Facilities Perspective (11/15)

After the arrival of the container on Thursday, 11/12, many members of the group turned their attention to the physical clinic building for three days, jumping in with Mark and Leo, who had been working on the building all week. Mark Kuiper is an engineer who came on the trip with his wife, Kristen Austin, MD. He was kind enough to provide a wrap-up on facilities as of Sunday, November 15th.

Facilities Perspective (11/15) -- by Mark Kuiper

When we arrived on Saturday, Nov 7, the basic clinic structure was in place with walls, a floor, and a roof. However, there were no functional toilets or sinks, storage shelves, or supplies to fill the shelves. There was lots of work to be done in our seven working days in Addis. We wanted to get it in working order for basic exams, even if laboratory facilities, x-rays, and other major technologies would have to wait.

Leo and Mark began the shelf construction project with a visit to the Merkato, the Ethiopian version of Home Depot, Fabrics n Things, and Fred Meyer. The Merkato to is a large open air mall that stretches for a half mile in each direction. One can find just about anything there. We found the building supplies section and proceeded to bargain for tools at a dozen different shops. With the help of Selam and Masresha (BNCO Executive Director and clinic administration volunteer, both Amharic speakers) we drove away five hours later having purchased some basic tools at a reasonable price. It was Monday with six working days to go.

Leo and Mark spent the better part of three days planning and constructing the pharmacy shelves. There were moments when we weren’t sure if we would finish in time. For example, while the Merkato shops did have the basic supplies we needed, the shops did not have the tool and screw size variety one might find at a home improvement store. Leo and Mark settled on sizes that seemed appropriate and moved ahead. During shelf construction, they discovered the need for longer screws. Without the luxury of longer screws, they looked at what we had and decided to pre-drill a deep hole in the wood. This technique would enable using the shorter screws. Unfortunately, the correct drill bit size to pre-drill the hole was not available. In the spirit of Ethiopian resourcefulness, they drilled a hole with a smaller bit, wallowed out the hole as much as possible, and finished the job by burning the hole to size with a nut driver bit and a healthy dose of friction. It was Thursday with three working days to go.

With the pharmacy shelves complete, Leo and Mark began constructing the records room shelving. During construction of these shelves, they taught Dante (BNCO carpenter) how to safely operate a power drill. It was Friday morning with two working days to go. The file room shelves were about 50% complete when news of the shipping container status arrived.

The container had been on its way from Seattle to Ethiopia since July. It contained many of the supplies needed for the clinic debut. Only there was a problem. The truck blew a radiator hose and was stranded just a mile away from the clinic. The truck driver borrowed the shelf construction hand tools, some plastic wrap, and a pop bottle and set out to fix his truck. Leo, Mark, and Sisay (BNCO public relations) joined him to help out where they could. The driver fixed the leak in short order. With the help of a siphon tube and a five gallon jug of water resting on top of Mark’s head, the radiator was filled and the container was on its way again. By nightfall with the help of a crane, the container was resting on foundation blocks at the clinic. It was Friday night with one working day to go.

On Saturday, an army of volunteers began sweeping out four clinic rooms, washing walls, and cleaning sinks. Leo hack sawed off the two customs locks and cracked opened the container. Clinic beds, chairs, and tables were unloaded. Clinic supplies were organized on the freshly painted pharmacy shelves. A 2000 liter water tank was erected onto a 4.5m platform using only Ethiopian human strength and ingenuity. Mark and Brian (BNCO photographer) visited the Merkato with the plumber to buy water pipe and couplings. Leo coordinated proper attachment of the sinks to the clinic walls. The clinic facility was shaping up.

The morning of Sunday, November 15th was a busy time. The medical staff arranged the rooms to suit patient needs. A patient medical history area was developed, complete with calibrated bathroom scale and pencil lines drawn on the wall for patient height measurement. The city water was now up and running which made additional clinic cleaning much easier. However, the sinks had never been tested with water before and several leaked. A crescent wrench and some silicone caulk improved the situation considerably.

There are still many items on the “to do” list at the clinic. The records room shelves need to be completed. Glove staging shelves must be built for each clinic room. Additional clinic rooms need cleaning. The reservoir and hot water tanks need attachment. The concrete floor needs sealing. Many of the clinic room doors need adjustment. And the clinic doors, walls, and shelves need a final coat of paint. Surely, it is a work in progress. However, progress surely has been made this past week.

Our first Thursday in Town

Our First Thursday in Town (11/12)

The first Thursday the team was in town, many of the providers returned to Black Lion Hospital for teaching and patient care. Others went to other sites, and Leo and Mark headed back out to the ROMC site to work alongside the BNCO carpenter and other workers.

Kristen Austin went to a Marie Stoppes clinic to help deal with a too-typical scenario. Someone had kindly equipped the obstetrics-gynecology clinic with a colposcope (a device used to visualize and biopsy the cervix of a woman who might have cervical cancer), but not provided any training on its use. No one at the clinic knew how to use it! Thursday morning, Dr. Austin taught the physicians how to use it, using a flower as a stand-in for the cervix. (How poetic!) She would return the following Thursday (11/19) to provide additional training with real patients in need of colposcopy. Marie Stoppes provides many services that are beyond the planned scope of ROMC (delivery by caesarian section, for example). They said that in exchange for our help with their continuing professional education, they would be able to work out discounts for extremely poor patients referred from ROMC when it opens.

After the morning's work, the whole team gathered for lunch and a coffee ceremony at the Addis Ababa home of BNCO Executive Director, Selam Kifle. Then the whole group went to the ROMC site, rolled up their sleeves, and got busy sanding, painting, and otherwise making the rooms ready for service. That was the night a container of donated items shipped from Seattle finally arrived - after a sea-voyage, delays in customs, and an overland trek from Djibouti. Leo Dirac relates the final excitement, below.

The Container is Here! (11/12)

Working in Ethiopia can be challenging for Americans used to a high-paced go-go-now culture. Things are more laid back here. Relaxed and happy mindsets dominate. Times are often approximate. All this can lead to delays.


Photo by Leo Dirac, available under a Creative Commons license (http://farm3.static.flickr.com/2767/4102577600_6a5de5ed8f.jpg)

Moreover equipment we take for granted in the US is often in short supply here. We loaded a 40' shipping container, the standard for international logistics. But here in Addis Ababa there are not very many semi trucks on the roads -- smaller trucks dominate. Hiring a semi to move our container to the site was complicated, and it broke down on the way to the site. To repair it, the drivers had to borrow some basic tools from the clinic construction site -- a screwdriver and a crescent wrench. The last bit of dirt road to the clinic site was barely navigable by the combination truck. All these delays meant that the crane (which was also quite hard to find here) had to unload the container in the dark, which nobody had expected. But with one borrowed headlamp and a lot of determination, we made it work.

Now the container is in its permanent home. Once fully unloaded it will probably be converted to an office. The whole mission crew is excitedly emptying its contents into the building, finishing the conversion of a concrete building into a real medical clinic.

OB-Gyn surgery and establishing referral networks

Wednesday

Wednesday, I was holed up at the Ras Hotel, sick. Leo and Mark returned to build at the clinic site. Most of the healthcare professionals returned to teaching and patient care at Black Lion, but two of them accompanied ROMC Clinic Director Amsale Yilma to Marie Stoppes clinic and Das Resten Hospital. Marie Stopes is a British NGO that operates more specialized clinics than ROMC, and Das Resten is the government-run district hospital where many referrals from ROMC would be made. Some of the volunteers' stories follow.

Ob-Gyn Surgery at Black Lion (Kristen Austin and Carol McLaughlin)

This morning we (“nurse Carol” and “Dr Kristen”) went to the Black Lion obstetrical and gynecology department. Carol was welcomed by the nurses, who put her to work helping on the labor and delivery ward. In very short order, the labor and delivery nurses had invited Carol to eat with them. Homemade injera with shiro and meser wot soon appeared with hot tea. It seems that socializing and eating at the labor and delivery nurses station is a cross-cultural activity!

Today was the gynecology department’s operating room day. Similar to back home, the ob/gyn doctors lament the few hours allotted them to operate every week. Also similar to home is the complaint of prolonged time between operations for set up and cleaning of the rooms. Some things are the same no matter where you are. Today, Dr. Mahlet had a diagnostic laparoscopy scheduled. This particular case was for a woman who had infertility. The ability to have and raise children is extremely important for many Ethiopian women. In some rural communities, if women are unable to have children, their husbands will leave them and they are outcast from their communities.

There is one laparoscopy room at Black Lion, and they have some nice equipment that is currently working. One of the big problems at this public hospital is there are few, if any, technicians trained to fix the medical equipment. One American neurosurgeon we met told us a CT scan (“catscan”) machine had been donated, but was sitting dormant, because some fixture broke, and no-one knows how to fix it.

Anyway, the laparoscopic equipment was working today, and I was able to help teach some laparoscopic techniques to Dr Mahlet and a couple of residents. On open laparotomy the Ethiopian physicians’ surgical techniques are excellent. Laparoscopy is something new here. I was able to teach several surgical “tricks” to help make laparoscopy safer and easier for the physicians. This was exciting for both Dr Mahlet and myself. On the other hand, Dr Mahlet and her residents taught me how resourceful they are. There are no lights in the operating room, so they position the patient facing the window. Fortunately, Ethiopia is a sunny climate. If they couldn’t see a certain area while operating, the resident who was not scrubbed would hold his cell phone light to illuminate the surgical field. There is no suction-irrigator machine, so some intravenous tubing connected to a hollow instrument was configured, and voila!, irrigation. A bladder catheter became the uterine catheter to evaluate if the patient’s fallopian tubes were open.

In general, the ingenuity of the Ethiopian people never ceases to amaze me. The operating room is no different.

Kristen and Carol.

Making Connections at Mary Stopes

Today we (Leslie, Amsale and Liz) had the opportunity to visit Marie Stopes International- a British based organization focused on family planning, safe abortion, prenatal care and delivery services. Marie Stopes is currently providing care to women in over 43 countries with 30 sites just in Ethiopia alone! Check it out at www.mariestopes.org.

We were hoping to establish a relationship that would enable us to refer patients for vaginal births and c-sections.. We initially arrived at the wrong Marie Stopes clinic(just another mishap that turned into a bonus!) and met a very warm and welcoming site director who was clearly committed to women’s health. Once realizing that we were not at the Marie Stopes obstetrical site (the lack of pregnant women should have been our first clue) we quickly hustled to the 3 story obstetric center. Again, the staff was incredibly welcoming- and obviously very busy! The building buzzed with activity- proud families, recovering moms, crying infants and laboring women with 5 to a room! (Two quick observations- women and newborns stayed at the clinic only 6 hours after giving birth and the operating room was on the 3 floor in a building without an elevator. Imagine carrying a laboring women up 3 flights of stairs for emergency surgery!)

After our tour of the facilities, we met to discuss future collaboration with a clearly very competent and skilled medical team. We agreed to sharing resources- particularly Blue Nile medical volunteers providing training for staff- in exchange for discounted prices for our patients. For example, Marie Stopes received a donated colposcope, but did not have any staff that knew how to use it - several members of our volunteer team do. Currently the cost for a vaginal delivery is around $10 and a c-section around $20- a shocking price in our country but well out of reach for most Blue Nile patients.

Following our visit to Maries Stopes, we were fortunate to have a brief meeting with the director for our local district hospital. Again he was very welcoming despite our unannounced visit and looked forward to working together on inpatient care for our patients.

Overall, a very productive morning!

Leslie and Liz

Our first few days

Sunday

Our first full day in Ethiopia was a Sunday. After a slow morning and a walk to the Hilton (to use their faster internet), we piled into the BNCO truck and a mini-bus to drive out to the clinic site. There, the BNCO orphans living in the clinic area gathered to meet the Mission Team.

The team distributed clothes, toys, toothbrushes and toothpaste (along with instructions on their use), and school supplies. The Team was impressed with the children's commitment to education. Small kids who received crayons and coloring books came back when they realized older kids had received notebooks, pencils and pens - they wanted real school supplies, too!


(Photo: BNCO staff, Medical Mission Team, orphans and foster parents gather at the site of the Richard Oslund Memorial Clinic.)


(Photo: Engineer Mark Kuiper shows some of the BNCO orphans how to take pictures and view them on his camera.)

Monday

Our first workday started out slowly. We visited with the Chair of Internal Medicine at Black Lion Hospital about our providers volunteering there. They were hesitant, because although we had submitted all of our papers to the Ministry of Health, the MOH had accidentally written all of our permission-to-practice letters to Gandhi Memorial Hospital, not Black Lion. We then visited the Dean, who gave his blessing to volunteer while waiting on the corrected letters. The Obstetrics-Gynecology department quickly swept up Kristen Austin, MD, and whisked her away to work with their team. Lynn Robinson, PT, also quickly found herself treating patients and teaching her local counterparts in the hospital's physiotherapy clinic. The remaining providers fanned out and visited the Emergency Dept and various outpatient clinics to find the right fit for their skills.


(Photo: ROMC Clinic Director escorts the BNCO Medical Mission Team to their first meeting at Black Lion Hospital. Black Lion is a large referral hospital associated with the medical school in Addis Ababa.)

Meanwhile, Mark Kuiper (husband of Dr. Austin) and Leo Dirac (husband of Maegan Ashworth, Health Professionals Coordinator) took off with Selam Kifle (BNCO Executive Director) to purchase tools and building supplies at the Merkato. They took the equipment to the ROMC clinic site to build shelving. This project would keep them busy for several days.


(Photo: Leo Dirac and Mark Kuiper build shelves in the ROMC pharmacy.)

Several team-members were ill, tired, or chasing down lost luggage at the airport that night, but a small group dined at an excellent restaurant, Hebesha, saw traditional dancing, and chatted with Rick Hodes, a physician who's been practicing at Mother Theresa's Mission in Addis Ababa for decades.

Tuesday

Today, Lynne, Kristen, Mark and Leo returned to the activities they'd started on Monday. Leslie Tregillus, MD (a Family Physician) spent the morning in Black Lion's diabetic clinic, and Michael Rogers, MD (also a Family Physician) went to Rick Hodes's clinic at Mother Theresa's mission. Celia Atkins and Morgan Royster (a nurse and PA) observed in the Black Lion operating room.

Liz McGovern (a family physician), Mesresha Zenebe (the BNCO volunteer that is setting up the administrative aspects of ROMC), and I visited the Medical Director for Marie Stoppes. We explained what BNCO is, described the ROMC, and asked if there were ways our groups could work together. He explained the mission and services of the Marie Stoppes clinic. Their group focuses on family planning and obstetrics-gynecology, and has more than a dozen clinics in Addis Ababa. He invited some of our volunteers to visit the one closest to ROMC the following day. Dr. McGovern saw this as a great opportunity to develop a relationship with a clinic where ROMC patients could be referred for C-sections or other services beyond our clinic's scope. Dr. Mesfin identified some areas in which his staff would benefit from education from our volunteers.

In the afternoon Liz and I toured the neighborhood near the ROMC, and then joined ROMC Clinic Director Amsale Yilma to pay a visit to St. Paul Hospital. (St. Paul's is a university hospital, like Black Lion, but located closer to ROMC).


(Photo: A neighborhood woman outside the ROMC. The neighborhood is called "Asko" and is located in "kebele" (district) 15/16 of the subcity Kolfe-Keranio. It is known for being crowded and poor, with no government-run healthcare facilities available there, the private clinics and even those run by NGOs charge more for services than most residents can pay.)

After the visit to St. Paul, Liz and I had the pleasure of joining Katie Wakefield and Selam Kifle for a meeting with the Community Health Agents that conducted a 2.5-month, 1000-household, door-to-door survey of health status, health knowledge, and healthcare needs in our service area. The agents are all members of a youth community improvement group that assists various NGOs with projects like these. Their data will help guide our clinical services and health education programs.


(Photo: Community Health Agents Meseret and Meron chat before meeting with BNCO staff. Ten young people from the kebele 15/16 youth improvement group were trained by ROMC Clinic Director Amsale Yilma to administer a health survey and provide health education June-August of 2009. Previously, members of the youth group have assisted with polio vaccination campaigns and other projects. We hope to continue working with them at ROMC.)

Making Lemonade in Addis Ababa

Shortly before departure, the BNCO November 2009 Medical Mission team received some disappointing news. The shipping container full of donated equipment, furniture and supplies for the Richard Oslund Memorial Clinic (ROMC) was delayed longer than normal in customs, so ROMC would not be set up and ready to open for the group’s arrival.

(The supplies were donated by a consortium of Catholic hospitals called CHUMA; the internet is slow here, so I won’t go searching for a link to more information on them, but do a search for them if you want to read about a great organization that helps outfit many small international projects like ours.)

The BNCO field staff has found other ways to put the group’s skills to work. They contacted several nongovernmental organizations (NGOs) with missions similar to ours. These NGOs can make use of a small number of doctors and nurses at clinics in other parts of Addis Ababa – clinics that also serve the extremely poor. Black Lion Hospital, the largest public hospital in the country, and the teaching hospital for Ethiopia’s premiere medical school, welcomes the remainder of the volunteer providers. Similar to publicly owned teaching hospitals like Harborview Medical Center, Seattle, hundreds of poor people with no other access to care are seen there each day. Our physician-volunteers will work alongside Ethiopian colleagues in their outpatient clinics.

The Team is also thinking in terms of the long haul for ROMC – several have offered to spend some days learning the Ethiopian healthcare system at Black Lion, and some days at ROMC, applying that knowledge in helping to set up the most effective clinic possible. Some of the Medical Team’s friends and family are here, too, and will help unload the container, set up the clinic’s computers and computer network, etc.

Meanwhile, the team of Ethiopian Community Health Agents (CHAs) hired and trained earlier this summer is compiling data. Led by ROMC Director Amsale Yilma, the CHAs went door-to-door in our service area (Kolfe-Keranio subcity, Kebele 15/16) to gather health statistics. They are already seeing similarities and differences between our population and Ethiopia overall, and are working on a final report.

We will visit the ROMC site and meet the ROMC staff and local BNCO orphans on Sunday afternoon. For Saturday, we’re just getting settled into our rooms in The Ras Hotel and getting accustomed to the altitude.

---Maegan Ashworth (Trip Coordinator)

(Photo: BNCO Project Manager, Katie Wakefield, greets family physicians Leslie Tregillus (Seattle) and Liz McGovern (Boston) in the parking lot of the Ras Hotel.)

November 2009 Mission

Three nurses, one physician-assistant, one physical therapist, three family physicians, and an obstetrician-gynecologist get on a plane...

It is not the beginning of a cumbersome joke, but the first ever BNCO Medical Mission. We depart for Addis Ababa on November 5th. We leave with the intent to care for desperately poor patients, share knowledge and technology with Ethiopian colleagues, and build solidarity across continents.

If you have donations of medical equipment and supplies, medications, school books, or clothes, please contact Maegan Ashworth (at Gmail) before October 30th.

We'll keep you updated on our mission, Internet access permitting.