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.

Care in the Community

Care in the community knows no bounds as Karen (though not for a while, see later) trails off to far flung Kebelles, health posts and the like with her scanner personalised risk assessments.  She occasionally takes me too, but I have to confess to feeling rather spare as there is a queue of the pregnant who have walked miles to see her and a scan and few who would give me the time of day.  Their stories are appalling with a litany of stillbirths and near death experiences the details of which alter by the moment making it difficult to give any advice other than come to hospital and we will see what we can do.  Best avoided though are domicillaries, as organised or rather black mailed into.  Take the lady with twins of blogs passim whose husband spends his time taking up valuable clinic time telling of bleeding pain etc. post caesarean of now some weeks if not months ago and his wife’s inability to travel.  Granted she lives in a windowless hut some way up a hill and at our inaugural visit darkness and lack of facility did rather make assessment of any problem difficult but anyway there did not seem to be much of a problem however another visit was demanded and acquiesced to…..

So after an interminable clinic, a lunch of shiro and dhabo (Karen currently has shiro poisoning) we set off for a home visit, to collect the patient, take her to a health post which may or may not be open (it wasn’t) where there may or may not be an examination couch (reputably there was) putting the land cruiser (Hercule or Tintin it is after all Belgian) through all its paces we arrive, wait for her to make it down the hill with assorted relatives (making it down the hill and presumably again upwards answered the question about her general health) but then loading her, twins remarkably still alive and husband together with 2 nurses into the car we set off to the local village and a private health facility which allows us access to the examination couch.  Not much can happen at the village as we are soon surrounded by many hangers on who do not do the usual stand and stare but struggle to get a view through the window requiring much shouts of ‘Demi =go away’ to get some space.  Needless to say scar ok uterus involuted and just general fatigue so purchase some iron and diclofenic for her and wearisome journey back after some hours of wasted effort.  On the way back we acquire another passenger who having heard of the service walks to find us and get a lift back to the health centre and yes another scan.  Advice, as yet not taken was to come to hospital as she had yet to have a live baby, two previous still births one in a ‘private facility’ and one I think on the road!

Another lady then appears in an Isuzu truck, allegedly bleeding and requiring attention despite my rising irritation and desire to get home so I was I fear rather short and hurried and perhaps did not explain my vaginal examination as fully as I might, causing some familial complaint about my bedside manner, which along with my reserve of human kindness had long since gone.  The only thing I could find wrong was some haematuria and my prescription for ampicillin was rebuffed by the local pharmacist as contra indicated in pregnancy when amoxyl was not (why???) anyway by that time I was beyond caring.  Another pregnant lady, also turned up with scaly lesions all over her probably psoriasis but I tried to do some skin scapings to look for fungi but the microscope reqired sunlight and sadly (and unusually) the sun was in so all I did was draw blood and receive another dent in my reputation as the caring doctor.  I did not add that our various passengers were all vomiting copiously by now.  Finally off home with a lady leaking liquor over the seat from her fetal abnormality, firmly clutching an airline sick bag we had nicked on our travels but happily not needed and equally unhappily not returned so down to just a few bags now.  So with my fund of human kindness now at an all time low we return late to various orphan boys awaiting pizza supper and film for which we are late.  But missionary zeal being all we do our bit and give them much of the limited supply of cheese.  They then get the lion king and popcorn with American sugary butter before being escorted off the premises, leaving a sugary muddy foot imprint extravaganza behind them. I wonder if the ancient cave paintings were actually children’s parties especially when I see a perfect foot imprint on the floor.  I arrange for them to help me wash the car next day….read on and begin to think that my life as a medical missionary might be limited.  Next day I wonder if my life might be limited.

Mechanical Trials

As readers of more politically correct blogs will know already, our carefully prepared landcruiser suffered total brake failure despite apparently having the brakes checked both in the UK and Kenya, causing Karen to accelerate down hill backwards at a rather alarming rate and then drive back for 2 hours plus on the hand brake.  It would appear that one of the back pads was so worn it disintegrated and caused the calliper piston to come right out with total loss of brake fluid.  We replaced these, not an easy task but it was apparent that the disc was also very worn (thanks again preparers) so a trip to Addis was in order. A new disc and a service later (during which our Oromo dictionary and a set o I POD ear phones took a hike – thieving bastards) and a few nice meals, we set out again for home for that is what Gimbie has become noticing that car starting was becoming a little sluggish.  Various warning lights, mostly to do with brakes started to come on, which we were told was to do with computers needing resetting etc.  We were told all was well bar some bearings (good service chaps) and continued on our way when even more lights came on so stopped to investigate.  Not a good idea as it was apparent that there was total electrical failure.  Happily we have an auxiliary battery (a better, and in Greg terms) only good development so christened the jump leads and setoff back to Addis, hairy as one by one more systems failed ending up with complete failure on the Bole Road diversion, which is a bit like Hyde park Corner at 5 pm.  So with cars shooting by I wired the 3^rd battery to the main battery with the jump leads, taping them with duct tape to the side of the car in the hope (springs eternal and this time successfully) that they would not fall into the fan system, but meaning I could not close the bonnet or hood to my American readers, so a fairly difficult last few kilometres back to the garage, where it became apparent that during the service they had disconnected but apparently not re connected the alternator or more probably just knocked  the wire off but even standing on a wheel, we had to do a lot of repairs and changing as there were nails in them, it was not the easiest thing to get at – but have power again now.  But what I do not understand is that with most cars, when the battery is not charging there is a large red light, not apparently though with this.  So now apparently we have repaired tyres, blown up to the right pressure, working brakes, tracked wheels, fresh service and all well.  Sadly not so as on the next trip back ‘home’ on the final stretch, braking round corners on the tarmac causes the ABS to come on rather dramatically bring the car to a vibrating and rather alarming halt, making me think that one of the brake sensors may be buggered.  When I have worked out what the button saying RSCA off does, I might try that. In the meantime the tyres may be a little hyper-inflated as they seem a little slidey on the rocks that pass for a road hereabouts but we shall see.  At least we are all in one piece and so are the wheels. I we go on doing this perhaps mechanical night school is called for.

However the trip to Addis included a visit to a (by Ethiopian standards) swanky private hospital by me, as they want to start laparoscopy  and endless trips to government offices by Karen in her quest for ethical approval.  Karen definitely wants her ethical approval but I am less sure about my desire to teach Ethiopians who have yet to pass the diagnostic laparoscopy hurdle how to improve their private practice by doing laparoscopic hysterectomy, but it may prove an interesting way to pass a few months.  Life in Gimbie although it takes up a lot of time is now at a slow pace as the vouchers dry up and one treats the worried well and with less of the high drama stuff than hither too.  I hope that those who are not coming are making it to other places but I know not. MWW however plough their furrow and who knows where that will lead.  Instant and equally instantly forgotten education I suspect, and with the rather dodgy supply of newly qualified and outstandingly incompetent midwives one can only guess and tremble. Care in the Adventist hospital has its limitations but by and large it is safe.  There has been a faranji invasion with a clutch of medical students on their elective visiting so much of my time is teaching them, which is interesting but not what I am here for.  If I can get them to think a little though perhaps I will have achieved something.  They are quite fun to have around.  Maternity worldwide personel are however a little isolationist and being predominantly a hospital worker I see little of them but given the rather back bighting politics that may not be a bad thing.  Equally I am pleased to report that the cancer project is going well and may actually make a difference.  So three months to go and Adventists in trouble with inadequate funding, MWW up their own fundament and general lost despair.  Adventists are praying for you I think!