- 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.
- 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’.
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!
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.
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 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. 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. She 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.
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.
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.
Over my time in Ethiopia I’ve worked in a number of Ethiopian government or University hospitals. I’ve had periods between two and five years over the time that I’ve been there, and for shorter periods in three others. Each morning in all of them it was seen as important to discuss the previous day’s admissions and operations.
A number of medical schools were suddenly started when the government decided they needed more doctors. There are over 20 at the moment, but remember the country’s population is now said to be 105 million. They didn’t have adequate qualified people to teach in any department or even adequate hospital facilities, at least in Arba Mintch.
Just as students began their clinical years of training in Arba Mintch, I transferred from Jimma University to Arba Mintch. I was paid by the University but, added to my University teaching responsibilities, I was expected to be the major surgeon at the hospital.
These, previously described, morning meetings were certainly held for the surgical department in Arba Mintch. I’m not sure about what happened in the other departments. Senior staff, post graduate trainees, interns and students were all meant to attend. In the established universities, where there had been trainees and students for a much longer period there were already buildings appropriate to the needs ; but this was not so in Arba Mintch. In Arba Mintch the University did not have an attached University hospital, so the students were sent to the Government Hospital, which was not given a grant to provide buildings for the students’ needs.
Initially we had 40 students per year, but by the time I left there were 170 per year. There were certain requirements laid down in the University laws which each student had to obey. For instance they had to attend 95% of all lectures and be signed in to have watched 20 operations. Apart from the first year of clinical attachment (4th year) we had students with us all the time as at that time there was no fifth year group. When the numbers were small we had the younger group half the academic year and the other half year we had the more senior class. Although they were with us full time for their attachment we didn’t have them all the time as they had to attend other departments as well. But at the end, because of the increase in numbers, in order to keep groups at a manageable size we had groups from both years all the time time.
For our morning meeting the expected attendance was – 3 surgeons; 2 or occasionally 3 post graduate students; 4 interns and up to about 65 students. The shed which we were given had no ceiling, old chairs, without enough for the people and no room for any more. The shed was about 10m by 7m. It is easy to imagine how crowded it was. So, as fortunately most were pretty slim, we could sit two per chair for some of them. I think some of them enjoyed that! We three surgeons had a general hospital to run, as well as the University department to run. In addition we were involved in the teaching programs for nurses, public health workers, anaesthetic students, and a course which tried to teach health assistants basic surgical procedures. Of course there were as well exams to be set and marked. We divided the numbers and apart from the morning meetings, which all had to attend, put a third under the wings of each surgeon. Not, of course, that I’m complaining or that I thought it ridiculous!!
The morning meetings lasted about an hour, then one surgeon had a clinical teaching ward round for his third of the students; followed by a ward round for the interns and nurses of the 60 or so patients in the surgical wards. One of the other surgeons was in the operating room. He had his third of the students with him. The third surgeon was in referral clinic with his third of the students.
PS I have opened a second blog under my real name and it deals in a bit more depth and with a few more gory pictures with some of my unusual problems. It is called Medical Memoirs at hicksmedical.wordpress.com
This is the story of one whom I’m sorry is not our son. The Australian government, I think for financial reasons would not countenance an adoption. They did give us a 6 months medical visa but we had to pay all expenses and he had to leave at the end of those few months.
He was run over by a train. His father was dead; his mother was cruel to him. I’ve seen the burn marks that she inflicted on his one remaining arm. He was a street kid, and I’ve no doubt a thief, a beggar and a bit of a rascal. He lived on the streets of the place I used to go to operate on Fridays. I’ve explained about Friday operating there before. I didn’t do his initial surgery but saw him on a Saturday morning round when he was just about to be discharged to be a street beggar again.
He had been operated on by a surgeon for whom I didn’t have the greatest regard. A boy to remember/a surgeon to forget.
Later the young boy told me that when trying to hitch a ride to a bigger town for better pickings, his friends who were pulling him onto the train let him slip and he fell under the slowly moving train. He lost both legs and his right arm. He told me later that when taken to the hospital he still had both knees, and his thumb and two fingers on his right hand. If you have to amputate it is a good thing to remember that the longer the stump the easier to use an artificial limb. And a few fingers can be very useful!
When I saw him that day both legs were amputated very high, and his right arm was amputated just below his elbow. He was in considerable pain because in his left leg stump the bone had not been smoothed, it was not covered with muscle and the sharp spike of bone was half way through the skin.
I took him home with me that day. It was interesting because he knew no English and my Amharic isn’t perfect by a long way. I asked him three questions,
Did he wake at night with night mares? The answer was ‘no’.
Did he need to pee at night? Asked, obviously, because I’d have to carry him to the toilet. He said ‘no’, which was usually correct.
Was he worried about the future? His answer surprised me. ‘No, there’s a God in heaven, He’ll look after me.’
On the trip back it rained a bit. When it stopped other traffic splattered dirt onto the front window so that I used the windscreen wipers and sprayed, as you do, water to clean them. He asked where the water was coming from. I told him that there were two little boys under the bonnet who peed when I told them to do so. He looked at me a bit shocked so I explained the reality. But I think it helped him to know that I was a real man, like his father used to be to him. We got on famously.
I remember his first bath. He’d never seen one or been in one. He clung to me as I lowered him in, screaming at the top of his voice. Having got in, and discovering it was warm and very pleasant he didn’t want to get out. We never had that problem again.
Soon he had to go back into hospital and have the bone in his left stump sorted out; of course, not at the same hospital.
The next while was a bit mixed up; he stayed with friends while we came back to Australia for my cancer surgery; then my wife returned to Ethiopia to finish the academic year teaching her grade 4 kids. Tenesaiyeh lived with my wife while she was there. We got a medical visa for him to come to Australia for artificial limbs. I had three years of troublesome, even if not overly serious, complications after my cancer surgery. So I had plenty of time to act as his personal chauffeur and physiotherapist while he got his prostheses made and began to use them. Before I had to take him back to Ethiopia he was slowly walking up and down stairs. He scooted around on a little skate board and used to love sitting in front of the TV conducting with Andre Rieu.
The local school allowed him to attend (this was new for him); he loved it and they were so good to and for him. He went around at school on his skateboard. I’m not sure how legal it was!
Australia wouldn’t let us adopt him but arrangements were made for him to be adopted into the USA. For legal reasons he had to spend time in an orphanage in Ethiopia before he could go to America. When I took him back, I spent a few days seeing him daily until I left to return home. He came to the airport with me and it took 2 people to pry him off me, for me to be able to leave. It was similar to getting him into the bath first time – except he didn’t enjoy the orphanage.
His new parents, for reasons I cannot fathom, soon found his prostheses too much problem and disposed of them. So he’s a wheelchair bound guy these days but a champion wheelchair Olympian. He’s a University student and we still correspond as ‘my American son’ and ‘my Aussie dad’. He tells me he wishes he had been allowed to stay here. So do I!
- Tensaiyeh was not his name. It is used as a boy’s name and means ‘my resurrection’.
As older professionals, whatever that profession is, we were all young and inexperienced once. So one must not be too judgemental of others’ mistakes. I used to tell my students that we all make mistakes, but, if possible, reduce your own by learning from the mistakes of others.
I mentioned in a previous post When to leave the training nest? that, for a time, I visited and operated with/for a friend every Friday. One week I discovered that a second, just graduated surgeon had been appointed there. Neither my friend nor I knew anything about him, but as there were 2 operating rooms he suggested that we had to appoint someone upon whom the new chap should be the surgeon. Maybe one of us should have watched him, but we were in the other operating room, both involved in a complex case.
To divert – you can get hernias in many places but the commonest are in the groin or at/near the umbilicus. A rough, workable definition of a hernia is a bulge of an organ (or part thereof) through what normally contains it. Basically three words are used in describing the way you repair a hernia.
- Herniotomy – the simplest of the three, where you push back the contents and just cut off the sac, which is usually a bit of peritoneum. This is the common way of repairing a child’s groin hernia.
- Herniorrhaphy – where you sometimes include a herniotomy but then try to repair back to normal anatomy.
- Hernioplasty – wherein you sometimes do the above but try to strengthen things by rotating something or adding some foreign material, usually some sort of plastic mesh.
We chose for him to operate on an about 8 year old boy with a common type hernia on which you did the simplest of the three repairs above, in colloquial language, it should have been a cinch. He did his operation and the boy was sent back to the ward.
On the next morning, while seeing my patients from the previous day, I came across this boy, screaming in pain and in obvious great distress. He had an exquisitely tender mass extending from his umbilicus to just above his right knee.
He was not my patient and I was not the head of surgery. So I asked my friend to contact the surgeon who had operated and ask him to see his patient. The guy didn’t answer his phone. I needed to go, so I suggested that my friend try to ring again in about an hour but that if didn’t come that my friend would have to re-operate himself – he was very capable to do that. The guy answered the next time, but refused to come; my friend operated. The top of the bladder had been cut off and left open, so the mass was all urine.
I’ve never heard on any occasion of such a thing happening. Can I forgive him? As I said at the beginning we all make mistakes. I find it very hard to understand this mistake, but certainly I don’t forgive his refusal to come when called to review his patient.
The kid recovered, but instead of a day case, his recovery took quite a while.
I have at least one follower who hates medical photos so BEWARE below the line. Continue reading “A boy to remember/a surgeon to forget.”