Ward Round

We arrive on the ward and there is anxiety in the air. The nurse calls me over, she looks quite flustered. There is a young woman, second trimester, gasping. She still has a pulse but clearly about to go into cardiac arrest. She needs to be ventilated so I ask for the usual bag-mask-valve combo we use to ventilate in the first instance. The nurse is frantically looking through a cardboard box and not winning so I go and help; a tangle of old tubes and oxygen masks, covered in dust, but not the one we need, and it’s not a great surprise. Back at the bedside, things have deteriorated and I ask the woman’s sister to step aside. I ask for a bag of fluids to get things going, but there is no stock. We have a look through the notes, not much is known yet, maybe meningitis, maybe malaria, maybe a blood clot to the lungs. No investigations back yet, the lab is not working and blood gets sent across town for analysis. Her breathing is worse, I consider mouth to mouth, but that’s for the movies, and this woman’s fate is sealed. The pulse weakens and stops. Another doctor has come and tries some chest compressions, and I ask him to stop. A moment for collection and the ward team start preparing the body. A bandage used to strap the mouth closed, the body covered in a sheet, and a cardboard tag with her details tied around her left big toe. Another maternal death, unknown cause. I offer my condolences to the sister who seems remarkably calm. She must be shocked. The death of her sibling won’t sink in until later. The patient in the adjacent bed looks terrified; they’re only a metre apart and there are no curtains. On with the ward round.

A few moments to settle the nerves of said terrified adjacent patient. She cries whilst I hold her hand, worried she’s in the same boat. Fortunately, she’s on a different journey. She suffered with severe pre-eclampsia, the high blood pressure disorder in pregnancy. Her baby was born early and died the previous day. She has three, but wants two more. Fluid has built up in all the wrong parts of her body from the inflammation of pre-eclampsia, but most importantly for her in the lungs. I can hear the two puddles of water in the base of her chest. The SHO (obstetrics and gynaecology trainee) has arrived now and says they have asked the cardiothoracic surgeons for an opinion. It’s a blessing that they won’t come anyway, the last thing she needs is a knife. Her body should pass the water naturally over the next few days. I counsel her that she may need blood pressure medication when she goes home, and her next pregnancy will be very high risk. She will need careful antenatal surveillance in case this happens again, a service she unfortunately will not get. She’s going to get stepped down to the general post-natal ward now, a room with 40 mothers and crying newborn babies, and she will feel her loss.

I notice the catheter bag of a lady in the corner is a brownish red and suggest we see her next. She’s not looking well. She presented yesterday from another health centre after a prolonged obstructed labour at term, her first pregnancy. The baby had already died, and the operation notes suggest a very difficult Caesarean section. She is now semi-conscious and breathing very quickly, heart rate too fast, oxygen sats low, blood pressure holding. She’s either bleeding, or there is infection. No investigations, the family can’t afford the blood tests. She’s on some nasal prongs with a futile amount of oxygen trickling through. We get her on a more appropriate mask, and get another cannula in her arm. She needs some fluids, then I realise we have none. The woman’s mother is buzzing around, so the nurse writes ‘normal saline’ on a scrappy piece of paper and sends her to the strip of private pharmacies that line the hospital fence. ‘Free healthcare for all women and children!’ the government announced some years ago… I ask if we can check her blood sugar, but there is no glucometer available. I have my own machine, and one last testing strip. It’s low at 2.1, we give her a push of IV glucose. I’m half hoping it really picks her up; she stirs a little, but not much more.

We need to see what’s happening down below, why there is blood in the urine. The specialist gynaecology consultant has arrived now, thank goodness, he knows exactly what to do. But it’s bad news for the woman; the wall between the vagina and the bladder has been completely destroyed, a large fistula. The end of the catheter has prolapsed into vagina, and is draining a mixture of urine and blood and infection. We clean the area and there is clearly rotting flesh. The woman is in septic shock. With some basic plumbing we manage to get the catheter to stay up in the bladder. Back to treating the whole patient. The woman’s mother has returned with the fluids and we are into the second bag. We get some stronger antibiotics into her. More cleaning down below. Then the gurgling that I recognise, some fluid in the chest, we need to slow down the fluids. Everyone is working well as a team, despite the difficulty of the case and the conditions. The oxygen levels have come up, the pulse reduced a little. It’s the basics of medical resuscitation, it’s exhilarating and shocking all at the same time. Then things change, the pulse suddenly races to 210 beats per minute, far too high, a sprint that the heart muscle will struggle to keep up with. The adrenaline from the pain of the internal examination has probably shocked the heart into a short circuit. We continue the resuscitation, I’m hoping the rate will revert spontaneously, but it’s not budging and the oxygen level is dipping a bit. It would really help to know what rhythm she is in, but there is no ECG machine in the hospital. I start weighing up the options – difficult without knowing the rhythm. Some beta blocker? Some amiodarone? Would it be safe without monitoring? First do no harm. No chance of a defibrillating shock if she crashes, no defibrillator! Her salts could be abnormal causing the rhythm, but no way of knowing as the lab is not working. Probably wise to give some potassium and magnesium in case, low potassium will kill quicker than high potassium. We manage to get an anaesthetist from downstairs. She agrees, chance of harm if we start giving other cardiac drugs blindly, let’s give her some time. On with the ward round. Another woman has had a stroke from the high pressure of pre-eclampsia, another is swollen with fluid as her kidneys have completely stopped working. She needs dialysis which the family can’t afford, and she too will die.

I drive out of the hospital with that familiar feeling, a bit disconnected, a little overwhelmed, but knowing it will pass soon. Everyone getting on with life as usual out here. Those women are out of sight and out of mind. Maybe it would be different if we were at the heart of a humanitarian crisis, but this is a capital city in 2018. 2018! Do you remember how futuristic 2018 sounded? Hover boards? A meal in a pill? In 2018 a pregnant woman teetering on that fine line between life and death can’t get a bag of fluids and a basic blood test, whilst all the world carries on. One assumes that the health system they are working in is on an upward trajectory but a longitudinal view over some years makes me wonder otherwise. The funding and systems in place are deficient, creating a demoralising environment for the doctors and nurses that work tirelessly to make things better, indeed they are the strongest cog in the wheel. Families are not shocked, because this stagnation is an accepted part of life. The problems are systematic, and they come from the top. Whilst I stand by the philosophy of singing the good news stories, sometimes one feels the need to lay out the truth of what is really happening on the ground. It can’t be right. What on earth are you meant to do about it? Who does one shout at when we all know that method doesn’t work? Surely it’s wrong that we let pregnant women die of preventable causes well into the 21st century. Frustration and anger, probably not constructive, but important emotions, to write down and perhaps to share.

The woman in the photo is a generic image pulled from the internet.

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The tightrope of pregnancy in Uganda

Pregnancy is an uncomplicated business (in the medical sense at least..) for most women, most of the time. But when things go wrong, the situation can rapidly deteriorate putting both the mother and baby’s lives at risk; babies get stuck, mothers bleed both prior and after delivery, and many suffer a serious disorder of blood pressure called pre-eclampsia which can lead to fits and strokes. The avoidance of such grave consequences requires a tight system of antenatal surveillance and rapid sequence of action when complications arise. Whilst the health system in Uganda has the potential to supply each of the component parts of this system, they are weakly tied together, and elements of the chain may break due to basic inadequacies in infrastructure such as electricity and surgical supplies.

Each year we teach a two week of module of maternal, neonatal and child health which forms part of the East African Diploma in tropical medicine and hygiene (DTM&H). Seventy-two post-graduate doctors from both East Africa and around the world pass through and will expect an introduction to the practicalities of clinical medicine and research in sub-Saharan Africa. Each afternoon we take groups to meet women and hear stories which exemplify both the public health and obstetric challenges a woman may meet along the tortuous journey of pregnancy in Uganda. We make an effort to celebrate good maternal and neonatal care, as well as pick up on shortfalls. The cross-cutting themes include the impact of gender inequalities, educational background, and socio-economic components of care-seeking behaviour. Here are some of their stories. Names have been changed.

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A group of students on the 2017 course

Respectful care

Robhina is a 26-year-old lady, with a good educational background. Her first baby was born by Caesarean section due to obstructed labour; the baby’s head was simply too big for the mother’s pelvis, a common problem worldwide but even more prevalent where woman’s growth is stunted due to malnutrition in childhood. A vaginal birth is possible after Caesarean section, but must be done in a very supportive environment, and probably avoided in the context of pelvic insufficiency. Robhina laboured at home for a considerable time before going to a health centre IV, which should be able to provide blood products and a Caesarean section if needed. She continued to labour there overnight in considerable pain before it was clear she would need an operation. Unfortunately no doctor was there to do the operation and was transferred an hour across town to our facility which was overflowing. She was received in a very poor state and in agony. After another hour she was in theatre; her uterus had ruptured along the previous Caesarean scar and the baby was found floating free in the abdomen and already dead. She got the blood transfusion she needed and the surgeons managed to repair the uterus and avoid a hysterectomy (removal of the uterus). The team did a great job saving the woman’s life, but it was too little too late for the baby. We see around 4 of these ‘fresh’ stillbirths every day. Rhobina told her story totally matter of fact; she clearly had no idea that this was an avoidable outcome. So common are such stories amongst women that they are normalised. I asked her why she hadn’t come to the hospital sooner to deliver. It came down to the way she had been treated previously; talked down to, no privacy, scorned for complaining. Why not have a go at home with loved ones around? Explanations like these remind us that the respectful care of women is an integral part of future health system reform.

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Hearing personal stories provides context and a deeper level of learning (East African DTM&H 2016)

A new wave of medical disorders in pregnancy

Urban Africa is not only about empty plates. There is a rapidly expanding middle class with a taste for refined sugar, and a culture which associates large abdominal girth with higher social class. As a result we are beginning to see a rise in cases of diabetes in pregnancy. Doreen is 31 and has just had her third child. The first was delivered normally and weighed a decent 4.2kg. The second was even bigger at 4.8kg and needed to be delivered by Caesarean due to obstructed labour. Big babies are the hallmark of untreated diabetes in pregnancy; the high sugar level means the baby lays down more fat around the shoulders and abdomen raising the likelihood of complications at delivery. They also get so used to the high sugar and produce so much insulin that when they are born into the world their sugar level plummets which can kill. There is no screening for diabetes in pregnancy in Uganda. We do not yet even know which screening test would be best, or even what we would do if it was picked up as management is not straightforward and beyond the present antenatal system. As I spoke to Doreen the story of diabetes in her case was clear. This recent baby needed a Caesarean as there was not enough fluid around the baby (diabetes causes both too much or too little fluid). Her baby was wrapped up in sheets beside her and I see a tiny area of the sheet flickering over and over again in a repetitive way. I ask to see her 2-day old baby and sure enough the tiny girl was having a seizure, repetitively jerking her left arm up in the air. Doreen has no idea, and no doctor has been around that day. One junior doctor usually has to cast an eye over around 80 women and their new babies in the course of a morning. Few get a thorough check, and besides Doreen has no diagnosis. We take her baby to the special care unit for anti-convulsants; perhaps a low sugar level soon after birth could explain the fits, or infection, or low oxygen levels, we don’t know. Fortunately both are discharged a few days later, but the impact of the seizures and damage to the brain may not be realised until months later.

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The Maternal HDU (High Dependency Unit) during clinical rounds with Dr Anita Makins

Living with fistula

Ruth is 43 and has travelled from a very rural farming community. She has a coy smile and has the air of a once confident person who has suffered too much hardship in her life. She came to the hospital after hearing a radio advertisement. She had been leaking urine for twenty years having developed a vesico-vaginal fistula (abnormal connection between the bladder and vagina) after the birth of her third child. She laboured at home for three days before giving birth to a baby who had already died; she had been unable to afford the transport to get to the nearest hospital 7 miles away, a mere £3. The pressure of the baby’s head, stuck in the pelvis, caused damage to the tissues leading to abnormal tract formation. It’s a condition very rarely seen in the West, but still common in areas without accessible and affordable health services. Since that time she withdrew from village life, and farmed alone, hiding her shame from the community. Fortunately a supportive husband stayed with her, though many are not so lucky. Ruth has had decades to contemplate her fate, has come to terms with her condition, and is now happy that something may finally be done about it – surgical repair. Opposite Ruth sits another girl, with the same condition, but at the start of her story. She is very small, and looks incredibly shy. She is only 16 years old, but as I gain her confidence she tells me her story. Her first statement says so much; her family was not able to pay for her to go to school, so she stayed at home and became pregnant, totally matter of fact about the inevitability of such a chain of events. Again she laboured at home and got to the hospital too late. A dead baby was delivered using a suction cup in what sounded like an extremely traumatic series of events. She started leaking urine 6 weeks later, again due to injuries from a prolonged obstructed labour. She looked very vulnerable and alone, in a room full of women with totally avoidable internal injuries, victims of a world that still fails to recognise the equitable status of women in society.

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With Dr Ed MacLaren, my tutoring partner for the module, and one of the HDU nurses

The antenatal visit

Annett is a 24-year-old lady, a bubbly character with a broad smile across her face. She had given birth to a baby boy the week before and is overjoyed. Her first pregnancy had not been so successful; she had suffered high blood pressure which hadn’t been picked up in her antenatal visits. They didn’t have the basic testing strips for analysis of the urine, and blood pressure had not always been measured. She lost her first baby at 34 weeks of pregnancy. The staff encouraged her to get to antenatal visits early in subsequent pregnancies. Annett had the confidence and educational ability to speak up at her antenatal visits and demand the basics were done. She also had some money to get an antenatal scan – less than £10 which is far more than many can afford. As often happens she suffered with high blood pressure again. She came into the hospital at 26 weeks and was managed with medication for another 5 weeks to give her baby the chance to mature. At 31 weeks her condition was so severe that her baby had to be delivered, since the placenta is the cause of the blood pressure disorder. Her baby boy was taken to special care unit. On the first day Annett showed me pictures on her phone, but the next day took me to see him in the neonatal unit. Seventy similar babies were lined up, many with NG tubes in their noses, their mothers expressing milk and pushing it down the tube with a syringe. One doctor has the job of looking after all these delicate beings. Annett tells me all about what she does several times per day for her baby, and in immense detail. This is a mother’s love and casts out the common attitude of ‘just another stillbirth, or just another neonatal death.’ Annett and her baby had received great care, using basic principles of medicine. But she only got there because she had the educational and financial means to transcend the gaps in the chain, a privilege of few. Four young women, one just 19 years old, died of this high blood pressure disorder in our two weeks on the unit this year.

They are morbid stories in themselves, but more frightening is the sheer number of similar stories that are told every day, even in this one hospital. An old friend presented me with an audit of the women’s health service in the same hospital from 50 years ago, 1967-1968. Each maternal death is detailed and the stories are hauntingly similar. However much we try to champion good progress in sub-Saharan Africa, with health statistics improving year on year, it’s hard not to feel like the two worlds in which I spend my time are moving further apart. Whilst total average worldwide wealth improves, the inequities both within and between nations are worsening. It’s easy to be paralysed by the enormity of the problem, but inertia is far from an effective solution. Sharing stories like this will not change the world, but the least one can do is advocate for those without a voice. It may at least help in appreciating the excellent standards that our National Health Service affords our women and mothers.

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The 2017 contingent graduating in the gardens of Mulago Hospital

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Tutor group on the 2017 course

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A group on the 2016 course

Landing in KwaZulu Natal

Word on the street is that the blogs are too long. In fact word on the street is that, generally, when I talk or write, I bang on for far too long. That is a lifetime’s worth of advice that I have refused to take any notice of. Here’s to a new start.

I’ve been in South Africa for 6 weeks now, tucked up on the north coast of KwaZulu Natal, the countries most Eastern province. Cue map. I’ll be spending a year working in a very rural hospital which looks after an entirely Zulu population. We have no specialists here. Each of the 12 doctors is a generalist and expected to cover all departments – medicine, surgery, obstetrics, paediatrics, psychiatry etc etc. Everyone knows a bit about everything and gives it their best shot. There are no doubt going to be some sweaty moments..

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The largest burden of disease in this area by far is HIV. The prevalence, so the proportion of people infected with HIV, is the highest in the world at 35% – down from 43% a few years ago. I’ve spent a good deal of time over the last couple of years learning about HIV and treating patients with the disease but only now are the stark realities of the epidemic really becoming apparent. Most of my medical ward are suffering with the complications of HIV and unfortunately our patients often come late and there is sometimes little we can do. I won’t get too dark too early, and I’ll probably leave it there for now. For 5 minutes on the subject with yours truly being a bit melodramatic see a recent video blog I posted a few weeks ago – HIV: are we winning?

https://www.youtube.com/watch?v=jYdgfOkeXuE

It’s been brilliant to spend time working in the other departments as well. My other passion besides tropical medicine is maternal health and I’m spending a lot of time in the obstetrics unit and doing some Caesarians and removal of ectopics in theatre. I must share a truly wonderful moment from Friday morning of my second week here. I was operating on a lady with a large baby who had gone into obstructed labour. The Caesarian is done under spinal block so the mother was awake and conscious. As we proceed she began singing in Zulu, and it must have been a well known song as all of the theatre nurses joined in, rich African voices, off tones and harmonies. All were singing as I cut through the uterus and found the baby. It was no easy job delivering the head and a couple of manoeuvres were required but the baby finally came to a crescendo of voices. I was relieved to say the least as the baby cried. I had goose pimples and thought ‘do you know what, this is f*****g brilliant’. A beautiful experience.

I know it's an indulgent photo and yes that is a shoe cover on my head

I know it’s an indulgent photo and yes that is a shoe cover on my head

My first night shift in the casualty department fell on my first Friday, doing what you can with whatever comes through the door. The fun started as a 20 year old man was dropped of by the police, naked and covered in blood, collapsed on the floor with a bushknife wound to the back of the neck. An artery had been severed and he had clearly lost a lot of blood, freezing cold with a feeble blood pressure requiring may litres of resuscitation fluid. He had a tattoo across his chest with the words ‘Not Guilty’… An hour later he was talking again. A brief history revealed the cause to be an argument over a girl, as standard. Not long after another young lad was carried through the doors with a gunshot to his leg. The wound was not to impressive but the shin had lost all stability. An X-ray revealed the true extent of the damage, both shin bones shattered. A bit of a clean, some strong opiates, a bandage, and a nice referral letter to the referral hospital 3 hours down the coast. The leg would need extensive surgical exploration by the specialists. The story behind it? You’ll never believe it, a tiff over over a fair madame, not far off a femme fatale.

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It’s not all medicine, we’ve already had a couple of trips to the Indian ocean which is lapping at the sandy beaches just 5km away. The surfboard has had a couple of trips out, but nothing major to report with the winds blowing out the swell, as is typical of the August season, but the snorkelling has been sensational. First trip to Mozambique lined up for next weekend. So there it is, as short and sweet as I can possibly make it. You’ll notice a recurring theme in the ailments I have described, the HIV medicine, the obstetrics, the trauma. It all comes down to one thing. Be kind to us girls, we get over-excited.

Kosi mouth

Kosi mouth

Black Rock

Black Rock

Tembe elephant park

Tembe elephant park

Full moon brai at the mouth

Full moon brai at the mouth

Crossing the channel when the rope has snapped

Crossing the channel when the rope has snapped

Crested guinea fowl

Crested guinea fowl

A complicated business

The Facing Africa Team

The Facing Africa Team

Finally pulling their weight. Sorry, couldn't help the caption... They pulled their weight all week

Finally pulling their weight. Sorry, couldn’t help the caption… They pulled their weight all week. This was Bill Hamlin’s (right) TENTH mission with Facing Africa in Ethiopia as head anaesthetist.

As soon as they were here they were gone. A big thanks to the surgical team, primarily coming from Great Ormand Street, for all their hard work over the last couple of weeks. Thank you for giving up your annual leave and private surgical lists and working for free. It was a busy week with two theatres performing more than 30 operations. It was a stressful couple of weeks for the patients who were watching each day as more of their friends were taken into the unknown. A little disconcerting when you still have your scheduled op and your friends come back swollen, in pain, and dribbling a mixture of saliva and blood.. Some of the operations performed are at the forefront of surgical technicality. The techniques are far from perfected and complications do arise. The next few days are critical in the long term success of the operations.

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Hiroshi Nishikawa and Anthony MacQuillan on the left – the plastics team. David Dunaway from the maxfax team on the right

It has been amazing to see some of the transformations that have occurred. Ayesha is about 15 and been confined to the house all her life, with a clamped jaw and a non-existent self-esteem. Today she looks another person, and she seems like another person too as she sits with the other children. The graft from her arm is healthy and she is looking at a different future than she had before her a couple of weeks ago.

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Ayesha – second from right – on the mend

Unfortunately this isn’t the case for all. Bekalich is about 25 and from South Sudan. She has three children including an 18 month old baby who is now in our care. There was some discussion as to whether a major reconstructive operation would be appropriate in her case; she was still breastfeeding a dependent infant; she was very slim with a BMI of 14; she had achieved important life goals of marriage and children; and she didn’t cover her face in her home village. In the end she went to theatre to have a forearm graft to replace her facial deformity. The first concern was the baby. The child was malnourished and not behaving normally for an 18 month old baby. He would cry whenever he was taken from the mother, at which point she would scoop him back up into her arms and to the breast, signifying attachment issues. The child would not take any interest in the world around him, and wouldn’t even react to loud noises. In the UK this behaviour would immediately be flagged as secondary to neglectful abuse. He received no stimulation from the mother. She did not play with or talk to the child who just sat silently in her arms. The child did not crawl and made no effort to move, and there was hardly any muscle mass on the legs. The child was socially and developmentally delayed, most likely secondary to the social exclusion that her mother has suffered due to her defect. Most obvious was that the child didn’t smile. His mother’s facial disfigurement was such that she couldn’t smile herself and I suspect this child had not had contact with many other people in his short life. We would look after the baby during his mother’s operation. We saw this as a valuable opportunity to feed up and stimulate the baby.

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Almost two weeks later and we are looking after a different child. This is due to an amazing effort by all the nurses and the patients here who has been stimulating the child around the clock. It has seemed like bullying some of the time but with positive results. As I look down the gardens I see him sitting up on his own. He is playing with a ball and moves onto his front to crawl at his own accord. I run down to get a closer look. I tickle him behind his ears and he squeezes his mouth together into a pout. We all tickle the baby a bit more and to our amazement a huge smile spreads across his face, milk teeth and all. This is the first time the baby has ever smiled, you can imagine the elation. As you would expect we kept tickling him until he cried…

The original version of this blog then went on to outline what has happened since. I must admit that the version I originally posted probably crossed patient confidentiality boundaries. As such it has been moderated. However the dilemma is till the same – what happens when advanced technology meets those that are not understand the basic principles of modern medicine, and how can one possibly obtain informed consent? This is an issue that the surgeons here are constantly debating. It behoves Facing Africa to be self-critical of their own work, a responsibility that I feel they take up with great wisdom.

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Right then onto the fun stuff. First of all it’s your favourite section – BIRDING NEWS. Two weeks ago saw the construction of a new bird table, FAs first foray into the world of conservation. It has to be said that the table was not built exactly to the specifications and design that I had drawn up, but TIA and it works. It took a couple of days for our beaked buddies to work up the courage to visit, but now they can’t get enough of the stale crumbs and dirty water. Here are a few of the highlights.

A Ruppell's robin-chat pays a visit. Acts like a robin but interestingly not actually in the same family as the well known red-breast

A Ruppell’s robin-chat pays a visit. Acts like a robin but interestingly not actually in the same family as the well known red-breast

If you see a flash of iridescent blue then it's probably our metallic friend the blue-backed starling

If you see a flash of iridescent blue then it’s probably our metallic friend the blue-backed starling

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A small siskin sitting in a tree

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Photographed AT LAST – the elusive white-cheeked turaco in a rare moment of stasis. In flight this turaco reveals brilliant crimson patches beneath the wings.

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Not a bird. Sue took us on a lovely walk to investigate these rat-like meerkat type animals. Anyone know what they are?

Last week also saw the first bonfire party for the kids (and mainly the adults). Coca-cola, crisps and chocolate, and very distorted music playing very loud on a speaker that was too small and couldn’t cope. One child was sick within an hour from excitement and was found with chocolate stuffed away in all her pockets and then cried at the end because whe was over tired, a ubiquitous occurence all over the world at this type of event. Here’s a who’s who of the night. Well done Julia and Sue for some inspired packing of animal onesies..

All smiles from the team, blood sugars rising rapidly

All smiles from the team, blood sugars rising rapidly

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Two of the children get this classic party game going. You’re meant to balance, not hold, the pillow on the head.

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Nurse Meron forcing a smile having expected to come onto a nice quiet night shift. Hands up if you’re at least two fantas down!

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Carnage on the dance floor

"There's nothing I like more than a strong gin and tonic and a dance with a young man." Julia Whiting - Feb '14

“There’s nothing I like more than a strong gin and tonic and a dance with a nice young man.” Julia Whiting – Feb ’14

Hanging out with the seniors

Hanging out with the seniors and Midiwe who stuffed her chocolates in the piggy bag

My two friends

My two friends

The surgical team arrives

The surgical team have now been in Addis for a week and the first of our patients are beginning to come back to our Cheshire home, typically with a swollen face and a fragile sense of humour. On Tuesday I was in theatre getting a sense of what our surgeons do. I was with Ayesha, a 15 year old girl who has a large noma defect on the left side of her face, and a jaw clamped shut. The extra bone that was formed between the facial bones was removed and the jaw released. This was overseen by the most brutish of the lot, the ENT surgeon, with a hammer and chisel. It’s a different experience watching this when you’ve had three weeks to get to know the patient.. This discomforting feeling was balanced with a sense of elation around the theatre as the mouth was opened, for the first time since Ayesha was a small child.

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The plastic surgeon then started work on the right forearm. A large flap of skin was dissected, as was the large radial artery, with a few of the muscle tendons that would be used later. The flap was then lifted off of the arm and put over the hole that was left in her face. Meanwhile the maxillo-facial surgeon had been dissecting the neck to expose the carotid artery and jugular vein. The artery and vein from the forearm flap were then threaded from the face and down into the neck. Then the microscope is brought out for the fiddly bit. The radial artery of the flap was sewn onto one of the arteries in the neck to give the new flap a blood supply (the superior thyroid artery in this case) and the vein of the flap was plugged into the vein of the neck so blood from the flap can drain. The needles the surgeons use are almost invisible to the naked eye, the calibre of the vessels being just a millimetre or two. The clamps were released and we all watched to see the flap come alive. A carpentry-like tool is used to raise a skin graft from the thigh to cover the donor site on the forearm. She will inevitably be left with a large scar here. Everyone got sewing again and the 9 hour operation was complete. However the healing is just beginning and the next few days are essential. Not all free flaps like this will survive.

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Dissecting the radial forearm flap

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The flap is mobilised and ready to be grafted to the face

Ayesha was an excellent candidate for surgery. She is young and will benefit a great deal from the functional and cosmetic improvement. However this week we said goodbye to some of our friends. Due to various reasons it was not appropriate for them to undergo a major operation.

GOODBYES

Kadyash is probably about 40 years old. Out of all of our patients she probably has the worst facial disfigurement cosmetically. Her face is dominated by protruding gums and teeth. She doesn’t have a nose and the left eye socket is destroyed. The outer third of her tongue has dried and keratinised and acts as her lower lip when she eats and talks. What is naturally surprising to us all is that she has three children, as does another patient with a large disfigurement about whom I have written before. As I examine the rest of her body I discover her heart is beating hard in her chest, and she complains of some chest pain when she walks too far. Her blood pressure is slightly raised so I order an ECG and she indeed has heart disease secondary to untreated blood pressure. This is an increasingly common cause of death in adults from the age of 40 in sub-Saharan Africa. It’s unclear whether she is fit for a large operation. Back at home she would have more cardiac investigations, but out here we can’t trust the investigations that are done. I sit down with her and have a long conversation, long for two reasons 1) because there’s lots to talk about and 2) because we have to go through two translators. She has come a long way, a three day journey from South Sudan, and has got her hopes up for an operation that will change the course of her life. Instead of telling her she cannot have an operation I give her the information that will let her make the decision by herself (this is a form of manipulation that doctors use on you every day). Although we would have loved to have helped with her appearance there was a risk of orphaning her three children. Once this was made clear it was a no brainer for her. Although she does indeed have a large facial defect that is amenable to surgery, she has lived with it all her life, learnt how to talk and eat, and completed important life goals such as having children. Unfortunately there is no room for cardiac follow up after her discharge. Her heart condition will deteriorate over the next 10 years, but she would have lived to the average life expectancy for rural South Sudan, and produced three children. There are times to interfere in the natural course of people’s lives, and there are times to keep clear. When importing high-tech surgical services such as these, it is essential not to abuse the temptation to do too much. Kadyash is an amazing woman. Although I’ll never get my head round the life she has lived, we’ll never forget her bashful smile.

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Julia and I saying farewell to Kady

Chot is about 30 years old and also from South Sudan. He came along with most of his upper lip destroyed, but good maintenance of jaw function. He was due to have an operation on Tuesday. The surgical team had planned to use part of his bottom lip and move it round to make a top lip. Before arriving at the hospital I had been informed he had refused to sign his consent and I was going to talk to him to find out why. Unfortunately on arrival I was asked by one of the management team to ‘work my magic’ and ‘persuade him to have the operation.’ The other two cases in that specific theatre had been postponed that day and there was apprehension about a potentially empty list. I went to talk to Chot, who was in a state of terror. It seemed that the shift from rural Africa to a private hospital had been a bit much. As we talked I found out the reason for his refusal. He said that although he wanted a new top lip, God had made his bottom lip perfectly, and it was not his right to undo God’s good work. This wasn’t meant flippantly, he meant it absolutely. This man’s religious beliefs had not been taken into consideration. Fortunately he was allowed to make an informed choice. He left the next day for the long journey home, disappointed, but having been allowed to make the choice that was right for him, and importantly, not us.

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Some of our patients help loading up the surgical equipment

Agino is a 24 year old lady from Bahir Dar, 10 hours north of Addis. She has had a large soft tumour growing on her face for the last 5 years. She covers her face at all times in public. She has an unusual case of venous malformation, the tumour made up of veins full of blood. Her relationship with her face is a little different from our other patients. She has grown up with a normal looking face, her fortunes changing having reached adulthood. Adversity and stigmatisation are not things she has grown up with but are new players in her life. Unfortunately our surgeons here are not able to operate on this condition. The risk of bleeding in this environment is too dangerous. The preferred treatment is ‘sclerotherapy’, injecting a caustic agent into the feeding veins to close them up. It’s a pretty specialist procedure carried out usually by interventional radiologists. It appears that there is no service available here in Ethiopia. So what do you do when a lady like this comes under your care? What I have done is probably a little naive. I promised this lady that I would find a way of helping her, before doing the research as to what it may involve. It’s not the first time someone has got carried away in a consultation, but it’s done now. This lady will probably need to travel abroad for private treatment in a specialist centre and she doesn’t have any money. So this is your first warning for a future fundraising campaign. Hopefully by exposing my promise I will be further motivated to make it happen, such is the power of accountability. If you know any interventional radiologists, get in touch! She is happy for me to use her photographs to appeal on her behalf.

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Now I know for a fact that some of you grudgingly wade through the medical stories to eventually get to all the latest birding news. Some of you are open about your passion, some of you remain securely in the closet. However I must tell you that bloggers get a lot of stats about their page and I can tell exactly how long each of you stares at the birding section. I know who you are. Here’s a few shots to get you through the week. Get ready for a bumper edition next week as we review the construction of a new bird table!

With a tail length that Chaucer would be proud of, it's the speckled mousebird!

With a tail length that Chaucer would be proud of, it’s the speckled mousebird!

A Grivet monkey, closely related to the East African Vervet

A Grivet monkey, closely related to the East African Vervet

Menelik's busbuck, this time the female

Menelik’s busbuck, this time the female

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Three common waxbills sitting in an Acacia tree

Out and about in the rural highlands

Out and about in the rural highlands

A human boy

A human boy

Who gets surgery?

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Today we will welcome the surgical team to Ethiopia. They are comprised of the UK’s most skilled and experienced maxillo-facial surgeons, anaesthetists and theatre nurses. They flew overnight and will drive straight to our Cheshire home where we will present the medical and surgical details of the adults and children to whom we have grown so close over the last two weeks. The questions on everyone’s lips is ‘who gets surgery, and who doesn’t.’ The anticipation of the patients is immense. Most have been living with this stigmatising condition all their life, and here was a dream opportunity to have it fixed by the best surgeons in the world, and for free. Some have travelled across borders, having never left their home village and surroundings. They have spent two weeks meeting others who have seen the benefits of surgery, talking about the new life that awaits them after an operation. Unfortunately not all cases are amenable to surgery, and not all the cases have been caused by noma. Some of our patients are inevitably going to be let down.

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Bekalich who feeds us every day

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The girls having fun

Who would you choose between these two cases?

Deshio is from South Sudan. She doesn’t know her age but from the profile of the unaffected side of her face she looks about 25. The damage to the left side of her face is extensive. The whole upper jaw has been destroyed and I can see deep into her oral cavity and the long tongue extending to the back of the throat. The roof of her mouth has also been destroyed and clearly in sight are the moist spiral conchi of the inner nasal cavity against which the tongue rests. It reminds me of the faces that have seen dissected for display in the anatomy demonstration lab, except the parts of Deshio’s inner face move as she talks. I am fascinated from a scientific point of view, but the face is unattractive. One would think that this woman was outcast from her village but in her arms is an 8 month old baby, and by her side is her husband, a striking tall man with a face covered in beautiful tribal scarifications. I take the history through two translators. I want to find out about both the functional impact of her injury, and the social impact it has on her life; she can eat everything normally, including solids; she has no trouble speaking or breathing; she is accepted in her village and does not cover her face; she is married and this is her third child; her primary concern is the aesthetics of her defect. She is likely to need a series of four major operations to repair the damage. We must consider that with four major operations there is a risk of leaving her three children orphaned in rural South Sudan. It seems like she is achieving a lot of her life goals, but the people have donated money to treat Noma, and here is a classic case.

Mascaram is a 17 year old girl from Northern Ethiopia. She has had a disorder of the jaw since birth. Her lower jaw, or mandible, has not grown in the normal way and remains very small in comparison to the rest of her face. The jaw does not function properly and is clamped shut but for about 3mm of movement. She’s only ever been able to eat a soft diet, hence a remarkably low BMI of 14.0. She is not married and has no children. When asked if she suffers bullying she becomes visibly upset. This disorder has plagued her childhood, and now it’s stopping her in all the social discourse that make up the transition into adulthood. An operation could successfully open her jaw, but previous experience shows that without quality post-operative jaw physiotherapy the jaw is likely to clamp shut again. Do we know this girl well enough to ensure she performs daily physio in the community with no professional follow up? An operation could change this girl’s life, giving her all the opportunities of marriage and children that may otherwise be out of her reach. However it was not noma that caused this jaw defect, and the money we are spending was given to us on good faith for the treatment of noma. The typical face of noma seems to generate a lot more money than a picture of a small chin.

These are the sorts of decisions that await our surgeons and anaesthetists later today. Between them they have many decades of experience, and for many this is a return trip with Facing Africa. We trust they will bring all their wisdom to the meeting. Let’s hope they got some sleep on the flight.

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Julia, Sue and Gez, covered in holy water (they claim..)

We continue to enjoy life at the Cheshire home. Last weekend Ethiopia ground to a standstill to celebrate Epiphany. There is no doubt in any of our minds that The Ark of the Covenant does indeed rest in Axum! Julia and Sue went into Addis to experience the celebrations and were covered in holy water. They even bought some back in a bottle for me. Here’s some of their photos from the day.

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There has been lots to explore in the surrounding area. There’s normally time for a walk in the evening around the farmlands that encompass us here, and time to meet some of the locals. Meetings comprise of two of three words of Amharic (impossible language…), several round of handshakes, and lots of smiling. There is nothing to complicate the simple experience of human beings spending time together, from different worlds, enjoying each other’s company.

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“There’s nothing I like more than a gin and tonic and a roll around in the hay.” – Susan Criswick, January 2014

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No pictures of birds yet and I can feel the birders getting twitchy. Pictured here is the stunning blue-breasted bee-eater, the most agile of birds in flight, with the distinctive ‘click’ as an insect is caught. Below our colourful friend are a pair of timid Erckel’s francolin, caught sneaking about during an early morning stroll.

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Blue-breasted bee-eaterImageA pair of Erkel’s francolin

I’ve been having a wonderful time with Julia and Sue, and I’m glad to hear that their friends and family have started following the blog. They are both very special people. Their kindness and energy is an inspiration, and there is hardly an hour that goes past when we are not all laughing together about something. I couldn’t wish to be here with two more joyful people. Slushy stuff over..

Many thanks to Julia who must take credit for all of the photos that I’m including in the blog.

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Noma – the face of poverty

The view from our home

The view from our home

Noma, or cancrum oris, is a disease that exclusively affects the poor. It disappeared from Europe around 100 years ago although there were sporadic cases during the two world wars. It is caused by an infection arising in the mouth, usually starting as a benign gingivitis. Children who are malnourished do not have a strong enough immune system to fight the infection. The bacteria spread into the skin, muscle and bone of the face, causing a gangrenous infection. Most (about 90%) of these children die, either because of overwhelming infection or because they have lost the function of the mouth and are unable to feed. Those that survive are left with defects affecting large parts of the face. The healing process is particularly fibrotic, and the jaw is often left clamped shut.

An example of Noma

It would be unfair to post a picture of one of our patients but this photo is taken from our website as an example of noma.

Derrn, an 18 year old girl from Somalia, is one of those that survived the infection as a child. The wound she was left with affects the majority of the left side of her face. As I removed her head scaff to examine her the first thing to hit me was the smell. Instead of a cheek I found a disordered mass of gum and teeth protruding, covered by opportunistic fungal infection. The lower half of the left eye socket has been destroyed and the globe of the eye was falling forward. The cornea of the eye is scarred and she is blind from that side. The jaw is clenched shut. I asked how she eats, and I am shown where teeth have been removed to allow her to squeeze in what she can, something she’s been doing since she was four. As doctors we see many gruesome things, defects of many different parts of the body, but when a face is affected to this extent, it affects you in a different way. I’m not ashamed to admit that I made an excuse to sit down for a minute, write some notes, and compose myself, before continuing with the examination. There is no other word to describe how you immediately feel looking into a face like that – you feel revulsion. The doctor’s office is often a stage, and I acted as best I could, but I think Derrn could sense how I had been affected, because she has sensed that revulsion in every person that has ever looked at her face, as long as she can remember. She has never been allowed to leave the house and she’s painfully shy.

The treatment for Noma is complex and expensive maxillo-facial reconstructive surgery. The is no condition that poses a greater challenge to the surgeon and anaesthetist. Intubation is often nasal, using fibre optic guidance. The condition occurs in countries with limited medical resources, and affects those with no money themselves for private care. As such the condition would remain untreated if it weren’t for niche NGOs. I’m in Ethiopia with ‘Facing Africa’, an NGO based in the UK which has been working here for around 6 years. They do three missions every year, treating about 30 patients per mission. The cost is about $3000 per operation. Complex cases may need around four operations. I am working at the opposite end of the care spectrum from where I am comfortable. My interests lie in widespread cheap measures which prevent disease, rather than expensive specialised measures which treat the condition in a few. But the argument supporting NGOs like Facing Africa is strong. As long as there are people suffering with the condition, there is a need, and the charity make all their own money for this particular condition. This argument is strengthened when you meet those with the condition, those who are suffering at the extreme end of the human condition. I look forward to seeing how my opinion of NGOs like Facing Africa change during the months I am here.

Kids at the Cheshire Home

Kids at the Cheshire Home

A morning game of football

A morning game of football

We are based about 30 miles West of Addis Ababa, in the arid highlands about 2,800m above sea level, and you can feel it on the incline. It’s a beautiful setting, with fantastic views across the highlands. Mornings are fresh and clear with fog filling the valleys. There’s an abundance of wildlife. We share the compound with a troop of black and white colobus monkeys, a giant tortoise, Menelik’s bushbuck, and some wonderful birdlife. We are guests at a Cheshire rehabilitation centre. Lionel Cheshire was the husband of Sue Rider and set up the homes in order to look after unfortunates. Many in the developing world care for children affected with polio. Here in Menagesha we are guests of around 50 children who are proud to show off their various limb prostheses, donated wheelchairs and crutches. You can hear them playing and laughing wherever you are; one legged football, wheelchair races, table football, the girls in circles making crochet. They are an inspiring group and fill the air with a feeling of strength against adversity, a feeling which is beginning to rub off on our patients. It’s a pleasure again to be living in a community dedicated to the care of the under-dog.

One foot in the rave

One foot in the rave

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Meneliks bushbuck, male

We get the feeling that we are living as part of this community, not just coming in to work. The psychological care of patients with Noma is just as important as the surgical care. We are living each day side by side and it’s amazing what progress has been made in a week. A few days ago the patients stood by themselves, a state which they are so used to. Some had never met another person suffering the same condition, and thought they were the only ones, in isolation. We have watched the friendships grow, and now there is just as much laughter coming from our side of the Cheshire compound. A huge part of this is down to the enthusiasm of the two nurses who have also come from the UK, Julia and Sue. Both from Dorchester, and their first experience of Africa, they’re taking it in their stride; big games of football and frisbee, colouring books, dancing, smoothie making. And who would have thought it – birdwatching. I had packed the binoculars and extensive field guide ‘Birds of the Horn of Africa’ for personal nerdish indulgences only, but they’ve been a real hit. Everyone’s into it. Many were new to the concept of binoculars, especially our desert dwelling elder Hassanbule from Somalia. He shrieks with laughter and flaps his hands to mimic the bird he has found down the eye pieces. The birdlife is rich. Highlights include this small forest goshawk, the white-cheeked turaco, and the male African paradise flycatcher, photographed here in breeding plumage, it’s white tail feathers perhaps five times the length of the body.

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Lesson 1 – Principles of identification

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Forest goshawk

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Male African paradise flycatcher, in full breeding plumage

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Whilst the boys play football

The other nurses are Ethiopian born and trained, and an absolute pleasure to work with. All the Ethiopians we have met are kind and gentle. They are elegant and smile easily, and keen to fill us with extremely strong coffee at every opportunity. The famous coffee ceremony is often put on. The fresh beans are roasted on a hot plate for all to smell, then crushed. The coffee makes three rounds – arbor, bereka and toner – starting strong and becoming weaker. The situation sums up what I have seen of Ethiopian culture – the ceremony seems to have Arabic roots, whilst the humour of the conversation is classically central African. It’s a beautiful and rich mix of influences from the north and the south.

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Our beautiful nurses – Merron, Marima and Aden

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The coffee ceremony

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Nurse Merron with Midiwe who had flap taken from her back last year to repair the defect which affected the left part of her face. Due for her next operation next week.

We have just 9 patients so far so things have seemed a little quiet, but there is no better opportunity to enjoy being part of delivering proper holistic care. This is a privilege not often afforded to the doctor, particularly not in the UK. Yesterday was epiphany and many patients would not make the journey until they had celebrated with their families. We are expecting 6 new patients traveling from South sudan today, and perhaps another 10 at the weekend, when the surgical team arrive, at which point the real work begins.

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Fosier, the guardian of one of our patients.

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Getting the hang of it and going solo