A physician in Freetown

By Dr Terry Gibson, Volunteer Consultant Physician at Connaught Hospital 

I joined the KSLP team in Freetown in April and Connaught Hospital has become my place of work and something of a home. My flat inside the duty house on the hospital grounds is where I sleep, and lets me see how the hospital functions after hours. Being right next door to the mortuary means the trundling mortuary trolley, followed by the sound of grieving relatives is a regular disturbance at night.

I arrived without a remit but with a shared expectation that through my long experience of acute and general internal medicine at Guy’s and St.Thomas’ I would be able to contribute to patient care, set standards for myself and act as a role model for house officers and students. That is precisely how it has evolved.

During the first week I was asked to share duties with one of the other three general physicians. On the first round together he excused himself to attend a meeting and asked me to carry on. For six weeks thereafter I continued in his place, performing daily rounds, one in three on call and a diabetic/general medicine clinic. When he returned I assumed charge of my own team so now there are four general physicians sharing the task.

    Ward rounds with junior doctors and interns

Each team includes a consultant and a minimum of two house physicians who have been qualified for one or two years and shoulder responsibilities well beyond their competence. For this reason I perform regular daily rounds and a slow survey on Sundays. If on call for a long weekend I conduct rounds throughout the weekends. Dedicated training procedures are limited. I regularly perform lumbar punctures and other invasive procedures, teaching as I go. Apparently despite the large number of unconscious HIV admissions lumbar punctures are rarely performed. Thus I have set one clinical standard in motion.

A weekly clinical meeting for medicine with cases of interest or of educational value is now a regular feature of the house physicians' timetable. My colleagues on the King's team had already launched this idea, but the arrival of a Guy's and St. Thomas' physician on the wards gave the meetings a lot more impetus. It has also acted as a forum for the other consultant physicians who rarely meet but now contribute to the clinical meeting as well as engaging in a separate gathering to discuss business issues. Recently the focus has been on improving the performance of the ICU.

My outpatient session has been connected into a rheumatology/GIM clinic. The number of rheumatic referrals so far has been small. The clinic is supported by two house physicians who have learned how to aspirate joints and examine the fluids under a microscope. Whether I can emulate my time as a visiting professor in Pakistan where I started the rheumatology service in Karachi that flourished 20 years later I cannot say, we shall see.

In the meantime the support I’ve received from the King’s team and the established physicians here has been nothing but positive. All things are possible and I am optimistic about the likelihood of leaving some sort of legacy behind.

The Eye of the Storm: Ethical Challenges at the Front Line of an Ebola Outbreak

By Dr Oliver Johnson
Programme Director
King's Sierra Leone Partnership

Last year I had the opportunity to spend time in Boston with Dr Paul Farmer, founder of Partners in Health, who generously gave me a copy of his recent book Haiti After the Earthquake, an account of the response to the devastating earthquake in Haiti in 2010.

Reading his description of their early work in the main hospital in Port-au-Prince, a sprawling colonial compound in need of a major revival, surrounded by urban slums, I was struck by the parallels with our own partnership with Connaught Hospital in Freetown – and have been kept awake at night since by an unresolved question: what would we do in similar circumstances, if disaster hit Sierra Leone?

On 25^th May 2014 disaster did arrive, not in the form of an earthquake, but with the confirmation of the first ever cases of Ebola in Sierra Leone.

The news was not a complete surprise – since the outbreak started in Guinea in March, the Ministry of Health & Sanitation had been on high alert, organising regular National Emergency Ebola Taskforce meetings to coordinate preparedness and contingency planning.

     Myself with Connaught staff Dr Martin Salia and Sister Cecilia (Sister-in-charge of A & E)  preparing the isolation ward. 

The King’s team were invited into this process within hours of the first Taskforce meeting, advising Connaught on how to adapt international guidelines to develop a Hospital Preparedness Plan that detailed how to identify cases, set up isolation facilities and safely protect staff and dispose of medical waste.

These guidelines were held up as a model for other hospitals, and King’s was asked to act as technical advisors to the Ministry’s wider national Ebola Case Management committee, along with groups such as Medicines Sans Frontieres, Emergency Hospital and the World Health Organization.
We then had two months of relative calm and many began to believe that, even as Ebola had spread like wildfire across Guinea and into neighbouring Liberia, Sierra Leone might have dodged a bullet and avoided the outbreak entirely. The confirmation of cases within Sierra Leone quickly dispelled that hope, pushing us all to lift our game.

As the King’s team worked to urgently provide refresher training to nursing and medical staff, suspected cases began to emerge. Sierra Leone has been awash with rumours and misinformation for weeks about Ebola and, with a nurse having been one of the first Sierra Leonean victims, the sense of fear amongst hospital staff was palpable. We therefore found ourselves amongst the first responders to these suspected cases, alongside heroic Connaught colleagues such as Sister Cecilia (Sister-in-Charge of the Accident & Emergency Department) and Dr Eva Hanciles (Head of the Intensive Care Unit) who did not hesitate to step forward and manage the response.

    King's volunteer nurse Karlin Bacher works with Nurse Susan to review the Ebola guidelines

Our volunteer clinical team were all re-tasked to provide support including consultant physician Dr Terry Gibson, junior doctors Dr Paul Arkell and Dr Sakib Rokadiya and nurse Karlin Bacher. They have been working late into the night to set up an expanded Isolation Unit and to provide treatment and take blood specimens from suspected patients. It has been sweaty and exhausting work, scrubbing floors with bleach whilst wearing gowns, masks and other personal protective equipment in the intense heat of Sierra Leone’s humid rainy season.

As we approach the end of the frenetic first week of the response, we are finally getting a chance to reflect on our response and the whole team has engaged in deep debate about a number of ethical challenges we have been confronted with.

The most fundamental question is whether we as an organisation should be involved in the response at all. Just like our Boston colleagues in Haiti, our work at Connaught Hospital is not aimed at providing hands-on clinical care to patients or at directly managing clinical services. Instead our focus is to support the long-term strengthening of the health system by providing training and technical advice. This represents a fundamental distinction between humanitarian and development work.

We’re therefore really not set up to provide a humanitarian response, it’s not what our team specialises in and we don’t have access to the sorts of funding or medical equipment that are needed for this. On the flip side however, we have a highly professional team of experienced clinicians, with two consultant-level physicians, two junior doctors trained in tropical medicine, two nurses, a pharmacist and a hospital manager, we have one of the largest and most senior international medical teams of any organisation in Sierra Leone. With that comes our close working relationships with local counterparts and our relative familiarity with the hospital facilities, culture and the Krio language. And we are on the ground already – whilst other international organisations take weeks to recruit a team and prepare for deployment, we are able to respond within minutes to a request for support.

Helping to respond to an outbreak of a viral haemorrhagic fever (VHF) is not a standard request for support however - it requires specialist expertise. We were lucky to have Dr Colin Brown on hand, our Infectious Diseases Advisor in the UK, who is well trained in VHF response and can draw on technical support from Public Health England and beyond. Even so, are we acting beyond our competency and putting ourselves and others at risk by taking on roles that we’re not set up to handle?

After discussing this as a team, with our local partners and with our senior colleagues back at King’s we decided, on balance, that we had a duty to respond and that we did have the capacity to do so safely and effectively – provided we coordinated closely with other specialist partners (such as the Lassa Fever Centre in Kenema and the World Health Organization).

    Setting up the isolation ward at Connaught Hospital

The decision to respond opened up a question about whether or not to put our staff on the front line. Ebola is highly contagious, particularly through exposure to body fluids such as blood, saliva or urine – this means that health workers are particularly at risk. Effective use of personal protective equipment (such as gowns, masks, goggles and gloves) and effective cleaning and waste disposal can significantly reduce this risk but at the start we didn’t have all the materials we needed available and you can never eliminate the risk entirely.

Different organisations in Sierra Leone have responded to the outbreak in different ways. Some immediately evacuated international staff when cases in Guinea emerged. Others said they would do so if there were confirmed cases locally. Some put restrictions on their staff, banning them from undertaking clinical work or going into clinical areas. One organisation actually closed their entire hospital to all patients.

This is a moral dilemma in the truest sense, every option available involves moral wrong and ethical compromise making it a matter of judgement about how to weigh up competing responsibilities.

As organisations we have a duty of care to our staff, not to put them at unnecessary risk. We also have to be mindful of reputational damage; many NGOs worried that if one of their staff members died of Ebola they would open themselves up to being prosecuted or to funding being withdrawn, damaging their wider efforts to help patients.

As health professionals however, we have a duty to our patients. Withdrawing from clinical activities would not only harm patients who are suspected of Ebola, but (particularly in the case of the hospital which closed) would have enormously detrimental impacts on the care of other patients. One NGO stopped doing outreach clinics in a local urban slum – a clinic which was the only health service available to many vulnerable patients, some of whom will certainly have died as a result. And having made this decision, at what point do you decide it is safe enough to return – for how many weeks, months or years do you stay away?

Most of the decisions made by international NGOs hinged around their international staff – but what of Sierra Leonean health workers? Is it not discriminatory to withdraw internationals whilst expecting local staff to stay at their posts and face the challenge alone – especially when international staff are often better trained in how to wear protective equipment and are at a lower risk as a result.

One senior colleague at the Ministry of Health articulated this clearly – to him and his staff on the ground, it felt like the civil war all over again, as NGOs packed their white SUVs and abandoned their local colleagues at the first sign of danger, often without even telling them of their plans. In this context, was closing the entire hospital, and providing the same protection for all staff, a more ethical decision – even if a greater number of patients ultimately died as a result?

At King’s, following extensive discussions with senior colleagues in London and Freetown, we took the decision not to restrict the clinical activities of our team. We were aware however that all our staff are volunteers and that this isn’t what they originally signed up for – so we gave them the option to withdraw from clinical activities if they wanted to, asking only that they make this decision in advance so that we could communicate it to partners and put contingencies in place. All of our team have decided to continue clinical work for the moment – but has this put unfair peer pressure on individuals to agree to remain, since everyone else in the group has decided to do so?

 

King's volunteer Dr Sakib Rokadiya dressed in protective clothing before assessing a suspected Ebola patient  

(who later tested negative to Ebola).

The moral maze does not stop here though. The only way we can test for Ebola is to send a blood sample to Kenema and results can take anything from six hours to days. When a patient comes to the hospital who fits the agreed case definition we have to isolate them immediately. The case definition is broad, so most suspected cases turn out to be negative, in which case the patient is likely to have another critical illness such as malaria. But those patients cannot have any other diagnostic tests until their Ebola result comes back negative, because it’s too dangerous to expose lab staff to potentially hazardous samples.

The range of treatments we can offer them is also severely limited – in particular, the National Case Management Committee agreed that it was usually too dangerous to perform surgery on a suspected case. For example a woman in obstructed labour or a patient with a surgical emergency like appendicitis might well have symptoms that match the Ebola case definition.

Patients and their relatives are, understandably, deeply unhappy about being placed in isolation and are often terrified by being kept in an Isolation Room and treated by staff in masks. They are angry about not receiving better care and therefore  often try to escape with the assistance of relatives. Seven suspected patients escaped from Kailahun hospital last Saturday, with lab results later showing that some of those were confirmed cases. This creates a massive risk of spreading the disease.

At Connaught our hope was that by providing better conditions and clinical care in the isolation room and communicating effectively, patients would not attempt to escape. But so far this hasn’t proved enough and the police have been called in for support. Do we now lock suspected patients in the isolation room or call in the army to contain them at gunpoint? Or do we respect their right to leave and risk letting the outbreak spread out of control?

Managing this outbreak has been an enormous undertaking for all involved – from senior ministry staff holding daily meetings, to health workers leaving the wards to attend training and money has been reallocated from other programmes. But is this disproportionate? People die from malaria every day in Sierra Leone – but there have only been a total of three confirmed deaths from Ebola so far. We know that Ebola is killing people, but is the Ebola response killing people too? Should we instead be putting our efforts into preventing other bigger causes of death?

None of these questions have easy answers. We at King’s have done our best to identify the ethical dilemmas we face and to respond to them with integrity, in consultation with our own team and our local partners. I don’t doubt that we’ve got some of our decisions wrong. Part of a rigorous approach though has to include opening them up for debate, so we welcome your feedback and suggestions and hope to initiate a broader discussion on how we can provide organisations and individuals with better guidance and advice for future scenarios. As the rainy season starts, concerns about a repeat of the 2011 cholera outbreak in Sierra Leone are emerging and Connaught Hospital has been asked to start contingency planning. Should we be repeating the same role for cholera, or position ourselves differently?

In the mean time, we’ll be back on the frontline in Connaught Hospital doing what we can to support our Sierra Leonean colleagues to control this deadly outbreak.

Connaught Fashpack

As a part time communications consultant working with the King's Sierra Leone Partnership I have very little to offer in the way of innovative management ideas, clinical skills and curriculum advice. However as someone who has a preoccupation with Sierra Leonean fashion (I have turned it into a serious hobby through my blog Freetown Fashpack I do feel qualified to comment on the uniforms of Connaught Hospital.

The Hospital is in many ways like stepping back in time.The uniforms remind me of the old photos my mother occasionally pulls out from her early nursing days in the 1960s. At Connaught, uniforms are worn with a deep pride and carefully reflect the hierachy within the hospital. According to Matron Kamara "There is a lot of dignity in our uniforms, they help with staff morale and self esteem. When I put on my uniform I look cute, and I feel very proud". 

I  recently developed a chart which displays the many uniforms worn by Connaught staff so that staff can be identified by visitors.  In doing this I learned about the rank and file of Sierra Leone's hospital workforce and was able to photograph several willing models who all looked perfectly groomed and were more than happy to pose for the camera.

 

Nursing aide Susan Sandy looks smart in her distinct green uniform.

Fatmata is a first year state enrolled community health nursing student (SCHN). Each year she will add an extra blue stripe to her nursing hat but will remain in the blue and white until she becomes a trained nurse. The 2.5 year SCHN course at COMAHS requires three O Levels to take the entry exam. 

Benson is also a SCHN student studying at COMAHS. The three blue stripes on his white shirt show that he is a third year nursing pupil.

State registered nursing students (which requires a higher entry qualification than the community nursing students) wear this pink uniform every day of class. Their year of study is identified by the stripes on their nursing hat. You can see Mariatu has three stripes on her hat showing that she is a third year student.

Ignatius models the crisp white male version of the state registered nursing student uniform. The single stripe across his pocket shows that he is a first year student.

 

Mac Joe graduated from the blue and whites many years ago ('don't ask it was a long time ago) and is now a state enrolled community health nurse. Trained male nurses always wear these light brown pants teamed with a white shirt.

 

As a fully trained state enrolled community health nurse Adiatu has also broken free of the blue and white and now wears a grey uniform with lace edged and white hat to work each day.

 

Agatha is a fully qualified state registered nurse and required five 0 Levels to be accepted into the three year nursing course at COMAHS . State registered nurses wear all white uniforms with a red belt. There are no hard rules about the type of belt, I've noticed the elasticized variety with a jeweled clasp is quite popular. Agatha picked hers up from PZ market in town, Freetown's shopping epicenter.

Dura Kamara shows us the male version of the staff nurse uniform - crisp, white and simple. As is the custom in Sierra Leone, he likes to keep his shoes spotlessly clean, "I try and clean them every day after work".

 

Sister Fatmata Kargbo, head of the pediatrics ward holds a Bachelor of Science degree and is known as a BSc ward sister. These senior nurses who deputize the matron wear an off-white uniform with blue detail. They don't have to wear a cap.

The boss lady Matron Kamara is identified by her white hat and blue belt. The four stripes on her epaulette indicate that she is the most senior nurse in the hospital.

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. 

    Myself and partner in crime Anna Davies at Connaught Hospital

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.

    The new triage pilot at Connaught in action.

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 entry of the triage at Connaught.

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 5^th 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.

Catherine Marshall, Mustapha Kamara, myself and Victoria Bakare in front of Hambledon wing, KCH

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. 

 In Tunisia with my fellow COMAHS students

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. 

 Taken the week I arrived at Connaught

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.  

 A lecture presented to staff at Connaught and students from COMAHS by WHO Ebola expert

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.

 Gloves are some of the supplies that have been pre-positioned in readiness for a potential outbreak.

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. 

 An isolation room has been set up at Connaught Hospital in case of an outbreak

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

    Myself and the triage team 

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. 

     Dr Ahmed Seedat trouble shoots like no other

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.  

    Triage training

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.

   We used the South African Triage Scale (SATS)

 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.

     Our triage students .

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.

     The final preparations for the triage room are made

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

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.

                                                        In action at COMHAS in Freetown

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.

All you ever need to know about Chimps

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.

                                                            One of the famous Chimps of Takugama

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.