Communication Failures

One of the persisting things in the Ethiopian psyche is being unable to answer a series of questions (you are likely to only get a half answer to one of them and never try a two parter, nor does it seem to part of the system to give clear and unambiguous information). So it was that my patient appeared in hospital fully dilated having had two previous Caesarean sections, something that I now believe is being encouraged in the ‘VBAC’ world of the west. Nothing ventured, nothing gained so I reached for the least battered looking suction cap but desisted (wisely it turned out as the swelling I thought might be bladder revealed blood on catheterisation) and subsequent laparotomy revealed dehiscence of both the scar and the bladder dome which was very adherent. Miraculously the baby came out crying and both are doing well. The moral of this story is not of course the advice she was given, which was ‘you need to have your baby in hospital’ but ‘you will need to have a Caesarean section’, which it seems would be far too unambiguous. Even better would be and’ you could be sterilised too. When asked why she did not come before the answer was, as it so often is, associated with transport difficulties, something that a ‘waiting house’ which is tax free might solve and an E-ranger (still in customs being wrangled over) might or might not depending where it and she were at the time. Simple solutions for simple problems are also not part of the psyche.

Despite general approbation from the clinicians in Surrey’s world of female genital cancer my request for limited funding to try and see if local clinicians could help local people with an otherwise fatal disease fell on deaf ‘lay ears’ with some surprisingly pejorative not to say ‘old testament’ remarks about the women in Ethiopia who, like their sisters in other parts of the globe have been challenged with oncogenic papilloma viruses but unlike many in more affluent parts have not been screened or offered preventive treatment or now vaccination. Whether by force of circumstance or choice, and it is rarely choice you have developed invasive cancer matters not a jot, the availability of effective treatment does. Here, of course there isn’t any and in Surrey wildly expensive minimal access therapy is, for the few that need it. From my time in the Surrey colposcopy clinics many of these could be termed ‘new Surrey women’ i.e. those from the Baltic states and eastern Europe whose life style and deprivation is probably broadly similar to that of the women I now see, but fill roles in wine bars, hotels and the service industry to provide the monied of Surrey with the services they aspire to. So it should be said are the stunningly attractive, if orthodontically challenged, young women of Ethiopia who regularly queue, for many hours at Immigration in Ethiopia for a passport so that they can head for the middle east and jobs in hotels, coffee shops and I suspect less salubrious employment where they will get exposed to oncogenic viruses and the cycle will continue. For those however, now in their forties and raising their children, death from renal failure, cachexia and chronic infection awaits, a death that might be avoided by a timely and skilled intervention. If anyone would like to help me help them to help themselves (Ethiopian psyche permitting) please let me know. This charitable concern comes with no overheads just the cost of the operation, around 2000 Birr a snip at £80.
For those of you who were distressed at the sight of the baby that tried to emerge into their troubled world face first I am pleased to report (see photo) that swelling has gone, feeding has been established and the traumatic emergence now the past – let us hope that the future is rosy. I am also amused to see that ‘attitude’ is alive and well in Ethiopia if tinged with ‘I must ask my husband’ which some would regard as a laudable trait in that a lady with quite worrying blood pressure is very reluctant to be induced or as they say in these parts ‘have the pregnancy terminated’ but I hasten to say that that expression does not have the western connotations that we would associate with it.

Happily she has now agreed, or more probably husband permitted, so termination is under way.

Yesterday was Ethiopian Christmas, a day that is as bad for cows here as it is for turkeys in Europe and there was much feasting. I do not know if it also bad for goats but there was a lone and vagrant goat eating in the garden and being male only good for eating or reproducing, perhaps it had wisely decided that it was an away day. We did our bit acquiring a slab of cow and with some difficulty as the knives are blunt and we have no sharpener, cutting it up, cooking it in the slow cooker and serving it with spagetti to our ever hungry youngsters and some Ethiopian friends with pancakes and the local equivalent of Nutella to follow (the latter ably produced by Clara). They all settled down to watch ‘Harry potter and the half- blood prince but I am not sure what they got out of it, more Shrek and similar movies probably required for this paediatric entertainment. One of the young men has infected feet which are being treated with antibiotics, like the gardener’s arm and I had that soaking for the afternoon. My only worry is that he has recently been bought some boots that look alittle large and more important military so I hope that I am not just treating trench foot with more infected salt water. Perhaps open toed sandals are what is required or that I am missing filiariasis or something equally exotic.

Baby 3 days after 'face presentation'

ruptured uterus pt day 2

No light at the end of the tunnel

As keen readers of this blog will know we are privileged to live in the Adventist bit of the compound which, at night is a dimly lit path of some 200 yards to the hospital. From the house for the first hundred yards there are or were a few ‘incandescent’ light bulbs (these are the sort that are regarded as bright and energy inefficient in the U.K and are thus difficult to get, and may well be energy inefficient in Ethiopia but bright – no). Last night, as I walked to the ward I noticed that the last one was not only not working, but gone …. stolen I suppose by a nocturnally challenged Ethiopian and joins if less valuably in commercial terms one of the head torches, the list of that which has been pilfered from trusting open pocketed faranjis. This is tedious as it is actually quite dark and the urban myth around here is that Hyenas prowl at night after various bits of offal that could potentially include me. Certainly there are jungle noises and quite a lot of rustling but I never seen anything other than the odd thin stray dog which we try not to befriend as it is yet another thing that will require, eventually some form of long term support. Allegedly you are supposed to be escorted by guards, who carry bits of pipe or stick but this has never happened, nor come to that have I felt in any danger- but light would be nice especially as the path is often covered in some form of ordure and it would if nothing else be good to avoid this. As I write I have just had to break up a Vervet monkey fight on the veranda and chase a particularly thick (Ethiopian borne) monkey out of the chicken cage. The chickens meanwhile have found a way into the vegetable garden and seem to like coriander so some blocking up will be necessary. They are becoming absurdly tame now and like being hand fed, one even does jumping tricks!

The coffee picking season is on us and as this is the main cash crop, illness real or imagined is banished for the little red bean so all is quite quiet except as I arrived this morning there was both fetal distress and an odd presentation which turned out to be a face, and very puffy to on delivery, but seems to be breathing but may not want to suck for a bit. There also seems to be an outbreak of hypertension which is quite difficult to manage when you have little idea of gestation and as soon as your back is turned there is exhibition of poly-pharmacy and is the headache from hydralazine or the underlying condition? Our last fitting patient has been out of it for a few days and I have had a tube in the baby but fortuitously auto-removal (quite common) has coincided with both a suck reflex and return of a sentient (well in Ethiopian terms) human and I can even discern a cheek bone.

Maternity Worldwide has now theoretically withdraw the ‘safe birth fund’ which was the main provider of cash for the maternity service of the hospital and there seem to be fewer women around and as my Ethiopian colleague has pointed out none of them look as if they can afford any sort of treatment - -perhaps and I hope, the Government hospital is taking up the slack as I would hate to see the pathology that comes through the door suffering at home. However what is sure is that the charity has made and is making no attempt to monitor the effect of its decisions, that would be too thoughtful and also the answer might be very uncomfortable. The main function of Maternity Worldwide is to provide training and they have 3 managerial staff, one of whom is keen to relocate to Addis and a midwife who is going around assessing training needs but not as yet delivering the needed training. The English training team, following a lot of wrangling appeared and being English did Stirling work but only just made it with the various barriers put in their path and the only useful help they got was not from the local management team but the ex-pat midwife who did much organisational work on their behalf (such as buying them food and photo-copying teaching material). It seems to me that there is a lot of ‘need assessment’ little in the way of ‘need delivery’ and crude if any measure of the effectiveness of the training that is delivered. It is all to do with something called EMOC but I am not sure what it stands for. Not so the delivery of useful clinical equipment though, and there has been a lot of counting of various toys, including some rather mouldering looking tents – I am not sure I envy the sleeping quarters of the upcoming cyclists. There is now an inventory but most of the drugs are out of date but I do not suppose that out of date iron is very dangerous, and might be quite useful for the young lady with a haemoglobin of 5 gms. and a 4 hour walk home, she is a bit breathless getting out of bed.

Our non Danish and probably unrepresentative of the English Maternity Worldwide volunteers (this being part of a political battle being played out in the U.K) brought with them useful goodies, such as scrubs for the local surgeon, swabs for surgery and sutures etc. Instead of the scrubs being handed over, the swabs dropped into theatre etc. all was laboriously counted into stores from which it is never likely to emerge, on the spurious grounds that the team will want to know what happened to them…do they care and do they care enough to think that it was worth the best part of a day of the teaching midwifes time? I actually have a personal gripe here as I went along to say hello to the local chap who is very nice, which took all of 30 minutes as he was working (probably looking after those who can no longer afford the Adventist Hospital now there is no ‘Safe Birth Fund’) and I did not want to hold him up. I was then left kicking my heels until I started to walk back when a car appeared as apparently as with a lot of NHS hospitals it is in a rough part of town and I might get robbed!

Meanwhile I am very pleased to say, our radical hysterectomy lady is home and well and hopefully will remain disease free for quite a while and certainly unpleasant, blood stained discharge free for a good length of time. She poor dear had been having symptoms for 5 years and some symptom alert information would have easily allowed her to have earlier treatment and a greater chance of disease free survival. Current efforts are about trying to pick up the disease in the premalignant phase by painting the population’s cervix with vinegar and freezing it with cryotherapy if it looks white. Probably harmless but for those of you who have done the evidence base module of the MSc I dread to think about sensitivity, specificity, and probably numbers needed to treat, but there are not many cryoprobes about and no obvious means of gas transport so the treatment will not be that available. A rechargable battery driven ‘cold coagulator’ which my generation might remember would be a more easily assessable treatment tool, and would have the advantage of self sterilisation. Perhaps a free screening service for those with symptoms and early recourse to surgery might be a better way to spend scarce resource – but then there is not any resource anyway and what is certain is the punter sure don’t have any of her own.

If there is a light at the end of the tunnel it will be the glimmer of a largely unlit and certainly unenlightened on coming Ethiopian train.

The Dark Side of the Moon

Are the forces of darkness gathering, if you are able to read this we have beaten the system! The problem is that we are having difficulty accessing the blog site. Karen is convinced that the Ethiopian thought police/bureau of state security has read the politically incorrect thoughts of Winston Wright and has thus pulled both blog sites and taken away our voice. If this is the case and we have circumvented it – read on. Ethiopians do not do criticism, which is possibly why they do not respond to any form of training and that sustainability is but a hollow slogan. As the famous philosopher ‘Pangloss’ would say ‘All is for the best in the best of all possible worlds’ and that must be the way of things in this strangely beautiful, over bureaucratised grubby and chaotic country. Karen and I have major discussions about the need never to offend, the politically correct view of never being forthright about what you believe as it will prevent progress as compared to mine which is speak and be damned if that is what you think. As Voltaire famously said (but in French)’ I strongly disagree with what you say but I will defend to the death your right to say it,’ so with two quotes from the same philosopher I have to defend my position to say in this blog, or elsewhere what I think, at the risk of casing offence, or even as has been locally suggested, cause all blogging sites in this country to be unreadable as the thoughts and stories emanating from them cause offence to the censors or leaders of the country. So is it better to tippy-toe around the manifest problems or to face them head on and say what you think. One allows you to co-exist in a cosy if false harmony, the politically correct and I would say soft centred view and the other is robust if sometimes uncomfortable debate – the problem to me is that no one these days really feels able to say what they really think.

The land here is rolling hills of teff the wheat that makes that sour dough the staple of the food, the trees that cover the coffee plants the main source of income (other than NGO and faranji tax) and with the vast population, rusty corrugated iron roofs that somehow blend into the landscape and from which pour forth small and snotty children if you ever stop with the familiar refrain ‘Faranj, you, you, you give me money (I have stopped carrying any and pull my pockets out to show that they are empty) to the amazement of the young. Meanwhile at home, the only place that Masie will now lay eggs is the basket of baby clothes on the floor, happily so far without skid marks. The noise she makes prior to this is enough to allow the practice to continue – anything for a quiet life.

Meanwhile, back at the ranch we are providers of NAN milk for the neonates of West Wollega as they survive the cold and wet. Wet is inevitable as there are no nappies and unless you are fit and well with enough material to dry the odd bottom that is the fate that awaits you. If you are ill by virtue of say being unconscious or confused having arrived fitting and on your own your baby is at the mercy of local forces and dressing is dependent on availability of clothes, now of course with the added advantage of chicken down duvets!

As ever I never have the head camera in the right place as a woman turns up having travelled many kilometres - the locals say about 4 hours, septic, with a ruptured uterus, the result of an undiagnosed brow presentation in a gravida 5 (aged 25 so if she dies that is 4 orphans) and strangely not too much in the way of blood loss. If I had pictures I would have shown you, assuming they would let it on to U tube, but with the current difficulties of getting this stuff on to the blog who knows. The cervix (in 2 pieces) and the lower segment are a soggy smelly friable mess, so as she wants (as they say in these parts) a BTL (sterilisation to you and me) I do a hysterectomy – very carefully with everything double clamped and particular care around the vagina as two ureters would be in the words of Oscar Wilde be careless. She comes from a different tribe up country and is clearly short of money as when I went to see her next day I was confronted with a request for money to pay for Tramadol, which they could not afford, the antibiotics presumably having exhausted their financial reserve. The charity for which we are here have pulled the ‘safe birth fund’ as of the beginning of the year, on the understanding that treatment is free in the government hospital (though it is not clear if this includes drugs) so the future is I fear even more uncertain for those travelling long distances in the hope of staying alive while giving birth. Those of you who know about third world (sorry politically correctly ‘developing world’) care will know about the 3 delay model. Commendably, here the third delay, that of getting treatment on arrival is virtually non- existent here as resuscitation is brisk, crystalloid and antibiotics and anaesthesia swift with no questions asked, no nonsense about CEPOD lines and fighting for space. The tough and antibiotic naïve seem to survive. Have also managed to find a better suction for the ventouse, so hopefully this will help my on-going struggle too.

In the meantime our second radical hysterectomy went home praising the Lord (not I note her surgeons) on day 4 without immediate mishap – I do hope she does well in the future.

Please feel free to comment then I know you have read this.

Hopefully to be continued……

For those of my readers that are interested I have written a begging letter to ‘GRACE’ which is a local (as in Surrey) cervical cancer fund and has helped fund the ‘Robot’ at the Royal Surrey Hospital. As you might imagine these parts are long way from robots but a very short way from a national problem of untreated cervical cancer. Some of this is treatable surgically and could be operated on by local surgeons with appropriate training – hence my cunning plan. If it works, and sustainability is all, they can all go on teaching each other and we have a rolling program of cervical cancer surgery.
However patients have to pay (probably around £80) for their surgery currently, (and this is out of range for the rural and affected population whose average working wage is £10 a week if they are lucky, nurses here who are trained get £40 a month) but if we could show that it works, even in the short term we could try to get the government to fund it in much the same way that they currently allegedly fund maternity care. Basically I am after around £1,000 to fund 10 cases and see how it goes. Have a read and if you know of a charity that would like to help let me know!

Illusions of sustainability

There is a glimmer of the illusion of possible sustainability on the horizon with an offer by one of the nurses, almost spontaneously to put down a nasogastric tube on an eminently salvageable 2Kg 32 week old neonate with no suck reflex and a rather bruised head from her backward entry into this world. A number of problems had to be overcome first however such as the availability of a tube even on the second hand market (there is a flat tin with various coils of damp plastic, but no 5F tubes). Apparently none in the hospital despite various calls – was a salvageable baby going to succumb or aspirate for the sake of a tube. Despite much energy being expended on inventories, this was at variance with local knowledge of a cardboard box to the right of the door, in the store which might contain what was needed. Finding the key had its difficulties as being quarter to five all had gone home (no guesses as to standard day finish) and the local key was held by a case of D&V who was reluctant to leave the home facility but needs must. Entry achieved to the locked room and indeed tubes available, sufficient for me both to keep a spare myself and sequester one in the room for another eventuality. A sugary regimen and we are away. It is up to you now mum, milk production or death.
On joining the ward round yesterday, (something I avoid unless I have to conduct it for its sheer tedium, I now know why it is so difficult to get an SHO on to the post-natal ward) I was struck by the large piles of human poo around one of the beds and was not immediately aware of its source until I spied a toddler, sans clothing below the navel and a mother (suffering a miscarriage I think) confined to bed. The high roughage diet is clearly high poo volume too, but why no effort to clear it up. The answer of course is that there is nothing to clear it up with – there are no paper, or come to that any towels, so nothing to scrape the offending ordure up with, so there it stays, and many do not have shoes. This was brought home to me by a visit to the Government hospital today to chat to their very nice obstetrician, who I watched – I kid you not – dry his hands on a piece of paper from the notes. This is not as bad as you might suppose as the paper is of low quality and is very absorbent, the only thing you can write with is non- absorbent biro, rendering me even more illegible than usually the case. Lest you be worried the O.R has reusable towels as with everything else, but the soap is running out I notice. Here, you wash your hands then someone pours an evil smelling alcoholic solution onto them, a smarting experience if you have a small cut.
The usual diet of obstructed labour and fetal distress has been broken recently by ectopic pregnancy, one a bit tachycardic and the other a chronic mess with the appendix buried in it and a radical hysterectomy which I am pleased to say went really well. This has inspired me to look at developing a service for early stage invasive disease – so do take the trouble to read my plug in the next blog which immediately follows this.
The absence of wheels and dependency is increasingly tedious and is being used a less than subtle form of control together with petrol costs and per deums (eating costs for the driver, and sleeping costs if we go to Addis). I am plotting ways of trying to get the car back as Karen now feels secure here, I feel claustrophobic and am looking for ways to put myself in danger or expanding my horizons. I think Aber Minch has possibilities but I suspect that there will be quite a lot of leg work both with the authorities and on the home front. Although the compound is a safe(ish) haven, bar the endless stream of people who call at the door, wanting a chat, money, both computer access or more time consuming computer lessons or feeding. While waiting rather endlessly outside the government hospital for my lift I noted people being carted in on stretchers and rather a lot of quite friendly looking people in Khaki smiling a lot but toting AK 47s with hollowed out shoulder rests and looking quite new. Why I wonder do the manufacturers bother with fake wood on these automatics? Feeding has its moments as Adventists develop sudden narcolepsy just before food and start muttering (probably to some deity) and marvel at the amount of Ribena we seem to be drinking from a box without offering any to them though we keep a supply of apple juice now for such visitors. The chickens have become very noisy and toxic trying to find a place to lay we hope, but have to keep chasing them outside and off chairs – they almost seem to like being picked up now, very worrying ,as is their incontinence. Lack of eggs culminated in me buying some from the village, Karen simultaneously buying some up country while walking back from a health post as there was the usual delay in transport, so with an egg glut – two eggs from our two. Egg mayonnaise sandwiches for lunch then. Karen has constructed comfortable looking but so far ignored egg laying boxes but they prefer the outside world as do passing stray dogs or the chickens themselves. Eating your own eggs probably does not amount to cannibalism and as not fertilised infanticide, but what I wonder?

Off to Aira hospital tomorrow, transport permitting, a haven of German Missionary efficiency where I hope to both discuss my cancer project and borrow a cystoscope so I can take stent out.
In the meantime the endless supply of lentils which ensures no bowel obstruction, and the peoples of this area, which ensures pelvic obstruction will continue. It is a far cry from St. P, but that does not sound that much fun at the moment either….
To be continued if anyone is reading………….

31st December 2011

Boxing day chat

Christmas Eve was certainly busy (and sadly dry) as I agreed to do the on call, 4 Caesarean sections, the last of which while our desert of pancakes waited, (sorry they were thin so crepes) culminated in a first for me of having to do an inverted T in both the uterus and the abdominal wall and pulling the baby out by its bum with a great slurping noise, though it seems none the worse for being jammed for many hours though by the amount of meconium about there will not be enough left for a meconium stool. The mother looks surprisingly well given that she had to travel a considerable distance and time while pushing hard to get to us. As ever the later borne 1.4 Kg baby was left cold and wet and hungry. There seems to be something in the African or at least the Ethiopian psyche that does not allow you to think for yourself or initiate any action at all of your own volition.
Chris a refugee from comfortable California, wanting to do good, put something back etc. has been working with computers, novice nuns and importantly access to God’s truck to which we have had some limited access, was struck by this when on a rest day he found them all listlessly sitting around and organised a football match in the compound which they all thoroughly enjoyed. The question is ‘Why like so much that is going on, could they not organise this themselves. Self-starters are in short supply and we are I think beginning to understand why but that will have to await another blog and probably from a better (Karen’s) mind.
Christmas day dawned and unlike today as I write this, surprisingly some internet access so we were able to skype friends and family and also send some e cards. The day was spent entertaining the rather too ever present young lads with no homes, shoes or food and who will consume anything put in front of them, on this occasion tuna pasta bake and coca cola. There feet are not pretty and they do recognise this and are reluctant to take their shoes (bits of rubber cracked flip flops off) so there is a thin layer of red African dust around the house. From the flood around the loo the concept of peeing in a water closet is also rather foreign. Despite three goes now they have yet to master the skills of opening perforations in cardboard to get the ever increasing sized advent chocolates (I do not think that they have spotted that they get bigger row by row0 but as there are 5 to a row and 5 of them it is only of academic interest, but bodes badly in terms of their ability to rise above the condition they find themselves in. Then along with our neighbours children, friends and relations, including one with mental health problems, though seems a little better we sit them down to a screening of Elf, almost brought to grief by one of the ever likely power cuts. They laughed a lot and seemed to like it, at least the slapstick parts. If we stay we may need to record rafts of Shrek, or other entertainment with visual gags, though if anyone would like to slip this onto a hard disc for us great. Karen thinks that Avatar might be too frightening and the complexities of Harry Potter are I think beyond them.
I am pleased to report that our last sortie into advanced gynaecology has so far, and it is early days, gone without immediate mishap as we managed to get out a 2b Ca Cx without too much trauma and with what appear to be clinically clear resection margins. I think that there may well be a place for radical hysterectomy without lymph node dissection for suitable women. As they are universally poor, and there is no ‘free at the point of delivery’ service (unless you have a prolapse and an American wanting to do it) we need to find a way of funding these operations without Adventists or any other NGO getting their slice.
Meanwhile it is now after school and time to cope with our increasingly demanding surrogate family, barren but obese and increasingly shitty chickens – the veranda would now count for barn reared on an advert – and is distressingly unhygienic as are the assorted snotty and unwashed orphans who we bought soap for (they say their clothes but their bodies could do with some too) and Jabber who being handed round lots now has snot and a febrile illness. We took the said yellow shirted youngsters to the ‘green bar’, us for a beer and them for some supper, bits of beef an egg and injera.* A v .large plate polished off in record time and some cokes, only full fat is available. The bar is fairly empty but Man U are playing in another time zone so those with satellite dishes (which also represent those roué enough to have a beer in public and afford it) are not there. Perhaps we can persuade a fan club to donate some orphans football shirts in various sizes.

*Injera is the Ethiopian staple which I may have described before. It looks like a dirty grey flannel and tastes sour and has an unpleasant chewy texture – I have not chewed flannels but I suspect……