|Fire in the engine?|
|Luckily we broke down next to this fruit & veg stall|
|KSLP vs Isolation Staff Football match|
Back to the point of my blog and probably what you are more interested to hear about…
Just before leaving Freetown at the end of January, Connaught Hospital Ebola holding unit was enjoying a relative quiet time. (All doctors will know that you should never say the ‘q’ word as it just jinxes things for later). There were nearly three weeks in a row when the unit did not have a single positive patient identified. There was general optimism in the team and things seemed to be improving all over the country with the daily case number consistently in single figures for the first time in months. The topic of discussion had changed towards how to deal with the low numbers of cases (and high proportions of patients testing negative in holding units) and keep vigilance high to prevent lapses in the screening process and so exposing healthcare workers in the main hospital to potential Ebola suspects. So it was with some frustration that in the first week of my return, I found the holding unit full and a few positive cases identified. We’re not talking big numbers but 1 or 2 positive cases every few days. As I’ve said a few times in this blog, it’s difficult to know what’s happening elsewhere in the city. There are so many different holding units now (which is fab) it just means the burden of the epidemic is spread and although Connaught hospital are only seeing occasional cases, if this replicated across 10 different sites then we still have a significant epidemic. In fact, the national data has shown a fluctuating daily case rate of between 2-12 new infections in Freetown over the last month. Dr Tom (the original ID consultant who trained me) has written an insightful blog entry about how the ‘last mile could be the longest’ in winning this battle and I very much agree with him. We are very far away from having 42 days (two incubation periods) of no cases, which is the current definition of end of the outbreak. Cases are still spread across different areas of Freetown, different districts of Sierra Leone and also the neighbouring countries of Liberia and Guinea… the whole region is so interconnected that each village, town or city really can’t afford to become complacent until all three countries are in the clear.
So it’s going to be a long time yet until we are ready to stop screening all patients that attend the hospital. This means that everyday sick patients who meet the case definition are getting non-specific and often inadequate care in an Ebola holding unit rather than seeing the ‘normal’ doctors in the Accident & Emergency departments. All this in order to protect healthcare workers and trace every last case of Ebola but at what cost to individual’s health? For example, a lady who is currently under investigation for possible Type 2 Diabetes at another health centre, attended our hospital feeling unwell, met our case definition and was admitted to the unit. Over the next two days she deteriorated and sadly died before her Ebola blood result was available. Simple investigations are put on hold due to the risk of Ebola, for example a glucose meter, which would have made the difference in giving this patient some insulin and preventing her likely diabetic coma leading to death. The family also have to come to terms with the fact she will have a ‘safe’ burial as an Ebola suspect – although this, as I discovered yesterday on a visit to the Kingtom Cemetery, is very complicated process and topic for a blog entry of its own.
We had a patient in our unit this week with tetanus. He was isolated for Ebola as the overlap of symptoms can mimic almost anything and yet as time progressed and his clinical condition developed it became more obvious that he had tetanus; recurrent tonic seizures with a classic lock-jaw, arched back and neck extension. He even had a puncture wound on his right foot where the often-deadly spore entered his body. I remember looking after a couple of patients with tetanus during my elective in an Infectious Diseases Unit in a tertiary referral hospital in Senegal. That was in the intensive care where they had oxygen, strong painkillers, and close observation for quick response to seizures. There are many distressing aspects about tetanus, patients remain conscious throughout their muscle contractions and experience a great deal of pain. Within the unit, we were able to initiate antibiotics and whenever a healthcare worker witnessed a seizure, we could administer diazepam and monitor him for respiratory depression. However, there are times when no one is inside the unit and so our care was suboptimal. Once the neurotoxin takes hold, “if patients can be supported through one or two weeks of muscle spasm and other complications, the chances of complete recovery greatly increase” (Current recommendations for treatment of tetanus during humanitarian emergencies, WHO Technical Note, January 2010). Also, the KSLP pharmacist, Suzanne, spent an afternoon trying to procure tetanus immunoglobulin from any pharmacy or hospital (including the private ones) in Freetown but nobody stocked it. Most frustrating of all is the infection is completely preventable with routine childhood vaccinations. The man had a negative Ebola test and has been referred to the hospital for ongoing support.
I mentioned in an earlier blog entry, non-Ebola healthcare, about trying to arrange a system for our negative discharges. This is very much work in progress but some successes have been achieved in the last few weeks. Connaught Hospital, with agreement from the Ministry, now waivers the 15,000 Leone registration fee for all patients who have come through the Ebola holding unit and tested negative and also Ebola survivors from treatment units. There’s now a referral method for reserving a bed in observation unit, even from other holding units across the city. This was essential because on countless occasions ambulances were coming to drop off patients for ongoing medical care when there were no beds available or without informing the patient’s relatives. It’s by setting up systems like this that I think Kings’ can have a real positive and sustainable impact on the functioning and efficiency of the health service.