Going out with a bang... if I ever go out

I think I got a little too comfortable in my last few days here...

I was supposed to be home in my very own bed right this second, but thanks to Lufthansa's strike I got an extra 48 hours in Addis.  It's not the worst thing that ever happened to me since I don't have any pressing responsibilities at home, but it's not the best either.  In any case, I decided that it bought me a couple days of freedom, and I didn't go into the hospital this morning and got a little extra sleep.

The literal bang I suffered can be filed under the "adventures in public transportation" heading that I had been meaning to write. Unless you are pretty affluent or a taxi driver, you probably don't have  your own car, because the tax on cars is about 200%.  I read that somewhere and thought certainly I misinterpreted or they mis-wrote, but it is true, that a car that is worth about $5000 USD (for example, the ever-present early 2000s Toyota Corollas), will set you back $15,000 USD, literally.  So most people choose the semi-public transport that they call public taxis but are really small blue and white mini-buses that travel on set routes around the city.  A normal "Lada" taxi (because most of them are the Soviet Ladas-- brings me back to the Republic of Georgia) will cost you about $2.50-5 USD for a national to take a trip, about twice that and on up for a faranji, but the public taxis cost at most 3 birr (15 cents in USD) for both locals and foreigners.  I have gotten pretty efficient with the public taxis between the hotel and the hospital, and a few other places in the city.  There are set stops where empty taxis start and you can get on in a reasonably orderly fashion, but if you want to get on somewhere along the route, you have to listen for the driver's assistant stick his head out of the window and yell the route as they're passing by, wave it down, and then many times push and shove other people out of the way to get on. There are seats for 12 people but the assistants sometimes try to squeeze 15 or 16 people on to get more fares. Yesterday I was doing a little pushing, shoving, and squeezing, and I took a tumble inside the taxi, hitting my neck on the exposed metal of what used to be a headrest.  Now I have a very sore left neck and a huge bruise that looks like someone tried to strangle one side of my neck or that I have a very aggressive lover.  Just when I thought I was getting the hang of it.

I also had a little more culinary daring last night than I should have.  (Should be traveler's common sense- never try something new or out there the day before you're supposed to get on a long flight.)  Alas... kitfo is ground beef that is seasoned and either very lightly or more heavily sauteed with butter.  I have had it before well-done and it was delicious, but it is more of a delicacy to have it almost raw.  I requested that we get it "at least a little cooked" which translated into "not still mooing, but almost."  Not only did I not really prefer the taste, my GI tract did not prefer it either and I am a bit nervous to leave my hotel room at the moment.  Hopefully some self-medication can improve my status before I get on a plane.

The Communist Derg Monument, a landmark in front of
Black Lion Hospital

Other than the slight travel missteps, I have spent my unexpected 24-48 hours in Addis by mostly doing work at the hotel.  I also went out walking yesterday to Meskel (or "Revolutionary") Square, the site of a lot of Addis and Ethiopian history, and went to the Red Terror Museum.  The Red Terror was the political torture and assassination of around 10,000 Ethiopians deemed to be political enemies when the Communist Derg regime overthrew Emporer Haile Selassie in the 1970s.  The museum presents historical items from that time including many bones recovered from mass graves to give emphasis to the gruesomeness.  The most striking thing to me was how recent this was- most Ethiopians just slightly older than me survived this, and although things seem stable now, there is always in the back of their minds that it could happen again.

Red Terror Museum

A shoe shine boy

I also did some very Italio-Addis things and got my Danksos shined by one of the many, many shoe shine boys on the street (they are beyond saving though), and had bombolino (basically like an unglazed Krispy Kream doughnut) and macchiato in the Ambassador Pastry shop down the street from Black Lion.  You feel like kind of a big deal when someone is fussing over your shoes while you casually drink your coffee.

Well currently Lufthansa is trying to foil my return again by announcing another strike tomorrow from 3 am to the evening (i.e. when I need to get from Frankfurt to Atlanta) for intercontinental flights.  Apparently now my flights are still scheduled so we'll see if I make back tomorrow!

Thankful

I expect at this time (4 am your time Saturday) everyone is sleeping off residual turkey coma and recovering from Black Friday shopping.  My Thanksgiving was, naturally, a little different this year.  I started the day like any other weekday here- having my breakfast at the hotel and the heading to Black Lion for morning report.  After morning meeting and before my 10 am appointment with the students for bedside rounds, I ran down to the corner where I had seen some pretty flowers I thought I would take to my friend's family who was having me for dinner for substitute Thanksgiving.  (I was subsequently informed by him that bring flowers to the family would imply that we were getting married-- vetoed.)  I then got a call from a resident at another hospital that would be transferring a patient to the Hamlin Fistula Hospital, and would I like to come with?

I had been dying, dying to go to the Fistula Hospital so I jumped at the chance.  The Hamlin Fistula Hospital, famous throughout Africa and among maternal/global health types like myself, also made famous by the stunning documentary A Walk to Beautiful (watch it streaming on Netflix!), is a hospital dedicated to the surgical repair and social rehabilitation of women who have suffered obstetric fistula from obstructed labor.  Ethiopia has a very high prevalence of obstetric fistula, which basically results from a woman being in labor at home for days with the baby unable to fit through the birth canal in places where obstetric services and cesarean section are not accessible.  After days of labor, the tissues between the bladder, vagina, and bowel start to decompose, forming permanent holes between vagina and bladder and/or the vagina and the bowel, resulting in constant leakage of urine and stool from the vagina.  In this scenario, the babies usually die.  Women lose their fertility and their dignity.  In most places, they are cast off from their husbands and from the community because of the uncontrollable leakage of waste.  Anyway, the Hamlin Fistula Hospital, founded by two British physicians, is completely dedicated to surgical repair of these injuries, and then rehabilitating the women by giving them skills to bring in their own income and giving them self esteem.  Our poor patient who was being transported did not have an obstetric fistula, but needed advanced urologic treatment after an extremely complicated hysterectomy the day before that left her with one transected ureter (which had been identified and repaired intraoperatively) and was subsequently found to have ligation of the other ureter and failure of the contralateral repair.  She also lost 2 liters of blood.  Gynecology nightmare.

Now that I have made a short story long, I got to see the famous hospital although not for long and not in any great detail.  What I did do was peak inside the wards where about 40 women in hospital beds were side by side in a bright, white, pristine room (this in contrast to the dirty and dark Black Lion and Gandhi hospitals).  As I sat in the courtyard full of flowers, curious patients walked up to me, looked me in the eye, and some of them extended their hands to me and said "salamno" to say hi.  (I can only imagine that most of these women come from remote areas, and even though Hamlin is famous, they have not seen all that many faranjis.  I can also imagine that they all have spent some amount of time in shame from their conditions, and to make eye contact with me, and for me to make eye contact with them and speak was no trivial matter.)  It was a brief, beautiful experience.

Thankful.

Not long after that, I set off in a minibus with one of the chief residents who pitied my lack of Thanksgiving to have a late lunch with his family.  It took us about an hour to arrive at the last city within Addis Ababa (which is not only the capital city but also the name of the surrounding region or province).  He grew up with 5 brothers and one sister in a small house with a courtyard filled with chickens in various life stages.  The house was small, with bunk beds in the room with the refrigerator, which may or may not have also been the actual kitchen. Everyone, in typical Ethiopian fashion, was quick to demand that I eat! eat! eat! and drink! drink! drink! everything in front of me.  My plate was never empty-- as soon as there was any open space, mother or sister would come over and fill it up with something else.  As soon as my beer was half empty, another was opened and put in front of me ("drink! why aren't you drinking??" they said). I certainly ate as much as I would have at a Thanksgiving dinner. Mother spent 30 or 45 minutes roasting coffee beans in a pan, grinding the coffee, and brewing it in the jebena (traditional coffee pot) on the living room floor.  Little brother (18) and little sister (13) shyly practiced their English and translated for their parents (who wanted to know what my and my parents' religion are, what did I think about Obama, and all kinds of other interesting and socially controversial things).   There were so many photogenic moments, but obviously it felt wrong thinking of taking pictures of someone's family as if they are a tourist attraction, so I have nothing to show.  At the end of the evening my resident friend gave his parents and his little brother a few hundred birr as well as some to pass on to his aunt who live nearby.  A resident's monthly salary here is numerically equivalent to my salary in the US, except that $1 USD= 20 Ethiopian birr.  That is to say, I make 20 times more than they do, and I don't even think of giving money to my little brothers.  Humbling.

Thankful to share a family holiday with another family, who made me extra thankful for what I have.  I truly feel like the Ethiopians' hard work ethic and open hearts have encouraged me to be a better person.

Now that night has fallen on Saturday after I spent the majority of the day in the hotel making questionable efforts at writing the concept paper for the Ministry of Health, I am left with two full days in Addis.  This morning I did venture out to sample this breakfast phenomenon called dulet.  I had been kind of avoiding it actually, since it is one of those staples of any developing world diet that combines the leftover organ meats of things together-- in this case, definitely lamb stomach, and other lamb and beef bits, possible kidneys and liver.  I'll try anything, but I wouldn't go out of my way for offal.  It is sauteed with butter and heavily seasoned with the local spices, and is eaten with the omnipresent injera, the fermented/sour bread product that is both foodstuff and the utensil/vehicle for the food.  The small place we went was full of people coming in for their Saturday morning dulet (some accompanied by beer at 9 am- I KNOW WHAT YOU'RE THINKING, NOT ME).

It was super delicious.  My mouth is watering just thinking about it.

Alas this Saturday night I am staying in and will probably have some leftover pizza, and rest up for some real work and the remainder of Addis sight-seeing tomorrow.  See you soon!

Big day

Exhausted after an exciting day- 

Last night I stayed up late[er than usual] preparing a workshop that some of the family medicine residents that had been in our cervical cancer course had requested on contraceptive implant and IUD insertion.  The residents to my surprise had very little experience using these devices themselves, but I learned, in what I think is appropriate medical task shifting, there are trained family planning nurses who are in charge of these procedures and contraceptive counseling.  Essentially, the residents don't need to know how to do them because there are other trained health care members who would like to.  Nonetheless, they asked, and as family planning is my passion, I definitely accepted.  I prepared a couple of talks about contraceptive implants and copper IUDs.  For those who are wondering, they use a lot of Implanon but also have available Sino and Jadelle, which are two-rod implants.  (I presented only Implanon since that's what I have experience with.)  They also have a copper IUD but no progestin IUD.  We did a practical session during which they had arranged some patients in the family planning room, and I had brought some uteri models to practice IUD insertion on.  Fortunately or unfortunately there were 3 patients who came who wanted their Implanon removed, and one who wanted one placed, and the one who wanted one placed left because she waited too long.  The fortunate part is that Implanon removal is possibly harder than insertion so it's good to practice, and also 2 of the 3 patients had used their Implanon for its entire 3-4 year lifespan, which made me happy.  So I think it was moderately successful.  Interesting anecdotal observations from family planning providers in this urban health center included that many of the commercial sex workers who come there prefer depo provera because they are likely to become amenorrheic after some time; higher income patients prefer the copper IUD because it has less additional hormone, and lower income patients who want LARC tend to choose implants.  An interesting KAP survey is waiting there...

The other exciting development is that I went with Dr. D to the Ethiopian Ministry of Health to offer ourselves to help organize training in VIA as part of a national cervical cancer screening program.  The mere idea of coming to Ethiopia with very little idea of how I was going to spend 3/4 of my time, and ending up in the Ministry of Health pitching a national cancer screening program, was amazing.  Dr. D as always has connections there, and we met with an adviser to the minister, who was cautiously interested in our input on launching a national cervical cancer prevention program.  With my last 5 days (eek!) I plan to prepare a short concept paper to submit to them addressing their particular needs and concerns that we discussed today.  

That in addition to attending the morning meeting and presentation (postpartum hemorrhage), bedside rounds with the medical students, a brief stop in a demonstration of the use of doppler in obstetric ultrasound, visiting the 15-year-old patient who broke my heart yesterday with another doctor and making her smile (which filled my heart), lunch with residents and a visiting gynecologic oncologist from the University of Michigan (yet another international visitor/consultant), and brief rounds at the women's hospital at Gandhi Memorial Hospital, another one of their academic training centers, with the senior resident on 24-hour call tonight.  

And so I spoiled myself by ordering room service of a bottle of Ethiopian cabernet sauvignon, which I am sipping while I write this post.  (In case you wondered if I am roughing it...)

Save travels for everyone on the biggest US travel day of the year.  My repeated pitiful comments to Ethiopians about how Thanksgiving is a big family holiday that would spend here in their country were answered!  One of the senior residents invited me to visit his family just outside the city tomorrow afternoon so I could have a substitute family experience on Thanksgiving.  I haven't seen my family on Thanksgiving for the past 3 years due to residency, so it's not a huge change, but it's nice that the day will have just a little bit of recognition.  I will be especially thinking of you, Family, tomorrow, while I am not eating turkey and gravy, and love you all.

The rawness of suffering

Suffering is universal but it seems that there are places where it is more prevalent, and also places where it is more present and more raw.  Today in particular I saw too many faces of suffering around Black Lion Hospital.

In the middle of the morning meeting and case presentation, my train of thought was interrupted by 5 minutes of the anguished wailing of multiple women that echoed up from the fifth floor to the sixth through the open staircase, down the hall, and through the closed door of the meeting room.  The presentation went on without interruption, and I tried not to show the distraction on my face.  It seemed that a baby had died in the NICU.

Incidentally, the case presentation (which is like our morbidity and mortality conferences for those in the know) involved a pregnant mother that I had some contact with about a week and a half before, when she was referred to Black Lion for fetal hydrops (meaning, essentially, heart failure of the fetus causing fluid build up in the baby's body), due presumably to Rh sensitization.  She was a G5P4000-- meaning that including the current pregnancy she had been pregnant 5 times, delivered 4 babies, and all of them had died.  This baby was showing dire signs of the same pathology, and on ultrasound it had fluid collections in the abdomen, scalp, scrotum, and a little in the heart.  I remember this case for the striking findings on ultrasound, but also the incredibly striking beauty of the patient, who came from some rural area not even speaking the national language of Ethiopia.  The baby was delivered by cesarean section a few hours after the ultrasound was done, and died 5 hours after birth.  In the US, this highly desired baby probably would have survived.

Ultrasound findings from the above patient showing thorax and abdomen: heart in right upper screen, abdomen in left lower showing massive abdominal ascites separating the two lobes of the liver and compressing the thorax so almost no lung tissue was visible.

Later on teaching rounds, we came to a 15 year old who had recently been admitted to rule out ectopic pregnancy.  Her mother had died of AIDS a year before, and ever since, she had been literally living on the street.  She had had multiple sexual partners, some consensual, and some forced, during that time.  As the huge medical team of 25 students, nurses, and doctors, most of them men, discussed her in English over her head, tears streamed down her face and from time to time she covered her face with her scarf, ashamed of her tears and her situation.

Anatomically correct dolls from the pediatric sexual assault clinic in Adama (called the Unit for Treatment of Children Who Need Special Attention) to allow children to demonstrate and work through their abuse

Thirty minutes later, we went to the "chemotherapy" ward (where they work up and treat non-surgical gynecologic cancer patients) to see a very sad case of recurrent ovarian cancer in a mid-thirties year old woman, who we determined to be inoperable.  As we were going to visit this patient, two women emerged from the next room sniffling and then promptly collapsed on the floor in sobs.  I was informed that the patient in the next room, who had been admitted for palliation of metastatic ovarian cancer, had just died.

Dr. D commented, "This is why I don't understand why they put gynecology patients with obstetrics patients.  On one side of the hall you can have good news, and on the other side, bad news."

And I said, "Well that is the nature of our profession."  And in my head I thought that one of the things that makes OB/GYN most rewarding is that we do get the great joys of taking care of healthy women, mothers, and babies to balance the sadness of the rest.

Courtyard of Black Lion

Lalibela

Lalibela is suggested as the one place to see in Ethiopia if you can only see one place, and so I went this past weekend.  It is famous for its 11 churches built in the 12th century carved into rocks and built into caves, thought to be a model of Jerusalem so that Ethiopian Christians would not have to suffer the pilgrimage to Jerusalem to worship.  They are estimated to have needed 40,000 workers at a time and at least 100 years to construct, but legend has it that they were completed in 40 days with the help of angels. They are still fully operational churches today, and surprisingly not overrun with tourists.  I was expecting the awesomeness and ancient history of the churches, but I was not expecting the spectacular scenery of the surrounding mountains, and to have a glimpse at rural life in the Amhara region (north of Addis).  Words are not sufficient to describe it all, so I will load as many pictures at the internet will allow me.

View from my hotel room (yup)

Scenes around town

Double rainbow!!  (Not all the way though)

A priest

Amazing art everywhere, who knows how old

Bet Giorgis church seen from above- you can really appreciate how it was carved into the rock

Bet Giorgis looking down

Saturday is market day in Lalibela!

Photo documenting with my high quality camera (iPhone 4S)

Bet Abba Libanos, incorporated into the rock from above

Traditional home

Me seamlessly blending in with worshipers leaving church on Sunday

Priest collecting holy water (natural spring) in Asheton Maryam Monastery outside Lalibela

Asheton Maryam

Lalibela sunset

 All pictures are taken by me, except those taken of me of course, which are courtesy of my co-travelers.

The fourth delay

I was talking with one of the residents yesterday in amazement of how few residents they have covering one whole hospital: for about 120 patients in a women's hospital, overnight there is one PGY4 and two PGY2s.  No attending on site!  Then I realized that there were several interns milling about, and said, oh, you have several interns (turns out there were 5), so that makes a big difference right?

And he said, "You know the three delays model?"

 (Global maternal health people might recognize this as the factors that increase maternal mortality in developing countries: 1- Delay in recognizing that advanced medical care is needed; 2- Delay in reaching a qualified health facility; 3- Delay in accessing a qualified medical provider once the facility is reached.)

"My interns are the fourth delay."

If at least one person reading this blog appreciates this joke, it will have been worth retelling.  I myself have been laughing about it ever since.

Today was full of educational activities: I went to the resident conference in the morning to hear a case presentation about steroid administration for preterm deliveries.  Then I myself conducted real old-fashioned bedside teaching rounds for the medical students.  It was the first time I had taught in that style, and it was fun!  Look forward to doing more of that.  Then I went to an ultrasound workshop put on by Norwegian maternal-fetal medicine specialists (so far, there has been a constant presence of foreigners helping with resident education.)  Now I'm preparing a short proposal that might be taken to the Ethiopian Ministry of Health since they have interest in our experience with training in cervical cancer screening, to consider it for a country-wide screening policy.  May be going to the Ethiopian MOH... no big deal.

My trip is half-way over already.  I can hardly believe it.

A little relaxation

Afternoon coffee with OB/GYN residents

The workshop is over after three days, 13/16 participants passing, 2 needing some remediation.  The OB/GYN residents were only in it half-heartedly and seemed like they had better things to be doing, but my real triumph is in the enthusiasm of the family medicine residents, the health officer, and the one nurse who completed the course.  They are super excited to spread the cervical cancer screening and the family med residents have asked if I could do a demo on IUD and contraceptive implant insertion for them!  Good things developing.  Suggestions from the OB audience welcome on how to accomplish that without any kind of model kit or supplies.  I don't have any implant available right now, but if I do, I was thinking maybe chicken breasts for the simulation?

Last night to celebrate finshing the workshop, Dr. G. treated us to massages at the hotel, which was AMAZING and cost about $13 USD.  It will be hard not to do that far too often.  We then went over to Dr. D's house for dinner and met his family, including his adorable 2 year old boy,newborn girl, and beauty queen-worthy wife.  Did I mention that Ethiopian people are beautiful?  I can't put my finger on it, I think it's something about the cheek bones.  Fortunately, along with diseases of poverty, there is a much higher prevalence of beauty in Ethiopia than other places.  I'd rather have one of those then neither, but we can work on the former.

This morning before Dr. G flew out we drove up to the nearby Entoto Mountains to get some fresh air and views of the city.  It was like we were immediately transported to a rural area- lots of livestock, few cars, women carrying impossible looking loads of firewood down a very steep road bent over almost 90 degrees.  It was nearly impossible to take inconspicuous pictures because everyone turned around to see who was driving the only car up the road and looked in to see the farangis (foreigners) inside, but I wish I could have.  There was also a small religious holiday today, and one of the churches up the mountain had a huge gathering of people- tens of thousands I'd say- flocking toward a church.  (They closed the road there, only public transport and farangis [seriously!] allowed to pass.)  Such a beautiful and somewhat eerie site to see thousands of people covered in white while the priest's singing emanated from loudspeakers coming from the church.  We made it to the top of the mountain where we found a couple churches, one of which Dr. G has visited several times.  We went to the other one.  So glad we did.  It had a huge mural on the inside made by a single painter 150 years ago (per the guide), filling the octagonal walls with many of the major stories from the bible.  The church (not having services today) was still filled with frankincense smoke.  It was stunningly beautiful and dramatic.  Outside was a 700 year-old church carved from rock that was the precursor to the 150 year old structure that we toured.  Amazing, amazing culture.

Now trying to make some friends with the residents with moderate success.  I'm going out for a "traditional" dinner with some of them any moment.  Meanwhile I'm texting with Charles on my iPhone over the internet... funny how some things can feel so much the same.

From Entoto