Medical Mission in Ethiopia: Week 7

Sunday, November 16, 2014

It is 05:30 in the morning.  I have been awake since 02:30am when Josh walked into our room, febrile and not feeling well.  He was ready for his next dose of Tylenol.  Yesterday he had his second febrile episode in as many weeks.  I freaked out (a little) and decided to bring him in to be tested for malaria.   For our $8.00 we were seen by the doctor in the urgent care clinic of the small hospital up the street, had labs drawn (CBC, malaria blood smear, typhus serum test), and were prescribed antibiotics for bacterial pharyngitis, probably strep throat.

But I digress.  The reason I am still awake is that there has been a continuous cacophony of middle-of-the-night prayers, broadcast over LOUD speakers.  And I mean cacophony.  I think I can currently distinguish about five different prayers and chants piercing through the darkness.   This has continued non-stop since I awoke at 02:30.  We were getting accustomed to the call for Morning Prayer every morning at 04:30, but this is beyond the usual.  Josh previously commented that he thinks many of the cantors should really have some voice lessons or at least some choir practice.  He is right.  I usually love religious chanting, but I think I have been spoiled with some quality cantors.  These men honestly sound like they have terrible indigestion.  A cow lowing is more melodic.  We live in an area called “Mosquite.”  It means Mosque.  There is one Mosque just down the street.  I think our usual 04:30 call for Morning Prayer originates from this Mosque.  Why tonight there are so many additional broadcast prayer “songs” and chanting I have no idea.  It is closer to 06:00 now and the normal sounds of a city waking up are being added to the ensemble.  The birds have started to chirp, twitter and caw.  Trucks and cars honk and rev their engines as they drive up our street.  The compound’s guard just tromped up the stairs to turn off the hallway lights and make his morning rounds. The broadcast prayers continue.

So, I am awake.  Josh has fallen back to sleep in my bed after his dose of Tylenol.  Mark moved to Josh and Sonja’s bed and they are both quiet, presumably sleeping through the concert.  I may as well take this opportunity to record my thoughts from the week.

One of the fistula surgeons came to Gondar Hospital on Wednesday.  Her name is Dr. Abaye. Twenty years ago she started her career as a fistula surgeon at the Hamlin’s Fistula Hospital in Addis Ababa.  In 2009, she and another fistula surgeon from the hospital started fistula centers in three university hospitals.  The non-governmental organization (NGO) that sponsors these fistula centers is called Women and Health Alliance International (WAHA).  Gondar University hospital is one of the three hospitals selected by WAHA.  The fistula center is remarkable in that it is clean, nurses appear more engaged in caring for the patients, and it is run relatively efficiently.   One of the fistula surgeons comes to Gondar every month.  In the interim OB/GYN residents admit patients who have obstetric fistulas.  The patients are often malnourished and sometimes have significant infections associated with their fistulas.  They are treated for their infections, nurses educate them about nutrition, health and hygiene, and they meet other women with similar situations.  Eventually the patients are seen by one of the fistula surgeons.  This week, Dr. Abaye decided to operate on eleven of the admitted patients.  Six on Thursday and five on Friday.  I took the opportunity to learn as much as I could from an extremely accomplished pelvic surgeon.  The residents were also eager to learn.

Dr. Abaye is indeed an accomplished surgeon.  She also loves to teach, to share her knowledge.  She wants the residents to learn this skill so they can at least repair basic fistulas.  She also wants them to know their limits and when to refer.  Several of the patients operated on this week were undergoing their second or third fistula repairs.  One woman had a vesico-vaginal fistula (a hole between the bladder and vagina) that was more than 5 cm wide and involved the trigone of the bladder, including the left ureter.  She needed partial ureteral reconstruction.  Another woman had a vesico-vaginal fistula that obliterated her urethra.  She needed urethral reconstruction.  Yet another woman had a vesico-vaginal fistula and an unhealed complete fourth degree rectal-vaginal laceration, she needed a rectal sphincteroplasty as well has a vesico-vaginal fistula repair. These women ranged from 17 years old to 25.  They all had similar stories.  Prolonged labors, usually days, followed by a vaginal delivery of a dead fetus.  Incontinence started several weeks to months after delivery, after the injured tissue became necrotic and finally gave way.  Most of the women were from rural areas, but some had given birth in local health centers.

Dr. Abaye’s eyes light up when she talks about her work.  She does not practice obstetrics any more, but she still talks about obstetrics with a passion.  “I love obstetrics!”  She talks about training urologists and obstetrician-gynecologists to do fistula repair work, but she feels that the work properly belongs in the OB/GYN field.  “This is an obstetrical complication, and obstetricians should be trained to repair these complications.”  She also thinks that urologists are not as accustomed to working through the vagina, they prefer to do everything from above.  Sometimes, surgeons don’t believe that the vagina can be repaired after such significant damage.  She spoke of her disappointment after a recent visit to a hospital considering whether to start fistula training, because the obstetrician/gynecologists were not interested.  But fortunately the urologists were.  “If someone is willing and eager to learn, I am happy to teach them!”  Ah ha!  This was my opportunity.  I asked about training foreign physicians…alas, her response was kind, but clear.  Although she is happy to show foreign physicians some of the complications and techniques, her focus is to train the Ethiopian residents who will be staying in their country to care for Ethiopian mothers.  In fact, she told me that even the Hamlin Center is no longer training foreign physicians unless they live in a country with a high incidence of obstetric fistulas.

Fortunately for Ethiopian mothers (and unfortunately for training purposes) the incidence of obstetric fistulas is significantly decreasing.   This is due to improved education and improved access to health care.  Every patient who stays in the fistula ward receives significant health education and then she is sent back to her community.  She is encouraged to testify about her own experiences.  She tells her community about the importance of receiving prenatal care and delivering with a trained health care practitioner.  The Ethiopian government has also constructed several new district hospitals with cesarean section capabilities.  There are now eight OB/GYN residency programs in the country, training more obstetricians.  Yes, this is a developing country, and it IS developing.  At times the development seems painfully slow, but progress is being made.

Another significant even this week was completing our first LEEP (loop electrical excision procedure) for cervical dysplasia.  On Monday late afternoon we screened a patient for cervical cancer with VIA (visual inspection with acetic acid).  She had obvious signs of a high grade cervical lesion and was a good candidate for a LEEP.  We asked her to come back the next morning for her procedure and she did.  The residents assured me that the LEEP equipment was all present and moved to the fistula ward.  Dr. Mulat wanted to move it there, because he thought the procedure should be done in an OR and that the fistula ward nurses may be more attentive with the equipment.   I decided to check the equipment myself prior to bringing the patient in the OR.   This brand new equipment, donated from Go Doc Go, had been attacked by rats.  Rats had gnawed through and severed the only electro-cautery connection for the necessary hand piece.   Those pesky rats had also chewed holes in the vacuum tubing.  RATS!  Fortunately I have a good relationship with the Biomedical engineering department, and the equipment was repaired in about an hour.  I then proceeded to discuss and demonstrate the procedure with the interns, residents and interested nurses.  Eventually we brought the patient back and very successfully completed her LEEP.  Hooray!  It literally took us 2 ½ hours to prep for the 20 minute procedure, but I was thrilled.  Thrilled that the procedure went well, and thrilled because the nurses were very interested to know how to set up and participate in the procedure, and then sterilize and maintain the equipment.  Tomorrow we have another LEEP scheduled.  We actually have three new patients who need LEEPS, but we only have one insulated speculum.  It takes about 90 minutes to complete the sterilization process, so one procedure in the morning and one in the afternoon is all we can reasonably complete.  I have emailed the Bioteque representative back in Issaquah to ask for some donated speculums.  I hope he is able to donate a few.  One of Mark’s work colleagues has generously offered to ship some small equipment in a care package.  I think the care package may include some Trader Joe’s chocolates as well…at least I hope that is what I overheard on a recent Skype conversation :).

It is evening now and the morning sounds of prayer have been exchanged for the partying music of another wedding in the Guest House reception hall.  The DJ has turned off his music, but that has not stopped people from singing traditional Ethiopian songs and dancing.  This music is fun.  It is very energetic.  The whole crowd knows these songs, and everyone chimes in.  There is usually a song leader, many of the songs echo back the song leader’s chants.  If we venture out into the courtyard we are usually invited to join the singing and dancing.  Ethiopians love their culture of music and dance, and they love to share it with us foreingees. It’s no use being shy.  Joining in is just what you do.  To decline would be rude.