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

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

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

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

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

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

“What is that?” I asked.

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

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

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

David xx

Rain etc.

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

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

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

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

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

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

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

James

Major Progress...

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

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

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

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

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

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

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

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

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

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

Watch this space!

All the best

James

Juba Link News

Dear All,

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

Click on the image below to download.

Enjoy!

James

Teaser

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

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

The more amusing sides of culture in Juba Teaching Hospital

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

Wedesday in Juba Teaching Hospital

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

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

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

The hollowed out shell of the male acute admissions ward.

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

Punctuality at Juba Teaching Hospital

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

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

I promise our teaching isn't really this bad.

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

When the rains come in Juba Teaching Hospital

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

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

Ta for now,

David

Students, X-rays, Audit

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

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


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






That's all for now.

James