Fieldset
An "ordinary" morning with Doctors Without Borders

What's it like to be a doctor in one of our projects? From his 6 am alarm through to fighting HIV and tuberculosis, Dr Tom Niccol shares his hectic schedule during just one morning...

There’s one question I find challenging to answer, which is "what is it like to be a doctor with Médecins Sans Frontières / Doctors Without Borders (MSF) in South Sudan?"

Back home in Australia, friends and family have an idea of the day-to-day activities of a doctor: this is aided in part by TV and by their personal experiences with healthcare.

Friends and family, however, cannot imagine life in Old Fangak.

The plan

Last night I was awake, pondering over the best way to describe even a few hours out here. I decided on Sunday night that I would take some time at lunch on Monday to write about my morning.

At that point I was unaware of exactly what my morning would entail…

06:00

Monday kicks off with a piercing 6 am alarm. I really need to change the volume; it could wake an elephant a thousand miles away.

I untuck the mosquito net from the bottom of the bed and roll into the adjacent chair. Still half-asleep and at this stage only semi-upright, I rub my eyes and check my phone for messages. To my delight, I’ve received another photo of my niece, Sarah.

Sarah is nearly one and is the unequivocal favourite of the family. This morning’s photo showed her in a Hong Kong café, perched upon the bench, staring at the baristas like a veteran coffee drinker.

I have a good laugh then locate the fragile remnants of my bar of soap and walk to the shower.

Scrubbing up

Shower time is always entertaining.

The vast majority of the global insect population have taken residence in our shower tent, so it is by no means a lonely affair.

As the water isn’t heated, I am propelled from drowsy to sprightly in a millisecond. Energised, I make my way back to the rope I have hung as a clothes line out the front of my tent.

Yesterday, I washed my clothes, as usual in a bucket. I’m not sure about my technique, as the white shirt I locate on the line has been getting progressively greyer. I’ll dial up the cycle next week.

Breakfast

After dressing, it’s breakfast. Options are a little limited as we haven’t had a plane in a month due to the wet season turning the airstrip to mud.

I discover my personal favourite, handmade bread purchased from a contact in the market. The bread is accompanied by an instant coffee that could power a small city for a month.

I proceed back to the tent to collect gumboots, a portable radio for communication with the team and wet weather gear because we can never be sure, even with blue sky above.

We journey to work on a small boat as the accommodation and hospital are located on the river bank.

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An MSF boat on the river around Old Fangak
An MSF boat on the river around Old Fangak

Large greetings...

Upon arrival to the hospital, I note that there are at least one hundred patients waiting to be seen.

The distant cries of baby and a melody of coughs and throat clearings fill the air. First order of business on a Monday morning is a meeting with the night shift to hand over care of new or unwell inpatients.

I’m pleased to learn that the patient I examined yesterday with a severe asthma attack has drastically improved. 

After the meeting, all the staff came up to say “hello” and shake my hand. We say hello in the local Neur language; the greeting phrases are numerous. I often use male mamigoa, which effectively means “large greeting”.

Being greeted by every staff member is not unusual: people are incredibly friendly in Old Fangak. We shake hands and formally say “hello” every morning. 

The huddle

Handover is followed by a group huddle where I update all of the MSF staff on the medical activities.

Thankfully we are seeing a downward trend in malaria cases: from over one hundred per day to around thirty.

However, while the downward trend is encouraging, I am a concerned that the community are becoming less vigilant and coming to get medical help later in the course of their illness.

On Friday, a patient with cerebral malaria died within an hour of arrival at hospital. They had been convulsing for 18 hours prior to arrival. I ask all staff to encourage their community to come to hospital earlier.

Following the update, the vibe in the team is jubilant

I then update staff about six patients who were transferred from Old Fangak to the capital city for surgery. I am ecstatic to report that all patients are well. This news is met with claps and cheers.

Because Old Fangak is a relatively small community, it’s not unusual for patients to be relatives or close friends of staff.

This news is also encouraging for all staff as it demonstrates that their hard work has value. Following the update, the vibe in the team is jubilant. 

“It must have been brutal”

After the meeting I am tapped on the shoulder by a member of staff I work closely with every day. I can tell that he has been assaulted, there is no mistaking the wounds to his face.

I take him to a private area where we chat.

He tells me about being beaten by a group of people he did not know. I am devastated learning this news, with the injuries sustained it must have been brutal.

We then meet with the MSF staff member leading the Old Fangak project to report the incident and decide on our approach. We agree that I will escort the staff member to the office of one of the town chiefs to seek judicial assistance.

He values his job and will move mountains to be present at the start of the working day

I explain the injuries to chief and the staff member explains the circumstances surrounding the assault. This chief explains that he will find the people involved, I am hopeful that there will be justice.

What I find particularly upsetting is that despite the injuries, this MSF staff member came to work because he didn’t want to miss a shift. He values his job and will move mountains to be present at the start of the working day.

I shout him a cola and explain that he is a valued staff member and if he’s unwell or something untoward occurs in his life, he can advise that he is sick, and this will not risk his position. I provide medication and send the staff member to rest at home. 

The first patient of the day

I open the door from the meeting area to hear about five separate people calling my name.

The first patient I see is a two-year-old child. This child has an infection in both ears. Their right ear drum has ruptured. The parents are terribly worried, however I’m optimistic the child will respond well to treatment. I provide medication and will review in the coming days. 

Three generations

When I open the door again, I see an older woman with muddy feet and torn clothes sitting on the floor, flanked by two young children.

I remember this woman from the weekend.

She’s an older woman who carried her adult daughter around five hours to our hospital. Sadly, her daughter had passed away in the hour before arriving.

The patient is over six foot tall and weighs less than 40 kg (around 88 lbs)

After they had finally arrived at the hospital, I was alarmed by the daughter’s severely malnourished state. Her condition made me worried that she had died of a communicable illness such as HIV or tuberculosis (TB).

The older woman said that her grandchildren were also unwell, so I requested they come into the hospital for review. I examine the children and refer for HIV / TB testing. 

HIV patient

I then receive a call over the radio to assist the HIV doctor with a severely unwell patient in the isolation ward.

The patient is over six foot tall and weighs less than 40 kg (around 88 lbs). He has just been started on treatment for advanced HIV.

This gentleman was breathing with the same intensity as an unfit individual finishing a marathon. We stabilise him, check his medication regime and will monitor closely over the day.

Staff health

I leave the isolation ward and take the boat back to the accommodation compound to assess a member of the international staff.

We are especially cautious with the health of staff because of this project’s remote location and limited resources.

The staff member has signs and symptoms indicating that the cause is possibly a viral upper respiratory tract illness.

However, in this setting we must also consider endemic tropical diseases such as malaria. I perform a malaria test which returns a negative result. I will review again at lunchtime. 

Burnout: A real possibility

I step back into the boat to return to the hospital. During the journey my alarm goes again. It’s still obnoxiously loud.

The alarm reminds me to meet with the project pharmacist. I need to check on progress with the budget for next year’s medication supply.

Our brilliant pharmacist finished the budget at 4 am! While this work ethic is admirable, I tell them to ensure they have sufficient rest. Burnout is a real possibility in this setting.

Final moments of the morning

I then meet with the on-duty clinical officer covering the emergency department. Clinical officers work in a similar capacity to junior doctors in hospitals back home in Australia.

The clinical officer needs assistance with a case. We examine the patient, who has a severe infection around their eye. This isn’t a simple infection and must be treated as an inpatient. We discuss the treatment strategy. 

I hear the call on the radio – the boat is departing back to the compound for lunch. On the way to the boat I stop by the isolation area to assess the vital signs of the unwell patient with HIV.

The patient has marginally improved. This provides sufficient reassurance that it will be ok to be away from the hospital for the lunch break.

On the boat

I take a seat on the boat, open a note on my phone and write this blog post.

This immense work rate is typical for all staff in Old Fangak. However, the composition of a morning is never standard, every day is different.

What the afternoon will bring is anyone’s guess.

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Read more: "Ordinary" days in our projects around the world

Greece: Diary of a night shift

Sierra Leone: The first 24-hour shift