The hospital is now full of Danish visitors, the great and good of Maternity Worldwide Denmark and also, suspiciously some researchers from a University. There is a stakeholder group meeting to which I am invited and it transpires that they are trying, with the help of poorly projected, overcomplicated powerpoint presentations (yes they get everywhere) to persuade the clinics to buy into a project whereby women can contact midwives on mobile phones for advice and receive health promotion texts. This is a big sell following moderate success in Madagascar, a small relatively flat island, with it must be said similarly poor obstetric outcome.
This area of Ethiopia is mountainous, with patchy reception and the most vulnerable would not know which buttons to press even if they could afford a phone, however they will press on regardless. Possibly more important if not the purpose of what I suspect is already funded research would be a decent transport infra-structure to get people to hospital, but the ranger motor cycle ambulances are tied a customs shed in Addis helping fill the coffers of the Ethiopian revenue authorities.
A morning of discussion of mobile phone coverage is more than I can take so I return to my on call….big mistake. Three Caesareans, emergency kiwi cup delivery (tip, if you are reusing a kiwi cup for the nth time and all the sponge rubber has fallen out put a gauze swab in the cup but be careful to make sure you count it. Two babies very flat so getting access to oxygen concentrator and prophylactic sugar as blood sugar monitor still sans battery. Allow American ‘resident’ with prolapse tourists to do two Caesars and a breech extraction-sadly a cord prolapse that has been out for some hours so she cannot do too much harm, though the cervical descent suggests that she will soon be getting a dress and shoes during the next prolapse tourist visit. The baby is left in the room next to the mother in a plastic bag, as she looks on at the asphyxiated babies lying there and little Jabba. It is indeed a heartless place sometimes, correction most of the time. The Caesar baby looks a little tachapnoeic but not much more I can do and Karen had a nasty surprise in the midwives sleeping and kettle room, but to find out what you will need to visit her blog – may be fewer sleeping midwives though. Sadly the very asphyxiated baby of the night before died today. As I am on call I have had to watch others drinking the red wine which was very sad and no film night.
With all this going on Jabba was getting a little hungry so I fed him his 4.30 feed at 5.30 and his 7.30 at 9.30 having re inserted his tube-those little hands are very active.
I spent the night playing paediatricians and the rather flat baby had glucose overnight I hope but both he and jabber were wrapped up together in the cold and wet this morning. Given that mother has relies around her, though she is not looking great post Caesar, I take baby and oxygen concentrating device to family and get them to cuddle baby who is more likely to retain his temperature that way and hope that either breast milk comes or the ‘C’ team who is on today feed him a little sugar water intermittently. I hope I am getting the hang of paediatric dosing.
What oh what have we come to!
Saturday, 5 November 2011
Thursday, 3 November 2011
Kafka again
Today was pure Kafka with a slight nod to Monty Python. I arrived, contrary to my avoud intent, not wishing to become too African, not to be too late to see Heidi with a patient in knee elbow position and the cord supported and various people trying to put up drips etc. A team was being sort of assembled but the problem was that despite earlier requests the prolapse tourists had simultaneously embarked on hour + cases thus effectively blocking both operating theatres. I can only assume that this was wilful disbelief that their need to provide support to the damaged pelvic floor, dresses, shoes, teaching for their residents or some spurious belief that they were doing ‘good’ rather than having a surgical spree outweighed the need to have some facility for dealing with emergencies, in as much as they can be dealt with successfully in this environment. Helpfully the Ethiopian staff had removed the curtains, we had constructed yesterday and the delivery bed we brought through so once again we were faced with doing emergency surgery, real emergency surgery in a recovery area with out even suction and no such thing as an anaesthetic machine in full view, not to say dust from passing traffic. However with a little bit of asset stripping (the portable suction) from the prolapse people who were I am pleased to say beginning to feel a little uncomfortable, and some ketamine, we were able to bring the patient through, anaesthetise her on her side and finally role her on to her back, only to find a significantly distended bladder and no catheter about. Catheter found insertion proved a little troublesome as there was both a circumcision and a head raising hand to contend with. However successful catheterisation was followed by the delivery of not one but two babies, the first having stuck his arm through the incision and had a rather rough entry into the world. V flat as they say and required quite a lot of chest banging and ambubagging to get going, the suction barely reaching the kid. Thinking paediatrically I though that a blood sugar for this young man might be in order and asked for one. The laboratory staff immediately refused as they did not have a form and then refused to come despite 4 calls. My initial suspicion, probably only partially founded was that they were too busy doing haematocrits for the prolapse tourists, but it appeared that in reality the blood sugar monitor did not work. There appear to be two, a blue one that does work and a white one that does not (made in China they said) and that the lab technician that uses the blue one hides it so that it is not broken when he wants it. The white one incidentally was only not working as the battery had gone and no one had had the wit to replace it but “TIA” I suppose. To be fair it is one of those strange batteries that look like coins and may not be easily available, but that being the case, the institution could order some with a little foresight, but see later, this is in short supply. Anyway we chucked some dextrose at the poor child and apart from being a bit floppy with a high pitched cry seems to be alive. A problem with this resuscitation lark is the paucity of anything dry, let alone warm clothes or even discarded cloth (politically correct speak for rags) to wrap these poor benighted citizens of Ethiopia in. Labour ward was heaving with the now not uncommon group of still births and the poor vomiting Jabba was not getting a look in, and most of his milk seemed to have disappeared, either (for the cynical) into the coffee of the midwives or into the abandoned baby, who spent the day on a shelf in the nursing station looking at a piece of wood. Having said that, the nurses having less to do, ignoring post operative patients is easier than ignoring labouring ones, they make less noise, they do have time to feed him and he seems happy enough in the tee shirt donated to him by Karen. Jabba ain’t doing well, vomiting and all, and I have tried to titrate a little metacloropropamide into his regimen, but with us going away next week his outlook is a little bleak unless he learns to retain his feed and more importantly suck. The Ethiopian view is that we will feed him when we have time and as he is vomiting, and thus, if we can be bothered need cleaning, try to give him less so he does not vomit, does not need cleaning and is less trouble. He is of course failing to gain any weight. Later, I am asked to look at a young girl with the most appallingly pustular and swollen vulva, who has been treated for that common problem vulval TB before seeking a further opinion. I persuaded our local colleague that in the absence of any fluctuant swelling, surgery is inappropriate, but the various (actually only gram) stains are unhelpful. Vaguely remembered originally pointless, but now quite useful, teachings from my time working in the GU medicine department (1974) point to lymphogranuloma venerium or chancroid, and a hasty look at my pocket book of tropical medicine point to chancroid as there seems to be no lymphadenopathy. The distinction is however fairly pointless as the treatment is the same doxycycline with a bit of added cephalosporin, which I start with some metronidazole thrown in for good measure. Before the cognisant of you as , the HIV screen is negative. Hopefully back in a couple of weeks and we will see.
Back at the coal face there is a section for overt disproportion, and greatly daring, some augmentation for failure of head descent for a primip with meconium. This is not perhaps the best idea in the world eventually as suction delivery for fetal distress, as measured by intermittent auscultation produces moribund baby in need of resuscitation. Problem! Pharynx full of meconium and suction cannula not changed from morning baby and midwife reluctant to use it, ambubag lost under pile of rags, but nothing to wrap baby in. Suction foot peddle not working that great either….adult ambubags do not fit that well on babies, but finally find one not put away and another in an obscure cupboard, so finally manage to produce a pink if floppy and destined to be cerebrally irritated infant. Give up on the blood sugar and tip some 40% dextrose into the child. Some oxygen might have been useful but there were initially no nasal delivery systems available. These are washed and used again, like everything else but washed and dried are two different things and the first few minutes were spent trying to blow water out of the tubes rather than down the nasal and other passages of the newly borne. Although Ethiopian colleague does delivery I end up stitching Episiotomy in semi-dark and being very grateful for my headlight. (The recovery room theatre to which we have been banished by the needs of the prolapse tourists is devoid of directional light.)
Nanny used to say, always have the right thing in the right place at the right time and this seems to be the total and abject failure of the dark continent to realise. There does not seem to be an ability to think or plan ahead, to replace after use or to prioritise. Unless there is very clear instruction there is little chance that anything will happen and there really does not seem to be any concept of independent action and enormous skills in the ability dissemble and cover up.
As I left, there was concern over the ability to do the next C.S for thick meconium at 3 cm in a woman with 3 previous stillbirths as the had not been able to wash the packs in time for reuse, but the prolapse team has some uses..we stole some of theirs!
Talking of foresight, we are eagerly awaiting the arrival of the ‘Danish’ team from Maternity Worldwide, 9 in number, but it appears that the non European of them did not get their visas in order and have been turned back at the frontier, and face a tedious journey back to whence they came, and the much vaunted stakeholder meeting will it seems be sans some stakeholders, and as I write this the landed stakeholders are still en route, so our supper meeting is abandoned and fatigue may play its malevolent part in the development of helping strategies for this part of the world, and it is good to know that charitable funds are being carefully spent.
We are certainly living in interesting times.
Back at the coal face there is a section for overt disproportion, and greatly daring, some augmentation for failure of head descent for a primip with meconium. This is not perhaps the best idea in the world eventually as suction delivery for fetal distress, as measured by intermittent auscultation produces moribund baby in need of resuscitation. Problem! Pharynx full of meconium and suction cannula not changed from morning baby and midwife reluctant to use it, ambubag lost under pile of rags, but nothing to wrap baby in. Suction foot peddle not working that great either….adult ambubags do not fit that well on babies, but finally find one not put away and another in an obscure cupboard, so finally manage to produce a pink if floppy and destined to be cerebrally irritated infant. Give up on the blood sugar and tip some 40% dextrose into the child. Some oxygen might have been useful but there were initially no nasal delivery systems available. These are washed and used again, like everything else but washed and dried are two different things and the first few minutes were spent trying to blow water out of the tubes rather than down the nasal and other passages of the newly borne. Although Ethiopian colleague does delivery I end up stitching Episiotomy in semi-dark and being very grateful for my headlight. (The recovery room theatre to which we have been banished by the needs of the prolapse tourists is devoid of directional light.)
Nanny used to say, always have the right thing in the right place at the right time and this seems to be the total and abject failure of the dark continent to realise. There does not seem to be an ability to think or plan ahead, to replace after use or to prioritise. Unless there is very clear instruction there is little chance that anything will happen and there really does not seem to be any concept of independent action and enormous skills in the ability dissemble and cover up.
As I left, there was concern over the ability to do the next C.S for thick meconium at 3 cm in a woman with 3 previous stillbirths as the had not been able to wash the packs in time for reuse, but the prolapse team has some uses..we stole some of theirs!
Talking of foresight, we are eagerly awaiting the arrival of the ‘Danish’ team from Maternity Worldwide, 9 in number, but it appears that the non European of them did not get their visas in order and have been turned back at the frontier, and face a tedious journey back to whence they came, and the much vaunted stakeholder meeting will it seems be sans some stakeholders, and as I write this the landed stakeholders are still en route, so our supper meeting is abandoned and fatigue may play its malevolent part in the development of helping strategies for this part of the world, and it is good to know that charitable funds are being carefully spent.
We are certainly living in interesting times.
more nights of joy
I had hopes of it being quiet, but no such luck. We fed the jabba the hutt and set off for bed but as soon as 12.20 struck so did the irritating jingle on my Ethiopian phone ( I have to learn how to change this as it is beginning to get to me ) and as communication is so difficult you have to fumble into your clothes and go take a look. I find a lady with two previous sections in labour as with no dates no elective caesareans and arrange her operation. The scissors are unbelievably blunt and I am reduced to dissecting down the bladder with a rather fearsome scalpel blade before a successful delivery and happily savaging of the fallopian tubes. As I go to the theatre the guards arrive with an abandoned, cold and hungry baby, probably a month or so old and looking rather wild eyed, so I arrange warmth and milk though when I return from theatre I find one of the nurses suckling it, not perhaps the best strategy when HIV status is not known but too late now. Very sweet and bouncy looking baby and now a rival for Jabba’s dwindling supply of milk. Clearly some Ethiopians live in desperate times. No sooner am I back in bed do I get another call. The para three (no I have no idea of names) ain’t making progress, is making an extra-ordinary amount of noise and the midwife cannot feel a head. It is very high and curiously I am unable to feel a single suture. When I keepher still for a minute the abdomen is a funny shape. Yes you have guessed it we have a brow and a fair amount of meconium. From the last update you may appreciate that I am a little sensitive about meconium, so back to theatre we go. The husband (they are both older and all powerful in these parts) initially fails to approve the thought of tubal ligation but while in theatre on the news that it is a boy relents, so hopefully she will not be back.
I sleep in a bit and then pop up to the ward to hand over the keys of office (the key to the ultra sound machine) and find the usual chaos but in addition Heidi struggling to replace an inverted uterus –para 5 delivered at home – and we manage to partially replace it hydrostatically but all not quite well so EUA needed. Problem, the prolapse tourist team are inhabiting both theatres and deep into lengthy abdominal repair procedures without much thought for the need for emergency space, words required later, but mange to clean an old delivery bed, carry it into recovery as it no longer has wheels and get a spinal in there which allows us to finish the job, and yes another sterilisation, there will be no intact tubes in Gimbie by the time I finish.
Have words with helpful (at least verbally) prolapse team and explain the problem that we are in danger of compromising the safety of emergency patients while they spend their donated $20,000 on re-suspending sagging denizens of the environs of Gimbie, each of whom I am told are sent home with a new dress and pair of shoes. This goes some way to explaining why the corridors and outside spaces of the hospital are thronged with would be prolapse sufferers.
We have acquired an Oromo tutor, who had been translating for me a few days ago. He soon launches into his hard luck story and how he and various hungry if not starving members of his family are dependent on him and he hopes us as he tries to draw us into his web of need. We are however happy to pay a reasonable rate for his teaching time but not become the welfare state.
This confirms my growing understanding of the malaise of Ethiopia which, thanks to western aid is now entirely a hand out culture with no sense as far as I can see of any entrepreneurial endeavour apart from trying to rip off the faranj (us) on any purchase we try to make and expecting people to do things for them which they are capable of doing themselves. Such is the desire to get free things, a pupil midwife followed me in to the theatre changing room to try to remove the crumpled jeye cloth that serves as my theatre hat as she wanted it and that was before the operation. I understand that it is possible to apply to the government for various things but that it is so much effort it easier to beg from the charities who provide masses of equipment, much of which if our exploration of store cupboards is anything to go by remains stored and unused, possibly of course because no one knows how to, but that is another story. The pointlessness of offering a training to the mass of people who either do not want it, think they do not need it or are only interested if they want more money will be the subject of further discussion, provided of course if I am not stopped before, ther is an ugly rumour the local state tries to screen all outgoing electronic traffic – could this be why the net is down as much as it is……paranoia strikes and kafka remains alive and well.
I sleep in a bit and then pop up to the ward to hand over the keys of office (the key to the ultra sound machine) and find the usual chaos but in addition Heidi struggling to replace an inverted uterus –para 5 delivered at home – and we manage to partially replace it hydrostatically but all not quite well so EUA needed. Problem, the prolapse tourist team are inhabiting both theatres and deep into lengthy abdominal repair procedures without much thought for the need for emergency space, words required later, but mange to clean an old delivery bed, carry it into recovery as it no longer has wheels and get a spinal in there which allows us to finish the job, and yes another sterilisation, there will be no intact tubes in Gimbie by the time I finish.
Have words with helpful (at least verbally) prolapse team and explain the problem that we are in danger of compromising the safety of emergency patients while they spend their donated $20,000 on re-suspending sagging denizens of the environs of Gimbie, each of whom I am told are sent home with a new dress and pair of shoes. This goes some way to explaining why the corridors and outside spaces of the hospital are thronged with would be prolapse sufferers.
We have acquired an Oromo tutor, who had been translating for me a few days ago. He soon launches into his hard luck story and how he and various hungry if not starving members of his family are dependent on him and he hopes us as he tries to draw us into his web of need. We are however happy to pay a reasonable rate for his teaching time but not become the welfare state.
This confirms my growing understanding of the malaise of Ethiopia which, thanks to western aid is now entirely a hand out culture with no sense as far as I can see of any entrepreneurial endeavour apart from trying to rip off the faranj (us) on any purchase we try to make and expecting people to do things for them which they are capable of doing themselves. Such is the desire to get free things, a pupil midwife followed me in to the theatre changing room to try to remove the crumpled jeye cloth that serves as my theatre hat as she wanted it and that was before the operation. I understand that it is possible to apply to the government for various things but that it is so much effort it easier to beg from the charities who provide masses of equipment, much of which if our exploration of store cupboards is anything to go by remains stored and unused, possibly of course because no one knows how to, but that is another story. The pointlessness of offering a training to the mass of people who either do not want it, think they do not need it or are only interested if they want more money will be the subject of further discussion, provided of course if I am not stopped before, ther is an ugly rumour the local state tries to screen all outgoing electronic traffic – could this be why the net is down as much as it is……paranoia strikes and kafka remains alive and well.
nights of joy
Well, the androgynous chicken was found having sex, and shortly afterwards found himself in a casserole, the first bit of real protein for a while. Chorizio does not count. Our other problem has been that the fridge, but bizarrely not the freezer has broken and this is proving a little tiresome. Parts are apparently on order but have to come from Addis so who knows. I can not stop the gardener digging now, perfectly good bits of scrub and virgin jungle are being turned into red mud. I suggested that a few fewer hours might be in order but got a spiel about starvation and a request to look at his rather damaged feet –no idea but look fungal to me and this was clearly an affliction of our predecessors in the house as there is quite a lot of suitable cream about. Meanwhile all about us think that we are good for a rip off, even the cleaning and cooking (currently for hundreds and thousands) lady charged 15 birr for 5 oranges which even I as a Faranj can buy at a birr each. As and when inflation reaches Ethiopia it will be the aid worker whot did it. We are also getting the catering that the Americans are so maybe there may be peanut butter in something soon.
The prolapse team has now swung down the Oregon trail and arrived. There are lots of Americans in flowerery theatre caps swanning around and about to start some operation fest, doing both abdominal and vaginal procedures, so I have sent Wasihun off to take part while I sat through a dreary clinic though may possibly have found an operative ca cervix, the second in two weeks. I may have re-invent myself as a cancer doc but no histology at all so just do your best. I suspect that they may be just prolapse tourist just honing their skills but (David take note) one does his prolapse repairs with a robot in Portland so open surgery must be quite novelty for him. I am wondering about how they got on as there were a series of power cuts this afternoon which would have caused a certain amount of disarray. Never go anywhere without your head lamp. I am doing my best to be a good obstetrician but you can not check urine for protein on site and ladies with raised BPs seem to disappear when you send them off for a urine test..I am not sure where they get to and just hope they do not come back twitching or worse. Orange lentils for both lunch and supper, but goody goody, reheated rice as well for supper and another box of red wine bites the dust.
Given that I am on call and my scrubs are wet I put them over the oven to dry – such extravagance – but do not fancy damp scrubs.
Wake up early for my day on call and arrive slightly early to find that Jabba has been gently roasted overnight as some one (nameless of course) had put the electric blanket on so roast Jabba basted in essence of Turd but apart from solidly refusing to gain weight as he vomits and is only fed intermittently he seems none the worse for his hyperpyrexia. Karen meanwhile has managed to find some oversize nappies so hopefully we will be able to try and keep his bum less sore. Mean while on the ward and within the dreaded ward round all is not well. The baby whose section was delayed for lunch and aspirated some meconium looks flat and terrible. As I listen to the wheezy and tight chest he crashes and we go through the saga of a 25 minute arrest routine and get the heart rate back twice continually bagging him but he is unable to breath, so sadly we call a halt and the baby dies in his mother’s arms. He is subsequently placed in a card board box marked a little ironically ‘handle with care’ as it is casually moved around the floor by foot. The prolapse team, those of flowery hats and strange American theatre foot wear are in full cry and filling the ward up but more importantly blocking both theatres as I want to do a caesarean section for failure to progress in a trial of scar with a bit of tenderness. The catheter which has something of a pre-used look about it is not draining despite appearing to be in the right place and I am reduced to draining the bladder with a 10ml syringe and a green needle-delaying my section somewhat but all well. I must return and see if she is now peeing. The arrival of the prolapse team and the thought of free operations (buy one get one free) is causing immense queues in outpatients which is more chaotic than usual however since the prolapse team is here they can now screen their own patients. I have sloped away for a cup of coffee and to write this. I had believed that once you got to hospital it would be safe if not nice and now have to revise this. Bit like the curates egg I suspect – good in parts.
Back at the house find the gardener busy removing greenery from the slope – so I fear soil erosion or worse a landslide or constant dust in the drying area. I fear he is finding things to do but now it is getting a little destructive but he gets selective understanding when you try to stop him. The compost pit seems to be doomed too as the concept of compost or throwing things away not in aplastic bag is foreign to the local mindset. Oh and no eggs yet!
The prolapse team has now swung down the Oregon trail and arrived. There are lots of Americans in flowerery theatre caps swanning around and about to start some operation fest, doing both abdominal and vaginal procedures, so I have sent Wasihun off to take part while I sat through a dreary clinic though may possibly have found an operative ca cervix, the second in two weeks. I may have re-invent myself as a cancer doc but no histology at all so just do your best. I suspect that they may be just prolapse tourist just honing their skills but (David take note) one does his prolapse repairs with a robot in Portland so open surgery must be quite novelty for him. I am wondering about how they got on as there were a series of power cuts this afternoon which would have caused a certain amount of disarray. Never go anywhere without your head lamp. I am doing my best to be a good obstetrician but you can not check urine for protein on site and ladies with raised BPs seem to disappear when you send them off for a urine test..I am not sure where they get to and just hope they do not come back twitching or worse. Orange lentils for both lunch and supper, but goody goody, reheated rice as well for supper and another box of red wine bites the dust.
Given that I am on call and my scrubs are wet I put them over the oven to dry – such extravagance – but do not fancy damp scrubs.
Wake up early for my day on call and arrive slightly early to find that Jabba has been gently roasted overnight as some one (nameless of course) had put the electric blanket on so roast Jabba basted in essence of Turd but apart from solidly refusing to gain weight as he vomits and is only fed intermittently he seems none the worse for his hyperpyrexia. Karen meanwhile has managed to find some oversize nappies so hopefully we will be able to try and keep his bum less sore. Mean while on the ward and within the dreaded ward round all is not well. The baby whose section was delayed for lunch and aspirated some meconium looks flat and terrible. As I listen to the wheezy and tight chest he crashes and we go through the saga of a 25 minute arrest routine and get the heart rate back twice continually bagging him but he is unable to breath, so sadly we call a halt and the baby dies in his mother’s arms. He is subsequently placed in a card board box marked a little ironically ‘handle with care’ as it is casually moved around the floor by foot. The prolapse team, those of flowery hats and strange American theatre foot wear are in full cry and filling the ward up but more importantly blocking both theatres as I want to do a caesarean section for failure to progress in a trial of scar with a bit of tenderness. The catheter which has something of a pre-used look about it is not draining despite appearing to be in the right place and I am reduced to draining the bladder with a 10ml syringe and a green needle-delaying my section somewhat but all well. I must return and see if she is now peeing. The arrival of the prolapse team and the thought of free operations (buy one get one free) is causing immense queues in outpatients which is more chaotic than usual however since the prolapse team is here they can now screen their own patients. I have sloped away for a cup of coffee and to write this. I had believed that once you got to hospital it would be safe if not nice and now have to revise this. Bit like the curates egg I suspect – good in parts.
Back at the house find the gardener busy removing greenery from the slope – so I fear soil erosion or worse a landslide or constant dust in the drying area. I fear he is finding things to do but now it is getting a little destructive but he gets selective understanding when you try to stop him. The compost pit seems to be doomed too as the concept of compost or throwing things away not in aplastic bag is foreign to the local mindset. Oh and no eggs yet!
Monday, 31 October 2011
Routine?
Life is beginning to settle into something of a rhythm now, even though we have actually been in Gimbie for only a fortnight. The garden is becoming established, and so far we have kept the monkeys off anything edible though they are eyeing my Nasturtiums a bit. Having hinted that we wanted some fresh eggs, last night we were presented with three chickens, one allegedly laying and other two soon to. The laying chicken however, temporarily named Betsy looks suspiciously male in the light of day and is making very male noises especially at 6.30 this morning. Karen is currently demanding instant removal and Danish neighbours are suggesting Sunday roast, which may distress Karen’s sensibilities so that he may survive another day. Certainly they are, given their shut in status a little noisy and egg free at present though enjoying a diet of pop corn and left over pizza. Film night last night was not an unqualified success given that the film was slow moving and with strong welsh accents, given it was about Dyllan Thomas who was according to this a bit of a shit. If film night is to continue we will need an action movie and I think we may have to reprise the Bourne Movies. Mat Daman here we come. The donors of the androgynous chickens were visiting with their adopted daughter Bella, who it appears was born here in similar circumstances to baby A and subsequently adopted by her mother who was working here as a midwife some 5 years ago and had returned to show Bella something of her roots. This has produced intensive local speculation that we will take on baby A which is a little concerning and we may have to sponsor him for a while. They are also concerned about our impending visit to Addis for car and daughter collection as feed preparation is a feature of Karen’s duties. We do now though have a few clothes and some feeding bottles. More rumour is now emerging about the run away mother, who now appears not to be the victim of personal tragedy, dead husband etc., but the unmarried mother of two, this one not wanted. Feckless parenting it seems is not the complete prerogative of the western world. Baby A cannot remain Baby A for ever and my suggestion of Harpo has been vetoed and Jabbo which means strong in adversity or some such been mooted. Sounds a bit like a star wars character to me but might be appropriate as that is where he is likely to end up living. More details and local agro are also emerging about the breech induction that polled up when I was on duty in that it appears, fully dilated she was given a piece of paper and then told to make her way by bus to the hospital and it was lucky that one was running that late. Driving in the dark in these parts is not to be recommended. Anyway both mother and baby remain well so tragedy averted more by luck than judgement. For those of you who know about the three delay model of care in the developing world, what one can say is the third level of delay is very low here, it is possible to set up a Caesarean section as fast as a category one section in the U.K which is indeed commendable.
I have spent this morning, the internet being down and all, reading Wasihun’s specialist training dissertation which is remarkably literate all things considered and has made some interesting points. It might be possible to caste it into a publishable paper and contribute to the rather sparse body knowledge on the best way to deal with uterine rupture (the real thing, not just boring scar rupture!).
In the mean time, the impending arrival of the American prolapse team and the ability to have a free consultation, rather than the 10 birr one (26.5 birr = £1) has opened the gynaecological flood gates, producing a rich crop of vaginal discharge (usually physiological but treated with cephalosporins), inoperable cancer of the cervix and uninvestigatiable infertilty which is a worrying personal problem but of little consequence to the country. So with the rumble of thunder in the background and at best patchy weather I go to find some hay for my androgynous and barren chickens in the hope that they might produce an….egg?
I have spent this morning, the internet being down and all, reading Wasihun’s specialist training dissertation which is remarkably literate all things considered and has made some interesting points. It might be possible to caste it into a publishable paper and contribute to the rather sparse body knowledge on the best way to deal with uterine rupture (the real thing, not just boring scar rupture!).
In the mean time, the impending arrival of the American prolapse team and the ability to have a free consultation, rather than the 10 birr one (26.5 birr = £1) has opened the gynaecological flood gates, producing a rich crop of vaginal discharge (usually physiological but treated with cephalosporins), inoperable cancer of the cervix and uninvestigatiable infertilty which is a worrying personal problem but of little consequence to the country. So with the rumble of thunder in the background and at best patchy weather I go to find some hay for my androgynous and barren chickens in the hope that they might produce an….egg?
Thursday, 27 October 2011
nenatal musings
Well the continuing neonatal care of this baby-yet to be named but I am favouring Harpo after Harpo Marx or Harpic given his birth place continues to have highs and lows. Having established him on breast milk his mother did a runner last night so onto formulae which he promptly aspirated so had a v bad night but a bit better now though still intermittently very cold and unless Karen is there only occasionally fed. We persevere and he is beginning to look around. Not out of the wood yet though. A dreary day screening women for the prolapse team-they all have procidentures and seeing women with normal looking vaginal discharge and infertility which is impossible to investigate-no ovulation testing, no tubal patency tests and no man prepared to produce-so a waste of a consultation. Looking at Hycose but probably far to expensive for here abouts. Found an interesting cause of vaginal bleeding in a 5 year old but failed to get a photograph sadly – that is a vaginal leech…removal by putting lime juice on it! The other excitement today was the old and rusty delivery bed collapsed mid delivery, the head end falling off with rust or metal fatigue or some such. There are some other delivery beds dotted around but we are assured that they are broken but probably not quite broken enough to replace the rusting relic that is the preferred place of delivery. We found an under-stair cupboard full of goodies, which are no being inventoried but include interestingly a series of boxes with new destructive instruments which I have some reservations about letting various semi trained ‘professionals, for want of a better word, loose on. The cupboard also seems to include a tent without tent poles and a stack of chairs and lots of un- opened boxes and-possibly useful too some breast pumps. I am beginning to understand how little ‘aid’ seems to get to the place it is needed.
I seem to be drawing the rather more wearying nights on call, last night spectacularly at 12.30 when all good aid workers should be tucked up in bed after their dinner of uniformly grey and un-appetising beans, I got called to the labour ward. There was a woman in whom labour had been induced at some local health centre with a fully dilated breech presentation, having been fully dilated for some 18 hours or so and with a transit, god knows how of some 2 hours minimum. Both were actually in surprisingly good nick and I am glad I did not go in for heroics as the baby weighed 4 Kg. however it does raise questions about semi trained professionals a. deciding to do inductions in peripheral clinics and b. being unable to decide which way up the baby is – a little knowledge is indeed a dangerous thing. A primip who had been shouting the house down for 4 hours or so was also struggling so, sod it I want to back to bed and bean digestion so that one comes out abdominally too. Happily a woman with lots of stillbirths delivers normally and now has a child.
I have ducked screening for American prolapse doctors today, but met Heidi in despair as she had failed completely to teach a loca,l pelvic floor exercises for her stress incontinence.
Failure of the labour suite kettle means that I have spent a lot of the day ferrying hot water bottles to and from the house to keep ‘Harpo’ warm and trying to supervise his feeds which he seems to be absorbing when he gets them which unless I stand over the staff is not often.
We have no dioralyte left so I set o fto town and have found some lem lem so it will be interesting to see how our young man gets on with a new flavour-curds and whey here we come
I seem to be drawing the rather more wearying nights on call, last night spectacularly at 12.30 when all good aid workers should be tucked up in bed after their dinner of uniformly grey and un-appetising beans, I got called to the labour ward. There was a woman in whom labour had been induced at some local health centre with a fully dilated breech presentation, having been fully dilated for some 18 hours or so and with a transit, god knows how of some 2 hours minimum. Both were actually in surprisingly good nick and I am glad I did not go in for heroics as the baby weighed 4 Kg. however it does raise questions about semi trained professionals a. deciding to do inductions in peripheral clinics and b. being unable to decide which way up the baby is – a little knowledge is indeed a dangerous thing. A primip who had been shouting the house down for 4 hours or so was also struggling so, sod it I want to back to bed and bean digestion so that one comes out abdominally too. Happily a woman with lots of stillbirths delivers normally and now has a child.
I have ducked screening for American prolapse doctors today, but met Heidi in despair as she had failed completely to teach a loca,l pelvic floor exercises for her stress incontinence.
Failure of the labour suite kettle means that I have spent a lot of the day ferrying hot water bottles to and from the house to keep ‘Harpo’ warm and trying to supervise his feeds which he seems to be absorbing when he gets them which unless I stand over the staff is not often.
We have no dioralyte left so I set o fto town and have found some lem lem so it will be interesting to see how our young man gets on with a new flavour-curds and whey here we come
Wednesday, 26 October 2011
Reality check in Gimbie
Well, our baby is still alive and the mother is bonding with it as, happily are the staff a mixture both of pride, now the baby has survived five days and the labour ward being very quiet. On the down side I was called to a very septic and fitting baby and there has been difficulty getting the fits under control, but now on phenytoin and a change of antibiotics so we can only hope.
An interesting day with an early start as we went cross country to Aiya(?) hospital. Lovely drive in the early morning, with stunning views particularly when we cross the pass and look down on the mist in the valley. The rolling hills a patchwork of green with teff, grass and the local equivalent of oil seed rape. We also stopped and looked at the coffee seeds that are now beginning to grow. At least we have now seen and might be able to recognise a coffee bush. The road is completely red sand with no gravel as we discover when we come back after a rain shower as it rapidly becomes very slippery mud, though not noticeably reducing the speed of the drive, which becomes more white knuckle than usual.
The hospital itself is a German Evangelical Mission hospital which, according to the stone in the front was set up in 1928, and I wonder what happened in the war years, but today it is thriving, clean and clearly very competent. There is currently no obstetrician the resident Danish surgeon remarking sourly that he had been stolen by Gimbie Adventist hospital. This was followed by the comment that they needed an extra 10,000 Birr (£400 aprox) per month as a top up salary in order to attract some one. This it would seem is the cost of disloyalty, apart from the fact that its total isolation makes Gimbie look like the city of lights! That said however, the midwives we spoke to radiated both competence and confidence and as far as we could judge a real pride in their work. The labour ward made a real effort to give the patients some privacy and dignity, gowns were provided and they had both a CTG machine and a scanner together, wonder of wonders a working incubator attached to some oxygen, though currently without a resident. The midwives do ventouse deliveries and there is a metal cup, though I gather the suction is a little uncertain. Currently the surgeons, of which I believe there are two, carry out the operative deliveries and repaired the ruptured uteri, which appeared with depressing frequency in the labour ward book (aprox 2 per page of 12 entries) but I could find only two maternal deaths in 2010 which was encouraging. Never the less each uterine rupture represents a neglected labour (all you natural childbirth mothers - for that is what it is – please take note). Midwives do the retained placentae but the surgeons are required to do the EVACs etc. interestingly Eric, the Danish surgeon said that our local obstetrician’s dissertation which in reality is probably gathering red African dust somewhere, like most MSc dissertations I know, was comparing the mortality of uterine repair following rupture with hysterectomy. This might make an interesting paper me thinks.
The other very interesting thing we saw was the ‘waiting house’ a dormitory for pregnant women who came a 36 weeks and stayed there, cooking for themselves while waiting the onset of labour so they could go to the hospital for safe delivery. The absence of any known dates and the unreliability of dating scans, means that this is safer for the unborn child.
Interestingly, and ultimately rather sadly I noted that I was being followed by a young woman who asked if she could consult me about her infertility problems and a corridor consultation followed which was listen to rapturously by an increasingly growing crowd. Her problem became apparent fairly quickly-anovulation and I had noted in the local pharmacy that clomiphene was available. However at that point we got shouted at as this consultation would reduce the revenue of the hospital not withstanding that they do not have the appropriate expertise. We told her to wait at the car but she was spirited away-Kafka strikes again!
Their delivery rate is lower than that for Gimbie but both, in areas of enormous need seem to only attract a tiny proportion of the local population, whether because of cost (despite the Maternity Worldwide safe Birth fund) or because of transport difficulties and getting the mother to a safe place of birth seems to be the issue. As a medical student and a junior doctor I was taught that the pain of a rupturing uterus was one of the worse pains imaginable, so severe that even an epidural did not filter it out so God knows what these poor women went through. Thus it seems to me uterine rupture must be the sine qua none of the neglected labour, crying out for intervention and perhaps ones role is to make that intervention possible – how many I wonder never make it hospital at all and become the great unmeasured statistic?
We return to Gimbie to scenes of wailing some young man it seems chopped a tree down on himself, and has died of his injuries and I wonder as I pass this scene if death in childbirth of a woman would produce the same outpouring of grief.
An interesting day with an early start as we went cross country to Aiya(?) hospital. Lovely drive in the early morning, with stunning views particularly when we cross the pass and look down on the mist in the valley. The rolling hills a patchwork of green with teff, grass and the local equivalent of oil seed rape. We also stopped and looked at the coffee seeds that are now beginning to grow. At least we have now seen and might be able to recognise a coffee bush. The road is completely red sand with no gravel as we discover when we come back after a rain shower as it rapidly becomes very slippery mud, though not noticeably reducing the speed of the drive, which becomes more white knuckle than usual.
The hospital itself is a German Evangelical Mission hospital which, according to the stone in the front was set up in 1928, and I wonder what happened in the war years, but today it is thriving, clean and clearly very competent. There is currently no obstetrician the resident Danish surgeon remarking sourly that he had been stolen by Gimbie Adventist hospital. This was followed by the comment that they needed an extra 10,000 Birr (£400 aprox) per month as a top up salary in order to attract some one. This it would seem is the cost of disloyalty, apart from the fact that its total isolation makes Gimbie look like the city of lights! That said however, the midwives we spoke to radiated both competence and confidence and as far as we could judge a real pride in their work. The labour ward made a real effort to give the patients some privacy and dignity, gowns were provided and they had both a CTG machine and a scanner together, wonder of wonders a working incubator attached to some oxygen, though currently without a resident. The midwives do ventouse deliveries and there is a metal cup, though I gather the suction is a little uncertain. Currently the surgeons, of which I believe there are two, carry out the operative deliveries and repaired the ruptured uteri, which appeared with depressing frequency in the labour ward book (aprox 2 per page of 12 entries) but I could find only two maternal deaths in 2010 which was encouraging. Never the less each uterine rupture represents a neglected labour (all you natural childbirth mothers - for that is what it is – please take note). Midwives do the retained placentae but the surgeons are required to do the EVACs etc. interestingly Eric, the Danish surgeon said that our local obstetrician’s dissertation which in reality is probably gathering red African dust somewhere, like most MSc dissertations I know, was comparing the mortality of uterine repair following rupture with hysterectomy. This might make an interesting paper me thinks.
The other very interesting thing we saw was the ‘waiting house’ a dormitory for pregnant women who came a 36 weeks and stayed there, cooking for themselves while waiting the onset of labour so they could go to the hospital for safe delivery. The absence of any known dates and the unreliability of dating scans, means that this is safer for the unborn child.
Interestingly, and ultimately rather sadly I noted that I was being followed by a young woman who asked if she could consult me about her infertility problems and a corridor consultation followed which was listen to rapturously by an increasingly growing crowd. Her problem became apparent fairly quickly-anovulation and I had noted in the local pharmacy that clomiphene was available. However at that point we got shouted at as this consultation would reduce the revenue of the hospital not withstanding that they do not have the appropriate expertise. We told her to wait at the car but she was spirited away-Kafka strikes again!
Their delivery rate is lower than that for Gimbie but both, in areas of enormous need seem to only attract a tiny proportion of the local population, whether because of cost (despite the Maternity Worldwide safe Birth fund) or because of transport difficulties and getting the mother to a safe place of birth seems to be the issue. As a medical student and a junior doctor I was taught that the pain of a rupturing uterus was one of the worse pains imaginable, so severe that even an epidural did not filter it out so God knows what these poor women went through. Thus it seems to me uterine rupture must be the sine qua none of the neglected labour, crying out for intervention and perhaps ones role is to make that intervention possible – how many I wonder never make it hospital at all and become the great unmeasured statistic?
We return to Gimbie to scenes of wailing some young man it seems chopped a tree down on himself, and has died of his injuries and I wonder as I pass this scene if death in childbirth of a woman would produce the same outpouring of grief.
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