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