Friday, December 28, 2012

Decisions : Good and Bad

Spinning Cotton
The other day I saw tears rolling down the face of a woman sent from the Outpatients Department for me to review. For about three years she had been complaining of abnormal bleeding and nobody did anything other than change her from one form of contraception  to another and back again. I examined her! She had an advanced cancer and even in the West it would be regarded as incurable, but amenable to palliative radiotherapy, which would at the very least control the bleeding – but here? Well there is no radiotherapy in the Faleghewot Referral Hospital at Bahar Dar, and nobody knew if it was even available in Addis. We carefully explained to her the serious nature of her condition, though I didn’t say it was terminal, and said she must go to Bahar Dar for another opinion. That was when I saw the tears and realised I hadn’t ever seen anyone cry here before.
And then yesterday I saw tears again – these were on the face of a relative of a woman who needed an emergency life saving operation but didn’t want me to operate on her. The operation itself was going to be hazardous because  try as we might, we couldn’t get blood for her. One of her relatives did turn out to be a match, a wiry middle aged man, but he was excluded at the last step in the process because he weighed 46kg and the rule was that donors had to be at least 50kg.  I decided to get my own blood checked against hers, because being O Pos I was a potential donor as well. I have previously said I was happy to give my time and any skills and knowledge they could use, but not my blood. However I changed my mind on this occasion because the woman was in this predicament  largely as a result of decisions I had made. She had arrived two days before and appearaed to be in strong labour but was only half way through her pregnancy and the baby was already dead. We waited for it be born but after a few hours this had not happened and her labour pains went away. I waited till the next day, hoping they would return, but when they didn’t  we put her on a drip but still, after several hours nothing happened. She was at risk of developing serious infection, and bleeding problems as well so I used the only other option, a drug called Misprostol which makes the uterus contract. There was minimal response to the first dose so the next day, yesterday we put in a second dose. A few hours later her pains returned but not long after that she developed very severe pain and her abdomen seemed to swell up and become tense, her blood pressure dropped and her pulse jumped up to 130. I was phoned to see her urgently, and quickly concluded her uterus had ruptured and she was bleeding. . They asked if we  could transfer her to Bahar Dar – this would entail a potentially fatal delay of at least six hours but possibly provide her with better access to blood – however on enquiry, both Hospital Vehicles were “non functional”  . So she was trapped here . A large crowd of family members and nursing students and midwives were crowded round her bed trying to convince her and then her husband to have the surgery .
And at that moment a woman I had seen a couple of weeks before arrived in labour. Her four previous babies had all died at birth because of what sounded to me like a very small pelvis through which babies would only fit with great and obviously traumatic difficulty. My plan was that when she returned in labour, if the babies head was not in the pelvis she would need an immediate caesarean section. It wasn’t and she did.
So now we had two women requiring immediate surgery, but my thought was we have to do the one to save the mother before the one to save the baby! I asked the midwives to prepare the second patient and as the discussions continued with the first one, I went to get my blood tested against Emaways, and to my really awful disappointment, it was incompatible.
Back in Maternity the family finally agreed to let me operate, and with great trepidation my brave anaesthetist put her to sleep, telling me she may not survive the anaesthetic. The uterus had indeed ruptured and the dead foetus still in its amniotic sac, and the placenta had been expelled out of the side of it into a structure called the broad ligament which is ordinarily a thin fold of membrane but was now distended to football size with clots and the uterine contents. Its never easy operating here because the lighting is poor, the instruments are a grab bag of discards from western hospitals, there are language difficulties so when I ask for say a Clip I get scissors – which are invariably blunt – and this sort of surgery is really way outside the sort of thing I am used to doing -  difficult complex surgery such as this is the domain of experienced cancer surgeons – but to add to all that in the back of my mind was the other woman waiting in line for her caesarean. There was some troublesome bleeding, much of which in the West would probably be quickly dealt with by electro-cautery – but without that, each bleeding vessel  has to be laboriously  tied with a stitch, and often, passing a needle through these delicate tissues other vessels are punctured and they too have to be tied off. At one point my anaesthetist, Amanu said “she is deteriorating” and at another her blood appeared to be losing its ability to clot by itself, a natural mechanism which if lost results in every bruised and damaged surface leaking blood, a phenomenon which is unstoppable without access to fresh blood.
Shadrach, Meschak and Abednego in the Fiery Furnace - and  a priest ringing a Bell for Donations.
I put a big wad of cotton packing over the raw edges from where I had by now removed the uterus and the right fallopian tube and ovary, applied pressure and just waited, watching the clock ticking and thinking about that woman in labour waiting for her caesarean. It was starting to look like Emaway wouldnt survive.  After five minutes we carefully removed the pack, and the bleeding seemed to have settled. We closed her abdomen and then waitied as she slowly started to wake up – when she took her first breath by herself we all felt tremendous relief. She was going to survive the operation at least – now it remains to be seen if her recovery will continue – today we will make further efforts to get her the blood she desperately needs.
And the other lady? We quickly cleaned up the theatre, brought her down and did the Caesar to deliver a gorgeous chubby little girl. Today they are both well.

Tuesday, December 25, 2012

Xmas Greetings from Ethiopia

The 2005 Xmas Mother and Baby
I had a really interesting day on Sunday. For a start, I wasn’t woken during the night, and when I went to the Ward Round there were plenty of people waiting to go, but no problems. So I went home and was reading my Kindle in the sun when Ibrahim turned up. Hes the young man from a poor but hard working family that lives over the fence from the hospital – he has a beautiful smile, and I mentioned him in a post last year when  he shared the bread I gave him with an even more poverty stricken old man, saying to me “He is poor person”. We chatted in the sun for a while – his English is poor but we manage – then he said he had to go and when I asked why he said “to take cows for water”. This sounded like fun so I asked if I could come with him, and of course he said yes. His family own half a dozen ox – one is a mother with a one year old calf, - plus a mule, and with the help of Ibrahims whip we moved them across a field of recently harvested teff to a waterhole half a mile away. Two small kids, a scruffy boy and girl followed, each carrying a rough basket on their backs – they were looking for animal dung and when we came across some, they  scraped it into a ball and added it to their basket.
Looking for dung for the home fire
On the way back a family of six girls went by, each with a large and heavy container of water on their backs – they had collected it from the river and were trudging barefoot back to their house in the village. Such hard work – but they were cheerful and friendly.
 Taking water home from the River
Later still I had coffee ceremony with Shewaye and her mother and two sisters, and a couple of neighbours who dropped in, and for a special I treat bought the two little ones an ice block, called Beredu, theyre sort of home made frozen cordial on a stick and cost about 1 cent each!
Tigiste ended up with two somehow.
From their place I continued on to the Sports ground to watch a game of soccer between the Hospital Team and the Team from the Health Centre. We lost four Nil. It was a wild game with a lot of what I would  call “smash and hope” with huge kicks of the ball which often headed for the moon, and not a great deal of passing and tactical running but it was entertaining. For most of the time I was there a small crowd of boys surrounded me staring, with the occasional brave one who would say “What is your name?” or ”What is the time” Every so often an adult passing by would wave a stick or shout at them and shoo them away but they would slowly creep back and encircle me again. They didn’t watch the game – they just stared at me!
The game started later than it had been supposed to, so half way through the second half when we were down 3 Nil I decided to head back to the hospital – and just as I got there I had an urgent call about a baby in distress needing help. We did a straightforward forceps and the baby was fine, so I came home and chopped up one of my pieces of chicken, fried it with onions, tomatoes and cabbage and some ginger, and ate it with boiled rice. Afterwards I had two lollies for desert.
Great kids! 

Monday, December 24, 2012

Communication Breakdown

Heading Home after the Market

I asked for it didn’t I ? – mentioning the “Q” word I mean. Shortly after that post was written I was reading my Kindle having a cup of tea sitting on my plastic chair in the sun at the back door when Zebiba appeared, somewhat breathlessly, saying they needed me in the Hopsital “Fastly come” she said. “Strange” I thought, “no one phoned me” and checking the phone I could see it was “On” and the signal was strong..
In the Hospital, a woman had arrived after a very long labour at home with her sixth baby, but it was still not born. These are the women who often die at home with a ruptured uterus, or arrive here barely alive with a ruptured uterus and dead baby, but this woman had neither – the baby was alive, and it didn’t appear her uterus was ruptured. However she was so dehydrated there was no urine in her bladder and because she had been in labour for such a long time she had developed an infection in the water around the unborn baby and was discharging the most foul smelling brew of pus, meconium and fluid I have ever encountered. As usual, being so very poor she was dressed in the filthy one piece dress, no underwear, and filthy from head to toe. She was very sick indeed.
Her baby was coming head first but facing the wrong way, and this was why it was stuck, and not deep in the pelvis either. I applied forceps – the baby needed to be delivered as soon as possible as rupture of the uterus could happen even now and seriously complicate matters for the mother. I pulled hard and nothing shifted. I puIlled even harder, then as hard as I possibly could – I knew I might fracture the babies skull but reasoned to myself that the baby was so sick it had little chance of survival anyway – and twice before when I have pulled as hard as I could and fractured the babys skull it came out and survived, apparently none the worse for wear, to my complete amazement. So I pulled again and found myself wishing the skull would fracture so I could get it out – but it didn’t, and I couldn’t. She would need a caesarean.
And then I found out why Zebiba had come to get me – the Mobile Phone network was “Non Functional”. Fortunately our anaesthetist lives in the Hospital Compound like I do and someone was sent to fetch him and the other two people we needed, while we rapidly prepared Zewedie for theatre. After an interminable 15 minutes waiting for the anaesthetist, word was received that he wasn’t at home and no-body knew where he was! Various people arrived and everyone was frantically checking their mobiles to see if the network was back on, but no. People started shouting and arguing about what to do, the hospital manager himself appeared, I noticed a hospital car and asked the manager if someone could drive to town and find  the anaesthetist – but the car was Non Functional also. Eventually one of the male midwives, Bawket, was sent off on a push bike and we stood around waiting while people carried on , gesticulating and shouting and walking back and forth in the walkway outside maternity. There was nothing to do but wait and I decided to just remain calm – we were doing all we could.
It got dark while all this was going on. And finally the anaesthetist arrived, and as I had made sure everything was ready, we started the Caesar not long after, perhaps an hour later than we would have if the phones had been working, a really long hour which I hoped would not result in things getting even worse that they really were. We had at least resuscitated the woman with fluids and started antibiotics.
The caesarean was straightforward, and we pulled out a very sick floppy, pale skinny baby that stank like you wouldn’t believe. Almost pure blood started to drain from Zewedies bladder indicating the severe trauma it had been receiving from that babys head sqashing up onto it for hours and hours. But – and I was going to write “remarkably” but I am slowly realising these amazingly tough woman are almost  indestructible – she and the baby appear to making a steady recovery, 48 hours later. The urine in the bag is yellow not blood stained, the baby has started sucking and feeding, there is no fever, so hopefully they will be going home in a few more days. To give the bladder a better chance of recovering completely from the trauma, I will leave the catheter where it is for a few more days yet – ordinarily it would be out by now.
So I wont mention the Q word again – on average about 20 babies are born every week – but there 7, including Zewdies that night, and a further 6 yesterday, so our little lull has ended with a strong gust.
And speaking of gusts, I have to thank my neice Tiffany – and probably rethink my attitude to social media and facebook – because she found the Vuda Point Facebook Page, asked someone on it about Sapphire and was told that the tarpaulin had been torn away as I expected but otherwise she appeared to be undamaged! How good is that! And my two emails have yet to receive a response –  email is just so last century!

Friday, December 21, 2012

Numbers Man

Its supposed to be bad luck to use the “Q” word when talking about work, but it has been surprisingly quiet so far. I am always interested in Statistics and Outcomes, so with time on my hands, I have been through the birth register and extracted all the information for this year up to a few days ago. The Birth register is a very wide flat book with 14 rows and innumerable columns on each page to record multiple details about each woman giving birth. Its not too dissimilar to the ones in use in Australia – though in some places there nowadays its all recorded electronically, depriving interested parties like myself of the opportunity to do mini audits and reviews, something I enjoyed doing and presenting to the Registrars at Royal Darwin Hospital. Audit and Review is an essential part of the continuous process called Clinical Governance whereby suboptimal outcomes can be identified, quantified and responded to with improvements for the future.
Unlike the Australian Birth registers, the Ethiopian one has columns for maternal death, stillbirth and neonatal death, and for the HIV status of the mother and baby, conditions which are so rare in the west they are not given separate columns. I’ve digressed somewhat – all I was going to report was that all year long there was never a page of 14 where all births were normal – until last week! A Tick in the NVD (Normal Vaginal Birth) column all the way down the page! Most pages of 14 had a Caesar and few instrumental deliveries, a stillbirth or neonatal death at least!
A typical Page from the Birth Register
Ive started to feel a bit redundant – in nearly three wweeks Ive done a coupple of caesars and a few forceps deliveries and not much else. To make me feel even less useful, twice last week when I went in for the round at 8.30 I was informed there had been a Breech birth overnight, and once, Twins! And no one felt the need to call me ! These midwives are remarkably confident and adept at most of these things- back in Australia its not uncommon for younger midwives and even trainee Obstetricians to have never seen, let alone conduct a breech birth! And if they did, it would always be under the direct supervision of someone “Senior”.
But then I should perhaps say, as I do to the midwives here, tongue in cheek, that this particular group of midwives have been wonderfully well trained - by me and Myrte last year, when they were students at Motta! None of the midwives who was here last year is still here - but four of the replacements are our former students. I must write to Myte and let her know that all her hard work was not in vain - I am continuously impressed at how good they are, and keep telling them and encouraging them to be proud of thier work!
When the stats are all in I shall post about them. It should make interesting reading.

Tuesday, December 18, 2012

Cyclone Evan

Cyclone Evan : Epicentre right on Vuda Point
As this amazing image of Cyclone Evan shows, it scored a direct hit on Vuda Point Marina, where Sapphire is currently stored in a trench. This unique storage method will hopefully have prevented her from being blown over, and she can’t take in water and sink or get ripped off a mooring and blown ashore or out to sea, which is the sort of thing that can happen to yachts at anchor or on ordinary moorings in a marina. However she may well sustain damage from rainwater getting in, or from trees or other debris falling onto her, and I don’t doubt that the tarpaulin cover I rigged  up before leaving will have been torn away, so I am a little worried to hear what has happened over there. Not that I will be able to do much about it from this distance.
Scouring the internet for news, I came across a video posted from Vuda Point. It was taken from the cockpit of a yacht in the marina, which is itself supposed to be cyclone protected – a relative term I guess – and it showed wild wind and rain, trees bending back and forth – I searched the background of the video for a glimpse of Sapphire but nothing much was visible through the heavy rain. Locals reported severe  flooding and houses being blown away at nearby Lautoka and Nadi, trees down everywhere, tourists from evacuated island resorts camped out in the airport, and wind gusts over 150mph. There was a photo of the Raymarine Wind instruments on someones yacht in the marina : 54 knots.
The Track of the Cyclone preddcited 2 days earlier
I tried to make use of “Social Media” – ie Facebook – and there were brief messages from people in various resorts in the area reporting flooding and trees down, and lots of requests for news about this place or that, but in many areas power is down, mobile phones aren’t working and roads are blocked.  I have emailed the Marina, but wont be surprised if I don’t hear anything for a day or two. They will be frantically busy cleaning up a huge mess I imagine – their lovely open air restaurant could easily have been blown away as its made mostly of tree branches, has a thatch roof and sits in an exposed position for a view of the Marina on one side and the ocean on the other.
Sapphires caretaker, that sweet old Indian guy called Bharros, doesn’t have a phone or email so Ive simply asked the Marina if they can pass on a message to him from me, and to give me some news when he can – for all I know his own place might have been wrecked so he may be preoccupied with more important things for a while anyway. I just hope his family and his house are OK. I can afford to live without my toys !

Monday, December 17, 2012

Tastes like chicken

Do-it-yourself KFC

Getaneh is the young man who brings me my water - he is not the same one who was here last time, because Moges has graduated from school and is apparently now at a University down south. Moges was a splendid guy, tremendously honest, always happy and hardworking, he lived in a concrete room about 12 feet square and slept on the floor beside a pile of school books. The guy who used to kill chickens for me has also gone from the hospital – he was also a charming guy but apparently he was trying to charm money out of the foreigners and was asked to move on. I’m told he failed his exams in Road Construction, so now he hangs around the coffee shops down town – believe me that sounds  a lot more glamourous than it really is – theyre nothing more than really dingy dusty run down little stalls with cracked cups and filthy chairs and a couple of wobbly tables. Whenever I pass he hails me and we have a chat, and he runs his latest scheme by me, tries to talk me into giving him some money, I pay for the coffees and  that’s it till next time. No hard feelings apparently. Actually I feel a little sorry for him because about 18 months ago a middle aged American photographer was in town working up a series on poverty or something for her Portfolio back home , and she seems to have become completely infatuated with this young guy – hes about 24. I know this because she has a Blog and she wrote the most adolescent sort of stuff on it about his dreamy eyes, and how her days lit up whenever he appeared, and how she longed to see him every morning – well she took her photos and headed home without him of course but made a big fuss on her blog about buying him a Gabi which is a traditional cloak sort of wrap everyone wears round here – they cost about 300 birr for a reasonable one –  less than 20 bucks! My poor pal read on her Blog her declaration that even though she was leaving Ethiopia she was taking him back to the USA in her heart. His  English is better than most but still poor, and the metaphor escaped him : when I met him several months later he was still waiting for her to send for him. He showed me the Blog to prove it was really going to happen – I tried to break it to him gently!
Chook Market
Anyway, the new water boy has almost no English but he still managed to get 100 birr off me the other day with some story about an exam he has to sit – I agreed to give it to him when he agreed – or so I thought – to kill a chicken and chop it up for me this weekend. So I duly went to the market with Shewaye, and got the chicken yesterday for 80 birr. Things got a bit busy in the hospital and there was no time to do it yesterday, and when I saw him wandering past late in the afternoon I called him into my flat and showed him the bird, legs tied, standing in the shower recess, and asked if he could do it in the morning “no , me fasting” he said, much to my disappointment – but then it was Sunday after all. “OK, Monday then” I said “Oh no, fasting to december 29” “So you cant do the chook till 29 december?”His face lit up “yes 29 december” “Good grief!What next” I thought!

Fasting here doesn’t mean the same thing as it does back home – there are various modes of fasting, all of which include eating food, but it mustn’t contain animal products – so no meat, eggs or milk, and for some they eat nothing at all during the day. After December 29 they can eat meat again!
So I lay awake long into the night steeling myself for the task I was now going to have to do myself – slaughter the chook that I was feeding and giving water to in my shower recess. I considered giving it away. Could I find someone else to kill it – but I had already paid Getaneh !!  And I was hungry and had been looking forward to some meat at last! It seemed like a massive problem, but it turned out to be a massive misunderstanding. He was just saying he couldn’t eat it – because he turned up in the morning all set for the kill!

Thursday, December 13, 2012

A Poor Woman

What a Cute kid !
Work has been quiet the last few days, but there have still been some memorable incidents. The first, late last week was in the midst of a busy afternoon of births that for the most part were progressing well - suddenly a great crowd of people appeared wheeling in a woman on a trolley who had been sent by ambulance from a village two hours away. She had given birth at home to her sixth baby at about 9am, had arrived at a village "Health Centre" four hours later with a retained placenta and bleeding, and there was given a drip and rushed to Motta, arriving some seven hours after she had given birth. Everyone was calling for me to quickly attend to her and I did - and the first thing I noticed was how cold she was. And then that the bleeding had stopped.And so had her breathing. And there was no pulse - her heart had stopped as well - she was dead! I found out later she was barely conscious when they put her in the ambulance.
Surprisingly, she was the first dead mother I had ever seen. The only woman that I looked after who died when I was here last time was taken from the hospital near death,at the families request and died at home from overwhelming sepsis. I had seen lots of women here I thought would surely die, or who were near death but in every case they were so tough that they didnt. But this poor woman exsanguinated while desperately trying to reach help, and expired in the back of a dusty 4WD. She was a typical poor country woman, filthy from head to toe, the standard ragged and filthy green dress with the zipper pocket across the front, very short hair with a black wrap tied around her head, and bare feet with thick cracked souls and  hard yellow nails. She was the archetype of the poor ethiopian woman, something like one in 12 of whom die, and most often in this exact way, from post partum bleeding after having had a large family. Probably her youngest is only two, but now all her children are motherless. I asked what would happen to the newborn baby - was there anybody who could breastfeed it? The answer it seemed was no, the idea of a relative feeding the baby seemed out of the question, and therefore to compound the tragedy, it would seem the newborn baby will die too. No one would be able to afford baby formula,and in any case even if they could its use usually results in fatal gastric infections because proper sterility is impossible in homes of mud that are warmed by fire.
So I filled in the paper work, declaring her Dead on Arrival. And then as I watched, the midwives prepared her dead body to be returned to her family. I wanted to take a photo but didnt - but it was interesting to watch as they firstly cut her dress off and then covered her face with a big wad of cotton wool. A long strip of ribbon gauze was then wrapped around her head to hold the cotton wool on, and then it was continued around her body to hold her arms folded across her chest, then down around her legs to keep them together and lastly, to keep her feet together, the two big toes were tied to each other.She was then wrapped in the blood stained shawl she came with and laid on the floor of the ambulance, which immediately left. They dont have death certficates here.
The other incident of interest was a scary moment for me when I thought a woman with twins was going to die when her anaesthetic went awry. She was scheduled for a Caesarean because  the first twin was a breech - coming bum first - and I wasnt intending to have a repeat of the ghastly situation that developed last year when I was here, when twins became locked and both died! No Thank you! After she was put to sleep it proved impossible to get the breathing tube down and she started to go blue. Fortunately we hadnt started the operation so we just ventilated her in a very simple way with a Bag and Mask and a basic airway until she started breathing for herself again. After she woke up and recovered, we sent her to Bahar Dar for the caesarean, as she was too high an anesthetic risk for Motta, but that couldnt have been anticipated until we tried to give her one.
Next time I shall think of something a bit lighter to write about.

Sunday, December 9, 2012

First Returning Thoughts

The Road down to the Hospital at Motta
I remember that when I left Motta after my first spell here, in January this year, I doubted there would be any lasting improvements in the way the Maternity unit was run – it seemed despite repeated attempts at instilling some basic principles of maternity care, nobody seemed to really get it. Since then the continuing series of volunteers coming here all seem to have reached similar conclusions as they came to the end of their time here, expressing the same frustrations and disappointments I did. In fact what I have found on my return, to my surprise, is that things have definitely improved: the rooms are cleaner, there is no actual mud on the floors any more, the stench from the toilets has disappeared, women are no longer lying on beds with filthy sheets  or even no sheets or blankets, Midwives are more often writing on the whiteboard and keeping it up to date, they are doing regular observations and updating the bedside charts, and, thanks to the husband of one of the midwives who came here from Australia there is running water to several taps in Maternity and the Operating Theatre.
I wouldn’t want to create the impression that things are all wonderful here now – far from it – in fact someone coming here for the first time would probably regard what goes on as appalling, and could hardly be worse – but if they had been here a year ago, they would realise that it has been worse and that now it is better, albeit not by much, but definitely better. The truth is that the cultural differences between us are so huge that bridging them will take a very long time. This I think is the lesson I learned last time.
Take medical records for example : much of our record keeping in the west is for “medico-legal” reasons, and we are almost obsessional about it – a midwife in Australia will usually note the exact time that she rings me to come and asses a labouring mother that she has concerns about, and record the exact moment that I get there as well – how has that got anything to do with managing the current problem? In fact it is recorded by the midwife to protect herself in the event that there is an adverse outcome and an investigation. Much of modern medicine is what we call “defensive” medicine – that is, we do things to protect ourselves from medicolegal consequences of adverse outcomes. It doesn’t  matter that an adverse outcome may have been unavoidable - if a lawyer can find a test or an observation or an investigation that could have been done but wasn’t, even if in the judgement of the clinician it wasn’t an appropriate test, or it  was so unlikely to affect the management that it seemed inappropriate to waste money on it, the clinician may then be found negligent. So we order all the possible tests without much reference to their appropriateness, and we do them again if they are slightly borderline, and document all this in the Medical Record.
My Op Notes from Caesarean Birth on Thursday night : note the Ethiopian Date should be 2005 not 2004!
Here in Ethiopia of course, there doesn’t appear to be any such thing as medico-legal concern – if a patient dies, the Doctor is presumed to have been doing his best and is praised for trying. This is a two edged sword of course – it means Doctors can be lazy and careless, they can fail to truly uphold the ethical standards of the medical profession and yet because nobody is any the wiser, continue to receive respect and be honored for the role they play in society. I am afraid I have witnessed this sort of behaviour here. The reality is that Doctors are people too, and subject to the same frailties, and the Legal profession plays an important role in maintaining standards in the west – but many of us feel sometimes it goes too far. In Ethiopia people more readily accept that “shit happens”  than they do in the West – perhaps because of their religious beliefs? In the west when something isn’t perfect  the tendency is to look for someone to blame.
In any case, getting back to medical records, though we obsess about them, my Ethiopian colleagues must wonder why – after all if the woman comes in and has a baby, why do we need to record at what time she arrived, at what time the baby was born exactly, exactly what the babies weight is, or how much blood the mother lost? Surely its enough to record she came and had her baby and went home?
There is more to it than that though – some of the information we collect in the west helps us manage a womans future pregnancies, it gives us information that when collected and audited can be used to improve and fine tune standards and outcomes that benefit all women . But here in Ethiopia we only have the resources for basic care – fine tuning is an unaffordable luxury for now. And in any case the filing system is so hopeless old notes are rarely found or of any use even if they are. Just today I saw a woman who had a stillborn baby when I was here last time – we did find her old notes but amongst the jumble of dusty paper I could find only one with my writing on it, and that was written on the day of her discharge from hospital – the preceeding page or two that would have had all my – yes, obsessional – notes were missing! 
So good note keeping is pointless if there isn’t a decent filing system, and pointless if no use is going to be made of all the information they contain, and not needed for any sort of medico-legal purpose either. So why do we hassle the midwives so much about doing it? The answer is because that’s what’s appropriate in the culture that WE come from. But what about THEIR culture?
For the time being, as far as note keeping is concerned I just would like them to get into the habit of writing something.  Its too big a jump to go from writing almost nothing to writing and recording almost everything!

Thursday, December 6, 2012

Getting to Motta

The Bus arriving in Motta
To get to Motta from Sydney I flew with Emirates  firstly to Dubai, a 14 hour flight which was rendered hellish by a shrieking toddler that didn’t sleep one minute the entire way. Its parents regularly lifted it up above the level of the seats so its whining penetrated the headsets of everyone tin the cabin and at one point a heavyset bloke not far from me yelled out something in a foreign language, no doubt expressing what everyone felt, that the damn kid would shut the hell up! The flight left Sydney in the evening so all we really wanted to do was sleep. However I did watch a great documentary about the life, music and tragic early death of Bob Marley.  We had a four hour stopover in Dubai, a place that just seems wrong to me – the ostentatious wealth, the massive skyscrapers in the desert, exploited foreign workers, women covered head to foot, those ghastly artificial islands crammed with luxury villas…..I never feel comfortable there.
And then four hours away is the Bole International Airport at Addis Ababa. There are wrecked and rusting planes and helicopters off the runway and the terminal itself is an almost empty shell of a building with a tiny Duty Free Kiosk selling cigarettes and not much else. Security and Customs are unsophisticated, so pretty soon I was dragging my one suitcase out the front door and along a rough concrete path to the Domestic Terminal, an even more worn out building where I tried to sleep on some plastic seats while waiting four more hours to catch my flight north to Bahar Dar. By the time I got there it was 8 pm local time, and dark. I had been travelling and had hardly any sleep for 36 hours. The Summerland Hotel courier van took me to the hotel and I slept well in a bed that sagged massively in the middle.
In the morning after breakfast of two fried egss coffee toast and jam I walked to a nearby Bank and got some Birr, then walked further along to meet Birhanu, the local co-ordinator for the BMF. These crowded streets area familiar to me now, the beggars in the dust, the people praying along the wall of the local church, the women wanting one Birr to weigh you, the shoe shine boys, the rubble of still unfinished building sites spilling onto the road… Birhanu took me for a tour of the BMF maternity service provided at one of the government run  Health Centres and showed me an overgrown courtyard surrounded by half fallen down buildings which are going to be removed and replaced by a new two story Maternity Ward, funded by donations to the BMF. I wouldn’t be surprised if there is a huge tangle of red tape and official obstacles to negotiate, and if they prove greater hurdles to clear then the fund raising.
I expected that next he would be bundling me into a mini van or a 4WD and sending me off down the rocky and winding 150km road to Motta, to there get a brief  “Handover” from Dr Rien  who would then return with the same vehicle to Bahar Dar. That’s whats happened in the past, so there is continuity of cover at Motta. However this time they had decided to do it in reverse – Dr Rien would come to meet me in Bahar Dar and then I would go back to Motta. It worried me that there would be half a day without cover but that was what had been decided – so be it.
Dr Rien and his wife and the midwife, Julie , arrived at lunch time so we met them at “Kariftu” which is an elegant and luxurious hotel on the edge of Lake Tana. They had all decided to splash out and stay there for a night – they deserved a special treat I am sure. We had a nice lunch and discussed what was  happening at Motta and then the driver arrived and I farewelled them all and we headed for Motta. Soon after we were bumping rolling and weaving our way round great clods of earth and rocks on a stretch of road that was undergoing repairs, when a loud peculiar scraping sound attracted our attention from the rear of the vehicle. The driver stopped and was outside poking round underneath for a while then returned saying we would have to return to Bahar Dar as the wheel bearing was damaged. I phoned Birhanu so he could arrange alternative transport but there was none available at this time of the day he said, and I would need to return to the Hotel and wait till the next day when hopefully the vehicle would be fixed. This stressed me out somewhat because now Motta wold be without cover for a day or more, and a day in Motta is long enough for a disaster or two, events I was meant to be there to help prevent.
We started back to Bahar Dar at about 5km an hour. A battered and overloaded bus approached, also bumping and weaving between the holes and the rocks – “Is it going to Motta?” I asked the driver – “Yes, Motta” he said “Shall you go on the Bus?”  “yes” I replied and he stopped and flagged it down. I scrambled aboard and squeezed into one of the seats near the front with two grubby poor women and a baby, my bag on the dusty floor , and off we went. I was relieved to be on my way albeit slowly and uncomfortably, but after a couple of hours one of the ladies got off and it wasn’t such a squeeze after that.
We arrived in Motta in the dark, about 7pm. Birhanu had already phoned ahead so someone who knew me was waiting when I got off – it was Shewaye the schoolgirl who had done washing and cleaning for me last time I was here. It was lovley to see her friendly smling face. I was tired and dusty and thirsty, so went into the Wubet Hotel nearby for a quick drink – we had just sat down  and I had a mouthful of beer when another familiar face appeared – Melesse, one of the Doctors, and after warm greetings and embraces  he told me there was a woman with an obstructed labour in the hospital, the midwives said she would need an emergency caesarean and they had sent a driver down to get me! So off we went, straight to Maternity where I asked someone to take my bags to the flat and I went in to see the woman whose baby was stuck. I was greeted  again with huge smiles and big hugs by Simagnew, the only midwife still there from when I was here a year ago, but we had to save catching up till later. When I examined the woman in labour there certainly were signs of obstruction, the skull bones of the baby so squeezed together they overrode one another like plates sliding one under the other to an extent one never sees in Australia – this is called moulding and is normal up to a point but this was extreme. However the head was well down the birth canal and I decided to try and deliver it with forceps rather than by caesarean section. The forceps went on OK and I moved the babies head around to a better position and then with about three almighty heaves dislodged it and brought him out in surprisingly good condition. Even the babies out here are tough! 
I was back. It felt good.

Wednesday, December 5, 2012

The Three Lucys

Lucy and the Concrete Croc
Ive stopped working for money again, after my fifth locum at the Royal Darwin Hospital. Once again it was challenging work made more interesting by the large indigenous population in the Northern Territory – they have a fascinating and ancient history, culture and languages, but as in many other places in the world, invasion by colonising powers has left many of them reeling and suffering at the bottom of the heap. I find Australian aborigines impenetrable – they often seem indifferent to the concerns we have for their health, and as hard as I try I don’t think I have ever managed to make any sort of emotional connection with a single one of them: they’re too absorbed in their own culture and family and world of dreaming to be bothered with me and mine. I think disinterest in much of western culture and values makes sense so I see in Australian aborigines a deeper wisdom at work, and I can’t help admiring them for it, but as I said, I really do find them impenetrable. The tragedy is how awfully western culture has degraded their proud traditions.
The Northern Territory is sometimes regarded as “Redneck” because theres a tradition of barramundi fishing, hunting and beer drinking, but theres more to it than that, quite apart from the indigenous art and culture. I went with a friend from work to a play about dementia and family secrets one night and on another we went to a stand-up Comedy performance by Australian Judith Lucy :according to one reviewer: ‘‘Lucy’s blend of venom and cheery condescension… is a joy to behold.’ A couple of years ago she went on a Spiritual Journey that was made into a funny but also insightful TV series, and she wrote a book about it called “Drink, Smoke, Pass Out”
Speaking of Lucy, my sister, another Lucy came to stay and ended up doing all the cooking and cleaning and washing for me. We went to Katherine for a week, 3 hours by car south from Darwin where there is a small regional hospital that needed Specialist back-up, and on another weekend, back in Darwin we did the Jumping crocodile cruise. We also visited Litchfield Park and had a swim at the Florence Falls. There were great markets to visit on the weekends and we went to the Museum and Art Gallery. It was very hot during the day and as the Dry Season was ending it started to become humid as well. 

And this is a rather weak seque I know but from Darwin I am returning to the home of another Lucy, the famous hominid discovered in Ethiopia that had a small brain but walked upright. These 3 million year old fossil bones are kept in the National Museum in Addis Ababa, but what you get to see in a pokey downstairs display case are replicas. I really had been looking forward to seeing the real thing. 
In my Sydney Hotel room, sorting out what to take to Ethiopia