Storm clouds and CT scans (and some food puns to chew over)

My Friday evening this week was spent in a seminar room in a Khartoum hospital, sheltering from the thunder and lightening outside, and listening to a presentation on radiology and orthopaedics.

These first few roasting weeks have sometimes left me looking like a tender young lobster who has fallen into some strawberry ice cream (so yes indeed, exotic AND delicious). Even though I’ve now become a little more used to the heat and the glare, such a dramatic change in the weather was quite fun. Huge storm clouds blocked out the sun, lightening stretched from horizon to horizon, rumbling thunder drowned out the traffic. On the road towards the university, wind whipped up dust to fill the air (plus eyes, ears, nose and mouth), and just a few rain drops fell.

So instead of spending the evening being fried and battered (by lightening, wind and sand), we (the three other international elective students and me) sped off to a hospital to learn about bones on a radiological plate. The lecture was delivered (in English) by a Sudanese radiologist recently returned from working in Britain. It explored ways in which radiology can aid orthopaedic surgery, focusing on knee and back problems. I’m including the event in this blog just because it was interesting just how little seems to change between medical contexts. Indeed, in many ways the session was identical to every clinical meeting I have attended in the UK (although there were a few differences).   

The audience was arranged around a conference table, with the presentation projected onto the wall at the far end of the room, just as it might be in the UK. The senior professors and consultants, dressed in white jellabiyah (ankle length gown) and imma (turban) were sat around the table, with the juniors spread out behind on both sides.   The presentation itself (on powerpoint of course) was about an hour long, during which the row of turbans in front of me bobbed and shook at significant points (just as the front-row of heads do in the UK).

Afterwards came the questions. It seems that senior clinicians throughout the world develop their own tried and trusted habits, techniques and theories – their own ‘flavours’. ‘Question-time’ is a chance to share these favourite flavours, to give everyone a good long taste. And, just as in the UK, there is always some culinary disagreement, leading to more bobbing or shaking and a second round of tasting. The dessert, after all that, was two presentations from the pharmaceutical companies sponsoring the event.

There were also some interesting observations about the way in which the Sudanese health system is fragmented. There are a large number of different hospitals in Khartoum alone, some public (state-subsidised), some private, some general and others specialising. This has many effects; it results for example in a large number of referrals between hospitals, with little continuity of care and no central patient data system. It also means that for disciplines such as radiology, where large and expensive equipment is involved, very few centres are large enough to afford such equipment, or will use it often enough to make it cost-effective.

I believe that health financing in Sudan is largely private, with patients at both private and public hospitals bearing most of the costs of their care. Health insurance companies and state health insurance also play a growing role. International organisations and mechanisms also support specific vertical programmes or local health facilities, such as the detection and treatment of tuberculosis or leishmaniasis. The balance between patients and profits is often a controversial one in health systems, and I suspect that a study of health financing in Sudan would make for some interesting reading (if anyone knows of any then please get in touch!).

So altogether, a stormy appetiser, some tasty morsels and plenty of food for thought!

Pete

Leishmaniasis galore!

My placement at Soba Hospital hasn’t really settled into any kind of rhythm as yet. Its all a little bit haphazard. I’ve spent quite a number of hours just waiting around, wondering if I’m in the right place. In some ways thats reassuringly familiar – its a major educational dimension of just about every placement I’ve had in London too ! But its also rather familiarly frustrating.

So I’ve started taking a little more initiative, and have been creeping (walking) around the hospital, lurking (waiting) in the places where I know my team of doctors might be – the outpatients referral clinic, the male medical wards, procedure rooms and so on – and then jumping out (standing up) and asking if I can join them.

Through this subtle method, I’ve found out the times and specialties of the clinics each morning, and I’ve seen some very interesting patients.

For example I caught the last three patients in the chest clinic today. The first man had pulmonary TB (in the lungs), with bilateral pleural effusions (water in the lungs). The second was a young man with congestive cardiac failure (a bad heart), with a very clear textbook pansystolic murmur (his heartbeat sounded wrong).The final patient was a young lady in her 70s, who had disseminated TB, including pulmonary, lymphadenitis (Scrofula or TB in the lymph nodes of the neck), Pott’s Disease (TB in the spine) and a TB psoas abscess (an abscess in one of the muscles of the leg). All of this can (and would) be treated, although I’m not sure of the prognosis. (Photo of TB Lymphadenitis below taken with permission of patient)

On Mondays and Thursdays I go the Omdurman Hospital for Tropical Diseases, a 20 minute bus journey across the Nile from Khartoum.

Again, each morning starts gently with some stretching and yawning in the consultation room for an hour or so. But when the consultant arrives, its a fantastic learning experience. I think I probably saw more tropical medicine in my first clinic there, than most UK physicians get to see in their whole careers, and after each patient we discuss the case with the doctor.

From a 17 year old boy, with portal hypertension (high blood pressure in the liver’s blood vessels) from chronic schistosomiasis, through patients with TB, malaria, leprosy, suspected HIV, tertiary syphilis, others with schistosomiasis, to three patients with Cutaneous Leishmaniasis. This disease is endemic in parts of Sudan (as is Visceral Leishmaniasis). One of these patients has a typical history. He is a soldier in his 40s, in the Sudanese army, and has been stationed in the south of Sudan (in South Kordofan State). He has three circular, raised, painless lesions on his arm, the largest is around 5×6 cm, with a dry, ulcerated centre. These are caused by the body’s reaction to infection with a species of Leishmania parasite, which is transmitted via the bites of sandflies. If left untreated, they may resolve themselves, but (depending on the species) may also spread further, or cause Mucocutaneous Leishmaniasis (involving the linings of the nose and mouth) (which is worth avoiding). I think there is a multinationally-sponsored programme for Leishmaniasis in Sudan, and so he will be put into this and recieve for free the treatment of Sodium Stibogluconate (Pentostam). Whilst it may be good in the long run, it has to be administered via painful injections (the drug has local toxic effects) – so this man has some tough days ahead.

For me, tomorrow holds a gastroenterology clinc, so lets see what that throws up (sorry for the pun!).

Pete