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.