Theory to Practice – My Elective with the King’s Sierra Leone Partnership

By King’s elective student James Barnacle

I had been interested in Global Health for several years before being lucky enough to study the intercalated degree at King’s College. It expanded and developed my interests, looking at how and why countries developed and the relationship between development and health. It was on the course that I first heard about the King’s Sierra Leone Partnership, and met Oliver Johnson, who at the time was teaching and tutoring on it.

Until my elective I had never been to sub-Saharan Africa and a year of narrowly spaced exams meant that I was reluctantly losing touch with the global health world. A medical elective with the partnership was a fantastic opportunity to consolidate what I had learnt, emerge myself in global health once again and see the theory and principles from the course put into practice. With this in mind, Anna (a colleague from Cardiff who had also studied global health) and I found ourselves outside the KSLP office on the second floor of the administration building at Connaught Hospital, not really knowing what to expect but very excited to find out.

What the KSLP office lacked in space it made up for with filter coffee, wifi and an incredibly friendly atmosphere. On our first day many of the faces were already familiar after we had joined several of the team the night before in a desperately empty national stadium to watch Malian singer Salif Keita! Oliver introduced the partnership’s work in Freetown and I was surprised at how discussions and seminars from the course were flooding back to me as I heard about KSLP’s recent achievements and future plans.

We were given several projects during the six week placement including collecting timings and demographics of those presenting through the front gates before and after the introduction of a triage system aimed at prioritising sick patients. In addition, we evaluated the nursing skills lab by performing an inventory, talking to nursing staff and students and identifying areas for improvement.

The partnership works closely with the nursing school, and more effective use of the skills lab will improve nurse training. We presented recent KSLP research at the annual Health and Biomedical Sciences (HBIOMED) national conference to leading academics in Sierra Leone. Finally, we helped analyse epidemiology data from over 350 patients to identify key presenting complaints, investigations, diagnoses and drugs. This will help direct the free emergency drugs initiative being introduced at Connaught, but in the future will be a reference for lab test requirements, disease burden and drug prescribing.

As well as liaising closely with the KSLP team, working with local staff and students was an integral part of our projects. Two nursing students, Benson and Sahid, worked closely with us collecting the inventory. In A&E, we had a strong rapport with Dr Cole and the nursing team who played a crucial part in the data collection. On ward rounds, we developed friendships with the medical students, some of whom had even visited Wales on their elective. They were enormously welcoming and always willing to answer questions about their challenges and experiences.

The autonomy we were given forced me to draw from the skills I had gained on the course, notably critical reflection in the context of health system strengthening, development and policy. Our time there gave us a window into an organisation working closely with the government to put the principles I had learned about into action. I could not imagine a more engaging and enjoyable way to put the ideas I had developed on the global health course into practice. I will stay closely linked with the partnership and hope to return to Sierra Leone in the future.

My student career at COMAHS

By COMAHS student Asad Naveed

My name is Asad Naveed, I am originally from Pakistan but I have stayed most of my lifetime in Sierra Leone and underwent my secondary education and now my tertiary education here. I have now applied for naturalisation.

I joined the six year Medicine programme at COMAHS, University of Sierra Leone in 2008 and will hopefully graduate this year.  Since starting my course at COMAHS I have been involved in student union activities. I have served as the information and communication officer in the student union for three years. When I was in 4th year, I had the opportunity to meet Oliver Johnson of King’s Sierra Leone Partnership and from the very start I was keen to be involved in the Kings Student programmes, one of which included participation in a research project by a King’s global health student- Danny Mclernon Billows on the problems affecting students at COMAHS such as high dropout rate and learning methodologies.

In August 2013, when I was in 5th year, I had the privilege to be selected to do my electives at King’s College Hospital in Denmark Hill. This was an important milestone as I was able to experience health care delivery in developed settings.  On our visit we received a warm welcome from Catherine Marshall and Victoria M. Bakare from the King’s Sierra Leone Student Partnership (KSLSP). In our first day, they showed around the hospital and introduced us to our supervisors. Later on they took us bowling ( my first time) and for pizza. We were also able to discuss issues about the KSLSP partnership.

Recently, I was part of the Sierra Leonean delegate to visit the International Federation of Medical Students Association (IFMSA) General Assembly in Tunisia. Tunisia is great country with beautiful scenery. For the very first time, I was able to meet a huge number of medical students from many countries in a single platform. The conference was truly international in every way. Every country had a say in the IFMSA decision making process which was great. We unexpectedly met Victoria in Tunisia as well who was part of the Medsin-UK delegate. She was able to link the Sierra Leone Medical Students’ Association (SLeMSA) with Medsin-UK a connection which helped SLeMSA get full membership with IFMSA. Upon return from the visit, I stood for presidency of SLeMSA and have successfully become the new President of SLeMSA.

King’s has made a positive contribution to my professional and personal development. I am much awakened now about public health issues which make a difference in our society and I look forward to further involvement with the partnership in the future.

Ebola was not part of the plan

By Dr Marta Lado

Three weeks ago, I flew from Madrid to Freetown to start my new role with King´s Sierra Leone Partnership at Connaught Hospital. I was nervous and excited about what was ahead – but my Terms of Reference made no mention of what I was about to be involved with.

The day I landed news broke about an Ebola outbreak in Sierra Leone’s neighbour Guinea. As a specialist in infectious diseases, being involved in an haemorragic fever virus outbreak response is both an incredible and threatening experience.

Fortunately, we have not found any confirmed cases yet in Sierra Leone, but being part of the National Ebola Taskforce within the Ministry as a KSLP representative is fascinating, but also quite daunting.

This role puts me at the forefront of the preparedness response. The Taskforce is regularly updated on the current outbreak and we participate actively in the preparation of the population and of health care workers in case the disease spreads to Sierra Leone. We gather at least once a week to improve the communication between the different health care units and prepare training courses for health workers.

Arranging isolation of suspected cases and preparing personal protection equipment (PPE) for the health care staff is very challenging in this setting and especially in rural areas, where basic equipment like gloves and gowns can sometimes be hard to get hold of. Our work must be therefore focused on adjusting all the protection and management protocols to a specific low resource setting but without underestimating the risk and the importance of every measure.

It is also critical to supply healthcare workers with extensive information through basic guidelines as well as sanitation and isolation PPE kits to reduce the risk of transmission. Ebola is transmitted by body fluids (blood, excrement) and therefore protecting every centimeter of the body and skin when a care giver or health worker is looking after a sick patient is essential.

According to our current guidelines and the WHO protocols, a suspected patient must be immediately isolated.  The doctor in charge must then communicate nationally and coordinate for blood samples to be taken. The patient is to then be referred to the Lassa Fever Centre in Kenema District to be managed by experts in haemorrhagic fever syndromes.

While this unexpected role has been extremely challenging, I have also learned an enormous amount and gained invaluable experience. We hope that the efforts made will help to prevent the spread Ebola in Sierra Leone and we will be on hand to support and counsel at any situation that arises during the next months.

Setting up a triage 101

by King’s volunteer Mike Bradfield

Prior to last week, Connaught had no functioning triage  – a system used in the Accident and Emergency ward to determine the priority of patients’ treatments based on the severity of their condition. Setting up a triage is a major project of the Connaught Hospital Improvement Committee and King’s has been working with key staff from across the hospital and the Ministry to lay the foundations for this project. My background as a paramedic has (hopefully) placed me in a good position to work with hospital staff to prepare for its launch and help it get off the ground.

We decided to start with a pilot to allow us to resolve any issues before the wider training and implementation takes place. In preparing for the pilot we identified four nursing staff recommended by A&E Matron Kamara. It was also decided that it might be worth checking with these staff that they actually wanted to do this, but following a brief meeting with Dr Ahmed and I, all seemed to have a firm grasp of what triage would involve and supported the idea. It was encouraging to see how much enthusiasm there was for change and improvement. So far, so good.

The South African Triage Scale (SATS) tool appeared to be relatively straightforward (note to self, no triage system is straightforward), and with a day assigned for teaching later in the week a training package was put together, handouts printed and a plan for the day written. Anxious to avoid death by PowerPoint, the training included a walk-around of the new triage area of the hospital and some discussions around the practicalities of how the new system would work.  We also wanted as much input from the nursing staff as possible and for them to be involved in decisions around the way it would be used. It seemed important to spend time ensuring staff have a good understanding of the rationale for triage and its importance at Connaught rather than focus only on the minute details.  But we still needed to cover how the SATS tool functions. Let’s be honest, it isn’t really first date material, however enthusiastic we all are about it.

In a warm room with no air conditioning, an hour session was extended to several due to a large number of questions and discussions.  In a bid to liven things up, we recruited Senior Nurse Nyama to role-play a difficult patient wanting to know why she was not being seen in turn.  Nurse Salamata was far better able to explain the triage system than I had been able to that morning and Nurse Hajara faced down any criticism of the system with a very succinct and direct summary of the reasons for waiting (which would be used by her again the following week to excellent effect).  It was beginning to feel that with this level of engagement and enthusiasm, we could make this work.

With the training started, the building work complete and the Facilities and Maintenance staff (Willie and Abdul, you know who you are, even if we rarely know where you are) working very hard to repair and clean the necessary equipment and areas, 3rd March was confirmed as a start date for the triage pilot. The Friday before the Monday that the pilot was due to start, we had very little equipment but we did have a desk. And we had a lot of phone calls and many more promises of equipment to be delivered yesterday. The list was not long, but it was important. Given that we had no blood pressure cuff, stethoscope and clock with a second hand, the whole process would be impossible.

With so many people having worked so hard to get to this stage, we had to get it right. Enter Dr Ahmed Seedat, medical doctor and troubleshooter with an impressive medical CV that also includes sourcing equipment, knowledge of plumbing, tiling, grouting and tireless negotiation. Ahmed soon helped smooth out those final few details just in time for Monday launch.

Setting up a triage takes time and contributions from many people, and I’m happy to say there was no reluctance from anyone to step up and help. With set up complete, now we just needed to start….

98 % Human: two interesting patients in Sierra Leone

By KSLP Technical Advisor, Professor John Rees

In the middle of January I flew out for my fourth trip to Sierra Leone to spend a week with the KSLP team to support a two-day faculty workshop to kick off a process of overhauling and modernising the medical curriculum at COMAHS.

On my last day, in what I thought would be a break from work, I decided to venture out to the Tacugama Chimpanzee Sanctuary on the outskirts of Freetown. Each month the sanctuary has a birds and breakfast walk on a Saturday morning consisting of a three hour stroll through the bush with two guides and then a cooked breakfast. My KSLP colleague Suzanne Thomas decided to take part. The sanctuary is a 30-40 minute drive out of Freetown for a 7.15am start.

We heard lots of birds identified by the guide, we saw rather fewer but still had some good sightings of bee eaters, paradise flycatchers and sunbirds and a really pleasant stroll around the forest and the dam, where we saw the resident crocodile. During breakfast we were politely ambushed by the veterinarian for the sanctuary with a request for our opinion on two problems. I later discovered that they’d spotted that I was a Professor at the KCL School of Medicine from the footer of my reservation email, and were lying in wait for us. It’s not uncommon to be asked for advice when people know you are medical but advice on sick chimpanzees was a first for us. Patient confidentiality prevents me from naming the chimps involved, but one has chronic osteomyelitis of the radius (ie a longstanding infection of a bone in the arm) after a bite from a friend. He has had lots of antibiotics but we were able to suggest some ideas for choice of antibiotic and length of course.

The second problem was more challenging and we were not the first to be consulted. They have noticed that some chimps come in from the forest with ataxia, lethargy and vomiting. Some go on to have seizures and some have died suddenly, sometimes in a stress situation after they seem to have recovered. None of the chimps in the small enclosures where they are being monitored after initial rescue from captivity have been affected. In contrast to human patients in Freetown the chimps have been investigated by autopsy, virology including PCR (molecular testing) of various samples, deep frozen tissue sent to laboratories around the world, opinions of plant experts, vets and other experts. The current theory is that this is related to a toxin from a local plant in the forest, which has properties used as a rodenticide.

We had a chance to look around the enclosures at Tacugama, avoiding a chimp throwing stones at us with accuracy showing he was not ataxic. We were still no clearer on the likely diagnosis but if anyone could tell us we are happy to pass on any ideas that anyone might have to the vet at the sanctuary.

Chatting with Tony Blair

By Suzanne Thomas, Education Lead

It was an unexpected surprise on Monday morning when Tony Blair turned up at Connaught Hospital. Like many of the patients who arrive at the hospital he swung in through the main gate – unlike your average patient though, his arrival was led by a convoy of police sirens.

Mr Blair is the founder of the African Governance Initiative (AGI), the reason for his visit to Connaught was to see first hand an example of the Free Healthcare Initiative, which has been a key project for President Koroma’s government.

Accompanied by the Minister for Health and several key officials from the ministry and hospital, he made his way to the paediatric surgical ward where our partners showed him a brief glimpse of the reality of healthcare in Freetown.

While Tony passed us I stood in a small group watching from nearby, intrigued by the scene in front of us.  Perhaps he was a little intrigued by us too, turning around to give us a wave and quick hello.

After he emerged from one of the wards Oliver (our Programme Director) and the Minister for Health chatted casually to Tony and explained the work of King’s Sierra Leone Partnership.

The moment seemed like a good opportunity for the ‘snap’! Jo (our Communications Consultant) was delegated the nerve-wracking task of lining us up for a photo.

It was then my turn to chat with Tony. He asked if I was part of the Partnership. I briefly explained my role with COMAHS which covers curriculum development, teacher training, infrastructure support and developing new healthcare professions training programmes, hoping that what I was saying made some sort of sense!

He then asked ‘What is the biggest challenge of your work here?’ A question like this would normally require a lengthy response. Conscious of all the important people listening for an answer I kept it brief and talked about the strong desire for better training and healthcare but that the limited human resources available results in staff being torn between their training and clinical roles.

The Minister for Health then joined the conversation ‘So it’s about capacity building’. I nodded, appreciating the interest that was being taken in our work.

Our Clinical Lead Ahmed also had his moment with Tony – explaining what he enjoys about his work at Connaught.

After greeting a small group of enthusiastic smiling patients he was off and onto his next meeting followed by a flight to South Africa for Nelson Mandela’s funeral.

I turned back to the office with a smile. You never quite know what’s going to happen next here in Sierra Leone.

Red Pigs and White Coats: A Freetown Vignette by B.A Sillah

While surveying the alley between the pharmacy and storerooms for a potential new main entrance, I pause to chase some unwelcomed guests from of the hospital grounds. Three pigs had wandered into the patches of grass and rubbish lying between the fence on Percival Street and the weathered wall of Ward 10. The rusting gates that enclose the colonial era compound could not deter the four-legged vagabonds, seasoned by years of navigating between the tin-roofed Kroo Bay slum dwellings below the cliffs our hospital occupies. After watching them scurry down the road for a while, I return to my work on this misty Freetown morning.

The afternoon’s responsibilities fluctuate at a moment’s notice. At times, I round the wards to recruit discharged patients for our daily focus groups. The next minute, I am either mapping out a new construction site or attempting to repair a CT scanner printer with only a ruler and German user manual to my aid. At the end of the day, I climb on the back of a motorbike, preparing to weave through gridlocked cars and potholes on the streets leading to my home in the hills. I playing a nightly game of “is this chicken or fish” at the dinner table and then walk to my balcony to watch the rays from the setting sun as they hit the exhausted-fueled evening haze enveloping the city below. Such is a day in the life of an intern with the King’s Sierra Leone Partnership at Connaught Hospital. For five weeks over Summer I worked at Sierra Leone’s main tertiary referral hospital between my first and second year of medical school at the University of Pennsylvania. Born the son of Sierra Leonean immigrants in the United States, my first journey to my ancestral home had been 23 years in the making. From the time I stepped off the plane at Lungi Airport to catch the aged ferry that steams across the bay toward city on the horizon, I knew I was in for a journey I would not soon forget.

Sierra Leone has been a country of fascinating contradictions and juxtapositions. Lively shantytowns lie in the shadows of sterile, towering mansions purchased during the recent mining boom. Traffic lights unused for decades dot the city among ruins of construction sites abandoned in the 1980s, haunting reminders of an era of prosperity cut short by eleven years of civil war. The bustling cities rapidly work to catch up with the modern world and just hours away lie timeless, untouched villages carved out of the jungle. My time in Freetown was more than I could ask both personally and professionally. King’s Sierra Leone Partnership’s unique relationship with the Connaught Hospital leadership and Ministry of Health and Sanitation offered a look into hospital management one could not experience in other settings. The group’s work ranged from clinical responsibilities, to researching staff/patient satisfaction, to strategizing for improved hospital operations and much more. The weeks of work culminated with a meeting with the Minister of Health herself to present our task force’s findings. Beyond the efforts at the hospital, I immersed myself in the energetic culture of Sierra Leone. I connected with family whom had only been faceless names and stories weeks before. The emerging expat community brought me together with like-minded innovators from around the world who are lending their expertise to Sierra Leone’s development. Afternoons of basking in the sun on miles of empty, untouched beach, wandering crowded markets, and chatting over a Star beer at a local bar gave glimpses into a way and pace of life I have not found elsewhere. All in all, my time in Freetown was the perfect way to spend the summer. I am already looking forward to my next trip to my new home. Swit Salone, a de kam!