Addis, Djibouti and then.....

So we are into our final week and although I remain fairly laid back the ‘so much to do and so little time to do it’ pressures bear down relentlessly.  The car is stalling a lot and intermittently  producing volumes of black smoke adding to the growing hysteria.  The internet sites to are producing dire warnings of the difficulties of obtaining Djibouti visas, which has had the added frisson of requiring a letter of support  from the British Embassy, an organisation that is dedicated to leaving British subjects bereft of any help, if it actually deigns to open or publish its rather elastic opening hours.  There may be a little help on the horizon as a phone call to the Djibouti authorities suggested that all that was required, other than the usual multiple photographs was $140 in cash per person.  African exploitation is alive and well here in the horn of Africa.  Our trip to Addis last week coincided with the exit of the medical director’s wife, who could stand no more and was back to the home state of Malawi.  They required dropping off at some guest house, of which they had only a scanty knowledge of the geography, sticking another 2 hours on the journey, and when they arrived decided that it was unsuitable so travelled on with us.  Sadly Lion’s den, the usual hostelry has been declared unsuitable, uncomfortable beds, crap showers poor breakfasts etc. and we have been moved away from the Greek Club, nice ambiance, splendid salad and wine by the glass.  Instead we were installed into a guest house which was newly opened and a little disorganised but comfortable enough if in the Addis equivalent of Twickenham.  This may have something to do with Camilla joining us as this is clearly where she feels at home.  Addis itself was fairly trying as the African Union was in town so roads were blocked off everywhere and we were not allowed to stop, so much so that I was forced to abandon Karen and it took the best part of an hour to do the back doubles to get her. (You will understand from this that we are now beginning to understand the local cartography a little better.)  Also in need of rescuing was the aforesaid Camilla who was either abandoned or escaped and found wandering down (or was it up) the Bole road as we were going for supper, before picking up our guests.  Unusually for this part of the world they arrived early (mid meal) so we had to send off a greeting party which was nice as they were able to join us, though Adam has been laid low since.  Buying all that soft paper seems to have been a good thing.  Sadly attempts to buy a picture to take back with us continue to stall, through lack of agreement and the somewhat touristy nature of the ones I like (vague shapes of priests in rock hewn churches).  However as Karen has had enough there may not be the need for many memories but we shall see.

Our long planned trip to Addis coincided with my oppo’s need to register his wife on some course the other side of Ethiopia so with these priorities the population was abandoned for a few days to a visiting obstetrician on call from the hospital down the road.  I arrived back to taking call and sorting out the hypertension of many days. Some poor soul had ruptured her uterus and lost the baby but was a least alive to tell the tale.  Nasty moment when she said she was leaking urine but happily this turned out to be retention issues so will not need the trip to the fistula hospital.  However I continue to be on call and there is as yet little sign of returning Ethiopian obstetricians though I live in hope and look forward to a gin and tonic.  Visiting 16 year old is embryonic doctor, so with only one fainting episode has been joining  the group that moves around with me. Jen, all bouncy enthusiasm, has declared the bus ‘impossible’ and required a lift to Asosa to catch the plane leaving Emily who has taken Adam under her wing and shows promise as an embryonic missionary doctor, she even beats him at table tennis pointing to a past of travel or youth clubs.

So back at the coal face it is business as usual but with some surprising cost savings as the hospital at Nejo (clearly the relevant doctor has gone away) had the wit to put two women with obstructed labour in the same car so they both arrived simultaneously producing the potential of some interesting ethical dilemmas, particularly - labour lasting some time – as both babies were not reaching their happiness potential, but as luck would have it one was deliverable vaginally.

This was duly pulled out with a second or third hand KIWI cup which is not something I will miss as they invariably break suction at the critical moment and spray unmentionable fluids at you which you are ill dressed to cope with.  The baby inevitably needed resuscitation which was managed with much greater competence than hitherto which was pleasing and when not sucking as a little shocked, they spontaneously put down a tube and gave sugar followed by breast milk.  Progress in deed.  Happily the shortly delayed a Caesarean produced a meconium stained (well they all are here) but otherwise very fit baby.

We went off to Aira Hospital to look at the labour ward book and pick up an Ethics letter and it was very muddy, causing me to put the land cruiser in the ditch at a rather perilous angle, there being a very deep hole in the middle of the rather narrow track which I had been trying to avoid.  Lots of sliding cursing a diff lock but with the directions of a helpful minibus driver and Karen we managed to extricate ourselves with nothing other than a few scratches (to the car not us). Predictably none of the documentation we required was readily available and the only way we could get the required letter was to track down the administrator who was doing a conflict management course (I kid you not) in some local but not easy to find school.  Permissions granted though with some suspicion,  we were able to look at the relevant books but were upbraided by a belligerent doctor who thought we were spies.  Bureaucracy delay and paranoia remain part of the Ethiopian culture and will I fear take a long time to change.  As I very gingerly did the return journey later I was given the evil eye by a larger bus  driver who could not understand what the fuss was about.  Next day was not so successful as we failed to get the car up a steep and muddy hill with a precipice off left so after the usual extrication, go back, we had to abandon the trip.  Our last mud extravaganza now is the trip to Addis.

So as we pack up and the stream of Ethiopians to our door for rich leavings grows ever longer, what have we achieved?  Hopefully we have shown that warm fed dry babies survive even when small and certainly they try much harder and this small development may be the best we have achieved.  I have demonstrated that oxytocin in primigravid women can work as well as a caesarean even (horror of horrors) if there is meconium about though at some personal cost as initially I had to sit there for the rest of the delivery.  We have tried to persuade the women with real risk to come to hospital with some result and a few have survived their obstruction, anaemia and even sepsis, for these individuals a result but for sustainability, well that’s another day.  I hope that I have also shown at least two individuals, that targeted radical surgery can certainly bring symptomatic relief at little cost and for probably the majority an improved survival if not cure and that the surgical practice of a different generation is what is right for the facilities available.  We probably have to resist the siren call of the instrument companies who are selling laparoscopic equipment and I equally, though it would be fun, have to resist the temptation to teach laparoscopic surgery to the private practitioners queuing to service the burgeoning middle classes of Addis.   Personally despite the downs the fatigue the squalor and the lack, a great adventure – possibly one that I would repeat, but would I have company?

Pearlygate

Visits of the great and good on ‘fact finding tours’ however brief and the latest such visit was brief achieve little but do destabilise.  So it was that a senior Adventist doctor arrived for 3 days achieved nothing but subsequently uncovered further debt in this debt ridden establishment where any accounting practice let alone good accounting practice seems to be non- existent.  Much money has been given for building projects, the result of which is decaying lumps of concrete but little in the way of concrete building, the rubric being that the money was diverted to running the hospital paying such essentials as salary.  Now it appears that in addition to essentials, holidays of American staff, car costs for travel, per deums (see blogs passim) and general living of ex pat Adventists have left holes in the accounts of several thousand dollars.  So it is good to know where all this charity money goes.  Certainly there are no published accounts.  However, has the arrival of ‘fact finders’ now two groups of them achieved anything?  Answers on a postage stamp – of course not.  Grandiose plans to build new buildings for the theatre, when the autoclave only works courtesy of a rock to appease a yet to be appointed surgeon who wants to do orthopaedics, when most of the staff remain largely demoralised, demotivated, and underpaid with little incentive in a failing institution whose management is divided between two fighting institutions.  The major players in these institutions, the church in Addis and the Adventist docs in ‘Lo Melinda’ southern California seem to be at loggerheads and refusing to meet each other so probably little will happen but as it has been here for some years now the hospital itself will go on lurching from crisis to crisis mis-spending  what little resource it has while remaining in the hands of Adventist children planning their next away day on what funds are available.  As they are all on tourist visas  and have no qualifications the schools and hospitals depend on the registered qualifications of such Ethiopians that are around for their registration, if of course they bother to get it and use of these qualifications do not come cheap – back handers all round chaps.  Meanwhile I shall pay my bill for the rebuilding of the mortuary like a good boy, the penalty for allowing homicidal orphans into my car, the ultimate irony of charitable giving I suppose.  Meanwhile the new medical director’s wife has had enough, and bought a one way ticket to Malawi and a free ride with us to Addis, and he moves into our lovely home when we depart but is unlikely to take on either the chickens or my ‘care in the community’ gardener, thus the sustainability of  my market garden is now in jeopardy.  I say market garden but my ‘greens’ are given away to vitamin deficient faranjis not sold.

Venal misuse of charity funds is not of course confined to religious organisations and, although on a smaller scale is rampant locally too.  The departing ‘program manager’ has set off on a family visit, prior to his departure to a BBC money laundering  operation, taking with him the charity car and forcing the hire of alternative transport adding to the costs of both the charity and the project fund.  Cycling money really well spent and no one about strong enough to say no.  The as yet to be appointed successor will be looking for his own fiddles soon enough. The dear departed is already fixing for a mate to step into his shoes and doubtless travelling Danish charity execs will see it his way. Working for ex-pat NGO’s is clearly the way forward as it seems to allow you both decent housing in Addis and access to furniture at a cost that would make you wince in the Harrod’s sale.  Sadly the charity for which we give our services spend more time with infighting than delivering help (sorry training to potential helpers, who are as demotivated as the hospital staff).  Meanwhile, the now voucher free (and therefor have to pay) wretched rural population will continue to struggle in with their obstructed labours  where at least this faranji will go on trying to rescue them and pass on a modicum of common sense to the sudden explosion of ex pat medical students that infest the place, the local midwifery students having declared some sort of holiday, it being the rainy season.  This particular wretched girl had been in labour at least 24 hours with a head firmly wedged and despite a fetal heart , a baby with fixed dilated pupils that did not get off the cushion that passes as a resuscitaire hereabouts.  A tutorial for the locals on obstructed labour this afternoon I plan.  I now understand the pointlessness  of partograms in these parts as no one labours anywhere near one, they arrive fully dilated and clapped awaiting miracle cure.  However access to miracle cure is only available to those with vouchers, Ethiopian post code lotteries again.

For those who have been following the cancer story I am pleased to report that the ureter has stayed in, and the woman gone home, if not cured at least symptom free, so hopefully some good done and all the money spent on her not free loading.

Meanwhile the delinquent puppy is now due to move on to a third  or is it a fourth home as it it’s propensity to eat small children and everything else is becoming a problem, has a future as a guard dog me thinks.  Message for faranjis – no dumb chums.  Far from dumb chums two chickens also be rehoming and the new tenant of this house is not showing much keenness and they are now absurdly tame, even preferring their tomatoes cooked.

So, forget the big picture, forget the petty and not so petty manoeuvrings of the organisations, just concentrate on the person in front of you and do your best for them – individual sustainability.

Miracle Worker ?

Currently there are 3 very junior and very advenist medical students in town.  They are all from the deep south and all very out of their depth.  The urban myth purveyed by the visiting U.K. near graduate is that they are so frightened of ‘germs’ that they have stuck paper from an exercise book over the place that they keep the loo paper so it will not get germs on it.  As the hospital cess pit is very close to them and overflowing, this being the rainy season, germs I suspect abound.  This is by way of introduction as I have probably unwittingly now increased their faith evermore.  As first year medical students, their exposure to the thud and blunder world of obstetrics had yet to occur until their arrival and their first visit to the OB room (labour ward to you and me but best described as a ‘birthing shed’) coincided with some previously undiagnosed twins in the late second stage.  The first delivered easily but then our problems started with a high but undefined presenting part, lots of limby type things to be felt through the membranes and a fair amount of blood as the first placenta was trying to come away.  The portable scanner was unequal to the task and the fetal heart difficult to detect, in fact not detected.  After a lot of thought and not wanting to rupture a uterus or possibly maim or kill a baby, together with a request to permanently put a stop to any more babies (if this one survived it would be 7 all told) I opted  for the abdominal route.  I explained to the young visitors that this baby may well be born dead so they immediately asked permission to pray (something that one could hardly refuse particularly in this environment) and they asked for divine intervention in this case when the heart could not be heard.  Yes you have got it, the baby came out asleep with a lot of ketamine on board but has survived to tell the tale and to confirm the hand of the Lord, Sister Susie, the nun from Ecuador happened bye with some visitors from California, thus confirming the ecumenical nature of this miracle.  The Lord works in mysterious ways……., but for some with faith I am sure it is strengthened.

I am hoping that divine intervention will help in another direction as in an attempt to introduce some sustainability into the cancer project I set the two Ethiopian’s up to do the next case, so they could carry on the good work, one helping the other, etc. etc.  Disaster as in macho efforts the uterine and ureter got confused and cut, not good in this cancerous field and with the cervix beginning to disrupt.  So trying not to be too snarly I made them finish and finding, surprisingly that there was enough give, have stuck the ureter into the top of the bladder.  So far, no leak, no loin pain and no temperature, so far so good.  However I am concerned that the sustainability of this project is uncertain.  Given that we are completely dependent on a small funding stream sustainability is dependent on funds, who knows what will happen.  However as proof of concept we are to a degree winning and it is something that I would like to continue doing. 

This may prove a little difficult as job opportunities are in smooth private hospitals that want laparoscopic surgery and the primitive rural life, and local scandals are taking their toll on those around me, who are now looking forward to a return to the land of Waitrose and kettle chips.

The tediousness of petty pilfering is also taking its toll as once again the light bulbs that light my path and shine on any waiting Hyenas, as I trail up to the hospital in the shades of the night have once again been purloined to light up others rooms, particularly irritating as the supply of AAA batteries is beginning to dry up too and the uneven steps have the added hazard of being muddy and slippery. These are however minor irritations as is the inability to keep a biro for more than a day.  We came out with hundreds but are left with but a handful, the others like most of our possessions being sold on in Gimbie town.

Meanwhile the usual politics have been accentuated by the decision to put all the guards into quasi military uniforms (olive green) and restrict visitors so the wards are half empty and disgruntled visitors are now another loose fingered rabble through which one has to pass as one enters or leaves the hospital.  The ‘big cheese’ from the Adventists has also flown in on a damage control mission and the staff have already been writing him anonymous letter saying how awful it all is, as they are undervalued, underpaid and under resourced, two of which are almost certainly true and he too is in for an interesting time as ‘e-relations seem to have broken down between him and the current medical director, whose sojourn here is now going to be short lived and his wife escapes next week leaving him to bachelordom and hopefully when he moves into smaller quarters (ours) the company of two chickens providing they survive the ovicidal attentions of Camilla’s puppy who spent the day either chasing them or nibbling me, the latter requiring corporal punishment, which seems to have done the trick.  Camilla, now the new temporary acting project leader, Mosisa being off to pastures new, though at what personal cost I know not,  was persuaded to take on an anarchic puppy which was spending a lot of time here, biting me and chasing chickens.  However with a week in the U.K. and a disastrous attempt at rehoming with the Ethio-American couple (sh*t all over the house) has now gone to the recipient of all that is in need of succour, Mackebie, so we will be inspecting Jabba for bites on his Saturday visit as well as for signs of his continuing Tinea Corporis (ring worm).

Sustainability, a failing dysfunctional hospital, a factional and riven NGO, venal idle and incompetent health centres and surgeons who cannot be let loose on their own, divine intervention required here too I think. 

Addis Interlude

So after an extremely muddy and slippery ride we find ourselves in Addis, obstensively to celebrate my birthday but more importantly for some relatively gourmet experiences, the power of excessive lentils having finally taken us to make the journey, which is longer than that from London to New York.  Not as gourmet as you might think as we have endured a Chinese meal of such oiliness that my fat free diet of the last few months has now been blown and it was served in a wind tunnel that actually blew the mosquitoes at you.  Karen is also paying the price of some other meal with intestinal hurry which adds another layer of discomfort to her intermittent febrile illness.  Discussions in the car and over coffee reveal that the Gimbie rumour mill has credited us with all sorts of sexual misdemeanours and proclivities that might be rather fun if they were true but are laughable as they are not.  The source of the gossip is the local ‘bad adventist’ drinking club at the ‘Green Bar’ a small all male group but transmitted by farangi gone native with much to be gossiped about.  Our consciences are entirely clear but there is much rustling of bed covers and much else in our little microcosm.  Our charity is melting down with the imminent departure of the project leader to pastures new (a BBC charity probably as loosely organised as this one) a farangi shoe in temporary replacement and a deeply dysfunctional local work force.  The hospital too is in turmoil as bankruptcy threatens, the work force has not had a pay increase and is in mutinous mood and inevititably the patients (such as can afford to come) are even more ignored than before.  The employment situation however is such as there are no other jobs, they have all been there for years and are far too frightened of moving as that would require effort, so they will just go on bitching and pilfering as before.  Even, sadly the new medical director has had enough and will depart in December, though his wife given half a chance would be gone yesterday, and the Adventist hierarchy is in turmoil, such that the church elders want to sack everyone and the seemingly terminally arrogant head of Adventist Health International is due to fly in on the equivalent of a ‘needs assessment’ visit. I say this merely on hearsay but this is on good authority, I have never met him and probably not being of the faith never will.  There is of course lots of needs assessment but little in the way of needs met.  As news of our impending departure filters through so do the visits of vultures to our doors to see what we might leave behind for them and the requests for clothes, sponsorship and money all become more urgent.  I have it mind to say we are going a week later than we really are and then ‘steal softly into the night’.

A visiting and very enthusiastic medical student has joined us, and virtually moved in.  this may be to escape from a bunch of first year, innocent and barely coping Adventist girls from America and we have set her to work trying to find out what happened to various women who have delivered in the health centres.  What is revealing about this is that all though the notes have covers with numbers written on them (seemingly random as men seem to have babies) the papers inside are bare of writing, the only note that I have seen is in my hand!  What is so sad is that the care offered in the health centres is so poor and so rudely and arrogantly delivered that the women vote with their feet.

Faranjis (us) with portable scanners and a smile get 60 odd women coming and we are able to give some sort of advice about where to have babies etc.  As an example of how sad  it can be, I saw some wretch who had attended 4 times, thought she was term and had a 22 week sized dead baby which had clearly been that way for some time and gone undiagnosed, despite gifts of sonicaids and all the rest.

Somebody also turned up with a fistula of about 4 years duration but they at least get free treatment and free transport.  The fistula hospital which I am about to visit is also in turmoil however having also been the subject of something of a putsch, though more of this later.

The two are probably not related but my departure coincides with a flurry of cancer patients and hopefully the skills passed on to the Ethiopians I have been training will bear fruit but I think that they will be scared of doing them without their hands being held.  However both I think will be on the move having learned what they can and also with the prospect of me going do not fancy being on duty one in one.  This may be a good thing though as I am encouraging them to build cancer teams and that might make a difference.  Screening too may in some nascent way become a possibility as someone wants to do pap smears.  So if there are any old Aylesbury spatulas and fixative about do save them.  What of the cancer?  The operations are possible even with big tumours, and can be achieved with relatively little morbidity, mostly wound infections, which I do not entirely understand as the caesars are relatively unscathed and so far reasonable clinical clearance.  I have found it difficult to persuade the pathologist to look at the vaginal edge and I am not sure that the formalin is a s strong as it could be given the slightly putrid smell that accompanied us to Addis with the last four specimens.  This mixed uncomfortably with the smell of vomit which always seems to occur when charity dictates that we fill the car with indigent freeloading Ethiopians piling in the back for travel to Addis or elsewhere.  We have tried to contain this with aircraft sick bags but they will not use them, merely steal them.

On a brighter note, having got the fetal monitor to work after a fashion, there is a lot of noise, I have achieved vaginal deliveries with inert primips pouring meconium, with the judicious use of oxytocin and a lot of patience.  More gloomily however the Adventists are getting more toxic about abortion, despite desperate pregnant unmarried teenagers who may well do themselves damage by going off to the back streets or abandoning their probably hypoxic and brain damaged babies, once they have delivered themselves at home.  Few misoprostol tablets and all would be safe, but then we move in strangely contradictory circles.

Venalmalignancy

For much of the time I have assumed that the Ethiopian condition is brought about by incompetence but I fear that the combination of grasping venality and cynical manipulation suggests that something much more malign is about.  This thought struck me as I saw various off white coats and our new (but shortly to depart as he cannot stand it) medical director down by the incinerator hut burning boxes.  The smell of cardboard mingled unhappily with that of plastic which I was to learn was that of many blister packs of just post- date drugs that would now no longer be able to help the needy.  These drugs it would appear are actually provided free at the point of use by the government but delivered, with the usual mountain of paper work when they are about to expire.  That is to say with only two months to run and as they know when they are about to expire they can come and do random checks, and hey presto the hospital is in trouble and a nice big hefty fine.  Meanwhile, blood transfusion sets (ones with filters) have run out and there was a plan to refuse blood to the seriously anaemic because of this.  I explained that the odd small clot would just block the cannula and not the vein but they were not happy.  Given that the planned recipient was about to die, (or expire as they say in these parts) with a haemoglobin of 2 gms I felt that this was the least of her problems but they were still being difficult about who was going to pay.  Currently too the charity to whom I am increasingly loosely linked is handing out free drugs (bought from the same government warehouse) to the local health centres in an effort to redress the imbalance set upby something called the 30-70 rule.  This seemingly sensible idea is that only 30% of a charities money should be spent on administration the rest given over to good works.  Problem is that ‘training’ is administration and readers of this blog will know that all our particular charity wants to do is train, so in order to redress the balance give a few sell by date drugs but only the sort that have the going cheap stickers that you see in super markets and that allows you more on your 30%, get the picture.  It also turns out to be a nice little earner for the health centre, or at least their employees too as might be expected they are sold on to the punters.  The antibiotics are probably useful but not many actually need the methyl dopa for their blood pressure and without careful monitoring actually probably counter- productive. (Venal and malignant?)  As the effort goes into training so the available funds for care fall away and there are now few health centres that have vouchers which does at least mean that my nights are less disturbed but the Government hospital takes the strain but only limited resource (this remember is going to health centres).  The result of this and probably chronic lack of planning was that there was an urgent call for cord clamps of which the charity store revealed 3, the result of some calamity when there was nothing in the government hospital to tie a new-born cords (not it seem even the apocryphal shoe lace), so a gauze was placed over the cord as the unfortunate bled to death, incompetence of an astounding malignancy in probably a very overcrowded area.  The local obstetrician who is competent and nice is clearly at his wits end and there are plans to expand, but need has to be shown.  How many have you got to allow to die before you show need and how many would receive at least some care if they were given a voucher, but no education is all so an institution with facilities and capacity is starved of funds and will probably close. (To be fair there are a lot of problems as well) while the institution down the road will drown and the punters will feel it more sensible to deliver at home and some will rue the day as they turn up too late (malignant planning, forcing disaster before change or just incompetent planning?)

This particular institution is particularly cash strapped at the moment, made worse by falling maternity income, but the employees who would otherwise vote with their feet work in an area of chronic unemployment so just have to stay, stay demotivated or beg (never borrow) or steal to survive (venal?).  Certainly the begging is increasing and the theft will certainly rise the former certainly and the latter probably as the date of our departure approaches.

Intra partum care now is largely care in the second stage and the combination of hypoxic encephalopathy and meconium aspiration is difficult particularly when useful drugs like phenobarbitone for neonates is not available which makes treatment difficult.  Not insurmountable though as you can take an adult tablet dissolve it in dextrose and pop it down the nasogastric tube.  We are getting a bit of explosive diarrhoea though but at least there is some breast milk.  The meconium aspiration, well we do have a little way to go.  If she had come in earlier and maybe that was cost it would have been a different story. (Malignant choices?)

A safe place of birth for the majority is I fear a distant fantasy.

 We seem to be running short of wine, now that is definitely a malignant change!

Closing debates

One of the things that Ethiopia’s poorly trained rural health service has been foisting on their local populace in an effort to keep the population down and to offer treatment for miscarriage is something called MVA which stands for manual vacuum aspiration and is basically a vacuum curette attached to a 50 ml syringe and I have even been persuaded to teach these locals how to use it using ripe avocados (quite enough of that) though personally I am not sure it has much to offer over some misoprostol under the tongue, but never mind there we are or were when I got the usual summons but this time to a 40 something old who had had this procedure some distance away and was not well, barely conscious in fact and very septic with a reported white cell count of 39,000 (normal range non medics up to 12) and a large abscess in her pelvis. After such resuscitation as is available a trip to theatre where I planned to just drain the abscess until I saw the state of her uterus but this was trick and the combination of blood loss and acute sepsis prompted sadly her demise which sadly is the way with overwhelming sepsis.  Of course she leaves 5 children, some of who were big enough to give her some blood with a little arm twisting but was her grubby initial surgery really necessary and could she not have got access to appropriate treatment before it was too late.  Probably not, this is after all rural Ethiopia and sepsis is the biggest killer but I still wonder if I had just drained the abscess she might still be ill but also still with us. 

I tell you this story as I despair of the health planning.  There are hospital but they are basic and cost but yes we do save lives.  There are health centres, they are very basic and theoretically free, but the staff are poorly motivated badly paid and by and large very poorly trained.  They are there because they have to be there and have no choice.  They are serving time before hopefully getting a desk job cooking the figures for the government and they care little other than to flog the odd free drug to increase their income.  Their rudeness to the patients is staggering and you might think that this is the lot they put up with, but most of the punters vote with their feet which is why there is so little take up of the service.  The pity is of course that if the service was taken up more things might actually get worse not better as the off the wall treatment is often worse than no treatment at all and the two things that might actually save the odd maternal life, misoprostol and magnesium sulphate are not allowed. My only contribution has been to persuade them that 5% Dextrose run fast can produce enough energy to start people contracting again and get the odd vaginal delivery, but things I am sure will soon slide back.  Simple things like welcoming your patients, giving them advice pertinent to them and exploring with them how they will get to hospital in reasonably timely manner if things do not work out well will go a long way to tackling MG5 (maternal health) which is nowhere near there but I am sure that the book cookers will sort that.  Investment into some sort of transport infra-structure would however be the biggest contribution.

Last Monday was a bank holiday here, celebrating the fall of the ‘Dirge’ (the communist lot) but as one Ethiopian wag pointed out (and Ethiopians with an overt sense of humour are rare) what they are actually celebrating is the change from overt to covert communism and you do have to ask what us NGO workers are doing, and more importantly what is our government doing, pouring so much resource into an environment that really just squanders it, but then it is probably more to do with the bigger political picture, it does after all contain the Somalis to the coast where the American Seals can blow them out of the water if they get too close to a ship.  Meanwhile the government here continues to bully, humiliate and despise the NGO workers, what they really want is the money not the people and probably they should get neither, but Chinese and others would come rushing in to fill the gap so we will doubtless just go on giving them the money -   A mad world indeed.

Meanwhile the organisations for which we volunteer seem to be going through one of their periodic convulsions about which I shall have to be careful as a local reader would be mighty cross if I was to tell all, but promise all will be revealed on or about 07 August.  Suffice to say many are looking for new jobs or may even have got them, some relationships are closer than they should be or is healthy and others are very strained indeed. Happily ours is not included but we are dispensing tea and sympathy while blithely pretending all is well.  The Adventist too, have their problems both with paper work and a general desire to maintain the status quo at all times.  I am told that when the work force come for discussions with their faranji counterparts the translating big wig Ethiopians who are all related start by saying that they are going to be told off but it is alright as they will protect them.  The problem however is bigger than this as the hospital is failing and there is a rival (probably equally failing but government supported) up the road and the withdrawal of safe birth fund funding means that a great proportion of the populace remain unsupported and the government hospital has not the resource.  MG 5 is indeed a long way off.

NB For those of you who do not believe in disproprtion see below!

Crossing The Rubicon

So it is two months to go before we pack up Hercule and head south then east for Djibouti then return home.  The assumption in this statement is that he will start, one of the batteries being a little suspect and spitting acid everywhere and that the outrageously expensive repair is up to it.  The back is clearly a little crooked and one can see the hammer marks where the trim has been ill returned as the majority of trim fixing screws are lying in some oily puddle back at the yard.  To call it a garage is too bigger a step of imagination.  We have also done our bit for global warming as they seem to have disconnected and not reconnected the air conditioning so much Freon has departed for the stratosphere to add to the world’s comfort blanket.  However the comfort zone that was Hercule is now the dust bowl of yestermonth.  I have been advising a period of R&R in Addis but the pressures of research mean that this may be delayed, the protestant work ethic being alive and well.  However the new medical director and his wife who have carnivorous tendencies commissioned the passing of a lamb so we propositioned for and acquired a leg, yesterday (Saturday being Sunday in these Adventist parts) we had lunch of roast lamb with mint sauce and apple crumble, the taste lives on and a jolly occasion it was.  Baa Baa did not die in vain. So we have now crossed the ‘Rubicon’ and are on the home straight to mix our metaphors.

Having just finished a fairly bruising 7 day stretch of continuous on call I have been getting more than a little growly so it was nice to say that I was not going near the ward for a couple of days or more particularly out patients which would try the patience of a saint. The stories are incoherent which would probably also be true if you could speak more than half a dozen words of the language and you could ignore the feeling that you were consulting in a Britrail ticket queue where someone had painted out the red line as the punters and their friends and relations crowd in and out of the room and have random loud conversations with each other the nurse and anyone else who happens to be around.  The outpatient nurse knows everyone and certainly knows all their secrets so they are all greeting her like long lost friends.  I have for some time now abandoned anything other than the most rudimentary history taking in favour of examination and basic ultra-sound but this has been stymied as all the ultra sound machines are now caput and we are relying on a 4” screened portable where the world of shadows (for that is what ultra sound is) is reduced to a few squiggly lines.  This does not stop the hospital charging for this service but it certainly adds to the difficulty of trying to fathom what is going on.  Previously no one knew their obstetric dates, or if they did they are sometime in 2004 as this is the Ethiopian calendar and I could make an intelligent guess but now no more.  This means that I am so nervous about induction that I put it off until they are so post term that the first contraction spawns a dip and a caesarean that delivers a baby covered in meconium.  This is though the norm around here.  Called at 4 in the morning and barely awake I applied a ventouse and as I was pulling the baby down it dawned on me that not many babies in these parts have white hair, so I ruptured  the membranes and all was well.  Less so the other complication that I have only ever read about, which was being called to some slightly preterm twins’  The feet were already at the introitus.  All was going well until the shoulders stuck and on disentangling them I realised that there was another head in the way, interlocked twins.  You are supposed to do disgusting things like cut the head off and I actually got a saw and was about to start when I managed to twist the head and dis-impacted the interlocked chins and deliver the now sadly dead twin followed by the sibling who lasted a couple of days before succumbing to some bleeding disorder.  All very sad.  Otherwise the litany of obstructed labour and mal-presentation continues but can be dealt with, usually with a satisfactory result.  However complications like severe haemorrhage and infection are more difficult.  If you want to clear the room of relatives, who gather ghoulishly around the bed at these times, just say (through interpreters of course) that unless there is a blood transfusion death is on the cards and they will all magically disappear.

As in Europe bank holidays abound in May in the horn of Africa too and today is no exception.  Bank holidays mean no outpatient clinics so I volunteer to do the day, Karen being out an about on her travels expounding the benefits of birth preparedness.  Things start badly as the unsecured battery (thanks again Greg) has finally shaken itself to destruction spilling acid, cracking a thick copper wire and draining the other battery.  This is a bore as the back is now un-open able without electricity and yes you have guessed it the jump leads are in the back.  Problem…..eventually solved by moving third auxiliary battery to position of second, ensuring second does not become an eco- hazard and that fingers are not going to drop off from acid burns.  Car starts and should be OK but await distress phone call from Karen.  Cannot believe that batteries are anything but mega bucks in this part of the world especially when they see a faranji on the horizon.  Will need to enlist a tame Ethiopia to help.

Forward planning however has a long way to go as my visit to the OB (labour ward – more labour cubicle actually – to you and me) coincides with a lady with twins, 1^st one out and the second breech and unhappy resulting in yet another blood spattered pair of jeans.  I am very grateful that the HIV status in these parts is as low as it is or at least reported to be.   Next door is a lady who has been in labour for some hours if not days with a high and unguessable presenting part, but who cares there is only one way out and survival is on the cards unless the poor chap decides to try a little in utero breathing and get the meconium soup that will be his bath fluid.  The last meconium aspiration is so far surviving to tell the tale, is sucking but still oxygen dependent so a way to go.   If ante natal care, such as it is, was more directed toward forward planning many could be rescued but I suspect that like millennium goal 5 (the maternal one) is a distant dream rather than reality which is the ever present nightmare.  Crisis management has always been a bit my thing but crisis management here is just part of the every day routine.

So as our sojourn draws to a close the next few blogs will reflect on achievements and failures, sustainability is probably a myth but some small babies survive, some mothers have survived and a few women with cancer of the cervix will survive, at least symptom free for a while.  The state of Ethiopia and its struggles will live on for quite a while I fear.

Post code lotteries

So here I am, only obstetrician in the hospital and used to relatively peaceful days and nights when suddenly solids and air conditioning come into distressing proximity.  First up is a lady from Ganji (the where is important, stayed tuned) who pitches up with a hard tender uterus, vaginal bleeding and not well with a low haemoglobin (5gms) and no relatives up for being blood donors.  Life is a little complicated as the old scanner is now the defunct scanner and has joined the pile of undisposed of aging ordnance.  The new scanner is of course awaiting repair and even with my best efforts to get it somewhere to be repaired this is going to take time.  As best as I can establish and she is not well enough to do talking and as I cannot understand her and can barely understand the nurses we are in difficulties.  However my presumptive diagnosis is an accidental haemorrhage (bits of placenta falling off inside) and I decide she is going to deliver so accelerate this.  Mindful though that the obstetric axiom is ‘it is the APH that threatens but the PPH that kills’.  While coping with this more trouble arrives (from Homa) in the shape of a 18 year old girl, recently aborted (? 20 odd weeks odd at that age and difficult to get family approval for abortion, one wonders about traditional ‘healers’) with in this case a haemoglobin of 2gms and very unwell. One relative, reluctantly willing to donate but incompatible and another apparently on the way.  Adventist faranjis and visiting medical students have their uses so one doctor, one medical student and two missionaries later we are at least circulating some haemoglobin but coughing mightily from heart failure, have an exciting transfusion reaction, or worse pelvic sepsis, pyrexia and only limited oxygen from the oxygen concentrator.  How about a little Lasix (diuretic) I think.  Problem, despite having been rescued by the good offices of some generous beyond the bounds of duty faranjis, Lasix has to be paid for, and who pays….(I am fed up with carrying money as it only gets nicked) but they come from Homa and Ganji and in the post lottery world  which our charity has created they are the chosen ones and entitled to vouchers to pay for this and other highly probable expenditure given the severity  of their condition.  If there was a critical list they would be on it.   I sadly however would not as I would be regarded as too old if such things actually exist.  So off I trot with the notes and letters to the MWW office to get vouchers and stop having to negotiate life saving drugs.  There is one person in the office as the others have gone off to organise school plays about the dangers of dying from haemorrhage if you do not seek help (no I am not making this up) looks at the very scruffy and clearly written in a hurry paper work and declares it invalid as it either has no stamp (very important here) or the wrong stamp or the stamp in a wrong place.  So in the post code lottery of life we have a missed call  and I am back to negotiating drugs.  Meanwhile some tosser, has raised the possibility that the temperature is due to malaria, TB or worse so I return to the nurse now wearing a mask (she is pregnant and anxious) and trying to do her nursing from a distance.  ‘Do I still need to do her vital signs, would every 8 hours do etc.’ and various other patients and their relatives now demanding her removal.  As is common in Ethiopia all this is acted out in front of a Greek chorus of standing watchful men and the ward is bulging and there is much muttered discussion, but I tell them to sod off.  (The Oromo word is Demi).  As I write this she is still alive though with very stiff lungs but 18 and tough.  I am told today that some vouchers will be forthcoming (perhaps a little embarrassment) but the sheer inhumanity of charity aparachnics in desperate circumstances is at best staggering.  The other lady duly delivered her fetus in a puddle of (old) blood confirming the diagnosis and is strangely quite well with a haemoglobin of 4 gms and not a donating relative in sight and all available faranjis already exsanguinated.  The hospital is currently having a cleanliness campaign (the wet season is not an ideal time as it is very muddy) but not down here as the place is hotching and with a further APH 5 Caesareans and two forceps later I am beginning to feel a little weary and any thoughts of cleanliness a distant memory.  In a bizarre Kafka like moment a member of the less compliant emerging middle classes of Gimbie refuses a Caesarean for her meconium, irregular fetal heart and 1 cm dilatation, but to be honest by this time I am too tired to care and when the contractions become more painful (and they will) so I can sleep for an hour or so before my 04.30 am call to play white knights.  Happily all is well and although a little shocked the baby is well and not like it’s  neighbour fighting for breath with meconium aspiration (well not yet anyway).

Sadly in all this chaos there is one avoidable still birth for which I am very sad.

Followers of this blog will know that Hercule (the Belgian land cruiser) is away having his rear beaten as land cruiser repairs take longer than head wounds so Karen is at the mercy of borrowed transport and managers to hitch a lift with the MWW DK players off to entertain schools with stories of maternal disasters and how to avoid them.  She is dropped at Ganji health centre (post codes remember) where some 30 odd women await her to get valuable individual ante natal advice (‘You have had a caesarean section, go to hospital to have your baby, You have twins did you know that, your blood pressure is very high etc.)  and come lunch time, the world stops for lunch here which must be either communist influence or a hangover from the Italian occupation and her interpreter is flagging, the Gimbie players fail to stop and pick her up.  Apparently they only have 45 minutes for their Injera and Watt or Shiroo and are in a hurry so a 15 minute walk through the town to shouts of Faranji, you, you, you, give me money is required for sustenance, which together delays the onward running of the clinic and the extra 20 women who have turned up will have to wait another day.  Having rushed their lunch the players are in for disappointment as apparently an unannounced exam has trumped school plays and discussion so they are sitting waiting. (they could of course have been ferrying but no that requires thought or even a little thoughtfulness).

Fortuitousness strikes however as, possibly with the knowledge that there is a faranji about a young girl who has been in labour for 20 hours and unsurprisingly has uterine inertia has arrived.  The highly trained and valued health officers have not been sure what to do, and the labour room was probably locked (it usually is but is now opened when Karen is there) so they have put her to bed and are waiting (what for you may ask – disaster?).  The visiting team contains a competent midwife and a doctor so a dextrose drip later, oxytocin being not allowed, contractions start, but the fibrotic ring that is all that remains of a mutilated vulva requires excision but the scissors are blunt but with a little chewing and an aging Kiwi cup you will be glad to hear that all was eventually well.  It is unlikely however that their little adventure will allow them to reflect on where their efforts should best be spent, trying to ensure safe care in the community and at hospital (assuming they have a chance of getting there) or teaching school children about what to expect.  If I was a teenager in Ethiopia I would go on depo and stay on it until I could join the middle classes and refuse care.

Interesting times again!

The photo of the baby is a severe meconium aspiration which i did not expect to survive but against all odds is getting better and the labour ward is after that night.  Cleanliness is next godliness but one wonders if they are causally related.

Business as usual

So with bruising settling and stitches out but scabs difficult to resist it is back to business as usual or at least sort of, naturally of course the local tittle tattle and politics continue unabated.  The ward remains quite quiet as the only way you can get through the door now is if you have money or you can get a voucher.  Money means middle class and they arrive with gold and their own sheets, so not difficult to spot.  Voucher means one of 4 local kebelles, mostly in relatively rich coffee growing areas but high on the hills (thus transport difficult) there are still problems and mostly the problems we see were (currently no car) scooped up by Karen on her travels, I think they look out for her now, and then brought in for derision and neglect at the hands of our caring midwives.  They are of course currently a little pissed off as the withdrawal of birth funding has been withdrawal of their extra pay, and with that of course good will.  But then of course it is a damn sight safer than being at home.  Recent e mail correspondence suggests that a similar scenario may soon be being acted out in the U.K. as pension raids are taking place.  One of the bores of all this patient transport stuff apart from the odour of unwashed body (not their fault, no water) is that lack of access to wheels means that they are very prone to motion sickness.  Partially digested injera, when projectile, which sadly it usually is, has a smell all of its own which engenders greater nausea, so the results are not pretty and the carpets only partially protected.  The water tank at the back has proved particularly useful on occasion.  My idea of producing sick bags purloined from our recent travels has worked reasonably well but they are clearly useful to those who have little so if not used for the designed purpose they are nicked and used for carrying chat or whatever.  However all this is in the distant past as currently the wheels are in Addis being panel beaten (we hope) or just open to the elements and partially repaired then abandoned in the wet season.  As we are not there and the stories of progress, or more likely lack of it, are increasingly vague who knows.  What we do know though is that glass is very expensive and there is none of this insurance stuff.  This has driven Karen to hire of crappy taxi (unreliable and picking up fares at her expense when not broken down on the road) or use of hospital car.  Remarkably helpful and allowed to drive it on her own until urgent calls for its return as urgent letter needed delivery.  Sounded suspiciously like administrative cock up to me, but these are an everyday occurrence here.  Forward planning is not well developed in these parts, which is another parallel with the NHS at home I suspect.  Although ante natal care is at best scanty some messages are getting through as a 4 foot nothing lady with a previous scar and dead baby turned up at term and surprisingly not in labour at the clinic in time for her this time successful elective section as did another, so 4 lives saved which is I suppose a result.  The lass with severe pre eclampsia and an equally severely growth retarded baby is doing ok despite continuing to pour all the third spaced fluid through her wound but the supply of NAN (baby milk) is running low and her supply of breast milk is equally thin, so the situation is a little bleak.  Not as bleak though as for the wretched child next door, who was like the majority of babies here was plucked out of the womb with fetal distress and thick meconium but unfortunately decided to breath some of it in with predictable results.   So antibiotics, fluids and oxygen, though concentrators so not much of that but still in with a chance.

Meanwhile our sponsors are busying themselves with drug supplies for the supported clinics, as the available drugs (largely unnecessary methyl dopa as not much chronic hypertension rather than useful magnesium sulphate and no even more useful misoprostol as bleeding kills) and sadly limited supplies of iron.  They actually have quite a lot as they sit there out of date.  I wondered why and the answer is that they are locked away and those doing the clinic cannot be bothered to get them.  That possibly explains why I recently saw someone quite anaemic being sent away with 4 folate tablets.  The government however is now apparently giving away iron (high time too) but predominantly to ante natal women though if they were sensible they  would horde them for their post natal use as it is when they have bled and they are trying to breast feed is when they will find them most useful.

Why though you may wonder is all this ‘obstetric ordinance’ being bought.  The answer, like to most things here is of course political.  The charity in order to survive has to show that only 30% of the cost is administration, though in fact most of its costs are salaries or expensive car journeys.  What better way to offset this than give away a few tablets, drip sets etc., then these can be locked away until they go out of date.  Locked away unless they get stolen, by of course the person with the keys……..When you do get to them they are so mean that they would worry a homeopathist.

One of the things that seems to mark the Ethiopian situation is the inability to get it together either chronically or acutely. I was persuaded to an Adventist peripheral clinic last week and saw 21 people the majority of whom had come on the off chance that they could get a free prolapse operation, which is a pity as the ‘prolapse tourists’ had left some weeks before and had had nothing to do for the last two days, let’s hope that if and when they return in November that these poor people will return as advised and some one will know that there is a team approaching.  Acutely it is sadly business as usual too with acute fetal distress at full dilatation.

Car(e)less in the Community

As part of ‘care in the community’ we offer friendship succour and entertainment to assorted feral orphan boys and finding activities for them apart from eating or pilfering can be challenging.  With a very dirty car and an upcoming wedding what better than a Saturday car wash.  Remember that in this particular compound Saturday is Sunday and what traditionally do the British do on a Sunday, yes you have it- wash cars.  So with assorted boys in tow I set off with hose and rags to get Africa off the paint work.  All goes well and off comes the red dust with repeated hosing and it actually begins to look quite clean, boys being responsible and doing quite well.  Time for the inside, which is as dusty as the out so one boy in the boot, very dusty and one in the front to do the windows….big mistake as child seriously irresponsible.  While supervising the back and standing there I am suddenly while shouting ‘obscene instructions’ I am trying to stop the car rolling back, fat chance as I am knocked under the car and watch in horror as the petrol tank passes over my nose and the wheels pass perilously close and rocks scrape my back.  A loud crash, tinkling of glass and I come to a halt and am struck that there is blood all over my glasses, can not see a lot either.  As I pull myself from under the car to screaming Ethiopians and chaos (all in under 30 secs) I hear the young lad scream ‘it was not my fault’ to which I replied ‘yes it bloody was’ as I watched them scarper down he hill, hopefully including the wretched child in the back who must have watched in horror as he hurtled down the hill toward the wall.  I dread to think what might have happened if the wall, appropriately to the mortuary had not been there.  Anyway car (see photograph) in wall Ethiopians screaming and panicking and Karen walking up the hill with screaming cook and foster mother to Jabba.  I want to get the car sorted and ensure kid in back OK, apparently he is as Karen saw him run off.  So with Karen saying she will sort out car and with blood streaming from my head I avoid going to very grubby ER and head off to find my surgical colleague who will be watching Manchester United matches with my oppo, arrive point at head and arrange for him to suture it in clean OR facility. Meanwhile creaming Ethiopians metamorphose into silent hopping around vultures and I worry for the spare wheel tools etc. which finally get roughly piled into the car back seat, thereby destroying the cleaning to date.  A truly wonderful country Ethiopia. Hope to do this relatively peacefully but no chance as whole of maternity Worldwide, Hospital and any other hanger on turn up to look at my bleeding head and naked chest (glad I have lost some weight) and they have looked at my shoulders but miss the very large graze on my bum….(good).  So still alive (which I could easily not have been) as falling under the tyre might have produced a lot of crush I return home and change my shirt and apply pressure to still bleeding head.  As I believe is an Ethiopian tradition, the world arrives to express condolences, gawp and in one case tell me that the view in the local church is that it is a punishment for working on the Sabbath (He works in mysterious ways).  In amongst this the feral lads return together with their Adventist sponsor and bringing with them a wilting poinsettia probably plucked from our garden path en-route.  She explains that Matty, the culprit, was just goofing around, when he put the car into neutral and probably released the hand brake when he should have been washing windows, nearly killing me and his house mate so of course it was not his fault.

Lots of hand shaking and not seen them since, but it does raise some questions as to whose fault it was, if one wishes to apportion blame.  Youth fails test of growing up and behaving responsibly and does have to take some, perhaps though I doubt it he may learn from it, particularly as he will be being reassured by the Adventist connection that it isn’t and he sadly given his background would not recognise responsibility if it stared him in the face.  The soggy American view is I am sure that his little psyche must be protected…hmmm.  Perhaps I should not have let him near the car or told him on pain of summary expulsion and no more pop corn and films not to touch anything.  Perhaps we should have ensured bigger rocks.  Perhaps the advice we were given about not using the handbrake too much with the park facility as sand gets in the drum and wrecks things is not as good as it might be. So perhaps it is all my fault (bound to be it always is)for trying to give assorted street kids a purposeful and fun afternoon.  But it is only metal (granted expensive metal) and brick work and no one is seriously hurt.  We even dress and steri strip the youngster in the back of the car’s foot, given the inadequacy of the attempts by his current carer, the milk of human kindness indeed runeth over.  The view I tend to is ‘feckless irresponsible little shit wrecks car, nearly kills friend and me and has no idea what he has done’ and, sadly probably never will, it is unlikely that he will have learned anything from the experience other than he can get away with it.  The Ethiopian lesson, sadly which I have yet to learn, is trust no one!  That may not be entirely true, though the failure to give the car back in a driveable condition at the last service suggests that is as the car has now been driven to Addis by the nice hospital driver and is hopefully being beaten back into something like its original shape though I suspect that it will crab down the road now, and parts are difficult around here, not much chance of a new window let alone two bits of door, and lets not worry about the wheel carrier as that was crap in the first place and has already caused considerable metal fatigue.  So hopefully the all filler car will soon return to us but I doubt at the promised time , that measure is pretty elastic around here. When you see it in ‘Auto-trader’  move on down.  Will we continue ‘care in the community for the little lads, deprived, hungry and now homicidal…watch this space.

Bloody, battered but unbowed.