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.