Saving Lives...

Firstly, if anyone wants to the check the weather in Juba, we suggest here.

Now follows the real stuff...

I wanted to just follow-up our previous post a little. Matt wrote about life on the Emergency Medical Ward in Juba and some of the difficulties and frustrations that that can entail – some of the patients are extremely sick and like many nations in the developing world (due to a multitude of factors) many people die in Southern Sudan who perhaps wouldn’t in the UK with our education, ambulances, hospitals, intensive cares and the like.

Look at that handsome devil

But we’re keen not to give the impression that clinically it’s only very bleak. Quite the opposite in fact. The immense and very real challenges of dealing with such desperate situations generate an immense sense of teamwork, friendship and almost family feel amongst the hospital staff here. (“Communitas” one of my favourite authors would perhaps describe it.) Without meaning any offense to any in the UK,  it’s one of the best working environments (from a staff morale perspective) I’ve ever worked in any hospital. There’s just not this much laughter back home. This is extremely rewarding in itself of course, but the medicine is also extremely professionally satisfying, as illustrated below:

Cleaning day

We’ve been having a good couple of days – the doctors are dribbling in again from the strike and the patients have all been quite stable and many clinically quite interesting. Today, Sister Anna alerted me to a patient outside, whom had not registered on my radar on my initial early-morning-ward-triage sweep. The reason he was outside as a new admission is because it’s Wednesday cleaning day, which is a whole other story... (I think Dave dealt with this on the blog last year. In summary: patients out, ward cleaned.) His story was one of 3 days of persistent vomiting and diarrhoea without the ability to maintain any oral intake. Examining him, I’ve never seen anyone quite so dehydrated. Very dry, Sunken eyes, reduced skin turgor, the works. He was also drowsy, unable to stand, freezing cold and clammy to touch (despite the >30 heat) a blood pressure so low he just didn’t have any radial (wrist) pulse to feel. In short, textbook signs of hypovolaemic shock.

Anna, being the awesome nurse she is, had already got two intravenous cannulae in and was fetching the fluids when she got me. Anyway, the point is this guy was at death’s door on arrival and thanks to the great team on the EMW was immediately picked up, and prompty fluid resuscitated. I couldn’t honestly believe the change after just 1 litre of fluid given IV – his warmth came back, the clamminess disappeared, his peripheral pulses returned and his heart-rate fell nicely. He actually told me “I feel much better – thank you. I thought I was going to die.” And he was right.

Some monkeys we saw at breakfast one day

 Now, I’m under no illusions here – the hero of this anecdote is of course Anna, who basically saved his life and my role as a doctor was more of a formality :o) However, the point is that it’s tremendously satisfying to treat patients like this. The stakes are high – most people are very very sick. But simple things done well and promptly can really save lives. It’s important to remember the success stories along with the sadder ones.

So there we are. In other news, we had a great evening the other night, wandering home in the evening to the mess, we saw a couple of the consultants (Mergani and Kajomsuk: O&G and Chest Physician respectively) just hanging around, having some tea. One of the many things I love about this place is how some of the best experiences just come along “unlooked-for” (to use a Tolkienien word). We cancelled badminton and just sat and just sat and chatted and laughed and the lady gave us some soup stuff she was cooking to try... it was great. They’re such good fun.

Anyway, that’ll do for now.

James & Matt

PS The following photos are mainly for Dave Attwood's benefit. Compare and contrast the progress of the landscaping from 2008 to 2009!

 

Week 3

A fine week in Juba. I feel we are acclimatizing to life, work and indeed the climate quite well. After a humid morning on the emergency medical ward (EMW) this morning a spot of lunch in the nearby Central Pub was in order. Being the wet season, sudden downpours are common and heavy with thunder, lightning and power outages.  The sight of two Kawajas (white people) scuttling back to the hospital taking shelter from the storm got plenty of joyful laughs from the school children we passed.

We got caught in the rain on the way back from lunch

The shouts of “Morning!” (whatever time of day it is) and “How are you?!” from small smiling children greet us on most of our trips out and about. We are quite a novelty. Although it turns out the little ones that come to the hospital from the villages far afield are less sure of us – often never having seen Kawajas before.

Emergency Medical Ward
This week on the EMW started dramatically. If you don’t mind, there’s a bit of a medical case history here – a bit involved but paints a picture of some of the patients here.

Shortly after arriving on the ward, one of the excellent nurses Sister Anna pointed out a very sick man who had arrived the previous day. 31 years old, he had rapidly progressing fever and reduced level of consciousness. Treatment for malaria and widespread infection of unknown origin had been started.

From the start, it was clear this man was very unwell. He was all but unresponsive and the snoring noise heard from the end of the bed indicated he was not maintaining his airway which was becoming blocked. He was breathing at 50-60 breaths per minute (very abnormal) and was incredibly hot to the touch (there was no thermometer available to take his temperature). It is important to remember this man had been completely well just over a day before.

James put his anaesthetic skills to good use and maintained this patient’s airway while I searched for an oropharyngeal airway (basically a plastic tube used to allow someone with a blocked throat to breathe).  A single one was found on the other side of the hospital. With the help of the medical ward doctors we gave this man treatment for this widespread infection with antibiotics, anti malarials and fluid resuscitation. There was no oxygen available to give and no further blood tests or imaging that could be done. There is no intensive care unit, nowhere in which to escalate treatment.

Despite being given all the care and treatment available he was too unwell to recover and died early yesterday evening. His case was more severe than many patients in Juba but not uncommon.

Some of the patients here come to hospital after a difficult and long journey from the villages outside the city. The standards of nutrition, drinking water and basic sanitation can be very poor and people are often very sick before they can make it to hospital for treatment. Malaria and typhoid fever, often severe and life threatening is seen and treated here every day.

The Emergency Medical Ward (EMW) in action

Despite this we have seen patients make impressively quick recoveries with appropriate treatment. They are often much younger than many of the patients I would see in the UK or New Zealand and their physiology can take much more of a battering.

The efforts of the nurses and doctors on the wards and the other JTH staff are Herculean. They work in very difficult conditions with very limited resources. Sometimes the hospital runs out of the most basic medicines, fluids and equipment. For many reasons I am merely beginning to appreciate (not least of which the destruction of this country’s infrastructure by many years of war) many of the therapies, imaging and blood tests that are taken for granted in the Western World are unavailable.

Despite these difficulties and the bewildering array of pathology seen, staff remain focussed and in good humour while working long and difficult shifts. Two of the doctors on the EMW have worked every single day that James and I have been in Juba, including weekends and several night shifts.

Matt & Dr Dobol, a very hard-working medical officer (SHO)

A Note On Hand Shaking
It’s a simple thing, shaking hands. A greeting, an affirmation of trust or of friendship through physical contact. Simple and quite wonderful. It is the culture here to shake hands with colleagues and friends on each meeting – sometimes several times per conversation for emphasis! Being stopped several times on each walk across the hospital makes for slow progress at times but is one of the many pleasures of living and working with the people in Juba.

James and Dr Maker. Note: James is 6 ft tall and has size 11 feet. 
These guys are built on a different scale!

So that’s my first attempt at blogging, hopefully not too wordy for you all... We spend our days working on the wards, meeting and getting to know the doctors, nurses and pharmacists here. We have a preliminary plan for some research into the medicines and fluids prescribed and their availability – the JTH pharmacies often run out of vital items and patients’ relatives (if they have any) have to take a prescription to an outside pharmacy to get treatment. Patients without relatives are not so fortunate. We are working closely with the staff here as we want to initiate research/audit that is:

1.    Wanted by staff
2.    Useful and important in improving patient care
3.    Replicable (we are only here for 3 ½ months)
4.    Feasible for James and I to undertake.

All the best from Juba

Matt (& James)

PS If you're reading this as a Facebook note you might like to consider visiting the blog direct at http://onedoc.blogspot.com

Quick Note

Just to let you know if you click on the photos you can get a bigger image.

If you care...

:o)

Second Week Stuff

Hi there. So here we are again – I’ll give some updates from the last week. A couple of amusing anecdotes and some other issues.
 

We always liked this old truck. It’s a nice feature in the hospital.

We’re doing pretty well in general and are settling into the hospital routine nicely. Matt and I agreed that it’s best not to rush headlong into any programmes or modifications, so we’ve been working hard in more a ‘shadowing’ (with participation) role in the medical department and elsewhere to get a feel for the hospital system. Obviously I have 4 months of experience last year but things aren’t always the same and time spent understanding and observing in the early stages is never wasted. So we’ve been working in and understanding outpatients, the emergency medical ward, chronic wards, pharmacy etc. We’re making progress, and seeing a lot of really interesting pathology.

Some interesting pathology...

In a lot of ways the last couple of weeks have been quite atypical in the life of JTH for a couple of reasons. Firstly the junior doctor’s strikes: this is certainly public information in Juba so I’m sure stating a few of my observations will be ok. I know there’s been some rumours, circular emails and anxieties back home about the current situation, so I thought I’d comment:

Since Monday last week (our first day!) a number of the house officers and medical officers (F1/HO and SHO equivalent in the UK) have been on strike in protest to not having been paid their incentives by the MoH for the past few months (a sum of several thousand US dollars each). In the very early stages there was apparently some nurse participation but this seems to have resolved. This has lead to the hospital being run by skeleton staff which is not ideal for patient care, but it’s still generally functioning. However, news/rumours of the situation have permeated Juba and is generally leading to fewer admissions as patients aren’t bothering to present to the hospital at all. I was looking at some admissions figures from the Emergency Medical Ward (EMW) today and a couple of weeks ago admissions were 30-50 per day, whereas for the past few days it’s been only a handful, and the chronic wards are virtually empty.

Some nice weaver birds in the hospital (to break up all that text).

There have been several negotiations between the Ministry and the Junior Docs but as yet I still don’t believe the situation to be fully resolved. This was further complicated by an unfortunate one-off episode last Thursday afternoon when some policemen turned up at the Doctor’s Mess (where we live although we weren’t there) and allegedly beat some of the doctors that weren’t working. Now I haven’t actually met any eye witnesses/victims so I don’t know the full details, but it seems to have been a relatively minor affair, although all the doctors clearly felt the threat of any violence completely unacceptable, which didn’t generally help matters in general. There have been more negotiations since and it’s unclear where the edict to the police came from, but everyone seems to condemn the actions and there’s certainly been no more trouble of that nature on the ground that we’ve been aware of. In general the senior directors in JTH are doing exceptionally well at holding the hospital together and still managing to provide emergency care to patients under these difficult circumstances.

Matt enjoying a fine lunch at the Sister’s excellent (cheap) restaurant.

A separate issue that’s been registering more on the NGO radar over last week but has less implications for us was a GoSS curfew (one day only) and military operation searching households and compounds seizing illegal firearms from civilians in Juba. Most of the hospital staff approve of the operation and it seems to have been conducted professionally.

From one report:

"Thousands of illegally and privately owned weapons including RPGs, PKMs, Kalashnikovs and pistols were retrieved in the town’s residential areas. Among them also included 12.7 anti-aircraft weapons privately owned by individuals.

The minister of Internal Affairs, Gier chuang Aluong, said the operation was aimed at freeing the town from armed criminal activities. Speaking to Sudan Tribune by phone, Majak Kuol, a resident of Juba in Atlabara B, said they started a cordon and search operation in the town early this morning. He added the joint operation by the SSPS and SPLA was a peaceful exercise acknowledging having been restricted movement."

Also anecdotally it seems to have worked. Chatting with some of the surgeons they tell me that they haven’t admitted a single gun-shot wound so far since the operation, so it seems to have been effective, which can be no bad thing. (Last year I was certainly seeing a few gun-shots per week.)

So on the lighter side of things, we’re making the most of the place. Our accommodation basically backs onto the Tearfund compound (with whom Dave and I made many friends last year) so we’ve been hanging out there a bit in the evenings playing badminton with a couple of their guys. Also they’ve kindly agreed to provide our evening meals which is just a real blessing, as the hospital is willing to pay and it’s good value all round. Recently we also tried our hand at some vetinary medicine...

Jasper the friendly dog.

So they have a puppy (rescued from marauding monkeys apparently) who’s a lovely little dog. Anyway, he needed an urgent blood test doing for quarantine regulations one day, and the vet couldn’t come (due to the aforementioned curfew.) Not afraid to try new things, we agreed to have a stab at it, so to speak. We didn’t have any knowledge of how best to go about it, so consulted the AQA text service, which astoundingly works here in Southern Sudan. They recommended the jugular approach, but we rejected this on the grounds of a) complete ignorance of the relevant anatomy and b) proximity of his teeth. A bit of exploration revealed a decent looking leg vein and with two assistance on restraining duties (which Jasper thought was a great game) I manned up and got 10mls without too much trouble at all. So there’s a first for us, but I always like learning new skills.

The tempting veins...

I generally like animals but I had a bit of a shock the other night when bedding down I felt something exceedingly strange scurry up my leg. Turned out a lizard had crept up there into my sleeping bag earlier and was probably just as indignant as I was at having it’s sleep disturbed. Anyway, we chased that out and now I’m more careful about tucking my mossie-net in firmly in the day time as well as night.

That darn lizard.

That’ll do for now. This week’s going pretty well and we’ve achieved most of our planned objectives for the week already, and some ideas and strategies are germinating so we’re feeling pretty good. More to come soon...

James & Matt

A Little Bit More...

Ok so you’ve made it through or skipped the boring previous preamble post. Well done. Now our internet access has been rather unreliable so far and I apologise. This means we have a little catching up to do over the past week, much of which relates to journeys and introductions, hence I fear this post may be slightly longer than I will usually aim for. However, once we get this orientation one out of the way then it should be much easier for us all. Right, on we go...

The journey was generally smooth – we (I) had some hassles at Heathrow regarding baggage allowances but that all turned out remarkably well. Addis was straightforward and actually rather pleasant as airports go and all luggage arrived ok. Juba airport can be a bit chaotic to the uninitiated but Dr Dario (Consultant Surgeon and Director of JTH) was there to meet us, chatting amongst the immigration officials no less (a well connected man), and hence we were warmly greeted.

The weekend was largely concerned with settling into the place. Our accommodation is in the Doctor’s Mess (the local junior doc’s accommodation) which is right opposite the hospital so location-wise it couldn’t be better. There’re still a few issues to iron out at this stage but we’re getting there. The main issues are security (it’s an open compound on the main road – no walls or gates or guards) and food. Our room locks though and everyone’s very friendly. Recently an armed guard has appeared at night. It’s a functional if not beautiful site with a hand pump for extra water if the mains is off. It’s a more authentic and culturally immersive experience than last year. The room itself is clean and perfectly adequate (although clearly a single room with two beds in) with a shower. Power is not working there yet, but we have a lovely air-conditioned office in the hospital which is a real added bonus. Food-wise the general consensus amongst the Sudanese it that we won’t get on well with the food they eat so we’re trying to come to a suitable arrangement on that one. So far we’ve been eating in restaurants which is not financially sustainable long term. The hospital will pay for our food but clearly we don’t want to abuse their generosity so we’re coming up with some creative (cheap) solutions.

 

 Our pump for washing clothes

 

Our Residence

It’s been a very tough week for the hospital with a lot of staff off on strikes over pay disputes and the atmosphere has been tense at times. There was a big police presence around yesterday which I think unsettled people. Also there was a city-curfew the other day with the army doing house searches and seizing illegal weapons. Generally this is considered a good thing, but it was quite disruptive to life in Juba. Throughout though, we have felt very safe and well looked after by all at the hospital and treated with incredible warmth and hospitality.

 

Matt and I on the Emergency Medical Ward. That's one of the nurse's kids

We’re using the time to refamiliarise ourselves with the hospital. It’s difficult to assess what’s ‘normal’ at this stage though with the strikes, however this has given us a chance to sort out some of the logistics in our accommodation. Yesterday Sister Anna took us to the market where we bought some bowls for washing our clothes, and also some more bed sheets. Matt chose us some nice floral numbers. I managed to acquire some bamboo canes today so I can erect my mossie net tonight (hitherto unused - I took a few bites last night and woke up itching at 0230). Our health has been good thus far.

 

 

I guess we’re still trying to work out what our main trip objectives are going to be, but we plan to start with some shadowing and working within the system to see how things are rather than going in all guns blazing. Certainly everyone’s extremely welcoming and happy to see us, and it feels more like a genuine reunion of friends than anything superficial. In a sense I don’t feel like I left at all – it’s a wonderful family here amongst the hospital staff. The respect and friendship took us quite a long time to earn and develop last year and it’s nice that it seems as strong as ever and should help us to get on and do things more quickly than last time. Patience is key here and not letting yourself feel frustrated at an apparent lack of progress. Generally most of the really good stuff happens when you least expect maybe after a couple of hours of general chit-chat. Certainly some of the best stuff that David and I did last year weren’t planned, they just grew organically. That’s just the way things happen over here, and never being much of meticulous planner myself, frankly I rather like it.

Anyway, I hope that wasn’t too unbearable. We should be able to get on to the good stuff now. If the above was too wordy (Nick) to summarise:

• Arrival safe
• People friendly
• Having fun.

Bye for now

James & Matt

New Blog

Hello and welcome. I’m James, this is my new personal blog. This will be largely a continuation of last year’s St Mary’s Juba Link Travel Blog (http://stmarysjubalink.blogspot.com) which some readers may be familiar with.

Matt and I

First some rather dry but necessary housekeeping (You can skip this bit...): The switch from an institutional blog title (i.e. St Mary’s Juba Link) to a personal one is largely one of logistics: Firstly I no longer work for St Mary’s hospital and although I remain in very close contact with and supported by the Link Core team at St Mary’s, the current trip to Juba Teaching Hospital has largely been privately rather than corporately arranged. Secondly I hope that this blog will continue in the future as I undertake further adventures in medical travels and an unmodified domain name would be rather confusing. Obviously the St Mary’s Juba Link is entirely relevant to our current trip to Juba Teaching Hospital which I’m sure will be reflected in future posts. In particular we’re looking forward to working a delegation from St Mary’s in December undertaking some fistula repair work, though more of that in due course. Incidentally, the blog title was inspired by a friend I made in India in 2004 and I always rather liked his blog.

In terms of my personal career progress since returning to the UK from Juba in 2008, (if you care) I worked as an SHO for 6 months in ITU and Acute Medicine until August, and secured a training job in Anaesthetics in Wessex, which commences in April 2010. Gaps in medical careers like this are somewhat rare gifts, and hence I was keen to grab the opportunity to do some more overseas work in Southern Sudan. Incidentally David, my partner-in-crime from Juba 2008, also obtained his first choice job and is currently doing core medical training in Exeter, though I’m convinced he’ll also be back in Juba at the earliest opportunity....

A fine specimen I found on our (outside) house wall

My current Juba buddy for 2009 is Matt Dennison, a doctor at the same level as me. We trained together in Southampton and worked together as House Officers in SMH. He’s subsequently been all round the place, latterly working in New Zealand. I’m sure he’ll be guest posting. The blog title in no way is meant to diminish his contribution to this current project, and is merely a reflection of the fact that I’ll be personally taking the blog further in the future.

Right, sorry to bore you with the above, as I’m sure you’re more interested in the good solid life-in-Africa-saving-lives(!) stuff. I strongly believe in keeping blog posts little-and-often and hence I’m gonna put that in a separate post to follow very shortly, with some photos if all goes to plan.

James