Choice #2

And we choose to do this...

I have been too busy to blog. Funny in Motta I was busy but my downtime wasn’t filled with errands, engagements and entertainment and I had time to blog. I am riding Cycle Oregon this week, which brings me back to my favorite topic choice.
We have too much choices in urban USA and western Europe. So many choices that we pack our days to a point where we have to grab our day planner to schedule time with our loved ones. It’s crazy and it’s exhausting.
My friend Vincent Tamariz, who is a pediatric emergency room physician posted a link to a recent New York Times article about ‘decision fatigue’, http://www.nytimes.com/2011/08/21/magazine/do-you-suffer-from-decision-fatigue. The article describes a study of decision made by Israeli Parole Board Judges. The presumption was that Arab Israeli prisoners may be less likely to be considered for parole than Israeli Jewish prisoners that have served the same amount of time for similar offenses. It turns out race is immaterial. The most important factor in determining whether a prisoner was granted parole was the time of day the judge decided on the prisoner’s case.
Prisoners whose cases were reviewed early in the day, were twice as likely to get paroled than prisoners whose cases were reviewed at the end of the day.
By the end of the day the judges were too tired to decide anything and not granting parole was a safer choice. It was a ‘non-decision’ so to speak. After making decisions all day long they couldn’t make decisions any more.
Having a lot of choices becomes difficult at a certain point because we all get too tired of making decisions about everything. So when we get to the super market we can’t even decide about something as simple as breakfast cereal.

It’s one of the reasons I love being in Motta. Life is easier with less choices in some regards. It’s why 2000 doctors, nurses, lawyers, TV producers and financial advisers sign up every year to bicycle 500 miles in one week and sleep in tents, eat bad food and use portable toilets. It’s pretty simple living for a week.
The only decision to make in the morning is how many clothes to wear.
In the evening it’s:”Which of the 4 flavors of beer should we try tonight?”
Aw, choice, it’s a blessing and a curse.

Better

Every morning I wake up with a dream about Mota. There is a delivery I am needed for. There is a baby that needs to be resuscitated. There is something that went wrong. By the time I wake up, I have forgotten what it is.
I love Atul Gawande, who inspired this blog. He is a surgeon and writer. He writes in his book ‘Better’:
“I used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just when you begin to feel confident that you know what you are doing, failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part about being a doctor, I have found, is to know what you have power over and what you don’t.”
Every morning I am figuring out what I had power over and what I didn’t while in Mota.
I was only in Mota for three weeks, a very short time period, in retrospect. While I was there, it seemed like ages, because every day was filled with so many new experiences.
Medicine is universal. People get sick and women have complications in labor all over the world. The diseases and the complications differ from place to place, but not as much as you think. What is different is how much resources are available to cure the diseases and tackle the complications.
In the US, we monitor a baby’s heart rate in labor because we have the resources to deliver the baby quickly if the heart rate goes down. In Mota government hospital, it takes an hour to get a patient ready for a cesarean section, and by that time the baby is either dead or the heart rate has recovered.
We had some babies die during labor in Mota. Their ghosts haunt me at night into the morning. The part of me that practices medicine in the USA with seemingly unlimited resources thinks I should have done more to save those babies. The part of me that realizes that we did not have the resources to predict which babies were going die in labor in Mota has made peace with those baby souls. I had no way to diagnose fetal distress in labor and no way to respond to fetal distress quickly enough to save babies. I know that, but boy is it hard to accept that I had no power over something that is such a part of every obstetrician’s fiber in the USA.
The biggest financial payouts in malpractice cases are for neurologically damaged babies. John Edwards, the presidential candidate, made most of his money prosecuting obstetricians who failed to recognize signs of fetal distress and failed to do timely cesarean sections. Many of my hospital’s labor protocols address what to do in cases of fetal distress.
Fetal distress is one of the reasons our cesarean section rate is 30 % in the USA. Because our tools to diagnose fetal distress are not very accurate, we often over diagnose fetal distress. We think a baby is going to have difficulty, but it’s fine. We don’t know and we err on the side of safety, because cerebral palsy is permanent and debilitating. I am trained to look for signs of distress and act on it. And I am well trained. As far as I know, I have never delivered a baby in my career that died in labor or that had severe neurological consequences as a result of the delivery.
So accepting that I had no power to save babies was hard, very hard. Delivering dead babies or babies that died right after delivery was hard, very hard.
And every morning when I wake up, I realize that I still do not accept that I couldn’t have done more to save some of those babies. It is why I will always feel some sorrow when I think back of my three weeks in Mota despite how many mothers we saved.
That brings me back to Atul Gawande, because in the last chapter of ‘Better’, he gives advice on how to grow in medicine, and any profession for that matter. He extols you to change, to obsess over your outcomes, and to change.
He also recommends that you don’t complain, that you count something, that you ask a random question every day. And that you write for yourself and for others.
I am writing

Photo by Joni Kabana

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grace

Dr. Zenaw checking in on a patient

What I miss the most about Ethiopia is the grace with which people treat their friends and acquaintances. As our guide to Lalibela said: “We are so poor without warm greeting we have nothing.” Every morning before rounds everyone was properly greeted and inquiries were made about how you slept and how you felt. We are too busy to greet each other in my office back home. We have lost this ability to connect with each other on a basic human level.
The last dinner with the doctors was amazing. All the general practitioners were there and everyone was ribbing each other and being playful. All their classes in medical school are in English so their language skills are impressive. It is much easier to joke when you have language in common. My bad for not learning Amharic of course, but one month was not enough time for me to learn the language. I realized at a certain point how much I was going to miss them and got quiet. Dr. Zanew immediately noticed and asked why I was being so quiet. I realized few of my friends in Portland would have even noticed I was quiet but Dr. Zanew did.
In a country where people have so little, TV, computers, and smartphones are a rarity. People actually look at each other when they talk and notice each other. They stretch out their hand when you trip because they are completely engaged with you when you walk together.
I will miss that engagement, that grace.

Leaving Mota

The hardest thing about leaving Motta is realizing that I can leave and Yamatan, Moges, even dr. Yllical and Simagnew cannot. A month of sponge baths has not made me smell any better and I am ready for a shower. We have running water four mornings a week. The hot water stream is anemic and a shower is not really possible. Simagnew, the midwife in charge, who is always available, never has running water. Compared to Yamatan’s , Moges’, dr. Mirawi’s , or Simagnew ‘s digs our facilities are luxurious. Yet I feel like I have been slumming it.
The hardest thing about leaving is having Tadele tell me about wanting to become a gynecologist and how he hopes one of the doctors will pay for his schooling. It is having Moges sit at the table with us and telling us he was a farmer but he discovered he was a good student. Now, he wants to finish high school, sit for his entrance exams and go to medical school. He is 23 years old. Until he gets to Medical School he needs money to live off. The hardest thing about leaving is having Yamatan tell me about his dream to become a road engineer. He didn’t pass his 10th grade exams. He would have to pay to go to a private school rather than a publicly funded school, which only accept the students that pass the 10th and 12th grade exams. He is the shoeshine boy at the hospital. He shines your shoes for 3 Birr, about 25 US cents.
The hardest thing is having everyone ask me for things. “Can I have that pot when you leave?” “Can I have a ride to the big city with you?” Can I have Misoprostol tablets?” The thing that is so hard about it is that I am exhausted and drained after a month of 24/7 call and working under very primitive conditions and I just want to scream: “No, No, No, I have had enough, I have given enough. I volunteered my time. I lost income while I was here because I had to pay some one to cover me. I have had diarrhea, I stink and I am covered by mosquito bites. I have given so much of me. I have nothing left!”
But, that isn’t true. I have so, so much more than every one here. I have a house with electricity and running water. I have a car. I have control over where I work and how much I work. I have enough money to take a month off to come to Ethiopia. I have my health and if something happens I can be seen and operated on in a hospital with a choice of surgeons, with a blood bank, with clean sheets, with every choice of suture, every choice of antibiotic, with Operating Room lights, with running water and so much more than Motta Hospital has, so much more. I have so much more, so much more to give.
I am just so overwhelmed by the need here that I can feel myself shut down. I can’t, I can’t possibly fullfill all these needs.

So many questions….

The last two days were hard. My stomach was upset and I didn’t sleep well.

We were called late Sunday, to come to the obstetrical ward. There was a patient who just came in with eclamptic seizures. She had already had three seizures at home and was unconscious. Her baby had died and she was completely dilated. We had to deliver the baby with forceps because she was unconscious. She had been subjected to female genital mutilation as a child and there where no labia and there was no clitoris. She was nineteen years old and had a tiny pelvis. I cringed as I put the forceps on praying I wouldn’t hurt her, but realizing that the quicker I could deliver her dead baby, the quicker her seizures would end and the better chance I had for her to survive.

The patient woke up from her post seizure coma yesterday after noon and couldn’t remember a thing. Today her family wants to take her home. They have no money to keep her here. We could pay, but the midwives prefer we don’t. It sets a precedent that is not sustainable. It’s hard to see her go.

What is going to happen to this girl? Is she going to heal up from her repair? Is her family going to bring her in for prenatal care next time so she doesn’t get eclampsia and so she doesn’t loose her baby?

I have all these questions. I am frustrated. I feel like I am just scratching the surface. There is so much underneath. So much I do not know about.

Yesterday, we had a patient come in with a retained placenta after a home birth 24 hours ago. Upon further examination it wasn’t just a retained placenta, but a placenta and a whole other baby. This is what happens if you have no prenatal care. The second baby was breech and dead. We did a breech extraction and removed both placentas. Today the patient’s blood count is 19%, half of a normal blood count. At least she has one baby that is doing well, but it will be a while before she feels better with that blood count.

She too will go home today. Will her family let her rest to recuperate? When will she be asked to fetch water or clean teff?

So many questions…..

Market Day

Today we went to the market, a crowded, dusty square next to the bus station in downtown Mota filled with donkeys carrying firewood and crowds and crowds of people. Goats and kids are mulling around the piles of rocks that have been dumped in the square for building a shopping mall. The square is crisscrossed with gullies where sewage and garbage collects.

Once you enter the chaos it is remarkably well organized. Here are the coffee and salt vendors. Here are the dried chili peppers sitting behind sacs of dried red peppers, coughing from the cathepsin in the air. Over there are the honey vendors surrounded by swarms of bees and the cabbage, potato and beet vendors holding umbrellas against the sun. And behind them are the girls hocking the most gorgeous greens for 10 cents an armful. All wares are neatly displayed on sheets of colored plastic laid on the dirt. Scales with lead weights sit next to the wares on the ground.

Here are the women selling onions and there are the spice vendors, the chicken vendors, the goat vendors, the orange vendors and the banana vendors.

At the edge of the market are rows of sewing machines and the people ironing clothes with old-fashioned irons filled with hot coals. This is where you bring your best outfit, clean or not and get it fixed and ironed.

In the middle ages, there were streets in European towns where everyone practiced the same trade. That’s what this feels like. Here is the guild of cobblers who make shoes from old tires. There is the guild of oil vendors.
We buy enough vegetables to last us four a week for less than five dollars. And then we leave after an hour to get out the midday heat and enjoy a fresh fruit smoothie under a parasol. Fresh mango and papaya juice: what a treat!

Joni and Jay return to market later to buy a chicken. They return to our cottage with a living rooster with his legs bound. Yamatan helped them pick a good one. He will also butcher the rooster, but in another hour because first he has to watch ‘Ethiopian Idol’ on TV. In the meantime, the rooster sits next door in the grass picking at the dirt. We keep an eye on him to make sure a dog doesn’t run off with him.

Yamatan dutifully returns in one hour and takes the rooster, folds his head back and slices his throat with a sterile scalpel from my medical supply bag of tricks. He then puts him under an upturned bucket to let him die, all in the grass in front of our cottage. This is where we sit and watch the sun set over the bales of teff and the village of Mota. This is where we sit and drink our one beer a day on plastic chairs listening to the crickets and the birds.
Blood stains the ground when he is done. He throws the entrails several yards away under some eucalyptus trees. The crows and the dogs will eat them in no time.
I am glad the deed is done. I always thought that I should be able to watch an animal die since I eat meat, but watching our rooster sit next to us alive and picking the dirt, is not easy. Somehow it is easier to look at him dead, when I know Joni will be making chicken soup from him.

photograph by Joni Kabana

Choice

Photograph by Joni Kabana

Choice is a luxury few patients can afford in Northern Ethiopia. In Portland, my patients get to choose whether they deliver at home, in a birthing center or in a hospital. Here in rural Ethiopia women rarely have that choice. They deliver at home. Rural Ethiopia is mountainous and there are no roads and no bridges connecting villages to the larger population centers in many places. During the rainy season you can’t cross the river and you simply can’t get to a health center.
If things go wrong, you can walk over three hours over a dirt path to a rural health center, where there may or not be someone working who may or not know something about delivering babies. If things go really wrong and you have obstructed labor, meaning your baby is too big for your birth canal, your baby dies and very often a part of you dies. And sometimes, mothers die as well.
The World Health Organization estimates that about 5 to 8% of labors are obstructed. The only way you can deliver a baby that’s too big alive is through a cesarean section or through a procedure called a symphysiotomy: a procedure where the pubic bone is cut open to make more room in the pelvis. When a baby has died, it will fit through the pelvis because it falls apart when it has been dead for a while. Before the baby dies, however, the pressure of the head on the tissue of the vagina may kill enough tissue in the vagina to create a fistula, a hole between the bladder and the vagina or the rectum and the vagina.
Among the Hmong of South East Asia, women’s obstructed labor rates are lower because women tend to have more room in their pelvis. In rural Ethiopia, women evolved to walk long distances and their pelvises are often narrow. Obstructed labor rates are higher here. Add to that natural disadvantage the fact that most people in rural Northern Ethiopia are subsistence farmers and live on plots of land too small to feed everyone in the family so girls are fed less, and your chance of a mismatch between baby and pelvis has just doubled.
In the USA, we automatically do cesarean sections for obstructed labor. In rural Ethiopia, there are few centers where women are able to have cesarean sections and even at those centers, a cesarean is a choice of last resort because it means the patient definitely needs to deliver at the hospital during the next pregnancy. Many patients cannot afford the 50 Birr ($3.03) for a normal hospital delivery.
Today I performed a rotational forceps delivery with Simagnew, one of our very skilled midwives. Obstetricians used to do them a lot in the USA, but stopped when the lawyers realized babies with scars are worth a lot of money. They do not have the Kielland forceps here, with which my mentors rotated babies. I struggled getting the forceps blades on right and I did not have the best application. The baby came out with a mark on his forehead but alive and screaming. The mother had a vaginal delivery and will be able to deliver her next child at home if she can’t afford to come to the hospital.
I practice medicine differently here, I have noticed. I do things I would not do in the USA, but I too am somewhat limited by the lack of choices my patients have here. If I can avoid a cesarean section in a patient, I at least offer her more choices.

Age Matters

photograph by Joni Kabana

Just before Christmas last year, Congress considered passing a bill condemning child marriage. Republicans blocked the bill because they were concerned the bill might lead to increase in abortion worldwide. The idea being if child marriage is illegal, young women who are pregnant might be forced to have abortions.
An editorial in the New York Times at the time argued the bill was probably blocked because the lame duck congress didn’t want to give Obama any more victories after the repeal of “Don’t Ask, Don’t Tell.” They felt a strong statement from the USA condemning marriage of girls under 16 would increase abortion worldwide.
Maternal and neonatal morbidity and mortality worldwide is closely linked to poverty and age of mother. Children born to mothers under 20 are four times as likely to die than children born to mothers over 20. Obstructed labor, and it’s terrible sequelae, fistulae, uterine rupture, stillbirth are much more likely to occur in the patients who are less than 20 years old. Neonatal and maternal mortality is the highest among the rural poor with little or no access to emergency obstetrical services.
The Ethiopian government is trying to address this problem in several different ways. Building rural hospitals and training midwives to staff those hospitals is one solution. Building roads is another answer. Outlawing child marriage is another way the Ethiopian government is trying to save the lives of mothers and their babies.
Darlene and I sat in the Outpatient Department seeing ‘cold ’, non- acute cases yesterday with the family physician. The first case was a strikingly beautiful young man who came in for an age determination. It is the week after Timkut, the feast of Epiphany in the Ethiopian Orthodox church, when everyone goes out in his or her most beautiful clothes and many young men and women fall in love. This striking young man wanted to marry. The GP counts his molars on both sides and determines he is over twenty-one based on the fact he has three on both sides. He signs his marriage permit.
Next comes a girl who looks very young, I guess, fifteen. She states she is eighteen and wants to get married. The GP checks her Tanner stage by looking at her pubic hair distribution and her breast development. We ask her when her first period was. She answers a year ago.
She is not eighteen the GP grumbles and turns his back on her. He writes on her government issues age determination form she is between fifteen and sixteen. She will not be allowed to marry. “Do some girls still get married,” we ask. “No,” he answers, ”It is not allowed.” “The government does not allow such a thing.”
Later, I ask Dr. Ayallu, our neighbor “Why do these girls wanted to marry so young?” “It is not them,” he explains, ”It is the family. They are farmers and they need cannot afford to feed their daughters.”
Abortion law is quite pragmatic in Ethiopia. Abortion is illegal in Ethiopia except for cases of rape or incest, if the continuation of the pregnancy would risk the health of the mother, if the baby has a fatal fetal malformation, if the mother is mentally or physically not able to take care of the baby for instance if she is less than 18 years old, or if the mother is in imminent or grave danger. If moms say they are raped and it turns out they were not, the abortion provider cannot be prosecuted if he or she acted in good faith.
We saw a sixteen-year-old girl who came in requesting an abortion. She was five feet tall and had hips the size of my thigh. She looked like obstructed labor in the making. So, if you are less than 18 it is legal for you to get an otherwise illegal procedure in Ethiopia. In fact you can request an abortion just based on your age. Maybe those Republicans in Congress, who were opposed to a bill that would ban child marriage, were right about worrying about more women having abortions when the legal age gets raised. But think of all of the babies’ lives that are being saved, all those fistulae that are being averted, all those mom’s lives that are being saved. Surely saving all those lives outweighs the occasional life lost from an abortion. Or am I being too pragmatic?

What really matters.

Finding out what really matters……

I just looked over my questions I had for Andrew Browning the morning before Darlene and I left from Bahir Dar to Mota, a three hour trip on a gravel road. They seem so naïve now.

Is there a bloodbank at Mota Regional Hospital?
No.

Can I transfer very sick or preterm patients?
You can transfer patients to Bahir Dar (over that same 3 hour gravel road), but chances are, the patient will be in better hands with you in Mota than in Bahir Dar and they don’t have any facilities for preterm babies in Bahir Dar.

How do the midwives keep track of labor progress?
On partograms developed by the WHO, but they rarely fill them out correctly.

These are questions from someone who practices obstetrics in a place where every possible thing is done to save a baby’s life, and a subspecialist often takes care of the complicated pregnancies. If you do not make a timely referral to a subspecialist or deliver your patient in a place where the baby can be resuscitated, a lawyer will gladly represent the patient whose baby didn’t do as well as expected.

Since I started at Mota Hospital eight days ago, there have been two stillbirths and three children who will most likely die once they go home. One baby was the product of a rape and the mother had no interest in the child, another was simply too preterm. Yet another was a twin girl who tried to come out with her arm first and who also was too small to suckle on the breast. Giving babies formula in the hospital here makes no sense because moms can’t afford formula and there is no clean water to mix formula with. Even HIV positive mothers are encouraged to breast feed here. The child will have a much better chance of surviving if it is breastfed.

I have managed two patients with severe preeclampsia with the midwives with some Misoprostol brought by my Dutch predecessor and Pitocin intravenous drip, dosed by counting drops per minute and a dilute Diazepam intravenous drip dosed by counting drops per minute. Administering intravenous medications by counting drops per minute is a very vague way of dosing medication even when every patient has one nurse assigned to them. In most Ethiopian hospitals, the main person responsible for being with the patient and emptying the Foley catheter and making sure they take their pills is a member of the family, not a nurse, because there are no nurses.

There are three certified nurse midwives on call each night. They are all one to two years out from their training and are all in their early twenties. They are on three to four shifts a week. Their skills are amazing. They deliver breech babies vaginally. They perform vacuum deliveries. They manually extract retained placentas. They perform manual vacuum aspirations for miscarriages. They manage and deliver twins. They resuscitate babies that have a difficult time transitioning. Some of them have better skills than others, but they help each other out and do an amazing job.

Despite having some really high risk patients, the cesarean section rate is only 6 % at Mota, thanks to the amazing skills of the midwives.

The only thing the midwives are not good at is keeping track of whether the patient has taken her medication to bring down her blood pressure from a systolic of 220mmHg and a diastolic of 160mmHg.

But they know they have to get the patient delivered as soon as possible, so they know to call me for the Misoprostol and they know to start Pitocin and they are much quicker in getting the intravenous line in the patient than the IV nurse at my hospital back home.

It is a different skill set. Back home it seems the nurses spend so time documenting what they did that they seem to have little time to actually take time of the patient.

At Mota very little gets recorded but at least from what I can see, patients get taken care of. At least as much they can be taken care of in a hospital without any lab on the weekends, no running water, torn plastic mattresses, rusty beds, blood stained steps to the obstetrical ward and goats grazing around those steps.

In a place without a blood bank and without an ICU, delay means death so you get patients delivered quickly and you get placentas delivered quickly. That is what the midwives excel at here.

I look over those questions again today and I realize that even though Andrew answered many of my questions before I came here, I didn’t really know what those answers meant until I got here.

photograph by Joni Kabana

First Impressions

Fields studded with little stands of eucalyptus trees and divided by dirt paths leading from one village of small mud and straw houses to another. Women cooking meals on wood burning fires in the yard with kids, goats and chicken scurrying through the wooden stick fences. Idyllic.

She hasn’t felt the baby for 2 days and has been in labor for a day. One look at her belly reveals Bandle’s ring, the telltale sign of obstructed labor. One hand on her belly reveals knees and hands just under the skin, a baby in the abdomen.

‘The uterus, it has ruptured and there are no heart tones. Can you do ultrasound to see if this is true”, the midwife asks in Ethiopian medical English, with the same tone of voice that he presented to the patients on rounds this morning: calm and matter of fact.

In the fifteen years I have practicing obstetrics I have never seen this. I have read about it, but never seen this. In his two years of midwifery training this is just another day at work for Simagnew, a twenty-one year old slender and soft-spoken man with kind eyes.

In the three days I have been here, two patients have come in with dead babies and two patients have delivered kids that will most certainly die because of prematurity. Six weeks early is too early if you deliver in a rural Ethiopia where there are even less pediatricians than obstetricians.

My first case at Mota, was a ruptured uterus with a fetal demise and a hole in her vagina. Her uterus ruptured not because of a previous cesarean section or because she received pitocin. It ruptured because when the patient went into labor the baby came down slightly angled differently than her previous children and the diameter of the head was too big too fit through her pelvis. Her uterus tried to push it through. It tried so hard that it tore a hole through the lower part and the baby escaped into the peritoneal cavity. Bandle’s ring, a dip in the abdomen near the bellybutton, a demarcation line formed. This is where uterus ends and this is where baby starts.

Simagnew made the diagnosis just by palpating, just by looking because he has seen it before. I immediately knew he was right, but I wouldn’t have recognized with one look and one hand the way he could because he has seen this before. He sees this every other week at the Mota regional hospital in rural Northern Ethiopian where most patients deliver at home rather than paying the 30 Birr ($2) to deliver at the hospital.

Simagnew graduated from his midwifery program two years ago. He sees the patients that do not deliver at home, the 15% that have some type of major obstetrical complication of which a third have obstructed labor.

The World Health Organization estimates that 5% of women worldwide need a cesarean for obstructed labor. If these women do not reach the hospital in time, like our patient, their baby will die and possibly they will die.

In Portland, Oregon many women think natural childbirth is idyllic and educated patients at times leave my practice to deliver at home rather than in the hospital. The complexities of post-industrial revolution urban life have made them desire a more genuine experience of the natural process of birth. They are afraid I will force them to have a cesarean section the minute they walk on to the obstetrical ward. Sometimes they see lay midwives who have no formal training and very little deliveries under their belt, because they want more control over their delivery.

I wouldn’t mind if my patients left my practice to see a midwife with Simagnew’s experience. Someone who can deliver breech babies vaginally because he has done more breech vaginal deliveries in two years than the average board certified obstetrician in the US would do in their entire career. Someone who can look at someone’s belly and say: “I think she has a ruptured uterus from obstructed labor. Can you please do ultrasound? Someone, who knows what can be hidden within that idyllic picture of natural childbirth: natural child death. Our patient survived, thanks to Dr. Andrew Browning’s perseverance in setting up the program that has been bringing desperately needed obstetricians like myself to Mota Regional Hospital.

Our patient survived because the Ethiopian Department of Health has been training midwives and nurse anesthetists at break neck pace. Our patient survived because Simagnew made a timely diagnosis, because Embiale, the nurse anesthetist, safely induced a general anesthetic. And last but not least our patient survived because my theatre sister, Darlene Nastansky, and I rolled up our sleeves and operated on her in an OR without running water, without electrocautery, without an oxygen saturation monitor, without an EKG machine or automatic blood pressure cuff.

Most women with obstructed labor in rural Ethiopia lack this option and do not survive the rupture of their uterus.

Simagnew, me and Embiale in the birthing room at Mota Hospital