A Journey to Africa by Dave Christie (@bagheera79)

At a little half past eight in the morning on the 25th of November last year I started on the ICU ward round with the team of residents, at the Black Lion Hospital in central Addis Ababa – the capital of Ethiopia. There were sixteen patients to see, with a high proportion of trauma – especially brain injury – and severe life-threatening infections. It looked so different from the unit here in Dumfries. It had big wide windows allowing in daylight, for a start. In a UK hospital, windows at this height would be securely fixed so as to avoid the kind of unfortunate incident that makes the headlines. Here, in Addis, one of the nurses was leaning right out of the window and yelling cheerfully to a colleague in the carpark over a hundred feet below.

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As I looked around I took in more differences. The beds were quite close together, with a low wall separating the heads of beds between the divided area. Instead of uniform ranks of identical equipment all bought at the same time, the pumps and ventilators were a mishmash of ancient and relatively modern kit. Huge, head height tanks of oxygen sat beside each ventilator, as there was no built in oxygen supply in the walls. Beside most beds sat a big bottle of caramel liquid – it took me a moment to work out that this was nasogastric feed. Of course! – they don’t have the pumps to delivery a trickle of feed continuously, so they have a supply for the day and administer it at intervals. Each patient’s bedsheets were different, brightly coloured, and obviously donated or brought in from home. Nobody was wearing aprons, or gloves – the bright smurf blue and purple hands of healthcare that are so ubiquitous in UK ICU were nowhere to be seen. I could imagine our own infection control team spontaneously combusting at the sight. Of course, they would likely have already lost consciousness at the sight of an entire team of doctors standing around the bedside in long-sleeved white coats – something which has been verboten in the UK for years.

But then, I looked closer and readjusted. Put into context, they were doing the same stuff we do. Airways were protected. Patients were being rolled, washed, and cleaned every day, with a change of sheets. Physiological parameters were being diligently recorded on big charts in close detail. Because pumps were usually either broken or in very short supply, sedation and analgesia were given by injection at regular intervals. They were being fed – one way or another. Patients were receiving regular chest physiotherapy to try to shift stubborn sputum and prevent pneumonias. Blood tests. The nurses still laughed and joked and teased each other. It’s the same stuff that we do, but in a much simpler, less precise way. And, a lot of the time, it worked. Which, to be brutally honest, is just as true of our own, ‘modern’ intensive care.

I turned my attention to the lady in the bed. Clearly profoundly affected by a severe head injury as a result of trauma, she also had signs of a severe chest infection. Here in the UK, it would be standard practice to send sputum samples off to the lab to identify the offending organism, certain specific blood tests might be done, and a chest x-ray would be a routine investigation in order to see the extent of the infection. I asked if they could do any of those things. Dr. Woubadel looked at me with a wry, slightly sheepish smile. “Well, we can. But we only have two antibiotics and our microbiologists have refused to analyse our sputum samples. And the lifts are out at the moment.”

Right. Wait, what? “You only have two antibiotics?”

“Yes, ceftriaxone and ceftazidime.”

If you don’t speak antibiotic, that’s a little like going to the supermarket and discovering that the only two cleaning products available are napalm and a hydrogen bomb. Given that antibiotic resistance is a real and growing threat, this is a disaster for the future.

And the lifts…. ah. The building of the Black Lion is definitely a little bit past its best, and was undergoing a phase of refurbishment. Almost all of the lifts were removed and in true, relaxed Ethiopian style, there was occasionally a warning sign. I had had a look at one of the lift shafts and it really was an open door onto a seven storey drop. Later that day, I watched a patient being taken urgently to theatre from one of the wards on the floor above the theatre complex. Four orderlies and a nurse were carrying the entire bed – with the patient lying on it – down a flight of stairs. Another nurse was carrying the drip. That morning, if they really wanted a chest x-ray, they’d have to do the same thing if the lift was out as there was no portable facility to take x-rays on the unit. And if need be, they’d have done it.

Dave C 1So why was I there? It’s worth pointing out that the Black Lion is a large teaching hospital in the city centre. It’s one of the lucky ones, as the facilities it has are relatively modern. They can even do cardiac bypass – provided there’s a visiting perfusionist from overseas to work the machinery. This definitely wasn’t one of the small hospitals out in the country. I was there along with Fanus Dreyer, a consultant in General Surgery here in Dumfries, to teach on a critical care course that he organises. The College of Surgeons of East, Central and Southern Africa overseas the training of surgeons in that part of the world, and the critical care course is part of the mandatory requirements of their training. It is a charity – the aim is to make the course (along with the others which deal with surgical skills, and research) self-sustaining in each of the involved countries. The idea behind all of this is to try to improve the healthcare in that part of the world, by standardising surgical training, ensuring basic competencies etc, in an area where healthcare is sporadic and frequently poor or non-existent. Peri-operative and critical care is a vital part of that – being able to competently do an emergency bowel operation is nothing if the patient dies post-operatively from a lack of care.

Being out there and teaching on the course was an extraordinary experience. Having had the chance to spend some time in the actual clinical areas, to see how they worked on a day-to-day basis, helped hugely as it helped give me direction on what the course attendants needed. The junior surgeons on the course had excellent clinical knowledge and ability – the real difference was the approach. They have the same knowledge as our junior surgeons – medicine is universal, fundamentally – but what they needed was guidance on how to organise the approach to sick patients, and how to structure their management. They were highly motivated, and very keen to learn. But as I knew, they would often be working in facilities that had next to zero resources, hundreds of miles from Addis. There’s no value in teaching about the potential uses of dialysis in critical care in that sort of scenario – but there is enormous benefit in teaching about the approach to sepsis. Being able to manage a patient with a critically endangered airway with simple techniques would be life-saving – even in the most rural surgical facilities there will be some sort of scalpel.

David C 3And over the two days of the course, in the four days that I spent there, I realised that the simplicity of approach is something that we are still striving to teach here, even with the advanced facilities available to us. Their ICU looked primitive in comparison to the UK, but it was still striving to provide the basics of critical care. I realised I was teaching the same things that I teach here – sort out the basics and communicate well. Recognise illness, recognise dying, and treat each thing in turn, with compassion. These things are universal – and we shouldn’t allow a distraction with technology to cost us our humanity.

 Dave Christie is a Consultant Anaesthetist at NHS Dumfries and Galloway

Fire in your belly by Euan Macleod

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What is the fire in your belly?

Euan 2When it comes to what you do? Do you feel passion for it and are you excited about the possibilities that could come your way, or is it a bit like the guys with the Gaviscon have just hosed you down and your fire is quelled?



Fire in your belly-you know when you’ve got it

You feel it

Euan 3Sometimes it is hard to find time to listen to our feelings in the midst of busy work schedules, the passion that you first felt when you entered a career in the NHS may have become blunted by the daily trudge-is it always going to be like that?

I recently mentioned in a blog the creation of the NHS and the welfare state.

Beveridge had a passion for that, but where did that passion come from?

Beveridge’ report might have been destined to be another dry and dusty Government document. What made it a huge public best seller was its breathtaking vision and passionate language. The fiery rhetoric largely came from Scotland after weekends spent with Jessy Mair in the spring and summer of 1942.

Jessy was Beveridge’s close confidante and companion for many years. His biographer, Jose Harris, highlights her influence on him during his visits north of the border:

“Much of his report was drafted after weekends with her in Edinburgh and it was she who urged him to imbue his proposals with a ‘Cromwellian spirit’ and messianic tone. ‘How I hope you are going to preach against all gangsters,’ she wrote. ‘who for their mutual gain support one another in upholding all the rest. For that is really what is happening still in England’. . . .”

Beveridge didn’t miss; the report sold 100,000 copies within a month. Special editions were printed for the forces.

The gangsters referred to by Jessy Mair were the deliverers of health care who profited from the sickness, squalor and disease prevalent at that time. Beveridge clarion call to a sense of community welfare based on need and not ability to pay heralded the start of the NHS.

No surprise that today many of us remain passionate about the values and aspirations of the health service, a service that many of us have experienced as employees, patients and carers of loved ones. There is still some fiery rhetoric and a will to retain and improve on the values and service which the NHS provides.

But it won’t be easy in this time of austerity.

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It might need

Guts-More fight

Grit-More passion

Gumption-Being courageous

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It means that you find a way to get better

It means that you’re putting in every ounce of extra effort you have

It means that you get pushed down but don’t stay there

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Easy to say

Perhaps harder to achieve

But unstoppable when it starts

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So what’s your passion and where is it taking you? Share the fire in your belly, it could start a bonfire

Euan McLeod is a Senior Project Officer for the National Bed Planning Toolkit





Towards a world free of kidney disease….. by Nadeeka Rathnamalala

Nadeeka 110th of March 2016 is World Kidney Day. Many activities take place around the world to raise awareness of risk factors for kidney disease, encourage systematic screening for high risk groups, encourage transplantation and advocacy of governments to take action and invest further in screening and treatment. Despite these efforts especially by organisations like World Health Organization (WHO) and International Society of Nephrology (ISN) we are still not equal in terms of access to treatment.

Sharing my own experience would perhaps shed more light on this. Having done my initial training in general medicine in Sri Lanka I came to the point where I had to undertake further post graduate studies in a subspecialty in Medicine. When I picked renal medicine, the common response from members of my family was “Are you sure?” Kidney disease outcomes were perceived as being worse than cancer due to limited access to dialysis. When I started my training in 2010 there were only 90 functioning haemodialysis machines in government hospitals in Sri Lanka for a population of 20 million (estimated prevalence of Chronic Kidney Disease (CKD) between 4-8%). Haemodialysis had been first introduced to the country in 1983 and attempts to introduce Chronic Ambulatory Peritoneal Dialysis (CAPD) had not been successful as the cost was much greater than the cost of in centre haemodialysis given that no plants for PD fluid production were in the region. Live donor transplantation was an available option but limited by long waiting lists in the government sector and availability of donors. I went through my training attending on patients who would present breathless with fluid overload due to ad hoc haemodialysis. The limited dialysis slots had to be prioritised according to the severity of symptoms. When I came over to the UK to complete my training in nephrology I was amazed by the free and unlimited access to renal replacement therapy. What was more they were transported back and forth from the dialysis centre at no personal cost!

On my return to Sri Lanka in 2013, to take up my first job as a consultant I was hit hard by the reality. I was appointed to be the only nephrologist in the southern province of the country to provide care for a 2 million population. I was to be based in the tertiary care centre in the region with 7 haemodialysis machines and facilities to perform a live donor transplant every fortnight. I also had funds to have a further 10 patients on CAPD. The hemodialysis machines were working around the clock and at any given time a couple of machines would be having technical faults leaving me with five functional machines at a given time. The total number of patients registered in the clinic was just above 1000 (at least 150 end stage renal disease requiring dialysis) and there would at least be another 5 to 8 in patients requiring dialysis in the hospital. The way I could prioritise was to give preference to the patients with acute kidney injury (with the hope they would recover) and those awaiting live donor transplantation. Everyone else who did not have a plan but were in end stage renal failure had to be fitted in to the left over slots. Despite our best efforts many patients lost their lives due to inadequate dialysis.

That is the heart sinking story of kidney disease in the developing world. 80 % of the dialysis population is in Europe, North America and Japan while the rest of the 20 % is distributed in the vast regions of South America and Asia. These figures are a reflection that dialysis is a luxury mostly the rich can afford. Though disparities in renal care are greater in the developing world, there is data to support inequalities in provision of care to the more disadvantaged populations in developed countries. For example, in the United States ethnic minorities have a higher incidence of end stage renal failure while in Australia figures show that aboriginal Australians are 4 times more likely to die of CKD than the non indigenous Australians.  

Concerted effort on prevention and early detection would be the way forward to minimise these disparities in the future. World kidney day is a global awareness campaign that aims to do just that. This year the theme is “kidney disease and children – act early to prevent it” and aims to highlight the importance of protecting kidneys from an early age. We hope to have a booth in DGRI on 10th March to hand out leaflets and badges to join in this world wide effort of raising awareness of kidney disease. We hope that staff as well as visitors will take the time to come visit us and support the world kidney day initiative.

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Dr Nadeeka Rathnamalala is a Locum Consultant Nephrologist at NHS Dumfries and Galloway