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.