After spending Christmas at home in Maryland, I took off on this latest circumnavigation of the globe, arriving at Duk Payuel. Included in the six bags of supplies the team transported is the start of the DOTS Tb program, one of the main priorities I had established on my last visit to the clinic. Almost immediately, the gear was put to use, diagnosing a case of the AFB (acid fast bacilli) strain in a relatively young woman, the first among many clinically suspicious cases.
We were greeted at the Duk Lost Boys Clinic with a large volume of outpatients for clinical evaluation, and an official visit by the highest-ranking Government of South Sudan officials, expressing gratitude for the team’s efforts.
We saw in the New Year at the Duk Lost Boys Clinic, as patients from the Fuk Payam discover that the team is “open for business. ” By training the local doctor in the use of a fetal Doppler heart monitor, we implemented one of the early parts of another long-term clinic priority – a Maternal and Child Health program. And so I began ’09 as I did ’08 — working in equatorial Sudan among needy people who are neither shivering nor shoveling (as they are at home in Maryland), but are instead sweating and swatting flies from their eyes.
Your survival is my obligation. Your health and safety are my concerns. Your comfort doesn’t even make it to my radar screen, ahead of these people we are going there to help.
The clinic building itself needs some attention, as it seems to be sinking. On a previous visit, we had created a hanging ceiling to keep the bats and other flying creatures out of the fallout zone for patients, especially those who might have cause to have their bellies open and contaminated by the overhead residents. There are new cracks in the walls and the doors which were hung two inches above the floors are now flush to the ground and sticking.
On New Year’s Day, I went for a run along the trail to Pokdap, security notwithstanding. I ran until I saw an unusual apparition: A dump truck, filled with a cement mixer and the Marsden’s mats which are used to interlock and make an instant airfield landing strip was sitting abandoned, stuck up to its axles in what was once mud, now hardened to cement. It must have mired in the rainy season and is now encased in hard block of mud in this dry season, apparently awaiting the arrival of the rains to soften it up again to get a team of men to rock it free.
When I had returned from a walkabout in town, I stopped by the clinic—mainly to see if there would be any solar power to trickle into the camera batteries and laptop—and I saw a woman who had been there the day before with a 15-month old boy. Our patient load was off to a slow start, due to ongoing security concerns in this unstable area, including an incident in a neighboring village in which six people were killed. But if all the patients we may have expected were substituted for by just one, this was the right one and a good lesson to review in our tutorial after hours.
The child had a fever that was suspicious for malaria, and also had pneumonia, and a course of ceftriaxone was initiated. But the child got worse. On examination, he was very sick unto death — with a heart rate of 140 and a breathing rate of 60, and only vaguely cognizant of his mother standing over him. The Elisa kit test was positive, and a course of anti-malarials was needed — pronto — but we had no IV quinine, which would be their treatment for this kind of malaria. We did have CoArtem, the artemesan-based treatment combination pills that would need to be pulverized and administered somehow to a child that was not capable of swallowing. We found some feeding tubes and immediately got out an appropriate size tube and inserted it.
A half hour later the child was awake, afebrile, and cooing at his mother. So, as I said at the tutorial held later, “If ever you question whether you are doing any good in trying to treat someone here in less than ideal circumstances, remember this ‘shoestring catch’ as someone for whom your presence made a difference.”
At the last minute, a number of surgical cases arrived, the patients overcoming their security concerns to get treatment. We did seven operations: five hernias, two direct inguinal hernias, one with mesh, and three indirect inguinal hernias, one circumcision and one excision of a tuberculoma of the thigh. In addition a very painful and afterwards very grateful patient had a peri-rectal abscess drained.
We were all also busy inventing substitutes for a particular problem or another. For example, Tall Paul, our treatment nurse, had a painful plantar wart, that called for some salicylate cream that dissolves in keratin — a “Compound W” equivalent. But there is no such agent here, so we made a potion for an occlusive salicylate cream. One of us had a tube of hand lotion, and we crushed aspirin in a mortar and pestle to make up the old-fashioned unguent to put under some non-permeable occlusive dressing – Duct tape!