Tom is Alive

African sunset

None of us men could even begin to imagine what it would be like. Maybe you ladies could. Try to imagine living in a family; being the first of four wives all living in the same compound; there are plenty of kids from babies to teenagers; you’ve delivered fourteen babies and they’re all dead.

M family home
Usually the husband had the largest house and each wife with her children had a smaller one.

Now you’re pregnant again and your heart is so full of hope!

Your husband loves you, but you share that love with three other wives. The months go past, your belly fattens, the kicks start coming, your hope and your fears grow and jostle in your mind. Seven months gone, only two more to go. A few days pass and your waters break. Oh, no, surely not another so tiny that it won’t survive,

But your husband loves you, so, although babies are usually born at home, he gets a horse and cart and takes you to the nearby infidel’s hospital so that maybe you’ll get a live one at last. He does really love you.

They have funny customs, but they look after you and you deliver a scrap that when you see him you can’t believe that he can live, and he certainly wouldn’t have in your home. They take him away from you. Not to say they are nasty, they care for you, express your breasts (both of them) and feed him through a little tube down his nose. They make another uterus for him out of a card-board box lined with cotton wool. They put an electric light in the end to keep his new home warm. They run oxygen into the box at first but after a few weeks decide he doesn’t need it any more.

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About this size he was taken home.

One of the foreign women takes him to her house each night because she explains that she wants to make sure he gets his 2-hourly feeds at night. You can see she loves both of us and wants him to live. You learn her name is ‘Hirut’ but lots call her ‘Ruth’. Her own two boys love to come and watch him with you. They love him, you can see, like a brother.

Gradually they teach you to sponge him down, and to feed your own milk down the little tube. Eventually you’re allowed to hold him for a while. He holds your finger; he pees into your face as only little boys can; he takes your heart in his hands and your hope grows. But then goes back into his box.

Then your breasts dry up and they start to feed him in a powder from a tin which they mixed with boiled water and let him drink from a bottle with a breast slipped over the end. They teach you to test the warmth of the milk substitute by dropping a bit onto your wrist. They always clean up the bottle and the little ’breast’. They explain this is necessary and teach you how to do it properly. They explain it is very necessary to do all this.

He’s soon no longer living in his box. They teach you to do it all so well. He grows so beautiful. You see Hirut would love to keep him, she has spent so many nights and so much effort, but she just encourages you and gives him lots of little clothes that her own boys wore. All the hospital love and they call him Tom. He kicks, he laughs, he cries, He’s beautiful. It’s time to take him home. The nurses give you a little party and then your loving man takes you home. Everyone there is excited for you and they love him.

Five days later, he’s running a temperature; another two days later little Tom is dead.

No one at home boiled bottles and their water came from the creek in which people bathed and near which they did their ‘business’. He got diarrhoea, started vomiting and died.

Later you got the courage to go back to the hospital and told them the news – they cried with you, and hugged you and loved you. As you left you missed hearing them say to one another ‘It was all our fault. We should never have been so clean.’

But sadly, Tom is dead.

Life isn’t meant to be that hard!

African sunset

 

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Life is different in the countryside in Ethiopia. There are kids everywhere and they aren’t taught not to trust you. This may cause some problems but I think that they are less likely to be molested than in the West. Median age of Ethiopia is 19.
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Only one arm (due to a native healer mishandling a fracture), but what a smile.

You may not want to read more if you’re a bit squeamish! But it isn’t as bad as many kid’s TV programs – except that it is real. I really loved the kids I dealt with!

Continue reading “Life isn’t meant to be that hard!”

Pandemic Funerals

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Pandemic limitations have reduced the numbers at funerals, but have also made it possible to attend (or at least listen to) funerals without travel. In 1968 we arrived in Ethiopia. The man who had been station head at the time when I had to leave in 1973 for health reasons, had a funeral last Saturday in Canada. My wife and I attended the ceremony. Well, not quite, but we watched it on U-tube last night.

Seventy years earlier he had travelled by ship with two other young men for their first term of missionary service. So it was interesting to remember not only my contacts with the man who had died but also with the other two.

The dead man had married a beautiful lady and by the time we knew him had 4 children. He was a good leader, but what I remember most was that his youngest child, a daughter was about the same age as our oldest son. We had a platform type swing in the front of our place, and his daughter and our son used to, during school holidays (they both went to boarding school in Addis) stand at each end of plank, goggle eyed, swinging back and forth. Puppy love, I guess; nothing came of it.

Some years later I met him again in Addis. He had remained in Ethiopia in an Administrative role during the time of the communist rule. I visited during that time for the Australian division of the mission. I wanted to visit my old hospital but was forbidden. Everyone thought that it would cause a riot. But, I did need to do a bit of travel in Addis. I did not have an in-date Ethiopian licence. One of his sons, who had a licence, was out visiting him. So my friend offered his son as a driver. His licence had been obtained to drive automatic vehicles. All the vehicles available had stick gears. I’m glad that the traffic wasn’t as busy then as it is today. It was a scary ride, but we did arrive both ways without an accident.

I knew one of the other men quite well but the story is second hand. Much later he and his wife adopted a young Ethiopian girl. I can’t understand how but the Ethiopian officials allowed them out of the country without a Canadian visa for her. The other end wouldn’t let the child into Canada. The guy, nice but a bit pushy, unsuccessfully argued with them for quite a while, but eventually put the baby on the desk and began to leave. ‘OK, she’s your problem now’, he said.

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He was called back, some agreement was reached, and eventually everyone was happy.

The other guy with his wife who went with him on the same ship reminded me of a couple who were working on the Ethiopian-Kenyan border. There were poor roads, no phones, his wife as the only trained nurse in a nurses clinic on site; there was no other medical help available without travelling hours on terrible roads. They were so ‘out-on-a-limb’, distance wise and in political uncertainty, that the headquarters in Addis had  radio contact with them each morning and evening. And describing the roads as terrible, I mean terrible, unmade, ‘mud-slides’ and rivers with no bridges to be crossed.

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Late one Saturday afternoon the husband complained of abdominal pain, his wife assessed him as having appendicitis. It was too late to fly a helicopter down but the decision was made to get everything set up for action in the morning. A helicopter was arranged, and everything was planned to be able to leave in the morning if he was still unwell. After the morning radio contact we would make a decision depending on what his wife thought. She was still worried, so another nurse, and I set out with sterile instruments, sterile disposable drapes, a spinal anaesthetic tray and a strong torch.

We had two alternative plans in place. If there was a fear that it was far progressed we would bring him back on the helicopter so that he could be watched in hospital in Addis, after surgery; or if it seemed the correct diagnosis but an early case we’d operate there and leave him in the care of his wife.

We travelled down at low altitude in a glass bottomed helicopter. It was soon after the civil war had ended and the people were frightened of low flying air machines. As we passed overhead, the men and their beasts out ploughing took off helter-skelter, often the men in one direction and the beasts in the other, still pulling their ploughs. I don’t know why the pilot flew low; it wasn’t funny for people on the ground; but it looked so from above! And when I say that we flew at a low altitude, what I should say was that we didn’t fly far above the ground. Ethiopia is mountainous so we had lots of ups and downs so as to not hit mountains. I guess we fluctuated between four and ten thousand feet, altitude wise.

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At any rate I decided (correctly) that he had early appendicitis so I operated on him on the kitchen table, using a strong torch for light (held by the pilot) and under spinal anaesthesia. After surgery we watched him for a couple of hours, had lunch and returned to Addis. The next morning on the radio his wife was asked how he was getting on. She said that he was in the garden watering. She called out to him; he was happy and said ‘Thanks for making house calls.’

Pathology proved the diagnosis correct.

Dominic Cartier

A personal review of things

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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!

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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!

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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!

DEALINGS WITH THE LAW

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Relationships with the law aren’t always easy. To quote the old saying “the law is an ass”. Yes it is, but no it isn’t. I think you know what I mean. Sometimes sticking to the strict letter of the law seems crazy, but I won’t follow that line any further.

I have three episodes at least of disagreements with law authorities in Ethiopia. There is a fourth more complex one that I may tell you about sometime, but not today.

In the first, the ‘traffic’ as they call them stopped me up in Addis. There you drive on the right. Coming to a corner where there were four lanes travelling each way I wanted to turn left. I wanted to cross in front of four lanes. Those coming in the other direction had a stop light. In the past, two lanes had been allowed to turn left, but, unbeknown to me, the rules, the law, had changed – now, one only could turn. So, doing what I thought I knew was right, I turned from the now illegal lane and was whistled over by the ‘traffic’.

As a bit of background, if fined in Addis they take away your licence, give you a fine slip, you immediately go and pay the fine, then come back to the same person, show your receipt and get your licence back. By then the person with your licence may or may not still be there. Or you can pay a bribe, which I am not in the habit of doing.

The guy asked for my licence. Resisting the temptation to tell him that I drove without one (I did have one) I simply said ‘no’. I think it shocked him a bit. ‘Why not?’ I was asked, ‘don’t you have one?’. So I explained that I did but that I knew how fines were handled, that I had a 500 km trip ahead of me and I wanted to be on my way. And, without stopping for him to get a word in, I asked if he had ever done wrong and been forgiven? Again, without stopping, I said that I knew that I had accidentally done wrong, and ended by saying ‘please forgive me!’ He smiled, looked at my licence which I had slowly taken out, and he waved me on. Nice guy!

A patient was brought to our hospital from the prison with a broken thigh bone (femur). We were ordered to treat him. It turned out that, according to him, ‘they’ at the prison had broken his leg. We did not have facilities to put in an intramedullary* nail which would have allowed him to walk in a few weeks, so he was put up in traction. Those bones heal slowly and usually need about three months to heal properly. I think the guy preferred our bed to the prison. Less than a week later the prison guards were there to take him back to prison. After a long and fairly heated discussion they left, without the patient, but with my promise that if they returned with an official letter stating that they would take him to the police hospital in Addis, I would fix him in such a way that he could travel the 200+ km to get there. It didn’t take long for them to get the paper. I knew that, as they drove out from our hospital, if they turned right they were going to Addis, if they turned left they were not. They turned left.

I was only about 30 in the late sixties. Maybe I was young and foolish. Not long before an important person had been involved in an accident near the hospital. Having treated the injured, I had been requested to write a legal report as to what had happened. The report obviously didn’t please the wealthy guy who had caused the accident. So, a policeman arrived in my office and offered me a considerable bribe if I would rewrite the report according to his suggestions. Maybe foolishly, but with great satisfaction (he was not a big man) I picked him up by the scruff of his neck and the seat of his uniform and threw him out the door. I am thankful that I heard no more, as I suspect I was right to refuse but wrong to do what I did!

* intramedullary nails were first used in WWII to allow the Germans to rapidly mobilise prisoners of war who had broken femurs, for example, pilots who had parachuted out of their planes. This concept is used a lot these days.

Dominic Cartier

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 baby is born

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A baby girl is born. So what’s so amazing about that? We’ll call the girl Rahel which isn’t her real name. Her birth mother had just been left by her husband, and none of her family wanted her. She was an epileptic, and fell into a fire and was very seriously burned. She lost her left breast and had serious full thickness burns on her left side and down her left arm. She was pregnant and at term. She delivered Rahel the day after she was admitted to the hospital. The mother would have nothing to do with her, I think understandably in the circumstances. The mother was dreadfully ill and sadly weeks later died, after lots of treatment. There were no relatives around.

But the story is about Rahel. She was taken to the special care baby unit, where after a few days they rebelled and said she wasn’t a sick baby so she couldn’t stay there. So she was brought into her mother’s ward, my wife bought infant formula for her, but they rebelled for the same reasons. So we brought her to our house while we tried to work out a solution. We were in the middle of adopting our second Ethiopian son who was about 10 at the time. We all loved her but didn’t feel as if we could or would be allowed to adopt her. Our next door neighbours were Europeans, supervising the care of  street kids whom they placed in willing local homes and financially supported the families to cover the cost of an extra child. Our neighbours knew English but their prime languages were different. Thus their household spoke four languages – their two home country languages (very different), English and Amharic, the common language of the local populous. They already had three boys of their own but after some consideration decided they would like to adopt her.

My wife, although she loved her very much felt that we should not even try to adopt her. I agreed. So when they decided to take her we were sad/glad to let them have her to see how the boys accepted her. They loved her dearly.

Then one after the other the three boys came down in series with chickenpox. So for the baby’s sake she came back to live with us until the risk of her getting the disease was over. Many times a day the non-infected boys would come to our door, accusing us of stealing her. They wanted her back.

During this time we went to a town a couple of hundred kilometres away to visit our first adopted Ethiopian, who was back in the country courting a young lady who is now his wife and the mother of their two children. IMG_2944 copy We were sitting in a little restaurant with our two boys and little Rahel. At a nearby table were sitting two well dressed men. They were talking in the tribal language of our son who overheard  and understood their conversation. Apparently there had recently been several cases of foreigners stealing babies to sell on the black market. They were policemen. They were deciding as to whether or not they should arrest us. Our son went over and spoke with them, explaining our situation. Then we joined them and it was all sorted out.

Chickenpox doesn’t last for ever and the family joyfully took Rahel back. The boys forgave us for stealing her! But then the birth mother’s relatives, who hadn’t come to the hospital, as soon as a legal adoption process began, came forward. They didn’t want her, but surely she was worth something. All I know is that after a bit of trouble they were able to adopt her.

The last time I saw her one of our Australian sons was with us. He knew one of the parent’s language. She sat on his knee and spoke with him in that language for about half an hour. IMG_1441 copy 2She spoke with us fluently in English. She also knew her other parent’s language and apparently knows Amharic well. At six she was fluent in four languages. Truly the little girl is well and truly born! The parents have since had another child of their own. A little girl.

You might not like the pictures below the ‘more’ line. They are of the birth mother’s burns.

Continue reading “A baby is born”

A view of Obstetrics

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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.