The Face of the Future in Sth Sudan

This scary looking guy works with me in Maternity just about every day, and he is a very valuable member of our staff, a friendly intelligent and reliable guy with pretty good English, excellent judgement and work ethic. Despite his appearance he is surprisingly gentle and softly spoken. He represents hope for the future of this struggling country, the necessary human bridge between the traditional and ancient ways of the Dinka people, and the world of modern medicine. Those lines on his forehead were made with a knife when he was about 15. It must have been agony to have the skin on his head incised right round to the back on both sides, several times, but he had to endure the pain without the slightest grimace or hint of emotion, or else risk humiliation. You cant see it but he also had the two front lower teeth knocked out, something  the Dinka women also endure for an apparently desirable cosmetic effect. The Dinka women also cover their abdomens with patterns of dots and dashes, scarring made by nicking the skin with something sharp. One Dinka father with similar markings told me his sons wont be subjected to this ritual, so clearly these traditional ways are going to largely disappear.

I am running out of time with only a few days left before once again I pack my bags. I have been so much busier here than I ever was in Ethiopia - the problems are much the same but there are three times as many. There are many posts still unwritten and I am not sure how much free time there will be for them. What I have to do in the next few days is write a report for MSF on my time here, and create a document I can give to my replacement who will be arriving here on the Plane coming to take me away on Thursday. Ideally the replacement arrives a day or two before, so he can be  shown the ropes by the person leaving - I got here a day later than I was supposed to because of the weather, so my "handover" was at the Airstrip - just a "hello, goodbye and good luck"  - but its a mystery why this time no time at all has been allowed for handover. All I am hoping for is good weather, because if I dont leave here on Thursday I will miss my connections back to Australia.

My Room for 42 nights

Outlook for Thursday

After the Rain

It’s the wet season here and what seems to happen is that after several days of hot and humid weather with mostly blue sky, clouds  approach from the horizon with lots of lightening and then with strong winds and a drop in temperature that makes sleeping quite comfortable for a change the rain arrives in a heavy downpour that lasts a few hours. When its finished it can be pleasantly cool for half a day but the heat quickly returns. The massive potholes have of course filled up once again and the walk to work becomes a slippery filthy obstacle course as we try to avoid the worst of the mud.  The mud dries over several days till only the deepest holes remain, and then the cycle starts all over again.

Another effect of the rain and storms is that airtravel to Aweil may be interrupted. Theres a surprising stream of MSF Staff coming and going – some are Officials doing the rounds and others are arriving or leaving at the end or the beginning of their missions in Aweil, or taking their mid-mission holiday. Last week and again yesterday, people who were expecting to leave didn’t, and others, such as the replacement anaesthetist, didn’t arrive. Maybe they will fly today – the rain has stopped. One of the people leaving has been visiting for just a few days, a French doctor called Romy Brauman who is one of the original MSF Doctors. He went to the Thai-Cambodia Border on his first mission in 1978 or thereabouts and was completely on his own. It was fascinating to hear his views about where MSF has been and where it is going. He predicted that once MSF leaves  Aweil, as in every other mission ever completed by MSF, the local infrastructure will not be able to maintain the standard that was set by MSF, that there is always an inevitable collapse to something a whole lot less than what had existed before, and that our success will not be so much in what remains, but in the help we gave to the people who needed it while we were here. He didn’t seem in the least a starry eyed idealist wanting to change the world, but a very pragmatic humanitarian.

 

One realises what a luxury a sealed road is

Next Thursday it will be my turn to head back, after six very fast weeks, weeks which have been much busier than the ones I spent in Ethiopia – there are more than three times the number of births here and again I am the sole Obstetrician. I am looking forward to a break but I don’t feel desperate to leave. In fact the  longer I stay the more work I seem to find and the more I discover that needs to be done , especially in what the local staff need to learn. In spite of what Romy believes – and I agree with him about the future of this place – none of us wants to leave and think that once we have all gone, nothing enduring will remain. What we hope is the people we are trying to teach will do better when we are gone than they otherwise would have done, and therefore, indirectly, South Sudanese will continue to benefit from this mission. What I am finding with teaching is firstly that there is an enormous amount needed, but that we are so busy dealing with the day to day challenges of sick women that there is hardly any time left for it. 

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.