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?

Exam Day: The results...

Friends and family already know this of course, but for those of you following this blog and the excessive posts about the exam, I thought I should write something about the results. Unfortunately, after two weeks I found out that I did not pass the exam. I was disappointed of course, but not entirely surprised. It is a tough exam. There were about 280 candidates of which 85 passed. So, a 30% pass rate and I was not among the 30%. I am sure I simply didn't answer enough questions because the negative marking threw me off.

So, for the past 4 weeks I have not studied. I think I picked up my embryology book once, before the results were even out, just to do some reading. Now I have to decide whether or not I will re-sit in April. Part of me says I might as well. I've already studied a lot, gone through it once, so should give it one more go. The other part of me wonders why I want to put myself through all of this again and the many hurdles to come! The thought of failing again is not pleasant. However, I also don't to give up. So, very likely I will start studying again very soon and give it one more go. I'll keep you posted.

In the meantime it's work as usual. Well, kind of as usual. I am off to Ghana this week for a conference that the West African College of Physicians is putting on in partnership with the Royal College of Paediatrics and Child Health. The focus is on postgraduate training, which is one of Welbodi's main interests. I will be attending with two colleagues and am hoping for a fun week and lots of useful networking and a visit to Korle Bu hospital and two of our residents there!

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!

Exam Day: Has come and gone...

The exam is over. What a relief. The 24 hours prior to the exam were the hardest. I was just ready for it to be over. And now it is!

I stopped studying at 7:30 pm the night before the exam and tried to focus on other things. I was the first one at the exam center on Friday morning, with a 7:40 am arrival since my colleagues dropped me off on their way to the hospital. The first person to show up after me came at 8:15! The official start time was 8:00 am. At 8:30 we were allowed to enter the exam room but there was still one person missing – he was stuck in traffic. I think we should have just started – seeing as it was clearly mentioned that we need to be on time. The final hour of waiting was agonizing. At least the invigilators decided to start handing out the answer sheets and exam instructions, which was quite entertaining. You see, there was a suitcase on one of the tables which was opened somewhat dramatically. The invigilator made sure to show us the big sealed DHL style envelopes containing the exam papers per specialty. Then there was a moment of hesitation when one of the invigilators said that a photo should be taken to prove that all of the envelopes were sealed, however, it was quickly decided that this wasn’t necessary. Next there was some discussion around ‘the clock’. There was a clock in the room but it did not have any markings. Then, to my surprise, one of the invigilators pulled another clock (with markings) out of the suitcase! After switching batteries from one clock to another, the exam papers were handed out and at the same time the final candidate arrived.

At 9:00 am the exam started. The first 15 questions were easy. I was surprised. I recognized topics and could answer all of the sub-questions. Then it became more difficult, with questions concerning topics I hadn’t even read up on. Normally, I’d take an educated guess and answer every question, however, this exam has NEGATIVE marking and so guessing is not a smart move. Basically your score is the number right minus the number wrong. One needs to find a balance in answering the right number of questions to get a passing mark. To make a long story short, I am now more concerned that I might not have answered enough questions to get a high enough mark because I was being overly cautious. I guess I will know in a week! The unfair thing is that for pediatrics 1 point is subtracted for every wrong answer, whereas for the other specialties only 1/5th is subtracted.  At 10:00 am there was another moment of panic when one of the invigilators said that pediatrics only had another 30 minutes. I was only on question 40 out of 100 (with 5 sub questions each). We were quick to speak up and say that the exam paper clearly states that we have 2 1/2 hours! Phew. So, at 11:30 we handed in our exam papers and left the room. We had to wait in the waiting room for another 30 minutes while the other specialties (who had 3 hours) finished their exam.

It was tough, but it’s over. Pass or fail, it’s done and I have time to do what I want! At least for a little while.  Of course, I would love to have passed in one go – I’ve never failed a medical exam and would like not to have to do all this studying again. However, if I do need to re-sit, it’s not the end of the world. I’d have 6 months (till April) and know exactly what topics I need to focus on (I think). Plus, the hospital won’t be accredited till March 2013 (that’s our goal!) and so I can’t start residency until that time anyway. If I pass, I probably still won't start clinicals till 2013. Right now, there's an x-ray department to set up!

Exam Day: T-12 hours...

Wow. It's almost time. My bag is packed: HB pencils, eraser and exam number. 12 hours from now I will be at Connaught Hospital waiting for the final instructions before I write my exam. I have stopped studying for now. It is time to eat some dinner, take a break and get a good nights sleep. 

I have no idea how this will go. I feel well prepared, however, I also know they can test anything under the sun and there is the dreaded NEGATIVE marking and the odd ambiguous question here and there. This is one of those exams that I feel like I could study another 6 months for and probably would still not know nearly enough! Oh the world of medicine is so big. I keep having to remind myself that I am doing this with the hopes that it'll ultimately, eventually, in the long-run, improve paediatric health in Sierra Leone. 

This sure has been an interesting journey so far and it is only the beginning. I'm still not sure what I am getting myself into. I'll battle the first hurdle tomorrow and then take it from there. Thanks for prayers, encouragement and support! Fingers crossed.

Exam Day: T-3...

"There comes a time when for every addition of knowledge you forget something that you knew before. It is of the highest importance, therefore, not to have useless facts elbowing out the useful ones." - Sir Arthur Conan Doyle

Three days to go. Eat. Study. Relax. Study. Take a deep breath. Study. Eat. Study. Chocolate. Study. Sleep. And try not to dream about studying. I can do this. Almost there. I picked up my exam number today, so in theory, I am ready to sit the exam. Of course, I feel like I don't know nearly enough but I'll give it a go. I'm still trying to cram in facts that I think will highly likely appear on this exam (who knows really!) and wrap my head around a few difficult concepts that are sure to be tested. Better get back to studying.

Exam Day: T-7...

Seven days to go.
As much as I do like studying, I have to say I can't wait for this exam to be over. I have no idea how I'll do, the only thing I know is that I'll give it my best shot. Let's just be honest, there's a lot of information to know, the exam consists of a lot of questions in very little time and the negative marking may just be a killer. I always think of the many people I met during the course in Nigeria who are attempting the exam for the second or third time. Ugh. In a few weeks we'll know. If I pass, well, then I am definitely celebrating big time and if I don't then I'll celebrate the fact that the exam is over, take a few weeks off and then start studying again for April. Either way, I'm celebrating!

I'm heading back to Freetown today. I'll spend the weekend studying, using my handmade flash cards (see photo): memorizing and hopefully retaining the information. These flash cards have become somewhat of a treasure - they never leave my bag - I'll be using them in the plane today and I better not leave them in the pocket of the seat in front of me. That would be a disaster. On Monday I'll go to the hospital for work and meet with my colleagues to discuss various things and help with some planning. Tuesday hasn't been planned yet but I'll stay West-side on Wednesday and Thursday to cram and hopefully not freak out. Friday morning by this time I will have arrived at the conference hall at Connaught Hospital, ready to take the exam!By God's grace I will get through the next 7 days in one piece. 

Exam Day: T-20...

My sister asked me yesterday if I was starting to feel nervous about my exam. I said "no, not too nervous yet but I do want to get through all of my Nigeria material before leaving Holland if I can". I was on chapter 17 of 30. (I've been reading a lot of text books since Nigeria, but decided 6 days ago to start revising power points & notes as a final revision. Until yesterday, progress was good. I think I needed a bit of a study break, which I took in the afternoon.)

Today, I feel differently. Why? I decided to look through some past exam questions. Bad move. I thought I'd look through a couple of questions and encourage myself that I know a lot of the answers.

Well, the first question was about the composition of breast milk versus cow's milk. I thought I'd nail it because I know breast milk has: less protein but of better quality, slightly more fat (but more is unsaturated), lower osmolality, more carbohydrates (mainly lactose), less vitamin D (need to supplement), better iron availability and lots of other good stuff like immunoglobulins.

Unfortunately WACP thinks I should know this in more detail and expects me to answer true or false to whether or not breast milk contains 4.2 g/100 ml of fat, has an osmolality of 400, has 60.0 kcal of energy etc. Ugh. Of course, I can't remember the exact figures at that point and am unsure of whether things are true or false! A quick glance at my flash card reveals the answers true, false (300), false (66.6). Why can't they stick to testing whether or not I understand concepts. Why focus so much on numbers??? Surely that's not any more helpful in medical practice, besides you can look it up if you need to.

For now, I will ignore the exam questions and continue to revise my Nigeria notes. Once I'm done I'll tackle past questions again, and hopefully I'll see that not all of the questions are so bad and I can answer a good percentage of them correctly. Time will tell.

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/

2 years with Welbodi Partnership...

Two years ago I arrived in Freetown to start working for Welbodi Partnership at the Children's Hospital. It's hard to believe it's been 2 years. I remember arriving at the flat at night - I was the first Welbodi person to live in the flat - and it was pretty basic and bare. I was happy that it was in a neighborhood I knew a little, since I had spent 4 years living about a ten minute walk away. I remember waking up the first morning to a flood in the living room. It was the start of rainy season and at that time we had a leaking ceiling. I remember going to visit staff at the Aberdeen Centre the next day and being reunited with many friends. Sierra Leone soon felt like home again.

This evening my flat mate and I planned to go to a Bible study which was cancelled last minute. So instead we decided to head down to the beach for a walk and a quick dinner at one of the beach bars. A friend would pick us up later to drop us off at home. When I lived here with Mercy Ships before, I hardly ever ventured out with public transport. Now, it has become the norm. At the beach this evening I was reminded that this place is pretty amazing. Despite its challenges, it really is a great country with amazing places to visit and friendly people to meet.

The Children's hospital is, well, changing slowly. So often it's easier to focus on the hurdles and challenges and keep thinking about the many things that still need to be done. Sometimes we need to take a step back. To look. To observe. To reflect. To see what works and what has improved. I do believe that the children at the hospital are receiving better care now than they were two years ago. There's still a long way to go, but we're a few steps closer. I hope to continue to contribute to making the hospital a better place. I want to see this hospital change. I want it to be a house of hope. A place of peace. I want to see sorrow turned into joy and doubt transformed into confidence. I want to see dedicated staff. And I want to see more children walking out of the hospital with smiles on their faces. That's what I want to be a part of.

*Pikin means child in Krio

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!

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/