On the Way Home

I am out of Gogrial.  And now I am back in the capital city, Juba.  The internet here is not as good as it was in Gogrial.  The power comes and goes, with no apparent reason.  The infrastructure in Juba is not very good, and sometimes, barely adequate.  There is a lot of room for improvement.
It is always hard at the end of a mission.  There are many people with whom you have worked hard, sweated, and survived.  It is hard to say goodbye.  But it is time for the next chapter.
The people in the OT have been great.  Angelo and Alessio have been the OT techs.  Abdullahi was the anesthesia provider.  We had a great team.

Alessio on the left, Angelo in front

I wish them all well.  Things are improving in Gogrial, but the influx of refugees at the camps near the border is overwhelming.  They estimate over 200,000 now, and they keep coming.  The camps have had to be moved due to flooding.  What a mess.  I feel fortunate that I was in a relatively safe area.  The stress levels at the camps is very high.  Many ex-pats have had to end their missions early, because of high stress, and illness.  I guess I have been very lucky.  I give a great deal of credit to the people who do this work.  It is hard work, and not glamorous in the least.  But there are people who need the help.  And I am glad to be able to help.
It is overwhelming.  So I am reminded of the parable of the little boy and the starfish.  It goes like this.  A little boy was walking along the beach after the tide went out, and he saw thousands of stranded starfish.  So he picked up starfish, one after another and threw them back into the sea.  An old man was watching him.  The old man told the little boy, "There are too many to help.  It won't make a difference!"  The little boy looked at the old man, then threw a starfish back into the water.  He said, "It made a difference to that one!"
So we do what we can in the face of overwhelming suffering and need.  And we hope to make a difference.

The Operating Theater (OT)

The scrub sink and the door into the operating room

The preop and postop area in the tent

MSF has used inflatable tents in areas of emergency.  These can be erected rapidly, are fairly mobile, and are very functional.  The OT in Gogrial is an inflatable tent.  The inpatient units include a Surgical Ward, a Medical Ward, a Pediatric Ward, and a Maternity Ward.  These are in fixed buildings that were built in 2010, and will eventually be handed off to the local Ministry of Health once the Human Resources and infrastructure to man and maintain them are present in the local community.  It is then that MSF will back away from this project.  This should occur sometime around 2015, but no one is holding their breath.

Sunday Morning

It is Sunday Morning, and the camp is still quiet.  This is the start of my last week.  I will start the journey back sometime later this week.  Time for some updates.
The man who was stabbed with the spear (A Piercing) survived and was sent home.  He was actually quite grateful for our efforts.  He offered to share his tobacco with me.  The man with the AK47 wound to his arm continued to worsen.  His family wanted him sent somewhere else, so we tried.  We sent him to Turalei, but there was no surgeon there.  And he returned to us.  They went to a traditional healer, but again he returned to us.  The gangrene in his arm continued to worsen.  His family finally decided that he did need surgery when they could see the maggots crawling amidst the wounds.  Because they had waited too long, the infection had climbed up past his elbow, requiring us to amputate higher than we originally planned.  We proceeded with an upper arm guillotine type amputation because of the nature of his infection.  He now looks much better, and his sepsis, which I was very worried about, seems to be resolving.
There was an attack two days ago by Sudan.  Three villages near Aweil were bombed.  There were several injuries.  A pregnant women sustained injuries to her back.  She is still in Aweil, but will be transferred to us tomorrow for more definitive surgical care.  (There is not a surgeon in Aweil.)
There are two women in our Antenatal area that we are watching closely.  One was thought to have a transverse lie, and would likely need a c-section.  After a number of evaluations, we felt that the baby was vertex, but the size of the uterus was concerning.  She might have twins!  The other woman has what we think is polyhydramnios.  We do not have an ultrasound or other way of evaluating patients other than clinically.  She may need a section as well.
So, the adventures continue.  There is not really a break.  I am the only clinical doctor here.  There is a fill-in administrator, that we call the medical focal point (MFP) who is a general practitioner, but he doesn't do much clinically.  He has been here for three days.  His responsibilities are primarily administrative.
The camp is stirring, and it is time to make the rounds and see the patients in the hospital.

How to Have a Meeting

Every day we meet in the morning.  We go over everyone's position and area so that everyone understands what the plan is for the day.  The other day, there was a song about malaria.  Today the song was about diarrhea.  Probably not on the top ten for most artists, but I thought that it would be fun for people to see how our meetings are held.  The guy that is singing is really quite good.
http://www.youtube.com/watch?v=Iet_Eci-6yo&feature=plcp

No Bicycles, No Motorbikes, No Cats

This is a picture of the sign that is posted near our meeting area.

There are a lot of things that should not be allowed into the meeting area.  I find it pretty curious that they find it important to list these out.  What about the mosquitos, the snakes, the porcupines, the hyenas, and the lions?

What They Don't Teach You in School

It seems that during our training as physicians, certain things are stressed as true and important.  I'm sure that this remains true in most of the United States.  But there are times when these truths are bent.  I remember learning that an open fracture is considered an important thing.  Something that should be fixed and cared for immediately.  Here in South Sudan, and I'm sure other places around the globe, open fractures are just another bump in the road.

I was just asked to see a six year old boy who broke his leg almost a month ago.  He came from another MSF site where there were no surgical capabilities.  When he arrived we did a quick assessment.  There in the middle of his leg, sticking out of the skin, was a ragged bone.  His tibia!  He has been limping around on an open fracture of his tibia for nearly a month.  Some emergency, I thought.  So much for all that secret orthopedic knowledge.  What I was lacking was the experience in treating open fractures where the bone is sticking out of the skin, and has been for weeks, and the bone left inside the skin has started to heal.  So once again, we did our best.  I took him to the OT where I opened the wound a little bit, and cut out the bone that was sticking out.  Then we packed his wound, and made him a type of splint that would allow for further dressing changes, yet give him support so that he can maintain some mobility. I doubt that he will ever run in the Olympics, but then again, how many of us with normal leg bones really have?

Charles Dickens and Tusker Beer

The nights are long near the equator.  The sun goes down just after six, and comes up sometime around six.  There is no night life.  No TV or movie theaters.  No restaurants.  The evening meal looks just like the noon meal, except colder and older.  So I read.  And what I have with me is Charles Dickens A Tale of Two Cities.  It is much better to read this story now than when I read it in high school.  I remember liking it then, but I'm sure that I didn't get it.  However, it is much better now.  To enhance the experience, there is Tusker beer.  It is made in East Africa, and is named after the elephant which killed George Hurst, one of the original brewers.  I had been told that Tusker beer is a terrible beer.  But when it is the only beer, it is also the best beer served.  Charles Dickens doesn't seem to mind.  Because, it was the best of times, it was the worst of times ...