Anyone for Valpolicella and lentils?.........

January 30^th

I mentioned previously that the diet here can be poor and it takes effort to ensure you eat properly. The local people vary in body shape due to different tribal origins but the one thing that they have in common is that they are all extremely lean. The average weight of women in the antenatal clinic is 50kg (and they are often at quite an advanced stage of pregnancy). It does make the management of problems easier (you can feel which way round a baby is and scan with a much higher accuracy with no body fat) and certainly the anaesthetics are easier because all the women are so slim. In the UK we use an aid called a "Pat-slide" to move women off the operating table but thus far nothing has been needed to help move a patient (with the one exception where it was all hands on deck).

One effect of the diet is that iodine deficiency is very common and so goitres (a swelling in the neck due to an enlarged thyroid) are almost universal.  Likewise although I have not seen it yet spinal bifida in newborn babies is more common due to lack of folate (there are no folate supplements recommended routinely here).

The poor diet is mainly a result of a lack of money to buy food but also the fact that the traditional diet is very low in fruit and vegetables (with calories/protein coming from a grain called Tef made into a rubbery unleven bread called injura, served with oily stews of meat or pulses). In fact the market has a good range of fresh produce depending on the season. Currently red onions, tomatoes, avocados, (with the largest stones you have ever seen but as they are only 1burr (5p) for 3, you are getting what you paid for) potatoes, carrots, bananas (2-types), oranges, limes  (that they call lemons) and fantastic large papayas are plentiful and I am told these "staples" are available all year round. With quality and price varying according to how abundant they are. There are two green vegetables that you can get hold of the are both called "rafu" one is recognisable as a sort of white cabbage and the other is a bit like spring greens (but very bitter).  You can also find pumpkin (sold in slices) and beetroot (unfortunately they discard to beet tops). I managed to get some green beans this week but these are seasonal and considered very expensive at 10burr (50p)/kg. The other problem for the local diet is that any fruit and vegetables they do eat are cooked for a long time, a habit I assume that developed to avoid food poisoning but unfortunately destroying important vitamins.

I have seen no evidence of meat in town but am told if you want it you can find it but that it is very tough by western standards. Ethiopians are meat eaters if and when they can afford it (they even eat raw beef with a resultant tape-worm problem). I made the decision to eat vegetarian in Gimbi (as I think it is easier to avoid stomach upsets) but I will be looking forward to a steak when I get to Addis in a couple of weeks.

My diet here is pretty healthy as unlike Ethiopians I am going out of my way to get a good variety of vegetables. One of the gardeners in the compound grows lettuce so it is even possible to have a carefully washed salad (lettuce, white cabbage, tomatoes, beetroot and avocado). I have also managed to find a number of different ways to cook all of the available vegetables, this is helped as chillies, and garlic and fresh ginger are also widely sold in the market. I have learned to like to lentils, which is fortunate as these are my main source of protein although there are also excellent (if very small) eggs available for baking and omelettes. I have a cook (Tadilho) who sadly doesn't seem to want to make Ethiopian food even occasionally however much I ask but I have persuaded her that chilli is fine and so her lentil stew (with extra added vegetables) is not quite a gourmet meal but something I can look forward to. She makes good (slightly sweet) bread and excellent carrot cake so this is preventing me from loosing a lot of weight. There is also no dairy available, which is a bit of a mystery since there are goats and cows galore roaming the streets of the town. If you want milk it comes in the form of dried "Nido" (the wonderful Nestle monopoly on the African market means that a small tin that makes 10lites of milk is 140burr-£7, which is a fortune here in real terms). So I use it sparingly in porridge and I also treated myself to homemade rice pudding one night (which was really good). You may wonder about the term "sparingly" as I know that I can afford dried milk but it is amazing that surrounded by so much need you become acutely aware of what you spend on food and you also become obsessed with ensuring that absolutely nothing gets wasted, planning meals to reuse left-over's and to eat anything that might be nearing the end of it usable life.

Finally, no alcohol for three weeks, which as many of you know a record for me as I suspect that the last time I abstained for this length of time, was before I went to college i.e. when I was eighteen. There is beer available in town but the establishments are not very conducive to a quiet beer and as the majority of the other "faringe" are Seventh Day Adventists (who don't drink, smoke, eat meat or have caffeine if they are doing it properly- although they are not evangelical and intolerant of all of these behaviours in others) there is no one to go with me. The good news is that my alcoholic fast ended yesterday as Tekle (the local Obstetrician) brought me a bottle of Italian wine when he returned from Addis. It is much better than expected but then after three weeks I'm not sure I can be relied upon for my wine criticism as I may have a temporary bias. I am planning to make the bottle last as I don't drink when on-call (alternate nights now) and I think that 1-2glasses is all I really need to wash down spicy lentil stew!

That's an awful lot of nothing................

January 27^th

So before you all think that I am already getting remiss in my blog updates, we have had a period with no internet connection. It seems that Ethiopia telecom is just like the trains in the UK and the slightest inclement weather takes the lines downs (or something of that sort anyway). I was told it was the dry season (which should last until end of April i.e. long after I am back in the UK- thus I came with no clothing for wet weather. No doubt someone in some meteorogical department will say that it is due to global warming but we had 2-days of intermittent torrential rain- there is no doubt that these 2-days left me relieved that I am not here in the wet season. One return trip from my bungalow left me soak to the skin (in spite of a plastic apron to make me both look like a local using whatever is to hand and theoretically to offer some degree of rain protection), thankfully "scrubs' & Crocs (which are standard wear for work here) dry out very quickly.

So back to life on labour ward in Gimbi. Monday presented me with my biggest challenge yet- this is meant in both a literal and a metaphorical sense. Late in the afternoon, a woman was transferred from the Government hospital in Assossa which is 5hours drive (300km) further west almost on the Sudanese border. A brief letter presented the facts that they had tried to delivery her by caesarean section (reason for caesarean not given) under general anaesthetic and that she had had a cardiac arrest but been resuscitated and they had abandoned the planned operation and transferred her to us. What the letter didn't say (but perhaps they felt it unnecessary as it was immediately apparent on looking at her) was that she weighed 150kg. This is the sort of weight that in the UK creates comment but we do deliver women who are very overweight relatively often but here where the women of all ages are all incredibly lean and have no body fat at all (there is the occasional wealthy person who might be reaching a BMI at the upper limit of normal) this woman was massively obese. Being this overweight is a health issue in the UK in spite of having special equipment (hoists and a bariatric operating table) and extremely experienced anaesthetist who will see the woman and careful plan the anaesthetic to try to make it as safe as possible.  So you can imagine the issues involved in caring for a woman of this size here, the only good news was that looking at her it seemed unlikely that she had had a genuine cardiac arrest as she was well in herself. The reason that they were going to deliver her was because she was in very early labour having previously had a caesarean section and they suspected she was carrying a large baby. I agreed with their suspicions about the size of the baby but of course the accuracy of clinical examination in this situation can be poor (the faithful scan machine was not able to add any information in a woman this big). So I bad a dilemma- should I let her labour and wait to do an emergency caesarean or just get on and do it now whilst there was no apparent urgency? On balance I decide to go for the latter option on the basis that it would be safer for her- the risks of the whole situation were explained to her and her family (or at least something was said).

In this situation it is the anaesthetic that is the issue not really the surgery (which is just more difficult) and so this was a serious challenge for Abate the nurse-anaesthetist. He tried a spinal anaesthetic but the needle wasn't long enough to reach her spine (we have special long needles in the UK) and so he was forced to give her a general anaesthetic.  Obesity makes this particularly dangerous as it is difficult to get the tube into their airway that is required to allow them to breath (they have fat, swelling and relatively shorter necks due to their body shape) and this is something that you only get one attempt at. Thankfully he managed to get the tube in place first time although her oxygen levels did fall to an alarmingly low level very briefly (which we suspect is what happened in Assossa resulting in them panicking and abandoning the operation).

So I was able to do the caesarean and delivery a large 4.5kg (9lb9oz) baby who has the body fat distribution of a laughing Buddha. This is a very large baby for here where the average birth-weight is about 3kg (6lb6oz) and the appearances all suggest that the mother had diabetes in pregnancy which would be in keeping with her weight. The operation was uneventful other than having to finish the skin with local anaesthetic as she was waking up and in the circumstances giving more general anaesthetic was not an option.

Thankfully 35hours on she is doing remarkably well and is mobilising better than an equivalent woman would back home. Her baby has a few feeding issues (unusually she is refusing to breast feed which only the very wealthy do here as formula milk cost $16 a tin).

I couldn't help but ask the midwife to ask her what she ate as on the basis of the diet I am eating here it is difficult to maintain weight never mind gain to any degree. The midwife asked her, she responded in a serious way and the midwife smiled and translated "she says she eats nothing doctor"!

Gimbi bibles..............

January 24th

There is no such thing as anomaly scanning here and so I had been a bit surprised not to see any abnormalities in the babies so far.
That changed overnight last night as there were two babies delivered with problems that in the UK would have been diagnosed before birth thus allowing a plan to be made for management after birth or allowing the parents to consider the option of a termination of pregnancy (depending on the stage of the pregnancy and the nature of the abnormality). Termination of pregnancy for severe abnormality is also legal in Ethiopia although in the absence of any scanning I assume this is rarely undertaken.
The first baby has a cleft lip and palate on one side (they can be in the midline or on both sides which is worse). The problem with this is that babies require an intact palate to be able to create the suction needed to breast-feed and also to prevent them accidentally breathing the milk in (aspiration) during feeding. In the UK this is all addressed by regional cleft lip and palate teams who spring into action when a baby with this problem is born and use a variety of devices to make sure the baby is able to feed. Of course here there is nothing locally- there is a hospital in Addis called the Cure Hospital that specialises in paediatric problems like this and will treat the babies for free but this is only possible if we can manage to keep the baby well enough to travel and undergo surgery, thus the challenge at the moment is to try to get the mother to learn to feed the baby via a naso-gastic tube, simple enough in a clean environment but here the big worry is infection and gastroenteritis.
The second baby has bilateral talipes (we used to call this "club-foot" but the term is no longer considered PC in the UK although it will not surprise you to hear that it is the term most commonly used here). This baby can also be sent free of charge to the Cure Hospital but more is available locally. In a visiting Canadian Orthopaedic surgeon who left just last week did some training on treatment of this condition and the local Ethiopian Surgeon is going to put some special casts on the baby to get treatment started. His baby also has problems with its wrists, which is worrying as it suggests that he may have a more global problem but at the moment he is behaving normally and I have no-one else to consult about him.
This and the other neonatal problems that I have had to manage is a bit of a l like a crash course in neonatology and I am very thankful of the help of one of the other visitors Joyce who is a neonatal nurse, however as she points out the responsibility for prescribing any treatment she undertakes in mine! I have fortuately found a Unicef publication "Management of newborn problems" which is now one of my bibles here.

The NHS may have his failings but at least we don't turn many people away.................

January 22^nd

 

My experiences in Gimbi are making me appreciate the advantages of a centrally funded Health service.

What happens here is that anyone can come to the hospital and pay a fee of 9Burr (about 45p) to be seen in general outpatients. This general OPD acts as a sort of "clearing house" come minor problem GP practice with the patients being seen initially by outpatient nurses who are able to prescribe a limited number of drugs (which the patient has to buy from pharmacy). They can also decide to refer on to one of three specialists: a GP who sees all medical problems, a surgeon who sees all surgical and orthopaedic problems or an obstetrician/gynaecologist (currently myself) who sees any thing pregnancy related or gynaecological. If required this specialist consultation is covered in the initial 9burr fee but again any medication or further treatment has to be paid for separately. The other way of accessing medical care is that they can pay 15burr (higher fee as it is open 24-hours I think) and be seen in the emergency room (sorry American terminology again) but any drugs, fluids, treatment or admission to hospital is charged separately. The Adventist Church tries to help out in very extreme or serious cases but overall their charity aims to support the infrastructure required in the hospital ( lie the building and equipment, electricity/water, supply network from Addis for drugs etc., "faringe" organisational & administrative staff and so on) requiring local people only to pay to cover the salaries of the local staff and consumables required for care.

Now 9/15burr may not sound like a lot of money but when you consider that the average daily wage is of the order of 15burr, it follows that most people scrape together the money for the initial consultation but are not able to afford surgery or referral on for other treatment. The other problem is that to come to outpatients or the emergency room may involve a journey of up to 12hours and this also requires Burr to pay for transport.

I saw three women yesterday with the sort of uterine prolapse you only rarely see in the UK (the high rate here is a result of the average birth rate of 6.2/babies per woman in this area) but is definitely operated on virtually immediately when it does occur. All three women are unable to afford an operation-this would normally mean that the only option for them was to continue to live with their prolapse (which is a pretty unpleasant condition but I will leave it to the imagination of the non-medical readers rather than risk upsetting the squeamish). Fortunately there is a ray of hope for these women at the moment, as a vaginal surgical team (not sure who/what exactly yet) are coming from the States for 2-weeks next month and so will be offering cut-price surgery (these sort of sales are very popular here!). Thus, I have added the names of the women I saw to the list that is being kept and if we are able to contact them (all three live more than three hours journey from the hospital and have no mobile phone) hopefully they will get surgery.

A more tragic case was a 50-year old woman who came to consult because of a three-month history of bleeding (she stopped her periods 12years ago-multiple children and nutritional status means that they all seem to have their menopause a lot earlier than the Western average of 51years). The hard lives people lead here means that at 50 years most women look very old (certainly older than their Western age equivalent)but unusually this woman looked extremely fit and well for her age (only 2-years older than me). Unfortunately on examination I found that she has a cervical cancer (no smear test here) that has spread such that an operation in Gimbi would not be ideal as the surgery will be difficult, she is likely to require a larger blood transfusion than we can provide and also would not be curative (in the UK a tumour like this would be treated with radiotherapy and chemotherapy not surgery). The best option should be to travel to the main Black Lion hospital (named I am told after some famous British regiment) in Addis where cancer care is available- although even if you have the necessary fee the waiting times to be treated can be long. Sadly she does not have any money and her daughter wept in the clinic pointing out that her mother "has no sons" to help care for her. She will come back next week when the Ethiopian gynaecologist has returned from holiday and perhaps he will decide to do some sort of palliative surgery in spite of the risks and the inability to cure her as this will be cheaper for the family and thus the only option available.

Thankfully the situation in obstetrics is different  and I now fully understand why Gimbi was recommended to me as a good place to come for a first experience of work in Africa. Thankfully the backing of Maternity Worldwide in obstetrics means that I don't have question whether a woman can afford to give birth in hospital or have a caesarean section, I can just get on and do whatever is necessary. Any woman who is pregnant can come to Gimbi to deliver, if they can afford to pay they will be asked to pay the full amount (about 2000burr for a caesarean delivery) but otherwise they have to find a smaller amount (30burr for a normal birth and 400burr for a caesarean section) and Maternity Worldwide via what is called the "Safe Birth Fund" voucher scheme pick up the rest. I am not absolutely clear how they work out who can afford to pay and who can't but the system does seem to work as I am not asked for vouchers for everyone (Ethiopian bureaucracy means I have to fill out and sign lots of forms that require an additional very impressive looking stamp). So for the many of you who generously gave donations to MWW, I see on a daily basis the difference that this makes in allowing poor women access to safer care in childbirth.

Did you know we take our Christmas trees down at Epiphany?

January 20^th

 

Yesterday was another bank-holidayin Ethiopia for Epiphany- not sure I had ever really registered that Epiphany was twelfth night but as we only mark it by taking our Christmas trees down and I'm not the most diligent of church goers I suppose it is hardly surprising. Another holiday meant a quiet day with no outpatients although I did do a normal breech delivery in the afternoon (these are not very common in the UK any more) avoiding a caesarean birth (that would make delivery more compicated next time which is important here).

Instead of medical stuff this time I thought it might be time to fill in a few details about my life when I am not working (especially since I have received a report that my accounts maybe too graphic for some-Nicola?). I am staying in a small bungalow, one of two that were built by Maternity Worldwide for visiting doctors such as myself. Bungalow is perhaps a slightly grand term for it but it is brick built albeit with a corrugated tin roof that almost all house in Ethiopia (and certainly Gimbi) have. The main disadvantage of the tin roof is the noise that the birds (crows and pigeons) make first thing in the morning as I discovered on my first morning when I was awoke with a start as it sounded like something was trying to remove the roof. So there is no lie in here and definitely no need to have an alarm clock, as they are at least regular in their activities at about 7am each day.

The bungalow is built on the hillside below the back of the hospital and have a lovely view over a small valley behind looking east so that the terrace gets the morning sun. Someone has fashioned a bird-table out of some pieces of wood and a small amount of bread or rice attracts an array of bird-life to watch from the terrace. The disadvantage of the position is that it means an uphill walk to the hospital which, given the elevation of 2000m in Gimbi, leaves me out of breath although I am sure my blood is getting thicker by the day.

The bungalow has a couple of bedrooms and there will be a midwife from Australia to keep me company from next month (which will be good as it can be a bit lonely). It is all quite compact but a lot more comfortable than I was expecting. I have a mosquito net over my bed which is just as well as I am one of those people who you want around as that they preferentially bite me before anyone else. It is also something very smug about lying in bed hearing a mosquito whining close by and knowing that it can't get you!

There is a small central seating area with an old style 3-piece suite which whilst ugly is amazingly comfortable and also a table and chairs.  I have my IPod here, which is a lifesaver as familiar music definitely makes a place feel more like home. The kitchen is very small but has a modern fridge-freezer and an oven/hob. Only problem here is that currently they are waiting for new gas supplies from Addis and my gas bottle has been empty since I arrived- any way it is amazing what you can manage to do on a single ring!

The bathroom has hot water (unexpected) but it will be a novelty to stand under a shower again rather than use a hand-held nozzle and to have cold water in the basin (the cold tap doesn't work). The water doesn't stop too often (1-2xweekly so far) and as I am only one in my house at the moment the tank holds out for a while and there are big plastic "dustbins" of water on standby for use in kitchen & bathroom (which suggests to me that it can be for longer periods than have occurred so far). Electricity is a bit more hit and miss with power cut for some period of time most days (the hospital has an emergency though ailing generator for these occasions) but I have my candles at the ready and don't open the freezer door.

The weather during the day here is pretty glorious (sorry I do know about the terrible snow in the UK). I don't know how hot it is but it is probably around 24-28 degree Celsius for most of the day with a few hours that are hotter in the early afternoons. Although I could sit out on the terrace, the sun is hot and local sensitivities mean it is "not done" to be scantily clad so I will save sunbathing for the holiday at the end. Thankfully the temperatures fall during the night and so I am able to sleep without a problem (although no covers are required until the hour or so before dawn). I am not sure if the weather will get warmer during my stay and no-one local seems to have any idea either with the only distinction they make in weather terms being between the dry season (now) and the rainy season (May-September) which they say is hotter. During the day I can open all the windows to let the breezes in and then can close them at night that keeps the insects and the noise of barking dogs, the mosque call to prayer and Orthodox Church loudspeaker sermons out.

I said I would tell you about my "anaesthetist" (& other stories)

January 18^th

 

I have now survived 4-nights on call and recon that I am probably about half way through my stint as the solo obstetrician and gynaecologist here (although the exact date and time of Tekle's return will be known only when I see him). Thankfully it is much quieter here than other places I have worked albeit the problems I see are much more extreme and everyone is well aware that on a 1:1 shift it is important that there are rest times.

Things also happen quickly, in that the decision about what to do next is obvious by the time a woman arrives on the labour ward here and so we are able to move swiftly into action. And when I say swiftly I mean exactly that, if I recommend a caesarean section (I could say order as there seems to be no question of anyone disagreeing with my recommendation) then the nurse midwife takes the consent (signature or more commonly a thumb-print), does the needful pre-op bits and wheels down to theatre (know as the "OR" as American terminology seems to have gained the upper hand). In theatre the team will be waiting and we will be ready to start within a very short time. All this is a far cry from the UK where at every stage there is massive discussion, coercion and even begging required to get anything to happen especially if you want it done quickly. The result of the speed here is that I can be called from my bungalow, see and assess a woman, do the caesarean, write notes and be back in my bungalow in only a little over an hour!

The only delay is if the surgeon is doing an emergency case as there is only one theatre. The level of workload is such that this doesn't happen very often. I did have to wait last night as they were patching up a guy involved in a stabbing incident (unfortunately the other protagonist was beyond the help of any hospital). It occurred to me that Gimbi on a weekend night is not dissimilar to Peckham as stabbings are the things that sometimes prevent caesareans (albeit in a second theatre) happening back home in King's.

There is no anaesthetist doctor in the hospital and an anaesthetic nurse gives all anaesthetics. He works 1:1 as well and has an even tougher deal than the on-call surgeon and myself as he covers both the emergency obstetrics, surgery and gynaecology as well as doing any elective operations that are required. Through all this he remains good-humoured and quite amazingly competent. So far he hasn't failed on any of the spinal blocks he has given for me which have all been rapidly highly effective with the woman apparently completely pain free. I have also done a few cases with Ketamine (a drug with many uses including as a Field anaesthetic in the army and more famously as a drug abused recreationally) for an anaesthetic. He can also administers general anaesthetics but I have not needed this so far. The latter is something I will try to avoid, as although his technical skills are fantastic I am not sure there is a great understanding of underlying physiology and so if things start to go wrong, the outcome might not be good.

It isn't quite like riding a bicycle..........

January 16^th

So this entry of my blog has seen me face a few more challenges (as I knew I would). The obstetrics is going fine (well I don't feel out of my depth) but the gynaecology is proving more challenging.

As most of you know although fully trained in gynaecology I gave up practicing over 10 years ago when I became a Consultant, so it is all a bit rusty to say the least. Now add to this the need to practice in a completely different way due to resource limitations and that is where I am. This morning, I was faced with a woman with an ectopic pregnancy. Because she was very anaemic (from bleeding from the ectopic), the male anaesthetic nurse Abate (who I will tell you more about on another occasion but is amazingly skilled) felt that giving her a general or spinal anaesthetic was too dangerous and thus I had to do her operation with only local anaesthetic and some sedation. As is often the case she had also presented very late so that everything in her pelvis was very damaged, making the surgery difficult with the result that I was unable to stop her bleeding without removing both her fallopian tubes. Committing a young woman to a lifetime of infertility is serious anywhere in the world but here where there is no IVF and people depend on offspring to care for them in old age, it has left me feeling pretty terrible and wondering of someone with greater skill could have done a better job. However on the day I was her best chance and at least I managed to stop her bleeding

I was told to look for the uplifting part of any case when I feel down and in this case it is that she clearly has a very a supportive family (she is young and unmarried)- how do I know this? At 10pm last night her predominantly male relatives lined up to be checked to ensure they had normal blood pressure (and were HIV negative) before having their blood groups checked to see if they were a suitable cross-match for her. Thankfully two of them were (and had very high blood counts) so they donated blood without which she would not have made it through the surgery (with or without her tubes).

Otherwise today is quiet in the Hospital as being a Seventh Day Adventist organisation Saturday is the Sabbath and thus there are no outpatient clinics or other elective work. The labour ward has been quiet this afternoon or at least I assume so as I have had no visits from the guard (there is no bleep system or telephones and so if the midwives need me the compound guard who speaks only a little English is sent with a note to fetch me). Hopefully it will stay that way for a little while to allow me the time to post this message!

In at the deep end

14^th January

Tekle the Ethiopian Obstetrician & Gynaecologist has left for a well earned holiday, hopefully he will be back in 8 or 9 days or so (the uncertainty is not because I am concerned he won't come back but because the reality of finding transport for the 10 hour journey from Addis back to Gimbi, is that a degree of flexibility in timing is required). So that leaves me in at the deep end doing a 1:1 on-call for anything they deem to be roughly within my sphere of competence.

Fortunately the gynaecology is coming flooding back which is just as well as the clinic today presented me with an array of gynaecology complaints. to manage including both a cervical and an ovarian cancer. I also saw my first woman with a urinary fistula, which is a problem virtually unheard of in the UK (I have seen it once before in my entire career) and is a result of labouring usually for days when the baby is stuck and can't get out (obstructed labour for medical readers). This woman delivered in September, she had delivered 4 children previously without a problem but with her fifth baby laboured for 3-days at home before presenting to the hospital. Her uterus had ruptured, the baby had died and she required a hysterectomy. Today was a routine follow-up and it was obvious (olfactory assessment) as soon as she arrived that she was leaking urine uncontrollably. She will require further very specialist surgery, the light at the end of the tunnel is that there is a specialist fistula hospital in Addis where she can receive treatment with a high chance of success for free.

More of an issue for my competence is the neonatology as in the absence of any other doctor this is my remit as well.  Neonatal resuscitation was something I was prepared for but the management of postnatal temperatures and feeding problems was not. I really wish I had brought a neonatology book although I have realised that my books are of limited use as most of the investigations and the treatments they describe are not available here. Fortunately I have managed to find a very basic reference book and look up antibiotic doses and feed volumes, we are not talking very high tech management since the limit of treatment is intramuscular antibiotics, feeding through an naso-gastric tube and nasal oxygen therapy. One of the other visitors is a neonatal nurse from America and she has been a great source of reassurance and advice.

There is so much that I could tell you about like the attitude of women to pain and to the loss of their babies (which sadly is a daily occurrence). There is also plenty to tell you about the nurse-midwives attitude to the same that, at times can be pretty shocking but I need to save something for future blogs as there are ten weeks ahead of me in Gimbi!

Sorry about the lack of pictures but unfortunately the dial-up is unable to cope with the file sizes so I will try to send some back mid-term when Mark comes out to visit.

Now it starts to get interesting.............

12th January

Did my first night as 1^st on call for obstetrics (& gynaecology) last night and finally feel as though I might be earning my keep. The night was busy with not much sleep opportunity and I was rather "wired" in the bits were I did get back to my room so sleep was fitfull even then- hence the short blog entry as I need to catch-up as the on-call is at best 1:2.  It all feels a bit like being a junior doctor again as this is a whole new way of doing things.  I am gradually adjusting to the reality of trying to manage things without any investigations and with none of the usual medications. Add to this the fact that they use the American version of many of the drugs that I am familiar with and you can begin to imagine the issues. Managed not to need to call on the local doctor (who definitely deserves a night off as he works a 1:1) but there were some moments of uncertainty.

I did a caesarean section this afternoon on a woman who came in from an external clinic and had been trying to push a baby out in a breech position for 12hours with a foot  (and scrotum) visible. Amazingly when she arrived the baby was still alive and he doing well on the ward after delivery.

As I expected the feelings of homesickness are abating as I get to know everyone and find my niche. There is a lot that could be done here but many basic resources are lacking (medical comment- we can't even dip stick urine for protein as there are no reagents!) and I am very certain I am not going to be bored!

Many of the other "faringe" have worked in Africa for a while or before and so there  is plenty of support and advice (the Orthopaedic surgeon from Canada worked in Burundi where they regularly ran out of sutures to allow caesarean to be done and knows all sorts of  ways out of trouble). Everyone is also very sociable and they have also come up with creating cooking solutions for the limited ingredients here (there is no dairy produce of any kind and aonly a small selection of seasonal vegetables) with someone making a delicious carrot cake yesterday. There is one problem I foresee, is that as I am surrounded by North Americans-you may have to forgive me if the occasional non- English syntax slips in!

Still struggling with the dial-up.................

 

11th January

 

The blog entry below was intended to be sent yesterday but had problems with dial-up (the blog entries are sent to the site by email).

(would like to blame Ethiopian internet but it turned out to be a "blonde moment" technical problem on my part- I will spare you all the details but needless to say I know now!).

 

10^th January

Settling in is more difficult than I expected- I thought that I was too old to get home sick but that doesn't appear to be the case. It is getting easier with each day but it is not a feeling that you have a lot of control over which is very frustrating. I think about the fact that I came here not expecting mobile phone signal and wonder how I would have got through without the ability to send/make occasional texts and calls.

Everyone is very welcoming. There are a number of other long and short term ex-pats working here (we are collectively know as "Faringe" by the Ethiopians which appears to be a term that is descriptive rather than derogatory in any way). Many though not all are Seventh Day Adventist missionaries as Gimbi hospital is an NGO run by their church. Perhaps it is a reflection on the type of people who do this sort of work long-term but I have been overwhelmed by the time people have taken to explain things and to help me to find my feet for aspects of day-day living.

Overall I have nothing to complain about as I have far more than I expected in the way of creature comforts and as promised we have electricity "most of the time" and water "most of the time". It can stop out at inconvenient times like this morning – getting going in the morning (afternoon/evening person) is a challenge for me any day but without coffee it is particularly difficult!

I've already had feedback about too much medical detail for the non-medic readers- apologies I will try to keep it sanitised and minimal but it is what I am here for after all. Things are a bit quieter than I was expecting. No one really understands the statistics here and certainly they are unable to make any future predictions but for some reason the delivery rate has fallen from 200/month to around 150/month in recent months. There is a brand new Government Hospital just opened in Gimbi, this is not seen by the Adventist Hospital as competition but a desirable alternative especially for people too poor to afford to pay for their care in medicine and surgery. The new hospital may be part of the reduced activity but it is not the whole story as the birth rate fall began a few months ago and Maternity Worldwide provides a "safe Birth" fund so that there is care available to all women here (additionally ex-pats from here visited the new hospital yesterday and found one inpatient in a 50-bedded hospital- can you imagine). Anyway this means an average delivery rate of 5 babies day here. The section rate is about 20% as the aim is still for SVB if at all possible, the midwives do all the suturing and also do straight forward vacuum deliveries (the re-use Kiwis here- sorry a very medical comment). The other thing is that unlike the UK, women are not in labour in the hospital for prolonged periods as they only come to hospital after they have been in labour for a long time at home with labours that are clearly obstructed and beyond the help of the ubiquitous syntocinon we use for slow labour in the UK. Thus review and action (usually caesarean) are swift. Overall what this means is that there is a lot of time waiting around for things to happen so I will have plenty of time for other things such as teaching or organisation once I find my feet.

Hope the cold in the UK is abating slightly. I won't gloat about the 30degree sunshine outside, as there are downsides to other supplies in Gimbi to make up for this!

 

 

Wow I had forgotten just how slow dail-up is.......................

7^th January 2010

I am now in Gimbi and due to the fact that unlike the rest of the world the Ethiopians never officially converted from the Julian to the Gregorian calendar it is Christmas day again. I have to tell you that unlike the UK it doesn't look much like Christmas as it is warm, sunny and very green outside.

The journey (yesterday) to Gimbi as promised was "long and hard" 440km taking 10hours. Two thirds of the road is fantastic (provided by the Chinese) but the middle third is truly terrible, although a fleet of brand new Chinese lorries and diggers is in evidence standing by to commence work on this section later this year. The driving here is some of the worst I have ever seen: the roads have little traffic but what is on the roads is either travelling very slowly or very fast. The belief that there will be nothing coming the other way results in some risky overtaking. Add to this the need to weave around paedestrians, dogs, goats, cows and donkeys in large numbers all with no apparent road sense and you begin to understand the tally of 7 over-turned vehicles on or near the road and 7 canine fatalities (assuming a hyena count in this category) that we saw on the journey here, thankfully non-witnessed.

Arrival was a big culture shock and I experienced my first pangs of severe homesickness and that "do I know what I'm doing" feeling was particularly strong. In fact a cup of tea brought it all into perspective: the accommodation is much better than I was expecting (rather like the hospital accommodation I stayed in as a junior), there is a hot shower, the cook had left me a more than edible supper and there is a mobile phone signal (so if O2 don't cut me off I can at least phone home when desperate). I put on some music (thanks to my ipod and portable speaker) and busied myself making it feel more like home (i.e. spreading my stuff everywhere). I also took solace from the good advice of a work colleague who has worked abroad and warned me that the 1^st few days would be dreadful but that it would soon get better (if you are reading this-thanks Asha).

I did my first round with the local obstetrician (Tekle) this morning and assisted him with a caesarean. Amazingly the threshold for LSCS seems very low- which many of you know goes against the grain for me so we will see how it goes. The differences with care in the UK are huge. Everything is done on the minimum resources, issues like patient confidentiality and privacy are considered luxuries beyond the most basic level, the neonate is secondary with little resuscitation possible, infection control is considered but limited by resources (beds are maximum 3-feet apart in the ward). This lists but a few however overall the sense of all staff trying their best (often working 1:1 on-call) given these constraints is obvious. I just need a bit of time to see if there are things that can be done that will make the staff's lives easier and/or help the women they care for.

As it is Christmas here are no clinics so I am now on-call for the labour ward with Tekle and hence have time for a blog update. Well that really is more than enough to expect any of you to read and I will try to keep it shorter in future but at the moment everything is very new and different. Keep warm in the snow-bound UK!

And so it begins..................

So I've arrived in Addis Ababa and now have to start to work out exactly what I am meant to write in a blog. I suspect I am best to keep it short so as to make it more likely I will get around to doing it and that people may feel inclined to read it.

 

I managed a dignified farewell to Mark at Heathrow (we've not been apart for more than about ten days in 18 years) and he waved me off over a prolonged period as I waited whilst they squeezed an impossibly large child's buggy through the xray machine ahead of me.

 

Bole airport was a surprise as it is bright, modern and apparently lacking the chaos that is typical of most African airports. It was all very efficient immigration, baggage (all arrived safe and sound), customs (a short discussion about the nature of a sonicaid required), bank (fortunate to get a wad of newish birr notes that have not yet been handled by half the population of Addis) and hotel transport located in under an hour without a single offer of a dodgy taxi.

 

I'm now checked into a hotel for a 24-hour stay before the 10 hour drive to Gimbi tomorrow and will do the boring Embassy registration and provision shopping today with hopefully time for a swim later. I think I need to make the most of these last moments of the creature  comforts I am used to as for the next few week it will be back to basics.

 

Well that seems about enough for the first addition and besides it is starting to feel like breakfast time (currently 06.45 in the UK and I have been up for 3 hours).