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The Elephant Cloud

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The Road to Mota

February 5th, 2011 by · Africa, Ethiopia

Halfway to Bahir DarThe tire was flat when the car arrived. When I came out to greet him, Mulu was already under the car and surrounded by the neighborhood children, who were better behaved than I’d ever seen them.

There is an adage in Africa that with film and video, it’s best not to linger too long. The gear is expensive and a temptation and over the past few weeks, we’d had it out far too much. There are other, now amusing circumstances as well, better shared over a beer at a later date, but ultimately, it was decided that we needed to get the gear out of this small town and into Bahir Dar. Joni and I were leaving first thing the next morning.

It was my single biggest disappointment of the trip. I did not want to leave Darlene, I had just found a seemingly ideal translator and photo enthusiast in one of the hospitals midwifes, I had plans to watch futbol with an Ethiopian doctor who’d become an increasingly good friend, and, perhaps most important, I was invited to play on the hospital team’s volleyball tournament that Sunday.

We packed all the gear into the land cruiser and set out. About twenty minutes out of town the road starts winding down a breathtaking canyon to a water crossing thousands of feet below. It was market day, again, and the line of merchants streaming into town was also crushing in that I wanted stay in Mota. My heart sank as donkeys, goats, sheep and shepard were all on foot marching toward town. Men and women and children in their gabis and wares, many barefoot, the march of walking sticks and the donkey carts. We head down the canyon and I texted Darlene that we were beyond town, freely on our way.

The blown out tireFreely, that is, until we started to climb out of the canyon and the back tire blew. I’d never heard a tire blow like that. I’m more accustomed to the slow leak.

A local boy helped change our tire, which included he and I rocking the vehicle back and forth so Mulu could wedge the jack in under the body. We eventually gave him a birr for his troubles.

The bald, "healthy" tireI inspected the remaining tires and found that though the spare was completely bald, it was not the worst one. The rear driver-side tire had no rubber at its center and we were two hours from Bahir Dar. The road is a never ending stretch of packed gravel with washboard grooves and sharp loose rocks. It wears a heavy coat of fine grain dust that gets everywhere and as I gazed out into the hot day ahead, I was preparing myself for the inevitable bus ride rescue.

But this is Africa, as they say, and somehow all the pieces more or less held together and after another hour we still had four tires full of air. We pulled into a little village where we patched one of the spares. Once again on our way and forty minutes later, we finally crested a small rise and saw Lake Tana and Bahir Dar spread out before us. It was beautiful. The lake expanse felt like the sea and the town of tree-lined avenues swayed in the breeze. By now the back seat and our gear was full of dirt from the dry countryside and we were looking forward to soothing our sunburned skin under cool, running water.

The spare

As we wound down toward town, we crossed a long flat stretch and slowly, the car decelerated. I pointed to a building under construction as the car rolled to a stop. “What are they building there?” It’s a new hospital, he said, pulling out his cell phone. He apologized, “it is my fault, I forgot when we were in the village, but I will call my friend and he will bring more petrol.” We were seven kilometers out of town and completely out of gas.

POSTSCRIPT: Though I left Mota four days before Darlene, she arrived here with me yesterday. On her return trip, the rear driver-side tire went flat and Mulu received four new tires that afternoon.  Her four days remained challenging in terms of the medical condition of Mota Hospital and it’s patients, but rewarding in the nature of her stay.

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Ethiopia’s Daughters: Chapter III

February 5th, 2011 by · Africa, Ethiopia

… continued from Chapter Two of Ethiopia’s Daughters

Chapter Three

A small unlocked Nokia cell phone with an Ethiopian SIM card floats between the white pockets of Dr.Dr. Philippa teaching ultrasound Philippa and myself. The number is scribbled on paper taped in the maternity ward. We are on call 24 hours a day, 7 days a week for almost four weeks. Other medical teams before us have stayed for three months, a feat I find holy.

Nurse midwives and doctor’s names fill our phone lists and tonight it is Abraham* who rings us two hours before midnight. ‘There is a woman in the delivery room, we have tried a vacuum delivery twice and still the baby doesn’t come out, there is fetal distress, can you come and help us?’
‘We are leaving now, right away, be there in 5 minutes.’ I pull on my pants, grab my head lamp and retrieve Dr. Philippa from next door. In our tiredness, we stumble over the dark path, rushing to get to the hospital.

Once inside, the scene is portrayed and everyone rushes to play their part. She is on the stirrup table, her legs shaking from long hours of pushing. One defeated midwife holds the vacuum attached inside the mother, another leans into her protruding belly counting the fetal heart rate, 140 beats per minute down to 80, there is fetal distress, this baby needs to be delivered immediately.

I turn to Dr. Philippa, ‘A C-Section, forceps, what shall we do?’ Calmly, she reassures the team, examines the patient and announces the head is transverse, lying sideways and therefore wedged tight. The goal is to turn the head so delivery can happen. It is too late for a C-Section she informs me.

With fifteen years of experience, she works with her hands, the vacuum, limited tools. An episiotomy opens the narrow passage further and within several minutes a head, with cord wrapped tight about the neck, is pulled through the canal. Deftly, Dr. Philippa reaches for clamps and scissors, releasing the cord. She turns, handing the blue, lifeless baby to Malsaman and me.

‘We should order a Neonatal Resuscitation book and leave it at the hospital,’ Philippa mentioned to me in passing a few months back, I took her recommendation to heart and three days later Amazon delivered such a book. I devoured the algorithms, protocols and ratio of compressions to breaths, the book is for high end facilities with oxygen tanks, neonatal bed warmers and medications.  Everything our hospital in Ethiopia is lacking.

Malsaman and I grab the floppy baby, its eyes closed, mouth open, and rest it on the table. An eternity churns before I understand what is before me. ‘I feel a heart beat, its slow, but its here,’ Dr. Philippa presses the umbilical cord, searching for a pulse.
The race begins, from the smallest of compressions, 1 and 2 and , two finger tips thumping the frail chest, the lungs have yet to just bornfill with air and the tiny oxygen mask is held in place, I try to keep the airway open, jaw thrust up. It swollen lumpy head lists to the left, making the ability to maintain an airway difficult. For thirty minutes, I don’t give up, I can’t give up.
A cough, a gasp, the heart beat quickens, we push air into her lungs, ‘come on baby, come on, you can do it,’ my mantra begins. Then it happens, her little chest begins to rise, she takes a breath and then another.
Turning to Malsaman, we are ecstatic and dance around, grasping hands, overcome with joy.

SupportThe mother watches from the delivery table, her feet in stirrups as Philippa delivers the placenta and sews beautifully her torn body back together. Finally, the family is allowed to enter, husband escorts his wife back to bed, there are no wheelchairs. The baby is brought to her side, she is surrounded by four other maternity beds in a small room. Here, there are no monitors, machines or oxygen tanks to keep life viable, only the mother. For she will keep watch, infant at her breast, and hope the spirit of death passes over.

bed from home Not much later, the cell phone rings, another midwife urgently inviting us back. ‘Another baby is stuck, she has been in labor since yesterday, we should go quick,’ Philippa informs me, grabbing her white coat and we walk the well trotted path together. The story parallels the first, only the cord is wrapped around three times, strangling any chance of survival. This time our attempts are futile, the little face is malformed, perhaps a chromosomal defect, an incomplete cleft palate, perhaps it is from pushing, its face lodged against the canal bones for too long.

I can’t fix the oxygen mask, air escapes before passing into underdeveloped lungs. The ailing heart pulses through the cut cord, ‘thump …….. thump.……..’ instead of a healthy 120 beats/min, there is only one every five seconds. More compressions, more oxygen, the heart beat slips further into the heavens, we try and try again. ‘Come on baby, come on, you can do it,’ my mantra begins, only this time no one is listening and over 30 minutes the little soul leaves us.

Looking into Malsaman’s eyes, a wave of defeat overcomes the room. I want to cry, but no one cries in Africa, there is too much sorrow for tears.

‘We have saved the mother,’ he touches my shoulder, now they can have more children, healthy children.’

* names have been changed

healthy baby going home

to be continued…

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Market Day

January 29th, 2011 by · Africa, Ethiopia

IMG_0255It is market day and the streets are full of donkey carts and barefoot pilgrims wrapped in their white gabi’s, driving their wares to the square. We buy potatoes, cabbage, beets, kale, onions, garlic, eggs and a chicken. Darlene named her Doro Wat, which is the national dish of Ethiopia, a spicy chicken stew. Philippa declared him a rooster and Joni sat on our patio and entertained the hospital staff with her arsenal of barnyard animal calls, drawing not only the rooster, but the sheep grazing in our yard. Yamatan prepared the bird for us, after I crawled into a shrub to retrieve the hobbling fowl as he made his break for it. We added pasta and spices and stewed him up in a pot we also bought from the market for just such an occasion.

The Imam's house...On the way home we took my favorite street, past the mosque and imams house, and like a child I peered thru the slotted wooden fence to the large golden wheat fields that makes up the eucalyptus lined yard. The men in the field across from ourhouse sift teff from hay and drive their cattle in circles to mix it up. Donkeys bray from somewhere out of sight and children run the dirt packed avenues with homemade pinwheels spinning in the wind. The hospital was quiet with two new births, the sun was present and ready as always.

IMG_0403Darlene spreads across the chairs in the yard, dark glasses on, reading a novel as the heat of the afternoon soaks her clothes with warmth. Our pails are full of water, as today is a water day. At the stadium, the hospital futbol team tied in a tough match and Manchester United, the town favorite, won on the tele. It seems the perfect day.

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Ethiopia’s Daughters: Chapter II

January 25th, 2011 by · Africa, Ethiopia

… continued from Chapter One of Ethiopia’s Daughters

Chapter Two

Operating TheaterWithout running water, sterility is difficult and conservation is everything, even during surgery. Faded green gowns and drapes, homesewn lap sponges, recycled tubing, everything in the operating room is used again and again. We enter building 24, the operating theater. A clear plastic apron, battered from use, is placed over our heads and tide in the back. I run my hands under trickling water from a bucket, passing the soap to Dr. Philippa, we scrub for surgery. A sweet smelling purple alcohol dries our fingers.

Putting patients under general anesthesia at our Hospital is an amazing feat undertaken only by one, a recent graduate of the nurse anesthetist school. Without the ability to monitor blood pressure, oxygenation, blood count or really anything else during our case, he does an exceptional job of keeping our patient stable. I’m in awe of what little maintenance will keep a patient alive. I feel this is what surgery must have been before technology or electricity.

Fingers across her taught belly, a lateral incision is made. It is now obvious the uterus has ruptured just as the midwife Abraham had predicted. We pull gently, dislodging the lifeless baby from her torn womb and pass it to the nurse. A quietness overcomes us all.
There is little time to be sad as we shift our focus to the mother, Samanesh. Working quickly, Dr. Philippa’s nimble fingers stop the bleeding as she removes the uterus and repairs the vaginal wall. Dr. Frantilal, a young local General Practitioner, his dark eyes concerned behind the mask, ponders our decision to save her right ovary, ‘I have never seen this done before.What is the use of this?’
‘Wouldn’t you prefer I save a testicle if I could?’ asks Philippa.

In remote rural areas, there are no roads, only narrow foot paths. Sometimes a six hour walk is required to reach a bus stop. And then they wait, wait for an overcrowded bus to transport them to the district hospital. During the rainy season, foot bridges are washed away, roads eroded, making the journey even more arduous. Often without shoes, these women labor on route.

Samanesh’s forehead perspired, she was familiar with birth, this was her fifth pregnancy. Her ‘pushing down pains’ began at home, surrounded by family, far from the hospital. Hours passed as the baby’s head wedged high in the birth canal, unable to slip into position for delivery. Labor stalled. A sense of urgency, something was wrong, her life was now in danger. Her family began the long procession to the hospital. Hours later, Samanesh arrived exhausted, bleeding and the baby no longer kicking in her belly.

Morning RoundsPoverty, lack of education,  malnourishment and the devaluation of women are obstacles in developing nations for a safe delivery. Once these are rectified, one issue remains at hand- access. While numerous health centers are within hours from each other, the hospitals are few and far between, once you reach a hospital there may be no physicians on staff,  not to mention no operating room or surgeon. The WHO reports there are more Ethiopian doctors in Chicago then there are in Ethiopia. Lack of transportation and lack of roads are a standing problem for these women.image by Joni Kabana

Early mornings we walk through the rusted blue hospital gate to make rounds, the maternity ward, building 28, is just waking, newborns crying out to suckle, birds chirping, staff yawning. We check our patient’s vital signs, looking for infection, any signs of decompensation. Samanesh’s devoted family remains at her side, they feed her injera and chai, change bed sheets and sponge her tired body clean. Days later her fever resolves and we stop the intravenous antibiotics. A week passes, her incision heals, she is able to return home with her husband. She returns a sister, a mother, a wife, a daughter.

to be continued…

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Ethiopia’s Daughters: Chapter I

January 19th, 2011 by · Africa, Ethiopia

Chapter One

‘You want a picture?’ he asked as we drove to the edge of the desolate canyon.

‘How about now? You don’t have camera?’

‘Later,’ I told him, ‘When we come back, when we return home.’

‘You sure? You sure you return home?’ he laughed.

That was a good question since I was wondering how this rusted jalopy, bouncing and speeding through curves, almost colliding with buses, was going to get us to Mota at all. Knuckles white, seizing a broken door handle, I watch as the broken speedometer oscillates anywhere from 0-120km while the gas gauge hoovers over empty.

‘We make the hospital in no time, maybe three hours.’

Image from Joni KabanaThe only two story hotel in town is painted pink, Hotel Wubit, and sits midway along the dirt highway stretch of 240km, the original eastern through-way connecting Addis Ababa with the North. Asphalt has yet to see this part of the world.
‘We are here, this is Mota!’ he smiles, pulling into the hotel parking lot, ‘Now we should have food.’ Inviting the driver to lunch, we collapse into wollen couches and share beyainatu, small portions of vegetarian food dumped over injera. We scoop potato, shiro, cold french fries, lentils and cabbage into our hungry mouths.

Road signs adorned in blue Amharic script line the road, we turn off towards the Hospital in search of our new home.

Blue and white paint coat the walls, colors of hospital and government. Only open for ten years, age prevails over the compound- a building has fallen, walls cracked, overgrown weeds and trash decorate the compound. An aluminum latrine sits downwind, but meandering the paths, one must be mindful of human scat.

Only in the last year has the hospital come alive- a water tank, the opening of an operating theater and a mini medical library. Water is pumped from the ground four mornings a week into the tank and keeps the plastic buckets in each ward filled. The small library houses a surprisingly large assortment of medical textbooks with two wooden desks filling the room and one dial-up computer with a lineup of staff waiting to check Facebook accounts.

Episodes of MASH come to mind passing through the aluminum doors into the operating ward. One room for minor procedures stays busy removing lumps and draining wounds. The main OR, reserved for gynecological emergencies, is open 1-2 times weekly. My visa and papers are stamped with such purpose, Dr. Philippa and I will become quite familiar with these quarters.

Patient TransportThe morning of our first day, a daughter recovering from childbirth is carried home by her family, she rests atop a wooden bed strung with goat skin. At the same time, another daughter arrives, supported by the arms of her father and husband. Her pregnancy is full term, but her labor has stalled. Abraham*, a quiet, unassuming midwife, his second year working at the hospital quickly recognizes her distress- a ruptured uterus, the baby has lost its heart beat.

To the untrained eye, her stomach bulges on top and bottom, a valley between- twins, a mass, a fibroid tumor? Instead, Abraham teaches us, it is the sign of a ruptured uterus bulging atop and the dead baby bulging below. ‘The mother will die if she is not operated on immediately.‘

This is why we have come, this is the purpose of the Foundation, to train local medical doctors to perform emergency obstetrical services.

We are here to teach, but we have much to learn.

CostsThe story is complex, these young women are often malnourished and under developed. Their pelvis is small, creating a problem for childbirth. The nurse midwives, three females and four males, are incredible talented at using their hearts and hands delivering even the most difficult of births. But their magic ends once a baby becomes stuck in the birth canal, the mother’s survival precedes the baby’s. A Cesarean Section vs. removal of the fetus through the vagina. There are no perfect solutions.

*Names have been changed.

to be continued…

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