Night Life

The nights here are dreadful. Usually its so hot in my concrete room that I lie sweating on top of the thin cotton sheet tossing and turning till it becomes a crumpled damp rag that my feet get tangled in and I am left on the mattress. The bed is enclosed in a mosquito net that makes the space seem close and airless. I am always on call so the mobile phone is nearby, but even in the daytime reception is poor and I have great difficulty being understood  and understanding whats being said to me – at night I go outside in the dark and wander about trying to get a better reception but not talk too loud and wake the other ex-pats sleeping nearby. On every second or third night I am First on call so have a small hand-held ICOM  VHF radio/walkie-talkie as well, but it seems to pick up interference from something and intermittently make a noise that wakes me, thinking I am about to receive a call for help from the Hospital, and I lie there waiting for it, and when it doesn’t come I wonder if perhaps its malfunctioning and they are desperately trying to call me and getting no response. I realize now, after a few disturbed nights and phone calls to Maternity to check I was not needed, that it’s a fault with the phone but when youre on call you sleep lightly, and are easily disturbed. On a quiet night at 5 am the call from the Mosque wakes me, but the most horrible thing at night are the packs of marauding dogs. We see them when being driven into the hospital in the dead of night, the only living things on the deserted filthy streets, packs of five to fifteen of them hurrying into the darkness as we approach. At all hours of he night they can be heard, sometimes a long way off and only faintly, but more often closer and sometimes on the street a few meters away barking snarling fighting and howling in number, a dreadful savage and chilling racket that erupts and then ceases after a few minutes with yelping and squealing. We are under curfew so are not allowed out of the compound except in a vehicle after dark, but  that’s not what would stop me wondering the streets – its those  mangy mongrel dogs. So sleep is never good.

A few nights ago, at 2am a call on the ICOM woke me from my usual sweaty and twitchy sleep and suddenly even being awake was a nightmare : “Please come quickly the peritonitis lady is very sick I think she is having a heart attack, I think she is dying”

Oh my God I thought – this was the woman I thought we had rescued from MOH and now she was dying. I dressed feeling sick and hurried to find a driver to take me to the hospital, all the time just feeling sick and overwhelmed and powerless.

On the interminable ride along the potholed mud track that passes for a road I tried to imagine what on earth had happened to her – she had been improving when I last saw her. Actually I already knew what the problem was because I had encountered it already with other patients: we have so few resources here its impossible to provide monitoring and care anywhere near as complete as would happen back home, so effectively we are “flying blind”, just guessing at whats going on inside her abdomen, her chest, her lungs and heart, her blood chemistry. At home such a sick woman would have been in a real Intensive Care, she would have had XRays and serial blood testing and balancing of  a multitude of biochemical and electrolyte markers, continuous heart monitoring, hourly measures of output and input, oxygen saturation, Blood Pressure and kidney function, and of course the input of multiple experts in surgery, intensive care, emergency medicine and nursing – all this and we would have had some idea of what was going right and what was going wrong, what changes  could be needed, what drugs should be changed or added or stopped altogether, how safe it would be to get her to drink or eat, whether or not her apparent improvement was masking sinister new developments. But here we had no idea, we just had to rely on gut feeling, prior experience, guess work, luck…and now it seemed we had guessed wrong.

Earlier that same day,  flying by the seat of our pants we had managed a complicated obstetric patient almost perfectly. She had come in because of vomiting and she was complaining of  pain in the upper abdomen and was discovered to have extremely high blood pressure (240/130 - for anyone not in the know, this is frighteningly high).  She was not in labour and it was her first pregnancy. The baby was alive and she said she was “eight months” Her urine was the colour of blackcurrant fruit juice indicating blood was being destroyed in the circulation (hemolysis,) a very serious complication, but there was very little urine being produced indicating potential kidney failure. A urine test with a dipstick showed abnormally high amounts of protein in it. We guessed she had a serious complication of preeclampsia called HELLP Syndrome but of the countless blood tests we usually would order to confirm this, and repeat every few hours to monitor her progress, and especially to check on her Platelet count, only one was available : Haemoglobin! It was really high indicating her blood was abnormally concentrated. We used all three types of blood pressure drug we have available in Aweil to get her Blood Pressure down to something reasonable and try to prevent a stroke, we gave her specific medication to prevent convulsions which she was at extreme risk of developing, and to keep her kidneys going, some fluid but I had to guess how much to give.

And then I had to decide how much time I had – her condition was going to continue to get worse until the baby was born – so one solution would be to immediately do a caesarean. Her platelet count was unknown but was probably falling, making difficult, even life threatening bleeding from surgery very likely, because Platelets are a vital component of the system which stops bleeding – and we would struggle to get blood to give her. Back home hardly anyone would have hesitated to do the caesarean – the baby was still alive, she had not developed convulsions and her blood pressure was under control – just – and her kidney function and platelet count were only going to get worse – back home we could even give her platelets, but not here - a caesarean could kill her, and the longer we waited the more likely that if we did it, it would. We would be flying blind again.

On the other hand, with her Blood pressure  adequately controlled, and her anticonvulsant medication and some fluids given, there was a small window of opportunity that could allow us to try to get her labour started and the baby delivered normally. Midwives have always believed that women with pre-eclampsia have quick labours and as this baby was small, at eight months, perhaps this young woman would prove the midwives tale true. We decided to try and gave her some medicine to start the labour – and wonderfully, it worked well, her labour established within a couple of hours and a couple of hours after that, to everyones huge relief and delight the baby was born in perfect condition, small but vigorous. From that moment on, the mother started to get better.

For that mum, our luck had held. But for this poor woman at 2 am, it seemed it had run out. I felt cursed, frustrated, angry, embarrassed and stupid : of course she would die, how on earth could such a sick person not die when  all you can do is guess at whats really going on, when youre not an Intensive care Specialist but a gynaecologist, when you have three drugs and two types of fluid and no monitoring other than Blood Pressure and Temperature, when the people trying to look after her have only ever had the most basic and rudimentary training? What was her Potassium level? What was her Sodium level? What was her kidney doing? What would an ECG tell us?  A Chest XRay? What? What? What?…it was all “what?” and the answers were all “I have no bloody idea so what am I doing here?”

The van stopped at the hospital gate and as I headed in, my phone rang again. I just knew he was going to be ringing me back to say “no need to come, shes dead”. And yes, just as I guessed “ theres no need to come” he said – “but I am already here” I replied – and then he said “ Its OK, Shes fine” She had just fainted!

That was a few nights ago and today she walked from the hospital. I hadnt realized until she stood up from her hospital bed what a tall and elegant and most beautiful woman she was, wonderful white teeth shining from her smiling black face, braided hair , long arms and slender hands and fingers that seemed unnaturally long, she walked from the ward hesitantly but proudly tall, and didn’t look back. 

The MOH

The hospital buildings at Aweil are arranged around a huge central open rectangular space of  gravelly dirt and dust and three huge mango trees.  During the day visitors and carers and mobile patients gather in colourful groups under the trees talking, sleeping, even boiling water on small fires and cooking food and kids play and roll around in the dust and filth. An enclosed verandah looks onto this space and links all the buildings, the ones used by MSF at one end and the rest, at the other end constitute the Ministry of Health Public Hospital  (The MOH).  The MOH is supposed to cater to all adults except for women who are pregnant  - they are looked after by MSF which also looks after all babies and all children, up to the age of 16.

The other day Maura, the MSF midwife I work with all the time, took me to see a woman in the Public Hospital. It was thought she might have an ectopic pregnancy, a dangerous complication of early pregnancy where there is internal bleeding which can be lethal. We went into the crowded ward to find an obviously very ill young woman lying on the stained and grubby thick  sponge of  a mattress whose vinyl covering had long since been ripped and damaged and thrown away. The bed sank alarmingly in the middle. The woman could barely move or talk and her face was shining and wet with perspiration. A crowd of onlookers, patients and their carers from adjacent beds moved in close to find out what was happening.

With the help of the translator, who accompanies me to see just about everyone, we learned this woman had been on that bed since the day before. Her abdomen was so painful she could barely move. She had not received any treatment because the hospital had run out of drugs to treat her, and no one in her family could afford to buy her any. Her Blood pressure hadn’t been recorded because there was no BP recording equipment. Her temperature had not been recorded because here was no thermometer. Nothing , absolutely nothing, not even her name had been written in her chart except for the names of some drugs on a scrap of paper. This was the list the family was supposed to fill. A pregnancy test hadn’t been done because there were no pregnancy test kits.

Thinking about it later I wondered if the health worker who asked us to see her had suggested the possibility of her problem being a pregnancy complication as a way to get around the rules which state adults are not seen by MSF unless they are pregnant. Her care up to that point could better be described as neglect, and she was going to die if that was allowed to continue.

We found a catheter and I inserted it and we got back a tiny amount of very concentrated urine and tested it – she wasn’t pregnant. Technically therefore she was not our problem , but she desperately needed help, and apart from resuscitation with intravenous fluid, and huge doses of antibiotics for the fever that was burning her up, she needed surgery because upon examining her abdomen it was obvious she had peritonitis.  I wanted to get help for her from MSF – a surgeon had joined our team the very day before – but how was I to get around the rules? I decided to pretend that her peritonitis might have spread from a pelvic infection – though for various reasons I felt this was unlikely, but the people I needed to persuade weren’t surgeons or gynaecologists.

Time was ticking by, and she lay there waiting while I argued her case back at Base for MSF to accept her. A week before I had leaned on our medical manager to get one of my patients transferred to an MSF programme   in a town 3 hours away because she had a bowel obstruction and might have needed surgery to relieve it. I had said she could die without  surgery and now I was saying it again “That is what you said about  the woman we sent last time but she didn’t die”  he said, and it was true. Maybe I was overstating the case? “At least come and see her first” And he agreed. Meanwhile she just lay there.

Eventually when he saw her I think he was shocked by her condition but still he felt MOH should be taking care of her. “If we look after her then all the people here will want us to look after them “ he said. “She is not our patient”

“ But now she is MY patient” I said in reply. “I HAVE  to give or get for her the best possible care I can. The rules are not my concern – they are yours and you will have to make her an exception. At least get the surgeon to come and see her, and see if he agrees with me that without surgery she will probably die”

And thankfully he agreed, and later still the surgeon saw her and was also shocked. She clearly needed  antibiotics, she clearly needed fluids, and she was almost certainly going to need surgery. At last it was agreed - she would become an MSF patient – so I hurried off to get all the supplies she needed, set up the fluids, gave her all the antibiotics she needed and wrote it up in her file. I explained again and again to the nurse there exactly what I wanted done overnight – it wasn’t difficult – all the drugs and fluids were there in a box by her bed - they just had to connect them – and when I returned in the morning they were all still there! Now, apparently they had decided she was an MSF patient and therefore not their responsibility.

Fortunately the patient was still there too, still very sick and when our surgeon reviewed her with me at 9 am he agreed she must have surgery, and before lunchtime, she did. What we found surprised us – no burst appendix, no pelvic sepsis, no perforated bowel but an inflamed kidney abnormally positioned in her pelvis on her left side and a fine sticky film of inflammatory exudate all over the bowels. We removed the appendix anyway, washed out her abdomen and sent her to recover in the MSF part of the hospital. She was not yet “out of the woods” and was going to need intensive post operative care, something that was obviously not going to be provided by the MOH.

Today she is still very sick.

Blood, Malaria and Syphilis

If you look in the mirror and pull down your lower eyelid, you will see its quite red on the inside. We do this to our patients here all the time to get an idea of how anemic they are –  anaemia is when the amount of red stuff in the blood – haemoglobin - is reduced below normal – and if there is less of it in the blood the inside of the eyelid is shades of paler red , pink even, or in the woman we looked at a couple of days ago, virtually white. To get a better idea of the severity of anaemia a blood test measures the Haemoglobin level, and normal is above 120; in Australia if is below 70 this is regarded as severe and would usually be treated with a blood transfusion. Mine, when last checked was 143.  And that woman with the white eyelids ? 19!! She is at serious risk of dying from heart failure as the tissue demand for Oxygen, which is what haemoglobin carries , makes the heart pump harder and faster trying to get what little useful blood remains in her vessels to whip round and supply all the oxygen starved tissues which themselves are functioning badly as a result. And those demands increase further if she is sick, fighting disease or the effects of surgery, or trying to recover from a difficult birth.

Everyone admitted to our unit has her Hb checked, and as virtually none is in the normal range , everyone gets a dose of antiworming medicine, iron tablets and a Malaria check. In my first week here we had a dozen or so pregnant women with malaria, so they received a standard antimalarial drug regime which usually cures them in three days. All women are given a brand new mosquito net which is impregnated with a mosquito repellant that lasts for five years, plus some soap, and they erect the net over their hospital bed and take it home with them when they leave. If the womans Hb is over 50, that’s all the treatment she gets. If its less, depending on her condition she may get blood but its in very short supply. Family members are recruited as donors, but if none is suitable but the very small Hospital Blood Bank has a suitable Unit of blood, it may be used as long as someone in the family donates a replacement unit, albeit of a Type that cant be given to the relative. That way the Blood Bank tries to maintain its meager stock of a few Units.

We give a maximum of two units to anyone who is not actively bleeding, and did so to that woman with Hb = 19. While she was receiving it I was asked by one of the Medical Assistants to prescribe for her drugs to treat malaria and also Syphilis. “I wasn’t aware she had malaria and syphilis” I said to him. “No, she does not have it” He replied “But the relative who donated the blood has and so we have to use it, but we must treat her as well”

So we gave her syphilis and malaria, as well as the blood.

Independence Day

The Flag of South Sudan : Red is for Blood

Today, July 9^th 2013 is Independence Day in South Sudan, now 2 years old. It is a public holiday and apparently leaders from many African countries have arrived in Juba, the Capital, for celebrations. Here in Aweil, celebrations are apparently going to take place in Freedom Square, a large open space of gravel and dust at the edge of the main market area. Theres nothing special about Freedom square  - maybe in the future it will be upgraded with paving or flag poles or something but for now its just a wide space which I think was once an airstrip.  However, something extraordinary happened there last week during a football match – the sky darkened as a storm approached, huge drops of rain began to bounce off the gravel as a tropical  rain squall approached, and then in an instant a man was killed by a lightening strike. I had been there watching a different football match, got soaked in the rain and saw lightening but it wasn’t until much later when the storm had passed and I saw a very dense crowd packed together in a different part of the square, and asked what was going on that I found out. I was also told that tradition has it that the deceased is buried where he was killed, so a crowd remained there for hours, presumably digging a grave and burying the poor guy.

Today however the crowds gathering will be much happier. Already – its 10am – there is a rising swell of crowd noise drifting into the compound from all directions, shouts, trumpet blasts, and occasional chanting and ululating of women, increasingly frequent clusters of happily animated laughing and shouting people hurrying past the compound walls with Flags and music, increased numbers of bikes and motorbikes, a sense of building excitement and anticipation. I am not sure what exactly has been planned for the Square but  peering over our razor-wire topped wall I saw a cluster of men jog past wearing tiny leopard skin sort of skirts, some crude white body paint, long poles in their hands and chanting as they ran, so I daresay there will be lots of local colour, traditional dance and song.

Unfortunately, all this excitement and nationalistic fervor is seen by our MSF leaders as representing an increased threat to foreigners. We have all been confined to Barracks since yesterday, and forbidden to walk outside the compound for any reason. When we need to go to the hospital we have to be driven there, and the route has been changed so we don’t go anywhere near Freedom Square. Its thought there may be an influx into the hospital of  accident and trauma victims, and if people move into Aweil from surrounding towns we may even have some extra babies to deal with.

To be excluded from participating or even witnessing all this of course is very disappointing , but its easy to understand why such a risk averse policy is so rigorously applied: there is a long sad list of MSF workers worldwide who have been beaten, kidnapped and even killed while in places like this, doing humanitarian work. Right now two MSF  workers remain hostages somewhere in Somalia, and this very week threats of murder have been made against MSF right here in Aweil!  These were made by a local person formerly an MSF employee who was dismissed when found to be a thief. Similar threats were made last month by another disgruntled former local employee who tried to set fire to our compound, and drew a knife when tackled in the very act of sprinkling petrol about the place!

The brutality and horror of civil war is very fresh in the minds of the people here, and violence, for so long a part of everyday life still seems to be close to the surface even now. No doubt there are still many guns around, many knives, many unsettled scores, grudges and grievances. I have spoken with people who have personal experience of atrocities and war crimes, some committed by the notorious “Koni” who operated out of neighboring Uganda and also in Southern Sudan, not too far from Aweil which apparently at one time was in the centre of much of the appalling violence. A lovely woman on the hospital staff told me  a horrifying tale of how she came to be raising her brother and sister-in- laws children – the children’s parents were murdered in random violence – the grisly details are too ghastly to repeat, but  believe me they would make you shudder.

So I can easily understand why today must be a day of huge celebration for everyone, the miracle of Independence, the end of so much horror and uncertainty, a chance to make a future and to be at Peace. Never-the-less, Independence Day is also a reminder of what went before, and for many it must be a day of very mixed emotion. Hopefully they wont get out of hand.

Every Day

For me there is no weekend or days off in Aweil. I am on call and go to work every day, and every day is much the same as the one before. This is how it goes:

I usually wake before six when its still not light, having had a horrible night on top of a sheet which is damp with sweat and all wrinkled from my tossing and turning in the heat. I may have been woken by a few cats on the wall behind my concrete cell, snarling and growling, or by the barking and howling and yelping of packs of dogs that fight and wander the streets at night, and aken for ever to get back to sleep. The heat makes me have vivid dreams, sometimes disturbing dreams of confrontations and conflict, I started dreaming about Sue again. I am always on call but have been woken to go into the hospital in the middle of the night only a couple of times so far, but its an eerie deserted scene except for the dogs in the unlit road. The stalls and streetside merchandise are all packed away there is no advertising or neon, no streetlamps, just the rubbish and the muddy potholes remain as we bounce and weave our way past, it all looks abandoned. The light on top of the Landcruiser flashes and illuminates everything momentarily as we pass with its orange beam. Outside the church an old man and a young boy sleep under a scruffy heavy old piece of plastic sheet, which they fold up and sit on once daylight comes, begging.

But in the morning, once I am awake, I go for my shower. It’s a cold one and I have to brace myself for the shock, stepping under it and shuddering at first, but then within a minute the cool water feels good. I then suffer as usual this awful itchiness on my legs and arms and back for half an hour, I dress in jeans and clean shirt and take the laptop over to the main compound where I have some horrible instant coffee and check my email and news on the internet. The connection is slow but we used to think dial-up speed was amazing so its not a problem. It just takes a bit longer. I usually then have some cereal and maybe  some fresh locally made bread, a sort of Pita bread, round pockets which are very tasty with nutella or some of that French processed cheese brand “La Vache qui Ris” . The others all appear at intervals, mostly preoccupied with their own waking thoughts and breakfasts and emails, and then  I go back to my room and brush my teeth, and head for the hospital. Usually I go with Maura , the ex-pat Midwife who has been here since February. By now, 8.30, the streets are busy again and all the stalls are opening up and the wheelbarrows of merchandise are back on the street.

At the hospital we have a quick look in Labour ward and then I do a round of all the patients. It is supposed to be a learning opportunity for the staff , but few seem to attend the round, and those that do often disappear and return at intervals. I am taking things slowly and not pushing the staff too much at he moment as I am still learning their names and their roles, but soon enough I shall start insisting on attendance because I am discovering how much they need to learn. The round usually takes a couple of hours. After that, there are usually particular people to sort out, scans to do, notes to sort out and a steady stream of new patients arriving to be sorted out, some for admission, some for sending back home. Most of this work is done by the local staff.

Eventually I return to the Compound for lunch -  its usually really hot by now, our faces are all wet with perspiration just from walking, our MSF T-Shirts  sticking to our backs. For lunch ? - well today we had barbequed chicken with rice and chopped up tomatoes and onion, chips and lots of cups of cold water – in other words Chicken and chips – and its apparently a regular on Wednesdays.

Afterwards I might check my email or read some of the news on the Sydney Morning Herald  website – there’s been lots lately with the sad ending of Julia Gillards term as Prime Minister. She has been replaced by the man she replaced three years ago, the populist and treacherous Kevin Rudd for the purely pragmatic and sole reason that he is immensely popular with the Australian voters.  She of course was not and the Labor party was headed for a massive thrashing at the election due in a few months. The fact that the same Labor party under Rudd, with the same history and more or less the same Policy platform has now made a huge gain in the opinion Polls demonstrates how much the Australian electoral environment has  degenerated into a Popularity contest between personalities rather than a contest of ideas. How sad. The positive for me is the possibility that the very unpopular opposition leader who was sleep-walking to an electoral landslide win while Gillard was the PM may now remain Opposition Leader after the election. That result is not widely expected but it is at least a possibility now. I dread the day Australia is led by a man who thinks the science of climate change is “crap”.

At some time in the afternoon I walk back to the hospital and see whats happening and check to see that all the plans we made for the patients in the morning have been acted on. Surprisingly they often haven’t been – theres a degree of disorganization bordering on chaos at times in the ward which all the people preceding me have been attempting to improve but it still needs work. There may be new patients to sort out as well.

Around five I walk back again, the stall holders and merchants are packing up , everyone is heading home, the sun is close to setting by 6, the air is starting to cool down a little , and back at base I open a cold  can of African beer, Tusker. A beer at the end of the day has never tasted so good.