Dr Peter: Dr Peter McCormick's first visit in 1996
Dr Peter McCormick became actively involved with the Appeal, following his retirement from General Medical Practice, in 1996. His input over the years has been central to the continued success of the project and I was especially thrilled when he accepted the role as Chief Medical Advisor to the Appeal. His advice and guidance over the years have been invaluable and his continued friendship is treasured.
Dr Peter, as he is affectionately known at the hospital, has spent a total of seven months working on the children's ward. This gave him the ideal opportunity to completely overhaul the medical practices on the ward. These two visits and the subsequent reports that Peter filed, identified the most pressing and urgent needs of the ward. The Appeal was then able to respond in full and was able to assist with the supply of the necessary medications, drugs and equipment to implement his recommendations.
One particular issue that Peter focussed on was the essential reduction of the extremely high death rate during the rainy season from malaria. He introduced a very simple procedure that resulted in the mortality rate falling, the following year, from 17% to 11% of all admissions for malarial conditions. There may have been other contributory factors which led to this decrease in deaths. However the Appeal firmly believes that both the implementation of Peter's recommendations together with the Appeals response in supplying the necessary equipment were the significant factors in this dramatic reduction in deaths.
Peter continues to be extremely active within the Appeal and remains its Chief Medical Adviser. He accepted an additional challenge in 1999 when he agreed to work on the Paediatric ward of a hospital in the Cameroon.
This is the report that was compiled by Peter from his diary notes following his return from his first visit to Bansang. Whilst some portions of the report are rather technical it does, however, give the reader a very real feeling of life in and around Bansang Hospital.
I arrived on December 13th 1996 and stepping out of the airplane at Banjul International Airport was like stepping into an oven. I walked into a wall of Tropical heat and remained in it for the next ten weeks. I also walked into another world, for here I found people without worldly possessions or property. Confronted with barefoot toddlers in tatters, the maimed, the blind, it was just like a scene straight out of the pages of the new Testament. Remarkable it was to me that these folk were so cheerful, so cordial and courteous, so willing to talk, so uncomplaining of their lot, and so appreciative of white people from Europe coming to help their people.
I was asked to work in the Paediatric Dept. at Bansang Hospital since it had fewer doctors than the rest of the hospital. This suited me fine. Many years ago I gained a Diploma in child Health and spent three happy years in Paediatrics in both Yorkshire and Northamptonshire. Along with my newly acquired Diploma in Tropical Medicine I felt suitably equipped to launch into Tropical Paediatrics at Bansang Hospital.
Bansang Hospital ! - Oh Anita Smith you have much to answer for! The hospital changed her life - it has changed mine too. I know that comparisons are sometimes inappropriate and even invidious, but because we have brains that are trained to compare and contrast, and to seek patterns, they are also inevitable. Armed as I was with intensive training and excellent books on Tropical Medicine I felt equal to anything Bansang might throw at me. But I had a few new thoughts coming! What I was taught in the Tropical Medicine course at Liverpool University and what was happening in Bansang hospital were very different things indeed.
The hospital has an open plan feel about it, and in those dusty open spaces between the various units is to be found a quaint collection of living things. Thin cats, septic dogs, chickens, goats, donkeys and vultures. Open storm drains thread their way across the campus. The drains are dry now save for a stagnant film of sludge. This is attractive to the rats which I have often seen in the channels. In the rainy season the drains will be turbid torrents two feet deep.
There are two areas set aside as little camp sites where the relatives of patients may rest and cook and eat and sleep. There are standpipes where women draw water and wash themselves and their clothes. There is a small mosque for religious people, and a small market at the hospital gate selling a few basic commodities for all comers to the hospital. One excellent sealed well, with a pump, installed by UNESCO, provides lovely water when the piped supply fails.
Behind the hospital is a sprawl of tiny rooms in which the nurses live. The standard of accommodation is poor, and I found it sad that such devoted and competent people should live in such humble circumstances. At the eastern end of the hospital is a comparatively new Nurses Training School containing the nucleus of a good library - the only repository of books in the hospital. At the west end is the Eye Unit, modern and comparatively well equipped, and linked to a National Eye Care scheme. To the south, across the road, and between it and the river are to be found the somewhat more salubrious accommodations of the doctors, the Administrator, the Principal Nursing Officer and other senior staff.
Though the Management knew months in advance that I was coming, my rooms were not ready until two weeks after my arrival. When I did get in there were cockroaches, rats, mice, and lizards to evict. Spiders, ants and, mosquitoes were little problems I had to learn to live with. The bat became a friend and I admired his silent accurate no-touch technique in flitting about my rooms.
Tuesday 17th December 1996 was my first day of work. My diary for that day states "It will be difficult adequately to describe the horror of this my first day's work…". The ward rounds were chaotic because my two colleagues had not hitherto allocated patients to themselves. Thus Dr Redenta would do a round of all the patients, write in the notes, order investigations and treatments. Half an hour later Dr Brown would review the same patients and likely as not change things that had only recently been decided upon.
Now that I have arrived it seemed to me that there would be trouble in triplicate and it seemed daft in the extreme to launch into such chaos. I therefore suggested on my first day that we have teams: Dr Brown's patients, Dr Redenta's patients and Dr Peter's patients. This was agreed and soon began to work well. We each collected our 'own' patients for whom we were wholly responsible both as inpatients and outpatients, for investigations and treatment, for follow-up and for discharge. We were by no means isolated from each other; we could and did ask each others opinions and advice from time to time.
Once a fortnight a 'Grand Ward round' took place with a Medical Research Council consultant Paediatrician and his retinue of senior nurses. The resident Bansang doctors would present difficult cases and then listen to the wisdom of the visiting doctor. This was good, and I learned a lot. On Monday to Friday the morning ward rounds were followed by outpatients clinics.
The turmoil here at the outpatients clinic had to be seen to be believed. Mothers and children just turn up from neighbouring towns and villages. No appointments, no referral letters, no paper on which to write notes. It seems that the only writing expected of me was a prescription to take to the Pharmacy. That had to change. To effect change here was time-consuming and added to the mayhem outside my door. But I didn't stop folk entering the room uninvited so that sometimes there would be two complete families in. Then some member of staff unknown to me would come in and say "Hello Dr Peter - how are you and how is the day and how is the job?"
The practice of Medicine threatened to become a spectator sport rather than the intensely private meeting of doctor and one patient. It took me a long time to let it be known that I would not have folk crashing in and out of the examination room without so much as a knock on the door. The clinics went on from 10.00am to 2.00pm Coffee breaks did not exist in the clinic, so after a week or so, when the bulk of the patients had been seen, I would bike off to my room and make myself a coffee then return to the fray.
The very first case I saw in the clinic was a four month old baby set down on the couch by the nurse "See this one first doctor it is very sick". She was right. It was unconscious and convulsing with a rectal temperature of 40c, a sunken fontanel and respiratory distress. Such was my introduction to Cerebral Malaria. I thought the baby would die there in the clinic. I certainly thought it would subsequently die on the ward. The senior nurses on the ward told me however that this baby will not die.
Their views cut across my teaching: The little black boy was comatose, convulsing, hyperpyrexial and dyspnoeic. All complications of severe malaria which should put him into the 20% mortality bracket, or survival with 10% risk of neuro-sequelae. The nurses were right. The sound experience of trained staff can be more reliable than Diplomas and book-learning. It was unspeakable joy for me to see this baby wake up on day four and be breast-feeding on day five. It was lovely to see him strapped to his mother's back on the day he was discharged, and I was thrice blessed when he turned up at the OPD two weeks later fit and well with no obvious neurological deficit. His mother gave me a small pot of soured milk as a present. I had to dash to the Pharmacy to get an empty tablets container for she needed her pot returned. The widow's mite. Little boy Ebrima Kandeh I will remember you for ever.
Examining another patient
The Children's Ward is badly designed. For all the intense sunlight of the Gambia very little filters through to the ward. The lights have to be on constantly - insofar as that is possible given the erratic electricity supply in Bansang. On several occasions I have bicycled through the hospital to the Generator shed and asked the man to switch it on so that we could start work on the ward. The ward lacks the clinical cleanliness one associates with western hospitals. Dust, dirt, items of clinical waste and cockroaches are everywhere. One day we killed 400 cockroaches in one hour. I counted them.
There is but one wash hand basin in the ward. It has a hole smashed in the porcelain. Only one of the two taps works. Hand towels were nonexistent when I arrived. It took constant nattering for several weeks, to arrange for one fresh towel per day. What was worrying was to think that if such basic concepts as soap, towels, hand-washing, the binning of used swabs and syringes, and the destruction of arthropods in the ward was a problem, how could I expect to help the standard of paediatric practice on the ward?
If the hospital will not buy soap and towels, how are they going to buy Cloxacillin. Indeed much more basic medicines than Cloxcillin ran out during my stay: There was a time when Benzyl Penicillin was not available - albeit very briefly. Chloramphenicol injections ran out. So did 5% Dextrose and Elastoplast strip. There has been no Erythromycin in the hospital during my time there - except for a small and treasured supply I took out with me, courtesy of General Practices in Kettering.
In a country where TB is endemic I could find no Mantoux PPD for testing, and it was a major battle to get any. Shortly after I returned to the UK, in March, the Rabies vaccine ran out, moreover I was told there is none in the country --and could we help from the UK? At all levels - from peasants to educated folk - I saw evidence of lack of forethought and planning. It was as though a quaint bit in the African CNS was missing.
They play football for it is immediate and physical. They play draughts too, but I never saw chess being played! I remember wanting to do an LP on a child one day, and was told by the nurse in charge;
"We have no containers for CSF. They are not available. They are finished".
How do you start to address that problem when you've rolled up your sleeves in preparation for working on a child with a bulging fontanel? It was all very frustrating.
For all its astonishing inadequacies Bansang Hospital was a delightful place to work, and that was because of the people. My heart and soul were in the children's ward and I loved every member of the staff there. They were charming people, and as friendly and welcoming as can be. It was always a pleasure to arrive on the ward and start work with them. Not only are they charming and cheerful, they are highly skilled in practical paediatrics. I have watched in wonderment both male and female Gambian nurses put up drips on neonates. I have prayed that they would succeed, and not ask me to have a go!.
They can set up blood transfusions on small children, calculate the amount required, calculate the drops per minute required, monitor the progress, and discontinue the transfusion when appropriate. This could all happen in the night whilst the doctors were away, asleep in their beds. The Nursing staff had diagnostic acuteness too.
One of them called me one day to say that a child was showing decerebrate posturing and what did I want to do about it. What would you have said?. They frequently distrusted path lab reports;
"This child's Hb is not as low as 5", or the other way round - "This child's Hb is less than 9 - it is 5 or less".
Again I remember saying one day;
"Why is this child scratching?"
"It is a side effect of the Chloroquine we are giving" said the attendant nurse.
One more example;
"Why doesn't this child's diarrhoea improve?"
"It will when we stop the Septrin doctor".
It's all true - have a look in the BNF!
I said to the senior nurse, Landing, one day.
"What would you do if all the Cuban and Nigerian doctors went home?". (The hospital is totally dependent on non-Gambians.)
"I would continue to run my ward.. I appreciate having doctors, but if forced to I could run the ward without them" said Landing…
Landing can prepare and stain blood films for malaria, study, read the slide with confidence, and set up the treatment.
The senior nurses are like doctors - they have the practical skills of SHOs. They are in effect nurse-practitioners. And yet they live in what we would consider severely substandard conditions. As to their pay - Landing, one of the most highly trained paediatric nurses in the country, has just been promoted to Grade 7, and now gets 2,600 dalasis per month, i.e. about £162.00 ($200.00) per month. Makes you think, doesn't it.
Because of the enthusiasm for side-room diagnostic power I became instrumental in setting up a small lab. On the ward. The centre piece is the Nikon microscope kindly donated by KGH, with a new 100x oil immersion lens donated by a UK scientific firm. There is a hand operated centrifuge which I picked up at a "flea market" back in the UK for a few pennies years ago. This enabled us to do urine microscopy. A small electric centrifuge would be more convenient and less sweaty though! Anybody know where there is one? We can also examine faeces for ova and cysts. An icterometer enables us to assess jaundice in neonates - and by the way apart from clinical assessment, this little instrument invented by the late Dr Gossett, who was a paediatrician at Northampton General Hospital - is the only way we have of estimating serum bilirubin in the hospital.
The one I acquired was a gift from the manufacturer in Birmingham. We have a glucometer and a small supply of the strips that go with it. I am at present looking for a sustainable source of strips at affordable prices, and again KGH is looking into that for me. A large haemoglobinometer has already been earmarked by KGH Pathology Lab for the main Laboratory In Bansang. I am looking into the possibility of a small handheld one for use on the children's ward. We will then be nicely set up with what I think will be a sustainable service.
Landing has said to me that as a result of UK donations to his ward, he has the best diagnostic facility in the Gambia and this includes the Royal Victoria Hospital in the capital Banjul where he trained and did research. A few books can be found in our ward lab too, a haematology atlas from KGH, two small manuals of mine from Liverpool, and another which found its way from the American Embassy Library in Banjul. I also relocated a nice little book on Poisoning in children. That one came from the library of the United States Peace Corps, also at Banjul. I must admit to the adoption of Mafia tactics in the acquisition of the latter books! It has been my pleasure to channel and consolidate KGH's donations into the tiny ward laboratory in the Tropics.
Make no mistake about it, those dear people are grateful to the UK and to Kettering General Hospital in particular for all you are doing to help rescue their sick children. I am proud to have been associated with them, and with you.
Bansang Hospital Appeal a UK registered charity ~ 1064469