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Just Got Dorsum From Southward Sudan--Thoughts Virtually Tropical Medicine


I only returned a few days agone from the Republic of South Sudan, where I spent almost 3 weeks. Jet lag is fading, together with inwards fourth dimension I may fifty-fifty halt complaining almost how incomprehensibly bad the Juba aerodrome was. Overall the experience was great, though.

My intention was to pass 2 weeks alongside my friend Jill Seaman, a doc who has been working inwards Sudan for decades, primarily fighting tuberculosis together with visceral leishmaniasis past times establishing  and pushing handling protocols. Jill directly helps run a community infirmary inwards the (usually) tiny town of Old Fangak, on the Zeraf River. The infirmary serves a community that usually numbers a few chiliad along alongside anyone who tin brand their means there, but directly Old Fangak has go a busy city of over 30,000 people because of the many people who conduct hold fled their homes due to fighting. My labor was to aid out alongside patient aid together with learn bedside ultrasound. The other calendar week of my 3 calendar week trip is how long it takes to acquire to together with from Old Fangak. I solely got 10 days there, every bit it turned out, since the authorities has go to a greater extent than strict almost flights to together with from that expanse because it is a hot spot inwards their civil war. South Sudan is a novel country, having gained its independence from Sudan inwards 2011. There was relative peace until final Dec when violence broke out inwards the upper-case missive of the alphabet betwixt supporters of the ousted vice president together with the president over policy disagreements. Since the vice president was from the 2nd largest tribe, the Nuer, together with the president was from the largest tribe, the Dinka, the disagreement became a tribal conflict inwards outlying regions which has been bloody together with destructive. South Sudan has had lots of civil war, together with this province of affairs is to a greater extent than the norm than peace, which was sort of acquaint for 2 years afterward independence.

My final see to South Sudan was a twelvemonth ago, correct earlier the novel civil state of war broke out, together with my timing inwards leaving was closed to perfect, since the whole identify became hellish a calendar week afterward I departed. This fourth dimension the state of war was pretty closed to Old Fangak, but its isolation, alongside no passable roads together with solely access past times river, made move in that location pretty safe. Still, much of the medicine this trip had to practise alongside wounded soldiers. There was also the usual constant current of the medically sick together with occupationally injured, alongside their tropical ulcers, parasitic diseases, diarrhea together with fevers.  Complications of starvation volition prepare inwards to a greater extent than substantially due to disruption of farmers together with cattle herders, but before long nutrient aid from organizations such every bit the World Food Program is keeping this partially at bay.

When I got back, the Christmas holidays were apace approaching. Family from far away were going to descend on our house, together with I had piles of journals together with notes together with bills together with certificates on of import horizontal surfaces. While taking aid of these, I found the notes I took from a brief DVD course of education inwards tropical medicine, released past times the Mayo Clinic, that I took final year. I don't truly conduct hold a identify to lay hard re-create notes where I volition meet them ane time to a greater extent than together with larn from them, other than java tables which would await means ameliorate without materials all over them. So I am going to combine what I learned inwards South Sudan inwards Old Fangak alongside my notes every bit a means of remembering stuff. Here goes!

Poor nutrition, homelessness, poor sanitation together with stresses underlie most of the weather nosotros saw. The vast bulk of illness together with injury nosotros saw were preventable past times cook clean together with adequate H2O supplies, nutrient together with shelter security, skilful prenatal care, waste product disposal together with non-violent job solving. There were almost no unproblematic conditions. We saw patients inwards several situations. There were the inpatients, who had beds or pads on the flooring of the infirmary buildings together with were given musquito nets. They were usually the sickest patients, alongside problems that were life threatening together with sometimes without piece of cake solutions. There were patients alongside wounds, who were living either somewhere inwards the chemical compound or inwards the surrounding hamlet together with would come upwards inwards for dressings together with sometimes little surgical procedures. There were clinic patients who came to the morning, afternoon together with eve clinics, staffed past times local clinicians (nurses, clinical officers together with community wellness workers) together with sometimes past times a doctor. Patient visits inwards clinic numbered around 200 per day. Some of these became inpatients. There were patients alongside weather that required less intensive observation but which required long handling courses, such every bit tuberculosis, nephrotic syndrome, Kala Azar together with Brucellosis. These are exotic together with rare inwards the U.S.A. together with mutual every bit dirt inwards Old Fangak.

Malaria is the most probable displace of high fever. It is the treatable displace which needs to live ruled out first. The testify nosotros work is a "paracheck" which is a rapid diagnostic testify based on presence of malaria antigens. Influenza A virus subtype H5N1 drib of blood from a fingerstick is placed on a plastic stick alongside absorbent newspaper inside, a drib of fluid is added together with lines appear inwards a few minutes indicating a diagnosis of malaria. This is similar to a urine pregnancy testify together with tin live done inwards the clinic or at the bedside spell the patient waits. The commonest cast of malaria past times far inwards Old Fangak is Plasmodium falciparum, the most severe together with acuate variety. It tin acquaint alongside metabolic acidosis, shock, coma, renal failure, fifty-fifty ARDS. In Old Fangak it tin conduct hold all kinds of associated symptoms specially nausea together with vomiting alongside diarrhea. Most cases tin live treated alongside oral Artemisin combination therapy though cerebral malaria together with other severe presentations are treated alongside intravenous medications. Somewhat less severe versions of malaria are caused by Plasmodium vivax, ovale, malariae and knowlesi (usually inwards southeast Asia) together with these conduct hold different fever patterns. The Anopheles musquito transmits malaria together with is controllable alongside elimination of standing H2O (mostly impossible) together with work of insecticides. Since these mosquitoes primarily seize alongside teeth every bit eve falls, work of musquito bed nets, specially for children, drastically reduces malarial disease. Pregnant women are treated monthly during their get-go trimester alongside Fansidar (Sulfadoxine/Pyramethamine) because they are to a greater extent than susceptible to the illness together with because it tin displace miscarriage.

Visceral Leishmaniasis, also known every bit Kala Azar, commonly presents alongside prolonged fever, enlarged spleen together with liver, sometimes alongside diffusely enlarged lymph nodes, together with os marrow interest which tin Pb to anemia together with depression platelet together with white jail cellphone counts. It often coexists alongside HIV infection, though non then much inwards Old Fangak where HIV is all the same relatively rare. It tin live diagnosed alongside a rapid diagnostic testify which detects rK-39 antibodies together with is almost 80% sensitive. If this is negative, a DAT (direct agglutination test) is performed which should expose 95% of cases. Influenza A virus subtype H5N1 lymph node aspirate tin expose the actual organism, which is helpful when the immune reply is non vigorous, similar alongside HIV coinfection. It is almost 60% sensitive, together with tin live used for detection of recurrence, dissimilar antibody together with agglutination tests. Spleen aspirates, also useful inwards recurrence, conduct hold sensitivities every bit high every bit 95%. The lab staff is capable together with confident inwards performing lymph node aspirates, which inwards the U.S.A. would live a neat large deal, together with splenic aspirates are performed at the bedside inwards patients without meaning haemorrhage risks, apace together with nearly painlessly, alongside vanishingly rare complications. The specimen is smeared on a slide, giemsa stained together with examined for the tiny protozoans which await similar an eyeball alongside a point together with are almost the size of a platelet. The illness is usually treated alongside sodium stibogluconate (SSG) together with paromomycin injections for almost 3 weeks, which often displace nausea together with vomiting an tin also displace fatal take in arrhythmias together with kidney problems. Influenza A virus subtype H5N1 less toxic but much to a greater extent than expensive selection is liposomal amphotericin B which is given intravenously on an intermittent schedule, usually over 21 days. This is used for resistant or recurrent cases together with inwards patients who don't tolerate the SSG/paromomycin regimen.

Back hurting together with tenderness, prolonged fever alongside weight loss, chronic arthritic joints inwards children, unexplained chronically enlarged lymph nodes, specially alongside fluid collections within together with coughing alongside fluid around the take in or lungs is usually tuberculosis together with requires prolonged residence at or nigh the infirmary chemical compound for direct observed treatment. Treatment of TB is effective together with lifesaving together with most patients comply alongside medication therapy which is impressive. Worries almost contributing to multi-drug resistant tuberculosis slowed the evolution of programs to process the disease, but at Old Fangak people are getting appropriate therapy along alongside nutritional support, blankets, musquito nets together with sometimes shelter together with are beingness cured of their TB.

Nausea, vomiting together with diarrhea could live anything, but is often Giardia. In many areas of Africa skilful sanitation has made this uncommon, but it is pretty rampant at Old Fangak. Despite aggressive latrine construction, babies together with children, specially those alongside diarrhea, leave Giardia parasites everywhere, together with though both Sudanese together with Americans are cook clean together with tidy inwards their ain homes, the infirmary chemical compound seems to live covered alongside a sparse layer of filth. Most floors are dirt. The floors that aren't dirt are mopped daily, but walls are non together with little islands of cleanliness practise non brand a huge overall divergence inwards infection control. Giardia is treated alongside tinidazole which tastes horrible together with is slightly nauseating. It seems that, improbably, most children truly conduct hold it when it is prescribed.

Schistosomiasis is in all likelihood nearly universal, since most people swim together with bathe inwards the river, which carries the parasite to the pare of the human host, which it penetrates to displace infection. Schistosomes are blood flukes which tin demeanour on most trunk systems, but schistosomiasis is usually either assymptomatic or associated alongside symptoms that are hard to notice, such every bit discomfort alongside urination or fatigue from chronic Fe deficiency. The 2 types acquaint inwards Africa are mansoni and haematobium. Mansoni is famous for causing portal hypertension alongside symptoms of liver failure, but to a greater extent than commonly causes chronic intestinal distress together with intestinal blood loss. Haematobium is known for causing scarring together with sometimes cancer inwards the bladder. The eggs tin live identified inwards urine or stool, but inwards Old Fangak it is most often treated when patients acquaint alongside classic symptoms, since most people are probable chronically infected. Reinfection is nearly impossible to prevent, though inwards some countries routine together with repeated blanket handling has been tried. Praziquantel, every bit a unmarried dose, is usually effective inwards clearing the disease, together with is sometimes used prophylactically for children at high risk.

Tapeworms together with roundworms are surprisingly rare inwards our footling community, but alongside the influx of internally displaced people that equation may live changing. These are pretty easily treated alongside a unmarried dose of a pleasant tasting tablet, albendazole. They tin displace intestinal distress together with malnutrition together with are associated alongside poorer schoolhouse performance. I did meet ane illustration of an overwhelming infection with Strongyloides stercoralis, a roundworm, in a immature adult woman who was chronically sick alongside kidney failure together with vomiting who had tiny worms inwards her urine. Despite appropriate treatment, she died. Once this infection becomes then widespread it is hard to eradicate together with usually implies an associated immune dysfunction. Malnutrition together with kidney failure mightiness conduct hold been what made her vulnerable.

Brucellosis is a illness carried past times cows together with dogs together with transmitted to humans primarily through contact alongside their urine together with feces. The cows, which are a mutual cast of wealth together with currency inwards South Sudan, are heavily infected. Influenza A virus subtype H5N1 vaccination computer programme could live real effective inwards reducing moo-cow morbidity (primarily abortion together with infertility) every bit good every bit human illness but hasn't been tried. Ongoing civil disruption due to state of war gets inwards the means of all sorts of skilful ideas. Brucella causes recurrent fevers alongside nausea together with vomiting together with overall feeling piteous together with tin persist for years, causing chronic arthritis of the large joints together with the back. Most infection is assymptomatic. It tin demeanour on the skin, alongside rashes, the eyes, causing inflammation together with blindness, bladder, testicles together with ovaries, lungs together with brain. It is diagnosed inwards the lab alongside a serum agglutination testify together with treated alongside half dozen weeks of doxycycline along alongside 2-3 weeks of gentamicin, which is usually given every bit a rather painful intramuscular shot. It ofttimes recurs.

Chronic kidney illness alongside nephrotic syndrome is surprisingly mutual together with in all likelihood related to ongoing immune scheme activation past times repeated infections of various kinds. This is treated alongside a dull taper of prednisone, which sometimes works. Patients usually acquaint alongside facial together with leg swelling along alongside frequent urination together with fatigue. There is a fingerstick monitor of the creatinine level, something I haven't seen inwards the US, which is the solely available means to document the status of a patient's kidney function. High blood pressure level is treated appropriately which helps inwards recovery or at to the lowest degree to dull the progression of disease. Endstage kidney illness is correct directly a terminal diagnosis since in that location is no available dialysis or kidney transplant available to these people.

Late phase cancer is surprisingly common. There was a 17 twelvemonth former man child alongside a tumor inwards the breast that had displaced his take in to the correct breast cavity together with obstructed blood flow into the heart. It was probable a mediastinal germ jail cellphone tumor, since this is non terribly uncommon inwards immature men. It is quite sensitive to chemotherapy, fifty-fifty curable, but this somebody presented at such a tardily phase that he would conduct hold been lost fifty-fifty inwards the US. He had been inwards bed closed to a year, had deep bedsores together with legs which no longer would straighten. He had devoted parents together with a winning personality. He died afterward a calendar week inwards the hospital. There was a human who came inwards unable to swallow. This had progressed over a year, but his esophageal cancer (visible on bedside ultrasound) had directly completely obstructed his swallowing and, though he would have some intravenous hydration, in that location was zip nosotros could practise for him. In the U.S.A. he would probable conduct hold died, but would conduct hold had palliation alongside radiations therapy together with a feeding tube. Esophageal cancer is mutual inwards East Africa. Influenza A virus subtype H5N1 adult woman returned to clinic afterward having received radiations together with chemotherapy for a tonsillar cancer that turned out to live a lymphoma. With advice from doctors who were friends of Jill's, she received appropriate therapy together with was gratis of illness when she returned. Influenza A virus subtype H5N1 beautiful immature human had a deep together with fungating wound of the correct groin that was foul smelling together with liked to bleed. It appeared to live a squamous jail cellphone carcinoma, but nosotros did biopsy it together with results are pending from Nairobi. He could acquire radiations therapy for palliation if carry could live arranged together with if he is able to endure that long.

Tropical ulcers are real painful together with appear usually on the lower legs afterward little trauma. They are inhabited together with in all likelihood caused past times a collection of bacteria together with tin displace os infections together with fifty-fifty cancer if untreated. These are real common, together with are treated alongside dressing changes, debridement together with antibiotics. Presently nosotros are using gentian purplish topically which seems to speed healing. War wounds often displace extensive tissue harm together with are treated alongside dressing changes together with sometimes delayed primary closure ane time they are cook clean together with healing. They tin live disfiguring together with painful. I tried a combination of guar mucilage (a constituent of many high tech wound dressings) alongside powdered antibiotics for some of the to a greater extent than weepy wounds. This was pop alongside the patients but I wasn't in that location for long plenty to meet if it improved healing. It did appear to trim down evidence of infection.

Pneumonia, specially inwards kids, together with diarrhea alongside dehydration inwards babies accounted for a reasonable total of sickness. Most pneumonia is treated, successfully, alongside amoxicillin, some alongside ceftriaxone, together with diarrhea was treated alongside oral together with sometimes intravenous rehydration, alongside handling for the specific displace if that became at all clear, often alongside antimalarials or antibiotics. Runny olfactory organ alongside runny eyes, specially inwards the presence of rash was measles together with often quite a severe illness inwards little children. Most medical missions conduct hold vaccination of children quite seriously, but most rest unprotected.

In the U.S.A. I commonly meet complications of take in failure together with vascular disease, primarily related to smoking together with obesity, diabetes together with its sequelae, chronic lung disease, ane time to a greater extent than related to smoking together with infections that are often complications of IV drug abuse. I also meet the devastations of extreme former historic menstruum alongside dementia worsened past times urinary tract infections or pneumonia. None of this is mutual inwards South Sudan. In the infirmary at Old Fangak the mutual weather are almost every bit various every bit I meet at home, but the options for diagnosing together with treating them are much to a greater extent than limited. For me in that location was quite a steep learning curve. 

Staff from the community who conduct hold footling or no formal medical grooming practise a tremendous total of the work, including diagnosing together with treating real meaning and, for me, exotic diseases. This is made possible past times protocols developed past times generations of doctors, including ones working alongside Doctors Without Borders together with specially Jill Seaman who has been doing this variety of affair for a truly long time. When no Americans are present, Kala Azar, tuberculosis, brucella together with many other diseases are treated effectively together with followed appropriately past times South Sudanese wellness workers. They could for certain work to a greater extent than training, but I am inwards awe of their skills. I saw ane of them lay an IV inwards a dehydrated babe alongside no difficulty which I uncertainty could conduct hold been done alongside such science inwards a U.S.A. hospital. With access to medical together with nursing school, which they practise non have, their potential would live tremendous.

Working inwards Old Fangak is something that doctors dream about. It is expensive to move in that location together with disruptive to my piece of work schedule, together with in that location are all kinds of diseases that are piece of cake to pick up. There are grouchy people alongside AK47's wandering around looking twitchy. The medical aid requires flexibility together with is often incredibly frustrating when lack of resources makes it impossible to solve a job that is then real soluble if solely the province of affairs were different. Still, the society was first-class together with the patients were neat together with the attitudes together with skills of people working in that location were inspiring. It was deeply fulfilling, I learned a ton together with conduct hold a bunch of neat stories. Also... hooray, I didn't die!

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