My experiences in Masanga Dr Louise Wade I spent 4 months at Masanga Hospital from September 2012 to January 2013. I went out there as a fairly junior doctor – having just over 3 years experience of working in UK hospitals behind me. Masanga is a small village pretty much in the centre of Sierra Leone. The village is next to a river and hidden amongst the forest. The hospitals’ origins were as a leprosy hospital and hence the location is quite remote. Before my arrival I had received an induction and some basic information about the hospital. It is a hospital of approximately 100 beds split into surgical, maternity and paediatric wards and a stabilisation centre for malnourished children. There is also a busy outpatient department. Before I arrived I understood that most of the time the hospital had no electricity, there was a large generator which was turned on only for a few hours each night and when operations were occurring. There was also no running water in the hospital with the exception of 2 taps in the operating theatre. My experience being limited to having only worked in the UK I could not imagine how a hospital with no electricity or running water would function. In truth it is amazing how little you actually need to provide good, basic medical care. A couple of weeks after my arrival I scarcely noticed the lack of running water instead getting used to using alcohol gel or a bucket of water collected from the well to wash my hands. Indeed even in the hostel where we lived a clever Danish volunteer had created a bucket with a shower head on it which could be hoisted up to provide a surprisingly good shower. As a doctor the learning experience in Masanga was incredible. I saw many conditions I had only read about before – Lassa fever, tetanus and onchocerciasis to name a few. Patients often presented much later than I was used to seeing in the UK, this meant that disease processes were much more advanced and unfortunately sometimes that people were just much more unwell. I found one of the biggest challenges for me as a western doctor was learning to work without the array of diagnostic tools I am used to relying on. In Masanga they have basic blood tests, an x ray machine and the ability to do some microscopy but that is about it. Once you adapt to this there is a lot you can do and it was a good challenge for me to learn to use my clinical skills more rather than relying on say a CT scan to provide a diagnosis. As a relatively inexperienced doctor seeing a range of diseases new to me and learning to work in a very different environment could have been extremely difficult but one of the greatest assets Masanga has is two Senior Dutch Tropical doctors. They have completed a training program in the Netherlands which equips them with everything from the skills to do a Csection to a good understanding of tropical disease. They were an immense source of support and knowledge to me throughout my stay and ensured it was not too daunting but an enjoyable learning experience. One of the most incredible things about Masanga Hospital is the local staff that work there. They have a number of clinical health officers (CHOs) who have received 3 years of training and essentially fulfil the doctor role. Despite having had only about half of the training time that a western doctor would expect they are generally very competent. Often they were the ones teaching me about the specifics of tropical disease or the WHO guidelines that they followed. However whenever there was an area where they had not had the same training or knowledge as me they welcomed any teaching opportunities. I have struggled sometimes with teaching medical students in the UK – it can be hard to find a convenient time or to make it interesting for them and not something they have done before. Teaching in Sierra Leone became such a pleasure as it was clear just how much the CHOs enjoyed it. Masanga also employs a large number of nurse aids and 2 fully trained state registered nurses. This is an unusual situation as when I was there the hospital actually had almost twice as many doctors as fully trained nurses. Masanga now has a nursing school on site though and this will be of great benefit as it is hoped a number of the graduates will come to work in the hospital. The nurse aids have also been trained on site, receiving 6 months of training, and all of them live in local villages. It took me a few weeks after I arrived to appreciate how fantastic the nurse aids were. I noticed that if I was there first thing in the morning or in the middle of the night I would often see the same faces working and attending to the patients. At first I put this down to coincidence, but later when we would have emergency patients come in I found you could see all of the nurse aids who were employed on that ward in attendance at the same time. Whenever it was busy or something was happening which they could learn from they would just come in from the village and do a few extra hours work. They were never paid, or expected to be paid for this. The way they all rallied round when someone was sick and we needed extra help was so impressive and made me question all of the times I had moaned about having to stay a little late at work in the UK. My main role in Masanga was to project manage the opening of a new Acute Admissions Unit for the hospital. Masanga, and in fact most of the hospitals in Sierra Leone, had never had an Emergency Department – something we consider fairly standard in the UK. When sick patients arrived they would undertake often a long wait to be seen in outpatients before being identified as quite unwell and admitted to a ward, or, if they arrived out of hours or self-triaged themselves as sufficiently unwell, they would present directly to a ward for admission. The Acute Admissions Unit would improve this process by giving emergency patients somewhere to go and creating a recognised system for triage and admissions. It was also to benefit from a higher nurse aid to patient ratio of 1:4 allowing it to also function as an high dependency unit area for the most unwell to be cared for in. On my arrival building work on the unit was nearing completion and my initial tasks were to help with hiring staff, arranging the equipment we needed and making arrangements for and educating others about how the unit would work in practice. We were fortunate to have our own separate generator for the unit, it used much less fuel than the large generator which powered the whole hospital site and therefore we could at times run it 24 hours a day. As we also had a new oxygen concentrator received form the UK this meant we now had the ability to provide electric lighting and oxygen at any time it was needed. These two simple measures greatly increased the standard of care the hospital could provide. The unit opened about 3 months into my stay in Masanga and as per local tradition a great opening ceremony was held. One of the special things about Masanga is the community of Danish volunteers who come out to help with the hospital. At any one time there can be anywhere from about 4 to 20 different volunteers. They all come out with specific projects to work on – some of them are trained health professionals such as midwives or nutritionists, others have business knowledge and help with running of the hospital others still have engineering skills and help with projects such as trying to develop a running water supply to the site. They bring a great energy and skill set to the project and indeed I think the locals really enjoy having them. The volunteers all live in a hostel on the hospital compound site and whenever new volunteers came or old ones moved on often a party was had. These were always well attended by the locals although they were never too impressed by Danish music and it was only ever a short time before it was replaced by music the Sierra Leonians felt they could really dance to. Finally a word about the patients who attend Masanga Hospital. The patients travel often huge distances to attend as the hospital has a good reputation and the fees tend to be lower than at the local governmental run hospitals. The make their own journeys, which can take several days, with severe pain and with uncertainty as to whether help will be available for them. They then wait, patiently and often for some time to be seen. When they are seen they are grateful for anything you can do and are without fail polite and a pleasure to treat. If they are admitted each patient must have a carer to stay with them. This is often a member of their own family who will stay with them, bring them food and wash their clothes and sheets. If the carer is a young woman they will bring their children too and you see these small subsections of families lovingly looking after each other each day. In UK hospitals with structured visiting hours we sometimes we see little of a patient’s family and lose out on this insight into their life and those that love them. It is easy for patients to become “the gall bladder in bed 6”. Masanga hospital is busy and crowded but in a way that I became very fond of. My four months in Masanga were an incredible experience. I learnt so much not only about tropical medicine but also about the challenges and huge advantages of opening a new facility in the hospital. From the people I met I learnt about resilience, optimism and strength. As with any hospital in the world there are further improvements that can be made – the road to the hospital could be paved allowing use of an ambulance, further fully trained nurses could be appointed, medication stocks could be better and the range of laboratory tests expanded. This all takes a great deal of money and time however and the level of care currently provided by the compassionate and hard working people of Masanga is an example to follow. I would like to say thank you to Oz and the Masanga UK team for enabling me to be part of this project and spend time in Masanga. Also to Dr Josien, Dr Alex, Dr Mark, Dr Jet, Bart, Anne-Marie, Patrice, Emma, all of the CHOs, nurse aids, the Danish volunteers and all the other staff at Masanga for their help and support with the opening of the Emergency Admissions Unit and for making my stay in Masanga so enjoyable.