St Mary's Juba Link Travel Blog

New Blog

2009-09-12T18:24:00.002+03:00

I've just started publishing a new blog concerning my time in Juba 2009.

Please refer to http://onedoc.blogspot.com for further details...

James

There and back again

2008-12-14T17:13:00.008+03:00

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

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

Some of our EMW nurses with new uniforms plus Sister Anna

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dave and James

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

Performance = (Knowledge x Motivation) / Obstacles

2008-12-11T23:21:00.007+03:00

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

One of the Nurses expressing her thanks for the training

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D & J

Endings

2008-12-08T21:09:00.005+03:00

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

Dave teaching our nurses the finer points of the glucometer

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

Louis' family and house

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

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

Louis and Baby Danga. A proud father.

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

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

Some of the key players in Comboni.

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

Jubalicious...

The UN, Statistics, and School Children

2008-11-27T20:37:00.007+03:00

Hi there.

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

*(can't do superscript in blogger)

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

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

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

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

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

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

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

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

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

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

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

OK, that will do for now.

Jem-ez & Daff-eed

For the people we leave behind

2008-11-24T20:17:00.010+03:00

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

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

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

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

Clean-shaven Richard

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

Richard "Hell's Angel" Kattan

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

http://www.justgiving.com/richardkattansmovembermission

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

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

Sophie and Tom relaxing after the South Down's Way

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

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

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

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

See you all soon,

David

Life

2008-11-23T21:44:00.002+03:00

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

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

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

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

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

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

In our ward, life has become precious.

David

Quick Follow-up

2008-11-18T20:54:00.003+03:00

Very quick post:

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

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

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

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

James & Dave

More Emergency Anecdotes

2008-11-17T23:35:00.004+03:00

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

Hello again everyone.

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

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

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

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

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

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

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

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

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

Sunday:

I took my first day off in four weeks

Monday:

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

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

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

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

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

So it’s all fun here in Juba!

David & James

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

James

Progress

2008-11-13T21:17:00.003+03:00

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

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

The new emergency ward is up and running!!!

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

James ducked out of surgery today to help in medicine

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

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

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

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

The improvised salbutamol spacer

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

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

See you all soon,

David

Emergency Medical Unit

2008-11-12T20:23:00.010+03:00

The enthusiasic new EMU staff

Two steps back...

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

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

...and one priceless step forward

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

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

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

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

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

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

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

Ta for now,

David & James

Acute Care

2008-11-10T23:04:00.005+03:00

Hello

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

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

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

Enough from me - a few words from David now.

James

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

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

Yesterday we took three huge strides:

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

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

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

David

Sunday Ramblings

2008-11-09T15:53:00.008+03:00

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

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

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

The ferry over to the island

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

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

Mangos ripening at Comboni

A large beetle I found

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

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

James

Cows, Birthdays etc.

2008-11-07T11:40:00.005+03:00

Hello again everybody,

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

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

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

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

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

Sister Anna teaching nurses

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

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

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

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

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

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

Dave's second party of the night at Comboni

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

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

David

The breaking of the fellowship...

2008-10-28T20:38:00.005+03:00

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

David and Dario at our poster/stall.

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

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

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

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

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

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

James

Guest Post from Zorina

2008-10-23T09:31:00.004+03:00

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

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

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

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

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

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

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

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

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

Just Giving

2008-10-20T09:02:00.003+03:00

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

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

I have to go for my ward round now.

James

Some more...

2008-10-16T17:50:00.005+03:00

Hello there

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

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

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

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

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

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

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

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

James

Recap

2008-10-09T20:29:00.007+03:00

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

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

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

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

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

Intensive care unit at Juba Teaching Hospital.

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

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

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

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

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

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

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

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

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

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

All the best,

David

A Brief Aside

2008-10-07T10:47:00.002+03:00

Dear All

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

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

That's all

James

A wind of change...

2008-10-06T20:34:00.005+03:00

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

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

“Excellent presentations.”

- Medical Officer, JTH

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

- House Officer, JTH

“More presentations please in other topics.”

- House Officer, JTH

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

- House Officer, JTH

“Try to keep talks under two hours!”

- Registrar, JTH

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

- House Officer, JTH

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

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

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

- Consultant, JTH

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

- Registrar, JTH

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

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

David xx

The Triage Experiment

2008-10-04T11:11:00.009+03:00

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

Our brand new flag pole in JTH

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

Triage

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

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

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

1) Was the triage model any good?

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

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

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

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

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

Could this be the world's largest name badge?

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

All the best,

David and James

A good weekend

2008-09-27T23:23:00.005+03:00

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

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

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

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

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

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

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

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

Sorry there’s not more photos today.

James

Some more news

2008-09-24T11:27:00.002+03:00

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

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

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

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

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

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

James

"I'm Listening..."

2008-09-21T00:14:00.004+03:00

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

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

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

James

On Monastic Life...

2008-09-19T20:20:00.014+03:00

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

Fr Valentino in the middle there.

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

Birthday party in full swing

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

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

That'll do.

James

A Good Week

2008-09-19T20:20:00.008+03:00

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

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

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

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

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

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

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

All the best,

David xx

Our new office - the hub of learning...

2008-09-16T18:11:00.009+03:00

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...

2008-09-14T20:48:00.002+03:00

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.

2008-09-14T00:13:00.007+03:00

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...

2008-09-10T19:20:00.003+03:00

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

2008-09-09T22:34:00.004+03:00

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

2008-09-08T20:34:00.002+03:00

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

2008-09-06T19:19:00.006+03:00

"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

2008-09-03T10:36:00.004+03:00

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

Easy as ABCDE...

2008-08-31T20:27:00.002+03:00

The Blog went well past the 500 hits today so thank you all, it’s good to know people are interested in our little adventures.

We had quite a full but also productive day yesterday. We'd prepared an afternoons worth of presentations and practice scenarios on approaches to the recognition, assessment and early management of the sick/unstable patient. This was very much aimed at the junior doctors here, but there were a lot of consultants from the different specialities there too, probably around 30 in all.

Starting with A...

Overall the afternoon went really well. We were just teaching the real basics (the ABCDE scheme, Airway, Breathing, Circulation, Disability, Exposure) which hopefully will provide a good foundation for all that comes next from us and others. We made the lecture style quite interactive which they really warmed to. (I get the impression that the usual method of medical education is much more formal...)

Physiology of circulation

At one stage I demonstrated the scheme in real time on a model patient (Dave) and the challenge was that I had to detect the pathology the audience had picked for him, and unknown to me. This lead into a section to round things off where we ran a few simple ALS/ATLS style practice scenarios in small groups to check they could put it into practice. To be honest this had somewhat of a mixed response – everyone tried which was good and some did well, but some of the doctors (at SHO level) really struggled. If normal undergrad teaching is formal / by humiliation and an interactive lecture is rather radical I reckon the concept of actually role playing scenarios was way out of their comfort zone which may have been part of the problem. Medical education is challenging even within a cultural framework that’s very familiar, let alone trying to address the issues of cross-cultural contextualisation. It does however pose us the interesting question of how do you make it even simpler than ABCDE? (That’s not a rhetorical question by the way, I’d love to hear suggestions.)

O2 applied, the patient feels much better. Capillary Refill is normal.

I think it all adds up to the realisation that these things are going to take time, hard work, perseverance and patience. None of this should come as a surprise really, so I suppose we’re just going to have to stick with it re-emphasising the basics, and try to provide positive role models in the way we go about our clinical work.

Overall as I mentioned the whole thing went down really well. I think it helped show them that we were serious about being here and the contributions that we can make, even as non-specialists. The consultants in particular absolutely loved it, and want to make it a weekly Saturday afternoon inter-departmental teaching session, so I think we’ve just inadvertently started Grand Rounds in JTH!

James

A few odds and ends

2008-08-30T08:43:00.004+03:00

Life is treating us well in Juba. We're working hard of course, but it's great fun. One of the medical elective students had a birthday the other day, and we all went out in the evening for food and beers with a bunch of other ex-pats from various NGOs. I actually had a very decent burger! There are some (admittedly expensive) but pretty nice places to eat out here. Obviously Dave and I have to do a little more exploring to find them all...

Below are a couple of interesting bugs we've found, both rather large.

Today Dave and I are making our formal teaching debut at JTH running a few sessions for the house officers on the recognition and early management of unstable patients, just the basic ABCDE stuff really. The Brothers here actually have a video projector which they're kindly lending us, for the day. (JTH doesn't have one, but it would be really educationally useful if anyone has a spare...!)

Naturally last night we had to test the compatibility... :o)

I've finished collecting and analysing data from the first round of an audit we did last week, and there are some really interesting results. I have to write it all up, but more on that later.

Bye for now

James

Trauma

2008-08-28T22:41:00.002+03:00

Trauma is a really big problem here in Juba. I’d say gun-shot wounds and RTA’s make up the bulk of our acute surgical takes most days. (Here surgery and orthopaedics are all one.) In fact, they experience what we would call a “major incident” at least once a month! These usually take the form of mass road accident casualties etc.

Well we had the first one of our trip last night. There was some tribal conflict (cattle raiding I believe) in one of the rural regions three hours out of Juba. This actually occurred three days ago, but the bus load only arrived today to JTH. There were about 20 dead, 50 injured. The majority of these were gunshot wounds and lacerations including, sadly, women and children with bullets lodged in various places. Amazingly, most of the patients were haemodynamically stable (I assume because the sicker ones had already died) but we still took 15 to theatre this afternoon on the trauma list. Generally surgical debridement was the order of the day (wounds three days old were by now horribly infected) along with fishing out the shards of bone shattered by bullets and fixing the fractures. I’ve never seen actual bullet injuries in the UK and I hope I never have to. They’re horrible.

There’s certainly a lot of challenges to meet in the acute care here, (especially given the volume every day and frequent major incidents) but we’re making progress. Obs and drugs charts are being printed by the MoH. The seniors here recognise the need and are supportive of our efforts, which is very encouraging. We’ve been given an office for the link on site. We’ve set out a teaching programme on some of the basics of assessment of the sick patient, which we begin on Saturday. We’ve completed the first cycle of an audit assessing the quality of the acute care. We’ve indentified a suitable ward to setup a rudimentary A&E Resus, and are currently looking at different models of triage.

There’s a lot to do, but there are so many opportunities out here: it’s brilliant. The hospital’s really moving forward and it’s exciting to be a (small) part of it. And the weather here is beautiful!

James

A doctor's life with 500 new patients a day

2008-08-27T21:14:00.008+03:00

Good evening everyone. I thought it was about time I made an entry on the Blog following an email from various individuals demanding an “Attwood-esque” installment. Well here it is...

Now I used to work at an A&E department when a busy day was 140 admissions. On my first day I went to the outpatients department and was greeted by this:

The day carried on in a similarly unusual manner as James has alluded to on his correspondence. Suffice to say my first day was a culture shock. However, many lessons were learned including the importance of coming to the hospital with toilet roll on your person.

Being of a medical persuasion, I find this place fascinating. It is literally alive with pathology and I have seen things that I have never seen before. Cerebral malaria, TB, HIV, more ascites than you can shake a stick at, splenomegaly, hepatomegly, and proximal myopathy. Yesterday I diagnosed my first ever diastolic murmur possible caused by mitral stenosis and today I saw a case of tetanus- just like in the textbooks! (sorry about this paragraph, all of you non-medics)

Sad things are seen here too. A 22 year old man came in with cerebral malaria and despite our best efforts we couldn't stabilise him. He presented too late and died later on that day. In St Mary's he would have been for full escalation of treatment and would have been ventilated on intensive care. He was a student at Juba University, no older than the medical students we have here with us from Southampton.

Sometimes the problems here seem so big that if you think about them all at once everything seems so impossible. However, the Southern Sudanese are the most inspirational people. After a war lasting 40 years, they remain optimistic and are working hard to re-build their country. Juba has already changed since I visited in March. The main roads in Juba are now all tarmacked and there are pavements, too. New housing is being constructed and buildings are constantly going up.

Things have changed in the hospital, too. It now has power 24 hours a day and has a new health resource centre with 8 wireless computers and a load of laptops. On my first day there was a computer course and they were being taught how to use Microsoft Access!

These people are truly remarkable. They are tenacious and optimistic in life and they are very industrious. They have interesting mannerisms that I am still learning. Everyone shakes hands here. If you see someone you know, you shake hands. If you see someone you know well, you slap your hand into another person’s hand before shaking it vigorously. It is common for men that are good friends (in the platonic sense) to hold hands whilst walking. This happened to me once which was... novel.

The staff here are very optimistic about the St Mary’s Juba Link. Yesterday we had a Link Committee meeting and they were so kind, complimentary and accommodating- it is this and their hard-working attitude to life that gives myself and James the desire to keep working alongside them. I only hope that we live up to their expectations.

I don’t want to tell you everything. I think little instalments are much better than one long email. So I shall sign off for now and tell you a bit about the culture in my next update because this in itself is fascinating. I leave you with a photo of me and James beavering in his room and another photo that we took for teaching this Saturday, where we try and demonstrate how scary it could be to take care of the sick patient if you know nothing!

All the best, team. Bye for now.

David

Whoops

2008-08-27T09:05:00.004+03:00

I had a little problem with my bathroom today. (Not my fault I hasten to add!)

The Brothers here all have different skills, and I'm waiting for the DIY Brother to fix it for me. I'm going to be late for work though...

James

Our trip objectives

2008-08-24T21:53:00.012+03:00

Hi there.

We’ve been observing emergency and routine ward work for a couple of days now, so I thought it was about time I discussed some of the professional aspects of our stay here.

Our role here is still developing, but over the past few days of clinical observation, discussions and meetings with the seniors here in both medicine and surgery, a few common strands are emerging. In brief, we feel that the main way we can be of use here is in the teaching and training of the junior doctors, both in formal settings and by modelling our approach to them in our clinical work.

There are several issues to be addressed, but one of the most important is the quality of emergency care (medical and surgical) delivered in the acute setting. It would be useful at this stage to describe the current system:

Description of the Accident and Emergency department
The outpatients department has become one of Juba teaching hospital's biggest challenges. It functions as an Accident and Emergency, Outpatient Department and Primary Healthcare Clinic all rolled into one. However due to the sheer volume of patients (around 500 attend the unit every day) there are serious problems with fulfilling its roles.

There is a central seating area in the middle with disabled access that is flanked by the pharmacy, laboratory, and X-ray dept. In front is the Emergency Ward with 9 Emergency beds. There are no fluids, giving sets, cannulae or drugs. In the top right hand side and to the right are 6 small consulting rooms about 3m x 3m (some smaller). Medical Officers (SHO equivalent) from the specialties Pads, O&G, Medicine, and Surgery sit here and interview patients

A&E/OPD

How the department functions
There is no triage. Patients book themselves in at reception and depending on their presenting problems are sent to various specialties by an untrained receptionist. For example if the patient has a limb problem then they are sent to the surgeons. This system is often inaccurate. Worse still, sick and unstable patients are not being recognised. David described on his first visit how poorly patients, lying on the floor, were stepped over so that well patients with minor complaints were seen. He also found a patient whom no one knew, who hadn’t been seen by a doctor, had died on an examination couch.

From a surgical perspective, my observations have been very similar; the other day I went to the department and found three or four poly-trauma patients lying on and bleeding all over the floor unattended, one with a clearly fractured humorous. The doctors on duty at the time were in the office seeing the patients with hernias who registered first in the queue.

Part of the problem is the actual structure of the department, particularly the lack of triage. The doctors are very over-stretched given the sheer volume of patients they are seeing, and this is something we’ll be looking into helping to alter in the future.

Another issue is the acute care delivered to the emergency admissions in the medical and surgical assessment units. Basic observations are generally not completely done, history and examination documentation are usually rather scanty, and there seems to be an inability to distinguish and prioritise the haemodynamically unstable patients.

David in part of the MAU

David and I see one of our key roles here as teaching the house officers how to improve their basic skills in the recognition, assessment, basic management (including documentation) of the sick patient. We’ve a few things in mind including:

Organising formal teaching sessions to run over and reinforce the very basics of the ABCDE approach, including the necessity of measuring the basic physiological parameters, basic fluid management, when to call for help etc.

Basic training on the importance of documentation

The introduction of Obs charts, fluid charts etc. (Currently there are none.)

Look into the restructuring of the A&E/OPD to include a triage system so critically ill or deteriorating patients aren’t unnecessarily left in a queue

Audit the current system of recording and responding to obs on admission (and identifying and responding to the haemodynamically unstable) then re-audit after training/introduction of obs charts

Model the approach to the House officers in our own clinical work and notes

Naturally there are plenty of other things to get on with now, but I think if we could just lay a bit of a foundation in these simple things we could make a really positive impact, hopefully with improved patient outcome.

I’m sorry if this was a bit of a long post but thanks for sticking with it. We’ll be keeping you updated on how it all pans out but I hope this sets out some of the big picture to put the rest of it in context. As I said, our role’s still emerging...

James (& Dave)

PS I promise the next post will have less text and more pictures!

Some Hospital Photos

2008-08-21T20:26:00.008+03:00

This is the road to JTH which we make twice a day. (This is the main hospital gate just coming up at that white sign post)

Here are some of the hospital buildings. Each ward is in a seperate building so it's more spread out than our hospitals.

This is looking back at the main gate from inside the compound.

Some more wards...

And finally a rather nice lizard I found on the way home this evening.

I hope these put you in the picture a little more about the place. The climate is hot and humid, but generally sunny and the country around is very green. I recall the Indian Monsoon being far more humid and generally unpleasant so all in all it's pretty good.

Dave and I had a very positive meeting yesterday with our bosses here to plan out what we aim to do and what they'd like of us, and luckily the two were pretty congruent. We're pretty excited about the opportunities here, but more of this at a later date. Needless to say they were very welcoming and supportive and it looks like we should have a really useful time here.

Bye for now

James

Life in Juba

2008-08-21T18:09:00.004+03:00

Good evening.

I note that the previous post was rather text heavy, so I thought to break it up a little bit I'd include some basic photos....

Below is my room in the monastry, which although sparse is roomy and comfortable, complete with en suite. The shower is cold or cold, but in this climate is rather nice.

I'll stick up some shots of the hospital in a little while (the upload process with this internet connection is rather tedious!)

James

Safe Arrival

2008-08-20T11:06:00.000+03:00

Hello there

Just to let you know I've arrived safely in Juba. It took a while longer than intended due to a flight delay (7 hours) in Addis. It's not a huge airport, so I became quite familiar with the place. The airport did give us a free lunch. This included some sort of meat dish - I'm not sure entirely what is was but I definitely caught site of a cross-section of vertebrae in there, so I politely declined. The rest of it was very tastey.

Anyhow, myself (and importantly all my baggage plus one undamaged yet very out of tune baby taylor guitar) all arrived ok and I was met by the guys here, so no worries. We appear to be staying in a catholic monastry of some kind. Lots of people there called "Father" who are all very nice. Accommodation is realatively good and the food appears well above average!

I'm still rather tired by it all but generally very excited to be here. No GI upsets so far...

When David and I formulate a masterplan and mission objectives for the trip I'll post again. The internet is intermittent and can be painfully slow, so I'll have to see how it goes uploading photos. I'll do my best as they're far more interesting for you.

Comments / emails always very welcome.

James

Welcome

2008-08-07T23:58:00.007+03:00

Hello there everyone and welcome to our Juba blog...

This is just a little post by way of introduction - this blog is intended to allow friends, family and those generally interested to keep track with our progress, and hopefully should be a little less formal than some of the other publications. We'll also try to put lots of nice pictures up as well.

It's been a stressful week getting everything ready to live and work in the Southern Sudan for the next 4 months, but at last everything is sorted. Dave flew to Juba on Friday and has arrived safely. I've been held up in visa-related logistics and hence am flying this evening.

Save to your favourites now and keep checking how we're doing! We'll both really value the support from all of you back home.

James