It’s cold and wet…

African sunset

It’s cold and wet , and I’m not feeling so hot today. Therefore I thought I’d take a look through the last couple of weeks photos from around our house. You may find them interesting.

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Looking through a new sliding door which our son had put into the dining area, onto a patio which he had just built. A very handy son to have around the place!
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Looking West from the patio.
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We just discovered a patch of white ants in the kitchen floor. Another job for our son and fixed already. 
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He gets to do a lot – here trimming the tops of the Japanese Bamboo which had got to about 8 metres!
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These two pups (about 7 months) are sisters from the same litter. I hadn’t realised that in dogs you can get multiple fathers at the one dropping. They love sleeping at my feet when I’m in my office! The mother was a German Shepherd. One part kelpie, the other 2 parts shepherd.
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This dam leaked badly. Another job for the son with a friend, spreading polymer. This absorbs water and sinks taking fine mud particles with it. It seems to have worked but with the recent rains we’ll have to wait a while to be sure.
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I am back to front, or maybe top to bottom, as this is a sunrise taken from the patio shown above. We live in a beautiful spot.

Hope you enjoy it

Dominic Cartier

 

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.

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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

King Jafir the second.

Most people know something about Emperor Haile Selassie of Ethiopia. One of his titles was King of kings. This is no reference to the Biblical title of Jesus whom Christians call King of kings, although Haile Selassie was an Orthodox Christian. The word king is defined as a noun meaning ‘a male sovereign or monarch; a man who holds by life tenure, and usually by hereditary right, the chief authority over a country and people.’ In many countries, however, there can be multiple kings. The term here is used to define a life-time position of authority over a group of people. Thus in Haile Selassie’s time there were many who were called kings. I, for instance, in southern Ethiopia have sat at a meal between the Buna king and an American Ambassador acting as the co-translator from the Buna king’s language to Amharic and then by me from Amharic to English. The king was there all powerful over his tribe even though by that time Ethiopia was a so-called democracy.

One of the kings under Haile Selassie was King Jafir II. His father King Jafir I introduced Islam into the Oromo people in the Jimma area of Ethiopia. The story as told from the Muslim and the Christian sides varies and isn’t of relevance to this article.

King Jafir II was born in 1861 and reigned as king 1878 to 1932. His palace although made out of mud still stands and is a major tourist site near Jimma. Unfortunately it is beginning to crumble.

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The king was a big man said to be over 7 feet tall.
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The open window is suitable for the average sized person; the closed one was specially built for him to look out over his kingdom!
Jafir collage
On the left you see an Ethiopian teenager sitting on Jafir’s chair. In the centre is his super-duper king-size bed. And on the right a double minaret-ed mosque which is just outside the palace.
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The outside of the palace. It has many rooms in part at least because he had many children. I have not been able to find a family tree for him but as a Muslim he was entitled to as many as four wives and many important people had even more.
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Children’s rooms were upstairs and the courtyard below for their pleasure both for personal involvement (eg in swordsmanship) and for watching various contests and acts.
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Overlooking Jimma city from the palace. Jmma is one of the larger Ethiopian cities.
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Jafir was king of a very fertile countryside – famous as the homeland of coffee.

I enjoyed my visit there.

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 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

 

 

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25 years ago. The school where one of our adopted children attended Solomon – the third teenager
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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 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.

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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.

 

Surgical teaching facilities

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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.

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This is the group in the adequate room at Jimma.

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!!

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This is about an average number of cases to be presented, assessed, and taught about each morning meeting. Note the doctor’s writing!

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.

Dominic Cartier

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