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!!

Have you seen this monkey?

Muddles is on the lam. It is alleged that he bit a lady as she crossed the road outside the hospital, though some say he was going in for a kiss but she moved. He has not been seen since and there has been the suggestion that mob justice punished him, and thus he fears to return to the area. Sightings of the furry fellow have been made in St. Josephs catholic church, where he was seen crouched by the alter trying to pronounce the words ‘Hail Mary’ without success.

Heidi, however, still carries ‘Monkey Stone’ wherever she goes. The smooth orb lies on the car seat overnight, and remains in her hand at all times outside of the confines of the concrete walls of the wards or offices. The staff now ask if she has it with her, and even suggest inviting Muddles for peace talks overseen by the Medical Director. Heidi has declined the offer up until now. Even when Heidi fainted after a long and hot ward round in the long stay ward, I came to find her lying on a hospital bed to which she had been carried, smiling, and with Monkey Stone placed carefully by her side, clearly rescued from the ground where she fell by the nurses.

Medical officers at their teaching

But what else has been happening? We had a meeting with the Head of the hospital to discuss the doctors’ attendance and reassuringly it has improved after some form of order was sent out from the top. The wards have now been divided between me and the other consultant so I look after the men, and he the women. This is working very well as you get to know the patients well, which speeds up the ward round and improves their care. The juniors have also divided themselves into two teams and this is allowing them to see the patients improve, providing them with some reward to their work along with seeing when treatments don’t work as well and getting a chance to ask why.

Some clinical medical students have started to arrive on the ward of their own accord. As we have previously mentioned, during the war the medical schools were moved to Khartoum in the North and now they are moving them back. However, all the lecturers are Northern and thus have not returned with them. As a result the 5^th years have had no teaching for 4 months and some have emerged from the four corners of Juba city hungry for some education. We have started teaching from our office one afternoon per week to these few keen students and with great results which is really uplifting, and have offered our services to the university so we will see what happens.

The junior doctors have gradually been appearing at teaching with increasing numbers and have started to do presentations themselves with us overseeing it all giving them feedback on their presentation skills which again has so far been a real success, and will hopefully continue. Bedside teaching has started as well as we are starting to teach examination skills and this is slowly taking off.

Heidi is working hard in theatres, focussing on getting the right drugs to provide a sustainable service there, rather than one that will cease as soon as we leave. Theatres are currently being tiled so little work is happening inside and Heidi is acting as the ultimate all-rounder, seeing medical admissions and the surgical patients.

A boat of returnees

Relaxation has largely focussed around the camp, with a few beers and Tangawizi’s on the water front. On a few of the evenings we have been greeted by the amazing sight of huge barges slowly cruising upstream to the port just upriver from our camp. The boats are crammed with people, on the bows, on the roofs, down below deck, in every available inch all cheering and ululating as the boat sounds its bellowing horn. These people are returnees from the North; Southern Sudanese who are finally returning home to help rebuild their shattered country and you can hear their excitement at coming home in their shouts, having spent many days on the river. These boats are followed by other barges, creeping through the pink haze of the evening sky, crammed with their belongings, including chairs, tables, donkeys; basically their entire lives piled onto a deck.

If you look closely you can see the little shop (next to the people walking) outside our camp

This is a view from the village looking at our camp (the green sign in the distance)

A picture of James enjoying a coffee - in the background is a flattened
patch of ground where a market was just a week before.

A common sight in Juba is small fires scattered along the streets
where people burn their rubbish, including many plastic bottles.