The breaking of the fellowship...

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

David and Dario at our poster/stall.

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

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

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

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

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

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

James

Guest Post from Zorina

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

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


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

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

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

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

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

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

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

Just Giving

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

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

I have to go for my ward round now.

James

Some more...

Hello there

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

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

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

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

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

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


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


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

James

Recap

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

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

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

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

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

Intensive care unit at Juba Teaching Hospital.

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

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

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

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

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

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

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

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

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

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

All the best,

David

A Brief Aside

Dear All

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

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

That's all

James

A wind of change...

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

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

“Excellent presentations.”

 - Medical Officer, JTH

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

 - House Officer, JTH

“More presentations please in other topics.” 

 - House Officer, JTH

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

 - House Officer, JTH

“Try to keep talks under two hours!” 

 - Registrar, JTH

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

 - House Officer, JTH

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

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

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

 - Consultant, JTH

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

 - Registrar, JTH

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

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

David xx

The Triage Experiment

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

Our brand new flag pole in JTH

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

Triage

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

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

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

1) Was the triage model any good?

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

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

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

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

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

Could this be the world's largest name badge?

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

All the best,

David and James