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.