Can I fetch you some water?

 

A local dignitary showing you a picture of their bowel motion on their phone is arguably not the preferred way to end an evening after a few drinks and rounds of Uno sitting in the hot dusk outside Victor's. The knowledge that a person is somewhat medically qualified seems to remove barriers to expected social norms regardless of culture and geography; I have an equally vivid memory of being en-route to a dance performance in London when a woman who I had been introduced to only moments before was very keen to discuss her recent diagnosis of an absent spleen, something I knew very little about.  Within the unscheduled (and slightly alcohol tainted) brief consultation with the dignitary I managed to suggest a stool test in the morning and reassured them not to worry too much as they looked well and their pulse was normal. In addition, given that they were thinking of having a drink or two themselves I judged the medical issue at hand unlikely to be too pressing. We made our excuses about it being past the boys’ bedtime and headed back up the hill to the hospital. Life here is many things, but it’s certainly not uninteresting.

                                          

It's been an undulating few weeks with new lock down measures in and around Freetown giving cause for concern, a staff strike resulting in temporary closure of the hospital followed by its re-opening which brought with it a rich tapestry of clinical and human challenges.

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I should have suspected something was up when a staff member unexpectedly turned up at the door at 7am and asked whether we needed any water bringing to the house. It seemed a little odd given that one of the hospital cleaners had been reliably helping us top up our water containers on a daily basis over the last few months. I politely declined his offer, naively unaware of the series of events that would consequently take place. By mid-morning, the same (seemingly helpful) staff member allegedly led a strike of the majority of hospital staff resulting in patients being turned away or sent home partway through treatment. A level of chaos ensued involving hurried wound dressings and potentially premature catheter removals. One midwife came to confide in us on our porch, scared to be seen attending her work, distraught for her patients but too afraid to stand against a collective mass whose tolerance in waiting for salaries to be paid in the context of increasing discontentment with pervasive difficulties at the hospital had been exhausted. That such strikes are not exceptional highlights the fragility of development in settings of tangible poverty.

Needless to say, the cleaner that usually brought us water had not felt able to come to work. In the evening I walked down to the well in the compound and found the gate to it to be locked. With no-one around I climbed over the circular wall and stood filling our yellow plastic containers from the hand pump, trying to make sense of it all whilst making a mental note to always think twice about declining an offer of water collection in the future.

Following a series of meetings and interventions, the hospital re-opened sooner than we had anticipated. Due to the very nature of childbirth, provision of emergency obstetric care is not something than can be delayed and therefore, unsurprisingly, the maternity ward was the first in which empty beds were soon filled. Through a mixture of experiences, twin deliveries had always been something that gave me palpitations; in the UK I often harboured an unproductive desire that babies in the wombs of women with twin pregnancies would opt to stay comfortably inside their mums until my shift was over.  Despite this fear starting to subside a little after a series of good outcomes, I still felt a significant level of apprehension when I was called to see a particular complicated twin referral case late on a Friday evening.  

The woman had delivered her first infant in a community setting, a healthy baby girl, 8 hours ago, but her second twin (who we sadly confirmed would be stillborn) was stuck. Usually second twins are born very soon after their siblings, the average being about 20 minutes.  On examining the woman, unfortunately her baby was lying sideways in her womb with the baby’s shoulder entering her pelvis; a presentation not compatible with a normal vaginal delivery. Furthermore, the situation had not been helped by medication given (not with malintent) at a peripheral health unit with the hope of making her contractions stronger to try and deliver the baby. This medication had increased the risk of her womb tearing by causing exaggerated contractions of her uterus against a baby whose position meant that such efforts were futile.  Whilst outside of my comfort zone, I knew there would be value to the woman, both in the short and long term, if we could avoid an operation. How quickly we could access the theatre was also unknown.  I have been very fortunate to know a kind, experienced colleague who was working in another part of the country whose telephone advice was always appreciated.  I was relieved when, being true to his word about being called anytime, he picked up the phone just after 10pm.  After discussing my proposed suggestion of giving an anaesthetic and attempting to use internal manoeuvres to bring the baby’s feet through the cervix to deliver him or her, I was initially reassured by his first response of ‘Yes that sounds like a sensible plan’. However, I was less keen on his follow up comments which included a word of caution about the possible complications especially given that the last three times a similar situation had arisen at his hospital, sadly subsequent events had resulted in the loss of the mother’s life. However, we agreed that there was no question intervention was required as soon as possible.  Thankfully after a few more phone calls we were able to move to theatre with a plan A & B and 2 units of blood due to her starting blood count being half of normal. An hour or so later, in which my heart rate felt as if it remained comparable to the patients (and I perceived I lost as much sweat as she did blood), her baby was delivered without the need for open surgery and she stabilised. After a restless night, I was pleased to find her sitting up the next morning breastfeeding her first baby; appearing, outwardly at least, coping with the conflict of loss and joy.

                               

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Thankfully, some patient encounters are more jovial than stressful. Although I had declined her polite request to pay for her transport back to her village, I didn’t actually expect the 60-year-old patient to jump on to my back when I jokingly offered her a piggy back home. Her athleticism, however, did demonstrate that she was well enough to be discharged; a debate I had been having (and losing) with her for the previous few days. Conversely it appears that patients inform their doctors when they are well enough to leave, not vice versa. Despite my incredibly slow progress in learning Mende (the most common local language) a shared understanding had developed between us during the time she had been on the ward. Initially my explanation that we would be unable to get her back feeling like the 20-year-old she yearned to be (her heart failure, significantly enlarged liver and spleen and ascites were not easily reversible) was met with bursts of dissatisfaction.  However, I persisted with suggestions that we needed to try and treat the things we could (like her anaemia, malaria and chest infection) to get her feeling as well as possible. Inroads into her sulky disappointment seemed fruitless for the first few days but as time progressed my attempts at flattering her with comments on how she was now the healthiest woman on the ward seemed to have an impact; a smile was shared and her eyes brightened. She has promised to come to outpatients to be reviewed next month - time will tell if she is able to keep her word or find the resources to fund an alternative mode of transport to my back