Lake Langano, the Simien mountains and a little bit of work!

I have been back in Ethiopia for four weeks now and feel that I have settled back into the very different way of life.  The ‘short’ rains are supposed to come in March and April, and we certainly had some spectacular storms when I first returned.  Unfortunately (but perhaps not surprisingly) the storms bring long power cuts.  It has been much sunnier and less wet over the past week, and I have enjoyed several hours in the sunshine on the balcony this weekend.
 

It was really good to see Helen again when I arrived back in Addis Ababa – she had flown to the capital on the same day in order to travel to Lake Langano for the VSO-Ethiopia annual conference.  The timing of the conference was great for me as it provided a gentle transition back into life here.  It was lovely to catch up with the volunteers who arrived with me in September and also to meet new people.  It was good to learn about the work that others have been doing and reassuring to hear that other health volunteers are facing similar challenges to me.  The setting by the lakeside in the Rift Valley was very tranquil and I think everyone appreciated the chance to share experiences away from their placements.

 

Beachside at Lake Langano

I travelled back to Haramaya with Helen and had a weekend to settle in before returning to work.  I brought back quite an eclectic mix of things from the UK – stickers to help organise paperwork at work, a HDMI cable to connect our laptops to the television, a pan brush, an Easter chick-making kit for Helen, a chick biscuit cutter, a large fabric planter for the balcony (together with seeds and plastic spade!) and plenty of chorizo.  I think Helen enjoyed making the pom-pom chicks and we had fun decorating some Easter chick cookies.  My colleagues were quite bemused by the icing and silver balls!  The seeds have now germinated and I hope to be able to harvest some salad leaves in a couple of weeks.

Easter celebrations!

I was apprehensive about what I might find when I returned to the hospital but was really pleased to see that the neonatal monitoring charts and medication charts that I introduced are still being used.  The patients are certainly receiving closer observation than when I arrived, perhaps in part due to my influence but mainly because of the arrival of the medical interns about six months ago.  I have formulated an action plan for the next four months which includes re-auditing neonatal hypothermia and looking at neonatal outcomes again.  I will continue to teach the clinical medical students, and will deliver the neonatal lectures to the second half of the 4^th year students.  Next week I plan to present the cases of two babies with bowel obstruction who died post-operatively to a joint paediatric and surgical meeting.  I will outline the ways in which I feel the care could have been improved and suggest strategies to achieve this. 

 
I spent just over a week at work before heading north for a three night trek in the Simien Mountains.  One of the other VSO volunteers had friends visiting from the UK so organised a trip and asked if I would like to join the group.  There were ten of us in total and we had a fantastic time.  I hadn’t realised just how spectacular the scenery would be and we were fortunate to see lots of gelada baboons, as well as the rarer Walia ibex and much rarer Ethiopian wolf.  We walked about 40km over three days along dramatic escarpments.  There are more than a dozen peaks over 4000m in the national park – we climbed to 4070m and luckily none of us suffered any significant effects of the altitude.  The nights were cold under canvas but the days were hot and sunny.  We all finished looking much browner than when we started, a healthy mixture of dirt and tan!

Dramatic rock formations

 

On top of the world!

Gelada baboons

Two Walia ibex (look closely!)

My focus has now returned to the hospital although Helen and I hope to have another trip away over Fasika (Ethiopian Easter) at the beginning of May.  I will be in touch again soon with news from Haramaya.

It's chilly!

I find myself unexpectedly back in the UK having sustained a needlestick injury at the hospital a couple of weeks ago.  Unfortunately this has meant taking medication to reduce the very small risk of HIV transmission.  The medication can be associated with significant side effects and this, together with the need for a bit of emotional support, led to me returning home to complete the 28 day course of treatment.  Fortunately I have remained well and it has been lovely to catch up with family and friends.  I plan to return to Ethiopia in mid-March and will keep the blog updated with my progress.

A very belated happy new year!

I apologise for the lack of a recent blog update - January was a busy month!

We had a very enjoyable Christmas Day complete with roast dinner, Christmas pudding and festive films.  Much to Helen’s delight, we were able to enjoy a second Christmas as Orthodox Christians celebrate the festival (‘Gena’ in Ethiopia) a couple of weeks after us.  We were invited to spend the day with one of Helen’s colleagues and his family, and were made to feel very welcome.  There was a very impressive spread of food and drink, and the family held a coffee ceremony after the meal.

Our Christmas dinner table - avocado, beef and tomato salad to start



Traditional coffee ceremony at Gena (Ethiopian Christmas)

My parents were in Ethiopia for much of January and we had a fantastic couple of weeks together. We spent a very enjoyable week exploring the south of the country and were very impressed by the diversity of people, scenery and wildlife. One of the highlights was a boat trip on Lake Chamo during which we saw hippos, crocodiles (at very close range!) and some beautiful birds. My lasting memory is being privileged enough to see a Hamer tribe bull-jumping ceremony. Bull-jumping ceremonies are important events in Hamer society and involve a naked male initiate being required to leap across about six bulls several times in order to prove his worth. If successful, he may then take a wife. I was initially unsure that I wanted to see such a ceremony as I was concerned that it may be a staged ‘show’ rather than an authentic celebration, and I had heard that the Hamer women were beaten as part of the proceedings. We were in fact the only farenji (white people) at the ceremony and, although some women were beaten, observing and understanding the context was very enlightening. The journey to the bull jump took us about 20km in our 4x4 vehicle across very arid countryside. We then walked for a further kilometre or so to a sandy riverbed where around thirty Hamer women were blowing horns, chanting and dancing with bells jangling around their calves. Many more men, women and children were gathered to watch the dancing. Some of the men’s faces were being painted and the women taunted these men to whip them across their backs. It was reassuring to see that the men were reluctant to do so but we learnt that the women perceived the whipping as demonstrating their strength and ability to be good wives. After an hour or so we walked with the tribe to a clearing where at least thirty bulls were gathered. The women continued dancing around the bulls before six animals were chosen and lined up for the initiate to leap over. I was struck by how healthy the tribespeople looked and it felt absolutely right that we were largely ignored during the ceremony. We left feeling very privileged to have gained a tiny glimpse into the lives of these people and our visit provoked much discussion about the future of such tribes.

Hippos...

beautiful birds...

and a very hungry-looking crocodile..!

Hamer tribe face-painting

Hamer women chant and dance

The bull jump

Mum and Dad returned with me to Harar where they spent a week exploring the city and visiting the hospital.  Dad’s Rotary Club had kindly donated some money to the paediatric ward which was used to buy some basic equipment (neonatal pulse oximeter, blood pressure monitor, ophthalmoscope/otoscope and thermometers).  It was great that my parents were able to deliver the equipment to the hospital and see it being used later in the week.  Visiting the hospital proved to be an emotive experience and it led us to discuss at length how best to support such institutions.  Money is certainly only part of the answer... 

Later in the week we had a very entertaining visit to the camel market in Babile, a town about an hour outside Harar.  The local people were very friendly and seemed intrigued by us – my ‘pop socks’ caused particular amusement!  At one point Dad was offered 99 camels in exchange for me but the negotiator made it clear that Mum was not wanted as part of the deal!

Camel market at Babile

I was sad to see Mum and Dad leave but there has been plenty to keep my busy at the hospital this week.  The fourth year medical students had their end of attachment exams so I was asked to prepare some questions for the written components, and spent three days examining long cases and the respiratory station of the OSCE (Objective Structured Clinical Examination).  The first group of medical interns will rotate to the Obstetric/Gynaecology Wards next week so I spent some time gathering their feedback on the paediatric attachment.  I was really pleased to hear that they have found the medication chart that I introduced to be very useful (previously there was no system for recording administration of drugs).  I was even more delighted to hear that the nurses are now asking for the charts to be filled in (the nurses initially seemed sceptical about their value) and that the interns would like to introduce the chart to the wards where they will rotate next.  Moments such as these certainly counterbalance the frustrations that I experience at other times.  I will be sad to see this group of interns leave – they have worked very hard and certainly bear hugely more responsibility than equivalently experienced junior doctors in the UK.

I have another couple of weeks at work before a friend visits from the UK.  I’m very much looking forward to seeing her and exploring the north of the country together – will need to dig out some warm layers for our trek in the Simien mountains, not had any need for such clothing so far!

Happy Christmas!!

Happy Christmas to you all!  Helen did a fantastic job of decorating our flat, which has now been nicknamed the 'grotto' and feels very festive.

Looking festive - the back of the bookcase makes a great fireplace!

Our Christmas celebrations got off to a great start on Saturday evening when Helen and I held a Christmas party, complete with a buffet, mulled wine and facepaints...



The fruits of our labour (with sparkle effect!)

Daisy wasn't sure about being a Christmas pudding... 

...but the boys enjoyed being big cats! 

We spent yesterday evening at Susie's flat and very much enjoyed a mince pie and (another!) glass of mulled wine whilst we opened our 'Secret Santa' presents.  Susie is cooking Christmas lunch today - we have managed to find a pork shoulder joint and a very small chicken to roast...  I've put together a quiz for later, and Helen and I have everything we need for the 'chocolate game'.  It will be a different Christmas but I am sure it will be full of fun and festive cheer!

I hope that you all have a very happy Christmas - I'll be in touch soon with more news from Ethiopia.






Christmas is coming...

In many ways it doesn’t feel like December but Helen is compensating for the general absence of Christmas by making sure we have plenty of festive cheer in the flat.  Our bookcase has been turned around so that we can create a fireplace (!) and Helen has been busy making snowflakes and paperchains, photographs to follow...

Daisy, one of the VSO volunteers based in Dire Dawa, visited last weekend so we went on a tour of Harar’s old walled city.  Binyam, our guide, was very informative and expertly led us through some of the many narrow cobbled alleyways.  Around 30,000 people live in the 1 square kilometre walled city which contains over 80 mosques.  We visited the home of the 19^th Century French poet, Rimbaud, as well as a traditional Harari house and a very peaceful Catholic church which sits on the same site as a school and orphanage.  I bought some of Harar’s famous coffee from the city’s small factory and have been enjoying it this week with milk from one of the farms on campus.



Showa Gate, one of the six entrances to the old walled city

Inside the walled city

 

Donkeys bring wood to the city



Local butcher...



View over the surrounding countryside

Another of the gates to the walled city


It was ‘Nations and Nationalities Day’ last Sunday so many of the university students dressed in traditional costume and took part in a parade on campus to celebrate the nine different regions of Ethiopia.  Later in the day Helen and I went for a walk with Gary, one of the other volunteers, through the eucalyptus forest on the edge of the vast university campus.

Students in traditional Harari costume take part in the nations and Nationalities parade



Sunday afternoon stroll with Helen

Life at the hospital continues to be busy.  I have now presented the findings of my short audit on the temperature of newborn babies, as well as the data I collected about admissions to the neonatal unit during October.  Keeping babies warm is a very simple but effective way of improving neonatal outcomes and an area of practice that I’m really keen to improve during my time here.  My audit showed that 49% of babies on the neonatal ward had a low body temperature.  I have now developed a guideline for temperature control in neonates which has been translated into Amharic, and I am encouraging staff to promote the use Kangaroo Mother Care (skin to skin contact of mother and baby) to keep babies warm.  I think the doctors were surprised by how high the neonatal mortality (28%) and self-discharge rates (44%) were during October.  The importance of regular monitoring of babies and effective communication with families (including managing expectations – the same all over the world!) cannot be overestimated.   I introduced a new observation and fluids/feeding chart to the neonatal unit last week and hope that this will help to improve monitoring of the babies.  I have also worked with one of the doctors to develop a prescription chart (currently medication orders are written in the medical notes and there is no documentation of drug administration) which we plan to introduce this week.

I have been really encouraged by the presence of the new medical interns on the ward and am sure that they will make a big difference to the quality of care given throughout the hospital.  I delivered a session on emergency paediatrics as part of their induction programme and included revision of the neonatal resuscitation that they were taught by Jo, the previous volunteer paediatrician.  I hope to run a similar session for the medical interns working on the maternity ward to try to improve the care that newborn babies receive.  I now spend two afternoons each week working with the interns in the paediatric admissions area so that I can share my skills in acute assessment and management, including the role of effective leadership and teamwork.  I also continue to enjoy my regular bedside teaching sessions with the 4^th year medical students.

I will be in touch again with more news and photographs, including progress with the Christmas decorations! 

A goat and a hyena

The weeks now seem to be flying by.  It’s just over two months since I left the UK and I am certainly becoming more used to my surroundings.  Every now and again, however, I am reminded that I am a long way from home.  The day that I saw a goat wandering around the children’s ward and the morning that a hyena stared from the roadside as we left the university campus served as such reminders!

Life at the hospital is busy and I am becoming more involved with the various activities of the paediatric team.  The fourth year medical student exams were held last week so I spent two days examining the students on ‘long cases’ (students take a history, perform a physical examination and then report their findings and management plan) and another day examining the respiratory station of the OSCE (Objective Structured Clinical Examination).  The OSCE consisted of a circuit of eleven stations, some involving clinical contact and some requiring the students to answer questions related to photographs.  I was asked to develop two questions on developmental milestones and newborn classification.  Forty four students are attached to the ward at any one time and watching them each spend six minutes examining a child’s chest felt like a bit of a marathon!

The first intake of medical students graduated from Haramaya University last month and started work as interns today.  Thirteen of them will be attached to the paediatric department for ten weeks.  I have worked with the paediatric doctors to develop an intern induction programme and suggested that it would be good for them to each have a clinical mentor.  I attended a meeting about the proposed roles and responsibilities of the interns at the medical school last week which was very interesting.  Professional accountability and continuous professional development have very different profiles here and at present there are no postgraduate examinations.  The medicolegal system is very much in its infancy but I am sure that things will be very different when the new doctors approach the end of their careers. 

My clinical contact continues to be mainly focussed on the neonatal unit.  I have been delivering weekly training sessions to the neonatal nurses but at times feel very frustrated by the lack of basic care.  I reviewed the log of all admissions to the neonatal unit during October and identified a mortality rate of 28%.  A further 44% of babies leave the hospital without medical agreement and I know that many of them will not survive.  At times things do go well though and it was lovely to see a preterm baby whose Mum brought her back to the ward for a ‘check up’ last week – she looked really well and was gaining weight which was great.

A happy Mum returns to the Neonatal Unit with her thriving preterm baby

I have been struck by the number of babies with congenital abnormalities here – many women do not have any antenatal care and few have antenatal ultrasounds scans.  I have seen three babies with no anal opening (fatal if not operated on), two with severe spina bifida (one who was born at home and didn’t come to hospital until he was three weeks old) and two with encephalocoeles (herniation of brain tissue through a defect in the skull) – more than I have seen in over six years of paediatric practice in the UK.

Helen and I continue to enjoy our Amharic lessons, and I helped at Saturday Club again last week.  I enjoyed pottering around Harar at the weekend – the market was really lively on Saturday afternoon and I managed to fill the fridge with quite a range of vegetables.  Green beans, lettuce and cucumber have become quite exciting!  I also located the alcohol shop so was able to enjoy a gin (with lemonade...) at an Ethiopian friend’s party on Saturday night.

I think I will have a busy week introducing the new medical students to paediatrics and delivering some of the induction programme to the interns.  Susie (VSO midwife) and I plan to visit the other government hospital in Harar tomorrow afternoon to arrange some refresher neonatal resuscitation training for the staff there.  I will be in touch again soon with more news.

City Break

I’ve had another busy couple of weeks and very much enjoyed a trip to Addis Ababa for the Ethiopian Pediatric Society Annual Conference.

I feel that I am beginning to make small changes at the hospital and that there is a definite willingness from the staff to work together.  The first training session with the two neonatal nurses went well.  We worked together to design a ‘Welcome to the Neonatal Unit’ poster which included photographs of the nurses and some ‘ground rules’ about infection control for staff and visitors.  I wrote the wording in English and one of the students translated it into Amharic, the national language.  The nurses very much appreciated having their own copies of the photos and seemed very pleased with the plastic bottles for alcohol rub – these were tied to the cots in no time!

Progress with infection control: bucket of water and soap for handwashing...

... and cotside alcohol rub

I am really pleased that a midwife with neonatal training has started working on the Neonatal Unit and that a neonatal nurse who has been on long term leave has also returned.  It was great that all four of the neonatal nurses were able to attend my second training session about intravenous fluids.  We’ll practise the various calculations again this week and I’ve printed some supportive material to put on an education board.  I’ve now delivered the last of the eight neonatal lectures for the 4^th medical students and have continued to do bedside teaching sessions with them.  It is the final week of their paediatric block this week and I’ll help with their clinical exams next week.

I travelled to Addis Ababa last Wednesday for the Ethiopian Pediatric Society Annual Conference and returned to Haramaya on Saturday evening.  It was my first trip back to Addis since arriving and I was quite surprised by how struck I was by all the Caucasian faces at the airport.  The clean flushing toilets (complete with toilet paper) were also quite a novelty!  The conference was held at the Sheraton Hotel which is beautiful.  The opulence felt a long way from my work environment and made me feel a little uneasy.  However, it was really good to understand how paediatrics is being led at a national level and I felt very encouraged by what I saw.  For me, the most inspiring speaker was Dr Dube, a paediatrician from Blantyre, Malawi, who worked with her colleagues to develop a triage system for their incredibly busy paediatric emergency department.  Previously patients had been seen on a ‘first-come, first-served’ basis rather than according to clinical need.  Introduction of this system had a significant impact on mortality rates and it has now been implemented across Malawi.  The team have developed a three day ‘Emergency Triage Assessment and Treatment’ (ETAT) training programme for health workers which is being rolled out across sub-Saharan Africa.   Dr Dube will deliver ETAT training to paediatricians in Ethiopia this week and hopes that they will disseminate their learning to colleagues across the country.  Dr Dube ended by saying that ‘insanity is doing things the same way and expecting to see different results’ - wise words which are very relevant to my work here.

 

It was really lovely to catch up with several other VSO volunteers in Addis.  In addition to the Addis-based volunteers, I saw some education volunteers who were attending another conference and met three new arrivals (two of whom I knew from a training course in the UK).  I certainly ate (and drank!) far more than I would usually but it was hard not to make the most of the beautiful lunches at the Sheraton and vast choice of restaurants in Addis in the evenings.

Life here on the university campus continues to be good and it was nice that the flat felt like home when I returned on Saturday.  Helen (my flatmate) and I helped at ‘Saturday Club’ at the school on campus last weekend.  The Club was started by a previous VSO volunteer and aims to teach school-aged children life skills and improve their English.  We had a Halloween theme - Helen expertly painted the children’s faces whilst I organised some Halloween-themed games.  Several of the children showed me around the school afterwards – I understand that it is very well-resourced compared to many others but class sizes are still large and access to books seemed limited.  Helen and I have also started twice weekly Amharic lessons with one of the English lecturers at the university.  It would be great to be able to have basic conversations with staff and patients at the hospital, and a little Amharic would probably help secure better prices when negotiating with taxi drivers and in the market! 

It is strange to think that the nights are becoming longer in the UK and that you’ll be celebrating Bonfire Night tonight – can’t say I’m missing the colder weather, the blue skies and warm days here are great!  I’ll be in touch again soon with more news and photographs.