Medical Mission in Ethiopia: Week 5

October 29, 2014
Tuesday October 22, 2014
We went hiking in the Simien Mountains this weekend.  Janis, the British anesthesiologist, arranged the all-inclusive trip and invited us along.  I was concerned that Josh and Sonja may not be able to keep up with the 5 adult hikers, but the trekking company “Explore Abyssinia” suggested that we hire 2 mules and the kids could ride when they wanted to, and hike when they felt like hiking.  This turned out to be a wonderful option. 

 
 
We drove up to the Simien Mountains in the trekking company’s van on Saturday.  Saturday is market day in the country.  The van swerved around goats, cows, cattle, sheep, horses, donkeys, mules and hundreds of people working their way to their closest village/town.  We saw very few vehicles, essentially public minibuses, some three wheeled taxis (Bajajes), and a few other tourist vans.  There are almost zero private cars on the road.  Everyone walks or runs everywhere.  There are also very few overweight people.  As we passed the animals and people, I noticed that the people carried just as much as the animals.  In fact, sometimes the horses or mules would not be carrying anything, but their owners would be laden with bags perched on their heads.  When we reached the center of town our speed slowed to a crawl as we navigated the sheep market, the goat market, the cattle market, the vegetable market, the bean and lentil market – all prominently displayed on the main road.  Fascinating.
 
 

 
We eventually reached Debark.  Debark is the gateway town to the Simien Mountains.  We stopped to register at the National Park headquarters and pick up our guide and scout.  The scout’s name was Adamse.  He is 50 years old, went to school through the 5th grade, grew up in the Simien Mountains, and has a face that has weathered into permanent smiling creases.  He carried the AK47.  Our guide had a four year degree from college in Tourism, and spoke English reasonably well.   Our cooks had joined us in Gondar.  After a 1 ½ hour bumpy and somewhat harrowing drive up the dirt road, we arrived at our starting point and lunch at a 3000 meter elevation.  The mule, horse, and mule men joined us here as well. 
 
 

 
That first day of hiking was exhilarating.  We hiked right through the middle of a huge group of Gelata Monkeys.  They were unperturbed by our presence, much more interested in eating and playing with each other.  What funny creatures!  Later I saw a woman who is part of a group of PhD scientists from the University of Michigan who is studying these monkeys.  Apparently the Gelata monkeys have evolved and formed their own genus.  They are only found in the Simien Mountains, and have few predators.  There is the mountain leopard, but he is rarely out.  These monkeys eat on the plateaued mountains during the day, then sleep in cave down the cliff sides at night.  I could have spent hours just watching these monkeys, but we had a destination, and so onward we hiked.  The views were also spectacular.   Huge cliffs that dropped 1500 meters.  We are at the tail of the rainy season, so everything was green and lush.  Simian Mountain native Ethiopians still live in this national park and continue their harvests of barley, beans, and wheat.  Horses and oxen pulled plows.  Kids ran up and down the mountain sides, herding the goats and sheep.  Horses, mules and oxen that were not working were grazing peacefully.  Eventually we reached our first camp, at around 3250 meters, and quickly changed into warmer clothes.  The van and cooks had arrived ahead of us with our things via the mountain road.  Hiking in the sun was comfortable, but as soon as the sun went down it was COLD.  I wore ALL of my warm clothes that I brought to Africa, including my fleece long underwear, wool sweater, wool hat, gloves and long down jacket.  I was barely warm. 

 



 
 
The night would have been pleasant enough, but unfortunately a little sore throat for Josh and Kristen in the morning turned into a full-fledged common cold that night.  I took some Benadryl earlier in the evening.  Around midnight Mark and I were awakened to the awful sound of Josh struggling to breathe in fits of stridor.  Josh was able to get some ibuprofen and Benadryl down and eventually his breathing improved.  But when morning came, Mark and I were concerned enough that Josh’s condition could worsen that we decided Josh and I would go back to Debark town and look for a pharmacy to buy some prednisone steroids.  About 5-6 years ago Josh had had a similar episode of wheezing stridor, instigated by the common cold.  Then, we were able to take him to Swedish ED, and he received racemic epinephrine nebulizer treatment with oral steroids.  All of a sudden we felt very far away from reliable medical care.  Fortunately, we were traveling with 2 anesthesiologists, a radiation oncologist and me, a gynecologist.  Between the four of us we discussed what we could remember of pediatric pulmonology (honestly, the anesthesiologists were very helpful) before I set off with Josh.  Mark, Sonja, Magnus (the radiation oncologist), Janis and Stephan (the anesthesiologists) continued the 2nd day hike with the scout.  The guide and van driver took Josh and me back to town.  Once in town we found a pharmacy, and after about 20-30 minutes of discussion I was eventually able to communicate to the pharmacist the medications that we wanted.  Initially he said he didn’t have any oral steroids, only eye drops, but after about the 10th time of me trying to pronounce “prednisone or prednisolone” in as Ethiopian an accent as I could muster he pulled out a huge jar of “Prednisolone 5 mg tablets.”  Hooray!  Success.  In the meantime, I also decided to pick up some theophylline and a beta agonist inhaler.  75 Bir later (that’s about $3.50) for all three medications we were back on the road and heading up to the Simien Mountains.  We eventually reached a much higher camp to park the van and the guide, driver, Josh and I hiked a mere 1 ½ hours down a valley and back up the other side to meet our group at the second campsite.  
 

The other part of our group hiked in record speed and covered a distance in 4 hours that the guide thought they would cover in 7 hours.  Stephan, the German anesthesiologist, is built much like Mark.  Tall, thin, strong with long legs.  Adamse, the scout, lives at this altitude and probably does this distance several times a day.  Janis and Magnus, the Brits, are in their early 30’s and athletic.  Sonja apparently rode the mule for 70% of the hike, and the mule wanted dinner.  When Mark told me that they had hiked really fast, I could only imagine their pace. 
 
 

 
 

 
That evening we witnessed civics in the high country.  There was an altercation amongst the mountain herders that almost came to fists.  But eventually a “counsel” of herder men gathered, heard both sides, literally pushed both parties away, the counsel then discussed the situation and brought back the two sides.  Both sides agreed to the decision and parted ways.  This was interesting, because Mark inadvertently happened to be on one of the sides.   Along the hike there was a horse shepherd who had followed the scout’s group for about an hour, asking if they wanted to put their packs on the horse or ride the horse.  They said “no” for about an hour, then Mark and eventually Magnus decided to let the horse carry their packs.  The scout did not speak English, and none of the group spoke Amharic.  We had bought an “all-inclusive” trip, and on the first day 2 shepherds with their horse and mule had appeared.  They thought that maybe this guy was part of the package.  There was some deliberate misleading on the shepherd’s part, because he was not a part of the pre-arranged trip.  And miscommunication due to language barriers on Mark’s side.   At the end of the trip, the shepherd wanted to be paid by the company for his work.  This led to the argument.  When the counsel formed, Mark had to give his side of the story and the shepherd gave his side of the story.  We talked about the whole process and remarked that there were no lawyers, no police, just judgment by peers.  And in the end, it all worked out. 
 
Our final day of hiking was beautiful and medically uneventful.  Josh took his steroids, Benadryl, and a puff of the inhaler and we all slept well.   We hiked up to 3900 meters, about 12,800 feet.  The views along the way were spectacular, which was good, because we hiked ourselves right into a big bank of clouds.   The clouds parted on our way back to the van, and showed us a glimpse of Adamse’s home.  It was a small box, perched high above a cliff.  These people are mountain climbers.  From the moment they are crawling, they are scaling mountains.  It’s truly incredible.
 
 

We left our three day adventure with an increased appetite for more.  The Simien Mountains are spectacular.
 

Friday, October 24, 2014
 
This week we started cervical cancer screening at Gondar University Hospital.   Dr. Semanawit is a General Practitioner who has been assigned to the Gynecology outpatient ward.  She hopes to be accepted into the Obstetrics and Gynecology Residency program next year.  She and I decided to start the screening on patients who had come to the outpatient ward for Gyn problem visits. We use the WHO criteria and screen patients 30 years or older.  Patients may come for problems such as utero-vaginal prolapse, urinary incontinence, irregular bleeding, amenorrhea or infertility.  The Gyn outpatient clinic consists of 2 rooms, about 8 feet by 15 feet in size.  One room has about 4 desks and 10 chairs squeezed like a tetras game into the space.  Usually 5 patients are being seen at one time in this room.  The interns and residents take the patient’s history.  Then, the patient is brought to the other room for their exam.  The exam room is in constant turnover.  As one patient is getting dressed, the next patient is getting undressed, and 2-8 interns and residents are squished into the room as well, trying to direct the patients as well as consult with their seniors about the patients’ exam, problems and management.  It is in this exam room that we decided to do cervical cancer screening.  Unfortunately, a few of the patients who presented with irregular vaginal bleeding already had advanced cervical cancer.  These were the patients who upon inserting the speculum, had fragments of tissue and blood clots just slough off, almost pouring out of their vagina.  There is nothing other than palliative care that can be offered to these women.  Gondar does not have radiation oncology.  Today I saw a very young looking 40 year old with advanced cervical cancer.  She was admitted with anemia, and given a blood transfusion and pain medications. 
 
The exam room had a fairly nice colposcope tucked in the corner.  On our first screening day I realized that the colposcope was not being used because the electrical outlet was on the opposite side of the room from the exam table, and the electrical cord from the colposcope did not reach to the exam table.  The autoclave to sterilize all of the speculums, tenaculums, ring forceps and other Gyn equipment is also in that room.  There is only the one electrical outlet, so whenever someone wanted to use the light for an exam, they would unplug the autoclave machine.  The autoclave would then need to be restarted and the one hour sterilizing process would recommence.  I asked if there were an extension cord with a multi-plug power strip.  “No, we don’t have one of those.” 
 
So, the next day I brought my bedside night stand extension cord and power strip and donated it to the gyn outpatient clinic.  I just hope no one decides to repurpose it.  Now we have a functional colposcope, a light, AND an autoclave that can all run at the same time.  Well, as long as the electricity is on.  The electricity goes out several times a day.  Sometimes just for a few minutes, sometimes for 20-30 minutes at a time.
 
I also brought in one of the kid’s hard-covered composition books to start recording our cervical cancer screening.   This week we filled three pages with patient names/card numbers/diagnosis & treatment.  Of those patients, we did 5 cryotherapies.  I hope that we are doing some good.  Visual Inspection with Acetic Acid (VIA) is trickier that I thought it would be.  I have done hundreds and hundreds of colposcopies.  But every woman who needed a colposcopy had a known abnormal PAP smear, so I knew I would most likely find some abnormalities.  Now we are looking at the cervix without any information about cervical cytology and we are initially looking at the cervix with our naked eyes.  Seeing abnormal vascular changes and acetowhite is much more challenging with the naked eye as compared to the colposcope.   Since we can now use the colposcope with my bed stand power strip we have been checking our VIA results with a quick colposcopy.  I still wish for a trusted pathologist who will check a few biopsies.  But, there are only 2 pathologists for this whole hospital.  The gynecology department has two tissue biopsy forceps.  Due to these constraints, we are only allowed to take cervical and vaginal biopsies from two patients on Tuesdays.   
After one successful morning of cervical cancer screening I offered to take Semenawit out to lunch.  We went to a hotel/caf´┐Ż just down road and ordered “Fasting Food.”  Ethiopia is a predominantly Orthodox Christian country, especially this Amhara region.  People who are Orthodox Christian traditionally “fast” on