Sunday, 25 January 2015

How (not) to communicate in an ebola crisis

16th Jan: A few days ago, I received confirmation of my interview in London on the 28th January for Core Medical Training – the next step in my training that will re-start in August. So I’ll be heading home a week on Sunday for 10 days for a break and to coincide with this interview.
On my one (half) day off last week, I started to think about interview preparation and looked to a list of sample questions:
  • Tell me about a time you’ve had to show resilience to achieve a goal.
  • Please describe a time when you were unsure whether what you were being told represented the patient’s true thoughts or feelings. How did you recognise this? What did you do about it?
  • All Doctors need strong communication skills. Can you give me an example of when you have used your communication skills in a difficult situation?
Ha! How am I ever going to talk about anything other than my experience at Connaught Hospital?

Communication in an ebola context – I could write a book about this! Just trying to take an accurate history from a suspect patient in the screening tent has been one of the hardest things I’ve done since leaving medical school. Firstly and most obviously there is a language barrier. Krio is a really cool language. It’s relatively easy to understand maybe 70% of it is actually English in a ‘slang, kind of sloppy accent’ with the odd ‘nah’ and ‘de’ thrown in between words… “Ah da go nah beach” for example. I’m getting quite good at asking a history in Krio, “you de bodi wam?”, “you de vomit?”, and my favourite… “you de toilet fast fast?” But even having mastered the lingo, it’s rare that you get a straight answer. It feels like there are about a hundred and one ways to ask if someone has a fever. They will often completely deny it, “no bodi not de warm, no, I not get no fever… but I get feel fo malaria and I de sweat beaucoup” and the person is obviously sitting there in a thick coat, dripping in sweat and shivering. You check their temperature and it’s 39 deg C.

Communication between colleagues is also tricky mainly because whilst wearing PPE your hearing is all muffled by the suit, your mouth’s covered by a mask and there’s nearly always a background din of arguments, distressed relatives or ambulance sirens nearby. It’s so essential that the team is well organised though and communicating effectively. Especially if it’s a busy morning in the unit with multiple negative patients to discharge and new suspects to admit, ensuring everyone gets the correct name band, bed number and making sure their paperwork all matches up correctly is essential. It also doesn’t help that there are only about 6 different surnames in Sierra Leone; so at times there can be many Kamaras, Sesays, Koromas, or Contehs on the unit along with multiple Fatmatas, Mohammeds and Ibrahims etc. You can see how easily problems arise!

Good communication skills is something that the western-trained doctors and nurses have had drilled into them since day one of their training. It would be easy to blame the ineffectiveness of communication to a simple difference in culture here but I do believe it is something that can be taught and practised and improved upon. The importance of this was no more apparent to me than on Monday when I was called by the doctor working in out-patient department to speak to a relative of someone who had just died. Assuming, incorrectly it turns out, that the doctor, who had assessed the patient when she was alive and witnessed her death in his small office, had told the relative I introduced myself to the husband and added “I’m sorry for your loss”. However his blank bewildered stare made me realise suddenly that no-one had actually told him. So, embarrassingly, I tried to back-track very quickly, took a brief history and broke the bad news (again) hoping he wouldn’t remember the first thing I said. Oh dear, what an example of how not to communicate - maybe not one I should bring up at interview!  Later, I talked directly to the doctor and asked him why he hadn’t told the husband. Looking uncomfortable, he made an awkward remark about how he prefers to avoid talking to relatives about death directly. “It often just makes them too upset, sometimes they can even get angry and aggressive and I don’t like it when the situation gets difficult like that”. This just made me feel unbelievably lucky for the medical training I received and the quality of professional care we have in the UK. This doctor didn’t know any different, he’d never been taught how to effectively talk to patient to elicit what’s going on, how to actively listen to someone’s ideas, concerns or expectations, or have compassion or empathy in informing a man that their loved one has died.

The NHS feels like a galaxy away. I know there are shocking news headlines of busy A&Es and unsociable work hour disputes in the UK right now.  A few weeks ago I would be right in there campaigning for a more just system as well, and of course, I still do support the negotiations for fair junior doctor contracts… and yet here, the debate scales into insignificance. Similar issues crop up, ofcourse, but in Sierra Leone it’s healthcare workers campaigning to get paid in the first place. Since the ebola response scaled up a few months ago, there are some nurses and cleaners in our unit that have still not been paid a penny for the dangerous job they have opted to take on. All ebola healthcare workers should get paid a ‘hazard pay’, which is a monthly financial incentive to work with high-risk ebola patients. A recurrent problem encountered in some of the other hospitals that KSLP supports (and many others, I’m sure) is the list of ‘hazard pay’ ebola staff seems suspiciously large compared to the number of people actually working in the unit.  There are numerous other examples of corruption in the system here, but I’m getting away from the point…

25th Jan: I never managed to post the above blog – got side-tracked/busy with IPC spreadsheets – oh how my Kings colleagues will tell you, “I do love a good spreadsheet!”  I’m currently sat in Casablanca airport on my way home. What will await me? cold weather – it was minus 9 in Amersham a few days ago; culture shock – just the journey home on the tube will feel like a jump in the deep end of technology, functional transport systems and busy, unfriendly people; a welcoming, comforting cup of tea with housemates – definitely.

How about stigma – well maybe? Since I’ve been in Sierra Leone, I’ve heard of countless examples of returning ebola workers facing concerns of friends and family not wanting to see them for fear of contracting ebola. There’s a common theme running through most examples, it’s always in reference to children. I was talking to one Save the Children medic on my flight just now who says he cannot go home to his wife and kids for the next 21 days because his children’s school will not allow them to attend if he sees them for fear of spreading ebola. Similarly, following very honest discussions with my brother, it was also decided that it was probably best I didn’t attend my nephew’s birthday party on Thursday, not because of the risk to his family but the concerns of the other kids’ parents that will be there too. I completely understand where this worry originates. I think the vulnerability of precious, innocent children and our inability to quantify risk appropriately as human beings leads to an emotive sense of overprotection. If the image of a sick, weak and confused patient vomiting blood doesn’t warp one’s sense of risk then I’m not sure what will.  Over the next 10 days I’m just going to have to remind myself of how I felt back at the end of November when I impulsively washed my hands after meeting a co-worker from Kings. Sometimes fears are irrational and there’s nothing we can about that. Let’s just hope I avoid getting the 'flu (and a fever that gets confused for ebola) so that I can actually attend my interview on Thursday!

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