dinner on Christmas Day and it was a splendid affair with oven roasted chicken (prepared and plucked that very morning by some of the team), stuffing, vegetables and roast potato.  Everyone contributed and I was allocated responsibility for snacks, crisps and Christmas pudding – perhaps an indication of how little my colleagues trust my culinary skills.

 

The chefs did an excellent job and as a result of the fine food and after effects from the Christmas Eve carnival, there was little energy left after dinner other than to sit back and enjoy a traditional festive movie.  Die Hard gets better every time I watch it!

Christmas Dinner

E is for End of Ebola

On 29^th December, the WHO announced Guinea to be Ebola Free.  Guinea therefore joins Sierra Leone in ending transmission of the disease and it is the first time since the start of the outbreak that there have been no cases in West Africa.  That is worth celebrating for sure!

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!