Merry Christmas...

Thanks to friends in Sierra Leone for making this Christmas special.

I enjoyed a wonderful Christmas eve carols & lessons gathering yesterday.

Followed by a spread of Christmas goodies- including snickerdoodle cookies, cakes, truffels, decorated sugar cookies (so fun!), apple cakes, etc.

I then had a lovely (late!) dinner with two friends in Aberdeen.

Christmas morning I almost tripped over a stocking that had been placed in front of my door.

Sweet!

My housemate and I sat in the living room like little kids unpacking our stockings.

Chocolates, sweets, balloons, inflatable beach ball, and other fun items brought smiles to our faces.

This afternoon I had a lovely Christmas lunch/dinner ("lunner") at the Aberdeen's Women Centre (my former residence) with a great group of people.

I had the opportunity to skype with my parents, sister, nieces, brother, sister-in-law and grandma.

It's been a lovely Christmas despite being far from family.

Not sure what tomorrow will bring.

I'm working on Monday and Friday but heading off to an island Tuesday through Thursday.

Can't wait to spend a few days away from Freetown.

Merry Christmas to all!

A unique Christmas gift...

Do you want to give something unique this Christmas?

How about giving Oxygen?

Last Christmas I raised $5000 for a water well in Ethiopia. With your help that was possible. This year I am raising money for oxygen concentrators for the Children's Hospital in Sierra Leone. Can you help me again?

Watch the video and then go to: http://www.justgiving.com/sandralako

MERRY CHRISTMAS.

First Journal Club at the Children's Hospital...

Today was the launch of the journal club at the Ola During Children’s Hospital. Two professors, seven national doctors and three expatriate doctors sat together in an office for the first meeting of its kind.

The journal club was launched as a part of the postgraduate training program in pediatrics that will hopefully kick off in early 2011 (more on this soon). Similar meetings held in the hospital or soon to be held include the morbidity and mortality review, the tutorial topics, lectures, grand rounds and the perinatal meeting. The momentum for an academic atmosphere is exciting.

The journal article chosen for today’s event was published a mere three weeks ago in the Lancet and depicts a trial comparing intravenous artesunate versus the gold standard of intravenous quinine for the treatment of severe malaria in children. This is a very relevant topic in a country where malaria is endemic. Malaria leads to a high number of hospital admissions and contributes greatly to the death rate in children younger than 5 years. To give you an idea, in October 466 out of 981 new admissions were diagnosed with severe malaria (not all laboratory confirmed) and 45% of the total hospital deaths were attributed to severe malaria.

One of the national doctors gave an excellent summary of the article including the methods, results and discussion points. His summary formed the basis for a discussion by the professor on the importance of criticizing such studies – pointing out both the positive and negative aspects of the trial. As this was the first time to evaluate such trials, she further discussed the research process and involvement of various players in research.

We then moved on to the application of the discussion points to clinical practice in the hospital. This to me is one of the most important parts of these meetings. Yes, it is good to discuss trials and outcomes and point out whether or not the trial was performed well but in the end one needs to analyze whether or not clinical practice is evidence based and whether or not it needs to be adapted.

The outcome of this trial is that intravenous artesunate is superior to intravenous quinine in the treatment of severe malaria with artesunate substantially reducing the mortality rate in children. Artesunate is said to be simple, safe and effective.

This sounds good and it seems like the best thing to do would be to switch to using intravenous artesunate in the hospital, however, in a place where artesunate is not affordable and scarcely available this is not a sustainable treatment option. So, we have to look at what we can do, which is make sure our use of quinine to treat severe malaria is optimal. You see, when reading the article I was reminded that the preferred way of administering quinine is intravenous rather than intramuscular and 8 hourly instead of 12 hourly. So I brought this up. This of course led to an interesting discussion and critical look at our treatment choice.

Yes, the doctors know intravenous is better than intramuscular, however, for various reasons (poor monitoring of a child’s blood sugar, poor monitoring of infusion rates, lack of fluids and other resources, lack of nursing staff) they choose to prescribe it intramuscularly arguing that it is safer in most cases and generally as effective. Of course, they give this 12 hourly to decrease the chance of an injection abscess. We discussed the issue and went back and forth, deciding to consult the guidelines. Seeing as the World Health Organization recently published the 2010 Treatment Guidelines for Malaria it seemed like a good place to look. So, based on the information and the high cost of intravenous artesunate (although a good cost analysis should be done of iv quinine versus iv artesunate), the patients will continue to receive quinine, but 8 hourly. When possible they will receive it as an infusion rather than as an intramuscular injection but in reality we will have to see how that works.

All in all I would say that the journal club was a success leading to a critical look at malaria treatment at the Children’s Hospital, which will hopefully lead to better outcomes for children coming in with severe malaria. This was a good start to the journal club.

As posted on the BMJ website: http://blogs.bmj.com/bmj/2010/12/13/sandra-lako-journal-club/

Christmas don com...

Driving through town this week has been rather pleasant. The journey is always interesting enough with so much going on and so much to look out for. It really can be quite entertaining. The hustle and bustle of people walking, pushing carts, selling anything from phone credit to bags of water to second hand clothes to air freshener. Carting around anything from containers filled with water to coal to large bags of flour to pigs. You name, they’ve got it, for the most part. The sellers are literally on the street- on some streets they actually cover the entire road. This means that when driving along you literally have to force people to pick up their goods off of the road and take a few steps back. We do feel slightly bad making them move their mobile shops, but then again, a road is a road.

The trips home this week have been more interesting. I keep coming across people I know – a carpenter I have known for years, nurses from the Aberdeen Centre, former patients’ moms. It’s great. The slow flow of traffic allows for a little bit of conversation but before you know it, the car moves on.

The best part of the trips this week has been the increased number of Christmas items available. Driving through town you can find numerous people walking around with Christmas trees - small, medium and large. Other people are draped with vast amounts of tinsel sparkling in the sun. Street sellers have an assortment of Christmas lights – colored, musical, etc. Special Christmas sweets are being sold at street side stalls. Christmas tunes are being played from shops throughout town. Even my driver now has “The First Noel” as his ring tone. Despite the 30 degree Celsius temperatures in Freetown, Christmas has come.

Unanswered question...

This morning I was in the Emergency Room briefly, to check on the supplies in the side lab. While there I overheard three family members asking the nurse to please find the doctor who was on night duty so that he could sign the death certificate of a child who passed away. The nurse was busy and I knew the doctor was down in outpatients, so I decided I would assist the family since they had already been waiting for over an hour and really wanted to settle the matter.

Apparently the 2-year old child was admitted at 10 am with severe malaria and anemia and was started on treatment. However, the child’s condition was poor and she passed away in late evening.

Officially, when a child dies, the doctor needs to pronounce the child dead, document this in the chart and fill out a death certificate. The certificate is then taken over to an office with the somewhat unusual name “Births and Deaths” where an official burial permit is given to the family so that the child can be buried at the cemetery. As you can imagine, this process can become quite a burden for a family who has just lost a child. If a child dies at night, the office is closed and the family has to return in the morning to arrange the paperwork before proceeding to take the child’s body home. This takes time and costs them money (transport) and generally is not something one wants to do after losing a child.

After comparing our hospital data with the ‘Births and Deaths’ statistics it is obvious that many deaths are simply not registered. The family simply takes the child’s body and I suppose finds someway to bury it without a legal permit.

Part of this is due to the system itself being complex with too many people who need to take part and many people who are actually too busy trying to save lives. Part of it is lack of communication to the families. A number of times, while entering data into our database, we have found a death certificate still in a patient’s chart. It simply did not make it to the ‘Births and Deaths’ office. Honestly, I think this is not a real worry. My concern is one I have had for some time now. Why did this child die within 12 hours of being in the hospital? Did she simply come too late?

In this case the family did return for the permit which proved more difficult since the death certificate had not been written at night and the doctor that was on call was no longer in the emergency room. Then, on arrival at Births and Deaths, the office was found locked. Fortunately we found someone else who can issue the permit.

While waiting on the paperwork I had the chance to talk with the grandfather and father of the deceased child. It was the second child in the family and apparently the child had been sick for some time. The mother had taken the child away to her family (possibly upcountry?) and the father and grandfather have no idea what took place. It was not until the mother returned to Freetown and showed up at the father’s house in the morning that they saw the poor condition of the child and brought her straight to the hospital. Unfortunately it was too late. I have no idea what happen. All I know is that likely this child was delayed in reaching the hospital. Is this due to lack of knowledge on the mother’s part, the traditional use of country medicine, the ease in buying anything and everything over the counter in a pharmacy? The question of why children come to the hospital in such late stage of disease remains unanswered. I’ll continue to search for an answer to this to see if there is anyway this can be addressed…

Saturday at Bureh...

Flying...

No, I am not flying anywhere at present. Although a trip back home to some snow sounds great. No, this has simply been a weekend in which I feel I am flying from here to there.

It started on Friday, leaving work at 4 pm (early for me!) and getting to the Spur Road office at 5 pm (traffic-free ride home!) After a few minutes of (slow) internet I walked the ten minutes to get home. I quickly changed and then headed down to Mercy Ships so that I could make it for their 630 pm dinner. Fortunately the taxi driver was going from Wilberforce to Aberdeen, meaning I did not have to change taxis at Congo Cross. Convenient! Traffic was crazy but I got to Aberdeen on time. After a lovely dinner (thanks to Aunty Fatu) it was time for a meeting. Six of us were meeting to discuss a Sunday school program for Sunday afternoon. We have invited 30 children from the Aberdeen community to come for Sunday school. So we had to rehearse a play we are doing and discuss songs, snacks, games, coloring sheets, etc. We were done by 830 pm. I chatted with some people and then headed off to the shower (since we still don't have water at our house). And at 930 pm my driver came to pick me up. I was so tired I was asleep by 11.

This morning I got ready and was out the door by 830 am. I took taxis down to Aberdeen and hopped into the Mercy Ships Landcruiser with 9 others and headed to Bureh beach. We decided to take the peninsula road meaning we drove through Lumley, Juba Hill, Goderich, Lakka, Hamilton, and past beautiful beaches like River 2, Tokeh and John Obey until we finally turned off at Bureh, 1 hour and 30 minutes later. The day was amazing even though there was a large beach 'outing' - busloads of Sierra Leoneans, loud music, lots of beer, and so very little privacy. We managed to find a spot that was a bit further away from the massive speakers. And we spent plenty of time in the water/sun.

I arrived home at 640 pm with just enough time for a quick bucket shower and turn around to head out the door again by 725 pm. I had a lovely dinner at Roy's with Hannah and Tim from the Africa Mercy Advance Team and was home by 1030 pm. It's now time for bed since tomorrow will be a crazy day.

I'll be flying from here to there again. First to church to help with Sunday school. Then to a supermarket. Then to Aberdeen for Sunday school there. Then to meet the family who lost a child at the hospital last week to pay my respects. Then to catch up with Thomas, my former lab technician, along the beach somewhere and then finally home.

Yeah, it's another busy weekend. But it's good. I definitely can't say I get bored here.

Happy Thanksgiving...

I’ll end the day with a list of 10 things I am thankful for today.

1. The lovely Thanksgiving dinner at the Aberdeen Women’s Centre this evening including turkey, mashed potatoes, gravy, cranberry sauce, stuffing and pumpkin pie!
2. The opportunity to work with Sierra Leoneans and join them in making improvements in pediatric care at the Children’s Hospital.
3. The little bit of water supplied by Guma Water Company every third day or so since it’s better than nothing.
4. Being able to use the Internet connection at the Aberdeen clinic in order to send the 12 MB hospital database to someone in Canada for reporting purposes.
5. Having an excellent driver who takes us to and from work and who I can always call in the evenings or weekends if I need a ride (for a little bit of extra cash).
6. The patients in the hospital that made me smile today.
7. Thankful for cell phones and text messaging.
8. That although my niece has been admitted to hospital, she is in Holland and not in a hospital here where I would worry about her even more. (Hoping she gets well quickly)
9. For my family.
10. And finally, for a network of friends here in Sierra Leone, both expats and Sierra Leoneans.

A difficult week...

This week is not over yet, but already it has proven to be a difficult week. One day this week 4 children died within a 5-hour period. It was a difficult day. I was actually only involved with two of the patients, and only towards the end. Still it was emotional. The magnitude of death was overwhelming.

As I walked through the corridor towards the Emergency Room I passed a mother and aunty wailing. They were frantic. I assumed that either a child was dying, or had just died and thought I better check if anyone needed a hand. I went into the very low-tech ‘intensive care’ unit with over 30 patients and saw the VSO doctor and nurse resuscitating a child. After checking the blood sugar and getting an airway for the child we assessed what could still be done; unfortunately, not much. The child was on appropriate medication, on oxygen and receiving emergency care at the level at which it can be offered at the Children’s Hospital. What more could we do?

Silently the father sat nearby. Watching. Waiting. There was nothing he could do either. We soon realized we had to come to terms with the fact that we could not save this child. He died. As we went over to condole the father, tears welled up in his eyes. He was speechless. The aunty, who had been looking on during the resuscitation, started wailing again. Another 5-10 minutes later the child’s mom came in. Her wailing was ear piercing. I cannot begin to describe it. It was pure, raw emotion. It was the sound of a mother losing her beloved child. Watching the mother grieve over her child and seeing the father in a trance brought tears to my eyes. On the bed opposite the patient sat a mother cradling her own child, tears rolling down her face. Other mothers were trying to encourage the distraught mom. And as I listened to what the mom was crying out I sensed her desperation. “I have given birth to two sons, and now I am left with none.” This mother had already lost a child. Today she lost another. Heartbreaking.

Around the same time, a mother and child came to the Emergency Room. Two months ago the child was referred to the hospital due to severe malaria but made a quick recovery. This time the child was referred due to convulsions and pneumonia. He was seen by the doctor in the Emergency room and commenced treatment. Four-hours later I saw him again, looking worse. His breathing was very labored and he was very irritable. It was worrying. The doctor reassessed him and the care available was continued. I left there that evening not knowing if he would pull through or not. Sadly, the next morning I found out he had passed away. I felt awful. I knew that another family was grieving the loss of their child. And I felt it even more since it was a family I knew. I questioned everything that had been done, wondering if we could have done things differently. I do not know that we could have. For some incomprehensible reason, this child passed away.

Working at the Children’s Hospital is tough. It is challenging to deal with the constraints, difficult to cope with the deaths and frustrating managing the slow pace. There is still so much to be done. Yes, the hospital has improved greatly since I first arrived in 2005, but the road is still long. Fortunately, working here can also be rewarding. We have some great projects underway, such as the development of the laboratory services and starting up a postgraduate training program in pediatrics for doctors. And yes, children do get better everyday. While attempting to resuscitate the boy, the little girl lying next to him on the same bed was struggling to fight meningitis. Now, two days later she looks much better. Likely she will survive. And that is our aim; improving pediatric care so more children will survive. That is what I am going to hold on to for the rest of this week.

Ministry, treks through town, phone numbers and nonsense...

Last Friday our driver had the day off. So, one of my colleagues (bravely) said he would drive. However, plans changed a bit. An 8 am meeting on the west side of town lasted till about 1030 am. At the same time I was summoned to the Ministry to get a document signed for the release of a container. My colleague who was scheduled to fly back to the UK that evening decided not to go across town to the hospital but stay on the west side and meet up with the specialist-in-charge there. So, I said he could drop me off at the Ministry and I'd take transport from there.

I went up to the 4th floor and met a lady from the company in charge of getting the container released. Seeing as the container has been in port since September and they still had not managed to get clearance, I was not impressed by this company. Anyway, the lady was not very professional and the mere fact that I was requested to come to the Ministry by this company to get their documents signed seemed a bit crazy. However, if that is what it would take to get the container out of the port, well, then that is what I'll do.

Unfortunately the Deputy Minister of Health just stepped out of his office and his secretary was not sure if he went out for a meeting or not. I realized this could mean a long wait. Fortunately about 20 minutes later, the Deputy Minister reappeared, but then disappeared again into his office. At least I knew of his whereabouts. Minutes later a Ministry official walked by who knows me from my Mercy Ships days and greeted me. I mentioned my reason for being at the Ministry and he was quick to move into action. He went into the Deputy's office and came out 5 minutes later saying the documents had been signed. It really is who you know and not what you know. Thanks Y. We were now one step closer to getting the container out of port. Having said that, the container is still at the port!

I then had to find a taxi to take me part of the way to the hospital, knowing that I would be better off walking the last 25 minutes due to heavy traffic on the east side. After about 5 minutes I found a taxi heading to PZ and hopped in. The other customers were very friendly and pleasantly surprised that I had a grasp of the public transport system. And of course, one of the men asked for my phone number. I 'politely' declined.

After a 30 minute (slow) taxi ride I got out and ventured through the downtown streets on foot making my way down Goderich Street, past Eastern Police, along Kissy Road and down Patton Street until I reached the hospital. On my way I bought two 250 ml bags of water. I was walking in the heat of the day and feeling somewhat dehydrated which made me wonder what would happen if I fainted on the street. Would people stop to help? Would my backpack (with laptop) get stolen as I lay there passed out? Would they take me to some dodgy pharmacy or clinic? I quickly guzzled down the bags of water and kept walking, reaching the hospital in a very sweaty state. Phew, I made it.

By this time it was 1 pm on a Friday afternoon and I had a number of things I wanted to get done. I rushed around and did as much as I could knowing I would have to walk back to the center of town and take public transport home. It was 545 pm by the time I left the hospital after sorting out medical records issues and meeting with the lab technicians.

The crazy thing is that on Saturday afternoon I had to go back to the hospital. So I did the whole thing again. Took a taxi from my house to Congo Cross, then a poda poda to Goderich Street and then walked to the hospital. And did the same in reverse order 4 hours later. I must say that 4 such treks in a 28 hour period is a bit much. By the time I reached the poda poda stop Saturday afternoon I was ready to be home, away from the crowd. I almost got pick pocketed, had numerous men ask for my phone number, had to dodge a thousand cars/carts/dogs/people etc. and had to endure a great variety of 'white man' comments. In the end I couldn't be bothered to engage in a conversation so I was short, to the point and basically ignoring the person next to me in the poda poda. That is, until I found out he works at Roy's, a nice restaurant/bar along Lumley beach; a beautiful spot for a Friday evening or Sunday afternoon. Seeing as I would likely see him again at Roy's I thought I better be nice and talk.

During the very next taxi ride, a similar thing happened, except this time one of the guys recognized me - he works at Bliss Bakery. We had a nice chat but him recognizing me still did not warrant a phone number exchange. Later that same evening as I headed to O'Casey's for dinner a guy on the backseat of the taxi (next to me) tried to convince me that we must be friends and he must have my number. I politely declined saying I didn't know him and wouldn't just hand out my number. But, like many men here, the response was 'if I have your number I can call you and get to know you'. No thanks. Funnily enough he then tried to convince me that because we were both on the backseat of the taxi, we were friends and supposed to exchange details. At this point the guy sitting in the passenger seat in the front joined in and also tried to persuade me that I needed to become friends with my backseat companion. Backseat passengers become friends. And front seat people become friends. Sounds logical, right? It was a load of nonsense of course but fairly entertaining. The best part being when the guy in front got out and asked for my number even though he wasn't sharing the backseat with me. My response this time was 'no, sorry, you're not on the backseat'. I was happy to be picked up by Farah, my very reliable taxi driver, later that evening. No nonsense, just normal talk.

Lessons learnt: Don't walk to the hospital and back two days in a row. Make sure you have Le 200 (USD 0.05) for a bag of water at all times. Get connected to people in the Ministry- it's who you know, not what you know. Never trust a company that says they can have a container out of the port in a few days. Always be cordial to fellow passengers (you might see them again). Don't give your phone number to anyone, not even your fellow backseat passenger friend.

Prospects and challenges of an x ray department...

The Ola During Children’s Hospital is close to having the x ray unit up and running. This is very exciting especially since it has been 6 years since the last x ray was taken at Ola During Children’s Hospital. Can you imagine a hospital without x ray services?

Presently children need to travel across town to Connaught Hospital for x rays. This is often a three-day process. The child receives an x ray request form on day 1, goes to Connaught very early in the morning on day 2, and goes back to Connaught on day 3to pick up the x ray and report. This is an obvious delay in the diagnostic process. Also, for very sick children, having to travel across town is simply not possible because there is no way to transport them safely, especially if they are in need of oxygen. Clearly, there is a need for a functioning x ray unit.

The new x ray unit will complement the ultrasound services in forming the radiology department shared between Ola During Children’s Hospital and Princess Christian Maternity Center.

In June the Ministry of Health and Sanitation promised to deliver an x ray unit to the hospitals. Honestly, I was a bit skeptical. However, they kept their word and mid-July an x ray machine was delivered to the radiology department. Step one was complete. The next step: assembling/installing the unit. This took longer than expected, but was a success. The next hurdle was to connect the new processor to the water supply. Unfortunately this proved too difficult, in part due to lack of high quality plumbing but also due to the poor water supply at the hospital. It was decided that for now the old processor would be used until the water situation has improved.

Now that the x ray unit is ready for use, the department is faced with the biggest challenge yet, namely, the lack of x ray films and developer and fixer solutions. The government supplied central medical store is in short supply and it is uncertain when or where the next stock will come from. To further compound the problem, Connaught hospital can now only give 10 children access to free x rays per day due to their limited supplies. Of course, one can still pay for an x ray but the majority of the families do not have the Le 30,000 – Le 40,000 ($8-10) needed for one x ray. Yesterday there were three children in the feeding center needing chest x rays who have already made the early 5 am trip to Connaught two days in a row and been turned back because the 10 slots for free x-rays for the day were already used up. This is a bit of a dilemma.

So, now I sit here wondering where the supplies will come from and how this department will be sustainable? Will the Ministry step in and be able to help with a constant supply? Will the hospital need to find funds to buy films and solutions from Guinea or possibly even the UK or USA? Will the hospital be able to provide free x ray services for inpatients or will it be on a cost-recovery basis in order to generate income to purchase more supplies? And what is the role of the non-governmental organizations (NGOs) in this? If the NGOs help with the initial supply, how long must they continue supplying and who will sustain this? It is a dilemma and I am afraid I do not have a solution.

So, if anyone does have a solution, feel free to comment. And if anyone out there has a never ending supply of x ray films and solutions that they could deliver to the door of the hospital free of charge, you would be more than welcome to do so.

Let’s hope that the x ray department starts functioning soon. It will improve clinical care for the children and it will also bring the hospital one step closer to accreditation as a teaching hospital. Ola During will move forward one step at a time…

First posted on BMJ

Water...

On Saturday morning I decided to do some hand washing. Unfortunately, half way through the process, the water ran out. Water don don. I thought it was a simple matter of someone forgetting to turn on the pump to pump water up to the tank on top of the house. However, I found out it was much more complicated. Not only are we being supplied with less water, but someone managed to damage the pump. So, there I was, without water. You would think I would have had water stored in preparation, but no. Seeing as we have had water non-stop for the past 5 months I didn't think it would be necessary.

It is amazing how much water I use without even thinking about it. Water for washing clothes, taking a shower, flushing the toilet, drinking, hand washing. I literally use water all the time. While preparing food in the kitchen I realized how often I actually wash my hands (which is a good thing I guess) because I kept turning on the tap to start washing my hands and faced with the 'no water' issue rather quickly.

Not being able to wash the dishes was annoying. Not being able to rinse my soapy clothes was a bit frustrating. And not being able to flush the toilet is just not pleasant. Fortunately on day 2 we were able to get 3 buckets of water to aid our situation. Not much, but better than nothing. I was also fortunate to able to shower at other people's houses on Saturday and Sunday.

In the end, I really can't complain. All I need to do is look at the world around me. I have neighbors who have to walk and collect water everyday, and have probably done so for years. There are children on the street that have to carry buckets of water on their heads multiple times a day. There are people who have to live without running water every single day. And they manage. They have to. So, although I hope we have water again soon, this has been a good reminder of how many people here (and in many places in the world) live. Let's remember that water is a precious commodity. It should not be taken for granted.

If you want to be a part of bringing clean and safe drinking water to people in developing countries visit:www.charitywater.org

Return to Freetown...

Return to Freetown - Wednesday 20 October 2010

Gone for 20 days, back for 3 and I feel like I have never been away. It’s good to be back.

I must say, at the check-in in Heathrow I already felt like I was well on my way to Sierra Leone life. Literally while checking-in, a Sierra Leonean joined me at the desk and started discussing his own check-in details with the lady. No space, no privacy. Honestly, the same has happened to me in the bank here in Freetown while trying to sort out Welbodi finances.

Later standing in the immigration line at the Lungi airport watching a few people being whisked to the front of the line, I remembered quickly that it is who you know that is important not what you know or maybe it is how much money you are willing to pay someone. I suppose this happens everywhere.

The baggage claim was hectic as usual with huge crowds waiting for their luggage. Surprisingly no one came to me to help with my bags. I didn’t mind because it can be a little annoying to be pounced on right away so I simply waited. Once I spotted my suitcases I did ask someone to help me, to make things easier. Why not ask someone to help out and pay them a couple thousand Leones for their services?

The wait for the shuttle to the Pelican Water Taxi was chaotic, which has not been the case in the past. I soon found out that there was no helicopter service that day and everyone was trying to take the water taxi across. Rather than pushing my way into a van I decided I might as well wait for the next shuttle. It was interesting seeing a bunch of expats force their way into a van, much like the Sierra Leoneans push their way into poda podas. It’s shocking how quickly people lose their friendliness in these situations.

While waiting for the next shuttle I chatted with a couple of expats and Sierra Leoneans about life in Freetown. It’s always interesting whom you meet. A Sierra Leonean veterinarian, an expat vet coming to visit for a few weeks, a doctor from Central America, an airport porter, a business man. We finally got in a shuttle and off we went.

Unfortunately when I arrived by boat at the Freetown side, I found out that my luggage was still on a boat at the Lungi side. Time to get used to being very patient again; something I have never been very good at. By this time it was 11 pm and I was ready to go home. After a good 45 minute wait the boat arrived and I headed home in my reliable taxi driver’s taxi.

I awoke early the next day to leave by 650 am to head to the hospital where I was greeted by many familiar faces. It was good to be back. It was back to business very quickly as I had to sort out container issues and other fun stuff. Unfortunately the reality of children dying became evident very quickly as well. In the first two days of being back I witnessed two deaths and know of two others who died in the night. That is one of the difficult sides to being back. Children dying. Mothers wailing. Hospital staff disheartened. However, this does in part reflect the reason for me being here; to try to contribute in some little way to improving child health in this country.

Out and about...

Another weekend in Freetown. I actually stayed close to home this weekend after plans to River 2 beach fell through. I still haven't been there since 2009! Friday afternoon I had dinner with some friends at Mamba Point and then went on to Roy's on Lumley Beach. I think Roy's has become my new hangout spot. There's an indoor restaurant and an outdoor raised platform with tables and chairs overlooking the beach. It has a nice atmosphere, great breeze and spectacular view. I actually ended up there Saturday evening again. Today I went up to church in Regent and was impressed that I managed to get a taxi from Regent back to Wilberforce for Le 1,000 (25 US cents) - I suppose it's the usual price for locals (that or Le 2,000) but as a white lady I am usually charged anywhere between Le 3,000 and 6,000. I won today. I'm now in Aberdeen using the internet at Mercy Ships (I must get my own at some point!) and going to walk on the beach for a bit later. It's been a quiet weekend.

I'm definitely out and about a lot more, having spent many evenings away from home, which has been a nice change. Of course, all of it is by public transport and so far that has gone smoothly. I do like being out amongst the Sierra Leoneans and attempting to do things their way. Last week, I did forego taking public transport when going from the hospital to home and decided to walk the entire way. In the end it took me an hour and a half. Which, considering it can take just as long by car in traffic, is not bad. It was quite hot though. I'm sure I'll do it again.

Someone asked me the other day if I have broken my rule and taken an okada (motorcycle taxi) yet... Nope, I haven't. And don't think I will. Even some Fullah men I was talking to at the roundabout this morning advised me not to. I'll take their advice. So for now, it's our own car with driver, taxis, poda podas or on foot.

The importance of prevention...

From: http://blogs.bmj.com/bmj/2010/10/26/sandra-lako-on-the-importance-of-prevention/

A few weeks ago a child came to the hospital with classic signs of tetanus: a locked jaw, rigidity of the muscles, and jerking of the body. The diagnosis was obvious. The doctors and nurses tried to cure the child, but in reality they had little to offer. The children’s hospital is not set up to manage these cases effectively. And so, a few days after admission, the child passed away and a preventable disease took the life of yet another child. Unfortunately the child was not immunised. This time it was tetanus next time it might be malaria.

Preventable diseases still make up a large portion of morbidity and mortality in Sierra Leone. Diseases like malaria, diarrheal disease, and malnutrition are rampant. Even tetanus is not uncommon. Although these diseases can be prevented, each one of them still takes an unnecessary toll on the children of Sierra Leone.

To win this battle a two-fold approach is needed. Curative services must be improved including adequate access to care, proper diagnosis, and appropriate treatment. Secondly, but arguably more importantly, preventive measures must be intensified.

Since the launch of Free Health Care in April, the number of patients seen at the hospital has increased. There are currently 8 medical officers and 2 house officers dealing with 1000 admissions a month plus outpatients. Add to this the inadequate diagnostic facilities, other staff constraints and a limited assortment of drugs and the challenge is obvious. Unfortunately cases that are easily treated in the developed world are difficult to deal with under such circumstances. However, progress is being made; a lab development project is underway, the radiology department is improving and there are significant steps being made in the area of staff training. All of these advances will aid in improving curative care. This is of course essential, since everyone wants sick children to be healthy again. However, although both approaches are crucial, prevention will have the greatest impact on lessening the burden of disease. Decreasing mortality is good, but reducing morbidity altogether is the key. Less illness means fewer hospital admissions, which in turn means that patients who are admitted can receive better care. And of course, less sick children should mean fewer children die. How can morbidity be reduced? The answer is clear: prevention.

Prevention is an integral part of public health in which health is seen as a basic right and should be maintained. Time and money spent keeping people healthy will have a huge impact on families, communities, and ultimately the country. The question is how to roll out prevention programs effectively in a developing country?

Examples of preventive measures include: hand washing, sleeping under mosquito nets, clean water for drinking, receiving immunisations, use of oral rehydration solution, use of latrines, ensuring good nutrition. It seems simple: make sure health messages reach the public and ensure that programs are delivered. However, implementation is where part of the problem lies. Simple measures can be difficult in a country like Sierra Leone where resources are limited. How does one promote hand washing, when water is not available? How can one expect a mother to walk for one hour to the nearest health post for immunisations when she has three other children to look after? These are the types of obstacles that stand in the way of effective programs. And, like anywhere else in the world, the biggest challenge is bringing about behavioral change. People need to be convinced that these measures will benefit them or they will not buy into them. In a society where traditional/religious beliefs are intertwined in daily life, behavioral change does not come quickly. This calls for perseverance from those delivering preventive programs.

Personally, I’m hoping that at the Ola During Children’s Hospital we will be able to focus more on prevention as well as continue to improve curative services. It would be great if the caretakers can be educated and in turn teach in their communities. One way in which this can be done is by showing health education videos in Krio as well as group sessions and one-on-one talks. Hopefully by taking the health messages onboard and implementing preventive measures in their homes, they will see that they can play a role in keeping their children healthy and happy. Hopefully an attempt will be made at all levels (ministry of health, hospitals, primary healthcare units, schools, religious places, etc.) to deliver high-quality, deliverable, and sustainable preventive programs. Sierra Leone, let’s make prevention a part of daily life.

Sandra Lako is a doctor from the Netherlands who previously spent four and a half years in Sierra Leone setting up and managing a pediatric outpatient clinic with an organisation called Mercy Ships. After a year at home, she returned to Sierra Leone to volunteer as medical coordinator with the Welbodi Partnership, a UK based charity supporting the only government-run children’s hospital in a country where 1 in 5 children do not reach the age of five.

Christmas Gift...

October 16, 2010.

It's 10 weeks until Christmas. For many people Christmas is a time to give. I know it's a little early, but this year, why not consider giving to the children of Sierra Leone - to those children who need your help to survive. Due to a shortage of oxygen concentrators in the Children's Hospital, children are having to share 5 liters of oxygen. Instead of 1 child receiving 5 Liters, it is split amongst 4 children. As you can see in the picture, the oxygen is split using tubing and connection pieces. Obviously this is not good enough and needs to change. I don't think parents in the 'west' would tolerate their child only receiving 1/4th of the oxygen needed to survive. Unfortunately the parents in Sierra Leone do not know any different. And the hospital is not able to bring about change in this issue in the near future. But I think that WE can make a difference. My goal is to raise £1800 by Christmas in order to purchase and transport 2 concentrators to the hospital in Freetown. Your donations will go directly towards this purchase. Please consider helping with this cause so that children in Sierra Leone will receive the care they desperately need. If you are interested please click on myjustgivingpage.

Thank you on behalf of the staff and patients at Ola During Children's Hospital.

Holland and Salone...

As much as I love being in Sierra Leone, there are definitely perks to being back in Holland for a few weeks. I forget about some of the simple joys of home. And it's nice to be away from a few of the annoying things in Salone, although having said that I am very happy to be going back tomorrow. I suppose every place has it's ups and downs. Below are some of the differences I noted while in Holland:

• Being able to drink water from the tap (and not risk getting sick!)
• Walking to town on my own without getting hassled
• Not being asked “Will you be my friend?” by strangers
• Riding a bike to town
• Getting on a train to visit friends
• Absence of car horns honking in the streets at all times
• The quietness in the neighborhood
• Eating cheese and drinking milk
• Good water pressure in the shower
• Not being asked for my phone number by anyone
• No loud music during the night
• Grapes and Pears (of course I'm perfectly happy with pineapples and mangos)
• No malnourished children seen on a daily basis
• Not needing to plan when to charge my phone based on availability of electricity
• Lovely brown bread
• Fast internet
• No random phone calls waking me up at 2 am
• Washing my clothes in a machine (not looking forward to the handwashing!)
• Wearing winter clothes (I’m not a fan, can't wait to pull out the flip flops)
• Seeing family (love you guys!)
• No need to lie about my marital status to avoid marriage proposals
• Watching television (although I don’t miss it at all when gone)
• Getting my blood tested including iron, vitamin B12 and folic acid levels (wow!)
• Lots of green grass
• Feeding ducks and petting well-groomed dogs
• Countryside with cows, sheep and horses
• Daring to get in an elevator assuming it won’t get stuck due to a power cut
• Traffic lights that work
• Well-organized public transport (although not nearly as adventurous)
• Not being confronted with children dying every day and the sound of mothers wailing
• Enjoying the outdoors

Ah. So many wonderful things. I've left it all behind now as I am in transit to Freetown. I am ready for all that awaits me there and eager to get back to work at the hospital. There are so many great things about Sierra Leone - just to mention a few off the top of my head - sun, beaches, friends, great colleagues, purpose in my work, adventures - lots of good and challenging times ahead. Salone, here I come...

Tribute to Opa...

My opa (grandpa) was a great man and I want to acknowledge that today. He was bright and influential. Not only was he a teacher but he was also actively involved in society as a musician and a politician. And at his funeral all of these aspects were brought to light. Opa had a positive influence on many lives. He will be missed.

Seeing as us kids grew up abroad we actually did not spend loads of time with opa as children. However, the times we did spend with him were special. I remember sleepovers at their house when we were on furlough - playing in the attic with all of our toys, riding opa's stationary bike in his study, eating french fries and applesauce, going to pick berries, rides on the sled, going to the petting zoo, story time. Opa and Oma did fun things with us kids when they got the chance. As an adult I tried to visit opa and oma when I could. But over the years, opa's health deteriorated yet he remained a caring and friendly opa.

Just before leaving Sierra Leone to come for my holiday I heard that opa had turned for the worse. I knew that this would likely be the last time I would see him. Shortly after arriving in Holland I went to see my opa, who had moved into a nursing home in the last 2 months. I spent 5 hours with him and my oma but for the most part opa was asleep. On Wednesday I returned for my final goodbye before going to a wedding in England. (The wedding was the whole reason for me making this trip) I was very fortunate (blessed) that opa was awake. I sat by his bed and talked with him and read Psalm 23 to him. As the minutes went by, my visit was drawing to an end. It was time to say goodbye. And this time, I knew it was the final goodbye. I am not sure if opa knew it as well, I suspect he did. With tears in my eyes I told him goodbye and said "I love you" and to my surprise (since he had hardly spoken prior to this) he responded saying "I love you too". These were our final words and this is also one of the last times my opa spoke. The next day he was unconscious and the following day he passed away. I was so thankful for my special farewell. I wouldn't have changed it for the world. The funeral service was a lovely reminder of who opa was and although difficult a good time of closure. I will miss my opa but I know he is now in a better place. Dag lieve opa...

Vacation...

20 days, 8 different beds, 1 wedding, 1 funeral, 2 birthdays and family time.

That pretty much sums up my vacation. The holiday was different than expected, mostly due to the death of my grandpa and the emotions that came with that and the time that took away from our immediate family but overall it was still a good time away. It was quite hectic though, moving around a lot, trying to plan around kids’ schedules, jet lags, trip to London etc. My time in the UK was great and Vez & Rob's wedding was fantastic. And as a family we did manage to go to the beach for a walk, eat at a Dutch pancake house, go to a family reunion (mom’s side), go for bike rides, etc. There was also some work to be done since I left Freetown in a busy period and some stuff just needed some attention. I didn’t mind though and am looking forward to being back. Despite the craziness and not having time to travel around and see friends I did enjoy spending time with my family especially since this was the first time we were all together since my brother’s wedding in 2007. I loved watching my nephew and nieces play together and seeing my parents with all of their grandchildren. Many firsts. We had some good times and fun photos to show for it. Hopefully it won’t be another 3 years before my family meets up again…it’s just difficult to plan when it involves families (small children and school-going children) and with us living in 4 different countries. We’ll make it happen though…

Night check at the hospital...

24 September 2010 - It’s 1:00 am. My colleague and I just returned from a surprise visit to the hospital. Three times a month we do spot checks on the wards; periodically we check during the early or late shifts and occasionally during the night and weekend shifts. The reason for these checks is that the Welbodi Partnership set up a performance-based incentive scheme a couple of months ago to monitor nursing care at the hospital with the aim of improving staff performance and ultimately reducing child mortality.

Unfortunately nursing care at Ola During Children’s Hospital has been suboptimal for a few years. This has various reasons, one of which is that for years salaries were low and nurses were forced to engage in work elsewhere, abandoning their posts at the Children’s Hospital. This caused a dramatic fall in nursing standards. Also, high consultation/medication fees meant that patient wards were half-full and patients often could not afford proper treatment and mortality rates were high. This was demoralizing and led to even more nurses not showing up to work. Lack of equipment and supplies worsened the matter.

Thankfully, a few months ago the government increased the salaries substantially, which led to an influx of nursing staff. For some nurses that was enough of a motivator to come to work when scheduled and perform well. Sadly for others, this was not enough of a motivation.

In April 2010 the Free Health Care initiative was launched for patients under-5 years. This led to more patient admissions and a heavier workload for the nurses. For some, this again made it difficult to stay motivated. Welbodi hopes that with the incentive scheme, nurses would be encouraged to provide better nursing care. For some nurses this works, for others, it doesn’t. There are many factors that contribute to this.

The set up of the scheme is to do spot checks using set criteria to monitor the level of care given. The criteria include checking if every bed has a mosquito net, if every patient has a sheet or ‘lappa’ to lie on, if soap and water are available, if all scheduled staff is present, if nurses are in uniform, if equipment is clean and well maintained, if sharps are disposed of properly, if patients vital signs have been checked, if medication has been given accurately, if the handover book is filled out, if the ward is clean and if the nurse’s station is tidy. The criteria are modified as time goes on and are often linked to what the nurses have been taught in a workshop.

Although the scheme sounds simple, it is actually quite complicated. The scheme looks at a ward’s performance, not an individual’s performance. So, if a colleague does not show up to work, the others on the ward are penalized. If a colleague has not documented medication properly, points are deducted for the ward and everyone is affected. It does not sound fair, but the idea behind it is that nursing care should be based on teamwork. When one person falls, everyone falls. Unfortunately we are not able to monitor each nurse’s individual performance because that would be a full time job. So, we look at the performance of the ward as a team. If one shift functions poorly, then the other two shifts will be affected.

Another matter is that the same scoring method is used on every ward, but every ward has a different workload. Obviously 3 nurses in the observation unit or measles ward will be able to handle their work load of 5 – 10 patients much better than 2 nurses in a general ward with 40 – 50 patients or 4 nurses in an ICU with 40 patients. Fortunately Welbodi encourages local ownership and makes sure to engage matron’s office in every check. This allows for Welbodi and matron’s office to discuss issues arising such as the number of nurses posted to each ward and so on. It also empowers matron’s office to enforce rules and the nurse’s code of conduct.

The actual checks are a bit of an adventure, especially the weekend or night checks. Sometimes it makes me a little nervous, not knowing what I will come across. Fortunately tonight was okay. Some things were not so good and definitely need to be improved/changed, but thankfully there were also areas that had improved. Most of the staff was present which was a welcome change from a few months ago. The main issue now is proper administration and documentation of medication but I am convinced that with more training, mentoring and feedback this too can improve. As I said before, it’s not simple. Constant monitoring and evaluation of the program is crucial to make sure the scheme still works towards improving nursing care. It needs to be a scheme that continues to encourage the nurses and not discourage them. Their job is not easy but it is so desperately needed and we need to help them find a way to regain a passion for what it is they do- helping the children in Sierra Leone.

The Clock Tower...

The Clock Tower from Sandra on Vimeo.

The clock tower, situated at Eastern Police in Freetown is a landmark for many. It is located at the intersection of some of the busiest streets in Freetown: Sani Abacha Street, Goderich Street, Kissy Road and Fourah Bay Road. Many people passing from the West or Center of Town will go by way of the Clock Tower when heading East. A whirlwind of activity surrounds the tower with street vendors trying to sell anything from umbrellas to pieces of hot dog to towels to fruit to sunglasses. Meanwhile pedestrians passing by are trying to stay clear of moving vehicles and weave their way through the street vendors. And the taxis, poda podas and okadas are honking their way through the city at a very slow speed often causing much of the congestion in town. It really is a busy place.

When the clock strikes 6 the most amazing thing happens. Besides the Westminster chimes, the clock actually has the National Anthem stored on a flash memory card so that when the clock chimed 6 times, Sierra Leone's National Anthem is played boldly from the tower. At this moment in time, everyone freezes. Vendors stop selling, pedestrians stop walking, market ladies stop their chatter, vehicles all come to a halt. Even the unknowing white person is called to a halt. The whole world seems to be at a stand still as the anthem plays. I love seeing it every time. It is like a scene from a movie. Lots of hustle and bustle and then all of a sudden, the world freezes as the anthem plays. And as soon as the anthem is finished, the whole world is on the move again. It's my Hollywood experience right in downtown Freetown.

The death of a child...

Last week there was an ultrasound workshop for the medical officers and I thought it would be interesting to join, so I did. The ultrasound room is adjacent to the emergency room so while we were waiting for everyone to arrive the internist and I were reviewing a few patients. There were many really sick children. One infant had been brought in due to rat bites, although I think the child must have been sick prior to the bites because the child was really unwell. Another child was very pale and in urgent need of blood. Another child had a very high fever and was convulsing. It was hectic.

After thirty minutes, the internist decided to begin the workshop, so off we went to talk about the ultrasound machine, the use of ultrasound as a diagnostic tool, etc. Meanwhile, the emergency department was bustling. After the workshop, we left the ultrasound room by way of the emergency room and I noticed two doctors resuscitating a child. However, minutes later they stopped, realizing it was ineffective. As I stood there and watched I could not help but realize that everyone else in the room carried on with whatever it was they were doing. The other caregivers were not paying much attention, nursing staff was preoccupied with other patients and even the child’s mother could not be found in the emergency room. In silence, the child passed.

After the doctors covered the child with a cloth, they slowly moved away, disheartened by what had just taken place. Meanwhile the now lifeless child remained on the bed and to her left and her right, two other children were struggling to stay alive.

Chills ran through my body as I realized again how much death, has become a part of daily life in Sierra Leone. The death of a child, that would bring masses of people to action in both the hospital setting and the home setting in the developed world, goes by almost unnoticed here. Why is that? It is because unfortunately 1 in 5 children do not reach the age of 5 years. It is not that the death of a child has no affect on people, but they react differently than someone from the West might expect. I’m starting to believe their response has to be different, or they will not cope.

The mothers wail to the point of throwing themselves to the ground in uncontrollable sobbing but seem to move on with life more quickly. They are told to “bear,” which means, “to put up with” or “endure.” They are told not to cry. To me this seems inhumane, but there must be reasons for this. Maybe it’s simply because a wailing mother will cause other caregivers to worry more about their own children. Or maybe it is easier for everyone else involved to cope better. Or maybe it is because in a place with so many child deaths, a mother somehow needs to accept that this time it was her child. I am sure that any time a child dies in the Emergency Room, the other mothers present are worried that their child might be next. What an unsettling thought that likely one or two more children will die in the emergency room today.

Of course the doctors and nurses are affected too, but rather than appearing shocked, they sometimes don’t seem phased by it. I am not saying this to be judgmental and obviously do not know what goes on in their minds but I have noticed how demoralizing child deaths are for the staff. Of course it hits them hard, but they tend not to show their emotions. They are frustrated with the lack of diagnostic facilities or treatment options to save a child’s life. They are irritated that caregivers tend to delay so much before bringing their child to the hospital. They are saddened that the health care situation is changing ever so slowly. When a child dies, the doctors and nurses tend to step back in silence. How long can they continue to give their all when the outcome does not seem to change?

Where the average doctors and nurses in the developed world rarely experience pediatric deaths, these doctors and nurses are faced with children dying every single day. How does one deal with children dying on a daily basis? I think that the only way one can continue to work under such circumstances is to distance oneself from the patients and guard one’s emotions. Clearly in a profession devoted to caring for people it is difficult to find a good balance between building a relationship with the patient and maybe even becoming attached to distancing oneself from a patient and becoming indifferent. When faced with death everyday one has to find ways to cope.

I do hope that the staff continues to cope with the dire situation and of course, hopefully one step at a time, the situation at Ola During Children’s Hospital will improve and child mortality will start to decrease. Maybe someday deaths will not be a part of daily life in Sierra Leone. One day. I just hope that until that day comes the doctors, nurses and other staff will continue to endure under such trying circumstances.

X-ray: coming soon...

The Ola During Children’s Hospital is very close to having the x-ray unit up and running. This is very exciting especially since it has been 6 years since the last x-ray was taken at Ola During. Can you imagine?

Currently children need to travel across town to Connaught Hospital for x-rays, which basically takes them half of the day to get it done and often they need to go back for the film and report the next day. It also means that children whose condition is unstable cannot have x-rays taken because there is no way to transport them safely, especially if they are in need of oxygen. There is no portable oxygen here. So, again, this is exciting.

The x-ray unit will complement the ultrasound machine in forming the radiology department, which is shared between Ola During Children’s Hospital and Princess Christian Maternity Center. In the end of June I was told that the Ministry of Health and Sanitation promised to deliver an x-ray unit to the Children’s/Maternity Hospital Compound. Honestly, I was a bit skeptical. However, they kept their word and mid-July an x-ray machine was delivered to the radiology department. Step one was complete, now onto the next step: assembling/installing the unit. This of course brought to light various hurdles but the doctor in the radiology department overcame them. The final step seems to be connecting the processor to the water system, although a temporary measure could be to use the old processor. It might sound easy to connect something to the water system, but believe me, the water system at the hospital is complicated and often very problematic, so this step to will take a little time. Soon though, the unit will be up and running. If the old processor is used, it could be as early as next week. I’ll be sad to not be here for that, but very happy to meet an x-ray unit up and running on my return.

Let’s hope that the x-ray department starts functioning soon. It will improve clinical care for the children and it will also bring the hospital one step closer to being accredited as a teaching hospital. Ola During is moving forward one step at a time...