Emergency and Critical Care Capacity in Kono, Sierra Leone Part 2

Paul Sonenthal, MD

Fellow, Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY-6

April 24, 2019

Delivering a training session at
Koidu Government Hospital

My schedule in Kono District began each day at around 8:30am, when I would arrive at Koidu Government Hospital (KGH) for the morning report. This is the meeting where all of the significant overnight events in the hospital are reviewed by a team of doctors, nurses, and clinical officers.

Following the morning report, I would make myself available to the clinicians working throughout the hospital to discuss particularly challenging patient cases that fell within my specialty of Pulmonary and Critical Care Medicine. Additionally, I held meetings with key stakeholders from different parts of the hospital and health system to informally discuss my research project and solicit their feedback.

Each afternoon, I traveled to a nearby clinic and conducted a 90 minute training session for nurses and clinical officers on pre-selected topics, including managing patients with shock, and initial assessment of critically ill patients. Immediately following these sessions, I would then travel back to KGH to conduct a second 90 minute training session for another group of nurses, clinical officers, and physicians.

Overall, I thoroughly enjoyed my time in Kono District—I learned a tremendous amount and received valuable feedback that will help with my research. Also, I am incredibly grateful for the hospitality and support of everyone I met during this trip. I very much look forward to getting an opportunity to return to Sierra Leone in the near future.

Emergency and Critical Care Capacity in Kono, Sierra Leone

Paul Sonenthal, MD

Fellow, Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY-6

April 24, 2019

Located in West Africa, Sierra Leone has suffered some of the worst health outcomes in the world. After the Ebola outbreak in 2014-2016, the health system in Sierra Leone was crippled with substantial challenges in human resources for health, due to loss of staff to Ebola and disruption of education and training programs. Efforts to rebuild the health system are underway, with continued need for improved quality of care in health facilities, particularly in public hospitals.

Most acutely sick patients in Sierra Leone are managed at district hospitals. Currently, 22 hospitals function as secondary district facilities and referral centers, managing critically ill patients (i.e. severely sick patients, with life-threatening conditions such as shock and respiratory failure) sent from the primary level. The management of these patients is critically deficient due to lack of skills among the health care workers.

View from the entrance at Wellbody Clinic

In the 2016 Annual Health System Performance Report, the Sierra Leone Ministry of Health and Sanitation (MOHS) emphasized that lack of human resources is “a major contributor to the poor health outcomes seen in Sierra Leone,” and identified “ongoing in-service training and support for all cadres of [health care workers]” as a key priority.

Kono District, in eastern Sierra Leone, has a population of 506,000 and is served by Koidu Government Hospital (KGH)—a secondary hospital with 170 beds and the only referral center in the district. At the epicenter of a brutal civil war and then Ebola, Kono district suffers from a particularly striking lack of skilled health workers, a high burden of disease and health outcomes that are routinely worse than the rest of the country.

During my fellowship in Pulmonary and Critical Care Medicine, I have collaborated with Partners In Health (PIH), to support taking initial steps towards addressing the gaps in critical care capacity at PIH-supported sites. I am currently working with a team of critical care and emergency physicians at Brigham and Women’s hospital to develop a mixed-methods survey to assess critical care capacity as well as a series of training workshops for front-line health workers on topics in Emergency and Critical Care Medicine.

With the support of the Partners Center of Expertise in Global and Humanitarian Health, I traveled to Kono District on March 23^rd, with a plan to meet with local stakeholders and solicit input on the survey instrument we are developing, as well as to provide clinical training and support at KGH and a satellite facility, Wellbody Clinic.

Reflections on Access to Care in Rural Mexico

Anna Ruman

Resident in Pediatrics at Massachusetts General Hospital

PGY2

April 10, 2019

Hello again! I’ve just returned from my one month rotation in Chiapas, Mexico with Compañeros en Salud. I’d like to briefly describe my time in Soledad, the second community in which I worked as a resident mentor to the local pasante, as well as my overall reflections on the elective.

Mountains and red soil, Soledad from above

Soledad is another small community in the predominantly coffee growing region of the Sierra Madre. It’s a little bit bigger and slightly better resourced that Matazano, which made for a slightly different teaching experience for me. Seleni, the pasante working in Soledad for the year, certainly saw more patients per day, which resulted in some later nights for us. With our limited teaching time, we chose to focus my educational workshops on asthma, bronchiolitis, and malnutrition as I had in Matazano. However, a few cases and projects proved more interesting than others. I saw my second case of varicella ever (the first I saw in Matazano), and we were able to look up both photographs and clinical guidelines since the Soledad clinic has the advantage of Internet on site. With the middle school right next door, we spent a quiet afternoon setting up a very popular condom dispenser in front of the clinic. Sadly, our most time intensive project involved an elderly man with schizophrenia who had elected to forego his depot antipsychotic injection that month. Without his medication, he became progressively more aggressive, frightening both his family and neighbors. Apparently in the past, he had required injections by force, and we were left with the conundrum of whether to ply him with food and money or to again inject by force. We visited him daily with snacks, hoping that that day might be the day that he would take his medication, but we were unsuccessful after three consecutive visits. I do not know the ultimate conclusion of this situation, but I was so impressed with Seleni’s empathy and utilization of Compañeros en Salud’s mental health team as a resource throughout this difficult case. After a week in Soledad, I returned to Jaltenango for the conclusion of my elective.

Companeros en Salud Clinic, Soledad

With respect to my overall experience, it was certainly both challenging and meaningful. Although I have worked in low-resource international settings prior (including a year living and working in Mexico after college), this opportunity represents my first actual clinical immersion abroad as a supervising physician. I’m still not sure exactly what type of pediatrician I want to be after residency (am currently deciding between primary care vs. a more acute care subspecialty), and I’m not sure that this elective helped me figure that out. However, it reminded me that global and community health will continue to be the focus of my career going forward, regardless of the level of acuity at which I plan to practice. In addition, I found many of the systems issues really engaging, i.e. how to maintain an emergency backpack in each clinic, fully stocked, with procedures about how often and when to revise it, how to ensure the contained medications and materials don’t expire, and how to balance what to include in the emergency kit based on most common complaints, typical resources/transport time (6-8 hours via car on a dirt road to the nearest pediatric hospital), and just overall resource limitation. (More to follow on this project! Will be continuing to work on this). Or the lack of access to microbiology cultures in the region, meaning that obtaining a urine culture on a simple UTI is challenging and requires extensive travel on the part of a patient, and GBS screening during pregnancy is absolutely out of the question. Lastly, it also reminds me how much I love to teach.  I’m already using some of the techniques that I practiced in Matazano back on the pedi wards at MGH. For me, education will certainly comprise a significant chunk of my career focus going forward.

One final reflection: I’m also really fascinated by the intersection between education and typical development for children in low resource settings. Compañeros en Salud is currently launching an infant development/stimulation program for typically developing infants in its target communities. I love the idea, and I wonder what’s next. What does it mean that most children from these rural communities attend school fewer hours per week than recommended? How does that impact their development and, from a bigger picture perspective, their ultimate educational and economic opportunities? For the well child, how can we optimize their opportunity for success? How do we take the next step? Again, the bigger questions of the role of healthcare vs. medicine vs. public health – those of interdisciplinary development - we probably won’t be able to answer today, but I hope that someday I will be able to help answer these and many more for some of the most vulnerable families and children, both domestically and abroad.

Thank you for reading and to the Centers of Expertise in Global and Community Health as well as the Massachusetts Medical Society for their grant support of this project.