Saturday, December 28, 2013

A Fact for you

Each year human activity currently adds over 30 BILLION TONS of CO2 to the atmosphere.

Thats a staggering amount of anything to be loading into the skies - 30 billion tons!  And as the graph suggests the amount is increasing rapidly. I cannot understand how anyone could assert that 30 billion tons of CO2 couldn't possibly  affect anything, let alone the climate.

What we are struggling to realise in the west is that the Planet is not so vast, or human activity so insignificant that we couldnt destroy it.

Just something to think about.

Monday, December 23, 2013

Things to Look At

Sculpture by the Sea in Sydney

I am not sure if I should be apologizing for the lack of Posts over recent weeks. If I thought that what I was doing would be interesting for others to read about then I would write something, but mostly what I am doing is not, so I don’t. 

But I know what its like to have a few favourite web sites that you click on for updates every so often, and to be disappointed when nothings changed. I don’t like to disappoint visitors to this Blog too often so Ive decided to accept my responsibility as a Blogger to the loyal readers and post something a little more often – maybe once a week?

At present I am in Burnie, a small  city on the northern coast of Tasmania, and I will be here for a couple of months. The hospital is up a steep hill from the coast road and many of the rooms have a sea view, out across the notorious Bass Strait that separates this Island state from the Mainland, 125 miles to the north. Today theres a strong Northwesterly, probably 20 to 25 knots by the look of the whitecaps and the big seas out there.
Later in the week, further east, a fleet of maxis will be racing across the strait in the famous annual Sydney to Hobart yacht race. They leave Sydney Harbor on Boxing day and if the wind stays like this they could do it in record time.

I am doing my usual thing, Obstetrics and Gynaecology , in a modern fully equipped up to date hospital with every modern convenience and no expense spared. It gets boring at times because my role here is to supervise and advise the trainees who are desperate to do just about everything, so I get relegated to being the assistant. One consolation is that late at night, once the tricky part of emergency surgery has been done I can go home and leave them to finish off, and I don’t have to bother with any of the paperwork. 

Before coming here, I was in my favourite place once again, Darwin. It’s a four and a half hour flight from Sydney, and a 2 hour time difference. One thing I look forward to, on the journey there or back is having a window seat and looking down at the extraordinary patterns and colours of the vast Australian outback. At first glance it looks bleak and orange and empty but if you look much more carefully at it, you see wonderfully intricate patterns and subtle color changes and almost everywhere, remarkably, but far far apart, thin mostly straight lines of tracks roads and fences, a very occasional outstation with an airstrip, and the odd  dam with radiating spidery cattle tracks. Its hypnotizing beauty.

Monday, October 28, 2013

Back in

Sailing in the sand

Sapphire finally went back in the water on Friday afternoon. She had a nice new coat of paint and earlier in the day her name had been stuck on, and she looked very smart. The Radios all worked, the SailMail prescription was renewed and SailMail tested with a GRIB file download of the weather, the new wind instruments I ordered from Australia had arrived and been reattached to the masthead and were working, I had freed up the almost frozen throttle/gear change cable, replaced the batteries, replaced the wrecked sheet winch, had the sail repaired, the dodger cover completely restitched, reattached the Hydrovane with larger bolts and backing plates – the third time !– and all I had left to do was see if the motor would start. And it did – straight away!

I felt the boat sway a little in the water as the travel Lift slings were lowered away and she settled - I felt so relieved at being back on the water. In a few days we would be heading out of the marina at long last, more than a year since arriving…wonderful!

Just before engaging the engine, as always I peered over the stern to look for the exhaust discharging all the rusty water that had been in the motor all that time – and craned over even more when I saw nothing other than a little smoke… “odd” I thought and waited a little longer for something to appear  ….still nothing!

I turned off the motor and went to check the through-hull water intake valve hadn’t been turned off – it hadn’t. But water definitely wasn’t getting through - maybe a bird or wasps or something had made a nest in the intake and blocked it? I shouted up to “Mo” the crane driver  - I would need a tow to my appointed jetty, and then I would sort out the water problem.

So my first journey for the sailing season was a tow by a guy in a tinnie to the other side of the circular marina where I was squeezed in between “Captain Georges” a 45 foot owner-built aluminium monohull from France and “Moonshadow” a beautiful shiny blue 56 footer from London. After tying up with two lines fore and aft I went below to sort out the water problem.

What I soon discovered was that the bearing in the water pump was seized, so I took the  whole pump off the front of the engine and eventually got it turning again. The bearing felt rough and stiff and I guessed would have to be replaced sooner than later, but after  a while I had it turning quite freely, I reassembled the pump and turned the motor on again. And this time? Still no water!

I pulled it all apart again: no it was all ok – but then I looked into the hole that the impellor shaft slots into on the front of the engine – the “slot” looking back at me was broken – there was nothing for the pump shaft to engage into – it had tried to turn against the seized pump and broken itself when the pump refused to budge. And it looked to me that to get at that broken bit you would have to pull half the motor apart! That was Friday afternoon, late, and I had the whole weekend to imagine various ways in which even though it looked impossible to fix simply, there would be a way : maybe a sleeve could be fitted over the broken bit, or maybe a stud could be drilled into it and a new piece fitted over the top like a crown on a broken tooth. There would probably be a special tool that can fit in and pull it out without dismantling the whole engine; even if they did have to dismantle the engine it wouldn’t take long; there would be a simple alternative pump you could use instead; I tidied up the front of the motor to make it easier for them on Monday.

And this morning was Monday. The mechanic came and within 5 seconds he was shaking his head. The motor has to come out! Apparently the bit we are looking in at is the end of a cam shaft that operates all sorts of other timing things  back there inside the motor – if you could pull it out, all these other bits would drop out of position and it would be impossible to put it back….there was no other solution. And the parts might be hard to find….

So I closed the boat up and went for a drive and a coffee. My sailing season was over before it had even started. Bugger!
The Third Installation of the Hydrovane, and new sign writing

Thursday, October 24, 2013

Rugby? Yes, but I wont be mentioning the Yachting.

"Grog" = Kava; Very important in Fiji - but I prefer the Icecream
Working at the Hospital in Lautoka was fascinating, challenging and rewarding. In Fiji everyone is incredibly friendly and there is an openness and warmth thats inclusive, and welcoming. When you experince it at the airport or in your holiday resort you might be tempted to think they are making a special effort for Tourists, but no, everyone really is like that, everywhere you go. So I was working in a  very warm and supportive environment with hardworking and fun loving people. The clinical cases were interesting, and I was given the specific task of beginning to develop, support and strengthen the relationship between the Base hospital and the five peripheral subdivisional hospitals. This meant I got to travel about and visit them all, meet the staff, inspect the facilities, conduct training and teaching sessions there, and then provide feedback and make suggestions about where improvements could be made. I also assisted the Regsitrars prepare for their exams by going to their teaching sessions and helping with Mock Exams. This was all quite different to the clinical work I was used to doing, but I did plenty of that as well.

One evening at 8pm when I was on call we received an urgent call from the subdivisional hospital at Sigatoka. A woman had been brought in from a distant barely accessible inland village in shock. It was thought she had a ruptured ectopic pregnancy, a complication of early pregnancy feared for this very reason, that women can suddenly collapse with massive internal bleeding, and die.  She needed urgent surgery, but was too unstable to transfer to Base, and  unfortunately there was no surgeon in Sigatoka. Years ago these little hospitals were staffed by clever old fashioned General Practitioners who could  do that sort of emergency surgery as well as  appendixes and caesareans,  and a few other basic surgical things. Unfortunately however, after a couple of Military Coups there was a massive depletion of trained medical personnel, many of whom were Indo-Fijians  fearing the worst left for Australia and New Zealand. Health services everywhere but especially in the districts took a massive backward step as a result, and they are still trying to recover from it. But the little operating theatres in each hospital are still there, though hardly ever used. The local solution to this awful dilemma is to activate "The Flying Squad". We didn't actually Fly to Sigatoka, we drove, so I suppose it should be called The Driving Squad but that doesn't sound anywhere near as glamorous or exciting.

The Flying Squad  consists of a couple of Theatre nurses, an anaesthetist and a surgeon - in this case, me - who are rapidly assembled and speed off in an Ambulance with lights flashing and siren blaring, taking with them a full set of sterilised theater instruments to the hospital where the patient is. We were supposed to also take blood but I hadnt known then that the subdivisional hospitals have only two or three units and expect us to bring more. Fortunately someone asked me about it as we headed south, but instead of going back we radioed ahead to Nadi Hospital, called in there on the way through and picked up the extra units. It was quite a scary ride, because the road is poorly lit and narrow, cattle and horses are often seen wandering across it, not to mention people and dogs and goats, but we made good time, and maybe ten minutes after arrival we began the surgery, and gave her the extra blood. The ectopic was the worst kind - cornual - but wasnt hard to deal with. We brought her back to Lautoka, arriving at about 2am, and a couple of days later she went home. There have been three deaths from Ectopic pregnancy in this district in the  last year, and about 7000 births - by comparison, in Australia over the three years 2003-2005 there were nearly 750,000 births but only one death from ectopic pregnancy.
The Course Participants at Sigatoka Traing Sessions
Clearly Ectopic pregnancy seems to be a particular problem in Fiji, with a mortality over three hundred times what it is in Australia. Its related to tubal damage from sexually transmitted infections, which occur at very high rates here, but this is not the cause of the excess mortality. The cause relates to what the WHO calls "The Four Delays" - delays in recognising theres a problem, delays in deciding to do something, delays in reaching a healthcare facility, and delays in receiving the correct care.The Four Delays apply to all causes of maternal death. In Australia every woman of reproductive age - say 12 to 50 - who comes to an Emergency Room, gets a Pregnancy test, no matter what the reason for her being there is, and there are usually prominent notices reminding nurses and doctors to do them. The nett result is pregnancies get picked up earlier, ectopic pregnancies are recognised before they have ruptured, and simple laparoscopic surgery usually means they can be cured and go home the next day.

The problem for Fiji is firstly the lack of education about the danger signs - this leads to delays in recognition and in deciding to seek help. The remoteness of many fijian villages contributes to delays in reaching help, and sadly the medical profession here is not as vigilant as it ought to be, so there are additional delays in receiving the correct care. Pregnancy tests are often not done, and thats often because they are not available. The Health budget, indeed the economy generally is not robust enough to supply the thousands of pregnancy test kits that would be needed - so overseas charities have often provided them, but on an inconsistent basis. I suggested to the subdivisional hospitals that they buy a few from the local chemist and recover the cost of each one directly from the patient , but they told me that would contradict the policy of care being free - but will do it anyway! The retail cost is $3.95 but they could get them for a lot less if they bought in bulk from a supplier.

This scenario is repeated at every level throughout the health service in Fiji, and made me realise anew what a massively expensive undertaking it is to develop and maintain a modern health system. There are liquid soap dispensers above many sinks - but they are empty, and so are the paper towel dispensers. Many lab tests become unavailable once the budgeted supply of reagents has been used up,  the recommended tests for diabetes cant be done because the special glucose drinks have all been used up, CTG monitoring paper is in short supply so the midwives run it for ten minutes at a time instead of at least 20, many of the hospital buildings are in need of basic maintenance and in the operating theatre disposable caps and masks are in short supply. We did three laparoscopic cases and then they ran out of the special cleaning fluid for the instruments so couldnt do any more. There isnt the money to run a proper cervical cancer screening program, so I have seen more cervical cancer in six weeks here than I ever saw in all my working life in New Zealand and Australia.  If these women need radiotherapy, its not available in Fiji. No doubt similar budgetary constraints apply in paediatrics and general surgery and medicine.

Anyone coming here from a developed country would probably be shocked - but having worked in Ethiopia and South Sudan I see the glass here as half full, not half empty ( or too big as an engineer once said)  In South Sudan and Ethiopia  most of these tests are NEVER available,  you can't diagnose cervical cancer let alone treat it because there are hardly any doctors, there is NO pathology service, and most of these women would never get to hospital because there are so few roads and so few hospitals.

There is therefore much to admire in what has already been achieved in Fiji. The Doctors and med students and nurses are really hard working, eager to learn and on the lookout for any extra bit of help they can get, but there is still much to be done.
Watching Rugby - very popular here. 

Sunday, September 15, 2013

Sailing Anarchy

Raki Raki Hospital, Fiji

If the National Movement for the Liberation of Azawad (MNLA) had not fallen out with its Islamist supporters in The Movement for Oneness and Jihad in Western Africa (MOJWA) I would probably be sailing today. That’s because when they started fighting amongst themselves the Government of Mali decided to ask the French government to help them recapture the northern parts of Mali that these rebels had taken control of. As a result, my mission to neighbouring Nigeria with MSF in March was cancelled and I was reassigned to go to Aweil in June – but I had been planning to be back from Africa by May, put the boat back in the water and go sailing. Honestly, I wish these people would start thinking about how their plans might affect other people before they go rushing off and rebelling all the time!

But “life” is what happens to you while youre busy making other plans, right?

So here I am back in Fiji, an incredibly interesting year after sailing here from Tonga and putting Sapphire into a trench – where she remains!  Since arriving here I have been working at the hospital in Lautoka as a volunteer locum Obstetrician. I don’t get paid – officially – but my accommodation and car is paid for, and I get a daily allowance for living expenses. I am going to earn in six weeks what I would earn in three or four days in Australia – but I am not complaining – its another interesting challenge and in a beautiful place with lovely friendly people, pawpaw for breakfast, and my Yacht is just down the road!

I had been thinking I might repaint Sapphire because I had left her with some untidy gouges along the starboard side following a close encounter with a wharf in New Zealand and she was really looking worn and untidy. My plan was to work on her in the evenings after work and on the weekends but that quickly proved impossible, as evenings are very short here and I often work till late. I am on call and get tired at times and  Ive just finished a whole week on call. Instead I decided to get a local yacht painter to do it for me. I had a couple of quotes and decided to go with Rons as it was the cheapest – I didn’t need a Superyacht finish, just a basic tidy up along with antifouling before going back in.

So I took the hydrovane off the stern – again! – and some of the deck fittings, and left him to it.  He’s probably going to be finished this week. After that there will still be dozens of things to sort out before I can go sailing.
Covers off after undercoats
Meanwhile Ive ordered- and received from Whitworths marine in Australia - a box of parts I need, like the wind instruments off the top of the mast, a small sheet winch that I smashed on the way over from Tonga, some plastic vents that the harsh sun here destroys in no time…

I will have most of October and November to go sailing

Sunday, September 1, 2013

Out of Africa

TukTuk and Tree

The last few days in Aweil were hectic. Quite apart from having to find the time and energy to write a comprehensive report on my six week mission and a “handover” document, there were patients to look after, emergencies to cope with, heat and rain and mud to put up with, and the endless round of exclamations, regrets, questions and farewells from anyone and everyone who realized my mission was about to end -  How was it?, where are you going? When are you coming back? Already? On Wednesday night everyone gathered at dinner time and thanked me for my contribution and wished me a safe trip home in the morning. All the goodbyes were said and I became a person in limbo, killing time before the flight in the morning.
Maura, Thomas and Kristin : wonderful colleagues
Looking back, I realize there were so many incidents and events and dramas I could have written about during those six weeks, so many near death experiences, so many extraordinary  examples of extreme obstetrics, of extreme poverty and awful neglect, that one merged into another during the hectic day that by the end of it, food and rest and escape from the flood of urgent crises was all that was on my mind.

I tried to maintain a diary, to keep track of everything swirling around me, and heres a couple of days from it – they are quite typical days:

Saturday 6th July
Started with emergency Caesarean before breakfast for cord prolapse : All good
The ward round
The hand seems to be improving   ( a patient had a horribly infected hand)
The SABO is not improving  ( = Sub acute bowel obstruction)
      took her to Green World Health Centre for AXR confirmed SABO, then gave enema with large result – tomorrow if not improving for transfer to Gogriel where there is a surgeon
       Green World was interesting, a collection of tiny shacks labeled Wards, the Xray building another concrete shack, and Margaret a big sexy woman from east Sudan somewhere
Evacuation of Molar Pregnancy after ward round
A spontaneous vaginal breech in primigravida
An iufd at 25 weeks delivered after arm and synto (IUFD - Intra Uterine Fetal death)
NVD twins   (Normal Vaginal Delivery)
Diabetic almost sorted!

Sunday 7th July
Busy day though its supposed to be the day of rest:
The hand is improving
The cachexia is not – she is dying and I don’t know why – probably TB
The SABO is not and needs to go to Gogriel where there is a real surgeon but its very hard to make this happen – pt has to be accompanied by a family member prepared to donate blood and to accept that if she dies MSF will not be able to return her to Aweil this seems inhumane to me especially as this weekend we have an MSF Official flown here from new york for god knows what reason, and another director from Juba also here. Got NG tube passed and large volume of bile stained fluid aspirated

Two casears  – a face and an obstruction with ROP in  multi

Destructive Delivery  – IUFD primigravid LOT after 2 days in labour, putrid hot mec stained pus and liquor. Demonstrated technique to Paulino

Bloody footprints
But even though  42 days on call is quite enough for anyone, its also too short a time, because I realized it took most of that time to learn everyones name and to learn which people I could rely on, and who I could call for help and and what systems and processes were in place that I could use to get things done, what was possible, what was not. I realized I had learned enough to start to become really useful just as it was time to go. But now at the end, mentally unwound I became ready to go.

 I was watching the weather and woke early Thursday morning to the sound of rain. I went in to do a quick ward round at 7 am so I could be back to go the airport at 9 – the rain had stopped, the clouds were lifting, word came through that the flight was “ON” and saying a last farewell to the few people still in the compound at 9, I hopped into the Lancruiser and went to the Airstrip.
Aweil Departure Lounge
There was an hour to kill so I just stood about avoiding the puddles and waiting. The “Terminal” was an open sided shed with a soaking dirt floor and a few puddles. A tiny drizzle of rain appeared – there was also a tiny new patch of blue sky on the horizon – and then a guy with a walkie-talkie had a quick look at the sky and cancelled the flight – “too wet” he announced. I had heard they tended to cancel flights at the drop of a hat and this was certainly an over-reaction – I was stunned.

Half an hour later the sun had broken through but it was too late; the flight was cancelled and I was taken back to the compound. It was a strange afternoon, because I reappeared in the compound and then went back to work in the hospital to everyones surprise, but no-one wanted to go through all the goodbye process again – I was sort of ignored, I felt like a ghost that nobody could see, as we coped with another round of dramas and traumas, anaemias and bleeding and pain and birth. I was mentally unwound and in a different space but had to  wind back up again.
In case I needed some?

The Nile at Juba
The next morning we went through the same process but this time the plane arrived and we left on time for Juba, a day late leaving but too late for my connecting flight.  I would have arrived in Sydney on Saturday evening, but with that delay the next available flight got me to Sydney on Tuesday,  the day after the end of the five day annual Sydney Boat Show. This was something I had been thinking of as a kind of reward for all the hardship of Aweil, something I had been looking forward to attending for months and it took me a while to get over my  disappointment.

But I was back in Sydney, back in the Hotel that had hot showers, really soft pillows, airconditioning, and Room Service! But better than that was seeing  family and friends,both in Australia and New Zealand a week later. From there I flew to Fiji, back to the boat and another beginning!