Resusci-ann’s Ethiopian Adventure
Travelling to Gondar
It occurred to me, at around 02H00, whilst tightly nestled between two well-built, champion snorers (who just so happened to be the friendliest Nigerians I had ever met), that perhaps, I was slightly out of my depth. The plane was packed to the max with passengers, and I was convinced that at any moment a scrawny chicken might burst forth from the overhead locker (this alas, did not happen). A melting-pot of languages, cultures and nationalities surrounded me. I felt overwhelmed knowing that I had accepted the task of heading off to ETHIOPIA of all places for 6 full days of basic and advanced resuscitation training, and was now more than halfway across the vast African Continent, hurtling through space and time at whatever the top speed of a Boeing 737-800 is. Too late to get off now…
I sat quietly between “praying man” and “goatie guy” (I had already affectionately nick-named my seat sharers) thinking about the fact that I had no visa yet (having been heavily reliant on potentially dodgy internet information about landing visa’s and tourist/business declarations), only some few Dollars in my wallet, and absolutely no idea what the beautiful, lilting Amharic voice of the airplane intercom lady was saying. What on Earth have I gotten myself into?
Once we landed, (I spied my ALS manikin box chilling on the tarmac and said a quiet thank you to the universe) the Amharic got intense. Surrounded by the constant sounds of this gentle language, the smell of incense and cooking spices that seemed to permeate the entire airport and tarmac, I realized that something was about to happen that had never, in my life happened to me before. I was for sure going to miss my connecting flight.
Racing through customs and security in my socks (because the little man in a suit at security thought my shoes could be concealing explosives…) I screeched to a halt at the back of the check-in queue, which seemed to snake around the terminal. Numerous guard types approached me to determine if they could assist, but alas, boarding was no longer allowed and the doors were closed. I purchased a second ticket to the city, whose name the locals laughed at when I pronounced (Gondar is apparently not pronounced Gonedaaar, more Gunder) and headed to the airport exit, determined to find the Wi-Fi the internet had boasted about.
Buying things with another country’s money feels a lot like Monopoly, especially when the notes are literally the same colour as the Monopoly notes. 350 Birr to pay for the next flight to Gondar (I have no idea how much money this is) and am fairly sure I would have been the easiest target if I had wandered from the safety of the airport, which I considered, as the security guard pointed me in the direction of a faded Coca-Cola sign in what appeared to be a beer garden right outside the airport gates. Giving the beer garden and slightly suspect looking cab drivers, clamouring for tourist attention, a miss, I decided it might be safer to sit out this wait in the boarding lounge.
In the distance Addis Ababa was bustling, with the mandatory taxi hooting and garbage smells wafting about, mingling again with the smell of incense and cooking oil. Ethiopia seems to be a place of smells. I hope my little plastic family managed to make the flight I missed.
After what seemed like a lifetime of waiting in the small tin-roofed building that turned out to be the domestic departures lounge, I finally made it onto the plane to Gondar. The wait was not uninteresting (the highlight being that lunch at the airport cost more than the missed flight payment). I soon realised that all meals in Ethiopia would follow a very similar theme, Western food was all heavily spiced so as to disguise the fact that Western food in Ethiopia SUCKS. “When in Rome” is probably the best advice I can give when eating in Ethiopia, try the local cuisine, they are AMAZING at all things Ethiopian (surprise). Initially, this was problematic as the menus in Amharic were fairly difficult to translate, and the only food whose names were written in English were “Western foods”.
Arrival in Gondar was a culture shock of note. I assumed that having worked in many rural spaces, and been privy to the private lives of some of Johannesburg’s poorest and most vulnerable populations, that I was well equipped for the poverty and development levels I was going to find on my arrival. I was horribly wrong.
My first surprise was the general level of development within the town. As the second biggest town in Ethiopia, there seemed to be 2 or three major tarred roads in the town. The buildings that did exist are reportedly left over from the Italian occupation more than 80 years ago. The countryside struck me as wildly hilly, and ridiculously treacherous, yet on each rocky outcrop there seemed to be a small community of shanty buildings precariously perched.
I am fairly sure that on my drive through town towards my hotel, my jaw must have hung open a fair amount of the time. Small children scantily clad with massive eyes that seem present in all rural African settings were present. The people are the same, the problems are the same, but here they just seem so much bigger.
Culture and Teaching
My first day of teaching was interesting to say the least; the people of Gondar with whom I came in contact were incredibly soft spoken and did not initially take well to my less than traditional teaching methods. The first hour or so of day one was a nightmare of confused stares and side-way glances. It took me a while to realise that I may have been speaking too quickly in a language that was foreign, in a South African accent (which is tricky at the best of times). More than before, these first few hours had me thinking “what on earth have I gotten myself into?”
Over the course of the programme the students definitely warmed up to my ridiculous sense of humour, and silly jokes. The students grew more excited at the prospect of learning new things, and I learned to speak a little slower and with a lower pitch. In terms of culture, I absolutely realised that teaching and interaction is VERY different in different countries. Cognitively this seems obvious, in practice however, this was a big surprise for me. At the end of the course, the magic that is hands-on, simulation learning won over, and by the end of the programme, a new culture within the classroom had been created. A new community of practice had been set up, and some of the students have since joined the Twitter world to follow #FOAMEd for further learning.
The Medicine/Clinical Environment
After day 1, having completed the first part of the programme with the students, I found myself with a few hours of spare time. Dr Mezgebu (my humble and soft spoken tour guide, and also Specialist in Internal Medicine at the University of Gondar), took me on a grand tour of the facilities. I was intrigued to find the hospital was in fact a large collection of small buildings on a huge piece of land. Each small building houses an individual department, and these buildings are often separated by 800m – 1km at times. As Gondar is, as previously mentioned, very hilly, the hospital is laid out from top to bottom gate over what seems to be a ridiculously steep hill (not so bad on the downhill, but the uphill climb left me breathless every. single. day.). The top gate and bottom gate appear to have been allocated arrival and departure gates as the locals seem to be dropped at the highest point, and then work their way through the facility to the exit gate so that patients can move constantly in a downward direction.
The ED surprised me; the first image on walking into the unit was a MASSIVE poster showing the triage scoring system. I don’t believe I have ever seen a larger, prouder poster in my life. The resuscitation room showcased another winning poster, with the resuscitation algorithm taking centre stage. The planning and thought that had obviously gone into the creation of these posters was evident.
The Emergency Department is situated at the top gate, which creates some excitement as when a patient requires an x-ray or admission, there is a rather steep, bumpy, downhill walk to any other department, with one benefit being that once a patient has been bounced to x-ray the chance is good that any fractured bones have been jostled back into place. Admission to the medical ward entails a hair-raising downhill ride along a steep gradient with an abrupt stop against the wall to the Internal Medicine Department if the stretcher driver is even slightly over-zealous.
At the very bottom of the hill – the medical wards, with hospital beds squashed into every conceivable space. Rooms that patients in our private facilities would complain are too small for a single patient housed up to 4 patients, with rooms separated by shoulder-high walling to provide some privacy. Drip bags hung from nails in walls, humanity packed into tight spaces, heaving with the blistering afternoon heat and scents. Mostly emaciated faces looked up in surprise at the only light skinned person on the hospital property.
The beds, despite being numerous, were spotless, floors clean, bedding neatly folded into comfortable-looking nests in each bed, each patient apparently well taken care of. Family members bustled in and out of the wards bringing a constant supply of food and drink to their loved ones. Nurses, doctors and family members seem to provide a network of round the clock care for the patients. The rooms were hot and musty, and the mandatory flies that can be imagined in a warm African town at 16H00 were flitting around the ward. I can’t say the wards were pleasant, but that was made up for by the care and concern that went into the care of each of the patient’s present.
I taught in a room next to the 4 bed ICU, where 2 ventilated patients could be catered for, however on my visit only one vent was in use. The staff were welcoming and warm, very keen to show off their ICU and equipment to visiting practitioners. It astounds me how much good medicine can take place in a space with so few resources. It cannot be emphasised enough however, that resuscitation courses are potentially NOT the ideal training programmes for the low income setting.
The training mandate for this programme was resuscitation training, and that is what was completed, however, the systems to receive the post arrest/pre-arrest patient are simply not there. With no EMS system to speak of in the more rural spaces (like Gondar), response times of 2-3 hours over horrendous terrain, limited/ no ICU cover (and limited beds and ventilators if the patient even makes it to the ICU), no cathlab within 12 hours, no CT scanner within 4 hours, no access to ABG on the hospital grounds, the basic outcomes and requirements for the basic and advanced resuscitation are relatively pointless.
Nonetheless, we soldiered on, and applied the most relevant information to the setting and available equipment to the teaching. We spent a lot of time discussing and practicing interaction where monitoring of vital trends to prevent arrest was the focus. During the teaching I had a fairly large clinical epiphany of my own.
It is strange to notice how far removed from the clinical, hands-on medicine we have become when we have so many tools to assess a patient. It is not that we are incapable of clinical assessment; it is that we have become removed from our patients ECG cables, and SPO2 probes and side-stream samplers and numbers and waves on screens, instead of using our senses to assess the patient, and even just make eye contact.
Some of the students had never in real life seen Pacing pads (or ECG pads of any sort). One of the ICU nurses relayed an experience where defibrillation had been delivered to a patient who was in ventricular fibrillation and woke up, despite the fact that he was defibrillated with paddles and wet crepe bandages for increased conduction. This is the true edge of medicine; it was a true privilege to teach these “McGyver Medics”.
I estimate that approximately halfway back over the vast African Continent, whilst on my way home after 7 days of teaching and interacting in Gondar, I realised that I had more than likely had one of the defining moments in my teaching career to date. I had participated in something I would probably look back on in years to come as one of the experiences that changed how I think about what I teach and how I apply the teaching to the settings in which I teach.
Probably the biggest lessons learned in this teaching experience, were learned by the instructor. The concerns that had plagued my journey to Ethiopia had been chased away by the absolute awe of the experience.
Thank you to:
- The University of Gondar (Dr Mezgebu Silamsaw, Yonael Mulat, Rezika Mohammed for hosting my stay in Gondar)
- Medicines for Malaria
- Africa Institute for Emergency Medicine (AIEM)