New Developments, by Richard Lowsby

It has been a turbulent few weeks; the country’s leader has resigned and been replaced, senior politicians have been stabbing each other in the back and the opposition are in turmoil.  The population are divided after a bitter referendum, promises have already been broken and the rest of the continent look on in concern.  The health system is in financial crisis with concerns over sustainability, resources are stretched to the limit and morale is at an all-time low.   Patients are suffering and the staff that care for them are engaged in a battle with the health secretary with no signs of a resolution or solution.  I refer of course, to the UK and not Sierra Leone.

Rich_August 2016
Dr Rich Lowsby with final year medical students, photo by Ibrahim Kabia

I have been home for a few weeks, a trip slightly longer than planned, but have left the political turmoil behind and now arrived back in Freetown to experience the full assault of the rainy season. Gone is the dust and in its place, a damp humidity but at least it is slightly cooler now.  The large majority of my time before leaving last month was spent supporting the development of the hospital’s new acute surgical and trauma assessment unit.  This was the second phase of the new A&E development following the opening of the new department in March.  The unit opened while I was away and I am keen to see how it is going.

I was told that the ward had opened in a bit of a hurry when several seriously injured patients arrived simultaneously following a major traffic accident.  The staff had coped admirably and had continued to do so.  The sister and staff nurse in charge have the ward running smoothly, there is a list of responsibilities for each nurse on duty for each shift of the day.  Each bed has a chart on the wall above it with a plan for the patient.

The high dependency bed currently has a patient being monitored and provided with oxygen after admission for a gunshot wound and collapsed lung.  The lung is now re-inflated after placement of a drain and he is improving.  A patient with a significant head injury has just arrived in the trauma resuscitation room after an assault and the staff are assessing him, supported by the medical officer.  The surgical team are reviewing patients admitted overnight after their morning meeting, a man with a suspected perforated ulcer and a child with an infected wound after a snake bite may need to go to theatre.

Some of my colleagues have been conducting training to support the opening of the ward and have worked tirelessly alongside the staff to ensure it functions effectively.  I am thrilled to see how things are progressing and I have realised how important good relationships and team effort are in moving things forward.  Work initially began over 6 months ago and is now complete, the hospital has a new Emergency Department.  This has been in the planning for a while, well before my time and I feel fortunate to have played a part in it.

It is not only hospital management, doctors and nurses that have contributed, but we have been working alongside builders, biomedical sciences, cleaners, engineers, infection control, hospital stores, maintenance, Ministry of Health and Sanitation as well as the UK Department for International Development.  As a result of everyone’s efforts, the hospital now has a department that is geared to assessing and managing acutely unwell and injured patients, that staff can be proud of and patients can trust.  It is everyone’s responsibility to sustain this good work.

Published, with permission, from Dr Rich’s Lowsby’s blog, Sierra Leone Emergency

Enhancing Resilience: supporting the next generation of health workers in Sierra Leone

Freetown’s College of Medicine and Allied Health Sciences (COMAHS) was forced to shut its doors for nine months during the Ebola outbreak. Finally reopening in June 2015, COMAHS is critical for rebuilding Sierra Leone’s health workforce, despite its limited training capacity, poor learning facilities, and a major shortage of teaching staff in most areas. This essay tells the story of the partnership between COMAHS and KSLP, formed with the goal of building capacity and resilience in post-graduate education in Sierra Leone.

All photos © Katherine Wise/Momenta Workshops 2015

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A Day in Connaught Hospital's Intensive Care Unit

Today we are in the Intensive Care Unit (ICU) at Connaught Hospital where the nurses are conducting their afternoon handover. Alongside Sister Elizabeth Kamara, the ICU sister-in-charge, KSLP’s Dr Ruth is leading today’s handover.

DSC_0071 It’s is a quiet day in ICU so Dr Ruth is taking time to test everyone’s knowledge on the importance of fluids and how to provide oxygen. Her energy is contagious as she asks about each patient:

“Ok, so why might this patient’s condition have changed?”


“Chest Infection?”

“Reaction to the blood?”

“Exactly, it could be any of those things, so if there is a change in the patient condition, we need to think about what might be the cause and what you need to tell the doctor in charge.”

ICU sister-in-charge, Sister Elizabeth Kamara,

Such on the job learning is highly valued in this unit. The daily handover is appreciated as much for ensuring the consistency of patient care, as it is for the opportunity to receive further training.

“Mentoring other nurses is the best part of this job,” said Sister Elizabeth. “It’s great to be able to share my knowledge and understanding with others.”

A close relationship builds between the nurses and their patients. In ICU, they provide ‘complete nursing,’ which includes everything the patient like feeding, fluids, and pain management. Any and every change in the patient’s condition must be recorded. This is a major responsibility, but all of the nurses shoulder it professionally.

DSC_0015 Each provides a detailed history of every patient at the end of the shift. Histories include details of why the patient was admitted, when he or she was last seen, and the critical points in his/her care and management. Despite seeing some tragic cases, optimism abounds in the unit. After all, “ICU is where we treat critically ill patients,” said Sister Elizabeth. They are the ones we know we can revive again and bring back to life.”

From Ebola Isolation Unit to Modern A&E Unit: Transformation at Connaught Hospital

KSLP Emergency Medicine Doctor Rich shares his reflections on the recent A&E refurbishment at Connaught Hospital

The entrance doors were unlocked, revealing dark corridors and empty rooms illuminated only by slivers of sunlight stretching out across the bare floor through broken panes of glass.  My eyes struggle to adjust, pupils dilating as I peer into the shadows. It’s humid and I can already feel beads of perspiration forming at the back of my neck.  The tiles have faded after repeated dousing in chlorine and a fine layer of dust has settled to give the ward an eerie, long-abandoned feel.  This was once part of the red zone, a place of fear and tragedy for many, a place where local staff worked alongside foreigners doing the best they could in a period of great uncertainty.  It is now silent, no one has been here for quite some time.

By the time the epidemic reached Freetown, hundreds of cases a day were being diagnosed across the country and the staff at Connaught needed to act fast to establish an Ebola isolation unit in an attempt to contain the virus and protect its healthcare workers.  Prior to the epidemic King’s had a program in place to help strengthen the emergency services at the hospital and had already introduced a triage system to expedite assessment of the sicker patients that presented to the hospital.   The outpatient department was re-branded as the Accident and Emergency unit to re-inforce the need for timely and effective urgent care for the critically ill and injured patients that attend there on a frequent basis.  An emergency that no one expected subsequently swept across the country at alarming speed and the Accident and Emergency ward was transformed into an Ebola holding unit.

In time, a purpose designed isolation unit was established alongside the hospital and the old unit, after decontamination, became redundant and stood empty; a dark reminder of painful recent events.  When I arrived, just over six months ago, we were isolating and managing suspect patients in the new unit.  I had heard some very upsetting accounts from colleagues, from both Freetown and abroad, that were around at the height of the epidemic and I struggled to imagine how challenging the conditions must have been. Before Christmas, it was opened up and I was able to enter inside.  Renovation work would soon be starting on a new A&E Department and I was curious to see what would be required to transform a place where the grief was still tangible into a facility that will aim to revolutionise emergency care for inhabitants of the city and beyond.

Dr Rich working on the A&E refurbishment at Connaught Hospital

During the epidemic, the emphasis of the government and international agencies was focused out of necessity in containing the disease.  This was no doubt to the detriment of other health related issues.  Maternal and child mortality rates will have increased, surgery throughout the country was suspended and I have seen many HIV and TB patients that defaulted on treatment.  Most health facilities shut down but Connaught remained open, providing a much needed service to those that were sick but not suffering from Ebola.  The A&E, in its temporary facility, continued to deliver essential care at the front door, at great personal risk to the brave staff that served throughout.

We have seen the country declared free of Ebola twice now since I arrived and with recent cases in Guinea, it seems unlikely that the country will never see another case.  The skill and expertise now exists in Sierra Leone to manage the situation and gain control rapidly, the focus is now on re-building and strengthening the health care system.  This is now the main emphasis of the work of King’s at Connaught and of my role in the Emergency Department.  The lasts few months have seen huge steps forward in the delivery of emergency care and much of the credit should be given to my colleague Ling who has worked tirelessly over several years now to develop the A&E in conjunction with the hospital staff and Ministry of Health.

Before: the future A&E unit pre-refurbishment
After: Dr. Ling stands in the newly refurbished A&E unit

The end of February saw work complete on the old isolation unit and the new A&E, along with resus and medical admissions units opened to patients. Equipment and patients were transferred seamlessly, coordinated by Sister Kamara, in under 2 hours and there was impressively no delay or impact on patient care and safety. Several of the staff came in early of their own volition to prepare the department and I was told off for being late by one irate nurse who had been there since 6am.

Ling is now back in the UK and is sorely missed by all the staff she worked with at Connaught, although she has left a strong legacy.  Several high profile figures have visited the department in the last few weeks including the deputy health minister, chief medical officer and chief nurse; all have been impressed.  The staff are revitalised and proud of their new department, they are eager to learn how to use the new facilities and equipment.  We have a new enthusiastic and motivated medical officer and Emergency medicine is enjoying a raised profile in Sierra Leone currently.  I’m sure that this is all having a positive impact on the care of the patients, who seem to be attending in ever increasing numbers. The big challenge now will be to sustain and build on this momentum and ensure that the ministry can support the hospital to develop systems and maintain a supply chain that will keep the acute care facilities functioning effectively for the benefit of the patients.

A lot has taken place over six months and a great deal more is to come. While work has the potential to become all-consuming at times, it is the down-time and the support of those who are close that is important to maintain a sense of balance and perspective. My personal highlight has been the visit of Alice, who arrived in Freetown last month as my girlfriend and went home as my fiancée. I was really pleased to be able to share my experiences and show her the highlights of what can be, at times, a beautiful country. In a place that offers tropical islands and idyllic beaches in abundance, I felt the most appropriate spot for a proposal would be in the jungle surrounded by howling chimpanzees. Fortunately, my gamble paid off and she agreed to marry me!

The Laboratories: a Perfect Representation of Both History and Change at Connaught Hospital

“Let me show you… So you take this cartridge, be very careful not to touch or damage the barcode when you put the sample in, otherwise it won’t scan. Then, we put 1ml from this vial in the cartridge and then place it in chlorine for 20 minutes. This kills anything from the sample that’s on the outside of the cartridge so when we put it in the machine it’s the deactivated virus being scanned.” We are in the laboratory department at Connaught Hospital and our colleague Mohamed is demonstrating how he uses the newly installed GenExpert machine donated by WHO to screen surgery patients for Ebola. This test, which takes only 90 minutes to process, can have a dramatic impact on the safety of both the surgeon and patients.

Mohamed demonstrating laboratory techniques

The laboratory department is a perfect representation of Connaught’s history and change in progress. In one room sits the original Microtome machine from when the hospital was opened in 1912; it is still processing histopathology samples (sectioning) to test for conditions like cancerous or malignant cells.  In another room, Mohamed is running the fully modern GenExpert machine to screen patients for Ebola and HIV, as well as other infectious diseases.

KSLP Labs Coordinator Billy in the Connaught Hospital Labs

Through Sierra Leone’s post Ebola recovery plan, we expect that the way labs operate will continue to undergo substantial changes. Billy, KSLP’s lab co-ordinator, will be working with the Labs team to drive improvements to help navigate this process.

Alumni Profile: Ahmed Seedat and the Importance of Building Relationships

I initially volunteered with KSLP as clinical lead from September 2013 to March 2014, having spent the previous six months volunteering with VSO (Volunteer Services Overseas) in Sierra Leone.

Amed SeedatIn those early days it was just Oliver and me, shortly joined by Suzanne, so our roles were a little more fluid and we had a bit more space in the office!

My role mainly involved supporting the Connaught Hospital Improvement Committee, particularly in strengthening the Accident & Emergency Department, supporting colleagues at COMAHS in delivering teaching and training for undergraduate medical students as well as working on postgraduate training with a focus on strengthening the internship programme.

I returned to Freetown in August – September for the Ebola outbreak.

Back in the UK I’m a Respiratory Registrar trainee based in South London but left for an OOPE (out of programme experience) in November 2015 – I managed to stay in the UK for just over a year!

Currently I’m in Yida, Unity State, South Sudan working as a medical doctor for MSF. In Yida, MSF are providing medical care for the refugee population affected by conflict in South Sudan and the disputed South Kordofan region.

Although the context is very different requiring a different approach and perspective I find that as with KSLP, relationships between national and international staff, the wider community and other key stakeholders are extremely important. This can be less than straightforward in an unstable region or area affected by conflict. Nevertheless, building relationships particularly with colleagues and the local community lays the foundations for trust, mutual learning and knowledge exchange which is not only helpful for us as individuals but hopefully translates into wider health gains for the local population.

A Passion for Nursing – Connaught Hospital Matron Isatu Kamara

Since she was a little girl she had Connaught Hospital relies on its team of dedicated nurses to keep functioning. Isatu Kamara, or as we all know her as “Matron,” has been at the helm of this team since 2014.

Since she was a little girl she had “the passion to become a nurse.” She started her career as a Registered Nurse at Connaught so she knows all the “nooks and crannies of Connaught.” She left Connaught to continue her career working in Kambia Government Hospital, Ola During Children’s Hospital, and Kabala Government Hospital. Before returning to her home at Connaught, she had been the Matron of Kenema Government Hospital for three years. She uses her extensive managerial and technical experience to ensure that the highest quality of nursinc care is available to all patients. 

When asked if she has advice for future nurses, her answer is that “you should be willing to perform, you should have the capacity to perform and have the opportunity to perform.” A strong enabling environment is particularly important to Matron who explains that “if we have the basic equipment, skills and motivation then the enabling environment is there for nurses to perform.”

Matron is very proud of the recent changes to the hospital, especially the cleanliness of the wards after the recent IPC training that has been conducted. “Connaught Hospital is such a different place, I encourage all people, partners and staff to make the most of the facilities available such as the Oxygen factory, the A&E Department and the Infectious Disease Unit.

Reflections from the Intensive Care Unit – Ruth Tighe

I graduated from Nottingham Medical School in 2004 and after many years out exploring countries and specialities, I finally decided on Anaesthetics/Intensive Care Medicine.  In the past most of my experiences working abroad have been aimed at improving my clinical skills, to ensure I have been exposed to extreme cases to hopefully make me a better registrar.

I would have always claimed global health was an interest but until January 2015, I wasn’t planning to adventure out to Africa again until I’d become a consultant.  But then the idea of Sierra Leone came up via one of my best friends, Ling – Emergency Co-ordinator for the King’s Sierra Leone Partnership and I couldn’t resist.

I chose to work with King’s because it proposed a unique way of developing intensive care in a low income country that has no post-graduate training and less than 5 anaesthetic doctors in country. The King’s approach thinks more about the system and the professionals you are working with rather than your own skill progression.  King’s encourages a gentle approach via role-modelling for staff working in the main governmental tertiary hospital, to instil comprehension and propagate behaviour patterns that will continuing after I’ve left. Essentially it is about being incredibly patient, building relationships, and working together to spot holes in the functioning of the Intensive Care Unit. Most solutions are achieved without huge changes in practice; the focus is rather on training, education, and monitoring outcomes to demonstrate efficacy.

Although we are mostly volunteers, we are trying to tackle large-scale projects to impact on the entire health system. One of my first tasks as Critical Care Co-ordinated was to support the ICU to improve the provision of oxygen in Connaught. My first four months were focused on the development of the first fully functioning oxygen factory in the country. The results have been impressive. In the three months since we got the first piped oxygen in the country, we’ve seen mortality drop by nearly 30%.  My dream is that my colleagues and I can start a program that shares our experiences with the five non-functioning factories in the districts so that all of Sierra Leone would have access to simple oxygen therapy. Our next project is to implement non-invasive ventilation and again hopefully see another fall in mortality and potentially expand this out to districts. It is incredible to work in a system where simple changes can produce such a drastic change in outcomes.

While I’m not necessarily getting awake fibre-optics or ECMO experience, I am getting more teaching, management, research, and quality improvement opportunities than I thought possible. Being passionate about this cause easily motivates me to work hard to get one project finished so I can start the next one.

Sierra Leone has been through a lot, yet there is an overwhelming sense of gratitude that they’ve come through the war and Ebola. Everyone here has such a strong faith, which is probably what holds them all together through such tough periods.

My respite is knowing I get weekends surfing at Bureh Beach – every week by the time Friday comes I’m so excited to get back in my new-old defender and bounce along the coast, hang out with friends to attempt to stand on my foamie board in the white water – it washes away any stresses from the previous week and gets me refreshed for the next.

I’d be lying if I said this wasn’t stressful.  Witnessing the poverty and the needless deaths of people who can’t afford their health care is extraordinarily draining. But any time it starts to break me, I reflect on our wonderful NHS (long may it last!),  and that I am lucky to be healthy, to have received a full education, and to be trained in a job that I love that lets me travel the world!

42 Days Ebola Free

Today is a day for celebrations, as Sierra Leone achieves its goal of 42 days without a new case of Ebola.

Throughout the epidemic, we have been privileged to work alongside and learn from our partners as they have responded to this challenge. Congratulations are due to all the health care workers of Sierra Leone who faced personal danger as they worked ceaselessly to stem the outbreak. Your bravery and dedication during this period has been inspiring.

isolationwardWe commend the Government of Sierra Leone for their leadership and management of the crisis. We look forward to working together in the recovery process to build a strong and resilient health care sector.

King’s Sierra Leone Partnership would also like to give a special thanks to all of our volunteers and supporters, who offered such amazing support during this time, both in Sierra Leone and abroad.

Ebola don don, leh wi take am so

Ebola is gone, let us keep it this way.