I'm sitting in the airport terminal at the Juba airport, preparing to return to the US after my first stint working as a teacher of junior doctors at Juba Teaching Hospital. As I watch expatriate aid workers arrive on the incoming flight from Nairobi, I feel like a seasoned veteran. "Ha, look at those newbies", I think. And yet I've only spent two months here. Sixty measly days. Barely any time to even get acquainted with a place. Eight short weeks. In some ways, though, and as many people who've been in Juba would agree with, it certainly seems like it's been longer.
Working at the Juba Teaching Hospital has been, well, challenging. Lack of essential medications, equipment, and skilled manpower makes taking care of very sick patients even harder than it should be. Certainly, some patients present too late to be saved, even if they were cared for in a first-class institution like the marbled halls of Massachusetts General Hospital (I haven't been to MGH yet, so there may not actually be any marble there). But many patients present very sick, yet early enough that they have a chance. Unfortunately, many that should make it do not.
On my last day there, we saw a chronically ill-appearing woman who had been admitted the previous day. I was surprised to see that she had survived the night. The report the day before was that she had been ill for a very long time and had been thrown out of the family by her husband. As she lay on the dirty concrete floor of our ward, as there were no available beds, I performed a brief evaluation. Cachectic, with abdominal swelling but no evidence of heart failure. But today, she was worse. She was minimally responsive, her pupils were dilated and hazy, and she had an unrecordable blood pressure with a fast heart beat. "Give fluids", I told the intern, "and make sure she gets her gram of ceftriaxone". The head nurse shook her head at me, "We're out of fluids. The whole hospital is out. They'll have to go to the pharmacy across the street". The intern asked a patient a few beds away if he could have her unopened bottle of IV fluid. She agreed. And, thankfully, one of the harder working nurses showed up with a box full of IV fluid. Apparently the whole hospital wasn't out. About 600 mL of fluid later, I re-examined the patient. She was worse. I had given her too much fluid, and now she was in pulmonary edema. Blood pressure still unrecordable, but she was breathing harder and her heart was struggling. If I had a way to place a central line, I would have administered strong medications that would have supported her blood pressure and strengthened her heart contractions. If I had a ventilator machine, we could have intubated her and breathed for her while removing fluid from her lungs. All I could do was give a small dose of furosemide, a diuretic that would hopefully relieve the strain on her heart without dropping her blood pressure too much. A female relative began to squeeze fresh orange juice into the patient's mouth until we stopped her. She was struggling to breathe and was not alert enough to safely swallow. Within half an hour, she had passed. Her 20ish year old son, now alone at her bedside, stormed outside in silence.
She was a patient that may have been too sick to save anywhere. I had not seen her sit or speak since admission. In addition to a weak heart, she probably had tuberculosis, HIV, or a host of other infections. And yet it's hard not to second guess myself. Should I have tried 250 mL of fluid at a time? Did I at least pull the intern aside to make sure he understood what had been the probable course of events today? Should we be putting our efforts in prevention instead of treatment, so that fewer and fewer patients present this late in the course of their illness?
The most striking part of it was that her death was lost amid the day's business. My stream of consciousness was probably something like: she was just too sick, brought in too late, but should I have been more careful with the fluid? But there's no other way to treat hypotension and tachycardia here. Need to check in on the guy with TB and the nasal septum abscess, hope the pus hasn't re-accumulated, I wonder how the postpartum woman with heart failure is, need to see her next, I can't believe the woman with stroke and aspiration pneumonia in bed 14 is doing better today, we've got to get some of these patients transferred to ward 4, what on earth is causing the woman in bed 16 to be so altered?, gotta check in on HK to see how he's doing on the male ward, getting a call from one of the expats now regarding his shortness of breath; where are the other doctors?, gotta make sure the four women outside get seen before the interns leave, where are the nurses? Oh, the guy that is saying hi to me outside is the one with HIV that I discharged and was afraid had a pulmonary embolism - and he's doing great! Yes! Wow, does that guy really have a hemoglobin of 1.5?...
And her death, and the processing that goes along with it, was pushed to the back.
Our goal is not to bring MGH to Juba. That is neither possible nor would it be a good use of time or funds if it was. With diligence, patience, and a cooperative attitude, we hope to raise the level of care to one that is expected of a national referral hospital in Africa. That is feasible. That is necessary. But it won't be easy.
There is so much work to be done. When an elderly patient admitted to our ward with diarrhea and weakness, unable to care for herself, receives no nursing care for 24 hours, I get angry inside. Why won't the nurses help clean her? Why doesn't she have a relative here to help her? When less than half of the junior doctors show up for a lecture I worked on 'till three in the morning, I feel disheartened. Why don't they take the opportunity to learn about a subject that is important and that they know little about? When a patient dies because there is no IV tubing to give medications and fluid, or when a patient with severe anemia fails to get the prescribed blood transfusion because no one walked the 25 meters to the lab and brought the blood to the patient, I feel like it's time to pack up. Get your bags, kids, we're going to Disney World!
Yet for some reason (maybe because it's hard to get a last minute flight from Juba to Orlando), we get up the next morning, and we try again. We calmly encourage the nurses again to clean the patient who's been lying in her diarrhea. We work with visiting pharmacists and lab specialists to address the myriad of medication and laboratory issues plaguing the hospital. We'll continue to bring in expert nurse and public health instructors to coordinate between the ministry, hospital, and the school of nursing to improve nursing care at the national level. And we'll continue to work side by side with the young physicians that are charged with caring for one of the most impoverished and traumatized people of the world.
I don't know what things will be like when I'm due back in August. Perhaps our continued presence and efforts will have made some visible and lasting changes at the hospital. Maybe things will run more smoothly, and morale will be higher. Perhaps Sudan and South Sudan will have resolved their differences and will base their economy on green energy and the exportation of love and daisies. We'll have to wait and see.
When a patient dies on Flinder's inpatient medicine service at our residency in Santa Rosa, CA, we light a candle during rounds to honor their life and their passing. The speed and bustle of rounds slows down a bit on those days, and we are reminded of the blessings we have. I think that was a partial motivator for my last night in Juba, as we turned off the noisy generator that is the only source of electricity for our house, started a fire in the yard, and lit about 30 candles to light our way. Yes, it was still about 90 degrees outside, and maybe hotter inside the house. But we took a moment to sit, to stare into the flames, and to remember.
Thanks for reading,