land Cruiser travels

First an apology to some of my readers who have been involved in the events as they unfold, and who have found my words harsh or unjust or both. If I have offended or upset you I am sorry but in my defence I write what I see as I see it and as far as possible without reflection and I do understand that this can be seen as unkind or uncaring but do understand that the cynical detachment with which I write is because I possibly care too much. My partner in life whose considered position is so juxta-opposed to mine does worry about my needlessly giving offence but in my defence I am trying to describe life here, and the multiple agendas that surround it as I see it and I do hope that my distressed readers will see this not as gratuitously insulting but more as a distorting mirror reflecting back a different view than their own both reasonable and deeply held view. No personal insult is usually intended.

Having said that the on-going saga of the land cruiser import is an opportunity for gratuitous insult, and now a week and considerable cost on, an opportunity to vent my spleen. Where to start. We set off with the ‘researching Danes’ who want to produce and study the effect of mobile phone picture messages on health promotion in West Wollega back to Addis in a surprisingly new mini van, where I manage to bag the front seat but am exposed to Ethiopia top 10 for 12 hours as previously described. The lion’s den is as ever welcoming and the beef souflaki at our now usual watering hole the more so. I am introduced to a friend of the hotel proprietor who thinks that he can get the car imported through the Ministry of Health. He arrives, understands, as I subsequently discover, little of what I have said and departs with a fistful of photocopies with a planned trip to the ministry and a call in the evening. Predictably by now neither materialise and a phone call elicits the information that he is preparing a letter and will return at 12.00 next day. Phone call next day mean that he materialises at 4 pm with instructions that I have to be registered, though I have told him that I already am, and import of the car this way means that I am supposed to donate it at the end of the year – not something that is on. Internet news flash tells me that the car has now arrived in Djibouti and we elect to fly there immediately, ditching Sophie with a ticket to follow. This turns out not to be entirely sensible as we fly in on Thursday pm to discover, Djibouti following Allah that most of Friday and Saturday are devoted to local deities and offices closed. Our non-responsive guide, (she who puts the telephone down when she can not cope) spends a lot of time and non responsive telephone calls doing bureaucratic jumps about non negotiable way bills and bills of lading and takes away our pristine carnet. (This is subsequently returned a rather battered relic with staples missing but happily still seems to pass muster.) A period of total inanition and probably prayers follow and we collect Sophie from the airport, who has only been given a transit visa in Ethiopia and has trouble getting a visa at Djibouti as she does not know where she is staying. The hotel offered by the import agency, dark dank and unwelcoming with a Miss Haversham flavour about it has been declared unfit by Karen so we are off to luxury (at a luxurious price – Djibouti is the Switzerland of the horn of Africa) hotel family room. Enormous double bed for us and camp for Sophie and plan, though nothing is planned in Africa, our next move which turns out to be accompanying our guide to the shipping office being lead through the streets by a large malodorous pink galleon in Edna Everidge glasses where the appropriate forms despite her misgivings are all signed. Progress but predictably enough not until next day when after hassle getting insurance (3 months Djiboutian Insurance for 18 hours needs to be negotiated down and ‘international insurance arranged). Then off to the port where a cracking of seals, payment of the appropriate bribe and the opening of the door of the container reveals an unscathed land Cruiser that stars first pull having first set off the alarm. A few stamps later and we are on our way back to the hotel though getting comprehensively lost on route (this is going to become a recurrent theme as sign posting is not an African habit). The other problem that raised its head about now was getting a visa for Sophie as she had been given a transit visa at Bole airport and it was by no means certain that she would get a tourist visa at the border so a trip to the Ethiopian Embassy was in order and, as we were playing the tourist card, remarkably helpful, though with of course two trips – but remarkably in the day – a first for our dealing with the democratic Republic’s bureaucratic machine.
To diverge momentarily the hotel is a resting place for highly testosterone charged navy seals and other protection people who are on the high seas blowing pirates out of the water and generally trying to keep Somalia down so it is quite amusing watching Sophie and Karen being followed by lustful eyes as they swim in the bathwater warm pool. The showers actually produce water too though interestingly one morning there was no cold water at all-steaming loos!
An interesting interlude before we set off through the desert (sand, camels, rocks, hunter gatherers with little tents and no water) and the appalling discovery that despite my spending money in England – no air conditioning, boiling cheese in the fridge and generalised sweaty discomfort. It is understandable that there is not a car in sight but long lines of enormous lorries with trailers, inching their way up the hills and requiring you to overtake in ways that would have you returning to the test centre in more western climes. We are greeted very civilly by a man in a sarong and taken to a windowless hut with a desk that is concreted to the floor and whose post has two pairs of handcuffs attached to it. Its function becomes apparent as we finish as customs officer (though difficult to spot, sarong tee shirt etc. frog-marches some young smuggler (or illegal immigrant) in, waving a cocked pistol about in our (or more accurately Sophie’s direction) and puts the hand cuffs to use. The young man looks a little distressed and the companions are shouting. We are rather alarmingly asked to accompany the pistol waver who pauses to throw some stones at his interlocutors, only just missing us and who cheerfully stamps our papers (it turns out in the wrong place) and happily waves us off to cross back into Ethiopia.
The Ethiopian side is more formal but no less friendly, apart from pointing out inaccurate Djiboutian paper work on the Carnet which may cause trouble in the future, and only giving us a month which is when our visas expire, and despite the dire warnings we are through…surprisingly relatively painless.
Not so the drive as we battle past centipede like lorries in the boiling heat, passing herds of cattle and people trying not to be there (apparently you are not supposed to live in the national park but many do) in little tents-real hunter gatherer and camel herder stuff. Fifteen hours later we get comprehensively lost in Addis and arrive at our hotel and guess what the ‘Greek Club’. It is bad news to go there late as a little subsequent intestinal hurry testifies to. An amusing interlude on the journey was Sophie stopping on the Ethiopian side to buy a drink and speaking in French. Initially a positive result as she asked for a boisson, yes said the man and led her down the road past several likely looking fridges to a small shop that produced a tin of Tuna. Boisson not Poisson you tit!

As a life long non cola drinker I am finding cold cola the drink of choice (full fat) as it is ideal for long car journeys, giving you a sugar load, a caffeine jolt and a little fluid, I may end up living on the stuff, particularly when I am on my increasingly arduous on call.

Another marathon journey next day as we return to Gimbie, disastrously with a 4 hour dtour that we some how got wrong and the glorious country side turned into a bumpy ride through unsign-posted villages full of mutes with no apparent knowledge of where they were, particularly in relation to where we wanted to get to and the map we had bought appearing to be a work of fiction. Got very tired and grumpy but finally arrived. Employed the usual venal and dishonest hanging around men to help us unload the car, which was not wise as next day some one slipped into the house and stole my watch, case No 4 the bed linen and the hospital glucometer I was mending. Perhaps they were not happy with the price they were paid for portering? Sadly we will have to continue to use worn, see through and bed bug encouraging Ethiopian sheets. The car was absolutely filthy from its travels so I was looking for a hose to clean it with and the ever helpful (and tediously omnipresent) Hunde said he knew some where we could go so off we set down town toward the river where there was amusingly the local car wash. I was ordered out of the car by some under age driver who proceeded to drive the landcruiser into the river, approximately the same colour of the dust on the car where it was set upon by a gang of cleaners who did a tolerable job at a faranj price of course. It all seemed a little muddy but they did manage to drive it out though the front number plate fell off and I had to spend some time finding some washers. One of the windows would not go up afterwards but managed to dry that out and the number plate. All rather worrying at the time (Faranj super car washed away in river etc.) and probably not worth it as we have another balls aching trip back to Addis next week to take Sophie back-jeep bottom here we come! Karen is out visiting the community clinics, not in our beast accompanied by Sophie who is enchanting the local pre-school or probably no-school kids with songs and Karen pushing numbers up by scanning which ups referrals locally and keeps me up at night. We return to something of a political maelstrom as all is not well and this small community stuff is breeding tensions, I am trying to maintain a lofty distance but there are dangers of being sucked in. I am under pain of open testicular biopsy without recourse to analgesia if I reveal all but it will slowly creep out.
Back at the coal face, the usual litany of unmanaged labour, obstruction and dead babies is lightened by the arrival of a young girl with an Hb of 5, positive pregnancy test, no blood donating relatives, and a strangely distended abdomen. No prizes for guessing this one and suggest immediate laparotomy. Go to change and return to find her sitting (if rather wobbly) on the bench outside the O.R (as they now say post prolapse tourists) sans clothes apart from a torn gown, sans drip and sans oxygen which I manage to sort and she does surprisingly well – tough lot these Ethiopians. Left quite a lot of the blood in in the hope that she will absorb it and also it must be said that the sucker was crap. Talking of prolapse tourists I can say that their complication rate is 4% but the abscesses are slowly responding to drainage and anti-biotics.
I have been trying to extend the repertoire of the local gynaecologist and as there is a hell of a lot of cervical cancer here, in thin multiparous women I decided to attempt a Wertheim and teach him how to do it, a side each. I carefully demonstrate my side to him and show him how to dissect the ureter out, a bit of bleeding and suddenly his ureter is in two. There is one well past its use by date ureteric catheter suitable for an elephant and no cystoscope. Catheterising the distal end with the sharp bit proves difficult and causes a perforation at the insertion into the bladder so I end up re-implanting it, well outside my safety bubble but determined not to show it. Pity really as the specimen looks clinically as if we have got the resection margins. So far no leak but early days. I have decided that I am not going to do the glands as my memory is that this is for diagnostic purposes and in these circumstances who cares. However doing re-implantations with strange sutures is not for the faint hearted and I suspect I will have to face the derision of Gordon Williams when (or faintly possibly if) she leaks. I am not sure how I am going to get the ureteric catheter out yet-perhaps I could use an amnihook? If anyone has any suggestions comments please.
Karen’s birthday present included a third chicken, rather passive and named ‘Buttercup,’ though not for long as I found her dead with her nose in a corner this morning – I just hope the cause of death was not catching.
If it was not for my unalloyed good humour I would have to wonder what I am doing here struggling with little resource, hopeless clinical conditions, venal grasping locals and increasingly dysfunctional ex-pats, unresolvable local politics and sadly no watch or decent linen. Another Caesar calls, an induction dipping at 1 cm without any fetal monitoring is not my scene.
To be continued……….

All is not well in West Wollega

All is not well in West Wollega, but more of that anon. An eleven hour mini bus journey, with Karen being bounced on the back seat, giving rise to muscular spasm even now 2 days later, an intermittently vomiting freeloading Ethiopian in the middle seat and me sitting on my own (having played the age and corpulence card) in the front listening to interminable Ethiopian music. (Ethiopian music is not likely to be the way to a future in the West for Ethiopian wanabee pop stars.)
I fear that my days of front seat fascism may be numbered if Karen has her way but I shall fight to the finish, but now we are safely in Addis, which is a different world and our perspective has changed already from thinking it cheap to thinking it expensive. Anyway we are into the endless round of frustrations, incomplete paper work and drives in condemned, smelly and dangerously treadles tired Ladas. We have developed the habit of turning up at Government Offices which for Faraanjis (for that is what we are) are invariably situated out of town where the less well off criminal classes are and beggars abound. You should understand that in this hand out economy criminality is the way of the world and your measure of success is how good you are at it, life is all about scrabbling for the extra Birr.
We went to visit the premier midwifery school in Ethiopia which is related to the Hamlin hospital and does its best to screen people to get the highest quality midwives and works hard to turn out an intelligent thinking product, and equip them to return to their villages and help. It is situated sufficiently far out of Adddis that they are unlikely to get to the flesh pots there, so they have little to do but study. They frequently go on strike as they feel that problem based learning is more difficult than lectures and as their diploma is not worth more than the government one, why should they bother. It would appear that in Ethiopia nobody fails anything which probably explains a lot.
I have a letter from the British Embassy to help (I hope) to get our car in but it was a pdf and as such totally unacceptable to the Ethiopian Authorities, however trying to get the original from the Embassy, with wilful obstruction rudeness and dissembling officialdom is proving at best bloody irritating. However one hopes that their response to letter of complaint will take them as long as it has taken me to get a response from them, and yes the clock is still ticking. Meantime I am missing (the result of momentarily keeping my eye off the ball) a crucial letter to get my immigration status sorted out and Surrey email for staff seems to have gone down grr - the endless frustrations. As I write this some venal agent who might be able to help with the car import is running late in the traffic – it is always thus.
Sorry West Wollega willhave to wait. Thae Academic censor has just read my offering!

Danish pastry

The hospital is now full of Danish visitors, the great and good of Maternity Worldwide Denmark and also, suspiciously some researchers from a University. There is a stakeholder group meeting to which I am invited and it transpires that they are trying, with the help of poorly projected, overcomplicated powerpoint presentations (yes they get everywhere) to persuade the clinics to buy into a project whereby women can contact midwives on mobile phones for advice and receive health promotion texts. This is a big sell following moderate success in Madagascar, a small relatively flat island, with it must be said similarly poor obstetric outcome.
This area of Ethiopia is mountainous, with patchy reception and the most vulnerable would not know which buttons to press even if they could afford a phone, however they will press on regardless. Possibly more important if not the purpose of what I suspect is already funded research would be a decent transport infra-structure to get people to hospital, but the ranger motor cycle ambulances are tied a customs shed in Addis helping fill the coffers of the Ethiopian revenue authorities.
A morning of discussion of mobile phone coverage is more than I can take so I return to my on call….big mistake. Three Caesareans, emergency kiwi cup delivery (tip, if you are reusing a kiwi cup for the nth time and all the sponge rubber has fallen out put a gauze swab in the cup but be careful to make sure you count it. Two babies very flat so getting access to oxygen concentrator and prophylactic sugar as blood sugar monitor still sans battery. Allow American ‘resident’ with prolapse tourists to do two Caesars and a breech extraction-sadly a cord prolapse that has been out for some hours so she cannot do too much harm, though the cervical descent suggests that she will soon be getting a dress and shoes during the next prolapse tourist visit. The baby is left in the room next to the mother in a plastic bag, as she looks on at the asphyxiated babies lying there and little Jabba. It is indeed a heartless place sometimes, correction most of the time. The Caesar baby looks a little tachapnoeic but not much more I can do and Karen had a nasty surprise in the midwives sleeping and kettle room, but to find out what you will need to visit her blog – may be fewer sleeping midwives though. Sadly the very asphyxiated baby of the night before died today. As I am on call I have had to watch others drinking the red wine which was very sad and no film night.
With all this going on Jabba was getting a little hungry so I fed him his 4.30 feed at 5.30 and his 7.30 at 9.30 having re inserted his tube-those little hands are very active.
I spent the night playing paediatricians and the rather flat baby had glucose overnight I hope but both he and jabber were wrapped up together in the cold and wet this morning. Given that mother has relies around her, though she is not looking great post Caesar, I take baby and oxygen concentrating device to family and get them to cuddle baby who is more likely to retain his temperature that way and hope that either breast milk comes or the ‘C’ team who is on today feed him a little sugar water intermittently. I hope I am getting the hang of paediatric dosing.
What oh what have we come to!

Kafka again

Today was pure Kafka with a slight nod to Monty Python. I arrived, contrary to my avoud intent, not wishing to become too African, not to be too late to see Heidi with a patient in knee elbow position and the cord supported and various people trying to put up drips etc. A team was being sort of assembled but the problem was that despite earlier requests the prolapse tourists had simultaneously embarked on hour + cases thus effectively blocking both operating theatres. I can only assume that this was wilful disbelief that their need to provide support to the damaged pelvic floor, dresses, shoes, teaching for their residents or some spurious belief that they were doing ‘good’ rather than having a surgical spree outweighed the need to have some facility for dealing with emergencies, in as much as they can be dealt with successfully in this environment. Helpfully the Ethiopian staff had removed the curtains, we had constructed yesterday and the delivery bed we brought through so once again we were faced with doing emergency surgery, real emergency surgery in a recovery area with out even suction and no such thing as an anaesthetic machine in full view, not to say dust from passing traffic. However with a little bit of asset stripping (the portable suction) from the prolapse people who were I am pleased to say beginning to feel a little uncomfortable, and some ketamine, we were able to bring the patient through, anaesthetise her on her side and finally role her on to her back, only to find a significantly distended bladder and no catheter about. Catheter found insertion proved a little troublesome as there was both a circumcision and a head raising hand to contend with. However successful catheterisation was followed by the delivery of not one but two babies, the first having stuck his arm through the incision and had a rather rough entry into the world. V flat as they say and required quite a lot of chest banging and ambubagging to get going, the suction barely reaching the kid. Thinking paediatrically I though that a blood sugar for this young man might be in order and asked for one. The laboratory staff immediately refused as they did not have a form and then refused to come despite 4 calls. My initial suspicion, probably only partially founded was that they were too busy doing haematocrits for the prolapse tourists, but it appeared that in reality the blood sugar monitor did not work. There appear to be two, a blue one that does work and a white one that does not (made in China they said) and that the lab technician that uses the blue one hides it so that it is not broken when he wants it. The white one incidentally was only not working as the battery had gone and no one had had the wit to replace it but “TIA” I suppose. To be fair it is one of those strange batteries that look like coins and may not be easily available, but that being the case, the institution could order some with a little foresight, but see later, this is in short supply. Anyway we chucked some dextrose at the poor child and apart from being a bit floppy with a high pitched cry seems to be alive. A problem with this resuscitation lark is the paucity of anything dry, let alone warm clothes or even discarded cloth (politically correct speak for rags) to wrap these poor benighted citizens of Ethiopia in. Labour ward was heaving with the now not uncommon group of still births and the poor vomiting Jabba was not getting a look in, and most of his milk seemed to have disappeared, either (for the cynical) into the coffee of the midwives or into the abandoned baby, who spent the day on a shelf in the nursing station looking at a piece of wood. Having said that, the nurses having less to do, ignoring post operative patients is easier than ignoring labouring ones, they make less noise, they do have time to feed him and he seems happy enough in the tee shirt donated to him by Karen. Jabba ain’t doing well, vomiting and all, and I have tried to titrate a little metacloropropamide into his regimen, but with us going away next week his outlook is a little bleak unless he learns to retain his feed and more importantly suck. The Ethiopian view is that we will feed him when we have time and as he is vomiting, and thus, if we can be bothered need cleaning, try to give him less so he does not vomit, does not need cleaning and is less trouble. He is of course failing to gain any weight. Later, I am asked to look at a young girl with the most appallingly pustular and swollen vulva, who has been treated for that common problem vulval TB before seeking a further opinion. I persuaded our local colleague that in the absence of any fluctuant swelling, surgery is inappropriate, but the various (actually only gram) stains are unhelpful. Vaguely remembered originally pointless, but now quite useful, teachings from my time working in the GU medicine department (1974) point to lymphogranuloma venerium or chancroid, and a hasty look at my pocket book of tropical medicine point to chancroid as there seems to be no lymphadenopathy. The distinction is however fairly pointless as the treatment is the same doxycycline with a bit of added cephalosporin, which I start with some metronidazole thrown in for good measure. Before the cognisant of you as , the HIV screen is negative. Hopefully back in a couple of weeks and we will see.

Back at the coal face there is a section for overt disproportion, and greatly daring, some augmentation for failure of head descent for a primip with meconium. This is not perhaps the best idea in the world eventually as suction delivery for fetal distress, as measured by intermittent auscultation produces moribund baby in need of resuscitation. Problem! Pharynx full of meconium and suction cannula not changed from morning baby and midwife reluctant to use it, ambubag lost under pile of rags, but nothing to wrap baby in. Suction foot peddle not working that great either….adult ambubags do not fit that well on babies, but finally find one not put away and another in an obscure cupboard, so finally manage to produce a pink if floppy and destined to be cerebrally irritated infant. Give up on the blood sugar and tip some 40% dextrose into the child. Some oxygen might have been useful but there were initially no nasal delivery systems available. These are washed and used again, like everything else but washed and dried are two different things and the first few minutes were spent trying to blow water out of the tubes rather than down the nasal and other passages of the newly borne. Although Ethiopian colleague does delivery I end up stitching Episiotomy in semi-dark and being very grateful for my headlight. (The recovery room theatre to which we have been banished by the needs of the prolapse tourists is devoid of directional light.)

Nanny used to say, always have the right thing in the right place at the right time and this seems to be the total and abject failure of the dark continent to realise. There does not seem to be an ability to think or plan ahead, to replace after use or to prioritise. Unless there is very clear instruction there is little chance that anything will happen and there really does not seem to be any concept of independent action and enormous skills in the ability dissemble and cover up.

As I left, there was concern over the ability to do the next C.S for thick meconium at 3 cm in a woman with 3 previous stillbirths as the had not been able to wash the packs in time for reuse, but the prolapse team has some uses..we stole some of theirs!

Talking of foresight, we are eagerly awaiting the arrival of the ‘Danish’ team from Maternity Worldwide, 9 in number, but it appears that the non European of them did not get their visas in order and have been turned back at the frontier, and face a tedious journey back to whence they came, and the much vaunted stakeholder meeting will it seems be sans some stakeholders, and as I write this the landed stakeholders are still en route, so our supper meeting is abandoned and fatigue may play its malevolent part in the development of helping strategies for this part of the world, and it is good to know that charitable funds are being carefully spent.

We are certainly living in interesting times.

more nights of joy

I had hopes of it being quiet, but no such luck. We fed the jabba the hutt and set off for bed but as soon as 12.20 struck so did the irritating jingle on my Ethiopian phone ( I have to learn how to change this as it is beginning to get to me ) and as communication is so difficult you have to fumble into your clothes and go take a look. I find a lady with two previous sections in labour as with no dates no elective caesareans and arrange her operation. The scissors are unbelievably blunt and I am reduced to dissecting down the bladder with a rather fearsome scalpel blade before a successful delivery and happily savaging of the fallopian tubes. As I go to the theatre the guards arrive with an abandoned, cold and hungry baby, probably a month or so old and looking rather wild eyed, so I arrange warmth and milk though when I return from theatre I find one of the nurses suckling it, not perhaps the best strategy when HIV status is not known but too late now. Very sweet and bouncy looking baby and now a rival for Jabba’s dwindling supply of milk. Clearly some Ethiopians live in desperate times. No sooner am I back in bed do I get another call. The para three (no I have no idea of names) ain’t making progress, is making an extra-ordinary amount of noise and the midwife cannot feel a head. It is very high and curiously I am unable to feel a single suture. When I keepher still for a minute the abdomen is a funny shape. Yes you have guessed it we have a brow and a fair amount of meconium. From the last update you may appreciate that I am a little sensitive about meconium, so back to theatre we go. The husband (they are both older and all powerful in these parts) initially fails to approve the thought of tubal ligation but while in theatre on the news that it is a boy relents, so hopefully she will not be back.
I sleep in a bit and then pop up to the ward to hand over the keys of office (the key to the ultra sound machine) and find the usual chaos but in addition Heidi struggling to replace an inverted uterus –para 5 delivered at home – and we manage to partially replace it hydrostatically but all not quite well so EUA needed. Problem, the prolapse tourist team are inhabiting both theatres and deep into lengthy abdominal repair procedures without much thought for the need for emergency space, words required later, but mange to clean an old delivery bed, carry it into recovery as it no longer has wheels and get a spinal in there which allows us to finish the job, and yes another sterilisation, there will be no intact tubes in Gimbie by the time I finish.
Have words with helpful (at least verbally) prolapse team and explain the problem that we are in danger of compromising the safety of emergency patients while they spend their donated $20,000 on re-suspending sagging denizens of the environs of Gimbie, each of whom I am told are sent home with a new dress and pair of shoes. This goes some way to explaining why the corridors and outside spaces of the hospital are thronged with would be prolapse sufferers.
We have acquired an Oromo tutor, who had been translating for me a few days ago. He soon launches into his hard luck story and how he and various hungry if not starving members of his family are dependent on him and he hopes us as he tries to draw us into his web of need. We are however happy to pay a reasonable rate for his teaching time but not become the welfare state.
This confirms my growing understanding of the malaise of Ethiopia which, thanks to western aid is now entirely a hand out culture with no sense as far as I can see of any entrepreneurial endeavour apart from trying to rip off the faranj (us) on any purchase we try to make and expecting people to do things for them which they are capable of doing themselves. Such is the desire to get free things, a pupil midwife followed me in to the theatre changing room to try to remove the crumpled jeye cloth that serves as my theatre hat as she wanted it and that was before the operation. I understand that it is possible to apply to the government for various things but that it is so much effort it easier to beg from the charities who provide masses of equipment, much of which if our exploration of store cupboards is anything to go by remains stored and unused, possibly of course because no one knows how to, but that is another story. The pointlessness of offering a training to the mass of people who either do not want it, think they do not need it or are only interested if they want more money will be the subject of further discussion, provided of course if I am not stopped before, ther is an ugly rumour the local state tries to screen all outgoing electronic traffic – could this be why the net is down as much as it is……paranoia strikes and kafka remains alive and well.

nights of joy

Well, the androgynous chicken was found having sex, and shortly afterwards found himself in a casserole, the first bit of real protein for a while. Chorizio does not count. Our other problem has been that the fridge, but bizarrely not the freezer has broken and this is proving a little tiresome. Parts are apparently on order but have to come from Addis so who knows. I can not stop the gardener digging now, perfectly good bits of scrub and virgin jungle are being turned into red mud. I suggested that a few fewer hours might be in order but got a spiel about starvation and a request to look at his rather damaged feet –no idea but look fungal to me and this was clearly an affliction of our predecessors in the house as there is quite a lot of suitable cream about. Meanwhile all about us think that we are good for a rip off, even the cleaning and cooking (currently for hundreds and thousands) lady charged 15 birr for 5 oranges which even I as a Faranj can buy at a birr each. As and when inflation reaches Ethiopia it will be the aid worker whot did it. We are also getting the catering that the Americans are so maybe there may be peanut butter in something soon.

The prolapse team has now swung down the Oregon trail and arrived. There are lots of Americans in flowerery theatre caps swanning around and about to start some operation fest, doing both abdominal and vaginal procedures, so I have sent Wasihun off to take part while I sat through a dreary clinic though may possibly have found an operative ca cervix, the second in two weeks. I may have re-invent myself as a cancer doc but no histology at all so just do your best. I suspect that they may be just prolapse tourist just honing their skills but (David take note) one does his prolapse repairs with a robot in Portland so open surgery must be quite novelty for him. I am wondering about how they got on as there were a series of power cuts this afternoon which would have caused a certain amount of disarray. Never go anywhere without your head lamp. I am doing my best to be a good obstetrician but you can not check urine for protein on site and ladies with raised BPs seem to disappear when you send them off for a urine test..I am not sure where they get to and just hope they do not come back twitching or worse. Orange lentils for both lunch and supper, but goody goody, reheated rice as well for supper and another box of red wine bites the dust.
Given that I am on call and my scrubs are wet I put them over the oven to dry – such extravagance – but do not fancy damp scrubs.
Wake up early for my day on call and arrive slightly early to find that Jabba has been gently roasted overnight as some one (nameless of course) had put the electric blanket on so roast Jabba basted in essence of Turd but apart from solidly refusing to gain weight as he vomits and is only fed intermittently he seems none the worse for his hyperpyrexia. Karen meanwhile has managed to find some oversize nappies so hopefully we will be able to try and keep his bum less sore. Mean while on the ward and within the dreaded ward round all is not well. The baby whose section was delayed for lunch and aspirated some meconium looks flat and terrible. As I listen to the wheezy and tight chest he crashes and we go through the saga of a 25 minute arrest routine and get the heart rate back twice continually bagging him but he is unable to breath, so sadly we call a halt and the baby dies in his mother’s arms. He is subsequently placed in a card board box marked a little ironically ‘handle with care’ as it is casually moved around the floor by foot. The prolapse team, those of flowery hats and strange American theatre foot wear are in full cry and filling the ward up but more importantly blocking both theatres as I want to do a caesarean section for failure to progress in a trial of scar with a bit of tenderness. The catheter which has something of a pre-used look about it is not draining despite appearing to be in the right place and I am reduced to draining the bladder with a 10ml syringe and a green needle-delaying my section somewhat but all well. I must return and see if she is now peeing. The arrival of the prolapse team and the thought of free operations (buy one get one free) is causing immense queues in outpatients which is more chaotic than usual however since the prolapse team is here they can now screen their own patients. I have sloped away for a cup of coffee and to write this. I had believed that once you got to hospital it would be safe if not nice and now have to revise this. Bit like the curates egg I suspect – good in parts.
Back at the house find the gardener busy removing greenery from the slope – so I fear soil erosion or worse a landslide or constant dust in the drying area. I fear he is finding things to do but now it is getting a little destructive but he gets selective understanding when you try to stop him. The compost pit seems to be doomed too as the concept of compost or throwing things away not in aplastic bag is foreign to the local mindset. Oh and no eggs yet!