Extreme Challenges, Multiple Sites
The provision of health care to support 900 personnel across 32 different sites in post-conflict Sudan required the medical teams involved to overcome extreme challenges. Successful delivery required fresh thinking on how to deliver best-practice support. Medical Director EMEA at FrontierMEDEX, Dr Phil Sharples reports.
Sudan is an inhospitable place. For the most part it's a desert, plagued by sandstorms. Bitterly cold winters follow scorching summers. There is little more than 12,000 km of highway, less than half of which is paved, no small problem for any organization attempting to establish itself here.
In 2006, while the country was still troubled by political unrest and violence, FrontierMEDEX (then operating as Frontier Medical) was appointed to provide medical support for 900 personnel. Its medics would be staying in camps which were the regional bases of the peace-keeping force provided by the African Union, in a project that was to last three years. Thirty-eight medics were employed to deliver both emergency and primary medical care. Most worked alone across individual locations. There was an additional medic in the support clinic in Nyala, the capital of South Darfur and a doctor manager in Al Fashir, the capital of North Darfur.
Medics worked on three-month rotations, not particularly long stints in the world of remote medicine, but long enough given the difficulties and particularly the isolation they faced. Many camps had no internet connection. Communication by satellite phone was sporadic and the mobile phone service largely inaccessible.
This lack of a reliable link to the outside world created additional pressure for professionals working alone in the field. It meant uncertainty in being able to access a Topside team if necessary and an additional factor to consider in mobilizing a medevac. As a result medics needed to work in an anticipatory mode, thinking sometimes as much as 12 hours ahead, acting on worst case scenarios long before they happened, to ensure they would be fully prepared and their patient communities 100% safe.
Poor communication also exacerbated the task of maintaining a regular supply of quality medicines, first into the country and then on and out by helicopter to the individual camps. In the end, these were sourced from Dubai under a UN contract.
The project came with its own particular medical challenges. On a day-to-day basis, most health issues revolved around managing the diseases of aging. The medics were tasked to support a largely unscreened population and needed to provide chronic medical disease management, dealing with acute medial mishaps such as heart attacks. However, there were other equally pressing and some unexpected challenges to break up their day.
For the teams working in the Darfur region, the impact of poor sanitation and overcrowding on the spread of disease were key concerns. The first medics were threatened by a serious cholera outbreak within just a few months of arrival. This presented a significant health risk because many of the local population were entering and leaving the compound daily. With the help of Topside Support, the team was able to implement very quickly the systems and protocols to prevent the possible spread of the disease. As a result of good management, contingency planning and team work, there was not one case of cholera.
The risk from most indigenous animals such as snakes, scorpions and mosquitoes across Africa is well-documented, but the medical teams on the Sudan project were to discover a less well-known culprit.
They were alerted by the number of patients presenting with what appeared to be symptoms of severe sunburn. Their symptoms were redness, peeling skin, blisters and other lesions - frequently leaving pigmented scars that lasted for some months. Consultation with the Topside team revealed that, although the lesions were a type of burn, the source was more earthly than solar. It was caused by Pederin, a toxic amide, an acid-like substance, particular to a species of the Paederus or 'Rove' beetle. Found in Africa, Asia and South America and more colloquially known as the 'Acid Ant' or 'Champion Beetle', it's the female of the species that manufactures Pederin. Although otherwise harmless, she will leave her mark and something to remember her by if unnecessarily crushed. The medics were able to alert and educate their patient community, introducing measures to minimize incidents.
Another challenge both in terms of the medical response as well as individual stress was the ongoing fighting between rebel factions. Sometimes this involved the African Union forces within the camps and inevitably crossed into the medics' day-to-day working lives. In Darfur, fighting between factions was an everyday occurrence, putting a particular kind of pressure on the team working here. After their arrival, the stability of the region regressed to a point where shootings in the marketplace become common practice. Medics working near to the Chadian border lived with a background of heavy gunfire from nearby villages and faced attacks on their camps, one eventually overrun by militia.
Despite being briefed not to get involved and to maintain as much independence as possible, it is probably too much to expect that a medical professional working in an area of conflict will draw a clean line between the job they are doing and the problems around them. It's important to understand that your medics will always step in to help in an emergency and you need to prepare for it and manage it. As a result, the medics provided pro-active and preventative support to the African Union medical teams co-located in their camps. They worked together to create joint plans for mass casualties and catastrophes, responding jointly when things went wrong and providing support in case management.
Working in isolation
Among all the very significant medical challenges, by far the biggest issue to overcome in terms of successful delivery of the project was the isolation, both in terms of its effect on morale and the possible impact on quality management.
Up front was the need to recruit a team who would be best-suited to working independently with this level of isolation, with the aptitude and skills needed for this type of medical provision. The recruitment processes a defined core set of skills that applicants needed to satisfy, both the required medical skills as well as the ability to deliver the necessary standard of care without the usual support structures and away from the context of their normal environment.
For this project, where medics were required to work without even the normal contact provided by regular phone and email, the operational teams decided on an African solution. They recruited from among candidates who, because of the very nature of their African health service, were most used to remoteness and isolation in their work. It proved very effective. Having identified the candidates, the medical teams then set up a training centre in Harare, working with local providers of emergency medical services to deliver pre-deployment training. Every medic recruited was brought fully up-to-date in the latest approaches to pre-hospital care, in particular cardiac and trauma management. Each was taught the procedures and protocols to co-ordinate an effective medevac.
Quality in adversity
Another issue was to build team spirit, which was initially achieved by providing group training sessions for all medics at the beginning of each rotation. The arrival of ten medics every month created an opportunity to bring them together and deliver refresher training, where protocols were reviewed, concerns tackled and skills updated.
Equally important were the systems devised by the in-country doctor which served both to keep the teams connected, but also and perhaps even more importantly, provided a vehicle for maintaining and enhancing their skills.
A Continuing Medical Education Program was developed, based on stringent remote medical guidelines. Papers were distributed regularly to the team in the field. They were encouraged to read around the proposed subject before completing their responses. Every medic then received personal support and feedback. Medics also kept clinical records and as part of an appraisal process, received a regular audit of their documentation and notes, again ensuring best practice and helping the teams remain clinically engaged.
Driver for change
Both the scale and the complexity of the Sudan project made it quite exceptional in the field of remote medicine. It gave both the operational teams and the medics an appreciation for working in an extremely hostile and difficult environment. Not surprisingly, the experience was a driver for positive change, with some of the techniques implemented to maintain quality in an isolated work force now part of everyday practice for FrontierMEDEX health professionals, wherever they are based in the field. Isolation and political unrest are a combination that will always throw up the unexpected, but today they are challenges that the teams are better equipped to take in their stride.