Baked Bean Curry & Tomato Plants

Even quite a drastic change in environment can soon become normal and life in Segbwema has settled into something almost consisting of a daily routine, even if that routine is one of regular interruptions that mean we are yet to complete our new favourite meal of a baked bean curry in one sitting. This newly discovered feat of gastronomy is made possible courtesy of an overpriced Lebanese shop in Kenema selling imported tins (including baked beans) but it appears that the novel aroma must be a lure for patients as the noise of placing our bowls on the table thus far has been universally swiftly followed by the sound of a student nurse knocking at the door with a new patient’s chart in their hand waiting to be reviewed.



One routine that has proved rewarding is our daily trips with a basket of food to Evelyn on the TB ward. Evelyn is a young woman who arrived at the main hospital several weeks ago. Half blind, emaciated and coughing up blood; she was not a well woman. I am not a fan of descriptions of malnutrition that often try to be colourfully emotive but I can’t imagine this fully grown adult weighed more than 30 kilograms and her arms were not much thicker than broom handles. She was stabilised on the ward and after the diagnosis of Tuberculosis was confirmed she was moved to the TB ward, a separate building situated at the bottom of the hospital compound. Although the separation is designed to limit the spread of the disease, the patients are somewhat isolated and it arguably contributes to any residual stigma.



The TB ward

 Many of the patients appear to improve significantly when their treatment is commenced so I was sadden to see Evelyn looking increasingly weak and frail some days after she had started her medication. Despite my Krio and Mende (the locally spoken languages) only extending to a few words, with the assistance of some signing, she was able to tell me that she had no food and had not been eating. When we returned later that evening with some rice, water and ground nuts she was laying on her bed under a mosquito net supported by wooden sticks and was half asleep. With no particular expectations, Janna returned the next day to pick up the bowl and found a huge smile on Evelyn’s face and possibly the beginnings of a new woman. Like her TB, her malnourishment certainly won’t be cured overnight, and we acknowledge we are by no means a long term solution to her nutrition problems, but at the most basic level having a hot meal inside her certainly helped.  It is reassuring to see that her strength has improved so that now when we go down each day she has carefully washed the bowls and cups and has them stacked ready in the basket.

Life sways between adrenaline filled moments and the benign daily grind. Last night I was traipsing out through the darkness and sheets of rain with my head torch and stethoscope to a pregnant woman with twins who had eclampsia (seizures). However, the previous weekend had been mainly filled up with hours spent washing clothes in buckets, drafting funding applications and labelling new folders for each hospital bed.  So much for the “African dream”; the reality of administrative tasks and household chores appear to be constant throughout the world. Hopefully the new folders will help make the hospital run a little more smoothly, as previously patient notes and drug charts on A4 sheets seemed to be scattered throughout the wards making it difficult on occasions to discern which patient was being treated for what.  It can be challenging to know where to begin with initiatives to improve clinical activities at the hospital, particularly when, at times, even some of the most fundamental ingredients are missing. When I arrived to assess the pregnant lady who had been fitting, there was no catheter available and only two vials of magnesium sulphate, the vital drug which needed to be given every 4 hours to stop any further seizures. (Even these two vials had been personally bought by the midwife.) Perhaps the unexciting hours spent completing funding applications will bear their fruits of a more consistent drug supply and make night time visits to the ward a little less daunting.

 On the first week we arrived I planted some tomato seeds. This was not for any particular symbolic reason, just in the hope that by the time December comes we may have a crop of fresh tomatoes to supplement our diet of baked bean curries. However, as they steadily grow, sitting in their individual coke cans, baked bean tins and empty sachets used for drinking water, they do serve to reflect that in the same way ripe, juicy tomatoes will not appear overnight on the kitchen table, changes and progress at the hospital, however small, will take their time.

Washing Gloves

I stood over the basin in the corner of the operating theatre and washed the blood off my surgical gloves. It was late on a Friday afternoon and we had just finished a caesarean section operation for a lady who had been in labour for 3 days. Normally after surgery you would remove your gloves and gown, dispose of them in the nearest waste bin and wash your hands. Therefore I was a bit puzzled when I was asked to clean my gloves before taking them off. I was soon informed that they would be rinsed further, powdered and then re-used for other clinical activities in the hospital. After a testing few days, one in particular in which 2 adults in comas and 3 convulsing children arrived almost simultaneously, the symbolic washing of a pair of supposedly disposable gloves that had been used only thirty minutes previously to assist the delivery of a new baby somehow summed up the extent of some of the difficulties and resource limitations.

Following the somewhat evident diagnosis of a prolonged obstructed labour the sequence of events necessary to deliver the baby were frustratingly protracted.  Firstly, the small team of theatre staff had to be located, who then had to establish whether surgical equipment used the previous day had been sterilised.  Next, it was necessary for the small generator to be moved to beside the theatre and diesel found to run it to provide power for the operating  theatre lights. The laboratory technician had to be called back to the hospital and finally the patients’ relatives encouraged to donate blood in case of bleeding.  Thankfully after the several hours it took to organise such matters, a foetal heart beat was still heard before going to theatre.

Despite the challenges encountered at the hospital, which at their worst had had me sending my wife Janna out in the middle of the night to buy drugs and drips for patients, there have been some small successes. Both the comatosed patients improved dramatically; one of whom, in retrospect we discovered had taken an overdose of his diabetic medication and simply needed a glucose drip to revive him. The other patient, a young woman,  most likely had cerebral malaria but responded well to intravenous quinine. In addition the three convulsing children were all discharged the following week and both the mother and baby from the caesarean are doing well.

Last weekend we attended a service in memory of the wife of my close friend Victor who sadly died suddenly 2 months ago. Victor is a friendly giant of a Liberian who first moved to Sierra Leone 20 years ago during the troubles in his neighbouring homeland. He is among the most kind-hearted and virtuous people I know, and, given his occupation as the owner of a small ‘bar’ in Segbwema, currently one of the most valuable as he is on hand anytime of the day or night to provide a cold Star beer and a haven outside the hospital compound.  We became good friends 3 years ago and although I did not know his wife well, they were obviously kindred spirits and proud parents to their 4 children, the youngest of whom is now 5. Tragically although they had been together for over a decade they only finally ‘tied the knot’ in a service 2 months before she unexpectedly passed away. With a life expectancy of only 48 years in Sierra Leone, death, even when it is that of a young mother and wife, is an accepted part of life. For a doctor, dealing with patients who do not get better is not uncommon and we become, to a certain extent, desensitised to the trauma of a person dying. Although it may seem insensitive, when I had to confirm the death of a young patient in the night, although I was upset, when I returned to the house I sat down and continued watching ‘How to Lose a Guy in 10 days’ on the laptop (Janna’s choice not mine). For me, the act of listening for a non-existent heart beat was something I have done as a matter of routine both in the UK and in Sierra Leone, but for the patient's family it was devastating and life changing. When I sat in the memorial service for Victor’s wife, even though I was not directly very close to her, this conceivably preventable death of a young mother felt very personal to me and I see the consequences of this to my friend and his family on an almost daily basis.

Victor with his wife and youngest daughter taken in 2010

Although it is necessary to have a certain detachment from the people we look after, sometimes seeing them not solely as patients but as a mother or sister or daughter, both ensures we remain empathetic in our vocation and arguably may allow us to rationalise activities such as sending your “better half” out to the village ‘pharmacy’ in the night for a vial of magic quinine when there is none to be found in the hospital.

Beginnings...

Showering outside in a Sierra Leonean thunderstorm with ‘Original Source’ mint shower gel is certainly refreshing. Somewhat exhausted on Sunday night after another  day  at the hospital I decided to save myself the effort of lugging a bucket of water from the rain water tank to the house to wash and simply stood on the patch of ground outside our front door and let nature and the rainy season do their best to me. It was at this point I thought I’d have a go at jotting a few lines down about our time here so far.

Despite a broken steering rod on the hospital vehicle and the resultant 2 hour delay outside Freetown, our journey to the hospital in Segbwema was smooth in comparison to my first visit to Sierra Leone as a medical student 3 years ago. Although we still had to contend with the unusual city planning that places the airport on the opposite side of a giant river mouth to Freetown, the capital city, at least British Airways successfully delivered us together with our baggage including emergency ‘cuppa soups’, a shortwave radio and a suitcase of medical equipment (unlike Royal Air Maroc who previously lost our bags somewhere between Casablanca and Monrovia…).  The options to cross to Freetown from the airport include a ferry (that has sunk not infrequently), a helicopter (with a dubious safety record) or a day’s drive on an unsealed road. We choose the speed boat on the basis that, given the worst case scenario, we could swim but not fly! Thankfully we remained dry and after a frantic day in Freetown organising the modern day luxuries (or essentials) of mobile phones, internet access and camping gas we departed for Segbwema, a village just over 300km east of Freetown, nearing the border with Liberia.

After two years as a junior doctor in the UK, my wife and I have returned to hopefully spend a year working at Nixon; a small mission hospital that is currently staffed by one doctor and still burdened by consequences of the civil war that ended in 2002. Although undeniably still relatively inexperienced, I hope another pair of clinical hands will be useful. The hospital attempts to provide medical care to a population of 20-30,000 despite having minimal electricity (a few hours fuelled by the generator every other night and on days when operations take place), no oxygen, minimal laboratory support, no x-rays and difficulties with drugs supplies.  And there was me thinking that my prior NHS employer in London had problems…
 

Although not wishing to be over formal, I hope we can keep anyone interested updated on our time here.  I hope you will forgive my poor literary skills and the spelling mistakes that I’m sure will creep in. Although I expect our readers are unlikely to challenge double figures and although I am someone who has only ever flirted with the likes of facebook, I am wary of the implications of documenting anything on-line and thus I hope any critical views expressed are seen within the context of a difficult situation and are not viewed as personal to any parties with interest in the hospital. Of course, where used, patient names are changed.

My first day at work was a long way from my previous experience of NHS inductions with their abundance of power point slides emphasising the importance of closing fire doors. On our way back from introductions with the Paramount Chief at the other end of the village, the current medical doctor passed me in the hospital vehicle on his way to the nearby town of Kenema for a personal matter. This left me as the sole doctor at the hospital with a row of patients calmly sitting on a bench waiting to be seen in outpatients and several wards of men, women and children to muddle through. A World Health Organisation manual usefully helped me stumble through the apparent swathes of malaria, worm infestations and typhoid that seemed relentless. Thankfully the other doctor returned that evening.

The stark realities and very human consequences of trying to practice medicine with limited resources reveal themselves both coldly and bluntly. Imagine a young man brought into the A&E department of a hospital in London. He is sweaty with a fever, breathing rapidly and has a racing pulse rate. His blood pressure is low and his abdomen is distended, rigid and exquisitely tender.  He has been vomiting and has not been to the toilet for ten days. He may have an obstructed and perforated bowel. He needs resuscitation with intravenous fluids, antibiotics, a tube from his nose to his stomach, oxygen, an array of blood tests, x-rays, an urgent CT scan, intensive care, anaesthetic and surgical input and probably emergency surgery.Late one night a man, whose age is not dissimilar to mine, was brought to the ward in the condition just described. He had been deteriorating  at home for over a week and self medicating with local herbs. By the time he had travelled to the hospital he was critical. Unfortunately only the first three treatment items on the wish list above were available to him and he died very soon after arriving. Regrettably, such cases are in no way exceptional.

However, not all patients have such a sad outcome. Of the many sick children with malaria I have seen over my first 2 weeks, one of the first was 18 month old baby Rosaline. She was struggling at 9.00pm in the evening when she was brought to the Children’s ward with convulsions, lethargy and fever. Her conjunctivae and palms were ivory pale from her anaemia and her chest wall was moving up and down very rapidly trying to ventilate her lungs. After advising for the need for urgent blood transfusion and anti-malarials I then had discomfort of witnessing the beginnings of a discussion between relatives regarding whether they had a donor available to give blood or the money to pay for the blood transfusion bag. Although not sustainable, or sensible in the precedent it sets, but with the child in extremis, I loaned the £6 needed to buy the blood bag and giving set. Thankfully one of the relatives had a compatible blood group. The laboratory technician was contacted and within 30 minutes blood donated from the relative was being transfused in to baby Rosaline. Going to sleep that night I knew that, even despite treatment, unfortunately it is not uncommon for such children not to survive.  The next morning I was therefore extremely relieved  to see my patient transformed into a toddler who was revitalized and alert to the extent she could show how terrified of the new ‘pumwee’ (white-person) doctor she was by kicking and screaming at me. As gratitude goes it was somewhat unusual but it certainly left me with a smile.

As the last of the diesel in the generator is burned, our luxurious few hours of power tonight shall soon end and therefore so shall these ramblings.

Ps: The generator has just run out but a trusty head torch will allow me to at least press the 'upload' button.