Two months in – Ferenji anaesthetist in Axum

With my Zambian experience as a warm-up or ‘warning-shot’, I headed back to the African continent on Ethiopian Airlines with an open mind. Leaving home again has been hard, but I’m even more determined to ‘be the change’ – or some other similarly idealistic goal. Everything you aim to do in this context is a constant battle between idealism and realism. You adjust your expectations and ‘to do lists’ every day. But I feel at least this time prepared for that and that I will be in for a change of pace. I’ve been thinking about the contents of my first blog for some time and I think the best start is discussing the differences between life and work here and at home.

It’s fair to say Ethiopia is like no other country I’ve visited before; I feel very far from home. It’s almost difficult to describe what it’s like here and why it’s so different as I’ve been here long enough to feel like I’ve been here for years.
I live in Axum; far north in the Tigray region of Ethiopia, neighbouring the Eritrean border. Axum is a popular tourist destination in Ethiopia due to the rumoured presence of the Ark of the Covenant in the local St Mary’s church, and a number of archeological sites of interest, and the birthplace of Ethiopian Orthodox Christianity. Consequently there are frequently other ‘ferenji’ in town, and the local people are more used to seeing foreign faces around. Our house however is in a less developed part of town and the morning commute involves walking along dirt paths dodging donkeys and carts, goats and chickens whilst being stared at by people who seem less familiar with ferenji faces. I am lucky to be joined by Vicki (a paediatrician) and Romil (a paediatric nurse), both VSO volunteers and we all work at Axum St Mary’s hospital and stay in the same house 10 minutes from the hospital.
In terms of differences in day to day life; I have no problem getting up in the morning compared with hitting snooze numerous times at home, I am usually awoken by the pidgeons at my window or running along the metal roof. Not only that I’m usually asleep by 9pm as it’s fairly quiet in the evenings and there’s only so many boxset episodes in a row you can watch (I reserve that comment to exclude Grey’s Anatomy Season 9 which kept me up until 2am). Lunchtime is a dedicated event rather than the grabbed sandwich back home – usually 1 hour to 2 hours. We head home from the hospital via the local shops, which are essentially the front room of the stone houses, and pick up some banee (bread rolls) and eggs for less than 50p. Some version of scrambled egg mixed with tomato, onion and chilli is concocted on the electric stove and washed down with filtered boiled water, which is a continual household task that keeps you busy. Depending on the exact route back to work and the number of children, you quite often reply to a number of ‘hellos’ and invariably handshaking. Hilariously, and possibly a sign of the times in international development and demographics of international industry, instead of being shouted at as ‘ferenji’ (the standard term for foreigner’), we are sometimes called ‘China’.
Sometimes lunchtime is spent at work, where we have injera (Ethiopian staple made from the latest superfood teff) with shiro. This is typically provided by the hospital kitchen and shared out among staff whilst sitting in the changing area/note writing room/tearoom. The staff are always keen to include me and make sure I know the food is for me also. The staff I work with are incredibly kind and everyday ask me how I am enjoying Axum, ‘am I comfortable?’ is a common question. Coffee break in the morning comes after tea, which when I ask for only one sugar I am laughed at, I definitely don’t have a sweet enough tooth for their liking. Coffee is made as a typical ceremony, first roasting the beans, where the smell wafts through theatre and is brought to you to smell, then grinding, and boiling with water before serving. Serving is done in order of seniority and the surgeon always is served first. It’s a real pleasure to be part of the team and they are all very keen to make sure I’m included.
Another feature of life here is my new ‘family’ in Axum. Thanks to Vicky having been here for 6 months before me, she has introduced me to a network of wonderful people who are living and working in Axum in a variety of voluntary and professional capacities. Surviving separation from home is definitely softened by sharing hard drive content of up to date films and TV series, heading out for Sunday brunch of special full (curried beans, eggs, yoghurt), and post work beers at one of the local pubs. Another popular past time is visiting each other for dinner, and spending time with a lovely American family who kindly provide us with meat and dairy products and other such luxuries which are not easily available here in Axum. It’s always good to chat to other people here who are involved in different projects and hear of successes and difficulties in different avenues of development.

So back to work. The intensity of work here is definitely different from home, Axum St Mary’s is a district hospital serving 1.5 million population, but the throughput of inpatients is definitely less than I’m used to in hospitals in Scotland. That said, the intensity for staff due to low staff numbers is not reduced. There are only 3 senior (consultant level) doctors; one internist, one gynaecologist and one general surgeon. There are 5 SHO level doctors and 4 interns (final year medical students who work as junior doctors). The rest of the work is carried out by health officers who have further training in specialties; for example emergency surgery masters. In anaesthesia there are 2 such health officers and between them they perform all anaesthesia for the hospital covering a 24 hour on-call service. Daily elective lists occur and run until lunchtime or later, and emergency cases fill the afternoon and often through the night. As this is a district hospital and there is no ICU; complex surgery is referred to Mekele; the largest town in the region. Although I have just been amused to read the WHO 2003 publication “Surgery in the District hospital” which recommends that anywhere surgery and anaesthesia is practiced should have the ability to provide postoperative ventilation. I’m not particularly positive about the prospect of offering ventilation and an ICU environment however when there are only 2 people in the hospital who can intubate.
In terms of my own capabilities, it has taken probably until the last week that I’m not permanently terrified about providing general anaesthesia to patients who I can’t communicate with, using drugs I know have poor side effect profiles, with really the most basic monitoring you can expect to use. It takes a while to come to terms with being the only anaesthetist in the village, but the 2 officers who are here have fantastic practical skills. I really have relied on their abilities to manage paediatric airways and difficult spinals, their practical experience in terms of volume and variety definitely surpasses mine. And at times, I have found myself wondering what if anything I have to offer or improve here. And then a patient arrives for a laparotomy with no blood results, or I find out blood is available for a patient, but not until 9am when blood bank opens and its 7am and they’ve just lost a litre and a half, or my patient has a HR of 190 and I have no idea what it is as there is no cardiac monitoring; so I realize maybe there are small things I can hopefully do to help.
I am getting incredibly well acquainted with ketamine, it can get you out of many a tricky situation it would appear (including failed spinals in a room with no vaporizer or anaesthetic machine). Halothane is less of a friend than ketamine, and combined with ketamine and atropine I have developed insensitivity for any tachycardia unless it’s above 130. Getting really good at multi-tasking; never really understood the meaning until you need to give the drugs, open your own laryngoscope, lift your own tube off the trolley, intubate (plus or minus remove the stylet), inflate the balloon, confirm position and ventilate, oh and don’t forget the volatile, keep hand ventilating as there’s no ventilator, secure the tube with tape (major error if you’ve not already prepared it), and then if you’re lucky and the pulse ox is still working you’ve got time to take the BP as you can be sure there’s still a pulse because you can still hear the beep. I’m not sure my West of Scotland propensity for cardiac disease can withstand the pressure. I didn’t know how spoiled I was with anaesthetic nurses at home, I mean I thought I did, but I really didn’t.
Anyway hopefully that gives a bit of an idea of life as a ferenji anaesthetist in Axum! Starting some teaching this week with the surgical masters, and hopefully aim to set up an HDU, implement the surgical safety checklist, and deliver an obstetric emergencies course in the coming months. Delighted to have support from AAGBI and Lifebox for monitoring and books for the staff here which I will be picking up when I return home for a weeks holiday at the end of the month.
a href=”https://docmccuedoesvso.files.wordpress.com/2014/04/hospital1.jpg”>Hospital1

Front Entrance to Axum St Marys Hospital
Front Entrance to Axum St Marys Hospital

Drug preparation

Preparing the coffee ceremony at work - a task for the circulating nurses.
Preparing the coffee ceremony at work – a task for the circulating nurses.