A twilight of Ages

A view of the maternal child centre with the relatives letting their clothes dry in the morning air

“Have you ever read Lord of the Rings?”

“I have seen the film,” Richard, one of my new house officers replied.

“Ah, the book is so much better.” I replied “Tolkien has a way with words that allows you to shut your eyes and imagine the world in his book. You can imagine all of the colours, the landscapes, the characters… did you know that after the Bible, Lord of the Rings is the most popular book?” He smiled and looked at me incredulously.

“Anyway in Tolkien’s book he talks about the four ages of middle earth. In many ways I think South Sudan has had four ages. The first age started at the dawn of the Egyptian empire and ended in 2006 with the CPA. It was a troubled time, where South Sudan constantly had its resources plundered and there was warfare and misery. In 2006 we entered the second age, a time where there was no infrastructure and we started from scratch. Indiscipline was rampant, attendance was poor and apathy- the arch enemy of healthcare- ruled the land.”

“We are now entering a third age, the age of change. This is the time where you undergo training, and become the consultants of tomorrow.”

“When that day comes, we will enter a fourth age, a land of blossoming leadership, of high quality primary healthcare, of patient education, a land where endoscopy units blossom, where we see renal dialysis, intensive care, and cardiology centres. This is a story that lies in the future. This is the story that you well tell when you become tomorrow’s consultants.”

“Why am I telling you this, Richard?” I asked with a wry smile on my face.

“I am not sure, Dr David!”

“Because this, my friend,” and tapped his admission clerking “Is a high quality clerking that is of the standard of a UK medical officer. The history is excellent, the examination is good, you have synthesised a sensible differential diagnosis and formed an appropriate management plan for the patient. I have absolutely nothing to add except that I think we have entered the third age.”

One of my medical officers examines the abdomen of a patient who has presented with weight loss. A house officer in the background re-clerking a patient

Richard was not the only one. I have inherited seven new house officers this week and this was their first week of medicine. The first week of January is an abysmal time for a change over.  All of the patients stay at home over the Christmas period and slowly start getting more sick. They then present very late and roaringly septic during the first two weeks of the new year.

My first batch of house officers. They really enjoyed their stay on the EMW and during this time learnt many of the skills of a good house officer. They did not really want to leave! From left to right: Drs Sandra, Grace, Elizabeth, Me, Intifada, and Nowella. To say thank you they all baked myself and Clare some biscuits (see tin). Yum yum!

I was the most senior doctor on the ward for this week. I gave my registrar a week off (he had worked Christmas and had not had a holiday since April). I had two medical officers (both good), and I kept back two house officers who we had trained over the last two months. The week was really busy. We were still dealing with the fallout of the major incident from last week and I had twenty men from the Nuer tribe on my ward. The ward overflowed, with patients on the floor and out in the veranda. It was by far and away the busiest ward in the hospital.

The Minister for Interior Affairs is taken to see some of the gun shot victims on the Surgical Ward. Things are settling down here and the refugees have been transferred to another area. We still get the occasional trickle of casualties.

During the week I inducted all of the new doctors in the ABCDE management of the sick patient and told them the one golden rule of medicine; the diagnosis lies in the history- what the patient tells you. In the meantime, my medical officers and ‘senior’ house officers showed them how to keep a patient list and taught them their roles.

The teaching immediately proved useful. I was called to see a lady who looked like she was dying. She was only 18 and her baby was beside her comfortably sleeping. She had stridor, a sign of impending airway obstruction. The house officers performed the ABCDE assessment and began supporting the patients airway with an ambubag (a means by which we can force air into the lungs and ventilate the patient). The stridor broke spontaneously and in doing so saved two lives.

On Wednesday a lady arrived to the EMW who was a known alcoholic and had cerebral malaria with aspiration pneumonia. For you medics out there, her oxygen saturations were 88% on 5 litres, her respiratory rate was 30, pulse 140 and we occasionally got a blood pressure of 80/60 (for you non medics, this is level 10 badness). Her family were poor and she had presented late because they could not afford the healthcare. So we opened the cupboard.

Despite our best efforts her organs were failing. Her kidneys stopped working at 5pm and any fluids we gave her to improve this ended up in her lungs. Slowly and inexorably the battle was being lost. She died peacefully at 6 am in the next day.

It was a sad tale but in many ways it was a remarkable one. If this had happened in July, she would have died with her family wracked with guilt that they could not afford her healthcare. This time it was different. She received the same care that a standard bed in a UK hospital could provide. She had access to the same equipment and drugs as anyone who had money. She received vital signs, urine output, oxygen, and cardiac monitoring. However, most importantly of all, she had a high care nurse who could monitor her and a junior doctor on call who would know what to do. It was a day that in many ways made history. Firstly, the country had witnessed its first level 1 intensive care bed. Secondly, we are a long way from healthcare being free for all. However, we are now at the stage where healthcare is available for all. She was not the only one. Several other patients have since received level 1 ITU support.

Sandy, our first high care nurse. The patient received suction, oxygen and cardiac monitoring.

Throughout the week I have seen a progressive improvement in the quality of clerkings. It is really good as a teacher to see your students learn what you have said. However, the greatest moment occurred when two of my house officers presented cases and I realised that I had nothing to ask in the history. They had asked all of the questions. “Martin, James,” I said. “This history is of a standard that a medical registrar in the UK would take. It would pass MRCP PACES. I have nothing to add other than to say if this is what you have achieved in one week, then I can’t wait to see what you are capable of by the end of your stay.”  I swear I was not lying and they beamed from ear to ear.

On Saturday I walked in to work to find a woman in a pool of blood. She had a peptic ulcer. We immediately ordered an emergency unit from our new blood bank and her relatives were screened as blood donors. I was surrounded by doctors who were putting in IV lines, squeezing fluid into her and getting blood from the bank. As I was putting in a cannula, I smiled thinking how this reminded me of a UK emergency. She had IV omeprazole (yes, IV omeprazole but the family had to buy it!). Today she looked at me and smiled “I praise God for Juba Teaching Hospital and for my life!” I told her to tell her family and friends to continue donating blood. As we enter the last week of our stay, I reflect upon the changes I have seen. I have witnessed a real change in attitudes. The house officers are working hard and want to work hard. All of our patients are being re-clerked on arrival. Jobs lists are being kept. Doctors are no longer absenting themselves from work. We have equipment, drugs, and high quality nurses who regularly check the cupboards to ensure we don’t run out.

Every Christmas, His Excellency Salva Kiir donates seven bulls to JTH. They are killed and the meat given to the patients and staff. Here are some people trying to keep them from rampaging through the hospital.

Clare has had a similarly good week and I think that her story deserves a separate account and blog post. As we enter the closing days of our stay, there are a few more loose ends to tie up and hopefully some more happy endings.

I thought I would end with a rather amusing photo taken on New Year's Day on my way to work. Two motorcycle drivers with their vehicles laden with live chickens.

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3 Responses to A twilight of Ages

  1. Frankie Dormon says:

    Please come and share some of your experiences on your return with us in Poole, so that we can spread the word to Wau – sending the same messages. You should be really proud of your achievements. Both of you.

  2. Don Attwood says:

    ‘All’s well that ends well.’ It’s great to finish on a positive note and to know up and coming medical professionals now have the training, energy, drive and enthusiasm to continue their challenging work improving Health Care services for both rich and poor in their own newly formed country. What a fantastic achievement which all involved should be very proud of and whom should be congratulated. Lets hope this model approach can be equally applied elsewhere and the enormous benefits derived can continue in the future. Us Rotarian’s look forward to your talk and sharing your experiences when you visit us in Gibraltar.
    Don Attwood

  3. Edward says:

    That is a great post David. And that last photo was funny. However, you did not take note of the terrible new year’s accident in the background between the saloon Mark II car and a UNHCR hardtop landcruiser where the people are congregating. The victims ended up in JTH, of course.

    It was great having you and Claire in Juba for the last three months. Have a safe trip back.

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