Some sweet success

Sam Gamgee was snipping the hedge below my window this morning – a very homely sound in this alien climate. The late afternoon rains are helping keep the vegetation verdant and the browsing bovidae spritely as well as providing employment for Sam. Last time we were here the landscape was reminiscent of Mordor but I’m hoping to see the impact of the wet season when we travel to Berbera next week.

Two of the trainees and a future prospect

Meanwhile group 1 have finished their training and are en route for their coastal community while we have a well-earned rest day. The awaited chest X-ray shows signs which may well be TB but her sputum is clear though AAFB is an unreliable sputum test. Four months of fever, nights sweats and weight loss in an HIV negative individual can’t be wrong.

Two of the trainees did a Caesar and we were able to attend, advise and encourage them as well as take photos and discuss the lessons afterwards in the classroom. Later the same day we had three visitors – husband, wife and sister – friends of Bashir, who had been advised on Caesarean at 42 weeks for a first birth. We used the opportunity for a ‘Circus’, something all medics recall from their student days when the fierce and feared consultants used to have us presenting cases to the whole class, often with the patient present, while they grilled us on our limited clinical skills and made a fool of our attempts to sound knowledgeable. I recall a minor triumph when asked the boiling point of mercury by Black Jack – the dreaded Dr Robinson – since my patient who was suffering after an accident in the laboratory had told me the answer already. I digress. Our trainees took a history, we discussed possible management options, and then two of them stayed up most of the night caring for the woman as she laboured. Their triumph was palpable despite the weariness they felt on our final day, as she delivered a healthy boy vaginally at 6am and escaped the surgeon’s knife, despite needing an episiotomy and release procedure for FGM, done by the midwife.

I think she’ll deliver …

Female Genital Mutilation is widespread and does restrict proper evaluation of the labouring woman as well as the application of the vacuum cup for assisted vaginal delivery. The latter procedure is used infrequently here perhaps because of this difficulty and because of lack of experience and confidence in its use as well as the failure to recognise fetal distress (the heart rate is not listened to often enough) which is one of the two main indications.

We finished the course with a feedback session in which the candidates basically asked for more training, more often and for more hands-on experience. After course 2 we will travel to their base hospital 2-3 hours drive and hopefully meet some of this expectation with the limitation of a facility that has one tenth of the workload of Hargeisa Group Hospital.

Health & Safety is out of the window and the speed bumps multiply…

The aftermath of rain is very pleasant in the air but a problem underfoot. The roads are muddy and full of holes and puddles and the route to the hospital is getting worse each day. There are lazy soldiers all along the route but the lazy navy is something else. Truth is we are grateful to Sa’ad our driver for travelling so slowly – we feel very safe with him and the ride is more comfortable that way. He avoids the bigger waterholes as we never know how deep they are.

With the rains we expect mosquitos but they are still strangely absent. Nevertheless I brought my pesticide impregnated bed net and determined to use it as a solitary mossie can ruin a night’s rest as I found in Addis some years ago. I unpacked the protective netting but could see no way to suspend it over the bed – no poles, no wall hooks or lights or pictures, no convenient furniture or curtain track – and then I spotted a screw in the ceiling clearly put there for the purpose, but how to reach it? The only way was to balance a dining chair on the mattress, stand on tip toe with my finger tips on the ceiling to steady myself while slipping a clove-hitch over the screw with my outstretched free hand. The string was from a luggage tag on my suitcase and served the purpose well. Thankfully I didn’t have to bail out and leap to the bed from a falling chair but I was well aware the method would not have passed the first step of any risk assessment.

Pulmonary TB or I’m a Dutchman

Today we began with ward rounds and clinical teaching. The round was conducted by a doctor from Khazakstan who speaks and writes only Russian. It was not a good learning environment and the staff complained to us. I am reminded of a visiting doctor in Cambodia who spoke only a little French and wrote his notes in English which the midwives could not understand. Good communication is obviously important for staff and patient involvement and safety. The first patient was delivering at 25 weeks after ruptured membranes for several days and I’m reminded of our own first child born at this stage who lived only a few hours. Our second patient was an emaciated lady with a chronic cough who has weight loss for 4 months, who delivered a scrap of a baby yesterday, and whose condition cries out “TB!” There were around 12 people on the ward round but no-one had a stethoscope! One was produced eventually and her chest was examined. There are many abnormal sounds – she will have a chest X-ray and the baby will have a BCG. Then we had hydatidiform mole, severe pre-eclampsia, secondary abdominal pregnancy and hyperemesis in rapid succession – plenty to discuss and teach on – before our mid-morning break and return to the classroom. Our participants are highly motivated and a delight to teach. They are a bright bunch and there is hope of improvement if they continue working here.

Best mates …

The animal conspiracy took a new turn today with an attempt on the part of the speed bumps to multiply. Shy Mr Tortoise has come out of his shell and Mrs T seemed well pleased with his attentions. We may have to wait awhile for the baby bumps and much longer for their contribution to traffic calming but here we need to take the long view …

Obstructions, road blocks and slow progress

Here we are in Hargeisa after a smooth transit from UK. We arrived yesterday on the ECHO flight – run by and for the delegates and donors of the EC who are working in Somaliland – in a 16-seat twin-engine Beechcraft which takes 3 and a half hours from Nairobi without a toilet. That’s fine, and we were forewarned and suitably dehydrated, but could be problematic on the return journey if we don’t watch what we eat and drink.

Rather proud of the national flag

We arrived on a holiday in celebration of Somaliland independence 21 years ago. The festivities were largely over but flags were still flying and some bunting remained over the hotel entrance. They are proud of the national flag as are most newly emerging states.

As I write it’s raining lions and jackals in the midst of a thunder storm and I’m feeling thankful for wireless internet. Lightening strikes can’t leap across a wireless connection can they. Can they? The sound of the rain on the roof is accompanied by another noise which I cannot locate or diagnose but it has a remarkable resemblance to the sparking of an electric arc or fly zapper and I’m hoping it’s some large drops of water hitting the floor rater than water in the switches and electric fittings but I can’t find any leak and I’m not chancing the light switches even though it’s gone rather dark outside. My accommodation in the Maansoor hotel is a single room in a small villa in the grounds – there are a large number of these and they offer a degree of privacy and solitude not provided by the regular rooms in the main building, so I am very grateful despite the heavy rainfall overhead.

Speed bumps

Once again a good level of security is provided – the sleeping policemen on the approach roads (lazy soldiers, they call them here), the barrier manned by alert armed guards in the morning (they insist on all the car windows being open as we drive through as they can’t see the occupants through the darkened and reflective glass) and manned in the afternoons by lazy guards who are awake but less alert and more careless after chewing khat all day, and the concrete blocks painted with zebra stripes to prevent a vehicle breaking through to the residential areas – but this time there is a new security force. The giant tortoises in the grounds (which I never saw last time I came and which I suspect are close allies of the mad antelope which attacks stray white men) have joined forces to create their own road-blocks – mobile speed bumps but actually not very mobile or speedy. They arrange themselves at intervals across the drop-off zone in front of the hotel and have to be forcibly moved on a few feet at a time by a patient but tired-looking hotel porter. They are too big for him to lift and the lack of wheels means that their feet scrape noisily in protest with each heave and shove.

Today was our first training session. We have fewer participants than expected – 3 doctors, one midwife and one nurse – but they are eager learners and rightly so for responsibility comes rapidly here. Bashir was one of the first Somaliland medical graduates in 2009 and he is already Hospital Director in Berbera – he does most of the Caesarean Sections there. Mahfuz is a second year intern and is leader of the Sahel Medical Emergency Team (Sahel is the district of Somaliland targeted by the current training programme). Abdisalan was a nurse on our March course and is now in charge of a dozen staff in a Rural Health Centre with several beds. Our topics today were Caesarean delivery, obstructed labour and ruptured uterus and we spent some time talking about progress in labour, or the lack of it. The maxim is ‘Where poor progress becomes no progress and no action is taken, labour becomes obstructed’ and the consequences can be disastrous here.  Perhaps the worst is the all too common scenario of the newly married adolescent girl who’s fortunes turn from expectation of motherhood and a lovely new baby to total incontinence, walking with a stick, family rejection and social exclusion, and the painful memory of a dead baby with no expectation of future fertility or health due to extreme birth injuries. There is hope for such as this thanks to the wonderful work of places like the hospital for poor women with obstetric fistula in neighbouring Ethiopia, but this kind of outcome can and must be avoided.

A rather smug camel

We travel by taxi to the Ministry of Health where we have been provided with a training room and we have a short walk to the hospital next door for the clinical component of the course. Our journey today was interrupted by several obstacles. A large contingent of armed soldiers had closed the road to the hospital and our driver made a detour through various back streets. There we encountered a posse of camels ambling along and interrupting the traffic from both directions. Once we safely negotiated passage through this animal hazard we came upon the soldiers again who prevented further progress by car. Our driver left his taxi by the roadside and, pulling rank as far as he was able on the strength of two visiting western doctors, obtained passage on foot and escorted us along the closed road as far as the Ministry of Health. Soldiers lined the route on both sides as the President was due and they were detailed to provide safe and speedy passage for His Excellency. Sure enough, the headlights, horns and whistles heralded the approaching motorcade and a couple of dozen vehicles sped by – blue and white police vehicles, army pick-ups with soldiers hanging all over the back and several smart 4x4s whose drivers and passengers waved cheerfully to the sporadic crowd. Can you have a sporadic crowd? I can’t find a better way to convey the sparsity and unenthusiasm of the locals who waved and saluted and the majority of those responding were the soldiers whose livelihoods depend on the existence and occasional appearance of the President. He had been opening the local Sprite factory – not a place that manufactures old Austin Healeys under licence from British Motors, nor a producer of Imps and Faeries but a very important offshoot of the parent company in Djibouti providing essential soft drinks in a very dry and temperate country. Aside from bottled water, we drink Coke and Sprite with all our meals thanks to the President and his men. We also heard that the President has learned a trick from Tommy Cooper – he habitually travels with three black cars in the motorcade which change places frequently so that no-one can be sure which if any vehicle he is in or who is waving at the absent crowd – you never could tell which cup the little ball would be under and all along it was behind Tommy Cooper’s left ear.

So there we have it. We have started but not yet progressed much. I have my thirst quenched but my appetite for more action is whetted. And you have your first dispatch from abroad, as promised, and I will try and keep in touch, Inshallah. Weather, connection and tortoises permitting.

Dandelions age and the wind blows …

Salaam alekhem! Greetings from London on the eve of my next Heathrow exit. The long overdue blog update is here at last!

Training in Liverpool STM

Soon after the apparent success of the LSTM-LSS course in Hargeisa I found myself involved in a second course in March, this time in Liverpool. The students in the School of Tropical Medicine studying Reproductive Health and Public Health attend the Life Saving Skills course before they return to their home countries. Liverpool’s Women’s Hospital also houses one of Europe’s largest reproductive medicine departments and a period of maternity leave for one of the doctors provided me with the opportunity to return to IVF work in April. Collecting eggs and replacing embryos in a centre of excellence is a far cry from delivering babies and picking up the pieces in the developing world but I find I switch readily from one role and context to another and fortunately my colleagues in the Women’s Hospital are sufficiently flexible and understanding to allow me to pursue both passions. Now I find myself with the opportunity to return to Somaliland for two weeks to train doctors in Caesarean delivery as part of a 3-person team.

One thing that has filled much of the spare time in the 3 months since my first visit (and has delayed the blog sequel until now – sincere apologies to all) has been the examination of 3 years worth of data from two of the Somaliland maternity hospitals. The larger unit in the capital delivers about 240 per month and the smaller one, in the coastal town of Berbera 2 hours drive to the north-east, less than 30. The C-section training is for the staff of the smaller hospital but much of it will take place in the capital because of the greater opportunity for clinical teaching, and to a lesser extent because of the cooler climate. In fact 10-12% of mothers are delivered by Caesarean by surgeons who are not obstetricians. Two 4-day courses are planned, catering for about 20 people including supporting staff. One of the sad statistics is the death of 10-12% of babies delivered in these maternity units. Stillbirth is the usual reason given but this term does not explain the underlying cause and newborn deaths are rarely recorded. I still don’t have a handle on the number of maternal deaths but it is thought to be around 1 in 250. Safe Caesarean is just one of many interventions required to reduce these unacceptable death rates.

The humble dandelion, common but fresh and beautiful

So it’s farewell once again to family, friends and fellowship, and to the flora and fauna of Bala and Penllyn. In the absence of other tourist destinations we plan to visit again the cave paintings of Las Geel. I hope to avoid the unwelcome advances of the antelope-with-attitude in the grounds of Maansoor Hotel, Hargeisa. My intention is to bring home some more wild honey as the supply has run out but no more vacuum packed dried dates which didn’t prove popular.

I think one of my bigger concerns is the overnight transit in Nairobi, since it is a less safe place to be than Hargeisa. In Somaliland the people are very friendly, the money changers sit unguarded in the marketplace with mountains of paper shillings, and armed guards of the Special Police Unit are detailed to look after our safety.

Too soon the flower goes to seed and the wind blows it away

Hopefully I’ll be able to update you when we arrive and this time I’ll try not to leave too long between blog posts. This time I’m travelling with Julie from a London teaching hospital. God willing neither of us will lose one another between flights and I’ll be back in Bala and Liverpool before all the dandelion clocks have gone …

Happy students and faculty at the end of course 2

The local hospital in the capital here was our first port of call on our way home from the Institute of Health Sciences where we have been delivering the training. We were delighted to find virtually all of the nurse-midwives we met there were our recent or current trainees and were welcoming of our visit. The single storey individual ward buildings were spartan in the extreme. There were beds of course, and screen curtains in various states of disrepair, and a desk which served as the nurse station, but there was little in the way of equipment apart from an old vacuum extraction unit, an ancient fetal monitor which no longer provided continuous records of fetal heart rate and uterine contractions but still had functional doppler ultrasound for intermittent or, to be more precise, isolated auscultation. The true state of affairs here was revealed by the labour ward register which already shows 22 births in the first five days of March, three of them born dead. We scanned the earlier months of 2012 and saw the same 15% newborn death rate on every page. The register is completed retrospectively and usually the facts are made to fit the outcomes so all babies which fail to survive are classified as stillborn. The concept of fetal monitoring in labour and intervention for fetal distress seems largely foreign to midwifery practice here. We saw one ventouse extraction record and two breech births, one of which was 4kg and stillborn to a mother of 7. Despite the improvements evident in trainees which have attended the Life Saving Skills Course more than once, the picture on the ground belies the skills they have acquired. There is still some long way to go from the theory acquired in training to the implementation and improved outcomes.

Blood donors beware

The contrast with Edna Aden Hospital is pronounced. Beautifully clean, and smelling clean as hospitals ought and once did in UK, this humanitarian enterprise has been functional since 2002 and maintains a high standard of training and care. Encouraged by the poster in the blood bank Tom and I were inspired to donate our pint of blood and were received by a very proficient laboratory technician who completed the process of testing and painless collection in double quick time. Real mosquitos were nowhere to be seen. We had encountered them for the first time since entering Somaliland in the wards of the national hospital no doubt attracted by the aroma of blood which inevitably lingers in places where mothers deliver and where the couches and floor are not adequately cleansed afterwards. The vicinity of a hospital is not the place one wants to meet mosquitos since they refresh their payload of parasites by feeding on malaria sufferers and then spread the agents of disease wherever they acquire their liquid diet. I think I shall continue taking Lariam despite the published side effects – they have always served me well.

Talada

On our return journey to the hotel we passed the monument where an airplane on a pedestal commemorates those who died in 1988 when Siad Barre’s regime bombed his own people here in the north. One local wag posed ostentatiously in the square, proudly displaying his loyalty to the current Somaliland government emblazoned across his T-shirt. His name and phone number were written for us on a piece of paper and should anyone visiting this region wish to make contact we can let them have his details.

As darkness falls over Hargeisa the familiar sight of Venus, Jupiter, the Moon and Mars spread along the line of the ecliptic remind us of home and continue to dominate the night sky, the waxing moon travelling steadily from the brilliant white evening planets towards the red orb in the east, night after night as our sojourn passes. The moon is almost full on our last night here in Hargeisa. We have one more training day tomorrow and then we transfer for the return flight through Berbera on Friday. Soon we shall see these night lights hanging in Penllyn skies, God willing, or they say here, Inshallah.

Two down …

Where on earth is Tom?

Fresh camel

We had 30 minutes warning of a dinner engagement and Tom was nowhere to be found. Losing faculty members seems to be our forte! We tried his room several times, each episode of knocking and calling louder than the one before. In the end our transport was due and we were concerned not to leave without him, at least not without knowing he was OK. Hotel security accompanied us to his room and we unlocked the door to find it empty, not in bed or in the bathroom, we were tempted to try the wardrobe but it seemed unlikely that he would climb inside and fall asleep, shutting the doors behind him. Back at reception they suddenly remembered they had seen someone sleeping in the lounge, and there he was, flat out on a sofa. He revived enough to agree to come, and off we went to try out the camel steaks at the Ambassador Hotel.

Tilt the head back to open the airway ...

So now we have completed course number two. Another 28 trainees of varying experience and ability learning, refreshing and practicing their knowledge and skills to prevent mothers and babies dying through childbirth. We are always seeking new ways to communicate and make relevant the important messages. The gerenuug is a great illustration of the extension of the head required to open the airway in a collapsed adult, and the cave paintings are a wonderful reminder to document what was found and done, after all good records last for thousands of years.

More cows and dogs in the camel’s waterhole

Las Geel is the place to water camels. That’s what the name means, but the first inhabitants never saw a camel. They were herders of cows and used dogs to help them. Here’s a few more pictures from our visit today.