Closing clinic...

While I am starting to count down the days until I go away I realize that it is very likely that I will have to close the clinic during my time away. Not only was I hoping for someone to work alongside me in the clinic since my former colleague left but I kept hoping and praying that a second person would also come to cover for me. But it's just me now adn in 9 days it's no one. 9 days to see as many kids as I can, pack my bags, pack up my whole room (since we are moving house), tie up loose ends and keep praying...

Although I am very excited about the opportunity to go to Thailand for a 10 day medical conference, followed by 4 weeks holiday (in the USA and Holland), I am torn. It's heart breaking to think that closing the clinic for that period of time means that hundreds of children will not get the medical help they desperately need. In a 6 week period, over 1000 consultations will not get done. Terrible thought. A thought that can make me feel somewhat guilty. Last year I postponed my holiday, knowing that someone could cover me a few months later, however, this year, there is no one lined up. And really, going to this medical conference (for continuing medical education) is also very important to me. So, I will go, but with a bit of a heavy heart. It will be the first time that I have had to close the clinic (other than for 1-2 weeks over Christmas) since the day we opened in May of 2005.

I still have a little bit of hope that maybe somehow someone from somewhere will be able to come to keep the clinic up and running. Not for me, but for the kids. For the many families in the Freetown clinic that come to the clinic for help. I keep telling myself God is in control. He knows...

Monday's thoughts...

11 hours and 45 patients later.
Time to think.
Or maybe it's better to stop thinking for a bit.
Time to rest.

This morning was strange.
With 35 tickets handed out there were still over 20 kids waiting in line.
Tickets done done I said.
And then diverted some of the children to other facilities.

It's hard to know how best to handle the line.
Take the first 35 or pick the sickest 35 (but who is sickest; potentially ever fever can be malaria)
One can argue that since we're outpatient, any we can't see can go to the hospital to be seen.
But then there's the whole financial dilemma; can they afford the hospital?

A dilemma that eats away at my conscience all day.
A severly malnourished girl at the end of the line.
See her anyway, or just tell her to go straight to the feeding centre.
She does not NEED a referral letter, she can just show up there, but can she pay???

A child with moderate to severe ARI.
Really just needs to be admitted and receive oxygen.
Should I have seen that child or just sent from the gate.
Not much I can do at our facility except maybe get the child into the NGO hospital.

An 11 year old with some dehydration.
Really the child was stable but definitely needed to be seen at a health facility today.
Did I have to keep feeling guilty for not seeing the child?
Or was sending her to a decent health facility 10 minutes away enough?

Maybe I will put my mind to rest and just remember the patients I did help today.
Because there were enough of them.
Some with small things and minor illnesses.
Others with malaria, dehydration, moderate chest infections, malnutrition, etc.

The most bizarre thought today was that while I was alone in the pediatric clinic,
there were 4 surgeons walking around in the VVF part of the centre.
Too bad they couldn't help me tend to the 20+ kids I had just sent away...
Why is it so hard to find a doctor to help out in the clinic?

In the end it was a good day.
Only sad part was that Namina is not looking too great. (see post)
Although not acutely ill, the hole in her face seems to be getting bigger rather than smaller.
And it saddens me to see her mom cry everytime we do the dressing changes.

Her mom is really worried that she'll lose her left eye.
And to be honest, I am a little worried about her eye as well.
I can only pray that the infection stops and that the destruction comes to an end.
And that the healing process begins...

Half birthday...

Really random thought.
Towards the end of this long day I looked at my phone.
To see how much longer till the work day was over really.
Not that I actually have a set 'end time' of the day!
Anyway, I saw on my phone 'January 23'.
And said to my friend, 'it's my half birthday'.
To which she replied, 'I don't even know when my half birthday is'.
So, random assignment for the day- figure out when your half birthday is.
V- yours is August 21.

Finally Friday...

Yay. It's weekend. Finally. This week has seemed awfully long. I guess cause I've made long days. I still can't believe how long yesterday was- almost 12 hours in the clinic. I am still not sure how I ended up with 46 patients. I handed out 36 tickets at the gate, sending away others waiting. I had 5 reviews. So you would have expected 41 patients. But no. By the end of the day I counted 46 medical charts. Hmmm. I asked my staff during our staff meeting today. They were all flabbergasted...wondering how 5 extra children came to the clinic. My response was 'I am not surprised they came to the clinic, and someone (guard or staff) probably let them in (in exchange for what?) or they snuck in BUT my big question is- how did all 5 unaccounted for children end up with medical charts??? Someone is not talking. Oh well. In the end it comes down to the fact that they obviously all needed to be seen.

I'm just happy it's Friday now. It's been a bit of a funny Friday today though. No chance to visit referral centers or do any admin for that matter. I was busy with patients all day somehow. One of my patients was Namina- the girl with Noma - so her wound care alone took about 30 minutes. Then there were 4 children from the previous day with malaria and Hb's between 6-8 that I had come back. One of them was looking a bit more lethargic with today an Hb of 5.5 so I referred her. Others looked better. Then i called the referral center only to find out that a malnourished 9 month old breathing at 80 per minute that I referred at 3pm yesterday only just showed up at the referral hospital- a 24 hour delay! Turns out she's HIV positive, so she's been referred to the government hospital. Then there were 2 VVF ladies admitted on the ward yesterday who came with their babies- well toddlers really as they were over 1 year. So I had to make sure those two were okay. They weren't. They both have malaria. Surprise surprise. I was a bit annoyed cause they had been at the center for 24 hours already and no vital signs taken and no one really checked on what they were eating etc. Oh well. Some things just don't change. So, got those 2 sorted out. Then checked up on one of our cleaners who was sick with malaria on Wednesday- I was asking about her medication and found out she is taking only half of the amount of tablets per day as prescribed. So- had to take her to my office and explain how to take the meds again and make her take the second half of todays dose right then and there. Oh Salone. Why do so many people here not understand something when you've explained it over and over and over. Anyway, it was another Friday come and gone. Unfortunately leaving some admin work for the weekend. But for now, it's off to bed...

Tears for Namina...

Namina.
3 ½ years old.
Weighing only 10 kilograms.
Inflicted with a devastating disease.
A disease rightfully referred to as the ‘Face of Poverty’.
It starts as a small lesion in the mouth and soon turns into a gangrenous infection.
Causing massive destruction to facial tissues within days.
Disfiguring the child for life.

Noma or Cancrum Oris.
A disease affecting the poorest of the poor.
Most commonly children with malnutrition and/or measles.
With a 90% mortality rate, few survive.
Although Namina is a victim of Noma, she is a survivor.
She pulled through after being admitted at a government hospital for a month.
And now she ended up at my doorstep.
With tears in my eyes I sit here, thinking about my newest patient.

My initial reaction was to send her away; ‘we cannot help’.
The ship is not around, surgery is not possible, what can I do?
But within minutes this little girl captured my heart.
I let her in.
At first she was very afraid and shy.
But after toys and hand games she warmed up and smiled as well as she could.
Then we took some pictures with the bandage still in place.
We then started her on her malaria medication after a positive test result.
And then enjoyed my lunch of rice with sauce as she needed it way more than I did!
Then the time came to assess the damage.

It was bad.
Sure enough it was Noma.
Namina has a gaping hole in the left side of her face.
I have rarely seen anything so disfiguring.
Her upper gum is destroyed.
Part of her nose has been eaten away.
Her entire check is missing.
You can see straight through to her mouth.
It is not a pretty sight.
It is heartbreaking.
But she is a fighter..

While cleaning out her cavity she was crying.
I tried to calm her down but understandably she was not happy.
Fortunately once the area was cleaned and covered she was alright.
She was even humming along as I took some more pictures.
And she agreed that we were still friends.
Meanwhile mother also agreed to let us pray for Namina.

I will see Namina again on Friday for follow-up.
This will be an ongoing process for some time.
My mission is to get this infection under control.
My hope is that surgery will be possible for her next year.
My desire is to be used to help this family in various practical ways.
My prayer is that God will transform inwardly the lives of Namina and her mother.
My request is that you join me in prayer for healing and restoration for Namina's body.

Juggling patients...

I am sure you can imagine that the conditions seen in the clinic are diverse; some of the children being much sicker than others, ranging from a child with a runny nose to a child gasping for breath or a child running around in the clinic to a child too sick to walk. Seeing the sickest children first, means triaging. As you can guess, this totally mixes up the order of the patients which can cause some commotion since they just spent 10-15 minutes trying to get in a line outside the gate in the order of arrival (as early as 4am)!

As soon as the clinic opens, the patients come in, and we prioritize using a color scheme. RED = very sick child needing urgent attention ORANGE = mild to moderately sick which needs to be seen fairly quickly (very pale, some respiratory distress, high fever, dehydration) GREEN = stable child needing no immediate attention, which will be seen in order of arrival. With 2 doctors you can work through the red/orange patients relatively quickly and at least get the REDs to referral centers as quickly as possible. When you’re on your own it gets a little tricky and often it feels like your juggling patients.

Today’s juggling act: a set of 3 week old twins, a staggering 9 year old, a dehydrated looking 5 year old and a very hot and pale 1 year old. And throw in an older sibling to the mix half way through the act.

The older two I took straight to the lab, sending the 5 year old in first. While she was inside, we checked the 9 year olds glucose outside the lab, then he waited to go in for other tests. Meanwhile I the nurse took vital signs for the twins and 1 year old. When the 5 year old was out of the lab she came to my office for history and examination. Meanwhile the 9 year old went into the lab. I then sent the 5 year old for ORS and to wait for results. Meanwhile the twins were ready to be seen. That took longer than expected so meanwhile the 9 year old was back in the waiting room, asleep on the ground. While busy with the twins, I was shown the 1 year olds paper- high fever so I gave paracetamol and sent her directly to the lab for a malaria test. Back to the twins; low birth weight, hypothermic and not feeding well so got lab tech to take some blood and carried on. When I was just about through with them I hear that family came with an older sibling so I started seeing her, so that I would have her results by the time the twins were ready to be referred. Time to stop juggling. I wrote referral letters for the twins and prescribed meds for the sibling. Off they went. 3 left. The 5 year old drinking her ORS, the 9 year old on the floor and the 1 year old on the bench waiting for me. The 9 year old couldn’t even walk so really needed to be seen. While examining him the 1 year olds result showed up- malaria positive. So I wrote up the first dose of malaria treatment. Then finished with the 9 year old, whose results I also received but unfortunately the referral center was not answering the phone, so he would have to wait a little longer. So, onto the 1 year old who looked alright besides being pale and having malaria. I would see her again in an hour. By this time the 5 year old finished her ORS and looked better so went home with medication. Finally at 11am I got a hold of the referral hospital and was able to send the 9 year old who was so weakened by malaria he had to be carried out. And the 1 year old ended up going home with medicine to be seen back tomorrow. Of course, towards the end of the juggling act, other patients made their way into my office and by the end of the day 40 patients were seen. At least after the intial reds and oranges it's not as hectic...

Endure AND enjoy...

Monday. Often a crazy day. And this time I was alone. No more doctors working alongside me. My colleague left on Friday. It’s been a good year and a half since I was alone in the clinic so needless to say, it’s an adjustment. I was a little nervous about today and worried I’d be really stressed. BUT surprisingly enough, I had a GREAT day. The day couldn’t have gone much better – except for maybe two things - stopping for lunch and realizing a little earlier than 2pm that I hadn’t even made a cup of tea yet. Otherwise things ran smoothly and I had a great time with some of the patients and parents.

Of course I had limited the patients to 35, with an extra patient and some reviews, making a total of 40 patients in the end. Knowing that I would have time to see them all, I actually took my time. I took more time to talk to very concerned mothers, time to tickle smiling 4 year old boys, time to talk to a family with a malnourished child about nutrition, time to pray with a child with a large mass etc. But I also made my staff run around a bit more than usual with lab forms and stuff.

My initial thought this past weekend was: “I’m going on holiday in 3 weeks so all I have to do is survive until that time. I can do it. 3 weeks on my own and then have a holiday to look forward to.” But, you know what, God not only wants us to work but wants us to work well and enjoy. I spent some time praying with a friend last night, which we usually do on Sundays, and we talked about how I should not only endure, but also enjoy. So, last night and this morning that’s what was prayed; that I would not only survive and endure, but also enjoy. Enjoy work, Enjoy the children, Enjoy my staff. ENJOY. And that is what I did. Of course, the day had its challenges, some very sick kids, some children that will be difficult to help, but I smiled many times throughout the day and have a great feeling about today. Lord – help me to continue to endure AND enjoy!

Webcamming Porter...

Introducing Porter Alexander...my adorable little nephew. (6 weeks 2 days old now)

Hearing that my brother and his wife were expecting was exciting.
Finding out on my birthday that they were having a boy was lots of fun.
But the actual news of Porter’s arrival was the best of all.
It was Thursday, December 4th.
I was seeing patients in the clinic at 2pm when I got an international call.
My brother called to let me know that the water broke!
The baby’s arrival would be soon.
That evening, I was at the heliport saying goodbye to my mom.
We received a call from my dad saying that my brother was trying to call.
My brother couldn’t get through with skype.
We called him and sure enough, he was a daddy!
An hour and 20 minutes earlier Porter Alexander had been born.
And what a sweet surprise that his middle name was chosen with me in mind!
(Sandra coming from Alexandra)
After seeing my mom off at the heliport I headed home.
I had told my brother I would call him again when I got home.
So, 2 hours later (110am my time!) we were talking.
He was CO in the hospital room – with internet access – and me in Africa.
And amazingly enough I was able to see Porter for the first time.
He was only 3 ½ hours old.
Skype and Webcam – amazing technology!
Since then I have been able to see Porter a couple of times which has been great.
Last night I called again and talked to my sister-in-law for awhile.
Great to talk and also fun to see Porter again.
This time I was trying to get him to smile.
He made some of the goofiest faces and I tried to capture them on camera!
I love this little guy already and can’t wait to meet him in person in 5 weeks.

Trip to town...

The week was long.
But after a good laugh watching Mamma Mia last night I was ready to hit town.
Although town can be crazy and chaotic at times, usually it's alright.
You just have to learn to ignore the 'white man' and 'white girl' comments.

First port of call- SN Brussels office.
My main reason for going to town was actually to pay for my ticket home.
So, once we found the place (it's a new office) we went in and I got that done.
I now have my Freetown-Brussels ticket for Febuary 6th! Yay!

Then it was off to Malama Thomas Street - the fabric street - to find fabric for a 2 piece outfit.
We were trying to figure out how much fabric I would need: 3 yards, 3 1/2 or more.
The owner of the shop said "3 go do, yu no get beaucoup bodi"
In other words- he was saying I only need 3 yards because I am skinny! We all laughed.

After that we headed to Montana's for some lunch.
Montana's is actually the place with the best ice cream in town.
But there was no ice cream yet today; too early.
So we enjoyed shawarma (lebanese bread with veg and beef/chicken) instead.

After Montana's we quickly went into the supermarket next door.
A bit of an unusual store with way more cosmetics than food goods and quite expensive.
But also the largest selection of soft drinks (sodas, pop); occassionally even Dr. Pepper there.
And guess what - they had it today! Another successful trip.

Now I'm back at the house and we have national power!
Unfortunately it doesn't generate enough power for the washing machine to work,
But I can use internet and don't have to worry about my laptop battery dying on me.
Ready for a relaxing afternoon...

And then there was one...

My colleague left today.
Strange.
After a year and a half of 2 doctors in the pediatric clinic, we're down to one.
Me.
For months I (along with some others) have been trying to find another doctor to come out.
So far no luck.
I guess I need to be thankful for the past 1 1/2 years!
Thanks Annekoos, Luzanne and Anna for your hard work!
For now, I will continue on my own; praying for someone to join me.
It's a shame really, because it means cutting down patient numbers.
It also means more stress for me and no one to discuss cases with.
I have decided to take in 35 patients a day plus review cases.
It's strange: before I experienced the luxury of 2 doctors, I was seeing 50+ patients on my own per day. I guess that was before I knew any better; I didn't have a choice in the matter. It was also a very stressful time with many moments that I felt I couldn't continue! Which is also why we decided to find a second doctor.
So, to sum up, I am seriously still hoping a doctor will come out.
In the meantime I decided to take care of myself a bit, as well as the children, and put up boundaries.
35 kids per day.
Plus review cases.
That's my limit.
The question is, will I be able to stick to it when I face the long line of children Monday morning?!

Oxygen...

How does one decide which child to give oxygen to?
Fortunately this is not a decision I need to make everyday.
But this is something that I was faced with today.
Not making the actual decision but thinking about the choice.

We went to Children’s hospital to follow-up on 10 patients we referred.
One was a 3 month old my colleague had seen Tuesday with severe respiratory distress.
Now, 3 days later, she was still having difficulty breathing.
Yesterday the doctor that saw her had written up that she needs oxygen.

Great thinking, but did she get it?
No, said her mom, they have not given her oxygen.
So why was she not given oxygen?
The answer was simple: unavailable.

Only a few feet away lay another child.
A child that was on the verge of death.
Next to the child stood an oxygen concentrator.
This child was getting oxygen.

My colleague asked the nurse why our patient had not received oxygen.
The response was simple- it was only available for one child.
The second concentrator was broken.
And the split tubing so that 1 concentrator could serve 2 children was missing.

A dilemma.
And not only for our patient.
There were 3 or 4 more children on that same ward that needed oxygen.
So, how do you decide who to give oxygen to?

Do you give it to the sickest child who will likely die with OR without it?
Or the slightly less sick ones that desperately need it, in which it can be life saving.
Children who could likely die without it but have a good chance with it.
It’s a hard call to make and really a decision that should not need to be made.

Oh Salone.
Once again we are faced with dilemmas of healthcare in a resource poor setting.
This time I didn’t have to find a solution but a colleague at Children’s does.
I hope that for the patients on the ward that day, a solution was found.

1st Clinic Day 2009...

It's back to work after some time off; that always takes a little getting used to.
Fortunately it was a good day with 55 patients, although we had to send another 15-20 away.
There were a couple of memorable cases today.
A 1 year old weighing 4.9 kg(!) who likely has tuberculosis and needed referral.
A very small 2 month old who's being fed rice porridge rather than breastmilk; time to educate!
A mother with a 1 month old (first child) who asked many 'parenting' questions, which is very good but uncommon.
A follow-up case from 2 weeks ago who's still not 100% but looks much better.

And then there was James. When I saw his name on his paper and 'twin 2' written next to it, I knew exactly who he was. James and John are twins that first came to see me in July 2006 at the age of 5. I had taken the above picture at the time and still love it. I hadn't seen the twins since. James is now 7 and unfortunately was sick today. John is well and at home. It turns out that James has malaria, so as long as he takes his medication correctly he should be fine. It was fun to see him again. And awesome to see his (and his mom's) face light up when I showed him the above picture.

A good start to the New Year. A year with many upcoming changes & challenges but also without a doubt a year with rewards & memories.