From A&E in Dr Gray's to GPST3 in Fort William

So it’s been a while since I posted on here. Since my last post in O&G in Dr Gray’s, I spent four months in A&E in Dr Gray’s and have moved down to Fort William for my GPST3 year.

A&E was a great job. It’s not a particularly big department, but sees it’s fair share of action and acute problems, as well as minor injuries. It’s smaller size also means less staff, so on those freakishly busy days and nights it could feel pretty crazy, I sometimes wondered where all the patients came from! But there were also quieter days too, with ice creams and the commonwealth games, and time to discuss cases with colleagues and seniors, and some impromptu teaching sessions in resus.

The department is run by two enthusiastic Consultants, Emergency Practitioners (who are GP’s with an interest in Acute Medicine) GP trainees, FY2’s and some great nurses. As a junior doctor there I felt a really valued member of the team, getting weekly teaching from the consultants, and lots of shop floor teaching from the EP’s and consultants. As a GP trainee it was particularly good working alongside GP’s and seeing their approach to patients and their follow up, getting used to managing patients, making decisions, dealing with acute problems like MI’s, asthma attacks and anaphylaxis, as well as minor injuries, pulled elbows, dislocated fingers, suturing, and general problem solving for mysterious presentations.

Having thoroughly enjoyed working in A&E I was a bit worried I would miss acute medicine, and the social side of working in a hospital, but I haven’t really. It’s such a relief not to be working antisocial shifts, nights, and having no routine. It’s amazing being able to plan out evenings and weekends away, without the stress of having to rearrange shifts and work ridiculous hours to make the time back. And there have been plenty of interesting diagnoses in GP, and you get to follow them up.

My GP practice has a practice population of about 3000 patients, 3 GP partners, a salaried GP, myself, an FY2 and the reception team. It’s in a lovely new building, alongside two other GP practices, a dentist surgery, health visitors, physio, social work and community psych team (and prob a few more..) The Belford Hospital is only a few minutes drive away in the centre of Fort William.

The view from the practice this morning:

My week is made up of about 6-7 surgeries, an on-call session, a tutorial session, a self study session, and every month we have a day of GPST group work – this year we are joining with GP trainees in Oban – so we meet alternately in Fort William and Oban, for a group led morning, and a facilitator led afternoon. Last month we managed lunch at a seafood café on the pier in oban, some paddling and a trip to the chocolate shop in Oban in our lunch break...

I have enjoyed my first couple of months in GP land much more than I did in ST1 – despite the GP practices having a similar feel to them. I think the extra experience I have gained from ST2 and my OOPE, and having done 6 months GP before, has given me much more confidence in managing patients – I don’t have as many awkward moments hovering in the corridor to ask simple things like what to do with someone who has wax in their ears?!

So it’s been a good start to ST3 – I had better stop writing this and get on with some AKT revision…and then start thinking about the CSA… I was warned it was going to be an intense year, but so far it’s been really enjoyable. It’s great things coming together, and putting things into practice. Mastering the art of good consulting is going to be a challenge, but as my trainer says, it is the purpose of ST3… Hopefully the beautiful scenery will keep my sane.

Training in the highlands...some pictures

There are so many amazing places to explore from Inverness...including nearly 300 munros...here are a selection of photos of my facourite places within 1-2 hours drive from Inverness. 

Loch Morlich looking up to Cairngorms

Getting better at skiing... into Larig Ghru from Ben Macdui

Learning to ski at Cairngorm Mountain

Top of Cairngorm

Winter climbing in the Cairngorms

An Teallach

Liatach

Looking north from Liatach to the Fisherfield hills and An Teallach in distance

Looking over to Skye from Applecross - where Monty Hall went on his 'great escape' on BBC2

The view from Bealach na Ba looking over to Skye

Stac Pollaidh on a sunny day

Glen Coul bothy in the far North-West. There is an amazing network of bothies up here - check out the MBA website.

Moy rock, bolted conglomerate crag 20 mins from Inverness

Gairloch

Achmelvich Beach

And around Oban...

The view from our livingroom window in Oban - overlooking Kerrera and Mull

Erraid, Mull, just a couple of hours from Oban

Scoor beach, Isle of Mull

Ganavan beach, 5 mins from the Lorn and Isles Hospital, Oban

And Orkney...

Climbing with Orkney Climbing Club

The Old Man of Hoy, and lots of unexplored cliffs...

and puffins

'Work' weekend away on Hoy with Isla on the pipes

Obstetrics in Dr Gray's and in Kambia...

The last four months have flown by and I have now rotated to obs and gynae, and am now nearly half way through my placement...I'm really enjoying it so far, it’s a pleasant change to be working on a ward run, in my opinion, very efficiently by excellent midwives and obstetricians.

Just before I started on this rotation a friend sent me this link to a video about giving birth in Sierra Leone, with the warning ‘horrible but important’. It is quite shocking and distressing, but happening. The girls dressed in blue are volunteer nursing aides, untrained and unpaid.

Dying to give birth: One woman's tale of maternal mortality

http://content.time.com/time/video/player/0%2c32068%2c89844377001_1994479%2c00.html

Although I didn’t spend much time on the maternity ward in Kambia, I was aware of some of the struggles that were faced there; I heard stories of unconscious and fitting pregnant women; I would hear the singing when a mother died; I would see the babies that had suffered the consequences of a complicated labour or lack of antenatal care; and I would see the malnourished infants who didn’t get enough food after their mothers had died in childbirth.

The next few months will hopefully teach me how things can be done with more resources and more training.

Dr Gray’s is a small DGH. The maternity unit was developed around 15 years ago, after a campaign to improve local maternity services. The unit sees just over 1000 deliveries per year, and high risk deliveries are sent to Aberdeen for more specialist care. The service is run by midwives, supported by four consultant obstetricians, and four of us junior doctors. We cross-cover the paediatric ward after 5pm and overnight. This works well for me as I enjoy getting some paediatric experience, and my experience so far is that we are very well supported by the consultants. There is always a 2nd junior doctor on call if it gets really busy, or someone needs to go to theatre.

During the days we are either on call or covering theatre and clinics. On the wards we cannulate women (cannulas are free and in abundance!), see new admissions and any emergency gynae patients, and review (with the midwives) pregnant women who present to the obstetric ward during their pregnancy. In theatre we assist the consultants doing c-sections and gynae procedures – useful for brushing up anatomy skills and seeing what these operations involve. The staff are all extremely friendly and have a wealth of knowledge to share with us. There are extensive labour ward guidelines to follow, and a helpful consultant around or at the end of the phone if we're not sure what to do.

I had thought to compare a few aspects of care in Dr Gray’s and Kambia, but I’ve sat here for over an hour trying think how to do this and I’m struggling. It’s maybe not fair to compare two health systems at such different stages of development. I can say that I am in constant awe of the services provided free of charge by the NHS. It’s amazing. Yes we pay tax, but it’s worth it.

I will try to give a brief description of the maternity ward in Kambia District Hospital (KGH) and you can make your own comparisons. Kambia District has over 12,000 deliveries per year. I’m not sure how many of these happen in KGH, but at least as many as in Dr Gray’s. When I was in Kambia there were 2 midwives, a trained nurse and one doctor, covering the ward 24/7. They are supported by volunteer nurses, who have no training before starting on the ward. Electricity was provided by a generator between 7pm-11pm and for emergencies. There was one tap with running water. There was no ‘gas and air’ and no morphine. They would have to pay for a cannula, and often IV fluids and drugs, although these were sometimes available on the 'free health'. C-sections were free. I never saw a CTG being used, I think there was a machine but no paper and no power, pinna were used to assess fetal heartbeat. There was an ultrasound machine kept under lock and key, not usually available when needed. There was some blood stored in the lab, but often not enough and the wrong blood type; patient’s relatives were always required to donate blood, to replenish any blood used up. Blood tests were limited to Hb (using a colorimiter) and blood films for malaria, and rapid tests for HIV. There is no rescuscutaire and no incubators for neonates.

Kambia Appeal midwife Noemi teaching student nurses about partographs

It paints a very bleak picture and maybe doesn't covey some of the lifesaving treatment that is being provided by staff at KGH. But there is a long way to go. Many of the interventions needed to reduce maternal mortality and help these women further do not need fancy equipment and specialist skills. Much of what we were doing in Kambia was not rocket science but I think it was helping. Encouraging nurses to do a drug round and give a mother her IV antibiotics regularly so they have a chance to work. Teaching the VNAs to check vital signs, and to check the babys vital signs and then treat for infection before it’s too late. Finding a cannula for a woman so she can have her blood transfusion and receive IV antibiotics. Treating high blood pressure to prevent an eclamptic fit. Experiencing first hand the problems that are being faced and trying to find workable solutions. Being there. Supporting local staff. Teaching. Sharing knowledge and skills. Learning from each other. It can be hard but also hugely rewarding. I’m sure things are a lot better now than they were three years ago. Steps are being made to ensure free healthcare to these women. There were lots of government training and initiatives aimed at 'primary care' at peripheral health clinics, aiming to prevent adverse outcomes. Roads are being built. Things are moving forward.

 

Outside the maternity ward in a Kambia  Appeal ‘motorbike ambulance’. With a shortage of vehicles, poor roads and the high cost of fuel, these motorbike ambulances have been donated to rural communitieis in Kambia District to try and tackle the ‘second delay’ in receiving life saving interventions (delay in getting to hospital) and reduce maternal deaths.

Other exciting news is that Mary Keniger, a friend and colleage of mine out in Sierra Leone is leading the next short term teaching trip to Kambia in April, and I will be going out as part of the team. It will be a maternity teaching trip, so I’ll have the chance to consolidate skills learnt during this placement! I will post more about the trip as it progresses.

This video made by amnesty international in 2009 is worth watching:

No woman should die giving birth: Maternal Mortality in Sierra Leone

http://www.youtube.com/watch?v=oHjwc4a57Vo&feature=c4-overview-vl&list=PL8A9A633294FED554

Broken bones in Elgin...

Someone recently asked me ‘how was Sierra Leone’, to which I replied ‘better than Elgin!’ Maybe a reply influenced by a week of long days and not enough sleep!

One of the ‘downsides’ to taking a year out, which I was aware of while organising my OOPE, was losing previously allocated jobs I had in Inverness. Although disappointing, it didn’t put me off (obviously), especially since past experience of working in smaller peripheral hospitals (Oban and Orkney), which I may not have chosen over Inverness, have been so positive. Let’s hope Elgin will be as enjoyable…I start in orthopaedics, then move on to O&G and A&E.

It’s been quite a shock getting back into full time work in an orthopaedic department. I was staggered by the number of junior doctors at our induction/welcome on my first day (maybe around 30, not including doctors already working at the hospital, and not including consultants), compared to one in Kambia, which has a catchment population three times that of Dr Gray’s in Elgin. The systems’ are so incomparable though. In some ways work feels much busier here in Elgin; expectations and pressures are so much higher.

I am working as one of four ‘middle grades’ in orthopaedics, and we cross cover general surgery ‘out of hours’. There are 5 orthopaedic consultants, all of whom are very approachable, and put up with a lot of phone calls and questions whenever I am asked for an ‘orthopaedic opinion’, usually from someone far more senior than me! An advantage of working in smaller hospitals is working closely with consultants, a privilege I have become used to working in North Scotland. We are also needed to assist in theatre, so knowledge of the anatomy of the hip and knee is getting better, and seeing first hand the complications of joint replacement surgery...

Last week was a busy week, travelling down to Stirling on Wednesday for a Practice Based Small Group Learning (PBSGL) facilitator course (which I would definitely recommend, if only for the free food which included a 2 course hot lunch!), back to work in Elgin on Thursday, then over to Inverness for GPST2 induction on Friday. Despite being a lot of travelling, it was really refreshing to have time out of the hospital to see that there is life beyond orthopaedics, and to see how much support there is for trainees from the deanery, and to get an idea of the GP ‘community’ and opportunities for ongoing learning/development after finishing training.

It’s also nice to be ‘taught’ instead of ‘teaching’; although I miss having the time to prepare and plan teaching sessions, and also the time to work on quality improvement projects. Despite being so much more developed there are still so many improvements/interventions that could be made to improve quality of care here, it’s just a challenge to find the time to tackle such projects when you’re working full time. 

And life goes on in Kambia; Hannah and Noemi are continuing the teaching programme, and have recently been joined by a retired GP, and are awaiting the arrival of a paediatric nurse. The next teaching trip is in November, and is focussing on severe malnutrition, and I am trying to produce a ‘malnutrition manual’, to give to all the hospital staff and form the basis of the teaching week. It’s really nice to still feel a bit involved with work out in Sierra Leone.

It’s been a difficult transition moving from a Kambia, where you can really feel like you’re making a real difference, to becoming a small cog in a much bigger system of the NHS. But I’m getting there…and trying to get back into the dreaded e-portfolio…

Back to the UK...

It feels like I've been in another world for the last 6 months. As I walked through Gatwick airport on the escalator floors, caught a train into London (which left at 9.13 on the dot, as scheduled), travelled on the London Underground (trains travelling in tunnels under the city of London!), bought a brie, tomato and basil sandwich, and caught an air conditioned train up to North Wales, with a power socket next to my seat (!!); it really struck me how basic life has been in Sierra Leone.

Four Weeks Left!

This week myself and Kadie, the district nutritionist, ran two one-day training courses for all the paediatric ward staff on assessing and managing acute severe malnutrition. The Kambia Appeal kindly paid for refreshments (a spicy egg roll and tea for breakfast, and a cooked meal of ground nuts and meat the first day and plassas (spicy pounded cassava leaves, a local dish) and rice on the second day. Apparently training events without food will not be well attended! The food went down well and I think everyone enjoyed the training, the feedback was all very positive. It was so good doing the training with Kadie, who could teach in Krio, and also had a much better idea of local ideas and practices. 

The Rains Have Arrived!

The rains have arrived! Initially with some spectacular nighttime storms, but they have gradually extended into the days; it has rained on the past 3 days (not continuously but for quite long stretches). Apparently Sierra Leone is the wettest country in Africa… and since it’s hardly rained in the past 4 months so there must be a lot to come! It’s much cooler when it’s raining. It was pretty unbearable just before it rained, and even after the first few storms, very humid and muggy.