Yay Children's hospital...

I thought I should share a story about a child who was treated well at Children's hospital (after my previous post: No money, No Doctor... ). Last week Thursday I saw a young child of about 2 years who had a hemoglobin of 2.7 g/dL. Amazing he was still able to sit upright, but other than that he looked quite ill and had very labored breathing. He had malaria of course, which is the most common cause of severe anemia here. The NGO hospital was full, so I sent him to Children's Hospital- the government run hospital in town. I did help them a bit financially, to cover the consultation fee and to get him started on blood and iv quinine.

This past Wednesday, to my surprise, mom and child showed up at our gate. And I got a big smile out of him! The boy had just been discharged so they came to let me know what happened. In the end they spent Le 150,000 (=$50) at the hospital (half months salary). A ridiculous amount, but, on the other hand, it was spend the money or lose her child's life. She made the right decision and did what she had to do. Unfortunately some people 'don't bother' to try to find the money. I was very happy to see the boy and his hemoglobin had come up to 6 g/dL. Unfortunately mom had left his medicine at home, so I wasn't sure if his malaria was fully treated, so I had him come back today. He had the correct medicine at home, but wasn't sure how to take it, so we gave the first doses in the clinic. Mom now knows how to continue treating him at home and will come back in 3 weeks for a follow-up visit. Way to go mom!

Today I went to the Children's Hospital to see other kids I referred this week. I sent 4 of which 1 died before being seen by the doctor (due to delay because of lack of money), 2 were admitted, and 1 was nowhere to be seen. The ones on the ward were on iv antibiotics, NG feeding, and oxygen if necessary. Their charts were filled out, the nurses were busy and the doctor was seeing them everyday. This is progress! I am glad to see the change and even though there is a long way to go, it's a step in the right direction. (yes, it is costing families a small fortune, but there are lives being saved).

No money, No doctor...

Last week I saw a little boy who was moderately sick. He had lost weight, had many palpable lymph nodes and a chest infection. I decided to treat as outpatient with a strong antibiotic and see the child again on Wednesday; unless he got worse that is, then the mother was to take him to the Children's hospital. I guess my thought was he likely had TB but I needed to try out a course of antibiotics first.

Yesterday he returned. And looked worse. He had lost more weight and also had diarrhea and vomiting. Obviously the mother had not taken my advice to go to a hospital for admission if he was worse. He definitely needed to be admitted now. I called the NGO hospital- they didn't have a bed and said to check back with them. I started the child on ORS and kept checking back with the NGO hospital. After 3 hours of observation and still no bed available at the NGO hospital I decided I couldn't wait any longer. I had to send them to the government-run Children's Hospital in town. The mother only had Le 10,000 with her and it would cost Le 15,000 to see the doctor. She had the father's phone number with her so we called him. He agreed to meet the mother and child at the Children's hospital. I said he needed to bring money, he asked how much, I told him, he said ok. So I sent the mother and child off, assuming they would meet the dad, see the doctor and be admitted, and hopefully recover. I was seriously thinking HIV/TB at this point.

Just a brief explanation of the money situation- treatment at the government hospital is not free. So, what happens??? Sometimes we do give money. Because I have heard if there is no money the child will not get seen by the doctor. Or if they see the doctor but don't have money for medication, they will not be treated. And it's not cheap either. It's outrageous to think some patients I have referred have spent Le 150,000 for their child's treatment. That's half a months salary for my staff and most of these moms I see are unemployed! Anyway, it is always a dilemma when referring a child to know how much money to give. It's hard to give money to all of them- because the parents do need to take responsibility. And I don't want everyone showing up at our gate with really sick kids because they think we'll give them money to be admitted elsewhere. Plus sometimes when we give money the mom's go home with it, rather than to the hospital. Many reasons for daily money frustrations. But often they really don't come to the clinic with much money- and to send them home first means more of a delay. So, if they have the money or can call someone to meet them, that's often what we do. Or we give them enough to see the doctor and start some of the treatment and tell them they will need to collect the rest at home after the child is stabilized. Not easy decisions.

Today the mother called. The news was not what I wanted to hear. The child died yesterday. The child never saw a doctor. First she said the doctor wasn't there. I told her there are many doctors there. Then she said they wouldn't see the child because they couldn't pay the registration fee. So mother and child stood there waiting. And the child died there at the children's hospital without being attended to because they didn't have the money upfront. I guess the dad was struggling to get the money together (why didn't he tell me he didn't have it on the phone?!) and got there too late.

Needless to say I was upset to hear this terrible news. Frustrated with the screwed up system. Feeling guilty for not having given them money. Wondering how people can sit behind a registration desk and watch little children die. Questioning why the father couldn't come up with the money when he likely did get money together for the child's funeral today. Thinking about all the things I could have done differently (and if they would or wouldn't have made much of a difference). Figuring out where my responsibility beings and ends (and where that of the parents lies). I guess in the end, what has happened has happened. I already knew the system was messed up and now I've seen it happen once again. I guess in the future I will at least make sure the mother has Le 15,000 when referred off. And pray that somehow, sometime soon, something changes at the government hospital...

3 months till Christmas...

Thursday 25 September, 2008.
First thought as I was driving to work-
Only 3 months till Christmas.
Crazy thought.
So soon.
But, is it really that soon?
Lots can happen in 3 months.
If the next weeks are anything like this past week, it will seem long.
(I've had a bit of a frustrating week)
Anyway, it's always fun to think about (& plan) Christmas...
Orphanages, beach trips, food, fun, Christmas plays, Staff party...

A don worry...

Last week Thursday my first patient was a 1 year old boy with a high fever and respiration of 97 per minute. Right away I was thinking admission. I assessed him and sent him to the lab, meanwhile giving paracetamol to reduce the fever in the hopes that his respiration would stabilize. A little while later I got his results; malaria and anemia. He had an Hb of 5.6 g/dL. Definitely low, however, for transfusing a cut off of 5 g/dL is generally used here. By 9 am he was already starting his antimalarials by mouth. After that we kept reviewing him every 1-2 hours. By 230 pm his temperature had stabilized and his respiratory rate had come down to 52, still a little high, but not bad. The NGO hospital had no empty beds so I was left with the option of sending to the government hospital or reviewing him at 8 am the next morning. His mother preferred the latter. So I sent them home with medication and instructions.

Friday morning started with torrential rains so I was already wondering how many of the 8 reviews I had scheduled, would actually show up. To my surprise, all of them came but one. And of course that happened to be the 1 year old boy. I was annoyed with myself for not going with my gut feeling the previous day! But it was too late for that. At 11am I secretly hoped he would still show up, seeing as the other 7 patients trickled in throughout the morning, having been delayed by the rain. No luck. At noon I thought it would be worth contacting the NGO hospital to see if a child with that name had shown up. Two hours later I received a text message, saying the child had been seen and admitted. Praise God! I was so happy to hear that; he was alive and admitted at the NGO hospital!

Today they decided to pay me a visit. It was good to see him again although he was a bit grumpy. He had been transfused and given iv meds and was now on the mend. I checked his Hb and it had come up to 8 g/dL. I told the mother “A DON WORRY” (=I was worried about the child), and that I was happy when I found out he was at the NGO hospital and not at home getting more sick, or even worse- dead. Apparently he had gotten worse (or mom had gotten more worried) Thursday night and she went to the NGO hospital, only to hear he needed admission but they didn’t have a bed. So she begged the security guards to sleep there and spent the night in the waiting room, and the child was then admitted Friday morning. I guess that’s how the system here works! This time it worked out well for my patient. I guess in theory I could tell more of my patients to try that tactic- but I don’t think my colleagues at the NGO hospital would be pleased. It is tempting though, rather than sending them home and reviewing them in the morning (with the chance they are much worse and that the NGO hospital is still full), to tell them to just show up there. But no, I can’t feed into the system like that. I will just have to send to the government hospital at times. Today for example, I referred 3 patients, 2 to the NGO hospital, but unfortunately the last one had to go to the government hospital because the NGO hospital was full. It's still better than taking chances at home...

Torrential rain...

Rain rain rain. Actually up until recently rainy season hasn’t been bad but in the past two weeks we have experienced torrential rains! This past Friday was particularly spectacular. It started raining at about 7:20 am just as I was heading out from the main house to my bedroom. Soon after that, at 7:30 am, with umbrella in hand, I made my way from my room to the car. It was all of a 20 foot walk or so and believe me, I was soaked from my feet to up to my knees! As we started the drive up our steep road we had to decide to turn left towards Lumley, knowing it was likely flooded and traffic jammed, or turn right to Congo Cross with less chance of a flood and of course, less adventure. I let the driver decide (so I wouldn’t get blamed) and fortunately he turned left! Lumley it is.

Just after we hit the roundabout we were stuck in traffic. The two lane road had become a very crowded one lane road- as one side was totally flooded with knee high water! Two poda poda’s (minivans used for public transport) were stranded – stalled I suppose – which was quite a sight. Even more so when 4 or 5 guys tried to push the poda poda (with 15-20 people still inside) to try to get it moving again. We waited as traffic inched along; the 4x4 vehicles braving the flooded lane, but most cars remaining on our side. For awhile we were stuck at an intersection, which was seriously more like a river crossing, since oncoming cars were not leaving enough room on the side for us to pass. It was wait or end up off of the ditch in a gushing river! Wait we did.

In the meantime we watched as people – men, woman with baskets on their heads on their way to collect fish and children – tried to walk across the road- practically having to cross a river. Now and then someone would fall but fortunately someone would help them up. The water was flowing quickly and any child that fell over that edge or likely even the adults (as most can’t swim) would have been in trouble; carried away by the current. Fortunately all that was lost was a couple of pairs of flip flops.

Anyway, it took us an extra 40 minutes to get to work. And although It was an adventure, and entertaining, thank God nothing went terribly wrong! I was again reminded of how blessed we are to live in a great house, with a roof over our heads, with vehicles to take us to and from work, dry clothes to put on, etc. And I am reminded to pray for those around me who are less fortunate.

No power and lots of rain...

So, as exciting as life can be in Africa I have to be honest and say that today was NOT one of those days. Once our generator was turned off at 10 this morning we were stuck without electricity. And it wasn't until 7 1/2 hours later that the national power authority decided to make us happy and give us power.

Now, don't get me wrong, I know there is a lot more to do besides things that require power but the fact that this is rainy season definitely narrows down the options. So, the options of internet, movies, beach, pool were pretty much out. I could go to town to do some fabric shopping but did that last Saturday and wasn't really up to the craziness. The options of using my laptop to do offline stuff and the option of listening to music were very shortlived since my laptop battery died after about an hour as did my ipod. So, I spent some time reading, writing and sitting in our gazebo talking to some of my housemates. All in all not a bad day, just not very eventful. I'll just say I am glad I'm not someone who gets bored easily! And hopefully next Saturday the sun will come out and we can enjoy a day at the beach...

Survived Monday, again...

Yay, it's Monday evening.
Another "crazy Monday" come and gone.
Seeing as it's already late (after a 12 hour clinic day) I'll be brief.
We met 90 children at the gate this morning.
But only let in 60.
That meant sending 30 children off to who knows where.
Some of them will likely show up tomorrow morning in the line.
Of the 60 we saw, many ended up waiting inside for hours.
Some weren't seen till 6pm.
That's a 12 hour wait for some of them.
It's a crazy world here.

Throughout the day a couple more kids showed up.
Ones we had sent for x-rays the previous week or for admission.
So we ended up seeing 67.
And guess who came back??
Hawa; the little girl I wrote about in my previous post.
She came to say 'thank you' and let me know she had been discharged.
She looked much better.
And her hemoglobin went from 3.9 to 8.4!
That's why we're doing what we're doing.
And that's why I don't mind the long days all too much.
It's all for the kids!

Indecisiveness...

One of my biggest frustrations this week has been my own indecisiveness when it comes to referring patients. I feel like there are times when I am just not sure if I am judging the situation correctly. Having said this I can already tell you that many of these children would be admitted in the West but have to be treated as outpatients here because of lack of bed space at the free NGO and the other option (government hospital) being unaffordable and of lesser quality. So, I suppose when you really think about it, my indecisiveness can be attributed to the poor healthcare infrastructure here, rather than to myself. Sounds like an easy cop out. Let me give you an example.

Hawa has come to my clinic since the age of 5 months. She is now 2 years and 10 months and came in on Tuesday with a 2 day history of fever, swollen feet and convulsions. She didn’t look great and her lab work showed she had malaria and a hemoglobin of 5.7. This is when the decision making comes in; try to refer her for admission or see if she takes her antimalarial medication fine and send her home. The decision was simple; I already knew there was no space at the NGO hospital, so I would try outpatient treatment seeing as the child was stable. She took her antimalarials fine so I told her to come back the next day. 24 hours later she showed up at the clinic looking worse; even puffier, breathing at 60 per minute, on and off nasal flaring. Her hemoglobin had dropped to 4.0 g/dL; time to refer. Praise God there was a bed available at the NGO hospital. I sent her off in a chartered taxi for a 25-30 minute journey. Two days later I went to the NGO hospital and heard that Hawa had been transfused, improved greatly and was discharged early on Friday; a good ending.

So, the dilemma of course is that you just don’t know if the children will survive till the next morning. Fortunately, although Hawa was doing worse on Wednesday, she was still alive and could be referred. But, she could also have died that night. And I would have felt terrible for not referring her on day 1. Then again, my only option of referring was to the government-run hospital. And sometimes the treatment can be questionable and it’s expensive. Again, the never-ending financial burden; money to see the doctor, to buy a notebook for medical notes, for medication, for a blood transfusion etc. Also many people don't like going there 'because so many children die' (in my opinion because many of them go there so late).

The hardest for me is when I decide to treat as an outpatient and see the kids back the next day and then they don’t show up. Did they get worse and go to a hospital overnight, did they get better and not see need for follow-up, did the parents get distracted or worse case scenario: did they die? If they don’t show up I feel like I have misjudged the situation and it's always hard to trace what happened. Bottom line, I'm faced with tough decisions every day and I don’t like this indecisive feeling. All I can do is pray for wisdom and trust these kids into His hands.

Insights into Sierra Leonean football...

Last Saturday the Salone Stars were on the field again; a World cup qualifying match versus Equatorial Guinea, which I learned is the only Spanish speaking country in Africa. Unfortunately even football does not function smoothly in Sierra Leone; apparently the star player, Kallon, had to buy plane tickets for a number of the players to come from Europe; crazy.

We bought tickets earlier in the morning at the police station. I’m not quite sure why they are bought there, but that seems to be the norm. My guess is the police must be making some money off of it. Due to rainy season we decided to go for the expensive i.e. covered seats just in case of some showers, which set me back $10. The cheaper seats are $3.

When we arrived, we parked at what looked like a car wash. We were rudely greeted by a bunch of young guys who continuously called us white girls “baby”. We were annoyed and quickly moved along. After some pushing and shoving, and one pick-pocketing attempt, we made our way into the stadium area. After entering we noticed that many vehicles were parked just outside of the stadium so we decided to move the car. The policemen were quick to tell us that we should beg one of them to ‘watch’ the car for us. As if. Nice try.

We made our way to the stands and were entertained long before the game officially started; the teams warming up, the referees running back and forth along the midfield line, the police marching band playing with a man at the front twirling a baton and marching with his knees practically touching his chin, men dressed in crazy Sierra Leonean colored outfits, and lots of noise from people in the crowd. During the game we filled our stomachs with peanuts, meat on sticks, soda and bagged water.

The game was great. Sierra Leone won 2-1. There was lots of lively discussion throughout the game by the multitudes of Sierra Leoneans watching on; arguing, disagreeing, cheering the team on. Just after the second goal the Stars fouled and a penalty was allotted to the opposing team. When the penalty was scored, silence fell over the stadium. I guess there were no supporters for the other team and I almost felt bad for them. Half way through the game the score board stopped working, not a surprise there. And as the game came to an end the riot police made their appearance and lined up around the outskirts, just in case the fans would storm the field. It remained peaceful and we soon made our way home, stuck in traffic along the way, only to be passed up by the football teams in their buses being escorted by police vans with sirens and flashing lights. Of course a couple of taxis and local mini buses turned on their hazards and followed them, piggy backing off of the easy way through traffic. We were good and remained stuck in traffic for awhile. Oh Salone, I love it!

Busy Wednesday...

Wednesday used to be a bit of a ‘breather’ in between busy clinic days; a day to compose myself, process the first half of the week, gear up for the second half. Well, it’s changed a bit. Wednesday is still REVIEW day but this week for some crazy reason (patients being more sick than usual?!) I had 32 patients keeping me busy all day, which also meant I did not get any admin done! Not that I am a huge fan of admin, but it does need to get done; maybe this weekend??! I must say it was a very interesting day, kids of all ages, with a large variety of conditions; many doing better, a few worse. Let me give you a run down by age:

2 month olds: Twins coming for weight check-up and vaccines. A happy wheezer, coming for third day in a row, finally improving. A baby who is not gaining weight for an unknown reason and needs more tests done.
3 months olds: Boy with a heart defect in a country with no treatment possibilities, coming for check up to see if he’s gaining weight. Girl with cleft lip & heart defect coming for her regular 2 week check-up until possible surgery on the Africa Mercy.
4 months olds: Complex case with encephalocele & hydrocephalus who I had to inform that she will no longer be able to have surgery on the ship. A happy set of twins looking well and gaining weight.
5 months: Bronchitis case finally on the mend after a few days of consecutive follow-up.
6 months: Child with a bulging fontanelle; usually a danger sign but this was a happy & well child! Little girl who was quite sick 2 weeks ago with sepsis due to a widespread skin infection, referred for admission and now discharged and much better.
9 months: Child with pneumonia who is improving. Cleft palate patient coming for her monthly check-up before surgery on the ship in October. Child treated for malaria last week but still has malaria parasites so now starting quinine.
11 months: Another pneumonia case (it’s pneumonia season!) doing better.
1 year olds: Girl who came 4 consecutive days last week with malaria and anemia (Hb 4.5), bravely treating as outpatient, now with Hb 7.0. Another patient coming for her third day in a row with malaria and anemia, slowly recovering. Child with persistent cough and chest signs, possible tuberculosis, trying a second antibiotic and then may need an x-ray. A malnourished child eating only porridge made out of biscuits, gaining 200g in the last 9 months who will need a lot of follow up.
2 year old: Child with many problems including malaria, chest infection, foot drop, malnutrition looking quite ill but there was no bed at NGO hospital so I am continuing to treat as outpatient.
3 year olds: Girl who started malaria treatment yesterday and also had anemia which today dropped to 3.9 and so she needed urgent referral. Child with eye problem referred to opthamologist in town.
4 year old seen yesterday with many malaria parasites, very lethargic but praise God much better today.
5 year old with malaria last Thursday, quite sick, a bit confused, took oral treatment well and now a week later much better besides mild anemia.
6 year old with malaria and anemia and now very painful limbs, possible sickle cell case?
7 year olds: Girl with facial mass since birth wondering if we’ll be able to help her on the ship. Another girl diagnosed with malaria yesterday, very lethargic, lying down on my office floor, looking much brighter today.
8 year old who was very sick 8 days ago (possible with tapeworm?), weighing 14 kg and now much better coming with a bag of bananas and oranges to say thanks.
12 year old with lump on face inquiring about treatment options.
29 year old coming to hear she is booked for cleft palate surgery on the Africa Mercy.

So all in all a busy & productive day!

Laundry time...

Tuesday night = laundry night.
As usual, I almost forgot. I suppose getting home from work at 745pm doesn't help matters when I am signed up for a 630pm laundry slot! But it's washed and now ready to go in the dryer. I thought I'd post the above picture for fun. In Salone laundry is left to dry in a multitude of places: on the ground, on rocks, on a line, on old cars, in trees, over razor wire, etc. I'm thankful for the dryer :)

charity: water...

It's always exciting to hear what friends are doing around the world. As I was on my way to church this morning I saw more woman and children than usual on the road with big yellow jerry cans on their heads; on their way to collect water. I guess maybe the rains haven't been quite as heavy this week and they've run out of water on their compounds. Or maybe the Guma Valley Water Company shut off the water supply to this area; it wouldn't be the first time. So now, these people, some being children around the age of 5 or 6 need to walk around trying to find the nearest source of water- usually a stand pipe in the area, or a broken water pipe. Or worse, sometimes they break a water line to get to water! As we headed out we had two ladies knocking on our gate asking for water.

This got me thinking about a friend who has started a non profit organization called charity: water; bringing clean, safe drinking water to people in developing nations. He is actually in Ethiopia right now- where they are starting to dig a well at a school there. Anyway, it's a great organization and you should check it out at http://www.charitywater.org/ There will be some video footage of the drilling as well. Exciting, life changing work...

Patient rescheduled...

Good news!
Shortly after writing my last post I received an email (in response to mine) from my friend on the ship in charge of scheduling patients. And, guess what?! There are still some open slots in the schedule and my patient is booked for surgery in November. Yay. I'm happy she'll have one more chance to go to Liberia for surgery. I'll see her again on Wednesday and tell her the news.

Overwhelming day...

Strange how a single day can bring out so many emotions. From laughter to tears. From frustration to enjoyment. An eventful day in too many ways. Days here can easily take you from one end of the spectrum to another. Today was one of those days. Actually this week seems to be one of those weeks...

Today it started when I had to turn children away at the gate at 8 this morning - frustration & guilt.
Then 2 children I had seen yesterday with a lot of malaria, came for review; only slightly better - concern.
A child shows up that I referred to Children's Hospital a few weeks ago looking great - joy.
Cleft palate patient missed her appointment for surgery on the Africa Mercy, showing up at our place a day after her surgery was scheduled - annoyance, frustration once again.
One of my staff goes missing and I found out after 1 1/2 hours she's at the bank - irritation.
Starting to film for our new clinic video in a nearby compound - excitement.
An expat lady comes with 3 patients instead of the arranged 1 patient - aagghhhh.
I found out 2 staff knew that the missing staff member was at the bank and lied to me - anger.
Hilarious conversation on the way home from work in the car - laughter.
Preparing worship for a Sunday evening service - contentment
Getting on facebook and wishing some friends were nearby - loneliness.
Struggling to understand decisions that are being made - anger, sadness, confusion, tears.
Holding on to the fact that God has everything under control - hope.
He has His hands on my patients, He has my future in His hands - peace.