An Artis Story

Prepare yourselves, I’m not going to lie to you this may be long, rambling and let me warn you most likely not worth it! So good luck x

I am lying in bed trying to get to sleep while noises alternate between the strained acceleration of a Landcruiser, the racket of frogs competing for airtime and the wind whistling though the reed fences which sounds like women and children screaming. When I eventually get to sleep it makes for some interesting dreams I can tell you! So why the new bedtime noises? Well, we are house (and kitten) sitting for a month, which means we have cooked roast chicken and eaten food hot for the first time in four months; this really has been a treat – although a good BBQ with a variety of meat is still a craving.

We each sit next to a kerosene lamp for another night of low lit reading; work has had to be abandoned again as it is too hard writing in pretty much darkness. Fuel in Juba has become a BIG issue the last couple of weeks and hence we have spent more time without electricity than with. Thankfully we have generally been able to charge the computer at the hospital, but today even that failed, so we treated ourselves to a drink at a restaurant that had generator power. The lines for fuel are getting on for half a mile and a friend with a vehicle had to drive miles to find a station with fuel on Saturday. So perhaps us feeling frustrated that since we returned from holiday we lost the use of the car is not going to be such an issue very soon if no one can drive anyway! But seriously being without a car here has been a struggle. We are walking to work which is fine from the house we are in at the moment, but it means that after dark, there is no real safe way to be mobile. The motorbike taxi’s, which we are reluctant to use except for one guy we know who drives very carefully, stop work around eight o’clock and there are no regular taxi’s to speak of, so unless we are with someone who has a car it means ‘curfew’ at 8ish! It is an exciting life we are leading!!

Heidi by her Kerosene Lamp.

So theatres, how are they? As we have said on an earlier post, well before we went on holiday they were all but closed except for emergencies because they were being re-tiled. When I heard this I asked the surgeon why? He couldn’t answer; the floors were actually pretty good. A cynical view I heard was that it was probably someone important’s relative that had some surplus tiles. So we waited for the tiling to finish, the speed of which is demonstrated that in one of the rooms when I went to check on progress there were only eight tiles left to lay. I returned two days later to see that room still hadn’t been finished! Finally theatres reopened, after a one week closure lasted a month.

For those of you who would like a technical update of things here goes: apologies for the jargon to everyone else. Anaesthetics are done by medical assistants who have been doing the job for varying lengths of time. Currently there are zero physician anaesthetists in Southern Sudan; except me that is. So there are three main theatres, one is used for minor procedures, generally done under local anaesthesia or nothing, this includes pulling wrists, plastering various broken bones and debriding wounds. The most disturbing I’ve seen is a 13 year old girl who had had an epileptic fit into her family fire. She had significant burns from the accident two weeks previously, which smelt awful and she was in so much pain it was terrible. She did get a bit of Ketamine but there were no intravenous pain killers in the hospital.... So as you might imagine various cries and screams often escape that room.

The other two theatres generally run at the same time and depending on the day will either be gynaecological cases or surgical cases. Until the orthopaedic surgeon arrived (he is here for one month) there was only one surgeon doing general, urology, orthopaedic, ENT and anything else that came along. He is trained as a urologist but works hard and tries to train his juniors despite being on his own. The anaesthetics will generally be Ketamine with some spinals. There is no long acting muscle relaxant so we give Suxamethonium (which is out of date but thankfully still works) boluses if required. There is a five litre oxygen concentrator with the option of nasal specs, but no standard face masks. The kit such as tubes, guedel’s, and face masks are woefully inadequate in variety and number (something else I am working on). However, there is a working saturation probe and blood pressure cuff in theatre which is now used on every patient – Hooray.

So I have been trying to get drugs, equipment, encourage more spinals and teach some peri- and post-operative thinking like giving antibiotics and analgesia which, granted, is at times impossible when you don’t have any but you can only do what you can do. So supervision has been the main thing, plus anaesthetising a few scarily small babies....

I hope this gives a bit of a feel for theatres and all from my kerosene light at 8.30pm! Now I will head to my bed for the chorus of noise; maybe the car sounds will have decreased tonight...

Oh, one last thing! So we thought house sitting would be easy, but the little eight week old kitten had other ideas! For the first week he was very excitable and ‘bitey’ and a little bit of a pain so we, well I actually, started a 10 minute timeout for him whenever he got too much for me, which of course wasn’t very often: you know how tolerant I am! I also decided that him getting up on the table to join in breakfast and dinner was no place for a kitten, so there has been a lot of lifting him on to the floor. James is very helpful in this exercise, not. I also read that clapping and shouting NO may stop the biting, but when at 7am I was doing this repeatedly James thought it maybe too much for the neighbours and put a prompt stop to it.... Then last Friday night we thought how cute he was being, curling up on our laps and being very chilled out. This continued on Saturday and then we realised he hadn’t eaten or drunk anything despite our efforts of ‘tasty’ food – oh dear. So followed a stressful few days building up until we got home from work and he couldn’t stand up – oh my goodness the cat is going to die on our watch what shall we do! The only vet we knew about was closed and so we decided to go in the morning and keep our fingers crossed overnight, plus a phone call to England to the owner to check the origin of the scamp – she was suitably reassuring and as a public health consultant pragmatic too. The next day thank goodness he was a bit better and has continued to improve and get stronger. Who knows what it was but he is well enough tonight to be play biting, charging me whilst I write and being generally ‘kitten-like’, I think the kerosene and torch light is confusing him with the shadowing and flickering. But if he bites me again it’ll be time for another ‘time-out’ shut in the other room.

Freddie the kitten pre illness

Freddie when ill - cuddling up to sleep.

OK done. Well done for those who got this far x

p.s. I almost forgot that damn monkey is back....

Muddles back on patrol.

The Pain Threshold

Another thought after a day on the wards.

One of our medical students asked me to see a relative of his that he had bumped into in the market. He had been complaining of painful lumps under his right arm for some months and local healing had failed to relieve it. I gladly saw him in our little room and after taking a history, using the student as a translator from the tribal language, and examining him I diagnosed a non-fatal skin condition. I did, however, want to perform a blood glucose check, to rule out diabetes, a common complaint here. We had been generously donated a bedside glucometer and I lined up to use it. Tugging the plastic cap off a small needle that I was to use to pierce his skin and get a drop of blood for the test I asked Chol, the student, to warn his relative of the soon-to-arrive ‘sharp scratch’. There is an intense exchange of words between them, of which I understood nothing and a smile spreads across Chol’s face. ‘what did he say?’ I ask. Chol chuckles, and replies ‘he said “I have been shot three times while in the bush during this war and he’s warning me about that tiny needle. As if we don’t know pain here. Please!”. What can I reply to that. I just did the test. It was normal.

Dr's Artis, Jenkins and Waller I presume?

The story continues, but in a different vein; a break from Juba. The town can become quite suffocating and claustrophobic. As we have no doubt described it is not straight forward to leave the confines of the city by road given their dreadful condition and the relentless police blocks that are guaranteed to find issues with your papers. And even when you get out of town you can’t cruise around in the bush in case a rogue landmine creeps underneath ones feet as sadly does still happen and we see the results at JTH. The town itself is heaving with NGO’s, UN and contractors and especially where we live there is a fascinating array of people from all over the world and Sudan itself doing some amazing things but it is always nice to have a break. After all, we spend three meals a day eating with everyone in the camp and you can sometimes run out of conversation.

So, Mum flew out and met us in Arusha, Tanzania and the adventure in Western Tanzania commenced. The roads are basically non-existent and given our limited time, and the fact that the Juba roads have rattled our skeletons enough we proceeded by plane to Mwanza to hunt out the site that Speke first saw Lake Victoria in 1858 and announced her, rather assumingly, the source of the Nile (much to his travelling companion Richard Burton’s annoyance as he didn’t fancy the trip up there and so missed the action). He was right, but he didn’t live long enough to hear the proof himself due to his rather untimely death resulting from accidently shooting himself on a hunting trip near Bath in 1864. The view of the Lake excited me, but rather less than enthused my two travelling companions who were hot and tired and it took a large slice of chocolate cake and two cups of tea to calm them down.

Next stop Kigoma where we hopped a boat to Gombe Stream National Park tucked up by the Burundi border. This little place is famous for wild chimpanzees and arriving at a sunken jetty after dark following a few hours on Lake Tanganyika with a storm brewing over the Congo hills behind us made it feel like the end of the earth. To save me finding a thesaurus for the appropriately imaginative descriptive language just picture that scene in Peter Jackson’s King Kong movie when they arrive at the cursed island. Exciting no?

The chimps were amazing and the bush experience, complete with eating termites pulled from their house in the ground, awesome. However, we did not account for one added team of locals- the baboons. These guys were big, rowdy and fearless and a stroll past their troop with anything resembling food in ones hand is rather like ambling down the main strip in Portsmouth at turn-out time, while referring to oneself as oneself. Pretentious, I know. Anyway, one of the alpha males decided to bust open the front door of the hostel in the bush (this thing is encased in a serious amount of iron to keep these guys out) and charge in. I was on the stairwell and Heidi and Mum were outside the dorm room. They stood paralysed with fear and I did what any true man of iron and honour would do and charged into the marauding monkey to rescue my family. The fight was tough and bloody. He was strong, but I was stronger. He was mean but I was meaner. The animal rage boiled over and as the sound of breaking bones and shattered teeth filled the concrete corridor I prized his canines from my throat and tossed him without mercy onto the dusty ground outside. He lay still and the silence seemed to last for an eternity, broken finally by the howls and cries of the rest of the troop, at least 40 strong, who were now proclaiming me, a human man, their new alpha male and leader of them all. History was made: A legend born.

Gombe was followed by a trip to Ujiji, famous for Stanley’s legendary words to Livingstone when they met under a mango tree there in 1871, and infamous for being a major slaving route from the ‘interior’. It was here, at the mouth of the slave road that we met these two boys playing Pool by striking marbles with bamboo cues on a T-shirt pulled taught on a wooden stand. The lads, no older than 10, were playing for money so I put down my cash and started to hustle, only to be unceremoniously whooped, but only after a decent crowd had formed around the table. The locals smelt that they were on to a winner- they had found a man with money and the unwavering belief that he is in some way good at the game (something for which I have been punished before in various public houses in England). Heidi dragged me from the throes of arms clutching wads of cash that was proffered in return for a game.

Kigoma to Katavi National Park was a long and joint jarring bus ride but the tea (cooked up on the Trangia we had with us- Duke of Edinburgh Award anyone?) sitting out by the river watching the hippos chilling their boots was a rewarding end, as was the walking safari the following day: the three of us and our guide stumbled across a pack of lions under a tree by the lake. They mistakenly thought we looked tougher than we are and ran away from us, preferring the ‘easier’ task of hunting a buffalo or similarly massive beast later on rather than sink their teeth into our buttery hides.

We cruised on to Kipili on the shores of the Lake and enjoyed some days paddling the waters, swimming and biking, the ominous shadows of the DRC ever looming in the distance. This then led us to Utengule coffee plantation in Mbeya, southern Tanzania, and a chillax there while we waited for the Tazara (Tanzania-Zambia Railway) to whisk us off to Dar es Salaam. The resulting journey, that took us through the depths of the Selous Game Reserve, stretched from an already not insignificant 19 hours to a mammoth 35 hours. I think we all wished the lion had had a little more sense at least at one point in the trip- or maybe even the baboon. But no, the whole thing was amazing, and as I have said, a welcome break from the office.

That is where that piece would have ended had Heidi not spotted the baboon section over my shoulder. It’s come clean time I’m afraid. To recap, a large angry baboon has broken open the door of the hostel and charged inside. Heidi and Mum are frantically fingering the small key into the dorm lock and I am on the stairwell. As I said, I did what any right thinking man would do. I pegged it upstairs into the empty dining hall, tried every door to find them all locked, bar one. And that discovery ushered in a solid hour seated on the floor of a bathroom with a leaking tap and a used toilet that wouldn’t flush with my back pressed firmly against the locked door. I was finally released by an American woman living there to study the baboon behaviour and informed that the fellow was long gone and all I needed to do was avoid eye contact. I pointed out that I rather fancied some time cooling myself on a moist toilet floor and had only been in there so long as I had found the lock troublesome to undo.

Anyway, back to Juba and back to work.

Trying out our hats - not the best photo but just so you remember what we look like!

Going for victory....
James playing 'pool' for 100 shillings (4pence), the felt is an old T-Shirt.

All smiles as the young man wins.

Tasty chapati's on the long local bus south.

On the boat to Gombe Stream National Park.

Heidi negotiating the jungle to find the chimps.

Tarzan grooming Titus.

Del enjoying watching the chimps.

Giraffe in Katavi National Park.

Some bush driving getting to Katavi.

James enjoying the walking by Katavi Lake (we saw the pack of lions by the tree in the back).

Hippos keeping an eagle eye on us whilst enjoying the mud.

A hippo less than impressed with us walking past.

James and Del enjoying a nap after lunch between walking.

Us drinking tea at sunset watching the hippos in the river.

Some good street food of egg and chips.

James enjoying the water as usual.

Del on the home stretch passing a village on our kayak around the island.

Heidi and Chris with the quad bikes in the bush.

A sunset at Kapili.

Birding.

The remnants of the popular game bao on the edge of the coffee plantation.

The Tazara Railway train stetching ahead of us.

A business transaction for lunch at one of the stops (some dried fish).

The Goat and the Gorilla

Why the title I hear you ask? Have Heidi and James been trekking the jungle in search of gorillas? Or even goats for that matter. The short answer to your telepathic questions is no. No, there are, as far as zoologists are concerned, no gorillas in South Sudan since they appear to prefer the cooler climbs of central Africa. However, I think you can see that the photos tell a different story. As I am sure you can see clearly the form of a large gorilla wielding a large club and spraying water from his mouth. This is ‘The Gorilla’ that bravely guards the entrance of Oasis Camp, surrounded by hoards of flamingos, elephants and, yes that is right, a goat large enough to threaten to crush the elephants that stand opposing it. But enough of this jibber-jabber. What’s been happening?


Work continues in earnest. The ward rounds continue and I continue to study tropical medicine hard. There have been some great presentations from the Junior Doctors at our weekly teaching and it is awesome to see their presentation skills improving. Not only this, but it is a great opportunity for us to learn. We have chosen a ‘top 20’ presentations based on signs and symptoms we have seen a lot of on the wards and have divided them into system categories (for example, cardiovascular system, respiratory system etc) and each week a topic is presented discussing the different symptoms or signs in general followed by a more detailed discussion about a specific disease (for example Typhoid, or viral hepatitis). They present on the ‘gold standard’ treatment that would be available with all tests and drugs at our finger tips and then we discuss the management of that particular disease in South Sudan, with the more limited resources at our disposal. It is very interesting and is actively changing my practice on the wards.

Our Acute Medicine ward rounds have wandered into some interesting obstacles. They are much longer than they are used to, and especially long if we are teaching as well, though still short by English standards; say 3 or 4 hours. We originally wanted to start at around 9am, but after a few days of turning up then it turned out the cleaners would do their washing then and this involves turning the floor into a swimming pool for a few hours so ruled out a round. Also, they do such a good job we didn’t want to get in the way. So rounds on the Acute Ward start at 10am. However, this means a finish on that ward at around 1.30pm and pharmacy shuts then. So, we started to get complaints from pharmacy that they would not issue any drugs to my patients, rendering the ward round pointless. Meanwhile, the nurses were complaining that ward round was creating too many jobs for them. Brilliant. We are still working our way to a compromise as we are reluctant to agree to the suggestion that we only see a couple of patients each day and leave the rest to battle the disease alone. We shall see if we can find a way out of this Catch 22.

As far as rest and relaxation is concerned we really stumbled in to a winner. After hearing about an up and coming trip down the Nile from the Ugandan border at Nimule to Juba we were keen to get involved and managed to join the first ever commercial trip down that stretch of the Nile. It involved a few days of bush camping in the depths of the Sudan bundu and a mixture of decent white water and long stretches of scenic surrounds. Much of the area is unpopulated and dense vines hang from deep green trees that cling to the riverside rock with long fingers of gnarled root probing the cracks to prevent them from tumbling into the muddy water. When camping it was sensible to stay near the river edge as some areas are still littered with land mines and while washing in the waters’ edge you could pull out unexploded artillery shells a foot long from Russian-made mounted machine guns at certain points along the voyage. It was an awesome trip and great to get out of Juba for a change. Thanks to Pete and Jane the South Africans who put the trip together.

A village on the road to Nimule (the Ugandan border)

Raft oreientation at the base of Fula falls, Nimule

Pete and Jane scoping out one of the big rapids

Running rapids

Heidi and her tea, bushcamp on the Nile

A local canoe from a hollowed out palm tree trunk

James putting in some oar time

Bushcamp on the Nile

Bush fire - in the distance an iron pot cooking a cake!

The impressive cake in the bush

Joining up the rafts to boil up some tea

Tea time in the rain

The Nile

Hauling the rafts up the bank - Juba

Anyway back to the grindstone!!