Aira Hospital

Breech deliveries are always a challenge since the largest part of the baby – the head – is the last to pass the pelvic outlet. There is a substantial risk that the head will stuck in the pelvis and if not relieved promptly the baby will die from asphyxia.

With primipara (first time pregnant women) we play it safe and perform a cesarean just as in the developed world.

With multipara (women who have delivered before) we allow vaginal delivery. But then you have to BE PREPARED! The risk of not being able to deliver the head is always there.

1)      The woman has to be placed on a table with the buttocks well beyond the end of the table and the legs in holders.

2)      Local anesthesia above the symphysis is given in time ahead so that a symphysiotomy (a cut through the symphysis to open up the pelvic ring) can be done fast when necessary.

3)      A catheter in the bladder is crucial. With two fingers in the vagina the urethra can then be easily identified and pushed to the side protecting it from the cut in the midline when the symphysiotomy is done  (Don’t ever try to do a symphysiotomy without a catheter in the bladder. The risk of injuring the urethra is huge, and if it happens you end up with a fistula which is very difficult to repair – I know from bitter experience!)

4)      The cut through the symphysis cartilage can be done under vision with a larger incision – open symphysiotomy – or blindly through a stab incision – closed symphysiotomy. Knife blade No 22 on a knife holder is appropriate.

Watch the following video. The head cannot be delivered and a symphysiotomy is done urgently to open up the pelvic ring and get the head out. The child is severely distressed, but recovers after oxygen and glucose 40 % solution rectally. Rectal administration works almost as fast as i.v. injection and is much easier to adminstrate.

VIDEO ← click here to watch video

Happy mother – Happy baby - Happy surgeon!

“Women should not die giving life!” A statement in a referral letter from one of our satellite clinics in which I can only agree.

That is also the “Millennium Goal” of WHO and other fancy international agencies.

But as top politicians and highly paid “experts” are consuming billions of dollars on high salaries, expensive secretaries, cars, business class, 5 star hotels and restaurants and not contributing with anything else but talking, we - the medical professionals in the third world - are fighting day and night to accomplish concrete results in spite of having nothing except our hands to work with.

The poorly paid, but dedicated (male) nurse who wrote the line quoted above is struggling day and night in a clinic with no resources, no equipment, insufficient financial support, no running water or electricity. In spite of that he is doing his very best to help the patients. At times things are just too complicated and luckily he (still) has a hospital to refer to.

In the referral letter mentioned he writes that the woman is referred from his clinic at 10 pm.

At 4 am the lady arrived at Aira Hospital in shock due to intraabdominal bleeding and sepsis from a ruptured uterus. It took 6 hours to carry her to the hospital and during that time the uterus gave up and ruptured. Why didn’t the family take her by car? Well it takes 2 hours’ walk to reach the main road, and how many cars are out there in the middle of the night? A part from that they might not have been able to pay the usually indecent demands from the car owners.

She was operated immediately after arrival. Thanks to a dedicated staff who bothers and are ready to work and save lives 24 hours around the clock. Not a given option in many other hospital where the staff would rather choose to neglect her and give priority to a sound sleep.

She recovered fast, as her two roommates who also came with ruptured uterus. One from nearby Guliso had to pay 300 birr to get a car ride (ordinary price 20 birr), but then she walked herself from the parking place to the maternity – with a ruptured uterus!

The third woman had paid 700 birr for a place in a car. Far more than the cost for the lifesaving hospital treatment. All three patients with uterine rupture are recovering fast. That means a lot.

Saving the life of a mother saves the whole family.

Then why is it considered so wrong by so many NGOs to support this kind of medical work financially?

Even our own Church of Sweden Mission does not consider medical work as their responsibility.

Women’s’ project – YES. Human rights project – YES. AIDS/HIV project – YES.

Medical work (apart from AIDS/HIV) - NO.

Recently the Church of Sweden Mission donated a second hand car to the women’s’ project in Addis Abeba (where there are so many cars at the head office that they are standing rusting in the parking lot) and one to the Bible Seminary in Nekemte. With all due respect it is indisputable that no of the women’s worker or the bible school students die from lack of transport, but our patients do.

Imagine how many lives could be saved, and how much suffering could be avoided if the hospital had a four wheel car which could bring women with complicated deliveries to the hospital at a reasonable fare. In that way the patients would not be skinned to the bones by greedy car owners, and the hospital would have at least some sort of income. Will that dream ever become true?

Sunday is supposed to be the day of rest. Not so in Aira Hospital. People need surgery even on Sundays and holidays – night and day all around the clock.

As you can see from the book we keep in the operating theatre there were 9 emergency surgeries during Sunday.

Six were complicated deliveries: a retained twin B (first baby born at home – second baby retained in the womb), a risk mother with two no children alive after 2 previous stillbirth and two cesareans, a breech presentation in a primigravida (first time pregnancy), a twin pregnancy with a shoulder presentation of twin A (the first twin), a face presentation and a ruptured uterus.

(Aira is not considered a project with “focus on mother & child health”?).

Besides all these complicated deliveries a sigmoid volvolus, an open tibia fracture and a stab wound of the abdomen was operated as well.

For the gender conscious 7 women and 2 men were operated.

The lady with the ruptured uterus had 5 home deliveries before, two still birth and three alive.

Now with the sixth delivery the uterus ruptured, a complication which was totally impossible to prevent with “preventive antenatal care” and totally impossible to foresee. 

The lady recovered fast and was on her feet already the day after surgery, just like an ordinary cesarean.

The patient with the open tibia fracture was referred from another hospital 3 hours by car from Aira. But to reach the referring hospital she had to be carried 4 hours.

You don’t need to be a professor in trauma and orthopedics to make the diagnosis and the treatment is straight forward: revision of the wound, reduction of the fracture and fixation with intramedullary flexible nails.

At the international meeting in Jena I was challenged when showing pictures of similar cases. Many colleagues questioned intramedullary nailing in open fractures with or without infected wounds. In our hands it works perfectly all right, and without blushing I will claim that we do not see any draw backs or complications from that treatment policy.

That lady was also on her feet the day after surgery. We wanted to discharge her, but as she will have to walk or be carried 4 hours from the last bus stop we gave her one day more to prepare the transport.

The last patient late that evening was an unfortunate fellow, a good man who tried to mediate between two hotheads only to be stabbed in the abdomen himself. That resulted in eventration and multiple perforations of the small intestine.

Ingratitude is the reward of this world!

Also he was on the feet the following day.

That is how we spend the Sundays in Aira while others are enjoying life at the lake Langano beach or at the pool in Hilton hotel.

No justice in this world either!

Four uterine ruptures the last 48 hours – all survived. But for particular one of the ladies it was a close call. She arrived in deep shock without blood pressure or pulse. After fast infusion of 7 liters of saline solution the pulse returned and we got a measurable blood pressure. Blood was requested from the relatives and the surgery started. The only compatible blood donor was the husband who refused to give blood.

With time I have learned how to deal in such situations. The staff dragged the husband into the operating theatre where his wife was on the table with the abdomen cut open. He was told that since he would not help his wife with giving blood we could also not help and he had to take her from the table immediately and return home with her.

Usually that helps. This time also. She got a unit of blood and survived.

One of the other ladies had her mother with her, but she refused stubbornly to give blood “I will not give a single drop to her”. The reason for that was that the daughter had converted from Islam to Christianity and blood from one religion cannot be mixed with the other. Everyone knows that. So the Christian husband gave one unit, but only after being grilled as usual.

One might think the relatives whom we are pushing for blood will show resentment later. But when it’s all over there are always smiles all over – not a sour face or any hard feelings. Another culture and another way of solving problems.

It is a miracle that we manage to save 97 % of all mothers arriving with uterine rupture in spite of our extremely limited resources. On the recent international meeting in Jena the maternal mortality from uterine rupture over one year in Aira Hospital was presented. The mortality rate was 2, 4 %.                A remarkable result which amazed the audience. One participant questioned the low mortality rate. But fact is fact, and the follow up was done by a doctor and nurse not working in the hospital. 

In the university clinics in this country hysterectomy is practiced as a routine with frightening high mortality. We go for minimal surgery and do a repair instead. That’s why the mortality rate is low.

Medical work is never boring. Never is one day like the other.

Sunday we had a visitor from the German Embassy in Addis Abeba. The embassy has supported the hospital with vital monitoring equipment for the operating theater and it was a great pleasure to show the third secretary from the embassy around the hospital.

Unfortunately the wards were half empty with not many patients around. It is said that people are too busy with the coffee harvest to get sick and come to the hospital.

Only two days later the wards are full again. In particular the maternity where some patients are admitted on stretchers because all the beds are occupied.

This night we did 6 cesareans on women with complicated deliveries referred from different clinics.

One of the referral letters was very long and detailed. The closing words were “women should never die” (giving childbirth) written by a male nurse (the profession as nurse is male dominated by tradition).

Another fine example of how the Ethiopian male shows concern for the opposite sex - contradicting the common but untrue picture of the Ethiopian man as chronic woman abuser/oppressor.

6 times up in the night doing cesareans is really not for an old man like me. Today I am tired and the blog is short.