Two vacancies with Welbodi...

The Welbodi Partnership is looking for people to join our team in Freetown to work at the Ola During Children's Hospital. We are advertising for two positions: a volunteer project coordinator and a project manager. If you are interested, please click on the links below for further details including the job description and application procedure. 

Vacancy: Volunteer Project Coordinator

Vacancy: Project Manager

Will you help us improve healthcare for the children in Sierra Leone?

If you know of someone else who might be interested, please forward this message to them.

Best wishes for 2013 on behalf of the Welbodi Partnership team.

Attitude change and sustainability...

This morning I had a brief conversation with my colleagues about bringing in a lab technician from outside of Sierra Leone to help develop the lab at the hospital. The first questions asked was: How can you make sure that all that person has accomplished is sustained once they leave again? Now that is the million dollar question. The simple answer is: I can't be sure.

I think that there are a number of factors contributing to the suboptimal lab services at our hospital. Think of training, availability of consumables, systems for writing/reporting/distributing results, motivation, equipment issues, etc. Personally, I think our lab has a lot of potential, even with its somewhat limited resources. I think that part of the problem is the lack of systems in place - for requisition of consumables, accountability of staff showing up to work, getting results back to the patients etc. Some of the systems really aren't in place, others are in place but ineffective and others are in place but people aren't motivate to use the proper channels. I actually think a lot of this comes down to staff attitude and motivation. I believe if you are motivated, you can get so much more done. If a system doesn't exist, you build it. If it doesn't function, you try to improve it. 

I think that we have reached the point that some long-term help would be beneficial but I agree we have to make sure this makes a big impact while that person is at the hospital which will continue once they've left. I would hope that this person could provide the hands on training needed not only to improve the efficiency and quality of the laboratory tests and put systems in place, but also to motivate people and get people excited about their job. To get technicians to realize that they are not just working with specimens, they are working with patients. Children who need a proper diagnosis in order to receive appropriate treatment. That's what we need to try to get across to them. And if we can get their minds thinking in that way, maybe sustaining good practice won't be so hard when outside help has come and gone. What do you think?

Back to work, the highs...

Can I just start by saying that despite the many challenges at the hospital, I love my job? Maybe it’s easy to say that since I just returned after being away for 6 weeks! I was basically in the office the entire day but it was good. Even with the very slow Internet I still managed to get a lot done. What I liked most about today is realizing again how diverse my work is and knowing/believing that between now and 6 months we will see a lot of positive change at the hospital. I’m convinced of that! Just to give you a glimpse of my job as it stands now, I’ll throw out some of the activities that I’m involved with. Bear in mind that some of this is leading up to activities that will take place early 2013.

Delivering Emergency Training to nurses

Co-organizing our first Paediatric Symposium

Improving laboratory systems and practice

Setting up a new x-ray department

Chasing auditors for the completion of an audit

Arranging a trip to Guinea with patients

Communicating with our residents in the sub-region

Database queries and hospital data compilation

Representing Welbodi at a conference in Accra

Immigration and medical registration logistics for colleagues

Planning the official hospital accreditation visit

Paying bills for the Welbodi flats

In summary, there is a lot to be excited about. This hospital has a lot of potential and I am determined to help bring some positive changes over the next 6 months. Yes, I know, I am back on the Salone roller coaster and the lows are inevitable but when those lows come I hope to remember that there are many highs as well. I am convinced that we will move things forward. Watch this space!

Clinical work...

Monday marked my first full day of clinical work at the Ola During Children’s Hospital. I spent the day in the outpatient department talking to parents, examining children, making an initial diagnosis, and starting treatments. It was a delight to be able to care for children again.

It has been difficult to combine my management/coordinating role with a clinical one. I love my job and definitely see the importance of what I am doing and the need to make sure that hospital systems/infrastructure/equipment are in place, but I often miss actually treating patients. Occasionally there are days during which I can spend a few hours doing clinical work, but it’s more of an exception than a rule.

A few months ago I was able to spend part of a week in our intensive care unit, which was difficult and intriguing. The patients were quite ill or had conditions that we could not diagnose and/or treat effectively due to limited resources, which was a challenge. At times we did not have enough oxygen to provide children with breathing difficulties with the oxygen support they needed. As you can imagine, this was a source of frustration however, it also reminded me of why Welbodi’s supportive role is so important. My experience in our “intensive care” unit was good, but I realized it is unfair to combine ICU work with non-clinical work. Those patients really need a doctor in there all the time. My plan was to see if the outpatient department was a better fit. It took me a while to get there, but after spending Monday there, I can say it is a much better fit.

I saw children with hydrocephalus, diarrheal disease with dehydration, severe anemia, pneumonia, malnutrition, probably tuberculosis, malaria, and cleft lip and palate. It was interesting to see such a variety of conditions, much like when I used to work in the Aberdeen clinic. I have to say though, compared to my previous job, the children at the Children’s Hospital are sicker with a high percentage needing admission. Admissions is something I missed in Aberdeen—it was tough at times having to refer the really sick children and losing sight of them once they were sent off. Now, I can admit them directly to the wards and even visit them at the end of clinic. This is definitely a bonus. It means I can chase up results, optimise their treatment plan, and arrange for ultrasounds. Of course some of this “chasing” can take time seeing as we have some glitches in our systems. Speaking of time, admissions are also more time consuming and so I end up seeing fewer patients a day compared to in Aberdeen. I didn’t realise it takes a fair amount of time to fill out the paperwork for admissions: history, examination, impression, treatment plan, treatment sheet, lab forms, prescription form, etc. However, it is worth it because I do like being able to admit patients.

Having spent some time away from clinical work it’s once again a bit of a learning process, but that’s okay, in the world of medicine we are continuously learning anyway. It’s a matter of reading up on specific diseases and treatment options as well as refining how to work as a doctor in a poor resource setting with limited diagnostic and treatment options. I have to continuously challenge myself to think outside the box a bit because it could be easy to give everyone a blanket treatment. You could potentially give every child an antimalarial and antibiotics and on average they would do fine. However, you would miss the more obscure illnesses and be over-treating a number of patients too. I want to stay sharp and give each of these children the best treatment possible with the resources available to me. I’m hoping to learn so much more in the near future and become better at something I am passionate about. For now, I’ll probably have to stick to one day a week in outpatients but it’s a start.

First posted @ http://blogs.bmj.com/bmj/2012/07/17/sandra-lako-clinical-work/

An X-ray Appeal...

As you may know from previous posts, the Ola During Children’s Hospital does not have an x-ray department. Patients in need of x-rays have to travel across town, a journey of up to one hour, which leads to a delay in the diagnostic process. Seriously ill patients cannot make this journey and miss out on these crucial tests and therefore, optimal treatment. The total cost of installing a digital x-ray machine and training local staff to use it is £120,000.

It excites me to let you know that we have already secured half the funds for the project from a charitable foundation. However, to access these funds we have to match these contributions by raising another £60,000 (USD 95,000) in the next two months.

This is a unique opportunity for you to double your money. If you would like to donate, please go to: http://www.justgiving.com/xrayappeal Any money donated through this page will go directly to this appeal.

Thank you for your support!

Second blood donation...

After a four-month wait, I was finally allowed to donate blood again at the Children's Hospital. I still think it's crazy that women have to wait 4 months, while men can donate after 3 months but rules are rules. Anyway, after lunch on Good Friday (great day to donate and reflect on the blood Jesus shed for us!), Shona and I headed to the blood bank to donate. Last time we enjoyed Christmas music, this time we enjoyed an Independence song serenade by yours truly: Omar.

I have to say, the whole process is quite amusing every time we donate. My Hb was 12.3 g/dl this time I believe, which is not bad considering I hardly eat meat these days. And I lost 3 kilograms since the last time I donated. I won’t complain about that either. So, Hemoglobin fine, weight fine, ready to donate. And that’s when my least favorite part comes in- the big big needle needs to be inserted into my arm. Ouch. And unfortunately this time, shortly after the needle was in place, the blood stopped flowing. After some slightly painful maneuvering, the blood still didn’t want to come out and so we decided to give it another go. This meant a second needle stick. Fortunately this time, the blood flowed quickly into the collection bag. And there was a fresh bag of blood, waiting to help one or more women or children.

I love the thought of helping others in such a tangible way. And what does it cost me? A little time and a little blood. Oh, and two needle sticks this time. I would again encourage everyone in Freetown to come and donate blood at the Children’s Hospital; every 3-4 months please. And really, if you come, I’ll buy you a coke!

World Malaria Day 2011...

Today is World Malaria Day and unfortunately, although a preventable disease, malaria still kills many people in the developing world. At the children's hospital I work at, we see malaria cases everyday. Some cases are very severe; the children are literally on death's doorstep and other cases are mild and improve with oral medication. As you can imagine, the disease has a major impact on child health in Sierra Leone.

In November of last year, we had 999 inpatients in the hospital and in that month (as often is the case) malaria was the most common reason for admission, followed by chest infections, diarrheal disease and anemia (unrelated to malaria). Sadly, children die at the hospital on a daily basis. In November, 54% of the hospital deaths were attributed to malaria. In November 67 children died at the Children’s Hospital as a result of complicated malaria. We obviously have our work cut out for us. Having said that, I do believe that the staff at Ola During is working hard to do their part in combating malaria. The staff, management and partners of ODCH and the Ministry of Health and Sanitation must be commended for their ongoing efforts to improve healthcare. The laboratory has definitely improved and more blood smears are being examined for malaria. Thanks to one of the partners in the hospital, malaria treatment is readily available. Improvements in the triage and emergency system mean that children receive their treatment more promptly. There is still a lot to be done, but progress is being made.

The theme for the fourth World Malaria Day is Achieving Progress and Impact. The theme recognizes the international community's renewed efforts to make progress towards near zero malaria deaths by 2015. We’re not there yet, but I like to believe that things are improving. Hopefully the country of Sierra Leone can tackle issues like: distribution and use of insecticide treated nets, prompt diagnosis, appropriate treatment, etc. Various barriers play a role, such as: cultural/traditional ideas impacting use of nets and quick presentation of child to a health facility, lack of experienced laboratory technicians, lack of rapid diagnostic tests, inconsistent supply of ACT medication or quinine, etc.

Hopefully, health education in the communities, training in health facilities (lab and medical staff), and improved supply chain will decrease the number of deaths related to malaria in Sierra Leone. The day that there are near-zero malaria deaths in the country will be a day to celebrate for sure. Count me in…

(see: http://www.worldmalariaday.org)

Do you know...

Do you know a doctor, nurse or healthcare manager who would like to join our team at the Ola During Children's Hospital in Freetown? Can you help us spread the word about this opportunity?

We have extended the deadline for our year long volunteer positions. We are looking for healthcare professionals (nurses or medical doctors) and individuals with management experience, particularly hospital management or in another healthcare setting.

Help us kick-start a new nurse training program, support postgraduate training for doctors, and improve the quality of hospital and ward management, among other exciting new and ongoing initiatives. This promises to be an exciting year for the Welbodi Partnership and for the Ola During Children's Hospital, and you can be a part of that work!

For details, please see our blog postings here http://welbodipartnership.blogspot.com/2011/01/volunteers-wanted-healthcare-managers.html and here http://welbodipartnership.blogspot.com/2011/01/volunteers-wanted-healthcare.html , or contact Emily Spry at emily@welbodipartnership.org. Interested candidates should send a cover letter plus resume or CV to Emily at the same address. We will be considering applications on a rolling basis, so please apply ASAP for consideration and circulate widely to friends and colleagues.

Thank you,
The Welbodi Partnership

Hello Sierra Leone...

In less than 12 hours I will be airborne (again) and on my way to Freetown, Sierra Leone via Malaga, Spain. And I can't wait. Well, I am not too excited about the actual trip, but I'll be glad to be back in Salone. Back in my own place and ready to get back to work. I'm going to count on one of my two trusted drivers to be able to pick me up and drive me home, that is, once I take the water taxi from Lungi to the other side.

Have I really only been gone for 12 days? It seems like weeks have gone by. It's been good to get a bit of distance but I really am ready to be home again. I'm looking forward to seeing friends again, going to the hospital, being at the women's group, enjoying the sun (although I might change my mind when I'm all sweaty), etc. I'm not looking as forward to the dust - and the forever dirty feet and the lack of a washing machine and internet. But for the most part, I'll be happy.

I guess my only concern is that I already know I am going to hit the ground running. There are meetings that need to take place with the Ministry and UNFPA, more oxygen concentrators arriving, work to be done on the lab project, medical records/database issues to sort out, liaising with other NGOs in the hospital, preparing for the next SLICH (Sierra Leone Institute of Child Health) Board meeting, and the list goes on. I told you I was concerned. Besides this, there's a big white ship arriving next weekend and along with that comes a list of people coming to Sierra Leone to connect with the ship that I would like to see while they're visiting. My social life is going to be a bit busy. But fun. Anyway, work wise my plan is to continue making 'to do' lists but to prioritize them properly. And focus first on those things that need to be done urgently and basically make sure those get done. If I can at least get the top 4 things crossed off of my list everyday I think I'll be okay. Maybe my goal should be to make sure I have one day (Sat or Sun) that I do absolutely no work, at all. Yeah, we'll see.

Alright, I am going to get some sleep before the day really begins. And, I hope you've enjoyed the regular blogging- I'm not sure if I can keep it up when in Freetown, unless I get internet at home sorted! I'll do my best...

Arrival, Assembly, Testing and Distribution...

"Oxygen for Christmas" = a success...

The ferry ride...

"Oxygen for Christmas" = a success...

"Oxygen for Christmas" = a success...

Over the Christmas holiday $11,760 was raised for oxygen concentrators for the Children’s Hospital in Sierra Leone. This is enough for at least 8 new concentrators! I was amazed to raise $5,000 last year for charity: water, this year I’m blown away! Friends, family, churches and strangers have all given generously to this cause. THANK YOU!

With only 6 oxygen concentrators at the Children’s Hospital, children had very limited access to oxygen. Often one machine was shared between 4 children! (see above picture) Obviously this is not sufficient and I can guarantee you that lack of oxygen attributed to child mortality in some cases. With the money donated to the Welbodi Partnership, through my church, my justgiving campaign and other donations in the UK, we were able to buy 11 oxygen concentrators. Seven of them arrived at the hospital a week and a half ago, the other four are due to arrive in the next two weeks.

The concentrators were sent by DHL to the Lungi airport, which meant that after attempting to get duty free concession from the Ministry (but failing) I headed to the airport with one of the Ministry’s procurement officers. I left home at 6am to be at the hospital by 645am, ready to leave by 7 am to catch the 8 am ferry across. All went well and even the paperwork seemed to be moving along until I was told there was a small problem. Because the shipment had been sitting at the airport for more than a week (because we were waiting for the paperwork at the Ministry!) we were told we had to pay Le 9,000,000!!! That’s almost $2,000. There was no way I was going to pay that. After explaining that the concentrators were for the government-run Children’s Hospital, saying someone should have mentioned that there was a storage fee if a shipment was stored for more than a week, some pleading and a text message to some good friends to ask them to pray, we finally got an okay and the paperwork was (slowly) signed off and the concentrators were released. Time was ticking away and we literally pulled up to the 11 am ferry just before it was set to leave the terminal. It’s always an adventure. We made it back to the hospital around 1 pm and offloaded the concentrators. The next morning Fred (my colleague) and I assembled the concentrators, tested them, marked them and delivered them to the wards. It seriously felt like Christmas. I was so happy. And so was the staff. And before we knew it, the machines were switched on, blowing out oxygen and children were benefiting!

Thank you so much to all who donated. A special thanks to: Kristin Harvey, Rene and Marianne Lako, Verity & Rob Boord, Jennifer Vardy, Alyson Denson and family, Niroshan Nadarajah, Jonathan and Joanna Payne, Emily Spry, Alex Paul, Anne Nesbitt, Maggie Ruth and Baby Jo, Jacco and Marit Groot, Susan Wagler, John Dawson (&Lambton Centre summer camping congregation), Lisa Gibson, Morgen Wilbourne, Sjoerd & Carmen Smits, Middle/High School students at Heritage Baptist Church in Texarkana, Doug Hunter, Gemeente de Wijngaard in Middelburg.

Donations can still be made to my justgiving page and will go directly to Welbodi Partnership to be used in some way to continue improving paediatric care at the hospital in Freetown. (It will not go towards more concentrators, as we now have a sufficient amount!)

http://www.justgiving.com/sandralako

Join our team...

The Welbodi Partnership is currently looking for 2 people to join their team at the Ola During Children's Hospital in Freetown, Sierra Leone as early as July 2011. If you are a doctor, nurse or healthcare manager and interested in volunteering with Welbodi for a year to help improve paediatric care in Sierra Leone, please apply! Not only will you be able to experience healthcare in a developing world, you will also be amazed by the beauty of Sierra Leone - both its people and its beaches are amazing.

Come for a year and make a difference at the Children's Hospital.

For more information go to the following pages:

Information for Healthcare managers

Information for Healthcare professionals (doctors and nurses)

Life-saving blood...

While driving past an NGO hospital last week a friend read out a sign painted on the hospital wall stating that patients need to come with their own blood donors. He thought that was very odd but having been here for years it didn’t seem strange to me. I suppose in the developed world, one would not see such a sign.

Every day children come to the hospital with severe anemia, mostly due to malaria. So, not only do they need to receive anti-malarial medication, they often need blood transfusions as well. Unfortunately it can take up to hours if not days for some of the children to receive blood.
The reason for this is that the blood bank runs on a donor replacement system.

Basically, a family member needs to donate a unit of blood to the blood bank in exchange for a unit of screened blood that is stored in the fridge, which will go directly to the patient. Meanwhile the blood donated by the family member will be screened and if uninfected, it is stored in the fridge and used for a patient needing blood at a later time. It sounds simple but unfortunately in practice, the system does not always work. The main problem is that there is often no family member willing to donate; either no one but the mother is around or relatives do not want to donate. And for some reason the blood bank often refuses to take blood from the mothers.

I do not know why, but in general Sierra Leoneans do not like to donate blood. They either assume that by donating they will get infected with something, or are worried about the HIV screen or various other things. This is a problem because it means a child will not receive blood from the bank because the unit taken out is not going to be replaced. And, in all fairness to the blood bank, if this happens too often the blood bank will be depleted.

I have seen in the Emergency Room and ICU countless children in urgent need of blood. Children literally come in with a hemoglobin as low as 1 or 2 g/dL. Some of these children will die if they don’t receive blood within the first hour. It is for these cases that I will take the child’s blood sample and blood request form to the blood bank and ask for a unit from the screened stock, explaining how critically ill the child is. I do end up getting the blood but not without hesitation. And in all fairness, I totally understand the concern because the more we make exceptions, the more relatives will refrain from donating, assuming we will arrange for them to get blood without having to replace it. This is obviously not sustainable.

In December I was asking for blood so often that I decided it was time to replace some of the blood myself. It was time to donate. So, together with Shona (VSO doctor) we headed to the blood bank on a Friday afternoon after lunch thinking we would be in and out in no time. I should have known better. Although it took a while, I have to say we had an interesting experience.

We wanted the technician to go through the usual procedure to make sure we were fit to donate so he proceeded to check our hemoglobin with the Hemocue. Unfortunately it was not working. He pulled out a color card, which literally was a piece of paper with various shades of red painted on it. I questioned this method and suggested he use the centrifuge for a spun hematocrit. We were rather unfortunate once again as the blood spilled out of the capillary tubes while spinning in the centrifuge. What are the odds? Since I had recently had my blood checked at home, I knew my hemoglobin was okay and we decided to go ahead with the donation.

After the blood grouping, we reclined on the two makeshift beds and got as comfortable as we could knowing a large bore needle was about to be put into our veins. We were more at ease when the technician started playing Christmas tunes from his cell phone. He inserted the needle with ease and it was amazing to see my blood flowing into a blood bag, knowing that it could potentially save a child’s life. It felt incredible to be able to help in such a tangible way and be a part of a child’s healing process. It also made me feel good to know I was giving a unit to the blood bank rather than just taking.

I later learned that my blood had been given to two different children and although I don’t know who they are or what the outcomes were, I know that I helped those children. I will definitely donate as often as I can at Children’s and I definitely recommend that people come to the hospital to donate blood. It is a very worthy cause. Seriously, if you come and donate let me know and I’ll buy you a coke while you recover. And, if you’re not in Sierra Leone, donate at your local blood bank. A unit of blood can impact someone’s life. It can mean the difference between life and death.

First posted @ http://blogs.bmj.com/bmj/2011/02/11/sandra-lako-life-saving-blood/

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/

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

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.

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 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.