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South Sudan Trip: Direct Maintain 4

I take maintain simply returned from Old Fangak, Jonglei State, South Sudan after my 4th trip. I seem to take maintain earned a welcome in that location for educational activity bedside ultrasound to anyone who volition larn too doing ultrasound whenever anybody asks. Also I create a hateful soup too brand delicious chocolate sauce inwards which a homesick American tin dip a slice of local deep fried breadstuff dough.

The infirmary I catch is a community wellness centre which has morphed into a total service infirmary for tens of thousands of people displaced past times chronic civil war. Jill Seaman, a MD friend from my abode town too a champion of handling for complex too fatal tropical diseases (particularly Kala Azar too tuberculosis), has coordinated the multiple functions of this centre for years. It serves as a distribution signal for nutrient aid, a triage centre for state of war wounded when the state of war is unopen by, a referral centre for handling of tuberculosis too Kala Azar too at i time a major outpost for Doctors Without Borders (Medecins sans Frontieres--MSF) inwards this surface area of the country. It also takes attention of patients amongst rashes too fractures, splinters too pneumonia, delivers babies, nurses the dying too treats those amongst chronic diseases such as epilepsy, pump failure, asthma too sadness.

It sits on the banking concern of the Zaraf River, so named for the giraffes that roamed hither earlier they were killed or driven off past times state of war too difficult times. The river is a beautiful deadening moving matter that flows past times the infirmary on its agency to the Blue Nile too and then to Juba, South Sudan's horribly dysfunctional capitol city. Tropical birds of vast diversity roost inwards the tamarind trees at the infirmary too fish inwards the river, including egrets, kites too ibis. There is a vibrant opened upward market, selling by too large inexpensive Chinese goods but also fish too locally grown vegetables, teas too nuts. (Also delicious dough creations for dipping inwards chocolate sauce when yous acquire the chance.) The state of war seems ever to live going on somewhere, but this yr it was non also close. Still, nearly everyone has suffered some terrible loss.

My niche, other than cooking, is to instruct ultrasound too live an internist. The ultrasound educational activity is an extension of my enthusiasm for bedside ultrasound which is real useful inwards a identify similar this, where in that location are 2 portable ultrasound machines (one inwards French, through MSF) too no x-rays or CT scans. Being an internist has benefits too, since internal medicine is all almost making sense of multiple complex symptoms or chronic diseases. I larn to a greater extent than tropical medicine each fourth dimension I visit, but am hardly an expert. What I tin produce is recognize patterns of affliction that tin Pb to effective treatments, too improvise handling from what is available.

My trip inwards ultrasounds:

Before I arrived inwards Old Fangak, inwards the calendar week earlier I left home, I got an electronic mail from Jill amongst a brief clip of an ultrasound of a boy's heart.



This clip was taken past times pointing an iPhone photographic tv camera at an ultrasound machine too shooting a picayune video. It shows a normal boy's pump surrounded past times a huge collection of fluid. The man child was brusk of breath, but had walked in. The status had come upward on slowly. In Old Fangak, collections of fluid some the pump too lungs are normally due to tuberculosis too oft answer quite chop-chop to a combination of steroids (prednisolone) too anti-tuberculosis medication. I told her that it was what she idea it was too that she should endeavor her usual trick. Jill has gradually expanded her comfort amongst ultrasound beyond obstetrics but this was such a dramatic finding that she wanted some other pair of eyes. When I arrived, this man child was i of the outset patients I saw, too his pericardial effusion was almost gone almost a calendar week after starting treatment.


In the adjacent bed inwards the infirmary was some other teenage man child amongst pump failure. He had been coming to the hospital for shortness of breath but despite medication had go so swollen too weak that he had been admitted. His ultrasound showed that his mitral valve was the problem.

Rheumatic fever is overwhelmingly a affliction of poverty too lack of access to medical care. It starts amongst strep throat, too then a few weeks afterwards develops into an inflammation that tin involve the heart. Years afterwards the pump valves tin go scarred. In his case, in that location is severe mitral stenosis, amongst real picayune blood catamenia through the valve separating the left atrium too ventricle, leading to stretching of the left atrium, abnormal pump beat too increased pressure level inwards the vasculature of the lungs. Seeing this status volition Pb to to a greater extent than appropriate medication too maybe fifty-fifty a pump physical care for if he tin acquire to the doctors inwards Khartoum (in the province of Sudan) who produce complimentary pump surgery.

Tuberculosis is mutual inwards South Sudan too the infirmary at Old Fangak is a major handling centre for people who alive amongst it. Patients who are diagnosed amongst TB take maintain upward residence inwards the TB chemical compound inwards the hamlet where they acquire daily observed handling for the half-dozen months it takes to cure the disease. The chemical compound is an surface area amongst a few buildings, a yoke of latrines too plenty apartment basis for people to campsite piece they acquire their daily tablets. The patients acquire plenty food, a musquito net, a blanket too a dedicated though thinly stretched staff of by too large nationals who assist them to live on piece they acquire better. At hospital a few days after I arrived, a guy who was getting handling for TB came inwards feeling brusk of breath fifty-fifty though he had been on appropriate handling for a few weeks.



The ultrasound of his pump showed some thick materials betwixt the pericardium too the pump which doesn't allow the pump to fill upward properly. He had tuberculous pericarditis which had transitioned to a nasty constrictive effusive mess. He was treated amongst steroids inwards improver to his TB tablets which may trim down the inflammation too allow the pump to part properly. In a perfect basis he would also take maintain the pick of surgical physical care for to take the rind of constricting tissue.

Influenza A virus subtype H5N1 strikingly graceful too beautiful half-dozen yr one-time miss came to hospital amongst her every bit striking mother, troubled amongst breathing problems. She was able to walk long distances, but non fast too got out of breath easily. On examine she had a real loud pump murmur. It is non terribly uncommon to come across congenital pump disease, too I expected that she had a ventricular septal defect (VSD), a hole inwards the wall betwixt the 2 primary chambers of the heart. When I looked amongst the ultrasound I saw cypher at all. Since her pump sounds were a picayune louder on the correct side of her chest, I looked for her pump there. Sure enough, she was turned around. Her liver was on the left, pump on the right. And she did take maintain a VSD.




Jill sent the picayune ultrasound clip to the pump surgeons inwards Khartoum. They may live interested. It would live wonderful for her to take maintain handling at a dedicated pediatric pump surgical physical care for subdivision inwards a major referral infirmary because her pump is actually weird too repairing may non live straightforward. Such a matter costs a lot of money, too she too her woman raise take maintain none.

Influenza A virus subtype H5N1 patient who had fevers too had been inwards the infirmary the previous calendar week amongst them came to the hospital because he hadn't gotten better. He had an fifty-fifty higher fever too abdominal pain. His sparse abdomen clearly had a lump inwards it. Ultrasound showed that it was a fluid filled majority almost the size of a large grapefruit inwards his liver.




The lump was a liver abscess too inwards South Sudan the most mutual crusade of this is an intestinal parasite called Entamoeba histolytica, or ameba for short. He was treated amongst a mutual antibiotic, metronidazole, too was significantly improve the adjacent day. His hurting too his lump persisted, though. We worried that he powerfulness non live improving, but on the 4th 24-hour interval he felt much improve too the lump, which had stayed large all this time, had shrunk to one-half its size. By the fourth dimension I left he was looking similar a normal guy. Small miracles.

An older lady was brought inwards past times her grown daughters because of fever too pain. Tuberculosis most oft presents as a lung infection inwards the US, but inwards Sub-Saharan Africa it is non at all uncommon for it to live primarily inwards other organs, fifty-fifty spread diffusely through the trunk too sparing the lungs. Her ultrasound showed clear lungs, but a collection of juicy lymph nodes close her aorta.

These would live probable to stand upward for lymphoma inwards the US, but she in all likelihood has TB. Her miss too then pointed out that her leg was swollen. My minute generation Vscan ultrasound has a transducer that tin aspect at structures such as veins, too she had a large clot inwards the correct leg, upward to the groin. The primal circular construction has some grayish cloth inwards it too doesn't collapse when I push, indicating that it is filled amongst clot.

Influenza A virus subtype H5N1 blood clot inwards the leg oft suggests malignancy, too she may take maintain cancer rather than TB, but TB tin live associated amongst blood clots too! It was possible to club inwards a shipment of anticoagulant injections for her, too it was in that location within a few days, so she may live able to resolve the clot. She volition non acquire lifelong blood thinners as she would inwards the USA because it's simply non practical. If she has TB, effective handling may take maintain attention of her risk. If she has lymphoma her prognosis is non good.


There are rotating doctors through MSF who staff an emergency room, available to care for patients whose problems can't hold off for hospital hours. Sometimes they would enquire me to produce an ultrasound when the diagnosis was a mystery. Influenza A virus subtype H5N1 teenage man child came inwards amongst the feeling that he couldn't urinate. He had had problem amongst his bladder off too on for the previous year. When he had blood inwards his urine he was dosed amongst praziquantel, the anti-parasitic medication that treats schistosomiasis. Schistosomiasis is caused past times a tiny organism that lives inwards bodies of fresh water, including the Zaraf River, too most of our patients take maintain been infected past times it. Influenza A virus subtype H5N1 unmarried dose of praziquantel rids the trunk of the parasite, which tin infect the bladder too crusade inflammation too scarring. He had persistent irritation when he urinated so had too then been treated for a criterion bladder infection amongst antibiotics. He may take maintain improved but his symptoms brought him dorsum to the ER. He was miserable.

His ultrasound showed a circular object that made a shadow correct inwards the middle of his bladder. I've seen patients amongst bladder stones before, but they were ever older men amongst large prostates or chronic urinary catheters. It turns out that bladder stones are non uncommon inwards the torrid zone inwards boys. I disclose cypher inwards the far reaching tubes of the internet that explains why, though a 1961 article suggests that in that location may live some nutritional constituent involved. The surgeon rotating through MSF had seen the status earlier too did a pocket-size performance to take the stone. The man child was real pleased too showed me the gnarly egg sized matter on flush rounds.
There were other stories, medical too otherwise, too to a greater extent than ultrasounds. Pointing an ultrasound at patients amongst diverse illnesses taught me things I couldn't larn from reading. I mean value I infected some of the other doctors too clinicians amongst the urge to aspect within amongst ultrasound, too the to a greater extent than they produce the improve they volition get. Once again, it was a privilege to piece of job amongst Jill too her dedicated staff too the other swain travelers who swoop inwards too out similar I do, trying to brand a difference.




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