Friday, 31 May 2013

Masanga- Later I'll let the tears fall

Day 6 (Monday) working in Masanga started off with a morning meeting detailing a long list of patients who were seen by the on-call team over the weekend. Some of the patients were in emergency, some now in the ward, others had passed away.
I rounded with the doctors in the paeds ward and happily saw that there were not many patients admitted, so I took my time playing with the kids, kicking the football and blowing bubbles, while my physio friend Jo, helped them do their exercises.

After lunch I wandered back up to emergency to find only nurse aids present, as the students and doctors were busy elsewhere. I took the time to ask one of the nurse aids about her job at Masanga hospital in the emergency ward.
During this time a couple of new patients came through the door and I had to convince the staff there that the patients needed to be seen first in emergency before being sent straight to the paeds ward. With lack of training and critical assessment skills in the staff, many patients are passed to the place that their paper says to go without being checked over first. Many patients had suffered unnecessarily due to delayed care from being sent straight in the ward and not seen, sometimes for a whole day.
After that patient arrived, I was really hoping for a doctor to arrive and not long later, to my relief, both  Dr Davids  walked in. As a couple of us began putting an IV in one baby, more and more small babies and children were walked in for admission to emergency. All beds were occupied but we moved children to the end of the bed to make more space. It seemed as we were doing one thing, something else began to happen and we'd switch to whatever was most critical.
A four day old baby (only 3kg), looking much like the one from the other day, was brought in. He also stopped breathing and we gave him his breaths while he paused and then after stimulating him out of his apnoea, he'd begin again. Not knowing what to do and the apnoea episodes were lasting longer, there was really nothing to be done. In a western country we would have already figured out what the problem was. He probably would have already been intubated to relieve his body from stress while scanned to find the problem, but here at Masanga, we have nothing. Just as we were deciding to stop and just let him do the work breathing himself the power went out, so we lost our oxygen supply. It made the decision for us.

As we began to clean up the resuscitation bed around the baby, one of the doctors brought over another baby who needed help. We moved the four day old into his aunt’s arms (the mothers don't want to hold or touch their dying babies) and a nurse watched over him while we worked on the next. The nurse explained that there was nothing we could do to keep this precious baby alive. We were very sorry. He would eventually stop breathing and we couldn’t stimulate him enough to keep him alive.
Before we knew it, this new little 3 month old baby Zainab on the table was crashing. We had slipped an NG tube down and were aspirating air and stomach contents. She had secretions bubbling out her mouth and nose as she struggled to breath. We have no suction, so we were using a syringe and a suction catheter to suck as much as we could away. Her sweet brown eyes were crossed as she used her accessory muscles to breathe. As we worked on her, I saw her little body cease to breathe. As I called it, our anaesthetist friend intubated her and I listened for a heartbeat. No, it was gone too. Chest compressions began and I know my heart was beating wildly and I saw the scene unfolding around me. Her Hb was only 4.9 (49 for the Aussies) and we still didn't really have a diagnosis but we didn't have time to figure it out. As we tried to keep her little body alive with all the measures we had, I surveyed the scene. There were syringes, catheters for suction, oxygen tubing, saturation and pulse monitoring leads, airway bags, and an array of other things spread over the gurney on which we were working. The space was small and people were great in number, the airflow minimal and the sweat abundant and the emotion numbing.

Even with adrenaline, blood transfusion, IV fluids and many other interventions, we lost the battle for little Zainab’s life. We couldn’t get her heartbeat back. After we cleared the table, just her little body remained. A nurse aid helped me to wrap her. I hate the moment the head and face are covered. My heart sank and I wanted to burst for the sadness weighing on me. Her parents were outside the room and everyone else walked away and so I sat there on the bed beside her little body, unwilling to walk away, just wanting to hold her.

There have been many moments in the last few days that I can't believe I have been in the middle of. When did this suddenly become my new reality? How is it that I'm seeing small children dying almost daily? Tears come in the moment that I look around, but I push them down. The mothers wail and scream and take themselves out of the room, throw themselves on the ground in tears and I just feel numb. Numb because I've pushed the sadness away, to deal with later and the physical situation now. Later I'll let the tears fall.

Sunday, 26 May 2013

Masanga- Weekend respite

It's amazing how luxurious life can feel after having so many things stripped away from your 'normal'. Over the weekend Steph and I went to stay with our friend Anna at Aberdeen Women's Centre in Aberdeen, Freetown. We got to sleep in a huge, air conditioned room, with the availability of hot running water, flushing toilets and amazing food cooked for us- a breakfast of bacon, eggs, pancakes, chopped mango and banana and a hot cup of tea, while also getting to spend time with precious friends, not only Anna, but Tiffany and Greta, who were visiting from the ship for the weekend.
To make the weekend even more amazing, we spent Saturday at Bureh beach. After a somewhat long, bumpy drive from Aberdeen, we reached our destination, hopping out of the car to gaze upon the glistening, blue sea and smooth sand.

The last time I was there was 2 years ago and it has changed a little from what I could remember. A river now winds its way from the land through the sand and rocks towards the ocean. The water in that river is deep enough in places to float your way downstream, avoiding the rocks and into the ocean.
We spent the day with different people, some ship friends, some new friends from Masanga, some new friends we met that day and a few little African girls from Anna's church group, who hovered around our table and chairs eager for our company and attention.

After a relaxing day, reading, swimming, chatting and watching the sunset over the water, we headed back to Aberdeen with our new friend Steve, but after only driving for about 20 mins we heard a pop and soon it was evident we had a very flat tyre. We piled out of the vehicle and were crowded by a group of children aged from about 2-12 years old from the nearby village. They stood close by us just wanting to watch what we'd do.
While the men sorted out the tyre, we started to sing a song we knew in Krio- Tell 'im Tenki and as soon as those words were out of our mouths, they picked up the rest with their strong, melodious voices. They continued singing songs and each time they ended one, someone would start a new one or one would whisper a suggestion of another into someone's ear and they would begin anew. It was a beautiful sight and sound to behold. I felt so privileged to know some of the Krio songs they sung and to listen to them sing so earnestly in such sweet voices.
It took quite some time getting the tyre changed and battling Freetown's horrible traffic so we stopped to eat on the way back to the AWC and by the time we arrived back to Anna’s and stood in the kitchen chatting with her and eating cookies, we had a bad case of the giggles. Poor Anna stood bewildered as the four of us, Steph, Tiff, Greta and I stood in the kitchen in uncontrollable stitches of laughter.

Sunday came and we made our way to the supermarket to see what we could take back to Masanga to excite our taste buds in the week to come, after spending the past week eating the same pasta and tomato sauce that I unfortunately threw up on the second day.  I had avoided that sauce successfully for a few days, but soon realised I would die of carb boredom if I didn’t start eating it again. Wednesday night is the only meat night at Masanga and the rest of the meals were pasta and the same meatless tomato sauce, except on Sundays we were made rice with peanut sauce. The alternatives are bread, with nothing to put on it. We did have nice fruit options when they were available; mangoes, bananas and pineapple. So at the supermarket, we found some essentials; peanut butter, Laughing Cow cheese, crackers and Ramin noodles.
In the afternoon, our friends from Masanga met us and picked us up from AWC and we made the long drive back to the jungle for another week of learning and experiencing health care in the middle of nowhere.

A random sign on the drive back to Masanga

Friday, 24 May 2013

Masanga- They just keep coming

Day 5 began with the shortest on-call meeting of the week that didn't mention any deaths overnight, except we knew there had been one tiny baby who certainly had breathed his last during the hours we'd been away.
I started the day rounding with the doctors in the paediatric ward, happily seeing one of the small malaria boys from two days before, well enough to discharge back to the village. It felt like a small triumph amidst the constant battle.

Paediatric ward

Back up in emergency the doctors had started a lecture for the medical students in a conference room, taking all but one away. When I headed up to emergency there was a small boy lying in a bed, sick with malaria. From the documentation I could see he had not yet been weighed and before any medications could be given we needed to know this. With permission from a nursing aid, I took the boy and his mama to the paediatric ward, to use the baby scales. While we were there another set of parents came in with their equally small boy, also about 18 months old (11kg), who was clearly very sick and in severe respiratory distress. Realising that they had been sent from somewhere for admission in the paediatric ward, I knew that he need to be in emergency and seen by a doctor immediately.
After weighing him, I took them up to emergency and had the medical student see him while Steph went to get a doctor. The boy was tachypneoic, febrile, lethargic and had a blood glucose level of 0.9mmol/l (16.2mg/dl for the Americans). We needed to raise his glucose level immediately.
As we searched for a vein to give him IV glucose, I ran down to the mini shop and bought a Fanta since we couldn’t find any IV 50% glucose anywhere in the emergency ward or in pharmacy. Using a 10ml syringe I fed him like a little bird and he sucked thirstily.
After the IV glucose was finally sourced and given and an action plan written, the boy vomited a dark fluid. Not long later he passed blood rectally and was noted to have bleeding in one eye. Suddenly the two British doctors present looked at each other, eyebrows crossed. Concern for this patient rose as we realised this case would be more complicated than we originally thought.

Dr David in the emergency, writing up a plan of care

After things settled down a little and each patient was getting their treatment, Steph and I walked back for a late lunch and to pack a bag for the weekend in Freetown, visiting with friends. Our ride to Freetown was with these doctors and colleagues. As we sat at the hostel waiting, we knew something must have been going on with this little boy since they were already running late. By the time they arrived, they just drove through to say they had to decontaminate and they'd fill us in after they picked us up.
Putting our bags in the car we waited to hear the story. After we had left emergency, the boy had bled again rectally, begun to bleed from his nose and vomited more blood. After reading a few chapters in the tropical medicine textbook they connected the haemorrhaging to a possible viral haemorrhagic fever.

As the doctors were discussing this small boy's case and he was bleeding from all these places, his little body stopped working and he arrested. CPR was attempted but ceased quickly as he continued to bleed and bleed. Another little life gone...
Now they were sitting in the car looking up viral haemorrhagic diseases to know if it was a true possibility and whether we had all been contaminated by coming into direct contact with him. A blood specimen had been sent to another town, Kenema, for a diagnosis. If the results ever come back we might know for sure. (The results did come back a week later and it was negative for Lassa fever.)
The car ride to Freetown was fun, hearing stories of our new work colleagues and answering a lot of questions about our lives on the Africa Mercy.
We were dropped off in Waterloo and took a poda poda from there to Forebay road, Freetown, just past the corner were we would turn to go down to the port. It was an area very familiar to me after 11 months of walking that street in 2011. From here we walked to the eastern police station until we could find an okada (motorbike taxi) to get us through the horrible Freetown traffic to Aberdeen.
After a successful ride through the city to Aberdeen Women's Centre, we met our friends Anna, Tiff and Greta and dropped our bags, overjoyed to be in more great company and the addition of power, running water and air con.


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