Sound of music...

In the middle of a consultation about a week ago my ears suddenly tuned in to "raindrops on roses and whiskers on kittens..." So I poked my head out of my office and glanced into the waiting area. Sure enough, there was Julie Andrews singing away in Austria to the Von Trapp kids. So, here I was, in Sierra Leone, in a Krio speaking country, in a children's clinic and we were showing "The Sound of Music" to the families while they were waiting for their chilren to be seen by me. Love it. I stood in the waiting area for a few minutes, not watching the TV screen, but watching the faces of the many moms present, smiles appearing on their faces while they were watching an unknown musical on television. My face lit up as I realized how much they were enjoying the film. A film I have watched over and over as a child now seen for the first time by many of these moms and making their wait in the clinic a little more bearable. Fun! However, after hearing the film 4 days in a row I did hope I would not get tired of hearing it. But even on that fourth day when I went out and again saw the glow on the moms faces I thought it was worth it. As long as the health education videos and Life of Jesus videos are shown everyday, I am fine with The Sound of Music being shown everyday as well!

Friday fun...

Fridays are always a bit random from seeing patients for follow-up in the clinic to administrative work to visiting children referred to other health facilities to restocking the dispensary drugs to picking up vaccines to sorting out lab issues to expat morning prayer to whatever needs to get done really. I like Fridays; a day that is not as chaotic with patients but can still be a bit hectic trying to juggle the day’s activities.

This morning was a bit frustrating when the plan to leave for the Children’s Hospital at 10:30/11:00 quickly became 11:30 and when we finally got around to leaving the compound another patient walked through the gate; 3 hours late for their appointment. AAAHHHHHH. I had already spent the morning running around trying to get all sorts of things done, trying to speed things along. Well, we couldn’t really not see the child, so it was another 20 minutes later before we were through with that and on our way again.

We made a quick stop to pick up the monthly supply of vaccines and were then on our way to the Children’s hospital. I visited one of my TB patients on the ward. He’s 11 years old and probably weighs as much as a 7 year old. He’s been admitted for a few weeks now, taking his TB treatment. It was great to see his big smile and speak some encouraging words to his family. We also went to the therapeutic feeding center, where we now have 5 patients (all referred this week. Praise God they all went for admission and most are already looking a lot better. They are a bit more active and not quite as miserable.

At about 2:30pm we left the Children’s Hospital. What to do next? Well, seeing as I am almost leaving, and the Kenyan clinical officer has only been here for a few weeks, we decided to go to the fabric street. One of our nurses thought it would be fun to go along. I figured, we’re in town, why not? So that’s just what we did; a little fun and games during the work day. It was fun walking along a street I’ve been to so many times and looking at the thousands of different fabrics available. After that it dawned on me that none of us had eaten since morning. So, what to do, go back to the office (in an hour of traffic) and forget eating, or spend a little more time in town and grab a bite to eat there. I was feeling a little guilty about staying out to play longer. But a number of the other expats often/regularly will go out for lunch on a Friday, combining it with team house shopping or another work activity, so I thought I could do the same. Why not actually sit down and have lunch during work time! So, the clinical officer, one of the nurses, the driver and I sat down in a place called ‘Delightful’ and enjoyed chicken shwarma sandwiches and cokes. After about 30 minutes we headed off again

Arriving back at work at 4:15 pm there was still more work today. And so for the next 2 hours I sat in my office replying emails, sorting out the week’s finances, writing a case report and completing some patient charts. Another eventful Friday come and gone. Time for the weekend…

Pikin don die...

My Monday morning started off in the worst possible way this week.

I was handing out tickets to the children waiting outside the gate.

Half way through the line our security guard walked towards me.

He was holding a child and said “Doctor, look at this one”.

I glanced at the child and said “Oh no, emergency”.

I took a better look and saw that the child was not breathing.

In Krio I said “this pikin* don die”.

I quickly realized I had said this aloud in the midst of a crowd.

And I had not yet seen the mother.

I told the guard we needed to go inside with this baby and the family.

Once in the clinic, it was confirmed that the little girl had died.

Resuscitation with bag and mask was attempted but quickly seemed pointless.

I then proceeded to tell the mother her child had died.

She wept and kept talking about the operation she went through.

I guess the child was delivered by C-section.

Was she thinking of the pain/effort she went through for this child?

Apparently they arrived at the gate at 4am.

The child came because of difficulty breathing.

And stopped breathing shortly before the gate opened.

The mother’s aunty and aunty’s husband were also present.

Why so many adults?

It is usually a sign of serious illness.

For some reason multiple family members show up when a child is near death.

All of a sudden everyone is concerned.

Unfortunately sitting outside of a closed outpatient clinic was not helpful.

4 hours of sitting and waiting.

Why didn’t they go to the Children’s hospital?

The child should have been admitted in the night!

Instead they chose to come to see a doctor here.

And in the end all I could do was confirm the child had died.

The next hour was spent sorting out a death certificate.

And a permit for burial.

Meanwhile the waiting room was full and other children were being sent away.

My colleague and I proceeded with the consultations.

Later, after paying $5 for the certificates, the paper work was done.

And the family could head home.

Due to a transport strike we decided to take the family home.

As I followed the family out to the car I held a little bundle in my arm.

Earlier that day a bundle of life and joy now a lifeless little girl.

One month and two days old.

Very sad.

Yet I was comforted that the mother asked to hold her baby.

It showed me that actually she did love her little girl.

But I could also tell she knew this would be the last time she would hold her.

*pikin = krio for ‘child’

Mary's little hand...

This is Mary’s little hand.

She has been in the hospital for 4 days.

I am so thankful she is alive.

The cannula you see is what enabled someone’s blood to enter her bloodstream.

Life saving blood and life saving medications flowed through her veins.

Mary is only 3 months old.

And lives in the far east of Freetown.

She came to my clinic on Tuesday.

The severity of her illness made her my first patient of the day.

She had been sick for one week with a fever and difficulty breathing.

She had a high fever and a respiratory rate of 86.

She was acutely ill and obviously distressed.

All in all her condition was poor.

Her lab results proved she would need a blood transfusion urgently.

Further tests showed VERY HIGH malaria parasitemia, fairly unusual in a 3 month old.

I was in a rush to get her referred as quickly as I could.

Unfortunately the (free and well equipped) NGO hospital was full.

The only option was the 1-2 hour trip across town to the government run Children’s hospital.

Not referring her would mean death.

A stat dose of antimalarials, a referral letter & some cash later and Mary and her mom were on their way.

Several times during the week I thought of Mary, wondering if she made it to the hospital and received blood.

On Friday I went to the hospital to check up on my referral cases.

And, to my surprise I found Mary there with her mom AND she was looking much better.

Mary was happy and smiling and breathing fine.

Her mother was very thankful and so was I.

Patient update from June 2...

On June 2nd I wrote a post entitled MAKE HASTE So, I thought I would write a post today to update you on the children I mentioned...

- A 3 year old weighing 9.7kg. Kwashiorkor malnutrition needing urgent admission at the therapeutic feeding center downtown.
Fortunately this child did go to the feeding center and was admitted straight away. I actually visited him there on the 5th and he was much less puffy and swollen by then. I saw him again this past Friday and he is soon to be discharged! Yeah!

- A 10 month old with a bacterial skin rash, moderate anemia and respiratory distress. Possibly septic. Needing urgent admission and sent to the NGO referral hospital.

This child was admitted at the NGO hospital and treated with iv antibiotics and discharged on day 3 of his admission there.

- A 1 day old brought to the clinic at 230pm looking as blue as a smurf. Multiple congenital defects including cleft lip and palate. Very floppy. Mother ran away after seeing the child. Here with father and granny. Sent to Childrens Hospital in desperate need of Oxygen. Unfortunately I think the chance of this child's survival is nil.

Unfortunately I have not seen or heard about this child again. We looked for the child on our trip to Children's on the 5th of June, but no one had seen the family. Either the child died on the way or the family decide not to take the child to the hospital. I have to be honest and say I think there was very little chance for this little one. He's in a better place now.

- A 2 year old with severe malaria. Deteriorating during the day so in the end sent to the Childrens Hospital for iv quinine.

This child was also admitted at Children's hospital. Yeah for Childrens. They've done well. The child was discharged on day 4 of admission. He had been given a prescription to buy quinine tablets, fansidar and an antibiotic. BUT the mother did not buy the medication. And I did not see the child until June 8th. So, of course, this delay in further treatment this does not help the healing process. I suppose in the end it was just a good thing that she came back to see me so that we could dispense the drugs here (at a much cheaper cost, which I am sure is what they were waiting for, but taking a chance the malaria would come back again with resistance!).

So all in all these patients did make haste and got where they needed to go (with the exception of the very sick neonate). AND three out of four of the cases improved and went home well. Unfortunately this is not always the case. And I need to be even more verbal in telling families they must get prescriptions filled as soon after discharge as possible!

Jay One bread...

Most people will look at this picture and think:" "Hmm. Bread."
But, when I see this loaf of bread, I think: "YUM. JAY ONE bread."
You see, not all bread is the same and of the breads I have tried (tapalapa, jay one, delightful, lebanese, plain brown etc.) Jay one is definitely the best.
Fresh. Tasty. Soft inside. Hits the spot.
And only Le 500 (or 1000 for the big one if I'm really hungry).
That's only 17 US cents.
And the best place to buy it is near Cline Town.
Maybe that's because we pick up our vaccines there on a monthly basis and arrive there around 1pm when my stomach is grumbling.
I will definitely miss jay one bread.

Coming from far...

Today I met the Tarawally family.
Hannah is 4 and Umaru is 6.
Both children have been sick for some time.
They live with their mom up in Kono - a day's travel away.
Mom had tried to treat the children upcountry but they were not improving.
She then heard from her niece who is going to school in Freetown about our clinic.
So she decided to make the trip to Freetown to visit the clinic in Aberdeen.
Little did she know she would have to make some effort for her children to be seen.
Arriving 2 weeks ago, she has tried to get into the clinic a few times, but did not succeed.
Unfortunately the lines outside have been very long and we have had to send many children away.
I think they had been sent away twice already.
Mom decided that if her kids were to be seen here, she would have to sleep nearby.
So, last night she begged someone across the street to let her sleep at their place.
That way she could wake up really early to line up outside the clinic.
And that is what she did.
She paid Le 4,000 ($1.33) for lodging and woke up at 3am to stand outside the gate.
Can you believe it?
She was very happy this morning when I handed her two tickets for her children.
And even more delighted when I saw them inside my office.
In the end both children had malaria and Hb's of 7 and 8.
They have been put on correct treatment and will be reviewed on Wednesday.
Let's hope they're better so that they can make their way back home!

*Le 4,000 for lodging sounds cheap, but it's not when an average day's wage is Le 15,000
And this mother is not employed.
Her clinic costs were: Le 1,000 per child for consultation and a total of Le 3,500 for medication for her children. In other hospitals she would have spent Le 15,000 for one consultation alone!

Sweet & Sour Alarm Clocks...

I am writing this in memory of my pet chickens
Today was the day they met their fate.
It was inevitable, they ended up in the pot.
Tonight's menu read: sweet and sour alarm clocks aka chicken.
And not just any chickens, but MY chickens.
The chickens were just making too much noise in the mornings.
Too early, too often, too loud.
It was time to put a stop to it.
No more early morning alarm clocks.
No more messy garden.
No more pet chickens.
Strangest thing about my chickens was that they would eat left over chicken.
Who knows what else they ate?!
But tonight, they were for chop.
Chickens don don.
A belly full of rice and sauce, that's what I am left with now.
I was the 'fortunate' one to have a heart on my plate, I passed it off.
Fortunately I did not put a piece of liver in my mouth, like my friend did.
Besides the internal bits, all in all they made a pretty tasty sauce.
Bye bye chickens, may you rest in peace.

River no. 2...

Another amazing day at River no. 2 beach.
Very few people around. Little noise. View of the mountains.
Amazing sky with occassional dark clouds but no rain.
Very blue and green ocean. Great view of Banana Island.
Decent waves for some body boarding. Accidental encounter with a sea urchin.
Fish kebabs and chips. Floating in the lagoon.
Walking along the white sand. Getting some color in the sun.
A very near perfect day. Oh how I'll miss River 2!

Make haste...

There are few times in Salone that people hurry. Unfortunately, one of those times is when a person is very ill needing urgent medical care. Often it is parents frantically rushing to the hospital with a sick child they have kept at home for too long. When the child is near death they run, expecting the doctor to be able to do a miracle. Of course, there are cases in which the child has not been sick for very long but gets very sick quickly and needs urgent care.

The times that I am making parents rush like mad, and calling out 'make haste' is when a very sick child comes to the clinic and needs to be referred from the outpatient clinic to a referral hospital. "Make haste" I say when I hand them their referral letter and send them outside with a nurse to charter a taxi to the hospital. To be honest, it's not like they can speed up the trip, traffic is traffic. However, what I really mean is: go straight to the hospital. Unfortunately in the past some mothers have gone home first. This leads to various outcomes: they delay admission, they reach the NGO hospital too late and the bed is taken, they wait too long till the child dies at home, the relatives discourage the mother to take the child to the hospital. When I say 'make haste' I mean get to the referral center as fast as possible.

I used this phrase a couple of times today. I referred 6 patients of which 4 were very sick and 2 were sent for non-urgent matters (physio and to start TB treatment). I hope they all arrived at their destinations in time. I worry about some of them. But, what can I do now. I have seen them. Assessed them and sent them on for further care. These are the children that were rushed off today...

- A 3 year old weighing 9.7kg. Kwashiorkor malnutrition needing urgent admission at the therapeutic feeding center downtown.
- A 10 month old with a bacterial skin rash, moderate anemia and respiratory distress. Possibly septic. Needing urgent admission and sent to the NGO referral hospital
- A 1 day old brought to the clinic at 230pm looking as blue as a smurf. Multiple congenital defects including cleft lip and palate. Very floppy. Mother ran away after seeing the child. Here with father and granny. Sent to Childrens Hospital in desperate need of Oxygen. Unfortunately I think the chance of this child's survival is nil.
- A 2 year old with severe malaria. Deteriorating during the day so in the end sent to the Childrens Hospital for iv quinine.

I hope they all took my advise and went as quickly as they could to the referral centers. What can I say. It has been a long day. And I suppose an even longer one for these families...

Last ALONE day...

What a bizarre thought.

While seeing patients today I realized it was my last day to be seeing patients on my own.

As of tomorrow, there is a clinical officer coming to work with me in the OPC.

Don’t get me wrong; it is great to have help in the clinic and that she can carry on for a few weeks after I've left.

But it does feel a little strange.

I worked on my own for the first 2 years.

Seeing around 60 patients on my own (how did I do that???)

I was desperate for help to come.

I then had a good 1 1/2 years with various doctors helping out.

Yeah for two clinicians in the clinic!

It made the work more bearable and made it possible to be more social!

But for the past few months (since end January) I was on my own again.

The change from two clinicians back to one was big.

I was not used to the pace I was working back in 2006.

I couldn’t go back to seeing 60 a day.

It seemed crazy to run myself to the ground like that again.

Instead I decided I would see around 40 per day, often ending up being around 45.

Still long days but I was satisfied that a good number of children were being seen.

Today again was crazy and chaotic but I again saw 42 children so it was worth the craziness.

Tomorrow I will introduce a new colleague to the work here.

And once the new clinical officer is up to speed we’ll increase our numbers again…