There and back again

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

“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

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...

The UN, Statistics, and School Children

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

For the people we leave behind

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

Life

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

Quick Follow-up

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

More Emergency Anecdotes

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

Progress

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

Emergency Medical Unit

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:

1. The first time this was brought out of its (rather dusty) box
2. 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

Acute Care

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

Sunday Ramblings

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