Goodbye for now

Back in KL for a short while and on to Melbourne then to the States for a month each before returning to South Sudan at the end of June.

In the pic to the left, you can see Yei "airport". The runway is basically a dirt path that has been cleared from trees and any underbrush. The small building houses the check-in counter, customs and immigration, and boarding gate all in one! Long queues form when more than one group decides to leave on the same day - especially since there are only three flights in and out per week. Everything's done manually (passport details and so on are laboriously handwritten into an exercise book) so the whole process could take a while, but that's ok since flights rarely arrive or depart on schedule; an hour within the stipulated time's considered pretty good!

All in all, though, thank God that this airport does exist otherwise we would be forced to take the long journey by road to the capital (Juba) in order to even leave the country. I'll probably not post many more updates in between now and the time of my return; or at least, ones that directly pertain to South Sudan. But please feel free to check back in two months' time :) Till then, take care and may God watch over us in these troubled and tumultuous times.

Addition:
In the meantime, read the story behind the Harvesters orphanage + school + hospital complex in Adventures Under the Mango Tree; having personally met its author, one of the co-founders of the ever-growing ministry, I can assure you that it would prove to be inspiring, touching and hopefully, life changing by the close of the book.

Let's play spot the fracture

Today's my last day in Yei before I leave for a two-month break (I'll return at the end of June). It was going pretty well until 3pm where I returned to the hospital after lunch and was greeted with the sight of a 9-month-old boy in extremis, complete with agonal gasps and all. He had been admitted to the ward by the clinical officer with a working diagnosis of gastroenteritis (one-day history of vomitting and diarrhoea). I got a call from the head nurse 10 minutes before I arrived, letting me know that no one had managed to gain IV access and to ask if I could come put in an IO (intraosseous) line - which I've never done before other than on practice mannequins. Anyway, I dropped by my senior colleague's house to request some supervision and trotted on to the hospital. And yup, there was a big crowd surrounding the bed, some wailing from the boy's relatives, and the little one deceased. Apparently, he went into cardiac arrest shortly before, presumably from hypovolaemic shock.

That wasn't the end of it, though. From that time up till the time I left (7.30pm), there were six new admissions, including:
- An 11-year-old boy who had fallen out of a mango tree earlier that afternoon (his right femur XR is displayed on the right),
- A 1-year-old boy with gross macroencephaly (literally three times the normal size of a child's head) secondary to hydrocephalus 8 months post ETV who presented with new-onset seizures, fevers, vomitting and a fixed, dilated left pupil (possible meningitis +/- stoma occlusion),
- A 30-year-old lady with threatened miscarriage (which became a complete miscarriage by the time I left),
- A middle-aged man with symptoms of subacute pulmonary oedema secondary to congestive cardiac failure, and last but not least,
- Two others kids with malaria, one of whom needed blood transfusion for a Hb of 4.5

Well, at least you can never accuse the work here of being mundane or boring! We do what we can, refer where we can, and hopefully most of our patients are better off because of it. Outcomes may never reach the standards to which we are accustomed in the West (for the foreseeable future, at least), but God willing, I believe we do make some difference.

On a lighter note, I somehow got roped in to be part of a mini choir on Sunday! It boggles the mind of anyone who's familiar with my singing prowess (or rather, lack of); to my left is our pastor and the second person to my right is the lovely wife of our American missionary doc while the others comprised the older girls from our orphanage. We presented a song during offering time at church service ("Presence Beautiful" by Daniel Thornton), which was followed by a special dance presentation - thankfully not including yours truly this time!

One of the advantages (some may call it a disadvantage?) of living in such a close-knit community is that we see one another almost literally all the time. We share our meals, work together, go to town together, serve in church together, etc. Sometimes, that means friction as we rub each other the wrong way. It'll mean disagreements from time to time, hopefully settled amicably. But overall, I guess it's practice for heaven, where we are one body in Christ:
Romans 12:3-8 For I say, through the grace given to me, to everyone who is among you, not to think of himself more highly than he ought to think, but to think soberly, as God has dealt to each one a measure of faith. For as we have many members in one body, but all the members do not have the same function, so we, being many, are one body in Christ, and individually members of one another. Having then gifts differing according to the grace that is given to us, let us use them: if prophecy, let us prophesy in proportion to our faith; or ministry, let us use it in our ministering; he who teaches, in teaching; he who exhorts, in exhortation; he who gives, with liberality; he who leads, with diligence; he who shows mercy, with cheerfulness.
Sadly, the current state of the church worldwide leaves much to be desired. Our saving grace is that our good Shepherd is very much aware of our failings, both as individuals and as a group, and yet loves us still.

If you could pray for my safe return to both Malaysia and Australia, it'll be much appreciated :)

Town & Country

I went visiting Yei town for the first time on Wednesday - my first real foray outside our missions compound! Very exciting as the only bit of South Sudan that I had then seen (even though I had been in the country for well over two weeks already) was our little patch of land; as nice as it is, it's good to get out once in a while.

The first place I visited was the Yei Civil Hospital, the major local public healthcare facility. On the left you can see a 'tukul', a traditional structure with a thatched roof (usually constructed with mud walls instead of the painted brick ones you see). These huts are currently used as isolation 'wards' so I thought it amusing that a whole herd of goats was lying around taking advantage of the shade. The hospital was not a single building but rather a whole series of small buildings spread out willy nilly. An interesting layout. As the operating theatre and surgical ward are being renovated at the moment, the current "operating suite" is a one-room building smaller than most chapels with only a door on each end, the width of which was less than my arm span and which could only be reached after surmounting a couple of steps. This also meant that there was no way to transport the patient using the traditional trolley bed (or gurney, as my American colleagues term it). When questioned, the nursing staff said that the patient would be carried in and out on a stretcher - over very hilly and rocky terrain across a distance of maybe a few hundred metres to the surgical ward. And no ventilator in sight. The pharmacy is also closed so apparently relatives of inpatients are sent out to the commercial pharmacies in town to purchase the meds they need to bring back for the nurses to administer. At least they seem to have a ready stock of HIV antiretroviral medications donated by the UN.

After lunch, I went to the local market to purchase some clothing items. As referenced in one of my previous posts, it isn't 'kosher' for females to wear pants in this culture so I had to find some appropriate skirts instead. The market reminded me of some of those back home (in Malaysia). It was very crowded, there was a variety of produce on display (vegetables in the photo on the right and fish in the photo below), lots of 'exotic' smells - some good and some not so good, and people shouting for you to come over to survey their goods (e.g. here, it's 'customer, customer' whereas back in KL, it's 'boss, boss'!). And just like in many parts of Asia, the fine art of haggling is practised ranging from the tried-and-tested incredulous "no, really, you've got to be joking" to the hopeful "just a little bit less, yes". Without my faithful 'tour guide' (one of the older girls from the orphanage who's also working part time at our missions hospital), I probably would have been swindled many times over due to my sticking out as a 'khawaja' (foreigner). Lest I be seen as being prejudiced, I would readily admit the same of Malaysian and mainland Chinese hawker stalls.

Speaking of which, I've started language lessons in Juba Arabic and am making good progress (I think). It's fascinating to observe the similarities between this strain of Arabic and the Malay language. For instance, I recently learned the days of the week:

Sunday - Yom ahad (arabic) - Hari ahad (malay)
Monday - Yom ihnin - Hari isnin
Tuesday - Yom telata - Hari selasa
Wednesday - Yom aruba - Hari rabu
Thursday - Yom khemis - Hari khamis
Friday - Yom juma - Hari jumaat
Saturday - Yom sebit - Hari sabtu

Amazing, right? Obviously, Arabic is the older language. But even the word for day - 'yom' - is the exact one used in the Hebrew language, which is yet older. It makes the words of the Apostle Paul to the Greek Areopagus two thousand years ago even more significant:
Acts 17:24-28 "God, who made the world and everything in it, since He is Lord of heaven and earth, does not dwell in temples made with hands. Nor is He worshipped with men's hands as though He needed anything, since He gives to all life, breath, and all things. And He has made from one blood every nation of men to dwell on all the face of the earth, and has determined their preappointed times and the boundaries of their habitation, so that they should seek the Lord in the hope that they might grope for Him and find Him, though He is not far from each one of us; for in Him we live and move and have our being, as also some of your own poets have said, 'For we are also His offspring.'"
We may look different from the outside, but are we not one blood and one flesh inside? As some others put it, we all bleed the same colour when we are cut. So why do we act as if it wasn't so?

Pastimes to pass the time

Those who have known me for a while will know that I lead a relatively sedentary lifestyle and rarely participate in any sports (although I do have a gym membership back home and try to use it every now and then). However, most of the aforementioned people would - or should - also know that I'm an avid supporter of Liverpool F.C., the most successful English side in the Champions League. Football - or soccer as it's known to Americans and Australians, the only two countries yet to embrace this truly global phenomenon - is the only sport I would willingly plonk in front of the TV to watch. It is also the favourite pastime of the boys in this country (as shown in the picture).

Today was my first afternoon off, and did I enjoy it! I wandered over to the school yard, watched these boys play a few games or so, then meandered over to the orphanage and picked up a toddler or two. The latter was a rather overwhelming experience as I was literally surrounded by little boys and girls who were either shouting, "Dr Wong, Dr Wong, look at my wound!" or trying to climb on top of me. One cherubic soul named Jimmy Michael even attempted to pull the little girl I was carrying, Baby Sue, out of my arms so I would carry him instead. Failing that, he turned to rummaging through my pockets to look at my mobile phone, pen and so on.

It gives a whole new slant on what Jesus said in Matthew 18:3-5 "Assuredly, I say to you, unless you are converted and become as little children, you will by no means enter the kingdom of heaven. Therefore whoever humbles himself as this little child is the greatest in the kingdom of heaven. And whoever receives one little child like this in My name receives Me." and again in Matthew 19:14 "Let the little children come to Me, and do not forbid them; for of such is the kingdom of heaven." These sayings have always perplexed me; what does it mean to 'become as little children'? Some interpret it as cultivating a childlike wonder or point to their (supposed) innocence and others believe it to mean a position of humility and dependence on God. It could very well be all of them, and more besides.

In the meantime, may I make good use of the time I have with these kids. They have already been put through experiences that would test even the toughest of adults. I nearly teared up when Mama Lilly (one of the co-founders of Harvesters) described how she brought some of the children to the airfield and how they panicked when they heard the sound of the plane approaching and asked her, 'do we run and hide?' You see, they were used to the sound of bombers from the north (Sudan) flying over their villages. This is going only a decade back! A deep ditch still runs along one end of the orphanage, the remnants of the bunker they would use for circumstances such as the aforementioned one. It's crazy to think how we humans perpetrate such horrific crimes against one another; not just by what we do but also by our silence.

Life in Yei

Nope, that's not a picture from a suburban area of Australia but of our compound at Harvesters (short for Harvesters Reaching the Nations). We're pretty well taken care of here, and my little room even has an ensuite (flushing) toilet/bathroom with constant running water and electricity. And I'm typing this using internet provided through a Wi-Fi network!

We've meals provided three times a day, seven days a week. Granted, it's red beans and rice at almost every single meal but with variations following the day of the week; e.g. "Mexican" style tortillas and guacamole on Thursdays, fried chicken on Sundays, etc. My diet here is generally healthier than the one I have back home (with all respect to whomever did the cooking). I did have one bout of gastro but thank God, that passed quickly. Consequently, one item that I brought over and have found the most useful is Dettol handwash - a hint to whoever's planning to visit ;)

I'm slowly adjusting to the rhythm of life here. Prayer meetings and bible studies with the older girls from the orphanage, regular meetings with other missionaries in this locale (mainly from the States but also from NZ, Switzerland and so on), learning to turn in for the night at the unheard-of hour of 10pm (I'm a night owl and I rarely ever sleep before midnight back in KL and Melbourne)...and the list goes on. The compound is pitch-dark at night as there aren't any lampstands or such, so I've learned to carry an electric lantern when called back to the hospital (bringing to mind Florence Nightingale).

And of course, work. This week has been crazy hectic and we've been in the hospital literally every single night - usually because a woman (or two or three) has presented in labour. The score so far: two C-sections, maybe ten deliveries now (including a case of footling breech and intrauterine foetal demise), three premmies (premature infants - all born at 32/33 week gestation), two deaths (both of which could only have been preventable with ICU support, really; one an end-stage pneumonia +/- CCF and the other likely hepatorenal failure from possible schistosomiasis [Hep B/C negative]), lots of bronchiolitis, and a baby with either cerebral malaria or meningitis.

Thank God, He's supported us all the way through. I was so encouraged when the head of Pioneers in the East African division, who was visiting the country, stopped by our team meeting and shared the following passage:
Isaiah 40:28-31 Have you not known? Have you not heard? The everlasting God, the Lord, the Creator of the ends of the earth, neither faints nor is weary. There is no searching of His understanding. He gives power to the weak, and to those who have no might He increases strength. Even the youths shall faint and be weary, and the young men shall utterly fall, but those who wait on the Lord shall renew their strength; they shall mount up with wings like eagles, they shall run and not be weary, they shall walk and not faint.
Amen and amen! Our strength is in Him and He gives us more grace. :)

P.S. Please pray for my auntie's mum, who had what seems like an iatrogenic rupture of a cerebral aneurysm during an attempted coiling back in Malaysia (translated into layman's terms, she had a catastrophic bleed in the brain).

A Tale of Three Clinical Vignettes

Clinical Vignette A:
As you can see in the picture to your left, we process our X-rays creatively using what natural resources that are available to us. In this case, it was a skull X-ray of a 19-year-old boy who was thrown off his motorcycle when it hit a dead cow in the road on Saturday. Upon presentation two days later, his GCS was 7 (E1V1M5), he had had minimal to nil oral intake, was non verbal and was obviously not doing too well. Bearing in mind that there is no neurosurgical service - or for that matter, a CT scanner - in the entire country and the nearest centre was in Kampala (Uganda), almost a day's drive away over dirt roads, we admitted him, commenced IV fluids, dressed his wounds and, basically, hoped for the best. Did I mention he's also got a fixed, dilated left pupil? At this stage, we've encouraged his family to find out if he could be transferred to Kampala so we're all waiting for his older brother who is currently in some far-away location to be contacted to make a decision.

Clinical Vignette B:
Last night was my first experience of a Caesarean section in South Sudan. It was a primip who we suspect had cephalopelvic disproportion and had been pushing for over two (or maybe it was three) hours. When I piped up and asked my senior colleague (a GP obstetrician from the States) if he was going to do the spinal, he asked if I was good at it; I answered that I could hardly say so and he replied, I might still be better than him anyway (!). Then, our missionary nurse from New Zealand informs me that we're down to our last vial of bupivacaine. Ok....pressure's on! Thanks be to God, my first spinal after a year away from anaesthetics was a success and the entire operation went smoothly. It's the first C-section I've seen where the surgeon prays with the staff and patient beforehand too :)

Clinical Vignette C:
In contrast, less than 24 hours later was also my first experience in this country of witnessing a patient's demise. It was a middle-aged man who was brought in by his family with acute respiratory distress associated with new-onset productive coughs and a possible one-month history of central chest pain and orthopnoea. Upon presentation, he had a RR of 40, HR of 160 and SpO2 in the 40s! Worse still, he was barely responsive and could not speak at all. We got the oxygen concentrator working pronto, but the sad fact is we can only get a maximal concentration of 5L (the usual maximal concentration on the wards back in Australia is 15L and we can double that by adding 'tusks' to non-rebreather masks or failing that, achieve almost 100% with a bag-mask-valve device). Our working diagnoses at this point were either severe pneumonia and/or acute pulmonary oedema secondary to cardiac failure. Hence, the choice to get a CXR asap and give IV ceftriaxone (an antibiotic) and po frusemide (a diuretic - we didn't have the intravenous form).

Well, 'things don't happen like they do back home' may be the understatement of the day (or year). A man was brought in at the same time suffering from a snakebite and all of my nurses and medical attendants went off to look after him in a different room and I was left scratching my head. Back in Australia, this man would have had a MET called on him, possibly even a Code Blue, and likely taken to ICU, intubated and ventilated. Here, I could not even get anyone to get meds for him for another 10-15 minutes! So frustrating. Anyway, he went into respiratory arrest right before my eyes and then died, just like that. To have resuscitated him at that point would have been an exercise in futility as there isn't an ICU to which we could transport him even if we achieved ROSC (return of spontaneous circulation).

Comparing that with the many sessions that all clinical staff back home are required to attend on recognising a deteriorating patient, I think there's definite room for improvement on this point. That's another difference between our cultures as well, I guess. The family of the deceased patient was totally understanding; one of the other men even threw up his hands and said, "it is God's will". Death is so common here and life so short. What we strive to do - or should - is to ensure that at the same time, life isn't cheap. Remember what God Himself said in Ezekiel 18:32 - "'For I have no pleasure in the death of one who dies,' says the Lord God. 'Therefore turn and live!'"