Dr. Geelhoed journal entry 11 Feb 2011

Series: 11-FEB-B-9

A SMOOTH AND SUCCESSFUL MAJOR OPERATION UNDER SPINAL ANESTHESIA—A FIRST-TIME EVENT FOR EACH PARTICIPANT, A THOROUGH ULTRASOUND DEMO AND TEACHING PROGRAM, AND OUR FIRST TRIP TO BOR TO MEET AND GREET THE GOSS AND JONGLEI OFFICIALS AS JACOB HAS BEEN DIVERTED TO JUBA ONCE AGAIN TO FREE UP THE OBSTRUCTED DELIVERY OF OUR CONTAINER OF SUPPLIES NOW PLANNED FOR ARRIVAL THE DAY AFTER TOMORROW’S FIRST-EVER JONGLEI MARATHON

February 11, 2011

THE FIRST MORNING OF THE WERKOK STAY IN WHICH I HAVE NOT RUN, IN PREPARATION FOR TOMORROW’S “JONGLEI MARATHON”

Today might have, should have, been the day in which the container would have arrived, which may have complicated our already full schedule of events including an elective operation that went very smoothly. Despite the abundance of official clearance papers in hand, the driver has been stopped in Juba and passage onward has been denied on the fundamental basis of all commerce in Africa: “Ahah! Here is Manna from Heaven, and it shall not escape until I have squeezed the last personal advantage out of it for my clan.” The driver has each of these officials looking papers with the Governor’s seal and the Minister of Health and the Exemption, and all of those papers “went missing”, of course, in the shakedown to see if some real money can be made by impeding progress. SO, Jacob, who has been faithful to a fault on each of these corruptible moments, has taken all the certified copies in hand and set out for yet another trip to Juba to hand deliver the same papers they have.

To get ahead of the story, we got a cell phone call in midafternoon from Jacob announcing he was ON the container and on his way back through Bor to Werkok with it. There are still many slips between the cup and the lip and we heard from yet another interested party today who would like to be the one apportioning the supplies for a purpose perhaps not in align with our goal of the Peace initiative. But, after all, Manna from Heaven has fallen into my jurisdiction.

A GOOD DAY OF OPERATING UNDER SPINAL ANESTHESIA AND ULTRASOUND DISPLAY BY THE NEW INTERSON PROBE

With minimal instruction, I had helped my senor medical student whom I had led through his first ever operations in Tanzania through the repair of this elective scrotal hernia and he did it well. Kirtus had never seen an LP and I had instructed each of the others in how to do so with an introducer needle so now it was their turn to teach one, and it was done. The clinic patients were seen and one postponed. Our cook is 42 years old and is 43 days from her last menstrual period. She came to ask if she is commencing menopause after having borne six living children or is there something else going on? This was the time for the InterSon probe to be put to work.

On last visit, Ajak had been brought to full speed and left with a lecture and Power Point on U/S and its use in OB and general imaging. So, we gathered all participants and had each load on the InterSon software to each laptop and then demonstrated the use of the probe and gel and the common uses of it in the abdomen of a male (Dan Fong) and female (our cook—in whom POC were confirmed.) POC are “products of conception” and that is helpful as information. The full course was taught by Ajak with me as only backup this time.

OUR TRIP TO BOR AND MAJOR “MEDICAL DIPLOMACY” MEETINGS WITH BOR HOSPTAL DIRECTOR AND A TOUR OF THE FACILITY AND ITS RUINS BEFORE THE INTRODUCTORY STOP ALONG THE WHITE NILE AND THEN THE DROP-OFF OF THE NEW TEE SHIRTS FOR TOMORROW’S RACE

We made our first trip in to Bor this afternoon, so that the participants could admire the big city and stare at the skyscrapers (there are now TWO two-story buildings). Moreover, they may be able to see the stark realities of what I had been telling them about the Bor Hospital once a teaching center, is the bombed out oblivion it was when the hostilities of North against South, then South against North, and then South against South have knocked it down and kept it down with no successful “takers” on reconstruction in such an unstable area of conflicts.

The overhead sun is not one for the faint of heart to stand around in taking photos, but I did council one shot—Dr. Ajak standing in the skeletal ruins of the hospital in which his father Abraham was once the Physician’s assistant and dresser, as his son was a Lost Boy destined to come back to the same area to try to help his people even as the odds mounted up against that—most from inside.

We sat in the office of the Medical Director General, the same table around which all the payams and Governor and associated claimants have met with me before against the “blackboard” now painted over which was once the chief instructional tool back in Abraham’s day. This time we had received the Medical Director of Bor Hospital and also met with Dr. Deng –Ajak’s partner at all times up to when he first met me at the airstrip in Duk Payuel when he was partnered with Ajak here at MCH and would be later to go to Bor to work for an NGO. The Director was more and more interested as he heard about me and the container, and suggested strongly that it should simply be brought to Bor since only from here would it get equitable distribution for the purposes I outlined.

I had re-enforced the it was Dr. Ajak who would be in charge of the distribution of these resources according to the plan we had carefully worked out which included some of the Dinka Bor’s harshest rivals the Murle and we would be as a volunteer group rather strict about how our voluntary contribution was distributed as once again I stipulated it would be through Dir. Ajak from MCH. I added that I was in the process of assembling another container load and what happened to it would be very much influenced by the history of this one forthcoming now but for its periodic delays on obstructions that should have been cleared by the Governor’s exemption letters. I cited that once before our donated supplies which had accompanied us had been diverted into the black market which was the last dealings we had had with that institution and its facilities and government and only after restitution would we consider going back. He still thought that only Bor should be the place where any large equipment or specialized technical devices—he cited auto analyzers for liver function tests which his own laboratory is seeking. I pointed out that we might even seek out such materials but only if no corruption of our intent and practice were in evidence.

He also was keen on nurse anesthetists and a training program for them, stating that there was only one in the whole of the state. I pointed out the travesties I had witnessed in Kardugli in the Nuba Mountains in which I had tried to get spinal anesthesia for C-Section and they used the one drug they knew Ketamine and inappropriately at that. All mothers who were so anesthetized usually hours before surgery and then left lying in hallways where delivered of non-breathing infants who never were resuscitated despite my course in teaching spinal anesthesia and neonatal resuscitation leaving all the equipment for each which were diverted immediately from the public hospitals to the private clinics.

We then took the tour—through all the devastated facilities and the patients which were temporarily housed just as before. We saw a few children with burns form scalds. We saw a young child with a very large swelling of the knee—proabaly inflammatory rather than neoplastic and likely to be TB. Other possibilities of a mass that large lasting for many months include Ewing’s sarcoma.

We met a 70 year old man with a large family in attendance. He has overflow incontinence from an obstructed lower urinary tract. I suggested if it were benign prostatic hypertrophy we might be able to operate to correct that if they had a triple lumen catheter and could be expected to solicit intensive nursing care from the extended family with him as I have often employed in such settings in Malawi and Chad and Ethiopia. He was eager that we come to do the operation in Bor and we may do so (having just seen the spacious but empty OR) but only if the man’s baseline health screens are OK and he has a sonogram for which he is scheduled. The patient himself is less than eager to have an operation but if he declines he will face a Foley catheter indwelling for the rest of his life.

As we left from a “ward by ward” review that included the Maternity where the midwives were the most effective clinical group (invited them to come run with us tomorrow!) we made a brief stop down on the Nile River so everyone who has not seen it before—all but I—could take their pictures and see the cattle abattoir and the folk fishing in and drawing water from as well as doing all other functions in the same waters, as clumps of Nile Cabbage and Hyacinth come floating down from Uganda and Lake Victoria.

THE BIG NEWS ON OUR RETURN TRIP FROM BOR—JACOB IS ON HIS WAY FROM JUBA WITH THE CONTAINER!

Jacob called by cell phone to announce his own breakthrough as he had hoped they would be driving through the night. We will see.

Oh, and yes—you will be interested to know and probably already know more than we about the details: rebel army groups under autonomous commanders are deserting from the army in the power vacuum left after the referendum voting and they are either going to go to the North or to make their way as independent warlords until they see what suits their own advantage. And as long as they are packing their heavy armaments, there is not much that can be done to stop them.

In Upper Nile Province near Malakal about a hundred miles from Jill Seaman in Old Fangak a clash of the rebels and army resulted in a hundred deaths with 47 of the deaths being civilians. This is not in our sandbox right here. It DOES however show the generalized lawlessness and rivalries of ancient clan cattle culture conflicts I had witnessed in Upper Nile as well as Jonglei Province. The Peace initiative if and as it works should be generalizable as well.