Another day in the hospital...

The day started with a flat tire and lots and lots of rain. Fortunately for us, we had a spare tire. Unfortunately it was a different type and the bolts were missing. However, the driver managed to find and buy bolts and changed the tire. By 8:30 we were finally on our way to the hospital.

Shortly after arriving, we went to the wards to check-up on the staff. The power was out and sadly the generator was not working. Hence, the children in the ER and ICU were not getting oxygen. Arriving in the ER we found one of the doctors ventilating a neonate. Luckily after about 30 min, the neonate started breathing again.

Only minutes later we were assessing a 1-year-old malnourished child. She had come in the previous day, in shock. Her breathing was now very shallow and her pulse slow. We started ventilating with bag and mask and doing chest compressions. Adrenaline after adrenaline and continued CPR proved to be unsuccessful. Another child gone.

As we were leaving the ER, a man with a large video camera rushed in. Before we knew it about 30 people were standing in the ER with a lot of press. It was the honorable Mary Robinson (former President of Ireland) and the Vice President’s wife. Having been caught up in the resuscitation only minutes before, I had forgotten about the visitors. After brief introductions and handshakes I hurried off to the neonatal unit.

After our informal ward check we headed back to the office. Fortunately the power was back on and I could send out some important emails. After catching up on a few emails I quickly checked facebook. Yes, Welbodi and Rebecca won the Vodafone Competition – second place.

Next I had to check up on our monitoring/evaluation/statistics staff. And what I thought would be a quick check-up turned into a meeting. It was a meeting with three groups, all collecting and reporting hospital data. Surely there is a way to make this system easier, more effective and more accurate. I am hoping they will see that the Welbodi system is the most efficient way to do it.

As I stepped out of that meeting, it was time for another – the pharmacy meeting. A brief meeting to discuss the way in which patients on the wards get their medication. Do the nurses go to the pharmacy to collect the drugs for each patient? Do the mothers need to go to the pharmacy? Do they need to show the charts as proof of what was prescribed? It is a very complicated system. The only real solution is of course having the medication on the wards at the nurses’ station. However, this is a huge step from where things are at now. A deeper level of trust needs to be reached, before this can take place.

Next was a meeting with the doctors. A chance to relay information to them and help them improve. A time to listen to them as they discuss problems on the wards affecting patient care. I’ll spare the details but let’s just say a lot was discussed. And there is a lot that needs to be done in so many fronts.

My meetings were done for the day. I had one more thing I had to do. Bring some extra (newly introduced) fluid balance sheets to the neonatal unit. A five minute job. In the unit, I saw the child that had been resuscitated in the morning. He looked awful. Grim, shallow breathing, very distended abdomen. All around poor. I quickly went to alert the medical officer in charge of the ward. As we were assessing the child, he quickly deteriorated. We started ventilating the child and shortly after we had to start compressions. I already knew this child had very little chance of surviving. As the granny watched on from a distance we continued the resuscitation. But after about 15 minutes, we knew it was over. Sadly I had to tell the granny that her grandson had died.

At 5:30 pm we headed home for a few hours before returning to the hospital. Our mission for the night was to do a surprise formal ward check. So, at 9:30 pm we headed back to the East side of town. I was anxious as to what we would find during the night shift. And, sadly, many of the rumors I had heard were confirmed.

Needless to say, it was a tough day. Busy, frustrating, discouraging, sad – all of it. But, as I look back on the day, at least I know I did what I could. And although the day was awful, I am still very glad to be right where I am. I am still hopeful that slowly but surely this place will change.

Help Welbodi - Vote for Rebecca...

Welbodi needs your help.

The Welbodi Partnership and UK nurse Rebecca Cridford are in the finals of the Vodafone World of Difference International competition, and we need your votes NOW to win Vodafone’s support for the next year for Rebecca as well as for our work at the Children’s Hospital. Rebecca Cridford (Becky) hopes to come to Freetown to work with Welbodi in August 2010. She will come for a year to work with and provide additional training for the nurses at Ola During Children’s Hospital.

So what can you do to help?

FIRST: Vote online for Rebecca Cridford through Facebook, at http://www.facebook.com/worldofdifference?v=app_10531514314&ref=ts#!/worldofdifference?v=app_20678178440&ref=ts

Voting closes on Wednesday 28th July 2010. VOTE NOW!

THEN: Tell everyone you know to vote as well. Post a link in your status. Message all your friends on Facebook. Tweet or blog about us. Email your friends, family, colleagues.

Please VOTE TODAY. It only takes 35 seconds.

Welbodi appreciates your support.

Freetown Weekend...

Another Monday morning, Time to get back to business after an eventful weekend.

The weekend started as soon as we left work at 5pm and headed to Bliss for some birthday cake. After choosing a fabulous piece of cheesecake and chocolate cake we settled down in the lounge to enjoy our tea and cake.

Later, a delicious meal of barracuda fish, mashed potatoes and stir-fried vegetables at Country Lodge made for a great birthday dinner with a lovely group of friends.

On Saturday we went to the hospital for a surprise visit on the wards as a part of the performance based incentive: the ward bonus check. Fortunately a number of wards had improved since the workshop, however, a few units were still struggling to perform well. On one of the wards 4 of the scheduled nurses were absent and many of the patient observations were not done. At least we know we have our work cut out for us!

In the afternoon we ventured into town to do some shopping. With the help of a former colleague, we went up and down the narrow streets looking for fabric, football shirts and children’s clothes. Meanwhile ignoring the many comments from the young men crowding the streets. After a successful shopping trip (for my flat mate mostly) we made our way home.

That evening, a former Welbodi staff threw a very impressive leaving party! It was very enjoyable and fun meeting other expats, but by midnight I was tired of trying to make myself heard over the music and actually I was just generally tired. I called it a night and left with some friends who dropped me off at the house. As I entered our compound I met our guard killing a snake! Sweet dreams.

On Sunday I went to Regent and met up with my Salone friends there and in the afternoon I headed to Atlantic to meet up with 4 Mercy Ships friends for a late lunch. I must say it is quite amazing to sit at Atlantic on a Sunday afternoon and look out over the beach and the Atlantic ocean. After a lovely lunch a few of us walked along the stretch of Lumley beach to Aberdeen and after a short stay there I headed home again in the evening.

The rest of the evening was rather uneventful until I found a baby bat hopping around in our living room. I thought it was a frog initially until I examined it a bit closer and saw how black and flat it was. It sure looked like a bat. Disgusting. Needless to say, we removed it from our flat and I am hoping to never see a bat in our house again. No more animals on our compound for me please.

Well, I have now reached the hospital. It’s 7:50am. Time to get moving on my to-do list. Happy Monday.

Intraosseous access...

After the nurses’ workshop on Monday I passed through the Emergency Room and noticed two of the doctors hovering over a nine-month-old child. They were attempting to get intravenous access. Like in many of the emergency cases, this child’s circulation was poor. While one doctor was attempting jugular access, I suggested inserting an intraosseous needle.

Having experience, albeit a year ago when I was last in Sierra Leone in the outpatient setting, I was handed a standard 19-gauge needle and attempted to get access into the tibia of the left leg. Using some force and a screwing motion I felt the needle push through the bone and within a minute or two the needle was in place. I quickly withdrew some bone marrow content confirming the needle was in the cavity. I then flushed the needle with normal saline to reconfirm the position. Thankfully, a few seconds later the child received dextrose and a normal saline bolus through the needle in the tibia. What a relief.

Now, I could only hope that the insertion of the needle had saved this child’s life. Since his condition on arrival was very poor, only time would tell what the outcome would be.

I checked up on the child every day to assess his condition and was glad to see a little bit of improvement each time I saw him. On Tuesday he was transferred from the Emergency Room to the Intensive Care Ward and on Thursday, after some searching, I finally found the child up in Ward 3. His grandmother was looking after him the whole time.

Finally, 8 days after I saw him initially, he was discharged. His condition was stable and he was looking much better. His grandmother was very happy to be able to take him home and I am hoping for ongoing recovery for him.

So, in conclusion, intraosseous access did save this child’s life and I think it is a procedure that should be done more often. It is actually not a difficult procedure to perform and as long as a sterile environment is created, the doctor is fairly confident and a large bore needle is available, it can be done within a few minutes. The chance of complications is very small if a proper (sterile) technique is used and as long as the needle is removed after a few hours. The benefits far outweigh the risks and in an emergency setting it is an ideal way of ensuring a quick delivery of fluids, blood and medication. I am definitely in favor of intraosseous access. INTRAOSSEOUS ACCESS SAVES LIVES.

Nurses' Workshop...

The Welbodi Partnership is privileged to have a pediatric nurse from the United Kingdom volunteering with Welbodi at the Children’s Hospital for two months. The first month was spent assessing the nurses on the wards and working alongside them in a mentorship capacity. This provided an opportunity to work with the Sierra Leonean nurses one-on-one and transfer knowledge and skills to them individually. As the days went by it was clear that a number of key areas of nursing needed to be addressed in a collective manner.

A four-day workshop was organized by the pediatric nurse trainer for all of the nurses at the Children’s Hospital to attend. The nurses were split into four groups and each group attended a full day of the workshop. The nurse trainer, a professor in pediatrics and trainers from the School of Nursing taught on various topics including professionalism and responsibilities of a nurse, monitoring vital signs, oxygen therapy, medication safety, fluid balance and documentation. Teaching varied from lectures, interactive group sessions, live demonstrations and case scenarios. The workshop also included a lovely lunch prepared by the hospital kitchen and soft drinks; both are definite musts for a successful Sierra Leonean workshop. Certificates of participation also play an important part in Sierra Leonean nurses and so each nurse will accept a certificate with pride.

In total, 81 nurses were present at the workshop and found it to be very educational. They were eager to learn and requested for more workshops in the future. They were given the opportunity to make known what barriers they felt were keeping them from being able to perform optimally. They gave many suggestions and ideas as to how the hospital could help their performance as well as ideas on what they themselves can do to function better. The Welbodi Partnership will do its best to accommodate some of their suggestions in order to improve the quality of pediatric care at Ola During Children’s Hospital. Some examples are the provision of basic equipment such as thermometers and glucometer strips, provision of consumables such as soap and gloves, improving nurse attendance on the wards and more in-service training.

Welbodi’s next step is to measure the impact of the workshop and follow-up on the implementation of what was taught. The nurse trainer will spend time on each of the wards to ensure that the nurses are monitoring patients as discussed and documenting all of their actions. Welbodi will also adapt its existing ward bonus scheme to include checking up on the issues taught in the workshop. Welbodi Partnership hopes that the workshop has brought about a desire for change and that the nurses will work towards providing excellent care for their patients.

Birthday wish...

For my birthday, I wish that Ola During Children's Hospital would have more oxygen concentrators in the Emergency Room and ICU, a well-functioning laboratory so that malaria, anemia and hypoglycemia can be diagnosed properly, more thermometers and pulse oximeters so that the nurses could do the observations 4-hourly, and the list goes on.

This year I am hoping to collect monetary gifts through Just Giving to raise money so that Welbodi can purchase some of the equipment mentioned above. I thought it would be great to start this since it's my birthday tomorrow, but hopefully as the year goes on, and people read about the needs at the Children's Hospital, more money will come in. Your money can make a difference to the Children in Sierra Leone.

To donate money, go to: http://www.justgiving.com/sandralako

THANK YOU!

Too late...

A little girl was born at 3:20 pm in a community clinic in Freetown.
The mother was doing okay but the child was not.
The little baby was not crying.
She was not moving.
As seconds passed by, the child was turning blue.

Meanwhile, at the Children’s Hospital, doctors and nurses were attending to patients in the Emergency Room.
Ready for patients to come in for stabilization and treatment.
At this hospital, children come in from all over Freetown as well as from up-country.
Some arrive to the hospital on time but others come in too late.
Too late for a good outcome.

Unfortunately for this little girl, she had been referred to the hospital for neonatal resuscitation.
Resuscitation that should have taken place immediately after she was born.
It didn’t however, and it took the family an hour and a half to get to the hospital.
By the time they arrived, it was too late.
The doctor in the Emergency Room had to pronounce the child dead on arrival.

So now, a new mother is grieving the loss of her child.
And a child has become another statistic.
The stark reality of infant mortality has shown its face once again.
Sierra Leone, a country where 123 out of 1000 infants do not reach the age of 1.
A country with a desperate need for improved health care.

For the mothers and fathers who have had to bury their newborn babies.
And for the children who are yet to enter this world.
Let there be change.
Training of healthcare staff in neonatal resuscitation should become a priority.
And resuscitation should be able to be carried out in all health facilities in Sierra Leone.

A case of Tuberculosis...

On Tuesday I passed through Emergency and saw a very sick boy sitting on the exam table.
He was extremely short of breath and very wasted.
I later found out he is 12 years old and suffering from Tuberculosis.
In this post I will call him Abubakar.

On Wednesday afternoon just as we were leaving the hospital a father asked me a question.
“My child is very sick, can you please help?”
Since I was on my way out and not in a clinical role at the hospital I suggested he find the ward nurse.
“Go tell the nurse, and if your child is worse, ask her to call the doctor.”

At that same time I decided to show my colleague the isolation room I had ‘discovered’ just next to our office a few days earlier.
Little did I know that that was where the man’s son was admitted.
As I peeked around the corner I saw Abubakar sitting upright, struggling to breathe.
I couldn’t leave now.

I quickly found the doctor who had treated Abubakar earlier and discussed with her.
The priority in this case was Oxygen; an available but limited resource in our hospital.
The fact that Abubakar could infect other patients with TB was a concern.
Should he be brought down to the emergency room and risk infecting the other patients?

I remembered seeing an oxygen concentrator in the Measles ward and knew the machine was not used often.
So, after obtaining permission from the specialist-in-charge I hurried up to the Measles ward in the next building.
Within minutes I was rolling the concentrator down the ramp to the other building and up to ward 3.
Unfortunately at that same time, national power cut out and the concentrator could not be switched on.

With an oxygen saturation of 81% it was clear that Abubakar could not be left without oxygen.
So, the decision was made to transfer him to the E.R. where oxygen is continuously available thanks to a back-up generator.
Poor Abubakar had not slept in 3 days and was literally fighting to stay alive.
We knew he was afraid because the only thing he managed to say to us was: “Please do not go, stay with me.”

Our hearts were moved and it was difficult to leave his side.
He was obviously very sick with severe tuberculosis and signs of heart failure.
Only time would tell the outcome.
Having put him on oxygen and handing the case over to the doctor-on-call we decided to go.

We learned that evening that Abubakar had been seen at another hospital a month earlier.
Not running a TB program, they referred him to the Children’s Hospital for Tuberculosis treatment.
Unfortunately, Abubakar’s mother took him upcountry to a good hospital, but one that was also not running a TB program.
So, in the end there was a month’s delay before reaching the Children’s hospital and Abubakar was now in a very late stage of disease.

When we entered the Emergency Room the following morning, we saw a wrapped up body on the cot next to the door.
The size of the corpse looked like that of a 12-year -old boy.
In our hearts we already knew what had happened to Abubakar.
This was confirmed when we sat down and talked with the doctor who was on call.

Abubakar died at 6am that morning in the presence of his father.
He died due to tuberculosis and heart failure.
Had he come to the hospital a month earlier, he likely would have gotten better.
The hardest thing for me was that Abubakar had been so afraid the previous evening.
He must have known the end was near.

Tuberculosis is one of the world’s deadliest diseases.
One third of the world’s population is infected with TB.
Each year, over 9 million people become sick with TB.
And each year, there are almost 2 million TB-related deaths worldwide.
Let’s continue to work on early diagnosis and proper treatment of this terrible disease.

Ola During: Then & Now...

During my time in Sierra Leone from 2005-2009 I often visited the Children’s Hospital in Freetown. At the time I was working in a pediatric outpatient clinic and frequently saw patients who needed to be referred for in-patient care. I had two options at the time: Emergency Surgical Centre and Ola During Children’s Hospital.

To be honest, I opted for the first choice when possible. The main reasons were because treatment was free, resources were available, staff was dedicated and it was only thirty minutes away. It was an NGO run hospital. At Ola During Children’s Hospital the user fees were high, there were few medications and consumables available, staff was not being paid and therefore either not showing up for work or showing up but not carrying out their duties and it could take up to ninety minutes to reach the hospital due to traffic. As you can imagine, the wards at Ola During were quite empty and the mortality rate was around 15%.

The situation was dire. It all seemed so wrong yet I could not point a finger. The doctors needed to collect user fees to subsidize their meager salaries, the blood bank simply did not have blood bags available to give them away and the nurses needed to make some extra money due to poor salaries and so they would sell medications to the patients on the wards at a higher price to make some profit. These people all had families to feed and they could not do that with their low salaries.

There were of course times when the pediatric ward at the Emergency Surgical Centre was full and I would have to refer patients to the Children’s Hospital. This always concerned me. I was never sure if the patients could afford treatment and if the medication needed would be available. Also there was no oxygen. Patients needing urgent blood transfusions were stressful because it was often hard to get relatives to donate blood and the families often did not have money for blood bags, giving sets, etc. I helped where I could but it was always a dilemma to figure out which patients needed assistance and how much money they would actually need.

Fortunately, on my return to Sierra Leone, and more specifically since I am now based at the Children’s Hospital, I can say that Ola During Children’s Hospital has improved significantly. Yes, there is still a long way to go and many improvements can still be made, but I can assure you that significant changes have taken place in the Children’s Hospital.

First of all, during my last year in Freetown, the hospital had oxygen.

Secondly, the Welbodi Partnership introduced a triage system and opened an Emergency Room in November of 2009. This project has proved to be a great success and although the E.R. may seem basic when compared to a Western Emergency Room, it has definitely increased the standard of care. An emergency case arriving at Ola During is now sent directly to the Emergency Room, staffed by a doctor and a team of nurses twenty-four hours a day and supplied with emergency drugs, consumables and equipment. The equipment, consisting of digital thermometers, a pulse oximeter and two oxygen concentrators is basic and limited but a huge step forward in delivering quality care. There are also two oxygen concentrators in the Intensive Care Unit. The ICU at Children’s is not a unit with a lot of equipment, monitors and alarms but more like a ward with the sickest patients and a slightly higher nurse-to-patient ratio.

Thirdly, on April 27, 2010, the Free Health Care Initiative was launched by the President of Sierra Leone, meaning that all children under five years old, pregnant women and lactating mothers are to receive free health care. As you can imagine, there are many challenges in the implementation of such a large-scale project but it is a big step forward. Currently children under five (which makes up >95% of the in-patient population) are receiving free health care, which includes free consultations, medication, consumables, laboratory tests, x-rays (at another facility) and blood transfusions. Outpatient consultations have doubled and in-patient admissions have increased by 25%. Needless to say, the staff has had to work very hard and it has been stressful for them. It does look like people realize Free Care is here to stay and numbers in outpatients have come down a bit. In short, free care is definitely a step in the right direction, but there are definitely challenges as well. The biggest challenge is probably the supply of medication and consumables.

Finally, prior to Free Health Care the healthcare workers went on strike, demanding a higher salary. I think doctors were being paid $100 a month and nurses $50 per month. They knew their work would become even more demanding and wanted to get paid for work done. The eleven-day strike was successful in the end for the healthcare staff and the government agreed to increase their salaries contributing to higher staff attendance and more dedication to work.

When I arrived in the beginning of June I have to say I was impressed to see the once empty wards now bustling with patients, the Emergency Room up and running, four oxygen concentrators providing children with oxygen, a neonatal unit full of neonates, doctors present at the hospital twenty-four hours a day and patients with proper charts. In my eyes, the situation has greatly improved since June 2009 but of course, we still have a long way to go.

Return to Freetown...

After being away from Sierra Leone for a year, it is good to be back.

Previously I spent four and a half years in Sierra Leone working for an NGO, running an outpatient pediatric clinic. Now, I am working in the government-run Children’s Hospital, volunteering as medical coordinator for a UK-based charity called the Welbodi Partnership. The contrast in jobs is great but I am excited about this new role.

I am keen on finding my way within the government system to contribute to bringing about positive change at the Children’s Hospital. I am looking forward to working alongside the national doctors to assist them where needed and to help bring them a step closer to their pediatric training through the Post-graduate Training program Welbodi has initiated. Part of this project will include the development of the x-ray department and laboratory in order to work towards accreditation of the hospital as a Teaching Hospital. Big tasks I know, but not impossible.

I am excited too about teaching the nurses and encourage them to carry out their nursing responsibilities well. I want the nursing staff to realize how important their jobs is and how we must all work together as a team in order to care for the patients well.

And of course, I hope to be able to help the children of Sierra Leone. I would love to be more involved clinically as time allows but of course, there are many other aspects of patient care that I can address/influence such as: the use of fluid balance charts, proper use of medication charts, providing the hospital with more oxygen concentrators, introducing protocols to ensure standardized management and good use of resources, etc.

The challenges will be great, but overcoming them will be even greater. Likely, I will make mistakes along the way, but as long as I learn from them it will be okay. I am here for a year (at least) and I hope that when I look back at my time here I can be pleased that Ola During Children’s Hospital has become a better place. Thankfully I am not on this journey alone and together with some key people in hospital management, the Welbodi team (on the ground and in the UK/USA), Professor Tamra, the medical officers, dedicated nursing staff and key people in the Ministry we can do this. We may take a few steps forward and then one step back, but we will continue to move forward. And one day, Ola During Children’s Hospital will be a center of excellence in pediatric care.