Water Equals Life

We hiked to the top of Jebel mountain today. On the outskirts of Juba, this stunning rock formation (granite, I think) gives a pleasant break to the eye after the flat terrain of Juba proper. It was cool and drizzly, and at the top I could close my eyes and just feel the wind and rain on my face and not hear a single car, dog, or generator. It was one of the nicest moments so far in Juba.

I went to the hospital after dinner to check up on a patient that was suffering from an asthma attack. Reports throughout the day over the phone from the South Sudanese doc in training was that she was receiving proper treatment but not getting better. I gave him some additional suggestions over the phone to try to relax the tight airways in her lungs in order for her to breathe easier and asked that the on call doc call me later to see how she was doing. When I didn't hear back, I came in to see how she was responding.

As soon as I got on the ward, I could tell that she was improving. She was receiving albuterol by inhaler (attached to a water bottle as a makeshift spacer), IV hydrocortisone to decrease the inflammation, and had just received a loading dose of magnesium sulfate (something they aren't used to giving but we are introducing as a drug that can help patients in status asthmaticus). There isn't any ipratropium around to compliment the albuterol, and there is an unfortunate practice of using aminophylline, a drug that has a narrow therapeutic window (you give a little too little, and it's not very helpful; a little too much, and you get dangerous side effects). We don't use it anymore in the US. I showed the patient and caregiver how to better administer the albuterol, had the intern update the medication plan for the night, and was wrapping up until the more senior doc called me over to see another patient.

This young woman was in clear distress, breathing fast with a rapid and weak pulse. The blood pressure was low, and the oxygen level in her blood was only 70% of what it should be. She was slowly receiving IV saline through a small IV in her left arm. Her hands were cool and clammy, and she was confused. I knew that due to a probable bacterial infection in her blood, her blood vessels were leaky and she was not getting rid of waste products and getting oxygen to her tissues. She had received antibiotics, but that was only part of the treatment. She needed fluids, and she needed them fast. No matter what we tried, we couldn't get IV access. We really could have used an intraosseus needle, a quick way to get fluid into the bone marrow and then into circulation. We also needed high flow oxygen, and not a half functioning oxygen machine with partially cleaned tubing that had already been used on countless patients. We also needed a ventilator machine, a way to check labs during the night, antibiotics that were not counterfeit, staff that realize that two IVs are needed stat on a patient with a systolic BP of 85 and a pulse of 150. We needed her to present earlier in her illness. Among other things.

Her femoral pulse became erratic, her breathing stopped, and then her heart stopped. It still feels like I'm giving up by not starting CPR. But without a ventilator, without a defibrillator, without a team of nurses and docs that can manage an intubated patient, there is no reason to start chest compressions.

Patients die so often here. I can barely think of a handful of patients that have died during my ER shifts in the States, and none of which died due to inability to get fluids into them.

From this loss, I will push to get intraosseus needles sent from the US to be available on the ward, and we will make sure there is a policy that places two IVs in any patient that is tachycardic and hypotensive.

Birthday In Juba

I turned 34 today. Looking back, I turned 30 in Lesotho, 32 in Malawi, and here I am in South Sudan for 34. The majority of people in this country are less than 30, so in at least one way, that makes me old and uncommon.

I started the day off with a 10K run with a few friends that were going to run the Juba Marathon before it was cancelled. The prize for the sweat and grime was a delicious homemade pancake by fellow frisbee player Niki, the first one I've had in Juba and the best I've had in a long while. In Juba, it's the little things that matter.

I then stepped onto the ward to see how the junior docs were doing with their patients. Unfortunately, none of them had shown up, and the patients had been seen by a clinical officer student. When I tried to see what he had discovered on history and physical, I was stuck since the files had been sent en mass to the pharmacy. We need to change that. Cathryn, the visiting resident from my old stomping grounds in Santa Rosa, gave a great lecture on asthma. We then broke for a nice Ethiopian lunch at Green Garden (photo of birthday present attached), followed by home-fired pizza with the Italians.

Except for some generalized lymphadenopathy and a bruised rib from frisbee, all is well, and happy to be alive. Thanks for the birthday wishes!

Blood...Blood...

The group I'm working with started a virtual blood bank at the Juba Teaching Hospital, and it was featured on the BBC podcast "Health Check" on Wednesday, April 11th (www.bbc.co.uk/podcasts/series/healthc). At JTH, normally family members must donate blood in order for their patient to get a pint or two of much needed blood. So typically a patient comes in with less than half the amount of blood in their body that they should have, and instead of getting a blood transfusion right away, they have to find a family member who is able to donate a pint of blood first. This van take days. Many family members don't want to donate due to many myths about donation, or they don't want others to know that they have one of the infections that are screened for before they can donate, like HIV. And when a patient comes in really hemorrhaging, and they don't have a family member available or willing to donate, they just die. So my friends here came up with the idea of getting a pool of willing donors (mostly ex-patriots), getting their contact info and blood type, and then bringing them in every 3 months or so when the stock is running low. And it appears to be making a difference. Pretty cool stuff.

Just Another Thursday In Juba

We started the day off in a meeting with a group supporting the training of nurses, midwives, and midlevels. It's great to think that we could have a bigger role in training obstetrics providers in a country with such a bad maternal mortality rate (it's said that women in South Sudan have a greater chance of dying in childbirth than finishing school).

Briefly stepped into the hospital to check in on things on the emergency ward, and a man that has been in diabetic ketoacidosis was looking much worse. He had probably aspirated oral or stomach contents into his lungs at some point, and he was now struggling to breathe, with an oxygen saturation of only 70%, and no ventilator machine available to help him breathe. Unfortunately, the odds are against him. I've never seen someone die due to DKA in the States. Here, I'm kind of surprised when they don't.

We then went to a meeting with the US Embassy security specialist to get an update on the situation in Juba. He continued to stress that things in Juba remain safe, that the occasional violence is far away on the border, but that we would be in close contact regarding updates.

We got a little sag paneer leftovers in us and headed over to the UN to play some ultimate frisbee. I pretty much played like I'd never held a disc in my life. But the worst part was that I let it really upset me instead of just laughing it off. It was kind of embarrassing. Maybe I need to get out of Juba for a bit?

Green Garden served up a delicious Ethiopian dinner, as is frequently the case. Ahh, veggie mixed dish does hit the spot. Thursday is, of course, Salsa Night at Central Pub, and we had a fun time chatting with the local expats: Brits, French, Dutch, Panamanians, Ethiopians, and a nice Spanish-speaking Swedish girl who had 10 year long dreads and looked like she was straight out of Hopmonk in Sebastopol.

Tomorrow we'll be doing bedside teaching rounds at the hospital, and hopefully I'll have a chance to show my friend Smiley around. He's an amazing photographer for the Houston Chronicle that has been documenting the great work Baylor College of Medicine and Texas Children's Hospital have been doing with pediatric AIDS in Africa. I'm glad he had a chance to stop off in Juba while he was touring East Africa.

Goodnight.

Playing Well With Others

Sorry for the blogging hiatus. I've been tired and a bit burnt out. But I've had some days off, and I'm feeling better. Recharged. Ready to take on the world! Or at least ready to wrote a blog entry.

I've been training for South Sudan's first half marathon, scheduled auspiciously on my 34th birthday this Saturday. Unfortunately today I heard it's postponed for a month due to a lack of proper permits. That's not cool. I'm not turning 34 in a month. Why wasn't I consulted on this? And I want my 12 dollar registration fee back, thank you.

The good news is that South Sudan and Sudan as of a few days ago are no longer at war. Well, that's not exactly correct, since I think they weren't really at war last week. And we might be at war today, depending on which politician you ask. But nevertheless, the South has pulled out of the border town and oil field they overtook. That should make everyone feel better, especially my Mom. There are rumors that the military is pulling out after hearing what my mom said she'd do to them. Thanks, Mom!

But the bad news is that the two countries are still refusing to get along. All this over some oil that happens to be a measly 98% of the wealth of South Sudan. I wish cars ran on love and it cost $100 a barrel. Do I sound like I live in Northern California?

Otherwise, things are status quo at the hospital. That's to say that things are not well. We continue to face the frustrations of medications not being given, labs not being drawn, and house staff not showing up. No electricity much of the day and night (apparently this has had an effect on the morgue), no IV tubing, little access to oxygen...you get the idea. We've just changed our consultant schedule so that the local house staff is given more responsibility (i.e., they do the work that we have been doing for them), and so that we can focus a little more on lecturing and bedside teaching instead of getting burnt out seeing the patients ourselves without speaking their language.

Viva Juba!

Sunday, April 8, 2012

Juba is an interesting place.

I found myself in our little local hole-in-the-wall Kenyan cafe called California Inn (I think) getting take-away. On the television was a Mexican soap opera, dubbed in English, with Luis Miguel singing a ballad in the background. The food was beans and cabbage, with chapatti that taste pretty much like tortillas. And of course there was salsa night on Thursday, where I got to meet a few people from Ecuador, Guatemala, Honduras, Argentina, and Panama who were working with the UN. Who knew of the South Sudan/ Latin America connection? Well, not me.

Work continues to be pretty intense. We had a man come in with a swollen epiglottis that suffocated in front of us and went into cardiac arrest. Another young guy in his thirties presented in a coma with a blood pressure of 240/120. There weren't many medications we could give him to effectively lower his pressure. He passed away overnight.

A young guy came in with a stroke, decreased consciousness, and a fever. In my little hospital in NorCal he would have been admitted to the ICU, blood work would have been drawn, and a CT scan ordered (with a follow up MRI from the neurologist in the morning). This young guy's family was too poor to afford most of the tests and treatments we ordered. His bed was also empty one morning this week.

Just about every day there is at least one patient that could benefit from a ventilator machine. Comatose patients that can't protect their airway enough to avoid choking on their own oral secretions, people with overwhelming infections leading to fluid and inflammation in the lungs called acute respiratory distress syndrome. We don't have a ventilator, so many of these patents just don't make it.

We've had some cases of people in kidney failure. There are no working dialysis machines in the country, just as I'm sure there are no working nephrologists in the country. An elderly, confused gentleman that was breathing fast turned out to have a creatinine of 17 (ten times the normal value, signifying massive dysfunction of his kidneys). The closest place he could go would have been an international trip to Uganda.

There are still surprising saves. A young man with meningitis so bad he couldn't bend his neck is slowly getting better. A confused woman with malaria and likely infected with TB who I was sure would expire last night was awake and sitting up this evening. A man came in confused with a history of three weeks of dysentery and a blood pressure of 70/50. With IV fluid, sugar, and antibiotic therapy, we were able to stabilize him. Hopefully he'll be with us in the morning. And I'm seeing some good changes in evaluation and treatment from some of the South Sudanese health providers we're working with. Little things, put good things.

And, we have mangos.