Sunday, May 10, 2015

10 years since opening the outpatient clinic in Aberdeen...

On May 10, 2005 a pediatric clinic opened in Aberdeen, Freetown, Sierra Leone. A doctor from the Netherlands came to set up the clinic and after two months of preparations the doors were opened to patients. Soon this became known as one of the best pediatric clinics in Freetown and parents and children lined up to receive good quality care.

It is hard to believe that it has been 10 years since I opened the outpatient pediatric clinic in Aberdeen. At the time it was called the ACFC - Aberdeen Clinic and Fistula Centre - operated by Mercy Ships. It is now known as the Aberdeen Women's Centre and no longer run by MS. Although the pediatric clinic is currently closed due to Ebola, I am confident they will reopen in the next few months.

I remember the two months leading up to the opening of the clinic - it was a bit of a bumpy ride trying to get the community to agree to the scope of services that would be provided. I was keen to open a pediatric clinic since the child mortality rate in Sierra Leone was the highest in the world and there was no pediatric care nearby. Fortunately the stakeholders agreed that this was a good idea. 

Day 1 of the clinic went well and I soon went from seeing 3 patients, to 18 patients, to 27 patients, to 50 patients, to anywhere between 60 and 80 patients per day. There were many mornings that I had to turn patients away at the gate which was very difficult. There were some occasions in which children died in the clinic because they came in such a bad state and there was so little we could do for them. Those were difficult moments in which we were faced with the reality of the high child mortality rate in the country. Fortunately there were many children, thousands, that my team and I could help and for that I am grateful. It's fun reading through some of my blog posts from 2005-2009 to see some of the adventures I had working in Aberdeen. There were good times and bad times but overall it was such a great experience. It was a really busy time, running the clinic, seeing patients everyday, overseeing the lab and dispensary, ensuring supplies were available, etc. It was worth it though. It was a very rewarding time. A few of my nurses still work there and it is great to be in touch with them. Sometimes I run into some of 'my former patients' or their parents in town or at the Children's Hospital and it is always a blessing to know that I was able to make a difference in their lives. 

Tuesday, May 05, 2015

Supporting World Hand Hygiene Day with my colleagues - #safeHANDS...

Katie, myself, Bob, Yembeh, Dolphine, Aminata,
Alimamy, Alusine & Aqueelah - #safeHANDS
Today, May 5th 2015, marks ten years of the WHO Clean Care is Safer Care Program and National Celebration of World Hand Hygiene Day. Approximately 800 hospitals in the African region have signed up to promoting hand hygiene and this includes the three hospitals that Welbodi Partnership is supporting: the Ola During Children’s Hospital, Princess Christian Maternity Hospital and Rokupa Government Hospital. As an organisation we want to promote hand hygiene and reinforce handwashing in the hospitals we support. Our Infection Control teams will go to the various wards in each of the hospitals to demonstrate appropriate hand hygiene using special GloGerm to show how important thorough handwashing with soap and water is in keeping themselves and their patients safe.

The Ministry of Health and Sanitation is also ready to celebrate World Hand Hygiene day in collaboration with its partner organisations and a special event will be held at Connaught Hospital, where the Minister of Health and Sanitation will sign a statement pledging support to address health care associated infections in Sierra Leone. This is a milestone in Infection Prevention & Control in Sierra Leone and a necessary step in the fight against Ebola, as we strive to prevent any further health care worker infections of Ebola. We aim for safer health care facilities for staff and patients alike as we move forward in this new era of infection prevention and control in Sierra Leone.

Save Lives, Clean Your Hands!


Tuesday, April 14, 2015

A moment in a movie...

For two minutes this evening I felt like I was in a movie, just for a moment.

I was driving along Siaka Stevens street downtown when all of a sudden the world around me froze. I realized it was 6pm, which is the time that the anthem is played and the flag is lowered in various parts of the city. During this activity, out of respect, no one is allowed to move. Our car also stopped. Everyone around me froze - people stopped in the middle of the street, okadas (motorcycles) stopped abruptly, vehicles stopped. Except for one man. He kept walking because he was apparently oblivious to what was going on - within seconds he was shouted at and told to stop, which he did, after he backtracked his steps a little and stood frozen in the spot where he was expected to stop originally. It's a bizarre scene. I wish I could film it. After 2-3 minutes the music stops, the flag is lowered and everyone starts moving again. Back to the craziness of Freetown but for 2 minutes, the neighborhood was quiet. 

The first time I experienced this was years ago on Fourah Bay Road near the Eastern Police Clock Tower - at that time I was the one who was shouted at and told to stop, which I did, having no clue what was going on. Now I know. I don't experience this 'frozen in time' event often, but when I do it really feels like I have stepped into a movie. It's a fun experience. Unfortunately the clock tower does not seem to play the national anthem anymore.

Tuesday, April 07, 2015

A quieter Easter Monday...

Easter Monday in Sierra Leone is a public holiday and generally one of the busiest, craziest days of the year. I think it's equal only to Boxing day (December 26th) as far as massive treks to the beach and possibly New Year's Eve and the Sierra Leone Independence Day (April 27th) celebrations. 

Usually the day is marked with devil parades in the streets of Freetown. It is generally not a nice atmosphere since the devils can be somewhat daunting and slightly aggressive in their approach. It's a combination of people singing, running, and dancing down the street, often combined with a lot of alcohol, and slight aggressiveness. The devil and his helpers force people to give money or make their followers bow down at certain points of time. The whole scene is a bit upsetting to watch to be honest with you. About 10 years ago I was once caught in the middle of a so called devil parade in the Eastern part of Freetown and it was a scary experience with drunk men climbing on our cars and not letting us proceed. We finally managed to get away from them and had to take a long detour to go home. All this to say, I do not like devil parades and am thankful that this year they did not take place. That is one of the few positive side effects of Ebola. No mass gatherings means no devil parades. I am not complaining about that.

The other most notable difference is that people are not allowed to gather at the beach. Today is usually the busiest day on the beach, Lumley beach in particular is usually packed, and today was probably one of the quietist days at the beach ever. I went to Lumley beach last year on Easter Monday and it was the busiest I had ever seen the beach. I guess today people found other ways to spend time with their family and friends. 

Anyway, for me it was just another day at work and thankfully a more peaceful day than it could have been. I was thankful that there was no traffic going home, no disruptive devil parades, and no noisy neighborhoods. I can't complain. 

Monday, April 06, 2015

Back after 18 days...

I'm back in Freetown, after being away for 18 days. It doesn't seem like I was away for that long, but that's probably because a lot of my time away was spent working. I had Welbodi Partnership Board meetings in London, some time at the UK office, a WHO meeting in Geneva and then a week with my family in the Netherlands, with occasional emails here and there. Despite the need to get work done, at least I was in a different environment for a bit and had some time to catch up on much needed sleep. 

On my arrival in Sierra Leone yesterday, I was welcomed by a pleasant warm breeze as I headed to the immigration line. First stop: the hand washing station, then immigrations and then the next stop: the temperature check. 36.2 Celsius. After that it was business as usual: trying to inch my way towards the conveyor belt in the overcrowded baggage hall to try to retrieve my luggage. I think I saw my suitcases circle the belt 3 times before I finally managed to get someone to pass them to me. After being waved through customs I managed to buy a ticket for the water taxi and before I knew it, I was in the bus on my way to the water taxi terminal. Within an hour landing I was on the boat, crossing over to Freetown - talk about record time - and my luggage was in the same boat. It was great to be picked up by a friend and head home to settle in. 

I spent most of the day today at work. The hospital was quieter than usual since it's officially a public holiday, so I used the time to catch up with some people. I caught up with some of my colleagues and was introduced to the more recent challenges, and some of the pre-existing ones that are on-going. There is an increase in the number of suspected measles cases yet still a difficulty in getting the surveillance forms filled out and the lab samples taken. There are more children being admitted to the holding unit to rule out Ebola but most of them have non Ebola illnesses such as severe malaria and anaemia and end up dying in the isolation unit because they do not have access to things like oxygen there. Waste management still has issues, with various organizations getting involved, but no right solution as of yet. The generator seems to have a problem but I couldn't find the right person to ask about it. Some hospitals have formed their infection control committees while others have not yet met. One of the hospitals we are supporting has not yet scaled down their holding unit and plans are still unclear. Welcome back, Sandra. I definitely have my work cut out for me over the next few weeks/months with finding solutions to these challenges and carrying out the many other tasks that need to be accomplished. Where there's a will, there's a way.

Honestly, although there is a lot going on and I know I will be very busy, I am very excited about the work ahead. Today I had good conversations with my Welbodi Partnership colleagues, with our new matron at ODCH (children's hospital), with the medical superintendent of PCMH (maternity hospital), with the head of environmental health at PCMH, with colleagues from other NGOs at ODCH and PCMH, and more people. It is encouraging to hear that people are keen to move things forward and improve the hospitals as a whole. With team work, motivated spirits, and a couple of deep breaths, this should be possible. 

Monday, March 23, 2015

EVD: conversations during my travels...

It's inevitable that some slightly awkward conversations will come up related to Ebola during one's travels having come from the Ebola region. I have to say that as terrible as EVD is, knowing the mode of transmission and the extremely small risk of it reaching the Europe, I find the conversations and people's reactions somewhat amusing.

Conversation with the immigration officer at Heathrow:
Officer: Good morning
Me: Good morning, how are you? [handing over my passport]
Officer: [scans passport and looks puzzled] Where did you just travel from?
Me: Brussels and prior to that Sierra Leone
Officer: Um, that's what I thought
[pause in the conversation]
Officer: I am sorry but I will have to call someone
Me: That's fine, that is what I expected.
Officer: I am going to have to have someone from public health England meet with you
Me: No problem
Officer: You haven't been around any dead bodies recently have you?
Me: No, don't worry, I haven't and I am well 
Officer: Okay, sorry, this is the first time I have encountered this
Me: You don't have to worry, there's no risk to you
Officer: Okay, please have a seat and wait

Conversation with the man sealing suitcases at  Luton (yes, my suitcase if falling apart):
Me: Good afternoon, I would like to seal my suitcase
Man: Okay, I can help you [takes the suitcase and puts it on the machine]
Man: Where are you traveling to?
Me: Amsterdam and then Geneva
Man: Oh, that sounds interesting, what are you doing in Geneva?
Me: I am going to a WHO meeting
Man: Oh, wow, what is that about?
Me: Ebola
Man: Are you sure it's safe for me to touch your suitcase?
Me: Yes, it's not a problem at all, you are safe, I am well, there's no risk 
Man: If my 11 year old daughter finds out about this she is going to be terrified
Me: Really, there's no risk
Man: My daughter is worried that I will get Ebola since I work at an airport. I better not tell her about this.
Me: I think you are pretty safe here in Luton, I wouldn't worry about it. Thanks for sealing my suitcase.
[and off I went with my sealed suitcase]

And there you have it. Some people just don't know what to do when they hear the word Ebola. I guess that is understandable. I have to say, I have wondered how people in the plane would react if they knew I had just come from Sierra Leone. I bet some people would feel pretty uncomfortable for no reason. Thankfully, so far, friends I have met up with in London have not treated me any differently and it's been great (although a bit weird) to shake hands and hug people again. And today for the first time in a long time I held a healthy baby on my lap - that's been a while. It made me realize how little physical contact I have with people now in Freetown. 

EVD: One year since Ebola was confirmed in Guinea...

A year ago today the Ministry of Health of Guinea notified WHO of a rapidly evolving outbreak of Ebola virus disease (EVD) in forested areas of south-eastern Guinea. As of 22 March 2014, a total of 49 cases including 29 deaths had been reported. Now, a year later, the numbers are  higher than anyone could have ever dreamed of.

In Sierra Leone alone we have had over 8,000 confirmed cases of which more than 3000 people have died. In the region, over 10,000 people have died due to Ebola and that is only counting the Ebola deaths. So many more people have died of other illnesses, in part due to the unavailability of health care services and fear of patients to go to health facilities for medical care. There is a real need for all facilities to resume regular services safely.

On Friday we had 0 new cases in Sierra Leone. Today we had 2. The numbers are definitely much lower than they were in November and December when we were averaging anything from 50-70 cases per day. However, although we have now reached the tail end, this phase of the outbreak may yet drag on for some time. The fewer cases recorded, the more chance that people become complacent and revert back to their traditional practices, such as following the traditional burial rites. 

Last week Liberia recorded its first case in more than two weeks of not recording any. In Guinea and Sierra Leone there are still pockets of high transmission. Even worse, in some incidences, is cases that arise without any known contacts. This is a cause of concern, as it means there are more cases out there that no one is aware of. 

Of the 13 districts in Sierra Leone, 4 of them are well past the 42 days without any new cases and 3 districts have gone 21 days without any new cases. However, the remaining 6 districts have all had cases within the last 0-8 days. There is still a lot of work to be done in the area of contact tracing and early case identification. For as long as there is one case in the sub-region, there is a chance that the the epidemic can ignite.

In the Children's Hospital our last positive case of Ebola was 12 days ago. However, staff must remain vigilant. They need to keep screening patients and isolating any children who meet the case definition. One Ebola case that ends up on the general wards in the hospital by mistake could have disastrous effects. We need to keep the safety of staff in mind and be on the alert for any suspect cases. Our plan is to do more training soon on effective screening and safe provision of care during an outbreak. 

Hoping to see zero cases for more than 42 days consecutively throughout the region someday this year...

Tuesday, February 17, 2015

EVD: difficult decision making...

Although the situation in Sierra Leone with respect to Ebola Virus Disease (EVD) has improved considerably since November, there are still cases in Freetown every day. With Ebola still present, it is important to stay vigilant and have a high index of suspicion. Every single person that enters the hospital compound needs to be screened according to the case definition, and anyone meeting the case definition needs to be isolated and tested. One positive case can infect many people, and that needs to be avoided. 

It's a skill however to find a balance between isolating the right cases in an attempt to keep Ebola out of the main hospital and stop further transmission, versus not unnecessarily isolating cases in the unit since by doing so you may expose the patient to the virus in the unit. It's not an easy judgment call and I applaud the clinical staff making these decisions multiple times a day. Unfortunately EVD presents like a number of other illnesses, some of which are very common in children, like malaria, and so it really is hard to decide which children to isolate. Work is being done in country to try to refine the case definition for children in order to improve identification of possible EVD cases.

At times it's not only the children who are unwell, but also the caregivers, who are then also isolated and tested. Sometimes we have a group of siblings who are all unwell and so they are all isolated and tested. If the results are negative, it's pretty easy, the patient/siblings/caregiver can either be discharged home or be transferred to the hospital for regular (non-Ebola) care. When the results are positive, it is also pretty easy, although sad, and the patient(s) is transferred to an EVD treatment centre. The difficulty arises when you have a negative patients who is still highly suspect or when the results for a group of patients that are related to each other are different.

What do you do when a mother tests positive and her child tests negative? 
What do you do when two siblings test positive and one tests negative? 
What do you do when a highly suspect child, with a contact history, tests negative and is very sick needing non-Ebola care, but possibly incubating the virus? Can she go to the general ward? Do you keep her in the unit with sub-optimal care and risk of more exposure?

This is when some difficult clinical decisions need to be made and fortunately we make them as a team during our morning briefing after I have shared the laboratory results. At that particular moment you do not know if the negative case is truly virus free, or if they are incubating the virus and may develop symptoms and start shedding the virus at any moment. It's not until 21 days later that you really know and during that time they interact with many people. Experience during this outbreak has shown that children especially, can go from being well to being very sick in a matter of hours, testing positive for EVD and posing a high risk to those around them. 

I remember a mother who tested positive and her daughter tested negative. The mother died before she could be transferred to a treatment centre leaving the toddler, who was improving, behind in the unit. We knew the child had been highly exposed so we kept her in the unit in order to re-test her. However, by keeping her in the unit for two more days she was potentially exposed even more. It was a dilemma. The child tested negative the second time and was referred to an observational interim care centre (OICC), where they monitor asymptomatic exposed children for 21 days. If they become symptomatic, they are referred back to the unit for testing, if they remain healthy, they are discharged home or referred to an orphanage if the family cannot be located or if no suitable relative caregiver can be found. Fortunately we could discharge her to the OICC where she continued to improve on her antimalarial treatment and did not develop any other symptoms.  

Sadly these situations do not only pose clinical challenges but they also carry with them some severe psychological and emotional trauma. Siblings who have been admitted to the unit have watched their fellow siblings pass away. Some have watched on while their fellow sibling has been taken away to a treatment centre, not knowing what their brother or sisters fate would be, and whether or not they themselves were yet to test positive, and whether or not they would be re-united. Mothers and fathers have watched their children die, either due to Ebola or non-Ebola diseases. And occassionally, children have witnessed their parent dying in the unit, being left alone. Recently I went to the unit and saw a mother with her child. I knew the child was positive. Sadly the sibling, also positive, had died only hours earlier. It was only a matter of minutes before a nurse would come to tell the mom that this child too was positive and would need to be taken away to a treatment centre. Sadly these are just some of the many stories.

We are all waiting for Ebola to end, but until that day, or actually until 42 days of consecutively having 0 cases in the country, we need to remain vigilant. All patients and visitors must be screened, patents on the wards must be monitored continuously and staff must use the appropriate protective equipment and exercise good clinical judgement.

~ Act Justly. Love Mercy. Walk Humbly. micah 6:8 ~