A personal review of things

African sunset

I write a fair bit about my time in ethiopia. Obviously one didn’t always feel on top of things. Here is a comment I have written elsewhere, when I was on sight and waiting for my wife to join me I have shown a few pictures before. A few pictures from the past.
It was, however, all both mentally and physically exhausting. There was little change or even desire to change the problem areas of the hospital. Some of the younger doctors decided not to seek my help – at least immediately. So one morning they came and informed me that the previous night, being unable to deliver a breech they had just cut off the head and left it inside – would I now please remove it. It turned out to be relatively simple but was a very gory procedure.
Then, on another occasion, two days after delivering the first of twins the duty obstetrician said that the other twin was dead and he couldn’t get it out – would I please help? I was in the middle of an operation but I asked him to bring the lady around to the holding room and I would deal with the situation as soon as I finished the present case. I must confess I didn’t even examine the lady but just put her up in stirrups and applied a suction extractor to deliver the twin – only to find that it was alive, and, in fact, the second of triplets! Both of them survived even though it was a rush to prepare and get into action with baby resuscitation equipment. I had learnt to intubate the newborn ‘flat’ babies without a laryngoscope but by putting my finger onto the top of the larynx and passing the tube along my finger into the trachea.
I have just come across a letter I wrote to my wife when I was alone at Soddo. I copy several comments here directly quoting from my letter home.
1. On the weekend I made a note in a chart that someone (a little baby) hadn’t been seen for 48 hours and was very sick and that the GP should be called.There was no record that any medicine had been given at all, he was nearly dead.This led to the accusation that I was accusing the GP of incompetence and that he would never work with me again.The other GPs all supported him saying that I should not write in the chart but send him a message through the Medical Superintendent.
2. Then on Thursday morning I arrived to find a little child grossly dehydrated and on the point of death. In spite of all I tried to do he died about an hour later. I notified the Medical Super and the Head Nurse. They chose for the case to be discussed at the next morning’s meeting. When the case was brought up next morning the situation was not discussed as the doctors said that the meeting to was to discuss out of hours admissions and this child had come in during the day.
3. I was able to intubate a woman whose operation had been cancelled while I was away because they couldn’t pass the tube. I can understand why they found it hard. She is doing well now.
4.There were a number of other very interesting and some sad cases this week. The saddest was a little baby who had his penis, scrotum and contents bitten off by a dog.
5. I’ve been able to put a few new beds in the medical ward and hope this will strengthen my relationship with the physician
There are other points made in the letter but I think that shows the tone of the working conditions.
Dominic Cartier.

A nightmare of a day!

African sunset

I am, at the strong encouragement of one of my sons, who says that there are some stories in my life worth recording, reviewing and extending a brief autobiography I wrote years ago. Going through a bit of it yesterday I came across this brief event of one day in my journey. This occured while I was briefly attached to a large teaching hospital in Addis Ababa.
I was on call one night on the eve of a large Muslim holiday. The next morning I left to go to the hospital surprised that I hadn’t had a single call over night. As usual we did a round of the whole surgical wards and early in the round I came across a poor lady lying in bed with most of her small bowel and a bit of her large bowel mixed in with a lot of dirt and gravel lying on the bed next to her. She had a large hole in her right side where all the tissues down to and including portion of the right iliac crest (part of her pelvis) had been torn off in a car accident.
Later I discovered the story. She had been hit by a car driven, by a nun, about four hundred kilometres south of Addis Ababa. The driver had taken her to the local hospital who stated, correctly, that they had no surgeon and the nearest hospital with a surgeon was one hundred and fifty kilometres up the road towards Addis. So the nun took her to that hospital, where she was told that they did have an appointed surgeon but he was away and they had no idea when he would return. They came to Addis, where the first three hospitals said that they had no empty beds. She was eventually admitted into St. Pauls – but nothing had been done for her. No IV fluids, no antibiotics, no dressings – in fact nothing at all except that she had been put in a bed.
I have learnt to be pretty patient but this stretched me to the limit. Why had nothing been done? The hospital was without water so the operating theatres were out of action and definitive treatment could not therefore be undertaken. I think it was planned to leave everything to the undertaker! So I organized for a drip and antibiotics and a clean moist dressing over the exposed entrails and planned to look into the water situation later. I had already noted a tap being used down the street by the general public.
Soon we came across another young man who had been stabbed in the back. He was as white as an Ethiopian can be. As he was of a higher social class he at least had a drip up but the blood bank was closed for the holiday. My wife had arrived in the country by this time and I arranged for her and a missionary nurse Jean Sokvitne to donate blood. With some difficulty we were able to collect it and cross match using Eldon cards.
I organized a group of workers and I worked with them. Between us, we carried water from the afore-mentioned tap and collected maybe a hundred litres in a large container outside the operating rooms. Grudgingly the staff agreed to operate. The young man when stabbed had had his renal artery and vein divided and fortunately the knife, avoiding the duodenum, opened into the peritoneum but not causing any bowel injury. He thus had a peritoneal cavity filled with blood but uncontaminated by intestinal content. We gave him two units of foreign blood and I showed the doctors how to filter the blood from inside his abdomen through gauze and we auto-transfused the patient. He survived and did very well.
Next we worked on the lady. It was difficult but we cleaned her intestines, cleaned the edges of her wound and after returning the bowel to its proper place closed the wound with considerable difficulty. She also recovered, although much more slowly than the young man. In addition to her physical disease she had underlying mental problems which added to her initial poor management and which made things difficult during her recovery.
The day after the holiday we had, as usual on working days, a morning meeting at which all admissions over the past couple of days were discussed. I was, surprisingly to me, severely chastised. Two motions were passed:
  1. Never again would doctors be involved in carrying water to the hospital or in arranging for it to be carried as this was a government responsibility.
  2. No auto transfusion would be used unless a modern cell saver were used (of course there were none in Ethiopia!) as the country was not a ‘banana republic’.

Dominic Cartier

I can get frustrated!

African sunset

Standards of nursing care, vary from place to place. I have sympathy for people in developing countries. Trained personnel are few; wages are low; materials are in short supply; sometimes patients personal habits are fairly low by the standards of those who have everything at their fingertips. Looking up Mr Google, the poverty line in Australia is said to be just under AUD67,000 annually. The wage of a newly graduated surgeon in Ethiopia is about AUD 500 per month. A house worker gets about AUD 50 per month.

I remember several events very clearly from my first few months in Ethiopia. I wanted to look down a patient’s throat, so I put my hand under his chin to lift it for me to inspect the inside of his mouth. He spat a glob of juicy purulent spit into my hand. Rather shocked I went out and washed my hand before coming back and trying again with the same result. It was the custom with no handkerchiefs, if you were sick a relative or friend took your sputum and wiped it somewhere, often on the wall. No wonder our walls looked like they did. But I learnt a cultural and very practical lesson.

When a second doctor joined me we made a combined effort to get the floors cleaned up. There was a layer, several, maybe five, mms thick of hard dirt ground into the floor. We got no response, until one day, walking through the ward, I accidentally put my foot in a ‘paw-paw’, their name for a bedpan. You will understand why now I never eat the fruit ‘pawpaw’. I enjoy Papaya, however.

But it made me mad. So I got the other doctor onside and, down on our knees with scrubbing brushes, we dealt with the floors of our 35 bed general hospital. I think it embarrassed the other staff as it was much cleaner after that. They talk about leading by example!

I remember a day when a new young worker was in the ward while I was doing my morning round. I was told that he had been employed as an assistant to the nurse. He seemed an affable chap. The next day he wasn’t there so I asked what had happened. There had been a patient with an IV Drip running and a tube into his stomach draining the contents as his intestines weren’t working. Without the drain he had kept vomiting. The new guy had been told that he was just to watch and learn for the first week or so. The nurse went for lunch and, on returning, was told that this patient had died. Apparently during the morning the new worker had seen someone put up another bag of IV fluid. Not content to wait , when this patient’s IV ran out, he took the gastric drainage bag and ran it into his IV line – with fatal results. What a tragedy.

I had two experiences at another hospital, which made me realise that I came from a different world. The first was when we had a Hong Kong anaesthetist for 2 weeks with me. We had got to know each other working in Australia and he came during his holidays to help me. He was an excellent anaesthesiologist. A man came in having been beaten and speared after committing a heinous act. We operated and I felt that we had everything under control, in fact, I expected a quick, complete recovery. Late in the evening I had a visit from my friend saying that he had just been to see the chap and everything was stable. The next morning he was dead. We couldn’t think of any reason why until I heard a worker say that he didn’t deserve to live, and I remembered hearing staff murmuring when he was admitted that he wasn’t worth the effort of operating on him. Judge nurse, I think had the final say.

Later I had a lady who with an obstructed labour had lost the baby, her uterus, her bladder, and needed a colostomy for bowel control. She survived after I did a colostomy and a very simple thing to drain her urine. When it appeared as if she would recover I created a new bladder out of intestine. On about the tenth day postoperative everything was going well and I took a two day trip to Addis. When I came back I went to see her and she wasn’t in the ward. They were honest enough to say that they thought that no woman in Ethiopia should live with that set up like that. So they had taken the opportunity of my absence to take everything out and send her home to die. Maybe they knew better than me, but it was hard to take.

We had many more good, rather than bad, results!

What do you think?

African sunset

I have a friend, an African friend, who did his medical training in Russia. I don’t think that he is a liar. He told me that when he was there, not infrequently, as he walked on the streets, he would feel people checking his lower back to see if he had a vestigial monkey tail. I have not checked for myself, but I know that he has an excellent brain! You probably think that in the twenty first century this behaviour is unbelievable. And yet almost all educators of today are teaching that we have come from monkeys. So why not test the theory?

You probably know the story of the little girl who asked her mother where humans came from and got the ‘God story’. She later asked her father the same question and was given the ‘monkey story’. At the evening meal she accused someone of lying to her. Her mother replied that she had given her the story of her, the mother’s, own family, and that the father had given the story of his family. He was dumbfounded! The child seemed satisfied.

This coronavirus affair has I’m sure made us all question the way it has been handled. That is not to say that we’re complaining at what has been organised, but we would be dumb domesticated animals if it didn’t make us think, and ask questions like..

  • How many have died of other viral illnesses, during the same period? And maybe, how many have died unnecessarily of other non-treated diseases?
  • Why can you have an abortion but not meet your ageing parent in a home?
  • Why are the suicide, domestic violence rates, and incidence of mental illness climbing?
  • Are we living in a runaway world?
  • What will happen to my family if I die?
  • What’ll happen to me if I die?

The list could go on for a lot longer and maybe your questions differ from mine.

When I was a Surgical Registrar in the 1960s I saw the film ‘Lord of the flies’. It was not based on a true story, but graphically pictured how a group of higher class youngsters from England gravitated into selfishness, murder and cannibalism when marooned, for roughly a year, on a deserted island. Just recently I have read an apparently true report of six Tongan boys who to escape the rigours of a strict school, stole a boat and paddled towards New Zealand. They coped by cooperating. They were marooned for more than a year on a deserted island, until they were found by a fisherman. This without doubt is at its root a true story. The recent report about this event leads the author to suggest that whereas the theory of the imaged book highlights the weakness of human character, the truth of the true story is that people are really basically good. And our basic goodness should be highlighted.

Compare how Australians pull together during bushfires versus why do Australians light bushfires and steal from what is left? How do we balance the generosity of the government when they want cooperation, with their usual treatment of some segments of needy society? Why do some blossom in community service at times like we are going through, and others crash into terrible attitudes and situations as mentioned above? Is there truly good and evil in the world? Should our goals be self-centered, financial, comfort seeking or maybe “goodness and truth”? The eternal question – why am I here?

One Sad Memory, One Glad Celebration

African sunset

The SAD One

When I returned to Ethiopia in the 90’s I had the ‘run-around’! I went with all the paperwork settled by both ends to become Associate Professor at the Black Lion (the large University) Hospital. The paperwork was not enough for a newly inducted set of hierarchy. So I was allocated as ‘Head of the Department’ at the soon to be opened Kidus Paulos Hospital (St Paul’s). Before it opened I was twice demoted to become another surgeon on the second surgical department in that hospital. In addition I was employed by the University on a contract – to be paid a salary, which was not exorbitant but livable. The contract was made in Ethiopian birr when the US dollar bought 2 Ethiopian birr. Within weeks without warning US$1 equalled 6 birr. At the moment it is nearly US$=30 birr. So my wage was effectively reduced by two thirds. I was still paid at the two birr level! Then the Kidus Paulos was slow in opening.

After pleading negotiations I was permitted to work at the Menelik II Hospital until Kidus Paulos opened. But I was paid from the Yekatit Asara Hulet hospital. Which brings us to “The Sad Memory” mentioned above.

Yekatit is a month of the Ethiopian Calendar. Asara hulet is the number twelve. (February 19th in our calendar – our calendars don’t match.) So why is that a sad memory?  It is quite a story….

During their occupancy of Ethiopia 1936-41,  the Italians had apparently built a huge poison chemical factory near Mogadishu in Italian Somalia. They had 37,000 gas masks kept for their own use. The fear, from an Ethiopian point of view, was that they themselves were a major target for attack by chemical warfare. In a failed attempt to assassinate  the Italian Viceroy of East Africa, Marshal Rodolfo Graziani; he was injured but several Italians were killed. The Italian response was over the next 3 days to slaughter over 30,000 Ethiopians, including about 20,000 in Addis Ababa (at that time 20% of the population of Addis!) Talking to local people they say that, as part of this slaughter, 1,000 people were lined up near the Sidist Kilo corner in Addis and the Italians shot every tenth one. The Yekatit Hospital is built at Sidist Kilo and there is a monument there until this day. Italians still walk and work in Ethiopia. The Emperor, on his return from exile in Britain after the Italians were driven out, said that they should be forgiven. Not many Italians, however, are seen out and about on February the 19th!

The GLAD One

If you look in your computer to see if an African Nation has ever conquered an invading European force unaided you are given “The Battle of Adwa”.  I can find no other. The Italian invasion discussed above was the second of their major attempts to conquer Ethiopia.  In 1896 the Italians planned to enlarge their empire in Africa. They already had Eritrea as a base. In the end after much fighting the countries faced each other at Adawa. Without trying to go into great detail the following facts seem to be basically true.

  • The Ethiopians had a much larger force being on home soil. Roughly 80,000 to 20,000
  • The Italians had much the better war machinery.
  • There was previously after some squirmishes an agreement between Ethiopia and Italy with different wording in the Italian and Ethiopian copies. Menelik II acted on his copy which meant having discussions with Europe without going through Italian sources. Italy by their copy of the agreement obviously saw Ethiopia as a subject nation and invaded.
  • On March 1st 1896 the Italians were routed. The story is complex but the victory complete and is celebrated with vigour every year.

 

Dominic Cartier

A little about the Amharic language

Amharic is the language of the Amharas, one of the major tribes of Ethiopia. Emperor Haile Selassie (The power of the Trinity) was an Amhara and sought to make it and English the main languages of Ethiopia. French was, for a while, a popular alternative and a number of words in modern Amharic also come from the Italian invasion. There are apparently 83 languages in Ethiopia giving rise to about 200 dialects. Ge’ez is the old language of the Orthodox Church and introduces the ‘ in the middle of a word to indicate a glottal stop.

To show how different these tribal languages are I will give four greetings with a rough English translation. I will use our script to give an idea of how they sound

  • Amharic greeting is classically Tenastilygn – a shortened form of the sentence Igzeehabeeyer Tena Yisterlygn  – May God give you health for me.
  • In Oromifa – Neggaa, Fiya, Errga – Hello, how are you, it’s nice to smell you. In this situation I think the ‘smell’ is conceptually ‘to have your presence with us’.
  • In Wolaitata – Sero Lo’oo Lo’oo Fiedaitey – Hello, How are you., nice to see you.
  • In Hadeyan – Tuuma, Tuuma. Hello, hello!

Haile Selassie attempted to make Amharic the common Ethiopian language and it was taught in primary and secondary school with English being added later in primary school. English was the official language of tertiary education. After Haile Selassie was murdered the era of Mengistu HaileMariam (The kingdom of the power of Mary) sought to elevate other tribal languages with English as the second language, leaving Amharic for the Amhara tribe. It is thought by many that, whereas Haile Selassie was seeking to unite the country, Mengistu was seeking to divide the tribes to make the country easier to rule.

3 languages
Above the sign is in Oromifa which uses the Roman script and a lot of doubling of letters eg baanke. In the middle Amharic, And below English. Addis Ababa is officially a Federal State but used to be Oromo territory so that comes first and Amharic is in smaller letters.

Certainly when I went back after the overthrow of Mengistu I experienced some trouble from this. I was living in the Wolaita area and patients coming from the Hadeyan area only 40 km down the road could frequently not be understood by the staff. The present government seems to now have a three language policy.

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The 3 languages used here are symbols, Amharic and English. In voting, because so many are illiterate each party has a symbol to show the voters whom they should choose. I never saw a radar gun on that road!

In Amharic there are two ‘t’s – both normal for them but with very different meanings. Also with ‘k’s and ‘ch’s  differences which we describe as soft or explosive. You can get into real trouble. I was in the bank with a couple of friends and our business was drawn out. I said to my friends  ‘Chiger alle?’ thinking I was saying ‘is there a problem?’ but actually saying ‘do you have pubic hair?’ Embarrassing for them and for me, when it was explained. But their letters are written differently and so easily read but not easily heard by us, who think anything like a ‘t’ sound is in fact a ‘t’. In Amharic ‘sebake’ and ‘sebake’, depending on how you sound the ‘k’  means a ‘preacher’ or ‘a bearer of false tales’.

In English we have many letters and letter groups with same or different meaning. We spell Monday with an ‘o’ and say it with a ‘u’. We have the ‘ou’ and say it differently in the following – cough, mouse, tough, through – and pronounce it differently in each word. We have the one letter eg ‘t’ and pronounce it differently in different words. The ‘t’ in tough and the ‘t’ in take are made with the tongue in very different places. Or more significantly the ‘c’ in cat and centipede. Say them and see how your tongue is in a different position for each. We have f’s and ph’s which sound the same. In some of the languages you don’t differentiate p’s and f’s, so people, when they speak in English  go to fray or pray at church; they wear certain clothes either because it is the new fashion or new pashion, without recognising the difference. In Amharic if you know the syllabet you can read it with the correct sound even if you maybe cannot understand it!

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The fidel is not really an alphabet but a syllabet. The second line is basically the ‘l’ sound but the seven syllables as go across from left to right are le,lu, lee, laa, ley, li, lo. There are 238 basic syllables and another 79 special ones, punctuation marks and numbers.

I once told a patient that, as I had spent hours fixing the problems which his venereal disease had caused, ‘that if you have sex with anyone apart from my wife after this, I will kill you!’ I used the sound for my instead of the one for your. Fortunately he spoke in Oromifa and after my Amharic speaking fellow workers got up from the floor, having ceased rolling around in laughter, they translated what I had meant to say!

Learning another language is always a challenge and we all make mistakes!

Dominic Cartier

Old photos from Ethiopia.

I cannot boast of being a good photographer. Here are a few photos from the past with a bit of explanation. The first photo was taken through an airplane window. The smokiness is real in that without electricity every home has an open fire, and picture was taken early in the morning.

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Ethiopia has 70 percent of the mountains found in Africa.  The highest is Mount Dashen at 4543m (14930 feet). It also has one of the lowest and hottest places in the world. The Danakil depression is 125m below sea level.
rock church Lalebella copy
The north is also famous for its 11 churches, hewn out of rock. The place is called Lalibela, where an Ethiopian Emperor of that name set out to restore the region to Christianity after a Muslim invasion. The churches are outstanding, being of a single piece of rock! Some believe that English knights, fleeing from Jerusalem during the wars there, helped in the building. This is maybe supported by the inclusion of the English Tudor rose in so many of the carvings. Others say that, at night time, angels came and helped in the building.

 

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There are seven monasteries of the Ethiopian Orthodox Church on Lake Tana from which the Blue Nile starts its journey into Egypt. Above is an example of the multitude of paintings painted  in typical Ethiopian style. They are found in abundance in these monasteries. Not in this painting which is of an angel watching over Mary and her Son but interestingly you see amongst the many paintings  two saints whom most of the churches don’t recognize. Kidus Pilatus (St Pilate) – sainted because he was the only one who sought to have Jesus released, when he was being tried before His crucifixion. Another called the Cannibal Saint, who supposedly loved eating human flesh but has been sainted because he gave a glass of water to a thirsty girl. The story is that Mary put her hand on the scales when he was being tried after his death.
At filling station copy
I don’t think they make the horses drink petrol, but these little carts are a very common form of transport in the countryside. Although the car per population ratio is low the car accident per number of cars is very high. One of, if not the highest, in the world.
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On a straight open bitumen road. Note the rocks placed to warn motorists. It doesn’t help if you are just topping a hill and the rocks start just over the top!  See lake Shalla in the distance – the deepest lake in Ethiopia. Its depth is 257 metres and its area 12X15 km.

 

 

Everyone has a story – Habtamu

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During our last term in Ethiopia we only had our youngest adopted son living with us. But that meant we had a house full of boys. Three ate with us three or four times a week and there were others from time to time. The memories of those three are precious to us and I might get to write about the other two sometime. I’ll call this one Habtamu, a name which means ‘the rich one’, although he was and is truly poor. As time passed we got to know the history of all of them.

Habtamu was scholastically the brightest of them all. In grade 8 where the pass mark was 37% in the government exam he got 80 something. He was the only one of the three who had a vision of a tertiary education. He was orphaned at age 5. His parents had bought a place in Arba Mintch, and having sold their village place were killed on the way to their new home in a bus crash. Their three children survived. The home which they had bought had 3 rooms. Their eldest child was a girl who was given the responsibility of bringing up her two younger brothers – Habtamu being the youngest. The sister is now married and has a child. Habtamu lives in a little room on the side of the house. He often asked our son to help him in the evenings or weekends when they, like the Israelites in Egypt years before, trod mud and grass together to patch the walls. We paid for all four boys to go to a private school (a cheap one – but they got a full days teaching, whereas in the public schools you only got half day teaching). When we left our son came back to Australia with us. Two of the boys started work but Habtamu wanted  to continue his education. Without being lavish we have continued to support him, with the help of a couple of generous people.

He still lives in that same small room on the side of his married sister’s home. But he may well be seen as richer than most because we have bought him a computer and a few other things. Have these things been a blessing? It needs  a yes-no answer.

Yes, it has allowed him to continue with his now tertiary education. His score was enough to get him a place in a University but not at the one in his area. He would have to have gone hundreds of kilometres away to do a course which he hadn’t chosen. He still tries to help care for his older brother who studies at a Government University far away. So he elected to go to night school for some extra points and is taking an accountancy course at a private institution. These are courses which have to be paid for.

The answer is ‘no’ because there have been many attempts to break into his room. (The home is not in a good place). A few months ago he was beaten up and ended in the local hospital. His injury was in the upper third of his face and particularly around his right eye with a lot of swelling and some lacerations.  Continue reading “Everyone has a story – Habtamu”

A few pictures from the past.

I’m sick of cataloging this afternoon. So here are a few pictures from the past, none medical.

David & Nancy
50 + yrs ago. He’s now a grandfather

 

 

school yard-S
25 years ago. The school where one of our adopted children attended Solomon – the third teenager
bridge building
Built to safety standards. We eventually got to drive over this bridge! 10 years ago
Government housing
The house provided for us at one place. My wife went home while I lived around the workers whom I paid to have it fixed. 25 years ago.
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One of the bed rooms.

And so it goes on. But enough for one day.

Dominic Cartier

A view of Obstetrics

babies

 

 

Having a family is exciting! Maybe not all beer & skittles but fantastic!

 

 

 

Modern obstetric care in the ‘so called’ first world countries is on the whole excellent. In quoting statistics one must remember the old adage ‘lies, damn lies and statistics’. The internet tells us that in the best countries the maternal mortality rate is 2/100,000 live births. In Ethiopia it is 421/100,000 live births, and I’m sure that it was worse 50 years ago. Around the world there is apparently an obstetric tragedy every 11 seconds. I cannot find figures for maternal deaths when the baby is born dead. That is the world I entered in 1968. This doesn’t include those who live with vesico-vaginal fistulae, of which there are 9,000 new cases annually in Ethiopia (quoted by the late Dr. Catherine Hamlin); nor those who survive ruptured uterus. I’m sure many of these died before they reached a hospital where they could be operated on.

I took out the figures in Soddo (my second long stay in Ethiopia) over a year period and we had a 95% survival rate of those who reached hospital alive. I had reopened the hospital in Soddo in 1993 after the country was freed from the communist era. I was the only surgeon there.  I was on call 24/7. After a while we had an obstetrician there who did the day O&G work and was on call at night every second week for obstetric emergencies. But initially I did them all , and later out-of-hours cases every second week. I was also called in to deal with the situation if there was also a ruptured bladder, which occurs in about 10% of cases.

I shall only mention one case here, as I know medicine isn’t everyone’s ‘cup of tea’. My children say they were brought up on such things around the tea table.

In the countryside antenatal care was almost non existent. We ran such a clinic, but few attended and everyone was so busy we didn’t chase things up as hard as we ideally should have done. Most babies were delivered at home. People didn’t come to the hospital until things were obviously seriously wrong. If you lived, for instance, 50km from the hospital, for the majority, there were neither ambulances nor roads so they had to be carried on stretchers over mountainous tracks and crossing waterways. People were frightened to travel at night; and it took, I am told, above 20 people to carry the patient, sharing the work; so it is not surprising that people arrived late.

My first case of ruptured uterus came within a few days of my arriving on my first time in Ethiopia. I was the only doctor in the place. The story apparently was that the labour made no progress, so the native healer tried to do what we call an internal podalic version. In other words by putting his/her hand inside the uterus they intended to turn the baby to get the feet at the bottom so that they could have something to hold onto to attempt to pull the baby out. I don’t know how but whoever it was managed to tear up the front of the vagina and uterus as well as the back of the bladder from top to bottom, and they still could not deliver the baby. The patient obviously rapidly became much sicker and she was brought into the hospital. The baby was dead, but I repaired the long internal tears and she recovered.

abd in ruptured uterus
The double bubble is what is usually seen in a ruptured uterus

Unfortunately she developed a small fistula for which she was sent to the ‘Hospital by the River’ in Addis. She did well and was later delivered of a healthy child. I’m not sure where she fits into the statistics. Later when I was met with both a bladder as well as a uterine tear I used to bring down some mobilised omentum to separate the uterus and the bladder.