Jungle Diaries

We see more surgical than medical admissions in Masanga. Many patients come with chronic leg ulcers – sometimes due to infections but often complicated by undiagnosed diabetes or peripheral vascular disease. Usually, patients have tried traditional methods of wound management initially, and often present months later than they would in a higher income setting. This is the same for patients with fractures secondary to trauma, most commonly road traffic accidents or falls from trees. During mango season people (especially children) climb to find the best mangos, and year-round palm trees are tapped for palm wine or kernels gathered for palm oil. Abdominal pain is another reason for presentation, and we see many more gastric perforations than I expected. This is probably because of accidental overuse of pain medications (NSAIDs), a higher prevalence of H. Pylori infection (a stomach infection that causes increased stomach acidity and is hard to treat due to antibiotic resistance), and perhaps dietary factors including spicy food and fasting. Masanga demonstrates nicely that infection is only a very small part of tropical medicine.

We do see plenty of patients with HIV and TB however. Despite affecting about a quarter of the population of the world and hundreds of years of research, TB is still remarkably difficult to test for and treat. Fortunately, diagnosing HIV is much easier. However, dealing with the consequences of HIV infection is very difficult. Stigma is a real issue. We refer to HIV in code – tests are called VCCTs, and HIV itself is “RVD” (retroviral disease). Most of our inpatients with HIV have travelled from other areas of the country, so they are not in the hospital that serves their community. One of our long stay patients who sadly died after a 2-month admission was a bit of a local celebrity. We only discovered he had HIV after his death – his admission tests were missing and so were repeated after a staff member was exposed to his blood. He knew he had HIV and was taking treatment, but he didn’t want hospital staff to know. This is clearly dangerous for us and impacts on the care we can give him!

We recently admitted a 37-year-old to the isolation unit. She was taking ART (anti-retroviral therapy) for HIV, but the date of her diagnosis and her compliance with medication was not clear because she was confused. She felt breathless and had abdominal pain. On examination it was immediately striking how thin she was, the bones of her skull very clearly defined in her face. She was breathing quickly and needed oxygen, but her lungs sounded clear. Her conscious level was not reduced, but she had a stiff and painful neck, and her coordination was terrible – she couldn’t stand without nearly falling over. Her liver was enormously enlarged and tender. She had swelling of both legs (pitting oedema), an extensive thrush infection of her mouth, and covering her entire body were dark raised lesions – Kaposi sarcoma.

Clinically she had stage 4 HIV disease (previously known as AIDS) – HIV wasting syndrome, Kaposi sarcoma, and opportunistic infections of the brain all individually would classify her this way. Her oedema may represent kidney disease secondary to the virus (HIV associated nephropathy). Being so affected whilst taking treatment is surprising, and most likely suggests poor compliance (maybe due to her confusion) or possibly resistance of the virus against the medication. Her lab tests showed a very low white blood cell count. Ideally, we would quantify this better with a CD4 count – these are the cells specifically destroyed by HIV which is the reason for immune failure. CD4 testing is a fundamental part of HIV management in most parts of the world, but it is not possible (to the best of our knowledge!) anywhere in Tonkolili District. This makes it harder to provide good HIV care, particularly for outpatients. We were able to do a cryptococcal antigen test (the first in Masanga, thanks to the Fever Study!) which was negative. USS showed fluid (effusions) on both lungs and around the heart, and fibrosis of the veins in the enlarged liver suggesting co-infection with schistosomiasis.

These patients can deteriorate very quickly, and with a limited (but growing) lab we are not able to confidently distinguish between many causes. It is therefore safer to treat all dangerous possibilities. Several antibiotics were given to cover for bacterial meningitis and toxoplasmosis. The most common cause of death for a patient like this is widespread TB infection, and we felt TB meningitis was the most likely cause of her symptoms and effusions. We started treatment for this also – a combination of four anti-TB drugs and steroids. The decision to start steroids in Masanga is not taken lightly due to the side effects. We also must be careful to treat for an intestinal worm called Strongyloides first – if not there is a risk of “hyperinfection” of the worm, which can cause very rapid deterioration and death as the worms migrate through the lungs as part of their life cycle!

Unfortunately, the outlook for this patient is poor. Many of her issues are hopefully reversible, but some causes of confusion secondary to HIV are sadly not. She was quickly placed on the hospitals charity fund because she was struggling to pay for all her medicines. Her family are aware she is very unwell. With stronger systems in place to detect, treat and prevent spread of infections such as HIV and TB, cases like this can be avoided. Masanga Hospital is working to improve its HIV/TB service, and just recently employed a new nurse specifically for these conditions. I hope the next few years see gradual strengthening of the national programmes too.

We have delivered a nine-week programme to two separate groups of MTPs (five students total). Most days have two hours of teaching – seminars or simulation training. The students all have a good grasp of basic science, and discussions during grand rounds often become very academic – Abdul from the first rotation was particularly proud of being nerdy! However, they all initially struggle to apply that knowledge clinically. Simulation provides a controlled environment to practise assessing an unwell patient in a systematic way whilst under pressure. After the first simulation session, Abdul told us “It’s like you’ve thrown us in a river, and we don’t know how to swim!”. They have all improved so quickly however, and seeing this improvement is very rewarding.

Outside of lectures, the students work clinically on the emergency and isolation units, and in the outpatient department. They see patients under the supervision of one of us UK doctors, and gradually develop independent practise. Bedside teaching/case-based discussion is by far my favourite method of teaching, and everyone is very receptive to it. Often nurses and other trainees will come over to listen and join the discussion when we are teaching the MTPs. Most of our inpatients have surgical complaints which makes things less interesting for MTPs but there is often something to discuss. Another aspect of our teaching has been in helping the students to develop good “housemanship”.

We are also involved in pastoral care for the students. This has at times also been tricky. The cost of living (mainly food) in Masanga is higher than the students expected, partly due to the transport premium – food must be driven into the village and fuel is very expensive. The second group of students asked for our help with this, and it required a lot of back and forth to resolve – unilaterally increasing the MTPs stipend would be unfair on the PTPs and STPs, but it’s hard not to feel for a student who cannot afford to eat. Accommodation for the students is free but very basic. It’s tricky for students from more affluent backgrounds to get used to life “in the jungle”, but we have learnt a lot for future rotations in terms of expectation management.

The future of Masanga Hospital I think depends on maintaining it’s role in education. As the planned 20-year period of NGO support comes to an end, the hospital needs to find a way to justify its existence in the wider system if the government gradually takes over. Becoming a “rural training centre” is the perfect way to do so! It’s nice to have contributed in a small way to this end.

Can you tell us a bit about yourself?

My name is Jenny, I’m a nurse practitioner from the Netherlands and work in the Emergency

Department. I have just got back from my fourth trip to Sierra Leone. I love the people and the

hospital!

Can you teach us something in krio?

“Me ar lek foh dae pikin foh geh welbodi”

“I want the children to get better”

How many nurses are working in Masanga and what departments are there?

At the moment there are 60 nurses across the Operating Theatre (OT) Emergency Unit (EU) Surgical

ward, Paediatric ward, Maternity ward, Wound Dressing team, Isolation ward, Outreach, Triage and

Physiotherapy.

What would a day in the life look like for you?

Every day is very different! My walk to the hospital is 15 minutes, slower on hotter days. Handover

with the team is first thing then I could be doing anything from teaching ETAT (Emergency Triage

Assessment and Treatment Training), assisting the wound dressers with ANTT (Aseptic Non Touch

Technique) for leprosy patients, making training sessions, having meetings, going on blood donation

outreach, the list goes on! I get to work with all the hospital staff, cleaners, security, STPs (Surgical

Training Practitioners) which I love.

What is one thing you can’t live without in Masanga?

A torch!

What will you miss about Masanga?

The people! Everyone is cheerful and people always make the time for you. Life is a lot slower.

What was your most memorable meal?

Our UK house caretaker, Jeneba’s pumpkin groundnut soup with rice.

The tailors in the village are very well known, what was your favourite thing they have made?

It’s very special that they can make something handmade for you – I was lucky to get some gorgeous

dresses as leaving presents.

Why should nurses or midwives come and volunteer in Masanga?

It can give you a new perspective on life, you see a lot of poverty, but you also see how resilient

people are and how well they cope with their struggles. You really get to see how to enjoy life

without materialism. It’s important that you come for at least 6 months otherwise it’s not helpful for

hospital staff and not fulfilling for yourself. Masanga gives you opportunities to work on all your

skills.

A Champagne-fuelled lunch is not the best preparation for a 5km run – or any run! But, to my shame, that is how I began my ‘12 Days of Christmas Run Extravaganza’ to raise funds for Masanga. 

Just a few hours after that festive, family gathering on Christmas Eve, I was pounding the drizzly streets of south-west London, dodging tipsy revellers, and wishing I was somewhere else! The cheesy seasonal music from my earphones – Wham, Slade, Mariah Carey etc – wasn’t helping.

And this was only the start. I had committed to running between 5-10km every day of Christmastide, a period that starts at sunset on Christmas Eve and ends on the eve of Twelfth Night (Jan 5).

My Run Extravaganza was inspired by hearing about the Dr Wouter Run which takes place annually at Masanga in memory of a young Dutch doctor, Wouter Nolet. He, very sadly, contracted Lassa fever while working at the hospital and died in 2019. 

My nephew and his fiancee, ‘Dr Paddy and Dr Becky’ who worked at Masanga for six months in 2022, had returned to Sierra Leone to take part in the run on December 17. It was the suggestion that friends and supporters of Masanga do their own Dr Wouter Run - wherever they may be in the world – that caught my imagination.

Since I’d drawn the short straw this year and was working through Christmas, I thought why not extend the run in an attempt to maximise the amount raised by sponsorship. 

I am an occasional rather than a regular runner, so it was a physical challenge as well as trying to find the time to fit the runs in while working. Christmas Day in a newspaper office is always busy with either too little news to fill a paper or too much news and not enough staff. 

This year was no exception, plus we had a fire alarm emergency that meant our skeleton staff spent 30 minutes out in the street while the Security team tried to work out how to turn the alarm off! 

Eventually, I managed to escape the chaos in London’s biggest green space, Hyde Park – only to be chased by an angry swan as I circuited the lake.

Boxing Day I found myself running in nearby Holland Park with its beautiful Japanese Garden - and actually starting to enjoy the experience, despite my creaky knees.

Day 3 was the turning point, an exhilarating morning run along the deserted Thames, with mist rising from the water and the odd heron investigating the detritus of low tide. 

After that, I found myself looking forward to every outing, actually wanting to run further than the day before. In fact, I enjoyed it so much, I clocked up an extra day, finishing on Friday January 6, feeling far fitter than I would normally do after the usual festive indulgence. In all, I covered 104.89km over 13 days and between us, Dr Paddy, Dr Becky and I raised £11,250.

I asked my sponsors for no more than £5/$5/5E but so many people were far more generous than that. I would like to take this opportunity of thanking them all – every single penny counts and their contribution will make a huge difference to Masanga and the staff and patients it serves. THANK YOU!

One of the main reasons for our visit is to develop our links with Partners In Health. PIH are an American organisation supporting Koidu hospital, 2 hours down the road from Masanga in the eastern Kono district. Just as the surgical and paediatric training programmes are run out of Masanga hospital with support from foreign agencies (Capacare and German Doctors respectively), so PIH are supporting the medical training programme. MasangaUK are going to be playing a key role in this by supporting medical rotations at Masanga hospital and delivering part of the curriculum.

We were welcomed to Koidu by Marta, a Spanish internal medicine specialist, key member of the PIH training team and general bundle of fun! Having just returned from a month away, she greeted every member of staff as a long lost friend as she showed us round. Koidu is a government hospital, supported by PIH on a much bigger scale than Masanga. It has an impressive array of facilities and services. We were particularly impressed by their neonatal unit, isolated TB ward and ever-growing non-communicable diseases clinic. Koidu has long been established as one of Sierra Leone’s biggest hospitals outside Freetown. Its bigger and busier than Masanga with a pleasingly large staff of government payed medical and non-medical employees, but by no means feels beyond the realms of achievability for Masanga. There’s a reassuring familiarity in the physical structure of the place and equipment we see in use. It’s easy to picture Masanga operating on a similar scale in the not too distant future. 

Over pizza and Sierra Leone’s finest Star Beer that evening, we sit with the PIH team to cement our partnership as we discuss the future of the medical training programme, agree timetables for junior and senior rotations at Masanga and discuss monitoring and evaluation processes. We’re looking forward to welcoming students to Masanga in early 2023 as part of their clinical training towards earning their BSc in clinical medicine. As the student presence at Masanga continues to grow and focus turns more and more towards education and training, it is only fitting that the hospital recently signed a new memorandum of understanding with the government to officially recognise it as a teaching hospital. This is a massive step for the hospital and a clear statement on the direction that the project is heading in.

Alex and I return to Freetown at the end of our all too short visit reinvigorated. We’re inspired by the huge steps we’ve seen the hospital take since we last waved goodbye, there’s an undeniable buzz around the place as it continues to embrace new projects and new ambitions and we’re excited for where we’re going next with our new partners.