Medical mission in Ethiopia - week 4

October 11, 2014

Saturday October 11, 2014

Where shall I begin? I’ll just start chronologically.

At Monday’s morning report I learned that a newborn baby whom I observed being born by cesarean section had died about 18 hours after delivery. The cesarean section was done at 35w6d for placenta previa. The patient had presented with bleeding, the bleeding resolved, but the baby had intermittent episodes of fetal tachycardia. Given the concern for recurrent bleeding and the fetal tachycardia, the decision had been made to proceed with cesarean section. The cesarean section went well, and the baby was delivered screaming, with Apgars of 8 and 9. He was large, almost 4kg, and he looked full term. He was admitted to the neonatal ward for hypoglycemia. From the verbal report it sounds as if he was discovered “expired” while one of the pediatric residents was making routine rounds. There was no autopsy and the patient did not have a detailed fetal ultrasound during her pregnancy, so we have no idea if there was a cardiac defect or other malformation which contributed to the baby’s demise. Routine diabetes screening is not practiced here. A risk based approach is used to screen for diabetes. The patient had 8 other children, one of them had just graduated from nursing school and was at her bedside during her hospitalization. This was the patient’s first delivery in a hospital. I can’t help but think that this baby would have survived back home. Of course I don’t know that, but it is hard to comprehend a screaming and healthy appearing baby at delivery dying within a few hours.

Again, I am impressed with the resident physicians’ ability to persevere. They continue trying to help women and children despite these emotionally deflating cases.

People who survive here are strong. They are just physically, mentally, and emotionally strong.

This week was a good week for me at the hospital. One morning I went to the outpatient high risk OB ward. We saw 10 patients, completed about 6 ultrasounds, and I learned more about the challenges pregnant women and their care providers face. Robil, the 3rd year resident, made me feel very welcomed, and actually asked me to join him. That feeling of being sought out and asked to join was huge. I must remember to give him that feedback. I am becoming more comfortable on the labor ward, going from bed to bed, asking the interns to tell me about their patients, and then trying to give some medical education and teaching in the process. I have now done my first cesarean section with a couple of residents. It was a good feeling to get in a comfortable and familiar zone. Skin, fascia, rectus muscles, vesico-uterine peritoneum, the challenge of delivering a baby’s head that was lodged in the pelvis after active phase arrest. This is something I know. We are finding that anything familiar creates a comforting feeling. Cesarean sections are no exception.

Wednesday and Friday was an interesting experience – oral examinations for the 5th year medical students. There were exams on Thursday as well, but I was home in bed with a fever, body aches, and nausea. These medical students will become general practitioners next year, and practice anywhere the country needs them. They could be very rural with no access to higher levels of medical care, or they could be in a major city with a hospital. I had flashbacks to my oral examinations as a medical student, and my bad luck of getting the topic of vulvar cancer, which I did not know very well. Now, 17 years later, I was in the examiners seat. I didn’t realize I would be giving part of these exams so I had not reviewed anything, and I will admit that some of the medical students knew their cancer staging better than I did. It is also remarkably difficult to come up with pertinent questions off the top of my head. We had no outline. No list of topics to cover. We had the student’s name, and a blank piece of paper. Many of the students were absolutely terrified. Oh, I remember that feeling, too. I think they expected me to ask them trick questions, because sometimes I would ask something fairly basic, such as “Can you describe the physiology of the menstrual cycle?” I would try to ask leading questions, “What hormone is produced in the luteal phase?” They would just freeze. Stare back at me. I would ask, “Did you understand my question? Is my accent difficult to understand?” More beautiful, big, dark eyes staring back at me. So there I was, trying desperately to think of obstetrical or gynecological questions that they may be able to answer, and often the response to an actual formulated question was silence. In hindsight, it was somewhat comical. Fortunately I was there primarily to learn how to give these exams, and the permanent attending staff would take over for the majority of the test questions. Prior to the exam, I learned that one of the attendings had a reputation for being easily irritable, but from what I saw the attendings seem kind and fair with the occasional chiding.

Thursday, the kids absolutely refused to go back to the community school. On Wednesday they had come home with more reports of fights between other students, being pushed down the stairs, hit with a stick, hit with a piece of plastic, hit with rocks, another teacher hit a student in the head with his hand. One teacher asked Josh to stand in the classroom to answer a question (routine practice), Josh did not understand the teacher’s English, and so said he did not understand, and the teacher said, “ahh, you don’t know the answer!” Then proceeded to laugh with the other kids in the classroom. I just couldn’t make them go back. And, I was feeling sick with fever, nausea, body aches, and extreme fatigue. So, I called our liason, Solomon, told him about Wednesday and said the kids refused to go back to the school. Solomon said he would try to get the kids in a Catholic school. In meantime, homeschooling, here we go.

On Thursday, I did some homeschooling. On Friday, Mark taught the kids in the morning then he went to the hospital and I came home from the hospital and I taught in the afternoon. We have found some science and math materials online. The first day I found an article about bedbugs, and wrote up some questions for the kids. They sat dutifully at the table answering the questions, and I tried to learn more about how to deal with bedbugs and fleas. Oh yes, just one more little discomfort. I thank the Swedish Ob/GYN – Issaquah group for giving me that wonderful travel-kit-going-away-gift that included hydrocortisone cream. Bedbug bites itch! I think they especially liked my extremely warm body on Wednesday night when I was running a fever. Today I think we will go visit a famous church in Gondar. Famous, because it was saved from invaders by a swarm of bees. Now it is the oldest church in Gondar. The writing assignment today? A report about Debre Berhan Selassie Church.

Last night we had the wonderful good fortune to eat comfort food&hellihellip; a variety of vegetables. The corner veggie stand received a shipment of red, yellow, and green peppers, cauliflower, green beans and parsley. I was so excited to see all these vegetables when I walked by the vegetable stand. The shopkeepers just laughed and laughed at me. We added this to our staple of carrots, tomatoes, onions and potatoes (the ONLY vegetables that are reliably available) and had ourselves the most wonderful vegetable stir fry. Oh, how wonderful they tasted. It was such a momentous occasion, that I even invited the British anesthesiologist who is living in the guest house complex to partake in the feast. Yum.

Wednesday, October 15, 2014

This week some Americans showed up in the ob/gyn department. Maggie Carpenter came to Gondar four years ago for to work for a week or two at the hospital. During her stay four years ago she met Dr. Mulat and discovered that Gondar did not do any cervical cancer screening. Gondar Hospital has a colposcope, but did not have cryotherapy or LEEP equipment. Per the World Health Organization (WHO) and JPEGIO guidelines, a single visit with visual inspection with acetic acid (VIA) and immediate treatment with cryotherapy is almost equivalent to our Western standard of the 3+ visit process of PAP smear screening/colposcopy/LEEP. There is no national program to do cervical cancer screening in Ethiopia, and more women die of cervical cancer than of HIV/AIDS or obstetric hemorrhage.

Maggie and I immediately had a connection. She completed her family practice residency at Swedish Hospital in Seattle in 2000. I started working at Swedish in 2002. The Swedish connection to Gondar continues. We enjoyed talking about some mutual physician colleagues, including my medical school classmate and Maggie’s residency colleague Ric Troyer, Swedish Family Practice attendings Carol Cordy, and some obstetrician legends Dave Luthy and Dale Reisner. After Maggie’s trip four years ago, she went home and started fundraising. Four years and $25,000 later Maggie and Ingrid returned with a cryotherapy machine, a LEEP machine, and instructional booklets produced with the assistance of Pathfinder. They are here for one week to do initial training for the OB/GYN residents, midwives, and some nurses. They have also coordinated with Ohio State University School of Nursing who will send a team in March 2015 with the intent to extend the training to some more rural area health centers. I also would like to contact SCOPE, another Seattle based organization, to see if we can piggyback off of some of their outreach efforts. SCOPE is an organization that is using the Ethiopian Orthodox Church influence to encourage women to come to Health Centers for antenatal care (prenatal care). Initially, their aim was to encourage women to be tested for HIV and get treatment if needed. Recently, they have increased their goals to include encouraging women to get prenatal care, period. Approximately 10% of deliveries in Ethiopia were attended by a trained medical care provider.

I am thrilled to be here now, because I can continue this training process with the OB/GYN department and midwifery department. In fact, we plan to start a VIA/colpo clinic this coming Monday. That is lightning speed by Ethiopian standards. Cervical cancer screening is one of my great interests. I find it such an exciting reality that we can save lives with simple household white vinegar, a CO2 canister that was obtained from the local brewery, and a relatively cheap piece of equipment, a cryotherapy machine (about $900). Last night I went home and “VPN’d” (remote accessed) into my Swedish account where I have saved many of the colposcopy photos taken over that last couple of years. I figured out how to make a slide show, and now all I need to do is match up all of the pathology reports with the colposcopy photos. These photos will help train the residents, midwives, and nurses.

Again, it is a comforting feeling to be doing something familiar. I will rest with this good feeling today.