How To Die In Sudan

Or no, actually, let’s go there.

Secondary to his renal failure, my gramps has had to have an indwelling urinary catheter to be kept forever. Urinary catheters are known to cause recurrent infections, and indeed he had been running a fever and getting more and drowsier for a few days, and we came to the hospital last Tuesday night with a full-blown urinary tract infection, which was so bad he was draining frank pus instead of urine. Admitted through the emergency room, we were kept in the emergency wards which are meant to keep patients for the first 24-48 hours of their stay, after which they are either discharged or admitted into the hospital itself. From the first minute of our admission, the only 2 questions we were asked over and over again were: which doctor saw him last time (because that would be the doctor to whose unit he will be assigned to), and what is his military rank? My uncle was in the army and died in the war with the South in 1996, after which he was awarded the second highest rank in the military. Being a military hospital, patients are assigned to wards according to their ranks; lower ranking officers are not allowed near higher ranking officers’ privileges. Since there was no room available for his rank, we were kept in the general men’s ward, where for the first night I slept sitting up at the end of the bed, and the second 2 nights I slept on a mat on the floor. There was no bathroom in the ward so I had to change and bath him on the bed and go upstairs to the female staff’s rest room to take care of myself. 3 nights later we were informed at midnight that a room was empty, and I went up to see it. There was already another male patient in the room with his sons. I told the nurse that we were 2 women staying with him and could not share a room with 3 men. She told me that I could take it or leave it, and naturally I left it, miraculously avoiding punching her impudent face in. No one cared about when his last meal was. No one bother to check that his medications were entered correctly. I don’t even know who entered the medications in the first place, and wonder if that person was even remotely related to the medical profession. We were in a constant war with the security because only one attendant was allowed to stay with him, when it took 3 people to lift him for bathing and changing. As for his medical treatment, it was a disaster. In a nut shell, the following potentially fatal mistakes were made:

1.       Full dose IV antibiotics were prescribed despite his renal failure (half dosing is required so as not to kill what remaining kidney is left)

2.       Oral iron prescribed despite his peptic ulcer (iron is very irritating for the stomach and large doses can cause bleeding and ulceration even without a pre-existing ulcer)

3.       Calcium prescribed once daily (should be given 3 times a day)

4.       No fluid charting: this was probably the worst issue, since he was a) very sick and strict fluid control is need to maintain hydration of the cells without overloading, and b) he is already in renal failure and can very easily overload anyway

I kept my own careful charting of his input, and on requesting the nurse to please empty the urine bag, I was informed that I was the one who would be doing so. How? Don’t know, don’t care. There was a basin of some sort shared between all the wards that I would have to go around looking for, and in which I would empty the urine bag, and then carry the basin full of urine to the men’s toilet and flush it down. He was drowsy and very difficult to wake up to feed, and even when awake he would sometimes keep things in his mouth and fall right back asleep again and could choke on them. A nasogastric tube was advised to be inserted, and a couple of young doctors showed up at 3 in the morning to insert it. I requested that it be postponed a few hours since he had just been fed and had fallen asleep, and they left, never to return again. The whole following day I went through the exhausting procedure of lifting the bed, propping up on pillows, padding his face with wet cotton, shaking, tickling and calling, in a futile attempt to wake up him, and then feeding half spoonfuls of fluids over hours, all the time worried sick about him choking and aspirating the food. On questioning the nurses about the tube insertion, I was informed that only doctors are allowed to insert tubes, and so we would have to wait until someone was kind enough to show up. They did eventually show up: 3 different teams of doctors, all passed by, but not to check up on their patient and complete their treatment plans, but only to inform me that it will not be their team that will take care of him, because someone else’s name was written on the card. But that someone else had not seen him last time, he had only supervised the dialysis. Don’t care, it’s not us, or the other people, or the third team. So who in God’s name is taking care of him then? Don’t know, don’t care.

Basically, if I, as a medical doctor and able bodied person, had not been by my gramps’ side, he would have died in the first 24 hours of his admission for one of a number of causes: fluid overload, renal failure, aspiration, ruptured gastric ulcer, or simple starvation. On the third day after we complained to the higher authorities, and my one of my late uncle’s friends who had come back alive from the war continuously harassed the hospital director, one of the teams reluctantly agreed to take over his care. Only then was a feeding tube inserted and his medications corrected and his fluid intake and output charted. At 1:30 am we were woken up by the sight of around 10 doctors with their consultant coming to do their rounds, and on the 4^th day we were finally moved to a proper room with a bathroom and a second bed. Better late than never.

I wish that was the end of it, but it wasn’t.

Due to the prolonged lying down and lack of a feeding tube, my gramps then developed aspiration pneumonia, which is a chest infection caused by choking and breathing in particles of fluid and food; a particularly nasty form of pneumonia and one that plagues elderly and bedridden people. I went to work on Sunday morning but was informed on the phone that he was breathing with much difficulty and had been making all sorts of sounds all night and morning. A doctor was called for several times, but showed up only once and advised physiotherapy and nothing else. At one point the nurses hooked him onto a an oxygen mask, but that was it. It took me over an hour to wrap up some things, get in my car and drive all the way from one side of Khartoum to Omdurman, and all this time not a single doctor showed up. By the time I got there he was in severe distress and getting more and more exhausted by the minute. I asked for the doctor, any stupid doctor, and was informed that the team was on their way. What about the on-call? Unreachable at God knows where. I started a nebulizer but that was all the nurses would do for me; it had to be their own doctors who would order the medication. Lucky for them, the team finally trudged in at 2 in the afternoon. They cruised into the room, asked their regular questions, auscultated his chest, and announced the obvious diagnosis of a chest infection that would need antibiotics. They very kindly asked the chest physician to please come and see the patient right now, at which point an equally young looking doctor came and again announced the obvious diagnosis of a chest infection. After much discussion, we (meaning I) put the first proper plan for management; including a select of antibiotics, regular steroids and nebulisers, regular suction, chest physiotherapy, positioning, and controlled fluid management. So again, if I had not been around, and had experience in managing critically ill patients, my grandfather would have died of any number of reasons: suffocation, overwhelming chest infection, simple respiratory exhaustion, or a cardiac arrest that would have whisked him away to the land of no return where he would be forever at rest and away from the torture of this system.

This post is not a nag about how bad our healthcare is and that we should all leave because we hate it so much. It’s a note that there is so much more to be done. The military hospital is very clean and very well equipped. The problem is that the people working here are the same people working everywhere else in the country: people who may care about patients and may have some knowledge about how to take care of them, but for some obscure reason do not portray this care or knowledge. The attitude they carry around is one that I can never understand. My gramps is doing dramatically better al7amdulillah, but I shudder to think where he would be right now if he was like most other patients who do not have the luxury of a medical doctor as an attendant. However, we still have 2 or 3 days more to go in this hell, and one can only hope that we are left alone and leave through the front doors on our feet and not in a body bag.