Last Day In Juba

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,

Jeff

Pump Failure

This morning we watched a man almost drown on dry land. He came in to the hospital, breathing fast, looking bad. He had the tell-tale signs of uncontrolled chronic heart failure. His legs were swollen. His hands were swollen. His belly was likely full of fluid. But most dangerous at that moment, what was causing his acute distress, was that his lungs were full of fluid. Since the left side of his heart, normally tasked with moving freshly oxygenated blood from the lungs to the rest of his body, was failing, his lungs were backed up with fluid. Having to deal with the extra work for too long, the normally relatively weaker right side of his heart had also failed, as evidenced by his water-logged extremities.

We hooked up our minimally functional, minimally clean oxygen machine and tried to convince him to keep the uncomfortable mask on his face. We administered IV furosemide, a diuretic that helps open up the veins in his lungs as well as gets the kidneys to dump fluid out of the body. One, two, three, and then four doses of increasing strength (up to a cumulative dose of 240 mg) and we weren't seeing a response. We gave him a pill of a different diuretic, spirinolactone, with the hope that it would potentate the action of the first diuretic, a risky move without knowing how well his kidneys were working. He was so short of breath he wasn't able to swallow it. The intern brought sublingual nitroglycerine from the pharmacy, hoping that he could place a tablet below his tongue that would then dilate the veins in his lungs and allow him to breathe easier. He spit out most of the dose along with some frothy sputum.

I could see that he was getting tired. That is a very bad sign in the world of heart and lung disease. In my hospital in California, respiratory therapists would have been paged to the ER a long time before this point and would have placed him on BiPAP. This non-invasive ventilator machine works by pushing fast-flowing oxygen into the lungs of a patient via a tight fitting mask, forcing the fluid out of his alveoli so he can breathe again. Failing this, he would have been intubated, placed on a ventilator, perhaps put on a nitroglycerine drip, maybe even dialyzed if his kidneys couldn't take off the fluid.

But instead he sat there, in severe respiratory distress, leaning onto his thighs, hands and arms cold and clammy due the reduced circulation and stress of the moment. And I thought he was going to slowly suffocate due to the fluid in his lungs, or perhaps have a build-up of carbon dioxide that would cause him to get confused and then take away his drive to breathe, or maybe have a heart attack or cardiac arrhythmia.

Amazingly, his breathing slowed a bit, his pulse began to improve, and he began to look interested in his surroundings. The medications had taken effect, and he was turning the corner. I have no guarantee that he will make it through the night. There are a dozen things that could go wrong between now and AM rounds. But the junior docs saw that such a sick patient could be stabilized. And we will hope and pray that he survives until morning.

Sunday Funday

Ahh, Sunday. It's nice to have a day off. Clinical work often times doesn't give you a day of rest, a chance to clear the mind. But today I'm off. I had time for a cup of hibiscus tea (from Khartoum), some bread (from behind our house) and cheese (brought in from Santa Rosa, CA), a piece Tiger Cake (Kenya) and some yogurt (Uganda).

We had a nice meeting with a group of physicians and public health clinicians from University of Alberta, in Edmonton. They have a lot of international experience and are hoping to expand their work into Juba. There are plenty of opportunities to get involved.

Aid is such a tricky thing. What is the best formula for bringing the developing world out of poverty? The big opposing camps are: 1. We're on the right path, what countries like South Sudan need is more money and more help from multinational donors and NGOs, 2. Our current approach for aid isn't working, and is actually making things worse, so it's better to pull out completely and let the countries take control and run things themselves. I go back and forth between these. As I'm writing this from Juba, clearly I'm currently a believer that aid can make lasting changes, especially when it comes as education. But there are certainly days I feel that we should all pack up and get out, let the situation get so bad that there is an internal revolution of sorts, and that changes are made from within that equal the playing field a bit between the haves and have-nots.

Just received a call from the house officer (intern). A patient with heart failure has low blood pressure and a fast heart rate, as well as signs of fluid overload and clammy skin. This would be a difficult patient to treat in California. Let's try some gentle fluid boluses and antibiotics and see how she responds.

Frisbee, a twice weekly bright spot in the schedule, lies ahead. I have just about a week and a half left in Juba for this trip. I'm looking forward to giving a few lectures before I leave, evaluation of chest pain and HIV opportunistic infections. Then, a chance to step away for a few months to bring some needed perspective.