Discoveries...

I kind of surprise myself when I tell people I’ve been in Sierra Leone for 5 years. Has it really been that long? Yes, it has - I arrived almost 6 years ago and took an 11-month break. In many ways this feels like home, but in some ways it does not because no matter how long I am here, I am still a “white man” and don’t blend in with the crowd. People still ask for my number all the time, ask to be my friend, beg for money, etc. And sometimes I wish it would stop. Honestly, there have been expats here for years now, you think Sierra Leoneans would be used to it by now and not have to call out “white man” or “white women” or “hey you” or “baby” all the time. But they do. And I should just get used to it staying like that. (sigh)

So, although I’ve been here for a while, I still discover things all the time. Here are some of the most recent:

There’s a little shop at the petrol station just down the road, which I’ve gone to in the past to buy cornflakes or oats when I run out and can’t get to the supermarket. Just last week I discovered that they sell both fruit juices and chocolate bars. Yum. And the chocolate bars are cheaper than at the supermarkets. As you can imagine, my chocolate intake has increased over the past week and I love it.

I’ve also discovered the weirdness of cravings and about three new popcorn stands. Last week after work we drove past a popcorn stand on Fourah Bay road the smell of popcorn lingered and was amazing. All of a sudden I had an intense craving for popcorn but we had already driven too far. Then we hit traffic. My craving got worse and we weren’t moving. I actually rarely crave foods, so this was quite bizarre but I really felt like I had to have popcorn then and there. It wasn’t going to happen. Finally we were moving again and passed another stand. Seeing as we were finally moving along, I didn’t want to stop traffic and we carried on. My craving got worse. Then a little while later we spotted another stand and pulled over and my driver hopped out and bought two bags of popcorn for Le 1,000 (25 cents). O happy day. It must have been the salt I was craving on a hot and sweaty day. I bought popcorn three days in a row.

Something else I found out is that my last name is also a Sierra Leonean name, found mainly in the Magburaka area. Go figure. Funnily there’s even a doctor at the maternity hospital with the same last name. The Lako’s are from the Temne tribe, so I think I better start learning some Temne.

I also tried a new snack I had never seen before, a snack that looks like a bracelet but is eatable and made out of groundnut (peanuts) and spices. It is crunchy and has quite a taste. The lady in triage at the registration desk actually showed me this snack for the first time since it is her sister that sells them. It’s always nice to try a new snack.

I also discovered the awkwardness of sharing the front seat in a taxi. The taxis I take to Regent are often quite full. Regent is a little ways out and so the taxi drivers want to get the most out of the trip. Understandable. Up until recently I always ended up on the back seat with 3 or 4 other people. However, recently I have been stuck in the front seat with another passenger. It’s not bad at all if you’re on the car door side, but when stuck in the middle it is terrible. How awkward to be squashed up against someone on your right and to be right up against the gears, with the driver resting his arm on your leg as he shifts gear. Not so pleasant. I guess this was a discovery that taught me to sit in the back seat to Regent from now on.

That’s it for now. I’ll be on the lookout for more new and exciting things in Salone.

The world I live in...

Oh no. It’s been an entire month since I’ve blogged, shame on me. I think this has probably been my busiest month ever, both at work and socially. That and still not having an Internet connection at home make blogging a bit more of an effort. So, to those of you who check this page regularly, sorry for my lack of blog posts, as they would say in Krio – “Oshya”. I will do my best to get into the habit again. Seriously, I love blogging and find it’s a good way to ‘escape’ the craziness of my world here.

So, what’s happening in my world?

Work has been really busy with a pre-accreditation that took place earlier this week, meeting with people at the Ministry of Health, checking out support services at Connaught (the main government hospital), helping organize some of the postgraduate training sessions with the residents on Tuesday and Thursday afternoons, signing contracts with national staff, trying to get the x-ray unit up and running, renewing my registration with the Sierra Leone Medical Council, attempting unsuccessfully to get someone’s container released containing items for the hospital lab, working on getting duty free concession for the oxygen concentrators, preparing for the Welbodi Directors’ meeting next weekend, compiling statistics, facilitating a Mercy Ships/Children’s Hospital partnership, and last but certainly not least (although it’s what I’ve unfortunately spent the least time on) sneaking on to the wards now and then to see patients.

There you have it, my work in a nutshell. Well, all of the above plus attempting to solve any immediate problems or small crisis that come my way. They are probably as diverse as the above. Some examples are: nurses coming to the office for connecting pieces for oxygen concentrators or batteries for pulse oximeters, trying to track down one of the doctors when rounds aren’t underway by 9, going into locked consultation rooms in the evenings looking for blank patient charts and prescription pads to put in the ER for the new admissions when ER runs out, running to the blood bank to get blood for a critically ill child, searching for the generator man when we have a power cut so that the babies in Special Care continue receiving oxygen and the list goes on. Honestly, there is never a dull moment.

So, besides work I have been about as busy in the evenings and weekends. I tend to get home at 6, 630 or 7 depending on when I get out of the hospital and what traffic is like and then sometimes have a 10 minute turnaround at home before heading out again. Someone said recently that they get quite bored here. What? Really? Not a chance. I feel like I’m hardly home. I am not even quite sure what I do every evening but I suppose there are various friends I visit, I’m often at the Aberdeen Women’s Centre (formerly Mercy Ships in Aberdeen), Tuesday evening women’s group, Wednesday evening house group, often out for dinner on a Saturday evening, catching up with Sierra Leonean colleagues, birthday dinners, goodbye dinners, beach trips, church, international service and the list goes on. The social life gives me a boost of energy although I have to say that as of late I have been quite tired as well. I suppose everything has piled up a bit and I’ve reached my limit. That might explain my need to buy a small Cadbury chocolate bar after work everyday last week. Desperate measures. Honestly, the last few weeks have been both very difficult and very good. An odd statement, I know, but that’s what life is like here. It’s an interesting world.

Happy New Year...

Best wishes for 2011.

I hope that I will be able to keep up with blogging a bit better in 2011. I realize I have not been posting very much. Not having internet at the house plus the busyness at work has made it difficult to post regularly. But, a go try!

Life is good. I had a wonderful holiday time, although I did work Christmas Eve, Boxing Day and New Year's Eve but hey, a hospital never shuts down right. Many of my national colleagues had to work, and since I had plenty to do, I figured I would carry on as well.

I did take three days off to go to Banana island which was fantastic. I also took Monday January 3rd off which was a public holiday and enjoyed a day at Lakka Beach with my expat colleagues. Around Christmas time there was a flurry of activities and I spent time celebrating with friends. New Year's was also spent with friends in Aberdeen and a countdown to midnight at Alex's restaurant. Good fun! I then went to the Ma Dengh beach festival on the evening of the 1st with my colleague Emily (visiting from UK for 10 days) and watched Emerson perform live! Very entertaining.

It's been a good start to 2011 and I look forward to a great year with lots of excitement. I'll still report back on 2010 since I have yet to write about my blood giving experience, the cleaner's strike, our adventure up the wrong mountain and my success in tracking monkeys. More soon.

Merry Christmas...

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

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

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

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

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

Sweet!

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

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

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

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

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

Not sure what tomorrow will bring.

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

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

Merry Christmas to all!

A unique Christmas gift...

Do you want to give something unique this Christmas?

How about giving Oxygen?

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

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

MERRY CHRISTMAS.

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

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

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

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

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

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

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

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

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

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

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

Christmas don com...

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

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

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

Unanswered question...

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

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

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

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

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

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

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