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.

Half Way!

Another few weeks have flown by and I have now passed my half way point in Sierra Leone, despite still feeling like I’ve only just got here!

There is a team of obstetricians and midwives from the UK out this week, delivering teaching and training to the staff at the hospital. Everyone seems to have enjoyed it but it has left the wards pretty devoid of staff, so it’s been a busy week on the wards for those of us trying to keep the wards running! It’s coincided with a busy week on paediatrics, so I’m looking forward to getting away to the beach this weekend!

Mt Bintunami and the Banana Islands

It feels like a long time since I updated my blog. As I get more involved with life here I have less time to sit and write about it! 

We have just had an amazing weeks holiday, we climbed to the highest point between Morocco and Cameroon, Mt Bintunami, in the Loma Mountains, and spent a few days relaxing on the Banana Islands.