Southcare continued its relationship with Australia Doctors for Africa (ADFA) with their July/August 2018 venture into Ethiopia. For those that don’t know ADFA, it is a leading non-for-profit organisation working towards improving hospital healthcare in various African nations. Over the past years assistance has involved building operating theatres, educating local surgeons and providing medical equipment.
The next project on ADFA’s list was Felege Hiwot, a public trauma Hospital in Bahir Dar. Our goal was simple, to promote active mobilisation and exercises on the orthopaedic wards in order to hopefully stimulate early discharge and reduce overall length of hospital stay.
Bahir Dar is the fifth largest city in Ethiopia some 350kms northwest from the capital Addis Ababa. As a leading tourist city Bahir Dar is well known not only for its location next to Lake Tana, the largest lake in Ethiopia and one of the largest lakes in Africa, but also for the highly visited Blue Nile Falls. It has a population of almost 175.000, although 81% of Ethiopia’s population (100 million people!!) live in rural towns. Making Bahir Dar’s hospital catchment significantly higher given it is the biggest city in the Amhara province and surrounded by a tremendous amount of rural villages.
Suffice to say we were expecting a crowded hospital and almost certainly overworked staff.
Our team consisted of myself and Bek, both eager young physiotherapists with experience in both musculoskeletal outpatients and hospital orthopaedic inpatients. The third and final member of our party was our translator “Jerry”, a nurse from Black Lion Hospital, the primary hospital in the capital Addis Ababa.
After months of preparation, 7 vaccine injections and a couple of pre-ingested malaria pills we were off. However, there is no such thing as a direct flight to Bahir Dar! After 35 hours, with stops in Dubai and Addis to pick up Jerry, we finally landed at our destination.
The first thing that hit us was the weather. It was smack bang in the middle of their wet season and Bahir Dar can get up to 400 inches of rain in July/August (Perth averages just 150!!). The next was the mosquitos. Thanks to our proximity to Lake Tana, the mozzies took a particular liking to Bek so from day 1 we needed to lather on the bug spray. The other immediate observations were the number of power outages. With the weather and a ‘not so consistent energy grid’, the electricity would regularly turn off several times an hour. But given our preoccupation with social media, perhaps this was a blessing in disguise.
Besides an initial sleep in, we wasted little time and walked to the Hospital conveniently only 15 minutes away. Bahir Dar’s streets were expectedly gridlocked however the hospital entrance took this to a whole new level. It was pandemonium, with a haphazard array of tuk tuks and lines of people at the emergency department awaiting to be triaged. The overcrowding wasn’t just limited to the ED, the orthopaedic wards were equally if not more restricted for space. There were so much congestion that hospital beds were literally spilling out into the corridors. Specifically in the orthopaedics department there was a total of four rooms that housed approximately 60-70 patients. Certainly a stark contrast to our cushy one-bed suites in Australia.
After a quick tour of the campus we met with Worku, Desalyn and Berihun; the head doctor, nurse and physio respectively. Following introductions over traditional Ethiopian coffee (which was considerably stronger than we were used to) we learnt a bit more about the inner workings of the hospital. Most of the trauma patients were admitted following car accidents, burns, farm accidents and bullet wounds. They explained it was not uncommon for patients to be left in their beds for weeks, (even months!!!) on end without getting up, whilst they waited for their wounds to heal following surgery. Furthermore there were only 6-8 physios on staff with only one of them on the ortho ward, who treated roughly 5 patients on the ward a day. Berihun nearly had a heart attack when we expounded that in Australian physios could treat 4-5 times that many. Moreover the roles of the 20-30 nurses in orthopaedics were mostly related to wound-care, leaving a substantial number of patients stuck on the wards without receiving any rehab.
After this revelation we decided to target the nursing team in our education sessions, given their greater numbers and capacity to help with patient mobilisation. After all, nurses are the most important faculty in any hospital and very little can be achieved without their influence.
Over the course of the next week we systematically took in groups of nurses and physios, providing lecture material to substantiate our claims that they could significantly improve discharge rates through early patient mobilisation and exercise. Specifically that studies tell us that that complete immobilisation and bed rest for only one week can lead to approximately half a kilogram reduction of muscle mass. This can be even larger in the elderly, not to mention those with significant orthopaedic injuries or high pain levels. Fortunately simple bed exercises and merely standing up occasionally (not to mention ambulating) can help offset this depreciation and even improve strength plus power scores.
Once we got the message across and practiced a variety of upper and lower-limb exercises, we put our words into action by demonstrating on actual orthopaedic patients. The response was immediate! Patients that been bedbound for weeks were all raising their hands to participate. All the instruction in the world would not have been as effective as seeing this demonstrated first-hand. One such patient Ayana (name changed for privacy), a young woman who had been in a nasty car accident. She had sustained a tibial fracture and ankle dislocation on separate limbs and had been in a large plaster cast for the past 2 weeks but hadn’t stood up properly in over a month! After consulting (and a bit of bargaining) with the medical team we had her standing up with assistance that afternoon and she was deemed independent enough to be discharged by the end of the week.
Throughout the trip (and no small amount of convincing) we had many more discharged patients, better teamwork between staff, as well as patients ambulating and completing their exercises independently. We couldn’t have been more proud. We also implemented more subtle changes including moving mobility aids into patient rooms instead of collecting cobwebs in the store room, and encouraging a physio and nursing presence during the morning doctors rounds, to help with collaboration between disciplines.
On the last day we awarded the nursing and physio participants with their certificates and celebrated with an oddly vegan cake and yet more super strong traditional coffee. We then bid our farewells and put in motion our plan to return to Bahir Dar later in the year with the plan to see a dramatic decrease in length of stay and expand our education of the medical staff to all wards and indeed the entire hospital.
Despite our fatigue the caffeine bursts kept us going so we treated ourselves to a traditional Ethiopian dance performance, lots of gyrating and laughing the night before for that very long journey home.
Even with the unrelenting mozzies finding a way to penetrate our invisible layers of DEET, It was an amazing and rewarding journey. The many hurdles facing Ethiopia’s healthcare and the conditions their hospital staff deal with on a daily basis certainly put our experiences in Australia into perspective. A big thanks to Felege Hiwot Hospital, ADFA and Lifecare for making this trip a reality and I look forward to continuing further adventures in the future.