Why a leap day...

So, today is leap day! Why? Well, it sounds simple- adding an extra day every four years compensates for the fact that a solar year is almost 6 hours longer than 365 days. But not quite, when you look at the details it gets a little more complicated. Some exceptions to the basic rule of adding a day every for years are required. Because a solar year is not exactly 365.25 days. It is slight less. So, how do we account for this????

Years evenly divisible by 100 are NOT leap years, UNLESS they are also evenly divisible by 400, in which case they ARE leap years. For example, 1600 and 2000 were leap years, but 1700, 1800 and 1900 were not. By this rule, the average number of days per year will be 365 + 1/4 − 1/100 + 1/400 = 365.2425, which is 365 days, 5 hours, 49 minutes, and 12 seconds. Got it?

Supermarket let down...

For those of you who have lived at our team house over the past year, you'll know how excited I have been about the Freetown Supermarket Chocolate Milk. I usually have a couple of half liter bottles in stock at all times. Well, this evening, much to my disappointment, there was no chocolate milk to be found in the supermarket. It wasn't on the shelf. I even went to the fridge- nothing. They have the peach and strawberry flavored, but no chocolate. What will I do? I have 1 lone bottle in the fridge and will have to save that for a special moment this weekend. After that I guess I wait for a new container with chocolate milk to arrive at the supermarket!To lift my spirits I went ahead and bought a milk chocolate and almond Magnum icecream :)

8 year old talking...

Last week Thursday 8 year old Samuel came to the clinic with a history of fever, vomiting and a cough for 5 days. He really didn’t look well. He looked miserable. And he wouldn’t say anything, to anyone. I examined him and sent him to the lab for tests. I kept my eye on him throughout the afternoon. His tests showed there was no malaria and his urine was fine. He was moderately ill and so I thought he might have typhoid (which is hard to test here) or another bacterial infection. I decided on a strong broad spectrum antibiotic- chloramphenicol. Used often in the developing world but banned from some countries in the West. Despite the possible side effects however, it is an excellent drug; also recommended by the WHO for a number of diseases.

As I was explaining the plan to the mom I saw the child had a coin in his hand. So, in an attempt to get some kind of response from him I asked him for the coin and ‘hid’ it in one of my hands. Presenting my two fists to him, he had to decide where the coin was. He caught on quickly. No smiles yet, but he was playing along. By the time his third turn came along, I closed my eyes as he ‘hid’ the coin. I chose his right hand- nothing. I chose his left hand- nothing. A grin appeared on his face and he produced the coin from under his leg. Smart boy! As he left with his mom I told him that when I saw him for review I wanted him to be well enough to talk to me.

Today he came back. Mind you, he showed up at 4:15pm for his 1pm review. African time! Anyway, he was full of smiles AND he was talking to me! He was much better and had no complaints whatsoever. We joked around again about him making the coin disappear last week. He went to school again today (hence the late review) which was a good sign too. Another child better. And the end of a good day.

UNICEF Fact of the week...

9.7 million = the number of children who died before their fifth birthday in 2006.

In 2006, for the first time since records have been kept, the number of children dying before their fifth birthday fell below 10 million, to 9.7 million. This milestone follows a long-term decline in the global under-five mortality rate since 1960. However, many countries still have high levels of child mortality, particularly in sub-Saharan Africa and South Asia, and in recent years have made little or no progress in reducing the number of child deaths. Global progress is insufficient to achieveMillennium Development Goal 4, which is to reduce child mortality by two thirds.

http://www.unicef.org/factoftheweek/index_42745.html

Dislike for snakes AND spiders...

Okay, I've blogged about snakes and my GREAT dislike for them,
Now let's talk about spiders.
Up until this morning I never thought I minded them so much.
A friend of mine was saying she can't stand spiders,
I thought, oh come on, they're not that bad.
That was until this morning,
When I saw a HUGE spider within a meter of my pillow.
Fortunately I had just gotten out of bed.
But had that spider been there all night?
The thought made me shiver.
After spraying half a can of insect repellant on the spider,
it fell onto my bed!
My first reaction was to grab a shoe and hit the spider.
As I watched it shrivel up and die,
I had to admit I dislike snakes AND spiders.

PS: I don't think these pictures do the spider justice.

Hottest run in a long time...

I just came back from a 20 minute run.
It was hot.
I am exhausted.
It was the hottest run in a long time.
What am I saying?
It’s one of the first runs in a long time.
Who was saying they wanted to run a 10k in January???
Well, that didn’t happen.
Early November my running partner got sick.
In December she went home.
Since then I haven’t been running.
Noone at the team house to run with.
And I don’t like being out alone around dusk.
So, it has been a long time.
Last Friday was the first run in about 3 months.
Today the second.
I feel drained.
Yet in some strange way it feels good too.
Exercise.
Sea breeze.
Sun.
Fresh air.
It was worth it.
And now, the day is done.

Ultimate cookies on a Saturday...

I’ve felt exhausted the last two weeks so I decided I really am going to take it easy this weekend. Yesterday evening I watched a movie with some friends and then a few episodes of Lost. Didn’t go to bed early in the end, but knew I could sleep in. Woke up a couple of times around 730 ish this morning and heard people going in and out but stayed in bed. Lovely! I have spent the day doing stuff around the house. Catching up on email, (yes we have national power today- so electricity on a Saturday!!!), blogging, listening to music, booking my flights for my holiday in April, baking cookies (Ultimate cookies- the best cookies ever!), watching Lost, playing guitar. Lots of nothing much really. It’s been good. This is what weekends are for.

So – the cookies – they really are the best. Chocolate, peanut butter, oats, raisins, cornflakes, the works! A perfect cookie for a Saturday, well for any day really. Here’s a quick glimpse into our African kitchen – the oven door doesn’t close properly so we have to prop it closed with a broken off broom stick and 5 gallon container of water. :)

Kit kats...

We have new additions to our Mercy Ships Team. Our cat, Kit, had 2 little cats on the 7th of this month. Aren't they cute? Kit delivered the cats under a rain water storage tank and kept them there for a few days before moving them into a cardboard box outside of our kitchen. Closer to her food I guess! Once these kits are 6 weeks old we'll need to find a new home for them...

Good news for baby Abu...

Actually, it's not only good news for baby Abu. It's good news for his mother, his grandmother and for me. Baby Abu is the 4 day old that came in on Monday- looking like he was on death's doorstep. A very floppy, listless infant. In desperate need of medical care. Well, after struggling to find a bed for him we managed to get him in a taxi and off to the hospital. To read his story go to http://sandralako.blogspot.com/2008/02/will-this-child-survive.html

I went to the hospital yesterday to join the doctor doing ward round. There lay little Abu. With his mom sitting by his side. He looked bigger somehow. He was looking around. He was much better. I picked him up and he was no longer floppy and listless. He was moving his little arms and legs. I could even get him to cry. The doctor there was pleased and said Abu could go home today. A happy ending. But this is not the end. Abu is only 8 days old. He has a long way to go. I wasn't going to let the mother go without a few words from me. So as I had her show me how Abu was feeding I encouraged her to take care of herself and her baby, to exclusively breastfeed, to take him to a hospital anytime he is sick. I hope and pray that she will look after little Abu.

Another frustration: Waiting too long…

Many people spend hours waiting in our clinic. Waiting for the doctor, for blood tests, for the results, for medication, etc. Some can spend up to 9 hours waiting from the moment they walk in the clinic, to the moment they go home with treatment. Obviously this means a lot of long days for me. This is not the frustration however; at least not for me. I suppose to some of the parents it can be a frustrating long day. But in the end most of them are just happy that someone took the time to examine their child, lab tests were available, and the correct medication was chosen for their child, rather than receiving a random collection of drugs to take.

What I am talking about is parents waiting too long to bring their child to a clinic. There have been children that have died due to their parents’ delay. Part of this is because they don’t recognize danger signs, part of it is because they don’t know where to take their child, part of it is because half of the ‘clinics’ in town are not functioning the way they should be (see previous blog entries: http://sandralako.blogspot.com/2008/02/white-doctor-good-clinic.html AND http://sandralako.blogspot.com/2008/02/clinic-frustrations-continue.html

There are many examples, but I’ll use the most recent one; a 4 month old girl who was brought to the clinic by her mom this past Tuesday.

She had been sick for one month. Her mother didn’t take her anywhere. She was only given country (traditional) medicine (=herbs) The father needed hernia surgery. So they made sure he received proper treatment instead.

She had a fever; a temp of 39.6 Celsius. A cough; with a respiration of 100 per minute!!! Her abdomen was distended; with a palpable liver and spleen of 3 cm each. At least she was breastfeeding. Her lab results: normal glucose, low hemoglobin, high white blood count and MANY malaria parasites.

I managed to refer her for inpatient treatment at an NGO hospital. After three days of iv treatment she was discharged home with medication. The mom is ‘lucky’ her child survived. As one of the sayings here goes: “Only the strong survive”. I guess this little girl is a fighter. I hope the mom learned her lesson for next time...

Someone's taken my pig again...

I’m not alone at my desk.
Let me introduce you to my desk companions.
Piglet. Camel. Rhino.
Of course, children here have never seen camels.
They have never seen rhinos.
They don’t know Winnie the Pooh or Piglet for that matter.
So, it’s fun at times to ask the children what they are.
Piglet is always ‘BABY’ (stuffed animals are also called baby)
Camel is either ‘DOG’, ‘GOAT’ or ‘COW’.
Rhino is usually a ‘BUSH HOG’.

Today was a bit over the top as piglet went missing 3 times.
I guess I wasn’t paying enough attention.
On various occasions you could hear me saying to a nurse:
“I think someone took my pig again.”
“Can you find my pig for me, please?”
“I think the pig is at the lab?”
And sure enough, a child will have run off with it.
Fortunately my nurses are great at rescuing piglet.
He’s back on my desk; safe and sound.
At least until the next child picks him up...

(This one was for you Luzanne)

Will this child survive...

At around 11:15 am 2 ladies enter the clinic with an infant.
He is 4 days old.
The nurse is quick to check the child’s vital signs and weigh him.
It’s then that I happen to enter the room.
I see the baby.
He looks very ill.

There is a history of prolonged labor.
Supposedly the child did not cry for the first 24 hours.
When he was 2 days old he was taken to a pediatrician.
The note states that he was having spasms, was cyanotic (blue) and cold.
He was treated with diazepam, 1 injection and a sugar-water solution.
He was referred to ‘somewhere’ for further management.

They did not take him anywhere else that day.
And on Sunday they also sat at home with the child.
Only on Monday morning at 11:15 am did they go seek further help.
They came to us.
A place that does not admit.
A clinic struggling to refer some of its patients for quality care.

The child is breathing.
His heart is beating.
But that’s about it.
For the rest he is floppy and lethargic.
He is not breastfeeding.
He looks like skin and bones.

I call the NGO run referral center.
They can’t tell me yet if they have beds.
I am caught face to face with the very recent dilemma of referral.
For some reason I am struggling to send my patients to the NGO hospital.
I have to call back at noon to hear if they have space.
The next 20 minutes feel like hours.

Meanwhile the mother is starting to beg, “please help us”.
I tell her I am trying.
Not realizing how stupid it is that she hadn’t been breastfeeding her child,
She was asking me to do something.
It is her first child.
Maybe she really doesn’t know what she’s doing.

Finally it is noon.
I call Emergency.
They have one bed.
We have 2 patients to refer.
This baby is worse off than the other child.
He is lucky to get the bed.

As he heads off in the taxi I am left with many questions.
Why didn’t they go to a hospital sooner?
Why did a pediatrician prescribe sugar-water solution?
Why don’t mothers learn to exclusively breast feed?
How many of these children don’t end up going to a clinic/hospital?
How many more children need to die due to ignorance?

Pretty awesome house in Kabala...

This little house was close to our guest house and for some reason I thought it was pretty cool looking. Well, not just 'some' reason, the reason being because of the huge boulders surrounding it. I thought it was pretty unique and just couldn't pass up snapping it. Supposedly it's the house of a baker...maybe it's even the bakery. That would make it the most unique bakery I've seen. We bought some freshly baked bread in the market the next morning and I could only imagine it had been baked in this little house : )

White doctor = good clinic...

People often tell me that the clinic is good because we have white doctors. Even a Sierra Leonean doctor made that comment. Well, I guess in a sense they are correct, but it definitely has nothing to do with the color of my skin. In my opinion it’s all about: trained staff, adequate resources (even if basic), focus on both cure and prevention, commitment, compassion, and calling. I try to explain to families that it is not the color of my skin that ensures health, it is quality of care- that flows from education, resources, etc. In my opinion quality care is made up of the following components:

HISTORIES: we take the time to ask what is wrong with the child. Unfortunately people often go to pharmacies or get treated by nurses in their homes and decent histories are often not taken.

EXAMINATION: we take the time to examine the child. In the informal setting (pharmacy, nurse’s home) this is not done, even in some of the official healthcare facilities this is not always carried out according to patients, due to lack of Time? Resources? Training? Attitude? Patients are often prescribed medication without being properly examined and so often not treated for the correct disease, getting sicker.

BLOOD TESTS: we have lab facilities and check a child’s blood before prescribing medication. Many health facilities in the area do not have a lab and so often people are treated based on their history, not knowing if they do or do not have malaria for example. So some are treated even though they don’t have it, other’s aren’t treated that do have it and then die. I do have to add that even our lab is very basic. But at least it helps us diagnose one of the main killers- malaria.

DIAGNOSIS: based on the above three items we make a diagnosis, sometimes multiple ones, depending on the case. I suppose others healthcare providers make a diagnosis- but it is often done like this: cough=pneumonia (even runny nose will get you ‘Septrin’ tablets here- an antibiotic), fever=malaria (although it can be 101 other things as well), or the famous disease typhoidmalaria= which is what many adults are treated for. Apparently most people think if an adult is sick it is either typhoid or malaria or both.

TREATMENT: we give the right medication for the right sickness; using national and WHO guidelines, prescribing doses based on the child’s weight, etc. The amount of nurses and pharmacies that are still giving out chloroquine is appalling. The drug is no longer effective for malaria in Sierra Leone and in my opinion should be banned!!! There are children dying because even though they are diagnosed with malaria, it is not being treated correctly. It can’t be too hard to follow the national guidelines. But I guess if chloroquine is all you have or all you know from the past, that’s what you do. I have also had children come in that have been given adult doses of sleeping tablets! Dangerous and scary. People do not realize that medication can do harm!

PREVENTION/EDUCATION: this is a key. This year we made two videos (with my nurses as actresses) on diarrhea/rehydration and malaria. They are great tools to use to teach parents how to prevent their children from getting sick! Another major issue is nutrition!

I am fortunate to work in a clinic that has trained staff and adequate resources so that we can carry out all of these components. These vital aspects of clinic care can ACTUALLY take place. Of course, we don’t always cure every child, some cases are complex, sometimes we will misdiagnose, sometimes the children come too late. But we do our best to provide a good standard of care. And that’s what people are seeing. Unfortunately in many clinics around the country resources are scarce, level of training is insufficient and many of these components of healthcare are missing. Some of this is due to the poor infrastructure due to years of civil war. But what saddens me most is that I think some of it is due to people’s attitude- not wanting to take the time to include all of these components, or wanting to make money off of people. I do hope that with time things will change. I firmly believe that any clinic with trained staff, adequate resources, and dedicated people should run well, whether the staff is black or white.

Hike in Kabala...

Having arranged for someone from the guest house to act as our guide, we set off towards the hill. Five minutes into the hike we realized that our guide had no clue where he was going. He was leading us on a vertical path, right up the steep hill, rather than zigzagging our way up. We became somewhat out of breath all too quickly and all of us being out of shape didn’t help matters either. Neither did the loose dirt. Fortunately we ‘ran’ into a group of boys who were supposed to be collecting firewood. After joining us up the steep path for a bit they revealed to us that this was not a good path to take. This path ends in tall grass, not passable by folks like us! They with their machetes would have been fine of course. Fortunately for us, they kids eagerly left their chores toguide us, on their flip flops! We were happy to reach the top of the hill. The view was great.



However, this wasn’t the peak that I wanted to reach- the peak being the top of the hill with the piled up boulders. So after a bit of convincing some of the others we continued our journey.



Luckily for us the boys were still up for a hike. They led us along a path, over a fence, past the banana tree plantation, through a two hut village, cutting through tall grass, and finally climbing onto the huge boulders at the VERY TOP of the hill. The view of Kabala was spectacular. Definitely worth the trip. Half way down the mountain the kids went their separate way. And we headed back down to the guesthouse.



A little while later we got in the car and headed back towards Freetown. We did stop at Magbenteh Community Hospital- just outside Makeni. The same hospital we stopped at on the way in with the Dutch doctors. Because friends of mine used to work there itw as fun to visit again and see how much building had gone on. The place looked great. We also heard that David Beckham was there the previous day (on the Saturday). So the reason the hotel was full on Friday night on our way through, was because Beckham and UNICEF had rented the whole hotel! An hour later we were on our way to Freetown again. Back to the busyness of life…

Makeni to Kabala...

After a simple breakfast on the porch we headed off once again. North bound to Kabala. Along the single lane “Kabala Highway” :) Soon after leaving Makeni we stopped to admire the “Camelback Hill” and chat with some of the farmers heading out to work.



We arrived in Kabala at around noon. While trying to find the house of a friend of mine who works up in Kabala we ended up seeing a little more of the town than we expected. I guess some would say we got lost, I think it was just somewhat of a detour. And in the end it was just fate, because just as we were going to turn around we saw the sign for a guesthouse. We needed to find a place to stay anyway, so checked it out. It was perfect. There were little suites with two bedrooms per block and a living room which joined them together. Each room had its own bathroom, mind you there was no running water in my tap and no shower, but once again the bucket sufficed. And there was 5 hours of electricity a night; mind you, my room was right next to the generator room, so by the time midnight came around I was happy for the generator to be switched off! All in all though, it was a bargainfor $10 a night.



After getting ourselves organized we climbed into the land cruiser once again and this time managed to find my friend’s house (after asking a couple of people for directions!). After a short visit we ventured out and explored the market; chatting with the locals and hearing bunches of kids yell out “snap me” and then getting all excited as we once again took a picture of them. That night it was dinner in one of the small local restaurants; cous cous and vegetables. Bed called early that night, as we were off for a hike the next morning.

From Lunsar...to Makeni...

From Lunsar we continued our journey towards Makeni, where we were planning on visiting a hospital that friends of mine used to work at. However, as we were cruising along the highway, the sun started to slip away, and darkness surrounded us. When we got to the hospital, it was a bit too dark to tour the facility, but we did meet the Dutch couple working there and decided to stop by on Sunday on our way back to Freetown. They were all really busy anyway, preparing for UNICEF’s visit to their facility the next day, so we went on our way to find a place to sleep for the night. We stopped at the hotel in Makeni- it was FULL. But there was a guest house just across the street with rooms available; the Buya Motel. The rooms were less than 10$ per person (a lot cheaper than the hotel) and the staff was very friendly. There was a small porch where we enjoyed dinner and breakfast, there was some electricity, buckets of water, and beds. A good place to rest for the night…except for the disco across the street, and the guy across the hall from us with his radio on full blast!

First stop...Lunsar...

After 2 hours of driving, we reached Lunsar, in the hope of finding my patient. After a few confusing (Krio) phone calls we figured out that most likely she was in the St. John of God Catholic Hospital at Mabesseneh (rather than the government run hospital). So that was where we looked first. As I got out of the vehicle and approached the hospital a girl of about 7 years ran up to me and threw her arms around me. My first thought was, wow, she’s super friendly. Soon enough I found out that she is on the same 4-bed ward as my patient. The family had seen our land cruiser drive up and decided to stand by the window to watch us, while this other little girl ran out to greet us, excited that we had come to visit her new co-patient.

We quickly made our way to the ward where we found 5 year old Mariama. Her family was excited to see us. I think it meant a lot to them that we came. Mariama herself was somewhat subdued; very quiet compared to the cheerful little girl I had seen in Freetown only 11 days earlier, full of smiles. A sign that she had started chemotherapy and it was kicking in. Despite the fact that she was a little down, this was a good indication. And fortunately, she seemed to have relatively few side effects thus far. Finally, 6 months after her jaw tumor first appeared, she is receiving the correct treatment. There’s still a long road ahead of her, with various courses of chemo to take, but there is hope.

After an hour of chatting, sitting, unwrapping crayons, a coloring book, a jump rope, a stuffed animal, etc., teaching Mariama how to color (although her father enjoyed it the most), playing with her baby brother (who loved the stuffed animal), it was time to leave again. As we left the hospital, I felt relieved, knowing that finally I had found a place to send my Burkitt patients to, so that they could receive proper treatment. I am thankful and full of hope. So is Mariama.

Freetown-Kabala upcountry trip...

A few weeks ago I mentioned that we’d be going on a trip from Freetown to Kabala. Well, we did. We left a little late on the Friday, but in the end the timing worked out quite well. From the busyness of Freetown, to the bumpy mountain road, the peaceful hospital in Lunsar, sunset on the way to Makeni, the simple guesthouse, the drive along the "Kabala highway", the hills of Kabala and back again. A great weekend, worth some blog posts. Also see: http://sandralako.blogspot.com/2008/01/going-upline-to-kabala.html

More clinic frustrations (2)...

Although I love my work here, it can be frustrating as well! I blogged about this in a previous post, which I ended with “to be continued…” See: http://sandralako.blogspot.com/2007/11/frustrations-in-outpatient-clinic.html. One thing I mentioned is that parents “load their kids up on meds”. This is no joke. I’ll give you an example:

On Monday I saw an 8 month old with a 2-day history of diarrhea and vomiting (D+V); she had been worse the previous day. Because the mom said the child had a slight fever I sent her to the lab; her blood showed NO malaria. To be honest, when I examined the child she was chubby, happy, well hydrated, and other than an eye infection looked healthy. So I put it down to an eye infection + viral gastroenteritis (stomach bug) and prescribed eye ointment, some packets of ORS (oral rehydration solution) and paracetamol. So she left the clinic with 3 medications and health education. Case closed, so I thought.

Well, of course, the story continues. On Friday I went to Emergency (referral center) to join the doctor for ward round. One of the patients was an 8 month old, admitted for dehydration on Thursday. I didn’t recognize her (we had seen 70 patients on Monday). As the doctor was talking, the mom pulled out a bag of medications: malaria medication, 3 antibiotics, vitamin syrup, paracetamol, eye ointment, iron tablets and some other colored tablets. She said she got them from Mercy Ships- not knowing I was from Mercy Ships! The doctor was annoyed that she had a bag full of drugs. I was annoyed that she said she got them from Mercy Ships. (gives impression that all we do is hand out bags of drugs!) I still didn’t remember the child, but could see by the packaging that out of all the meds she had, the only thing that looked like the packaging we have was the eye ointment, paracetamol and iron tablets. Anyway, the mother was obviously lying. I’ll leave out some details. I’m still not sure exactly why the child ended up being admitted, she looked well on her hospital bed. I guess probably the D+V continued and the mother wasn’t giving ORS. Instead she ‘loaded up her child on meds’ while her child became more and more dehydrated to the point of needing iv fluids. And people wonder why so many children die of diarrhea!!!

Still annoyed that this lady would say she got meds from Mercy Ships, I decided to check our database for the child’s name. As I read her file I saw that the mom was right, I had seen the child, but wrong in saying we gave her all those meds! The history is just as I stated above. A simple case. Nothing special. Typical outpatient case. So, why the frustration?

This is another classic example of an ignorant mother, the influences of culture (the more meds the better), incompetent healthcare staff (you can buy ANYTHING in the pharmacies here!), lack of [health] education etc. This patient would have done well at home if the mother had given her the ORS as told. But she didn't. Instead she went to the pharmacy. If there’s no instant recovery they believe they need more medication; usually tablets and syrups, often injections, sometimes iv’s. Sometimes patients will actually do all of this BEFORE seeing a doctor. Two weeks ago one of my patients had spent Le 60,000 (US$20) before coming to see me! A daily wage here is Le 15,000. But most of these mom’s are unemployed! What a waste of money. Unfortunately many people don’t understand that every medicine works for a specific disease. They don’t realize medication can be dangerous. The scary thing is that many children (and adults) are treated in their homes, by trained nurses. Why??? And why do pharmacies sell so many drugs to one patient. Is it to make money? Rather than to make people better? I think this is something I will never understand. And I am afraid this is not something that will change overnight.

I can only hope that somehow, sometime, people will start to understand some of these concepts!