5 to Children's Hospital...

I referred a record amount of patients to the Children’s Hospital today; 5 children in one day. (Plus Anna referred 1) It was an unusual amount of referrals for one day anyway but especially to the government-run hospital. I prefer to refer to the NGO run hospital closer to our center (because it is free, they have better facilities, use protocols etc), but all of their beds were full today, so it left me with no choice; except not to refer.

I could either treat the children as outpatients and see them back the following morning hoping/praying they didn’t deteriorate overnight, or send them in to the government-run hospital, with less facilities. Less facilities meaning they often do not have electricity which means the oxygen concentrator won’t work, they often don’t have running water, lab facilites are limited, etc. And of course the never-ending dilemma of COST; Le 15,000 ($3) to see the doctor, Le 30,000 ($10) for blood transfusion, money for medication etc. Note a day’s wage is Le 15,000 and most of the mom’s that come to the clinic don’t have more than about Le 5,000 with them, so getting the money together for Children’s Hospital is always a bit of a dilemma, involving them begging, us trying to figure out how much money they do have, trying to call family members, etc. - more on that another time!

I decided to refer. A 2 month old with a severe pneumonia. A 3 year old with malaria and severe anemia. (Hb 3.7) Two siblings – both with malaria, one vomited the oral medication we gave and the other was very irritable (I’ve never seen her like this before and I know her well). Another little girl with malaria and severe anemia. (Hb 4.7)

Often it’s a struggle to convince the parents that the child needs to be admitted because of the financial burden. And most times they are afraid of the hospital because many children die there, mainly because they come in such a late stage of disease. All valid reasons I suppose. But the other option is to take the chance that the child gets worse at home overnight and dies. Today the mother’s were more sensible and willing to go. They managed to call the father or aunt who would meet them at the hospital. Good.

To be honest, maybe the siblings would have done ok with oral treatment at home- but why take the chance when they look unwell. And the little girl with an Hb of 4.7 might have been fine till tomorrow morning, but her Hb was bound to drop anyway and I would have had to refer tomorrow. So why risk her getting worse overnight at home? I hope they all went and were put on the proper treatment…

Clinic photos by Esther Havens...

These pictures were taken by a friend and excellent photographer, Esther Havens.
For more of her work, go to http://www.estherhavens.com/

Just Goggle it...

Yes, that's right.
It says "goggle" not "google".
After a very long day at work on Thursday I came home to a lovely meal.
And all of our expats sitting around the table already enjoying.
Lots of talking, telling stories etc.
It's always fun because everyone has had so many unique experiences.
We come from various countries etc.
So as you can imagine sometimes the stories can get pretty funny.
Like the story told by a Dutch plumber.
Telling us about a time he was handing out free GOOGLES to Liberians welders.
At the mention of the word 'googles' many of us smiled.
After the second or third time we were quick to correct him, "it's goggles".
As the conversation continued the word google had been used so many times it even made me have to think about what I was saying.
Needless to say there was much laughter as well.
As the topic changed and we started talking about something else, a question came up.
No one new the answer.
So what to do...
Just GOGGLE it.
From now on we'll be goggling at our house!

Trip to Lunsar...

Three weeks ago me and my colleague climbed into the landcruiser and headed toward a hospital in Lunsar- the hospital 2 hours away that is treating our Burkitt's patients. About a month earlier I had a patient show up with Burkitt's of the left eye and only a week earlier I had seen a younger boy with Burkitt's of the jaw. So I thought it would be a great opportunity to visit with them and discuss a couple of things with the doctor. So off we went...

I was very happy to find both of my patients being well taken care off. The one on the left was responding well to treatment. The boy on the right had only been there for a week and so was still trying to stay on top of the chemotherapy. He had developed a fever the previous night and was not feeling too well. They were thrilled to see us...

...as were many of the other children admitted in the hospital. There were some other Burkitt's patients there as well as some other children admitted with surgical problems who had been there for awhile. There were even 2 kids there who will be going to Spain for surgery at some point for surgery, but for now, they are waiting. Anyway, many of these kids have gotten to know each other at the hospital and spend lots of time playing and laughing. They absolutely loved the extra attention we gave them and of course the cameras. We had a big photo shoot on the ward, while we were waiting to see the doctors, who were very busy finishing off their ward rounds. It was great to see the children again and to see them getting better...

Referral place found for Burkitt's patients...

A five year old girl showed up at the clinic gate in January of this year. About 6 months earlier her parents noticed swelling of her left jaw and took her to a government hospital in the south of the country where she was treated for a dental abscess. The tumor, however, continued to grow so the family came to Freetown. When the child arrived at our clinic the facial tumor was obvious; it was large, ulcerating and foul smelling. The child was diagnosed with Burkitt’s lymphoma, cancer of the lymphatic system, which in most cases responds well to chemotherapy. However, in Sierra Leone chemotherapy is expensive and often not in stock so it is difficult to find a place for these children to get treatment. Once they are admitted they cannot always complete the full course of chemotherapy due to expenses. We have even had new patients show up at our gate with intravenous cannulas still in place because the family ran out of money for treatment. Needless to say, these patients are desperate for help. And I was getting desperate to find a place for them. After making some phone calls, I was happy to hear that an NGO hospital, 2 hours outside of Freetown, was treating children with Burkitt’s lymphoma. After talking to the expatriate doctor at that hospital I referred the little girl. And a few weeks later on our way upcountry we stopped in to see her at the hospital. She had started treatment earlier that week and was already looking healthier. Her family was thrilled that we came to visit. She was discharged after about 6 weeks of admission and the hope is that she will continue to go back for follow-up and further chemotherapy. In the first six months of 2008 we have referred a total of 6 patients to this hospital for chemotherapy and I am very thankful for the collaboration we have with them. More stories to follow soon...

Abu restores power with kitchen knife...

When I got home at 7pm this evening I came home to a dark compound.
Luckily for me this is not usually the case.
Everyday at 630pm the guard switches on our generator and we have electricity until 730am.
Well tonight, apparently, the generators were acting up.
What to do?
Call Abu, our mechanic who had gone home for the day in the hope that he would come back.
Actually he had gone to pick up his brother who was discharged from a hospital.
Which made it even worse to call him back in.
But being the great guy that he is, he came back.
And within minutes he had diagnosed the problem.
I was very impressed, because I was clueless (as was the rest of the team).
I had thought of checking the fuel level - and 95 gallons seemed like plenty!
For the rest I didn't know what else I could check.
Well, I guess Abu is kind of like a 'generator doctor'.
If there's a problem he knows how to diagnose it.
What would we do without him?
So apparently the genertor would start, but we wouldn't actually have any lights, etc.
There was a problem in the panel- something with the lever to switch between generators.
Before I knew it I was running around to find a torch (flashlight).
And then I was asked for a kitchen knife.
Yes, a kitchen knife.
And within seconds the 'Generator Doctor' was doing surgery on the switch panel.
A loose screw was the cause of the trouble.
And tightening it with the knife was apparently the solution.
How easy can it get?
Anyway, it was Abu, in the generator room, with the kitchen knife that saved the day!

Rain = interesting Sunday School...

Since April 2007 I have been attending River's Edge Community Church. We meet every Sunday in a community center, which has recently been painted a bright orange, for free I suppose by Africell- a mobile phone company. Why not?

Since December 2007 I have been helping out with Sunday School. Supposedly 2 weeks on, 2 weeks off but I end up doing sunday school more often than not. I don't really mind. I love being with the kids. In the dry season we sit in front of the church; the big kids on wooden benches, the little kids on the steps. It seems to work well.

However, in rainy season it is a different story. Last year we had to keep the kids in the church building for the whole service which meant them sitting very quietly throughout the 1hr sermon. Not easy for 2-14 year olds! It's not even easy for adults at times. This year I thought we needed to do something about this. Why not build a shelter? After weeks of talk, I finally pushed for action. This is the result. "STICKS & A TARPOLINE"

The very next Sunday the shelter was up. There was no rain. We tried out the shelter anyway and it was perfect. The big kids sat in the shelter and the little kids and myself sat on the steps. Dry.

The following Sunday it was raining. The shelter was fine when I arrived but after worship we went out and saw it had collapsed due to heavy rain. Oops. The tarp was half off of the shelter, the benches were soaked. Back inside we went. It meant sitting in the back of the church again with the kids. At least I brought something for the kids to do on paper. 4 Sundays in a row now we've been inside due to rain.

I recently decided to teach the 2-6 year olds (rather than the older kids with complicated Krio). Well, teaching 2-6 year olds is not easy when sitting in the back of the church, needing to whisper, with a preaching talking loudly through the microphone, to children that only understand Krio and are easily distracted. I realized that a Bible story and a craft works best. And to be honest, going through these Bible stories again was eye opening for me. Week 1: Noah's ark. Week 2: Daniel in the Lions Den. Week 3: David and Goliath. Week 4: The Lost Sheep.

Here is David getting ready to kill Goliath- note the stones glued onto the picture. And one of my kids- Alfred- proudly showing off his piece of art. These lessons do take some prep work. Fortunately I have an excellent coloring book so I trace the pictures out of that. I actually trace 10 copies and then hand these out to the kids.

And then the shepherd with the Lost Sheep. And the kids coloring quietly in the back of church, using a bench as a table. Children here are not used to coloring, cutting, glueing etc. So we take it step by step. Color the grass green, color the staff brown, color the clothes different colors, then glue on the cotton wool in this case. It takes up a bit more time that way too!

This would be my youngest participant. : ) Isn't she adorable. Actually, her mom sits with her and joins in. I think mom likes coloring in the pages just like I do! So, Sunday school is always an adventure. And I love it. Unfortunately it's not so easy to teach these little ones. They get their stories mixed up quickly and Noah ends up being Jesus, as does Daniel. One of the kids finally got David's name right today. That made me happy.

Matthew 25...

Tonight we were discussing poverty, God's heart for the poor, His command to reach out to them, etc. Very interesting. One of the passages was taken from Matthew 25- about feeding the hungry, clothing the naked, visiting those in prison etc. The second half of the passage has to do with those not helping the poor and Jesus' response to them in verse 45 "I tell you the truth, whatever you did not do for one of the least of these, you did not do for me." That is quite the statement and got me thinking.

I am here to serve the poor and more specifically the children in the Freetown area- a vulnerable group, often pushed to the side. And although i do my best to serve them everyday, I find myself wondering if I do enough. What is God thinking when I turn children away at the gate?

Take today for example. Wednesday, not a clinic day, but a day for immunizations and follow-up cases (of which we had 48 scheduled!). Still a busy day. However, sometimes patients show up for clinic. And often they are sent away because if we let one in this Wednesday, next week we'll have 10 patients trying to get in and before you know it we have a full blown clinic day and no time for follow-up.

So I did send one patient away today- one that I know. The father had called me 10 days ago on Sunday saying his daughter had a cough and fever. I told him to come on Monday or Tuesday. He didn't. He called again this past Sunday, I said again, you need to come on Monday or Tuesday. He didn't. He showed up today. Anyway, long story. But he was playing the system and I couldn't give in or he would do this over and over again.

At the same time however, there was another patient at the gate: a 2 year 4 month old boy who was severely malnourished. It was obvious that if he wasn't referred properly he wouldn't survive for much longer - probably for a few more days, but not much more than that. So after having just sent another patient away, I did let this child in.

So where is the justice in that? Sending one child away, and letting another child in? Showing mercy for one child, but not for the other? I felt bad. And what should I have done according to the passage in Matthew. Do I go ahead and let in every child? Where do my limits lie? At some point it seems like I have to say no.

Another example. Monday. Clinic Day. Many patients waiting. Nurse hands out 65 tickets to the first 65 kids. A full days work. But there are another 6 children waiting. I have compassion on them. After discussing with my colleague we decide to see them all. But, shortly after making that decision, I regretted it. I realized that by letting more patients in, it meant my staff would have to work even longer. We ended up seeing 74 patients and working till 8pm. Although I was happy not to send patients away, I felt bad making my staff work so late. And I don't think it's appropriate to do this all the time. But, where do the boundaries lie? What is expected of me according to the passage in Matthew 25?

And what about one of my favorite verses: Micah 6:8. Act Justly. Love Mercy. Walk humbly. Every day. All the time. I can only pray that this becomes a part of my daily life. And do my best to serve.

Blogged too soon...

Just as I thought our watertank might have miraculously fixed itself it started overflowing again. Oh well, it had been at least 5 nights since the last waterfall. Besides, I have noticed that just after the tank has overflowed and the valve is switched off is when we have the GREATEST water pressure. Meaning the BEST SHOWER EVER. Seriously, I haven't had a shower with so much water pressure in ages. So, after finding the guard to come and switch off the valve I went inside and enjoyed a lovely shower. Now it's off to bed and hopefully I'll have water in the morning...

He came back...

Fortunately the 4 year old boy I blogged about a few days ago came for follow-up.
He arrived with his aunt, the lab results and the chest x-ray.
They came at 3pm as scheduled but I didn't get around to seeing them till about 7pm.
It was a busy day (lots of patients 70+, new lab technician, complex reviews)!
I also wanted to make sure I'd have the time to talk in depth with them.
When I called them in to my office we took a look at the results.
Unfortunately his HIV test came back positive.
Not a surprise, I guess, seeing the condition he was in, but I had been hoping for the best.
If it was negative, I would try hard to 'mend' this child (as they say here).
But with it being positive, I cannot really offer this child what he needs.
All I could do was refer the child to a specialist doctor in pediatric HIV cases.
And hope that he will be fully assessed, put on antiretrovirals if he meets criteria, etc.
I am glad that the aunt came with him and glad we know the underlying cause of his illness.
But it's sad to look into the eyes of a 4 year old child and know that he is infected for life.
And that his wellbeing depends on his family; most of which have abandoned him.
As he was holding onto me I felt terrible that I could not do more.
I know in other countries doctors are faced with the HIV dilemma everyday.
But this is one child I saw today and a child that tugged at my heart.
And it's hard to see this boy suffer as a consequence of his parents' behaviour.
I can only hope that his aunt will look out for him and learn to love him as her own.

Sleeping guards...

Anytime a new guard is deployed on our compound and I’m around, the guard ‘in charge’ will tell the newcomer: “no sleeping here”. Well, I can tell you, I think that I have caught all of the guards we’ve ever had sleeping on the job at least once. And to be honest, I can understand why. They work 12 hour shifts, sometimes 6-7 nights in a row, go home during the day to very noisy compounds, many have day jobs to make more money to take care of their family, some go to school, and basically they get paid very little. However, when working as a security guard, you really can’t sleep. At least not both guards at the same time.

A week ago, on a Friday night, I went out to see if the front door to the house was locked and in the process found both guards sleeping; one in a chair, the other on the ground. Sleeping on the ground while on duty is a bit unusual; sleeping in the chair I had seen many times. Anyway, it ends up that one guard was sick. “Run Belly”. He had abdominal cramps and diarrhea. Poor guy; he really did not look too great. He was told to call in (by radio) to their office to ask to be replaced.

Two hours later; at about 11:30pm, he was still sprawled out on the ground. Seeing as I am a doctor I figured not only did I need this guard replaced but I needed to make sure it was okay to send him home rather than too a hospital. Well, he obviously had stomach cramps, but there were no signs of an acute abdomen (thinking appendicitis), no fever, etc. So, at about midnight, there I was trying to get a replacement guard and mixing up 2 Liters of ORS for our sick guard. I ended up having to call one of the higher ranked security guards out of bed to get him to call the office. Finally at 12:30 am the replacement guard came and our sick guard went home.

Before heading off to bed at 1245, the last thing I heard our guard tell the new guard was “no sleeping here”. I had to chuckle, hearing this from the mouth of the guard who had been caught sleeping in his chair only 3 hours earlier. Of course, he had told me he was only resting his eyes...

Busy, busy, busy...

So, if running the clinic, running the lab & seeing patients isn’t enough, why not add House Management, Security, and Water to the list. Who needs sleep anyway? Okay, so I am being a little sarcastic here. But as you can imagine, life is busy right now. A few of our long term staff are on holiday and lucky me has been asked or assumed to take on some of their responsibilities. Ugh. Most of the time I don’t mind, but sometimes the questions about milk, bread, jam, peanut butter or potatoes can get to me. As can the security issues at night and the overflowing water tank. Actually the tank seems to be behaving a bit better, I think it’s been three nights without a waterfall…

So, basically my extra responsibilities are as follows:
+ prepare guest rooms (I must remember we have people coming in on Tuesday
+ make sure rooms are cleaned after guests leave (fortunately I don’t have to do the cleaning)
+ get the house laundry done (bring laundry to center and it gets done there)
+ put the ingredients needed for dinner out on the counter so that our cook is set for the day
+ pick up food from the center’s kitchen before going home after work to feed our house guards
+ chat with the cook when I get home about next day's menu and what odds and ends she may need
+ give shopping list to the cook at the center who does all of our fresh produce shopping
+ make sure we have 2 night guards on duty and if not call the security company
+ check that the cats have food
+ deal with the water tank when it overflows (fortunately I get the guards to climb up there now)
+ get stuff out of storage when we run out of things like jam, powdered milk, etc.

I think these responsibilities will last for another week. Then we have one of our expats coming back who will take over for me. I guess it does make me more appreciative of what others do. But on time of a ‘more than full time’ job already, I can say I will be happy to handover again

Oh yes, and on top of these things, with so many expats gone on holiday I have kind of taken it upon myself to organize our Bible Study nights (delegating responsibilities!) and arranged this months International Church Service.

Oh, and then there is Sunday School in the church I go to in Regent Village. I teach the 3-6 year olds...I think 4 Sundays in a row. Love it, but it also takes some prep time.

No wonder I'm so tired...

Random Freetown news...

While driving in a vehicle through heavy downtown traffic you can learn a lot from your local colleagues. Here are some random, probably not-too-interesting bits of information...

- apparently the President has moved from his residence in Goderich to the Presidential Lodge in Hill Station. The plan was to move after road works in Goderich were done but I think some of the outcomes of the recent council elections sped up his move. This could be rumor
- the popular cellphone company Celtel has apparently been taken over by a company called Zain, unfortunately I have still not received my monthly phone credit from them.
- supposedly a famous Nigerian popstar is performing in the stadium tonight. Part of the reason traffic was blocked around the Congo Cross area was because of the 'parade'. We could have taken a detour but our driver wanted to see what was going on. So we ended up driving right by many young Sierra Leonean guys, dancing to the beat of loud music, all following a car with Alhaji himself sitting on the car, with more guys running around in front of the car handing out freebies. Our driver was happy to receive a cap.
- it's easier for a local to sneak a child into the government adult hospital. Joshua's granny is sick. When we went to visit last week they wouldn't let me take him in. "No children allowed". Today the locals walked right in with him. Mind you- there seemed to be no guard at the gate, so maybe that's the explanation.