Medicine, Juba-style

I only have one week left here in Juba, I'm not quite sure how that crept up on me, but it has. I haven't written much recently, not because nothing has happened, but because I haven't known what to say about it. As I near the end of my time here, I get asked about my feelings about leaving; there are lots of thoughts that come into my head, but I know that I'm ready to leave. It's going to take a while for me to work out what I've achieved, learnt, experienced and given here; I think it's too early to start making those conclusions - I'm going to need a bit of thinking time for that.

Over the last few weeks, I've been trying to go to the government hospital and get involved where I can. It has been a bit of a struggle though, the more I go, the more emotionally and mentally draining I find it. On ward rounds, I frequently end up having in depth discussions with the consultants or other doctors about the approach that is being taken towards a particular problem. It has been pretty difficult to know when to say something and when not to. As I've probably said before, I'm determined not to be the western guy who comes along and tells people that because they are doing things differently, they must be wrong. That can't be the way to improve things - it doesn't help relationships with staff, and if you don't have a relationship they aren't going to take an interest in anything you do or say. However, the real dilemma comes when they are doing something wrong - what do I do then?

I probably need to expand on this. There are lots of reasons that people get different investigations or treatments here in South Sudan. Firstly, it could just be that treatments or investigations are unavailable or too expensive; this isn't exclusively referring to getting an MRI scan or serum rhubarb measurement, many people can't afford the most basic drugs and are at the mercy of the erratic and unpredictable supply of free drugs from the hospital pharmacy. So sometimes really odd drugs are prescribed because they are available for free, and they probably will work. Sometimes drugs will be given that are just plain bizarre; aside from multivitamins that are used for a plethora of random indications, drugs that I've never heard of such as piracetam (for myoclonic jerks) will be used to "improve memory" in stroke patients, without any evidence of memory problems (also, piracetam is contra-indicated in haemorrhagic stroke, and until recently no-one was getting a CT). In fact a stroke patient is much more likely to get piracetam than aspirin and a statin (the most basic medications that have evidence showing they help if people have had a stroke). Sometimes older investigations and treatments are used as they are cheaper or the only thing available.

This all leads to multiple occasions where I don't know if the other doctor is coming up with medical brilliance in the face of adversity, or if they've just made something up. I may have mentioned before, that the doctors do care, and want to do something to help the patient, even if nothing that is really helpful is available, but sometimes they end up possibly causing more harm than good. If a consultant prescribes an incorrect drug then the juniors all take it as law that you must do that when faced with this sitiation, without ever thinking about what is actually happening. I get mentally exhausted trying to work out if what has been said is true or not throughout the entire ward round, and emotionally exhausted when trying to work out when I should argue my case or when I should stay quiet. This is without thinking about all the patients who the healthcare system here cannot help. with or without multivitamins.

It's a shame, because one of the challenges of doing medicine here that I find most rewarding  is trying to do the best with what you have available, whether that be in diagnosis or treatment. A lot of the time you have to be a bit creative with the treatment, working from first principles of a disease, rather than just knowing that you give drug x in a certain situation. Often you have to make you 'best guess' of the diagnosis from the examination of the patient and minimal investigations. There is no safety net of investigations for precise confirmation of diagnosis. Wherever you work, medicine involves a degree of uncertainty, but here things are much less certain than elsewhere.

Thoughts of a Coffee Drinker

Powdered milk makes tea taste of cheese, which somewhat limits the enjoyment of drinking it. However, it is possible to get decent coffee in Juba. I was going to conduct a rigorous scientific survey to identify the best coffee here, but it turns out that there is so much variation within each establishment that I couldn't afford enough coffee in order to have a large enough sample size. I have tried though.

While sat in a very pleasant cafe the other day, for coffee research purposes, I had a bit of time to reflect on my last few weeks and to take in my surroundings. The week or so following my last post was incredibly frustrating, I think a lot of little things about working here got to me. I was very frustrated with the system, and many of my colleagues who didn't seem to care about patients or improving the systems they work within. I got to the point that I was dreading going in to work. I don't know if I was fed up of telling people we couldn't do anything for their illness, or if doing the ward round and finding that my colleagues hadn't done anything for any of the patients since I last saw them.

I have realised that there are huge cultural differences between myself and the local doctors, partly stemming from the fact that they have to make do with what they have here; I get frustrated when I see people prescribing completely random medications for people (ranging from the ubiquitous multivitamins to anti-hepatitis B drugs in people with any kind of liver problem), they are just trying to do something for the patient. As medicine here improves (and it is, if you have money at least) the old attitudes are hard to let go of, and evidence-based medicine is having a tough fight to break through. I imagine if I had always worked in a limited-resource setting such as this, I wouldn't be so emotionally involved with my patients, as there are so many of them that you can't do anything for. Even if you can't cure someone back home, there are almost always things you can do to help their symptoms and to ensure their emotional wellbeing.

Part-way through my second pot of coffee, I realised that I had almost written up a report on an audit that I started last week. I found myself looking forward to my shift at work, and my trips over to the government hospital. Some of the things they do still drive me completely mad, but I think I've learnt some tolerance and understanding about what makes my colleagues tick. I was determined that I wasn't going to be the guy who came out and told everyone that they're doing it wrong; it's a tricky balance to strike, because people do ask how we would do something in the UK, but I need to remember where I am and the limited resources that we have here. I think my week or so of giving up is over, but with less than 3 weeks left here, I have a lot still left to do.

Getting Blood From a Stone

Last night, I discovered that getting blood from the government hospital might be more of a challenge. I apologise, this post is quite medical, but so is my life here. I want to tell you about a patient who I have been looking after and some of the challenges which we face here, as well as my feelings and reflections on it. I'll try and write in normal language, but will put some geeky medical details in for those that care.

Two nights ago, I admitted a patient who had been suffering from bloody diarrhoea for nearly a week. Over that time, he had lost a significant amount of blood (his Hb had gone from 10 to 4 g/dL in 4 days) and had become quite unwell. He was severely dehydrated, as well as suffering the symptoms of anaemia - breathlessness, lethargy, and just generally being quite unwell. I did all the simple things and requested some blood to transfuse; this has to be collected from the government hospital blood bank in return for donations from friends/relatives to replenish stocks. After about 4 hours, a single unit of blood appeared for transfusion, with the news that no more was available until the following day. The patient was stable, so I let the doctor on the night shift know all about him and finished my shift.

Last night I was on the night shift, and very early on I was called to the ward to see this same patient. If you're particularly sensitive/squeamish, you just need to know that things had happened which meant that he needed more blood, and I'd probably skip the rest of this paragraph. I found the patient face down on the floor in a metre-long pool of blood and clots, which he'd just deposited as a bowel motion. He was still just about conscious (and somehow had a reasonable BP, but was very shut down).

I'd discovered that on top of this new issue, nothing had really been done for him all day, and even when I arrived, there was no particular hurry to do anything. I decided that wasn't really good enough, so surprised the ward staff by running round the ward finding cannulae and fluids and administering them within a couple of minutes (usually a fluid challenge will take about 30 mins to be given, unless you do it yourself). Without any clever plans to stop the bleeding until the morning, all I could do was give him more blood to replace the losses. After the previous night's issues, I decided to go to the bloodbank myself with 7 donors to request the blood that the patient needed. After a lot of discussion with the staff there and about 1 hour, I returned with 1 unit of blood, having been told that I wouldn't be able to get any more until the morning, despite all my best arguements.

Making the most of what we had, I made a plan for overnight and he recieved the blood and fluid. Thankfully, he was a little bit better by the morning, and I managed to get a second unit of blood for him in the morning (it did take another 2 hours though). The doctor who is currently in charge here took over from me in the morning, and we discussed a plan for the day to ensure he had more blood and was reviewed by someone who could possibly investigate the source of the bleeding. I went to see him this evening, and although he's still stable, nothing has been done for him all day.

Last night was one of the very few occasions where I've become outwardly frustrated/angry in a medical setting. It happens very rarely, when I feel that patients aren't receiving the care that they need for no good reason. I'm not proud that I got angry, it never helps anything happen any quicker, and I think sometimes it might even make people more obstructive, thankfully it didn't last long and the calm me got a lot more done than the angry me. Having slept and thought about it, some of the problems last night were not solveable, but some really were.

In the blood bank, there were many other samples waiting to be matched for units of blood for transfusion for patients who had been shot, had fallen off their motorbikes, had just given birth, and had severe malaria. The 'blood bank' is in fact a fridge, which is barely larger than the one in your kitchen, and serves the whole of the city. If I'd got all the blood I'd wanted last night, it's quite possible that I would have exhausted their stocks of that blood type. So I probably was a bit unrealistic and demanding to expect to get so much blood last night, given the limited-resource setting that I've found myself in, remembering that my patient probably wasn't even the most unwell patient in town.

However, the apparent lack of interest from my colleagues, and the constant excuses of why things can't be done (I had to convince the nurse that the electricity going off in 3 hours was not a reason not to give a blood transfusion, and that the pool of blood which had recently formed on the floor was a very good reason why we should give it now). Maybe I'm too emotional, but I get a bit upset when people don't seem to care. It isn't a problem I have to deal with too much at home, but I don't know how to change the attitudes of a whole hospital (or so it seems). If anyone has any bright ideas, there are many people here who would love you rather a lot.

Anyway, that's enough for today. Sorry it was a bit of a medical rant, I promise my next post will be about my hunt for the best coffee in Juba or something like that.

Normality

Something starnge has happened over the last few weeks, I can't put my finger on a particular day or moment, but something has changed. Being in Juba has become normal. I no longer feel like being here is a novelty or completely foreign to me - I have adapted my way of life to how things are here, and it feels like I was never anywhere else. Don't get me wrong, there are many things that I miss - friends & family, white tea that doesn't taste of cheese, climbing, feeling cold, the sea, and good beer to name a few - but in the same way that I miss the snow in summer and the sun in winter, it's just normal.

I think part of this is that I have developed a routine; I find this odd because I always thought I thrived on chaos, but over the last few years I realised routine is good for me. It isn't strict routine, it never can be when I work every fifth night and random shifts, but there is definitely a routine. I don't know if it just helps me know what day of the week it is, or if it's the fact my routine often includes 'normal' things like going for runs, meeting friends, and going to church. It could be that I just know what is coming over the next few days, so life isn't quite such a mystery.

I spend time with people who have been working here for much longer than I have, and they all speak of life here as if it is normal. Obviously some of the things that we discuss as normal would be completely alien back in the UK, like not being able to reach other towns in the rainy season (or people not coming to work because it's raining - imagine if that happened back home!). Just having a social network of sorts makes life more normal too.

Having 'normality' means that I'm just trying to get on with all the various projects which I've found myself involved in: work, teaching, audits, service improvement, and learning medicine. That's pretty good, as I only have just over a month left here, and still have a lot to do (in a couple of areas I've probably bitten off more than I can chew). I doubt that I'll finish everything that I've started but that's probably a lesson in itself - discovering how long things take to achieve and quite how hard you have to push to get things done here; it can be pretty time-consuming, but overall, very satisfying.

Differences

Everyone is different. That's a pretty exciting thing about life; some differences are pretty big and some are tiny and virtually inconsequential. There are a few differences that I thought I'd mention today, for no particular reason, other than they happen to be rumbling round my head.

I had a long conversation with a patient today about his treatment for diabetes. He was rather frustrated, and was requesting that I refer him to a more advanced hospital in a neighbouring country because, after a whole month of medication, we hadn't cured him. I don't know how things were explained to him a month ago when he was diagnosed, but somewhere along the line, the concept of a chronic disease has been lost. Back in the UK, most of the patients I see have at least one ongoing disease, which is highly unlikely to ever be cured; I spend a significant amount of time dealing with complications of treatment for chronic conditions. Here, things are different; far fewer people are diagnosed with chronic diseases (I'm not sure why, maybe because they have a better lifestyle, maybe because the life expectancy is less due to acute illness - it's probably too complex a question for me to answer) and several times over the last month or so, I've had patients who are very suprised that their diabetes or epilepsy hasn't been cured after the first month of medication. Like many problems in healthcare, good communication can go a long way; explaining that even if I referred my patient to the best hospital in the world, he still wouldn't have his diabetes cured and that all we can do is control it the best we can with daily medication and try and avoid the complications. I'm sure as things continue to change in South Sudan that this and many other differences may be addressed by doctors and patients alike.

That example was of a difference, which is more towards the negative end of the spectrum. Lots of differences are much more positive, and lots are just different. Everywhere you look at lunchtime, people are eating together and chatting - often if I'm out running in the evening, the pavement is blocked by groups of men sitting round and drinking tea. There seems to be, in some respects, more of a community than there is back home.

Some differences are completely trivial, but for some reason happen to stick with you. Almost without fail, whenever I ask a patient to lie on the examination bed in clinic they put their hands behind their head - I'm sure people don't naturally do this in the UK. It doesn't matter at all, I just find it odd that everyone does it. I imagine they find it odd that I drink my tea black and without sugar (powdered milk makes it taste of cheese) when the average is about 4 sugars in each cup.

All in all, differences are what make going new places and meeting new people so interesting - it lets you see that there isn't just one way to think about something or do something. We all have a lot to learn from our differences. Who knows, maybe I'll start expecting diabetes to be cured, I know for sure I won't have sugar in my tea though...

It's Not All Work

I've realised that all of my posts so far have been serious and have just been about work and some of the problems that I've found while out here. Although that's the reason I'm here, it isn't all that I do. I've been really luck to get involved with various social things and have found ways to keep myself occupied in between my shifts.

When I arrived here, I knew nobody. Through a series of very random meetings, I have now made quite a few friends and found some leisure activities. Juba is a funny place, there are hundreds of NGOs based here, and the local economy has adapted to cater for their needs. There are several bars and restaurants which cater mainly for the desires of foreign workers; interestingly, since the last time I was here, you see a lot more South Sudanese locals also frequenting these places. It is a sure sign that at least part of the population is becoming more affluent.

There are often stark contrasts when visiting these places, next to some of the riverside restuarant/bar/hotel places is a graveyard, which is a little sobering; however it isn't a graveyard like the typical ones you see back home - between the gravestones are lots of small huts, where people live in complete poverty. Across Juba, this contrast is evident; new, large houses surrounded by tiny straw shacks. Currently it seems like there's quite a class divide.

Apart from going out for drinks and dinner, there's lots more to do. Those of you who know me will know that I like to be quite active, and although I haven't been that good for the last month, I'm starting to get out and do some exercise. If you know where to look there's quite a lot to do - I've started playing Ultimate Frisbee, which isn't technically a sport, as a dog can play it, but it is a good excuse to run around for an hour and make some new friends. The locals who walk past while we play look a bit amused, that might be because they haven't really seen people playing frisbee, or it could be because they can't imagine a situation where they would need to do more exercise or have time to. I certainly get some quizzical looks when I go out running too.

Of course, theres also my main sporting love, which is climbing. There are some exciting looking boulders dotted around the city, which would be amazing if they were more than a metre tall. Outside the city there is a 'mountain' which has some rocky bits, but I haven't made it there yet. Rumour has it that someone has bolted some routes there, but I only have my shoes, so I'll stick to the boulders. While I wait for an opportunity to get out on some rock, I've found a way to keep my fingers strong. When making my room, someone very kindly added a small (1.5cm) foot ledge around the bottom; combined with the corners and doorways, some fairly testing bouldering problems can be found. I think I have a problem, and it's not going away any time soon. I can live with that.

Healthcare's Dark Secrets

Before I came here, I knew I was going to come across problems that I hadn't seen while working in the UK. Some of them were pretty obvious, such as having to work with limited resources. It doesn't make it any less challenging, especially when you have to tell patients that they have a serious illness, but we can't treat it; telling someone they need to go to Egypt for chemotherapy, or even a CT scan, never gets easier or less surreal. Some of the problems I face are a bit more of a surprise to me, and they make me a bit angry sometimes.

I thought that I may see patients who had not come to see a doctor earlier because they had tried traditional remedies first, and although I see occasional signs of traditional medicine, it doesn't seem to be the major reason for patients presenting late in Juba. To set the scene, I should probably explain the health system here. Healthcare is provided in Juba by a huge number of private clinics; some of them are large, clean(ish) medical complexes; most of them are dirty, small and completely under-resourced. They are all for-profit, as far as I can tell. From my experience at one of the better clinics (the hospital where I work most of the time) and the government-run hospital, it seems that most patients will visit one of the smaller clinics first if they become ill and if the don't get better will either try a more expensive one (if they have money) or go to the government hospital (if their money has run out). In theory, this model isn't the worst, at least there is healthcare provision, but I have found that there is a darker side to many of these clinics.

What I'm about to say is all based on my personal experience and the views of people that I have met, but I have found no evidence that it isn't true, and plenty that it is. Many of these small clinics are staffed by people with minimal training, and without trained medical staff to consult with, following inaccurate algorithms according to what the patient presents with. Although this isn't ideal, you can understand it happening when there aren't enough doctors to go round. Sadly this isn't the main problem - many of the patients who are seen in the clinics are diagnosed with "Malaria and Typhoid", and given treatment which may or may not be effective for the condition they actually have (which may really be malaria and/or typhoid). The basis of these diagnoses is laboratory testing, which is often hugely flawed and often not even done at all. Yesterday I had a patient who had "malaria and typhoid" and had his notes from the clinic he had visited (a rarity in itself) - he showed me his results 'proving' the diagnosis, which consisted of a negative malaria test and an estimation of his white blood cell count (which isn't even the hugely flawed test for typhoid that everyone uses here - it's just a non-specific marker of infection and inflammation). He'd been prescribed various injections, but none of them were appropriate for his actual problem of indigestion, which is why he found himself visiting me, after not getting better. This is not an isolated case either.

Sometimes it is even worse, with patients being admitted to private clinics and paying lots for expensive tests (which may not even be performed) in more complex cases until their money runs out, when they are discharged and told they don't know what is wrong and that they need to go to the government hospital instead, or ideally to Egypt or Uganda (which is hugely expensive).To make matters worse, even if patients are correctly diagnosed, and prescribed an appropriate medication, the actual medicine they buy might not actually be genuine. I read recently that over 35% of antimalarial drugs tested in Sub-Saharan Africa are counterfeit, which at best means that the patient recieves a placebo, but could mean that they get a sub-therapeutic dose of the medicine (a highly effective way to cause resistance to one of the only effective medications we have) or even something highly toxic. False drugs are a global health problem, and hit the poorest people hardest (as the false drugs are cheaper than genuine ones).

All of this makes me a pretty angry, as there are people who are clearly putting money ahead of people's lives and wellbeing. I don't know how far this spreads and who makes the money out of these clinics and false medicine. If it is local people here, fighting to make a living, then maybe you can see why they think it is ok to do this (it still definitely isn't ok at all) and maybe a solution can be found by providing other ways for them to survive which don't but people's lives at risk. If it isn't people fighting on the poverty line, then I just don't get it - how do people justify making a profit from harming other human beings? I don't think this is a problem limited to Juba, but it's never talked about and having seen the effects of it for myself, I thought other people might like to know.

Some Things Never Change.

Over the last week, I've started going across to the teaching hospital (where I was as a medical student 5 years ago) on ward rounds with one of the consultants who also works at the hospital where I work.  Having seen the huge changes elsewhere in Juba, I was intrigued to see what had happened to the hospital since I was last there.

On my few visits so far, it seems the last 5 years haven't been so kind to the hospital. When I was last there, basic medications were available for patients free of charge, and there was an air of optimism around the hospital. Now there are no drugs or fluids, and often limited electricity. There are hard-working doctors and nurses, but they have very limited resources. Patients have to go and buy any medicines that they need, and apparently they often need to buy their own cannula and the gloves for the staff who are inserting it - which adds even more pressure if its a difficult cannula.

It's strange to see all the change in Juba without a corresponding improvement in government healthcare. I'm sure there are lots of reasons why, although I think part of it is that there has been lots of private investment, without much government investment. It will be interesting to see if anything changes, as the ongoing problems between north and south over oil revenues seems to be less problematic than it has been, so hopefully the country should get some money.

My work at the private hospital is going quite well, although it's often not very busy, which means that shifts can drag a little bit. The rounds at the teaching hospital are a huge contrast from the private one - there are lots of patients in the teaching hospital who have presented late (for various reasons) and who are very unwell. The prevalence of TB is huge, and it presents in a huge variety of ways. Thankfully, basic TB and HIV (which is also quite common, when people are actually tested) is free thanks to the WHO, among others.

Apart from all the tropical conditions, which are rare in the UK, we also have our share of patients who have more "common" conditions such as strokes and heart failure. We currently have 3 patients who have had strokes, all of whom have a very different future compared to similar patients in the UK. Here we don't have stroke units with intensive physio and OT input, specialist nursing and doctors who walk around looking important. There are some pyshiotherapists around, but they seem pretty stretched, if they are at the government hospital, and expensive if they're private. Even after the acute "rehabilitation" they receive in hospital, there are no government funded carers or specialist equipment; their families have to look after them without any formal outside help. Compared to many other places, disability doesn't have as much stigma attached to it, and family groups are often close-knit; but on a practical basis, having someone who isn't able to earn money or run the home, who needs to be supported, is going to make it pretty tough for a family who is probably only just managing as it is.

Motivations

As I get properly into the swing of things, I’m trying to work out what I’m meant to be doing here and why I’m doing it. If by late June, when I plan to leave, I have just gained experience of tropical medicine in a limited resource setting, will I feel satisfied? Or will I think that there was much more that I should have done? Currently I’m just doing “service provision” without any attempt at “service improvement”, which could be much more productive in the long term. I’m experimenting with ideas for teaching and for audit, but it’s difficult to know what is actually useful in the long term. I could gather data and do an audit on anything, but how do I know it will actually be any use? I think a bit of patience, and waiting for a problem to become apparent – either from experience, or from talking to the staff here. As for the teaching, I don’t want to be the western doctor who comes over, tells everyone they’re doing it wrong and then disappears again. I want to set up a system of mutual development, which will continue when I leave – this might be a little romantic, but at least I’m setting out with good intentions.

Intentions and motivation are an interesting point, which I’ve been thinking about a bit over the last few days. My reasons for being here are many, and vary quite widely. Some are at the more self-centred end of the spectrum; I want new experiences, to maybe make me a broader, more interesting individual and to help me understand myself more. I would also be lying if I said that this trip, and doing audits and teaching wouldn’t be helpful for ticking boxes and career progression in the future. As long as I’m honest about these, I don’t think they’re particularly bad reasons to be here, but they’re not my only reasons. I’ve known for quite a while that I should come back here and be more helpful/productive than I was when I was a student (not really that hard), and I do really care about South Sudan and its people; I think I’m meant to use the skills I’ve been given to do something productive here, even if I’m not quite sure what the big plan is. As for future big plans, they’re quite hazy still – several friends that I’ve met that are working with NGOs out here have asked about future plans, and right now, I really don’t know the answer.

On a broader level, it’s been interesting to find out about the motivations of the other doctors that I work with – it has definitely been challenging. One of the doctors that I work with also works at the government hospital, and at another private clinic. He’s easily doing the equivalent of 2 full-time jobs. When I spoke to him about why he works so much, he explained that he supports his mother and brothers, who are in Sudan and Uganda, to ensure they have enough to live on and study. I didn’t ask for a copy of his accounts, but from what I know, at least two-thirds of his ‘disposable’ income goes to his family. That made me realise just how fortunate I am. My motivation for doing medicine is not money; that said I’m incredibly fortunate that I get paid well for doing a job that I love. I’ve realised how lucky I am that this can be the case, my family haven’t been displaced by decades of conflict, and they live in a country that has a pretty good state welfare and education system (sorry daily mail readers, but it’s true in comparison to a lot of the world); when someone gets sick there isn’t the need to spend all my money on private healthcare for them, because we have a health system that provides excellent care. I’ve got a bit of a new perspective on life; I wonder how (if at all) it will change me?

One week in...

The last week or so since I arrived has been a pretty interesting time, I've had to find my feet in a new hospital, new city, new country (new to me and new to itself) and new culture. Although I've been here before, I've realised it's very different when you're by yourself, especially when you're not naturally that assertive or confident. Thankfully, I have settled in and have got to know the hospital, some of the staff, and have even made some friends from outside the hospital. Every day I think of something that I could write about on here, but no-one wants to read what I think that much, so I think I will just pick up a couple of thoughts that I think are particularly interesting, and help me to give a picture of things that happen while I'm out here.

While I was planning this trip, one of my main aims was to improve my clinical medicine (to any non-medics reading this, clinical medicine is using what the patient tells you and what you find on examining them, rather than test results), because it isn't as easy to run a whole barrage of tests like we do in the UK. However, I am learning that it is not going to be straight forward.

When I am working, I spend most of my time in the clinic, which is where all the patients initially present to the hospital - if the are really sick, we admit them, if they are a little bit sick we give them treatment and send them home. Common presentations in clinic are fever, vague abdominal pains, headache, diarrhoea, and a myriad of rather weird complaints. A lot of the histories are quite vague, which I struggle with; I like to spend a while working out exactly what the pain is like, and the complete sequence of events. I was thinking about why this might be and realised it's probably a mixture of a 3 main things. Firstly, there are a number of language barriers; most of my patients speak english, but sometimes I need someone to interpret as the patient speaks arabic or one of the many tribal languages. This is definitely less effective than me talking to another native english speaker. Secondly, a lot of the conditions that I see present quite vaguely anyway - the main one is malaria, which can have a huge range of symptoms - fever, headaches, diarrhoea, coma, heart failure. The final reason is to do with patient education; even though a lot of my patients are from the South Sudanese middle class, the rate of secondary education is pretty low. Often the descriptions of symptoms are pretty bizarre, or inaccurate - several people complaining of complete leg weakness even though they can walk normally. It is interesting to compare this to patients back home who are often very well informed on their condition, although this often isn't a good thing - there are lots more websites telling you that your headache is a brain tumour rather than the classic migraine that you're having.

I'm slowly getting to grips with the subtle nuances of history taking here, but the standard approach from the doctors here is to take a quick history and then run off an array of tests, almost blindly checking for malaria, amoeba and other infections. So I'm not sure that I'm going to be a diagnositic genius by the end of my time here, but I should get better at assessing sick patients. A lot of the tests that I would do on a very sick patient (O2 sats, blood gases, cultures, regular monitoring) aren't available here, so I have to trust my clinical skills and frequently re-examine patients to see if they are improving or if I need to do something else. This should be useful when I'm back in the UK as tests take time, and often making decisions on what to do next is based almost entirely on clinical judgement.

That's probably enough for now.

Welcome to Juba

Well, I'm actually here. I'd all but given up hope of actually coming out to Juba, having spent at least a year talking about it. For those of you that don't know, I came out here as a medical student in 2008, and have always wanted to come back and be a little bit more useful than I was then. In the last 5 years, a lot has changed - the most striking thing is that in July 2011, Southern Sudan became the world's newest country: South Sudan. Juba has changed hugely since 2005, when the second civil war ended, with a lot of foreign aid being pumped in to try and build up infrastructure. Since I was last here, buildings have sprung up everywhere, and many of the rutted, red-mud roads have been paved. There is a lot to say about Juba and South Sudan, and I'm sure I'll write about it in future.

I will be working at the Juba Medical Complex, a large private clinic in Juba. It is just across the road from Juba Teaching Hospital where I went last time I was here. I had originally planned to go back to JTH, but it became evident that I couldn't arrange anything with them - apparently it is quite chaotic there currently. I will go and visit and see for myself, and hopefully be able to do a little work there too. JMC is a rapidly growing unit, it currently has pretty good lab services, plain Xray, Ultrasound, Endoscopy, and there are currently building another building which now contains a CT scanner (it isn't operational yet) and will hopefully have an MRI scanner and high-care ward. The plan is, after a week or so of cramming tropical medicine into my head and shadowing some of the doctors, to join the rota as a medical officer - which is an SHO equivalent, as far as I can work out.

At the moment there isn't too much more to say, as I've only been here for 2 days. I'm sure there will be plenty to tell you in due course though.

Things are getting real

So, after what seems like an age, I finally have a date to go to South Sudan. For those of you who have spoken to me over the last year or so, you will know about the vague plan that I have often mumbled about, but never seemed any closer to happening. After a lot of trouble communicating with the appropriate people on South Sudan, and a bit of visa faff, I've managed to be sure enough that I'm actually going to book flights. I will be flying out on Thursday morning, and about 23 hours later I will hopefully be in Juba, the capital of South Sudan.

The plan is to work as one of the medical doctors at the Juba Medical Complex, which is a fairly new, but quite basic hospital in Juba. I'll be one of the team, working normal shifts but hopefully doing some teaching and audit type stuff too. I will be there for 3 months, and will hopefully learn huge amounts about medicine and myself. My aim is to share my experiences on here to give you a flavour of what is going on out there.

I'm pretty excited about the whole thing, but it also feels pretty surreal, as I've been talking about this for so long, but without having a solid plan, so I haven't actually had to face up to the reality of it yet. Given that I've had so long to prepare, I also feel like I'm not at all ready, but I'm sure i'll be sorted in time. One of my main concerns is that I haven't done any proper ward medicine for 4months, so I'll probably be a bit rusty, especially as I'm going to see more malaria every day than I've seen in total since qualifying. It will probably be a pretty steep learning curve

Sorry I haven't written much lately, but I've just felt in limbo as I've been pretty close to having this organised but without any kind of confirmation and the nagging feeling that it might just not happen. Since my last post, I've been skiing for the first time, having an amazing time doing something exhilarating in somewhere beautiful with some pretty great people. I also have a job lined up for when I get back from Juba, with a 2-year core medical training job in Bournemouth.

Anyway, I think that will probably do, I will try and be more frequent now that I have things to write about.

Slate Fun

Sorry, I seem to have been rather slack in posting anything new of late, mainly as I have actually been doing some work, have had an interview for jobs for next year, and have been playing in the snow. Before that though I had a fun weekend of adventures in North Wales. Although it was nothing new, it was good fun, and I finally have replaced my camera, so there should be pictures from now on.

As you might have guessed from the title, my weekend involved some of the old slate workings that litter the landscape in north Wales. If you've never been, they're quite a surreal mix of industry and nature, and although they can appear as huge grey scars on the sides of mountains, they are also a part of our history and can be strangely beautiful.

Saturday saw us head to the huge Dinorwig slate quarries above Llanberis, which apart from being an exciting tunnel-filled place to wander around is also a major climbing area. There are some historic routes on huge faces and tiny holds, as well as a lot of recent sport development. Combined with the very specific climbing style of slate, all this makes it one of my favourite places for sport climbing and fun. We spent a very cold, windy day winding our way up the multiple tiers of the Australia sector with pitches from F5+-F6b on A Grand Day Out, although the hardest bit was the first 4m - a really thin slab. After a lot of shivering and a couple of amazing pitches (including one where I was struggling to stay on due to the strong wind), we were rewarded with a view from close to the top of the quarries and a fun walk down where the main aim was not to shower the person below you with sharp slabs of slate the size of table tops.

Part-way up A Grand Day Out with old quarry buildings and tunnels.

Typical left-over ironwork with mountains in the background.

On the Sunday, we decided to go underground and do the SUMC favourite Croesor-Rhosydd through trip. For those not in the know, this is a fairly serious (albeit well-equipped) trip through two old slate quarries/mines which were abandoned in the early-mid 20th century, along with a lot of the slate workings in north Wales. I had done this before, about 5years ago, so was nominated navigator. Thankfully all the fixed gear was in even better condition than the last time I was there - including the addition of a zipline! I won't give a blow-by-blow account of the trip, but a guide can be found here http://ukcaving.com/wiki/index.php/Croesor_Rhosydd_Through_Trip Thankfully I managed to locate the various abseils and bridges without getting very lost. Unlike standard caving, there was barely any bending down and squeezing through tiny gaps, the main challenges were technical - with the first half being a bit like underground via ferrata. The highlight of the whole thing is the huge, flooded underground chamber where you abseil into a boat and get pulled into the darkness. Since my last visit, someone has managed to get a rigid 2-man canoe into the lake, which is no mean feat, and is less nerve-racking than the previous inflatable dingies.

My little camera struggled in the cave, but did take a couple of accidentally cool photos.

Gramps abbing down into the in-situ canoe

Whilst we were in the cave, it had been steadily snowing, which gave the effect of coming out of the other side of the cave into a completely different place, which was pretty cool. All in all, it was a fun weekend of slate adventures. It is pretty amazing that we can play in these former industrial sites (I'm sure my parents told me not to play in these places), but its also pretty humbling to think that people used to make a living risking their lives working in these places in horrific conditions.

All Change

Life seems to be going in distinct one-month blocks currently. November - locuming, December - climbing, and now January is the month of sorting. Currently the next month seems pretty scary - lots to get sorted and not very much time; combined with the fact that trying to actually organise working in South Sudan requires the use of what I shall call "non-definitive arrangements" which is one of many ways that I will avoid actually admitting that I have no idea what's going on. The future is more than a little hazy at present (more of a full-on fog). But a month is enough time to get everything sorted, and as always, it will be fine (this philosophy requires a liberal view of what constitutes "fine").

Well, as theres only so long I can ramble on about how I have no idea what is going on, I think I'll write about my climbing trips and Christmas instead. Over the last month, I've thought of lots of interesting things that I thought I should write in here, but never really got round to it. Don't worry, I won't  bore you with too much. I've been really lucky to have been on 3 climbing trips over December, each quite different, but all enjoyable. After writing about how much I like to improve and push myself in climbing, I have also realised how fun it is to climb things that are completely in my comfort zone and just enjoy the climbing, rather than feeling any pressure (internal or external) to push myself in terms of difficulty.

Apart from the climbing, I've also had the opportunity to catch up with old friends, spend more time with existing ones, and make new friends, which has been as good as the climbing itself. I finally was able to return to the Costa Blanca in Spain and climb a few routes that had been on my mind since my first outdoor lead climb there in 2005. I found myself leading a couple of climbs that I had tried the last time I was there, which I had struggled up on toprope, thinking that the people who led the climbs were super-heroes. It was a surreal moment when I realised this halfway through the delicate, technical crux, feeling pretty comfortable.

My month of sorting is progressing slowly, probably not helped by disappearing off to Snowdonia for adventures this weekend, but some offers are too good to turn down - places I love, with amazing people.