Tuesday, November 23, 2010

we've come a long, long way together!

It’s amazing to be back.

Things have changed so much that it’s hard to even know where to begin. The last time I walked through Ola During Children’s Hospital, a year and a half ago, all I could see were broken systems, missing equipment, disenfranchised healthcare workers, and dying children. I left Sierra Leone feeling frustrated and somewhat defeated after a year of battling what felt like insurmountable challenges.

Now, the seeds we planted have finally taken root, sprouted, and begun to blossom. All of the pieces are coming together. Government, donors, hospital staff, other NGOs – everyone seems to be working with a level of energy that I’ve never seen before. It’s truly breathtaking.

You enter the newly paved hospital compound, and first are struck by the construction activity which surrounds the entire campus. The feeding center for severely malnourished children has been de-roofed and will soon acquire a second story. VIP latrines are being built around the back of the hospital. Bricks are being laid for the new staff canteen. The main hospital facade gleams with a fresh coat of white paint.

Inside, the changes are even more dramatic. Women and children fill the benches in the registration and triage area. Gone are the days when mothers carrying sick babies would enter a deserted hospital, desperately find their way up to the wards and be forced to beg and bribe for medical attention. Back then, untold numbers of children died without being seen by a doctor, without so much as an IV in place. No record existed of them ever having entered the hospital, having suffered, died. Today, every single child who enters the hospital is registered with a unique patient number, is measured, weighed and has vital signs taken by specially-trained nursing staff.


The sickest kids go directly to the emergency room, where children lie two to a bed receiving timely care of a quality that is rarely found elsewhere in Sierra Leone. We now have oxygen concentrators, enough for many (although by no means all) who require it; a back-up generator so that power outages don’t cost lives; doctors on call in the hospital 24-7 (with comfortable sleeping quarters and recent government salary increases that allow them to devote their time to government service); a free supply of most essential drugs (for which we have the Ministry of Health and the German Emergency NGO, Cap Anamur, to thank); and a more motivated staff to provide much-needed care. Since the removal of user fees for children under the age of 5 in April, hospital numbers have skyrocketed. The place hums with the energy that is being devoted to the business of saving lives.

The Emergency Room in Action

And we do, indeed, save lives.

I remember the days when the hospital mortality rate was upwards of 20%. We will soon publish data which shows that mortality has almost halved, which represents hundreds of lives saved over the past year alone. It’s a compelling argument in favour of free healthcare, targeted interventions to improve the quality of clinical care, collaboration between government and NGOs, and, crucially, the slowly-slowly locally owned approach that we have tried to demonstrate.

Much to celebrate! And, as always, lots more to be done.

Dr. Toyin Ajayi is a Director of the Welbodi Partnership and spent a year in 2008-2009 working as the Medical Coordinator in Freetown. She will spend the next few weeks at Ola During Children’s Hospital and in the surrounding communities, and will be blogging frequently about her experiences.

Friday, November 19, 2010

Prospects and Challenges of a new x ray unit...

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…

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.

First published on BMJ Group Blogs

Sunday, November 14, 2010

Night check at the Children's Hospital.

It’s 1:00 am. My colleague and I have 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 is due to various reasons, one of which is that for years salaries were low, and nurses were forced to work elsewhere, abandoning their posts at the Children’s Hospital. This caused a dramatic fall in nursing standards. Also, high medical 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.

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 made it difficult to stay motivated again.

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.

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, and if soap and water are available. We also check if all scheduled staff are present and in uniform, and if equipment is clean and well maintained. Sharps must be disposed of properly. We look to see if patient’s vital signs have been checked, if medication has been given accurately, if the handover book is filled out and the ward is clean and the nurses’ station 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. It 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 issue 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 Welbodi and the matron’s office to discuss issues 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 on the weekend or in the night. Sometimes I am a little nervous as I don’t know what I will come across. Fortunately tonight was okay. Some things were not so good and definitely need to be improved, 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 they do- helping the children in Sierra Leone.

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.

From: http://blogs.bmj.com/bmj/2010/10/08/sandra-lako-on-a-night-check-at-the-hospital/

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.

Posted by Sandra Lako, Welbodi Medical Coordinator in Sierra Leone

From: http://sandralako.blogspot.com/2010/09/death-of-child.html

Intraosseous access saves lives.

One afternoon I passed through the emergency room and noticed two doctors hovering over a patient attempting to get intravenous access. As in many of the emergency cases, the patient’s circulation was poor. While one doctor was attempting jugular access, I suggested inserting an intraosseous needle.

Having experience, albeit a year ago when I was last in Sierra Leone in the outpatient setting, I was handed a standard 19-gauge needle and attempted to get access into the tibia of the left leg. Using some force and a screwing motion I felt the needle push through the bone and within a minute or two the needle was in place. I quickly withdrew some bone marrow content, confirming the needle was in the cavity. I then flushed the needle with normal saline to reconfirm the position. Thankfully, a few seconds later the patient received dextrose and a normal saline bolus through the needle in the tibia. What a relief. Now, I could only hope that the insertion of the needle had saved this patient’s life. Since the condition on arrival was very poor, only time would tell what the outcome would be.

I checked up on the patient every day to assess the general condition and was glad to see a little bit of improvement each time I checked. The patient was soon transferred to a general ward and finally, after about a week, discharged home in good condition.

Fortunately intraosseous access did save this patient’s life. And although many people are not as familiar with this procedure, I would definitely advocate that it should be done more often. Contrary to what many people may think, it is actually not a difficult procedure to perform and as long as a sterile environment is created, the doctor is fairly confident and a large bore needle is available, it can be done successfully within a few minutes. The chance of complications is very small if a sterile technique is used and as long as the needle is removed after a few hours. In my opinion, the benefits of this procedure far outweigh the risks and in an emergency setting it is an ideal way of ensuring a quick delivery of fluids, blood, and medication. I am definitely in favor of intraosseous access.

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.