Sunday, 28 December 2014

An Alternative Christmas

At about 4pm on Christmas Eve wherever you are in the world it seems there is always some element of desperation to leave work on time/early, the last-minute dash to the shops and frustrating traffic jams. For a few of us at Connaught this process was interrupted by a phone-call from the group that had already made it to the beach the day before warning us that we may have difficulties. There were soldiers on the beach warning them that there would be military personnel on the beach to enforce no swimming or use of the beach on Christmas Day and that there would be absolutely no travel allowed out of Freetown on Christmas Day.

Since I was fortunate enough to be in the group due to be leaving on Christmas Eve and returning on Boxing day we chose to risk it and set off for the beach in the afternoon via the supermarket for that all important ‘dash’. We were stopped at a number of check-points along the new Chinese-built super highway to Burreh Beach but had no trouble passing through them as we were ushered along with chirpy “Compliments of the Season”, the Sileonian equivalent of “Happy Christmas”.

And oh my goodness was it worth the ‘risk’. A beautiful white-sandy picture-perfect expansive beach. We were staying in little huts (well actually I was camping, why not make it an even more alternative Christmas?!) right on the beach, nestled in amongst the bustle of Burreh village and next door to the Sierra Leone’s first surf club. Unfortunately, the swell was less than 1 foot high so no actual surfing took place! Instead, Christmas Day for me entailed a 3 or 4 mile run barefoot along the beach, followed by a dip in the bath-like clear warm sea, omelette and coffee for breakfast and then present opening courtesy of guess who? My wonderful Mum for a little pack of goodies including yet more Christmas yummy-things for my colleagues, she’s getting quite a reputation! There was not a hint of military presence on the beach all day and another car load of volunteers arrived in the afternoon having worked the morning shift in the unit – they had no troubles getting through the road blocks either.

After being here nearly two weeks without a day off (completely self-inflicted as I went on a general medical ward round with Dr Terry on my day off!) I was more than ready for this break. It certainly felt like we were a world away from the stresses of the ebola epidemic and daily challenges at the hospital. And yet, I was also very aware that we were the privileged few that could leave all that behind and comfortably turn our backs on the situation for a day or two. Even taking the risk of meeting resistance at the road blocks or the potential of defying the police presence by going to the beach sat uncomfortably with a few of us. We felt like we were taking the luxury to celebrate Christmas when others had no opportunity to do this. As a dear friend of mine wrote to me in an email this week... "isn't the world a strange place, where you can have such beauty and enjoyment in close proximity to such suffering." Too true.

On the way back in the evening of Boxing Day, feeling refreshed and happily sleepy from maybe a little too much sun and fresh air, the polluted stench of Freetown hits you a hundred times worse than you’re expecting. Overwhelming rancid fumes of exhausts mixed with burning plastic, as my housemate Katie puts it, simply ‘the smell of poverty’.  At a roadblock just entering the outskirts of Freetown we all had our temperature taken by some guy in a grubby t-shirt who definitely didn’t know what he was doing. They use these infra-red thermometers which are a bit like a plastic gun, that you hold at your temple at a distance of 5-6cm to get an accurate reading. This guy half-heartedly leaned across the driver to point it vaguely at Pete who was sat in the passenger seat at a distance of maybe 50cm and told him his temperature was 30 deg C. He then directed it towards me, a bit closer, and told me my temp was 34 deg C. He obviously had no idea what he was doing and certainly didn’t know the range of a normal temperature. Frustrated, I started to teach him how to use this thermometer, but he shrugged his shoulders and claimed ‘but it’s quicker like this’. Oh dear, where to start?!

If you haven't already seen it, tune in to Channel 4od to watch friend and colleague, Will Pooley's Alternative Christmas Message for a few scenes from Connaught Hospital. 

Wednesday, 24 December 2014

Christmas is cancelled… or is it?

Inflatable santas
Last week the Sierra Leone government announced plans for “The Surge”, an ominously named attempt to curb the spread of ebola before Christmas. It’s a promise to scale-up community teams searching for unwell patients, holding centre beds, laboratory services, ambulances, treatment centre beds and burial teams. So basically what everyone has been trying to do for the last however many months. It came into action on Wednesday 17th Dec, overnight. Yesterday, a local radio station interviewed me to give my assessment of whether it had made any difference. Firstly, it has to be said, that I am working in only one ebola holding units of many, a very small piece in a big jigsaw - I think there are 11 in the Western Area (Freetown and surroundings), so whatever I see first hand cannot be extrapolated to the whole area but to me it hasn’t made an obvious difference.

The chocolate eclairs disappeared in a day at the office!
Local staff members tell me that Christmas is simply the best time of year in Sierra Leone. It’s not too hot and it’s usually one long party month, music blaring with parties in clubs and on the beach in the lead up to Christmas. You wouldn’t have guessed it from the Freetown I’ve come to know. I’ve seen the occasional inflatable santa and Christmas decorations, but since The Surge started on Wednesday I’ve noticed an even greater change in the atmosphere. The streets are empty and the place is relatively quiet. The government has ordered, in addition to the scale-up of resources, all shops, restaurants, football cinemas and bars to close at 6pm on weekdays and 12pm on weekends. And yet, people don’t generally catch ebola from restaurants or shops they catch it looking after their sick relatives at home. So in my opinion this aspect of The Surge is only damaging the weakened economy even further and it seems like an exercise to show that the police and army can still exert their power.

Christmas Cake was a big hit too!
On a personal level, it’s certainly making life difficult for us volunteers because after a long day in the unit we value our downtime, usually eating in restaurants or having a couple of beers together in the evenings. We’ve had some recent serious discussions about stocking up on food supplies for our houses so we don’t go hungry!  As for Christmas - for us volunteers is very much NOT cancelled. The admin staff here have done a fantastic job of making sure that we all get a couple of days break over the Christmas period whilst ensuring enough staff remain on duty in the unit. So at various different times this week we’re all heading off to the beach for a couple of nights of well deserved ‘downtime’, fun and festivities on an idyllic white sandy beach, swimming in the sea, with newly formed friends. Not a bad way to spend my first Christmas ever away from home…  

Happy Christmas one and all.

Friday, 19 December 2014

The Isolation Unit at Connaught Hospital

I’m not quite sure where to start… time passes in strange ways here, I arrived less than a week ago and yet it feels like I’ve seen so much, met many amazing people and beginning, ‘slow slow’, to get my head around the current situation.  I also should warn you that this blog makes for fairly upsetting reading. I promise to try and focus on less gruesome topics in future blogs but I thought it was quite important to set the scene initially.

So I’ve started working in the Isolation Unit at Connaught Hospital. I had 3 days of thorough one-on-one training about PPE and the how the unit runs from Tom, an HIV Consultant from South Africa, who has been here for about a month. We talked through the PPE training together in a classroom, then practiced putting it on and off in the correct 22 steps and order. On Friday, I walked through the unit for the first time for an induction. Eyes wide open, blinking through the foggy visa of my mask, hands clasped firmly at my waist in a surgical pose, not touching anything but just allowing it to sink in. I then continued to shadow and work with Tom for another couple of shifts until now it feels like I’ve always known how to wear PPE.  

Getting into PPE
We have 16 beds and 2 cots in our unit. All patients coming to the hospital are screened outside the front entrance with a questionnaire. If there are any suspicions that they have symptoms of ebola (fever and 2 other symptoms) they are then isolated in a tent outside the hospital gates. Once there is a bed available in the unit, our role as doctors is to take a patient from the tent into the unit to have their blood test taken to confirm ebola or not. We try to take the sickest patient first; Tom tells me an easy way to triage is to do a very crude visual check; the sickest (and therefore most infectious) are first to get in the unit are those usually lying on the floor, then those sat on the benches and finally the least unwell are standing.  The first day I arrived there were about 10 patients in the tent, some had been there for more than one day. The alternative is to send patients home with a self-isolation pack and tell them to come back tomorrow – a less than ideal situation given the risks of onward transmission. And yet, this screening tent is the reason why Connaught Hospital has remained open for non-ebola medical care compared to most (if not all) other hospitals. Without a screening process, the patients all sat together in the A&E waiting area and the staff would have no idea until it’s potentially too late whether someone is a suspect ebola patient or not. This is the way healthcare workers get sick and fear spreads causing doctors and nurses to quit - something I can completely understand. As it is, at the moment, the rest of the hospital (300 beds) has only one doctor (Dr Terry, a recently retired medic from London).  All the junior doctors are currently on strike and the other few senior doctors have all died of ebola in the last few months – their faces in posters haunt the corridors; a continual reminder of the consequences of this devastating epidemic in a country that only had about 350 doctors at the beginning of the year.
In full PPE - I'm smiling I promise, you just can't tell!

Back to the Unit… once inside, a suspected ebola patient gets antibiotics, anti-malarials, water, oral rehydration solution and a blood test for ebola. They also get food twice a day from the hospital canteen. We are trialling IV fluid lines in the more stable patients with full auditing of any problems (there had been some previously) as rehydration is the most important intervention available. The blood tests take 1 – 2 days to come back so our 16 patients are told to stay in the beds, pee in one bucket next to their bed, poo in the other, and wait. There is plastic sheeting hanging between beds to prevent cross contamination. There’s a stench of chlorine (even through the mask) from the buckets in every room where we wash our hands between patients as we do all we can to try to prevent those negative patients becoming positive during their stay in the unit. When the test results are available, we give the negative patients a shower, a set of new clothes, a certificate and a bit of money for transport home. The positive patients get taken in an ambulance to a treatment centre – often Kerrytown, which is about an hour and half drive away.

There’s a fantastic team of local nurses and cleaners who we work alongside. They are often in full spirits and have been really friendly and welcoming to me. Inside the unit we all work together, helping patients to drink, giving medicines, washing down the beds, clearing up diarrhoea, vomit and blood and putting deceased patients in body bags and into the mortuary. It’s gruelling, hot work and exhausting in full PPE. In the decontamination room, we take off our PPE in the specific way required including the ‘shrug and wiggle’ move to get the suit off.  Lastly, we all compare sweat patches! Luckily this last week has not been so hot as the Harmattan has started (a West African dry wind that lasts for a few weeks).

My first shift proper, on Saturday, felt like a bit of a jump in the deep end, but actually I’ve come to realise it was probably fairly representative of an average day in the unit. Arriving at the main entrance of the hospital, I noticed an elderly woman slumped in a wheelchair that not many people were taking notice of, people just walking past her on the way to A&E and other parts of the hospital. Her relatives were sitting on the bench waiting for her to be seen at A&E themselves. I had no idea how long they had been there. However, it was quite obvious to me that she had died. I don’t know how long ago – whether she’d arrived at the hospital alive or even had been transferred to the wheelchair already dead. A nurse walked by in gloves & apron and, as I had no protective clothing on myself, she confirmed the absence of pulse but she didn’t want to tell the relatives. So I broke the bad news to the daughter, slowly, giving a warning shot, careful to use those good communication skills that had been drummed into us at medical school, even though we were stood there in front of her dead mother. She was upset but did not seem too surprised. Informing Tom of the situation, it was only then that I realised all sudden deaths had to be treated as ebola suspects. This woman’s daughter had told me she had a history of high blood pressure so I had just assumed she’d had a stroke, maybe she had, but the nature of the ebola epidemic is that you can never be too cautious. So all sudden deaths have to be dealt with full protection.  That had not occurred to me at all. Within, a few minutes, in full PPE we wheeled her into the mortuary, took an oral swab for ebola, covered her in chlorine and put her in a body bag with a nametag for an unmarked, unceremonious burial. There was simply no time for the family to grieve.  
A pretty blue wooden house we pass on our
way to the hospital each morning.

We then went to one of the open wards, where the nurses were concerned a patient had ebola and wanted him taken to the unit. Walking into the ward in full PPE, you could see the fear and silence descend amongst the other patients and their relatives (a surgical ward - patients with awful third degree burns, broken legs, head injuries etc). We transferred him to the unit and placed him in the only free bed, next to a young boy who lay curled up at one end of the bed facing the wall - the boy was the same age as my eldest nephew. Sadly, the man we had transferred died a few hours later before he had his ebola blood test taken so we took swabs instead. Again we put him in a body bag and transferred him to the mortuary. All the while I was thinking that poor little boy is witnessing such horrible scenes, how can he comprehend it all? He must have been so scared. In the isolation unit the scene can vary drastically day to day. The sickest patients nearly always end up lying on the floor, confused and too weak to move. They are also sometimes found lying in pools of diarrhoea and/or blood just next to comparatively well patients sitting quietly on their bed looking fearful.  On Saturday, one agitated patient, muttering to herself, had actually pulled herself towards another patient, holding onto his bed linen. It’s difficult to give any sort of reassurance through the barriers of the PPE and the patients unhelpfully just have to wait and sit it out.

The busiest time of day is when results are available and there’s a mass change over of patients in the unit. Yesterday the little boy, who had been curled up facing the wall, was discharged because he had tested negative. He was given new clothes, some jeans that were far to big for him, a yellow t-shirt and new flip-flops. He left the unit via the clean entrance where I was ready to greet him with a certificate and 10,000 Le (£1.30) to get the bus home. He was quiet and I’m not sure if he really understood the situation. With my arm around his shoulders, I gave him a big squeeze – the first human contact he’d had in 3 days, I tried to make him smile and reassure him that everything would be ok. We contacted his family and they came to pick him up an hour or so later. I was worried that this would be the first time I would witness first-hand stigma from his family, but thankfully I was pleasantly surprised.  His mother and grandmother arrived, all smiles, gave him a big hug and took him away. We are all thankful for those moments of happiness which so important to hold onto in such terribly difficult times.

Friday, 12 December 2014

A big thank you

I just want to say an enormous thank you to everyone who has sent me their well wishes, either directly, on facebook or via my mum! (I know she's been telling lots of people!)

Here's a little collection of cards I'm taking with me :)

It has meant a tremendous amount to me to know that so many people are supporting me, praying for me and generally keeping me in their thoughts. I'll try update this blog as much as I can - if there's anything you particularly want to hear about please let me know.

I'd also love to continue to hear from friends and family while I'm out there so please email me and keep in touch… a few routine day-to-day tales of ‘normal life’, especially over Christmas would be fab.

What to pack?

I've arrived safely, settling in and everything's fine so far! This is a blog that I wrote the day before yesterday that I can upload with the wifi at the office :) ... more updates to come soon.

So I'm sat in my living room and the day of departure is finally here.  In front of me are piles of clothing, a few pairs of shoes, 20-something pairs of socks (they recommend bringing plenty as you sweat through 2 or 3 in every 6 hour shift wearing PPE), a lantern, a UV water filter, my bikini, and various other things that I hope will be useful. I'm also taking a suitcase full of important equipment for the charity e.g. thermometers, printer toner, a couple of laptops. Finally, my parents are on their way to my house to bring me a 3rd suitcase which is stocked with yummy Christmas treats for the staff at Connaught Hospital!

(My mum has a sneaky habit of winning raffles and other such prizes. Sure enough, at the Missenden Christmas Fete last Saturday... mum not only won the main prize of a luxury Marks&Spencer's Christmas hamper and a 4.5kg fully iced Christmas cake but also the 'guess the number of sweets in the jar' (521 chocolate eclairs!). Combine that with the 4 packets of mince pies that Kings SLP sneaked into their suitcase, and the volunteers at Connaught might begin to feel a bit spoilt.)

So having had 6 weeks since my interview to prepare and get my head in gear, how do I feel?The main emotion, at the moment, is definitely excitement. That might come as a surprise and obviously there is a healthy amount of fear and anxiety mixed in there too.

In fact, I had a real nervous period a few weeks ago. Initially, it was fear of contacting ebola via a needle stick, slipping in my PPE or even an unknown exposure in a public space. I even had an unnerving dream I was inside the Royal Free Hospital my parents encouragingly waving back at me through the plastic sheeting.  But actually fears of contracting ebola have been somewhat alleviated by the few returning volunteers I’ve spoken to and general communications with Kings who know their protocols are tried and tested and are safe.

A but of an ‘eek’ moment was when I found out the accommodation facilities were fairly basic; external water supply, generator electricity for the lights and fridge only, meaning there would be no getting home from a tough day at work, having a normal shower and settling down to a good DVD, and certainly no wifi. This made me doubt my ability to mentally cope outside of work. Once again, however, having spoken to a few returning volunteers, they report conditions are not too tough. They reassured me that the team of volunteers is so friendly everyone makes sure there is sufficient ‘down time’. Hopefully I'll be able to send an update in a few days... So ultimately now all those fears have been replaced with excitement and eagerness to get out there.

However, if you've been watching the same news programmes and media sources as me then you'd be forgiven in thinking ebola is no longer much of a problem. It's certainly not half as prominent a news story as a month ago. I’m beginning to kick myself that I hadn't gone earlier and worried that there wouldn't be much for me to do when I arrived. And yet my daily HealthMap ebola email last night told me otherwise, it's 3 main alerts related to Sierra Leone: 1) More ebola cases recorded in SL than Liberia... 2) Junior doctors in ebola-plagued SL stage strike... 3) Ebola still spreading fast in western SL. So the demand for help on the ground is still very acute and it's with slightly anxious anticipation but lots of excitement that I pack my bags, hoping I've also packed my courage!

Monday, 8 December 2014

Irrational fears?

I’ve had quite a few conversations with people about what happens when I get back. My housemate cautiously asked me the other day, “Claire, will you, um, be staying here when you’re back?” gulp, an uneasy look in his eye. I can completely understand that there is a fear that returning healthcare workers (or members of the public, for that matter) bring back ebola to the UK. The issue of enforced quarantine certainly reached the media headlines in the US in a big way. I don’t think it has been very well explained in media that unless someone starts showing symptoms they are not infectious and they pose no risk to others. So I took the time to explain to my housemate that he will be perfectly safe to live with me, share the same cutlery, sit on the same loo etc when I get back as long as I am well (i.e. no fever, muscle aches, diarrhoea or anything else). And trust me if I have any doubt that I am developing any symptom whatsoever I will lock myself in my room and call 999 requesting a PPE-pick-up (personal protective equipment) ASAP.

Armed with this knowledge and understanding of the virus’ transmissibility my first ‘hands-on’ (excuse the pun!) irrational fear of contracting ebola took me completely by surprise. It was last week when I went to the Alma Mata talk at the Royal College of Physicians. I met one of the returning KSLP volunteers after the talk. He had just got back from Freetown a few days before and without any thought I held out my right hand to greet him. He made some reference to no-one shaking hands in Sierra Leone but he would allow me to decide whether to shake his or not now he was back in the UK. (I already noted that he had said earlier in the talk that he didn’t have a fever and I’m sure he wouldn’t have been there if he did!) I grasped his hand in mine and gave it the firmest shake I’m capable of, I think my left hand might have joined in as well just for good measure.  Almost immediately, I realised I had the picture of Barak Obama demonstrating how one should approach a survivor of ebola in my mind and not someone who may be incubating it! All of a sudden I became distracted, he was talking to me but I wasn’t really listening, all I wanted to do was wash my hands! I knew I was being irrational but a moment later I made some excuse to run to the bathroom and scrubbed my hands a few times until they were clean, then a bit more! I was so annoyed with myself for letting my irrational fear overcome sense and science.

This experience made me really aware that it doesn’t really matter how many times I say to my housemate or anyone else that they will be safe. There’s always that human instinct of distrust and fear and I suppose that’s what the media has taken grip of unfortunately. All I can do is be respectful of how this pathogen makes even the most sensible of us feel and try not to be too judgemental or condescending!

Saturday, 6 December 2014

I'd be nothing without my family...

One of the first questions most people ask me when they find out I’m going to help with the ebola crisis is “ What do your parents think? “ I am extremely fortunate to have a very supportive family who are behind me all the way. That doesn’t meant they are not nervous, obviously they are.  The two are not mutually exclusive. Actually, I think my mum’s doing remarkably well keeping her worries mainly to herself. The occasional bubbling thought, “have you got your malaria tablets yet?” or “will you be ok getting from the airport to the boat at 4am, when you arrive?” pops out somewhat accidentally.

My nephews on the other hand were a bit more blatant with their fears, little cries of “Auntie Claire, don’t die, don’t get ebola, come back!” accompanied by humongous hugs around the waist. This was the goodbye I got in the A&E reception of Nottingham Queens Medical Centre (where my littlest nephew had just been admitted with croup the day the family were all together at the end of November – he’s fully recovered now). I found myself fighting back the tears. I didn’t want the boys to see that “cool” Auntie Claire is actually quite nervous about getting ebola and does very much want to come back. Children really do have an uncanny way of saying exactly what’s on their mind, and yours, with no holding back. I love them to pieces.

I think one of the toughest things I’m going to find when I’m working in Connaught Hospital is looking after children with ebola. My nephews’ fear pale into insignificance in contrast to the reality of so many children who are fighting ebola themselves or are orphaned and vulnerable having witnessed their whole families torn apart by the disease. I read a wonderful light and cheerful blog by one of the volunteers at KSLP at the moment who is a paediatrician. I’m so looking forward to meeting all these amazing people that I am going to work with.

Monday, 1 December 2014

I want to be an Ebola doctor....

Back in August when the world was slowly waking up to the scale of this epidemic in West Africa, I started thinking about how I could help. I started looking at MSF recruitment but they required doctors with 5 years training and infectious diseases specialists.  No-one else seemed to be recruiting. I was stuck, I would have to resort to watching it unsatisfactorily unfold on the tv screen.

Then on 22nd September this email arrived in my work inbox and within 24 hours I had applied. In October, I also applied to the Kings Sierra Leone Partnership. To be honest, I wasn't sure if I would be qualified enough to go so it seemed like quite a distant idea at the time. Ever since that time though, with every article and news programme I watched about the increasing numbers of patients affected and the relief efforts struggling to control it, I knew I wanted to go and help and the sooner the better.

I had my interview with KSLP on the 30th October, and a few days later it was confirmed that I would be ready for deployment at the beginning of December. Since then the weeks have been dragging by somewhat and now I'm just eager to get out there, do my PPE training, meet my colleagues, learn some Krio and help in the little way I can. Obviously as the time creeps closer, there have also been emotional ups and downs, fears coming and going, and recently a few teary goodbyes.

I recognise that I am in quite an unusually convenient position in my career to be able to volunteer. I am currently on a year 'out' of training with no family or financial dependence, giving me a huge degree of flexibility. At a discussion panel run by Alma Mata on Thursday night it was frustrating to hear that a number of doctors 'in' training who wanted to volunteer were struggling to be released from their NHS commitments. There are all sorts of barriers such as missing out on training, covering the rota, the threat of being quarantined on return (which currently doesn't and shouldn't happen, by the way, as it makes no sense from a public health perspective - there's no transmission in the asymptomatic incubation phase).  Financial reasons shouldn't be one because DFiD is reimbursing the cost of replacing the doctors so that routine NHS care can continue. (I love the NHS!) The sooner we sort out some of these barriers the quicker more volunteers can be deployed and help in the efforts to contain the epidemic.

Meanwhile, I have my flights booked... I leave on the 10th December, eek!