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.