So What Are We Here For?

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

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

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

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

Dario and Louis

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

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

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

Ward Round with Dr Andrew

Dario showing us his (not quite finished) house

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

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

Teaching for the Obs and Gynae department

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

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

We play badminton with varying degrees of success

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

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

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

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

Louis' house

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

Pretty cool giant millipede Ben found. They really tickle.

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

Goodbye

James & Matt

Fire and Food

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)

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

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...

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

Now follows the real stuff...

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

Look at that handsome devil

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

Cleaning day

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

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

Some monkeys we saw at breakfast one day

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

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

Anyway, that’ll do for now.

James & Matt

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

 

Week 3

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

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

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

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

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

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

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

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

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

The Emergency Medical Ward (EMW) in action

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

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

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

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

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

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

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

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

All the best from Juba

Matt (& James)

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

Quick Note

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

If you care...

:o)