Developments in Mental Health at Connaught

I joined the King's Sierra Leone Partnership (KSLP) team as a volunteer Doctor in February 2015. Like most people, I had followed the news about Ebola, particularly the devastating effects it was having on Sierra Leone and its people. Having been born in Sierra Leone, the events were particularly personal to me. I moved to the UK when I was 6 years old, but have many links to the country with family and friends still living there and many fond memories of my childhood.

As a Psychiatry trainee at South London and Maudsley NHS Foundation Trust, I hoped to be able to provide not only physical health care but also psychosocial support to those affected. I was keen to come out to support colleagues, both local and international, who had been working tirelessly to control the outbreak. The process of being released from my training programme was straightforward and I was granted a 6-month sabbatical.   

Dr Stania Kamara and Jennifer Duncan examine patient records 

When I arrived in Freetown the number of Ebola cases had dramatically reduced. It was great to see that the months of hard work were paying off and there was a sense that things were settling down; however, our clinical leads were, understandably, being prudent and cautioned against complacency.

I went through a period of training on how to work safely within the Isolation unit at Connaught Hospital including how to wear PPE. Within days I started work in the Unit, a holding bay for patients suspected of having Ebola and awaiting their blood tests. Whilst they await their results, they are given treatments to combat other possible diseases that could have caused their symptoms.  These duties are performed by both local and international staff. The team is comprised of doctors, nurses, surveillance officers and Ebola decontamination cleaners. It's a great and inspiring team to work alongside. 

On the way to the isolation unit one day, I noticed a middle aged man stooped on the walkway clothed in torn pyjamas.  He was disheveled and confused. I was told that he was a patient with TB and HIV who had spent some weeks at the hospital displaying bizarre behaviour. He would not take his medication, had absconded from the ward on multiple occasions and had spent the last few days living in the corridors of the hospital grounds.  

It was clear that he was experiencing psychotic symptoms and this was likely affecting his ability to comply with his medical treatment. Following some discussions with senior clinicians, we were able to admit him to the hospital and initiate treatments for his medical problems as well as his mental illness. Despite this, the man passed away, succumbing to his medical condition. 

Jennifer Duncan, a Mental Health Nurse, speaks to a patient at Connaught

This patient reminded me of the importance of good mental health care and how integral this is to any healthcare service. Had his mental illness been identified and treated earlier , his compliance to medical treatment would have been better and therefore more successful. His sister explained that he had been a professional with a well respected job; however, over the last year his mental health had deteriorated. The family had been unable to access appropriate care. She seemed to have reached the point of exhaustion having been the sole person to shoulder the burden of caring for her only brother, and she was comforted by the thought that at least he would no longer suffer.

I found myself in a challenging situation: I had volunteered to be an Ebola outbreak Doctor, albeit one with specialist mental health skills that I was sure would be useful in helping patients affected by Ebola. However, faced with a reducing numbers of cases and a clear and acute need for mental health care, I felt increasingly driven to giving my time to those with mental health needs. I recalled the WHO slogan 'no health without mental health' as I contemplated a change in the focus of my work. 

I shared my sentiments with Oliver Johnson, KSLP Programme Director and was enthused by the support he expressed for me to do more direct mental health work. Mental health is a priority for KSLP, and one of the key areas in which they have been making great strides. Prior to the Ebola outbreak, Katy Lowe, a mental health nurse from South London and Maudsley NHS Foundation Trust had been volunteering with KSLP to provide training and supervision to some newly trained mental health nurses. Unfortunately this work ground to a halt with the Ebola outbreak, and Katy switched focus to providing support for staff and patients affected by the outbreak.  It was clear KSLP were keen to resurrect the training and supervision and were committed to working with local partners to develop robust and effective mental health services.

Prior to the Ebola outbreak there was poor provision of mental health services in Sierra Leone. The majority of people requiring mental health and psychosocial support were unable to access it. There is only one Consultant Psychiatrist in the country, now retired, to serve a population of over 6 million people. There is one mental health hospital in Freetown and little mental health or psychosocial support otherwise. This situation has worsened during the Ebola epidemic. A recent study by the International Medical Corps Sierra Leone found that many people affected by Ebola are reporting psychological problems and require mental health care.

  

Whilst I envisioned spending my time here in Sierra Leone sweating through scrubs in full PPE in fact I am now spending most of time working outside of the Ebola holding unit supporting KSLP mental health projects. It feels like exactly what I should be doing especially as the need is so great. 

At Connaught I am fortunate to work with the brilliant and enthusiastic Jennifer Duncan, one of only 20 recently trained mental health nurses posted throughout the country. Together Jennifer and I are providing psychosocial support focused on stress management and psychological first aid principles to healthcare workers at the hospital. Many of the staff have been directly affected by Ebola and lost colleagues, friends and family to the disease; together, they share experiences and promote psychological resilience.

Using the new official ledger to record patients

A new department is born

We are also supporting Connaught to set up a mental health and psychosocial department, the first of its kind in the country. It will offer an in-hospital liaison service and an outpatient clinic for the local community. It is wonderful to work with the senior management team who are fully committed to providing comprehensive, integrated and responsive mental health services at Connaught. They have shared with us their vision for this service to be the model on which other such units are created throughout the country; thereby providing a much needed service to a greater number of people. We've started seeing patients and the need is clearly visible: our work so far has been varied and has included supporting families to facilitate the treatment at home of individuals suffering from acute mental disorders, providing advice to the inpatient medical teams on the management of acute delirium, and identifying livelihood opportunities for patients affected by the Ebola outbreak. 

Within the KSLP team, I am also supported by the Mental Health Group; a UK based group of clinicians and non-clinicians, led by Dr Peter Hughes (Consultant Psychiatrist) who meet regularly to support our work here. 

It's great to be working with KSLP and Connaught Hospital and to know that by developing mental health and psychosocial services we are meeting a crucial, and so far unmet, need. It is exhilarating work, in an exciting and dynamic environment, and I'm proud to be a part of it.  

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.