Dutch drama on Queens Day...

I just got news from my parents that a terrible tragedy occurred in Holland while people were celebrating the Queen's birthday! A day usually filled with fun and laughter ended abruptly when a man attempted to attack the Royal Family. All further festivities were immediately cancelled. Unbelievable. I just don't understand what makes people do things like this...

Five cheering spectators killed after speeding driver makes assassination attempt

Attempted attack on Dutch royal family leaves 5 dead

Another theft...

Is it terrible to say that I am not surprised anymore when I find out we have been thieved by people we know? By people who are supposed to be guarding our compound, people here to ensure our safety and watch out for our stuff. People we are supposed to be able to trust. People we have become friends with; laughed with, talked with, hung out with.

????

Terrible or not, I will say it again. I was not surprised to hear this morning that 2 of our guards were caught stealing diesel in the generator room. I guess after living here for 4 years and being thieved on numerous occassions (whether it be money, a safe, diesel, bags, chairs, etc. it was always by people we know), it just doesn't baffle me anymore.

So, I am not surprised but I am annoyed. Annoyed that once again it was some of the guys that I got along with and befriended. Annoyed that people here seem to think stealing is alright as long as you do not get caught. Annoyed that people risk their jobs, their source of income for their families, etc. by stealing from us. Yes, I know people here have little and any chance at some extra money is very appealing. But still, these guys had it good at our compound, at least better than many other posts. Why take a chance?

Most annoying of all is that once again I am faced with the reality of life here. The question: "Can I trust anyone here?" keeps haunting me. I just don't know if I can trust everyone. Or is it anyone? It saddens me to say that I really am not sure who I can trust here. As soon as I think I can trust someone and they seem loyal, they are the ones who end up stealing. Uggghhhh. This has got to be the hardest part of living in Sierra Leone - not being able to fully trust.

Salone rollercoaster...

I don’t know about you but I love rollercoaster rides.
The faster the better, the more loops the more fun.
Up and down, up and down.
Today felt much like a rollercoaster ride.

The rollercoaster ride I experienced was “The Ride of Emotions”.
Maybe you know the ride.
The one that takes all day, taking you through an array of different emotions.
Joy, sadness, surprise, frustration, excitement, amazement, devastation, to name some.

Join me on a segment of the day’s ride…

JOY - Ramatu, one of my hydrocephalus patients, showed up again after days of delay.

SADNESS - My former neighbor, 3 year old Jeneba, who I had sent to the feeding center where she also received TB treatment in 2007, was not doing well, still only weighing 7kg and not walking or talking.

SURPRISE - 4 month old Lamin, who I saw last Thursday with a moderate to severe pneumonia, showed up for review, 5 days late so I was wondering if I had lost him.

FRUSTRATION - N’gardie, the 1 year old weighing 4.6kg, did not show up for review today with her granny and aunty, so I am now hoping that they went straight to the feeding center.

EXCITEMENT - Ibrahim has been coming to the clinic for review for months waiting to hear if the expat cardiologist was scheduled to arrive and today I could finally tell him that he would be arriving in country next week.

AMAZEMENT - I went to our pharmacy to look for a specific drug for a patient (that we do not have on our inventory list) and found a box of that drug in our donated drugs pile; and it wasn’t expired yet!

DEVASTATION & SORROW - I visited a 4 year old patient with cancer at his house and saw how much this child was suffering and knew there was nothing I could do for him except for supportive care..

It was quite a ride.
And of course, most days here are like this.
I guess that is what makes this work special.
Being able to share so many moments with so many emotions with my patients and staff.

5 interesting cases...

Another long day with about 40 patients keeping me busy from 8am till 630pm of which 5 were quite interesting/memorable and I should be seeing again. Let me introduce you…

First of all there was 2 year old Hussanatu who had been sick with diarrhea and vomiting for 4 days. She went to a hospital 2 days ago but staff couldn’t get an iv line started so the mother took the child back home. When she showed up at the clinic it was a shock that she was so dehydrated. We got to work right away to start rehydrating. 4 hours and 800 ml of ORS later and she looked much better and even wanted to play with my toys. I hope to see her in the morning!

Second there was Sulaiman, 2 years old, who looked fairly okay except that he was very pale. Sure enough he had an Hb of 5.5 g/dL! Unfortunately I could not find the cause as multiple malaria tests were negative and he has not previously had this problem. Worms? Nutritional? Hemolytic disease? Seeing as he was stable I am treating him as outpatient with antibiotics and iron and folic acid and will see him again tomorrow when he returns with his results (blood film and sickle cell test). We’ll see how this unfolds!

The strangest case was a very playful 1 year old who made me wonder why he came. His mother proceeded to give a somewhat bizarre history of him having seizures everyday for the past year. Nothing quite added up. I wasn’t sure if I should believe it. Well, to my surprise, while in the lab later, he had a very short seizure-like-episode so I did refer him for further assessment. Interesting!

Most interesting was a 7 year old boy who lives upcountry and pain/difficulty urinating for 2 years! He has been to various hospitals upcountry, been admitted, been transfused, given country medicine. Of course, no diagnosis was ever made. When I asked him to pass urine to collect a sample he did so, but was in obvious pain; poor little guy. The long history was bizarre and I was hoping for some clarification through the lab. Fortunately his results pointed towards infection.First of all he had malaria which explained his large spleen. Second of all his urine showed many signs of infection: blood, leukocytes, nitrite. So, he is on antimalarials and antibiotics and I’ll see him again on Friday. I pray this problem clears up after 2 years. If not, maybe we are looking at a more complicated urinary tract problem!

My most adorable but also most worrying patient is a 1 year 2 month old girl weighing only 4.6kg; sweet but too small. Her father died just before she was born and her mother left her to the granny and aunty when she was only 5 months old! Now she is not thriving. Her weight for age is at the bottom of the chart. Her mid upper arm circumference is tiny, probably the smallest I have measured yet. So, I have referred her to the therapeutic feeding center and they’ll have to check for HIV, TB etc. However, the social situation is complex, so I will actually see the whole family in the morning to discuss admission with them. Hopefully I can convince them…

World Malaria Day...

April 25, 2009 marks World Malaria Day; a day to focus on how we can play a role in reducing the impact of malaria world wide.

The impact of malaria hit home once again this week when I met Mohamed.
Mohamed is 8 years old and came to the clinic on Thursday with a temperature of 39.7
He had been sick for only two days but looked ill enough to be prioritized.
Sure enough the lab results showed he had malaria: 3+ - a high parasite count.
After drinking ORS he was looking a little better so I decided to try oral treatment.
If he vomited either of the anti-malarial drugs, I would refer him.
Thankfully he kept the drugs down and even managed to eat rice in the afternoon.
That is when I had to decide: refer for in-patient treatment or treat as out-patient.
The never-ending dilemma of a shortage of beds and financial strains.
Since he took the oral meds, I decided on out-patient treatment, taking a slight risk.
And sure enough, once Mohamed left the clinic I started having second thoughts.
Maybe he really was too sick to send home, maybe he would only get worse in the night.
My decision had been made and he was gone; it could go either way.
I hoped I had made the right decision.
At least his mother was sensible and knew where to take him if he got worse in the night.
I was to see him again on Friday morning, Lord willing.
I thought about him multiple times through the night.
At 7:50 am on Friday I headed over to my office wondering if Mohamed would come.
As I passed the main gate, I was thrilled to see Mohamed sitting there with his mom.
He made it through the night, was looking a bit better and even gave me a smile!
I made him take his second dose of his anti-malarial drugs in the clinic.
And had him wait another hour to make sure he did not vomit them.
This time he did not just lay around and sleep the whole time like he did the previous day.
He was slowly improving.
I gave him some other medications cause his hemoglobin had dropped a bit.
And I told him to come again next week Wednesday.
If he'll also take my advice to use an insecticide treated net I will be even happier!

In the outpatient clinic I see malaria every day of the year.
Some children are only mildly ill, others moderately ill and some severely.
It's not uncommon for me to have to refer a seriously ill child due to malaria.
Or refer for a blood transfusion due to the severe anemia (Hb <5g/dL) it causes.
And unfortunately at times these children die.
They die a death that could have been prevented.
We can keep children from getting malaria.
We can cure children who get malaria.
But it requires resources; nets, spraying, diagnostic measures, treatment.
We need to work together to decrease the burden of malaria.

Visit: http://www.rbm.who.int/worldmalariaday/index.html

Only 1.6 kg...

On Monday I saw a beautiful girl who was only 6 days old. Her mother was only 7 months pregnant when she went into labor. This little one was tiny, weighing only 1.6 kg. Surprisingly she had no problems at delivery; and few problems now. But she had one major problem; she was not breastfeeding. The only way this child was being fed was by squeezing breast milk into her mouth. She was also being given water which is unfortunately given to most newborns here. This was not good enough for this premature baby. We would need to do better.

Observing her mother trying to breastfeed confirmed that she really was not sucking. We had the mother express milk; 30 ml. And then tried feeding the child with a syringe; she would not drink it. There was not much more we could do except refer the child to the Children's Hospital. And hope that with a nasogastric tube, she would be able to get the nutrients she needed so that in due time she would gain strength and be drinking on her own.

This is what we discussed with her mother and father. Both were obviously concerned. Their first child needed to go to a big hospital. We explained as best as we could and comforted as much as we were able. Soon they were on their way to the hospital in downtown Freetown. But unfortunately 3 days later I received news that this little one died; sad. The good part of this story was that both her mother and her father cared. They were sensible to come to the clinic with her and took our advice to go to the hospital. Despite their efforts though, they have lost their precious little baby. I am sad for them.

My malnourished kids...

On Friday I ventured out to the Feeding Center; seeing as I had 4 patients there, it was time for another visit. I mostly enjoy my visits to the feeding centre. Yes, it is sad and sometimes shocking to see how small these kids really are, but it is also great to see how the mothers interact with each other and to see the remarkable change in so many of the kids. Every time we show up there we are warmly welcomed by both the nurses and the patients. We were a bit later this Friday, showing up around 1pm which was good because chores were done and it was time for socializing. My patients made up at least ¼ of the patient population that day, so that made it even more fun. We all sat around and talked and watched the children. Some were playing. Some were just sitting. Some were crying. Some were sleeping.

Two of my patients are not doing very well yet. Moses is on his TB drugs but still unwell and very grumpy. Sidikie is 2 years old and only weighs 7 kg. He was also quite fussy and clung to me as I was holding him. Sadly enough his mother died not too long ago. To my surprise I noticed a very prominent spine on his back, which I didn’t remember seeing before. The nurses at the feeding center also had not noticed it so I told them they need let the TB doctor know, because if he has TB of the spine, he will need yet another strong medication (streptomycin) to be added to his daily drug regime. Let’s hope these two kids start improving!

The other two already look much better. Victoria, who is 1 year and weighs 5.6 kg, has only been admitted for 4 days. But seeing as she also had malaria when I referred her, and that has been treated, she has perked up a lot. I think she will do great. Then there is Abibatu, who had all sorts of this going on when I referred her on April 7th. She is now on TB treatment and thriving. Her mother is thrilled that she is doing well. And seeing as she has been there the longest, she is the one giving other mothers advice, encouraging them, etc. It was a lovely way to spend an hour on a Friday afternoon. Spending quality time with my patients and their mothers and wondering what it would be like to run a Feeding Center…

Not Connaucht...

I have to admit that one of the mistakes I have made over the past 4 years was to send a 12 year old child to the main government hospital. Maybe it was bad luck, maybe it was this particular case, maybe I do not have all the facts, but I feel like this child’s fate was decided for him the moment he stepped into that hospital. Okay, so that’s probably not entirely true. I think he was so sick, that maybe the outcome would have been the same had he gone to the Children’s Hospital. Either way, things did not go quite right at Connaucht Hospital. I do not want to be too critical since I am not very familiar with that hospital, but I will tell you what happened in this one instance, as relayed by the family…

It all started late March. Actually, it started mid-March, because by the time I saw the child he had been sick for at least 2 weeks with a fever, headache, abdominal pain and bloody stools. He was staying with his granny who did not take him anywhere. It was only three days prior to seeing me that he arrived at his mom’s house, who immediately took him to the local pharmacy for ‘drips’ (iv fluids). On Monday morning he showed up at the clinic, too weak to stand. He was thin, jaundiced, had a fever, palpable liver and spleen, blood and protein in his urine, blood in his stool; in short, a somber picture. At 10 am I heard there was no bed available at the NGO hospital. I checked again at noon, but no luck, I would have to send to a government facility. By this time he had been in the clinic for 4 hours, drank 2500 ml of ORS, had 9 watery stools and was still looking terrible. Because the child was quite tall, and my staff thought that he would be too big for the beds at the Children’s hospital (on the main wards they only have pediatric cots), we sent to Connaucht. Later we found out that they do have ‘adult-sized’ beds on a ‘special ward’ at the Children’s hospital.

At 1245 the child was referred. At 630pm I called the family to see how the child was doing. He was STILL waiting to see a doctor. He had been at the “Emergency Department” since 2pm. Meanwhile he was still passing watery stools. I was furious, the family was annoyed. I called again and talked to a nurse. Finally at 8pm a doctor arrived and the child was seen. He was started on iv fluids and was told that in the morning, he would see the doctor again and be given a prescription for drugs. Talk about delaying treatment!

Day 2: I called the father. The child was again waiting to be seen by a doctor. By mid-day he was transferred to a ward, but still not seen by a doctor and so still not on any medication. Finally that evening he was seen by a second doctor and given a prescription.

Day 3: The father came to visit me and had the prescription in hand but no money to pay for the medication. He had paid Le 30,000 for blood tests ($10), Le 50,000 ($17) for a bed and Le 20,000 ($6) for consultation. I sent him off with some money for the drugs. The father was discouraged; he said 4 people died on the ward that day.

Day 5: I visited the child at the hospital. He was still very weak, sick and pale. He had been seen by a doctor and on the previous day two of his uncles had each donated a unit of blood. He was to be transfused today, but the nurse on the ward that day was not qualified to assist with transfusions. He would be transfused in the evening when the doctor was in. That evening the father called, the transfusion was put of until the next day. Another delay.

The child was eventually transfused, and did receive various medications. But it sounded like there was little improvement. For a little while I did not hear anything. Then, on Easter Sunday, the father called me. His son had died. It was the end of a drama; a bad ending. Who knows, maybe this child would have died no matter where he was treated. I do not even know the diagnosis. All I know is that there were numerous delays and a lot of money changing hands. And, that in the end, another life was lost. My lesson learnt was that I will stick to Children’s hospital if the NGO hospital is full.

Hard Rock...

Although the weekend was already packed with outings and activities, I managed to be persuaded to join the Timpers family for their final beach trip on Sunday afternoon. It didn’t take all that much to persuade me I suppose, except the arrangement to leave later in the afternoon rather than right after church. The timing was perfect. We left our compound at 4pm and headed out to Lakka beach; a 40 minute bumpy road, out of town and towards the ocean. On arrival we decided to arrange our dinner at the Hard Rock Restaurant first, so as not to order later and still have to wait hours for our food! Seeing as there was only fish on the night’s menu, the decision was easy. Fish it was. On our way back to the sand, we walked past the outdoor kitchen and were shown the big Bonita fish that would later wind up on our plates. We were more than pleased. After a lovely swim in the ocean we sat down to our evening meal with the backdrop of a blue ocean and orange tinted sky and the sound of waves crashing against the rocks. It was amazing. What a fantastic ending to a great weekend; tasty fish and chips, a gorgeous sun set and excellent company.

Night at Bure...

An overnight trip to the beach. What an amazing experience. The beach itself is beautiful. But to have the beach to yourself is fantastic! On Friday there were no other beach visitors until later in the afternoon, and they only stayed briefly. It was very nice to have the beach to ourselves.

On Saturday, it was a different story. By mid morning there were 2 beach outings taking place with van loads of local people attending. Despite the large amount of people it was actually quite entertaining, and not nearly as loud as anticipated. Yes, there were loud speakers and they had music booming, but it could have been much worse! And the people themselves were quite fun to watch too- it was like a fashion show. Men with funky hats on trying to make a statement, women wearing their coolest outfits, many items of clothing that we would not be caught wearing! What variety. From men in dress pants, to African shirts, to underwear only...

We stayed overnight in a tent. Just two white girls and some Sierra Leonean guys as our guards. They actually ended up sleeping next to the fire a couple of feet away from our tent. But hopefully they would have woken up to the noise of any intruders! Maybe looking back it wasn't exactly the wisest to be on a deserted beach alone. But hey, we have to take some risks in life, right?! The guys also cooked dinner for us- baked fish and rice. It was delicious! The cook was embarassed that he showed up with the food an hour late. But hey- this is Africa. As if we were surprised. And who really watches time when they're at the beach overnight anyway?!

The most fun was on Saturday when we took the body boards out for some adventurous wave riding. The waves turned out to be fairly decent and we managed to catch some waves all the way in. At this time more and more locals were showing up, so I think us two white girls gave them quite a show on our body boards. Fun times. Late afternoon we decided it was time to head back to Freetown...taking the peninsula road...driving along the coast, enjoying some peace and quiet before the craziness of a new week.

Alive...

He lived in order to die.

He died so I may live.

He gave. I received. He loves. I believe.

HE IS MY LIFE!

Time to reflect...

Does a day ever seem like one big blur to you? Today was definitely one of those days.
45 patients and 11 hours later I have time to sit and think. What actually happened today? So many faces, so many problems. Thankfully it was a diverse day.

Tonsillitis. Boils. Sickle Cell disease. Torsion of a testicle. Severe pneumonia. Malaria. Hydrocephalus. Anemia. Post-cicumcision urethral fistula. Virusses. Septic arthritis. And more.

Many children could be helped. At least two are admitted for urgent medical care. Two will need to spend lots of money at the government hospital for surgical treatment. And one child likely cannot be helped.

It is this one child that is now on my mind; 4 month old Ramatu.
Her large head makes her problem obvious; she has hydrocephalus.
Her fontanelle is bulging and her suture lines are separating.
She is showing signs of raised intracranial pressure.
What are the realistic options?
None.

Shunting can be done in places like Ghana and Kenya.
But they are too far away, too expensive and require too much follow-up.
Recently I learned about a new procedure: the ventriculocysternostomy.
Complex, I know.
It's a new technique to cure hydrocephalus without the need of a shunt.
Definitely a good solution for these children.
But this new procedure is only being performed in a handful of places.
As far as I know, it is not available in West Africa.

So while I sit here thinking of new techniques and ways to cure hydrocephalus.
I am brought back reality.
Ramatu's world.
Sierra Leone, where this procedure is not available.
News of this technique is of no help to Ramatu and her mother.
And I am left with little to do.
Except think, and hope, and pray.

My new name...

I have been here for over 4 years now and still have not been given a Salone name. I suppose since my name is fairly easy, there has not been much need for a Sierra Leonean name. However, I did think it would be fun to have one.

After our outpatient clinic staff meeting on Wednesday- which was a bit of serious talk and lots of fun (I love my staff) – I mentioned to my three nurses to think of a Salone name for me. They start coming with very bizarre names that I had never heard of and would likely forget very quickly! To make things easier, I suggested they choose on that begins with an ‘S’. They rattled off some more names I have never heard of. And I must say, after having seen over 13,000 kids in the clinic over the past years, I have heard a lot of names. I suggested they think of one a little more common. And then one of my nurses said: “How about Saffiatu?” And I replied saying: “I will take that one”. Saffiatu it is.