Wimbledon versus Chad

Murray versus Djokovich

Great Britain versus Serbia

Men in Turbans versus men in shorts

Arabic commentary versus Sue Barker

Strawberries and cream versus peanuts and hibiscus flower juice

A Wimbledon final starring Murray, GB’s long awaited hero, in Chad was an odd experience allowing myself and fellow Brits to celebrate the best of Britain but also led us to reflect on some of the idiosyncrasies of England- the increasing brightness of sun burn on display, the tidiness and order of the courts, the impressive skyline of London, the tiny sun dresses (leading to some Chadian ladies declaring in dismay that the girls were not yet dressed), the green of the grass, even where it was almost non-existent following two weeks of trampling and the delight that such an anticipated win bought to the whole crowd.

Wimbledon versus Chad. You would have difficulty finding a starker contrast between two worlds, but it was certainly a fun afternoon, with an extra twist of… weirdness!

Achta

Young Achta* was a normal healthy 13 year old girl. She lives in a village near Lake Chad with her parents, brothers, sisters, grandparents, aunts, uncles and cousins. Their village is made up of a collection of round huts constructed from a wooden frame and walls made of packed dried goat dung, topped with a thatched conical roof. To the untrained eye, it would seem the village is in a random location apparently no different from the next sandy spot a few kilometres away. A closer look however reveals the presence of some green trees, suggesting a water source deep underground. School is for the male members of the family so home life for Achta meant looking after the many younger children and helping her mother cook, clean and fetch water from the well. The men of the family tended to their cattle and livestock, frequently leaving the village for days, sometimes weeks at a time, to trade in the city. They would return with small amounts of money and supplies that could not be sourced in the village for the next few weeks.

In the village sickness is a part of life and it seems that there is always somebody suffering from some ailment or another. When Achta began to feel more tired than usual and began with fevers, she tried to continue her work as best she could. However, she soon noticed that she could not feel the rough ground beneath her feet so well, or the 4cm long thorns scratch her legs as the weakness caused her to stumble into a thorn bush.

Two days later Achta could no longer move her legs, control her bladder and from her mid back down, where a new lump had appeared, had completely no sensation. Her family called for the village traditional healer who cut deep lines into the lump to cause bleeding in order to allow the illness to leave the body.

However, Achta’s condition continued to deteriorate; she found moving her head impossible from stiffness and intense pain in her neck, speaking was increasingly difficult, while the fevers that raged and waves of nausea, left her exhausted.  At this point her family, having gathered enough money from other family members and neighbours, began the long journey to the city to seek further help. Initially they set off by foot carrying Achta in a quickly constructed stretcher made of cloth over a wooden frame and then having reached a transport route on a mud road, continued on in a packed mini bus, luggage piled high on its roof.

As the city neared the road became paved, and as the bus approached the outskirts, the driver stopped, waving in the direction of a dirt track on the right, informing Achta’s family that the nearest hospital was 5km in that direction.

Afia assessing a patient in Triage

On arrival at Guinebor hospital, Achta was identified by Afia, who works in Triage as very sick and was immediately taken through to the Emergency room where her initial assessment was carried out by Paboula, the Emergency Room nurse. While the male members of her family waited outside with their bundles of belongings, anticipating a long stay in the hospital, Doctor Mark thoroughly assessed Achta. He admitted Achta to the paediatric ward with an unclear diagnosis; Meningitis? Sepsis?  Brucellosis? Her treatments began immediately with strong antibiotics and medicines to help her sickness, fevers and pain.

Two weeks later, Achta’s fevers had lessened and her neck was freer but otherwise, little had changed in her condition. She continued to have no movement or sensation in her lower extremities below the mysterious lump on her spine and experienced generalised pain. Her exact diagnosis continued to baffle us, but Dr Mark increasingly believed that brucellosis, a disease affecting those working or living with cattle in close proximity, was at the source of her illness.

Her treatments continued along with regular physiotherapy with Rosane, our physiotherapist from Brazil. Although her prognosis continued to look poor, Achta and her family seemed to take each day in their stride and had ready smiles, allowing some sort of friendship and relationship to form despite the fact that we had no common language.

One ward round as we approached Achta’s bed, I felt my usual apprehension and sadness as I anticipated the almost daily neurological exam to be once again negative. As before, a small needle was pressed along the length of legs- no sensation. Reflexes were checked. And then Achta was asked once again to try to wiggle her toes. As her face contorted into an expression of intense concentration, I watched her feeble feet hopelessly. But what was that? It was slight, almost undetectable, but that was a definite movement! Achta tried again. Yes, there was no mistaking! Achta could wiggle her toes for the first time in over a month! 

Wahoo! Who would have thought that such a small action could cause such excitement, rejoicing and, for the first time in a long while for this young girl, a glimmer of hope!

How much Achta would be able to move and the extent to which she would be able to recover, we had no idea, but that morning she made a small but incredibly significant step forward.

In the following weeks, Achta’s ability to move and the level of sensation in her legs, increased daily. Before we knew it, Achta who had been bed bound for 2 months, was sitting up with less and less help, could lift her leg one at a time from her bed and could wiggle her toes to her hearts content! Miraculously, and all of a sudden, Achta took her first wobbly weak steps with the support of a walking frame, amid the applause and encouragements of the staff and her family. The sadness that had seemed to engulf her began to be replaced with a beautiful smile that would light up her face as she was frequently seen practising her walking up and down the hospital walk ways.

Two months after being admitted paralysed and desperately ill with a bleak future, Achta left the hospital walking with crutches, going from strength to strength. And “the lame walk…”

Achta on the day of her discharge from hospital

(*Achta’s name has been changed to protect her identity but her family agreed to me sharing her story. Some of the details of Achta’s village life before hospitalisation have been added purely to help communicate more of the background of many of the patients who come to our hospital).

Never in the NHS

 May 2013 marks my first year working as a nurse in Guinebor, Chad. I knew that nursing here would be markedly different from working in the NHS, but there have been some days, at the end of which, I’ve looked back and realised that never in the NHS did I do that. Here are just some of those things….

• -          Conducting ward rounds in a minimum of 2, but at times, up to 4 languages! French to Arabic, Arabic to another tribal language, such as Kanembu and when there have been visiting doctors with no French, English has been thrown into the mix too. This not only takes up a lot of time, but assessing and even asking the simplest of questions can have rather confusing, if not bemusing results!

• -          Battling with the local wildlife; chasing chickens and lizards from the wards and stemming the influx of flies and mosquitoes with the aid of sticky paper and nets.

 

    

  

• Sweating like I have never sweated before (disgusting I know, but it’s true, it’s a new experience of nursing here!). While assisting in operations, I’ve had sweat drop off my eyelids each time I blinked, collected in the face mask so when I remove it a little waterfall fall and gathered in the sleeves of the water proof gown so that each time I’ve moved my arm I have felt a little sloshing sensation!!!

• -          On a more serious note, working here is allowing me to learn new skills that I would not have had the opportunity to do at home, such as giving anaesthetics and learning how to plan, budget and implement new programmes of care.

• -          Problem solving is a key skill for any nurse and here where resources are more limited, it is a skill called upon more often with greater creativity required. For example, devising a way to link oxygen tubing to deliver oxygen to 2 babies from one oxygen concentrator at the same time, constructing traction with water or oil cans with string and well placed groove in the bed, or making a stoma bag with the aid of a plastic bag and a lid of a tin of oats.

• -          Taking on complete new professions, such as generator technician, gardener, anaesthetist, an AA worker, called upon to pull out stuck vehicles in the wet season

       

• Pumping water from the hand powered  village well in the dark to fill any water container I and my colleagues could lay our hands on to ensure that the hospital still has water available when the generator or water tower breaks

• -          Unpacking boxes and boxes of medical supplies from 2 huge shipping containers

• -          Trying to do a drug round with the aid of a mobile phone light only- it is quite a challenge it see and assess the patient as well as find the prescription, find and dispense the drugs and write all with one hand! Thankfully the arrival of solar means this is no longer such a problem.

     

• Opening my fridge at home to find boxes of drugs and a bag of blood on the shelf below my marmite and chocolate as my fridge temporarily takes on the role as the hospital pharmacy fridge while the proper pharmacy fridge is fixed to desperately try to get the internal temperature below 20C!

There have been many more moments when I’ve taken a step back and just seen the bizarre or funny situation I have found myself in, and no doubt there are still many more to come, but I like those moments. Moments when I appreciate the opportunities I have here, that are just a little out of the ordinary!

Lights, Camera, Action!

Lights:

Giving out medications, assessing a child bought into the Emergency Room, delivering a baby. Just some of the everyday tasks that are performed at the hospital which in themselves are routine, yet when performed at night, in the dark, can prove to be near impossible and potentially hazardous.

Two huge, gas guzzling monsters of generators had to be switched on as absolute need dictated, but torches and lamps were used when possible. This was hardly an economical or efficient system, but it was what we had and we used it the best we could.

However, one thing that Chad does not lack is sunshine. And so we are in the process of harbouring its power to bring light the hospital 24:7. We are going solar!

So far we have solar in the Emergency Room, the Maternity Unit, the laboratory and the administration offices. This week has seen the wiring being installed in the four wards and this will be connected up to the batteries and the solar panels by the end of the week.

The staff and patients of the hospital are seeing the light!

Camera:

In other news, our long awaited and much anticipated x-ray machine has finally been installed in our brand new Radiography Unit.

Ousman, Moussa and Victorian have been trained up in taking good images and the necessary safety measures. Since the installation of the machine about 4 weeks ago, the three have been busy snapping away enabling the diagnosis of several lung infections, broken limbs and the worse pelvic fracture any of the ex-pat doctors here have ever seen.

Ousman prepares for a morning of taking x-rays

The machine is not only enabling quick diagnosis of problems and being a source of income for the hospital, but it is also saving, at times very sick, patients travelling 5 km into town for their required x-ray.

Action:

Each and every day here continues to bring new challenges, breakthroughs, surprises as well as the mundane. The past few weeks have seen us treat and care for, amongst many others, several cases of severe cerebral malaria, temporary paralysis from various causes, amputations, skin complaints, babies born, some by caesarean section,  fractures, routine hernia repairs, rheumatic fever, complex chronic wounds, cleft lip repairs, many mysterious illness and the one closest to my heart, children with malnutrition. And this is just a small selection of patients in the in- patient service.

The laboratory continues to churn out result after result for the many patients requiring a whole host of tests, the pharmacy has dispensed many drugs and the outpatient clinics are frequently overrun with many seeking help, while those in administration and other supporting roles have worked tirelessly to enable the hospital to continue to function.

Manga working in the lab

Patients waiting for their appointments

Activity, as always, ebbs and flows, but overall seems to do much more flowing than ebbing!

With this in mind, plus the fact that hot season is making its presence known, I’m very much looking forward to a short escape from the activity and my upcoming 2 weeks retreat and holiday in South Africa!

Every two hours this little baby required syringe feeds. She is now home growing well!

Faces Behind the Numbers

Before coming to Chad, in a bid to prepare myself, I read lists and lists of statistics. I read of poor literacy levels, high maternal and under 5's mortality rates, as well as just how high the temperatures could get. Of course, statistics can only tell some of the story and over the past 18 months, I have met just some of the people who are the human faces of these, at times, incomprehensible numbers.

According to WHO (2010), 15% of children in Chad are affected by severe malnutrition, a shocking statistic. But, as I meet just a few of these children, the enormity and tragedy of the problem continues to hit me. Let me introduce you to some of them.

Moussa was admitted to the hospital with skeletal features, too weak to cry. The outlook for him looked bleak and he was at great risk of becoming one of these statistics. He was immediately started on our programme of intensive re- feeding and treatment. I was surprised and overjoyed to see in the following weeks his little body strengthen and eventually he was discharged home with free enriched porridge, plumper and happier.

Ajit was three years old, admitted desperately thin and weak. He was even too weak to drink his milk, so we gave it via a feeding tube. After some time, despite our best efforts he continued to weaken. As a team, having done all we could, we prayed and waited. Amazingly, the next day when I went to check on his progress, he looked stronger and more alert than he had done for days. This however, made it even more upsetting when the next day I went to check on his progress over night to discover that hours earlier, he had died.

This was one of my lowest moments last year. I was devastated. The statistics were no longer dry numbers on a page, they were becoming alive to me and it was painful.

The causes and influences of malnutrition are extremely complex and cannot be solved by one single action. However, one of BMS World Mission's latest relief grants is committed to preventing further needless deaths and has raised an incredible £36,000! See www.bmsworldmission.org

This year, I will be working alongside Chadian nurses in using this money to provide a comprehensive hunger prevention programme. The programme, as well as continuing to provide inpatient re-feeding and free enriched porridge, will facilitate early identification and intervention for malnourished children. A Malnutrition Clinic will offer support and education, including cooking lessons for the mothers, while their children's progress will be recorded regularly  Blank walls will be decorated with health promoting messages and we hope to shortly offer vaccines.

At this time of year the number of children coming to us with malnutrition is small, but we are making the most of this time preparing for the increased numbers that the upcoming dry, hot months will bring. It is my hope that this year, with early intervention, the number of children dying with acute severe malnutrition here in Chad will be reduced, even if it is just by a few.

Welcome

It’s Monday morning, about 10am. As I walk by, I hear chatting, laughing… there are women coming and going, some looking anxious, others exited, others calm, some carrying huge bundles of cloths and mats, many wearing swathes of material that cover them from head to toe. I enter the room, the activity is frantic; people pass to and fro in a blur, some are writing, others giving orders, questions are asked in one language before being translated into another before the response is translated back again, others sit quietly watching, waiting.

Just then, a door to my right opens, out walks an older lady proudly carrying a bundle from which a small fist protrudes punching the air, followed by a strong cry demanding attention. A young tired looking girl gingerly is led out by a vision of pink to a bed in the corner where other women who have been sitting, shift to make room. As the young girl collapses and is given a well-deserved coke to drink, the pink vision whisks her baby off to be weighed.

Welcome to the Maternity Unit of Guinebor II!

While Monday morning is a particularly busy time for the unit as this is one of the two days the antenatal clinic is held, November proved to be the busiest month yet. We welcomed 103 new little ones to the world, including twins and our first set of Triplets!

Unable to resist joining the fun, my friend Louise who is a community midwife in Bradford, came and spent 2 weeks working alongside the midwives. She delivered babies, took blood pressures, mopped, helped with the clinic, doing whatever she could, all with a smile on her face and a word of encouragement at the ready. 

At times some rather graphic acting was required to overcome the language barrier, which although was not always easy, did create a lot of amusement and Louise was able to form good relationships with the midwives, even managing to do some training in neonatal resuscitation.

As busy as November was for our Maternity Unit, it looks like a trend that is set to continue, but in all the activity, we look forward to welcoming more little ones to the world.

A crazy last hour or two of a busy day

Two babies: 1 born today 2 months premature and oxygen dependent. The other, 5 days old just out of the operating room following a formation of a colostomy and who suddenly stopped breathing. 

1 oxygen concentrator, 1 sats probe to measure their oxygen levels and an ambu bag. 

Queue what would have been a scene of comedy, if it hadn't of been so critical, of lining babies next to each other, equipment between them, giving each baby a turn and attention depending on which was the most serious at the time!

It was evident that we needed a way to give both babies oxygen. With a bit of creativity and a modified nasal cannula, I was able to construct something that worked well while the resuscitations continued.

Sometime later,  they were both looking pinker and stronger, and although the premature baby continues to need oxygen, they were both maintaining good oxygen levels.

Now to move them to a place where they can be cared for during the night.

Shifting patients around freed up a bed on the ward, a generator with fuel found, extension leads located and with precision planning of a military operation, one person grabbed the heavy oxygen concentrator, I and another nurse carried a baby each and then after a count of three, we were off. In record time, the babies were safe on a bed, receiving oxygen, having their oxygen levels checked.

By this time the day light was going, so we finished setting them up for the night wrapped up in hats, woolly jumpers, socks and blankets by torch light, both breathing well.