"Yes, but aside from the hernia..."

6.29am. Hear a knock at the door. Greeted by a nursing student who hands me the chart of a new patient on the maternity ward. ‘Sister sent this chart for you to see the patient”. Try to establish from the student how unwell the patient is, whether any vital signs have been recorded and whether I can finish brushing my teeth. Student insists she is only the messenger and that ‘Sister said you should come’. Decide it’s too early in the day to give my nursing triage tutorial on the doorstep and head to maternity. Thankfully, the woman who is 30 weeks pregnant is not too unwell but has been feeling progressively worse with fevers, ‘generalised body pain’ (a favourite symptom which features in most patient’s complaints) and headache. I organise our limited panel of blood tests (blood count and a malaria test), commence her on treatment for malaria, advise the student to monitor her observations and after examining her, reassure the expectant mother that her baby’s heart rate is healthy.  

8.24am. Drop into lab to check on the progress of the arrival of HIV tests as since the previous night current stocks have reduced to zero preventing any testing or blood transfusion.

8.30am. Arrive at the outpatient department and catch up with the other junior doctor from the UK.

8.43am. Telephone medical superintendant to see if we should start the ward round without him. Informed that (at short notice) he and the sole midwife for the hospital have been called to attend a training workshop in Bo (Sierra Leone’s 2^nd city) for 3 days. Advised to start ward round without him and continue for next 3 days.

8.57am. Maternity ward. Thankfully, no women are currently in labour and the woman from earlier is starting to look brighter.  Good news from a lady who had a caesarean, whose scar, which was infected, has now fully healed and her baby who weighed a meagre 1.7Kg at birth has now breached the 2Kg mark and is breast feeding well.

9.40am. Children’s ward. Together with the other doctor, weigh up our options for a child admitted with sever malaria and anaemia who needs a blood transfusion. Despite explaining to the family that we cannot offer safe blood transfusion currently until the HIV tests arrive, they feel there is no option for them to travel to another hospital. Telephone the lab again. Informed that someone is picking the tests up from Kenema as we speak. Maintain the child with fluids and continue treatment in the interim. Continue to see the remaining patients on the ward and also have to give a lengthy reassurance to a mother whose child is happily running wild around the ward that, unlike the first child, her little boy would not benefit from a blood transfusion.

10.32am. Start to get exasperated with patient on Men’s medical ward, whose sole response to questions in any language is that he has a hernia. On examination although he does in fact have a small reducible unproblematic hernia, more worryingly his heart rate is twice as high as normal, he is incredibly dehydrated, struggling to breath, anaemic and in heart failure. Try to prevent outward signs of further infuriation with relatives who, despite the obvious visual malady of his critical condition, also voice the only problem to be ‘hernia’ for 10 years(!) and request that we schedule surgery. Explain that his hernia is not currently the most pressing concern and we need to initiate emergency medical treatment.  

10.58am. Start seeing outpatients. Usual mix of patients; one group of whom are very well and most of my time is spent convincing them that they do not need injections or lab tests despite their insistent requests, or trying to advise both patients and nursing students that malaria is not a symptom but an illness. The second group of patients are those whom appear pleasantly unaware of quite how unwell they are and most of my time is spent negotiating with them and their relatives on the need to be admitted to hospital. Admit 3 patients to the ward; a 12 year old boy with a massively swollen abdomen, tense with accumulated fluid now making it difficult for him to lie flat or breathe, an infant with malnutrition and malaria, and one young lady, very unwell with suspected TB.

12.14pm Check in on the lab to find out that happily the HIV tests have arrived enabling blood transfusion to be organised.

2.47pm. Breathe a momentary sigh of relief as the last outpatient card on my desk is duly handed back to their owner and they are instructed towards the pharmacy. Try to not look disheartened/anxious/confused when 30 seconds later, two members of the Sierra Leone army walk into my office and request for me to see one additional outpatient who, unfortunately for him, has a rather unequivocal diagnosis; very unusually, they have brought me a corpse. Thankfully they do not have expectations of resurrection but simply need a medical doctor to confirm that the person was, in fact, deceased. For a moment I think they are going to bring him straight in to the consulting room but they agree to take their vehicle and the body round to the room we use as a temporary mortuary next to the men’s medical ward to be examined.

3.12pm. Conduct a superficial scan of the wards and check on the earlier admissions.

4.00pm. Walk down to the nursing school classroom to teach the final year nursing students on (ironically) safe blood transfusion, including the prerequisites tests required and a separate lecture on the safe use of antibiotics. Correct various assumptions about the role of antibiotics. The prize for most unusual applications goes to one female student who is confident that antibiotics should be taken every month after a woman has her menstrual period in order to ‘cleanse her’.  I wonder why we have problems with antibiotic resistance…

6.04pm. Called to the delivery room to assess a woman in labour.  

6.24pm. Telephone my Nan in the UK to wish her well for her cataract operation.

6.33pm. Supervise the delivery of a new healthy baby boy. Almost miss the key moment when his shoulder get stuck due to the above telephone call (whoops). Nevertheless, new mother and child do very well.     

10.57pm. Called to Men’s ward to assist the other doctor with a young man admitted vomiting large amounts of blood due to a suspected bleed inside his stomach. Manage to place a line in his arm to give him intravenous fluids and, after establishing which family members had a compatible blood group, several units of donated blood.

2 am. Called back to Men’s ward. Greeted by a policeman in the middle of the ward and a semi-conscious patient at the other end of the ward with a trail of blood connecting the two. Informed by policemen that man was seen drinking excessively earlier, then possibly got into a fight with a ‘friend’ and was found semi-rousable beside the main road with blood seeping from the back of his head. Begin to assess the patient who becomes more alert, starts thrashing violently, swears at everyone on the ward and then vomits profusely. Thank the policeman for his kind delivery and begin to think I have been transported back to a certain south east London A&E where I treated not dissimilar patients. Once he is slightly more amenable to assistance I give him some intravenous fluids, clean his head wound and place a temporary dressing. Realise that the plastic apron has not been especially effective at protecting my clothes and shoes from the patient’s bodily fluids.

2.38am. Return to house. Wash blood and non-descript bodily fluids off clothes and shoes and climb back in to bed.

Shameless advert: If this sounds like fun, the hospital is about to begin searching for and recruiting medical doctors. Details to follow soon. Please note, (naturally) the post will not be compliant with the European Working Time Directive.

Update May 2014. Please see links below for details of medical post.

 ·         http://healthmattersinsegbwema.blogspot.com/p/medical-opportunity-advertisement.html

·         http://www.workingabroad.com/database/medical-doctor-nixon-memorial-hospital-segbwema-sierra-leone