mothersofafrica's blog

Defibrillation : Liberian style...

By Dr Sue Catling

All over Phebe hospital there are cupboards and offices full of the stuff they get sent by Charities – most of it technical and complex state of the art kit.  Trouble is, they don’t use it. Partly this is down to unfamiliarity and lack of training- unsurprisingly!

Take for example the defibrillator ....

 

There it was, state of the art modern defib, sitting in a dark alcove and  obviously never had its cable unwound from the original packaging. Complete with three pin plug.

As we say  - as much use as a chocolate teapot.

So using our head torches to illuminate the aforementioned dark alcove we cobbled it up to one of our electric adaptors  we had brought and it sprang into life much to the delight of the students, who had never seen one in action.

Dave volunteered to have the paddles put on his chest to demonstrate it in “monitor” mode .........now that’s what I call dedication to teaching, not to mention trusting your colleagues!I’m not quite sure who was more nervous – Dave with the live defib across his chest, or me methodically going through the sequence but stopping short of the 'charge and deliver shock'!!The students thought it was great!

Good news is:  I managed not to kill him.

Margaret's Story* (*not her real name)

One student told us her story: and has given us permission to write it down.

Both her parents were killed in the war and she and her siblings only survived by hiding in the bush whenever necessary. They had no clothes and slept under banana leaves . They walked miles to find water, and often had to keep walking because the  water was contaminated by dead bodies. Sometimes they were so thirsty they had to push the bodies aside and drink the water.  When asked how come she could still smile she said – I’m alive.

 In the classroom today she gave us a learned presentation on intravenous induction agents.

Her journey from that river to our teaching classroom is totally unimaginable. Don’t ever think that things can’t get better, never give up.  What a woman, what can we teach her, and what can she teach us?!

 

Adapting the programme

By Dr Sara Hunt

Teaching today was against a background of a child screaming non-stop as it had a circumcision with just “ local infiltration”as anaesthetic i.e.  local anaesthetic injected around the site of operation.

This is very ineffective as it doesn’t block the specific nerves and the child will have experienced severe pain. It would never be acceptable in the UK.

This was a very difficult situation for us. We felt we had to question the method, but this would be confronting something that is obviously a regular part of the local practice. Presumably some of their own sons had been circumcised like this and, by directly suggesting an alternative, we might be treading on cultural divisions as well as directly criticising the status quo.  

So a few days later we introduced a teaching session on how to perform a penile block anaesthetic, which is safe and effective. We hadn't planned to teach this, but it seemed to be the best way to change practice without directly questioning established method.

 It was very well received and we hope they will try this in future.

 

 An example of how you have to adapt the plannned  teaching to what you actually find you need when you get there.

 

 

Night time.....

By Dr Sue Catling

Tonight we heard a woman screaming …….. Labour?grief?what?

We don’t know what it was about, but none of us really felt we wanted to go and properly investigate.

Its funny - you tuck yourself into your mosquito net, you spray DEET and Raid and feel safe, and then you hear something like this - a woman screaming, louder and louder , on and on, tearing the night apart. And you think: if this was the UK I’d run out there and investigate, she obviously needs help- is she being attacked, murdered, raped. Or is it grief – has a loved one just died in the hospital?

But because it’s Africa, and unfamiliar, you don’t venture out, and you never find out the answer.

And the next day you feel guilty, but reassured by the fact that no-one else went either. What are the limits of the risks that it’s reasonable to take I wonder?

 

From the Lassa fever unit to Miller’s bar: 50 yards and a million miles ....

By Dr Sue Catling.

 

 

So, nobody told me that Phebe Hospital contains the isolation unit for Lassa fever cases from all of Liberia and Guinea.

(For those of you who don’t know Lassa Fever is an acute viral hemorrhagic fever whose symptoms include fever, facial swelling and bloody vomiting among many others. On average 15-20% of hospitalized patients die. It’s a pretty horrible one.)

 

Originally set up by charitable donation with all mod cons and barrier nursing, the unit has now deteriorated to a building with no facilities, with “keep out” signs . 

 

 

 

 Apparently there are no barrier nursing packs, no bed linen ...patients simply are put in there to be isolated, and to die.  Liberia does not have a facility to test for Lassa fever – the bloods get sent to Germany and the results take up to 3 weeks to be sent back –but treatment with anti-virals is only effective if started within 6 days. At first, i felt really uneasy even walking past this place -  I felt outraged that I didn’t even know that this potential life-threatening thing was so close to where we were!

This is a disease that is spread by aerosol droplet infection, i.e. you can catch it like a cold, and yes, the unit had several patients -  one of which was admitted and died of haemorrhage while we were there.

 

And then something interesting happened. We found Miller’s bar. Miller is a trained anaesthetic nurse who, as a sideline, runs an on-site bar he inherited from his dad. The bar is a shack made of corrugated iron sheets and gaily decorated with striped wooden poles.

 

It looks absolutely amazing – a triumph of the human spirit over adversity!!! It sells cold beer (via a cooler powered by the hospital generator) and you can sit with the scraggy chickens at a rickety table outside and watch the local boys play footie with empty plastic bottles.

And .....it is 50 yards from the Lassa fever Unit.

Within a week at Phebe, we sit laughing in the mud on the steps of Miller’s bar, swigging cold beer over the bottle, joking about the proximity of the lassa fever unit and thinking “hey, this is a really nice spot to sit, and this beer is really cold” .

 

 

And we listen to the story of how the latest patient was admitted by one of our very own students, and we buy her a Coke (she doesn’t drink beer!).   With grateful thanks to Miller and Family.

 

Africa sort of resets your definitions of everything.

The level of student knowledge....

By Dr Sue Catling and Dr Sara Hunt

The students can do some things well e.g. spinal anaesthetics, ketamine anaesthetics, but they lack the resources to do a full spectrum of anaesthesia at the moment.

 

They are so keen to learn and they have the intelligence and ability to do things right – surely this is the huge resource that we can encourage.

 

Not knowing what I’d find out there, I'd brought with me 6 Uk spinal needles and the drugs to give a safe spinal (just in case any of us got appendicitis). But, while I would have been happy to let them give me a spinal from the technical point of view, I would have been worried about basic asepsis and infection.

This summarises the whole problem with the current system in Liberia.

 

Theatre case...

By Dr Sara Hunt and Dr Sue Catling

26 yr old man with compound fracture of tibia and fibula after falling from palm tree.

Horrible injury, with bone coming through the skin and the lower leg almost turned round the wrong way. Despite the pain the patient was uncomplaining and, although he had lost a fair amount of blood, this hadn’t been life –threatening up to now!

The surgeon had to put it back in place and fixate it- an excruciatingly agonising procedure - without an anaesthetic. The anaesthetic student planned to use just morphine for this procedure which would have been inadequate pain relief. Sara suggested  a spinal anaesthetic (what we would do in the UK). The student thought she couldn’t do that because patient was not starved but, in fact, it was the most appropriate technique in these circumstances.

 Student then  wanted to give 2mls 5% lignocaine. We checked the dose and suggested 1ml. Resident anaesthetist not present, we suggested student called him. Spinal performed from head end (NB although appropriate for this case apparently in liberia they always use this approach, which is awkward for the anaesthetist to bend around  -  perhaps we should advise to change this?), good asepsis, no gown, 22G Quincke needle – didn’t work, repeated, immediate effect, patient smiling.

We felt disappointed that despite the students’ theoretical knowledge, with teaching all day about pain control and spinals, that this was not translated into practise.

 

 It appears that pain relief is not regarded as a basic need here – we take it for granted in the UK, but perhaps it is a luxury if you don’t have  the necessary resources. The fascinating thing is that they did have the resources they needed for this- so why didn’t they think to use them?

Is this a cultural difference to the role of analgesia??? Or is it something we can correct with the right education?

Afterwards much needed beers at the hospital cafe – The Flagpole, where we devised a plan to use the whole incident as teaching scenario tomorrow.

Teaching.....

(By Dr Sue Catling)

 

Tried to use all modern teaching techniques as in UK, but some interesting differences e.g.  handing out prizes of books, pens, and sweets! At first I thought this was going to be embarrassing and feel very condescending, but the students were very comfortable with it and indeed clearly expected it – next time we’ll bring even more wine gums and humbugs!! Student s fed back that they particularly liked the small group discussions – which are of course the most demanding to teach – you really have to know your stuff to face 14 eager faces asking “why” – no hiding behind powerpoint slides

 

 
I always learn from my fellow teachers, and for me the abiding memory will be of  (sorry to non-anaesthetic readers here, too technical to explain in a blog, but for any anaesthetists out there – its a winner!!) Dave explaining the relationship between oxygen saturation, oxygen content and haemoglobin in terms of taxis(red cells) driving to Monrovia either full  or half full  ( oxygen saturation)  of passengers, and how that defines how many people arrive in Monrovia  (oxygen content)......that’s how I’ll teach it in future Dave, thank you!!

No AK47s in A&E please .....

(By Dr Sue Catling)

 

So most casualty depts. have a plethora of signs over the door : no smoking, no hot drinks, no mobile phones etc.

Phebe hospital has this one...

 

 

.......no AK47s , no bullets.

 

So we had a good laugh and took a photo, and we were already imagining the various lectures/talks where this could be added in as a hilarious “funny slide” (every good lecture needs one!)

Then we saw this ....

 

 

 

It’s the graves of the 3 doctors who were shot by the rebels when they swept through Phebe. It’s right at the front of the hospital, beautifully cared for and manicured . Apparently Mr Fassah, the Head Anaesthetic Nurse, led his colleagues and students into the bush to hide. They survived to come back and try to remake everything that was destroyed.

 

Hmmm....no AK47s in A&E indeed.

Not funny after all.

 

First problems....

(by Dr Sara Hunt)

Apart from the deep seated medical problems of the country, there were a few basics we had to grapple with first….

- Communications: No internet at all. Much to technophobe Sue’s delight our I-phones don’t work (Dave and I gutted!!). Sues ancient Nokia seems to be working beautifully – I’m sure we will be reminded of this on a daily basis. (come on O2- get with the programme!)

- No grid electricity. On the drive from the airport were houses and lots of people … but it was pitch black. People just sat around fires and cooking pots. The hospital compound has a generator that supplies dusk to dawn electricity, but it would sometimes fail leaving us using candles and having to pump water, once for 48 hours (We had to carry the water buckets 200 yards – they were ridiculously heavy! How on earth do the people here carry bigger buckets on their heads for miles?? See.......

 

(the girls carrying the load.....)

 

(martha trying to teach Sue how it's done!)

 

 It’s unfathomable thinking about operating in a scenario where everything might just turn off.

- No milk : caused by a lack of cows and fridges. The thought of doing on-call without coffee is terrifying!

And of course, all the time – at the back of your mind is the niggling idea......what if I get ill myself? What if I need surgery here .....appendicitis,etc?  Of course , we had brought with us a small pack of drugs and equipment (modern spinal needles)  for just such an eventuality....but supposing we got seriously ill and needed ITU in Liberia........beam me up Scottie?