Post code lotteries

So here I am, only obstetrician in the hospital and used to relatively peaceful days and nights when suddenly solids and air conditioning come into distressing proximity.  First up is a lady from Ganji (the where is important, stayed tuned) who pitches up with a hard tender uterus, vaginal bleeding and not well with a low haemoglobin (5gms) and no relatives up for being blood donors.  Life is a little complicated as the old scanner is now the defunct scanner and has joined the pile of undisposed of aging ordnance.  The new scanner is of course awaiting repair and even with my best efforts to get it somewhere to be repaired this is going to take time.  As best as I can establish and she is not well enough to do talking and as I cannot understand her and can barely understand the nurses we are in difficulties.  However my presumptive diagnosis is an accidental haemorrhage (bits of placenta falling off inside) and I decide she is going to deliver so accelerate this.  Mindful though that the obstetric axiom is ‘it is the APH that threatens but the PPH that kills’.  While coping with this more trouble arrives (from Homa) in the shape of a 18 year old girl, recently aborted (? 20 odd weeks odd at that age and difficult to get family approval for abortion, one wonders about traditional ‘healers’) with in this case a haemoglobin of 2gms and very unwell. One relative, reluctantly willing to donate but incompatible and another apparently on the way.  Adventist faranjis and visiting medical students have their uses so one doctor, one medical student and two missionaries later we are at least circulating some haemoglobin but coughing mightily from heart failure, have an exciting transfusion reaction, or worse pelvic sepsis, pyrexia and only limited oxygen from the oxygen concentrator.  How about a little Lasix (diuretic) I think.  Problem, despite having been rescued by the good offices of some generous beyond the bounds of duty faranjis, Lasix has to be paid for, and who pays….(I am fed up with carrying money as it only gets nicked) but they come from Homa and Ganji and in the post lottery world  which our charity has created they are the chosen ones and entitled to vouchers to pay for this and other highly probable expenditure given the severity  of their condition.  If there was a critical list they would be on it.   I sadly however would not as I would be regarded as too old if such things actually exist.  So off I trot with the notes and letters to the MWW office to get vouchers and stop having to negotiate life saving drugs.  There is one person in the office as the others have gone off to organise school plays about the dangers of dying from haemorrhage if you do not seek help (no I am not making this up) looks at the very scruffy and clearly written in a hurry paper work and declares it invalid as it either has no stamp (very important here) or the wrong stamp or the stamp in a wrong place.  So in the post code lottery of life we have a missed call  and I am back to negotiating drugs.  Meanwhile some tosser, has raised the possibility that the temperature is due to malaria, TB or worse so I return to the nurse now wearing a mask (she is pregnant and anxious) and trying to do her nursing from a distance.  ‘Do I still need to do her vital signs, would every 8 hours do etc.’ and various other patients and their relatives now demanding her removal.  As is common in Ethiopia all this is acted out in front of a Greek chorus of standing watchful men and the ward is bulging and there is much muttered discussion, but I tell them to sod off.  (The Oromo word is Demi).  As I write this she is still alive though with very stiff lungs but 18 and tough.  I am told today that some vouchers will be forthcoming (perhaps a little embarrassment) but the sheer inhumanity of charity aparachnics in desperate circumstances is at best staggering.  The other lady duly delivered her fetus in a puddle of (old) blood confirming the diagnosis and is strangely quite well with a haemoglobin of 4 gms and not a donating relative in sight and all available faranjis already exsanguinated.  The hospital is currently having a cleanliness campaign (the wet season is not an ideal time as it is very muddy) but not down here as the place is hotching and with a further APH 5 Caesareans and two forceps later I am beginning to feel a little weary and any thoughts of cleanliness a distant memory.  In a bizarre Kafka like moment a member of the less compliant emerging middle classes of Gimbie refuses a Caesarean for her meconium, irregular fetal heart and 1 cm dilatation, but to be honest by this time I am too tired to care and when the contractions become more painful (and they will) so I can sleep for an hour or so before my 04.30 am call to play white knights.  Happily all is well and although a little shocked the baby is well and not like it’s  neighbour fighting for breath with meconium aspiration (well not yet anyway).

Sadly in all this chaos there is one avoidable still birth for which I am very sad.

Followers of this blog will know that Hercule (the Belgian land cruiser) is away having his rear beaten as land cruiser repairs take longer than head wounds so Karen is at the mercy of borrowed transport and managers to hitch a lift with the MWW DK players off to entertain schools with stories of maternal disasters and how to avoid them.  She is dropped at Ganji health centre (post codes remember) where some 30 odd women await her to get valuable individual ante natal advice (‘You have had a caesarean section, go to hospital to have your baby, You have twins did you know that, your blood pressure is very high etc.)  and come lunch time, the world stops for lunch here which must be either communist influence or a hangover from the Italian occupation and her interpreter is flagging, the Gimbie players fail to stop and pick her up.  Apparently they only have 45 minutes for their Injera and Watt or Shiroo and are in a hurry so a 15 minute walk through the town to shouts of Faranji, you, you, you, give me money is required for sustenance, which together delays the onward running of the clinic and the extra 20 women who have turned up will have to wait another day.  Having rushed their lunch the players are in for disappointment as apparently an unannounced exam has trumped school plays and discussion so they are sitting waiting. (they could of course have been ferrying but no that requires thought or even a little thoughtfulness).

Fortuitousness strikes however as, possibly with the knowledge that there is a faranji about a young girl who has been in labour for 20 hours and unsurprisingly has uterine inertia has arrived.  The highly trained and valued health officers have not been sure what to do, and the labour room was probably locked (it usually is but is now opened when Karen is there) so they have put her to bed and are waiting (what for you may ask – disaster?).  The visiting team contains a competent midwife and a doctor so a dextrose drip later, oxytocin being not allowed, contractions start, but the fibrotic ring that is all that remains of a mutilated vulva requires excision but the scissors are blunt but with a little chewing and an aging Kiwi cup you will be glad to hear that all was eventually well.  It is unlikely however that their little adventure will allow them to reflect on where their efforts should best be spent, trying to ensure safe care in the community and at hospital (assuming they have a chance of getting there) or teaching school children about what to expect.  If I was a teenager in Ethiopia I would go on depo and stay on it until I could join the middle classes and refuse care.

Interesting times again!

The photo of the baby is a severe meconium aspiration which i did not expect to survive but against all odds is getting better and the labour ward is after that night.  Cleanliness is next godliness but one wonders if they are causally related.

Business as usual

So with bruising settling and stitches out but scabs difficult to resist it is back to business as usual or at least sort of, naturally of course the local tittle tattle and politics continue unabated.  The ward remains quite quiet as the only way you can get through the door now is if you have money or you can get a voucher.  Money means middle class and they arrive with gold and their own sheets, so not difficult to spot.  Voucher means one of 4 local kebelles, mostly in relatively rich coffee growing areas but high on the hills (thus transport difficult) there are still problems and mostly the problems we see were (currently no car) scooped up by Karen on her travels, I think they look out for her now, and then brought in for derision and neglect at the hands of our caring midwives.  They are of course currently a little pissed off as the withdrawal of birth funding has been withdrawal of their extra pay, and with that of course good will.  But then of course it is a damn sight safer than being at home.  Recent e mail correspondence suggests that a similar scenario may soon be being acted out in the U.K. as pension raids are taking place.  One of the bores of all this patient transport stuff apart from the odour of unwashed body (not their fault, no water) is that lack of access to wheels means that they are very prone to motion sickness.  Partially digested injera, when projectile, which sadly it usually is, has a smell all of its own which engenders greater nausea, so the results are not pretty and the carpets only partially protected.  The water tank at the back has proved particularly useful on occasion.  My idea of producing sick bags purloined from our recent travels has worked reasonably well but they are clearly useful to those who have little so if not used for the designed purpose they are nicked and used for carrying chat or whatever.  However all this is in the distant past as currently the wheels are in Addis being panel beaten (we hope) or just open to the elements and partially repaired then abandoned in the wet season.  As we are not there and the stories of progress, or more likely lack of it, are increasingly vague who knows.  What we do know though is that glass is very expensive and there is none of this insurance stuff.  This has driven Karen to hire of crappy taxi (unreliable and picking up fares at her expense when not broken down on the road) or use of hospital car.  Remarkably helpful and allowed to drive it on her own until urgent calls for its return as urgent letter needed delivery.  Sounded suspiciously like administrative cock up to me, but these are an everyday occurrence here.  Forward planning is not well developed in these parts, which is another parallel with the NHS at home I suspect.  Although ante natal care is at best scanty some messages are getting through as a 4 foot nothing lady with a previous scar and dead baby turned up at term and surprisingly not in labour at the clinic in time for her this time successful elective section as did another, so 4 lives saved which is I suppose a result.  The lass with severe pre eclampsia and an equally severely growth retarded baby is doing ok despite continuing to pour all the third spaced fluid through her wound but the supply of NAN (baby milk) is running low and her supply of breast milk is equally thin, so the situation is a little bleak.  Not as bleak though as for the wretched child next door, who was like the majority of babies here was plucked out of the womb with fetal distress and thick meconium but unfortunately decided to breath some of it in with predictable results.   So antibiotics, fluids and oxygen, though concentrators so not much of that but still in with a chance.

Meanwhile our sponsors are busying themselves with drug supplies for the supported clinics, as the available drugs (largely unnecessary methyl dopa as not much chronic hypertension rather than useful magnesium sulphate and no even more useful misoprostol as bleeding kills) and sadly limited supplies of iron.  They actually have quite a lot as they sit there out of date.  I wondered why and the answer is that they are locked away and those doing the clinic cannot be bothered to get them.  That possibly explains why I recently saw someone quite anaemic being sent away with 4 folate tablets.  The government however is now apparently giving away iron (high time too) but predominantly to ante natal women though if they were sensible they  would horde them for their post natal use as it is when they have bled and they are trying to breast feed is when they will find them most useful.

Why though you may wonder is all this ‘obstetric ordinance’ being bought.  The answer, like to most things here is of course political.  The charity in order to survive has to show that only 30% of the cost is administration, though in fact most of its costs are salaries or expensive car journeys.  What better way to offset this than give away a few tablets, drip sets etc., then these can be locked away until they go out of date.  Locked away unless they get stolen, by of course the person with the keys……..When you do get to them they are so mean that they would worry a homeopathist.

One of the things that seems to mark the Ethiopian situation is the inability to get it together either chronically or acutely. I was persuaded to an Adventist peripheral clinic last week and saw 21 people the majority of whom had come on the off chance that they could get a free prolapse operation, which is a pity as the ‘prolapse tourists’ had left some weeks before and had had nothing to do for the last two days, let’s hope that if and when they return in November that these poor people will return as advised and some one will know that there is a team approaching.  Acutely it is sadly business as usual too with acute fetal distress at full dilatation.

Car(e)less in the Community

As part of ‘care in the community’ we offer friendship succour and entertainment to assorted feral orphan boys and finding activities for them apart from eating or pilfering can be challenging.  With a very dirty car and an upcoming wedding what better than a Saturday car wash.  Remember that in this particular compound Saturday is Sunday and what traditionally do the British do on a Sunday, yes you have it- wash cars.  So with assorted boys in tow I set off with hose and rags to get Africa off the paint work.  All goes well and off comes the red dust with repeated hosing and it actually begins to look quite clean, boys being responsible and doing quite well.  Time for the inside, which is as dusty as the out so one boy in the boot, very dusty and one in the front to do the windows….big mistake as child seriously irresponsible.  While supervising the back and standing there I am suddenly while shouting ‘obscene instructions’ I am trying to stop the car rolling back, fat chance as I am knocked under the car and watch in horror as the petrol tank passes over my nose and the wheels pass perilously close and rocks scrape my back.  A loud crash, tinkling of glass and I come to a halt and am struck that there is blood all over my glasses, can not see a lot either.  As I pull myself from under the car to screaming Ethiopians and chaos (all in under 30 secs) I hear the young lad scream ‘it was not my fault’ to which I replied ‘yes it bloody was’ as I watched them scarper down he hill, hopefully including the wretched child in the back who must have watched in horror as he hurtled down the hill toward the wall.  I dread to think what might have happened if the wall, appropriately to the mortuary had not been there.  Anyway car (see photograph) in wall Ethiopians screaming and panicking and Karen walking up the hill with screaming cook and foster mother to Jabba.  I want to get the car sorted and ensure kid in back OK, apparently he is as Karen saw him run off.  So with Karen saying she will sort out car and with blood streaming from my head I avoid going to very grubby ER and head off to find my surgical colleague who will be watching Manchester United matches with my oppo, arrive point at head and arrange for him to suture it in clean OR facility. Meanwhile creaming Ethiopians metamorphose into silent hopping around vultures and I worry for the spare wheel tools etc. which finally get roughly piled into the car back seat, thereby destroying the cleaning to date.  A truly wonderful country Ethiopia. Hope to do this relatively peacefully but no chance as whole of maternity Worldwide, Hospital and any other hanger on turn up to look at my bleeding head and naked chest (glad I have lost some weight) and they have looked at my shoulders but miss the very large graze on my bum….(good).  So still alive (which I could easily not have been) as falling under the tyre might have produced a lot of crush I return home and change my shirt and apply pressure to still bleeding head.  As I believe is an Ethiopian tradition, the world arrives to express condolences, gawp and in one case tell me that the view in the local church is that it is a punishment for working on the Sabbath (He works in mysterious ways).  In amongst this the feral lads return together with their Adventist sponsor and bringing with them a wilting poinsettia probably plucked from our garden path en-route.  She explains that Matty, the culprit, was just goofing around, when he put the car into neutral and probably released the hand brake when he should have been washing windows, nearly killing me and his house mate so of course it was not his fault.

Lots of hand shaking and not seen them since, but it does raise some questions as to whose fault it was, if one wishes to apportion blame.  Youth fails test of growing up and behaving responsibly and does have to take some, perhaps though I doubt it he may learn from it, particularly as he will be being reassured by the Adventist connection that it isn’t and he sadly given his background would not recognise responsibility if it stared him in the face.  The soggy American view is I am sure that his little psyche must be protected…hmmm.  Perhaps I should not have let him near the car or told him on pain of summary expulsion and no more pop corn and films not to touch anything.  Perhaps we should have ensured bigger rocks.  Perhaps the advice we were given about not using the handbrake too much with the park facility as sand gets in the drum and wrecks things is not as good as it might be. So perhaps it is all my fault (bound to be it always is)for trying to give assorted street kids a purposeful and fun afternoon.  But it is only metal (granted expensive metal) and brick work and no one is seriously hurt.  We even dress and steri strip the youngster in the back of the car’s foot, given the inadequacy of the attempts by his current carer, the milk of human kindness indeed runeth over.  The view I tend to is ‘feckless irresponsible little shit wrecks car, nearly kills friend and me and has no idea what he has done’ and, sadly probably never will, it is unlikely that he will have learned anything from the experience other than he can get away with it.  The Ethiopian lesson, sadly which I have yet to learn, is trust no one!  That may not be entirely true, though the failure to give the car back in a driveable condition at the last service suggests that is as the car has now been driven to Addis by the nice hospital driver and is hopefully being beaten back into something like its original shape though I suspect that it will crab down the road now, and parts are difficult around here, not much chance of a new window let alone two bits of door, and lets not worry about the wheel carrier as that was crap in the first place and has already caused considerable metal fatigue.  So hopefully the all filler car will soon return to us but I doubt at the promised time , that measure is pretty elastic around here. When you see it in ‘Auto-trader’  move on down.  Will we continue ‘care in the community for the little lads, deprived, hungry and now homicidal…watch this space.

Bloody, battered but unbowed.

Care in the Community

Care in the community knows no bounds as Karen (though not for a while, see later) trails off to far flung Kebelles, health posts and the like with her scanner personalised risk assessments.  She occasionally takes me too, but I have to confess to feeling rather spare as there is a queue of the pregnant who have walked miles to see her and a scan and few who would give me the time of day.  Their stories are appalling with a litany of stillbirths and near death experiences the details of which alter by the moment making it difficult to give any advice other than come to hospital and we will see what we can do.  Best avoided though are domicillaries, as organised or rather black mailed into.  Take the lady with twins of blogs passim whose husband spends his time taking up valuable clinic time telling of bleeding pain etc. post caesarean of now some weeks if not months ago and his wife’s inability to travel.  Granted she lives in a windowless hut some way up a hill and at our inaugural visit darkness and lack of facility did rather make assessment of any problem difficult but anyway there did not seem to be much of a problem however another visit was demanded and acquiesced to…..

So after an interminable clinic, a lunch of shiro and dhabo (Karen currently has shiro poisoning) we set off for a home visit, to collect the patient, take her to a health post which may or may not be open (it wasn’t) where there may or may not be an examination couch (reputably there was) putting the land cruiser (Hercule or Tintin it is after all Belgian) through all its paces we arrive, wait for her to make it down the hill with assorted relatives (making it down the hill and presumably again upwards answered the question about her general health) but then loading her, twins remarkably still alive and husband together with 2 nurses into the car we set off to the local village and a private health facility which allows us access to the examination couch.  Not much can happen at the village as we are soon surrounded by many hangers on who do not do the usual stand and stare but struggle to get a view through the window requiring much shouts of ‘Demi =go away’ to get some space.  Needless to say scar ok uterus involuted and just general fatigue so purchase some iron and diclofenic for her and wearisome journey back after some hours of wasted effort.  On the way back we acquire another passenger who having heard of the service walks to find us and get a lift back to the health centre and yes another scan.  Advice, as yet not taken was to come to hospital as she had yet to have a live baby, two previous still births one in a ‘private facility’ and one I think on the road!

Another lady then appears in an Isuzu truck, allegedly bleeding and requiring attention despite my rising irritation and desire to get home so I was I fear rather short and hurried and perhaps did not explain my vaginal examination as fully as I might, causing some familial complaint about my bedside manner, which along with my reserve of human kindness had long since gone.  The only thing I could find wrong was some haematuria and my prescription for ampicillin was rebuffed by the local pharmacist as contra indicated in pregnancy when amoxyl was not (why???) anyway by that time I was beyond caring.  Another pregnant lady, also turned up with scaly lesions all over her probably psoriasis but I tried to do some skin scapings to look for fungi but the microscope reqired sunlight and sadly (and unusually) the sun was in so all I did was draw blood and receive another dent in my reputation as the caring doctor.  I did not add that our various passengers were all vomiting copiously by now.  Finally off home with a lady leaking liquor over the seat from her fetal abnormality, firmly clutching an airline sick bag we had nicked on our travels but happily not needed and equally unhappily not returned so down to just a few bags now.  So with my fund of human kindness now at an all time low we return late to various orphan boys awaiting pizza supper and film for which we are late.  But missionary zeal being all we do our bit and give them much of the limited supply of cheese.  They then get the lion king and popcorn with American sugary butter before being escorted off the premises, leaving a sugary muddy foot imprint extravaganza behind them. I wonder if the ancient cave paintings were actually children’s parties especially when I see a perfect foot imprint on the floor.  I arrange for them to help me wash the car next day….read on and begin to think that my life as a medical missionary might be limited.  Next day I wonder if my life might be limited.

Mechanical Trials

As readers of more politically correct blogs will know already, our carefully prepared landcruiser suffered total brake failure despite apparently having the brakes checked both in the UK and Kenya, causing Karen to accelerate down hill backwards at a rather alarming rate and then drive back for 2 hours plus on the hand brake.  It would appear that one of the back pads was so worn it disintegrated and caused the calliper piston to come right out with total loss of brake fluid.  We replaced these, not an easy task but it was apparent that the disc was also very worn (thanks again preparers) so a trip to Addis was in order. A new disc and a service later (during which our Oromo dictionary and a set o I POD ear phones took a hike – thieving bastards) and a few nice meals, we set out again for home for that is what Gimbie has become noticing that car starting was becoming a little sluggish.  Various warning lights, mostly to do with brakes started to come on, which we were told was to do with computers needing resetting etc.  We were told all was well bar some bearings (good service chaps) and continued on our way when even more lights came on so stopped to investigate.  Not a good idea as it was apparent that there was total electrical failure.  Happily we have an auxiliary battery (a better, and in Greg terms) only good development so christened the jump leads and setoff back to Addis, hairy as one by one more systems failed ending up with complete failure on the Bole Road diversion, which is a bit like Hyde park Corner at 5 pm.  So with cars shooting by I wired the 3^rd battery to the main battery with the jump leads, taping them with duct tape to the side of the car in the hope (springs eternal and this time successfully) that they would not fall into the fan system, but meaning I could not close the bonnet or hood to my American readers, so a fairly difficult last few kilometres back to the garage, where it became apparent that during the service they had disconnected but apparently not re connected the alternator or more probably just knocked  the wire off but even standing on a wheel, we had to do a lot of repairs and changing as there were nails in them, it was not the easiest thing to get at – but have power again now.  But what I do not understand is that with most cars, when the battery is not charging there is a large red light, not apparently though with this.  So now apparently we have repaired tyres, blown up to the right pressure, working brakes, tracked wheels, fresh service and all well.  Sadly not so as on the next trip back ‘home’ on the final stretch, braking round corners on the tarmac causes the ABS to come on rather dramatically bring the car to a vibrating and rather alarming halt, making me think that one of the brake sensors may be buggered.  When I have worked out what the button saying RSCA off does, I might try that. In the meantime the tyres may be a little hyper-inflated as they seem a little slidey on the rocks that pass for a road hereabouts but we shall see.  At least we are all in one piece and so are the wheels. I we go on doing this perhaps mechanical night school is called for.

However the trip to Addis included a visit to a (by Ethiopian standards) swanky private hospital by me, as they want to start laparoscopy  and endless trips to government offices by Karen in her quest for ethical approval.  Karen definitely wants her ethical approval but I am less sure about my desire to teach Ethiopians who have yet to pass the diagnostic laparoscopy hurdle how to improve their private practice by doing laparoscopic hysterectomy, but it may prove an interesting way to pass a few months.  Life in Gimbie although it takes up a lot of time is now at a slow pace as the vouchers dry up and one treats the worried well and with less of the high drama stuff than hither too.  I hope that those who are not coming are making it to other places but I know not. MWW however plough their furrow and who knows where that will lead.  Instant and equally instantly forgotten education I suspect, and with the rather dodgy supply of newly qualified and outstandingly incompetent midwives one can only guess and tremble. Care in the Adventist hospital has its limitations but by and large it is safe.  There has been a faranji invasion with a clutch of medical students on their elective visiting so much of my time is teaching them, which is interesting but not what I am here for.  If I can get them to think a little though perhaps I will have achieved something.  They are quite fun to have around.  Maternity worldwide personel are however a little isolationist and being predominantly a hospital worker I see little of them but given the rather back bighting politics that may not be a bad thing.  Equally I am pleased to report that the cancer project is going well and may actually make a difference.  So three months to go and Adventists in trouble with inadequate funding, MWW up their own fundament and general lost despair.  Adventists are praying for you I think!

Educational travels

The current and well established political maxim the world over is that the key to success is education so with the recent visitation of a keen primary school teacher and teaching opportunities I looked forward to hearing how education for the emerging middle classes of this land was faring. You will not be surprised to hear from the reports I received that all is not well. Much of the classes seem to be spent with the pupils in the room undertaking or not various set activities, but apparently without much in the way of resources, while the teachers sit in rows outside the class room chatting before presumably moving on to their second job. There is a (locked) resource room which contains books and other useful educational material which is apparently used but the dust on the books raises suspicion that this may not be the case. Lessons by our visitor seem well received after initial embarrassment but the only interaction between the regular teachers and the pupils was calling out answers to times tables questions. Overall, and I was not there to witness this, there is perhaps an insight into why the Ethiopian psyche is as it is and the ability to synthesise information or even to use it usefully rather than just partially absorb is as it is. Melanie Phillips (Guardian Journalist, sorry about that) once wrote a polemic entitled ‘All must have prizes’ decrying the state of British education and here in the horn of Africa the combination of patchy dumbed down education (morning or afternoons, you take your choice and not at all when required to pick coffee) together with great difficulty in failing anything goes a long way to explaining the poor level of understanding that exists. If however you have found a Faranji to support you failing becomes very important as you can go on repeating years for some comfortably financially remunerative time until someone finally pulls the plug on you. Thus is the state of the unemployed poorly educated of Ethiopia. Many of these sadly hang around the gates by the car, shout abuse, demand money with menaces and even lob the odd rock. Welcome faranjis all! Travel, it is said, broadens the mind (and here possibly the waist too) and thus we set out to be tourists last week and slipped comfortably into that bubble taking a bemused local Ethiopian with us so that she could see her country and have her first ever aeroplane flight. After the usual terrible drive we got to Addis and having cracked Addis by car found wonderful restaurants and met up with friends. My trip to Immigration, usually fraught with banana skins was mercifully easy and having completed endless forms and brought all sorts of photocopies, I am now resident and legal again! Nearly fell at the last post though as I did not have enough Birr, as Karen thinks I am too demented to handle money so she had to hand me more through the bars (high security) for my replacement green card though the other snake was a Kenyan not an Ethiopian police report and a wrong form filled out. Any visitors, you just wait! So off we flew to Gondor (castles and Simien mountains) and Lalibela, rock hewn churches and angina inducing mountain walks to monasteries, all this going on in the fasting week leading up to Ethiopian Easter. Thus the churches were full of Ethiopians chanting Ge’ez , the fore-runner to Amharic but oblivious to our visits but handy to have a guide and they really are quite dramatic. If by the way you are having problems conceiving your troubles can be sorted by dunking in a rather septic looking pool (see photo, the reeds are not usually there, something to do with palm Sunday I believe. What our stunningly attractive but largely silent Ethiopian guest made of it I do not know but I am embarrassed to think that we probably spent more money in a week than she earns in a year but I hope she enjoyed the experience. Although deeply supressed I think she may be capable of deductive thought as I was left to entertain her while an overlong pedicure was taking place and I espied a Sudoku in a magazine and taught her how to do it – suddenly she was thinking, something I had not seen before. Perhaps mind expansion for Ethiopians is through puzzles, but what is apparent is that it is not through their education. Our current administrative mine field is the Ethiopian national Ethics committee, regulations down loaded from an English Ethics committee site and an Ethics committee manager out of the helpful English, make sure this stumbles mode. Ethiopian Ethics required because U.K. Ethics say this is necessary but U.K. ethics probably not necessary but number required if wish to publish so here goes. Having given in papers, complete with Afan Oromo consent translation, though most probably cannot read it and letter from local NGO organiser saying O.K.we now need letter from local health office saying they happy too. Not of course told about this before and also if goes in post never seen again. So more trailing around offices, I am beginning to understand why they all have sofas. But may be we will have to deliver it ourselves. Trip to the bright lights of Addis to deliver said letter perhaps! My Afan Oromo lessons have taught me that Addis Ababa means new flower. Meanwhile back in Gimbie, there is no internet (so when this goes up is any one’s guess) and my Ethiopian oppo is delighted to have someone else to do the nights with him. I think local obstetricians must be away as there seems to be an upturn in obstructed labour, heavy bleeding (Hb 2.8) and mal-presentation. Some of the local health centres have clearly decided that episiotomy is in, though they seem to be cut on the latera lwall and into the ischeo-rectal fossa producing some interesting haematomas and reconstructive surgery, carried out with the helpof a head light and the left overs from a recent influx of prolapse tourists most of whom I managed to escape by visiting churches. Happily so far I am not left with a lot of pelvic cellulitis but early days. Out patients, (there was a failure of pre planning) is now full of the hopeful but droopy and they will either have to wait till the next trip in November or pay up. Equally the new regimen means that women with previous caesarean sections, and small of stature are being turned away and scandalously a lady with a ruptured uterus and little circulating volume, until she could come up with the reddies. For a predominantly socialist country a little socialised medicine would be a good thing. Those of you in the U.K. system will know that it is ‘elective season’ and the place is crawling with faranji students so I am teaching them more than anyone else and little other than enthusiasm changes, otherwise they would not be here, however like medical students (though all girls) the world over they have discovered the ‘Green Bar’, however sadly and our medical politicians have a lot to answer for, their education to date is –perhaps- a little Ethiopian. They are perhaps having their minds broadened here! The pool is a fertility pool, dunk your self in and there you go.

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).