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.