I can't believe a month has gone by since I arrived in Monrovia! A month feels like a long time and no time at all with the pace at which things happen here. On the one hand, things move slowly...getting anything done (even something as simple as a blood pressure, and even in an emergency situation) can feel like it takes ages. On the other hand, time flies by as the days that are packed with dozens of sick patients needing various evaluations and interventions.
I thought a month was enough time to share a bit about what my day looks like here. Because there is a residency program, a lot of aspects of the day are familiar, with a Liberian twist :) No days are exactly alike but they tend to have a general pattern, something that goes like this:
6:10 am: alarm goes off. Depending on how late I stayed up worrying about this or that sick patient, I either hop out of bed to do a quick home workout or scroll through my phone a bit. I drink a ton of water as there's no clean water to refill my nalgene bottle with at work and take my anti-malarial pill. I usually listen to a podcast or audiobook while getting dressed ready to go. Liberian doctors tend to dress pretty formally (and have great style) so unless you're on call no one wears scrubs- they will typically dress in business attire with a lot of beautifully patterned custom-made dresses and suits sewn from lappa fabric (more on that another day.) I usually wear business attire and a white coat with a small notebook, pen and the WHO blue book (basically a global health pediatric bible) in the pockets.
7:00 am: the sun has started rising just enough that its safe to walk to work (as someone who is obviously Western you can't really blend in here, and petty crimes aren't uncommon.) I usually bring my breakfast to work- a banana, coffee and peanut butter smoothie that I may have become slightly addicted to. The hospital is 15 minutes away and if the weather is nice I get to catch a beautiful sunrise through the Sahara dust that blankets the atmosphere during the dry season.
7:15 am: I arrive in the pediatric emergency room to pre-round. The room is shaped like a T- the base of the T has a a row of chairs on one side where patients who have been triaged wait to be seen, and a large desk and chairs on the the other side where the docs can sit and review charts, interview patients and document. Unless there is an active resuscitation going on (which isn't that uncommon,) I sit down here and review the charts.
The top horizontal bar of the T contains 8 patient beds (there's also two doors to the left- one leading to the outpatient department, one to another room for patients who will have shorter admissions.) These are the sickest and/or newest patients. After reviewing the vitals, notes, diagnosis and medications served, my goal is to examine all of these kiddos before 8 am. Because of the aforementioned codes/high acuity (new sick patients arrive all the time, or I may get caught up addressing a patient who is getting worse right in front of me), this doesn't happen as much as I'd like. You just kind of have to take things as they come here.
8:00 am: morning meeting occurs on the wards in the main hospital, meaning I am usually dashing upstairs at 7:55 am to grab my white coat and make it in time (some things never change; I will forever be afraid of lateness, even when it isn't uncommon here.) Similar to the U.S. system, the overnight team presents all admissions from the last 24 hours, as well as any deaths. The consultants (attendings) and specialists (board eligible pediatricians in the process of becoming attendings) will comment and highlight teaching points on various cases. The West African medical teaching and lecture style is pretty formal compared to American training, but I try to weigh in occasionally if I feel I have a useful or unique perspective to add. Residents and attendings can also share announcements, concerns and issues at the end of morning meeting so they can be discussed in an open forum where everyone can have their say.
9:30 am (ish): this is where the day becomes more fluid. After morning meeting I head back to the peds ER for rounds. Depending on the specialists, rounds can either involve significant teaching, be rapid fire/brief, or not happen at all if the ER is very chaotic with a large volume of patients to see. We usually have several medical students, an intern and 1-2 residents around to present each patient, discuss the current medications and plan, and decide what the next steps in care are.
Something that's been a fascinating adjustment for me is patient ownership. In the U.S., as a resident I'd arrive on the wards each morning with a neat list of 5-10 patients I was primarily responsible for that day. Here, every patient is under the care of all of us as a team; the resident presenting the patient is arbitrarily chosen and the third year, specialist and consultant all agree on the plan together (though the most senior person has the final say.) Its been a fascinating deviation from what I am used to that is a better fit for the Liberian culture and practice style.
We see a lot of very sick patients; birth asphyxia (when the baby is deprived of oxygen and comes out critically ill with neurologic damage,) sepsis and other infections, and severe malnutrition are incredibly common and come with very high mortality rate.
One factor we consider in decision-making that I didn't expect was the cost to families; apart from a limited selection of medicines, everything we choose to do costs money. From a CBC to an x-ray, to selection of the correct antibiotic, parents have to scrounge up what little money they have to buy sometimes life-saving treatments for their kids. For a parent who makes only a dollar a day, even spending five dollars on a lab test or medication can be close to impossible.
Noon- 2 pm (ish): after rounds I tend to stick around for a bit to see how I can help without impeding work flow. This could mean I am writing in the chart, following up on a blood pressure or discussing a complex case a bit further with the residents and specialists. Eventually I make my way upstairs to work on research, helping the residents gain uptodate access, and looking up papers and articles on various interesting cases we've had to share with the team.
2 pm- 5 pm (ish): Depending on the day, there's loads of things going on during this time. Like any residency program, various lectures are given, either by the residents or by a local or visiting consultant or specialist. There are also various official exams at any given time of year; currently the first years are preparing for their exams (something between a Step 1 and Step 2-type of test) and we meeting regularly to review topics and go over questions. I also spend time with our research nurse entering data, tracking down missing information and troubleshooting whatever issues may be arising in the ongoing research work on a given week.
While the clinical work is a great learning experience for me, I find my work in the afternoon to be more rewarding; because of resource limitations there's not a whole lot I can do to improve outcomes on the level of individual patients. It can be incredibly emotionally draining to see your third newborn in 24 hours die from the same preventable illness (true story. More on that later.) But with collaborative research, and with actionable, big-picture policy changes, slowly over over time you can start to enact meaningful changes, and hopefully over time see improved outcomes.
5 pm-6 pm (ish): I check in with the peds ER 1 last time before heading home. If things are quiet, this could just be hanging out with the specialist, or reviewing patients of concern (watchers) with the overnight resident team to come up with contingency plans. Its not unusual for an actively crashing patient to be rushed in though, requiring resuscitation of some kind. These cases are the hardest because if I don't leave before dark it isn't safe to walk home, and because of recent gas shortages its not always easy to find a cab to drive you. So much of this job causes scenarios like this, of moral discomfort. I can't say that leaving feels like the right thing to do, but I can't help anyone if something bad happens to me. There's way more to unpack there than I feel up to sharing at the moment, but it is definitely an uncomfortable conundrum I encounter pretty regularly, so it would feel odd not to at least acknowledge it.
6 pm: If I don't stop at the supermarket or fruit stand by the hospital to grab more bananas, I arrive home, usually covered in sweat. I tend to immediately throw on my swimsuit and jump in the pool to cool off if I have time. Taking a couple minutes to swim some easy laps and unpack what I've seen/heard/felt throughout the day helps me to transition from the "everything is on fire and everyone is sick" mode into a more relaxed and reflective state. I tend to cook something easy and quick, maybe watch 20 minutes of a show while having dinner, then read on a few topics I jotted down throughout the day or get some research work done, depending on what's on my to-do list.
9 -9:30 pm: wind-down time before bed. One thing I really appreciate here is a consistent schedule; not working evening and overnight shifts like I do in the U.S. is one of the nicer luxuries of my time over here. The overnight team can call me any time but usually don't unless there's something they feel I can specifically help them with. I usually read a novel, listen to a podcast, watch something or whatsapp call family before going to bed around 10 pm.
And that's a typical day as a clinical pediatric fellow in an urban Liberian referral hospital! In the future I may share more of the specific types of cases we see, or how the health system works, and hopefully introduce some of the incredible doctors I have been working with, but for now I just wanted to share what happens on a day-to-day basis. Hope its interesting to someone :) Feel free to share any particular questions or thoughts in the comments. PS- You can also follow along on instagram if to see more of the day to day things, if you are curious.
I thought a month was enough time to share a bit about what my day looks like here. Because there is a residency program, a lot of aspects of the day are familiar, with a Liberian twist :) No days are exactly alike but they tend to have a general pattern, something that goes like this:
6:10 am: alarm goes off. Depending on how late I stayed up worrying about this or that sick patient, I either hop out of bed to do a quick home workout or scroll through my phone a bit. I drink a ton of water as there's no clean water to refill my nalgene bottle with at work and take my anti-malarial pill. I usually listen to a podcast or audiobook while getting dressed ready to go. Liberian doctors tend to dress pretty formally (and have great style) so unless you're on call no one wears scrubs- they will typically dress in business attire with a lot of beautifully patterned custom-made dresses and suits sewn from lappa fabric (more on that another day.) I usually wear business attire and a white coat with a small notebook, pen and the WHO blue book (basically a global health pediatric bible) in the pockets.
7:00 am: the sun has started rising just enough that its safe to walk to work (as someone who is obviously Western you can't really blend in here, and petty crimes aren't uncommon.) I usually bring my breakfast to work- a banana, coffee and peanut butter smoothie that I may have become slightly addicted to. The hospital is 15 minutes away and if the weather is nice I get to catch a beautiful sunrise through the Sahara dust that blankets the atmosphere during the dry season.
 |
| Beautiful mural at the hospital's main entrance. It depicts the history of medicine in Liberia, including the traditional healers all the way up to the present day. |
7:15 am: I arrive in the pediatric emergency room to pre-round. The room is shaped like a T- the base of the T has a a row of chairs on one side where patients who have been triaged wait to be seen, and a large desk and chairs on the the other side where the docs can sit and review charts, interview patients and document. Unless there is an active resuscitation going on (which isn't that uncommon,) I sit down here and review the charts.
The top horizontal bar of the T contains 8 patient beds (there's also two doors to the left- one leading to the outpatient department, one to another room for patients who will have shorter admissions.) These are the sickest and/or newest patients. After reviewing the vitals, notes, diagnosis and medications served, my goal is to examine all of these kiddos before 8 am. Because of the aforementioned codes/high acuity (new sick patients arrive all the time, or I may get caught up addressing a patient who is getting worse right in front of me), this doesn't happen as much as I'd like. You just kind of have to take things as they come here.
8:00 am: morning meeting occurs on the wards in the main hospital, meaning I am usually dashing upstairs at 7:55 am to grab my white coat and make it in time (some things never change; I will forever be afraid of lateness, even when it isn't uncommon here.) Similar to the U.S. system, the overnight team presents all admissions from the last 24 hours, as well as any deaths. The consultants (attendings) and specialists (board eligible pediatricians in the process of becoming attendings) will comment and highlight teaching points on various cases. The West African medical teaching and lecture style is pretty formal compared to American training, but I try to weigh in occasionally if I feel I have a useful or unique perspective to add. Residents and attendings can also share announcements, concerns and issues at the end of morning meeting so they can be discussed in an open forum where everyone can have their say.
9:30 am (ish): this is where the day becomes more fluid. After morning meeting I head back to the peds ER for rounds. Depending on the specialists, rounds can either involve significant teaching, be rapid fire/brief, or not happen at all if the ER is very chaotic with a large volume of patients to see. We usually have several medical students, an intern and 1-2 residents around to present each patient, discuss the current medications and plan, and decide what the next steps in care are.
Something that's been a fascinating adjustment for me is patient ownership. In the U.S., as a resident I'd arrive on the wards each morning with a neat list of 5-10 patients I was primarily responsible for that day. Here, every patient is under the care of all of us as a team; the resident presenting the patient is arbitrarily chosen and the third year, specialist and consultant all agree on the plan together (though the most senior person has the final say.) Its been a fascinating deviation from what I am used to that is a better fit for the Liberian culture and practice style.
We see a lot of very sick patients; birth asphyxia (when the baby is deprived of oxygen and comes out critically ill with neurologic damage,) sepsis and other infections, and severe malnutrition are incredibly common and come with very high mortality rate.
One factor we consider in decision-making that I didn't expect was the cost to families; apart from a limited selection of medicines, everything we choose to do costs money. From a CBC to an x-ray, to selection of the correct antibiotic, parents have to scrounge up what little money they have to buy sometimes life-saving treatments for their kids. For a parent who makes only a dollar a day, even spending five dollars on a lab test or medication can be close to impossible.
Noon- 2 pm (ish): after rounds I tend to stick around for a bit to see how I can help without impeding work flow. This could mean I am writing in the chart, following up on a blood pressure or discussing a complex case a bit further with the residents and specialists. Eventually I make my way upstairs to work on research, helping the residents gain uptodate access, and looking up papers and articles on various interesting cases we've had to share with the team.
2 pm- 5 pm (ish): Depending on the day, there's loads of things going on during this time. Like any residency program, various lectures are given, either by the residents or by a local or visiting consultant or specialist. There are also various official exams at any given time of year; currently the first years are preparing for their exams (something between a Step 1 and Step 2-type of test) and we meeting regularly to review topics and go over questions. I also spend time with our research nurse entering data, tracking down missing information and troubleshooting whatever issues may be arising in the ongoing research work on a given week.
While the clinical work is a great learning experience for me, I find my work in the afternoon to be more rewarding; because of resource limitations there's not a whole lot I can do to improve outcomes on the level of individual patients. It can be incredibly emotionally draining to see your third newborn in 24 hours die from the same preventable illness (true story. More on that later.) But with collaborative research, and with actionable, big-picture policy changes, slowly over over time you can start to enact meaningful changes, and hopefully over time see improved outcomes.
5 pm-6 pm (ish): I check in with the peds ER 1 last time before heading home. If things are quiet, this could just be hanging out with the specialist, or reviewing patients of concern (watchers) with the overnight resident team to come up with contingency plans. Its not unusual for an actively crashing patient to be rushed in though, requiring resuscitation of some kind. These cases are the hardest because if I don't leave before dark it isn't safe to walk home, and because of recent gas shortages its not always easy to find a cab to drive you. So much of this job causes scenarios like this, of moral discomfort. I can't say that leaving feels like the right thing to do, but I can't help anyone if something bad happens to me. There's way more to unpack there than I feel up to sharing at the moment, but it is definitely an uncomfortable conundrum I encounter pretty regularly, so it would feel odd not to at least acknowledge it.
 |
| My favorite fruit stand...its bananas how good the bananas here are (pun intended) |
6 pm: If I don't stop at the supermarket or fruit stand by the hospital to grab more bananas, I arrive home, usually covered in sweat. I tend to immediately throw on my swimsuit and jump in the pool to cool off if I have time. Taking a couple minutes to swim some easy laps and unpack what I've seen/heard/felt throughout the day helps me to transition from the "everything is on fire and everyone is sick" mode into a more relaxed and reflective state. I tend to cook something easy and quick, maybe watch 20 minutes of a show while having dinner, then read on a few topics I jotted down throughout the day or get some research work done, depending on what's on my to-do list.
9 -9:30 pm: wind-down time before bed. One thing I really appreciate here is a consistent schedule; not working evening and overnight shifts like I do in the U.S. is one of the nicer luxuries of my time over here. The overnight team can call me any time but usually don't unless there's something they feel I can specifically help them with. I usually read a novel, listen to a podcast, watch something or whatsapp call family before going to bed around 10 pm.
And that's a typical day as a clinical pediatric fellow in an urban Liberian referral hospital! In the future I may share more of the specific types of cases we see, or how the health system works, and hopefully introduce some of the incredible doctors I have been working with, but for now I just wanted to share what happens on a day-to-day basis. Hope its interesting to someone :) Feel free to share any particular questions or thoughts in the comments. PS- You can also follow along on instagram if to see more of the day to day things, if you are curious.
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