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...