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.
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.
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.