Swine Flu: Front Line Staff

Sorry to all who got a little tired of looking at that last blog. I am extremely busy right now and have an extra 15 minutes to upload this new "face of the moment". Guess who is front line NHS (National Health Service) staff for the impending swine flu epidemic? Yes, folks...this is the only effective mask that actually keeps most of the germs out. It took the hospital half an hour just to properly fit it to each staff member. Sort of sexy, don't you think?

Mrs. Muntala

Nigel writes: Mrs Muntala was quite an extraordinary woman. She was the sister (UK title for "nurse") in charge of the operating rooms in Malawi’s Cure Hospital where I worked for 3 months. We became very good friends after a rocky start. I had not realized that it was custom to greet those women older than you as ‘Mrs’ – a cultural mistake on my part but I soon rectified this. Mrs Muntala was often a little grumpy and would complain about all sorts of things though her work did seem impeccable. I managed to find the knack of making her smile and even just my saying "good morning Mrs Muntala" made her beam from ear to ear. I soon discovered that she had a very sweet tooth, like most Africans, and was very partial to a piece or two of Michal’s banana cake. She would carefully divide it up so that each person had a piece and have a few extra pieces for herself to take home! She made us laugh.

Sentinal Events

Nigel is doing a lot of reading and studying lately on the NHS (UK's National Health Service) in preparation for interviews. We were talking about one hospital he had visited which had the stairs almost inaccessible to the public leaving the elevator the only obvious option. The hospital didn't want patients suicidally throwing themselves off a high floor down the stair well to the bottom. He described this as one example of a sentinel event that a hospital wants to avoid at all costs. There were a list of these sentinel events that he listed to my horror that would be catastrophic for any hospital to have happen. One that he had mentioned to me that doesn't seem to be on this list is child kidnapping from a hospital. The following is from the link he sent me: What is a Sentinel Event? A Sentinel Event is a subset of adverse events specified by the Department of Human Services (DHS). These events rarely occur but are more serious and are therefore reported to DHS and investigated immediately using a Root Cause Analysis process. DHS describes a Sentinel Event as a relatively infrequent, clear-cut event that occurs independently of a patient's condition. They commonly reflect hospital systems and process deficiencies and result in unnecessary outcomes for patients. DHS has specifically outlined 9 Sentinel Events, which must be reported: 1. Procedures involving the wrong patient or body part 2. Intravascular gas embolism resulting in serious neurological damage or mortality 3. Haemolytic blood transfusion resulting from ABO incompatibility 4. Patient suicide in hospital 5. Retained instrument or other material after surgery, requiring re-operation or further surgical procedure 6. Medical error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs 7. Maternal death or serious disability associated with labour or delivery 8. Infant discharged to wrong family 9. Other

Liberia: Transformation

I thought I would post some of the stories I have done as a writer/photographer/graphic designer in the past several months. This is the finished product used as a marketing tool for Mercy Ships.

This story is about Alimou, a patient that Nigel anaesthetised. Click on each image to get a bigger view.

Gaye Waylee

Late one evening the phone rang in our room on the ship. It was the hospital lab asking if I might give my O+ blood at a moments notice. There was a patient on the ward with an unknown bleed in his abdominals. His haemoglobin levels were dropping dangerously low and new blood would bring his levels up again.

“Is it okay if we need to phone you in the middle of the night?” They asked.

Of course not.

It was early the next morning when the lab technician came looking for me. Swiftly but calmly she told me, “we need to take your blood immediately ”.


Mercy Ships has a wonderful blood donor system where crew are tested and used as blood donors as the need arises. Unlike western hospitals that separate the different parts of blood this is whole blood ready to be used. The blood is so fresh it is still warm it maintains its clotting factors, which disappears when blood is refrigerated.

A nurse approached me later that day to tell me the patient, Gaye Waylee, had received my blood and was doing much better.

“Gaye wants to meet you.” she then told me.

I agreed and was led down the long hall towards his ward. The doors opened and there was a hive of activity. The nurse pointed to a young man sitting on a bed.



“Gaye, this is the person who gave you blood”.

His eyes lit up as he turned to me and shouted across all the activity, “you are my sister! I have your blood in me.”


He introduced me to his aunt who was visiting and I was welcomed into the family.

Gaye is a mature, chatty 21 year old with a welcoming personality who had succeeded in charming the entire hospital staff. He was bright, well spoken, and perhaps a bit bored by being confined to a hospital ward in a ship. I visited Gaye on several visits down to the ward and learned his story. (Click on the two images at the end to read Gaye's story).




His month long stay on the ship began with skin grafts taken from his upper leg and placed over the open wound on his foot. Gaye will return in June for surgery to reset the bones in his upper leg. In the meantime, he is staying with relatives in Monrovia and coming to the ship twice weekly to have his foot dressings changed. He insists on seeing me each time.



His upbeat personality and determination will help him finish his last two semesters of grade 12. When I asked him what he wanted to do afterwards he confided in me that he was determined to go to university to study accounting.

Junk for Jesus

Nigel writes:
This is an expression I have heard a few times this year. It refers to the massive amount of useless and often expired or malfunctioning equipment donated to poor countries in Africa from the West. I must not be too cynical, since I know many useful items are donated in good faith. In fact Mercy Ships and Cure are careful to put out proper ‘needs’ lists so that willing donators know what is and is not required. Unfortunately, some people put together huge containers of their unwanted items and send them off with the assumption that Africa will be able to use it all. Sadly, and more often than not, they can’t and in the case of malfunctioning equipment, they have no resources to fix them. Worse still, where are they supposed to dump this stuff? I guess the point is: if you can’t or don’t want to use it in your own country, then the likelihood is they won’t be able to use in Africa either.

The storeroom in Malawi's Queen's Hospital.

The term "Junk for Jesus" is most commonly used in religious organizations that work abroad in the "developing" world, one of which we are working with now.

I was talking to one of the surgeons on the ship about this topic. He pointed me to the old Jewish writings in Malachi chapter 1 (Old Testament) which speaks of God’s anger when the people bring defiled offerings to him. God points out that not even their governor would accept such offerings. An interesting reminder.

More junk.

For more of Nigel's medical posts click here.

Extreme Pathologies

Nigel writes:
Another problem faced in Africa is the huge need. In Malawi, the hospital I worked in treated children with orthopaedic deformities and also burn contractures. Here in Liberia, we treat similar conditions including facial tumours and malformations, vesico-vaginal fistulas (VVF), thyroid tumours, hernias and cataracts, both in adults and children. A lot of what we see here are pathologies we rarely, if ever see in the West. This is usually as a result of the lack of clean running water and basic medical care. Some examples are:

1. Club Feet – a congenital condition where the foot is turned in and if not corrected the child learns to walk on the outside aspects of his feet. At home this would be treated by a series of casts over the first few months of life. Left untreated, it involves complex surgery followed by months of intensive physiotherapy.


2. Facial Tumours – Often these are benign but grow dangerously throughout the mouth and face. They can affect eating, breathing and threaten eyesight, not to mention the hideous disfigurement and smell that they produce, destroying not only tissue but the person’s self esteem.



3. VVF – Due to a long and protracted labour where the baby is obstructed in the mother’s pelvis, the tissues in the bladder and urethra become compromised of their blood supply and die. After a few days, the mother delivers a dead baby. Later, a fistula or opening occurs between the bladder and the outside world so that the woman is now incontinent of urine and becomes outcast from her husband, family and community. Good obstetric healthcare can stop this from happening. Worse still perhaps, in Liberia, 1 in 16 mothers die in childbirth, 1 in 2500 in the US, and 1 in 29,800 in Sweden.

4. Noma (cancrum oris) - is derived from the Greek meaning “to devour”. It is an opportunistic infection promoted by extreme poverty. It could be treated with an antibiotic as simple and cheap as penicillin. The peak incidence is in malnourished children aged 1-4 with a mortality of around 80%. Survivors are subject to disfigurement and disability caused by soft tissue and bony damage –some are missing lips, cheeks and even noses. This condition was last seen in Europe in prisoners of the concentration camps of the second world-war.

5. Burns – severe burns are common in Africa. Most cooking takes place over charcoal fires and since many places have no electricity, light is provided by candles and lanterns. Children are especially vulnerable. The aim is to correct the healed contracture so eyes can blink again, mouths open and elbows and knees move once more.


6. Cleft Lips and Palates are common all over the world. They are repaired in the first year of life but the outcome is not purely cosmetic. The repair promotes feeding, speech and development of teeth. Apparently it is not uncommon in West Africa for such babies to be buried soon after birth by local witch doctors in an attempt to kill the perceived “bad spirits”.


7. Cataracts in children are often congenital in nature or sometimes due to infection. If left, the sight of the child will never develop. In adults with this condition, one becomes slowly blind, reliant on family members and walking aids.

With all of these problems, the person becomes marginalised by their community. They may look unsightly. They may even smell from their fungating tumour or constant leak of stale urine. Often considered to be possessed by an evil spirit, they become more and more outcast in a society where survival is hard enough for the able.

Mercy Ships' Dr. Gary Parker on BBC Radio

One of the most humble people we have ever met...Dr. Gary Parker, Africa Mercy Chief Medical Officer and maxillofacial surgeon, presented the opening lecture at the British Association of Oral and Maxillo Facial Surgeons annual scientific meeting in Cardiff, Wales, earlier this month.
With 21 years experience in surgery with Mercy Ships Dr. Gary's topic was "The Right to Look Human: Oral and Maxillofacial Surgery for the Poor of Our World."

Previous Doctors on Mercy Ships: (L-R) Leo Cheng, Peter McDermott, Luer Koeper (Germany), Tony Giles, Gary Parker

Dr Gary was also interviewed for the BBC Radio Wales programme "All Things Considered" this week (Sunday 20 July at 8.30am, repeated on Wednesday 23 July at 6.30pm), by Roy Jenkins.

ATC: Gary Parker / Mercy Ships 20 Jul 08
This week, Roy Jenkins’ guest is Dr Gary Parker, a surgeon who works in some of the poorest countries of the world, restoring the faces of those who have been affected by deformity or disease. He talks about his remarkable and challenging work and about the Christian faith which inspires him.
Duration: 28mins | File Size: 13MB

Available until: 7:02pm Wednesday 30th July

Click here to listen with BBC iplayer
or
Podcast

(it is well worth the listen!)

Limits

Nigel writes:
I know one of the hardest things I have seen and been involved in is saying no. Turning people away from a modern hospital ship. Of course to them, we can treat anything and why shouldn’t they queue for hours? They are desperate.
I can see the difference between those working here for a short time and the approach of those that have been here many years. As healthcare providers, we are not used to turning people away. If we can treat someone, then we do. As a short-termer, the instinct is to treat anybody that can be helped. Both Cure and Mercy Ships could treat more conditions; trauma in the case of Cure, infection (abscesses, osteomyelitis) along with some medical conditions in the case of Mercy Ships.

Those that have built up the services and programmes offered by these organisations have done so after several years of living and working in Africa. They have had their many successes and failures. They know what works well and what doesn’t. They too find it hard to say no and they are always trying to push boundaries and see who else can be helped. However, they also have a bigger picture of their surroundings and realise their limitations and what impact, for example, accepting one patient with an abscess might do if that infection spreads to the many patients with healing wounds, implants and skin grafts.

In my first week on the Africa Mercy, we received some insights on bringing hope and healing to the poor and needy. Two things amongst many stood out in my mind. Both were insights Mother Teresa had.

The first was, “If you can’t feed a hundred people, then feed one”.

The second was, “God has not called me to be successful, He called me to be faithful”.

Finally, Micah 6:8, “He has showed you, O man, what is good. And what does the Lord require of you? To act justly and to love mercy and to walk humbly with your God”.

Scratching the Surface

Nigel writes:
The two organisations I have worked with this year are Cure Hospital in Malawi and Mercy Ships in Liberia. Both have a similar objective to follow the example of the figure of Jesus, trying to be his hands in a needy world. The mandate of the Mercy Ship’s is to ‘bring hope and healing to the forgotten poor’. The practicalities of bringing these two things are overwhelming. One of the reasons is that many people don’t fall into the Extreme Pathologies that these organisations target. When people do, however, they are received regardless of their ethnic background, religious affiliation or ability to pay.

Typical town life in Bong Town, Liberia

These organisations provide first class care and the results are impressive; physically, emotionally, and spiritually. Both organisations have had to adopt limitations for who they can help. For Cure, they are not able to treat trauma in children as there is simply too much of it for their small hospital. They have to leave that to others. Instead they are making huge inroads into wiping out club feet in Malawi following a successful model in Uganda.

The Ponsetti Technique of casting being used in Malawi to treat club feet.

Meanwhile, over the last 30 years, Mercy Ships has been performing complex surgeries on a hospital ship, travelling from country to country. They have performed over 35,000 surgeries along with many land based health initiatives and construction projects. This will be the ship’s 4th visit to Liberia over the last 3 years. Those who have been here for all that time, feel we are now dealing with less serious pathology, a sign that the work here has been successful.

However, you only have to look beyond the ship and you see a war torn country, people dying of malnutrition, infection and diarrhoea. There has been no electricity or running water for 14 years. We really are scratching the surface in terms of who we can help. The important thing to remember is that for those individuals we do treat, it makes a 100% difference. Their felt need is being met. It offers the enormous opportunity to no longer be an outcast in your own culture and to gain health and healing. This is my simple view and the basic level at which I cope.

A Year of African Anaesthesia

Nigel:
Having spent almost a year in Africa as an anaesthetist, first in Malawi for 4 months and now in Liberia with Mercy Ships for what will be 7 months, there is both a satisfaction and frustration.

Teaching local biomedical students in Liberia about the working of anaesthetic machines on Mercy Ships.

Firstly, I have learned that it was God who was willing to use me as his hands for this time and it is through his strength that I am here, not my own. I have been fortunate enough to have been born in a country where achieving a medical training was an opportunity at my door as long as I was willing to work at it. My training was free and I only had a small amount of debt after 5 years of study. Back then, and still now, a job is pretty much guaranteed and the financial reward is handsome.

In Africa, even if I wanted to become a doctor, the chances are as slim as becoming the next president. Such is the daily struggle just to earn a simple living and put food on the table.

The next thing I have observed is how ‘easy’ it is to practice in the West. Don’t get me wrong, medicine at home has its own stresses in terms of complex patients, quality assurance, targets to meet and departments to run on a fixed budget. This however is relative to the situation in Africa.

Two Malawian anaesthetists prepare a patient for surgery at Biet Cure Hospital.

Here, the majority do not have access to even basic medical care. 70,000 people die each day needlessly of causes such as water, basic sanitation, AIDS and easily treatable conditions. Where there is a hospital, it works on a system of payment and bribes for your treatment. The anaesthetic facilities are basic and the conditions the anaesthetists work in are difficult. The equipment is out of date and often non-functional, there is often little or no monitoring of the patient, drugs are scarce and techniques are kept simple. Looking after a patient for even moderately complicated surgery is beyond their boundaries. Recovery rooms in these hospitals do not even have oxygen!

Queens Hospital, Blantyre (Malawi), anaesthesia cart with draw-over apparatus and a brick to hold the syringes.

In Malawi, there is only one anaesthetic doctor and in Liberia there are none. As in most of Africa, nurses provide this care in harsh circumstances and I stand and watch them in complete admiration. The 3 nurses I helped teach in Malawi (and let’s face it, I learnt much from them too) still did not earn enough to travel or buy a house. They would tell me that their wages went to feed and clothe their extended families which could be up to 10 people. I can go home, find a job, work with other doctors and a trained assistant and have all the drugs and equipment that I need at my disposal. If something does not work, you simply swap it for one that does. I know my patients are going back to a ward where they will be cared for properly. It makes me angry when people complain about the NHS (National Health Service) in the UK. You do not need to travel far to have a reality check.

Our friends, Polina and Patricia, in Malawi.

More Than Just Secretions...

During my current position as an anaesthetist with Mercy Ships serving in Liberia, West Africa, I was a little shocked at what I recently found in a child’s mouth before extubation. Upon routine suctioning of the pharynx following a cleft palate repair, apart from the usual blood and secretions one normally retrieves, I was greeted by 2 intestinal roundworms (Ascaris Lumbricoides) each approximately 15 cm long.

Ascaris is one of the most common parasites found in humans and it is estimated that 25% of the world’s population is infected with this nematode. The worms are a potential cause of airway obstruction and it is worth considering this in patients returning from or living in areas of endemic parasitic infestation(1).

Nigel Barker m/v Africa Mercy, Liberia, West Africa

1. Faraj JH. Upper airway obstruction by Ascaris worm. Canadian Journal of Anaesthesia 1993;40:471.