A good weekend

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

Some more news

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

"I'm Listening..."

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

On Monastic Life...

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

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:

1. Recognition, assessment and management of the sick patient
2. 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

Our new office - the hub of learning...

The St Mary's Juba Link office.

This is where all the small group teaching goes on

When it comes to teaching, there is nothing more satisfying than seeing ‘the moment of revelation’- the part where a student suddenly understands something that had hitherto eluded them. Their eyes light up, they smile and they nod knowingly as the epiphany is realised. This happened numerous times today.

The St Mary’s Juba Link is in full swing and I feel really encouraged and hopeful of the future. The recent audit has alarmed the doctors and plans are underway for a full restructuring of the way the departments run and the introduction of triage. The audit also highlighted a huge deficit in training and a postgraduate training programme has been created, the first of its kind in Southern Sudan. Nurses have sessions in the mornings, and we teach the junior doctors in the afternoons after our ward work is over. Every Saturday from 12.30 pm there is a grand round for all departments, although this is often frustrated by weather conditions...

Monday teaching with the ward sisters.

They are learning about observation charts

We are starting with the foundations of learning- the recognition and management of the sick patient using the method of airway, breathing, circulation, disability, and exposure (ABCDE). To many people in Juba, this is a completely new concept and the teaching is often slow to start with, as one would expect. However, today it was lovely to recap on Mondays teaching and people were shouting back the answers that they had learned the day before.

Teaching today. Some of the ward sisters are already taking the initiative and teaching others how to do observation charts

We are currently training the ward sisters in ABCDE and by the end of the week, they will know some common causes of problems with each, how to assess each component and the basics of management. They will also be able to write in an observation chart and urine chart. Yesterday they couldn’t write obs. Today, they were proficient. Next week (and for the next month) they will be the teachers and together we will teach the junior nurses ABCDE.

Todays teaching with the photo taken next to the whiteboard

The junior doctors are being taught in the afternoon. They learn the same things as the nurses but in a bit more detail.

Today we taught the doctors about airway and breathing. James shows the doctors a chest x-ray showing fluid in the lungs (a pleural effusion)

The aim here is to make ABCDE the common language of healthcare in the Southern Sudan and also to make people appreciate that this is the first building block of training- all internationally recognised healthcare courses such as Advanced Trauma Life Support, Advanced Life Support, Paediatric Life Support etc use ABCDE at their heart.

I am secretly hoping that in one month, there will be observation charts on the wards and everyone will be talking ABCDE and recognising sick patients and managing them early. However, in the Southern Sudan things take a lot longer to happen than in the UK. I remain hopeful but am mindful of this fact. Patience is the key.

That’s all for now. I shall tell you how we got on at the end of the week.

Bye for now,

David xx

But I don't want a crew cut...

Following our abortive attempt to meet the Minister yesterday, James and I decided that next time we saw him we would look better if we had well trimmed hair - it shows you mean business.

So, at about 3 pm yesterday, James and I pulled up outside the only hairdressers in Juba. The hairdresser was situated in a sky blue portakabin flanked by a bright pink picket fence. In a bid to attract customers, an artist had painted what looked like a young version of Lionel Richie complete with black leather jacket, a rakish moustache, and very beautifully presented curly black hair.

James asked “for a grade 4 round the back and sides with a trim on the top please.” I asked for “A grade 3 round the back and sides please and leave the length on top.” “Okay,” the barber (whos enthusiasm and confidence perhaps outweighed his ability) replied as he began to hack at the top with some trimmers.

I just managed to stop him in time. For James, however, it was too late. He was left with a grade 4 all over with a fringe at the front. He wisely decided that it would be prudent to remove the fringe, and apply some shorter blending at the back and sides to avoid the 'tennis ball' look.

For the next half hour, I watched as the barber creatively carved my hairstyle into something that looks like several palm trees growing out of a pot. Near the end he sprayed some blue/purple liquid around my neck. My nose caught the strong aroma of alcohol, like paint stripper.

“What is that?” I asked.

“Methylated spirits,” he replied. Just what everyone wants.

After the methylated spirits had evaporated, my neck received a generous dusting of talcum powder, followed by a stern wire-brushing of the face to remove the excess hair. I parted with 15 sudanese pounds for the privilege- about £4.

Ah well. It should grow back by Christmas...

David xx

Rain etc.

When it rains here, everything stops. Doctors and Nurses don’t turn up to work, but luckily patients don’t tend to turn up to hospital either. Unfortunately for us, this includes internet connections, which is why you may not have heard from us as regularly as we’d like. Still, there we are. It’s been raining a lot here recently which makes for quite a refreshing change in the heat.

In the previous post, I mentioned the exciting developments, which were supposed to culminate today in a big inter-departmental meeting in JTH with the Minister of Health, and all his heads of department in the Ministry. This was precipitated by the audit we’d done, which highlighted the need for some structural rearrangement regarding how acute admissions are handled, together with the need for increased training of the nurses and doctors, increased numbers of doctors, and increased stock of some basic life-saving kit on the wards. Sadly, this meeting was postponed by the Minister who had to go urgently to Kartoum following a bereavement in his immediate family. He should be back in Juba on Monday, so hopefully we can reschedule early next week.

Understandably this was slightly disappointing for us, but of course it’s nobody’s fault. Often I find with such things, you never know how changes in time-frame are going to ultimately work out, and it’s often for the better. We’ll see. Obviously we’ve done all the work for the presentation so we could give it at very short notice - a couple of extra days for preparation certainly won’t do us any harm either.

In the mean-time here are a couple of general photos from last week...

Views of the JTH central courtyard and main entrance.
This where we do a lot of standing and waiting for people...

My friend Dr Daniel (HO) and I in our lovely theatre hats

For all users of Google Earth (and if you’re not using it then you’re missing out) here’s the coordinates of Juba Teaching Hospital: 4°51'0.40"N 31°36'31.46"E Paste that in the search bar and it’ll fly you straight there. Juba’s all in high resolution satellite images so you can have a good look around!

James

Major Progress...

Today has been a very fruitful and significant day...

Firstly, our blog hits passed the 1000 mark, for which I thank you all for your support and interest. It means a lot.

Secondly, I need to update you on some of the recent developments. You may recall that recently we did a little audit. This was actually an idea I had on a bit of a whim, and not one of the original objectives. Improvement in the acute care of emergency admissions (which is almost exclusively dealt with by the junior doctors and nurses) has been our focus of attention for some time now, because quite simply, this is where you can save the most lives, and with basic training, it’s very easy to do. In the study, we looked at the whole hospital population and analysed their admission sheet, to see if basic observations of vital signs (such as pulse, respiratory rate, blood pressure and temperature) were being done (these of course form much of the core of the ABCDE assessment for any sick patient) and where shock/instability was recognised, was the basic treatment appropriate.

The short answer was “no” (75% of admissions hadn’t had a single observation done) and “no” (The vast majority of shocked patients were not given adequate fluids or oxygen.) Where deficits are identified, part of the audit process involves looking into the causes, and making recommendations to be implemented to improve the outcome. Part of the causes were obvious – no oxygen was given because there is none, for example. Fluid mis-management is an issue of training. Probably most significant is the workload of the junior doctors: they are spread so thin it’s hard for them to have time to do what’s necessary to optimally treat the patients in their care.

So, we took the audit to some of the Consultants, who said “this is brilliant – show the medical director.” So we showed the Dr Maker, the Medical Director, who said “this is very useful useful – we need to show this to the Ministry of Health!” So later that Monday, he drove us down to the Ministry of Health, and we presented to the Director General of Research and Development. This directly resulted in Governmental approval for the mass production of obs, drugs and fluids charts to be implemented in Southern Sudan, starting in Juba, ASAP. (Currently there are none, and this I’m sure is part of the reason for the poor results demonstrated.)

But it went further still – on our way out, Dr Maker suggested “actually we should really show this to the Minister...” so he went up and secured us an appointment for today. So that’s the story of how I came to be sat down with His Excellency Dr Joseph Manytuil Wejang, the Minister of Health for the Government of Southern Sudan with my little laptop, presenting our audit to him, and suggesting recommendations. Do not underestimated the power of graphs!

Myself, H.E Dr Joseph Manytuil Wejang and Dr Maker.

I thought that it couldn’t go much higher, but the Minister was so impressed (and also “alarmed” in his own words) that he’s arranged a further meeting on Saturday where he wants us to present it again to his entire cabinet in the Ministry of Health (i.e all the Director Generals of each of his departments) all the hospital heads of department, senior doctors, senior nurses, and as many junior doctors as possible. This is an unforeseen and very encouraging outcome, because it shows he’s taking this seriously.

The reason that the Staff at JTH are so keen that we present these findings to the MoH is because they support what they already know, ie there’s not enough doctors, not enough equipment etc. but they’ve never had hard data (and graphs) to prove it. Worse still, it proves that such deficiencies are directly having a negative impact on the health (and even mortality rate) of the people of Southern Sudan. Hence they’re very interested in using the results to support an application for more funding to improve services. We’ll leave the specifics of that to the different heads of department, but now we need to prepare for the mother-of-all audit presentations on Saturday.

David and I remain completely blown away at the magnitude that the St Mary’s Juba Link is having here - I don’t think any of us expected to shape national health policy! We’re incredibly grateful to be here as part of this project and are very excited about what the future holds. We’ve got a lot of other irons in the fire as well which we’ll tell you about another time, but it’s really rewarding to see things beginning to come together.

Watch this space!

All the best

James

Juba Link News

Dear All,

After many days of work the latest issue of the official Juba Link news is now available.

Click on the image below to download.

Enjoy!

James

Teaser

We had a very intresting and productive day today, but you'll have to wait until tomorrow to hear about it...!

In the mean time, here's a Praying Mantis we found on our window...

The more amusing sides of culture in Juba Teaching Hospital

"When in Rome do as the Romans do...” The same applies to Juba. Culturally this place is very different from the UK and every day we learn some new quirks. I have already spoken about the vigorous hand shaking that goes on here but there are some other things that are even more novel.

Wedesday in Juba Teaching Hospital

Wednesday is cleaning day in JTH and on Wednesday all wards are cleaned from ceiling to floor- no stone is left unturned. All patients are taken outside and wait in the shade with their drips, drip stands and other medical paraphernalia:

Patients in beds outside the male acute admissions ward, whilst cleaning is underway

A hosepipe is then brought into the ward and the whole area is meticulously cleansed, kind of like watering a garden in the UK. The patients beds and mattresses are then vigorously scrubbed and dried and the patients are then laid back on the beds and wheeled back inside. The whole process starts at 9 am and normally finishes at lunch time.

The hollowed out shell of the male acute admissions ward.

The water on the floor in the foreground is from the hosepipe.

Punctuality at Juba Teaching Hospital

In the UK when we are told that teaching starts at 9 am, if you are even 5 minutes late, there is a sharp intake of breath on your arrival. In Juba if you organise teaching at 12.30 pm, then at 12.30 pm the room will look like this:

A very empty conference room at 12.30 pm, the start of our teaching session.

I promise our teaching isn't really this bad.

When I spoke to one of the Obs and Gynae Consultants, he said “If you start teaching at 12.30 pm then people will start arriving at 1.15 pm and by 2 pm you should have enough to begin teaching. There is ‘UK time’ and then there is ‘Africa time’. But ‘Sudan time’ is in a different league.

When the rains come in Juba Teaching Hospital

During the wet season, when it rains, it hammers it down. Everything stops during the rain- it’s kind of like England when there is a light dusting of snow. All the wards run with a skeleton team because there are many absences and even the usual 500 patients a day remain at home- outpatients was like a ghost town this morning. We were teaching today and the event had to be postponed.

This is normal in the Southern Sudan and I am not quite sure why. There is an interesting mentality here which I really do warm to. On the one hand, there are these interesting little eccentricities. On the other hand, the Southern Sudanese are likeable, hard-working people who are polite and complimentary at all times. When you meet the Southern Sudanese, they make you glow on the inside, kind of like a warm brandy on a cool Winter's day. Sumptuous people. I love them.

Ta for now,

David

Students, X-rays, Audit

Yesterday we said goodbye to Tiff and Becky, our excellent medical students on elective here. They're off to UK via a well-earned little holiday in Kenya. They've been working really hard here and made a good impression with all the departments in JTH and we wish them well in the future!

I've mentioned gun shot wounds before, and there's no need to really really labour the point. I did however want to show you a remarkable x-ray. This was a 7 year old child who was one of the many patients who came in from the countryside following some tribal conflict. She'd taken a bullet from above the shoulder. Amazingly, she was completely asymptomatic - a really happy and well child! She was discharged a few days ago.


I'm currently also working on a follow-up Grand Round teaching session on Fluids and Shock for all the doctors to be delivered on Saturday. I've finally finished the first draft of an audit looking at the acute care here. It basically shows that David and I are spending our teaching and training time in the right areas! It's the simple things that can make a difference here. (Hence the teaching on ABCDE, Fluids, Shock etc...) Below are a few of the graphs which illustrate some of the salient points. I hope when I re-audit later on we can demonstrate some measurable differences that the link has made to Juba.






That's all for now.

James