Halloween, but not here

We had another pretty good day at Tikur Anbessa though most everyone is away at the Ethiopia Pediatric Society meeting at the Sheraton.  We decided we should stay and teach and round in the NICU.  We also did some more work on our CPAP changes.

Lots of babies under phototherapy today.
Two others needing it as well.

The hospital ran out of reagents for bilirubin testing so the parents have to pay to have the test done in a private lab.  The parents of the baby on the far left could not afford it so he has not been tested though he looks pretty jaundiced.  The test costs 67 birr ($3.50 US).  Another reminder of how lucky we are.

Aluminum foil to increase the surface area exposed to the light!
Brought a box in on Monday, now it's being used for everyone!
That was easy.

We heard we would see exchange transfusions...so far none.
That's good
If you are wondering, not twins.  It's quite common to share the resources.

Then we had quite a ride home!!  This doesn't completely capture the traffic at this intersection.  We got safely through and didn't see any other casualties.   As you see these, remember, that all the cars and people are moving--no one stops, just accelerate or decelerate.  Honking is a catalyst.  Cindy noted that all the drivers ride on the white lines so they can move from lane to lane more quickly as needed.

Cars in all directions, people crossing.
No bikes in this series but we've seen some.  

almost Halloween

Cindy and I spent the day working on new CPAP delivery system.
Here she is with Dr Adane admiring our work.  

Our little Ms Mohamed recovering from surgery and her mom
(our favorite patient and mom!)

medication delivery time in room 1
The nurses have to draw up the meds and then administer them.

me checking out the labels

here are some of the meds and the MARs

Labor and Delivery Room bed

Back to business--Monday at TA

We had a very good day today with the residents on rounds.  I had thought we would let them do their work rounds and then we would teach afterward.  Instead we went around together in Room 2 with the term babies.  We did some teaching during the rounds and I think it was fun with good dialog and learning and no one becoming defensive.  We will try and do it this way again tomorrow. 

We spent some time with Sister Berhane and discussed nursing care.  We will split up tomorrow and each go with one group; also include the nurses in the discussions.  Cindy and I spent some more time fiddling with trying to get what we think will be a better CPAP circuit.  We will have to cut up some tubing to see if we can fit one together without the 3 way stopcock. 

I went to lunch alone—got some dry erase markers for the white board Sister brought in this morning.  I had thought I would use for teaching and will from time to time.  It seems preferable if I can do on rounds though.   I also got a roll of aluminum foil and we lined the sides of two cribs where babies are receiving phototherapy.  I think that should help.  I will look for any literature evidence for this practice tonight on the internet. 

After rounds I went back into Room 1.  Kediyah Mohammed, the baby with the ileal perforation looks great and her mother is mostly smiling now rather than tearful.  That is very nice to see. 

On the other hand, one of the babies presented at morning report was a 7-month-old former 32 weeker admitted over the weekend with pneumonia/respiratory failure and rickets.  He died.  Very sad.  One of the attendings blamed the neonatology program and the fellows for failure to identify the baby’s rickets in the follow up clinic.  Easy to do when they are not here to speak for themselves.  

the baby's wrists showing his rickets

He also had pneumonia and didn't respond to supportive therapy.  There isn't a ventilator.

After, we chatted with one of pediatric residents and she described the conditions in the clinic.  Sixty or more children come and they are all together and being seen by the residents at the same time.  It sounded very hectic and certainly seems like it would be possible to miss the diagnosis in that setting.  What system improvements might be possible there to decrease the incidence of missed and delayed diagnoses?  

Weekend at the resort!

We are at the Dreamland Hotel in Debre Zeyit.  Zewedu picked us up at nine at the Red Cross.  Quite a ride here, only about 40 kilometers from Addis, southeast, but a little over an hour driving.  There was quite a bit of traffic in both directions.  Big trucks were coming the other way from Djibouti which has ocean access.  There was quite a bit of industry as well and most of the way was built up.

The hotel is quite nice and away from the main road through town so quiet.  We've gone next door for both lunch and dinner and it's a lovely little restaurant that looks out on the lake.  There's wireless most of the time.  Who could ask for more?

The view from the balcony outside our rooms--Lake Bishoftu
A crater lake

another view.  I think this is the highest peak
But we are only at about 6200 feet elevation in town

yet another view of the lake.
We saw some children swimming

The Coffee Ceremony Room at the Resort Restaurant.
That's popcorn in the front.  

me!  

The Dreamland Resort/Hotel from the street

Lots of pretty flowers along the wall outside and inside the hotel grounds

more flowers

After lunch I went for a walk.  These two let me take their picture
But they were mugging and really, just wanted chocolate!

A family having lunch at the restaurant
Quite a delightful spot to eat, looking out at the lake

My Machiato, perhaps not spelled correctly
Post lunch which was spaghetti with meat.
Dinner later was a delicious cheeseburger and french fries with ketchup!  

Sunday morning from my balcony--nice reflection in the lake

More Sunday morning beauty

Ethiopian coffee ceremony description

I don't think I could do any better to describe our experience at Asfaw's home yesterday.  These descriptions borrowed from two internet sites.  The ceremony is a time for good discussion with both the men and women in the family.  We had only heard about the ceremony in the morning because we saw women carrying grasses they had bought at the market near the Former Women Fuel Wood Carriers store.  

"First, the woman who is performing the ceremony spreads fresh, aromatic grasses and/or flowers across the floor. She begins burning incense to ward off evil spirits, and continues to burn incense throughout the ceremony. She fills a round-bottomed, black clay coffeepot (known as a jebena) with water and places it over hot coals.

Then, the hostess takes a handful of green coffee beans and carefully cleans them in a heated, long-handled, wok-like pan. Holding the pan over hot coals or a small fire, she stirs and shakes the husks and debris out of the beans until they are clean.

Once the beans are clean, she slowly roasts them in the pan she used to clean them.

The pan is similar to an old fashioned popcorn roasting pan and it has a very long handle to keep the hand away from the heat. At this time most of your senses are being involved in the ceremony, the woman will be shaking the roasting pan back and forth so the beans won't burn (this sounds like shaking coins in a tin can), the coffee beans start to pop (sounds like popcorn) and the most memorable is the preparer takes the roasted coffee and walks it around the room so the smell of freshly roasted coffee fills the air.

The roasted coffee is then put in a small household tool called 'Mukecha' (moo-ke-ch-a) for the grinding. Most restaurants at this time incorporate modern coffee grinders into the process, this is to save time and it does not take much from the ceremony. For those interested mukecha is a heavy wooden bowl where the coffee beans are put and another tool called 'zenezena' which is a wooden/metal stick used to crush the beans in a rhythmic up & down manner (pistil and mortar).

The crushed fresh roasted coffee powder then is put in a traditional pot made out of clay called 'jebena' (J-be-na) with water and boiled in the small open fire/coal furnace. Again the boiling coffee aroma fills the room, once boiled the coffee is served in small cups called 'cini' (si-ni) which are very small chinese cups.

As you sip your first cup of coffee, you've gone through the full process of watching seeing the coffee beans being washed, roasted, grinded, boiled & now the culmination you're drinking them. By now the process is finished at most restaurants, but traditionally Ethiopians stick around to get at least a second serving of coffee and sometimes a third.

The second and third serving are important enough that each serving has a name, first serving is called "Abol"; second serving is "Huletegna"(second) and third serving is "Bereka". The coffee is not grinded for the second and third serving, a portion of coffee powder is left on purpose for these two ceremonies."

We only had two servings.  

Remarkable Friday

Since it was holiday, we had Zewedu drive us to the see where the Former Women Fuel Wood Carriers have their weaving center.  Philip Platt, who has come to Addis for the project had been here and told Cindy about it.  Perhaps because of the holiday, the store there was closed, but we were able to see the weaving.  Then they did open the store for us so we shopped.  I bought 10 pieces but Cindy outdid me.  The place and the women were remarkable.

The Welcome Sign 

Several of the looms 

Here is the thread before it was taken off into the ball

One of the workers with a big spool of thread that had been created

Cindy on her way up into the store.  Zewedu keeping
an eye on her progress.  

Cindy in the store shopping.  Lots of scarves behind her.

Here are some of the scarves that were being displayed

 It was quite a drive to get there.  We were in a major traffic jam for a while as everyone was headed to church.  Also the market nearby was open.  Quite a snarl.  Zewedu's little toyota heat warning came on but he just popped open the hood, turned on a fan switch and it was fixed.

After, Cindy and I went to Ethiopian Airlines to plan a trip north.  Cindy had talked with Misrak by phone about a possible tour.  The woman helping us said those didn't exist any longer but she helped us with flights to several different places and it was quite cheap.  So we will be off with Rosie next weekend.

Then, we got some more Birr at the ATM and headed over the hospital to wait for Asfaw Yemiru to pick us up.  He is a friend of Jeffrey Horbar from Vermont Oxford who has started and run schools here in Addis for more than forty years.  His own story is pretty amazing and our afternoon with him and his family was grand.  I will put some photos here. I'm not sure this will work but there is more about him at this web address:   http://worldschildrensprize.org/asfaw-yemiru.  If not, everyone should "google" him though and read the articles there about him and the schools.

Since today was a holiday, there were no classes.  So Cindy and I are going back on Wednesday next week to see the students.  As you can see, we had lunch and then Asfaw asked his daughter to show us the school buildings and grounds.  We also had coffee in a traditional Ethiopian coffee ceremony.

Lunch.  Cindy and Asfaw.  I think this was our first real
Ethiopian meal and it was wonderful...not too spicy!!

Cindy and I "proving" that we are eating lunch!

The big meeting room at the school.  Used for meetings,
celebrations.  Finished in 1992.

A close up of the stage in the meeting room.
Probably not close enough to tell those are faces.

Asfaw's daughter Ephrate and a 5 year old girl who is staying with the family
showed us around the school and grounds.  Ephate is 12 and in 8th grade.  Likes math and chess.  

the Guest House

Cindy on her way into to Asfaw's House

One of the school buildings.  There was one for each of the 4 grades
and several classes for each grade

When we were done, one of the teachers, Benyam drove us back to Black Lion.  Benyam went to the school himself and now is a sophomore at the University studying biology.  He also teaches biology in the 8th grade.

Quite a day!  Tomorrow we are off to a resort for the weekend.  We were lucky to get a room this late.

Thursday--Cindy stayed home.

Today I ventured out a bit further on my run but still around the Red Cross only.  There were a few cars but it seemed very safe at 6am.  The road is bumpy however.  There are other men and a few women here in the early morning also waiting for the aerobics class.  Some of them run around the grounds until the class starts.

Cindy still looked a bit pale this morning and so I went alone to the Black Lion with Lemma.  I took my big camera hoping to better capture the chaotic traffic at Meskal Square.  Alas, not bad today.  Lemma also let me know that tomorrow is a national holiday and he would not be driving us.  Turns out that it’s a three day weekend at the hospital as well, so we are rethinking our weekend plans now.  We are planning to meet Jeffery’s friend Asfaw at the Black Lion.  We will have to make a few calls. 

Anyway, at the hospital, I went right to the NICU to see what was happening with the two sick babies from yesterday afternoon.  The little 26 weeker’s parents had arranged for him to be transferred to a private hospital so he could be placed on a ventilator if needed.  That was a surprise!  Another place Cindy and I should try to see while we are here.   The other little one went to surgery finally this morning.  She most likely had a spontaneous ileal perforation.  There was local necrosis only and meconium in the peritoneum.  She came back with an ileostomy.  She seemed better actually though there was bleeding at the ostomy site.  We placed a bit of a pressure dressing and the nurses will watch for ongoing bleeding.  She is getting fresh frozen plasma and blood also. 

Before rounds Adene and I worked on having a simpler CPAP circuit.  It seems like would be easy enough to do.  Even with the current nasal cannula prongs, there should be a way to make the circuit simpler and more effective.  Sister helped us as well by bringing out an entire box of cannulae and circuits.  We will tackle this again on Monday.  There is still the problem of inadequate pressure in the system.  I will try and call Phillip over the weekend.  I believe there is a technical component but also related to competition for the oxygen tanks and poor hospital infrastructure related to the air compressors.  I am not hopeful we can fix that.  

Rounds this morning were a bit painful again.  Adene was there with his students.  Lots of questions so the residents don’t get to just have a narrative discussion about each baby.  Abebe, the senior resident was not happy.  I did some teaching as well.  It would nice to just go around with the residents and the nurses.  

After that, I walked around the hospital neighborhood a new direction, by the Swedish Embassy, National Archives, some banks, the National Theatre and eventually to Ambassador Park where there was some lovely music playing.  I read and had lunch and then headed back to the hospital to check on the NICU before heading back. 

Got a little closer to this guy.  My photo of the sign in front isn't clear,
but it's French Sculpture dedicated to Haile Selassie in 1955.

There is a wheel chair training program here at the center this week and there are many people here getting fitted and trained for chairs.  It seems like a very nice program though it must be extremely difficult to travel by wheel chair in Addis. 

The office said that Bogale called to check on Cindy, so he must be keeping track of us even though we have not seen him.  

Quite a day

In the morning, the resident report was cancelled and then the senior residents were also called away to a meeting.  So Cindy and I made rounds with the interns and a junior resident.  It seemed quite chaotic to us.

There is one baby who is quite ill.  She was a bit distended on Friday and by Monday, she was very distended and much sicker looking.  Her x-ray looks like she has a distal bowel obstruction.  She has not been getting better.  We suggested trying a saline enema yesterday since she has yet to have a bowel movement and the surgeons do not want to operate.  Other options like gastrografin are not available here.  We've also been told surgery here is not good.  The surgeon has been coming by and we were told in the morning that the baby was going to have surgery today.  Then just as we were preparing to head back to ERC, Adane called me and said the surgeon wanted us to try the enema.

At around 12, a very immature baby boy was admitted.  26 weeks, quite cold, respiratory distress.  Delivered after induction because, after days of ruptured membranes, the mother developed chorioamnionitis.  I think the baby was born outside the hospital, but I'm not sure.  We placed him on CPAP and wrapped him in plastic to warm her.  He looked pretty good actually.  There were different interns then.

Anyway, we came down to the NICU to do the enema.  Not very successful results.  Then, when I looked over, the 26 weeker was not breathing and looked quite dead.  Abebe, the senior also saw that.  We started doing resuscitation, breathing and compressions.  After a few minutes, his heart rate was better but he did not breathe and still looked quite blue.  We realized then that the oxygen was empty.  We then moved the baby across the room to the same bed as the big baby with Downs so we could oxygen.  AFter a while, the little one started breathing and I turned up the CPAP pressure to 10 cm.  Of course, he was then quite cold, so we had to move him back to the working warmer where he started.  Once the O2 tank was changed of course.  I rigged up a chin strap to see if that would help.  The nasal cannula prongs are just too small though so not much of the pressure is transmitted.

We also heard the surgeons have decided to do surgery on the other one in the morning.

In the middle of all of that, Cindy became ill with likely traveler's diarrhea and disappeared to the bathroom.  I missed that though I knew she was gone.  And our driver, Lemma, was quite unhappy that he had to wait for us.  Sister came to tell us he was ready to go and I said we would be staying until our two sick babies were more stable and we had a plan with the residents.

Here are some photos!!

The warmer between the two beds.
Also the power strip.  Other devices plug into that.

The little one with Down's.  That's his oxygen cannula.

the twenty six weeker shortly after he was admitted.

here he is from a distance.  The blue tube connects to
the water bottle and is delivering cpap.  

His oxygen saturation was quite good for a while.
This is the proof.  On 65%.

Our sickest little girl with distention