Saturday, December 25, 2010
Posted by Sandra's Latest... at 9:51 PM
Thursday, December 16, 2010
Posted by Sandra's Latest... at 8:16 PM
Tuesday, December 14, 2010
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/
Posted by Sandra's Latest... at 8:16 AM
Thursday, December 09, 2010
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.
Posted by Sandra's Latest... at 6:43 AM
Wednesday, December 08, 2010
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…
Posted by Sandra's Latest... at 9:12 PM