Man Cannot Live on Banana Alone

My staple food is banana sandwich, but now I'm getting more variety with feasting and funny conversations with a few of the students (Rebecca and Marian - picture):

• We exchanged holiday traditions.  I tried to explain what we do during Halloween, and I'm not sure if they really understood it.  I also said we had St. Patrick's day, and the student exclaimed, "Oh! We have St. Mary's day where we go to church and have festivities."  And I had to explain how on St. Patrick's day people just drink.  There were two interesting holidays she told me about: 

1. African Children's day: This is when all the kids go march out on the streets and have a festival.  Then they go to different "jobs" - some are lawyers, some are drivers, some are actors, and they get paid a small amount at the end of the day.
2. Bob Marley's day - celebrated on the day he died.  Apparently this is the day when they "drink and smoke marijuana."  

• I made an agreement with another student that I'd teach her how to make chinese/american food, and she'll teach me how to make Salone food.  The other day, we made eggplant and garlic! 
• I tried to explain the concept of chopsticks to her, but I don't think she really understands - I'll have to find two sticks and demonstrate.
• While we were waiting for the food, she wanted me to sing something, so I just sang Doe, a Deer - on hind sight, that wasn't the easily song to explain.
•  

Other random thoughts:  

• Language: There are two languages spoken here: Krio - pidgeon English, which I can understand bits and pieces; and Mende - a completely African language that I've only managed to master "Hello" and "I'm good."  All the students speak Krio and English, but most of the population only speak Mende.  While I usually have a student translate Mende for me, during a brief period, there was only one student who only spoke Krio, so she had to find a random girl outside who speaks Mende.  So I asked questions in English to the student, she said Krio to the random girl, and random girl said Mende to the patient.  It really pretty painful.
• Secret Society: The public health students were sent home because there are secret society events/inaugurations going on right now and it would be dangerous for them to go out to the villages if they don't belong to the society.  From my understanding, they could get killed. O_o

Frustrations

These are the things I found frustrating:

• Trying to get reflexes.  Nobody seems to understand what "relax" means.  I've tried shaking their leg, having many people standing there translating for me, hanging my stethescope and showing them I wanted their leg like that...I really can't seem to get people to relax their leg for a reflex.  The only time I got an accurate reflex was when the person's arm was paralyzed.  
• Trying to get basic things like a plate and a spoon.  I don't have a stove, so I've either had people cook for me, go cook with them, or buy off the street.  And today, the person who brought my food forgot to include a plate and spoon, and I was too lazy to go buy them in town so I ate off the lid with a knife.
• The useless library.  It's only open a few hours of the day, and the rest of the time, the class librarians are supposed to keep the key, but either the students don't know who's the librarian, the librarian's on vacation, or the librarian doesn't even know where the key is.  So when I ask nursing students to go look up something, most of the time, they really can't. :(
• Buying moldy bread: twice I've bought the bread, forgot to check it, and turns out it's kind of moldy.  Darn it!
• My leaky sink: Well, the faucet actually doesn't work, but the drain is leaky too and trickles on my feet, so instead of using the sink, I use another bucket and use that water for my toilet. I'm being eco-friendly!
• The mysterious megabyte drain: I'm pretty sure gchat itself only uses a few megabytes, but for some reason, sometimes many more megabytes would disappear and I have no idea what background programs are doing that. I want my megabytes back!!!
• People walking by me and saying "ching chung" or "he hong": I make it a point to ignore them.
• STUDENT NURSES!
• Don't give scheduled drugs because they forget or don't look at the progress notes or drugs are not in the patient's drug box.  But instead of telling the charge nurse, they just ignore it and sit in the middle table talking to each other. It's especially a problem when the dispensary is closed (after 2p and weekends), and they don't even try to get it from the emergency cupboard.  
• Forget about PRN drugs or don't put the time when it's given
• Leave without giving report to the next nurses
• When I say hourly vitals, they don't do it and just sleep.  Same with urine/stool output and po input recording - I ask for it to be done, I write it down to be done, I emphasize and say many times to have it done, and still no one does it.
• Don't give drugs for a whole day because the nurses forgot to give drugs from the ER box and it took forever to get the drugs from the dispensary.  The nurse who was supposed to get the drug from the dispensary was taking PICTURES of herself in her new uniform.  2.5 hrs later, still no drugs.
• They don't think or ask questions and are so used to just being told what to do or what to memorize.
• People don't care enough. :(
• When I say I need blood transfusion on a kid, they say they will do it tomorrow, but then come the next day, they say there's no money, and when they get money, they say there's no donor...there goes 2 days.
• There is so much chaos initially because nobody is assigned to any patient and they all try to work together on all the patients, so there's no sense of responsibility or patient ownership.  Everything is a little better now that a week has passed and I started to assign student nurses to patients.  
• The charge nurses are frustrating too - some complain of too much work and sometimes even stay at home or go off somewhere to buy fishballs and can't be found.  There are two who I really like though - Sister Francis and Mr. Niru - they are hard working and genuinely care about the kids instead of just exercising their power.
• For the longest time, I didn't even know who the maitron was (person who's head of the nurses/personnel of the hospital) because he's never there.
• There's a perfectly good ultrasound that can't be used because it's stored in a room that has no electricity and it's not allowed to be moved because it's said to be fragile.
• Holidays - there are too many holidays for no good reason and all it does is kill patients because outpatient, dispensary, and lab are all closed and not much can be done.
• Not being able to administer oxygen unless there's electricity - which is every other day from 7pm to 11pm - or OR is running (Tuesday and Thursday for a few hours).

Blessings and Random Connections

I've been very fortunate and blessed to have met some truly nice people.  Whether it was the story of how I ended up in Sierra Leone or how I managed to get to the bus station without getting mugged.  

How I ended up in Sierra Leone:

People keep on asking me how I ended up in Sierra Leone, and I have to refer them to my undergrad days.  How on a whim I took a global health class (D-Lab) focused on developing appropriate technologies like peanut grinders or making charcoal from sugar cane waste.  I had a 50% chance of getting in, and I got in.  We ranked places we wanted to go, and seeing Sierra Leone is still recovering from civil war, I ended up with it.  The trip itself was interesting, but mostly to evaluate SL's compatibility with future D-Lab groups.  When I got to med school, I knew I wanted to go abroad that summer, so immediately I contacted Dr. M to see if he could let me go to Malawi, but sadly, all the places were filled up.  Yet, out of some sheer luck at an elective I was taking, he heard I had gone to SL before, so he asked if I wanted to help out with the new Plumpy Nut (malnutrition therapy) factory in Sierra Leone.  I said, "Yes!" and that was the extent of the conversation and how much (or rather, how little) thought I put into it all.  And now that I've gone there twice, it only made sense that for a 4th year away rotation, I would go there again, especially since I'm going into pediatrics and Sierra Leone has one of the highest childhood mortality rates.  

I was shuttled around a bit though.  Through previous contacts and the MAP Scholarship, I got in contact with the Ashers, who are a couple working as doctors in Kamakwie Hospital.  But after I had already gotten my plane ticket and visa, they told me they were leaving Kamakwie because of conflict with the corrupt Wesleyan church leader (corruption is rampant in SL).  After a month of uncertainty, they finally referred me to Nixon Hospital at Segbwema - and that's how I ended up on the eastern side of the country where I had never been.  

How I didn't get mugged:

What made me think about all this was when this one guy I met at the train station said that I was really blessed to meet all these nice people.  And he was referring to something completely different.  Dr. M and his crew here have been amazingly generous to me.  But the people in Sierra Leone have also been some of the nicest people.  When I was trying to get to the bus station to buy my ticket, people would help me flag down taxis and lead me to the right place from where I got dropped off (taxis only stop at certain places, they are almost like buses, but with fewer ppl).  And when I got to the bus station, which was unfortunately closed already, someone explained when I needed to come tomorrow and waited with me forever to make sure I got on the right bus.  Oh yes, I also accidentally got off the bus at the wrong place, ran to catch up with it, which was possible b/c of the terrible traffic, and had everyone laughing at me after I got on the bus again.  

The next day, I needed to get to the bus station around 5am, which was pitch dark. First another person staying at the compound got up to see if I needed a ride, which I deferred.  When I was waiting for the poda (van bus, see picture), a lady didn't think it was safe and convinced this guy to help me out, who turned out to be some kind of president body guard/security/public representative and he went with me all the way to the bus station, even though he had just come from a club. Haha. Club.  He claimed to have been the youngest soldier in West Africa and he fought in the civil war when he was 13.  Apparently he was super popular because when he showed me where to buy stuff, he couldn't walk a block without someone saying hi to him.  Meanwhile, when I went on this 7 hour bus trip, I almost got left behind because they had stopped, I had gotten out to buy some stuff, and was waiting by the wrong bus. Oops.  But the bus driver found me. :D  Of course, I gave everyone another good laugh.  Someone said I managed to hold up 2 buses because the other bus was confused why I was waiting by it. Double oops.  

I'm Scary

When I stayed with a host family in Bo, there was one little kid who would start crying whenever he saw me.  He must have been about one or two, and he would run to hims mom and hide and keep on crying until I left. He probably thought I was a ghost.  It's so sad, I don't like kids running from me.  I like kids!!  Anyhow, the mom tried to train him to not be afraid of me and actually made me hold him, but poor kid, he was sooooo scared.  He was probably traumatized for life because of me.  I quickly let him go and he promptly ran to hims mom.  Everyone in the village was laughing at this poor kid.  

Fatness

Previously, I had mentioned how people want to be fat, but I didn't realize the extent.  Apparently people purposely take this drug/herb/something to make their butts bigger.  Hahaha, I was warned that if I wanted to get a dress made, it might not look very good on me because of my lack of curves.  Meanwhile, I was told that breasts weren't considered a sexual organ, but only for the purpose of breastfeeding whereas the key attraction is a big bottom.  (In my head, I'm singing, "I …like… big butts, and I cannot lie…") 

Meanwhile, I was amusingly listening to the UK midwives discuss the issue of obesity.  They conceded that obesity was a huge problem in the UK, but they couldn't believe how unashamed Americans were in showing off their bodies on the beach despite oozing out of their bikinis.  One was telling us a story of going on Southwest, and seeing a very large man, and feeling sorry for whomever was going to sit next to him – of course, that person ended up being her.  She continued to describe how unpleasant her trip was because he was taking up 1.5 seats, how the seat was slanted towards him because of the weight, and how she kept on sliding towards him.  At the end of her trip, her whole left side was wet from his perspiration.  And she is just this tiny 5 foot lady.  She claimed that Southwest was putting obese people in the window seats so they would not cause an obstruction in the case of an emergency.  Hahaha, what an interesting theory.

The other midwife mentioned her experience to Disneyland where people were being weighed before getting on rides (I had no idea that was happening!).  And there were people who were so big that they needed strollers – which definitely reminded me of Walle.  Meanwhile, the other midwife complained people should get to take on the airplane a combined amount of weight of their bodies and their luggage – so that lighter passengers should get to take heavier luggage.  Hahaha, it totally makes sense, but I can see all the Americans getting angry about discrimination or something like that.  

Typhoid Girl

The general atmosphere and attitude of the people here towards the sick is so frustrating!  They've come to accept death as part of daily life, so when people do die, sure the mother and female direct relatives might wail, but the rest of the community just goes on living their lives as if nothing happened.  Even at the scene of death, you see these nurses just sauntering about as if there's nothing going on.  It's so frustrating!

And the reason I say that is because I recently found out that the girl we did the paracentesis on and prayed her had passed away - probably on the day I had left for the training!  I was pretty angry and disappointed when I heard that because I had really thought she had a good chance of improving.  At the same time, I knew she was really doing poorly, and I thought she needed a bowel washout and repair and probably a pleural drain for her all the pus that I thought was in her lungs, and I kept on saying all that to the doctor, but he just ignored me.  Well, not exactly ignore, but he would say he's at the outpatient, or I would just not round on her properly in the mornings, or refuse to take her to the OR because it's the night time/afternoon or the weekend, or not a theater day, or there's construction going on in the main OR.  I had even warned him that I'm pretty sure she had pleural fluid and maybe an empyema, and to drain her on Monday because I was leaving, but I doubt he actually did.  Ugh, I had too much a false sense of security after she improved a little symptomatically after the paracentesis - she even passed stool.  I felt so guilty knowing that I could have done something earlier, but didn't push enough to get them done.  I felt guilty leaving for a training session and not finishing caring for her.  Given my lack of clinical experience, I have a hard time knowing when I should push for something to be done or not, especially when other people who are more experienced clinically than me choose not to do it because of their laziness or apathy.  And most of the time, I only know afterwards that it was too late.  

When I had spoken to the UK doctor, he comforted me slightly by saying that a perforated abdomen was a really poor prognosis anyways for typhoid (which I think she had given the gross fluid from the paracentesis), but I still wish I had pushed for the paracentesis/lung drianage/empiric sepsis antibiotics earlier.  

:(

Female Genital Mutilation

While talking to a midwife who had stayed in Makeni for a year teaching midwife students, it was interesting to hear her say that of all the people she took care of, all of them had undergone female genital mutilation (FGM).  I remember seeing a center for FGM awareness when I first came to Sierra Leone, at Lunsar, but I hadn't realized how prevalent it was.  I didn't think that it was something that ALL women upcountry had, but according to this UK midwife volunteer, that seemed to be the case.  It would make sense, considering how high the maternal mortality rate is and how frequently there's obstruction of labor.  But at the same time, the other UK ob/gyn who came infrequently was super surprised about this claim of how frequent FGM occurred, so I was slightly skeptical as well.  But then today, when I was talking to a Nigerian anesthetist volunteer at the course I'm taking, he also brought up how prevalent FGM is.  I didn't understand clearly whether this happened in all the ladies, but it appeared to have caused obstruction in at least 6 ladies since his two months at Bonthe.  It's interesting that despite how prevalent it is, nothing is mentioned about it.

Appearently it took the midwife volunteer six months to get the confidence of the women she worked with (including midwife students) to get them to talk about FGM.  A women talked about how they remembered being dragged into the bush by her "auntie," getting all fours pinned down, and experiencing excrutiating pain.  Then afterwards, they'd get dressed up and given copious amounts of gifts and foods and had a party.  For most girls, it seemed like they had no idea what was going on, and most of what they recall was the party and gifts.  But apparently the FGM ranged from getting a cut and scarring to complete cutting off to stitching.  Apparently the men didn't care much for this practice, but often it was the grannies and old aunties who continued to get their daughters or granddaughters cut.  According to the midwife, the more educated Krio people seemed to be doing this less, but it was still pretty prevalent in the villages.

Essential Obstetric and Newborn Care Course

So I'm currently at an obstetrics/newborn training session for midwives/nurses/physicians.  It's pretty cool, cuz it's put together by the Liverpool school of tropical medicine and the royal college of obs/gyn and WHO.  I think it's a really good program because it's actually improving the skills of people who are dealing with these ob/newborn emergencies.  It's pretty amazing how little people know, and it's also amazing how much people are learning.  I'm supposed to be a participant, but because I was invited last minute, my role is almost kind of in between an observer and a participant.  I'm learning stuff too as well.  Anyhow, I really think these classes could play a huge part in decreasing the maternity death rate (which at one point was 20%).  

Anyhow, another good thing about this course is I got to talk to some people from other hospitals to get an idea of what other hospitals are like.  And I'm surprised to hear that Nixon hospital is actually not that much worse than the other hospitals.  Sure, they may have more staff (3 vs. the 1 at NIxon), but in terms of equipment, most of them don't have oxygen, many don't have the drugs that one might find to be every-day-use drugs in the states, etc.  From the participant's surprise in hearing about doing basic resuscitation with the ABC's (airway, breathing circulation), it sounds like they don't really have much in terms of emergency care/resuscitation either.  Some of the participants also work in peripheral health units, which means they don't even do blood transfusions, c/sections, etc...and they mostly just do basic stabilization (with IV fluid), and then refer to another medical center. I would really like to visit a few of the other centers and see how their organization is.  I hear the Women's Health/Pediatrics Center in Alberdeen (Freetown) is super well-run/organized, so maybe I can arrange a short rotation there.  

Master of the Keys

The hospital does have a generator, but they only use it for the OR on tue, thur, and sat...and mon/wed for a 2 hours to autoclave.  it's pretty sad they don't have electricity when they actually need it for inpatients like for the oxygen machine.  and make patients pay for petrol to run the generator.  the whole idea of health care is so weird.  the other day, a guy came in from a motorcycle accident and he was bleeding a lot from his face, and the nurse said we cant start treatment bc his family isn't here yet and hasn't paid his admission fee, and his type of ppl might just run away from the hospital befoe paying for it like the other girl the other day!  And this is a Methodist hospital!

It's pretty crazy how controlling everyone is of everything. Ok, fine, it makes a little sense b/c there is a lack off resources, so it can't be like the states where med students can go into the supply closet to just take as much as they want to practice or 6 ppl going into a room and putting on contact precaution gowns that cost $5/person everyday, or the copious yet much needed glove usage...I can go on forever.  Anyhow, there is a key for everything, and it seems like I can't get anything done w/o finding the right person with the right key.  

For example, today, there was a baby seizing, and all I wanted was diazepam to stop his seizure, but the pharmacy was closed, so we had to use the emergency stock, but the emergency cupboard was locked, and the nurse in charge who has the key was at home! Really? If you're on service, why are you at home?  But then I found out the men's ward nurse was there, and he fortunately also had a key, but when he went through the cupboard, he couldn't find diazepam.  Really? I had just told the nurse who was in charge of it to restock it EVERY DAY! Oh man, the organization, and everything is so crazy.  Then, another nurse came in, apparently, nobody was around (Saturday), so she came in, but she happened to have wandered off to the under-5 clinic, or maybe she came from there, I'm not sure.  Anyhow, this whole process was NOT helpful for the kid.  At least we finally got his seizure to stop after giving some glucose (also in emergency cupboard) because he mom was giving him water when young babies should only get breast milk.  

The other day when a guy came in with crushed fingers, it took forever to open the OR doors, and get all the supplies we needed to look at his finger, etc.  The main door was locked, and then every door within it was locked too.  Really? Is that really necessary?  And apparently there are just a whole bunch of rolly beds and other equipment sitting in the OR not being used, but just locked up for safe keeping.  Later, after telling me there are no bag mask ventilators, someone found one in the pharmacy/dispensary.  It seems like they're so keen on rationing material that they just don't want to use it during anything.  

OMG, using the ultrasound is such a pain too.  I wanted to scan some ladies with big pelvic masses, and then the doctor says do it when there's electricity - which is every other night.  And so I wait to next night, then he tells me at night the OR (where they keep the ultrasound) doors are locked, and so I can't scan, and I needed to get the key from them during the day.  And because the OR ppl only come every other day, it's another 2 day delay.  Of course, when I want to scan during the day when the OR electricity is available b/c they have a case, the doctor says he's busy with this or that.  Finally, when he sees me doing an ultrasound and I ask if he wants to see it, he says, "I don't know what's normal, what's not" and continues to walk away.  I could do these basic ultrasounds, but I'm not gonna be here forever!  I think he's not comfortable with new equipment/tools, and just avoids them.  

This incessant need for power and control is just ridiculous.  When I asked to use an oxygen machine from the OR over night when they don't have cases, they say no, but then when I say the hospital needs to work together, the guy kind of budged, so maybe people just need to be reminded they are working in a hospital, and not the government?  Well, at least there are some changes - small small.  

Fumbling in the Dark

Today I got some pretty crazy experience again. as usual...trying to deal with a motor vehicle accident with no electricity/light.  Everyone had their phone lights on.  It was pretty crazy.  The guy was the third person on a motorcycle and they had crashed into a truck.  The first two people died instantaneously, but this guy was lucky and fell and hit his head but with no loss of consciousness.  Of course, we're concerned for brain injury, etc., but based on assessment, looks like he just had a large laceration on his forehead and maybe a bruise.  Needless to say, he is really lucky.  But still, trying to assess him and help him when there was no electricity and at 7pm at night was really quite a hassle.  To top it off, surprise surprise, the doctor wasn't reachable by phone at first.  

Also did my first paracentesis on my own.  Initially the doctor wanted me to do it myself, but then I pretty much begged him to watch me do it.  And then I probably aspirated 500ml of dirty, green, pussy fluid from this girl's abdomen with a 10ml syringe.  It was pretty epic...in a unpleasant, I-can't-believe-she-has-this-in-her-belly sort of way.  And then I continued to do another one from this other guy.  Pretty sure the technique was not the safest way ever, but it had to be done.  Also something funny happened then.  While the nurse was watching me, at one point I told her she should pray for the patient.  She asked, "Really? Now?" and I said, "Yes!"  But all she did was get up and walk away.  Then after 5 minutes, a group of maybe 10 people showed up singing a praises and prayers while clapping.  Even the patient joined in!  All the while, I was still sitting there holding the syringe attached to the cannulla in her abdomen.  Haha, that was a nice surprise!

Despite how I'm talking about death all the time these days, my friends were talking about how it's also an opportunity to make the hospital better.  I'm already seeing a few improvements.  I'm really glad the one UK doctor came, so I could talk to him about my frustrations, and he actually has the authority to make things different.  Yay!!  And I've been able to kindly cajole them to make a few changes, like actually have the bag mask ventilators in the wards and not locked up, or to actually use the oxygen machine every once in a while.  Still a hassle to get electricity when I need it.  And the other day, I was definitely switching the oxygen mask between kids because I couldn't decide which kid needed it more.  Sadly, the one that had the oxygen mask still died. :(  Man, I feel bad talking to you guys about these sad things.  I feel like all I talk about is death these days.  So happy thoughts...the one kid where I was holding its head for a large portion of the night looks sooooooo good now!  He is super active and playing and getting discharged!!!  Yay! Praise God!