Ministers, Medical Department, Miller-Fisher, Motorcycles….and Money

The week has been an eventful one and true to African form, we have witnessed the full spectrum of emotions from the hopeful to the hopeless and everything in between.

This was a great day. The nurses and doctors were there in all their finery. There was clapping and singing and cheering and dancing as the Minister approached

On Monday the Minister of Health visited Juba Teaching Hospital. The Ministry had given a good amount of warning and JTH had time to prepare. As the convoy pulled up they were greated with a massive poster to commemorate their arrival.

I wish I had an entry poster like this to the Royal Devon and Exeter! On the left is H.E. Michael Milly Hussein (Minister of Health), the centre is President Salva Kiir, and on the right is Deputy Minister Yatta Lugor. We sat with Dr Yatta at the wedding.

We all lined up in our lab coats and when the convoy passed through the main gates, the hospital was awash with cheering and cries of “Ye-ye-ye-ye-ye-ye!” After the milieu of hand-shaking, singing, dancing, and general happiness, the speeches began followed by the guided tour of the hospital.

H.E. Dr Michael Milly Hussein and Dr Yatta Lugor shaking hands with the doctors and nurses. Behind His Excellency is Dr Wani Mena, the Hospital C.E.O

At about 11am the Minister arrived on our ward. He looked at me quizzically and asked me what I thought of Juba Teaching Hospital.

“Your Excellency,” I began “I am an outsider and a guest of this hospital. The one thing that I have seen is that the people work very hard. The conditions are hard, yet every day the nurses, doctors come to work for the good of the people of South Sudan.” A spontaneous applause erupted and I could see that the Ministers were happy with this remark. I went on to thank the Ministry for their unwavering support for JTH.

“What problems is the Emergency Medical Ward facing?” the Minister enquired.

“Your Excellency, there are three problems that face our ward:

“1) I would like to create 4 high care beds. However, these high care beds use equipment such as oxygen concentrators require electricity. When power to this hospital is cut, our patients will die.

“2) We lack essential equipment such as cannulas, fluids, and gloves. If JTH could develop its own budget it could source its own supplies and we would never run out.”

Therefore my problems are 1) Power and 2) Equipment 3) We need to be in charge of our own budget.”

Later on that afternoon the Ministry praised the Hospital staff for their devotion to their work and their people and pledged to solve some critical issues facing the hospital.

Shortly after the Minister's meeting to the Emergency Ward it absolutely chucked it down. This photo is taken from just outside the EMW.

The week also witnessed an improvement in the Medical Department. We now have bi-weekly teaching, with a structured timetable that includes case-based discussions, mortality meetings, tutorials, audit presentations (yes, the Medical Officers are beginning to undertake audits!), and general meetings. Attendance to teaching is good.

This Tuesday was a general meeting and we talked about Acute Care (care in the first 24 hours) for the Medical Department. In 2008, James and I had demonstrated that 50% of the deaths that occur in Medicine do so in the first 24 hours. The junior doctors currently work hard and do one oncall every 4 days- this includes days and nights. Despite this, they pledged to develop a rota that included one Medical Officer (Senior House Officer) and one House Officer permanently stationed in the Emergency Ward to admit, clerk and review the sick patients. This will be backed up by final year medical students and should go some way to bridging the 24 hour hole. I told the C.E.O. of their decision and praised them for their commitment to the Medical department.

However, all was not perfect. On Tuesday I admitted a man who had enteric fever two weeks ago, which was treated with antibiotics. One week later he developed weakness of the nerves of his arms and legs. Examination revealed that he had the Miller-Fisher variant of Guillain-Barre Syndrome, a disease that weakens the nerves and causes paralysis of the arms and legs. Sometimes it can be so severe that it destroys the nerves involved in breathing and the patient dies.

His condition steadily deteriorated over the two days of his admission and I started to fear for his breathing. In the UK we would manage this patient on the Intensive Care Unit and he would be ventilated.  He would receive drugs called Immunoglobulins; one dose costs £3,000. If a hospital in the UK can’t provide this care, then they are transferred to one that does. This transfer requires several things:

  1. Tarmacked roads
  2. Ambulances
  3. Paramedics
  4. Supplies for the transfer to ensure that if the patient deteriorates, they can be ventillated.

I have none of the above and the nearest hospital to transfer my patient to is Nairobi, which is an airflight away. This, by the way is a standard economy class flight on a commercial jet plane. We don’t have emergency transfers.

I spoke to the family and explained that without an air transfer to Nairobi, he may die. The nuclear family called an emergency meeting that night. Africa is blessed (and sometimes cursed) with big families with >50 people who all pull together for a loved one. However, even with all these people, they told me that they could not afford the cripplingly expensive airfare to Kenya. In the end it was decided to transfer him, by bus, to Kampala in Uganda. He was discharged from our ward on Thursday at 6am. The family carried him, by hand, to a bus and his twelve hour journey to another country began. The family were fully aware that he may not survive the transfer but also knew that we had little choice; given his progressive symptoms, he would almost certainly die in JTH.

We thought we would end on a light note and a “watch this space” note. Regarding the former, motorcycles or “botta-botta’s” are ubiquitous in South Sudan. They are used for a variety of purposes and we thought we would enclose this rather amusing photo of a goat being carried by motorcycle.

Sorry about the poor quality picture but I just wanted to demonstrate the random things you see on our commute into the hospital!

As for the latter, Friday started with me trying to source equipment for the EMW and ended with me agreeing to undertake a research project that would ultimately show how much JTH costs and allow JTH to develop a business case to have its own budget. More on this next week.

See you round,

David and Clare x

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