So from all the jollity of weddings etc. to Kafka meets Monty Python. There are currently three of us and one down the road but now after a meeting and the usual coming to no particular conclusion (very similar to the NHS here) and we all sit in one tiny consulting area seeing patients in a totally chaotic environment as they get filtered and sent on. I wish I had my copy of ‘Bluff your way in ultra-sound’ as most of the punters are dating scans and I am not sure where the on off button is (Brenda come back all is forgiven) but the others are all to keen and Karen keen to learn, so I try to look knowingly in the back ground. It is not however at all clear to me what happens when they leave the room or if they ever come back, but there are an awful lot of breeches about and no very good plan as to what happens to them though I try to give them plans-perhaps I will find myself doing some breech deliveries. The other houseman game I have had to be playing is screening patients for the ‘prolapse team’ due to arrive in a fanfare of American ‘second coming trumpets, though there is a lot of discussion about where they are going to stay-one thing is sure not here. Most prolapses and they are big but with tiny atrophic uteri in them are quite impressive and largely described as polypoid growths that extend out so far that it must be difficult to walk. Human ingenuity being what it is though they have invented all sorts of things to hold them up, plastic rulers and the like. If anyone wants to send me out some shelf pessaries they would be a great help. My first laparotomy was a pelvic mass 4 months post Caesarean, which we should probably in this environment draw a veil over but suffice to say it would be an SUI elsewhere of the x ray identifiable variety, however happily no harm done. Sitting in out patients a women presented herself with bleeding in the late midtrimester, but nu apparent pregnancy on the scan-at which time she told us the baby was in the loo-where we discovered him still alive. Now 4 days on we still have primitive intensive care with hot water bottles, an oxygen intensifier and thanks to the internet and Paul Crawshaw a feeding regimen. The mother has now produced some breast milk and an interest (previously missing) so there is still some hope but a long way to go. I have done my first, wearying, night on call in which I was called to a baby with a temperature, God knows why but good tone and lively-cracked and treated with ampicillin and seems better (even managed to work out the dose). Then had to deal with my first multip OP a failed Kiwi cup which is not something I know about then failed manual rotation and forceps-strangely shaped with a solid blade- and finally a Caesarean section at 3 am and all well despite spectacularly suturing the front wall to the back and leaving the non existent lower segment, actually cervix floating in the breeze, but discovered what I had done and rectified the situation so no harm done except to my pride! I put it down to the appalling light but in reality I think it more related to my relative out of practice state. Later further section for failure to progress in previous C.S but happily head high. Knackered I go to bed for the morning but am kept awake by God calling up the hill. I fear that I was taking Mohammed’s name in vain. The endless unintelligible and untuneful dirge that rises from the valley is actually something to do with the orthodox church-3 am today which is pushing it more than a bit however I am told it is much worse on saints days of which there are many so can only go down hill. Out- patient clinics of which there seems to be a continuous stream vary endlessly from dysfunctional bleeding, post- menopausal problems to ante natal care and just now stage 3b Ca cervix with a hydro- nephrosis. There is only one radiotherapy machine in Addis with a 6 month waiting list and quite a lot of money to have treatment which they cannot afford so situation pretty hopeless. How much of this they take in, who knows and they drift out of the consulting room probably never to be seen again. Back on call I do a tubal ligation one hour after delivery under local and she goes home a few hours later. She is the oldest at 30. Both caesars had steris and they are only 25 but that I believe is quite old in these parts.
Our up market mud hut (it is apparently made of mud) is becoming home and we have visitors, not least thieving hooligan monkeys one of whom nipped in and stole two bananas and then I found his head peering round the door looking for more and we have also had a film night with pizza and popcorn.
So what are our reflections. The baby has been particularly taxing as it has been difficult to get the Ethiopian nurses to take an interest and we cannot sustain 24 hour nursing ourselves and if we are to try and do something it does have to be sustainable, but now they seem to be taking more interest but are also slightly resentful of being watched. There is clearly a need for low tech small baby care but equally a long way to go and there are real issues about the sustainability of such interventions but it is difficult to watch babies die of dehydration and cold. There are many, largely poorly trained, pupil midwives about whose role is to stand and stare but it would be difficult but rewarding to put them to use caring for these young. There is a long way to go and no easy answers. There is also an underlying feeling that despite the poverty and general grubbiness there is no desire or will to change and the various NGO s achieve relatively little as they are frustrated at every turn and that much of the valuable asset is wasted. Certainly the breakfast conversations I eavesdropped on in the hotel in Addis which seemed to be a meeting place for querulous visiting charity representatives and prosperous looking local representatives needs assessment and scoping with very little doing or delivery and there is scant evidence that I have seen that aid gets where it is needed, but early days. The other issue, local visitors aside is aid tourism as the effort, costs and time involved in getting out here has to be worthwhile in terms of what can be achieved and has to be useful to the population rather than an adventure for you – yes of course it is rewarding to resolve difficult situations and you will learn much of how you can cope with really very little but the only value to the community of coming is to leave skills behind and that is where the real difficulty lies as imparting skills and knowledge is very difficult in these circumstances and to a group that I suspect feel that what they are up to is fine and are resentful of interference and people telling them that they could do it better (which manifestly they could) and deep down it is the way it is and cannot be changed.
Thus I do have mixed feelings about prolapse teams swinging in to do lots of operations and fistula tourists all of whom are coming in to hone their own skills rather than leave a cadre of people behind who can both deal with these problems but more importantly stop them happening in the first place by better obstetric care and reduced family size.

To be continued……….

So, Gimbie here we come, devastatingly early wake up and luggage dragged downstairs to await land cruiser, sundry passengers and an improbable pile of luggage including scarce to obtain items in Gimbie such as milk. All luggage finally strapped to roof and on our way at break neck not to say white knuckle speed avoiding wandering goats, cows humans and even monkeys with a fine disregard for blind corners, brows of hills or white lines courtesy of Chinese engineers who still have to finish a peculiarly grizzly 120Km. Finally we arrive at the hospital and our new ‘home’ a bungalow that has stood empty and unvisited for a few months, with that typical musty smell and worries (unfounded thankfully) of little visitors who have made it their home. That night and the following day we set to work with various sprays, fairy liquid from home and a mop that has seen better days to clean and prepare. Now vaguely habitable with a mosquito net that looks like an anophelean super highway to sleeping skin it has so many holes we are settling in. A trip to the high street was greeted with the usual cries of farange, you, you, you and give me money, and the inability to buy any cutlery at all (they eat with injera and their fingers) and with the sad news that the haven of the European, Jimmy Juice had closed through lack of trade. The recession stretches far it seems.
That night had supper of lentils and other pulsey looking things with our Danish neighbours and Clara. Danes greeted red fluid of vineous extraction with delight. Also there was the Ethiopian doctor who was nice but shy and quite clearly wants to do it all, which is fine by me but although a Farange I am the only registered specialist in the place. However I assisted at a tolerable section, and watched him do a postpartum tubal ligation under local anaesthetic without making the patient wince too much. The patients are largely thin with divarified recti so it is not that difficult. Ends of tubes have to be inspected as there is nothing like histology here. To add to the practice curiosities the caesarean section was performed using chromic cat gut, which those of you of my generation will remember well. With the Danes, local employee who wants to do it all and me we are rather over doctored at the moment or at least all the doctors are in the wrong place. Karen has headed off to the Health Centres today so look forward to her report with interest. Yesterday was even more bizarre with an invite to a local Adventist wedding, a glorious mixture of American Evangelism, largely, no totally lost on me because it was in Oromo and African dancing and singing. Much of the service and lacy dresses are however missed because the video camera is all and all you get to see is the butt of a camera man dressed like a break dancing rapper. The service was interrupted by bang of exploding balloons as the light man got to close to them, the inevitable bleat of various mobile phones and random people walking up to take photographs. Even the bride paused to read a message mid sermon. A curious custom is the best men turn up at the groom’s house together with the groom’s guests, including us, to dress him, watch him pray and eat something with elders of the church before accompanying him to the church. (This is when the first of a series of horn honking auto processions takes place.) We then hung around the church (there was at this time a power cut) while he went off to collect his bride, and leave her at the back to process in and then greet her and her family half way down the aisle, various brides maids and boys with candles processing before. All this was done to a rendition of the triumphal march from Aida (it has another unfortunate title too). There was some nice if slightly fractured Oromo part singing and some splendid African male voice singing which together with some ululating produces a splendid sound.
Back in the cars all squashed together we have another high speed honking chase to the wedding feast where we sit in rows in front of a dais where the major guest eat and enjoy the meal. Karen bravely went for the boiled goat, I went for the vegetarian option, rice and cabbage (yes I will be thinner when I return) and Clara trumped all by getting a spoon. Eating rice with bits of injera is a skill I have yet to acquire. All this was being endlessly photographed and videoed for posterity. There was a large multi-coloured wedding cake on display which was ceremoniously cut and fed to senior guests (a singular honour) and then put back into its box-we got chewing gum.
Photos continued by a rather beautiful old bridge, a relic of the Italians, before we all set off another white knuckle ride, briefly interrupted by one of the passengers having a road side chunder.
We were dropped off at the hospital while others went on to deliver bride and groom to their new marital home. A fascinating experience and honoured to be asked, but bride and groom did not speak to any of the guests at all-we were all there as voyeurs.
So first impressions are mixed, all superficially very friendly, roles yet to be established and the ‘need’ not particularly apparent in this hospital and not being addressed in the community in a way in which women are coming forward – we shall see how things go over the next week, month, year so stay tuned. As I close some religious activity has started coming up the valley-it is very loud and distorted-the Lord works in mysterious ways, his wonders to perform.

Addis and On

Well a week in Addis eating endlessly in the Greek Club because we could think of no where else to go, though latterly we have found a bar with football machines and cold draft St Georges in the friendship tower, also home to dodgy dongel dealer, several trips to get it to work and still very temperamental. Dodgy is however what it is about in that neck of the woods. People come and talk to you, not a bad thing you might think but next time tell them politely to F off. This one persuaded us that he worked for an Irish NGO, had a day off and would take us to good shops. shops ripoff and while he was chatting us up a small boy came and nicked my camera-far to close. Any way he gave chase and returned 20 mins later with camera sans case, and spare memory cards but with tough guy pretending to be (no probably actually)gangster and took 800 birr offme for returning it. 800 birr aprox 40 quid. So in summary I was mugged by an 8 year old-great! Have found micro brewery German style beer garden which was fun, but unmentionable things begining to happen in the transit times locally.

Other painful experience was driver conveniently parking next to pavement and on opening the door and stepping out-no pavement just 4 foot hole down which I descended to shoulder height. Luckily landing soft as full of rubbish though smelly, dusty and humiliating-motto look before you step,though difficult when you are climbing down from a land cruiser - no not ours - clutching computer cases and what ever. Theeek has been spent touring various government offices of varying degrees of scruffiness with long queues bobbing up and down on chairs and pedantic form checkers who seem visibly upset when they can not find anything wrong, so check again and again. Payment for a work permit 600 birr £30 involves going to one office where a receipt is written out, next door where the receipt is stammped and money taken, before going to two more offices for further stamps. Getting registered, tedious but friendly enough once the endless form checking was passed had held me up a day as i had topass muster infrony of some committeee (kafka again!) The same has to said for the British Consular office too who are both never open when you want to call, have long queues when they fleetingly are and treat you extra-ordinarily badly while signing photo copies of your driving licence at 900 birr £50 a throw, stirling or credit cards not accepted. You do not feel welcome in what should be a small part of England. at the end of the week I have a medical licence, rare it seems where we are going and awork permit. Karen however is one up having licence to stay and all the rights of an Ethiopian women but I am sure she will tell you about that. Long car journey to Gimbie now and more anon. Land cruiser import is just a matter of
enormous despair.

The journey not the arrival matters

This autobiography of Leonard Wolf sums up the travails of travel.  last few days in U.K stressy and with too much to do and too little time things inevitably got forgotten most spectacularly the spare set of car keys (Sophie please remember to bring them out for us!!)  Splendid farewell party and then chaos of clearing house (ha ha) and packing before setting off for airport and our first taste of Ethiopian hyper bureaucracy-weighing in-which results in queues of querrulous passengers and general bad temper.  Such was the chaos and also the breakdown of the duty free tills-Terminal 3 is appallingly shabby-that we failed the get Gin test so are sorely bereft.

Arrival in Addis marked by silent imigration man and being pulled by customs not for carrying unmentionables but for having a scanner and printer-needs taxing.  Much protest and looking smiling and senior with assurances that they will leave the country with me allowed me through-result!

The day was spent trying to get paper work sorted, hampered by Friday prayers, a closed consular section of the Embassy-stated  hours on the web site and actual hours on the printed sheet in the window are very different- suggesting that government cuts have hit here too.  Now not open till Tuesday.  Getting paper work is like snakes and ladders-we will invent a new board game called 'Going to Gimbie' when you start at Woking and via a trail with many mishaps you finally get there-we may even make it into a computer game that two or more can play.

Karen got her work permit in a day which must be an international record, though there was a near snake at the last throw of the dice as one government form did not have a signature but there was a copy.  So she has a little green book and I don't.  In order for me to get a work permit it seem that regtistration with the Food and Drugs Agency is required, but happily the paper work for this is in order bar a covering letter that needs to come from the NGO here and hopefully will appear on Monday as some approval committee meets on Wednesday so perhaps thing will happen then...well perhaps or perhaps not-stay tuned.

Had amusing lunch with old mate Gordon and got further insights into Ethiopian life together with some useful contacts which may prove useful in some of the training work we have in mind.  The local obstetrician I will be working with seems very young possibly even pre-registration by our standards so look forward to interesting times.  Also greeted with the news that a surgical team is flying out from Oregeon to undertake prolapse surgery-they brought a lot of equipment out on a previous trip which they hope is still there-it will either be unopened or long gone.  Anyway it should prove an interesting diversion.  i will be interested to hear of their adventures in Customs. 

There is no doubt that we are entereing an 'Alice in Wonderland' world and I am bagging the part of the 'Mad Hatter'.  Currently now having a totally inert week end but stay tuned for the further adventures of the 'Mad Hatter' (Bates hat of course).

Ethiopia update- nearing deparure day

Have pension will travel.  Took the lump sum in June and now doing my locum till end of this month and my successer appointed-good luck looking after the women of Surrey- Shaheen as we hopefully set off for Gimbie on 6. October.  Why hopefully, well although we have got the airline ticket we yet to have a work permit, a combination of bureaucratic obduracy and charity incompetence or probably more charitably ignorance.  Despite having had a number of volunteers it is apparent that they have never had the correct paper work in place.  work permit requests to the Ethiopian Charities agency start with the expression 'We humbly beseach........' do we now (!) and require a fistful of documents-certainly enough to tip you over the starter pack cheap deal in DHL.  Your original degree, not anything useful or relevant like GMC registration needs to be found (trip down memory lane in the attic) and this needs to be notarised, then legalised by the Foreign and Commonwealth Office and finally stamped and signed by the Ethiopian Embassy before being sent to the Agency.  Do you want me to notarise everything else that goes with it, such as supporting certificates health certificates, job offers etc.?  No no not necessary until you send the stuff over, wait interminably for it to be picked up and then turned down as 'job offer not notarised. Snake-start again, so not there yet!  other little money earner is length of work permit-should be s ix months but try and get more than three-so more trips to Addis I suspect-12 hour journey will be nothing as we will be able to buy food and more important wine so perhaps not a bad thing.  Work permit is probably good thing as web site says work without work permit = gaol, not a pleasant prospect anywhere-specifically one suspects Ethiopia.  Now this presents us with another snake-no work permit no permission to take a car into Ethiopia for personal use without paying mega bucks in tax, and car essential for escape from Gimbie and indeed to carry out projects etc.  Alternative is to take it out on a 'Carnet', as a tourist but this has its own problems as entry may be denied as not coming in on a tourist visa-all great fun if you are not the one in the middle.  With obstruction at every turn, I wonder if any 'volunteer' has ever had a work permit-certainly not in the charity we are going with.  The 'truck' itself is another story of potential venality if not incompetence as it required buying a left hand drive land cruiser in Belgium with very little guarantees that it would arrive and delays, evasions and failed phone calls to the level that you seriously wondered if it would...avoid internet dealers offering purchase of left hand drive cars.  When it arrived the tyres were shot the car unloved, suggesting a long time in a dealership and the paper work missing.  one understands that cars from Belgium have to have the Belgian equivalent of an MOT-this one did not. However some conversions later it is probably ready to go though I have not seen it for 6 weeks and when I phone to ask most things are about to be done, so we will see.  with all the extras it is now of course outrageously expensive so tax on admission to Ethiopia would pay for lots of mothers and babies to have care.  this is of course the main reason for going though on the basis of what is happening would seem to be what they are trying to prevent.  maybe, politics being all they are the wrong babies in the wrong place.

While we were out visiting we copied a year of the delivery book and have, with the help of the redoubtable Hazel been analysing this, a snap shot of the world of hospital obstetrics in West Wollega.  there are 1,500 deliveries a year of which 40 odd percent are paid for by the charity and probably represent the tip of the iceberg of the deliveries in the region.  Appropriately the majority are primips as most primips even in the developed world, with their untried pelvis, are probably best delivered in a institution that may but I hope that this is not a reflection on the care they get and their reluctance to return.  The Caesarean section rate is around 22% but mostly for obstruction and with a worrying number of dead babies.  Being a twin is also bad news, it is rare for both babies to make it.  Four mothers, all under 25 died in the year, one of eclampsia and the others of blood loss-preventable and unnecessary.  These statistics though, sadly are some one's child, sister, partner and their loss will be keenly felt.  How much more carnage, the result of a normal process, is going on the community is any ones guess.  We would like to do something sustainable to stop this loss of life, damage to 'parts' and suffering, perhaps a triage system to direct the appropriate people to a safe birth place-even one that is vaguely nice to people as well would be nice- but such triage systems have not been shown to be robust in the developed world, though they might offer some hope in the developing world.  This together with Education is what we will be trying to do-work permits and car permitting of course.

Aftermath

So, back to the UK and to the next stage.  we have sent our rather soft report off to maternity World Wide and look forward to feed back.  In the mean time we have started looking at the next stage which includes the nightmare bureocracy of car importation.  The most helpful has been from an import agency whose basic advice is don't based on the difficulties of it sitting in some dock side in Djibouti collecting storage charges.  carnets count for nought and the British Embassy have not rushed back with advice yet-but we will get there.  there are also issues about bringing in useful bits and pieces for the hospital-lots of gift certificates etc will be required.  How about trying to source a left hand drive land cruiser with English number plates to import..Thought we had found one but it looked v. dodgy with no paper work french number plated and the suggestion that the front and back were not the same.  for those of you wanting Land Cruisers for overland avoid English sounding second hand dealers in West Yorkshire whose sales force answer to Mohammed.  Worryingly the sales site had a pit to take cars off lorries from the continent.  Boring because it is going to take for ever to get the paper work in order but finding the right vehicle is also problematic.  Now coming accross internet sites that specialise in being tantalising but keeping you apart from the vendor.  Now using european contacts (and very grateful) to try a nd source a suitable truck as they are called in the venacular for us.  Three cheers for Greg from Landcruisers overland for all his help.  Will shortly have to write to Gimbie to set out what we require-letters etc and to get some more info for our paper-Hazel is getting hard to work cracking this so may become all very interesting-watch this space..
Jeremy

To Gimbie and back

So, an exciting 9 days with a myriad of sights, sounds and not least smells!  After a flight that makes Ryan Air look like business class we arrived in Addis and were whisked off to a hotel on the out skirts which was suprisingly quiet but backed on to a school full of international football hopefuls, if their break was any thing to go by.  Curiously the inflight information on the screens of the telly are in French and the Ethiopian Airline logos on the side of the aircraft are stuck on which makes me wonder if we are flying in old and possibly borderline airworthy Air France stock.  one worries that it has fallen off the back of some galliclorryAfter a whirlwind trip around Addis including pick up an English Oromo dictioary we had a tolerable meal in the hotel which was Ethiopian in origin and included my first though regrettably probably not last taste of Injura.  It looks like a dirty grey flannel or a soggy flattened crumpet.  It is not as nice as a crumpet and I have never eaten a flannel but I can imagine.  Next day we were picked up distressingly early in a battered and already full ancient land cruiser and having also stuffed in our luggage we had a 13 hour journey to Gimbie West Wollega, far off the tourist track but the route was suprisingly full of people, goats, cows, donkeys and marauding baboons-the only visible wild life.  We stopped briefly for Ethiopian breakfast-broken up beefburger, omlette and injura and lunch looking strangely similar.  Sadly this was the start of a gastric disturbance that stays-what will the microbiology show.  This however is more than you need to know.  Inevitably the landcruiser broke down with a burnt out clutch, so we were towed the last few miles by a truck with a by now also extremely stressed clutch and then carried our luggage to our new accomodation, which we share with a fellow volunteer.  The truck is not seen again but seems to have been involved in a crash in the past and have a lot of problems bar the engine, and it was absurdly expensive.  The accomodation is dire and unloved.  There is strong forensic evidence that the drawers in the strange wardrobe in my small single room have been quartered by a murine visitor who has left its calling card and I do hope that it is n longer in residence!  I understand however that they come in in the rainy season which happily is not now, but this does say something about the thoroughness of the cleaning between residents.  Having heard about bed bugs and having looked at the rather thin grey nature of the sheets provided I have opted to sleep in my sheet liner on top of the bed and spray for mosquitoes instead.  Happily not bitten during stay by either those flying in or those crawling through.  Although I have bought gloves for use on the wards a pair is pressed into service to takle the bathroom, particularly the shower tray.  I did not believe it was really yellow with rust spots when I first saw it and it is now white and yellow with rust spots so I can bring myself to stand in it.  The shower curtain is hanging drunkenly too but that is fixable.  The hinges of the loo seat are another area of concern but have gone unnoticed by tennants past too.  There is however a daily lady what does so perhaps things can be improved.

Next day we set off for our first ward round and what a scene confronts us, with all the sights (and smells) of Africa.  Patients wear their own clothes in bed and have probably been wearing them for sometime and this is obvious.  Our main focus is obstetrics and although there is no such thing as the obsteric inpatient there is a mixture of those who have survived to tell the tale with their baby and sadly those who have survived, just, but without their babies.  Hearbreakingly there are also those who will survive but their babies wont so they just sit their with them till they die. The ward round is a strangely veterinary affair as communication is difficult through interpretors, who interpret longish questions in a few grunts to be returned by half nods and shy smiles.  The normal or near normal deliveries seem fine but those having Caesars fare badly both in terms of infection and poor obstetric out come.  The ward staff do drug rounds, a lttle haphazardly but any caring is done by the family if any who also bring in food etc.

Even communication with the Ethiopian doctor is a little sporadic as he speaks Amharic and all the local patients peak Oromo so all rely on translators.  We will need to speak Oromo....

It is a crowded ward that is difficult to keep clean and one suspects that the cleaning is a little episodic and those episodes are not frequent. As this is a public blog I will spare you the details but if you want more and have the stomack do comment....!

It is however not all bad, mothers and babies are rescued and some who would otherwise die of complications, such as uterine rupture have the opportunity for timely intervention and a reasonable out come, but those who come late do not.  The real national problem though is not those who come but those who do not..what happens to them in their Kebelles or villages we do not know but i suspect that it is not good.

All this should be compulsory viewing for the National Childbirth Trust.  More will follow together with photos and maybe even a you tube video for those with a keen interest.