“EMERGENCY! EMERGENCY! Doctors, we need you!” was the cry accompanying the loud hammering on the door of our tin shack. The voice was that of Julius, the head of house-keeping. It was 10.30 at night and we had been relaxing and watching DVDs under the mosquito net. We immediately jumped up, scrambled on some day clothes and answered the door. Julius was frantic and asked us to follow him to help one of the staff, Mary, who was known to have “heart problems”. “What heart problems?” we asked as we followed him to Mary’s room. “I don’t know but she just came back from treatment in Kenya,” he replied. The room was tiny and full of scared looking people, but we were allowed through. A lady, who looked about 50 years old, was lying on the bed in the corner. Her airway appeared unobstructed, but she was not breathing. We could not feel a pulse. We had to decide whether to start CPR. That last sentence may sound strange to any medical or nursing staff working in the UK, but here it is a valid question.
CPR is non-existent at Juba Teaching Hospital. If we were to attempt to resuscitate this patient and transfer her to JTH, whilst continuing CPR on the way, there would be possible access to a 3 lead ECG, but no defibrillator at JTH. There would be no access to a ventilator, should we decide to intubate and ventilate her (theatres are closed for all but surgical emergencies). In fact, access to an ambu-bag and oxygen would be impossible on the emergency medical ward. There would be no Adrenaline or other resuscitation drugs. This would all be further impeded by the absence of electricity (and therefore light and power to ECG machines and ventilators etc…….) in the hospital for the last 72 hours.
This is the thought process silently ran through both of our heads. It only took the few seconds that we used to assess Mary, and resulted in the decision that attempts at CPR would be futile. Within those few seconds, David also had the quick thinking to try a precordial thump, as he thought a ventricular arrhythmia was a possibility (and what else did we have to lose?). Sadly, and not unexpectedly, this didn’t work. Mary had died. We then gently informed Mary’s husband that she had passed away. Again, I was in awe of the dignified South Sudanese response to this news: Quiet acceptance and respectful thanks for our help.
David and I walked slowly, in silence, back to our room. I know that I felt guilty. I’m pretty sure that he did too. We hadn’t done anything. This was a relatively young patient, who had had a witnessed cardiac arrest just a few minutes earlier and we hadn’t attempted CPR. That would be unthinkable in the UK. More treatment would have been performed by UK paramedics en-route than is possible in the whole of JTH. JTH has ambulances, but they are used as staff taxis and contain no paramedics or equipment. There are no paramedics in this country. The ambulances are arguably best used as taxis, because there is no number for members of the public to call when they need help in an emergency. The only landline in the hospital is in the CEO’s office.
When back in our room, we discussed what we could have done differently. We came to the conclusion that we had done the right thing and that starting CPR with no hope of continuing it or having the facilities to support a patient afterwards would have offered false hope when there was none. In truth, the outcome in the UK would probably have been the same. I think that what felt worst was that in the UK, Mary would have been given every chance of survival, from the second that help was called for. In South Sudan, we did nothing, because that was the best thing to do.
Below is a diagram of something called the “swiss cheese effect”. It is something that is referred to in the UK, when analysing adverse events, both in medicine and in many other industries.
When the holes in the cheese line up, an adverse event may occur. However, this does not often happen. I have come to the conclusion that in Juba, the cheese is currently made of more holes than edible bits. At the moment, it often feels like a minor miracle if something goes right. However, sometimes this does happen…………..
Not unexpectedly, we had a bit of a poor night’s sleep and woke up feeling less enamoured towards Juba than normal. We made our way to JTH. I couldn’t face the thought of another frustrating day, with no electricity, no running water and limited productive work. 3 straight days of this had beaten even David’s positive outlook into submission. However, when we were greeted by the usual smiling faces and handshakes, things started to brighten up. When we went into one of the offices and noticed a cool breeze, things got even better. When we looked up and realised that the breeze was generated by an overhead fan, we both got a little giddy! The generator had been fixed that morning!
David and I both had successful days from that point onwards. He made a huge dent in a big study that he is doing. I went to theatres, prevented a spinal being performed at about the level of T11/T12 (a level that puts the spinal cord at risk of damage) and then gave a little ad-hoc teaching on the subject. I then proceeded to watch the removal of yet more amazing pathology from another South Sudanese resident. This was a dermoid cyst and it even contained hair! The pathology here is very interesting. To the surgeons here, it is normal. Even the ultrasound reports pre-surgery do not make reference to the size of these lumps, but I have seen HUGE masses being taken out of very small people.
I have seen two football sized masses removed from one lady’s abdomen. She would still have fit into size 6 clothing pre-operatively. Admittedly, it’s sad that things get to this point before people can afford to get themselves (and their family for the cooking and laundry) to the hospital, but it is also fascinating. A pathologist is arriving in Juba soon, so we may even find out what some of these lumps actually are.
I then proceeded to help run the Triage and Malariology course test for this week’s students. Most of them passed and were so happy and grateful for our interest in their work. One issue was that our usual translator (a wonderful nurse called Anna) was on night duty, so our Arabic speakers struggled at first. However, another nurse kindly stepped into the breach. On the way back, I bumped into a group of over 20 nurses, some of whom I knew and all of whom wanted to speak to me….. a lot. I then realised that they were returning from their English lessons and using me for practice. One day the doctors and the nurses may even speak and write in the same language!
That afternoon, David held a teaching session, with full attendance from the medical juniors. This was a first and he was buzzing. I made great progress with one of the O&G juniors, on an audit that we have designed together.
Later, we met up with a team of doctors and public health people from Harvard University. They are here to teach medical students and we would really like to integrate out post-graduate training plans with their undergraduate plans. We also drank beer, ate good food and had a laugh.
This all took place within the space of 24 hours. To be honest, this 24 hours was not as dramatic as some that we have had. It was not even that abnormal. And I was wondering why I have been feeling a little bit tired recently…………………….