Week 11

Hi there. Well it’s been a little while, but we’ve been having slightly better luck internet-wise. We’ve been pretty busy lately doing various things, but time to pause a while and write a little more on the blog. I say a little...

The Poole Team with Dario and Anna

We had a good weekend recently where we welcomed a group from Poole Hospital to Juba – they have a similar link to Wau Teaching Hospital, also in Southern Sudan, accessible via an internal flight. We tried to be generally useful and did an orientation tour of Juba Teaching Hospital o n the Sunday to set some of the scene for healthcare in Southern Sudan (although to be sure Wau is more basic than Juba). Some of them get back to Juba on Friday, so it’ll be good to hear what they’ve been up to. See also their blog.

Here’s Matt on a story of a little trip we made the other day...

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The registration process for voting in the 2010 general election has begun in earnest. There are posters, tee shirts and announcement s everywhere encouraging people to register now in order to cast their vote next year. Last weekend Dario invited us on a trip to the village of Lomboko, his birthplace, so he could register. I found to be asked to his home to meet his family and see where he came from to be quite an honour in the first place. And especially as we have (by necessity of having no transport) spent most of the last two and a half months in this city within walking distance of our accommodation, getting out of Juba was a welcome change.

The trip began with a large meal at a Sudanese restaurant in town. Many Sudanese eat just one meal per day so they are often very large (and dangerously effective at putting you to sleep on warm afternoons as James and I have discovered). Myself, James, Dario and his friend Mr Mannas (a dentist) set off in Dario’s big JTH 4x4 out of Juba. Crossing the Nile we headed South past Rajaf (where we went to church with father Jo a few weeks ago).

At first the terrain was mostly scrubland with small bushes in the outskirts of the city . There were the blackened trunks of small trees and scorched earth of controlled brushfires lit by local herdsmen. As we climbed up into the hills past Rajaf the signs of human influence waned and tall, man high grasses and native trees took over. We passed troupes of monkeys resting in the high branches, the air was filled with hundreds of dragonflies and we saw many large birds of prey circling above. Later we would see a large wild cat and nocturnal foxes darting into the grass as we disturbed their hunting on our journey home.

We climbed further into the mountains and the road became a single rutted track. At a rocky outcrop with a commanding view over the surrounding land we passed by the wreck of a burned out tank left since the end of the war. This viewpoint was the site of a long range artillery emplacement, where the guns were aimed at the city of Juba, just a few years ago. Dario told us the surrounding land still contains many landmines. The surgical team at JTH all too regularly deal with the results of these devices - traumatic amputations of lower limbs, often in children straying off the usual paths.

We continued on through the grasslands and after a few hours came to Dario’s home turf. The air was cooler up here and the views of the surrounds were stunning We stopped to greet the chief of the neighbouring village and visited the health centre there – a small building built from sun hardened mud and holding a store of medicine, fluids and a few hospital beds. It is run entirely by a small grey haired man, a clinical officer who seems rightly proud of his small but important clinic – the only source of medical care for the entire population of the surrounding villages. We signed the visitor book at his request and moved on.

After several hours journey we arrived in Dario’s village. There was a long queue of people under a grove of trees with a desk, a voter registration poster and collection of soldiers with guns. I have become quite used to seeing assault rifles on a daily basis here – they are sadly an expected part of life and a universally understood symbol of power.

Voter registration under the mango trees

Registration over, we drove to Dario’s home itself. We met a neighbour of his who was attacked by the LRA some years ago (Lord’s Resistance Army, a group of seemingly apolitical rebels that actively recruit soldiers through kidnapping – especially children). He had his lips and both ears cut off in this attack. We were told this in a fairly matter of fact, undramatic way. Many people here don’t have the privilege of being unfamiliar with such brutality.

Some of Dario’s family were sitting down to eat as we arrived. Three generations of family sat under a tree together, the sun just ready to go down with a gentle breeze disturbing the red dusty earth. The bare ground was immaculately swept clean of fallen leaves. His family (uncle, sister in law and nieces) ate their greens and sorghum while Dario showed us quietly around his childhood home. There were several tukuls (mud huts with conical thatched roofs) – one for each of the family members aged over 10, a small brick building with a tin roof and a patch of land for growing crops. A few of their goats tramped around nibbling at tussocks of grass and anything else they fancied in a typical goat fashion. We were proudly shown where nearly all the family’s food is grown and the large guest house under construction by his neighbours. The atmosphere of peace and warmth was wonderful.

Growing up in a rural village with no electricity, running water, high-tech appliances of any kind and above all with no shelter from war and violence is so far removed from my early life. I’m not going to over-romanticise the lifestyle we glimpsed, I’m certain living this way is difficult in ways I can’t imagine. The blind luck I had in being born in a country where I had all the basics of a healthy life, let alone all the luxuries I am accustomed to must not be forgotten. But being in Dario’s village, sat just for a short time with his family, made me feel strangely content and at peace.

All too soon it was time to leave as it is easier to cross over the mountain road while there is still some daylight. We said our goodbyes, were given a handful of freshly roasted ground nuts (peanuts) each by his niece and began the journey home.

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James again. So in other news, gunshot analysis is going well and we’re starting to get some results. We’ll keep tapping away at this mountain (We’ve got around 1000 cases ) and get it done in time to present to the ICRC War Surgery Conference which is happening later this month. One real frustration is that one of the log books is at present lost, and the man who may know where it is in Khartoum. This means there’s a big old hole in our 2008 data which is annoying. Hopefully it’ll turn up.

Also, we’ve been getting into some teaching again recently. Teaching’s fun here, and we’re mainly focussing on nurses, sisters and clinical officers (like doctors but not quite.) The material would be very good for junior docs too but sometimes attendance can be a struggle so we just teach anyone who turns up willingly. It’s true that Juba is in many ways very basic in the medical service it offers (no fancy tests and scans) but at the heart of all good clinical medicine, wherever you are in the world, are certain simple-but-crucial clinical skills that only need good questions for your patients, your eyes, ears (and stethoscope) and hands. These are the kind of basic core skills we’ve been focussing on, in the context of common emergency conditions that they see in Juba. (And also ones we have a hunch could sometimes be managed a little better.)

So last week, following on from some of the basic ABCDE teaching from last year, we were focussing on failure of the circulation (shock) in general and also, almost by way of illustration, a separate session on management of acute gastro-intestinal bleeds. Common, important, relatively easy to manage well and can be life saving if done.

This week we did a session on assessing and managing patients presenting to the emergency department with shortness of breath, (the keen observers amongst you will notice that we’ve cunningly thus expanded more fully Airway & Breathing & Circulation...) Respiratory emergencies are quite a big topic, but part of the fun is selecting and arranging material that’s important and relevant to local need, whilst remaining punchy, interesting and avoiding overload. Another challenge which I enjoy, is that of communicating complex of abstract concepts in a way that is easily understood. Plus I feel it’s important to give useful information to Sisters/Doctors whilst still not leaving anyone behind who have less of a medically educated background.  (For example, some of the basic nurses were recruited during the war for sheer service need, and didn’t have a complete training.) Throw in English-as-your-second-language to that mix and you’ve some real educational/communication challenges!

But we like challenges, and with a bit of creativity it’s actually not that hard. Being a good teacher is not someone who shows off to the class how clever they are and how much they know and leave the pupils impressed with them, but generally bewildered and still ignorant about the content. That  is bad teaching! A good teacher explains things well and helps people to understand, to see for themselves, and often this is best done in simple ways. Such an approach doesn’t flatter the intellectual ego of the teacher as much as the first approach, but is certainly preferable in terms of outcome.

That’s a little bit tangential. What I mean to say is, I like explaining things simply, using good illustrations. So for one thing, diagrams are definitely in, as our practical visual demonstrations. For example, in teaching how to resuscitate someone who is bleeding, it’s important to put a big cannula into the vein to give fluids/bloods. To illustrate this, we arranged a race between two bags of IV fluids into jugs, one with a small (pink) cannula and one with a large (grey) one. And it illustrated very well (better than just a bullet point on a slide) how important it is in managing bleeding.

Another example is the difficulty explaining some slightly complicated physiology related to circulation. Well, actually in this culture (even us) everyone physically uses hand pumps for water. So talking about the heart as a pump in some ways probably makes more sense to them than us. So whilst we struggle as 1st year medical students to get our heads around “Cardiac Output = Stroke Volume x Pulse Rate” I can just say (with the aid of a photo of my noble colleague Dr Attwood furiously pumping away at a genuine JTH borehole) “How do you get more water? Answer, pump harder, or faster, or both!” Which is essentially the same thing.

I had another crazy idea for an illustration today which again seemed to go down well. I was trying to teach about a tension pneumothorax (not so common, but very life threatening and very treatable hence important) and was trying to get a good angle. (For non medics, this won’t make much sense but wikipedia’ll fill you in on the background.) I mean concepts like pressurised gases, to people without GCSE science which we take for granted, are hard to explain. So I took half a bottle of coke and demonstrated the pressure of the gas inside (by sqeezing it) and then simulated the increasing rise in intra-thoracic pressure by shaking it up (with the lid on.) This shows how the pressure increases as the bottle is no longer compressible, and illustrates how pressure can be a significant force and can collapse the lung and stop the heart working. Then, my favourite, I demonstrated the treatment by decompressing the bottle with a needle (which is exactly the same principle as the treatment of a person) complete with satisfying hiss of gas escaping. Followed up with some good diagrams on the screen and job done.

My decompressed "tension pneumothorax"

Anyway, so that’s some of the fun we have. This has gone on for quite long enough I deem, so let’s wrap up. Not long to go now!

Bye

James & Matt

Week 9

I thought I’d follow James’ advice and do a little bit of blogging a bit more often...

Yesterday we went our separate ways for a time – James spent time in the operating theatre and I went to the Emergency Medical Ward with Dr Andrew. Fascinating in very different ways. James was in theatre with Dario – one of the senior surgical consultants here. He’s a true general surgeon and his work demands experience in all aspects of general surgery and orthopaedics. Along with the other surgeons he regularly manages everything from gunshot wounds and fractures and plastics (skin grafts) to hernia repairs and major abdominal surgery, and when the emergency need arises to open a chest or skull. He’s also a thoroughly nice guy and has been very supportive of us throughout – he’s the man who has requested we look into the records of gunshot wound surgery at JTH and formulate a report.

Amongst other things, James saw a lumbar hernia repair yesterday (something I’ve never seen in the UK or NZ), and was impressed with the surgical skill displayed in performing a mesh repair on this rather large abnormality.

The EMW was pretty full yesterday (as it is most days).  Many of the patients were admitted for treatment of malaria. It has a huge variety of presenting signs and symptoms. One of the most striking appearances is that of a patient with cerebral (brain) malaria. We have seen them present with anything from abnormal behaviour to confusion to outright coma.

One of the patients on the ward yesterday had the malarial symptoms of body aches, fever and nausea with additional signs of cerebral involvement.  Progressively stilted, odd movements and slow, uncoordinated movements together with limited speech and confusion all point to this clinical picture.

Cerebral malaria has a poor prognosis even in well resourced Intensive Care Units and is a major cause of morbidity and mortality worldwide. But despite this I have seen people make startling recoveries over a short space of time with good ward based care.

At Dave’s wedding earlier this year Dr Hakim (a UK based medical consultant and originally from Juba) told me of my upcoming trip to Sudan “You will see things you have only read about in textbooks”. And of course he was right. For example, nearly every ward round I go on here reveals patients with massive splenomegaly (an abnormally enlarged spleen due malaria, typhoid, certain anaemias and a multitude of other causes). I can think of very few times when I treated patients at home who had such findings.

Liver cysts, signs of liver failure, the neurological signs of cerebral malaria, numerous skin lesions associated with infection or with HIV/ AIDS, the sunken eyes and cardiovascular findings of profound dehydration are common to name just a few. The patients here have such a burden of advanced illness yet as I’ve said before, patients, their relatives and staff approach these difficult situations with grace, pragmatism and intelligence. People deal with great pain and suffering with very minimal complaint – very humbling to witness.

We took a trip to a church outside the city with father Jo last Sunday. The President of South Sudan Salva Kiir was present (the second time we’ve seen him in the last month or so). Along with the Archbishop of Juba, the president  gave a rousing speech to the congregation including an encouragement to register to vote in next year’s general election. The next few years will be a time of great change for this country for many reasons perhaps best left to those in politics to comment on. The massive importance of the election in 2010 and subsequently in the referendum of 2011 to the political situation here really struck me. Whether people vote or not will have a direct influence over the future of this long troubled country.

The US Envoy to South Sudan was also present – this combination lead to an impressive security force and a motorcade of several hundred soldiers with too many AK47s to count. Being in a bit of a hurry to get home after the service for a well deserved lunch (he had been up behind the altar with the other priests for the last 4 hours) Jo pulled out just a bit behind the president’s motorcade and we drove just in front of a pick-up with what looked like an anti-tank gun anchored on top. An interesting weekend. I also crossed the White Nile for the first time – deep, wide and fast flowing at Juba even several hundred miles before it joins the Blue Nile in Khartoum.

And finally... Snakes! Or a single snake in fact. “Oh look, there’s a snake” said James in a rather matter-of-fact manner yesterday evening as we sat in our office. And indeed there was a green fellow just over a foot long and half an inch thick calmly making his way along the floor – probably having slipped under the door. Not exactly a maneater but pretty disconcerting.

Being both practical and deep-thinking men we rapidly discussed our options (from the safety of standing up on the sofa). You must bear in mind we’re not experts in snake behaviour, venomous or otherwise in South Sudan and happen to know the only anti-venom is kept by the UN in their compound which is some way away.

1. Ignore him - he might be harmless? No, as we work in this office nearly every day and don’t fancy the prospect of sharing it with a potentially lethal interloper.

2. Capture or otherwise detain it? A swift scan of the room revealed a distinct lack of reptile-proof containers and anyway what would we do with an imprisoned and probably angry serpent?

3. Kill it? Yes, we decided. But what with? How tough are they? Unsure of the answers we thought perhaps a heavy object dropped from above might work – but again the standard office set up doesn’t include accurately droppable snake killing objects.

So I went for an old fashioned approach of beating it soundly about the head with my shoe. It took quite a few hits and finally lay somewhat dead on the floor. We paused for James to take a picture (with ruler for guidance) of the offending beast and then threw him out the window. Sorry snake, we aren’t men of violence but given the situation, you had to go.

Sister Anna had a look at our picture today and told us most snakes here are venomous and we probably did the right thing. Disaster averted we went on with our evening and watched an episode of Band of Brothers to put our snake problems in perspective.

All otherwise is well here. We have five weeks left in Juba, are getting on well with the gunshot wound research with plans going well for teaching sessions for clinical officers and nurses. The rainy season is coming to an end – the previously daily rainstorms now come less than once a week and the roads are dusty and red. And it sure is hot. We are both still happy and healthy and finding time to indulge our common interest in Tolkien.

Matt (and James)

So What Are We Here For?

You may think that the title of this blog post may imply some deep existential treatise on the human condition to follow, so I apologise but the intended scope is a little narrower. Actually, having passed the halfway point in our trip now, I wanted to offer some reflections on why we’re here, what we’ve done and what we’re planning to do.

By way of another sad announcement, subsequent to some recent upgrading at Tearfund, our computers no longer recognise the internet. This limits our connectivity severely, to the extent that posting anything is difficult, especially photos. I'm borrowing a laptop at present but it still takes a long time. We get a trickle in the mornings at the hospital, enough for emails (without attachments please) but otherwise we're struggling

Part of our overall game-plan this time in Juba has been deliberately much more reactive than last time. I think if Dave and I reflect upon some of our aims and ambitions coming to Juba in 2008 it’s clear that what we had in our mind for our objectives before coming ended up not being relevant at all, and some of our best achievements cropped up completely unlooked for. Even though coming back here having spent all that time last year and I was well orientated within Juba and the hospital, we still felt it a worthwhile strategy to come with the aim to above all be useful to the Southern Sudanese and let them set our agenda, and not push our preconceptions of what we think they need.

That’s not to say that we’re completely aimless, mind. We always plan and structure our week’s objectives in advance to guide our time. But having the luxury of a decent amount of time here, we planned to observe (generally from within by participation) hospital life for a good few weeks before trying to fiddle with anything in the name of “improvement.” It’s an absolutely fatal mistake to suppose, even in the name of ‘aid’ or ‘development’, that the Southern Sudanese (and I guess by extension Africans in Africa in general) are incapable of solving their own problems without Western intervention. We’ve been fortunate enough because of our situation working here, with and for these guys, that this kind of tacit and insidious ‘white superiority’ thinking (doubtless aided somewhat by prevailing media images of helpless babies covered in flies and the like) has never had the opportunity to take hold. It simply can’t when we see every day how hardworking, dedicated, talented, creative, clinically competent (and brilliant in some cases), warm, welcoming (and not forgetting downright hilarious) these people can be. And yes, I guess there are some lazy folks here too, but pick at random any hospital, or group of people worldwide, and you’ll find the same.

Dario and Louis

So given the above, it would both unwise and perhaps insulting to come marching in with our agendas trying to change this or fix that. For one thing, just because a system is not like ours, doesn’t mean it’s wrong. Often there are very good reasons, and an equivalent Western system wouldn’t work here. Something worth remembering. So we feel time invested in being ‘actively passive’ is never wasted. I mean, for one thing we’ve learnt a heap about tropical diseases that we’d probably never see in the UK, which is extremely valuable professionally if nothing else. So basically we’ve been here working hard, making friends, getting to know the place.

Of course have certain advantages having been educated and worked in British hospitals, which we’re in a position to share with people here. In fact, on reflection I think that many of the things that could most improve the hospital care here (if done sensitively and sensibly) is good clinical governance, management systems and education structure - probably more so than pure clinical work. This is something we can help a little with, having observed and absorbed a lot of these modern hospital concepts. We came here last year with a deep commitment to the power of teaching, rather than the typical knee-jerk (and beloved western) reaction to give ‘stuff.’ I still hold to that presupposition, but I think my position has matured somewhat. “I think you’ll find it’s not as simple as that...” to quote the marvellous Ben Goldacre (As an aside, Bad Science was one of the best books I read last year.) Teaching’s important as a central pillar, but can only function as intended as part of a multifaceted and sustainable approach.

Now, sustainability is the name of the game in any kind of development work (although I’m reluctant to apply that term to our work – it seems a little grandiose!) and the problem with just doing clinical work (I mean seeing patients, going on ward rounds, the normal doctor stuff) as just pure service provision for the hospital, is that it’s totally unsustainable, i.e when we leave, that service (small as it is) finishes. It’s not completely pointless because a) it’s a good education experience for us, clinically and in terms of hospital structure and function b) it’s a good way to make friends and gain credibility with hospital staff c) it’s good fun and professionally satisfying to just ‘be a doctor’ and treat patients and d) a lot of ‘teaching’ (in the broader sense of the term) happens outside of the classroom and on the job with modelling good practice and examples. But it’s certainly in itself not a long-term sustainable solution to any clinical needs that exist within JTH.

Ward Round with Dr Andrew

Dario showing us his (not quite finished) house

So we’re keen to always a) be useful and take our cue from the bosses here and b) offer the things we can provide more uniquely as Brits (there are plenty of other very competent Sudanese doctors on the wards). This tends to nudge us more towards sharing things to do with modern hospital / clinical governance concepts and paradigms such as evidence based medicine, clinical audit, research, some teaching (such that we can) and ultimately, perhaps more unglamorously, spreadsheets. This is a (medical) cross-cultural exchange in action for mutual benefit.

So, this has formed another part of our day to day work. Being doctors and thus having a good grasp of the clinical issues but also being familiar with concepts in research, data analysis and clinical audit and of course IT, a couple of the consultants here have set us to work analysing some data for them. It’s not as outwardly sexy as “saving lives” or whatever but if you think about it, it fulfils our ambitions very well as a) It’s lead directly from the demands of JTH b) It something unique that we can offer because of our training and background c) It’s sustainable and has long term benefit because the data is useful and important (knowledge is power, after all) and can guide hospital policy in the future.

Teaching for the Obs and Gynae department

A good example of this from last year is the clinical audit work we did on recording and acting on vital signs, together with the research we did on the peak in hospital mortality occurring within the first 24 hours of admission, implying a focus was needed on acute care. This of course directly guided a lot of our work, but I’m only just realising how that data and those graphs we generated have seeped into the hospital’s subconscious and is still working. (For example, only the other day we found out that, completely independently of us, Matron Susan has set up a sort of resuscitation room in Outpatients to make sure that serious medical cases have been cannulated and started emergency fluids and treatment before getting to the ward. Brilliant.)

Specifically, at the request of Dr Merghani (the head of Obs & Gynae) we’ve analysed and presented all the years worth of caesarean sections conducted in the hospital. A pretty important topic (especially in a country which reputedly has the highest maternal mortality rates in the world) and also uncovered some interesting anaesthetic-related data which, in an audit component, has great potential to improve patient care. We’re currently working on another, more involved research project for Dr Dario (the head of surgery) analysing all of the operated gunshot (and mine/grenade blast) wounds in JTH since 2006. Data recording is frustratingly limited, but it’ll be very interesting to try and look for trends developing from essentially war-wounds in the post-war years in Juba since the Comprehensive Peace Agreement in 2005. And it’s useful data for Juba because no-one’s analysing any of it, so they don’t really have any concrete ideas of numbers (which makes planning very difficult.) We’re also looking at trends in demographics over time, and looking for any other patterns. The results again have implications for surgical and anaesthetic training and all sorts. It’s a lot of quite tedious spreadsheet work (750 cases processed so far and still going) but on the flipside, afterwards we’ll know more about operated gunshots in JTH (2006-2009) than anyone else in the whole world! Which is quite cool to think about... :o)

We play badminton with varying degrees of success

So we’re plugging away at that (we have a deadline in November because Dario wants us to present it at an ICRC war surgery conference), doing some ward work, and also planning some more teaching on basic emergency medical care (and some other things) for the nurses and clinical officers in due course. We’re always on the lookout for other ways to generally be useful, so doubtless other opportunities will present themselves. So I hope that offers a bit of an explanation. We had a trip to the Ministry of Health the other week and met Dr Loi, the Director General of Curative Services (i.e. the hospitals) and had a good chat and showed him some of our work.

Artist's impression of us getting rained on up the mountain

So what else? Well, socially we’re getting on well with each other and all the various other people we meet along the way. We had a good walk up a mountain (ish) the other weekend, which started overcast, and then the clouds came down onto us (as we were at the top) and we got drenched. However, after a slippery descent, some picnic coffee and cinnamon buns courtesy of Kate cured all our woes. But the cloud did spoil the views of Juba city somewhat, so it may need another trip.

We had a good time out the other afternoon with Dario and Louis taking us to show us the houses that they’re building for themselves. That was good fun – Louis is further along with his and it looks rather grand with some great pillars etc.

Louis' house

We’re looking forward most to hot showers and cold nights (and warm beds) and of course Christmas at home with family and friends. Also some nice cheese. And proper cups of tea. Let’s not get ahead of ourselves...

Pretty cool giant millipede Ben found. They really tickle.

Sorry this post has been both overdue and rather longer than usual. I’ve said that I think blogs should be little and often, and I stand by that. Turns out I’m just not able to live up to that standard! Although I partially blame our internet woes.

Goodbye

James & Matt