So from all the jollity of weddings etc. to Kafka meets Monty Python. There are currently three of us and one down the road but now after a meeting and the usual coming to no particular conclusion (very similar to the NHS here) and we all sit in one tiny consulting area seeing patients in a totally chaotic environment as they get filtered and sent on. I wish I had my copy of ‘Bluff your way in ultra-sound’ as most of the punters are dating scans and I am not sure where the on off button is (Brenda come back all is forgiven) but the others are all to keen and Karen keen to learn, so I try to look knowingly in the back ground. It is not however at all clear to me what happens when they leave the room or if they ever come back, but there are an awful lot of breeches about and no very good plan as to what happens to them though I try to give them plans-perhaps I will find myself doing some breech deliveries. The other houseman game I have had to be playing is screening patients for the ‘prolapse team’ due to arrive in a fanfare of American ‘second coming trumpets, though there is a lot of discussion about where they are going to stay-one thing is sure not here. Most prolapses and they are big but with tiny atrophic uteri in them are quite impressive and largely described as polypoid growths that extend out so far that it must be difficult to walk. Human ingenuity being what it is though they have invented all sorts of things to hold them up, plastic rulers and the like. If anyone wants to send me out some shelf pessaries they would be a great help. My first laparotomy was a pelvic mass 4 months post Caesarean, which we should probably in this environment draw a veil over but suffice to say it would be an SUI elsewhere of the x ray identifiable variety, however happily no harm done. Sitting in out patients a women presented herself with bleeding in the late midtrimester, but nu apparent pregnancy on the scan-at which time she told us the baby was in the loo-where we discovered him still alive. Now 4 days on we still have primitive intensive care with hot water bottles, an oxygen intensifier and thanks to the internet and Paul Crawshaw a feeding regimen. The mother has now produced some breast milk and an interest (previously missing) so there is still some hope but a long way to go. I have done my first, wearying, night on call in which I was called to a baby with a temperature, God knows why but good tone and lively-cracked and treated with ampicillin and seems better (even managed to work out the dose). Then had to deal with my first multip OP a failed Kiwi cup which is not something I know about then failed manual rotation and forceps-strangely shaped with a solid blade- and finally a Caesarean section at 3 am and all well despite spectacularly suturing the front wall to the back and leaving the non existent lower segment, actually cervix floating in the breeze, but discovered what I had done and rectified the situation so no harm done except to my pride! I put it down to the appalling light but in reality I think it more related to my relative out of practice state. Later further section for failure to progress in previous C.S but happily head high. Knackered I go to bed for the morning but am kept awake by God calling up the hill. I fear that I was taking Mohammed’s name in vain. The endless unintelligible and untuneful dirge that rises from the valley is actually something to do with the orthodox church-3 am today which is pushing it more than a bit however I am told it is much worse on saints days of which there are many so can only go down hill. Out- patient clinics of which there seems to be a continuous stream vary endlessly from dysfunctional bleeding, post- menopausal problems to ante natal care and just now stage 3b Ca cervix with a hydro- nephrosis. There is only one radiotherapy machine in Addis with a 6 month waiting list and quite a lot of money to have treatment which they cannot afford so situation pretty hopeless. How much of this they take in, who knows and they drift out of the consulting room probably never to be seen again. Back on call I do a tubal ligation one hour after delivery under local and she goes home a few hours later. She is the oldest at 30. Both caesars had steris and they are only 25 but that I believe is quite old in these parts.
Our up market mud hut (it is apparently made of mud) is becoming home and we have visitors, not least thieving hooligan monkeys one of whom nipped in and stole two bananas and then I found his head peering round the door looking for more and we have also had a film night with pizza and popcorn.
So what are our reflections. The baby has been particularly taxing as it has been difficult to get the Ethiopian nurses to take an interest and we cannot sustain 24 hour nursing ourselves and if we are to try and do something it does have to be sustainable, but now they seem to be taking more interest but are also slightly resentful of being watched. There is clearly a need for low tech small baby care but equally a long way to go and there are real issues about the sustainability of such interventions but it is difficult to watch babies die of dehydration and cold. There are many, largely poorly trained, pupil midwives about whose role is to stand and stare but it would be difficult but rewarding to put them to use caring for these young. There is a long way to go and no easy answers. There is also an underlying feeling that despite the poverty and general grubbiness there is no desire or will to change and the various NGO s achieve relatively little as they are frustrated at every turn and that much of the valuable asset is wasted. Certainly the breakfast conversations I eavesdropped on in the hotel in Addis which seemed to be a meeting place for querulous visiting charity representatives and prosperous looking local representatives needs assessment and scoping with very little doing or delivery and there is scant evidence that I have seen that aid gets where it is needed, but early days. The other issue, local visitors aside is aid tourism as the effort, costs and time involved in getting out here has to be worthwhile in terms of what can be achieved and has to be useful to the population rather than an adventure for you – yes of course it is rewarding to resolve difficult situations and you will learn much of how you can cope with really very little but the only value to the community of coming is to leave skills behind and that is where the real difficulty lies as imparting skills and knowledge is very difficult in these circumstances and to a group that I suspect feel that what they are up to is fine and are resentful of interference and people telling them that they could do it better (which manifestly they could) and deep down it is the way it is and cannot be changed.
Thus I do have mixed feelings about prolapse teams swinging in to do lots of operations and fistula tourists all of whom are coming in to hone their own skills rather than leave a cadre of people behind who can both deal with these problems but more importantly stop them happening in the first place by better obstetric care and reduced family size.

To be continued……….