I have now returned from Ethiopia, safe, sound and thoroughly exhausted.  Many thanks for following along my trip and all the well-wishes!  Happy holidays!

Until next year……………..

And we have power.

I have been here more than 2 weeks now and since I first arrived I have wanted to get the new power dill up and working. I was determined to do it.  I was secretly afraid that if I didn’t the set would sit in a corer somewhere, gathering dust, until a rainy day…..

It took a week to find a cord adapter – one that would attach the cord I brought to the compressed air outlet on the wall. Finally, we crossed that hurdle, late last week. With the drill attached to the wall I turned the power on, anxiously waiting for that oh-so-familiar sound and …… nothing…….  The charge nurse, Wirknish, tells me we forgot to turn on the air supply to the room. She takes me to the main line in the hallway – there is no pressure reading. She turns the hand- valve – it won’t budge. She gets a large hammer and proceeds to hit the valve to try to encourage it to move. I don’t think this is a good idea but I stand by and watch, taking a step backwards just in case.  The valve doesn’t move an inch.  She tells me to wait while she tracks down one of the engineers.  I didn’t realize that we had engineers.  He repeats the same process that she just had, hammer and all.  I thing there must be an error in the translation of the word “engineer”. He leaves telling me that he will return. I am unclear when.

Later that afternoon Wirknish tells me that the air compressor is not working. It has been down for a week.  She says that the engineers (or whomever they may really be) have gone to the market to try and find a replacement part. I am not sure the market is the place to go for such things but I hold my tongue. Although I am encouraged by this initiative, I know that this is not good news. It take ages for things to get fixed around here……………….

Today Wirknish reports to me that the air compressor is now working. I have my doubts. I have been here before. I instruct her to get the drill and the cords. We hook up the system and I power the drill on and I hear…………  that oh so sweet sound……….  I look down to see the drill head spinning. I am in awe. She is soooo proud. She deserves to be – I would have bet money that it wasn’t going to be up and running before I left. “Sterilize it for tomorrow’s case!” I order her. I am overjoyed.  It seems like I will be leaving Addis on a high note…………….

This being my fourth visit to Addis over 6 years I have seen many things change at the hospital.  And with each new development the cynical part of me wonders – occasionally out loud – whether this is truly progress or whether in adopting a western model of medicine …………

There is now an “emergency department” for the hospital.  Alongside this, there has been the development of the specialty of emergency medicine.  To me, it seems more like just a name change.  Previously, the same space had been called the OPD = Outpatient Department.  Granted, the area is a bit larger but it remains a zoo of ill patients crammed into a too-small space.  In the year since I was last here they have expanded to put patients in the hallways as well, thereby creating an additional 10 or more beds.  Patient beds are lined up approximately 3 feet apart.  Only a handful of beds have curtains for some modicum of privacy.   Like the admitted patients there are several family members always present to help care for their loved ones.  The net result is a large open space with way too many people in it – many suffering all kinds of ailments and adding their wails to an already overly stimulating environment.  Most of the patient here at any one time are in fact admitted patients – ones for whom services like ours has deemed require admission but for whom there is no actual floor bed available.  As a result, they languish in the ED often for days awaiting their actual admission.  The “waiting for a bed” situation is not unlike what is often experienced back home in Canada, where I trained, although far more extreme.  While still in the ED here they fall under the purvue of that department and as a result are usually suspended in some form of medical virtual space in which they get some basic minimal care but are often not actively investigated or treated, it seems, until the admitting service can finally take over.  In short, from a neurosurgical perspective only, I am not convinced that the development of the emergency department has resulted in anything more than a slightly enlarged waiting room for patients………..

The availability of advanced imaging.  When I was first in Addis 6 years ago more then 90% of the patients whom I saw with head traumas had skull xrays as their primary and only form of imaging.  Even if you are not in the medical field, you probably recognize the inadequacy of this in the 21^st century.  This included those who had a GCS score less than 8 (i.e. comatose).  The reason for this was twofold.  Firstly, I was told patients could not afford to pay out of pocket for scans costing just over $100 USD.  Secondly was availability.  There had been a CT scanner in the hospital the year before but word on the street was that it had been intentionally broken by one or more of the owners of the 3 private CT facilities in the city at the time.  As a result, these comatose patients would have to get transported across the city – often in the back of a taxi cab – in order to get scanned, if they could even afford it.  Oh how times have changed.

Now, almost all patients get scanned prior to admission.  The hospital did get a new CT scanner earlier this year, although that is not the reason – it has already “broken down”.  For one thing, each private imaging center now owns its own private ambulance which will conveniently come and pick up patients and bring them back for a price that is included in the cost of the scan.  Secondly, patients now appear to be able to afford these advanced imaging studies.  I do not understand this latter explanation at all.  I am pretty sure the population is not any richer than it had been previously.  Definitely the scans have not gotten any cheaper.  Despite my interrogating multiple sources no one has yet to give me a good explanation for this sudden acquisition of wealth.  The residents tell me that people are not as poor as they claim to be and that if you insist it has to be done then it will be.  Knowing that a CT scan costs more than half the monthly salary of a publicly employed physician (which is why most also have very active private practices on the side), makes me truly wonder how the average blue-collar worker could afford one of these tests.

All of these imaging studies have lead to a couple of interesting quandaries for us now.  The most significant it the treatment plan for these patients.  Just because a patient now has an MRI which clearly demonstrates extreme spinal cord compression following a bad fracture dislocation – something that was already suspected based on history, clinical examination and Xray – is that going to change the patient’s treatment plan or admission?  There still are no beds for admission.  Their life expectancy is still reduced to one of months or a few years regardless of whether we do surgery or not to stabilize their spine as nothing is going to cure their paralysis.    And, with often several such patients arriving daily at the hospital but OR time to manage maybe 1-2 of such cases per week, not to mention the extremely limited spinal equipment, most will never be admitted.   Meanwhile, the emergency room physicians order these studies before they are even assessed by neurosurgery.  I almost feel, given the helplessness of this situation that they are forcing these poor patients and their families to pay out unnecessarily.  Certainly back home these types of patients would get the “million dollar work up” with the associated highest level of care but here…….  Some would argue that we would now have radiological proof of their diagnosis.  Although I cannot argue that their might be some academic knowledge gained from these imaging studies, I try to point out that more clinical proof I do not need.  No one seems to pay me much attention on this point.  They are already fighting too many other battles.

The other interesting off-shoot of the availability of imaging in Addis is the emergence of the back pain patient.  As a spine surgeon, back home my clinics are filled with patients who want to see me about their neck pain and their lower back pain.  According to statistics, over 80% of people will suffer from this type of pain at sometime in our lives.  Most of them end up inevitably with MRIs.  After age 30, most patient’s spinal MRIs will contain some sort of abnormality – whether or not said patient is actually having back pain, or not.  In the USA, back pain + abnormal MRI = request for surgical consult although for the vast majority of them, the abnormality is not the main source of their pain.  Ergo, much less than 5% patients who present in this fashion are actually surgical candidates.

It used to be in Addis that those patients who came to clinic with back pain usually had some serious issues.  Some had infection, others had tumors, still others had significant spinal deformities as a result of congenital abnormalities.  Granted, I have still seen a few of these in clinic over the last 2 weeks, the vast majority of patients who come in complaining of back pain now have a normal examination and an MRI with some minimal degenerative changes only.  I have no problem telling them no surgery – and in general they understand that.  What I have difficulty answering is the question – now what?  Back home there is a whole potential team of people who can help these patients out including Physical Medicine and Rehabilitation Physicians, pain management doctors, physical therapists, chiropractors.   In Addis, there is me and me alone.  I can give them some anti-inflammatories and a note to rest, and most are happy.  All request to see you again in a few months time.  I notice from the patient’s chart that some of my counterparts here have been seeing them in follow-up 3-month intervals.  With an up to 6-month waiting list to get in to see a neurosurgeon in the public hospital system, an average 1/2 clinic day in which we see over 30 patients each, and so many other patients presenting with advanced pathologies I think seeing these clearly non-surgical patients in follow up is unethical.  Not that I want any of them to suffer but with the system already overloaded the way that it is I have been discharging every one of them that I see from further neurosurgical care.

Reflecting on the scenarios now it makes me consider the price of progress.  The side-effects, if you will, of effecting change in one aspect of the medical system without anticipating all the consequences.  Six years ago, when I was first here, the thought of developing an emergency room seemed ideal – somewhere where patients could get immediate and urgent care.  The reality is so much different than that dream, atleast from where I stand.  Likewise, the lack of advanced imaging studies on patients with neurological injuries used to be so frustrating to me.  Now that we have those studies I am no less frustrated, and possibly more so, as most of them still can’t be helped.   It makes me wonder if we can truly call this progress…………….

Everything is old here in the hospital.  I suspect everything has been donated in a gently or not-so-gently used condition.  The patient beds look like they we made in the 40’s and 50’s, their wheels are often rusted over and don’t work, the pain has long worn off exposing rusting metal.  The OR beds only partially bend the way you need them to.  The anesthesia machines are clearly decades old with many functions often not working.  The problem is that when anything electronic breaks down over here – which is frequently – it usually gets tossed into a corner somewhere.  I have seen old OR lights, fluoroscopy units, bipolar units all get stranded and gather dust.  Since my last visit the scrub sinks outside of the neurosurgery OR have stopped working.  It has been months apparently.  As a result we usually have to wander a few ORs down and scrub up there and then walk through the halls to our OR.  I am not sure why things don’t get fixed.  I have asked, but nobody seems to know, or seem to care.  It may be a lack of skill and knowledge or maybe a paucity of motivation (too many things to fix, too little time).  Truthfully, I suspect it is a combination of the two.  It surprised me when I first came to Ethiopia years ago. I expected to see innovation in the face of adversity.  Afterall, that’s what they show on TV all the time……..

I expected to see cervical collars been woven out of grass, electrical units being rewired,  piecing one component of one system with another from a separate system and making it work.  But, that has never been the case.  Instead, broken pieces of OR equipment become decorative artwork in remote corners and hallways everywhere.

Western Store Bought Cottonoids

I was pleasantly surprised on this visit to find that some things may have changed.  Firstly, the neurosurgery charge nurse has gotten organized.  Equipment and supplies – no matter how scarce, now sits in neatly organized cabinets.  The former storeroom – which previously I could not even enter because things were strewn all over, is now neater than my closet at home.  Well, maybe not quite, but close.  The C-arm has been rewired with a LCD screen allowing for pictures to be viewed.  In the corner during the cases when they are not busy nurses are sewing cottonoids or micropatties by hand.  These are small pieces of fabric – usually similar to felt – with strings attached so that they can be placed in tight corners of the surgical field and allow us to safely suction up pooling blood without sucking up the brain.  You can appreciate the importance of these little squares.  The strings ensure that they don’t get inadvertently left in the surgical field when close.  The nurses sit with small pieces of special OR gauze, cut up into small squares, and stitch threads to them by hand.  The new patties then get sterilized for use.

Ethiopian Cottonoid Sewing Kit

I am not sure which has caused this switch in mentality but it gives me some hope.  Perhaps it is the new coat of paint in the hallway which so easily transformed the dreary hallway into something bright and even sterile looking – just what you want to see in any OR.  Perhaps it is the new recovery room.  A collaborative effort, I am told, between 3 different institutions who independently had been working here for years effecting little change but together have created a post-anesthesia care unit in less than 1 year that finally approaches those available in the developed world.  Previously, patients recovered from their anesthesia while being driven back to their rooms on their OR stretcher, accompanied by their dutiful, although not-so-well-trained porter.

Wirknish Making Cottonoids

Regardless of the cause, I am encouraged by the switch which gives me hope that there has been progress.  System-wide progress.  As the old axiom goes – bring a man a fish and he will eat, teach him how to fish then……… That is the whole reasons why I believe as much as I do in these trips.  But if he learns how to make his lures, fix his broken rod and freeze his fish then……………

I have a confession to make – I have a housekeeper here in Ethiopia.  Her name is Wubi.  She is widowed.  She has 4 children that she has raised on her own.  Her oldest works as a receptionist, the next as a stewardess at Ethiopian airlines.  Her two youngest are both boys – one is finishing off high school, the other is in college.  Given where she has come from, this is an amazing accomplishment.  She does not know how old she is but she says she is “around 46”.  Like most Ethiopian women she is beautiful and looks atleast 10 years younger despite the hardships she has faced in life.

I met Wubi 6 years ago during my fist stay in Addis.  When I first arrived I was asked if I wanted to hire a housekeeper.  I politely declined.  I was a resident at the time and having a housekeeper was certainly a luxury I could not afford.  I was then told about Wubi and her children and how she needed to work to support her family.  The cost was $10/week.  I was sold alone on the story.    For $10/week Wubi cooked 1 meal a day, did my laundry, made my bed, cleaned the apartment and went grocery shopping.  That was a bonus because she was a local and she knew where to shop for food cheaply.  I found out shortly after I arrived that this is the way things are here.  There is a clear class system and everyone above the poorest of the poor has people hired to help them.

Most surgeons I know here have 3-4 full-time helpers depending on the size of their house and their wealth.  This includes cooks, housekeepers, gardeners and sometime even drivers.  Even the residents who live in the same apartment building as me have housekeepers and cooks.  Often they share them.  These housekeepers live in dorm-room style with bunk beds in a windowless room in the building.  It can’t be a fun existence.  Usually they are young girls, poorly educated, who come from the countryside in search of work to at least support themselves if not their families.  Many look very young – not much older than teenagers if even that.  I see them wearing the same clothes day in and day out.

I have visited Wubi at her home in the past.  I think I was probably the first ferenji (white person) to step foot inside the complex – I actually felt I was a bit on display.  She lives in a small complex that consists of 4 small 1-story buildings divided into 1- and 2-room units for about a dozen different families.  It is it’s own little community.  The buildings are arranged in a circle with common space in the middle consisting of a dry muddy surface.  There is no greenery. There is one outhouse for the whole complex and one source of running water.  Wubi and her family live in one of the larger units – a 2-room unit.  Her children share the small bedroom where 2 bunk beds are crammed in and one chest-of-drawers.  1 drawer per child for their clothes and personal possessions.  No closet.  Wubi herself sleeps on the couch in the main room.  In the corner there is a kerosene burner to cook on and a few kitchen implements.  There is no electricity – at least not in her apartment.  They work by candlelight at night.  I gave her one of the solar lighting units I brought over on this visit.  I think it will be useful.

Secretly, I love having someone making my bed every day.  It is a chore I detest.  The cleaning too I am happy to give up.  Although, I am not so sure if what she does for me is truly cleans as much as moves dirt around – my current apartment floor in particular is filthy with years of dirt and grime caked on.  Truthfully, I am not crazy about her cooking – it is fairly bland and she uses way too much oil.  I usually have her cook only once or twice/ week as a result.

I trust Wubi too.  Although I am not there when she is, I am pretty sure she has never taken anything from my apartment. In the past whenever she has needed anything – like medications for her children – she has asked for money.  And, even then, she has asked for a pay advance only.  I am sure, however, she does take advantage of the situation.  Despite the $10 a week I pay her for 1-2 hours work per day, I know by comparison to what she would be paid if she worked for a local family, it is generous.   It is what they would expect to pay for a full-days work.  Other Ethiopians have in fact told me that it is “too much”.  Usually if more than 1 foreign physician is visiting she can help out several a day.  Often when I have too much food left at the end of the week I give her the bulk of it to take home – most often it is fresh fruits and vegetables from the week.  With limited refrigeration, they spoil easily.  Now, I am pretty sure she buys too much on purpose – knowing that I will give her the extra.  It is hard to know what to do knowing this as it is so little for me but probably means so much for her.  I usually leave her a “bonus”when I leave as well as odd and end things I don’t want to take home or think she can use.  I notice on this visit she has my old croc sandals stashed in a corner from my last visit – she puts them on to clean. I think they are in better shape now than when I left them.  They are two sizes too large for her but she doesn’t care – she still tells me how grateful she is for them and and all of the other things I have given her over the years.  Her gratitude is humbling – especially knowing that most of what I do leave behind is well-worn, and yet she is thrilled to receive it.

Maryanne – if you are reading this – I gave your generous donation direct to Wubi for her and her family.  With tears in her eyes, she thanks you.

Something excited happened in on of my ORs in Addis last week of which I am proud. Very proud.  Sadly, you will never hear about it any where but here. Heck, the nurses who were working in the OR with us did not even appreciate the significance of the case, let alone the other surgeons in the building. Only Mersha, Azarios and myself appreciated that neurosurgical history was made in Ethiopia.

The patient’s name was Girma. He was a 47 year old male patient who had fallen. He suffered an incomplete spinal cord injury as a result of having broken his neck and then dislocated it. This meant that he could still move and feel but he was weak all over. His neurological function was recovering somewhat but his fracture meant that his spine might start bending abnormally causing his spinal cord further damage. To help him the best thing we could do was to to fix his spine in position – with screws and rods. As they have never had the screws and rods available before, this was never possible – until now. I am now even more grateful to Aaron and Samantha for our last minute scramble for equipment on my departure day.

Mersha has seen the procedure before – and even done it. He did a 3-month mini-fellowship in spinal surgery in South Africa last year. I have always known him to be an aggressive overly-confident surgeon. Thinking back over the time I have spent with him, I have always struggled trying to teach him because of this. This day was no different. As him and Azarios did the initial approach to the surgery I comment that they look like a couple of orthopods as I watch them from the foot of the OR table between their physical manipulation of tissue and their blood loss. Once they have exposed the spine I demonstrate and talk Azarios through the insertion of his screws. I try to do the same for Mersha, but he wants to do things his way. What most people don’t appreciate in surgery is that there is more than one way to skin a cat. His way is not wrong, but I try to explain what I think are the benefits of doing it my way. Thankfully Azarios is keen to listen to me talk so I don’t feel like I am wasting my breath. I feel vindicated when the shortcomings of Mersha’s way are abruptly and concisely demonstrated as he attempts to insert his third screw……  Thankfully the patient is no worst off for this attempt, and I help him to salvage the screw. I tell Azarios quietly later that next time I will show him how to expose the spine less traumatically. He tells me that he knows how – I showed him the last time – but that Mersha would not let him do this as it took too long with no benefit……………..

In the end everything went smoothly and the patient did well. I let out a not-so-silent woohoo at the end of the case when Mersha confirmed for me that this was, to his knowledge, the first time anyone had fixed the spine from the back (a posterior cervical instrumented fusion) in the country. As one of only a handful of practicing neurosurgeons he would know. Underneath my mask I was silently beaming with pride. Although technically these cases are not difficult ones, I think it represents a landmark achievement in the progress of neurosurgery in this country. 6 years ago I never would have imagined when this day was to come, let alone that I would be present for it. With all the frustrations of working under conditions where so much is needed this moment was a little beacon of light for me, helping to convince me that we (meaning myself, the others like me who volunteer their time, as well as those that live and work here every day of the year) are making inroads into the development of neurosurgery in this country.

Later in the week we achieved another historical landmark by placing screws and rods in a 51 year-old man, a hospital employee, who had an unstable, non-healed C2 fracture. It was a far more lengthy and dangerous procedure that I almost had to convert to a plan B part-way through due to technical difficulties. Thankfully, despite the hiccup, all went well in the end. Mersha was nowhere to be found during the case, but Azi could barely contain his excitement at being the only one in the country who had ever seen, let alone

Clinic day is always a crazy day. It is Tuesdays. The waiting room is overflowing with patients – they spill out into the hallway. There are crying children, there are moaning women.  Some are limping, others are blind. Many patients are accompanied by one or more family members – several have to be quite literally carried in to the offices. There seems to be no clear organization to the clinic. All patients arrive by 9am when the doors open. A huge stack of charts is divided into 3 piles – one for each of us who will be attending (Dr. Mersha – the other attending here and one of my former students, Azarios and myself) and we start seeing patients.

Before clinic starts today I apparently am running my own “private” clinic – patients who were sent in specifically to see me. I am not quite sure how this has happened – and no one else seems to know, or care either. There is a young girl with a potential neck injury that Dr. Tadios, the former chairman here who has just retired, has sent in for me to evaluate. One of the attending radiologist is also here – with a herniated lumbar disc and an MRI – seeking my opinion. Before I have a chance to speak to her, however, she steps aside to give way to a somewhat distinguished looking gentleman.  I think it is a cultural thing – a woman giving way to a man, although, as it turns out she is higher up in the pecking order than he.  He is a health officer – a nurse with extra training that acts as a physician extender. He comes with an MRI in hand as well. He has been going blind in his right eye. It turns out he has a brain tumor. Like most brain tumors I see over here it is large, very large. And it is deep, wrapping precariously around important blood vessels at the base of the brain and putting pressure on the optic nerve and chiasm– and hence is blindness.

The good news for him is that it is a benign tumor, slow growing. The bad news it its size and location. He ask me what to do. I try to explain the situation for him. His English is excellent but still Azarios helps to translate. Like most Ethiopians he doesn’t want me to explain or give him options he wants me to tell him what to do. Given the size of the tumor and his progressive symptoms surgery would be the best, although even in the most well-equipped north American center this tumor would be a huge challenge and surgery would not be without substantial risk. I ask him where he wants to have treatment. His answer surprises me.

Most wealthy and well-connected Ethiopians fly “abroad” for treatment. Depending on their financial reserves this could mean anywhere from Kenya or India to Europe.  Occasionally some venture across the Atlantic as well. In his position, he planned on being treated here, in Addis.  I recommended he try the Korean Hospital. It is a private hospital subsidized by the Korean government. Patients have to pay for treatment there  – it is too much for most but “affordable” for those who have some means. There, the equipment is far superior than at the public hospitals. That alone helps improve outcomes.

Finally with my “personal patients” aside we start attacking the plethora of patients stacked up in the waiting room. I think in the past I have referred outpatient clinics as neurosurgical textbooks of pathology. Today is no different. We see children with hydrocephalus, patients with tumors in every possible location, all way larger than almost any we see in north America and a surprising number of patients with back pain. My favorite patient of the day had to be an old retired army major. Many years ago he had been shot in the arm and suffered at that time an injury or his median nerve, one of the nerves that supplied both sensation and movement to the hand. He is now complaining of a new tremor in his right hand whenever he writes.  Other than the old issues with his median nerve I can find nothing else wrong. I refer him onto a neurologist. He is upset that I can’t fix him. He is 79 years old.  For Ethiopia he 30-years past the average life expectancy here despite the time spent in active combat. I smile as he leaves, I think he is doing pretty good……………………….

Although all of my colleagues thoroughly support my endeavors here in Ethiopia, I am sure that part of them thinks I am off on an extended vacation.   Perhaps a better analogy would be that it is kind of like a overnight school field trip.  Technically you are off campus learning but in reality you are having way more fun that you ever would be back at school, if only by getting away from the usual daily rigors.  No question I have fun while I am here – I am doing what I love to do – combining teaching and surgery – while consulting on some of the most challenging cases I will ever see in my career.  But if anyone thinks this is a vacation for me, allow me to dispel that misconception right now.

Exhibit 1: My apartment

It is located on the hospital compound approximately 100 feet from the Emergency Department.  The reason?  So that residents at any time of day or night can cross the driveway that separates me from it, knock on my door and review a case or some imaging.  Now that I have arrived, I will be on call every day until I leave.

The building itself is intended both for medical residents as well as visiting physicians.  Far from a dorm room, many residents live here with their entire families.  It is a 3-story building.  It has been organized in a somewhat hierarchical fashion with the most senior/ chief residents and visitors on the top floors and the junior residents on the lower floors.  Interns get the basement.  The intention behind the plan is pretty simple in so far as I can tell; often the building floods.

My apartment itself is approximately 400 square feet.  It is large by Ethiopian standards.  Usually apartments of this size house entire families so I am lucky to have this space to myself.  There is a living room area with a sofa set that is set so low to the floor my knees almost touch my chest when I sit.  It is green in color with a funky leaf pattern made out of a strange textured synthetic material that has to be felt to truly be appreciated.  I can’t figure out why they were designed this way, it is not as if Ethiopians are short people.  The floor is tiled but well worn such that in fact less than half of it is still tiled and the remainder is either old adhesive material or exposed concrete from where the tiles have worn off.  They are not particularly clean. I bought some pink fuzzy slippers to wear around the apartment anticipating the condition (another Target find for $8.97) – they are already turning grey and it hasn’t even been a week.

In one corner of the apartment there is a small kitchen consisting of a stove with 2 out of 4 working burners and a small bar-sized fridge.  For these things I am truly grateful as both are considered luxury items and most apartments in the building share a common kitchen with limited space and no fridge.  There is running water in the sink.  Only cold.  Some days it works and some days it doesn’t.

In another corner of my apartment is my bed.  Granted the bed is kind of hard and the sheets are lucky to be 50 and not 500 thread count but it is clean and warm and no doubt will be my sanctuary for many times to come.

I have a bathroom.  Again, a luxury in this building where many apartments share common bathrooms, especially on the intern floor.  Even more of a luxury for Ethiopia.  With Addis being considered by Ethiopian standards a “rich” city 95% of households in this, the capitol city, have access to safe drinking.  In contrast, less than 15% have flush toilets.  I will be forever grateful – if not always feel a bit guilty -  that my apartment falls into that 15%!  It doesn’t always work and I keep a filled bucket of water at hand for those days when the water supply is unpredictably shut down but I have my own seat on the throne none-the-less.  The shower is a bit more of a challenge.  Technically it has a water heater.  One of those electrical energy efficient kinds that heats up water as it passes through a small heated section of pipe.  The reality is it is energy efficient because I don’t think the heater works much:  I would be optimistic if I called the water lukewarm.  My first shower gave me flashbacks to my first visit to Addis 6 years ago when my shower was stone-cold and I got into the habit of combining a large pot of boiling water with a half bucket of cold water and used another pot to scoop up water and shower myself in the morning.  I might be resurrecting my bucket shower again shortly…..

As for the “accessories”, they are sparse.  The walls are concrete painted with a coat of egg-yellow paint.  Because they are concrete there are no hooks in the wall on which to hold any décor.  There are a few traditional wool rugs on the floor to help camoflage the broken tile.  Only half the light sockets work.  Only one power outlet is live and it is shared between the fridge and the stove.  I lied – there is in fact another outlet that sits somewhat loose into the wall socket and depending which way you move it you can get power – I know it is live when I see the sparks fly in the exposed wires.

In someways I kind of think of it a little bit like camping – trying to make do with what I have -  without the threat of wild animals or the smell of the great outdoors.  There is no question that it provides me with a unique set of challenges.  It also humbles me as I look around the apartment and once again appreciate how fortunate – if not spoiled – I have it back home.

The family members surrounding the patients provide 24/7 basic care, often sleeping on the floor.

Less than 24 hours on the ground and I am at the hospital.  Rounding.  With Azarios, the resident currently assigned to Neurosurgery at the Black Lion Hospital.  I remember him from last year.  He was an intern then – on his general surgery rotation at the same hospital – trying to get involved in anything neurosurgical he could without anyone thinking he was being derelict from his general surgery duties.  And, he was smart, quoting facts from Greenberg (the neurosurgery resident’s bible) as quickly as he could spew them up.  Now with almost a year of neurosurgery experience under his belt he has some experience to go with his book smarts.  I am glad he is “my resident” for the month – especially when I learn he is particularly interested in spinal neurosurgery.  He confessed to me later that he was actually schedule for his month of vacation this month but decided to give it up when he heard that I was coming so that he could work with me.  I hope I don’t disappoint him.

It turns out that the neurosurgery service here has “expanded” – we now have 22 beds across the hospital – at first pass that sounded promising.  In reality, many of those beds are occupied by chronic patients with no place to go.  Patients with severe head injuries – most of them non-surgical – but who were given supportive care and survived to exist in permanently vegetative states.  Because they received tracheostomies as part of their management, and none has successively been weaned off, with high amounts of secretions none can be discharged.  Rehabilitation centers or chronic care facilities simply do not exist here.  The best you can hope is to demedicalize them enough to get them home.  With most families at their bedside 24/7 anyways, they have learned how to take care of them and, quite frankly, would probably prefer to do so in the comfort of their own home rather than taking turns sleeping on a piece of cardboard by their bedside.  Either way their prognosis is poor and they are mere shadows of their former selves – both cognitively and physically.

In North America victims of severe traumas do tend to physically waste away during their prolongued hospital stay – a combination of the severe stress their body has been under combined with difficulty providing nutrition in these states.  As you might imagine in Ethiopia, there is not much protoplasm there to begin with so after a just a few weeks in this state most patients appear incredibly emaciated.  There was one patient who was never “claimed”.  No ID, nobody ever showed up to identify him after he was brought in, a pedestrian hit by a car.  He still has no name.  Back home he would be called “John Doe”.  Here there is no equivalent.  With no family, he looks in even worst shape than the others.  No doubt he will die here one day, slowly wasting away.  It is not a fate I would wish on anyone.

Then the crazy cases begin – the ones they have saved for my input.  A plethora of spinal traumas – most victims of “road traffic accidents” who have been rendered paraplegic of quadriplegic as a result of their trauma.  Almost all have presented to the hospital in a delayed fashion to the hospital – from a week to 2 months out.  The reasons for the delay are varied.  Some had visited many other hospitals before being referred to ours, others could not afford the trip.  I suspect many simply waited at home with their families willing their legs and arms to move.  Eventually, when none of the local remedies worked they made their way to us.

One 9-year old boy who had fallen 12 feet and dislocated his mid-thoracic spine 2 months before was completely covered in bed sores.  Sadly, him and his family looked to me – the white doctor – as the one who was going to perform a miracle and help him walk again.  It was not going to be the case.  Azarios was more realistic – he simply wanted me to straighten out the bump on his back.  Technically that was possible, although it would have been incredibly challenging so long after his injury.  But I wondered – out loud – what this poor child would gain by this.  Yes, he would have a scar, instead of a bump on his back, but he wasn’t in any pain.  In all likelihood he had already fixed his spine in its new position.  I suppose he might develop more spinal problems in the future when he hits his growth spurt but given the number and extent of his bedsores in this type of environment I am not convinced that he would survive that long.  Sometimes, I have learned, it is better to do nothing.  As a surgeon, however, that is always a hard thing to do, nothing………….

I am not one for giving out advice but if I could offer anyone reading this one practical piece of advice: never ever take a piece of clothing on a trip without first giving it a good test run prior to departure.  You see, I bought a new sweater.  The day before I left I ran to Target to purchase a few last-minute items for the trip when I came across this nice brown sweater.  It looked warm, it felt sooooo soft and I thought this would be the PERFECT traveling sweater for not one, but two, long haul flights.  Plus it was cheap enough that I could also leave it behind when I left with one of my many friends in need.  Perhaps I should have thought then and there about the quality of it but I have bought Target clothing before without issue.

I got my first hint of my problem before I had even left the country – before, in fact – I had even arrived at the airport.  As I got out of the car I looked down at my pants and shirt and noticed I had dozens of little fluffies all over.  My new sweater was shedding something fierce.  By the time I had checked in, their were dozens more.  And they were clinging to my leggings for life.  I calmly visited the ladies’ room in an attempt to shake of the fluffies.  They returned with a vengeance by the time I had boarded the plane.  I was covered in them!  When I arrived in Frankfurt for my lay-over I actually spent time wandering around the airport trying to find some other sweater to purchase for the duration of the trip.  Unfortunately, for the only time in my life when I have actually wanted one of those tacky tourist shops that sells all kinds of useless souvenirs, I could not find one.  Nope, there was no neon pink sweatshirt to be had at this European airport, only fancy European designer sportswear that even I could not afford.

So, I decided to ignore my situation figuring I was unlikely to run into anyone I knew halfway around the world.  I was doing OK with it until an American woman sitting across from me in the waiting lounge gave me a funny look as I got up.  I felt the need to explain the situation and she starting laughing at my plight, telling me I looked like Linus, from the snoopy cartoons, trailing a pile of dirt– or in my case – fluffies – behind  me…….