Category Archives: Somaliland

Notes from Cerigaabo

Dr Torbjørn Eggebø, who has travelled to an MSF clinic in Cerigaabo, Somaliland, with MSF representative Saskia Spijker, tells us about life in the field:

“On May 4th the rest of the ISUOG team returned home. I had promised to extend my stay in Somaliland for one week. I followed Saskia and Harriet from Médecins Sans Frontières (MSF) to a little town called Cerigaabo where they support the hospital. It is in the east of the country close to the border of Puntland. We travelled with a Cesna airplane and had a wonderful view of the country. Already the same afternoon, we started our work at the hospital. MSF is running a local hospital, but in two months the local government will take over responsibility of the hospital. The purpose of our visit is to educate the local staff before the handover.

Dr Eggebo continues his teaching in Cerigaabo

Precise diagnoses are important in a labor ward, and that’s why ultrasound might be helpful. I have been training the local midwives, auxiliary midwives and nurses and the local physician in performing ultrasound. Many of them have never touched an ultrasound device before, and I really have to start from the beginning and focus on the simple and most important findings – presentation, is the fetus alive, are there twins, placental location and assessment of amniotic fluid. The measurements are difficult for the beginners and we focus primarily on the BPD. Many of them struggle with measuring HC, AC and femur length. But some of them improve very quickly and at least four of the midwives are now able to perform all the basic six steps including measurements.

I also have been able to demonstrate the use of ultrasound in clinical situations. First a primiparous woman at term arrived with suspected foot presentation. A breech presentation was confirmed with ultrasound, and we could see that the fetus was “sitting on the legs” and therefore safely could be delivered vaginally. Four hours later, she delivered a healthy boy and I had the opportunity to teach the midwife how to perform a breech delivery.

Live demonstration of ultrasound scan

The next morning a woman arrived with polyhydramnios. Using ultrasound a “double bubble” was seen, and a duodenal atresia was diagnosed. Unfortunately no one can operate this condition in Somaliland, and the family cannot afford an admission to Kenya. The outcome for this baby is not good.

Last night a woman was admitted with severe antenatal bleeding. A placenta previa was suspected. The fetus was dead at arrival to the hospital. In these situations it is very important to differentiate between placenta previa, abruption of the placenta or uterine rupture. We performed a thorough ultrasound and were able to see the placenta on the posterior wall. I also showed them how to perform a transperineal scan and we were able to confirm that the placenta was not a previa. The woman safely delivered during our lunch break today and while she has lost her baby, she is so happy that she is alive and well. In this instance an unnecessary caesarean section was avoided.

We have also managed to scan successfully both with and without ultrasound gel. As we cannot guarantee a reliable supply of ultrasound gel to this community in the future, we have been practicing scanning by substituting gel with water. The image resolution is not compromised in any way and by using water there is no risk of damage to the probe by using oils. This has been an important message to communicate to the midwives here.. water works just as well!

MSF clinic

The raining season has now started, and there have been some very heavy rain showers and the runway of the airport is also partly destroyed by the rain. We hope they will be able to fix the runway so we can start our return on Saturday.

It is a very great experience to be here. Everyone is friendly and I enjoy spending my time with MSF. I hope to be able to leave some of my knowledge to the local staff in the hospital here.”

Sunset in Somaliland

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Trip Back

Dr Alfred Abuhamad, Outreach Committee Chair, shares his thoughts on a successfully concluded Outreach Training Course in Somaliland:

“On the morning of the last day on Friday (May 4th), we all had breakfast together on the nice terrace of Adam’s Inn overlooking the city of Hargeisa. We wished Torbjorn good luck on his weeklong adventure in Erigavo in Eastern Somaliland with MSH Holland to continue the training locally at the hospital in the city. He will help solidify the skills that the trainees acquired during this exciting week of training.

Waiting for a scan

Our journey out of Somaliland took us through Djibouti on a chartered MSF flight (see a small video of the landing in Djibouti). We then boarded a commercial flight to Nairobi through Addis Ababa. We had the pleasure of experiencing the beautiful and changing landscape of East Africa from the desert of Somaliland to the tropical landscape of Nairobi. We spent the night in Nairobi at the Woodmeere Hotel in the heart of this bustling and modern city, a huge contrast from Hargeisa. The traffic in Nairobi on a Friday evening, especially in combination with torrential rain was rather impressive.

We are currently in the Nairobi airport awaiting our long flights home. We had the pleasure of a relaxing day today after a very busy and productive week where all set objectives were met.

It is my sincere observation that the ISUOG team functioned superbly and cohesively. All trainers were very dedicated and worked hard with trainees with obvious commitment. As we go back home to our daily busy routines, we will reflect on the valuable experiences that we gathered and the everlasting relationship that we built amongst each other. More importantly the friendship that we established with the trainees is the most touching as many of their personal stories and quest for knowledge is so impressive despite their daily struggle and challenges.

We were ever so humbled by being part of their lives.”

New friends

A final day of lectures and some results from the trip

Dr. Cohen-Overbeek’s thoughts on the final day of the trip:

“Last night we went out to a restaurant with Edna and her senior obstetrics staff.
Chuck Cavanaugh from the US arrived the day before and joined us – it was his first time in Somaliland. Over the past four years he created Edna´s website, particularly established to gain funds. We celebrated Alfred’s birthday and Edna brought a huge decorated cake. After coming home, all the pre and post tests on 1st and 2nd trimester obstetrics, 3rd trimester obstetrics and gynecology scanning were corrected in order to present these results in the morning.
Most trainees showed an important improvement over the past 4 days (figure 1).

Figure 1. accumulation of the individual results in the pre and post tests

It became evident that pre test knowledge on 1st and 2nd trimester obstetric ultrasound was least present which may reflect that the majority of pregnant women only attend antenatal clinics in the third trimester and doctors and midwives alike are more confronted with problems during that period. The accumulation of post test results reached for all three tests approximately the same level. Trainees and trainers should be very pleased with this outcome.

A trainee writing a report

On the last morning we assembled again on the rooftop terrace. All problems with the local bugs were overcome and we enjoyed the clear blue sky and the daily omelet and were kept company by small very pretty grey / white birds who seem to carry a little hat. Torbjorn, who from all of us knows the most about nature, unfortunately cannot identify this little creature.

Alfred started the teaching with an impressive lecture on post partum hemorrhage and its management. Very useful information particularly for this region as the problem is encountered much more often here than in the western world. Blood not being available, only if the family members donate this, makes the management also quite different from that which we are used to. Talking with the midwives Hattie and Lesley, who are on this outreach coarse and both work in different projects of MSF in Somaliland, enlightened us on the way pregnancy and health is dealt with in Somaliland families. The different ethical approaches need to be respected but are an eye-opener.

Dr. Eggebo giving a lecture

Finally all tests were presented and the answers discussed. Julian took on the first and second trimester and as he hadn´t made the questions it proved occasionally quite a challenge, only enlivening the discussions among the trainees. Lisbet had prepared all certificates and in a small ceremony everyone was presented with it. Edna helped the team with pronouncing all names the right way. The last afternoon was again spent with hands on scanning and many patients turning up. This week I have been really impressed with the gained skills of many trainees either on their first or second course. The little portable SonoSite NanoMaxx machines make very good images and although at this stage a detailed fetal heart scan is not required it could be easily done on them.

A final day spent in Hargeisa

The day ended with a tour of the local market where we acquired traditional ministoves for incense, camel bells and belts. On the way back we noticed to our great surprise that the river, which was completely dry 2 days ago, was flowing with water as a result of thunderstorms in the west. Unfortunately as it was very dark we cannot provide evidence with a picture. Tomorrow the team will head home except for Torbjorn who stays another week and goes to a project in Erigavo. Good luck and we look forward to your news.”

Happy Birthday, Alfred!

Yesterday was Outreach Committee Chair and Somaliland team member Dr Alfred Abuhamad’s birthday, which he celebrated in Hargeisa with the team and a lovely cake baked by Edna’s staff!

Birthday cake in Somaliland

Here’s to many more, Alfred!

Dr Abuhamad and his birthday cake

Hands on scanning and some team bonding

Dr. Eggebo shares his thoughts from Day 3:

“The day begins early here in Hargeisa. We have a mosque close to the hotel and at five o’clock in the morning the imam calls for the first prayer. To my best knowledge, none of us has joined this prayer yet. Half an hour later, the birds start singing, and at six o’clock the sun rises.

We meet at the terrace where we have our breakfast and spend almost an hour together. We are served omelette and bread. There is a nice view over the city Hargeisa. We are not in a hurry during the morning time, and spend some time sharing our experiences. We all feel like foreigners here in Somaliland. The culture and way of living are far from our daily lives. It is good to be a group, and we have become quite close to each other.

The sun is shining all day, and the temperature is comfortable. Edna Adan was worried about the change in climate. This should be the raining season, but the river passing the city is still dry. We only saw a rain shower passing by on the distant horizon.

Dry river bed despite rainy season

At 7.30 we go to the hospital and start the lessons. The trainees are very interested, and listen to all the information we try to give them. It is difficult to include all knowledge of ultrasound in five days and sometimes we probably overload them with information. But we try to focus on the most important findings, and think we give them a good platform to start scanning. Some of the trainees followed the first course here in Somaliland, and some of them are really good.

The most important is probably the hands on sessions. We have four SonoSite NanoMaxx ultrasound machines, and six trainees in each group. They should all learn the six important steps – presentation, fetal heart rate, number of fetuses, placental location, amniotic fluid and measurements of BPD, HC, AC and femur length.

Downloading images on the new SonoSite NanoMaxx

We ended our third course day having dinner at the terrace. The stars were shining. The Orion is rotated and almost lying in the same way as the moon. This is related to our position on the earth, close to the equator. Still more exciting days are waiting for us.”

Orion

Day 3: Focus on gynecology

Dr Robinson tells us a little bit more about his experience in Hargeisa:

“A delightful evening dinner with Edna was a prelude to day 3. Sitting outside after sunset with some traditional African food had the team in good spirits and replenished energy reserves for more teaching and supervision.

Dinner with Edna Adan

Alfred’s penchant for traditional fire cooked bread was quite remarkable and Lisbet acquited herself well in that department also. Some casual scientific study noted the highly developed Pavlovian response of the local cats, and as the bill was signed they invaded the table top in force, a coordinated classical military pincer attack. Alfred and Julian beat a disorganized retreat, but Torbjorn got some excellent photo shots of the wild cats – fortunately of the smaller variety. Titia steadfastly rescued the camera that had been left behind in the rout.

Well rested, the ISUOG enthusiasts gathered just after sunrise for the now traditional terrace breakfast and planned the day. A full day of gynecological ultrasound curriculum was planned. Again Lisbet demonstrated some deft maneuvering mixing up an interesting agenda of lectures and case presentations.

Dr Abuhamad in a lecture to trainees

The day went well with some lively interaction and academic discussion. Titia received the most valuable player award today for a challenging set of case presentations.

Filling out an ultrasound report

The afternoon clinical session was a busy one and serendipitously some interesting gynecological cases attended to tie in with the subject du jour. The afternoon finished at about 4.45pm and a tired crew piled into the tour bus for the return trip to basecamp.”

Strong progress on Day 2

Dr Julian Robinson has sent us the following update (and a friendly jab at Outreach Chair and team mate Dr Alfred Abuhamad). We’re very happy to hear that it is going so well!

Dr Robinson takes a break during a long day

“Day two of the course and all is going well. The day started with a sturdy breakfast on the terrace and an impressive view. The trainers have had a day to find their stride and the students have been completely engaged from the start.

Ectopic pregnancy session

The team is quickly forming a cohesive unit and it is a collegial group. So far there are no problems with language barriers and teaching (at least to our knowledge), but I am sure we will get a better idea about that perception when the post-test results come in.

Dr Eggebo speaks to trainees

To date, we have covered the basics of ultrasound and are know moving rapidly into the clinical application phase. The most essential part of the training is the live scanning and we have been fortunate that the proficient organizational skills of the Edna Adan Hospital has provided pregnant women in abundance. It is remarkable how quickly the clinical sonology skills of the attendees are improving, and we are only on the second day.

It is becoming obvious that the function of the course is not restricted to education as an impressive amount of pathology has been diagnosed. This later aspect of the ultrasound experience gives the local doctors and midwives a dynamic lesson in the clinical usefulness of ultrasound.

Dr Cohen-Overbeek demonstrating a scan to trainees

So all in all, everybody is pleased with the progress so far. Thanks to Saskia of project partners MSF for keeping the organizational bus on the road, a task that has not been without significant logistical challenges to date and that is not to mention the difficulties of managing Alfred. Thanks to Lisbet for been very capable in running the academic syllabus and making it malleable to ensure clinical scanning opportunity is never compromised. We hope Torbjorn’s computer’s sickness is not a chronic disease and congratulate Titia on mastering the local fashion challenges.”

We hope Day 3 is as, if not more, successful.

Somaliland Day 1

Dr Lisbet Hanson has sent in the following update from the first day of the Level II training in Hargeisa:

“Great day! We had 24 Trainees, 18 had participated in the Level I course, 6 were new students. We started with registration at 8 AM, Edna gave us a warm welcome and we moved on to the pretest and lectures.

Ready to start the day.

The team covered topics from How to Optimize Use of the Ultrasound, Early Pregnancy, Ectopic Pregnancy, Basic Fetal Measurements and The 6 Steps of Doing an Obstetrical Ultrasound. Torbjørn and Alfred ended the morning with a live demo on a young pregnant woman (G8P7!).

As 22 patients had showed up early for the hands on training scheduled for the afternoon, lunch was taken in rotation as we moved directly from the lectures to the practical scanning. Four stations were set up in the Outpatient Clinic area of Edna’s University Hospital and each Trainee had a chance to do a scan as well as observe their colleagues do scans.

Titia guides a trainee in her scan

Most of the women were in the third trimester and healthy; some were coming in with concerns of pain, bleeding or uncertain dates. Husbands and children usually accompanied the woman. Unfortunately a third trimester fetal demise and a woman with pseudoceisis was diagnosed but otherwise most patients were happy to have a scan. A young woman with pelvic pain was diagnosed with Mullerian agenesis – an absent uterus and vagina with a horseshoe pelvic kidney was confirmed on ultraosund. The scanning and reports were finished by 4 PM.

After a brief Team meeting, reviewing the day and planning some adjustments for tomorrow, we headed to the hotel in our highly decorated 11 passenger van. Edna shared a wonderfully aromatic gift of frankincense with us as we were leaving!

Riding home after a long day.

Another beautiful sunset and dinner was enjoyed from the roof top.  It is really wonderful to be back in Somaliland with our old and new friends!”

We hope both trainers and trainees get a good rest as tomorrow is another day of hard work!

Safe arrival and rhinos

Despite a five-hour delayed flight, the team made it safely to Nairobi on Thursday night where they would spend Friday briefing on the upcoming training and getting to know each other after months of planning conference calls.

Dr Titia Cohen-Overbeek and Dr Torbjorn Eggebo on the way to Nairobi

After a fruitful day of briefing the team found the time to enjoy a short safari in the outskirts of Kenya’s capital, where they encountered a rhinoceros.

Rhinoceros!

On Saturday, the team packed up for the second leg of their journey. They once again experienced some travel delays but fortunately arrived safely in Hargeisa.

Dr Julian Robinson, Dr Cohen-Overbeek and Dr Alfred Abuhamad in Hargeisa.

The team met with Edna Adan at her hospital where the training would take place and to go over some final details that would ensure a successful week of training.

View of Hargeisa from the guest house roof.

They finished off the day with dinner on the guest house roof where they enjoyed the cool evening and picked out constellations in the night sky.

Team breakfast of champions.

We look forward to hearing how the first day of training went!

Stopover in Nairobi

The Somaliland team are currently in Nairobi before moving on to Hargeisa this weekend. We hope they are getting a good rest (some will have travelled 35 hours to get there!) before an intense but rewarding week of teaching and learning with the Outreach trainees in Somaliland.

We wish the team a good week and look forward to hearing about their experiences in the next few days!