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.