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…?)