20% Mechanically Separated Turkey (Happy Christmas)

“26% turkey, 20% mechanically separated turkey”; such percentages on a tin of meat leave a lot to the imagination and the words ‘mechanically separated’ do little to tempt the taste buds. However, a can of ‘Ye Olde Oak Turkey Roll’ was the best of a mixed bunch of traditional festive offerings in the Kenema supermarket. We did splash out on a tin of Danish ham with a slightly more reassuring meat content of 84%. Once we threw together a few handmade Christmas decorations and crafted a cardboard tree from an old drinks box, our festive plans were complete. Whilst there may be many things we shall miss this Christmas, the simplicity of our preparations and absence of anything resembling a crowded shopping mall is unquestionably refreshing.  

The hospital has sympathetically quietened a little this week and we’ve closed the outpatient department from today through to Boxing Day.  Nevertheless, as with any hospital there are still enough emergencies to keep us in business; unfortunately the increased number of festive travellers and some dangerous road conditions created due to excessive dust and gravel on the half -finished Segbwema –Kenema road have combined to result in a worryingly high number of accidents.

In some ways it has been difficult to get into the festive spirit, but I felt the Christmas atmosphere arrive last week courtesy of some impromptu music in the hospital to help calm a nervous patient.  A young girl was having a procedure performed under local anaesthetic in the operating theatre and had started to become increasingly anxious towards the final stages of her surgery. Fortunately I had my IPod in my bag and we decided to put on some music to help her relax. After a quick search for a ‘Merry Xmas’ album, a stillness descended and we all enjoyed a serene moment of calm and quiet as voices singing ‘Silent Night’ filled the room.

I popped down to the TB ward this morning to see Evelyn and her gang to deliver a food package for the next few days including some fresh beef from the market. Incidentally, we saw the cow from which the meat came being led down through town as we sat having a drink at Victor's bar last night. Although perhaps not quite matured for 21 days, at least we knew it was fresh! (It appears that I’ve come a long way from my vegetarian years as I certainly enjoyed the portion of Daisy the cow which we had for our lunch).

After we re-opened the hospital library we set the student nurses an essay competition on “strategies to reduce the burden of maternal death in their local community” to encourage them to do some research.  Last week we happily began to peruse their entries and I shall end this Christmas Eve by sharing a few of their words of wisdom.  

On the importance of punishing those involved in sex crimes:

“As the saying goes, when the first frog falls into the pit, the others behind will take caution.” (MS)

On the need to work together on health interventions:

“In order to achieve (a reduction in maternal mortality) there must be collective cooperation. That is pregnant women, husbands, neighbours, the youth, the elderly, health workers, drivers and government workers each have a role to play. Their joint contribution in one way or another will help to save lives”. (SK)

On the importance of family planning:

“A father should be encouraged to remember that the community will judge him as much by the health of his children as the number of his children.” (AM)

Happy Christmas!

Magnesium Sulphate, Coke and Other Drugs

Thanks to a generous grant from a UK charity we found ourselves in Freetown a few weeks ago on a ‘drug run’ aiming to initiate a sustainable supply of medicines for the hospital. With 48 million Leones (about £8000) next to me in plastic bags, sitting in a wholesale pharmacy surrounded by packets and plastic containers of several decades of pharmaceutical development, I felt like a child in a toy shop with a year’s worth of pocket money to spend supplemented by a large Christmas bonus. Naturally, as is the way in Africa, it wasn’t quite as simple as turning up with our shopping list, and a number of items on our newly developed formulary were very difficult to locate in Freetown’s almost impenetrable congestion. Adult naso-gastric tubes, thiazide diuretics and blood transfusion bags appeared to be like gold dust. Efforts to secure 100 vials of magnesium sulphate (the precious drug needed to treat seizures in pregnancy that was unavailable on one of my recent night time visits to the ward) involved a “BBC apprentice” style mission consisting of negotiating with the Women’s Centre in Freetown to find their supplier and then abandoning the vehicle and dashing through the stand-still traffic to meet him in a central location for exchange of goods and money before we left town. 

 At some points when rushing around in the suffocating hustle of horns and swarming masses of people that comprise Sierra Leone’s capital city, I wished I had my stethoscope with me. Fortunately, this desire did not come from an unseen medical emergency, but from a craving for that moment of quiet and solitude you get from closing off the outside world as you place a stethoscope in your ears. Perhaps I am not alone in this, but not uncommonly I leave my stethoscope on a patient’s chest for a few seconds longer than is clinically really necessary, just to enjoy that moment of uninterrupted calm, with only the “lub-dup” of the patient’s heart in my ears; in amongst the chaos of hospital life it is possibly the only time when you are rarely interrupted.

Although it has been a significant boost to know that we now have most of the core essential medicines available, the art of medicine is often more complex than finding the right combination of pills. An older woman on the female ward was becoming what one would unkindly refer to as a “heart sink” patient. Each day the observation chart would show everything to be normal, examination was always unremarkable and yet each day she would have a new complaint to tell me about. Although mental health and psychological support are spoken of little here, it was clear that some of her problems may be related to a low mood, not helped by an absence of any visits from family members. I was doubtful that anything from the pharmacy would improve her list of ailments. After a few days of her not leaving the ward or getting out of bed, I decided to bargain with her that if she had a walk outside I would find her a can of coke. ‘You’re all talk and no action pumwee (white person), ’ was her vague reply. However, I was true to my word and went and found a couple of cans of Coca Cola, and she willingly kept up her end of the deal and came and sat with me outside for a drink.  For the first time I saw a glimmer of a smile on her face. In a week that saw me exhausted from not sleeping due to a noisy contractor staying upstairs, half blind from catching a purulent conjunctivitis, and miserable from eating only bread and ‘cheeze balls’ for 5 days after our camping stove malfunctioned and caught fire, I’m not sure whether it was the patient or me who most needed that 10 minute sit on the wall outside the ward in the sunshine with a coke on a Friday morning.

I would be lying if I said that sometimes the daily grind doesn’t get me down and that the tiredness and frustration of seeing the human cost of unmet healthcare need doesn’t upset me, but I know it would be naïve to imagine that I’m the only exhausted worker in the world. This time last year I was working in A&E in London which was an endurance activity in itself. I especially remember a certain sense of despondency on night shifts when colleagues whose shifts started earlier in the day gradually left every couple of hours throughout the night, until 2am when there was only 3 or 4 doctors left working in the department until morning. It wasn’t uncommon, particularly on a Saturday night, for the list of patients on the computer screen waiting to be seen to increase at a faster rate than the team of doctors could cope with, and thus the number of patients breaching the stipulated 4 hour target by the time morning came was sometimes embarrassingly long.  But however bad the night was, there was some comfort in the knowledge that at 8am a healthy brigade of fresh A&E doctors would arrive and within a few hours the department would usually be more respectable; however low you may have felt at 5am, you knew by 10am you’d be at home in bed and someone else would be clearing up the mess. The only difference here is that at 8am nothing changes and there is no cavalry coming over the hill.

Evelyn update: Evelyn came back from the village a couple of weeks ago and so far appears to be making reasonable progress despite the gap in her treatment. Unfortunately she has an ever growing number of patients for company on the TB ward as diagnoses are on the increase, possibly contributed to by problems with continuity of the government’s TB drug supplies.

Tomato update:  Plants are doing ok but since being planted out into old rice bags one or two have fallen by the wayside. Naturally I am suspecting sabotage from my noisy contractor house guest. (Does lack of sleep make you paranoid…?)