Helle Sorensen, Communications Officer
in conversation with
Dr. Ruth Tighe, Volunteer for King’s Sierra Leone Partnership (KSLP)
Volunteering in Sierra Leone. Dr Ruth Tighe, (12 years post-graduation and trainee in anaesthesia and intensive care medicine in KSS deanery), gets in at 7 am to do ward rounds at Connaught Hospital in Sierra Leone. Here, she talks about volunteering for KLSP – granted £4000 by the Intensive Care Foundation – and where one starts in a country with only two anaesthetic doctors, six million people and no oxygen.
The recent Ebola crisis in Sierra Leone devastated the basic systems that remained post-civil war. Significant numbers of healthcare workers were infected, contributing to a reduction from 17 to 3 health personnel per 10,000 population. With two anaesthetic doctors and less than 10 specialist surgeons in a country with a population of six million, resources are limited.
Connaught Hospital is the major referral centre in the country, based in Freetown. It is the only government hospital with an intensive care ward. “By UK standards, it is a good medical ward with high staffing levels, 10 beds, no oxygen (until September 2015) and no advanced facilities such as a ventilator, blood gases or dialysis. That’s the level we were at”, Ruth describes.
With the approach that KSLP takes, encouraging long-term volunteers to work closely with key local staff to initiate and implement projects they define as important, results throughout the hospital are staggering only three years after the launch of the project.
What is it that you do, exactly?
I work as a long-term volunteer here at Connaught Hospital. Usually, I am at the hospital at 7 am to do ward rounds. We have 10 beds and Dr Hanciles, a Salone anaesthetist who supervises the unit. From 10 am I spend my time on clinical role modelling, teaching and planning projects.
We have a very small budget, so I also spend time searching for fund-raising opportunities. Policy and advocacy are key for ensuring sustainable change so we meet with the Ministry of Health and the hospital’s management – a lot of my work is also about getting right people together.
Has the grant from the Intensive Care Foundation made a difference?
The short answer is: Yes! The mortality rate in ICU has reduced significantly with the simple introduction of high flow oxygen, early warning scores, ICU nurse teaching and mentoring.
The ventilator purchased with the grant is here and it is ready to go, but as with any medical equipment if we rush and introduce equipment before staff are ready, it could cause its own problems and this could affect future use. As I’ve learnt, project timing and buy-in are as important as content and details if we want to be successful.
Right now we focus on staff empowerment. I train nurses in handovers, referrals, recognition of sick patients (by introduction of early warning scores throughout the hospital) and ICU outreach.
What is the key to success in such an environment?
Intensive care in this setting is fundamentally about nursing care. A lot of what I do is to reassure staff that what they are thinking is correct. Most of the time they get it right and my job is just to say ‘yes that is correct’.
It is the sustainable way to do it. A new volunteer will take over when I leave in six weeks (and KSLP’s plan is to work in partnership for 10-20 years), but at some point the project will end, and the aim is to have developed staff skills and systems that will remain functional and continually improving long after KSLP leaves.
This method of partnership only works if you instill it and believe it yourself – often solving a problem just means next time you get asked to fix it again – helping them come up with a solution and fix it themselves is the ideal – and it works! The hospital management, contractors and mechanics have formally arranged a maintenance plan for the newly functioning oxygen factory to include regular servicing. Seeing all the Salone staff work well together to get great outcomes is when our projects together really seem to shine.
What are the highs and the lows?
With a job like this, there are massive highs and massive lows. It’s has been hugely rewarding for me professionally. My non-clinical skills that often only a consultant would be allocated in the UK, are being tested to the max. I will be a more all-rounded trainee when I come home (with a better understanding of leading, team-working, communicating, problem solving, monitoring and evaluating, research, quality improvement etc).
But at times I feel overwhelmed and helpless. Here 1 out of 5 children will die before their 5th birthday. It seems like an impossible task.
Then I think of some advice a friend gave me – ‘the good stuff can be because of interventions you’ve worked with your partners to achieve, and the bad stuff can and does happen daily’. That, and all the intense interactions and relationships with patients, relatives and staff means that you get to really know the country and the culture you’ve chosen to move into – making me more attentive and considerate to each patients needs and expectations.
One of my most memorable patient experiences was ‘FO’, a 60 year old patient with acute MI leading to pulsed VT – amiodarone was given, but after 2 minutes the patient started to lose consciousness. AED had been donated, but never used (only 2 pads donated with it). Nurses had not received training for it, and I’d only been in Sierra Leone for one month so obviously concerned that a wrong move at this point would jeopardise all future work (i.e. them witnessing UK doctor ‘electrifying’ a patient unsuccessfully – they potentially would be too doubtful to learn this modality when the time came for me to train them on it).
The patient needed 20 shocks (intermittent cardioversion each time but kept reverting back to VT) as well as high dose heparin, aspirin and lignocaine to fully remain in sinus rhythm. He was discharged 5 days later. KSLP ran a BLS course the following week for the ICU nurses, and they successfully resuscitated a patient two weeks later without me present.
Absolutely overwhelming to see the shy smile of my fantastic nurses Augusta, N’Mah, Francess and Alma telling me they’d done CPR and the patient telling me they were his angels!
Finally, the very long answer from Ruth – the statistics:
- 392 patients have been admitted to the ICU since the beginning of the project. 57 % of them are men and the mean age is 40 years.
- The mean admission rates per month fell to 5 per month during the ebola crisis (compared to 22 per month before), but are now back up to 20 per month.
- Mortality has improved from 46 % baseline to 28 % with ICU interventions and high flow oxygen provision in the period from September 2015 to November 2015. A peak in mortality was seen during a flood in October 2015 and with a petrol station explosion in December 2015.
- Data shows that a reduction in mortality can be achieved by implementation of high-flow oxygen in a resource-limited environment. Despite no organ support facilities, the ICU post-operative care gives 85 % survival.
The ICU team’s successes:
- Building an oxygen factory to supply reliable high flow piped oxygen (permits 95% inspired oxygen compared to oxygen concentrators providing max 35%)
- Early Warning Scores implementation and hospital-wide training
- Intensive care nursing tutorials and training
- Free drug scheme for first 24 hour care
- Resuscitation drugs readily available (previously drug administration delayed as patient funded and purchased)
- Facilitation with the Ministry of Health to establish a National Surgical Forum, to address findings of Lancet Commission on Global Surgery 2015 and apply to Sierra Leone specifically.