The Evil Eye

Dont mess with The Military Man

Its Wednesday today but I couldn’t head down to the Markets because the Telephone Network was once again “Non Functional” This meant I had to stay in my flat in the hospital compound so that someone could come and get me I should be needed in Maternity, but I wasn’t, so when it came back on again after lunch I took my backpack and headed to the market. I mostly wanted some more Bananas but was also after some tomatoes and another beetroot. However by the time I got there all the quality produce was gone and many of the stalls were vacant, a few goats and donkeys were snacking on leftover cabbage leaves and spilled grain, and I returned empty handed. Whenever I head into town, and on my way back I try to vary the trip by going down different cross streets and paths rather than take the direct route by the dusty main road. I can walk past the prison for example, where at each corner there is an elevated guard tower with an armed guard – you can see through the prison walls because they are upright stakes made from the thin trunks of the Australian gum trees which grow everywhere in Ethiopia – indeed everywhere in Africa I believe. There is a colourful circular orthodox Christian Church within the prison compound, and religious people – just about everyone here – stop as they are walking past, turn towards the church, cross themselves and mutter a few words before continuing on. The really religious ones go up to the gate and repeatedly kiss it as they continue to pray and bow and cross themselves. There is also a shop that sells things made by the prisoners. Another route takes me past a busy outdoor mule cart repair place. They’re usually really busy on market days with wheels or suspension on these rickety carts needing repair – lots of hammering and grinding with sparks flying, a bit of welding, all without the benefit of safety eyeware, and the placid mules usually still attached.

Your basic Mule Cart takes a beating on these roads.

Today coming back I walked past a place where often, especially if am walking alone, a man in a nearby house starts yelling non stop at the top of his voice from the moment he sees me to when I disappear from his view. Is he abusing me, trying to tell me something, just vocalising gibberish, needing help? He is speaking Amharic so I have no idea what hes saying but he doesn’t sound happy.  It took me a while to work out exactly where he was but in the shadows of the building I eventually identified a small window like opening quite high up with the head and unclothed  upper body of the man on his side  half protruding through. I was told he was once a successful local small businessman but he lost his business and went mad, and now he is chained up in there because he is too dangerous to let out. The people who told me this didn’t seem to regard that as unusual or cruel treatment!  There are several other mad people in the town, but not chained up. One is dressed like a soldier in khaki fatigues, worn and filthy, with a military looking cap and a rifle on his back – apparently its “non functional” !  Theres another mad person, a woman who usually comes right up to me talking about something and grabs my arm. I nod and smile and give her a friendly pat and say hello and then after a minute she lets go and hurries off. There are others that I run into as well but these three I see regularly. On another street I also regularly see an old man sitting on a pile of dirt and rubbish with possible personal belongings among them, begging for money with hands that have no fingers. His feet are similarly affected, presumably by Leprosy, and at other times I see a sad insane figure lying in the dust, not even begging, just lying like a donkey or goat would in the filth and dust of the road.

Discussing these people with some of the doctors  here I was asked if I believed in the Evil Eye. I learned  that amongst the general populace madness is not seen as a mental disorder but as a result of some sort of spell or demonic possession that is transmitted by the Evil Eye, a traditional rather than Christian or muslim belief. I couldn’t quite understand what the Evil Eye is exactly but there is clearly a widespread belief in a supernatural world of spirits and strange powers. It helps to explain the unusual response I got from Shewaye and some of her friends when I showed them a simple Magic Trick – making a coin disappear and finding it later inside Tigistes pocket! I am still not sure they realised it was just a “Trick” rather than something “Magic”. I think it frightened them a little that I could do that!

The last Day of 2012

Deep fried crispy packet with a few lentils inside: "Sambusa"



About now I think its next year in Sydney, but in Motta the hot sun has been shining brightly and its December 22^nd 2005.This is what happened.

For breakfast I had my first cup of coffee and the last of yesterdays bread roll with two small bananas, then after tidying up the room and the dishes went across to the Hospital at 8.30. at which time every day we do a round of all the patients. Sometimes there are surprises waiting for me – things that have happened overnight – but as I got there this morning, the midwives were struggling to deliver a baby with a vacuum device – I watched for a couple of minutes – it wasn’t coming so I delivered it with forceps, and we started the round a bit late. Today we sent Emaway to Bahar Dar for some blood –  her family had wanted to put her in the back of a bus and take her there yesterday but I wouldn’t let them, but today she is just well enough to travel. Her Haemoglobin concentration is 31g/L – normal for an adult woman is over 120, mine is probably 140, in Australia we usually give blood if its much under 70 and I don’t know if I ever saw someone there with such a low Haemoglobin. As I said before these women seem to be indestructible. .. We also sent Laku home with a catheter in place after confirming she does indeed have a fistula. We have spoken to the Fistula Hospital Service that operates out of Bahar Dar, a service that was started there by Andrew Browning, who then set up the Barbara May Foundation which is how I came to be here - they will see Laku after she has fully recovered from her caesarean. We also sent home the woman who had the caesarean straight after Emaways hysterectomy, reminding her that she must come to the hospital early in the next pregnancy so we can accurately plan a caesarean rather than wait for labour to start as we did this time. There was a bit of paperwork to do and then I bought my daily bread- 3 bread rolls for 10 cents each and the sambusa (pictured above) for 12 cents, and went to sit in the sun at my flat, read my Kindle and have a cup of tea.

Sooner or later I get called back for an Ultrasound scan – the first one today was for a woman who was said to have been treated for a molar pregnancy a couple of months ago but had returned with bleeding and her pregnancy test was still positive. There hadn’t ever been any actual tissue diagnosis – it is never available here - and the usual monitoring of this bizarre placental abnormality in which there isn’t usually a baby just placental tissue – involves blood tests that aren’t available here either. So we just have to make a clinical judgement, and on this occasion, because my ultrasound scan showed a persisting abnormality, I decided the best option for her would be a simple hysterectomy, which is in fact the treatment that was usual about 50 years ago in the west before chemotherapy. We explained all this to her and she left saying she will  discuss it with her family and return in a few days if they decide to go ahead with the operation. This is quite a common response to this sort of advice – usually they return but not always…

The other scans were ordinary pregnancy check ups, and when these were done I walked back along a newly forming path, a short cut across a recently harvested field of Teff, for my lunch, another bread roll, this time with tomatoes and slices of the beetroot I boiled yesterday, and another coffee. On my Kindle I am reading “Eureka: the Unfinished Revolution” by Peter Fitzsimons at the moment. It’s the story of a rebellion by Gold Miners –“Diggers” - in Victoria around 1855. I am not half way through yet but the story seems to be one that polarises Australians, some saying the rebellion was an honourable movement whose aims were democratic and libertarian, others that it was a mob of lawbreakers who needed to be brought into line. This happened just before the era of the Kelly Gang in another part of Victoria, and Ive just finished an “actual” book and a Kindle book on that subject, another one which divides Australians into Pro and Anti factions, which I found fascinating as well.

Typical dusty and rutted back street of Motta near the hospital

So I sat in the sun reading till called back for some more scans at about 2.30 and after that walked into town. It was a lovley calm sunny afternoon and a pleasant walk, but one gets a bit tired of being yelled at by every kid on the street “Hi” “Give Money” “Birr”” What is your name” ”What is the time” and I try to limit the number of traditional hand shakes I get from small filthy kids with snott running out of their noses!  Ive been here a month and was heading for the bank -  I’m obviously living it up, having spent almost $150 so far! They seem to have dispensed with that crazy counterfeit note detector they used on my US Bills last year, so the transaction was pretty quick. I crossed the road and got my haircut – I had been warned the price had gone up from 4Birr it cost a year ago – but 10 Birr was a shock – 60 cents! But they do a good job – one thing that surprised me was having my ears stuffed with cotton wool to stop hair going in! As usual a large crowd of kids stood round outside watching me getting this done, while beyond them standing almost motionless in the middle of the street was a sad old white horse, ribs visible and a sunken back, the tired old pony stood there as people and donkeys and even a couple of trucks passed on either side of him.

I walked home after getting some essential supplies – lollies, biscuits, a card to top up my internet useage-  and watched some news on BBC World Middle East – Syria, the Fiscal Cliff, Hilary Clntons clot – the usual stuff - then cooked my evening meal – rice with carrots onions tomatoes and cabbage.  And after posting this I shall hop into bed as it gets cold at night, and read a bit more about the rebellion.

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.

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! 

 

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!

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.

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 !