Mattdocfilms and AMREF FD

Amazingly I've managed to get myself entangled in quite a few projects over the past couple of months with a few of them coming to a head this week, hence the delay in posting stuff. Last week I was involved in the official symposium with government officials, the CDC and John Hopkins University to discuss the progression towards an integrated EMS response in Kenya as I discussed in 'Fledgling Paramedics' post last month. I'll write a bit more about that later. For now, I'm writing the Handbook for volunteer physicians, completing an audit looking into critical care patients and creating an induction and continuing training programme for the staff using a few lessons from our pilots.

However one thing I have been doing has been collating a montage of video clips of my time with AMREF FD. I have put it on my youtube channel ' mattdocfilms' and I thought I would share that instead of doing another story. Enjoy!

http://www.youtube.com/watch?v=QeogQHIibl4

(ps - if anyone is free and has the appropriate experience, AMREF FD is looking for a volunteer physician next month.Go to flydoc.org if you are interested, I know it is short notice due to a late drop out.)

Plane Crash in the Rift Valley

“Mayday, Mayday, small aircraft has crashed at Waso Airstrip. Plane destroyed. No fire. Four casualties taken to Entasopia clinic in a pickup truck. All have survived. Pilot has a bad head injury. One passenger severe back pain. The other two have limb injuries. Please send air ambulance to Entasopia airstrip immediately.”

So that’s my Monday afternoon call. I had spent the morning lazily looking through some case notes when this pulse-quickening call came through. Air crashes of small aircraft are not all that uncommon out here. The combination of poorly tended airstrips, poorly maintained aircraft and poorly trained pilots means that AMREF FD attend at least one air-crash per year. Of course, some good pilots in good planes can just be unlucky. Freak winds, dust devils and large animals are just some of the hazards a pilot must face working out here. But really, given the distances and quality of the roads, flying is the only way to do it! Kenya has such a wonderful tradition of small aircraft aviation and there are so many little airstrips that it just makes sense. If you come to Nairobi, come down to Wilson Airport and visit the Aeroclub of East Africa to get a glimpse into the crazy ex-colonial aviation history of the place.

Locals came from all around to take a look

Both Waso and Entasopia are pretty close to Nairobi, down in the Rift Valley about 25 minutes in the slow but versatile Cessna caravan. For their closeness they may as well be on another planet. It’s a stunning area but rather poor, inhabited by mostly Masai pastoralists. It seems that 4 chaps who worked for a tourist lodge further toward the hills, were in the process of doing a resupply in the little company airplane. On take-off , at the level of the low tree tops, for some reason the plane was witnessed to veer off to the left side of the runway and bits of plane were all that was left. On our way in we were rushing to the patients, so didn't get a chance to inspect the crashsite. Mercifully the wreck had not burst into flames or it would have been a more familiar story of four critical or, more likely, dead patients.

We loaded and were leaving Wilson airport within 30 minutes. I was entirely expecting to do two runs back and forth for both pairs of patients especially if any of them were critical. We were told to fly into Entasopia airstrip and while Kisito and I were in the back preparing for the worst case scenario, our pilot Phil started banking back and forth trying to find it. I’m generally pretty good with motion sickness but after the third aggressive, tree skimming, banking maneuver trying to find this airstrip, I was on the verge of re-examining my lunch. Soon Phil found it and lined up like he was going to take a crack at landing there. As we descended Kisito’s eyes widened and he said “That’s not a runway; that’s a driveway!” Calling it a driveway was generous. That strip had not been used for years. It was overgrown with bushes, bumpy and completely unsuitable to land a plane. Phil already knew this of course. He had no intention of attempting a landing, he just wanted a closer look. I wished he had told me that before I considered adopting the brace position and kissing my arse goodbye. As we flew very low along the old runway we terrified three Masai tribesmen who jumped from the bushes and ran for their lives. Whoever had told us there was a usable strip at Entasopia needed to do some more research!

For all those with a 4x4 in London - this is what they are for!

We flew over to look at the nearby airstrip at Waso where the crash had actually occurred and found it clear and usable so we landed there. We were met by a friendly conservationist who is currently studying lions; working out ways to stop them killing livestock and therefore keeping both man and lion separate and safer. He offered to drive us to Entasopia with our kit and we could also use the pick up there to bring the guys back. Phil offered to call in a helicopter as well but we opted to check out the patients first.

The road was as bad as I’m sure you can imagine and wound its way uncomfortably through the stunning countryside. There was a giraffe standing by the side of the road, and chewing contentedly, watched us go by with all the outward anxiety I would expect from a Devonshire cow.  We passed small herds of livestock with their tenders until it took us into the village where they were replaced by small herds of children instead. There was a big crowd gathered at the clinic. I don’t care where you are, a plane crash is pretty big news and the word had definitely got around. We were greeted by the AMREF clinic nurse who had done a grand job on her own for
the four men. The first, the pilot, had suffered a head wound and had briefly blacked out after the crash. But now he was orientated and able to tell us that he had had a brief period of unconsciousness but now just had a headache. He had a slightly mashed left arm but otherwise was unscathed. Given the mechanism of injury was such that (by most normal rules of the universe) he should be dead, we were unable to rule out an injury to his cervical spine according to the Nexus/Canadian C-spine protocols. So he had to go in a collar. He really didn't want to go in a collar. Protesting to us that his neck was fine. 'Look' he said, as he happily rolled his head around and up and down. Now this causes EMS providers a dilemma...

Now I really shouldn't go into my feelings about routine spinal immobilisation (the collar, head blocks etc) on the basis of mechanism of trauma alone but, at the moment, that’s the rule so that's what you do as a pre-hospital provider. Imagine you have been in a car crash and have got yourself out of the vehicle. You are walking around, even chatting on your mobile. Then the paramedics come along. Even if you have no pain, no tenderness on examination, no problem with your nerves, have a full free range of neck movement and are completely conscious, paramedics will still probably strap you down, force your neck into a collar and you will stare at the sky/ceiling until someone has taken some pictures in hospital. I am never surprised I have so many irritable, claustrophobic, uncomfortable patients brought in to the Emergency Department by paramedics. Don't get me wrong, there's still a tiny tiny chance you could have an occult fracture but it really won't be unstable, the collar provides little benefit in those cases and can often cause harm (especially in the elderly, I've written a paper about that incidentally)

and there is no evidence to say that comfortable conscious patients can't be allowed to sit up and just keep their head still if they really want. Their head will not fall off, trust me. Anyway, I think I may be drifting into a characteristic controversial Dr Edwards rant about Evidence Based Medicine, pseudoaxioms and my issues with the medical behemoth that is Advanced Trauma Life Support so I will stop. I would like you to enjoy reading my blog and I suspect I may have just lost you.

So, back to the story, Kisito managed to persuade him that, quite rightly, he had just been in a horrible plane crash, we couldn't 100% exclude neck injury and the road was really bumpy and his head probably would fall off, so he accepted the collar. The other stretcher case had some para-spinal tenderness in the lumbar region but no suggestion of spinal injury or an unstable fracture. He was otherwise unharmed. The other two men

between them, had a hand injury and some mild lower rib pain but that was it. So we took two out on stretchers, utilising the local tribesmen as extra manpower and the other two men simply walked out to the 4x4.

On the long ride back to the plane, the pilot was able to explain to us what had happened. As the plane left the ground, the pilot’s seat lost its grip on its runners and suddenly slid backwards. All he was holding onto was the controls so they went back  with him and the plane's nose pitched up. He lost control of the plane and a wing clipped a tree. The fuselage rolled along the side of the runway about three times coming to rest in some shrubs having thrown off its other wing, the tail and the engine. It was a sorry sight and difficult to imagine how anyone had survived. I don't use the word miracle but they were lucky beyond anything I've ever seen. Look at the picture below and you will see what I mean. So maybe the neck collar wasn't such a bad idea after all, (he says rather sheepishly.)
I can tell you they are all making a full recovery with only minor fractures and two are already discharged.

Into the wilds of Tanzania

Having recovered from travelling the length and breadth of the the continent last week, I've been doing a few shorter retrievals into the wild expanses of Kenya's neighbor to the south - Tanzania. I've done a few medevacs from there in the last month but haven't written much about it. But as I seemed to be spending more and more time buzzing around it's vast landscapes in the co-pilot seat of a Cessna caravan, I thought I'd expand on my experiences there.

I was first called out to a young man stuck in the middle of the game reserve of Katavi, the other side of Tanzania and close to Lake Tanganyika, with resistant malaria. Now if I've learnt to respect one thing out here it's malaria. I suppose I am exposed to a pretty severe case-mix to be fair. If the local treatment isn't working or they are in a collapsed state we get involved. Some of these guys are impressively sick and I suppose, now I reflect on it, I think what is actually affecting me about this is the number of young people with critical illness I'm seeing on this placement. Working in the UK I'm so used to critically unwell elderly patients but I've just not been asked to manage many elderly patients here. Well apart from the minister in Musoma and the jogging octogenarian rose farmer who had broken his hip in Kampala but they don't count as really ill. They could both beat your average middle aged Brit in a race, even with a fractured neck of femur.

I was lucky enough to be allowed to sit in the co-pilot seat for the trip there. It was a long journey in the caravan but you simply couldn't get bored with that view. We flew past the famous Ngorongoro crater into the wide open plains of the Serengeti. I was told on the way that the crater is an incredible, almost 'locked-in'

ecosystem of a huge variety of animals. Even though Sir Arthur Conan Doyle's Lost World was based in South America, it's tempting to believe the crater could have been an inspiration for the tale. It is truly vast and few animals, especially the lions, seem to see the need to cross the rim. As we made our way into the Serengeti plains I could not stop humming Toto's rock ballad 'Africa' - it drove me mad.

Migration trails out of the Serengeti

We had to fly fairly high over the Serengeti National Park and so any animals were tiny specks down on the ground but you could see the impressive migration trails made by the herds. From above you could get a scale of how many thousands of these beasts must march along these tracks every year. It must be incredible to see. I wonder if somehow I will get a chance. It can be put on my 'bucket list' for the future if not.

\Soon we were landing in Tabora for a fuel stop and then continued south west towards Lake Tanganyika. The landscape became relatively featureless and it reminded me of flying in Antarctica. The huge marshlands of the Katavi National Park came into view - the home of a huge number of hippos and billions of bloody tsetse flies unfortunately. At least when you went to see Antarctic wildlife you didn't have to cope with their irritating, disease-spreading, insect entourage.

That's a hippo, honest.

We managed to find the secluded airstrip and did a dummy run to clear it of about five impala. No wonder cheetahs struggle to catch those things - they move incredibly fast. At most of the Tanzanian airstrips we have to get rid of a number of large animals standing in the way. Not something most pilots normally need to worry about. There are certain interesting considerations to this animal clearing such as; if you are going to land between two herd animals, bail out and climb. If it is just one, it will run away so you can land. The instinct to herd is so strong when they are threatened, that they will run together. So if the plane is landing between them, the likelihood is that one of them will run into the path of the plane and that would be sub-optimal for a landing.

Our patient was not too bad so was quickly popped into the plane and connected up to some fluids etc. I am told he has been treated for recurrent malaria and is recovering well.

My second mission over the weekend was to attend to an unfortunate gentleman tourist who had collapsed and had had a 'cardiac arrest' with ROSC (Return Of Spontaneous Circulation) while at a remote retreat in Grumeti, just over the Kenyan border and within the Serengeti Park. Again you don't need to be a doctor to realise that having a cardiac arrest in a place like that is likely to have a poor outcome. I've heard of AMREF arriving to a situation in which the poor bystanders have been doing CPR for a few hours, only to tell them that any continuation would be futile. However if someone gets a pulse back after a short period of basic life support in the field then we could really do some good with post-arrest care (if we get there quickly enough).

This was a shorter journey and the route was thronged with wildebeest (with a couple happily grazing on the airstrip). When we arrived on the beautifully secluded airstrip we found our patient, who was alive, cheerful and looked pretty chipper! We examined the circumstances surrounding this cardiac arrest and it was very short, while he was witnessed drifting off to sleep. It is possible that someone's heart can stop due to an abnormal heart rhythm briefly and then it reverts to normal when someone starts thumping on their chest. It's possible. If that was the case, then he is one lucky guy. For our years and years of research into the outcomes of out-of-hospital cardiac arrest, we know that the only people who have a reasonable chance of walking out of hospital with an intact brain are those who are witnessed to collapse and have good early bystander CPR. Just look at the survival outcomes they acheived in Las Vegas! (Valenzuela, NEJM 2000) The situation is slightly different in the middle of the Serengeti I'm afraid. There are many different explanations to what happened to this chap, including the fact he might have just been asleep, but the key fact was that someone was at his side and and started life saving actions immediately. I can only hope that, in the event of  a sudden collapse for myself or my loved ones, someone close-by acts as promptly.

Critical in the Congo

I’ve had about 36 hours of extremes mostly involving the Congo. I’m amazed how I seem to end up doing evacuations from one country for a few days then don’t go there again for ages. For example I’ve not been back to Somalia for two weeks. Well the latest theme country has been another hotbed of discontent and political exasperation, the Democratic Republic of the Congo.

This series of patients had a theme of miscommunication. Assumption really is the mother of all f*£k ups, and hence why we prepare for the worst case scenario. Even with that modus operandi, our time in Congo took the biscuit for surprises.

My first flight at 0700 took me into the airstrip of Goma in the Congo, on the Rwandan border. It's yet another interesting African town with links to the Rwandan genocide and still rather bubbly with political violence. Only last year it was seized by rebel forces and hence why we do not retrieve patients from the hospital, no matter their condition. We were going to retrieve a man who had been involved in a RTA on a motorbike and had was supposed to have sustained nasty facial fractures and suspected other injuries. With that information we were expecting a patient with multitrauma and a swollen difficult airway so we prepared for a critical patient with all the toppings.

After about an hour of wrangling with self-important airport officials in French, we were approached by another two men. I asked if the patient was on his way, in my best pigeon French to be told by one of the men, with a hearty handshake and a smile, that he was the patient. It seemed he sustained ‘suspected’ facial fractures after bumping his face into his friend’s motorcycle helmet when they fell off at low speed a week ago. He had even driven himself from home! So not exactly requiring of a critical care transfer. Oh well I had some work to do on my laptop anyway.

Nyiragongo simmers in the background

The most striking thing about Goma is the Nyiragongo volcano and cleared piles of volcanic rock alongside the airstrip. I am told that about 10 years ago the volcano erupted spewing lava straight through the surrounding town destroying about half of it and right along the runway down to the Lake Kivu. It killed many people through asphyxiation and rendered the airport completely incapacitated. It took a long time to clear enough of the rubble to get the airport operating again but it still only functions with about 2/3rds of its original length runway. It also has a reputation of being phenomenally dangerous with a way-over-average number of aircrashes with a plane overshooting the runway in 2008 smashing through a market and another nasty one in March of this year!

After this unexciting medical case we were called out to a little dirt airstrip out in the sticks of Tanzania to pick up a member of Raleigh International. I am currently trying to persuade my little cousin to do something useful with her gap year and Raleigh are one of the organisations I’m looking into for her.  It was interesting to hear more about what they are up to from the horse’s mouth. I particularly like their ability to focus on the personal development of young people from all sorts of backgrounds in the UK and combine that with sustainable projects for these rural populations.  Crucially they have a good reputation for safety with excellent logistics and medical support. So the information we had from these guys about the casualty was exemplary. The casevac went extremely smoothly with a beautiful low level flight across the plains and hills in the Cessna Caravan.

Just when we thought the medevacs had wound up for the day we received word of an urgent case needing transport from Kinshasa in the DRC going to Johannesburg. ‘Malaria and bronchopneumonia. Condition deteriorating.’ was all the information we had prior to take off. I tried to get more but nothing was forthcoming. Flying all night across the Congo in a small aircraft is not something you want to do unless it is absolutely necessary. One of the reasons for this is that this area is known for some of the most aggressive and tallest cumulonimbus storm clouds on the planet some climbing up to 60,000 ft. Radar is a great help but the pilots really want to see what is going on around them. These clouds can tear planes apart. Added to which, there are few alternates on that route that you can safely land a jet at night.

We set off about 2230 and flew towards the jungles of the Congo and the unknown. We requested the patient be brought to the airport in time for us to quickly land, fuel, package up the patient and head south for the 4 hour trip to SA. Upon arrival, however, we were told that the ambulance crew would not leave the hospital until we had touched down. This does happen from time to time and it is rather frustrating. We are left waiting airside at the airport twiddling our thumbs when we could be sorting and settling the patient. For some reason this time it made me uneasy. Why would they want an absolute guarantee that we were here and waiting before setting off? I asked our liaison about the state of the patient and he assured us she was stable but requiring oxygen pointing to his nose implying nasal prongs. So we relaxed and I sat back watching the aerobatics above us as bats pursued bugs around the floodlights.

Soon the ambulance arrived and sped towards the plane. That was also odd, normally it’s a rather sedate affair. The ambulance backed towards us and the back doors swung open to reveal a rather big surprise. Three medical staff removed themselves from the back and were dressed head to foot in masks and infectious disease protective equipment. Maurice the flight nurse and I looked at each other. Then back into the ambulance where we could the familiar waveforms of an Oxylog 3000 ventilator. This woman needed more than a bit of oxygen! She was a critical care patient with maximal oxygen requirements and circulatory drug support. My eyes widened even further as her medical discharge note was handed to me. In French of course. Now my French was good enough to translate the gist of the case. It looked like she had been given a diagnosis of malaria with a high parasite load and then in hospital became increasingly short of breath. A CT scan of her chest showed that some process was obliterating her lungs and she was intubated. Despite maximal ventilator pressure settings, to the point of risking popping her lungs, they were unable to adequately oxygenate her. Hence why they were transferring her to South Africa intensive care to see if things like Nitrous Oxide might help her. NO is a lighter gas reducing the work of breathing but last I read on it, it has very little evidence of benefit in such cases. Nevertheless how they thought a long duration, high-risk transfer in the middle of the night was in her best interests is beyond me but that’s what the doctors and family wanted.

To go or not to go?

At that point one of pilots came around from checking the fueling and said “What the f*£k are they wearing those masks for? There is no way that patient is getting in my plane with some freaky disease that we are all gonna catch. No way!” I asked the medical team to explain the barrier protection and failed to get a decent explanation. It seemed that this was just their standard practice for any patient who was short of breath. There was nothing they were specifically worried about but for a time I felt like I was in the introductory scenes of some Hollywood apocalyptic outbreak movie. Conversations between the concerned pilot and one of the medical team became more heated (despite the fact neither could understand the other) as I pawed through the medical notes and the CT scan to work out what the hell was going on. I couldn’t believe I was standing there in the middle of the Congo in the dark surrounded by bats, bugs, masked medics, irate pilots and concerned relatives trying to make this decision about a woman who could take no part in it.

The case seemed like a pneumonia with probable ARDS (Acute Respiratory Distress Syndrome) complicating malaria with profound anaemia. I explained to our team that if she was breathing for herself, coughing away on the plane with ‘some freaky disease’ then yes we would be at risk. But she was already on a ventilator with a filter and a closed circuit so we were about as safe as we could get. In fact if I was significantly concerned about communicable disease in a conscious breathless patient, ventilating them for the flight might be reasonable to protect myself and the crew from whatever they had caught.

While all this was going on Maurice had been beavering about setting up our ventilator, pumps, drugs and stretcher. Having an experienced unflappable ICU flight nurse like Maurice was absolutely vital and there’s no way I could have done it without him. In addition the medics there had made some weird decisions about the drugs they were using and there was a virtual Christmas tree of infusion pumps going into this poor woman. It was all pretty complex in English, let alone trying to work it out in French!

We managed eventually to sort it out and started lifting her and all her bits and pieces into the plane. Of course then as we were about to lift her, a massive ugly flying bug landed on the patient’s chest. Three of my assistants jumped and nearly dropped her!

Every time you transfer a ventilated patient there is a risk of displacing the tube in their throat. For her that would have probably have been fatal. This ladies oxygenation was so critical that, when we had to detach her from the ventilator for less than 20 seconds to change a cylinder for example, her saturations plummeted down to the mid 60s. To explain how bad this is, if you give a normal adult pure oxygen to breathe and then stop them breathing, a drop in saturations won’t happen for several minutes. Pop a probe on your finger and try to get your oxygen saturations down to 60% by holding your breath. I’m sure it will take longer than you can tolerate. So if her tube had come out from an accidental tug I doubt there wouldn’t have been enough time to ventilate her via a mask effectively or intubate her again before her oxygenation dropped to the point she would have had a cardiac arrest.

After about half an hour of fiddling in the plane we had sorted the spaghetti of wires and were ready to get the hell out of there. On the flight she was a classic ‘spinning plate’ critical care patient. No sooner had you sorted one thing out, something else started going wrong; the kind of ICU patient you spend all night tinkering to try to stop their spiral around the plughole. I’d like to claim that normally I’m pretty good at being proactive rather than reactive but that night I felt like I was chasing my tail.

At one point I took the opportunity to look out the window as the sun started to rise. In the midst of the
stress and exhaustion (we were close to 24 hours solid flying by that point) it was one of the most beautiful scenes I’ve ever seen. In amongst a perfect panorama of stars, the moon hung directly above the spreading orange and blue glow of the breaking dawn with a bright thin crescent marking its lower rim. (My camera was dead but I think someone managed to get a shot with their iPhone.)

After what seemed like an age we arrived in South Africa and managed to get the patient to their resuscitation bay in one piece. We handed over as much as we knew about the case, advising them that a French translator might not be a bad idea. We stepped out of the hospital into the sunshine finally free after 30 hours of solid flights. We got to our hotel, ate our fill and slept like the dead.

Peter and the Lost Boys - Seriously Sick in South Sudan - Part 2

When I returned from my exciting trip to Yei my housemate Peter excitedly told me that his family were from Yei district. It seems a good point to tell you a bit of Peter’s story; a remarkable man who I have been lucky enough to live alongside for the last month.

I may have mentioned that I have been living with three chaps who have been attending a residential course at the main AMREF training centre. They all work for or with NGOs concerned with African health or development. Abdi, I have mentioned already, is from Somaliland, Kebba, who I will come to later, is from The Gambia and then there is Peter from South Sudan. I had the privilege of sitting with these guys for dinner most evenings and I learnt so much about African politics, life, the universe and everything.

One of the things I notice among a lot of Africans I meet is the ability to tell a story. Holding a small audience is a respected skill it seems and one I feel our multimedia-based society may be losing. I think it should be goal in life to be able to sit around a table, hold a group’s focus and massively exaggerate stories like our grandfathers. Peter would sit at the table, two fingers raised waggling back and forth as he made his point or his punchline. Often he would get the giggles as he was on the verge of finishing his story. Which inevitably set us off laughing as well. I think we actually heard only about 50% of the end of his stories. He would suddenly come out with some wonderful comments, two of my favourites being: -

“Explain this to me about you mzungus (white guys). You all only have two children. What exactly is your problem?”

“This guy came back to the village and had been studying in Denmark. He had a PhD! We were very impressed until he told us it was in bee-keeping! We couldn’t stop laughing. Any fool with a box can keep bees.”

Peter is an electrical engineer by trade but has been doing the course with AMREF on monitoring and evaluation of health programs. One day he insisted on escorting me to the local barbers for a haircut. On the way he told me the story of his life in exile around the Sudanese civil war. It’s a story of one man’s struggle to get educated in the face of tremendous odds. As a boy he understood education and training was the only way out of the impoverished situation of his immediate family. I was not aware until then that I was in the presence of one of South Sudan’s ‘Lost Boys’.

He was born in Morobo, in-between Yei and the Ugandan border. He was one of ten children, six brothers and four sisters born to a ‘peasant farmer’ as he put it. Unfortunately two of his sisters and his father died when he was young, either in traffic trauma or due to ‘a sickness’. He was certainly one of the smartest of the siblings and so was sent to school in Kanyara. Like many in Africa this involved long walks in barefoot everyday. In his early-teens the rebel forces took the town and he was unable to get to school. No one was getting in or out. So he and his friend Isac (he hasn’t seen Isac in many years. Last he heard he was in Libya and fears he is probably dead) decided to make their way to Juba the capital and try to finish their schooling there. Peter had sold his only cow to make this journey and pay his way seeking an education.

The situation in Juba was not much better. A generation of young adults were being deprived of a good start by instability and insecurity. Isac had family in the town of Atbara up in the north of between Kartoum and the Egyptian border. The situation was said to be better there. So they managed to pay their way onto a cargo flight to Khartoum. They travelled to Atbara on top of a train but Peter was unable to establish himself there for reasons I can’t remember so he left his friend and he made his way back to Khartoum to try his luck there. By this point the war with the south was intensifying and they introduced conscription in Khartoum. Young men and even children were being rounded up all over town to fight the rebels. Sympathising with the rebels cause and having no intention of fighting his own countrymen Peter fled Khartoum.

This was the period many in South Sudan went into ‘exile’ as he called it. During this civil war it is estimated 2.5 million were killed and further millions displaced. His family had fled south from the conflict into neighbouring Uganda. The clan he is from ‘the Kakwa’ are also very common in north Uganda so they found themselves among friends. Peter knew his family would head south with their Kakwa brethren so knew where to aim for. Peter fled across Sudan from Khartoum into the Congo. He traveled with other South Sudanese boys and mostly at night. Colloquially these displaced fleeing young boys and men were known as the ‘Lost Boys of Sudan’ by international aid workers. It most often refered to the young boys who escaped the slaughter in the villages because they were out with the cattle. Or frequently they had also been taken by forces on either side as child soldiers (the militias telling the parents they were getting safe escort to school) and some managed to escape. Thousands scattered into refugee camps in Kenya and Ethiopia in particular. As we sat there waiting for my turn to get my hair cut, he told me me 'It was a scary time.'

He managed to make his way along the border to Uganda and with the assistance of UNICEF managed to
find his displaced family. They remain in northern Uganda to this day and Peter managed to get his education. He qualified in electrical engineering is now married with six children. His eldest daughter is doing extremely well at school and wishes one day to become a doctor so he says.

It’s a rather humbling story and yet another reminder of how much I should be thankful for in my own upbringing and education. I wonder what I was doing as a teenager while Peter and the other Lost Boys were jumping borders in the dark and dodging the torches of Sudanese soldiers? To look at him now you would never know he has been through so much to get where he is.

Seriously sick in South Sudan - Part 1

Juba from above

In the last few weeks I have ended up in South Sudan on a fairly regular basis. Most will be aware of the terrible civil war and of its recent divorce from Sudan in 2011. Obviously its partner in the north has been the news considerably more frequently recently in regard to the humanitarian crisis in Dafur. Unsurprisingly for this region of Africa, bordering the Congo and Somalia, South Sudan is not an exemplar of peace and equality since its hard fought separation but it is working on it so I'm told. Both sides in that conflict were responsible for horrific slaughter and human rights violations during the civil war and then there is always the continuing tension with the north about the contested region of Abyei slap bang in the middle of the two.

Juba from the ground

The two nations maintain their prickly symbiotic relationship with a flow of oil and other mineral resources. South Sudan is rich with resources and no good way to export them, whereas Sudan is relatively poor in mineral wealth but has access to a massive port and maintains the pipelines from the oilfields in the south. I do wonder what will happen if Kenya makes good on President Kenyatta’s recent pledge to build pipelines across to South Sudan from their northern coastline. A bit of competition will be interesting (possibly about as interesting as kicking a hornets nest) but I would be surprised if it actually happens.

Anyone who has been to countries in this area will be starkly aware that, no matter their huge mineral wealth, very little of this trickles its way to the ordinary man on the street (if there is anything resembling a street). That applies particularly to healthcare. The only reasonably functioning healthcare facilities I’ve visited have been private clinics in the capital Juba (which seem to mostly serve foreign technical staff, businessmen and diplomats) and missionary hospitals out in the sticks like the town of Yei.

I’ve picked up some extremely sick patients from Juba, mostly European nationals. The medical staff there work extremely hard and do a great job despite the limitations. When the stars align correctly we are probably minimum 4 hours from call-out to bedside in Juba and considerably more to the smaller airstrips. There is very little critical care equipment and expertise, so getting seriously ill in South Sudan has a pretty high mortality. Despite our vaccinations, prophylactic medication, alcohol cleaning gels and ‘health and safety’ culture, we foreign nationals seem to get ill or injured quite a lot in these places. One thing I have noticed is we often do some pretty stupid things. Perhaps this is because we lapse into a state of false security and stop doing things because they are not routine practice in the cultures we find ourselves in; like wearing seatbelts or helmets, not drinking and driving, taking malaria prophylaxis, practicing safe sex and so on. Or decide that South Sudan is the perfect place to learn how to ride a motorbike. Enough said.

 

Yei airstrip

In the rural town of Yei I was called to evacuate a poor young lady who was being cared for by the inspirational doctors and nurses working at the Harvesters ‘Bet Emin’ maternal and paediatric hospital. It is a missionary hospital and is doing some remarkable work for the local population. This lady was not pregnant but had been cared for there as she had links to the charity. She had developed the relatively rare condition known as Guillain Barre’s syndrome. It is a classically post infective autoimmune, demyelinating, ascending polyneuropathy. It’s classically associated with outbreaks of Campylobacter Jejuni gastroenteritis or certain viral respiratory infections which are nasty enough in their own right, but then, just when you thought you were getting better, you start losing feeling and strength in your legs. Then your arms become effected and it starts to creep towards your core, potentially getting so far as to effect the nerves operating your heart rate, your lungs and your ability to control your own swallow. It shouldn’t take a medical degree to work out that, unless you do something for someone whose own immune system has rendered them paralysed, unable to breathe or swallow, they will not be long for this world. Luckily in the vast majority of cases, they don’t get to that stage or if they do, they recover eventually as the little supporting cells that surround their nerves start to grow back. I’ve seen three cases requiring intensive care and ventilator support back in the UK and from what I understood of the medical report, this lady was going to be my forth. But as often happens with aeromedical cases, the case had considerations far more complex than the underlying pathological process.

 

The funding for her treatment was coming from a charity and I did not know whether they were at all clued up about the potential length of her ICU stay. If these patients need ICU, it’s often for a long time. Like our long stay patients with critical illness polyneuropathy, they can sit on the unit for weeks, even months. Patients and their families luckily do not need to consider that in the NHS but they do here. It is not an infrequent occurrence for a patient to ‘stepped down’ prematurely from the ICU to the ward because the policy will no longer cover or family can no longer pay the bills.

 

Downtown Yei

Also this lady was Sudanese with poor English and no passport. We had got clearance for her but her husband’s clearance was more problematic. Our window of opportunity was closing fast and we could not reliably establish whether these things had been taken care of before we starting loading the plane. The worst case future scenario we could consider was of a poor lady paralysed on a ventilator without her spouse, unable to understand those around her and eventually passing away in a foreign country as her funding ran out.

 

Where are we going?

Fortunately we got word as we touched down on the dirt airstrip that the charity was committed to the care no matter the length and her husband would be joining her. This was so far the most rural setting I had visited since being with AMREF and it was remarkable. The pictures do the experience more justice than I can. But at that time, with every pothole and twist of the track, I was more concerned about how I was going to safely get this lady on a ventilator all the way from the mission hospital to the plane. Fortunately she had improved and had enough strength and vital capacity to cope with the trip on only oxygen. Dr Edwards dodges another bullet.

While we assessed and prepared the patient for transport, the doctors at the hospital gave me a quick tour and even tried to pick my brain on a few cases. Given these were either post-partum or paediatric cases (not exactly my forte) I’m afraid they got slim pickings but I suppose it’s always nice to discuss a case with a colleague. The current medical director Dr Graham Poole originally trained in Tazmania, has been doing some incredible work there and kindly took me to see one of his success stories.

 

I was taken to see a 9 year old lad who had arrived with them out of the bush about a month ago. Even for a child in one of the poorest regions on the planet he had his cards stacked against him. His father had died, his mother was an alcoholic and his frail grandfather was looking after him. Then he became ill with an expanding growth exuding from the left side of his face. It had reached the size of a mango by the time his grandfather took him to seek help. Burkitt’s lymphoma is the most common childhood malignancy in Africa but you may have never heard of it. From what I remember a combination of genetic factors in equatorial Africans and environmental factors chronic malnutrition, malaria, Epstein Barr Virus and HIV, make it extremely prevalent. It responds well to chemotherapy but that’s in rather short supply in East Africa. His grandfather was told nothing could be done and, I forget the details, but the boy disappeared. After a while when he couldn’t be found and given the severity of his illness, it was assumed that he had died. In fact they even had a funeral for him in his village. But news of his death had been greatly exaggerated and, after what must have been days of walking, he arrived alone and weak at the Harvester’s hospital in Yei.

With little hope of a good outcome given his general condition, Dr Poole started treating him and a few months later the growth has completely receded and he is slowly regaining his strength. The picture shows the facial damage the lymphoma has left in its wake. His grandfather visits frequently, overjoyed that his grandson managed to make it to someone who could help.