Tidying up & rethinking the location-specific implication of Down's syndrome...............

February 28^th

Believe it or not Friday was another public holiday in Ethiopia (3 in my stay so far & another on tuesday)-it was a Muslim holiday, most people seem to think that it was to celebrate the birth of Prophet Mohammed but no one is absolutely certain and my Bradt guide has failed me as for once this holiday is not listed. That a predominantly Orthodox Christian country should have Muslim public holidays is a testament to the apparent peaceful co-existence of Muslims and Christians here with no evidence of any  of the cultural tensions sadly so common in more developed countries.

This holiday meant that there was no outpatient clinic to occupy my time in the morning and there were no women in labour either so I decided it was time to force a tidying of the labour & delivery room (Mark knows to his cost that leaving me with unexpected time on my hands is likely to prompt me to embark on some sort of "clear out" exercise). The lack of resources results in a reluctance to throw anything away which is laudable until the place is so full of items saved for a "rainy day" that finding the things you actually need becomes difficult (and obviously in a hospital such items can become an infection hazard). There were a number of things that in spite of extensive enquiry no one could remember (if they ever knew) the function of, there were drugs & other packaged supplies that had expiry dates in the last century (in a country like Ethiopia there are reasons to be flexible in such matters but never with drugs that could become ineffective and even for other items there are limits!) and in addition to these things there were large numbers of stored empty boxes (just in case). I'm not absolutely sure what the midwives thought of the whole exercise (eccentric "Faringe" most likely) but they went along with it and only a few items that I threw away were retrieved from the bin!

Laundry is another area that was very chaotic in the delivery room and I felt a bit like Florence Nightingale must have, as I insisted that everything was pulled out of the cupboards prior to being sorted, folded and then being returned to the cupboards in orderly piles- allowing  things to be found more easily. Unfortunately this order also made it much more obvious what a severe shortage there is of linen there is as folded neatly it looks a lot less. I use the term linen very loosely- it compromises: 1) large plastic aprons (for the midwives and doctors to wear to save their scrubs or clothing during delivery- rarely with both neck band and ties but I have learned how to tie an apron very effectively with only a single string), 2) a very small number of gowns for women who require caesarean section (fortunately we rarely do more than 3 per day), 3) plastic aprons now devoid of any strings that will serve on for anything requiring a waterproof sheet (with a selection of other plastic "tarpaulins"), 4) pieces of sheeting (we might also use the term rags!) in a variety of sizes that are multi-purpose from wrapping babies after delivery, to cleaning mothers or surfaces or more rarely as a dignity cover for a mother- these are all carefully laundered in spite of the fact that some of them have more hole than cloth! and finally 5) rectangular pieces of thick plastic that are used to cover the delivery beds.  Describing this I realise how much I have moved on as when I first arrived the bleakness of these items was shocking but 2 months on I realise that although newer & less thread-bear items would be nicer, patients care is not materially affected by them as they are carefully, regularly and well cleaned  The stationary supply was also in chaos with a shortage of the items we use on all women and massive overstocking of items we use rarely (I can only conclude that someone enjoys photocopying). I was able to take 300 proformas for observation of women undergoing induction of labour to the Maternity Worldwide storeroom on the basis that we have induced no more than 10 women since I arrived at the hospital (5 years stock in circulation seems excessive).

So at the end of our efforts the delivery room is much more orderly with everything in an appropriate place- of course it now remains to be seen how long it will stay this way!

I was about to go for lunch when our first labouring woman of the day arrived. As is so often the case she had travelled from far and had been in labour since the previous evening. This was surprising (and immediately worrying) as it was her 6^th baby- with her five previous children having been born normally at home.  The baby was alive with a normal heart-beat (as ever against the odds) and on feeling her abdomen it was unusually difficult to tell which way around the baby was, so I immediately assessed her internally and for a moment thought that she had a breech (bottom first) baby in advanced labour. However it didn't feel quite right and I realised that it was not a foot but a hand and not buttocks but the shoulder of the baby that I could feel. I hope that even the non-medical readers will be able to appreciate that a baby trying to exit shoulder first is not good- it being technically impossible & possibly causing the uterus to rupture as the labour is obstructed but the contractions remain very strong trying to overcome the obstruction (a bit like squeezing a toothpaste tube hard with the top on). We moved quickly to do deliver the baby by a caesarean section- this proved to be one of the more difficult caesarean deliveries I have ever done as the baby was sort of folded in half (head and feet up and the arm & shoulder down- not a very comfortable position even for a flexible fetus) making it very difficult to effectively unfold in order to allow delivery through the incision. Anyway I managed to deliver a live girl with a bit of a struggle (happy to explain to the details at a future date to the initiated or interested), resuscitated her as she was very floppy at birth (not sure if I've mentioned that if the baby needs more help than the midwife is able to give I have to leave the operation mid-way and resuscitate the baby, returning to the mother when the baby is stable) and returned to the mother repairing a bigger uterine incision than is usual for a caesarean section but thankfully without further complication or excessive bleeding.

I hadn't really had chance to look at the baby in closely during the resuscitation as I was keen to get back to her mother as quickly as possible but immediately after I finished the operation the midwife asked me to look at her again. She had a hugely swollen arm (easy to explain as that had been the front bit that was being pushed down the birth canal) and swollen legs and one side of her face (less easy to explain but I think the result of being folded and squeezed for a number of hours). However these were not what was concerning the midwife- who had noticed a typical facial appearance. I examined her and agreed that she has features strongly suggestive of Down's syndrome. Thankfully her heart appears to be normal, she also rapidly established breastfeeding suggesting she doesn't have any of the bowel abnormalities and the initial floppiness (which can be a feature of Down's syndrome) seems not to be very severe. I was worried about the future for a child with such a significant handicap in an environment where even normal children seem to struggle to survive.

On the ward round next morning I asked the midwife if anyone had explained to the mother that I thought that her baby has Down's syndrome (no blood tests available to confirm here- so clinical suspicions have to be acted on). The midwife shrugged and said what did I want to tell her as there is no Oromifa word for Down's (not absolutely sure even the midwife knew what we were talking about although there is a Down's syndrome orphan in Gimbi town). In the end we agreed she would tell her that this child would be different to her other children, that would require everyone in the family to encourage her by playing with her and helping her to learn to walk and talk. The mother accepted this without question and it made me realise that I must not to make assumptions based on my views of the world as a citizen of a developed country: in a society where few people can read or write, where the majority of people will do manual work and the extended family is very strong- being born with Down's syndrome is not the same handicap as is in the UK.

I won't be switching to General Practice in the foreseeable future......................

February 25^th

Back from my clinic trip to Muggi and am now able to appreciate what a thriving metropolis Gimbi is by comparison. Also enjoying the feeling of knowing what I am doing in clinic and of having what now feels like a large diagnostic and therapeutic armamentarium in the hospital compared to a remote clinic.

Muggi is a very small town about 40km (as the crow flies much longer by road) from the border with Sudan and about 120km from Gimbi. Unfortunately only the first 15km are asphalt road and the rest is "gravel" so the journey there takes 5 hours. The countryside on the way is stunningly beautiful with rolling hillsides, traditional thatched circular hut villages (& one refugee tarpaulin camp with migrants from Sudan) and a lot of vegetation as it is at a slightly lower altitude than Gimbi. The lower elevation also means that this is the heart of coffee growing country and the clinic was held shortly after coffee harvest meaning that the local population were feeling relatively affluent and hence potentially keen to see to lingering health needs. The nearest large town to Muggi is called Dembi Dollo and this has a small government hospital but this is still an hours drive away. There is a very large town called Gambella about three hours drive further along the road towards the Sudanese border (which is not technically open fro crossing). Gamebella & the immediate surrounding area is the only part of Ethiopia that was a protectorate of anyone, as the British managed to make a stand there. This was because there is river access in the wet season that allows boats to pass all the way through to the Mediterranean and thus it was important for coffee supply (information courtesy of my knowledgeable husband). The boats ceased going some time ago and there is now a National Park in the area unfortunately if you look at the Foreign Office website Gambella is also the only area in Ethiopia with an advisory notice not to travel there so I was happy to stay three hours away.

Muggi is one of 6 out-reach clinics that the Adventist hospital runs- each clinic has a small staff (2 nurses, a guard/caretaker, a lab technician and a cleaner). This allows local people who live very far from a hospital to have some access to basic healthcare as the clinics carry basic drugs (for example painkillers, antibiotics, TB & malaria treatment). As there are limits to the things that the nurses feel able to manage, the hospital tries to send doctors out to the clinics every few months with the trips advertised in advance so that the patients can attend for review if the wish. Unfortunately it is often difficult to find doctors to go as they are needed at the hospital so on this trip it was myself (theoretically advertised in advance as someone coming to see obstetric and gynaecology patients) and Daisy who is a very competent final year medical student from Edinburgh doing an elective in Gimbi. Daisy had an advantage over me in that she has had the opportunity to spend some time in the medical outpatients at the hospital and so knows how to manage some of the common problems found in Gimbi and the surrounding areas.

In spite of the "advertising" there were few obstetric and gynaecology patients came to clinic over the two days. This was a great disappointment to me as there must be lots of pregnant women in Muggi and the surrounding area (people travelled from significant distances to the clinic) and it seems unlikely that they are all well, low risk and experiencing no pregnancy complications! As one of the important strategies in reducing maternal mortality is to try to identify risk and recommend delivery in hospital (this would have been Dembi Dollo Government hospital rather than Gimbi) I had hoped in some small way to help- but it was not to be the case on this occasion. Instead I became a "bush" GP- I'm afraid I wimped out and declined to see men (22years of specialisation means that there are some things that are just too foreign to me now and the first man I was offered had "swollen testicle"- "to Daisy " was my response.), so I saw all the women (and children although there were remarkably few of these) and Daisy did a male clinic.  Goitre (swelling of the thyroid) gland is endemic in the area due to the lack of iodine in the soil and about a third of consultations were for this problem. The remainder were a mixture of joint pains, abdominal symptoms and the occasional lump and bump. I sat with my Oxford textbook of Tropical medicine to hand but no one seemed to have TB and although I requested a few blood films for malaria all were negative. I will always wonder if I missed some other rare and fascinating tropical disease but if I did the presentation was subtle.

One good point is that the women here & especially in Muggi (it would be different in Addis) never smoke or drink. However the bad point is that many of the problems I saw are largely intractable as they are related to poor nutrition (constipation due to poor fibre, headaches due to the lack of fluid) and to the field work that women do here carrying heavy loads from dawn until dusk resulting in knee & back pain. This can also create difficulties as there is a great desire for investigations and prescriptions amongst the patients regardless of their problem and the administration of basic "life-style" advice can leave them dissatisfied with their clinic visit.  One consultation exemplified this well- a 17year old came in and declared that she has swollen and painful feet. In order to examine her feet, I asked that she remove her shoes (in Ethiopia the majority of people do wear shoes usually made of single piece of moulded plastic, rather than flip-flops or going barefoot as is the case in many other poor countries). As she struggled to remove her shoes it was clear that they were not only about three sizes too small (perfect imprint of the shoe remained on her foot after removal) but they were also ridiculously pointed (like the ones I wear albeit in the correct size for reasons of female vanity for brief periods when I will not be required to walk far) and although slim she had broad feet. I naively asked whether she had other shoes fully knowing the answer without a real need for a response. I gently explained that her problems were because she had outgrown her shoes and that these were an unsuitable shape for her feet.  This was translated was followed by an exchange of some length between her and the interpreter. Eventually I interrupted & enquired as to the nature of the conversation and was told, "she wanted me to prescribe something to cure her tight shoes". I tried to point out that the cost of any prescription (if I were to have an Alice in Wonderland "drink-me" solution to shrink her growing feet) would be more than the cost of going to the market and purchasing new, bigger and broader shoes.

We stayed in a small hotel opposite the clinic which was basic (and this is not English understatement) but then it only cost 20burr (£1) for the room that I shared with Daisy so it would seem unreasonable to expect more than a double bed, relative cleanliness (no roaches seen) and a plastic wash bowl with water from a canister in the communal wash cubicle (the toilet is best left without description but suffice to say I have used worse in French railway stations). Any way it was sufficient to clean up after the journey (very dusty) and for a good nights rest (braying donkey and 5am prayer call aside). We had brought sleeping bags and didn't inspect the sheets too closely but it seems unlikely the room rate included regular laundry. The room also had a bare electric light bulb and a candle but we made more use of the latter as there was only electricity for 3 hours of our 48hours in Muggi- some towns are not more atmospheric by candle light. Anyway the fact that I survived my two nights in this hotel should stop Illona (our travel agent at Steppes Travel who is arranging our trip at the end of my time in Gimbi) worrying about whether we are tough enough to cope with the two star hotels we will be staying in for some of the trip.

We returned to Gimbi (along the same beautiful but bumpy road) slightly earlier than originally planned as the initial torrent of patients dried up by lunchtime on the second day and the symptoms were becoming less serious (if you have a genuine problem you come as soon as possible on the first day) and also more bizarre (my interpreter declined to translate to me when amongst an array of other symptoms one women said "she believed that she was being nibbled by cats" suggesting instead that I might break my non-prescribing rule just to get her out of the clinic room). In total I saw 64 patient- the four O&G cases I was well qualified to deal with and thankfully on reflection I don't feel I missed anything serious or did anything too harmful to the other 60 who technically I am less qualified to deal with.

I always have had an enormous respect for GPs, as doing a good job is stressful and difficult. So my experience in Muggi has consolidated this opinion and made me absolutely certain that I made the right career choice!

Feeling a welcome guest..................

February 21^st

A short interval from my last blog but making up for lost time last week and also for the fact that my next posting after today will be on Friday at the earliest as tomorrow I am going off to a distant outside clinic to spend three days returning on Thursday evening. Not exactly sure what I will be doing in this clinic but I am sure it will be interesting as I seem to be the only doctor going so I will be packing my tropical medicine book!

I suspect that Gimbi is going to feel like a massive metropolis compared to where I will be for the next few days but in fact it is far from that: the town is rather like those that exist in Western (i.e. cowboy) movies with everything revolving around the single road through the centre of the town. Gimbi begins slowly with increasing signs of habitation from the sign that says "Gimbi' on the road from Addis and gradually peters out at some unmarked point on the road towards Assossa and the Sudanese border (as Ethiopian road markings do not stretch to signage for the end of a town). The road through town is tarmacked (an improvement courtesy of the Chinese in the last two years) and there is a pavement of sorts on either side- I say of sorts as it is made of concrete blocks that like many things in Ethiopia probably had another life before becoming the pavement in Gimbi as the blocks have a metal ring embedded making them a little hazardous to walk along especially in darkness (there is only limited lighting in the evenings). As a result most people choose to walk in the road in spite of the hazard that through traffic doesn't slow much as it passes through town and the minibuses may pull into the edge as any time expecting the paedestrians to move rapidly out of their way. There is some unspoken rule that there is a "one-way" system so that you walk into town on one side of the road and back from town on the other side. This means that you need to be organised as shopping around for an item can increase the hazard by requiring more crossing of the road multiple times so in general the shops on the side of the road on the out-bound trip tend to do better business from me than the shops on the other return side but I assume it all works out as there must be people coming from the other end of town in the opposite direction.

The road from the hospital (we are at the Assossa end of town just off the main road) to the market is a distance of about a mile,  it does take 20-30minutes to walk there due to the need to detour around cows, sheep, goats and groups of people who gather along the roadside to pass the time of day. The market is not like the one of your imagination as it is all at ground level with everyone laying out their produce on mats, this in itself creates problems as it is not an entirely satisfactory solution to selling given the free range goats and it requires constant vigilance on the part of the seller not to lose a proportion of their stock to these wily & persistent animals.  Remarkably the mats seem to be laid out in the same places from one day to the next so that there must be some rules about ownership of a particular pitch. This is useful as it means you can have a reasonable idea of where to find the things you are looking for. There are also a number of shops described as "supermarkets" but this is nothing like what we mean by a supermarket and simply describes a small shop in the ground floor of a building that opens onto the street (in a stall like fashion) selling dry goods, all these supermarkets sell similar things and there is no price differential so everyone tends to find their favourite places and stick with them.

Going into town is an experience designed to remind you (in case you had forgotten) that you are different to everyone else around: Calls of "faringe,faringe"or "you , you" abound from adults and children alike as you walk along, more unusually "china, china" is also called out (foreigners all looking the same and Chinese road builder's having been here in large numbers in the recent past). However these calls are always made in a friendly way (albeit it can get slightly wearing) and the wonderful smiles you receive from everyone make this very clear that you are a always a welcome guest in their town.

Sorry about the inability to accept comments on my blog

Just a quick note and an apology for any of you have tried to post comments but failed. Unfortunately I am unable to access my blog directly online as the Ethiopian filters block all blogspot sites- thankfully I have a way of email my postings to the site but this doesn't allow me to review the comments you try to post and the site will only accept them if I accept them first (to stop malicious comments I assume).

 

Email is better than I ever expected (although requiring perseverance and patience) so always delighted to receive a message to lkpenna@aol.com if you want to comment on something.

Always remember to look at the bigger picture.................

February 20^th

I travelled back to Gimbi on Wednesday, thankfully having a safe and uneventful trip (only two accidents observed on the roadside this time!). The second half of my trip is going to be different to the first half as I now have a housemate (Marie who is the midwife from Denmark) as well as sharing the on-call with Steve (American ObGy who is here from Australia where he now lives). It has made me realise that I had settled into a slightly solitary existence with a lot of time spent writing journal, blog and emails as well as reading. Currently Camilla & Sycret (journalists) are also staying in the Maternity Worldwide bungalows (sharing with Steve) so meals in particular have become a sociable affair compared to my previous meals for one. Another change is that there are now people who are keen to accompany me into town for a beer  after work so this aspect of my detox diet is going to be much less severe in this half of the trip.

So back to business- I was on call yesterday and had my busiest and also saddest night on duty since I arrived. I think that I finally realised yesterday that although the obstetrics in many ways appears the same as in the UK, in fact we are playing by a completely different set of rules (and unfortunately sometimes it feels like they have forgotten to give me a copy of the new rule book).

I know that it was inevitable that it would happen eventually but yesterday we had our first maternal death since I have been here- the inevitability has done nothing to make the sense of helplessness any less. When I arrive here one of the other "fairnge" said to me to remember not to take it personally as "people die very easily here", perhaps true and good advice but when it happens still not easy to heed.

The mother was 18 years old and in her first pregnancy. The case is a double tragedy as although the baby is currently alive, he too will die in the next few days as he has suffered severe brain damage due to lack of oxygen during his birth. The mother was from one of the tribal villages some distance from the hospital and she laboured at home for many hours before going to a local clinic for help. There are a number of peripheral clinics that are administered and staffed by the hospital but there are no doctors (or midwives) in these remote locations and the nurses who work there have to do the best that they can to help given their limited experience and resources.  At the clinic they had tried unsuccessfully to help the baby deliver using suction equipment (something used more commonly than forceps as it is much safer for the mother) and so transferred her to Gimbi for further management.  The transfer took a few more hours, amazingly the baby was still alive when she arrived and so she was assessed and delivered by a caesarean section (all this occurred whilst I was in Addis). The caesarean all seemed uncomplicated (although this sort of caesarean is always difficult as the baby's head is very deep and impacted in the pelvis) and the baby resuscitated easily.  The next day it was clear from the baby's posture/behaviour that he had severe brain damage with the result that he was unable to swallow at all. This was "discussed" with the parents and the plan made was to allow the natural course of events to occur and not to give the baby tube feeding (directly into his stomach) which overall would just prolong the inevitable. All this was all tragic enough when the mother, who had seemed well on that first morning became severely unwell and deteriorated at an alarming rate- all her clinical signs suggested that she had a severe infection. We managed her overnight with the strongest antibiotics that we have here but by the next day she was critically ill and Tekle (local obstetrician) made the decision that we must operate on her again to see if we could find the cause of her infection. The expectation had been that we would find some problem related to her bowel but at operation we found that her uterus was the cause of the infection, as for reasons impossible to explain it had become ischaemic (this means the blood supply was cut off to it and as a result the tissues die). A rapid hysterectomy was performed and we continued with the antibiotics, fluids, blood transfusion (donated by "faringes" as no family were available due to the distance), oxygen and the basic monitoring that we can do here. In the West she would have been immediately admitted to a high-level intensive care unit, kept ventilated, received high tech monitoring and multiple drugs to stabilise her heart, kidney and lung function not to mention specialist transfusions to keep her blood count and clotting as normal as possible.

She was young and her body fought hard to try to recover although she never regained consciousness.  Sadly by 11pm she was showing signs that her lungs were failing and also that her blood was no longer clotting properly, forcing me to accept that there was no more that I could do and that it was only a matter of time until she died. She was restless and possibly in pain so I gave her a  very small dose of painkiller, avoiding a larger more effective dose as I was obviously not completely accepting what was going to happen didn't want to depress her breathing any further.

Bizarrely although she died in the early hours of the morning, this is so much accepted as a "normal" event here that the midwives didn't call me to see her again or even to certify her death (a legal requirement in the UK). In the UK all deaths of women who are pregnant or have been pregnant in the last 12-months have to be reported (in addition to the normal death registration) there is no such system in Ethiopia -death recording happens within the hospital but no other notification is required. Sorry for the sad detail but this is a partially cathartic exercise for me!

On the face of it not a very uplifting blog but I have to remember the bigger picture: although I keep thinking that we should have been able to do more for this particular woman, I push these feelings away by reminding myself that before the arrival of Maternity Worldwide in Gimbi the maternal mortality rate was 6% (now about 1%)- this would have meant 12 deaths in the time period I have been here so that however inadequate it may feel, something we do is saving lives.

I apologise for this entirely necessary weekend of self indulgence.......

February 15^th

So the weekend that I seem to have been waiting for ever since I arrived in Ethiopia has been and gone in a flash.

Thankfully my journey back to Addis was uneventful although longer (11-hours) as the four-wheel drive vehicle is still under repair having had a close encounter with an ox some weeks ago (new part are slow to arrive and body-work repair takes forever I am told) so a different driver with a sturdy but slow mini-bus was enlisted to deliver me to my destination. Doing the journey as the only passenger in a minibus created a new feeling of guilt about being well off in a very poor country as almost all minibuses on the road are a stopping bus/taxi service and are overflowing with people and cargo. In spite of the fact that the bus was a different colour to the usual stopping services (all taxis and buses are painted blue and white which I assume must be some sort of regulation as it is so strictly adhered to in Addis, Gimbi and all the places in between), people constantly ran to the roadside and tried to flag us down throughout the journey and seemed disappointed that we didn't stop for them and their goats, fire wood bundles, numerous water canisters or whatever else they were transporting.

The second piece of transport good news was that Mark's flight on Air Ethiopia arrived on time rather than encountering some sort of delay for which the airline is notorious. Unfortunately the website I was tracking the flight arrival time on seems to have gone on past performance and so showed the flight as arriving 20 minutes late rather than the 30-minutes early that was the reality- this resulted in me not being there to meet him as he sped through immigration (multiple entry tourist visa obtained in advance), bank (he assumed incorrectly I would have money), baggage collection (terminal 5 could learn a thing or two from the baggage handling in Bole international airport which is very fast) and customs (he seems to have walked so fast no-one managed to stop him to try to interview him about the bit of obstetric equipment in his bag lucky as on questioning he would have been forced to reveal he had not the foggiest clue about purpose) and got from the gate to the arrivals area in 15minutes. Thankfully his initial grumpiness as documented in a series of "where are you?" texts (and an accusation that I appeared to be living on "Ethiopian" time schedules already) quickly disappeared once I arrived in person.

We had a great weekend, relaxing together, getting uncharacteristically rather sun-burned (never under-estimate the equatorial sun even when cloudy), swimming, eating good food, drinking goodish wines, pretending to do a bit of culture with one museum visit to see "Lucy", the replica skeleton of a 3million year old biped, lost-link ancestor found in Ethiopia and of course filling one another in on the events in both our lives over the last six weeks (there was plenty to tell on both sides describing very different life styles resulting in virtually non-stop talking for 2-days). The only problem of course was that like all much anticipated good things it all passed far too quickly. I have also enjoyed soaking in a bath (rather than my hand-held shower), having a massage, wearing clothes other than "scrubs" for a few days, having clean feet rather than red from the Gimbi dust, sleeping in a bed with a proper mattress & bedding and abandoning my detox diet for a few days with meat, red wine/G&Ts (definitely out of practice) and chocolate! Mark has also supplied me with a number of food special requests (like pesto, parmesan and mayonnaise) that should ensure I lose less weight in the second half of my trip that I have in the first six weeks.

So Mark flew back this morning  (brief return of home-sickness but I pulled myself together) and I have a couple more days in Addis before the journey to Gimbi on Wednesday in the company of Marie, a new midwife (arriving for a 9-month stay at the hospital) and two journalists  (arriving for a 1-2week stay)-all from Denmark where there is the another branch of Maternity Worldwide.

I expect to be back in the thick of it on Thursday and so will resume my blog with more interesting & charitable tales of others rather than the self-indulgence described in this posting!

A time for reflection (and a hug & a glass of red wine)................................

February 11^th

Tomorrow I will do the 10-hour journey again to Addis in order to be there on Saturday morning when Mark's flight arrives from London bringing us together for a short weekend (he returns first thing on Monday morning). This weekend was a distant beacon of light, to look forward to in the first week when I was so very homesick but as I settled in I have sped towards it very rapidly. It was chosen as it is not only Valentine's day on Sunday but also is the weekend where I am exactly half way through my "working time" in Ethiopia (our planned holiday at the end would make it less than half way but I see this as a separate chapter in my journey here).  Although I am sure I will continue to see new and challenging things and still have so much to learn about how to provide the best care with few resources, I thought that this would be a good time to reflect on my experiences over the last five weeks.

There are very many things that I have learned although these are rarely things that will be very useful to my clinical practice back home as the myriad of Health & Safety and infection control recommendation, not to mention risk management processes would take a dim view of many of the practices here.

Some of the things I have learned:

-       That the Ethiopian pelvis is tricky and so babies get stuck more commonly.

-       That the Epthiopian midwives despite relatively basic training manage amazingly well (although there are occasional short-falls in care that I feel are understandable though need work to try to avoid).

-       That you can manage obstetric problems effectively with a lot less resources than I would ever have believed possible (we only have a choice of five antibiotics here compared to dozens in the UK).

-       That fortunately I was well trained in gynaecology and so after 12-years I managed to drag the skills and knowledge out of storage and back into use.

-       That yet again I wish I had done neonates when I was training but that even a relatively old dog can learn new tricks when put through immersion/flooding therapy.

-       The importance of avoiding waste and considering a second life for many items that we usually throw away (more about this in a future blog).

-       That I never want to work anywhere with anything other than a state funded Healthcare system (a controversial statement I realise- but completely heart-felt).

-       How people appear happy in spite of adversity- often of the worst type I can imagine.

-       How easily a full term babies can get sick and die and how unlikely to survive even a slightly premature baby is (the first lottery we unknowingly enter with the winners fortunate enough to be born on a developed country)

-       On a personal level how easily you can adjust to having less comfort than you are used to without any detriment to real happiness (although this is not a hardship experience by any means).

-       That I can manage without a glass of wine at the end of a busy day (however reluctantly).

-       How well you can feel on a diet of vegetables, beans and pulses (but no epiphany here I'm afraid as I do miss meat and chocolate).

I am plan to continue my blog which more than anything I intended as a permanent memoire for me but I have been heartened by the messages from friends & family who are following it and finding it interesting. There is still so much to tell as I have written little about the wonderful people with their cheerful fortitude or of the complexities of the Oromifa & Amharic languages, or of Gimbi town itself and the surrounding countryside, of the pitfalls of an Ethiopian outpatient consultation (which I am still learning to avoid) or the terrible perinatal mortality rate and the response of local people to it- so I have plenty of things that I want to write down and that is before I write about any of the interesting cases I manage on a day to day basis.

The pargmatism that comes with being poor....................

February 8^th

Sometimes it is frustrating here as even though we can too our bit obstetrically, other resources are so limited that it is not enough to avoid tragic outcomes.

This week a young 18year old was admitted in labour. She was an amazingly beautiful woman from a tribal area about 3-hours drive from Gimbie. The people are ethnically distinct tall; slim with perfect erect posture and ebony skin. They practice skin scarification, which is not just on the face but also all over the chest and abdomen and was particularly beautiful in this woman (I am told that the practice is now disappearing as more "education" occurs in the tribes).

She had been in labour for 3-days and had travelled many hours to get here walking part of the way due to lack of transport. On arrival the baby was still alive and seemed to be in reasonable shape (compared to many). The baby did not feel particularly big but that is not particularly unusual as the narrow diameter of the pelvis (from back to front) that exists in women here means that there can be problem during birth even if a small baby is not in the ideal position. However when I examined this woman although the labour was obstructed and she was not fully dilated it felt different to other seemingly similar situations that I have managed here. Being a scan doctor when faced with anything seemingly unusual the natural response is to do a scan, which is what I did. The scan revealed that the baby had a lot of fluid on the brain (hydrocephalus) making the head so big that it would be impossible for the baby to deliver through any pelvis. Sadly I was also suspicious that the brain development might already have been affected. Sometimes operations are performed here when babies have died during the labour to decompress the head so that the mother can avoid the morbidity of a caesarean section and deliver vaginally. In this case this was not an option as the baby was alive and also the head was in a position that this sort of operation can be associated with a lot of maternal complications and therefore could not be performed.

I delivered her by caesarean section, which was still a struggle to get the very large head to deliver. The baby was born in good condition and at birth required no resuscitation.  It is definitely the worst case of hydrocephalus that I have ever seen. In the UK most cases like this would be found on the 20week scan and the majority of women would choose not to continue the pregnancy as the long-term prognosis for mental and physical handicap is very poor. Initially the baby handled well, she had a good suck reflex and so she breast fed well albeit she had classic textbook signs of severe hydrocephalus (an enlarged head & a sign called "sunset eyes" where the pressure of the fluid in the brain presses on the eye balls so that they are pushed downwards so that only upper half of the pupil is visible above the lower eye lid- hence the name of the sign) and a rather unusual high-pitched cry.

In the UK a brain scan would occur virtually immediately and then a special drain called a shunt would be inserted to relieve the pressure on the brain. There is no question of anything like that being done in Gimbie so any further treatment would have meant going to Addis but even this assumes that the family can afford to pay for treatment and that there is someone in Addis able to do the surgery. The family could not afford to pay but sometimes there are charitable funds to help with this sort of treatment available but unfortunately it all proved theoretical, as when he phoned around we could not find the details of a neurosurgeon able to undertake the surgery anyway.

In the meantime the tragedy-unfolded further: the woman is unmarried and the pregnancy was the result of a rape by a distant family member, this had been reported to the police (although I am told successful prosecutions are rare). By the 3^rd day of life the condition of the baby deteriorated significantly- she developed a high temperature, her head was getting bigger, she developed very abnormal postures/tone and was irritable with movements suggesting she was fitting whenever she was touched. The prognosis even if we could find immediate treatment for her was clearly very poor. So the pragmatism that poverty seems to promote took over, such that the woman unprompted (supported by her parents) asked if she could take her baby home to await the natural course of events. There was never any question of us disagreeing with this suggestion, as we had nothing further we were able to do so that we too were waiting for same outcome. Thus it seemed a small positiveto allow them to go home to the privacy & dignity not available in a public ward.

It's hard to believe my hand-writing could look any worse................

February 5^th

Although the work in the labour ward is very rewarding, I have been looking for ways to add a more lasting value to maternity and the hospital in general. With this in mind I have agreed to teach a module to the 2^nd year students in the Gimbi hospital nursing school. I have to apologise that the module is known as the "OR module" rather than by its full title "Provision of pre, intra & post operative nursing care"- yet another Americanism but entirely understandable as the theatres here are known as the OR (Operating Room).

There are a number of nursing schools in Gimbi and unfortunately some of them work on the principle that if you pay a fee you should get a diploma with no emphasis/requirement that this process involves learning anything. This can result in a poor standard of nurses applying for positions in the hospital and it can be difficult to tell. A good from a bad diploma .I should also point out that the midwives I might have written about in previous blogs are not midwives in the way we think of midwives, but are nurses (usually the brightest and best) who through sponsorship by Maternity Worldwide have been able to do a short course on midwifery to give them more understanding of labour and delivery. Thus having a poor quality of nurses will result in problems finding the midwives of the future for Gimbi.

To try to circumvent this problem the hospital decided to set up it's own nursing school where a better quality of graduate could be guaranteed and through donations specifically for this purpose to Adventist International they are in the process of building a new brand new school although classes have been running for three years in older buildings. The fees charged for the hospital school are low compared to most schools and it is made clear to applicants and to the students at all stages that in order to graduate both attendance and performance are required.  The presence of a school also allows the hospital to sponsor people who come to work as practical workers (similar to what are called healthcare assistants in the UK) and are good at their job.

However I am told, there have been stormy times over the past two years with occasional small student rebellions over the high expectations of the school. The last one was over anatomy textbooks provided for each of them by a previous"faringe" lecturer that they were expected to read. It required the head of the hospital to explain to them the reasons for the school wanting them to have real knowledge and skills (the argument is strengthened by the fact that currently Ethiopia is producing a lot of nursing graduates and there are unlikely to be jobs for all of them). A refund was offered to students who wanted to leave. Three students chose to leave and all are known to have enrolled in the worst "diploma for cash" school (where 2-hour lessons last 15minutes) so all in all everyone is happy!

There is a requirement from the Ethiopian Government that the course is taught in English and they also set a detail curriculum (which at this school is followed properly). My module is sixteen 2-hour lessons which as this is not an area where I can "wing" it, require quite a lot of lesson prep but I am learning all sorts of things I probably should have known about such as infection control and other topics. Teaching the students here is very hard work. Their education to this point has been "Victorian- style" i.e. teacher stand by black-board and writes list, student memorises list and recounts with no requirement for understanding or any encouragement of any sort of creative thinking or problem solving. Unfortunately being a good nurse doesn't require list memorisation but the ability to problem solve and particularly to do this in a rapid way and also in the face of a rapidly evolving clinical deterioration. I am drawing on every resource from my "Teaching the teachers" courses to try to engage them, get them to interact and to engender thinking behaviour rather than rote learning. Add to this the very mixed ability in English and sometimes the problems can feel insurmountable but I am not one to be beaten and I take solace from the fact that although I am not sure how much is going in, they all in their different ways seem to be enjoying the classes (done 4 now) and the attendance is better than I would expect from students in the UK.

If I learn nothing else it will be an appreciation of my medical students in London who can be persuaded to think and actually object to having to rote learn. It has also reminded to me that bad handwriting looks even worse in cheap chalk on a blackboard.

Is there any option but to go along with it?........................

February 2^nd

So I am into my second month in Ethiopia (both in calendar terms and also this is day 29 of my trip). There are so many things to write about that it is always difficult to know where to start but I have decided that today I will write about the wards.

The wards are strictly single sex (well this is as far as patients go) which considering there are no curtains between the beds in the ward at all it would seem just as well. The men's ward is on one floor and the women's ward (where the women I look after are cared for is on the floor below next to the four bedded labour and delivery area). There are officially 29 beds but extra beds often supplement this number as the solution to capacity issues is very simple - they just bring more beds into the ward (if only addressing capacity were so simple in the UK!). The beds are very close together with barely enough space to get along side them to examine the patient especially at the times when extra beds have been brought in. The ward takes maternity, gynaecology, surgical and medical patients. This is an issue as the medical women may be having treatment for TB or other infectious diseases, which is a significant risk for a newborn baby. There are three bays and the nurses are strict about ensuring that the majority of mothers and babies are in the first bay and the majority of medical women are in the third bay with the second bay being the first place for surgical and gynaecology women, this creates some barrier but of course women and babies do go into bay 2 when it is busy.

The ward is full already but then visitors swell the numbers. further These people are entirely necessary as they provide care for their sick relative in helping them mobilise to the toilet, washing and feeding (the nurses do not expect to or have time to provide this sort of care and there are no Physios or OTs here). The relatives also go to the market and purchase food for the women (a very rudimentary ration is provided twice a day by the hospital which makes NHS portions look positively generous) and will also go to pharmacy to purchase drugs & IV fluids that are prescribed (if they are not a maternity patient with a voucher). The other issue for visitors is that home may be many hours away and although there are hotels in town the chances that they can afford a hotel and the hospital charges for their relative are slim. Thus the relatives are present all day and all night. Going to the ward after 10pm is a source of amusement to me as there will be at least two people but often three people in every bed with additional people sleeping on the floor and on the benches in the communal areas outside the ward. I should point out that there are no cots for babies and these sleep in bed with the mother as well as the other relatives. Fortunately as previously described Ethiopian people are lean or otherwise there might be more issues related to these sleeping arrangements (sadly we did have a healthy baby die in the night 2-weeks ago as the mother accidentally rolled on to it in her sleep).

There is a clean sheet and blanket provided for each bed on admission by the hospital (well most of the time-unfortunately there are significant issues of linen going "missing" in the laundry so that it is not uncommon to run out.) Due to the fact that these are donated from a variety of sources I am not sure I have ever seen two sheets or blankets the same yet (or a sheet without holes).  Add to this the fact that all the beds are different (many over 20years old but still with working back rests and raising mechanisms- they don't make them like that any more) and it does mean that the ward have that slightly disorganised appearance  reminiscent of the pretend- hospitals I used to create as a child, when the beds & covers for my doll patients were whatever I could get hold of.

The biggest issue on the ward that I still find difficult to deal with on a day-day basis is the lack of privacy for the women. At ward round times all the visitors are banished from the ward (and they obey unquestioningly) and the doors are locked but at any of the windows there will be a crowd of faces peering in. There are curtains but these are rudimentary and certainly do not stop every prying eye. On the ward round "intimate" examinations (I will leave to your imaginations as you know I look after obstetric and gynaecology patients) may be undertaken which the women seem to accept as entirely normal without any concern for who is watching. These sort of procedures also occur outside the ward rounds when the ward may be full of visitors and no one seems to think it inappropriate to carry on. The nurses have got used to the fact that other than in an emergency I will take the woman into one of the obstetric observation beds to be examined where there will be a maximum of one other woman (and no visitors) present during the procedure, however they clearly consider it rather eccentric and unnecessary.

I realise this lack of privacy and dignity all poses an ethical question about my being complicit in perpetuating this behaviour but given the ward environment there doesn't seem to be any option other than to go along with it . There is no doubt the women consent to be examined in this way never showing any hesitation but I suspect that they feel like me that there is no option that to go along with it and unlike me they do not know that anything else is possible.