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!