Illusions of sustainability

There is a glimmer of the illusion of possible sustainability on the horizon with an offer by one of the nurses, almost spontaneously to put down a nasogastric tube on an eminently salvageable 2Kg 32 week old neonate with no suck reflex and a rather bruised head from her backward entry into this world. A number of problems had to be overcome first however such as the availability of a tube even on the second hand market (there is a flat tin with various coils of damp plastic, but no 5F tubes). Apparently none in the hospital despite various calls – was a salvageable baby going to succumb or aspirate for the sake of a tube. Despite much energy being expended on inventories, this was at variance with local knowledge of a cardboard box to the right of the door, in the store which might contain what was needed. Finding the key had its difficulties as being quarter to five all had gone home (no guesses as to standard day finish) and the local key was held by a case of D&V who was reluctant to leave the home facility but needs must. Entry achieved to the locked room and indeed tubes available, sufficient for me both to keep a spare myself and sequester one in the room for another eventuality. A sugary regimen and we are away. It is up to you now mum, milk production or death.
On joining the ward round yesterday, (something I avoid unless I have to conduct it for its sheer tedium, I now know why it is so difficult to get an SHO on to the post-natal ward) I was struck by the large piles of human poo around one of the beds and was not immediately aware of its source until I spied a toddler, sans clothing below the navel and a mother (suffering a miscarriage I think) confined to bed. The high roughage diet is clearly high poo volume too, but why no effort to clear it up. The answer of course is that there is nothing to clear it up with – there are no paper, or come to that any towels, so nothing to scrape the offending ordure up with, so there it stays, and many do not have shoes. This was brought home to me by a visit to the Government hospital today to chat to their very nice obstetrician, who I watched – I kid you not – dry his hands on a piece of paper from the notes. This is not as bad as you might suppose as the paper is of low quality and is very absorbent, the only thing you can write with is non- absorbent biro, rendering me even more illegible than usually the case. Lest you be worried the O.R has reusable towels as with everything else, but the soap is running out I notice. Here, you wash your hands then someone pours an evil smelling alcoholic solution onto them, a smarting experience if you have a small cut.
The usual diet of obstructed labour and fetal distress has been broken recently by ectopic pregnancy, one a bit tachycardic and the other a chronic mess with the appendix buried in it and a radical hysterectomy which I am pleased to say went really well. This has inspired me to look at developing a service for early stage invasive disease – so do take the trouble to read my plug in the next blog which immediately follows this.
The absence of wheels and dependency is increasingly tedious and is being used a less than subtle form of control together with petrol costs and per deums (eating costs for the driver, and sleeping costs if we go to Addis). I am plotting ways of trying to get the car back as Karen now feels secure here, I feel claustrophobic and am looking for ways to put myself in danger or expanding my horizons. I think Aber Minch has possibilities but I suspect that there will be quite a lot of leg work both with the authorities and on the home front. Although the compound is a safe(ish) haven, bar the endless stream of people who call at the door, wanting a chat, money, both computer access or more time consuming computer lessons or feeding. While waiting rather endlessly outside the government hospital for my lift I noted people being carted in on stretchers and rather a lot of quite friendly looking people in Khaki smiling a lot but toting AK 47s with hollowed out shoulder rests and looking quite new. Why I wonder do the manufacturers bother with fake wood on these automatics? Feeding has its moments as Adventists develop sudden narcolepsy just before food and start muttering (probably to some deity) and marvel at the amount of Ribena we seem to be drinking from a box without offering any to them though we keep a supply of apple juice now for such visitors. The chickens have become very noisy and toxic trying to find a place to lay we hope, but have to keep chasing them outside and off chairs – they almost seem to like being picked up now, very worrying ,as is their incontinence. Lack of eggs culminated in me buying some from the village, Karen simultaneously buying some up country while walking back from a health post as there was the usual delay in transport, so with an egg glut – two eggs from our two. Egg mayonnaise sandwiches for lunch then. Karen has constructed comfortable looking but so far ignored egg laying boxes but they prefer the outside world as do passing stray dogs or the chickens themselves. Eating your own eggs probably does not amount to cannibalism and as not fertilised infanticide, but what I wonder?

Off to Aira hospital tomorrow, transport permitting, a haven of German Missionary efficiency where I hope to both discuss my cancer project and borrow a cystoscope so I can take stent out.
In the meantime the endless supply of lentils which ensures no bowel obstruction, and the peoples of this area, which ensures pelvic obstruction will continue. It is a far cry from St. P, but that does not sound that much fun at the moment either….
To be continued if anyone is reading………….

31st December 2011

Boxing day chat

Christmas Eve was certainly busy (and sadly dry) as I agreed to do the on call, 4 Caesarean sections, the last of which while our desert of pancakes waited, (sorry they were thin so crepes) culminated in a first for me of having to do an inverted T in both the uterus and the abdominal wall and pulling the baby out by its bum with a great slurping noise, though it seems none the worse for being jammed for many hours though by the amount of meconium about there will not be enough left for a meconium stool. The mother looks surprisingly well given that she had to travel a considerable distance and time while pushing hard to get to us. As ever the later borne 1.4 Kg baby was left cold and wet and hungry. There seems to be something in the African or at least the Ethiopian psyche that does not allow you to think for yourself or initiate any action at all of your own volition.
Chris a refugee from comfortable California, wanting to do good, put something back etc. has been working with computers, novice nuns and importantly access to God’s truck to which we have had some limited access, was struck by this when on a rest day he found them all listlessly sitting around and organised a football match in the compound which they all thoroughly enjoyed. The question is ‘Why like so much that is going on, could they not organise this themselves. Self-starters are in short supply and we are I think beginning to understand why but that will have to await another blog and probably from a better (Karen’s) mind.
Christmas day dawned and unlike today as I write this, surprisingly some internet access so we were able to skype friends and family and also send some e cards. The day was spent entertaining the rather too ever present young lads with no homes, shoes or food and who will consume anything put in front of them, on this occasion tuna pasta bake and coca cola. There feet are not pretty and they do recognise this and are reluctant to take their shoes (bits of rubber cracked flip flops off) so there is a thin layer of red African dust around the house. From the flood around the loo the concept of peeing in a water closet is also rather foreign. Despite three goes now they have yet to master the skills of opening perforations in cardboard to get the ever increasing sized advent chocolates (I do not think that they have spotted that they get bigger row by row0 but as there are 5 to a row and 5 of them it is only of academic interest, but bodes badly in terms of their ability to rise above the condition they find themselves in. Then along with our neighbours children, friends and relations, including one with mental health problems, though seems a little better we sit them down to a screening of Elf, almost brought to grief by one of the ever likely power cuts. They laughed a lot and seemed to like it, at least the slapstick parts. If we stay we may need to record rafts of Shrek, or other entertainment with visual gags, though if anyone would like to slip this onto a hard disc for us great. Karen thinks that Avatar might be too frightening and the complexities of Harry Potter are I think beyond them.
I am pleased to report that our last sortie into advanced gynaecology has so far, and it is early days, gone without immediate mishap as we managed to get out a 2b Ca Cx without too much trauma and with what appear to be clinically clear resection margins. I think that there may well be a place for radical hysterectomy without lymph node dissection for suitable women. As they are universally poor, and there is no ‘free at the point of delivery’ service (unless you have a prolapse and an American wanting to do it) we need to find a way of funding these operations without Adventists or any other NGO getting their slice.
Meanwhile it is now after school and time to cope with our increasingly demanding surrogate family, barren but obese and increasingly shitty chickens – the veranda would now count for barn reared on an advert – and is distressingly unhygienic as are the assorted snotty and unwashed orphans who we bought soap for (they say their clothes but their bodies could do with some too) and Jabber who being handed round lots now has snot and a febrile illness. We took the said yellow shirted youngsters to the ‘green bar’, us for a beer and them for some supper, bits of beef an egg and injera.* A v .large plate polished off in record time and some cokes, only full fat is available. The bar is fairly empty but Man U are playing in another time zone so those with satellite dishes (which also represent those roué enough to have a beer in public and afford it) are not there. Perhaps we can persuade a fan club to donate some orphans football shirts in various sizes.

*Injera is the Ethiopian staple which I may have described before. It looks like a dirty grey flannel and tastes sour and has an unpleasant chewy texture – I have not chewed flannels but I suspect……

Yuletide Musings

Well Christmas Eve for Faranjis (as with all things Ethiopian all is not straight forward and Ethiopian Christmas is 7. January) and Sunday is an Adventist working day, they were all trooping off to Church in their Saturday best as I went to do my on call, and the dreary ward round of the recently delivered and septic. There were plans for me to do a radical hysterectomy tomorrow, Christmas, but even though there is no Turkey that is not how I plan to spend my day especially as I may be up all night (I seem to collect tedious on calls).
Christmas dinner is likely to be cheese fondue and a Christmas pudding. We were hoping for custard with eggs from Masie and Daisy but they have become barren and Karen will not countenance having them for dinner. The boys who are now spending a considerable time on our veranda have cottoned on to faranji Christmas so cheese fondue (cheese is a rarity in these parts) may turn into Tuna pasta bake. We had the boys round last night for pizza (which they enjoyed bar one with the Chorizio, his protein loss) and Harry Potter which they probably didn’t but none of them were too frightened. However, being half starved their appetites are prodigious for full fat coke, popcorn and surprisingly, hot chocolate. I do not think that even the middle class Ethiopian washes a lot but these poor kids wash little and the odour lingers. The concept of a flush toilet is also elusive and they disappear into the dark, though where they actually pee is unknown – one hopes not the vegetable patch. They are rather little shadows and what with them and Jabber we are quite the Montessori, but with 5 of them around all with adult appetites it involves more shopping visits and in the absence of wheels there is a lot of carrying- Karen’s as I am stuck in the hospital, silver lining to the cloud! I do feel sorry for them but they are surviving though their long term future is uncertain.
Most Ethiopians have stony faces and are difficult to read but I saw, for once some real emotion. I diagnosed an intra-partum stillbirth at some god forsaken time in the morning, the fetal heart having been present on admission. Dodging responsibility, the midwife looking after the woman asked me to break the bad news in translation which I duly did. As I returned home I saw the husband crying outside, so I sat with him for a bit in a show (I hope) of mutual support for a few minutes before going on my way. What he thought of this Faranj sitting with him with a hand on his shoulder, I have no idea, but I did try. Fetal monitoring is at best primitive and in addition to no vacuum extraction there are also no batteries so no listening to fetal hearts in any meaningful way. The absence of suction apparatus means that the forceps are coming out more and with this some impressive neonatal black eyes and equally some rather torn looking perineums. However help is on its way as Nick has identified a hand pump that works so perhaps the silastic cups will come in to their own. The combination of hard steel and the African pelvis is not a happy one.
I thought I was about to deal with my first uterine rupture in the wee small hours, with the arrival from circa Assossa (where else) of a lady with tribal markings, significant obstruction with a wedged dead head, what appeared to be some fetal part palpable suprapubically and a hard mass in the epigastrium. Haemoglobin satisfactory but WBC 20,000 +. Resuscitation for all these cases is now becoming routine, 2 litres of crystalloid fast and 2gms Ampicillin, before a quick trip to the O.R, none of this stuff about stabilisation and lines. Laparotomy revealed that my fetal parts was actually a surprisingly high Foley catheter in the intact bladder, the longest lower segment I have ever seen , a Bandles ring (This for the non obstetric readers is a constriction ring that you get in obstructed labour – read about but seldom seen in western or really northern hemisphere practice-)and happily no rupture. Opening the uterus produced a foul (and I mean foul) anaerobic smell, a spray that hit me above the mask (ugh) and after some difficulty a large dead and decomposing baby – not pretty. Post op she is doing O.K. despite an ileus, a weak but recovering leg from her neuropraxia (nerve bruising that should recover) and her sepsis. Her wound is oozing a fair amount of gunk but should hold. She will be in for a bit but she comes from a tribal area and has tribal marks which means a hefty walk back so hang on to her for a bit. Well out of area but I think she came on the ‘safe birth fund’ but as this is now stopping on the grounds that government hospitals can cope, which they manifestly cannot, I suspect that many of these unfortunates will be left to die at home. Worryingly there was little bleeding from the lower segment, but brisk from above, so I hope that this and the bladder base is not going to slough off- - we will see. My Ethiopian ‘oppo’, we do alternate nights, kindly said that it was an incipient rupture , but I wonder with more experience of these things I would have avoided a large midline laparotomy and pulled the dead fetus out with a destructive operation. ‘Old dog and new tricks perhaps.
Karen has been dragging me off to Health Centres in Kebbeles (small towns or villages to you and me) to do ante-natal clinics as part of her screening program. This involves an appallingly early start, a bumpy 2 hour journey which I dread to think what is like as an emergency back and arrival at a health centre where you are treated (as are the women) with indifference by the majority of the staff and do pointless scans on women about 28 weeks pregnant while those with advanced pregnancy stay away or are out picking coffee beans. This being the season, and coffee being the important cash crop about now. None of them are ill as far as I can see and the equipment to test for anaemia, probably quite common, is not available though, strangely the test for syphyllis (on their own admission vanishingly rare), is. Having said that, the box I investigated, marked USAID ferrous fumerate actually contained injectable contraceptives, useful I know but not in this context. When I suggested some treatment what was on offer was 5 days of folic acid, of which I think there is quite a lot in Teff the local wheat. The concept of a little prophylactic iron for the white of conjunctival multiparous remains unknown and could be actually useful. My doubts about the value of ante-natal care are strengthened and I observe posters from ‘WHO’ (who drive about in large 4 wheel drives, like I am not allowed to have, doing very little – bitter me no surely not) with strictures about focussed ante-natal care which is observed in its non-compliance. I have yet to hear any dietary advice (which they could not afford to take) or hygiene advice (which they do not have the facilities for) or see many blood pressures taken and no urinary dip stick taking. When we are there most women appear as they hear faranjis with a scanner are there and the scanner confirms that the local examination which is a bit like kneading bread misses most mal-positions, but who cares which way the baby is lying at 28 weeks. They are probably better picking coffee beans which may allow them to be better nourished or buy some iron tablets or boil their river water. However, on my experience of what arrives in the hospital their ability to detect mal position in later pregnancy (if they actually see any one) requires a little adjustment. I am however doing my best to teach, I hope with some success, simple palpation skills. What is depressing however is that they quickly revert to what they were doing before. There is a lot of sitting around by all the staff, which is depressing as they could usefully tidy up around them as litter, discarded syringes, drug vials and dirty swabs abound. The concept of danger is also missing. While there I was called to a woman, bleeding with retained products in her os which were duly removed. I am told she was HIV positive, but the dirty instruments were still there when I was asked to assess a woman with cancer of the cervix, as were the remains of a not so recent delivery. Poverty is one thing, inertia and not trying is entirely another. Training was also present as the ‘Maternity Worldwide’ midwife put up a small black and white poster encouraging the use of alcoholic gel, nasty and sticky, both before and after examining a patient, which would be fine if there was any gel, but I could not see any other than what we have brought ourselves. The worried well that we did see had the usual aches and pains that you see everywhere. Karen is encouraging me to visit the even more rural ‘health posts’ where she reckons that the women are even shorter, but we have no idea of what happens to them when they are in labour.
I would like to think that grubby ill equipped health centres, staffed by partially trained paramedical staff present a better alternative than do it yourself at home and ultimately they probably do, in that in terms of delay models ,in that it may dawn on them that transfer to a hospital might be appropriate earlier than at home, I remain unconvinced in their present form they represent the way ahead or that the efforts put into training with visiting teams of trainers, such as we have just had, have any meaningful impact on the delivery of care, but we can only hope. WHO I note work out of Geneva, I cannot believe that their recommendations, however worthy, reflect the thoughts of those who are actually on the ground, or if they do they have become so politically correct from the influenced of those from more prosperous parts as to become meaningless for the environment in which they are supposed to work. How about iron for all, a few albustix and turn up at 36+ weeks and see which way up your baby is. And oh yes, go somewhere sensible to have it!

So as you embark on an orgy of gorging and we enjoy an alpine speciality and Christmas pudding, I wish you all a splendid Christmas and an exciting new year. I am accused of being too negative so we will try to say something about what works. Certainly the decision to section time here makes the NHS look like the slow lane. Despite the difficulties, Ethiopia has an expanding population, less violence than many of its neighbours and nice coffee. If they could only learn to smile, think ahead and do something to look after their environment.. it would be great!

Have a good one and back soon – internet and thought police permitting.

For those of you who are wondering the 'stretcher thing is an Ethiopian flying ambulance it is carried on the shoulders with grass to stop it rubbing not kidding!

The Prisoner

So, return to the ‘parish pump ’politics and tittle tattle of small community living with the added bonus, now being virtual prisoners being sans car and almost sans everything. The added frisson is that access to the Maternity Worldwide car is being controlled for reasons as far as I can ascertain for reasons of wear and tear. Life is taking on a rather down market version of ‘The prisoner’ for those of you who remember the Patrick Magoohan saga set in the faux village of Port Merion on the Mid Wales Coast, but who is No. 1, I certainly do not want to be No 22 or wear a blazer with ribbon on it. The local uniform is more international ‘scrub cast offs’, the Danish ones all Any pandy with elasticated trouser bottoms and rather absurd short sleeved white coats, the American with embroidered names and the U.K almost saying ‘stolen from’. But life does have that rather surreal quality to it, particularly as we have a self confessed ‘Bad Adventist’ in our midst who has taken up with our midwife but has also charmed the Equadorian nuns into letting have access to their dodgy wheels, something that we have tried to emulate but for us it requires the permission of the priest and the bishop, all is well then in this Marxist state, yes control is here.
Meanwhile, news is filtering out of withdrawal of financial support by Maternity Worldwide and our thoughts (and at the moment they are just thoughts, of our moving to pastures new) and this is causing muted distress both in the greater European community of maternity Worldwide and in our own parochial world. Even the very minimal contribution from charity sources to our presence here is under discussion but we shall see. Having said that initial enquiries to other charity agencies have met with enthusiastic response but, having been done over in Kenya Karen finds the relative security of our open prison comforting, I on the other hand, now being free of the NHS do not want and rankle under the control that this wheel free environment now has.
The other news with interesting repercussions is that the temporary surgeon is no more as he has returned to Addis with a swollen leg, and the hospital has been under the ‘emergency provision’ of the Government hospital surgeon, though nobody at the time told me when I did my next night on.
Apart from the now common diet of obstructed labour, dripping meconium and rescue surgery for the very small of stature I was summoned to a sick patient who came to me by virtue of the fact that she had some regular light monthly vaginal bleeding that was occurring at that time. She also had an unrecordable blood pressure, a tachycardia and an acute abdomen. The lab technician was unavailable, it being night and Sunday, but she did not look that pale. She also improved a bit with some crystalloid, all that is available in these parts. The absence of a local surgeon, and also no knowledge of an alternative, the concept of a hand over is unknown in these parts, made me realise that laparotomy was required. This revealed a belly full of pus and on extension of the laparotomy a perforated gastric ulcer. It is a very long time since I last over-sewed an ulcer and put on an omental patch but surprisingly she is doing reasonably well, has not leaked and her aspirates are falling but well outside my area of expertise.
I am surprised by how sanguine one gets about obstetric emergencies too. Found ruptured membrane with a beating cord under the head so just took her through and did a section – none of this supporting the head nonsense but did put her into knee elbow position. Alarmingly she had a crash induction that consisted of a slug of ketamine, no airway protection but clearly some form of laryngeal response by the strange noises she made throughout the procedure. Happily neither she nor her offspring seem any the worse for their experience at the time of writing, let’s hope that ketamine has an amnesic effect and does not just give you a bad trip – this one would be real though.
The aftermath of the ‘prolapse tourists’ live on with a neuropraxia treated locally with Ibuprofen. The unfortunate sufferer had been prescribed ibuprofen by my colleague and turned up at the clinic (he having developed severe man flu) saying that they could not afford it. The advice that it probably would not do a lot of good so not to bother did not go down well. I can see how the desire for pointless poly-pharmacy develops.
The other rather taxing thing at work at the moment is the total absence of any method of delivering babies vaginally by suction. All the overused Kiwi cups have now stopped any thought of vacuum and the silastic cup suction apparatus is U.S too, the hand pump requiring a fit pumper and so far they have failed to maintain adequate negative pressure, and the electric version not sucking. As I was called one of the midwives/trained birth attendants/less trained birth attendants/no training but good adventist (being an adventist is a requirement for a job in the hospital) was trying to deliver a baby with a silastic cup and failing miserably, but the unrecognised catch was that the usual spray of blood and other body fluids as the cup detaches was not apparent – pump not working! (Subsequently, when I took it apart it was apparent that the filters were all wet and blocked and when dry there is a negative pressure but I doubt that it is enough to effect a vaginal delivery.) I was reduced to using the one pair of Wrigley’s that is available and then a strange device with large metal spoons that did not fit easily. Both these deliveries required episiotomies, one of which extended and made for an interesting suturing experience as the light was not working, and head torches which require you to bend your head and bi-focals which require extension leads to difficulties and eventually a stiff neck.
However adaptability is as they say ‘the key’.
The return of the star feature of the ‘Maternity Worldwide’ winter news letter to the U.K means that we are surrogate entertainers and feeding station for the local motherless band of actually quite polite reprobates, but their need for sustenance far exceeds mine so they are welcome to faranj bananas, fruit pastils and mandarine orange juice. The purchase of schoolbooks and supper is on the horizon later today, together with clothes a football and Man U

shirts on our return to the U.K.

So life now consists of being a registrar, surrogate parent to an infant and supervisor of assorted rising stars of an Ethiopian football team (Gimbie Wanderers?), however lack of wheels, lack of sleep and probably lack of any meaningful infra-structure or support takes its toll. However there is also a growing stream of the indigent poor with unaffordably treatable prolapse, and the middle classes with uninvestigatable infertility beating a path to my door (two mixed metaphors in a single sentence). Shelf pessaries or clomiphene for all?
I am not a number, I am a person. I am number 6, you are number 22, but who is number 1?

Kenyan trials and Ethiopian Tribulations

Interrupted by a Sunday and Kenyan Independence day we finally made it to the High Commission who were mercifully quite empty so we were able to start the process (£95) of getting an emergency passport. This requires copies of the police statement, airline tickets, which can be tedious as airlines require sight of your passport which of course you have not got and identity which has also gone, but scanning every possible document into your computer helps. Plans to get back to Addis next day are complicated by a significant delay in getting the said pass port, a trip to the Immigration department (more long sweaty queues) and getting the car off to its new and hopefully temporary resting place next to a swimming pool in a smart gated Nairobi suburb. Will we ever see it again and will it be repairable are of course the big and as ever unanswered questions. The man at the consulate is nice but the passport pickup is long and tedious so there are Kafka signs of having to go from office to office. The other piece of classic mis-information was that we needed a stamp from the Kenyan Immigration office, and when we got there we were told that we would need $50 which of course we had not got, requiring mad dash to hotel and back again to get a signature from a bored, silent lady doing a cross word at……..no cost but several hours of coronary tightening anxiety about missing aeroplanes. The emergency passport allows us to go to London through Ethiopia but the question of course is will the Ethiopians. I write this in the departure area of Nairobi airport – lounge would be too good a description. We are looking at car hire but it does seem exorbitant and seems to come with a driver and all that sort of thing so possibly not.
E mail interest has started in us possibly relocating to Kenya and this now becomes a distinct possibility but finding somewhere interesting will prove a battle as I am sure will be the wearying trips to various government offices and collecting stamps. The next big battle of course will be to get a U.K passport to get to Geneva and I can see many trips to London during our short sojourn in the land of the free. The hotel bill is astronomic but hopefully we will be able to slough some of this off on the insurance. Telephone call account for significant losses and the absence of credit cards is causing some stress. Have had to spend some hours dealing with American Express, the hopefully English appearing number being routed to America and then you have guessed it India. Have your checks replaced within 24 hours is pure farce and the usefulness of these cheques is not in doubt – they are quite useless and getting the money back, particularly when you are not sure where the receipts are is going to take a long time. Time readers to destroy any vestiges of anything you have to do with American Express in protest.
So an uncertain future awaits us and the only glimmer of hope on the horizon is a bottle of gin and a bottle of Pimms – festive warm Christmas fare, only we do not have a fridge and thus no ice so we shall see. Any non egg laying hens may finally realise that they are under Christmas threat but as they seem to be becoming part of the family I suspect that this may not happen.
Curiously, apart from being put in the wrong queue by some moron from Ethiopian Airways getting into Ethiopia with a photocopy of my residency permit was a breeze, as they looked me upon the computer, stamped my emergency passport and there we were. The wheeze for getting the car in would not have worked and we would have been cought doing something naughty in Ethiopiaand been regarded as bad bad bad.
After a few hours sleep, a wearing drive and a stop at a strange Ethiopian transport café and we are back again. Not a lot of help from local organisers and still no fridge but Karen feels she is home.

I go on the ward round and find young Jabber fighting fit, so much so that a trip to the orphanage looms, prospective adopters please note! Otherwise there is the usual litany of ill informed patients trying to kill themselves and certainly managing to kill her baby – para 5, section with the 4th for a face presentation, got away with it for the 5th., but the 6th. Got her with a face presentation and hole in uterus. Assured that she had been told to come back after the C.S – does education help probably not. Many thanks those in the U.K. for help with histology but chronic folliculitis does not move things on at all and the oxytet though helping slightly is not a lot and my colleague has her on anti-TB treatment now. Dianette and Retinoids would seem to be the order of the day but fat chance now.
In the meantime the remaining alive twin and a lady with some immune compromise await my attentions tomorrow. However I still have a broken car in Nairobi and an uncertain future to sort. However for those of you who enjoy this back to some mainstream and irreverent blogging for a while. Upcoming discussions will include thoughts of the cynical (partners would say far too negative and cynical volunteers, in an environment in which the local and transnational NGO wars mean you count for little – but actually we knew that any way.

PS a fridge has just arrived, penicillin encrusted and small and without shelves but still a fridge so there is ice for the gin and tonic now.

PPS Who can spot the chickens?

Time for a Phoenix to Arise from the Ashes

As we arrive in Addis and get to the Lion’s Den we are greeted by hordes of very friendly policemen who are sitting around the gate in their sandals enjoying tea ceremonies and cursorily frisking us. The AID’s tourists are in town and evident in their well padded prosperity, suits and conference badges, increasing the cost of hotels several fold as the Government is sponsoring some self congratulory conference. The conference venue is also well guarded and people are not even allowed to walk along the pavement outside. In a last ditch attempt to keept he car we a;- phone a friend (number given to us of assistant to Minister of Health who tells us to sod off and b;- try to get a tourist visa with a predictably negative response, so off to the Kenyan Embassy who after protesting great business give us a visa, but this largely takes up the day with two visits etc. As ever we get no further than the Greek Club who welcome us, despite bulging with Aids tourists with open arms. So next morning we navigate our way south out of Addis and set off for the rift valley lakes, though see little water or lake and Moyale the Ethiopian border, the road being tolerable but bumpy and the journey much longer than expected. There are various road blocks which we are waived through except for the last which we try to pass and stopped with waving of torches, guns etc. and stroppy customs officers. Karen is convinced that they are imposters despite the presence of uniforms and starts getting arsy, hopefully just through fatigue, we have been driving for aprox 12 hours but not a good idea. I creep, to the anger of Karen and finally we are on our way and arrive at what passes for a hotel (artful rush huts and beer and spaghetti) and have a tolerable if anxious night as this is malaria country before setting off on an early start next day. Our early start is like so much else kyboshed by finding a nail in the tyre and that a vital bit of jack is missing (thanks Greg) but improvision is all. This gives us a dilemma as I have not mended a puncture yet and getting it repaired will delay the coming journey more, so hopefully we press on which could have been a big mistake. We manage to bounce through the Ethiopian border without spotting it as it is a sleepy guard in a chair and having had our passports stamped in Kenya have to go back. The Ethiopian immigration man has a familiar red shirt, the computer is down and it is turn to be arsy, mine to Karen’s ire to be even more creepy and Karen to become rather shrilly protesting. There is the prospect of waiting there until power and internet connection is resumed but finally he relents and we are on our way. The carnet is stamped with little ceremony, we get Kenyan pass and set off.
In order to protect more sensitive readers I have been under instruction not to reveal that Northern Kenya is an area of badlands with appalling roads, tribal wars bandits and Somalis in abundance though we see none of these. We have been advised to take two armed policemaen with us and that these have been arranged but as we are late they are no longer in evidence – sod it we will do it on our own and off we set through bone and suspension crunching pot holes with complaining and increasingly rattling car. Bumps, dust and heat are indescribable, the passenger window in danger of falling out and strange noises coming from the left side suspension, not good, equally hardly a person in sight which may be good or bad. Villages are marked by a guard with a rusty stinger to stop you passing and the usual crowds of children, the first with shouts of Faranj which makes us wonder where we are but this fades. Third village in the duty soldier asks us to take police reservist and ailing 16 year old daughter (stomach troubles of some sort) to Issiolla at the end of the road to which we agree so he climbs in with 2 litres of goats milk for the journey, anorexic looking daughter and a loaded but unused looking Kalashnikov. This is slightly concerning as his cataracts are so bad I do not think he would know where to point this rifle should the need arise and with all the real and terrible bumps I pray (not sure to whom) that the safety catch is on and with it cradled between his knees it is not going to pump bullets into the roof, and the protesting rattely Rhino rack. Apparently the road was closed two days previously and it is frankly terrible now with deep ruts, corrugations, pot holes that you could sink into and not emerge and sandy detours that others have taken and greatly daring we take but worry as we know about getting lost. But this is desert with rain which means grass and scrub so you can keep an eye on the road. We break the journey about a third the way down in a half arse town called Marsebit but surprisingly it contains an ATM a petrol station and a man that mends tyres and having watched him I could now do it myself. Our misty eyed copper with Kalashnikov recommends an unfinished hotel so we spend the night as the only guests in a buiding site but are cooked a tolerable meal by torch light and eat in the subdued lighting of a two stroke generator which is turned off the moment our lights are. The bed is minute with a large satin heart on the coverlet that does not inspire any ardour but tolerable sleep given our fatigue. We are into our third 12+ hour drive. Next morning our guard turns up in civvies without gun having established from his police pals that the road ahead is safe and he does not want to lug his weapon around Issiolla. The road is even worse than before and in a moment of lost concentration I run it into the side after which there is a very strange noise and the side I did not run it into is lower than the side I did. It is making a very strange rubbing noise as you move along – all is not wel lwith the suspension but we are at least 300Km from help so very slowly we press on with a large bubble coming from Karen’s head with ‘It is all your fault written on it and increasing acidity. The suspension, in my defence has been making strange noises for a bit but I suspect straws and camel’s backs. One of the quarter lights has also fallen out and is rattling against the paint work, the various plastic fittings having shattered but sticky tape is a wonderful thing. Despite the little red light coming on the whine of the pump from the reserve to the main tank is no longer there. Over this time white ‘South African constructed (under licence) charge past with their suspension going nineteen to the dozen suggesting that soft European land cruisers, even when converted with tough suspension, extra tanks, expensive roof racks, mega tyres etc. are just not up to it. If you are going to do something like this buy in South Africa and distrust pale British conversions. Engine going fine except acceleration crap as turbocharger seems buggered and when you are trying to overtake lorries with trailers this can be tedious. Life improves with Chinese (what else) road initially smoother dirt and then ashfelt – we have done it. Well no disaster strikes in a grid lock traffic jam in outer Nairobi in the dark when trying to help Karen reverse a few feet with shouting Kenyans, suddenly the previously locked back door is suddenly opened and credit cards, passports documents and cameras disappear with fleet of foot car mugger – f*ck – and great distress from Karen and still with road works no idea where we are. Finally get directions from bunch of women of the night and guard so after 14 hours in broken car and now limited resource we get here, but have on the advice of the hotel to go to the local nick to report the loss. The policeman keeps his pens in an old C.S gas cylinder, marked ‘C.S irritant gas for riot control’ and we were interrupted by a ‘murder report’ which does put things in perspective – but we have our crime number.
So we are now ensconced in our guarded tourist hotel with fat cat safari tourists sans money, passports cards and sadly cameras with an uncertain future, will we get back to Ethiopia on a temporary passport. I would show you some stunning photographs but fear that they are being erased from the camera before it hits some market or other. Time for a phoenix to arise from the ashes….perhaps.

Defeat and Despair

Keeping despair at bay is increasingly difficult as we are at an impasse with the car and the endless fire fighting is becoming wearing. I have come to the conclusion that Ethiopians, or possibly Ethiopia does not want to change, they just like being proud and incompetent, incapable of independent thought but very capable of looking for hand outs. Some random young man in a yellow tee shirt turned up on the veranda yesterday and asked for money to go to Addis and the blood taking technician keeps on telling us how he wants to become a doctor and needless to say wants sponsorship. I hid in the house while Karen dealt with the former and she was not happy at the lack of rescue. I am now 4 days in to permanent on call (and the resultant absence of alcohol) which is becoming a little wearing. This is interspersed with out patients and the need to do scans for which I am woefully unprepared. They all want to know the sex of their babies of which I have a 50% chance of getting it right. I totally failed to get the ureteric catheter out but produced bladder biopsies and haematuria so have desisted-just hope that I have not put her back too much.

Battling to keep people alive with patchy ( a polite description, non-existent would probably be better) is an uphill struggle and any baby not with its mother is doomed to a soggy hypothermic existence unless rescued by a faranj. The Jabber appeal, (he survives on faranj pressure here but is a hit on the western blog) means that we have a meagre supply of nappies, which are not something we have a lot of and are not in general use, means that we can try and keep other small and neglected babies a little drier. Assossa of which I have made passing reference, is proving and interesting source of death and near death experience with one down and a number of near misses. Last night an 18 year old turned up fitting, probably from the morning with a blocked drip containing a woefully inadequate dose of diazepam for which she was doubtlessly over charged, but with her head well back and a few creps in her lungs from her doubtless aspiration that was the least of her problems. As you might expect there were various midwives and nurses standing about waiting to ignore what ever suggestions or instructions were coming. The local Mg SO4 comes in 20 ml platic containers marked 50% and the local instructions are in gms. which may cause a little confusion and they are used to using it intra-muscularly, but one has to wonder with what efficacy. So anyway time for some emergency medicine mindful that the last one failed to reach her wellness potential, so starting with simple things like putting the mother on her side I administer some rectal diazemuls, re-site the drip give some rectal diazemuls, IV magnesium and set up a mag sulph drip after some hasty calculations carefully checked by Karen as arithmetic is not my strong point. For those of you who want to know 50% mag sulph is 1gm in 2ml, so a loading dose is 10ml and then 1gm per hour is 40ml in a litre with a drop rate of 20 drops per min. Keep it going for 48 hours and hope. Although small, rather miraculously the baby was alive and a caesarean section later (rather dodgy under ketamine and with a mis-intubation and very anaesthetised baby which I had to resuscitate leaving Clara and the surgical nurse to suture the skin, which had unfortunate consequences) they were both alive. Rather than allow the baby to get cold and die, which is local policy we put a feeding tube down and she gets to share Jabber’s milk. Come back to find skin bleeding though not excessively, so mattress sutures are the order of the day. Next day unsurprisingly, platelets seem in short supply so arrange for husband and mother to donate some blood and they are now doing o.k though still lying down making chest worse and awaiting suck reflex. Stirring of the waste products is now in order as there are tensions on the ward and the blood transfusion is blamed on skin stitches rather than platelets and I am blamed for not suturing skin myself…..no you can not win in this game. As I am now into a week of continuous on call (and more concerning no alcohol) dealing with endless operative deliveries of obstructed labours surrounded by listless morons, kiwi cups that have lost any pretence of being able to maintain a negative pressure and specifically in one instance nothing I could do a rotational delivery with, I may begin to despair! (I actually managed the roation by putting in one forceps blade and rotated the head with that before then applying the other. Apart from a shower of meconium (meconium is the norm hereabouts) they were both unscathed but I was covered in every and any body fluid. All very unpleasant but isshy (O.K.) as they say around here. All is well that ends well. With all this I am beginning to detect a certain malignity which stems from weak and devious management, small community tensions and bitchiness and a general desire to stir solid waste matter to combat boredom. The important thing is to keep a certain distance from it all and carry on doing what you can. The prolapse tourists have struck again as a very obvious DVT has arrived – classical medical student stuff – but getting hold of some heparin is proving a little difficult. My absent colleague says it is not available but the nurses say it is so we will see what happens before she shouts for a bed pan and drops down dead. This is what I said to her next day on being told she could not afford the drugs and that there no more ‘prolapse funds available – not a lot of prolapse contingency planning here but then American surgery never goes wrong does it! The out patients today was full of post prolapse patients though none seemed smilingly grateful in their new dresses, shoes and necklesses, more winging about their urinary frequency As I write this Karen is off to a wedding, more boiled goat and chewing gum, while I hold the fort here. This means that I am sitting on the veranda playing Wagner quite loud, probably to the bewilderment of my neighbours and disappearing briefly into another, but actually no more ordered world. A sword and tarnhelm would go down quite well now!

A team from Chelsea and Westminster have now arrived and are setting up to teach on obstetric emergencies, which I am sure they will do well. They also mentioned talking about millennium goals but I do not think that is what they need. They will all turn up on their per deums and have fun but the African condition is about not putting into practice what you have been shown as was brought into sharp relief on my last night on of this long run when I was summoned to a retained placenta of some hours sent down from a health centre some where. That is not much of a deal but having pulled it out I was asked ‘What about the baby and I saw in the cheese counter a wet cold gasping mite wrapped in a wet blanket and, possibly more worryingly a very wet and steaming heat pad. This is now the third such baby that has arrived and once again the midwifery staff were sitting round folding gauze squares with bovine stares and total indifference to what was going on. Making a baby warm and dry is not rocket science, a naso-gastric tube and some sugar might help and then a little maternal cuddling and you are in with a chance but do they think about this, do they hell.
I was for the first time a little snarly as I was when the lady had not had any heparin as could not afford it. If we cannot do anything why bother to have her in hospital?
Myself I have to cofess tofalling into the registrar trap of not examining abdominallbefore undertaking a vaginal delivery as I coul see the caput. Thirty minutes later having lost all self and I suspect others) respect and surrounded by every available instruent i had to admit defeat and section.
I will put the picture of the slightly beaten up infant on in the next few days as i do not have the technology with me at the moment.
As I write this we are back in Addis and have totally failed to get the paper work together to keep the car in the country nor had the opportunity to drive further than Gimbie, and ironically just about getting the geography of Addis sorted. So tomorrow another bone jarring journey, this time down south and across the border to Kenya, where we will leave the cruiser for a few months before moving there ourselves. I am tinged with regret but now have had enough, though my plans for a year are in ruins…Ethiopia is a donor culture that is rigid and unhelpful. I am now firmly of the view that it is time to close down the cash flow as most of it, no probably all of it is wasted squandered or used for political or personal gain. Any dealings now should be on a commercial basis and come with costs. The government is arrogant, officialdom more so and as the people see so little benefit why bother. If as may be the case there things to get out of the ground like minerals by all means do deals to get them out, buy the coffee (remembering that the government are exploiting the farmers) and be commercial. All the water schemes and such like are placed where the cronies are and the opposition is not there (members are all in gaol) so I think a little more deprivation may produce a little more reasonableness and one day Ethiopians ( a proud race they say) may actually have something to be proud about. The shout in labour is Malo (help me) and of course I will but is it not time they also started helping themselves by effort rather than to the hand outs, and perhaps by applying some of the cascaded (buzz word in NGO circles) learning (ugh) that they have been paid to receive or by actually learning to think for themselves – a novel thought indeed. Ethiopia is indeed an infuriating, strangely beautiful but hopeless place. Until they learn the secrets of reactive contingency planning and the concept of ‘can do’ rather regulatory negativity they never will. By the way the E- ranger motor bikes that could be ferrying all these eclamptics, retained placentae and obstructed labours to a place of safety have not arrived as the order did not include the spare parts and these are subject to tax, and that is not in the budget….see what I mean

Faranj, you,you you Give me money

So here we are back in Gimbie, with the timeless rhythm of calls to labour ward, previously undiagnosed malpresentation and unresuscitated haemorrhagic shock and incomprehensible problems in outpatients, most of which are uresesolvable. This is interspersed with people asking for sponsorship, the latest being a sister doing computer studies, some one wanting to give away her 2 year old so she can continue her studies and general impolite demands for Hori (money) as you walk the streets. One of the troubles with having got the land cruiser over here is that it marks you out as rich and therefor deserving of even greater efforts to extract cash from you. The fridge, despite having spent the day outside with various ‘experts’ working on it is still at least room temperature, but then who cares as dried beans seem to keep for ever.
The two chickens, having recovered from the loss of their new play mate but now resolutely not laying again, have been allowed out and even wandered into the sitting room today. Perhaps with their new found freedom they will find secret places to lay eggs so as to ensure that the thought of a fresh egg is a thing of the past.
Splendid banana and raisin cake for Karen’s birthday which was celebrated with orange juice, a trip to the green bar and spaghetti napoletean, washed down with South African red.
I decided that a spare tyre on the roof of the cruiser was a temptation too far and have now with the help of Abdi (semi orphan in as much as his mother is a maid in Nekempte some 200 Km away and never sees him so he lives in a house with 5 others and does not have sternum which means you can see his heart beating through a thin membrane and I think causes him some anxiety, it would me) who shot upon the roof and helped me down with the tyre and to put the spare in the boot and did not ask for a Birr. He was rewarded with coke, cake, pencils and a rubber and seemed to trot off happy. Meanwhile we get shouted at from behind the compound barrier which is a little tedious.
As a welcome change from beans, we had cooked by Sophie Thai red curried pumpkin and rice, washed down by me with a dwindling supply of orange squash as I was on call and by others with beer (St George) or red wine according to choice. Pumkin itself like so much on the menu here is a little bland but the curry was a welcome change of taste. As above I spent the night playing registrars.
We had a successful skype link with the charity AGM in Brighton but were only able to see Adrian and they only silhouettes as lighting bad here and we were able to talk about our nascent projects in a generally upbeat way, but as is the way in Ethiopia nothing is certain except the undoubted need to go to an office somewhere and get another stamp. There is a round of this coming up when we do the hellish journey to Addis later this week.
Jabber continues to do well with intermittent high quality care and intermittent neglect but looks quite cute if drowned in his new western clothes. What though of his future? So far my implantation seems to be holding up. This is despite a serious bout of infection having found her on the ward unrousable – apparently from some time earlier but probably regarded as just sleeping, it being well known that 60 year olds with urinary trauma and who have been allowed to lie completely flat for some days regularly have no blood pressure, no urinary output laboured breathing and complete unconsciousness. It is apparent that my attempt at major surgery is about to pop her clogs, and more important cost her relatives a small fortune. It transpires that she thought she had a prolapse and was due for the free dress shoes and neckless, not a nasty cancer and lots and lots of complications. In passing you should know that there are no reagents in the laboratory and all we have to go on is no urine an improbably high blood sugar and an improbably normal white cell count – she is a little hot but the thermometer is missing. ITU time but no ITU so we improvise with some out of date dopamine, an oxygen concentrator and having raided our dwindling supply of batteries an oxygen saturation monitor which is not giving good news. An added difficulty is that our ITU expertise (Karen) is up in the boondo some where and dosages were never my strong point. (You try working out 2.5.micrograms per kilo per minute when the solution is 8 mg. per ml. and god knows how much a drop is, but then when finally in range we get the answer - 30 drops per minute). (The patchy telephone coverage by the way suggests that the richly funded (they hope) Danish project may be dead in the water.) With many visits now 10 days on she has actually survived all this and is actually sitting up in bed a bit. Discussions with Gordon (of Fistula hospital fame) suggests that we can get the stent out in 10 days (surprised?) as if they do not leak by then and she has not leaked as yet they will not do so. There is however a paucity of equipment with which to do this.
The land cruiser, predictably is becoming a disaster area with now only two weeks to run and the various officials becoming ever more unhelpful with the smiling helpful faces with which they impart this information which is as ever, ever changing as the sand and sadly the sands of time shift not in our favour although some say that our fully insured carnet paid etc. car can theoretically stay. The desire to stay and help the venal dishonest and donor recipient culture we have entered is now wearing a little thin so we may, rather sadly from my point of view (deep down I must be some sort of medical masochist) be moving on which means that I will be deserting my garden and chickens. The latter rather irritatingly, having become very free range have started laying around the garden rather than sensibly in their nice house but we have had so far a nice local omelette from them.
Ethiopia remains sadly an outstandingly rigid and closed bureaucracy and is unable to help itself. Their credo is summed up by the shout you hear all the time on the street- faranji, you, you, you give me money. They deep down do not want to change their poverty, ignorance, unquestioning culture or the fact that nobody can be seen to fail when failure is the norm, but that failure is never anyones fault and did not happen anyway. The important thing is we go on getting money from faranj, big faranj for big projects (Chinese for roads, Bharanians for flowers and any old Brit you can con as apparently we are big aid givers on the big scale and any old visitor on the small scale. I have recently finally cracked and given £5.00 so my erstwhile Oromo teacher whose translation is not what I hear going on around me can have some rotting sugar cane infected dental stump pulled out, though I am not supporting his sister through computer school and I have set my face against new glasses for a nurse and continuing wasted educational support for the whole of Gimbie.

Not quite sure what we will do with the automobile but Karen has set her face against admitting defeat and putting back in a container to the U.K and her anti Ethiopian Officialdom and grasping culture is high so we may take it down to Kenya and move there ourselves which I see as something of a defeat but she a new adventure, however things there are gloomy but not decided, surely they will in due course be recorded. What I do not want to do however is teach laparoscopy to the fat cats of Kenyan private practice in Nairobi.

One of the reasons why this blog has not been updated for a while and if I have any followers I apologise, is due to the travels to try and sort out the car and lack of access to internet or time to record the immediate thoughts and record them so I can share with you. So much happens and is so immediate that the immediate absurdity is lost so quickly so will try to make amends. I return to be greeted with parting Danish doctors returning to bacon cheese butter and other luxuries having imbibed precious commodities such as wine and departed with our Ethiopian resident leaving me in sole responsibility so dear registrars I am you with no respite and if I am good no recourse to alcohol for the next week. In addition to the endless vaginal repairs with their slightly septic look and grey re-used packs looking a little yellow and giving off volatile sulphur compounds like a mouthful of crowns there is now a steady trickle of serious obstetric mishap either happened or about to happen from Asosa some 200km due west, desert and the home of 200,000 souls and no obstetric care. On the ward is a 22 year old who has been fitting for three days, delivered by forceps on arrival of her surprisingly alive baby but deeply unconscious, with fixed dilated pupils an complete renal shut down being treated with fluid restriction. On my arrival on the ward it is apparent that she is brain dead and within a few minutes, sadly just dead. This to my surprise produced a temporary show of emotion from the midwives with wet eyes, the only real emotion I have seen since arriving. Such is the social scene hereabouts, it appears the mother of the recently deceased has a child of one that she is breast feeding and has produced some milk for the baby and will probably take it on, so out of disaster there may be some resolution however sad. Equally sad is that she failed to get simple and indeed free medication that might have saved her life. Later another fitting proteinuric refugee arrives but this time delivered and with malaria-is it cerebral malaria or eclampsia – transfer to physicians after some Mg SO4 and so far no further fits so their problem.. In ‘House of God ’terms this is what is called a slough!!. However 3 days on she still looks pretty blotto to me and is just lying there but no more fits. Although this sad this is medical sad so really have to keep my distance.

So life for the rest of this week when not worrying about the car and not being able to make contact ( I write this off line as the internet is down) I will do ward rounds on my own punctuated by gynae clinics mixed with obstetrics extremely dodgy scanning and obstetric emergencies, there is quite a lot of obstruction around here. Life does not change, those of you in theatre will know as my trousers seem to want to fall down, no longer pushed down by bulk but by being a bit loose! Karen says I was virtually baring all while suturing some tear I had caused having abandoned the multi use no suction kiwi cup for a pair of strange looking forceps with no fenestrations and finding that there was no scissors to do an episiotomy and the baby was not very happy there being loop after loop of cord around the neck. Some of you may know that Ethiopians do strange dancing that involves swaying a lot and I suspect that this happens in utero too giving rise to multiple cord problems. Perhaps dancing is an instinctive trait like chickens following their mothers? Remarkably I delivered a baby today without any meconium. Interestingly also saw an 18 year old with a three year old fistula which is high and close to her cervix, her pelvic floor being largely intact. In another place this would make a very interesting laparoscopic repair and here would do well at laparotomy but should probably go to Addis and they get the bus fare from maternity World Wide for a while at least. Also asked to see a 10 year old with a history of sexual assault, though happily did not looked damaged to me. I suggested that an HIV screen might be appropriate and as my note had to be typed it came back as tasted for HIV rather than tested, but I think like many they struggle with my hand writing.

So as I survey my garden, freshly sprouting greens and increasingly bold if largely barren chickens, obduracy of Ethiopian Authority means that we are likely to be on the move which is sad for both the research, which may well bear fruit and the adventure but equally I am sure that further if possibly tamer adventures wait. A little flexibility would be a wonderful thing.