In general, I hate going first. Ask anyone in my family, my friends, my colleagues, my supervisors, they will all attest to this.
I woke New Year’s Day, 2020, in Canberra to the world’s worst air pollution with the knowledge friends and colleagues were in the midst of active bushfires engulfing the south coast of NSW during the worst bushfire season the country has seen.
I spent time indoors, cogitating about what to pack for my first assignment with Médecins Sans Frontières/Doctors Without Borders (MSF), my first experience living in Africa, my first experience working overseas.
I’d always wanted to work for MSF and to dedicate part of my career to humanitarian work, helping those most vulnerable whilst gaining experience working in fascinating areas of clinical medicine with limited resources.
The day I flew out of Canberra to Sydney for my final debriefings and onward flights to Liberia, the town just south of the ACT border was evacuated. Residents in Canberra were told to activate their bushfire survival plans. I left with my bushfire survival plan stuck to the fridge with magnets.
I was making my way to Liberia to take on a role as the paediatric doctor in MSF’s paediatric hospital. Liberia, on the west coast of Africa, is on the opposite side of the globe from the east coast of Australia. The MSF Paediatric Hospital, or Bardnesville Junction Hospital (BJH), was established in 2015 in response to the need for high acuity general paediatric care for children between one month and 15 years of age. MSF has had a longstanding presence in Liberia, a country that has experienced two civil wars, followed by a devastating Ebola outbreak, resulting in a significant depletion of its health workforce.
I arrived in Liberia after 28 long hours of travel. Driving into the capital, Monrovia, from the airport we passed long queues of cars and motorbikes waiting to get into petrol stations. There was a severe fuel shortage in the country. This had a huge economic impact and a direct effect on hospital staffing.
As for firsts… The clinical medicine and acuity at the hospital was challenging, rewarding and career-changing. I ran simultaneous resuscitations in ICU on my first day and clinically diagnosed cardiac tamponade on my second.
In six months, I witnessed cardiorespiratory arrest from all the reversible causes. A young patient named Surprise taught me to clinically diagnose severe hypokalemia (<1.5mmol/L, once we had access to electrolytes) in children with severe acute malnutrition, children who were so floppy that in Australia your top differential diagnosis would be a primary congenital neurological diagnosis. Without an ECG, Princess too was diagnosed with severe hyperkalaemia (based on bradycardia responsive to salbutamol).
One-month-old Success presented with a temperature of 33.3̊C and a respiratory rate of 10, but her clinical severity was recognised and managed early, resulting in complete recovery within 48 hours. Promise had severe hypoxia from numerous causes managed well with our consistent, reliable supply of oxygen and bubble CPAP.
Blessing presented with hypovolaemic shock secondary to severe anaemia, with significantly low haemoglobin levels. Like almost all children who were admitted to the ICU, Blessing’s condition resulted from acute illness in addition to complex co-morbidities including malaria, E. Coli sepsis and severe acute malnutrition. Blessing made a complete recovery following blood transfusion and early antibiotics – managed and initiated by the local emergency room staff.
Prince had severe subcutaneous emphysema resulting from complications of bubble CPAP with likely tension pneumothorax. Godgift had unrecordably high liver transaminases from paracetamol toxicity (paracetamol being readily available in the community), and undefined local herbal treatments. Prayer had symptoms consistent with venous sinus thrombosis with ongoing neurological recovery.
Not all children survived.
I was briefed before arriving that the mortality rate was unusually high, even for an MSF hospital in a low-resource setting. This is mainly because many children present very late to the hospital due to lack of access to primary healthcare and poor health-seeking behaviours. I have welcomed plenty of advice in my career. Some of it was pertinent during my time in Monrovia. Palliative care specialists and general practitioners have taught me not to abandon dying patients and to keep in mind that as doctors, although we do not treat dying patients differently, families can often feel abandoned. This advice was a stalwart of my practice in Liberia, however difficult it was to uphold. I’d read a blog before departing from a paediatrician who worked at BJH, which said, “you’ll never get used to the screaming [of grieving parents]”, and you don’t.
I don’t know that any doctor, particularly a paediatric doctor, has a clear sense of how to professionally and personally deal with an overwhelmingly high mortality rate, though, the support and experience of the local staff and the wider MSF community has proven invaluable.
Those who worked in the project before me had suggested that the clinical work was not the only challenge. As an Australian paediatric trainee, we have excellent training, fabulous clinical skills and knowledge. In the project, however, there are additional difficulties that come from other aspects of the job: working in a new context, movement restrictions due to security reasons, the tropical and humid weather, and living with those you work with.
Despite that, outside of clinical work, I swam on the west coast of Africa for the first time, learnt to run in 96 per cent humidity and participated in my first friendly staff kickball match on the beach!
The COVID-19 pandemic made its way to Liberia in March 2020. Liberia was one of the first countries in the world to close its borders internationally and enforce a period of mandated quarantine in addition to a nationwide curfew.
COVID-19 meant that the hospital had to suspend the surgical program due to even greater difficulties with staffing. The acute shortages led to my first experience writing recruitment tests, sitting on an interview panel and planning staff rosters. Staff transitioned to working in surgical masks, and arrangements were made to manage suspected or confirmed COVID-19 cases. The local staff adjusted their skills and ensured the hospital continued to function at a high level.
Initially, I was worried that I would not be able to contribute more than what MSF, the hospital and Liberian staff would teach me. I experienced so many firsts and I am thankful to have done so in a setting with such a legacy – and most certainly didn’t expect to do so in the midst of a global pandemic! I am most thankful to the children of Liberia, the patients and their families, and their humour. From the nicknames: ‘Chinese woman’, ‘white woman’, ‘big doctor’; to teaching me the ‘ABC’, how to count, language, how to ‘bus’ and offering to accompany me home in my suitcase!
This year has been like nothing else. Do I still hate going first? Absolutely. Would I do it again? Absolutely.
Click here to find out more about working with Médecins Sans Frontières.
According to the CIA World Factbook (yes, it is a thing!), has one of the lowest GDP per capita in the world, ranking at 221* (out of 228). Over 60% of the countries 5 million people are under the age of 25. Unfortunately, it also has one of the woods highest maternal mortality rates (661/100,000) that is heavily influenced by the high incidence of female genital mutilation.
And the name? Liberia was founded as a homeland for freed African-American slaves in 1847. The flag bears a remarkable similarity to the star-spangled banner. Perhaps one of the reasons that Steve Mnuchin got the two confused?
* In case you were wondering Ireland is 10th, USA is 19th, Australia is 29th and the UK is 39th.