Sunday, 22 April 2012
Educational travels
Wednesday, 28 March 2012
Angles saxons and history
Those of my readers (if there are any now that I am effectively censored) who remember any of the history they were taught at school particularly early history will know that if you want to understand the present you have to study the past. The teaching of history however is now so impoverished that all anyone knows anything about is the origins of the Second World War, and Tudors and Stewarts. However, if you go back further you may recall how the Vikings fought with the Angles and Saxons and discovered that it was less costly in lives and more profitable to extract money with promises of safety from further attacks (menace money in modern parlance), the so called Danegeld (nothing to do with Germany). So after various incursions on this foreign soil by both Angles and Vikings an uneasy truce now exists though inevitably the locals are bloodied and having to rebuild their lives now it seems as educationalists rather than the bringers of relief, but both I am sure are important. It is however currently 30 luv to the educationalists (that is quite enough mixed metaphors). I am however saddened, being used to a system where care is free at the point of delivery to see people turned away if they have no money and to watch, as I am at the moment, a young woman die of heart failure as her family are either unable (possibly the case) or unwilling (probably the case) to donate any blood. I will do my best to keep her alive but am concerned.
We have more faranji visitors now in the shape of midwifery students from Edinburgh, who are innocents personified at the moment but will I hope develop as a result of their experience and might perhaps decide that a career, particularly an early career in the developing world may greatly add to their ability to cope in the developed world and perhaps see some of the flaws in the system from whence they came. You can keep people alive and safe even with minimal resources and perhaps that may be enough, certainly rescuing people from their obstructed labour when you can will keep them alive, and perhaps some education may stop them getting into that situation again, but in this country the education has to be directed at the husband and keeper of the geld as it seems wives are expendable, and not worth either transport costs or a temporary 2 Grm drop in haemoglobin. I have suggested to our Faranji visitors that they try to look at the history of those who turn up with obstructed labour (sadly fewer as no danegeld to pay) and see where the delays occurred. I am told we have some medical students coming too so maybe I can get a research team together – we shall see. The private sector which if nothing else bought me alimony and children’s education was fine when there was an alternative but is uncomfortable when real need remains unmet, but then I am sure that sustainability and education will stop all this!
Meanwhile my other nearly exsanguinated patient (bad tear, normal delivery, yes it happens here too), is well and going home as her brothers rallied to the cause and she is pink and well and now home. I am off on a week’s holiday soon to visit Lalebela and rock hewn churches etc. happily over the time that the prolapse tourists arrive so I will not have to vent my spleen on them though I have hopefully arranged for the mesh erosion ladies to return for their remedial surgery over this time, I wonder if they get a second dress? Our own complication is a wound infection following removal of rotting cervical tumour but it is granulating well, though her husband is pursuing me with unstamped receipts and tales of starvation. She comes a distance so I hope we can get her home soon. Histology reports are beginning to trickle in but contain no useful information like resection margins but tell us like many histology reports, what you already know – er got cancer. Ultimately they will either survive or not, but as Thomas Stone remarked (yes I have read the novel, novel reading is unusual for me) you do not want to operate on a patient on the day of their death and I have yet to do that on one of the cancer patients though one of the young septic obstructed labour patients sadly succumbed from her complications shortly after her twins. All avoidable of course if intervention had been timely, perhaps education would have helped.
If it were not for the importance of Karen’s research which also suffers from obstruction but of another sort, I would leave the Angles, Saxons and Vikings to fight it out with their local lascars and go south to where an unwell single handed obstetrician would welcome a hand and a new medical school would welcome some teaching input, but no I will remained a censored voyeur and continue to report in more guarded terms to my remaining readership, in academically correct and measured words (get real that is quite enough cant).
We have more faranji visitors now in the shape of midwifery students from Edinburgh, who are innocents personified at the moment but will I hope develop as a result of their experience and might perhaps decide that a career, particularly an early career in the developing world may greatly add to their ability to cope in the developed world and perhaps see some of the flaws in the system from whence they came. You can keep people alive and safe even with minimal resources and perhaps that may be enough, certainly rescuing people from their obstructed labour when you can will keep them alive, and perhaps some education may stop them getting into that situation again, but in this country the education has to be directed at the husband and keeper of the geld as it seems wives are expendable, and not worth either transport costs or a temporary 2 Grm drop in haemoglobin. I have suggested to our Faranji visitors that they try to look at the history of those who turn up with obstructed labour (sadly fewer as no danegeld to pay) and see where the delays occurred. I am told we have some medical students coming too so maybe I can get a research team together – we shall see. The private sector which if nothing else bought me alimony and children’s education was fine when there was an alternative but is uncomfortable when real need remains unmet, but then I am sure that sustainability and education will stop all this!
Meanwhile my other nearly exsanguinated patient (bad tear, normal delivery, yes it happens here too), is well and going home as her brothers rallied to the cause and she is pink and well and now home. I am off on a week’s holiday soon to visit Lalebela and rock hewn churches etc. happily over the time that the prolapse tourists arrive so I will not have to vent my spleen on them though I have hopefully arranged for the mesh erosion ladies to return for their remedial surgery over this time, I wonder if they get a second dress? Our own complication is a wound infection following removal of rotting cervical tumour but it is granulating well, though her husband is pursuing me with unstamped receipts and tales of starvation. She comes a distance so I hope we can get her home soon. Histology reports are beginning to trickle in but contain no useful information like resection margins but tell us like many histology reports, what you already know – er got cancer. Ultimately they will either survive or not, but as Thomas Stone remarked (yes I have read the novel, novel reading is unusual for me) you do not want to operate on a patient on the day of their death and I have yet to do that on one of the cancer patients though one of the young septic obstructed labour patients sadly succumbed from her complications shortly after her twins. All avoidable of course if intervention had been timely, perhaps education would have helped.
If it were not for the importance of Karen’s research which also suffers from obstruction but of another sort, I would leave the Angles, Saxons and Vikings to fight it out with their local lascars and go south to where an unwell single handed obstetrician would welcome a hand and a new medical school would welcome some teaching input, but no I will remained a censored voyeur and continue to report in more guarded terms to my remaining readership, in academically correct and measured words (get real that is quite enough cant).
Monday, 26 March 2012
Just when you thought it was safe to get back into the water
So just when you thought it was safe to get back in the water (fade up scary music and read on).One of the abiding rural myths in these parts, and indeed Africa is that humans get attacked by crocodiles, particularly if they go down to the same place more than twice. This is I have to tell you actually no myth as walking through the operating theatre I spied a young man awaiting secondary suture with these injuries. It would appear that he was bathing with his mates, somewhere near the source of the Blue Nile, which is reasonably close when set upon by a hungry reptile and only survived because it was beaten off by his friends – a lucky escape but he will bear the scars.
Meanwhile having thought that the financial changes and withdrawal of funding would mean undisturbed nights of sleep I was rudely shocked by a night of registrar activity which included sedating a young lady who subsequently died as a combination of stroking out with her eclampsia (probably but being at home not really clear) and her sepsis, a sad and squalid end in the open ward, the other patients weeping quietly. Other activities included a breech delivery on a pre-eclamptic lady who laboured quietly in the ward, two retained placentae, an emergency section for a breech that looks strangely Down’s syndrome like and to round the night off a shoulder and cord presentation at full dilatation! I remain unclear as to where they all came from, whether they were paying for themselves or did they come bearing vouchers which will soon be rejected. Although wearying for the aging obstetrician manqué it does restore my faith, albeit temporarily, that I am possibly doing something useful. One of the worrying features however is that people come either when it is too late, preterm delivery at home and brisk bleeding having had two previous caesarean sections, and another fully dilated with a very low fetal heart rate. The latter is doing O.K. but the former baby does not look that great. I suspect they hang on in the hope that they can save the money and this may reflect the lack of a voucher, but I do hope not. The new MWW rubric is educashun and as part of this there are chats to women’s groups and worrying stories that either suggest education failure or male dominance of a degree that even disturbs this bastion of male domination. Women ruptures her uterus at home and kills baby, uterus sutured, has next baby at home, surprisingly ruptures uterus again, kills baby has hysterectomy and now ‘quote’ @must bear this burden. Failure of education, understanding or permission of husband? Who knows but goes some way to explain the Ethiopian condition. Not so though the trip to Gueliso I was conned into taking together with the ‘Adventist team, which was recruited patients for free prolapse operations, yes time to herald the return of the prolapse tourists, this time a slightly different team but still due to arrive any day, so some punters might get an operation and they can sort out the mesh erosion that popped up last week. Happiliy I will be away for a good portion of their time here so will not get too irritated I hope. One of the reasons, falsely it turned out, for going was to see if there were any cancers about but none came forward. Histology so far has shown resection margins clear but out into the parametrium so hopefully a slightly longer life. We await more punters but I suspect that the other hospitals, though not offering surgery are jealous of their trade.
So as we move into the final third of our trip here (3 X 4 = 12) but actually slightly over half as we are doing 10 months it is an interesting time to take stock. I have I think been a little over harsh on the Ethiopians, not because of what they do but why. There is no government net so they rely on local support and a sort of Marxism rules in that if you have and they have not you are expected to share, the more you have the more you share (and thus presumably you have less) but faranjis always have more so start there.
Do they care, they certainly stand and stare and invade your space, there is relatively little in their lives so anything is a free show and they are clearly trained to remain expressionless until there are episodes of collective joy (singing at marriages etc.) or collective grief (ululating at funerals) but they do turn up in their multitudes when there is illness but whether to help or watch I do not know. The occasional happy smile is a sign that they do have feelings and when you do get to know them you will get some idea of these. Though if you do piss them off this may well last for ever. If you live small parochial lives (and mostly they do) you get small parochial views and it only those with satellite TV that are ever likely to move away from this.
Will they steal anything from anybody even their friends, if you are the street kids yes, the top to my memory stick has been nicked from the table outside where it was left for 10 minutes during a recent visit – irritating as useless to them and quite important to me. This adds to the list of trivial nicking, which includes for the second time one of the outside bulbs, doubly irritating as it lights my path when summoned to the ward in the wee small hours. The kids sadly, and this goes for the vast majority, are bored feckless destructive, begging bastards, whether it writing on the car with stones, shouting obscene requests for money while being vaguely threatening (Teenagers) or if ‘orphans’ taking faranj hospitality and gifts while outrageously upping the ante, more expensive food and drink when being entertained, and lording it about in football kit that they only just manage to keep clean, though to be fair when given a tub of water they did wash their clothes followed by each other. I suspect that their life consists of intermittent neglect and then the showering of treats when what they really require is tough love and life lessons.
Life here is hard and in the main brutish, with low living standards, little in the way of facilities and a government service which is more in what they say they do rather than what actually happens. There is a lack of care and in a strange parallel with our own health service it is more about measurement than delivery, and that which is delivered ain’t that great. Despite this they are survivors, but with only a little help, and a little real thought rather than the parroting of what they have been told, they could make great strides, but that would require initiative and sadly, in the last analysis that is what is missing
Meanwhile having thought that the financial changes and withdrawal of funding would mean undisturbed nights of sleep I was rudely shocked by a night of registrar activity which included sedating a young lady who subsequently died as a combination of stroking out with her eclampsia (probably but being at home not really clear) and her sepsis, a sad and squalid end in the open ward, the other patients weeping quietly. Other activities included a breech delivery on a pre-eclamptic lady who laboured quietly in the ward, two retained placentae, an emergency section for a breech that looks strangely Down’s syndrome like and to round the night off a shoulder and cord presentation at full dilatation! I remain unclear as to where they all came from, whether they were paying for themselves or did they come bearing vouchers which will soon be rejected. Although wearying for the aging obstetrician manqué it does restore my faith, albeit temporarily, that I am possibly doing something useful. One of the worrying features however is that people come either when it is too late, preterm delivery at home and brisk bleeding having had two previous caesarean sections, and another fully dilated with a very low fetal heart rate. The latter is doing O.K. but the former baby does not look that great. I suspect they hang on in the hope that they can save the money and this may reflect the lack of a voucher, but I do hope not. The new MWW rubric is educashun and as part of this there are chats to women’s groups and worrying stories that either suggest education failure or male dominance of a degree that even disturbs this bastion of male domination. Women ruptures her uterus at home and kills baby, uterus sutured, has next baby at home, surprisingly ruptures uterus again, kills baby has hysterectomy and now ‘quote’ @must bear this burden. Failure of education, understanding or permission of husband? Who knows but goes some way to explain the Ethiopian condition. Not so though the trip to Gueliso I was conned into taking together with the ‘Adventist team, which was recruited patients for free prolapse operations, yes time to herald the return of the prolapse tourists, this time a slightly different team but still due to arrive any day, so some punters might get an operation and they can sort out the mesh erosion that popped up last week. Happiliy I will be away for a good portion of their time here so will not get too irritated I hope. One of the reasons, falsely it turned out, for going was to see if there were any cancers about but none came forward. Histology so far has shown resection margins clear but out into the parametrium so hopefully a slightly longer life. We await more punters but I suspect that the other hospitals, though not offering surgery are jealous of their trade.
So as we move into the final third of our trip here (3 X 4 = 12) but actually slightly over half as we are doing 10 months it is an interesting time to take stock. I have I think been a little over harsh on the Ethiopians, not because of what they do but why. There is no government net so they rely on local support and a sort of Marxism rules in that if you have and they have not you are expected to share, the more you have the more you share (and thus presumably you have less) but faranjis always have more so start there.
Do they care, they certainly stand and stare and invade your space, there is relatively little in their lives so anything is a free show and they are clearly trained to remain expressionless until there are episodes of collective joy (singing at marriages etc.) or collective grief (ululating at funerals) but they do turn up in their multitudes when there is illness but whether to help or watch I do not know. The occasional happy smile is a sign that they do have feelings and when you do get to know them you will get some idea of these. Though if you do piss them off this may well last for ever. If you live small parochial lives (and mostly they do) you get small parochial views and it only those with satellite TV that are ever likely to move away from this.
Will they steal anything from anybody even their friends, if you are the street kids yes, the top to my memory stick has been nicked from the table outside where it was left for 10 minutes during a recent visit – irritating as useless to them and quite important to me. This adds to the list of trivial nicking, which includes for the second time one of the outside bulbs, doubly irritating as it lights my path when summoned to the ward in the wee small hours. The kids sadly, and this goes for the vast majority, are bored feckless destructive, begging bastards, whether it writing on the car with stones, shouting obscene requests for money while being vaguely threatening (Teenagers) or if ‘orphans’ taking faranj hospitality and gifts while outrageously upping the ante, more expensive food and drink when being entertained, and lording it about in football kit that they only just manage to keep clean, though to be fair when given a tub of water they did wash their clothes followed by each other. I suspect that their life consists of intermittent neglect and then the showering of treats when what they really require is tough love and life lessons.
Life here is hard and in the main brutish, with low living standards, little in the way of facilities and a government service which is more in what they say they do rather than what actually happens. There is a lack of care and in a strange parallel with our own health service it is more about measurement than delivery, and that which is delivered ain’t that great. Despite this they are survivors, but with only a little help, and a little real thought rather than the parroting of what they have been told, they could make great strides, but that would require initiative and sadly, in the last analysis that is what is missing
Monday, 19 March 2012
longer boats
And so the long boats left, this time with a new helmsman as the usual and trusty driver, Kume has had enough of the dusty Addis road and has turned his hand to house building for a few weeks, and the representatives of MWW.DK return to inhabit the land of Hans Christian Anderson.
There is, if my readings of their deliberations are correct, now a completely new approach to the provision of financial support for those needing help with paying for intra-partum care (delivery). Previously (see blogs passim) vouchers paid for intra-partum care for those in need and this had been rapidly accelerated to those who asked and care was delivered in a mission hospital at a cost. Now the maternity worldwide voucher now pays for medication, if required in a government hospital for those in a rural community, provided they are seen to be in need by a committee of their peers. Means testing comes to West Wollega. Medicines here are remarkably cheap by western standards, some chloramphenicol eye drops and paracetamol syrup cost me 16 birr yesterday. Private travel is however not and some poor wretch with a ruptured uterus was required to pay 2000 birr (£80) for a lift on a lorry surrounded by eucalyptus logs for emergency surgery that was to cost her 1600 birr (£60) at this now private facility, having initially, despite being moribund been turned away either as a result of poor assessment or having no money as it had been spent on transport. The former being less morally reprehensible. For someone who has been brought up in what the Americans would describe as ‘socialised medicine’ it is a rude shock to realise that I am to spend my last few months here working in the American commercial sector. The parallels sadly run deeper as the Adventist Hospital boasts two obstetricians, by local standards adequate resources, much provided by western benefactors not least our own supplies and access to emergency surgery more quickly than is available in many U.K. hospitals (no nonsense about CEPOD lists in this neck of the woods). The government hospital meanwhile is under bedded and under resourced but with a keen and competent obstetrician who has trained one of his general doctors to do the caesarean sections when he is not around, though with the more complex surgery who knows, though it might explain 2 ruptured uteri in one day here. There is however only one operating theatre and if in use by others, tough. Another NHS parallel here as there is usually only one emergency theatre and surgeons wrangle over access to it. Transport as ever remains an issue and there has been much discussion over the deployment of e ranger motorcycles currently children’s play things with ever flattening batteries (they have discovered that it is fun to turn the lights on and off) ensconced in the hospital foyer but soon to be deployed in two rural areas and will with shoulders of strong villagers, a single health centre car and local buses become the transport at either cost or means tested subsidy for those on their way to the government facility whether or not they bear vouchers offering them free antibiotics to help offset the incipient sepsis from their obstructed labours as they await skilled help and access to an operating theatre - we live in interesting times.
The new watch words are of course sustainability and training and much training is to be offered to those in health centres, though little is delivered on site as trainees like to gather in centres to be instructed as this carries transport and the ever important per deum. (these are a day rate for attending courses and are an important income stream for health officials and explains why they are regularly at these courses at every possible opportunity). Hopefully they will learn useful skills like recognising when labour has become obstructed (it has been going on for more than 12 hours and no end is in sight) and make provision for transfer to somewhere that can do something about it before it is too late. Sadly restrictions on what is permissible in health centres, basically an outpatients with a labour ward, means that oxytocin, a uterine muscle stimulant, is available for third stage problems but not intra-partum, so the prima-gravid with uterine inertia are condemned to a long ride to hospital and a caesarean section to protect their multi-gravid fellows from possible overstimulation and uterine rupture. Storing up trouble for the future me thinks and the training will never be subtle enough to make this distinction.
Although the management of first stage uterine inertia may require more skill and judgement than is available in health centres the management of eclampsia does not and is much needed given that the maternal death and other acutely nearly dead people I have seen could have been rescued by earlier and very straightforward intervention and with this in mind I have on my trips to various health centre offered some in situ but per deum less scenario training around patient stabilisation prior to transfer. Treatment is by magnesium sulphate, cheap but actually apparently available free and safe, effective and easy to administer (painful injection in the bum) and probably does not matter if you have the diagnosis wrong (cerebral malaria is about in these parts) and might actually save a few lives. Problem – well yes, though apparently free not yet available in health centre or indeed a couple of local hospitals which may go some way to explaining why some women have come a long way, apparently passing various treatment centres to be here. A strange and topsy turvey world we live in. What is on offer, curiously is large amounts of free methyl dopa, useful if carefully judged in the chronic situation, but requiring frequent monitoring, which is non existent and to be given in appropriate doses, which by enlarge it is not, effective emergency treatment is just locked away. Sustainability is about training and retraining to understand and react to the problems we encounter in an appropriate and in this case diagnostic or therapeutic way, but in order to do this one requires the tools. The training is shaky but the tools which that training should equip you to use are yet to be put in place.
Those of you who are reading this will realise that you are now on a restricted reading list as the forces of, well I am not sure what, are so upset that what I have said, which has actually gone, and now probably more important what I might say that I am strictured only to allow it to the select few. I am told that I need to reflect on what I say as it is deeply hurtful, which indeed it may be. The hurt equally should probably reflect on why they are hurt as however distorted there is always a grain of truth, but if I have been too negative and hurtful I am of course sorry, but those to whom it has happened will probably no longer get to read this. I am too incompetent to get a link but listen to the words of longer boats cat stephens on you tube!
There is, if my readings of their deliberations are correct, now a completely new approach to the provision of financial support for those needing help with paying for intra-partum care (delivery). Previously (see blogs passim) vouchers paid for intra-partum care for those in need and this had been rapidly accelerated to those who asked and care was delivered in a mission hospital at a cost. Now the maternity worldwide voucher now pays for medication, if required in a government hospital for those in a rural community, provided they are seen to be in need by a committee of their peers. Means testing comes to West Wollega. Medicines here are remarkably cheap by western standards, some chloramphenicol eye drops and paracetamol syrup cost me 16 birr yesterday. Private travel is however not and some poor wretch with a ruptured uterus was required to pay 2000 birr (£80) for a lift on a lorry surrounded by eucalyptus logs for emergency surgery that was to cost her 1600 birr (£60) at this now private facility, having initially, despite being moribund been turned away either as a result of poor assessment or having no money as it had been spent on transport. The former being less morally reprehensible. For someone who has been brought up in what the Americans would describe as ‘socialised medicine’ it is a rude shock to realise that I am to spend my last few months here working in the American commercial sector. The parallels sadly run deeper as the Adventist Hospital boasts two obstetricians, by local standards adequate resources, much provided by western benefactors not least our own supplies and access to emergency surgery more quickly than is available in many U.K. hospitals (no nonsense about CEPOD lists in this neck of the woods). The government hospital meanwhile is under bedded and under resourced but with a keen and competent obstetrician who has trained one of his general doctors to do the caesarean sections when he is not around, though with the more complex surgery who knows, though it might explain 2 ruptured uteri in one day here. There is however only one operating theatre and if in use by others, tough. Another NHS parallel here as there is usually only one emergency theatre and surgeons wrangle over access to it. Transport as ever remains an issue and there has been much discussion over the deployment of e ranger motorcycles currently children’s play things with ever flattening batteries (they have discovered that it is fun to turn the lights on and off) ensconced in the hospital foyer but soon to be deployed in two rural areas and will with shoulders of strong villagers, a single health centre car and local buses become the transport at either cost or means tested subsidy for those on their way to the government facility whether or not they bear vouchers offering them free antibiotics to help offset the incipient sepsis from their obstructed labours as they await skilled help and access to an operating theatre - we live in interesting times.
The new watch words are of course sustainability and training and much training is to be offered to those in health centres, though little is delivered on site as trainees like to gather in centres to be instructed as this carries transport and the ever important per deum. (these are a day rate for attending courses and are an important income stream for health officials and explains why they are regularly at these courses at every possible opportunity). Hopefully they will learn useful skills like recognising when labour has become obstructed (it has been going on for more than 12 hours and no end is in sight) and make provision for transfer to somewhere that can do something about it before it is too late. Sadly restrictions on what is permissible in health centres, basically an outpatients with a labour ward, means that oxytocin, a uterine muscle stimulant, is available for third stage problems but not intra-partum, so the prima-gravid with uterine inertia are condemned to a long ride to hospital and a caesarean section to protect their multi-gravid fellows from possible overstimulation and uterine rupture. Storing up trouble for the future me thinks and the training will never be subtle enough to make this distinction.
Although the management of first stage uterine inertia may require more skill and judgement than is available in health centres the management of eclampsia does not and is much needed given that the maternal death and other acutely nearly dead people I have seen could have been rescued by earlier and very straightforward intervention and with this in mind I have on my trips to various health centre offered some in situ but per deum less scenario training around patient stabilisation prior to transfer. Treatment is by magnesium sulphate, cheap but actually apparently available free and safe, effective and easy to administer (painful injection in the bum) and probably does not matter if you have the diagnosis wrong (cerebral malaria is about in these parts) and might actually save a few lives. Problem – well yes, though apparently free not yet available in health centre or indeed a couple of local hospitals which may go some way to explaining why some women have come a long way, apparently passing various treatment centres to be here. A strange and topsy turvey world we live in. What is on offer, curiously is large amounts of free methyl dopa, useful if carefully judged in the chronic situation, but requiring frequent monitoring, which is non existent and to be given in appropriate doses, which by enlarge it is not, effective emergency treatment is just locked away. Sustainability is about training and retraining to understand and react to the problems we encounter in an appropriate and in this case diagnostic or therapeutic way, but in order to do this one requires the tools. The training is shaky but the tools which that training should equip you to use are yet to be put in place.
Those of you who are reading this will realise that you are now on a restricted reading list as the forces of, well I am not sure what, are so upset that what I have said, which has actually gone, and now probably more important what I might say that I am strictured only to allow it to the select few. I am told that I need to reflect on what I say as it is deeply hurtful, which indeed it may be. The hurt equally should probably reflect on why they are hurt as however distorted there is always a grain of truth, but if I have been too negative and hurtful I am of course sorry, but those to whom it has happened will probably no longer get to read this. I am too incompetent to get a link but listen to the words of longer boats cat stephens on you tube!
Monday, 12 March 2012
Corinthian letters
‘And if thou hast not love, thou hast not anything, you are but a sounding brass or tinkling bell’, which is how I think that letter to the Corinthians runs, and is perhaps the epitaph of the departing hospital administrator. Though it could of course equally apply to your correspondent but he at least recognises himself as a ‘sounding off brass’ if nothing else.
So we have the changing of the guard. St Paul after a lengthy if muted send off (we buggered off to Green bar B at 18.30 but it went on to 20.30 with speeches and Ethiopian delicacies) is off back to the good old US of A via Norway and is to be replaced by Austin (of statement beard fame). Austin is now moving into the CEO house next door and will hopefully be adopting the orphan deer. He is now in a partnership with Becky (are you keeping up) the Adventist with strong views on alcohol so we may see some more puritanical changes in these parts. However responsibility has seen the statement beard being replaced by designer stubble and a more normal hair style and my reading of the community is that they look forward to the change. So what will Paul’s epitaph be, given that he was thrown into the lion’s den at a time of crisis and with little experience to deal with it. He has given the hospital a reasonably secure electricity supply which for night time operations is a bonus and he has (for which he is not popular) made big staff changes. Is the hospital a better place for his tenure, on balance yes, it was I believe in dire straits before he arrived. But the delivery of much medical care remains in the hands of the very poorly trained on the dubious grounds that some medical training is better than none, but not realising the reality that it can actually be more dangerous. Certainly there is the handing out of antibiotics in profusion when you do not know what you are treating. The most common medical diagnosis in these parts is pneumonia, that well known chest condition of the tropics. His relationship with our sponsoring organisation remains unhappy and the loss of maternity funding means that the staff remain uncertain in their jobs. His legacy is thus mixed as indeed is the future of the hospital but I suspect, despite protestations to the contrary, the hospital is a little better than its government competitor down the road. He does however irresistibly remind me of Kaa (thanks Karen L.) and if he has a future in the first world he would make a good CEO of a hospital in the U.K. or USA or even an academic administrator. New arrivals include a Dutch missionary doctor (predictably and no they would not listen or read Karen’s wise words on how to do it) his registration is hopelessly bogged down in the Ethiopian administrative system and his wife a midwife who are now housed in the surgeon’s house though eyeing ours. He drank Ethiopian coffee which is a good sign (Adventists do not do coffee I believe) and one hopes that missionary zeal will be tempered with some medical good sense but too early as yet to say. We did not stay long enough at the ‘hail and farewell’ to chat to him and I know not whether we were really missed. Today is an Adventist rest day and yesterday the hymn singing coming from next door was lusty. We were invited to that and temptingly mango ice cream but had to decline as it was unlikely that the invitation included increasingly unwashed orphan boys with remarkably smelly feet whom we were entertaining with spaghetti and spam and tomato source followed by monsters inc. (this was not as much of a hit as Shrek and we only have the trailer to Shrek 2). Even the orphans declined to sit next to Lalisa’s feet and we ended up soaking them in Moulton Brown Shampoo for the whole of the film and the bucket is still pretty nasty and his socks…..information you would rather not know.
Continuing the biblical theme there is a ‘star in the east’ as there is a move to pull out of Gimbie where ‘our work is done’ and head to the pasturalist communities of the east which appear to be poorly provided for despite being a relatively easy commute to Addis so there was a move to follow that star at least by two wise persons if not kings and certainly not the desire of Queens, so off they set on a mission. Star following in the modern parlance is called ‘needs assessment’ and this is what was planned, i.e. a jolly to Awash(beauty spot withnice lodge, waterfalls etc.) and beyond, but was not to be as the appropriate ‘permissions’ had not been obtained, this is after all Ethiopia not Galilee, so the two wise persons are now hold up in Addis, one bored in a grubby hotel and the other on a family visit, their camel master on his per deum in an adventist hostel awaiting the arrival of the angel Gabriel on a flying visit. In terms of nee d there is really no need for an assessment ‘Gold and hold the frankincense and Myrrh’ though the latter two might be useful for the feet round here. In terms of ‘Gold’ well spent a little sad as the trip of star following was ill planned and thus came to naught. Presumably cost of stay in Addis met by charity.
The Angel Gabriel and the bringers of Danegeld in the shape of the Danish team re- arrive next week on a ‘visit’ suspiciously similar to that of the Adventist’ of last week, and were unsurprisingly as communication is not the watch word totally unprepared for the changes. Given that relationships with ‘St Paul’ had reached a record low, that particular meeting was not me thinks on the agenda but now there is a flurry of e mails wanting us to set up getting to know you meetings – Karen as Mary Poppins or the U.N. however the question of course is whether the ‘geld’ will go East or West. We are scheduled in for a meeting on Tuesday evening sans local organiser – paranoid times. Given that most of these meetings revolve around communication (or lack of it) there is little shuttling due.
Gee I am glad we have our car despite the costs and the grief as communication about travel and places in cars etc. reaches all times complexity and yes some have to take the bus and sit in really bad bench seats – all jealousy and bad feeling, and sadly probably unnecessary, yes communication again!
Despite protestations to the contrary there is no doubt to me that the poor and needy of Gimbie and Environs are not being catered for here unless moribund or with 1000 odd birr to spend (and some do, the coffee is picked) as unlike the first few months there is often little activity apart from the multiparous middle classes dropping their sprogs and then sitting around for a couple of days in their private sheets or the occasional nearly dead arriving with some ancient birth fund voucher which seems to get them a nearly free Caesarean section.
For those of you who are following the cancer of the cervix project the word is out and patients are beginning to come in, despite the best efforts of the lower echelons of the hospital to charge them, and despite my writing over the admission slip that the project pays. Equally distressing, the communication gap is such that operable cases with medical problems in which we start treatment (blood pressure tablets) disappear and do not reappear but will probably do so when they are beyond help – with limited funding I am loathe to admit them to the ward for a week. Soon off on a mass screening project so we will see. A difficulty unforeseen is the clinical diagnosis of cancer which I thought would be relatively straight forward but is complicated by such issues as previously undefined and undefinable vaginal surgery and my Ethiopian colleagues desire to operate on every fibroid that comes through the door ,by calling them cancer – sorry but we have limited funds.
So, we live in uncertain times and the forces of political correctness bear as ever down, trying to ensure, that the unpalatable vision of truth is wrapped in soft soap and that no one is ever upset by the vision of the world as maybe it really is.
Here endeth the lesson, but is it teaching or learning?
So we have the changing of the guard. St Paul after a lengthy if muted send off (we buggered off to Green bar B at 18.30 but it went on to 20.30 with speeches and Ethiopian delicacies) is off back to the good old US of A via Norway and is to be replaced by Austin (of statement beard fame). Austin is now moving into the CEO house next door and will hopefully be adopting the orphan deer. He is now in a partnership with Becky (are you keeping up) the Adventist with strong views on alcohol so we may see some more puritanical changes in these parts. However responsibility has seen the statement beard being replaced by designer stubble and a more normal hair style and my reading of the community is that they look forward to the change. So what will Paul’s epitaph be, given that he was thrown into the lion’s den at a time of crisis and with little experience to deal with it. He has given the hospital a reasonably secure electricity supply which for night time operations is a bonus and he has (for which he is not popular) made big staff changes. Is the hospital a better place for his tenure, on balance yes, it was I believe in dire straits before he arrived. But the delivery of much medical care remains in the hands of the very poorly trained on the dubious grounds that some medical training is better than none, but not realising the reality that it can actually be more dangerous. Certainly there is the handing out of antibiotics in profusion when you do not know what you are treating. The most common medical diagnosis in these parts is pneumonia, that well known chest condition of the tropics. His relationship with our sponsoring organisation remains unhappy and the loss of maternity funding means that the staff remain uncertain in their jobs. His legacy is thus mixed as indeed is the future of the hospital but I suspect, despite protestations to the contrary, the hospital is a little better than its government competitor down the road. He does however irresistibly remind me of Kaa (thanks Karen L.) and if he has a future in the first world he would make a good CEO of a hospital in the U.K. or USA or even an academic administrator. New arrivals include a Dutch missionary doctor (predictably and no they would not listen or read Karen’s wise words on how to do it) his registration is hopelessly bogged down in the Ethiopian administrative system and his wife a midwife who are now housed in the surgeon’s house though eyeing ours. He drank Ethiopian coffee which is a good sign (Adventists do not do coffee I believe) and one hopes that missionary zeal will be tempered with some medical good sense but too early as yet to say. We did not stay long enough at the ‘hail and farewell’ to chat to him and I know not whether we were really missed. Today is an Adventist rest day and yesterday the hymn singing coming from next door was lusty. We were invited to that and temptingly mango ice cream but had to decline as it was unlikely that the invitation included increasingly unwashed orphan boys with remarkably smelly feet whom we were entertaining with spaghetti and spam and tomato source followed by monsters inc. (this was not as much of a hit as Shrek and we only have the trailer to Shrek 2). Even the orphans declined to sit next to Lalisa’s feet and we ended up soaking them in Moulton Brown Shampoo for the whole of the film and the bucket is still pretty nasty and his socks…..information you would rather not know.
Continuing the biblical theme there is a ‘star in the east’ as there is a move to pull out of Gimbie where ‘our work is done’ and head to the pasturalist communities of the east which appear to be poorly provided for despite being a relatively easy commute to Addis so there was a move to follow that star at least by two wise persons if not kings and certainly not the desire of Queens, so off they set on a mission. Star following in the modern parlance is called ‘needs assessment’ and this is what was planned, i.e. a jolly to Awash(beauty spot withnice lodge, waterfalls etc.) and beyond, but was not to be as the appropriate ‘permissions’ had not been obtained, this is after all Ethiopia not Galilee, so the two wise persons are now hold up in Addis, one bored in a grubby hotel and the other on a family visit, their camel master on his per deum in an adventist hostel awaiting the arrival of the angel Gabriel on a flying visit. In terms of nee d there is really no need for an assessment ‘Gold and hold the frankincense and Myrrh’ though the latter two might be useful for the feet round here. In terms of ‘Gold’ well spent a little sad as the trip of star following was ill planned and thus came to naught. Presumably cost of stay in Addis met by charity.
The Angel Gabriel and the bringers of Danegeld in the shape of the Danish team re- arrive next week on a ‘visit’ suspiciously similar to that of the Adventist’ of last week, and were unsurprisingly as communication is not the watch word totally unprepared for the changes. Given that relationships with ‘St Paul’ had reached a record low, that particular meeting was not me thinks on the agenda but now there is a flurry of e mails wanting us to set up getting to know you meetings – Karen as Mary Poppins or the U.N. however the question of course is whether the ‘geld’ will go East or West. We are scheduled in for a meeting on Tuesday evening sans local organiser – paranoid times. Given that most of these meetings revolve around communication (or lack of it) there is little shuttling due.
Gee I am glad we have our car despite the costs and the grief as communication about travel and places in cars etc. reaches all times complexity and yes some have to take the bus and sit in really bad bench seats – all jealousy and bad feeling, and sadly probably unnecessary, yes communication again!
Despite protestations to the contrary there is no doubt to me that the poor and needy of Gimbie and Environs are not being catered for here unless moribund or with 1000 odd birr to spend (and some do, the coffee is picked) as unlike the first few months there is often little activity apart from the multiparous middle classes dropping their sprogs and then sitting around for a couple of days in their private sheets or the occasional nearly dead arriving with some ancient birth fund voucher which seems to get them a nearly free Caesarean section.
For those of you who are following the cancer of the cervix project the word is out and patients are beginning to come in, despite the best efforts of the lower echelons of the hospital to charge them, and despite my writing over the admission slip that the project pays. Equally distressing, the communication gap is such that operable cases with medical problems in which we start treatment (blood pressure tablets) disappear and do not reappear but will probably do so when they are beyond help – with limited funding I am loathe to admit them to the ward for a week. Soon off on a mass screening project so we will see. A difficulty unforeseen is the clinical diagnosis of cancer which I thought would be relatively straight forward but is complicated by such issues as previously undefined and undefinable vaginal surgery and my Ethiopian colleagues desire to operate on every fibroid that comes through the door ,by calling them cancer – sorry but we have limited funds.
So, we live in uncertain times and the forces of political correctness bear as ever down, trying to ensure, that the unpalatable vision of truth is wrapped in soft soap and that no one is ever upset by the vision of the world as maybe it really is.
Here endeth the lesson, but is it teaching or learning?
Wednesday, 7 March 2012
Teaching Times
The return of my Ethiopian ‘oppo’ allowed me a night out, which was spent in part feeding the 5,000 (actually 5 orphan boys of prodigious appetite) but allowing me the privilege of a barely cold St. George beer. Remarkably and a first the beer was bought for me by an Ethiopian rather than the other way round – he was a bit boozed up and as he had wanted to borrow the car for a wedding I am glad we said no. This became slightly guilty as sitting there I was accosted by the most Adventist Adventist of them all (drinking wine is an offence to Adventists of blogs passim) and to cover I offered to do a teaching session for her midwives which was eagerly accepted. Thus this afternoon found me with 10 keen souls (I am sure that they too are all Adventists or pretending to be Adventists) and one patient who had no idea why she was there to teach a bit about pre-eclamsia.
When I picked her up I was amused to see that she was sitting up by her bed and that her husband was fast asleep in it, this is after all the Ethiopian way. Anyway best described as keen, shy and ignorant but hopefully by making a story of it we managed to impart a little that might help when they come across a that situation but we had a great deal of difficulty with treatment. Good luck to the hypertensively challenged pregnant women of West Wollega and others who come under midwifery care hereabouts. I repeated this teaching episode a couple of days later with the ‘male midwives who the feisty feminist alcohol abhorrent Adventist midwifery tutor tells me bully the little ladies. If I was worried (which I was) about the ability of the ladies to recognise and cope with a little pre-eclampsia I would be a good deal more concerned about their male equivalents. I am begiiining to understand more and more about the challenges facing this country and although I rail about the inadequacies of what we do here it is Queen Charlottes nor the equivalent to what happens in the deep rural areas…see below.
It seems that I loosely promised (and failed to keep) to get a camera case for someone and he is now haunting me and I do not quite know what to do. Karen says that I have to learn to say no but I am always caught on the hop.
Academic challenge. You wish to change some dollars for birr, and go to a bank which insists on putting your dollars through a machine that rejects most notes, when put through multiple times (usually around 10) Do you doubt the money or the machine……the money of course, but you can bring them back tomorrow and try again..! logical positivism at its best. But I did though with different notes and it worked
Yesterday’s night on brought with it another tragedy in the shape of a 17 year old girl of extremely short stature and odd facies who had been labouring at home for at least a day before transit to a health centre and on to here. Undiagnosed twins, the first a dead brow and the other about to expire. She acidotic and with an oxygen saturation of around 86% (not good) and with massive abdominal oedema and very confused. Sadly fluid resuscitation, caesarean and oxygen failed to improve her and she died an hour later despite our best endeavours. What is so tragic is that the treatment is free, be it here with a voucher or at the Government hospital which has a very competent obstetrician but that for what ever reason or reasons there was a failure of ante natal care (she did not get any) a failure to recognise that she might be at risk (very small very big bump) and a failure to recognise that she might be in trouble until she was an irreversibly septic mess. Even then she had to catch a bus into hospital. What one wonders were her parents thinking and what were the health advisors thinking or were they punishing her for under-aged sex –who knows…though some of the answers to Karen’s questionnaire about preparation have the response that ‘God will provide’ but he does work in mysterious ways. Perhaps it is a blessing that this time no orphans.
Those of you who have been following the cervical cancer project will be pleased to know that word is getting about but sadly a disappointed customer as my colleague tried to slip one under the net. I grant you that menorrhagia with fibroids is very uncomfortable and the lady is disappointed as the operation will not be free but this is not open season for hysterectomy (and being Ethiopia not the U.K. not much else is on offer) so with our limited budget she will have to save some money (about £100 which is quite a lot in these parts).
My first academic offering from Ethiopia is now ready for submission and has the approval of my trusty literary editor (Vasanth) but not yet that of Karen, who in true academic style has it on her desk in the’ I will read it when I have time mode’ thus in my dotage I am given less priority than her MSc students. The unsurprising findings are that predictors of dying from a uterine rupture are taking more than 24 hours to get there and rupturing your uterus in your first pregnancy which chaps is not as rare as you might think. Will it make BJOG which is up I see for a new editor? Meanwhile I am pleased to say that her birth preparedness study runs on apace and if she can find a way of stopping small 17 year olds getting into trouble it would be a very good thing.
Slight concern as new medical director has arrived (Dutch Missionary recently in Malawi, and no he failed the paper work test at the first round) as I was asked to show him our house in which he and his wife were very interested….five months would be an eternity in alternative accommodation in the housing stock available here so may have to put up the barricades though currently am assured not..but long stay Adventists are I suspect thin on the ground.
I am failing miserably in my medical treatment of the most appalling pustular folliculitis of the vulva and am trying to get a four month course of roaccutane for her but prescribing difficulties in the U.K. are making this difficult as is internet cost. If anyone has any lying around or can lay their hands on some my niece is coming out at the end of this month and a young Ethiopian would be very grateful.
So, as the middle classes of Gimbie arrive for their elective sections and repeat scans the rural community awaits virtually ineducateable midwives uneducated health workers and a grizzly and preventable death, teaching times maybe, learning times I fear probably not.
When I picked her up I was amused to see that she was sitting up by her bed and that her husband was fast asleep in it, this is after all the Ethiopian way. Anyway best described as keen, shy and ignorant but hopefully by making a story of it we managed to impart a little that might help when they come across a that situation but we had a great deal of difficulty with treatment. Good luck to the hypertensively challenged pregnant women of West Wollega and others who come under midwifery care hereabouts. I repeated this teaching episode a couple of days later with the ‘male midwives who the feisty feminist alcohol abhorrent Adventist midwifery tutor tells me bully the little ladies. If I was worried (which I was) about the ability of the ladies to recognise and cope with a little pre-eclampsia I would be a good deal more concerned about their male equivalents. I am begiiining to understand more and more about the challenges facing this country and although I rail about the inadequacies of what we do here it is Queen Charlottes nor the equivalent to what happens in the deep rural areas…see below.
It seems that I loosely promised (and failed to keep) to get a camera case for someone and he is now haunting me and I do not quite know what to do. Karen says that I have to learn to say no but I am always caught on the hop.
Academic challenge. You wish to change some dollars for birr, and go to a bank which insists on putting your dollars through a machine that rejects most notes, when put through multiple times (usually around 10) Do you doubt the money or the machine……the money of course, but you can bring them back tomorrow and try again..! logical positivism at its best. But I did though with different notes and it worked
Yesterday’s night on brought with it another tragedy in the shape of a 17 year old girl of extremely short stature and odd facies who had been labouring at home for at least a day before transit to a health centre and on to here. Undiagnosed twins, the first a dead brow and the other about to expire. She acidotic and with an oxygen saturation of around 86% (not good) and with massive abdominal oedema and very confused. Sadly fluid resuscitation, caesarean and oxygen failed to improve her and she died an hour later despite our best endeavours. What is so tragic is that the treatment is free, be it here with a voucher or at the Government hospital which has a very competent obstetrician but that for what ever reason or reasons there was a failure of ante natal care (she did not get any) a failure to recognise that she might be at risk (very small very big bump) and a failure to recognise that she might be in trouble until she was an irreversibly septic mess. Even then she had to catch a bus into hospital. What one wonders were her parents thinking and what were the health advisors thinking or were they punishing her for under-aged sex –who knows…though some of the answers to Karen’s questionnaire about preparation have the response that ‘God will provide’ but he does work in mysterious ways. Perhaps it is a blessing that this time no orphans.
Those of you who have been following the cervical cancer project will be pleased to know that word is getting about but sadly a disappointed customer as my colleague tried to slip one under the net. I grant you that menorrhagia with fibroids is very uncomfortable and the lady is disappointed as the operation will not be free but this is not open season for hysterectomy (and being Ethiopia not the U.K. not much else is on offer) so with our limited budget she will have to save some money (about £100 which is quite a lot in these parts).
My first academic offering from Ethiopia is now ready for submission and has the approval of my trusty literary editor (Vasanth) but not yet that of Karen, who in true academic style has it on her desk in the’ I will read it when I have time mode’ thus in my dotage I am given less priority than her MSc students. The unsurprising findings are that predictors of dying from a uterine rupture are taking more than 24 hours to get there and rupturing your uterus in your first pregnancy which chaps is not as rare as you might think. Will it make BJOG which is up I see for a new editor? Meanwhile I am pleased to say that her birth preparedness study runs on apace and if she can find a way of stopping small 17 year olds getting into trouble it would be a very good thing.
Slight concern as new medical director has arrived (Dutch Missionary recently in Malawi, and no he failed the paper work test at the first round) as I was asked to show him our house in which he and his wife were very interested….five months would be an eternity in alternative accommodation in the housing stock available here so may have to put up the barricades though currently am assured not..but long stay Adventists are I suspect thin on the ground.
I am failing miserably in my medical treatment of the most appalling pustular folliculitis of the vulva and am trying to get a four month course of roaccutane for her but prescribing difficulties in the U.K. are making this difficult as is internet cost. If anyone has any lying around or can lay their hands on some my niece is coming out at the end of this month and a young Ethiopian would be very grateful.
So, as the middle classes of Gimbie arrive for their elective sections and repeat scans the rural community awaits virtually ineducateable midwives uneducated health workers and a grizzly and preventable death, teaching times maybe, learning times I fear probably not.
Sunday, 4 March 2012
Deserted times
Karen, with her developing Adventist relationships was spirited away as driver and clinician manqué to a far flung outpost of this particular Adventist empire, allegedly by a lake but in actuality some 2 hours away to see Ethiopian primary care (in the private sector) in all its glory leaving me to be on call here (I am now in my 5th. Day as sho/reg/consultant/ making life and death decisions like, do you give a pint of blood now or in the morning (now, you never know about the fridge) and intermittently doing caesarean sections, usually in the wee small hours. My suspicions about now operating on the Gimbie middle classes was heightened by observing some quite up market and unadventist like ear rings (Adventists do not do body piercing I am told) on the lady in question and by the fact that she brought her own surprisingly clean sheets. I am tempted to put in a bill. Further down the ward however is a tall thin very dark tribal looking lady with lots of ‘cosmetic scars’ and a completely broken down and smelly perineum, the result of many days in labour and a dead baby. When I stood her up to take her to the labour bed to have a better look I was alarmed by the passage of much urine but hope, following catheterisation that this may be retention rather than a fistula. It is going to take a long time to heal though and I do hope that the ward will try and keep it clean for her. She did not come with any sort of voucher that I could see so I wonder who will pick up the tab. I understand that having a faranji at your wedding, or more probably a faranji car in the hooting procession which has resulted in invitations to the weddings of those who I do not know but may have something to do with the hospital. The last one had a rather friendly looking sheep being lead into the kitchen and shortly after bits of raw meat being served though no piteous baahing noises, never the less all slightly disturbing to ones karma.
Both chickens currently have the ovine equivalent of phantom pregnancies and sit around on empty boxes trying to starve themselves to death. Being on the ground at night also puts them at risk of being supper to some passing carnivore so we are having to do aversion therapy, which Karen regards as pet abuse, but like children, with distraction they will recover, but they sure are being tedious( and eggless) at the moment.
With the late return of my oppo last night I came off duty and was able to (a) have an alcoholic drink and (b) enjoy an Ethiopian style Aromatic crispy fried duck served with Pimms. Our faranji guest enjoyed it immensely but the Ethiopian leader of the pack stayed away, preferring beer and raw meat in the Green Bar. I suspect that in some typically Ethiopianly undefined way we have upset him sohe has taken the hump. Is it being too friendly with Adventists, saying harsh things about him (which I do not think we have) to English maternity world wide Wallahs, who have been here in profusion and asking difficult questions or just staff troubles? It may of course be that all the stresses of living in Gimbie and sparring with Adventists far away from the family are taking their toll, but this has now prompted another trip to Addis and on to see if there are things to do in the East – closer to Addis me thinks. Another all expenses trip from Denmark is in the air so perhaps changes are a foot. They most certainly are in the hospital with the arrival of various missionary doctors to fill various roles and the imminent (but I suspect as yet unannounced) departure of Paul and his replacement by Austin of the long and platted statement beard. He it seems is developing a relationship with another young Adventist who might make life even more frugal and religiose. She remarked that drinking wine was deeply offensive to Adventists when we were in a restaurant with her, glass of wine in hand…bit of a conversation stopper that.
I am currently feeling a bit of a heel as I have said no both to a wedding and, which is what they really want, use of the car. If they were to crash it who pays and anyway you do not just lend it to anyone – weddings anyway are usually associated with excess alcohol consumption. Rather sulky faces but there we go. Probably a bit of loss of co-operation too but livable with. It is probably not unrelated to the various cars being out of town what with visits to the east and collection of Adventist doctors etc.
It is interesting to note how various obstetric crises now have a ‘developing world’ predictability as despite being off callthe message did not get through and 04.30 hours brought yet another obstructed brow and this morning the baby still has an odd posture but is doing O.K. Another little lesson for local gynaecolgisti was that removal of a large pedunculated fibroid on a stalk in an infertile woman does not require hysterectomy, just some gentle twisting and they are all delighted. I am constantly being hugged by a lady of some voluptuousness as having lost her wages we have bailed her out (despite our strict rules) and she is now about to become karen’s translator and may help in our quest for cervical cancer patients.
So hopefully now avoiding weddings, a day to our selves.
Both chickens currently have the ovine equivalent of phantom pregnancies and sit around on empty boxes trying to starve themselves to death. Being on the ground at night also puts them at risk of being supper to some passing carnivore so we are having to do aversion therapy, which Karen regards as pet abuse, but like children, with distraction they will recover, but they sure are being tedious( and eggless) at the moment.
With the late return of my oppo last night I came off duty and was able to (a) have an alcoholic drink and (b) enjoy an Ethiopian style Aromatic crispy fried duck served with Pimms. Our faranji guest enjoyed it immensely but the Ethiopian leader of the pack stayed away, preferring beer and raw meat in the Green Bar. I suspect that in some typically Ethiopianly undefined way we have upset him sohe has taken the hump. Is it being too friendly with Adventists, saying harsh things about him (which I do not think we have) to English maternity world wide Wallahs, who have been here in profusion and asking difficult questions or just staff troubles? It may of course be that all the stresses of living in Gimbie and sparring with Adventists far away from the family are taking their toll, but this has now prompted another trip to Addis and on to see if there are things to do in the East – closer to Addis me thinks. Another all expenses trip from Denmark is in the air so perhaps changes are a foot. They most certainly are in the hospital with the arrival of various missionary doctors to fill various roles and the imminent (but I suspect as yet unannounced) departure of Paul and his replacement by Austin of the long and platted statement beard. He it seems is developing a relationship with another young Adventist who might make life even more frugal and religiose. She remarked that drinking wine was deeply offensive to Adventists when we were in a restaurant with her, glass of wine in hand…bit of a conversation stopper that.
I am currently feeling a bit of a heel as I have said no both to a wedding and, which is what they really want, use of the car. If they were to crash it who pays and anyway you do not just lend it to anyone – weddings anyway are usually associated with excess alcohol consumption. Rather sulky faces but there we go. Probably a bit of loss of co-operation too but livable with. It is probably not unrelated to the various cars being out of town what with visits to the east and collection of Adventist doctors etc.
It is interesting to note how various obstetric crises now have a ‘developing world’ predictability as despite being off callthe message did not get through and 04.30 hours brought yet another obstructed brow and this morning the baby still has an odd posture but is doing O.K. Another little lesson for local gynaecolgisti was that removal of a large pedunculated fibroid on a stalk in an infertile woman does not require hysterectomy, just some gentle twisting and they are all delighted. I am constantly being hugged by a lady of some voluptuousness as having lost her wages we have bailed her out (despite our strict rules) and she is now about to become karen’s translator and may help in our quest for cervical cancer patients.
So hopefully now avoiding weddings, a day to our selves.
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