In at the deep end

Well, my ten-day handover period with Sally the outgoing nurse is well and truly over and apparently I should know what I'm doing now.

Well, my ten-day handover period with Sally the outgoing nurse is well and truly over and apparently I should know what I'm doing now. Just to give you some idea of exactly how confident I'm feeling in my knowledge and skills at this precise moment I can tell you that I was frighteningly close to flinging myself onto the ground and clinging to her ankles at the airstrip, begging her to stay!

All credit to her: it has been a great handover, phenomenally well organised and thorough. She was another first-timer nine-months-ago and has steered the job role a great course from the looks of things. But more about that in a moment...

On first glance the MSF hospital doesn't look like much - a dozen or so decidedly mismatched ramshackle buildings with tin roofs linked together by interconnecting dirt and concrete walk ways. But inside you'll find everything you could need in this setting including inpatient and outpatient therapeutic feeding centres for malnourished kiddies, a two-bedded emergency room, an adult medical and surgical ward, an operating theatre (emergency surgery only), a maternity ward and delivery room. The lab can do parasitology and blood crossmatching and there is one building (blessedly cool on the inside) where all the medications and vaccines are carefully stored under controlled conditions.

You won't find an X-ray or a CT scanner, there's no life support machines, cardiac monitoring or dialysis, nowhere to grow blood cultures or fill oxygen tanks, but what MSF may seem to lack in fancy first world equipment they more than make up for with a wealth of experience in working in resource-poor settings. The bible for all medics out here is the MSF Clinical Guidelines book, which takes you through a basic, but thorough clinical assessment, diagnosis and prescribing for all common conditions - common conditions for here that is. Given that that the average life expectancy is below 50 I don't expect I'll see a single case of heart disease, emphysema or diabetes while I'm here - and that stuff is the bread and butter of my A&E at home.

There is also a six bed Intensive Care Unit - although again, I imagine no one from my hospital at home would probably recognise it as such! It's covered by one health worker usually although, during my first buddied oncall night last week with Sally, an extra one was called in. A post-op septic man, two very very sick babies on oxygen, and a five-year-old girl seizing and comatose probably as a result of meningitis. Genuinely one of the most frightening things I have ever been around.

In retrospect, one of the most dominant emotions during that whole experience was not what I expected. Fear? Yes. Concern? Check. Sympathy? Tick... But revulsion?

It took over 24 hours and three more trips to the ICU during the course of the next day to sift through that one. The revulsion was not at the fitting child itself - who would do that? But at the full frontal experience at the barefaced wrongness that is a system, a country, a world, where a child could be this sick and not have more done for it. In any western country that child would have been sedated, ventilated, monitored, have a central line, a feeding tube, a catheter, a BIS neuro monitor taped to the tiny forehead to catch low grade seizure activity...

But here, the only way for us to gauge seizure activity is to test the arms for rigidity, or lift the eyelid and look for the faint flickering movement that betrays an electrical storm going on inside the brain. I watched and learnt from Sally and our doctor: stay calm, use the protocol in the book, base your fluid boluses and IV diazepam on their vital signs, monitor regularly. Too much diazepam and you depress the effort of breathing, making it shallow and ineffective. Too much and the seizure continues unchecked...

Somehow they all made it through the night. And so did I. Albeit tense, tired and slightly tearful.

I'll only be doing on call nights for the hospital about once a week, so that sort of experience I sincerely hope will be the exception rather than the rule of my day-to-day routine.

As South Sudan establishes its government and the various ministries begin to take shape, MSF is hoping to hand over sections of projects to the Ministry of Health (MoH). Nasir is one of the first places to be trying this - primary healthcare is the first to be shifted and that shift just happened in December. It means that out of the ten-odd expat team based here I'm pretty much the only one to spend next to no time at the actual MSF hospital! The MoH facility that the Outpatient Department (OPD) is now based in is a 10-15 minute drive across the market area and this is where I will spend a lot of my time. For the OPD, think like a General Practice surgery or Minor Injuries Unit in the UK - just with no appointment system - just turn up and wait! There are nine MSF national (local South Sudanese) staff under me there including Clinical Officers with diagnostic and prescribing skills and pharmacy dispensers helping to set up and get the MoH staff trained and functioning well. The plan is to spend nine months supporting the transfer of this one department, gradually stepping back and handing more and more responsibility onto them and adding other outpatients facilities a bit at a time. As a first-timer with MSF it's a slightly daunting prospect - in my first two weeks I've had a good taster of how hectic it can be; Monday mornings are just the same in hopsitals the whole world over!

(Just a little disclaimer. Although I want to be as honest as possible in this writing for obvious ethical reasons to protect the identity of patients throughout this blog I have to anonymise and avoid using names - or if I do they will be false names. Boys will become girls, a five-year-old child will be written up as eight, etc, etc. Only the diagnosis will remain unchanged. If you are one of my direct collegues you may recognise a case - if you are not then there is no chance that you would ever be able trace one.)