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