Written by Dr Clare Attwood
Here is my next blog from the rather unpredictable and rather intriguing world of South Sudan. I have included aspects of life and of medicine, so feel free to pick and choose what you read!
One of my aims in coming out to South Sudan was to promote spinal anaesthesia for caesarean sections. Countless studies have proven that regional anaesthesia is safer for both mum and baby when compared to general anaesthesia…. let alone when compared to Ketamine anaesthesia. Ketamine is the drug of choice at Juba Teaching Hospital and it is now becoming apparent why that is. There are not doctor anaesthetists, but there are specialist nurses (known as medical assistant anaesthetists), who have mostly been working with Ketamine for donkey’s years and have had no ongoing training since starting work. Ketamine is easy to use and it can be used even when there is limited equipment. For example, we have one pulse-oximeter (oxygen saturation probe) in the whole of 3 theatres and this is temperamental at best. When taking over a patient’s airway, a pulse-oximeter is a must. With Ketamine, the patient maintains their own airway (unless they obstruct with increased secretions – one of the many pitfalls of Ketamine) and oxygen saturations are less of an issue. It also means less face masks and endo-tracheal tubes are used – something that there are not many of, as there is not always oxygen in the tanks – meaning that we have to make do with the lower concentrations delivered by the wonderfully reliable oxygen concentrator. Ketamine is also in bountiful supply, whereas most other medications are not. In summary, there are multiple obstructions to using anything apart from Ketamine. However, the anaesthetic assistants are sometimes using spinal anaesthesia and seem open to the idea of using it more and the spinals that I have been witness to have been brilliant. I did question whether we could give a patient an Entonox (“gas and air” – 50% nitrous oxide, 50% oxygen) combination to use in addition to their spinal anaesthetic, in order to help with the inevitable “push and pull” sensations associated with a caesarean section. The head anaesthetic assistant, a lovely guy, was absolutely certain that this was a very bad idea, as “why give a general anaesthetic when the patient has a spinal?”. I tried to explain the benefits, but he was not budging and I really didn’t want to create tension about something so relatively trivial. I was left wondering why he thought it would put the patient to sleep, when not even 100% nitrous oxide (the pain relieving component of Entonox) would anaesthetise most people. This, however, soon became clear…….
Having only seen lots of Ketamine anaesthesia and a few spinals, I’d been wondering what they have been using to keep patients asleep for major operations, ie. when a patient needs to be kept asleep for longer than a bolus of Ketamine…… it turns out not much! They have been anaesthetising the patients with a bolus of Ketamine and then giving them the Entonox combination for the rest of the procedures. Arriving half-way through a nephrectomy (I had just anaesthetised for another emergency c-section – spinal of course!), I asked what else they were giving to the patient to keep them to sleep, as I noticed that the anaesthetic vapour canisters were all empty and they denied giving further Ketamine. They looked at me like I was crazy – Pancuronium (a muscle relaxant), of course! However, as any UK anaesthetist knows, this would just be paralysing the patient, so they couldn’t move. I (silently) freaked out after quickly realising the likelihood that some of the patients will have been awake but unable to move during surgery, including the patient in front of me having major and painful surgery. The patient was demonstrating a panic response of sweating, tachycardia (high heart rate) and hypertension (high blood pressure). Luckily, the 3 anaesthetic assistants were open to listening to my concerns (relayed gently and as non-dramatically as possible). When I was racking my brain for the best solution, I discovered that they actually have some supplies of Propofol, which is an IV anaesthetic. However, they have never used it, because no one has ever shown them how and also because “that’s the drug that killed Michael Jackson”. Even the surgeons questioned if I wanted to use such a “dangerous drug”? I explained to everyone that Propofol is the best drug that we have in the UK and that Michael Jackson used it because he was rich and wanted the best! I explained that it is relatively safe when used correctly and quickly worked out a bolus-based protocol (talk about thinking on your feet!), as there are obviously no syringe-drivers. I have demonstrated its value in two further major operations and the anaesthetic assistants are now accepting teaching on the topic. I will teach about this before trying to evangelise about spinals. The thought of more patients being awake for their laparotomies is just too horrible.
Despite these experiences, the anaesthetic team have been very welcoming and appear reasonably open to accepting my assistance. They are fully aware that they are not fully anaesthetically trained (they openly admit that their role is to assist the anaesthetist, but there have rarely been any doctor anaesthetists to assist), but have stepped into the breach when their hospital has needed them. They are aware that they lack the most basic of equipment and drugs, but are making the best of what they have. One of the anaesthetic assistants said he had better equipment when working “in the field”, during the war. Ketmaine-based anaesthesia is what is used for war casualties, when equipment and expertise are often lacking. The anaesthetic assistants are bright and enthusiastic and are often surprising in their ability to “make do and mend”. I look forward to working with them over the next few months.
Teaching the nurses about “Malariology and Triage” is going well. Our course is going down a treat and 75% passed an exam that we held at the weekend. I really think that this is where we can make the biggest difference. I’ve also written a triage assessment tool and hope to have it accepted by the hospital, so we can put our hard work into practice and save some more lives. The head nurses seem keen, but the issue is, as always, a distinct lack of staffing and equipment.
After a rocky start with attendance, the Consultants (and even some of the juniors) are now coming to our Postgraduate Medical Education course. We hold the session twice weekly, introducing a new topic each week. We have even been asked to come back sooner, so that we can teach them more quickly – a fantastic response! I appear to have gotten over my fear of presenting to large groups of senior doctors. Thank goodness! David and I are also heading up a number of audits and research projects between us, keeping us in contact with most departments and practicing what we preach. It’s just a shame that this all involves so much work and that we have both always had issues saying “no”!
Thank you to everyone who got in touch on or around my birthday. I had an interesting day (the day of the nephrectomy) at work and then went for a walk with Dave in the evening. Being on South Sudan’s only bridge over the Nile at sunset was beautiful. I took some beautiful photos. The only downside was that the military police made me delete them. It seems that there is still some residual paranoia – this is what comes from decades of war. Although I’m not sure that we look like typical North Sudanese spies about the bomb the bridge (let alone that most of the photos were not of the bridge itself!). Oh, one other downside was when a crazy lady chased me and tried to pull the clothes (much less nice than hers by the way) off of my back! I still don’t know why and didn’t stick around to find out!
We went to a wedding on Saturday. It was one of the doctor’s from the hospital. We were very honoured to be invited and were the only white faces in the crowd. And I mean a crowd! There were around 2000 people seated and about 500+ more standing. It was an amazingly noisy, amazingly happy and amazingly long evening (but not boring). The pomp and ceremony was something to see. So many different stages and all to a mixture of 80s love ballads, hip hop and African beats. Somehow it all worked well. When 1000 ladies start doing the high-pitched “yeyeyeyeyeyeyeyeyeyeyeyeyeye” on top, it was so loud but so wonderful. I have some videos and photos to remember the experience. The journey home was another experience in itself. We couldn’t get hold of our taxi driver, but one of the senior administrators said we could use the hospital bus to get us home (this was at 1.30am). We were grateful that this service had been arranged for hospital staff. When the bus arrived, the driver was surprised that we said we didn’t mind sharing the bus home with lots of the nurses we had bumped into. We fit about 30 people onto the 20 person bus and wondered why the nurses were so grateful to us both, instead trying to redirect their thanks to the driver. It was a very fun journey, with lots of singing, more “yeyeyeyeyeyeyeyeyes” and some pretty horrendous roads to various tin shack homes. It turned out that the bus had been especially arranged for me and Dave and that the nurses would otherwise have had to walk the whole way home (we think – the language barrier persists, although our Juba Market Arabic is slowly improving). The thought that this had been arranged for us, when we had been so stupid as to not book a return journey in advance and the thought that these nurses were so lovely and happy and grateful, when faced with such an ingrained class system, was rather humbling.
Anyway, apologies that this blog is even longer than usual. I do find the process very cathartic! Any comments, suggestions and support is always very welcome.