Christians to the left of me, preachers to the right...

As soon as heard just how religious the community is that I would be sent to I knew things were going to be hard for me. I am an unashamed, and self-confessed atheist, however I had the good sense to keep this particular fact to myself on my arrival. At first the exposure to a completely different world, the world of God, was interesting. However, that feeling was short lived. In our first week the hospital held a ‘week of prayers’ where a very charismatic preacher from South Africa was invited to run a 90 minuet service each day before work which all staff were expected to attend. Unfortunately for me, this particular preacher was very fond of the Old Testament and gave a wholly traditional service. In one he spoke extensively about the sin of woman, and their tendency to lust for men outside of the marriage. Not a single comment was made about the men and their equal, if not greater, tendency to also commit this sin. Instead he was solely focused on the discretions of the female race. How weak we are, first tempted by the apple or knowledge, and now this. As a modern-day feminist this quite literally made my blood boil, even more so when all the women in the congregation started verbally expressing their agreement with the preacher with cried of ‘Ahmen’ and rounds of approving applause. In another service the preacher referred to those who openly admit and celebrate their non-faith as arrogant heathens, full of sin and wicked people who would lead the faithful towards an equally wicked path. I guess if people knew the real me this is how they would view me, as an arrogant heathen. Which is ironic as I actually share so many similarities to Jesus himself. I live my life with compassion and kindness, I’m inclusive to all and an advocate for minorities, I definitely prefer wine over water, and I have many friends who work in the sex industry.

On Thursdays we sing hymns and pray over the patients on the wards

 

As interesting as the work is here, being placed in an isolated community, with such different cultures and customs to home, is unsurprisingly very isolating. My last placement was equally as remote, but the big difference there was the large number of western doctors, who I was able to form a close knit community with making the experience very different. Its not that the staff at Maluti are not friendly, they are very friendly. It’s just that over here no body shares my interests, people struggle to even understand me when I speak because of my accent, and everyone prefers to speak in the local language of Sosotho, which means I can’t join in with conversations happening around me. I’m sure people do fun things in their spare time here, but so far I haven’t heard of anything more exciting happening than a baptism. Theres only so much I can pretend to be interested in talking about Jesus, and with the daily morning prayers, I have more than had my fill of God and religious talk.

Sadly, my UK companion isn’t much in the way of social relief. Surprisingly, giving what we have signed up for, I’ve managed to get myself paired with a rather unadventurous person. Her idea of a good time is attending a church group or reading alone. In a way her ability to be so content with such little variation is quiet of impressive. My ADHD tendencies cause me to constantly be chasing the next big adventure or seeking new and varied social interactions. She, on the other hand, knows exactly what she likes and has no interest in stepping outside of what is familiar to her, so much so that she has never even eaten a courgette, because why risk it. She has her friends and family back home, and that appears to be more than enough for her. Forming friendships outside of this would be a waste of energy, which is a real shame for me personally as it leaves me in a perpetual state of loneliness out here. At times I feel as though I am Moses, wondering through a desolate landscape, barren of social interaction. If this is a test of my faith, then I feel I should remind what ever cruel puppet master has placed me here that I have no faith. But then again, I don’t believe in puppet masters, divine plans, karma, voodoo, or any of that stuff. (That’s not to say that I don’t believe in anything, I’m a big fan of science, reason, and occasionally logic.) Sitting here, contemplating this situation I’ve so expertly trapped myself in, I can almost hear the god-like wisdom of Radiohead whispering in my ear—‘You do it to yourself, just you, you and no one else.’ A lyrical prophecy, proving once again that Thom Yorke’s omniscience rivals that of the Almighty Himself.

Living in La La Land

 I must admit, I was really quite excited about working on this new project with Adventist Health on improving the way in which the hospital stores and manages patient files and data. I mean, you should see the state of the current filing system for the notes. The hospital stores all old records in 5 massive shipping contains. I went to see them with the Data lead Pady. He’s currently in the process of ‘organising’ all the files, and by organise, I mean picking them up from the piles they lie in on the floor, and placing them on the shelves he has bought (at great expense) in order of year. Still not a great way to organise patient notes, but it’s better than the floor system operating previously. This data QI would make a huge difference to the hospital, not only would old files be accessible for clinical staff, but it would allow management staff to keep track of what is actually happening in the hospital. The current problem doesn’t just exist here in Maluti but many hospitals across the globe. If we did this right, it’s the kind of project that could get published in a national journal and then could be replicated all over the world!

The old 'filing' system

The day after our meeting with the American’s, me and Sarah sat down with our QI lead and CMO and worked through the task. We knew that in order to get this project approved by management, we would need to somehow show that it could make the hospital money, and not just cost them money (because as I have already explained, the hospital has no money). Luckily our QI lead, a lady called Mem’ Ntoate, is not only extremely smart and passionate, but also knows the hospital better than anyone. Together, we figured out that by not being able to keep track of patients being admitted, the hospital was losing money in unpaid bills. Anyone with an outstanding bill could return to the hospital, get a new ‘patient ID number’ as they are unique to each visit not each person, and any outstanding debt wouldn’t be attributed to them. Using a few contacts from my network of doctors back home I was quickly able to learn how other hospitals in various parts of the world have found a low cost, low tech solution to this problem. We discussed this with Mem’ Ntoate and she explained how the hospital had tried many of these systems previously and explained why each one of them had failed. We were starting to narrow down our list of possible solutions and work out a strategy of selling our big idea to management. It felt like this project might actually be possible!

The new and improved shelf system

Before the Americans left we had another meeting with them. They had put us in touch with a lady on their team who had done projects like this previously in other hospitals they had worked in. They seemed to have in their team and expert on everything. Speaking with her it became clear that they had much bigger plans than anything me, Sarah, Mem’ Ntoarte or the CMO could ever had imagined. Unbeknownst to us, the Americans had been having meetings themselves. They didn’t just want to a project to create a unique patient identification number (a tall enough order in itself), they wanted to totally digitalise Maluti hospital and turn it into a paperless system, a totally mammoth task! There are still hospitals that I have worked at in England that haven’t achieved this goal (shout out to Fairfield General). In the meeting the American started talking about how they wanted to bring in new servers to store data on, create a digital computer network, buy all the staff ipads, and bring a version of HIVE to Maluti Hospital (Hive is an amazing but very expensive and colossal medical data system used mainly in the states but has been implemented in a few NHS trusts in the UK. The system is so massive and generates so much data that it has led to near bankruptcy in the one trust in Manchester that adopted it, resulting in massive staff redundancies to balance the books). The Americans saw mine and Sarahs role less as joint leaders on this project, and more in the remit of dogs body, running around collecting data and doing audits for them on request. The main part of the project, the implantation of this mega IT system, wouldn’t even be done whilst we still in the country. They just wanted us to do all the leg work for them to make it happen.

Their plans were huge, and to be honest I was quite shocked that this is what their ‘expert’ had recommended. Converting an entire hospital to a paperless system in a region that still has regular black outs with every big storm (of which there are MANY), didn’t seem like a smart idea. The hospital frequently has to rely on its generator when the power cuts to keep the lights on and the water pump working for running water. Will it be able to handle supporting this mega HIVE system as well charging every single staff members ipad. Also, the wifi in the hospital is patchy at the best of times and frequently goes down for weeks until a technician from the capital is able to visit this remote mountain village. There are currently over 10 different networks running across the hospital as each one can only hold a maximum of 30 people at a time, and has the range about the radius of a hamster wheel. They would need to import a brand new wifi system from South Africa (as this is quite literally the best available in Lesotho) if every member of staff was to be on the same network. With all these extra IT systems being discussed I couldn’t help thinking, can the power supply to the hospital even support this? Do they plan to upgrade the national grid to the region too? And what happens when the ipads brake? There isn’t a single apple store in the whole of Lesotho, let alone up her in the rural mountainside of Mapoteng. Maybe they were planning on building this too? Will they also be providing 24/7 technical support for this computer system to help staff re-log in at midnight when they have forgotten their password, or to resolve the inevitable system failures which are bound to happen at some point (probably quite frequently with the power surges here)? This project was starting to look like an absolute fantasy. I’m not sure that just providing more money to a single hospital will solve the problems surrounding lack of national infrastructure, but then again I have no idea how much money this church based organisation actually have. It also didn’t seem like they had even consulted the local team. It felt more like they were just telling us what they were going to do to the hospital, not with it.

And so with that, I gracefully bowed out of this inevitable cluster fuck of an idea. Back to the far less glamours project on lab investigations then.

Two Steps Forward, Eight Steps Back...

Alright guys, brace yourself—you're about to be taken to the very edge-of-your-seats, on a thrilling, electrifying, heart pounding, rollercoaster ride that is… quality improvement. I can already hear your enthusiasm. 

I cant tell you how sad this
 obs chart makes me

As you might be able to recall, my modest task was to try and reduce the hospitals over all mortality rates by 5% in just 10 months. I knew I had to try and somehow find an actual project shaped focus for this problem. In my first meeting with management everyone seemed very keen for me to introduce an Early Warning Scores (EWS) system into the hospital. This is basic practice in the UK, and something that as an A&E and ICU Reg I’m highly trained in, so I so I thought it might be an easy project for me. After speaking with people, it turns out this was a project that the hospital had been trying to do for 12 years now, and has failed each time. Its not a concept practice anywhere in Lesotho, so the idea is very foreign to both doctors and nurses. When I visited the wards, I soon learn that staff didn’t have access to enough observation machines to carry out the observations at the frequency for them to act as an early warning system. I can see why its failed so many times.

 

With that idea dead I decided to read over all the notes from patients who had died in both January and December to see if I could find any patterns as to why they were dying. The notes were quiet enlightening. It turns out some truly mad things are occurring in the hospital. I read through plans that not only made no sense, but to my mind would have hastened death, significant investigations that were seemingly ignored with disastrous consequences, and noticed that a lot of patients seemed to be, not so silently, aspirating themselves to death (choking on their own saliva) but it was somehow not being picked up by the medical team. Having worked in a low-income African country before I knew there must be more to this. The doctors and nurses here are not stupid or neglectful. They are all highly intelligent, trained, devoted individuals. Given the right (or wrong) circumstances, everyone is liable to making bad or dangerous decisions. As I read through the notes I kept telling myself ‘We listen, but we don’t judge’…but it was hard if I’m being honest. 

So, I decided to go out onto the wards and speak with the staff about what it is actually going on. I had wondered why none of the doctors had requested a renal function on patients who clearly had signs of renal injury, but apparently for the entire month of December the lab had run out of reagent for Creatinine so was unable carry out the test, and nurses were not used to measuring urine output to act as a clinical marker. They were currently facing the same problem with full blood counts (a basic yet extremely essential test, without which, practising medicine becomes less of an evidence-based science, and is more akin to a medieval pursuit of removing the bad humours from the body). When I asked if I could look at some of the chest Xrays for the patients who’s notes I had reviewed, I was told that there wasn’t any hard copies of them. A few years ago, the government had bought the hospital a lovely new digital Siemens Xray machine, higher quality images, less radiation, beautiful. Unfortunately, this machine did not come with a server to store the high quality, large image files on. So, staff would take a grainy picture of the Xray on their mobiles and WhatsApp it to the Dr’s WhatsApp group before the original image was lost forever. The same system was used for reporting urgent blood test or tests from other hospitals. Unfortunately, with the ever-rotating pool or locums, not everyone is on this WhatsApp group, meaning new Drs have no way of seeing old investigations for patients when they start. But without doubt everyone told me that the biggest problem the wards faced was the locum doctors. With only 1 permanent medical doctor, the remaining 4 posts were filled with locums, who would come to work at Maluti during their annual leave from their full-time jobs elsewhere in the country to make a bit of extra money. The locums might only stay a week, they have no idea how the hospital ran, what they were supposed to be doing, or who was supposed to be supporting them. 

After chatting with the staff on the wards my head was buzzing with possible ideas on projects to improve things. Later that week I had a meeting with the Chief Medical Officer (CMO), I had already discovered that any project I wanted to do would need his approval. I presented my findings and listed a few ideas of projects which I thought could reduce mortality, and thankfully he was very receptive to all of them. It finally felt like I was making progress on turning this huge goal into a manageable QI size project. One of my ideas was to improve the situation around the locum doctors, but the CMO quickly told me that although he was very much in favour of this idea, management wouldn’t want me to focus on them. The hospital had plans to bring in specialist and so soon would not be in need the locums (although they had been saying this for over a year now and the specialist were no closer to arriving). I asked the CMO who’s job it was to oversee the locums, check if their plans were sensible and offer advice if they were stuck. It was him, although he admitted to me, that as he is a surgeon by background, he felt out of his depth consulting on medical problems, and technically he was still waiting for his licence to practice in the country and so was supposed to be doing strictly non-clinical admin work. 

Eventually we settled on a project. I would focus on trying to improve the use and review of investigations to try and avoid the common situation of extremely significant investigations (such as bloods and Xray sect) not being seen for days, if at all. Under this pretence I would also create a locum induction booklet which would at least put down in writing what was expected of the locums and detail how to do various essential functions around the hospital, as well as hospital protocols. Whether or not these locums would follow the rules of my induction booklet was another problem for another day, but at least I finally had a project. Or so I thought. 

Out of nowhere the hospital was invaded by 22 Americans from a NGO called Adventist Medical. One day, when I arrived at work I was met with a barrage of American accents flooding the corridors—loud, overenthusiastic, and declaring even the most mundane observations like they were breaking news. For one week only they had brough personnel to help in every single area of the hospital, from technical support in the labs to assistance in the sterilisation process of theatres. They even had a team dedicated to improving water purification in the villages. QI was not left out of the onslaught, and so a special last-minute meeting was set up with us to speak to them. 

They could not have been less interested in what mine and Sarah’s project where. Fair enough I guess, they want to upskill the local staff, not us. Unfortunately, they also didn’t seem that interested in what the staff had to say either. It appears as though they had there own agender, and finally, by the end of the meeting it became apparent what that agender was. They wanted to upgrade the hospitals data filling system. To be honest the current system was about as efficient as exchanging CPR for a motivation TED talk, so its not a bad idea. At the moment patients are not given a unique patient identification number on admission, so there is no way to track down old notes or past investigation results. Once discharged notes are filed based on date of discharge and nothing else. Walking into the filing rooms is the stuff of nightmares, single handedly run by one very short man who any day now will disappear under a landslide of poorly filed notes. The Americans asked if we would be interested in exchanging our projects for this one, defiantly a worthy endeavour I thought, but that would put me right back at square one…

The Kingdom In The Sky

 

Thaba Bosiu Cultural Village

Until this week there was a good chance that the country Lesotho may never have crossed your mind. As the present of the United States so kindly pointed out, its a country that 'nobody has heard of'. It has a small population, about the size of greater manchester, and its not particularly prevalent on the world stage. But it is a very proud nation with a fasinating history. So let me tell you a bit more of what I’ve learnt about it so far

Lesotho is known (by those who do actually know it) as the Kingdon in the sky. This is because its made almost entirely of mountains. It’s a relatively young country, only 200 years old. It was founded by a man called Moshoeshoe (pronounces Moswaysway) who seems to have been a pretty impressive man. Somehow he managed to not only unit 16 rival tribes, who had been at war with each other for longer than anyone could even remember. He was also able to defend off multiple attacks from the Boer despite the fact that he was significantly outnumbered and out armed. The secret to his success was geographical. He formed a relatively large settlement on a flat mountain top which was large enough to keep live stock on, grow crops and have a fresh water supply from the 3 natural springs that popped up on the top of the mountain. From there he had the advantage of high, and with only 2 possible routes up the mountain, he was able to defend his lands effectively and the Boer were unable to starve his people out of their secure spot. Unfortunately, the relentless attacks from the Boer did cause problems and eventually King Moshoeshoe had to ask for help from the English who after stopping the attacks, handed over half of the territory of Lesotho to the Boer, giving them the more fertile, lower lands, now known as the free states of South Africa.

 

I visited this historic mountain which is just a few miles from the capital Maseru. At the base of the mountain is a replica village, set up to resemble life back in time of Moshoeshoe’s reign. The houses are circular huts with thatched roofs made of brick and covered in cow dung, which not only acts as a natural and extremely effective insect repellent but also a fantastic insulator keeping the huts warm in winter and cool in summer. Oh and in case you were wondering they are odourless. Life for the villagers would have been very strictly divided in terms of gender. The men fight, keep livestock and do carpentry. The women cook, bring up children and tend to the crops. The women would also all live together from the age of 10 to 21, away from the men, and could only be married off once they turn 21. As well as the mock village there was a museum at the base of the mountain, which was really interesting, but a little depressing when I realised that it had hardly any artifacts in it. Instead, they had pictures of items on the with little description next to them explaining that the real items were held in various museums around the world, mostly the British history museum, presumable locked away in the volts unable to be viewed or enjoyed by the people who’s history they actually represent.

Cafe What, Maseru

Lesotho today is obviously quite different from back then. People no longer wait until they are 21 to be married, they live in square houses with tin roofs now and many people are online with smart phones and drive cars. Life is still very different here from the west though. There are no high rises in Lesotho, no flats or multistorey buildings. The people of Lesotho like to keep livestock, grow their own food and many of the houses, even in the capital, will have cows or sheep living in the gardens meaning everything is very spready out as having land is very important to people. In the villages many people live a very self-sufficient life. Money is rare in many villages, goods are exchanged or bartered, communities look after their own and they make or grown most things they need. Sadly, in Lesotho today, violence is high, especially gender-based violence. Many of the women I have met have scars across their faces, and I was told that a few weeks before our arrival to the hospital an elder from the village, well known and respected in the church, was seen brutally beating his wife in the middle of town because of something she said. Like in many poor areas, gang crime is high. Gangs from illegal diamond mines (one of Lesotho’s main exports after wool and water) can be a big problem. They identify themselves through music and it is common for people to be shot for playing the wrong kind of music. As one local told me, life is cheap in Lesotho. When I arrived, I was told all of these scar stories, but my experience of the people of Lesotho so far has been the complete opposite of this. Everyone I have has been so warm, kind and welcoming and has gone out of their way to help me. Everyone, without fail, really wants to ensure that my time here is positive, and so far it has been. I guess everywhere has its issues, but the beauty of this place and its people seem to be brighter than their dark side.