One Day in Bahir Dar

Each morning, there is a siren which sounds throughout the city, reminding those without clocks or wristwatches that the work day will begin soon. Already, the birds have been announcing the presence of the morning, although instead of cock-a-doodle-doo, it’s a bang, pitter-patter-pitter-patter as various they land ungracefully and walk on our metal roof. Satisfied with our staple breakfast of eggs, bread and honey, bananas, and mango juice, we pack a small daypack with the essentials: toilet paper, hand sanitizer, water, our bibles, money and ID, my white coat and medical review book, and Ryan’s list of contacts. We step outside, walking down the steps and the dirt path to the gate, exchanging a greeting to the faithful night guard. The mornings are refreshingly cool. The sun has not yet chased away a mist which shrouds the landscape, water vapor from the lake mingled with an almost pleasant smoke from cooking fires. Near our compound, a man tends the rich black soil littered with various green plants. Our guard smiles and waves at us from the gate. On the road, we join the steady stream of people walking, biking, and driving toward the city. Near the second roundabout, a large Ethiopian Orthodox Christian church stands. Women with heads covered in white scarves and men stand at various places along the stone wall surrounding it, praying with lips moving, bowing slightly and repeatedly, hands making a cross over their body. On small tarps laid out on the ground, crosses and small religious books and posters of Jesus and Mary and various saints are displayed for sale. Beggars sit at the church gate. It never fails that we will be asked at this corner whether we would like to hire a boat to visit a monastery on the lake- understandable as the city does rely on tourism.

Across the roundabout, the bajaj wait for customers. It’s the Ethiopian version of a rickshaw, a three-wheeled open vehicle which carries 3 passengers. They regularly go from St. George’s Church to the hospital and from the hospital to the open market. To stop anywhere along the route, you simply tap the driver on the shoulder or say, “Bak a.” They weave around bicycles or other bajaj and duck out of the way when a larger vehicle like a car or truck come from behind. At the entrance to the hospital, a large banner reads Felege Hiwot Referal Hospital. As I walk, I pull out my white coat and put it on. Some days I have joined the gynecology ward or the surgical ward for morning rounds, but today I am going to the fistula hospital, which is at the back of the main hospital grounds. We divert our course to the left, avoiding the main patient areas. A gravel road curves around the administration building. Under the shade of a few old and tall trees, plastic chairs and tables are arranged and people dart in and out of a traditional round hut with coffee and tea for those sitting there. Ryan and I part ways here. It is a perfect place for him to wait, read, make phone calls with our borrowed cell phone, or sleep. I continue for a short time on the road which skirts the outside of the hospital buildings. A green sign ahead reads “Bahir Dar Hamlin Fistula Hospital.”

There are benches under the shade of trees, a small garden of flowers,and the main hospital building to the right. On the left, there is a small building for health records and documents and a building in the back for laundry and cooking injera, the local food staple. Several bikes are parked near the entrance to the hospital, likely belonging to Dr. Andrew Browning and some of his staff. I walk in. There is a physical therapy room, a spacious bathroom, one exam room which looks like it doubles as an office, and then a nurses’ station. There is one large area which makes up most of the building, and this is where the patients stay. There is a low wall separating two sides of the room. Pre-op patients are lined up in beds making an aisle on the right, and post-op patients line both sides of the aisle on the left. Along with creating a comfortable family atmosphere for the patients, it must be convenient for the staff. I can imagine a conversation.“How are the patients doing today? Did everyone get something to eat? Is anyone in pain?”

“Let me check,” as she looks up from her desk. “There are 17 pre-op and 25 post-op. Looks like everyone is eating. And, no one is in pain. Anything else?”A frosted glass door is at the far end of the building.

Behind it is the surgical area. Before we begin the day’s work, Dr. Browning gathers the staff. A passage from the bible is read, first in English by Dr. Browning, then in Amharic by the head nurse. Dr. Browning then says a prayer for healing and safety in surgery for the patients and for us as we take care of them. The Ethiopian staff then whisper prayers of their own, often bowing and crossing their hands in front of them as we had seen in front of the Orthodox church.

Rounds begin. A wheeled cart with patient charts neatly filed and daily logs for the nurses is pushed along as we move from patient bed to patient bed. On the post-operative side of the room, most exams consist of mainly checking to see if the bed is dry, the abdomen is soft, and the urine in the catheter is clear. On this day, there is even an infant joining her mother on the hospital bed, which is a joy. Dr. Browning explains that it is very rare to have a live-born child and sustain a fistula. 93% have a stillbirth. On the pre-op side,there is a new classification system for me to learn. Each number or letter describes how far the fistula is from the urethra, how much of the bladder/urethra is involved, and how scarred the tissues are.There are patients waiting for a second stage of their operation if their case was complex, newly-admitted patients, previously-cured fistula patients who are now pregnant and awaiting delivery (which will be at the hospital next door), and finally a young, brave girl less than 9 years old, a victim of trauma.

We finish rounds relatively fast and head through the frosted glass door to the surgical area. We change into scrubs, wearing cloth hats and masks. Everything is reusable, even the gloves. There is no anesthetist, so either the OR nurse or Dr. Browning administer the epidural. There are two operating tables in one room. As Dr. Browning finishes his first case, a second patient is brought in. We step outside and have some tea and bread. The second case is for the Ethiopian surgeon who is here for training for a couple of weeks. Dr.Browning says he would have me do parts of the surgery if there were not any doctors here from various places in Ethiopia or Africa scheduled. “But we are nearly always booked with trainees,” he confides. I am content to be learning by observation from one of the best fistula surgeons in the world. “There are only 4 dedicated fistula surgeons in the whole of Africa outside of Ethiopia,” hestated. “I had 8 job offers last time I was in Nairobi.” Indeed, it appears that his presence in Bahir Dar will not be needed indefinitely. He is training himself out of a job here, which is a great thing for Ethiopia.

The atmosphere in the surgical ward is quite relaxed, yet still efficient. Dr. Browning goes in to watch the next case, tea and bread in his hand. We sit behind the guest surgeon, having our tea break. (For all the non-medical people reading this, food and drink would never even be allowed past the equivalent of the frosted glass door in the US). The third case is a previously-cured fistula patient who went into premature labor. She was unable to get to a hospital to deliverby caesarian, and her fistula re-opened. “This is a difficult case,”says Dr. Browning. “There are 4 principles of fistula repair: mobilize the tissue, protect the ureters, keep the urethra length as long aspossible, and do a dye test to make sure you have adequately sealed the hole in the bladder. Here in Bahir Dar, we’ve added a fifth: finish with a sling using [some of the pelvic floor muscles]. It has dramatically reduced our stress incontinence rate. I wrote it up in a medical journal when we first started using the sling, and the bloke (Dr. Browning is Australian) who designed the mesh that is used in the developed world wrote to me that it would never work. Well, I’ve been using it for 8 years now. Never had a problem.” He turns back to his work. He turns to me again, saying emphatically, “The mesh is $600. If you divide the number of major operations by the number of patients,we spend $250 per patient. I just cannot see adding that expense if the other works so well.”

All 3 surgeries are done before 11:30am. It is quiet in the hospital. Normally he has 6-8 surgeries before lunch. Since they are just at the end of their major holiday season, fewer patients have come to the hospital for treatment. I walk past the patients who are in the physical therapy room, listening intently to an instructor. Ryan is waiting for me under the trees by the café. He has made contact with Jose, a Spanish doctor who is here to make improvements to the government hospital. Ryan has had a chance to discuss the state of Ethiopian health. We begin talking about our day and the things we have learned as we walk down the road to a nearby restaurant for lunch.

The day has turned warm. The sun feels close, but not intrusive. Young children yell out, “Hallo forenje!” and then hide when we look their way. The main road is paved, with wide stone paths nearly the width of a car lane on either side of the road for the majority who are walking. “Where are you going?” we are frequently asked. “Are you fine?” “How do you find Ethiopia? Is it good?” and even, “What do you think about the Ethiopian Airlines. It was just an accident.” They are very proud of their country; at the same time, they would likely jump at the chance to come to America. We heard the statistic that there are more Ethiopian doctors in America than in Ethiopia. Sad.

We arrive at our new favorite place to eat. SubAfrica. There is the same Asian gentleman that I have seen every day at lunch. Soon after our food is ready, a Swedish couple I have seen every day comes again. We talk to the owner again. The talk turns to religion. “So you are a Christian. Now the question, what kind?” I say, “We follow Christ, we follow the bible. That’s what we look for in a church.” He pulls up a seat, “Good, I read a chapter every day. You should too. It will change your life.” We discuss what we have read, Ryan mentions that he is reading through the bible in one year again and how that has impacted him in the past. We discuss the end times. It is stimulating conversation. This American-born hippie running a random sub shop in Africa who has lived all over the world and is very anti-government is also very versed and passionate about the Bible. I suspect we will have many more conversations.

Ryan walks with me back to the hospital. He leaves for the church where he will be running a soccer practice. (Bug him to blog about it!) I return to the government hospital to the gynecology department. There are at least 7 patients lying on mattresses in the hallway. Now this happens from time to time in America, especially in the emergency room or in ob triage in America. But this seemed a permanent solution to space problems. On the wall above the mattresses, there are numbers written on the wall and nails where a few IV bags are hanging. One patient looks like she is in serious condition. Her father squats next to her, holding her head. As I stand there, the doctor approaches me.“What is the management for a patient with ecclampsia?” Oh, that’s what she has. “Deliver the baby. Right away,” I say. “Correct. That is what we have to do. She is being induced right now. Previously, they had her in the medicine department because they thought she had cerebral malaria. Instead, she was seizing from ecclampsia.” Wow, cerebral malaria wouldn’t even be thought of as a possibility at home!Another woman in the hallway is moaning. The floor is wet like water has been spilled. A student whispers to me, “Her bag of waters is broken. She does not want the baby. Now she will go to the obstetrics ward.” How is she going to get there in this condition?

In the gynecology office where Ryan and I first came when we were at the hospital, we sit to wait for a procedure. The students ask for my medical review book. Each night, a different student will ask to take it home for the night so they can prepare for a presentation. They are so eager for books. I decide to borrow their main book of ob/gynlecture notes. It looks similar in content, except with more emphasis on physical examination than on laboratory and radiological tests. Soon, the doctor comes in and motions for us to come. They are doing an ultrasound. We walk in a dimly-lit room which is the width of a bed. There is a woman on the bed. An ultrasound machine is turned on. We crouch around the screen. Surprisingly, it has a fairly good quality picture, but the screen is about half the size of the computer screen I am typing on. It does the job. We measure the BPD (biparietaldiameter, which is a fancy way of saying we measure how big the head is) to see if we can determine how far along the pregnancy is. According to their medical lecture notes, antenatal (before birth)pregnancy care is only used by 28% of the population, so most patients will not have any previous way to know how many weeks they have until they deliver. Maternal mortality rate in Africa is 650/100,000, East Africa is 680/100,000, and Ethiopia is 871/100,000. With a fertility rate of 5.7 children, these women have a 1 in 21 chance of dying as aresult of pregnancy and childbirth.

I catch the bajaj to the market, and walk to Berhanu’s office where Ryan is waiting. He looks sun-kissed and so do his shoes. The dirt has a red tinge here. He explains how he conducted soccer practice without using words. “At least when I coached the LeTourneau girls, they knew what I wanted them to do even if they didn’t always do it.” He smiles.“I had to take a kid and stand in one place, act like I was playing defense, and take another kid and stand there and act like I was playing offense. I thought they understood, but then the offender kicked it straight to the defender. I gotta learn Amharic.” There is free coffee here, and Berhanu allows us to use his internet when the power is working. He gives us suggestions on where to eat tonight. We walk down to a restaurant that serves pizza. It is not American pizza, but it is good. We walk home. There is time to play Carcassonne, read, prepare for the next day, and type our emails so that we can copy and paste at the internet cafés.