RAKCOK

1 June 2021  The HPF (Health Pooled Funds) were an innovative way of addressing the medical problems in South Sudan.  A consortium of countries, particularly the UK, Sweden, Germany pooled their resources and tried to work through NGO’s (non-government organization) to administer health care in South Sudan, thus bypassing the MoH, because they knew the funds would be stolen by the MoH.  It did work for a while, but South Sudan shows no tendency to get off the mat.  Therefore the HPF are being withdrawn.  Therefore the bad situation in South Sudan is about to get much worse.  This involves not only medical care, but also employment, for the hospitals and clinics have been the biggest employers of South Sudanese (schools are probably second).

Despite that, our hospital employees (we were never a big part of the HPF) are striking for higher wages.  It makes you want to scream.  It’s like the stewards on the Titanic going on strike.  Small wonder this is a failed state.

2 June 2021  The state motto (did you know they had such things?) is “To be rather than to seem.”  If South Sudan had a national motto, it would be “To seem rather than to be.”  Rebecca Yom Jima is a friend from my first year in Mapuordit.  She was in the first class of the Rumbek Nurses Training School and was the head nurse on the Medical Ward when I came here in 2013.  Later she went to work in the “Chinese Hospital,” a structure built by the Chinese government.  The school collapsed because the MoH dictated that the teachers be from South Sudan, but there were not enough qualified teachers from South Sudan to run the school.  The Chinese government wanted to run the Chinese Hospital for 5 years to make sure it was established and worked well.  No, the GoSS (government of South Sudan) decided they would run the hospital from the start.  Now it is ghost village, nice housing but no medical care.

3 June 2021  While I was busy admitting a couple of maternity cases, one of the green students came from Medical Ward to inform me about “the patient on bed 83.”  Perhaps in the past I may have been able to remember patients’ bed numbers, but not now, particularly since they have recently changed.  He told me the patient vomited blood and “his tongue was sticking out.”  I gave him some IV Ranitidine.  When I finished the others, I went to see him.  He was a psychotic patient receiving Haldol, and he was struggling to breathe with his tongue protruding half a meter.  I recognized this to be a dystonic reaction and told the student to give IV Promethazine, but when he attempted to push the drug, most of it spilled out.  I went to get some more from the pharmacy, but found another vial and successfully gave it.  When I came back, it was clear that the neck was less forcibly extended and the tongue seemed a bit less protuberant.  His breathing was quieter, enough so that his mother was concerned, but his pulse was strong and regular, so I reassured her.  I also had the student give IV Dexamethasone.  Within 5 minutes of my return, the man woke up, cleaned his mouth and his tongue returned to its original position.  I have been in medicine for a long time, but it is still amazing to see a dramatic reversal like that.

7 June 2021  A woman came to me with a “pregnancy for 1 year.”  She did appear to have about a 6 month uterus, and she had amenorrhea for 1 year.  On ultrasound, the mass (presumably the uterus) was filled with fluid and spidery filaments.  I aspirated about 300 mls of virtually frank blood, though the woman was no anemic.  I called Dr. Rosario and he was convinced this was an ovarian cyst, almost undoubtedly cancer.  Still, I had some questions.  The mass was so midline that it appeared to arise from the uterus, not the ovaries.  Also, there was no ascites, but ovarian cancer tends to cause ascites early. I looked up online images of uterine cancer and TB.  The uterine TB images were virtually identical to what I had seen.  I have trouble with the blood, but I want to offer a trial of TB drugs before they go to Khartoum or Juba for treatment.

8 June 2021  I was on call several weeks ago when a woman presented with fairly typical signs of malaria, and she had a big spleen, but she also had large inguinal nodes.  She had been seen earlier in OPD and diagnosed as an abscess, and she had been cut.  However, there were multiple, deep nodes on each side, and where she had been cut, she had a draining sinus.  She returned today as I intended and I found that one of her nodes had suppurated (turned to pus), so I was able to aspirate 10 ml of guacamole looking fluid.  I sent it for PCR for TB and it was positive.

We do have a lot of TB here, as a close friend of mine noted recently, but the discouraging thing to me is that the clinicians here seem unable to recognize it.  I realize CO’s (clinical officers) tend to try to weed through their patients as quickly as possible, but it was obvious this woman had TB from the first time I saw her.  At least now we will start her on appropriate medications.

9 June 2021  The first of two young women with hip problems presented with pain in the L hip for 8 months.  She had fever at home.  On exam, her L leg was shorter.  She had a mass in the area of her L hip.  She could bear minimal weight on that leg.  We got an x-ray that showed a “moth-eaten” L femoral head and neck, and possibly a femoral neck fracture.  There is essentially no joint.  I am fairly certain this is TB osteomyelitis of the femoral neck and head.  That joint is ruined and she will never walk normally (unless she gets to the US for hip replacement).  However, my initial thought was an osteosarcoma, and that carries a virtually certain death sentence.

10 June 2021  The second young woman was about 11 years old.  She has had swelling in the L hip and L jaw for 7 days.  The L hip trochanter was in the normal place, but she had a mass in the L hip region.  Her x-ray showed some bony changes, but more soft tissue.  She also has a hard, somewhat tender mass in the L jaw.  It is not fluctuant or warm.  Her ESR is 90.  She has a mildly elevated WBC.

I think this is Burkitt Lymphoma (BL).  I saw two children in Gidel with BL in the femur/thigh.  We cannot get biopsies, but we can give a trial of chemotherapy and see what kind of response we get.  We have a younger child with BL in the abdomen and the mass is about 1/3 the size initially 3 days after the first round of chemotherapy.  This is clearly not infectious.  If it is another tumor, it probably is some kind of sarcoma, and she will not do well, but I am hopeful this is BL.

11 June 2021  I try to be somewhat selective in ordering x-rays.  Most of the x-rays I order turn out to show pathology.  That is not true of those from OPD.  Most of the patients you could be assured would have a normal x-ray by their history and complaints, but I end up having to read most of those.  Therefore, I was unprepared for Athiei, who came to me with a CXR that showed an enormous heart, the classic “water bottle.”  She had a loud pericardial rub and her liver was 6 cm below the R ribs.  Ultrasound showed a large pericardial effusion.  She clearly has pericarditis, and the most common reason in the world for that is TB, and that is even truer here in South Sudan.  This morning I could also appreciate a murmur that sounds like Mitral insufficiency, suggesting Rheumatic carditis as well, so we will get an ASO and ESR, but we have started her on RHZE.  Her ASO was elevated, so it appears she has both Rheumatic carditis and TB pericarditis, a combination I have seen frequently.

12 June 2021  The patient 10 June was started on chemotherapy yesterday.  She vomited a couple of times, so we will increase her anti-emetics.  However, she seemed to respond remarkably.  The mass in the L jaw is less than half the size it was.  The L hip is not as dramatic, but it does feel somewhat softer, though that could be my own placebo effect.  What is objective is that when she came in, she could only walk with a stick, but now she can walk fairly comfortably.  The jaw is clearly not placebo effect.  The jaw is clearly smaller, and that really encourages me that this is Burkitt Lymphoma and I am hopeful she will do well.

13 June 2021  I was in academics for about 10 years, and our divisions had strong social services compartment.  It was needed, because many of the patients with pulmonary problems were poor.  Indeed, we used to joke that you could tell if someone was coming to pulmonary vs allergy (we shared a waiting room) by doing a wallet biopsy.  Many of our patients were from a distance; food and transportation were critical issues.  There is inequity in the US medical system.  But when you consider South Sudan, we have to shift several orders of magnitude.  Dr. Rosario called me about a patient I had been seeing.  He is the proverbial “train-wreck,” with a large goiter, paraplegia, hypertension, probably hyperthyroidism, and an abdominal mass that is bony.  I knew he was from Nyang in Yirol East (probably 4 days walk), and I did not ask how he got from one area to the other.  Dr. Rosario told me he has been living in our “co-patient” area for months bumming food when he can.

We are going to try to get him home.  We are going to give him transportation and medications for several months, but with the realistic expectation that he will die quietly at home.  When we think about the distribution of medical care and needs, there is almost complete disparity.  Severe disease distribution and doctor distribution are virtually opposite.  The big killers—HIV, TB, malaria—are in Africa and to a lesser degree in South America and Asia.  Doctors are in Europe, the US, and the part of Asia where those killers are not.  Nyang has nothing.  This poor man needs social workers as much as he needs a doctor, but it will never happen.  Not in my lifetime, and I think I have a lot of years ahead of me.

14 June 2021  A young man was brought to me on call.  I had seen him months earlier and admitted him for severe cellulitis of the leg.  He was in the hospital for weeks at that time.  He was discharged and told to return to wound care 2 days later.  Instead he stayed home.  For the next month, he walked around, but then it became too painful to walk.  That was about a month ago.  When he came in, he stank.  His leg was necrotic and smelled of dead tissue.  His BP was 46/26.  The wounds were clearly gangrenous and the tissue up to his mid-thigh was of questionable viability.

I gave him lots of fluids and started him on IV X-pen, Gentamycin, and Flagyl.  We added steroids, because (as we used to say) “no one should die without the benefits of steroids.”  I think it unlikely he will live.  If he does, he will almost undoubtedly need an AKA (above the knee amputation).  Sometimes you just shake your head and wonder.  What a tragedy.

15 June 2021  A man was admitted to surgical ward for “constipation” but was found to have ascites on ultrasound.  A couple of days later, I felt a tender protrusion at the lateral aspect of the liver.  I repeated the ultrasound and found a mass with a sediment and fluid level.  I suspected an amoebic abscess, though he was not having fever.  He was tender and had ascites.  I started him on high dose Flagyl 800 mg 3 times daily.  Over the weekend, I felt like I could hold the mass close enough to the skin to aspirate, and we aspirated 54 ml of dark yellowish-brown fluid.  That confirms this is an amoebic abscess, and he should do well with the Flagyl.  The studies say there is no need to aspirate again.

16 June 2021   A young woman was admitted with urine retention.  That is a much more common problem in men, usually either prostate problems or urethral strictures, but her bladder was higher than her umbilicus.  She was admitted and had a urinary catheter placed, which relieved the problem.  The next day I felt her abdomen and felt a mass above the pubis.  I ordered a urine HCG (pregnancy test), but unfortunately the lab ran a urinalysis.  I discharged her on Septrim with the diagnosis of UTI, but I asked her to come get an ultrasound to confirm her pregnancy.  On ultrasound, she had a huge mass (11 x 10.4 cm).  On PV, the mass was smooth and was in the posterior rectum.  She has HIV.  I am sure this is a tumor, though whether a Kaposi sarcoma or some other cancer is unclear.  I admitted her to surgery, though I suspect she will be referred.

19 June 2021  A 60 yo woman was brought with a urinary catheter in place and some agitation.  She seemed confused to me, and her BP was 156/0.  Other history was that she quit walking three months earlier and severe back pain.  She presented to the hospital in Rumbek with urine retention and the catheter was placed, but no other history from that hospital.  It was unclear whether they were referred or just left.  I thought the woman must be in urosepsis with such an unusual BP, but I thought her underlying problems originated in the spine.  She did not have a gibbous, but she was really tender in the lumbar spine.  It did not appear to be a bacterial infection of the spine, so I thought it was probably either a tumor, viral transverse myelitis, or TB of the spine.  She would be the fourth patient we are treating for TB of the spine.  It is a hard call.  One man had a gibbous but no neurologic signs.  One woman had paraparesis (weakness of the lower legs) and she is starting to make some steps.  Without MRI and with limited resources, it makes sense to give a trial of TB meds.
 
21 June 21  The 11 yo girl (10 June) was treated with chemotherapy for Burkitt Lymphoma.  Her response was dramatic.  The swelling in the jaw completely disappeared after 1 week.  She was walking with the assistance of a stick before, but she was able to walk alone 2 days after the infusion.  She had some relatives nearby, so I allowed her to go out.  They took her to the witch doctor who incised her hip and drained “pus.”  I was furious with the grandfather and told him if he took her again I would refuse to see her any more.  The reason for that is that I seen witch doctors kill children after they have been successfully treated.  Today I aspirated a fluctuant area on her hip.  It showed some necrotic fluid (pus and blood).  Our nurse felt that what the witch doctor said suggested our diagnosis was wrong, but in reality, this was just the tumor dying.  It is more of an assurance that we are on the right track.

23 June 2021  We had a patient admitted a month or so ago with epilepsy.  She also has HIV and is mentally retarded.  Pauline and Sr. Rita, two wonderful women in our community, hired a man to supervise the administration of the medications—Carbamazepime and Phenobarbital.  She came back today doing well (only 2 convulsions in the last month).  What I loved, though, was the man supervising her meds.  I do not even know his name, but I speak to him regularly.  He gets around with a pole (the South Sudan equivalent of crutches) and always has a cheerful greeting for everyone.  So he is helping another and getting a contribution (I am sure far less than the world’s idea of poverty, but fairly good for South Sudan) and he takes his responsibility so seriously.  What a blessing.

24 June 2021  In the theatre today, I had a man with hemorrhoids—probably five, though I only corrected four.  When I examined him, feces poured out.  Obviously he did not get an enema.  We cleaned him off and gave a dose of Gentamycin after the procedure.  Dr. Derek refused to do them, so the staff has forgotten the routine.  We have to get them back on track.
 
26 June 2021  A 16 yo boy was admitted some time ago and has been a challenge.  When he came in, he had high fever and was in some distress.  He was referred to Dr. Rosario for an acute abdomen, but that did not seem to hold.  I felt a spleen and so admitted to Medical Ward as malaria, and he improved greatly on Quinine and then Coartem.  But then he started changing.  He had more pronounced crackles in his chest, and his CXR suggested TB, so he was started on RHZE.  Then he developed a draining wound in the shoulder and severe pain in the hip.  We treated him for Staph and the shoulder would improved, but his hip did not.  We finally got an x-ray of the pelvis (several issues arose in the x-ray department) and he has osteomyelitis of the femoral neck and head.  However, I am starting to believe that the shoulder and the hip are also TB.  He is HIV (-).

28 June 2021  I went to Rumbek today.  I am a bad traveler.  I get motion sickness on virtually every form of transportation.  I have never been seasick, but I have always stayed on fast moving boats.  Because of my motion sickness, once I get somewhere, I tend to stay.  But I went to Rumbek today to get a Covid-19 vaccine (more on that later).  Unexpectedly, I met Thon Bec, a friend of mine from when I was in Akot and he was student at Hope and Resurrection School.  He was there taking some exams from some distant learning courses on secondary education.  I asked him about his sporting ministry.  It has been going exceptionally well.  His thought is to promote peace by sponsoring sporting events between communities.  He has a four team tournament between Akot, Paloc, Thon-Aduel, and Atiaba.  Since he had no outside funding, he got all the teams to contribute to the “pot” and the winner takes all.  This is impressive for a couple of reasons.  First of all, those four communities have a history of revenge killings between the tribes, particularly between Akot and Paloc, but the conflicts between Atiaba and Thon-Aduel have been almost as vicious.  Second, the chiefs of the area have gotten behind this.  I asked specifically about Mathiang Dut, the Paramount Chief in Akot, who is a friend of mine.  He came and cheered on one of the games, but he brought no guns and there was no fighting.  I realize there is some danger in this approach.  Riotous behavior has seemed to become a critical step to show true devotion to sports teams (as idiotic as that tendency is), but I am hopeful there will be good competition that overcomes tribal issues.

29 June 2021  As bad as the situation is in Uganda right now regarding Covid-19, you would expect to see long lines seeking the vaccine, but in fact there is so much misinformation out there that the people are too frightened.  I have had the disease and tend to believe what has always been true—having the disease promotes better immunity than the vaccine.  But eventually I will need to travel, and having documentation of the vaccine will become critical at some stage.  A second reason I am doing this is because all of my friends on the Visitor’s compound are worried about the vaccine.  If I do not keel over and die in the next couple of weeks, they may be more willing to get the vaccine.  Even though I traveled to Rumbek and back (about 3 hours of misery each way), I exercised when I got back and I am hopeful that will limit the soreness in my arm.

30 June 2021  We have two girls on the Medical Ward receiving chemotherapy for Burkitt Lymphoma.  The five yo has an abdominal tumor.  She was mentioned last month.  She has had two cycles of chemotherapy (her second was delayed because of neutropenia).  The mass is about 1/5 the original size.  The second was mentioned 10 June and subsequently.  Her jaw mass is completely gone.  The mass in her hip is harder to discern, though it is clearly much smaller.  The dramatic thing for her is her gate.  When she came to us, she was using a long stick (the South Sudan crutches).  Now there is scarcely any limp and virtually no pain except when we are probing.

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