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).