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A Day In The Life
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Catherine Hoelzer, MPH, PA-C
The author works with Christian Mission Aid in the upper Nile region of southern Sudan. She has indicated no relationships to disclose relating to the content of this article.
6:30 am
The sun is blazing and the sky is clear. It’s going to be a hot day here where I work with an NGO called Christian Mission Aid (CMA) in the upper Nile region of southern Sudan. It has suffered from the longest running civil war in African history, which just came to an end in January 2005. War continues to plague the nation of Sudan in Darfur, but here in the southeastern region of southern Sudan, the main troubles are interclan conflicts and militias in the south being armed by the northern government to disrupt the peace process.
We work in four regions providing health care and other services to underserved and difficult-to-access communities. We employ locally trained Sudanese community health workers (CHWs) and nurses to work in the primary health care clinics. My husband and I joined CMA as missionaries, and we love our work. Although I also loved working in the states as a PA, mainly in internal medicine and urgent care, I knew I would eventually use my knowledge and training to serve in developing nations, especially in regions that have suffered from war and disaster. In the past I have worked in other war-torn countries, such as Northern Iraq, Bosnia, Afghanistan, and Chad, and I have always enjoyed being able to help those who have so little.
9:00 am
This morning, I’m supervising the CHWs in the maternal child health clinic. The majority of the patients we see in the first hour are children with watery diarrhea—not uncommon in a region where there are only one or two wells. Much of the population gets its water directly from the swamp that surrounds the region we work in.
10:00 am
A young mother brings in her 1-year-old child with complaints of bumps on his head that won’t go away. Her husband has been buying penicillin from the local “healer,” and when the child gets the injections, he does a bit better. He has two fairly large, hard, cystic-type lesions at the base of his left mastoid and multiple smaller, boggy, crusted lesions on the top of his head. The CHW confers with me, as he is not quite sure how to diagnose this child’s illness. I have seen these lesions before. The ones on top of the head are usually caused by poor hygiene or mosquito bites that become secondarily infected. I’m a bit more concerned about the other two cystic lesions, as they may be TB adenitis, which is common here. I tell our CHW to please have the mother come back if the lesions have not resolved after the child finishes the course of penicillin. We might have to refer the child to the County Hospital in Old Fangak, which is a 2-day journey by foot, as we have no roads here and no vehicles.
11:00 am
A nurse wants me to see a 3-week-old child whom she suspects is having febrile convulsions from neonatal sepsis. When I get to the ward, I notice that the child looks more like he is in spasm than in convulsions. I ask the mother if she has ever been immunized against tetanus. She has not, so I next ask if she gave birth alone or with the assistance of a trained traditional birth attendant. She gave birth alone and cut the umbilical cord with some grass. Now I’m quite sure the child has neonatal tetanus and realize we must get an IV in him and begin all the proper medications. We must also try to keep the child in a quiet environment. All of this is very difficult when you have several family members in the one-room ward, chickens and dogs running in and out, and other children laughing and crying. I try to explain to our CHWs that we have to get this room quiet somehow. As I walk away, I hear the noise in the room begin to grow. I pray that God will put His hand on that child and heal him. This is often the only hope we have.
12:00 noon
A mother tells us that her child has been coughing for 2 months. She came to the clinic last month and was given some amoxicillin for a respiratory tract infection. However, as the child has been waiting to be seen I have not observed him coughing at all. As we get the history from the mother, we learn that the child’s illness first started off as a common cold and then about 2 weeks later he started having bouts of coughing that would end with vomiting. When I find out that the child has never been immunized, I realize he is suffering from whooping cough. The treatment for this is erythromycin, which is effective only when the child is in the catarrhal phase. I prescribe the medication anyway because it can also help decrease the spread of the disease. This is important in a region where so few have been vaccinated.
12:45 pm
We have finished seeing patients, and now it is time for lunch, but I’m called to the inpatient department to evaluate a difficult case. A man brought in from a village 2 hours away is in severe respiratory distress. He has a history of asthma and now is in status asthmaticus. He was put on an IV drip and given hydrocortisone, aminophylline, and salbutamol. We don’t have oxygen or nebulizers here, so this is all we can provide. When I see him, he is sitting tripod, cannot speak, and is coughing up large mucous plugs with much difficulty. I advise that we give some adrenaline if he doesn’t improve. As I leave, I think of all the equipment I used to have available to me when I worked in the States. There is so little here, yet the equipment would be useless because we don’t even have electricity.
4:00 pm
The heat is beginning to subside, and we make rounds in the inpatient wards. I see that our man in status asthmaticus has improved slightly and can now speak a bit. We have a variety of other patients in the ward who are suffering from severe gastroenteritis or hemorrhaging from first-trimester miscarriages. I’m saddened by the number of children who suffer from diseases that could be so easily prevented by simple measures such as immunizations, clean water, and using insecticide-treated bed nets.
5:30 pm
I go back to the children’s ward to check on the child with neonatal tetanus. He’s still in spasm and is getting too much stimuli. I try to encourage the mother again to keep the baby covered and to let him rest. While in the clinic, I’m asked to help with a few of the patients. One is a 7-year-old girl who broke her arm falling out of a tree. She has an open compound fracture that was put back in place by the CHW and then put in a crude splint. The child’s father took his daughter to the traditional healer after she fractured her forearm, and the healer “cut” her, a common practice here. They cut a small incision to release the “bad blood.” Once the blood is let, they put in some traditional herbs to help healing. We try to explain to the father that this type of practice won’t help a fracture and encourage him to bring his children to the clinic first. We cleanse the wounds thoroughly, and we put the girl in a plaster of paris cast and encourage the father to bring his daughter back in the morning. I can only hope that the bones have been put back together well.
7:30 pm
I’m tired and ready to head back to the compound for dinner. As I do, gunshots begin filling the air just outside the compound. I worry that there might be fighting going on over the food that has been dropped by the World Food Program. We have had a large number of soldiers hanging around here this past week. We figure they heard about the food drop and have come to get some for themselves. The residents are powerless against them, and it stirs up quite a bit of anger. I also hope that it is nothing more serious, as southern Sudan is in a precarious time of peace. We are all relieved when we learn that the shots were fired by two drunken soldiers. Even so, we hope that the peace will remain and that southern Sudan will finally begin to develop and prosper.
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