_ One Doc's Blog _

Southern Sudan Medical Journal

2010-05-04T12:46:00.000-07:00

Exciting news!

We've just finished designing a website for the Southern Sudan Medical Journal. This is a project that I've been involved with for some time now. It's still early days but I feel that it's a very worthwhile pursuit and allows us to actively contribute to the education and training side of things even whilst not there physically...

Do have a look - www.southernsudanmedicaljournal.com - feedback/comments welcome.

James

Conclusions...?

2010-01-11T11:31:00.000-08:00

Well as you can probably tell from the photo (admittedly not taken at the height of the snow) I’m back home in Southampton now and it’s extremely cold. 1 degree C here at the time of writing although oddly it feels warmer than it has last week. To be honest I’ve been meaning to conclude this blog episode for a while but it’s been hard to focus with Christmas and all. It seems a life-time away. I’ll come back to that thought later...

So our last week, from what I can recall (the blazing sunshine and high 30s temperatures are hard to visualise at present) went very smoothly. We had arranged quite a lengthy to-do list which we got through, mostly revolving around saying our goodbyes, chasing folk and assembling all the relevant paperwork, wrapping up or handing over all our projects etc. You know, the slightly tedious necessities.

Other highlights included going round for dinner on one of the last days to Sister Anna’s house with Mike (the surgical registrar). This was a really great afternoon – some of our most precious memories (both from this trip and last) have come from spending good time building friendships with folk here, sharing their hospitality, homes and lives. I feel it’s important in these trips to make sure you’re not so busy chasing a schedule of things to do, you have no time left to just be with people. Actually African culture is far better at this than we are, and it’s been a lesson well learnt. Oddly enough, time spent in this way generally enables you to get a lot more stuff done anyway as time invested in getting to know local people, their systems agendas and problems, chatting through some ideas etc is extremely important and valuable. (And fun.) So everyone’s a winner.

Matt, Anna and I at her family home

We had a more formal farewell dinner on the Nile with all the St Mary’s Fistula team and officials from the Ministry of Health and some of the key hospital staff which was good too. Our journey home was very smooth with no delays, lost baggage or any other hiccups that make one stressed at airports.

So that was that. Back to the UK just in time for Christmas, over-indulging in cheese consumption. It feels good to be home again and with friends and family. Naturally I observe that Christmas, complete with its many great features simultaneously encompasses some of our society’s more ugly under-currents (consumer/materialism particularly) but that’s quite an obvious thing to say which doubtless has been said many times before and more eloquently than I could. So I’ll simply acknowledge that observation and move on.

Inside Anna's immaculate house...

I’ve been deliberately resisting qualitatively comparing Juba 2008 with Juba 2009, both publically and privately in my own mind and I shall continue to do so. I think to do so would diminish both. They were both very different with their own merits and weaknesses. One thing I do observe going back, is how normal Juba has seemed. I really felt like I was able to slot back into the hospital family and it was all quite normal. The first time you go to a place like that everything’s very “Wow – it’s so different!” but given some time living and working there, it normalises. What was interesting going back was that I didn’t really get the initial “Wow!” then normalising process, it was very much like I’d never really been away. I take this as a good thing, as personally I feel that you can get a lot more useful work done when you’re more integrated into the place. But it was a bit odd.

One of the main things I’ve come to realise about the world is how small it is. Basically anyone reading this (with the necessary paperwork and funding) could be in the exact places where I’ve been within a day or two. I find this thought especially helpful when watching on the news or reading about “far away” places in the world. In many ways it’s really not helpful to compartmentalise one’s view of the world as “home” and “far away”, “us” and “them” (although it’s convenient to do this when considering, for example, the implications of our western consumerism/trade justice/environmental impacts of our life-styles.) We’re all much more connected to the wider world than we may think. I’ve been recently been experiencing a quite bizarre blurring of the boundaries separating my own compartmentalising which is how I’ve come to notice it. One part of this was meeting our friend Sarah (Tearfund’s HIV advisor in Southern Sudan) in London the other week. It was great but I’ve only ever seen her in Juba before, so the context was British context different. Even more significant I think was seeing Louis in Southampton.

Dinner at Louis' house in Juba 2008...

Louis is a paediatric registrar in Juba Teaching Hospital and has been a good friend and looked after us very well throughout 2008 and 2009. He’s also been extremely key in getting the Link established and running well. So he’s currently doing a clinical placement in Poole hospital (Poole have a link with Wau, another hospital in Southern Sudan). So I went to visit him with Rachel and he stayed with my parents and I for the weekend and we hung out and went to church together and had Sunday lunch. It was great and all very natural, although slightly surreal to see him being very much a part of my “normal” (i.e. UK) life, as Dave and I had been part of his when we spent an afternoon at his family home in Juba a year ago. It actually had quite a nice cyclical feel to it. I’m struggling slightly to clearly articulate my thoughts on it all – it’s still in the processing phase. Maybe that story’s of some use to you, maybe not.

...Christmas with my parents, Rachel and Louis in Southampton 2009

So anyway, let’s sum up and put this thing to bed until the next adventure. Once again it’s been a remarkable experience and huge privilege to work and live with the Southern Sudanese people. In my thinking at least, I’m a million miles away from any condescending ideas about being some sort of aid worker or ‘white knight’ thinking. I’ve come here done my best to work hard, learnt heaps, helped where I can, and above all made great friends, both Southern Sudanese and ex-pats. I’m sure I’ll be back soon. I hope Matt approves of my thoughts here – had I been more organised then I’d have sent this draft to him for editing, but I’m not. So maybe he’ll leave a comment or write a post-script, we’ll see.... :o) We’ve had a great time together too.

Hope you’ve enjoyed reading. Comments/emails very welcome.

James

PS: For your interest, I’m based back in Southampton for now and doing some formal study in post-graduate medical education, writing up our Juba papers and audtis, working on the Southern Sudan Medical Journal website (to be announced soon) and doing some locum work as well. This will be until I start full-time anaesthetic training in April. I’m also involved in some work for Wessex Deanery related to my time working overseas which is exciting.

Matt’s back in Wales applying for GP training and doing some further study and qualifications in tropical medicine.

My blog will probably be updated periodically but not regularly until the next time I undertake something worth reading about :o)

Bye for now...

Some of our favourite places...
(Click on the image for higher resolution.)
Download Google Earth and go explore the place for yourself!

Homeward Bound

2009-12-08T05:59:00.000-08:00

How many photos have you taken of your home and work recently? Not many I guess. It’s funny we were looking at some of our photos from this trip and noticed that they’ve definitely been tailing off after an initial spurt at the beginning. It’s an interesting observation because I think it’s a sign of our life here normalising. We noticed, in fact, when the St Mary’s team came and it was all cameras again. Photo shoots at lunch time etc. Now obviously this is not a criticism, just an observation. But it would be weird if I was eating lunch during a normal working day in the UK and someone whipped the camera out for a few group shots...

The St Mary's Team

You see I think we’ve moved beyond tourism in Juba sometime ago – weeks or maybe months in fact. And now it’s quite familiar and normal. ‘Home’ in some ways, complete with a whole set of new friends about the place. That’s not to say that we don’t miss home or Juba is perfect, but I guess it’s an insight which should prepare us, as we leave for the UK at the weekend, that leaving is going to be hard and we’ll miss being here considerably. I certainly feel that I miss home and I’m very much looking forward to being at home again with friends and family. But it doesn’t follow that consequently I’m looking forward to leaving here at all. I’m not particularly to be honest – I rather like the place/people. That’s the paradox.

The ICRC War Surgery Conference

Anyway, enough whining. So let’s get down to business. We’re in the end game now and have basically been tying up all our loose ends. A team from St Mary’s have come to join us (now I’m in Juba with two of my old consultants!) to do some obstetric fistula repair work, coordinated by the UNFPA. It’s been really nice to see them all and breaks up the trip for us quite nicely. We’ve been working hard and both feel in urgent need of a break so we’ve been slowing down a little this last week (we still go to the hospital office 7 days a week for one reason or another but still!) so it’s nice to have that overlap. I think there’s been some good contributions the team’s made here which is great.

Fishing on the Nile

We finished up our gunshot research analysis and presented that to the ICRC war surgery/trauma meeting in Juba last week. That was a 3 day affair we attended to learn more about trauma/war surgery with a load of other Southern Sudanese surgeons from across the country. It was quite a nice little break in itself actually. So we presented the research and that seemed to go very well. It was a good time actually, though surprisingly tiring in itself. We’ll have to write the thing up now and hopefully publish it somewhere but that little delight will be awaiting my attention when I get home and need something to fill those long winter evenings...! We still need some missing data ideally. I don’t know if we’ll get it, but I’d consider even coming back to Juba for a long weekend to get it...!

Assembling the Cystoscope

Teaching we’ve been doing as and when. Usually the limiting factor has been administrative/logistical, as is so often the way here. We plan something and then suddenly there’s a meeting or something on the same time. You can’t fight that, you just have to adjust yourself to not let it bother you and have something else up your sleeve to be getting on with. But it’s been good and what we’ve done has been warmly received and feedback has been positive.

Matt and Mr Walsh Reassembling the Cystoscope

On Sunday we went to Kator Cathedral again with Jo from Comboni where he was presiding. It was a really great experience actually. The singing in particular was very beautiful and it seemed a fitting way to spend our last Sunday. Salva Kiir was there again and gave a speech at the end which was fine - how funny that going to church with the president of Southern Sudan, or going for a beer with ministers of health, doesn’t even raise an eyebrow with us now? It’s a strange old life. And also a real highlight was visiting Comboni for the last time in a while. It’s such a great place to be and sitting under the mango and banana trees chatting with Valentino tell stories of Sudan in the 50s in his gruff Italian accent was such a pleasure. It’s such a serene place to be.

Matt and Valentino at Comboni

So I’ll be wrapping this up now. Next blog will either be from Addis airport or an epilogue from the UK I guess. We should be arriving in London on Sunday morning. I hope you’ve been enjoying reading about our adventures.

James & Matthew

PS: Here are a few miscellaneous photos that I couldn't fit anywhere else.

Jasper...

Week 11

2009-11-19T00:57:00.000-08:00

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.

==============

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

2009-11-05T04:56:00.000-08:00

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?

2009-11-02T08:15:00.000-08:00

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

Fire and Food

2009-10-13T08:43:00.000-07:00

So it turns out Hollywood has been lying to us. For years I’ve been lead to believe that a couple of stray bullets here and there, or maybe even taking a speed bump too fast, is enough to make a car explode in a massive fireball. We now have reason to question these assumptions.

Whilst walking to dinner the other night, we found an (empty) car in the middle of the road with flames coming out of the bonnet. (People were around and no one seemed to be injured.) In anticipation of the potential imminent explosion, we scuttled on past to address the more pressing issue of dinner. The hotel where we ate was only a little way down the road and we were sitting outside so we certainly would’ve heard something if it did go off. We essentially sat down, had a drink, ordered food, ate it, had another drink and chat, paid up and walked home. And still not even a pop from the burning vehicle. And this afternoon, on the way to lunch, it was still there roughly intact. Hence the photo.

Tearfund's Compound

Unfortunately for the poor contractors, this incident took place on a road that’s currently being re-surfaced. It’s a process we’ve been watching with interest for a couple of weeks now. It’s a main road, and there’s usually at least a couple of massive juggernauts digging and flattening the earth. The road is blocked off at either end of course, but there’s seemingly a more relaxed attitude to health and safety and related regulations here. Often cars will remove the barriers drive down the work-in-progress nonetheless: “How dare you stop me driving down that road...can’t you see I’m in a Land Cruiser?! Out of the way – I’ll dodge those bulldozers...” So everyday it’s flattened and every night churned up again by traffic. And now there’s a burnt-out wreck there to cap it off! Poor guys.

We had a nice relaxing weekend. On Sunday after having been to church and had lunch at Comboni (and watching Napoleon Dynamite), spent a fine evening (beautiful weather) in Tearfund’s compound playing guitars. We eat there every day so I thought I’d put a photo up or two to show you the place. It’s very relaxing (if the Guinea Fowl are absent, there’s no call-to-prayer, and Jasper’s behaving.)

The particular dinner I mentioned in the second paragraph was a weekly special treat – pizza at the Paradise hotel. (5 mins walk away from our house.) Parma ham and olives. Delicious. That’s our Sunday evening treat of choice. For the sake of completion, I’ll share our other routines:

Breakfast is had in the office before work (where we have our fridge.) This is either weetabix, or bread (bought on the day) with processed cheese or some other (marmite, peanut butter etc.) with instant coffee. The mid-week treat is on Wednesday, when we go for the omelette option, again at Paradise. Their coffee is also excellent which helps.

Lunch revolves between the Sisters’ Kindergarten Restaurant and Central Pub. Both about 10 mins walk from the hospital. Sisters’ sells proper Sudanese food and it’s generally beans and rice. We’re not up to eating one each (big portions) so we share one. That means we eat for $1.5 each. Job done. Central is a Lebanese restaurant and isn’t good for much, except they bake fresh pitta bread throughout the day which is excellent. Combined with a humus dip and green salad, you have the makings of a very refreshing lunch in the heat. Way more expensive though at around $15 each, so we only go for that twice a week.

Friday lunch is another treat. Again, the sisters, but it turns out their chips are superb. I’d be extremely happy to be served chips of that quality in a UK chip shop. Combined with the beans, you have a winner.

(Evenings Mon to Sat we eat dinner at TF for a bargain price of $5 each per night which is very nice.)

So there we are. Hope that clears that up. I’m planning to come up with a more serious and reflective post soon, but we’ve got quite a bit on this week so hope that’s ok.

James & Matt

Week 5 (Boring title)

2009-10-08T08:31:00.000-07:00

Hello all. Week five is here already, hard to believe. My time in Juba continues to provide wonderful insights into a different culture, climate and continent. We are both learning a great deal, seeing things I’ve only read about in textbooks and remain grateful recipients of the kindness and good humour of the people in Juba.

Here follow some events and observations of mine from the past week or so. Those who know me will be all too familiar with my enjoyment in discussing all sorts of random facts and I’m afraid James’ blog gives me ample opportunity to do just that...

A note on language
The most commonly spoken language here is Juban Arabic – quite different from the classical Arabic spoken in the North, with its own vocabulary and pronunciation. Even to the untrained ear it is relatively easy to tell the two apart (even if you can’t understand what’s being said). We are picking up a few words – mostly medical I suppose. Hello is “salaam” thank you is “shukran” and pain is “waja”. As in, “waja-ras” – headache. At times our history taking is reduced to pointing at parts of the body and inquiring “waja?”

Since white folks here are called “kawaja” I certainly hope “ka” isn’t the Arabic for “arse”.

The language of medicine, including patient’s notes and prescriptions is (thankfully for us) English. Most of the staff in the hospital and a few of the patients have a very good command of English which is infinitely useful for us in our daily work.

Along with Arabic there are numerous tribal dialects spoken, reflecting the cultural diversity of this part of Africa. The Dinka, Nuer and Bari languages are spoken by those respective tribes along with many others, sometimes instead of Arabic. One of the medical officers (SHO doctors) revealed the other day that he speaks Arabic, English, Dinka, Nuer, Bari, Spanish (he trained in Cuba) and can even get by in Finnish!

As well as regional dialects, Juba attracts workers and travellers from all over Africa. We’ve seen several Kenyans and Ethiopians in particular with whom we speak English.

Today we witnessed a four way conversation from a Nubian to a Somalian to another Somalian who spoke in Arabic to Dr Andrew (the medical consultant) who kindly explained to James and I exactly what was going on in English! I think all of us, especially one of the Somalians, saw the humour in this somewhat bizarre interchange – especially as it was, rather predictably, about poo.

Sunday Morning

Last Sunday we had the pleasure of a trip to the Juba Cathedral with Father Joe (one of the Comboni priests that Dave and James stayed with last year). We arrived just at the end of the Arabic mass and watched Father Jo lead the English mass to a packed congregation. The cathedral itself is a huge concrete structure and the largest building I’ve yet seen in Juba, with a high arched ceiling, grand tropical hardwood doors and a fine aroma of burning incense.

There were hymns, prayers and bible readings from Father Joe and several members of the public. Also the President of Southern Sudan was present and walked directly past us on his way out!

I particularly liked the part at the end – I think it’s called “sharing the peace” - which is typically Juban I think. Everyone in the cathedral embarks on an attempt to shake hands with their neighbours and each person who is even remotely within reach. A break from what I would think of as the formality or grandiosity of some church services I found it to be quite a touching demonstration of brotherhood and togetherness.

Above all of this I will probably remember the singing the best. The small choir sat in the front row led each of the five or six hymns in beautiful harmony that filled this vast building. With no instruments other than an occasional drum and with no preamble, they launched into perfectly pitched song with effortless timing and impressive volume each time. Having rarely been to church, I have dim memories of half hearted choruses of “Oh come all ye faithful” from early school. This was a world away from that and I would like to see (and hear) a lot more while I am here.

Work
This last week we have been involved in some research regarding caesarean sections in JTH. Each caesar – elective or emergency – is recorded in the operating theatre logbook along with indication for surgery, type of anaesthetic and the baby/ babies’ weight and sex. Dr Murgani (consultant obstetrician and all round lovely man) asked us to look into some of this data last week as the information has been dutifully recorded for some time but not fully analysed.

After a flurry of digital photography of the logbooks, a crash course in Microsoft Excel (for me anyway) and some time and effort we have catalogued the 430 caesarean sections performed at JTH from October 2008 to September 2009. Today we also summarised all non-operative births over the same period – over 3500 in total. Phew. We are currently going through the data and generating a report on indications for surgery, foetal and maternal death rates, anaesthetic used etc to present to the obs and gynae department.

As I’m sure Dave and James alluded to last year on their trip to Juba, opportunities for learning, teaching, research and hopefully being useful often come unlooked for and from unexpected sources.

On last week’s blog
Just wanted to point out that when James said “you might think from the above...” in last week’s entry, I’m fairly sure he wasn’t speaking in reference to the picture of the monkey scratching his bum which, by pure coincidence, was placed directly above. This would be terribly rude and not at all in line with the kind of serious image of ourselves we wish to portray. Hope that clears that up ;o)

Week 4

2009-10-03T09:19:00.000-07:00

So here we are at the end of week four, and I don’t think we’ve been looking forward to a weekend break this much for a while.... Work’s going well but we’re upping our level of responsibility clinically on the Emergency Medical Ward. We’ve tended to employ a rather deliberate strategy of hanging back for the first few weeks whilst we observe and figure out the place (and the pathology) but now our role is naturally growing and evolving (certainly in terms of pure clinical service-provision for the hospital) rather well.

On Thursday, for example, for some reason there were no doctors on the ward, so we did the whole round ourselves with nurse translators. This went pretty well, and I think was an important milestone. Still, it was about 50 patients and took all day. Language slows things down, and on average people are far sicker than in the UK, and they take time. However it’s nice to feel useful and just do pure doctor stuff. These days we’re very familiar with managing malaria, typhoid and acute diarrhoeas these days which is most of the tropical medicine we see routinely. There’s actually far more interesting medicine here if you look for it - much is more familiar territory... Diabetes, GI bleeds, strokes, cardiac arrhythmias, heart failure, liver failure, renal failure, anaemias of varying causes, epilepsy, chest infections, meningitis, asthma, deliberate self-harm (overdose), cancers...even “collapse ?cause” :o)

It’s a challenging environment to work in though; physically, it’s hot, humid and sweaty (and often a little smelly) on the ward. Clinically it’s challenging not only to know what correct management is or should be, but also a whole other level of clinical problem-solving comes into play i.e. what can be done with the limited resources we have here? (This of course applies to investigations as well as treatment.) Emotionally, it can be draining to handle the incongruence between those two particularly when most days people young people die of acute diseases who almost certainly wouldn’t have in the UK.

You may think from the above that it’s a struggle to get up to go to work in the morning, but you’d be wrong. There’s a really special sense of teamwork (not to mention humour) here amongst doctors and nurses, not to mention the satisfaction derived from patients that are successfully treated here – and that’s the majority. I’ve seen young folks literally comatose (GCS 3) from cerebral malaria one day and walking and talking the next. Quinine may well be my favourite drug. I said it was challenging, which it is, but probably more rewarding for that. It’s no holiday, sure, but who really cares?

Having said the above, it’s important to have a bit of emotional insight and get some good relaxing in too. Fortunately Matt and I share many of the same relaxation pursuits. (Many is the evening discussion we’ve had along the lines of “Those Orcs aren’t going to slaughter themselves...” :o) And there’s healthy amounts of guitar playing and film watching and coffee drinking and pizza eating all happening. So it’s good.

Personally, I’m continuing my experimentation with Catholicism and spending a lot of my Sundays hanging out with my Comboni chums from last year. Last Sunday we went over the river to a new monastery-type outfit that had just been built for its official opening by the Bishop. The Mass was really fun actually, lots of great African singing and dancing. The children in particular made me smile an awful lot. The chap at the door mistook me at first for a priest and tried to seat me on the stage (a little embarrassing as none of the other Priests had come in yet and I would’ve been on my own) but luckily the Comboni Sisters (nuns) were all sitting in the front block and understood my dilemma (with much amusement I may add) and let me sit with all the ladies. It was all in good humour though so no problems. All followed by a delicious Sudanese lunch. So that was that. I’m going to the cathedral tomorrow so that’ll also be an adventure.

Two final notes:

Firstly, one of the stray hospital dogs has adopted us and follows us everywhere now. We don’t know why and certainly haven’t encouraged it in anyway. We try and kick it away but neither of us really has the heart to actually harm any animal particularly, particularly one so mournful looking. (The attempted kick becomes reminiscent of The Simpsons’ Mr Burns’ “I’m giving you the thrashing of a lifetime...!”) I found that a splashing of cold water quite effective, but then we saw it getting all picked on by another stray pack and felt bizarrely sorry for the wretched beast. We’ll see what happens.

Secondly, at breakfast the other day we beheld a man using a modified bicycle to drive a grindstone to sharpen blades. Personally I thought it was one of the most awesome things I’ve seen for a while, so we had to take a photo. It reminded me so strongly of something one would find in the back garden/work-yard of Kitchener Road that I felt a bizarre sense of kindred. Anyway, there it is.

Thanks. Bye for now.

James & Matt

PS Also check out this huge beetle I found.

Saving Lives...

2009-09-24T09:41:00.000-07:00

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

2009-09-22T10:31:00.000-07:00

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

2009-09-19T06:56:00.000-07:00

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

If you care...

:o)

Second Week Stuff

2009-09-17T09:00:00.000-07:00

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...

2009-09-13T09:43:00.000-07:00

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

2009-09-12T08:11:00.001-07:00

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

There and back again

2008-12-14T06:13:00.000-08:00

It will be strange working in a hospital without goats roaming free...

It is 8.10 pm in Addis Ababa Airport and we are waiting for our flight to England which leaves at 00.25 am. In twelve hours time, we will land in London Heathrow and this whole tale will seem like a dream. Already our old lives in Juba seem to be shrinking into the shadows as we dwell in the limbo that is Addis. It is now time to write the epilogue of this most glorious little adventure.

Some of our EMW nurses with new uniforms plus Sister Anna

On Friday myself and James did the last clinical work we would do in JTH. Rather fittingly it ended when one of our nurses alerted me to a sick patient who was really sick - they had to go urgently for an operation for necrotising pancreatitis. The rest of the day was spent doing a formal handover to the folk at JTH. They will have a busy life ahead of them instituting triage, setting up structured medical teaching, continuing nurses training and continuing with the restructuring of the acute care services. However, from working with these people I have faith that they will do it- they are wise beyond their years and hard-working.

Part of Dario's House. It was a beautiful summer's evening

That evening the Hospital Director, Dario, invited us to his house along with all of our friends in JTH to say goodbye to us. About 30 people were present and Dario’s family laid on a fine feast with wine in the aftermath. Although Dario lived in Juba city, it felt more like we were in a close-knit village. There were about 25 people living in 6 tookalls (the huts they live in) within a fenced compound, all of whom were Dario’s relatives. The courtyard was everyone’s “lounge” with tables and seats outside. They all take their meals together, chat together and the kids play together. It was a really lovely, friendly set up, which made for a relaxing experience. A perfect end for us, marred only by the rancidity of having to say goodbye to all of our close friends. James summarised the event quite poetically, “I am glad saying goodbye has been so hard. It is a sign that we have made some strong, true friendships. It's a price worth paying.”

Hanging out with some of the JTH crew at Dario's

The next round of goodbyes came when we had to bid a fond farewell to the Comboni’s. Valentino gave us a big hug and they all said that we would be welcome back any time.

As I sit here in the internet cafe in Addis, I cannot help but reflect on the times I have had with these people and all the smiling and hand-shaking that went with them. The trust and friendship that we had traversed our cultures and brought us closer.

We had some awesome conversations that I would never have in the UK. The most memorable one had to be with the Ward Sister of the Emergency Medical Ward, Anna, when I jokingly told her she had the memory of a goldfish:

“What is a goldfish?”
“It is a small orange fish that we keep in a tank.”
“Do you eat them?”
“No!” I laughed
“Well what do you do?”
“We watch them swimming.”
“Why?”
“Because it’s what we do. It’s fun.”
“How can this be fun?”

I realised how stupid the whole thing must have seemed to her and when I thought about it, it is. It’s little things like this that make you chuckle.

Oddly enough, it is being here with these people, immersing yourself in their way of life that makes you realise some of the imperfections in our own society. Allow me to elaborate.
I spoke to Martin, the Obs and Gynae Consultant about English Society. “Do you speak to strangers when you wait at a bus stop, Martin?” “All the time.” He answered.“At home,” I continued, “We do not speak to strangers. If I was to speak to a stranger, the first thing that would go through their mind is ‘What does he want?’”

James and I have often talked with the Comboni’s and we find it interesting that we started out as Westerners thinking that African society was not as good as Western Society. Many people want to “help” Africa by making it more Westernised. Although in some respects this is good, is it all good? Probably not when you consider that 25% of the British population have been registered as depressed at some point in their lives.

I believe that all of us, whether we be African or English, have profited emotionally and spiritually from this experience. For us, we have developed a new found humility and respect for Southern Sudanese values and their way of life. These guys know what they want and they will achieve their goals irrespective of the St Mary’s Juba Link, NOT because of it. However, they really appreciate the helping hand.

Anna and Magdy often said that they were guilty of not thinking ahead and this is true. I often used to say to them that the only thing I would want to export from my culture was a sense of planning ahead - here people wait until something runs out before they replenish stock, which causes a truck load of chaos. I think this has been exported, our drugs cupboards have never run out of supplies.

However, there is something that I am going to import from these people - their humility and gratitude for the good things (such as oxygen that flows out of the walls of hospitals, drinking water from a tap etc.), their kindness and hospitality to strangers, and their sense of family and community. Our anonymous and fragmented society, hopelessly lost in the relentless worship of consumerism, would do well to learn from them.

Dave and James

PS: We both got back safely to the UK. It's going to be tough for us both I think to readjust. If you've enjoyed following our journey then do comment on the blog or email us. We'd appreciate it.

Performance = (Knowledge x Motivation) / Obstacles

2008-12-11T12:21:00.001-08:00

“Look to the east, on the morning of the fifth day” Gandalf said to Aragorn. Aragorn was to go on and assist commanding the defence of Helm’s Deep whilst Gandalf went off in search of Eomer’s army to relieve the defenders from the evil armies of Isengard. This ended the battle of Helm’s Deep but the battle for Middle Earth was far from over.

One of the Nurses expressing her thanks for the training

Today the armies of Isengard, represented in Juba as the evil forces of apathy, hopelessness and low self esteem were delivered a long overdue, crushing blow. We have often talked about the plight of the nurses, the down-trodden profession of Southern Sudan. Their self-esteem is low, morale is non-existent and their pay amounts to £50 a month, which is hopelessly inadequate to feed a family of 6 or 7. The only way out for these people is promotion and this comes from training and good patient care. As a result their thirst for knowledge is insatiable.

Dr Dario adressing the audience.
With him is Jo who was covering the event for the news

You will also recall that we have helped develop the New Medical Emergency Ward, staffed by nurses that we had trained and had volunteered to work in the ward. It’s much busier than all the other wards, and they weren’t expecting anything in return. On November the 13th the ward opened. We had well trained nurses. We had the life-saving medicines and equipment. The question was “could they deliver good patient care?”

Dr Yatta, Director General for Curative Services, MOH/GOSS

To answer this question, we compared the mortality levels in July with the levels since our ward opened and the results are, quite simply, breath-taking. The mortality reduction was immediate and absolute. Although the number of admissions had actually increased since the wet season, we measured a 40% reduction in 24 hour mortality and a relative reduction of 18% in overall medical mortality (For the medical folk amongst you absolute difference is 1% hence our NNT is 100). We had shown that these nurses had delivered staggering patient care and had training. The stage was now set for the grand finale - the empowering of the nursing profession - in short a massive reward.

We asked the senior medical and nursing staff in JTH about the best way, culturally, to employ these nurses as an example to motivate and empower others. The glorious thing about the people here is they know exactly what gets their people excited. A few high level meetings were held, a modicum of strings were pulled, and the results, you see below:

Nurses (and indeed everyone) here love ceremonies. So the JTH staff held a ceremony for the 120 nurses who graduated in the courses we had ran over our stay here. Present at the ceremony were two key players in the Ministry of Health, Janet Michael (Director General of Midwifery and Nursing) and Dr Yatta Lugor (Director General of Curative Services - i.e. secondary care).

There was lots of singing and dancing as well which was thoroughly enjoyable

During the ceremony, the Medical Emergency Ward received modern, new, blue uniforms to replace the old 1950’s white uniforms that they usually sport. But life just kept getting sweeter. Following a personal recommendation from our Hospital Director, Janet and Yatta vowed to promote all of the Emergency Medical Ward nurses.

Janet Micheal, Director General for Nursing and Midwifery, MOH GOSS

“I want to send one clear message to all my nurses.” Janet said. “There is only one way to get more money and that is through promotion. This comes from training and through good patient care.” She had empowered the nursing profession by offering them hope and a way out of poverty. Furthermore, the uniforms that our Emergency Medical Ward nurses wear will serve as a constant testimony to all nurses that if you work hard, there will always be a reward. This is some powerful motivation, which is vital in the long term strategy for capacity building. And who better to build Southern Sudan’s capacity than it’s own people?

At the end of the ceremony, we were surprised and very touched when we received three sets of presents from three parties, the Juba Core Team, the Ward Sisters and the nurses on the Medical Emergency Ward, who had all clubbed together.

The greatest present, however, was a wooden plaque in the shape of Sudan that read:

"The entire community of JTH will always remember you and miss you. Thank you for the services you offered in Juba Teaching Hospital. We wish you all the best in your profession and your service to God's people."

It is gifts such as these that are the most generous and greatest gifts of all because these are the gifts that people have given up their time to make. In a land where days off are still a luxury, the time and efforted invested in hand-crafting this is, quite simply, priceless. and we were rendered speechless (and a little tearful, I may add) with gratitude. We know the people here very well and even after four months, they will still surprise and amaze us.

Tomorrow we are going to Dario's house for our leaving party. He has promised to slaughter us a goat...

...the next time we write will be from Addis on our way home.

D & J

Endings

2008-12-08T10:09:00.001-08:00

I’m sorry we haven’t written much for a few days; life is tremendously busy for us at the moment. A well written story has a strong beginning, middle and end, and we feel it’s important to arrange a good strong ‘ending’ to our work here, which has been occupying a lot of our thoughts and activities for the past couple of weeks.

Dave teaching our nurses the finer points of the glucometer

The Emergency Medical Ward continues to be a success – the doctors and nurses are very happy with it. In a world of evidence based medicine and clinical governance, we need more than anecdotal evidence however, and we’ve been involved in both clinical audit and research into mortality rates and distribution to prove its efficacy. The results from both are very encouraging and we’re arranging a final big presentation for the hospital and the Ministry of Health to present the results. This will also be combined with a big public reward ceremony in JTH for the nurses we’ve trained to acknowledge and commend them for their dedication and hard work. They are the real heroes and it’s largely been the nursing staff (with a little training and guidance from us) that are responsible for the improvements. Nursing here has traditionally been a profession which is rather downtrodden, and so it’s important to actively continue to take steps to change that culture.

Louis' family and house

Louis & Dario: two key players in JTH. (Dario's our boss)

One of the greatest privileges we had during our time in Juba has been the opportunity to get to know and forge real friendships with the Southern Sudanese doctors and nurses we’ve been working with. They really don’t see us as outsiders anymore. The folks here are always very polite to foreigners, especially ‘kawajas’ (white people) but beneath this there are some very definite suspicions of their motives. (And in some cases rightly so...)

Louis and Baby Danga. A proud father.

William, the hospital administrator. William's a huge Sudanese man who has a handshake that could break your wrist, but a big heart.
He also has 4 wives and 21 children!

On Sunday afternoon we were invited to Dr Louis’ (Paediatric Registrar) house to eat with him and meet his family. It was wonderful to share in his hospitality. We had a great time actually. I think we would both agree that it was far better to eat there in his home than a pizza in an air-conditioned restaurant full of kawajas. Dave and I have also recently been enjoying our after-work beers in an African ‘local’ pub rather than the posher hotels for the similar reasons. For one thing, it’s cheaper(!) and for another, what’s the point of coming to Africa and spending as much of your free time as possible trying recreate the western world you’ve just left? Peer support and relaxation is important in often demanding circumstances, but I think it’s also easy to get too sucked into that world.

Some of the key players in Comboni.

We’ve learnt a lot of this philosophy from (other than Bruce Parry) the examples we see in the Comboni Missionaries we live with. We have the utmost respect for their unrelenting identification with and love of the people here. They didn’t even leave Sudan during the civil war. “Well the Sudanese people can’t leave for safety so why should we? It wouldn’t be right!” Brother Valentino once told me in the context of a story about how their village was being shelled. Incredible.

Jubalicious...

Endings

2008-12-08T10:09:00.000-08:00

Dave teaching our nurses the finer points of the glucometer

Louis' family and house

Louis & Dario: two key players in JTH. (Dario's our boss)

Louis and Baby Danga. A proud father.

William, the hospital administrator. William's a huge Sudanese man who has a handshake that could break your wrist, but a big heart.
He also has 4 wives and 21 children!

Some of the key players in Comboni.

Jubalicious...

The UN, Statistics, and School Children

2008-11-27T09:37:00.001-08:00

Hi there.

We can hardly believe that we’ve only got a couple of weeks left in Juba. I think we both have very mixed feelings about this. There’s a tension of not wanting to leave the people and the work we’re doing, but also missing home. It’ll be good to be back with family and friends for Christmas, but on the downside we haven’t had a day below 30 degrees* C for the past 4 months so we’re anticipating absolutely freezing back in the home-land.

*(can't do superscript in blogger)

It's pure coincidence I appear to be wearing the school uniform...

Yesterday we had the hilarious experience of being mobbed (in a nice way) by a group of school children on our walk into work. It was too good a photo opportunity to miss, which of course excited them further, so I’m sure their teacher wasn’t too pleased that morning. It’s funny how even at this stage amongst all the bad stuff we see this place can still surprise you completely out of the blue and bring a smile to your face.

Right – down to business. The Emergency Medical Ward is continuing to go very well. The nursing staff are just great (great fun and also great at nursing) which makes it a real pleasure to work on. The morning team of nurses actually volountarily stayed for a couple of hours after their shift this afternoon (for no extra money) because we'd had a busy morning with some sick patients and they wanted to make sure as much of their work was wrapped up as possible so the afternoon team didn't get lumped with it. I've never seen that in the UK. Also the junior doctors are unanimously in favour of the system, and the consultants are also very impressed. Sustainability is the name of the game at this stage, and we’re making good in-roads into this as well.

These visitors had banners which we never had. Oh well.

There's been a delegation of consultant surgeons, anaesthetists and nurses come over from Saudi Arabia here for the past week working and teaching in the hospital. It's been quite an insightful experience actually watching 'Juba newbies' come in and do similar things to what our link is doing. By all accounts they've been doing a good job.

We’re keeping a very close eye on mortality rates in the department, and at this juncture they are looking quite good. I think one of the things we feared was that we could cut down 24 hour mortality on our ward, but it would all shift to day 2 when they were transferred. However, this is just not happening at all, which vindicates our repeated emphasis that early recognition and intervention really does have a better overall outcome.

Ward shot. Notice the Oxygen concentrator we have full time now. Very important.

Patients are still dying on our ward of course (and we’re keeping a detailed log of who and why) but the key thing for us as doctors is that we know in good conscience that they probably would have died in a UK hospital. This is mainly down to the late presentation issue, which is somewhat outside of our influence. In other words, we’re (and by’ we’ I mean the whole team on the ward) are doing everything possible for them. Mortality in the department of medicine is hovering around 4% at present, from over 5% in July. This may not seem much, but it means that the new ward system is saving 1 life every 100 admissions, which is roughly every 4 days. (ie. the number needed to treat is 100 for those statistically minded.) It’s still early days but I know that anecdotally I’ve seen the nursing staff save the life of patients who would have otherwise died. It would be the icing on the cake (in a world of evidence based medicine) to demonstrate it formally, but we’ll see.

John Holmes shaking hands with Dr Magdi, the lead Consultant Physician in emergency medicine.

The UN arranged a flying visit by John Holmes, one of their top officials this afternoon who was looking into the state of healthcare in the Southern Sudan. He was only here for a day I think which was why he couldn’t get out into the rural areas where things are much more dire, so he came to the hospital here instead. The Jubans of course were only too delighted to proudly show the whole entourage round which included (unexpectedly I may add) a trip to our new emergency ward. Luckily it was tidy... The Minister of Health came visiting the other day (see photo in an earlier post) and was generally pleased with the clinical care, but thought that the place was looking a bit dirty and wanted more bed sheets etc. So we’ve been working on making the place look a bit prettier recently (blue sheets for the male bay and pink for the female no less!) which was convenient for this visit. Apparently he said to Dario afterwards that "Juba Teaching Hospital is one of the best hospitals in the developing world I've seen." High praise indeed.

Gratuitous cute photo from one of my favourite wards.
It's getting into mango season now as you can see.

OK, that will do for now.

Jem-ez & Daff-eed

The UN, Statistics, and School Children

2008-11-27T09:37:00.000-08:00

It's pure coincidence I appear to be wearing the school uniform...

These visitors had banners which we never had. Oh well.

Ward shot. Notice the Oxygen concentrator we have full time now. Very important.

John Holmes shaking hands with Dr Magdi, the lead Consultant Physician in emergency medicine.

Gratuitous cute photo from one of my favourite wards.
It's getting into mango season now as you can see.

OK, that will do for now.

Jem-ez & Daff-eed

For the people we leave behind

2008-11-24T09:17:00.001-08:00

Hello everyone. I have been spending much time talking about our endeavours in JTH. It is true to say that the work of the St Mary’s Juba Link has had a huge impact in JTH. However, none of this work would be possible were it not for the kind efforts of our friends back in the UK. So for the friends and family members we leave behind, this blog post is for you.

The St Mary’s Core Team have been working hard on the Isle to set up the St Mary’s Juba Link Bikeathon. The event took place last week and below is a glorious photo of the UK’s only Southern Sudanese Consultant on his bike:

Dr Hakim, Consultant and Medical Adviser to the St Mary's Juba Link

Continuing the biking theme in London, one of my good friends Richard (Edward Wilson Kattan has decided to “grab life by the bars” by growing his very own handlebar moustache for the entire month of November (aka Movember). This is Richard with his clean shaven baby face on November 1st:

Clean-shaven Richard

And this is Richard 3 weeks into his glorious facial hair growing extravanganza:

Richard "Hell's Angel" Kattan

Our blog will continue to update you of Richard's facial hair growing antics. Curently he has raised over £300 for the St Mary's Juba Link by ritualistically humiliating himself for one month. So if you feel like donating some money to this man for our benefit then please visit:

http://www.justgiving.com/richardkattansmovembermission

Dan (left) and Tom (right) taking a rest before cycling up another rancidly steep slope

Back in September some other good friends of mine, Sophie Quarterman, Dan Westlake and Tom Kenyan, decided to cycle the South Downs Way. for the St Mary's Juba Link They cycled solidly for two days covering 75 miles on the lumbering slopes. "Doing this was the hardest thing I have ever done for charity," Sophie said. "There were 20 miles of slopes that were too steep to cycle up and too steep to cycle down."

Sophie and Tom relaxing after the South Down's Way

A special mention should also go to Dan “The Man” Westlake who managed to do this herculean distance on a BMX!

Some of the beaut views on the South Downs Way. Dan's BMX is in the foreground

We would also like to thank everyone for their countless emails of encouragement and words of advice and support. In the days when smiling is difficult, a small email can make a huge difference.

So to my friends who have been supporting our efforts, I extend my thanks. Access to healthcare is the most basic of human rights and in a land recovering from 40 years of civil war, in a land where only 25% of the population have access to healthcare, the need to train healthcare professionals has never been more immediate and dire. Your kind words and novel approaches to fund-raising make us smile, keep us motivated, and will ultimately transform the healthcare given at JTH.

See you all soon,

David

For the people we leave behind

2008-11-24T09:17:00.000-08:00

Dr Hakim, Consultant and Medical Adviser to the St Mary's Juba Link

Clean-shaven Richard

And this is Richard 3 weeks into his glorious facial hair growing extravanganza:

Richard "Hell's Angel" Kattan

http://www.justgiving.com/richardkattansmovembermission

Dan (left) and Tom (right) taking a rest before cycling up another rancidly steep slope

Sophie and Tom relaxing after the South Down's Way

A special mention should also go to Dan “The Man” Westlake who managed to do this herculean distance on a BMX!

Some of the beaut views on the South Downs Way. Dan's BMX is in the foreground

Life

2008-11-23T10:44:00.001-08:00

In a UK hospital, when a young patient dies, it is a huge deal. The general public do not realise how hard hospital staff fight to keep their patients alive. Sometimes, despite our best efforts, the illness claims our patients life. We then have to tell the patients relatives the bad news and they leave, crying. However, for the hospital staff that lose the battle, it is also devastating- a sombre air descends on the whole department as each person inwardly reflects on what happened and how unfair life can seem.

In the Southern Sudan life is cheap. Young patients die on our wards with an uncomfortable regularity and the staff seem detached and apathetic to it all. I am not surprised - after a war spanning three generations, where over 2 million people died and horrific atrocities were committed, hope remains a distant dream.

However, on Saturday, something special happened on our Emergency Ward. I was summoned by the nurses to assess a patient who was obviously very sick and we turned his bed into a high dependency bed. He received monitoring, suction, and oxygen. There were lines and tubes coming out from all parts of his body. I summoned my seniors. For two hours, myself, another SHO, a Consultant and two nurses fought desperately for the life of this 21 year old man. However, despite our best efforts, we were losing the battle.

One by one, his organs were shutting down. His kidneys were the first to go. His digestive system was next- we passed an tube into his stomach and blood was aspirated. Whilst trying to solve these problems, we noted the electrical readout to his heart was changing, a worrying sign that there was inflammation of the heart. His blood pressure then plummeted and his heart slowed. I looked at my Consultant and he shook his head. The family, who had been present throughout this, knew that there was nothing that could be done.

H.E The Minister of Health came on a visit to the ward last week

Our 21 year old patient died at 3.05 pm. I looked around at the nurses faces and in their eyes I beheld something that I had not seen since I started at JTH - they were devastated that a life had been lost. “Well done everybody.” I said. “We all did our very best. There is nothing further that we could have done. He would not have lived even if he was in the UK.”

In our ward, life has become precious.

David

Life

2008-11-23T10:44:00.000-08:00

H.E The Minister of Health came on a visit to the ward last week

Quick Follow-up

2008-11-18T09:54:00.001-08:00

Very quick post:

1) The lady we transfused is alive and sporting some much more stable vital signs

2) A man who was admitted yesterday peri-arrest (with oxygen saturations of 67%) was sat up joking with his relatives this morning after receiving good supportive care

So it's nice to see some of the fruits of our labours. Nursing morale is also very high on the Emergency Ward as they are increasingly being recognised by all in the hospital as being very professionally competent and also from the satisfaction of seeing patients turn around as a result of the basic resuscitative measures they're practicing.

It's still hard work but things are going pretty well.

James & Dave

Quick Follow-up

2008-11-18T09:54:00.000-08:00

More Emergency Anecdotes

2008-11-17T12:35:00.001-08:00

Dr Magdi (Consultant Physician) and Sister Anna on Emergency Medical Ward

Hello again everyone.

Much has happened in the four days since the creation of the medical emergency ward and I thought it was about time to update you all. You will recall I predicted bedlam. My prediction was correct - the first four days have witnessed the chaotic birth pangs of a new system in evolution. Here are some highlights:

Friday: Day 2 of the Emergency Ward
Why Bed Managers Are Important

At 8 am I walked into a ward that was simply heaving. I have never seen anything like it- the patients were two to a bed, there were patients outside, patients on the floor, and in the corridors. The first order of the day was to move all relatives outside so that we could see who the patients were. Then we spent the morning with all nurses transferring patients.

At 10 am the male patients we were transferring started arriving back because there were no male beds (the wards are male medical or female medical). In fact there are about 70 female medical beds and 22 male medical beds. This problem was finally ironed out today when Matron Susan (the Head of Nursing, a good friend, a powerful ally and a Pastor for the Catholic Church) re-designated some of the wards.

Saturday: Day 3 of the Emergency Ward
The Nurses Show Their Worth

At 11 am I was dealing with a very unwell patient and saw the nurses taking the suction machine out of the Emergency Cupboard (for you non-medics this is not a good sign - it means there is a sick patient lurking on the wards).

At 11.05 am I was asked to see a patient by the nurses. The patient was unconscious and without any help they had done a full ABCDE assessment on the patient, which included:

1) Sucking secretions from the airway
2) Measuring observations (temp, respiratory rate, pulse, BP and conscious level)
3) Inserting a cannula and starting a drip
4) Taking basic bloods to the labs
5) Diagnosing low blood glucose levels

I want you to appreciate the magnitude of this in Juba Teaching Hospital. Three months ago, nurses couldn’t do ABCDE and were deemed too stupid to do observations. Three days ago, the nurses wouldn’t have had any life-saving equipment on the ward to help them. Today I walked in whilst they were giving the glucose to the patient and my heart melted as the patient woke up. Six hours later the patient was discharged. Four days ago that same patient would probably have died.

Sunday:

I took my first day off in four weeks

Monday:

Day 5 of the Emergency Ward- the birth of the “High Care Bed.”
We had a patient admitted who was horribly, horribly ill (to the medical folk out there, she was severely malnourished, septic and febrile, oedematous and had a BP of 50/23 with a Haemoglobin of 24g/L- and no this is not a misprint, it was actually 24g/L). However, our ward had a few tricks up it’s sleeve:

1) She received 1-2-1 nursing with 20 minutes observations, including hourly urines
2) She became the first patient to receive pulse oximetry and non-invasive automated BP monitoring on our funky monitor (and the first patient in a ward to receive this)
3) She had oxygen! (Nasal cannulae only but it’s a start)
4) Her family were too poor to buy any medical treatments so we opened the emergency drugs cabinet and gave her drugs that our hospital had run out of
5) We gave her some blood to increase her haemoglobin levels

This means that our “High Care Bed” was functioning almost to the standard of an ordinary UK hospital bed.

Now blood is in very short supply out here - if you need it the relatives have to donate it. The only person she had was her husband and a 12 year old granddaughter. So, as a doctor my duty of care went a little bit further:

Thanks to the screening, I also learned that I do not have malaria, hepatitis B or C, syphilis or HIV. When I left her, she had received the first pint of blood and had two units waiting for her. She seemed to be turning a corner- certainly the vital signs were looking better. The technician had a bit of trouble siting the (large) blood taking needle but luckily James was on hand and only too glad to ram it home, so all was good. Bearing in mind the important “3-1 rule” of replacing blood loss with fluids, we went to the pub on the way home to round things off.

So it’s all fun here in Juba!

David & James

PS:
In an unrelated note, this little monstrosity is what is often seen around the hospital cutting the grass. In a land where we've often witnessed car wheels come flying off their axels down the road, you can understand why being anywhere near one of these little bad boys in action makes us very nervous...

James

More Emergency Anecdotes

2008-11-17T12:35:00.000-08:00

Dr Magdi (Consultant Physician) and Sister Anna on Emergency Medical Ward

Friday: Day 2 of the Emergency Ward
Why Bed Managers Are Important

Saturday: Day 3 of the Emergency Ward
The Nurses Show Their Worth

Sunday:

I took my first day off in four weeks

Monday:

Progress

2008-11-13T10:17:00.001-08:00

James has never been a fan of inserting exclamation marks into blog posts and I agree with this approach. However the next sentence warrants three...

After 8 weeks of preparation, training, enlisting support, and a few courtesy steps backwards, we have done it:

The new emergency ward is up and running!!!

We have a dream team of nurses and they seem to be loving it. The work is hard but one of them said to me today "I do not mind hard work if we are making a difference."

James ducked out of surgery today to help in medicine

The impact has been immediate and absolute. In the past, there would have been no in-ward medical cover from the time the patient was admitted until the next day. The mortality figures amply demonstrated this with >50% of all medical mortalities occurring during this time.

Now there is medical cover and most importantly, nurses trained in the basics of acute care. Today was a first for many things:
1) The first time an emergency cupboard was opened to save a patients life
2) The first time a ward performed obs on all patient admissions
3) The first time a prescription chart, fluid chart, observation chart and acute care pathway were used
4) The first time that the doctors and nurses were working together as a team

Today was another first for me- it was the first time I saved an asthmatic patients life with the power of creative thought. We had a very unwell asthmatic (who was also very dehydrated and had a chest infection) brought in today. We had no medicine for this at JTH so I sent his grandson who was only about 10 to the Pharmacy to buy some asthma medicines (I needed 3) and some antibiotics. He had spent what little money he had- he could only afford a salbutamol inhaler and the antibiotic. He looked at me with tears in his eyes.

An idea dawned. A salbutamol inhaler can be made more effective if you attach something called a "spacer" which a well made static-free container (we don't have these either). In fact it is as good as a machine that we use in the UK for our severe asthmatics (called a nebuliser). So I took a large mineral water bottle, cut out a hole in the bottom and covered it with tape. Then I made a smaller hole in the tape and put the inhaler in that end. I got the patient to put their mouth at the other end and breath. After 10 puffs on this, 3 litres of fluid and some antibiotics, there was a massive improvement. This chap would have almost certainly died if it was not for this new ward.

The improvised salbutamol spacer

At 5 pm, one of the patients relatives came to me. "Khwaja (means white man), I want to thank you for the work you are doing. That child was crying because he thought his grandfather would die. I have just left the man- he is sat up and talking to my husband."

The nurses were amazing. They seemed to be enjoying themselves and (with the exception of a few minor hiccups) they slotted into the new system like a glove. The day was much less chaotic than I anticipated and I left at 6pm physically exhausted but mentally exhilarated. I am certain that two people would have needlessly died today if it was not for the nurses and the New Emergency Ward. However, anecdotal evidence in Medicine is of no value, which is why we are going to monitor all deaths and see if there is a noticeable reduction.

See you all soon,

David

Progress

2008-11-13T10:17:00.000-08:00

James has never been a fan of inserting exclamation marks into blog posts and I agree with this approach. However the next sentence warrants three...

After 8 weeks of preparation, training, enlisting support, and a few courtesy steps backwards, we have done it:

The new emergency ward is up and running!!!

We have a dream team of nurses and they seem to be loving it. The work is hard but one of them said to me today "I do not mind hard work if we are making a difference."

James ducked out of surgery today to help in medicine

The improvised salbutamol spacer

Emergency Medical Unit

2008-11-12T09:23:00.001-08:00

The enthusiasic new EMU staff

Two steps back...

“Your teaching has been cancelled today,” said William the Director of Admin and Finance “ We have an Indian delegation arriving with the Undersecretary for the Ministry of Health.” We are very good friends and he didn’t mean it to sound rude. It’s just he doesn’t speak English very well so it comes out rather brusquely.

I had planned this teaching for three weeks and it was designed specifically for nurses who would be working in the Emergency Ward. However, in Africa you have to adapt. We moved the teaching to the next day and moved back the opening of the ward. It now opens on Thursday (assuming there are no further delegations.)

...and one priceless step forward

Today, however, we took the necessary step forward. They learnt the principles and delivery of oxygen, how to write in prescription charts, how to write in fluid charts, and how to work medical machinery like nebulisers and suction machines. What they loved most was a special present I saved for them- a monitor that shows oxygen concentration in the blood (oxygen saturations), pulse, and blood pressure. All they had to do was press a button and the blood pressure cuff inflates and deflates automatically and gives you a reading.

Dr Magdi, Lead Consultant in Emergency Medicine demonstrating and teaching the monitor

We have 8 of these monitors and they are in storage because no trained in their operation. Today was:

The first time this was brought out of its (rather dusty) box
The first time certificate nurses in JTH were trained in its use

And they absolutely loved it! They were amazed that it cost $6,000 and were more amazed that one of the adaptors alone cost $400. For me, I see these things on the wards in NHS hospitals all the times. The ability to measure the concentration of oxygen in your blood (and indeed have oxygen therapy to give at every bed) is second nature in our hospitals. I found myself thinking fondly of the NHS, then feeling gutted that these people had so little to work with when we have so much, then thinking “Stop thinking useless thoughts and do something productive like training these nurses. Come on boy!” This cycle all took place within 10 seconds.

The day was a good one. They were all excited about being the first nurses to work in a ward with basic life-saving equipment and medicines (something completely taken for granted in the UK). However, today I saw something else. They were actually proud of themselves. In a land where nursing is the most downtrodden profession and the nurses self-esteem esteem is low, seeing this was a priceless experience.

The ward opens on Thursday - I shall keep you informed but my prediction is one of chaos that turns to order as the dust settles over the first week. The long term strategy for acute care is very much a step-wise one. We're aiming to get medicine running first, and then the model can be rolled out to Paeds and the other specialities. It's tempting to do try and do everything at once (particularly as time is running short) but we feel the wisest thing is to just get a small(ish) thing right first and then leave the Jubans with the tools to press ahead with the rest.

Ta for now,

David & James

Emergency Medical Unit

2008-11-12T09:23:00.000-08:00

The enthusiasic new EMU staff

Two steps back...

...and one priceless step forward

Dr Magdi, Lead Consultant in Emergency Medicine demonstrating and teaching the monitor

We have 8 of these monitors and they are in storage because no trained in their operation. Today was:

The first time this was brought out of its (rather dusty) box
The first time certificate nurses in JTH were trained in its use

Ta for now,

David & James

Acute Care

2008-11-10T12:04:00.001-08:00

Hello

I justed wanted mention a few points of progress regarding the improvement of acute care services in Juba. There's been some good consequences from my presentation to the Ministry of Health at GOSSHA2 (see previous blog entry) recently. Amongst other things, we clearly demonstrated in a mortality distribution study that 60% of inpatient mortalities (and 70% of paediatric mortalities) in JTH occur within the first 24 hours of admission. We concluded from this that in order to reduce hospital mortality, attention would be best spent on improving the acute care delivery services.

What's been really great is that people are actually taking this seriously. Dr Dario (my Consultant and Director General of JTH) has created a new permanent post in Juba: Director of Emergency Services, and appointed Dr Thomas to the task to coordinate it all. This is really encouraging and improving acute care is now high on the hospital's agenda.

Another good outcome from GOSSHA2 has been that Dr Dario managed to put forward as an official recommendation to the ministry that the current procurement system for hospital supply should be revised. Consistent supply of life-saving drugs and equipment, whilst we take it for granted back at home, is a huge issue here. There's few things more frustrating and upsetting as a clinician than seeing delays in, or worse still no treatment at all for a sick patient because there just are no, for example, venflons in the hospital. So in the old system we got what we were given by MoH rather than what we said we needed. Hopefully this will change and the hospital will have more autonomy in procuring supplies.

Enough from me - a few words from David now.

James

The new emergency drugs cupboard on the Emergency Medical Ward.
It may not look much but you wouldn't believe the amount of effort required...

“How was your day?” the Comboni’s often ask me at supper.
“Same as usual,” I often reply “Everyday we move two steps forward, one step backward and one step sideways. But always, we move one step forward!”

Yesterday we took three huge strides:

The purpose of the cupboard is to provide medicines at night time when there are no pharmacists and to allow access to life-saving medicines that you need within seconds. Currently, if a patient needed urgent treatment I would have to send a nurse to pharmacy. More likely than not the nurse would get side-tracked in vigorous hand-shaking and salutations, the Pharmacy would probably be shut, the Pharmacist would be out, or there would be no drugs. This lamentably slow process would take 15 minutes at best. At worst the word “Bukra,” would be given which is a word I hear rather frequently (it means “tomorrow”).

We have selected the Male Emergency Ward as our new Emergency Ward because it has two separate wings. One wing can be for females, the other for males. Handover and the drugs cupboard is in the middle. Today we have been moving the patients out of the Male Emergency Ward and redistributing them.

I am holding out high hopes. We have enough staff, they are all trained, we have the medicines and equipment we need. In the future, we will see if it impacts on mortality.

David

Acute Care

2008-11-10T12:04:00.000-08:00

Hello

Enough from me - a few words from David now.

James

The new emergency drugs cupboard on the Emergency Medical Ward.
It may not look much but you wouldn't believe the amount of effort required...

David

Sunday Ramblings

2008-11-09T04:53:00.001-08:00

Well it's a hot Sunday today, a day of rest, so I thought I'd just write briefly about some non-clinical things. We'll follow it up with more work-related content soon as things are moving along nicely...

Part of Father Luciano's vegetable garden at Comboni.
(A favourite spot of mine for sitting etc.)

I haven't been feeling so recently so I've had the past couple of days off from the hospital to rest up a bit. This has been a very good thing. Comboni House is a very restful and peaceful place to be and sit and play guitar around. The chapel is also very nice.

The ferry over to the island

We took a little trip out onto the Nile with some Combonis the other day to go walking on an island. (There's quite a big island in the middle which I hadn't quite appreciated before. See for example Google Earth 4°51'48.49"N by 31°37'38.58"E). It's very green and lush. A little bit like our Island back home. Come to think of it, a lot of Southern Sudan is actually very green. I was quite ignorant about Africa before coming here and tended to think Africa = arid and generally beige but the countryside around is really quite lush and rather pleasant.

The Nile is pretty swollen at the moment due to the recent rainfall. We had to take a little boat over which was punted by a sudanese chap. His pole was really a little too short for the task and we drifted downstream quite a bit and had to work our way back up the reed-beds in the shallows but we got there all ok. So we just went walking around really for an afternoon. It's good to get out of Juba actually (even if not very far.)

Mangos ripening at Comboni

A large beetle I found

Limes at Comboni. We drink these in our water every day. Delicious.

So that's me for now. Back to hospital tomorrow...

James

Sunday Ramblings

2008-11-09T04:53:00.000-08:00

Part of Father Luciano's vegetable garden at Comboni.
(A favourite spot of mine for sitting etc.)

The ferry over to the island

Mangos ripening at Comboni

A large beetle I found

Limes at Comboni. We drink these in our water every day. Delicious.

So that's me for now. Back to hospital tomorrow...

James

Cows, Birthdays etc.

2008-11-07T00:40:00.001-08:00

Hello again everybody,

Apologies for the lack of blogging but time is rapidly running out and we are working around the clock in a bid to make all the good things we have achieved continue in our absence. We have 39 days left and are trying to achieve the following:

Organising trainers to continue teaching
Re-opening a new Medical Emergency Ward, stocked with drugs and well trained nurses
Training people to implement triage
Organising ceremonies for all nurses who have received certificates with us (should be around 200)
Travel to another hospital 500 km away to conduct a fact finding visit for another potential link
Practice medicine

It is safe to say that we have never been busier...

Yesterday I celebrated my 30th birthday in Juba. The morning routine began much the same as any day; on arrival at the main entrance, there is the exchange of many greetings which involve more than a modicum of vigorous hand-shaking, shoulder patting, and hand-holding (I can now say I am used to holding a man’s hand).

However, my birthday also started on a bit of a low. The evening before, I admitted a 25 year old woman with acute diarrhoes who was very unwell on arrival. This is potentially a nasty illness but thoroughly treatable - they just need good rehydration and close monitoring with hourly checks of vital signs (pulse BP, respiratory rate).

Sister Anna teaching nurses

Sadly, there were no nurses on duty that day and there would be none in the night either. There is a high level of absenteeism amongst the profession - a salary of £50 a month is not enough to feed their families and they need to do other jobs to supplement their income. I did the best for my patient- I gave her 2 litres of fluid and hoped. Sadly it was not enough. She passed away in the small hours of the night, leaving behind a two and a half month old baby whom she was breast-feeding. I don’t hold out much hope for the child; the family will not be able to afford the formula feeds. God bless the NHS - I swear I will never complain about it again.

However, as is typical in Southern Sudan, there were many highs; two drugs cupboards have been completed for our new Emergency Ward. This is the first time a ward in Juba Teaching Hospital will stock life-saving medications and fluids and in a land where minutes literally count, this will save untold lives. The Ward will be re-opened on Tuesday and all the nurses staffing it will have received training on managing medical emergencies. I am holding out high hopes.

I will be working on this ward with sister Anna, one of the brightest ward sisters in this hospital and she also does the nurses training with me. I mentioned to her that I was getting married next year and she asked “How much is the wedding?” I went on to tell her that a typical British wedding costed £15,000.

“Ah but this is not much though,” She replied.
“Not much?” I asked, slightly bemused. This is a massive amount in the Southern Sudan.
“My bridal price will be 200 cows. This is about 1,000 Sudanese pounds a cow so that is about... 200,000 Sudanese pounds (£50,000).”

I asked what made her so expensive as a bride and she told me. “It is because I am tall and I have black gums and white teeth. This means I will give birth to tall, strong, fighting men!”
I asked her how much my future wife would be worth in cows.
“What colour are her teeth?” I answered they were white.
“What colour are her gums?”
“Pink.” She tutted at this.
“And how tall is she?” I judged that my fiancé came upto my shoulders.
Anna shook her head. “She is not tall so all your children will not be strong. She is worth one... maybe two cows at the most. And a few goats.”

At 5pm we enjoyed a beer with some friends we have made in the NGO (non-government organisation) community, whereupon I was handed a selection of fine cheeses, including a particularly strong smelling stilton - you can’t even begin to imagine what a luxury this is out here.

Dave's second party of the night at Comboni

The evening ended on a high in Comboni, where we drank and feasted on various Italian delights that had been prepared by the priests for my birthday which was very kind of them.
On days such as these, I think of previous birthdays I spent with family, friends, and fiancé that are left behind in England. I smile when I think of these times gone by because I would never have guessed back then that I would be celebrating my 30th in a monastery.

Anyway, I had better go. I shall see you all before the new year is out. Take care everyone,

David

Cows, Birthdays etc.

2008-11-07T00:40:00.000-08:00

Organising trainers to continue teaching
Re-opening a new Medical Emergency Ward, stocked with drugs and well trained nurses
Training people to implement triage
Organising ceremonies for all nurses who have received certificates with us (should be around 200)
Travel to another hospital 500 km away to conduct a fact finding visit for another potential link
Practice medicine

Sister Anna teaching nurses

Dave's second party of the night at Comboni

The breaking of the fellowship...

2008-10-28T10:38:00.001-07:00

We did a research project a couple of weeks back in JTH looking at the distribution of mortality in the hospital. We were particularly interested in not only who was dying but also when they were dying. As you may know my professional interest is in acute care, and this is very much the area where David and I are focussing our attention here in Juba. We wanted to know if we were barking up the wrong tree in terms of making a dent in total hospital mortality rates. We aren’t. In fact, we clearly demonstrated that >60% of hospital mortality (and >70% in paeds) occurs within 24 hours of admission. Anyway we’re writing this up at the moment.

David and Dario at our poster/stall.

There’s a massive convention on at the moment called the Government of Southern Sudan Health Assembly 2 (GOSSHA2) which is the second annual health assembly where representatives from over 40 NGOs (national and international) all get together with the whole MoH/GoSS and State Government representatives to talk, present and generally make important decisions concerning national health strategy. The theme is ‘Building Effective Health Systems in Southern Sudan.’ The whole thing was opened by the President of Southern Sudan, so basically it’s quite a big deal.

I’m still not quite sure how it happened, (but probably it’s due to the fact that our work is in Juba and JTH’s heavily involved with MOH) we ended up acquiring a slot at the exhibition where we could do a poster presentation of the research and also generally tell folk about what we’re up to here.

I generally do the photography which is why I'm not in many of them, and I completely forgot to photograph myself at our stand. However, our nextdoor neighbour was very keen to photograph me at his stand and it's the closest I have!

Anyhow today at GOSSHA2 the Director General for Curative Services in MoH (who’s our Boss in GoSS as it were) was doing an address on ‘building an effective referral system’ and invited me to present the research findings to the assembly as part of his time slot. So Dr Dario (my Surgical Consultant and Director General of JTH) introduced me and off I went. On reflection it was actually quite relevant to the theme; part of an effective health system involves secondary/tertiary care, and what we’ve shown is that to make that hospital care more effective (at least in terms of reducing mortality) you need to focus on the acute care service delivery. I got some positive feedback afterwards too which was encouraging.

Here's a couple of shots of the presentation. You may just be able to make out the graphs - the red bar is <24h mortality

In other news, we bade farewell to the senior team from St Mary’s last Saturday. I know everyone in Juba was extremely grateful for their input in JTH over the 3 weeks they were here: they’ll certainly be missed, and I’d like to think they had a great time too. We had a great meal out on the Nile with a load of the hospital folk and also some people from MoH on Friday which was a real treat. Highlights for me included an African jazz band which featured a vocalist who sounded just like Louis Armstrong and the chance to eat a large steak. Anyway, life is back to relative normality (for Juba) again and now it’s just David and I plodding ever onwards...

James

The breaking of the fellowship...

2008-10-28T10:38:00.000-07:00

David and Dario at our poster/stall.

Here's a couple of shots of the presentation. You may just be able to make out the graphs - the red bar is <24h mortality

James

Guest Post from Zorina

2008-10-22T23:31:00.001-07:00

The first team of trainers left from London Heathrow on Monday 6th October. You can see how happy Tim Walsh was to leave the cold!

And here is the rest of the happy team preparing for the overnight flight to Addis Ababa and then on to Juba.

On arrival at Juba airport we were met by a whole team from JTH, James and David and luckily someone from the Ministry who got our passports stamped, otherwise we would still be in the queue! The Ministry of Health have kindly booked us into a fairly decent hotel (by Juba standards) but it is Chinese owned so money doesn’t stay in Southern Sudan and the food is virtually the same every evening – beginning to hate the sight of chicken!! After a meeting to discuss our plans with the Senior doctors in JTH and with James and David we set about our business.

Tim has set up a teaching course in Applied Physiology for the trainee doctors each afternoon but is frustrated by the Sudanese timings – start at 2pm, turn up at 3pm go home at 4pm!!

France has set up a 3 day workshop for midwives and that is running very well with 14 midwives attending each day. She is planning to repeat next week. She also delivered a baby the other day which the family decided to name "France."

Jane is trying hard to establish relationships with the psychiatric department (who didn't know she was coming.) Ward 11 is at the far end of the hospital and also accommodates patients with African Sleeping Sickness. Rooms are incredibly cell-like and the nurses are general trained on rotation. Very little English is spoken by the nurses who are all very kind and caring.

The department is headed by George, the Senior Medical Assistant. He has the most amazing therapeutic relationships with patients who are so ill. Resources are poor, no activity rooms and no food for those without families – medication is limited. George also heads the prison wing for mentally ill, who have not offended. He works so hard to improve the conditions, which he describes as “completely unacceptable.”

Some of the medical assistant students are keen to pursue a career in mental health and Jane will be teaching them each morning. They will be dealing with all presentations in remote areas when they qualify.

Zorina is spending time trying to pull everything together, set up a training programme, arranging meetings, seeing possible accommodation sites and answering emails!!

Guest Post from Zorina

2008-10-22T23:31:00.000-07:00

The first team of trainers left from London Heathrow on Monday 6th October. You can see how happy Tim Walsh was to leave the cold!

Zorina is spending time trying to pull everything together, set up a training programme, arranging meetings, seeing possible accommodation sites and answering emails!!

Just Giving

2008-10-19T23:02:00.001-07:00

I apologise that I haven't featured the guest post from the team yet. I still haven't got the photos, but am working on it.

In other news, the St Mary's Juba Link has now been registered for online donations at Just Giving, so if anyone fancies it then click here or the logo below and you'll be pointed in the right direction.

I have to go for my ward round now.

James

Just Giving

2008-10-19T23:02:00.000-07:00

I apologise that I haven't featured the guest post from the team yet. I still haven't got the photos, but am working on it.

I have to go for my ward round now.

James

Some more...

2008-10-16T07:50:00.001-07:00

Hello there

I thought it was about time for another post. There's not too much to report actually, so this is more of a "life in Juba goes on" kind of affair. We're still working hard and the days go by: it's not all glamorous life-saving! :o)

We have our team from St Mary's here who are having a good time, and it's been really nice to see some familiar faces. We'll have a guest posting tomorrow from the team, providing I can get some of their photos to illustrate.

The room was full of keen nurses for an 11:00 start, and most were there before we arrived. Amazing.

One of our recent projects has been some research looking into the mortality figures for the hospital, and in particular their chronological distribution. In other words, not just who is dying but when. We've generated some very interesting results actually, which basically demonstrate quite clearly that the bulk of mortalities occur within the first 24h of admission. This is partially expected given the characteristic late presentation of patients, but it also very nicely justifies our focus on improving the delivery of acute care as an area of priority. There's plenty of scope for such improvements, and it's occupying most of our time at the moment (outside of basic clinical work of course.)

So we're looking at the structure and staffing of the A&E, have set up a steering committee with representatives from the various departments including senior consultants and nursing staff. When we work out a definitive solution (of which triage will certainly be key - see the earlier post on triage) we'll present it all to the MoH and try and get them on board.

Part of delivering good quality acute care is the recognition of the unstable patient. This is basically done by simple vital signs (together with their proper interpretation and subsequent management). Hence we're working on training (or perhaps 'refreshing' is a better term) the nursing staff who need to staff the emergency wards in basic ABCDE, obs taking and recording. They're doing really well actually - they're very receptive, which is a real pleasure. They're incredibly keen, and I was stunned that today they were early for the session. I cannot emphasise enough the significance of this fact in this culture.

The House Officers all rotate around this time, so we'll be getting a new bunch in Surgery soon. I see this as a positive thing as I can focus on getting the basics of acute surgical / trauma management right with them from the outset. (And reuse teaching material hence saving time in preparation!)

That should do for now, I hope you liked it.

James

Some more...

2008-10-16T07:50:00.000-07:00

The room was full of keen nurses for an 11:00 start, and most were there before we arrived. Amazing.

Recap

2008-10-09T10:29:00.001-07:00

Greetings again one and all. We found out why our blog has suddenly doubled in its readership. It seems that our site is getting linked to other more popular sites and our adventures are reaching a wider audience. Myself and James would like to bid a warm welcome to the new arrivals and now, I think, is a good opportunity to recap on what we are, our goals and how we came to be here.

Organisation: St Mary’s- Juba Link. The hospital that we work at is called St Mary’s Hospital. We are twinned to a Hospital in the Southern Sudan called Juba Teaching Hospital (JTH).

Goals: To send NHS staff from the UK to assist with training in JTH. This will increase the number and quality of healthcare professionals in the Southern Sudan.

How we fit into the big picture in the Southern Sudan: The 40 year civil war in Southern Sudan has destroyed its infrastructure and left it with some of the worst healthcare statistics in the world, including the highest maternal mortality (1 in 5 mothers die in pregnancy) and one of the highest child mortalities (1 in 7 children will not live to see their 5th birthday). Health institutions are sparse in the Southern Sudan - only 25% of people have access to one.

In the Southern Sudan, hope abounds. The people, tired of war, are industriously re-building their shattered country. Aid from the West is pouring in and many hospitals in the Southern Sudan have been refurbished. More hospitals are being built. Juba is the capital, and Juba Teaching Hospital, is the Southern Sudan’s flagship hospital. Its wards have been re-decorated, there are tiled floors and many new buildings have been constructed including laboratories, and Radiology facilities. Ventilators have been purchased and an intensive care unit has been created, complete with suction machines, oxygen concentrators and electrical observation machines for continuous non-invasive monitoring.

Intensive care unit at Juba Teaching Hospital.

However, why are the ventilators still in their packaging? Why in the height of the wet season when people are most ill, are there no patients in the beds?

The simple answer is that there are no staff. Intensive Care Units need very well trained doctors and nurses. In the UK, it takes five years to become a doctor and another ten to twelve to become a Consultant in Intensive Care Medicine. It takes three years to become a nurse and another two to do intensive care at least. It is clear that a fully functioning Intensive Care Unit is a dream that lies over a decade into the future.

So in summary, there is an absolute deficit of professionals in all branches of healthcare in the Southern Sudan. Those that are present are not receiving adequate training because there are no trainers. As far as we know, in the entire Southern Sudan, the St Mary’s Juba Link is one of only two charities that are assisting with training in a secondary care setting.

It is relatively easy for charities to buy "stuff" for hospitals here. They feel good about it, and can tell and show their donors what they've contributed. There is a roll for this of course, but if you don't consider the wider context of the healthcare system you're involved with, you run the risk of it sitting unused, or unmaintained and broken. Training the workforce is vital, but it's also slow, unglamorous, and hard for people to visualise. However, we passionately believe that this training is the best system to sustainably impact the healthcare of the Southern Sudan.

The wider world of hospital links: In 2005, the then Prime Minister Tony Blair commissioned Lord Nigel Crisp to write a report on how the NHS could benefit the developing world. The result was the Crisp Report, which strongly advocated sending NHS staff to the developing world to train. The NHS has many many highly skilled professionals who potentially have a lot to offer in terms of training in the developing world, though it is often difficult for them to get out there. One of ways of overcoming this difficulty is via hospital-hospital links.

The St Mary’s Juba Link is one of over 80 links that have been developed by hospitals in the UK, to work in partnership with hospitals in the developing world. Such links are a two way relationship, and there is much benefit for staff from the UK. Hospital links are coordinated helped and supported by the Tropical Health Education Trust, THET.

On Tuesday, the St Mary’s Juba Link received 4 reinforcements from the UK - Tim Walsh (Consultant Surgeon and our Project Lead), Zorina Walsh (our Education Lead), France Reed (a midwife - very important), and Jane Newson-Smith (a Psychiatrist - there is currently no strategy for mental health in the Southern Sudan).

It was lovely to see some familiar faces and these guys have been getting stuck in as soon as they got off the plane. They are all absolutely loving this place. They have been bowled over by the generosity and hospitality of these people. We have been planning their stay so that when they arrived, no time was wasted in preparing for teaching. Mr Walsh did his first teaching today which was awesome and I learnt a lot.

Tim Walsh teaches junior doctors the importance of fluid therapy in his first applied physiology tutorial

Anyway, this is more than enough for now. We really appreciate your interest!

All the best,

David

Recap

2008-10-09T10:29:00.000-07:00

Organisation: St Mary’s- Juba Link. The hospital that we work at is called St Mary’s Hospital. We are twinned to a Hospital in the Southern Sudan called Juba Teaching Hospital (JTH).

Goals: To send NHS staff from the UK to assist with training in JTH. This will increase the number and quality of healthcare professionals in the Southern Sudan.

Intensive care unit at Juba Teaching Hospital.

However, why are the ventilators still in their packaging? Why in the height of the wet season when people are most ill, are there no patients in the beds?

Tim Walsh teaches junior doctors the importance of fluid therapy in his first applied physiology tutorial

Anyway, this is more than enough for now. We really appreciate your interest!

All the best,

David

A Brief Aside

2008-10-07T00:47:00.001-07:00

Dear All

Over the past couple of days our hit rate has gone through the ceiling. I'm very happy with this but am also slightly curious about how this has happened.

If anyone can shed any light then feel free to comment below.

That's all

James

A Brief Aside

2008-10-07T00:47:00.000-07:00

A wind of change...

2008-10-06T10:34:00.001-07:00

Today we are right underneath a massive tropical storm which is both frightening and awesome at the same time. It has gone completely dark outside and the sun hasn’t even gone down yet. Before the sun went down, it became overcast and an unearthly yellowy-orange descended on the Comboni compound.

Weather aside, the Link is aging well in Juba, like a fine wine. After 9 weeks, a firm trust has developed between the hospital staff and ourselves. So I thought that instead of talking about us, I would let them do the talking. What follows is a selection of quotes from our teaching evaluations and one or two awesome quotes that will always be remembered. Although English is their second language, they can make very heartfelt and poignant remarks:

“Excellent presentations.”

- Medical Officer, JTH

“These steps are very useful. It won’t be forgotten.”

- House Officer, JTH

“More presentations please in other topics.”

- House Officer, JTH

“I realised working in Traumatology without ABCDE in mind is completely rubbish. The course is completely very very useful. Thank you so much!!!"

- House Officer, JTH

“Try to keep talks under two hours!”

- Registrar, JTH

“I had no knowledge of ABCDE and recognising a sick patient before I met you guys. Now I have the knowledge and I will be able to pass this on so that others learn.”

- House Officer, JTH

“This is the first bit of training I have had in years. I will remember this forever and it will really help my patients. Thank you so much.”

- Translated into English from a certificate nurse who only speaks Arabic

“The Western world keeps asking us if we need equipment. We do not need equipment. We need trainers!”

- Consultant, JTH

“I want to thank David and James of the St Mary’s Juba Link for giving up their time and giving up their lives to come to Juba to teach. They do not have to be here. They are far away from their loved ones. Yet they are here and they spend a lot of time and effort designing these presentations. This is a completely new style of presentation and we are very lucky. Even Khartoum does not have this where hard concepts are taught simply.”

- Registrar, JTH

Attitudes amongst the staff in JTH are changing. Ward sisters want to learn how to teach their juniors. Consultants are coming up with novel research projects. New ideas are being thrown around. New plans are being laid out. We sense a resurgence of hope in this corner of the world as people dare to believe that Juba Teaching Hospital could become great.

So many things have come to pass in 9 weeks. However, the greatest achievement has been the creation of a lasting friendship and trust between our hospitals. We no longer feel like a charity: we are a partnership campaigning for a better world.

David xx

A wind of change...

2008-10-06T10:34:00.000-07:00

- Medical Officer, JTH

“These steps are very useful. It won’t be forgotten.”

- House Officer, JTH

“More presentations please in other topics.”

- House Officer, JTH

“I realised working in Traumatology without ABCDE in mind is completely rubbish. The course is completely very very useful. Thank you so much!!!"

- House Officer, JTH

“Try to keep talks under two hours!”

- Registrar, JTH

“I had no knowledge of ABCDE and recognising a sick patient before I met you guys. Now I have the knowledge and I will be able to pass this on so that others learn.”

- House Officer, JTH

“This is the first bit of training I have had in years. I will remember this forever and it will really help my patients. Thank you so much.”

- Translated into English from a certificate nurse who only speaks Arabic

“The Western world keeps asking us if we need equipment. We do not need equipment. We need trainers!”

- Consultant, JTH

- Registrar, JTH

The Triage Experiment

2008-10-04T01:11:00.001-07:00

One of the rules of blogging is that it’s best to try and have frequent short, sharp posts. We’ve broken that today, as unfortunately we’ve been having real problems with the internet recently. So apologies for unanswered emails of late and length of post. Please forgive us...

Our brand new flag pole in JTH

Today is a very special day- it is our millennium edition. Yes, the blog now has a readership that numbers over 1000 unique individuals. So may I begin by thanking you all for your interest and ongoing support. Today I thought we would tell you about a little experiment that James and I did on Tuesday.

Triage

We all know how important triage is. It is a system that gets the sickest people to doctors first so that they can be seen earlier and sorted out. Never has triage been more important than in JTH when over 500 patients come through our doors every day, a mixture between primary care, hospital follow-up and the critically ill.

To set the scene, what appears "the obvious way to do things" to us in the UK is that the sickest patients, i.e. the closest to death, need to be seen most urgently by a doctor. You can say what you like about A&E waiting times in the NHS, but that fact is we’re pretty good at this. Our "obvious" way of doing things is of course an entirely culturally conditioned phenomenon, and is exactly the kind of assumption on which you cannot rely to be "self evident" in other cultural settings. In JTH, for better of for worse, the queue is managed by medically-untrained security staff guarding the doors to the doctor's offices. It’s a first come, first served system where the patient’s condition in irrelevant. If you’re unlucky enough to be unconscious on the floor (as many often are) then you tend to be stepped over by the well, thus effectively going backwards in the queue.

So with the Hospital Director's permission and encouragement, James and I set up shop outside the reception window. We were armed with the Triage Early Warning Score (TEWS) a triage model based on simple vital signs designed in South Africa, which was simple to use and designed specifically for resource poor countries. If you were well, you got a green colour. Yellow people were slightly more sick. Orange or red patients were the sickest. The purpose of the experiment was to ask two important questions:

1) Was the triage model any good?

2) How many staff are needed for triage in outpatients?

The answer was more than myself and James. As fast as we were triaging, (and it was fast, believe me!) they were coming. For some reason there is a mad dash for the hospital between the hours of 9:00 - 11:00 am. After that, it settles steadily to a trickle. We probably did core obs on and categorised around 300 patients that morning.

We have taken many photos of the chaos at outpatients. For the first time ever, the chaos turned to order. Patients were no longer blocking the doors and corridors. An ordered queue formed behind us. However, every five minutes we had to sub-triage the queue: there was no point in the sick people normally at the queue in the door waiting in the queue for triage! But crucially, we were processing the queue far quicker than the receptionist would have.

There were some low points during our stint. At one stage mother appeared carrying a limp child and we had to tell her that the she had died. The child was still warm.

However, that day, the sick folk got to the doctors early. The doctors on duty in outpatients loved it. That same day, the Paediatricians reported the highest Paediatric mortality on the wards for a long time. Six children died. The sick patients were getting to the wards, but there were still not enough doctors to monitor them on the emergency wards. We know that otherwise they would have died in the waiting room in the queue. It is clear that a triage system forms part of the solution but there are many other problems to deal with. One step at a time though eh?

Could this be the world's largest name badge?

On a lighter note, I thought I would leave you with a rather amusing photo of a wonderful man, a good friend, and a fine Consultant Physician, Dr Magdhy. He is a man of pure heart and his mind overflows with hope. He is passionate about his job and you can see his determination to do good in his eyes when he talks. A true inspiration. James caught site of the scene and took the photo the other day. (He gave his permission to put it on the website hoping it might make him famous.)

All the best,

David and James

The Triage Experiment

2008-10-04T01:11:00.000-07:00

Our brand new flag pole in JTH

Triage

1) Was the triage model any good?

2) How many staff are needed for triage in outpatients?

There were some low points during our stint. At one stage mother appeared carrying a limp child and we had to tell her that the she had died. The child was still warm.

Could this be the world's largest name badge?

All the best,

David and James

A good weekend

2008-09-27T13:23:00.001-07:00

When we used to go to work in St Mary’s, we often used to jokingly tell each other we were off to another day of “saving lives.” Now of course, the fact is in UK medicine, particularly as a junior doctor, most work is very routine, and the actual opportunity to save a life is very few and far between. (Maybe more in A&E resus, but still.) Not so in Juba! I’ll come back to this thread later...

So teaching this week to the Grand Round was on Shock and a little bit about fluid balance. This is a big issue for JTH, as often patients in circulatory collapse are not fluid resuscitated adequately, or at all. Everyone there knew this was relevant and mattered to them, and we had a really good turn-out, including a lot of the House Officers (first year doctors) who needed to know it more than anyone. This was actually quite a significant breakthrough, as we’ve been struggling bit with attendance. However, progress is being made, and we’re getting very positive feedback from those who are coming. Moreover, we were still getting questions right until the end (18:00!) and we nicely facilitated a lot of comments and discussion points from the seniors to the juniors and each other throughout. Again, a healthy sign in any presentation.

Reflecting on teaching style and delivery, we feel that there’s generally a negative attitude from juniors to teaching, as unfortunately their undergraduate medical education is delivered in a rather, shall we say “old school” manner. That is didactic lectures and teaching by humiliation. So not only are we trying to teach new things, we’re also trying to do them in a new way. These things take time. Nonetheless, as I say, it’s well received

and slowly but surely we’re getting there. We have some UK consultants from St Mary’s coming to join us next week which should help pick up the momentum a bit and roll things forward.

In other news, we had a very restful Sunday, which mainly included hanging around with our friends from Tear Fund, which included the consumption of bacon for breakfast. Very nice. Then later, we visited an expat church which was another interesting experience. All in all, a good day. The weather’s heating up though – it’s been around 37oC here today and very humid with it. I’m hoping for rain tonight, but no signs so far.

So to come back to today. My first patient of the day had been shot in the chest, and my last had been stabbed in the back, so a good solid day of Juban trauma. (They were both fine by the way.) You just don’t get all this stuff on the Island! So, to come back to life saving. I came out of the surgical emergency unit back into outpatients and found an elderly man lying on the floor looking very sick. There was no word of English spoken, but I gathered he had had diarrhoea. This is technically a medical rather than surgical problem, but my boss was there, and I asked if we could just stabilise him on our unit (it was quite quiet.) He agreed.

Now, another important part of our overall teaching strategy is demonstrative and working alongside the house officers, so I took one of them along with me and we worked through the problems and management together. The diagnosis was clearly late stage hypovolaemic shock, the treatment was rehydration (with the correct IV fluids) which was exactly what we’d been talking about on Saturday. It's the basics done well here which make the difference, and it worked very well. This was a) a relief and b) a great teaching aid! I’m in no doubt he would’ve died on the floor otherwise, and I made that very clear when I thanked the House Officer and Nurse helping me. It’s a great way to start your day. His family came and thanked me later on when he’d perked up a bit – again, not a word of English, but it was touching nonetheless. Perhaps more so.

This case also introduces the complex issue of triage here (and the lack thereof) but I’ll keep that back for another day.

Sorry there’s not more photos today.

James

A good weekend

2008-09-27T13:23:00.000-07:00

and slowly but surely we’re getting there. We have some UK consultants from St Mary’s coming to join us next week which should help pick up the momentum a bit and roll things forward.

This case also introduces the complex issue of triage here (and the lack thereof) but I’ll keep that back for another day.

Sorry there’s not more photos today.

James

Some more news

2008-09-24T01:27:00.001-07:00

We had another interesting development yesterday. A couple of days ago, Dave and I were enjoying the African evening (by far my favourite time of the day) over a beer in one of our local haunts after another long day in the hospital. We were chatting to the waiter about what we were up to here in Juba, and this English chap came up to us:

“Hello there – I couldn’t help overhearing you were doctors working here. I’m the UK Shadow Minister of Health. I have to go to a dinner now, but let’s meet for breakfast tomorrow and chat.”

Us and Mr O'Brien. A rather cheesey photo I know, but the other was totally out of focus!

So we did. And that’s how we ended up with Rt Hon Stephen O’Brien yesterday over breakfast. He was actually in Juba with Malaria Consortium, but was very interested in our work. It was a very positive meeting overall, and gave us a good opportunity to chat about the Hospital-Hospital link concept, the role of THET, the vital need for building sustainable postgraduate medical education etc. It was also helpful I think to discuss some of the practical and logistic difficulties which Trusts and individuals face when trying to undertake such projects. We have an email address and may well talk further in the future.

So all in all, very good. Clinical work is progressing well and generally uneventfully. I was quite touched today when working with the acute admissions that one of the Medical Officers (my equivalent grade) asked my advice on a patient he was seeing, and actually took it! It doesn’t sound much but actually in a hierarchical system it’s important to have these little breakthroughs now and again.

We’ve been invited to give another teaching session on Saturday (weather permitting, presumably) which will be fun. They love the Powerpoint and I’m particularly proud of the this one!

James

Some more news

2008-09-24T01:27:00.000-07:00

Us and Mr O'Brien. A rather cheesey photo I know, but the other was totally out of focus!

We’ve been invited to give another teaching session on Saturday (weather permitting, presumably) which will be fun. They love the Powerpoint and I’m particularly proud of the this one!

James

"I'm Listening..."

2008-09-20T14:14:00.001-07:00

We’ve had quite a restful weekend. We’d planned to give an interdepartmental presentation again on Saturday but had to postpone due to lack of a venue. There are really only two options: one is the main conference hall which is hosting a 4 week long Obs and Gynae course, the other is the lecture theatres in the school of nursing which are currently hosting exams.

One of the Comboni activities is the running of the Catholic Radio station here in Juba, which sometimes runs programmes on health related issues, so one of the Brothers invited David and I to make a guest appearance. So we went on their radio show for an hour and talked about some things. Often questions from the interviewer were slightly vague, such as “Any comments on first aid?” and “what do you have to say about drug prescriptions?” but we had fun nonetheless, usually working back to importance of hand washing, anti-mosquito measures, take your drugs as instructed, the importance of crash helmets for motorcyclists etc. We also had some live phone-in callers which was novel!

Otherwise, things are ticking over without much to report: Ward rounds are ward rounds, acute abdomens are acute abdomens and jobs are jobs - we’ve actually been quite light on admissions in surgery for the past couple of days which is a nice break. Other work is progressing slowly – I reckon you probably need to schedule at least 3 meetings which won’t happen before you get one that does: a process which may well take several days. Teaching attempts are often frustrated by people not turning up which is a little annoying. Having said that, a few times today I’ve been stopped around the hospital by various house officers asking when the next tutorial is because they’re very helpful. So there we are – take we just take the encouragement, hold on to the good and ignore the rest.

James

"I'm Listening..."

2008-09-20T14:14:00.000-07:00

James

A Good Week

2008-09-19T10:20:00.003-07:00

When it comes to training, you have to be culturally sensitive- if you don’t do things the African way, you will accomplish nothing. Take the nurses for example. They like structured, formal teaching with an exam and a certificate of attendance at the end. This is precisely what they got...

As you know, I have been running a few teaching sessions this week in:

Recognition, assessment and management of the sick patient
Use of obs and urine charts

Today, through popular request, I set a small test. Twenty sisters sat it and with the exception of four (who only began attending from Thursday), everyone passed.

I issued certificates of attendance to all that passed and encouraged the late arrivals to attend next week- it is difficult to give a certificate of attendance when you haven’t attended!

Next week, the sisters and I will all be training the junior nurses the same thing and we will also be showing them how to measure pulse, temperature, blood pressure, respiratory rate and conscious level. At the moment only the ward sisters and doctors know how to do these observations and this is part of the reason why there are no observation charts- hardly anyone can do observations, let alone fill in the charts...

I have made good friends with all the ward sisters. I thought I would include a photo of them all after our teaching today:

All the best,

David xx

On Monastic Life...

2008-09-19T10:20:00.002-07:00

In case any of you were wondering where we're living and perhaps haven't followed from the beginning, I should point out that Dave and I are staying in a Catholic Monastry. These are Comboni Missionaries and have been based here in Sudan for many many years. And I'd also add that they are awesome individuals. They're a mixture of ages and nationalities, some Sudanese, others from Europe and Mexico. There's an adjacent Nunnery as well where the Sisters all live, and they frequently have joint socials! (In addition to the two church services a day, that is...)

Fr Valentino in the middle there.

Anyhow, I write this now because we had the pleasure of a birthday party yesterday. Father Valentino was 86. He's an amazing man, and has been in the Southern Sudan since the 1950's and remembers the days of the British rule. The Sudanese civil war has been the longest in Africa (4 decades) and he's been here throughout. Needless to say, they have some great stories, and the insights that we've been able to glean from them into the Sudanese culture and mindset have been invaluable.

Birthday party in full swing

Not only that, but they've been incredibly welcoming to David and I. I'm not sure what I would have expected such people to be like - but I'm sure the reality far exceeds it. The Brothers are friendly, warm, down-to-earth, generous and very funny; our shared meals are a real pleasure and they've really helped to make us feel at home here. They insist that we join them for beer on sundays! There's a really wholesome community spirit in the place which we've both really appreciated, as it's certainly helped eased the cultural transition and frustrations and difficulties associated with it.

Professionally speaking, I've been off the wards with some of the other surgical SHOs and consultants attending a course in War Surgery that the ICRC have put on in Juba. Really fascinating stuff. You learn a lot in ATLS about how to initially treat things like gun-shots etc. but I've no real clue about the longer term managment, but now I have an idea. There were a couple of surgeons running it who were working in Darfur: one was an Italian liver-transplant surgeon turned Anaesthetist, the other a Swiss surgeon who started war surgery before I was born! Very intersting indeed.

That'll do.

James

A Good Week

2008-09-19T10:20:00.001-07:00

As you know, I have been running a few teaching sessions this week in:

Recognition, assessment and management of the sick patient
Use of obs and urine charts

All the best,

David xx

_____ One Doc's Blog _____

Southern Sudan Medical Journal

Conclusions...?

Homeward Bound

Week 11

Week 9

So What Are We Here For?

Fire and Food

Week 5 (Boring title)

Week 4

Saving Lives...

Week 3

Quick Note

Second Week Stuff

A Little Bit More...

New Blog

There and back again

Performance = (Knowledge x Motivation) / Obstacles

Endings

Endings

The UN, Statistics, and School Children

The UN, Statistics, and School Children

For the people we leave behind

For the people we leave behind

Life

Life

Quick Follow-up

Quick Follow-up

More Emergency Anecdotes

More Emergency Anecdotes

Progress

Progress

Emergency Medical Unit

Emergency Medical Unit

Acute Care

Acute Care

Sunday Ramblings

Sunday Ramblings

Cows, Birthdays etc.

Cows, Birthdays etc.

The breaking of the fellowship...

The breaking of the fellowship...

Guest Post from Zorina

Guest Post from Zorina

Just Giving

Just Giving

Some more...

Some more...

Recap

Recap

A Brief Aside

A Brief Aside

A wind of change...

A wind of change...

The Triage Experiment

The Triage Experiment

A good weekend

A good weekend

Some more news

Some more news

"I'm Listening..."

"I'm Listening..."

A Good Week

On Monastic Life...

A Good Week

_ One Doc's Blog _