Jessie vs. the storeroom (the difficulty with donations)

Last Friday was inventory day in the hospital storeroom, my first monthly inventory. Sinkinesh is the storeroom manager. She explained that at the end of each month, she counts up the number of supplies in the storeroom while the clinic manager keeps tally on the inventory checklist. If only it was that easy! The storeroom was tiny, cramped, and dusty. The floor space was taken up by dilapidated boxes of IV fluid that blocked most of the shelves, and the little open floor space was occupied by a wooden chair used to reach the high shelves. I stood in the doorway since there was no room for both of us to enter. Sinkinesh somehow knew where most of the supplies were located, although it seemed that our list only included about half the stuff in there, and the stuff that did make the list was in no particular order. The corners were piled high with untouched bags and boxes. Spiders were not on the inventory list, but they far outnumbered everything else.

The problem, it seems, is donations. Donations never make the inventory list, and since no one at the clinic knows how to use half the stuff – or is not accustomed to using it, since it is not always available – the forgotten donations pile up unused. So this weekend, when the hospital was quiet and empty, Edwin and I cleaned out the storeroom. All kinds of crazy things turned up. Some were useful, like extra boxes of spinal needles for spinal taps and a whole box of plaster to make casts and extra scales and otoscopes, all kinds of things that we would have bought if we hadn’t found them. Some were silly, like a pack of laryngo-mask airways and endotracheal tubes – advanced stuff for intubating people. There’s not a ventilator for 150 km! Some were nice but difficult to use – such as boxes of disposable needles, which are unnecessary because the syringes we buy have needles attached already. The most frustrating were wound care supplies. A huge canvas duffel bag full of individually wrapped gauzes and some German hybrid of bandaids plus Tegederm. A handful of iodine swabs. A pack of hydrocolloid dressings. It’s so hard to use a few packs of things when there are no continuing supplies. It doesn’t fit into the way people generally do things, so no one thinks to use it, and it ends up back in an unused corner of the storeroom. So many good intentions, collecting dust.

So. We found homes for all the boxes that crowded the floor (although Sinkinesh will kill us on Monday since she won’t be able to find anything) and carefully cataloged all the previously unlisted supplies. Chest tubes, bottles of chlorhexadine scrub, boxes of butterfly needles, interosseous lines. It took the better part of two days. I took a scalding hot shower afterwards, positive that there were spiders in my hair and ants in my underwear. My pants were caked with fine brown dirt. Probably all I accomplished was wrecking Sinkinesh’s system. But it’s nice to be able to stand in the storeroom without standing on anything, and who knows, maybe I’ll find a use for that random zip-lock baggie full of plastic droppers.

Frustration by Jessie

Three children in a row with abdominal pain. No vomiting, diarrhea, or constipation. Just decreased appetite, with weight loss and bloating. No physical findings. “Can you point to where your tummy hurts the worst?” Who knows if my purposefully-chosen gentle language is actually communicated through the translator. They all point to their belly-buttons. Periumbilical, not much help. For two weeks, for two months. Question after question, involving seeming long discussions between the translator and the patient’s parent that result in suspiciously brief replies to me. Fever? Blood in the stool? Anyone else sick at home? Worse with eating?

In the States, if it’s not an acute abdomen or early appendicitis, vague abdominal pain with a normal exam in a 6-yr old doesn’t get me too worked up. Dietary changes. Look for stresses in school or at home. Maybe reflux. In Ethiopia, however, there is a whole raft of parasites and helminths and various sundry worms that can cause “stomach shouting,” or “noisy abdomen,” or “something moving in my stomach” and lack of appetite, without falling into my convenient algorithm for acute infectious diarrhea. Even things that are supposed to cause diarrhea don’t, like giardia. Stool samples are not as helpful as I wish they would be. Everyone here has worm eggs in their stool samples, and “many motile bacteria,” which are not technically normal, but since they appear in every stool smear regardless of the presenting complaint, it’s hard to find them threatening. All children have ascaris – big worms that look like spaghetti and live fairly peacefully in the intestines unless you get too many in there. The kids with round bellies? They’re not chubby. That’s a belly full of worms. Not that I could order a stool sample for these kids anyway, since we have been out of cover slips for the microscope slides for weeks. No stool samples, no urine micro.

So treat everything. Cotrimazole (like Bactrim) gets most offensive bacteria, metronidazole covers most of the parasites, one dose of albendazole decreases worm burden. All this, after giving a lecture to the nurses about over-prescribing antibiotics. All this, when maybe it’s stress, maybe it’s early gastroenteritis or reflux, maybe it’s an ulcer, maybe it’s schistosomiasis or typhoid or something else that I don’t really know how to diagnose.

Next, a whole neighborhood that ate the raw meat of a possibly rabid “crazy” cow. All of them are terrified. For Pete’s sake, can you really get rabies from eating a rabid animal? I’m pretty sure that you have to be bitten or exposed somehow to the rabid animal’s saliva. But I don’t really know. Can’t really jump on the internet and check Emedicine or Up-To-Date. And, a nurse tells me that a while back some people got rabies in a similar fashion – totally anecdotal. So, after discussing the risks and benefits of the sheep brain rabies vaccine that requires 14 days of consecutive painful injections and carries a 1/200 risk of permanent neurologic damage, all the patients still want the vaccine. They have all seen people die of rabies, and nothing I say will make them believe that the risk of the vaccine is greater than the chance they’ll get rabies in this unconventional way. I’m not sure enough to withhold the vaccine. Once again, I can’t prove anything. So treat everything.

To the hospital, where I meet a newly admitted patient with a blood pressure of 60/40 who was put on Lasix for acute unilateral lower extremity edema. Hmm, mental note, talk to the nurses about when it’s appropriate to use lasix. And this is the second acute unilateral lower extremity edema this week – hope it’s just cellulitis, and not a blood clot. Not that I could diagnose a blood clot, no ultrasound. Or that I could treat it. No heparin, no warfarin. Not that I could put him on warfarin, no way to check INR’s. OK, d/c lasix and start aspirin. And ps, he’s having abdominal pain and bloody diarrhea and there are rales in his right lung. Augh!

Funny thing, I remember being really frustrated in the US, too. Frustrated by seeing so many patients in clinic. Frustrated by having to memorize a million different formularies to decide which medicine I can give patients. Frustrated by inability to get records from other hospitals, by my overflowing chart bin, by not being able to find a parking place in front of our apartment. I wonder if maybe, really, it’s me. Not the situation, not Chicago or Ethiopia. Me. It seems like the world will never be exactly how I want it, regardless of where I am. Maybe I need to let go a little. The system isn’t perfect. I am not perfect. All my frustration never found me a better parking place in Chicago, and I guess it is no more likely to help me find the right diagnosis in Ethiopia.

Hope, disappointment, and goiters by Jessie

The “Ethiopian ambulance” brought a patient to the clinic – a woman on a make-shift stretcher fashioned from bamboo rods and huge banana leaves, carried by five or six of her neighbors. Sometimes people come in on stretchers because they twisted an ankle and can’t walk, or because they’re in labor and don’t really want to walk five hours to the clinic. Sometimes it’s because they’re dying. This woman was somewhere in between. She appeared very weak, and her breath came in gasps as she tried to suck air past the huge goiter that was compressing her airway. She had not eaten in seven days because she couldn’t swallow solid food.

Goiters are common. Ethiopia is landlocked, with little access to iodine-rich seafood. No one in rural areas can buy the expensive iodized salt that is sold in the big cities. Unfortunately, as far as I can tell, once you have a goiter the size of a football it will never regress, not with medical treatment. This patient needed surgery. Fortunately, we were planning to drive to Jimma the following day. Jimma is the big city four hours down the road where we buy our medicine. There is also a university hospital there. Most people in Chiri are terrified of going to Jimma – it’s in a different zone that speaks a different language, and most have never been to a city of that size before. And, the cost. Transportation, a place to stay in the city, navigating the medical system there, paying up front for any medicine or surgery that you may need. It’s out of the question for most patients.

Except. If we are making a trip, we can take patients with us to save their transportation cost. And once in Jimma, they can stay with the Missionaries of Charity at their “Home for the Destitute and Dying,” where 500-800 sick people are housed. The patient must stay there by themselves – no room to house family also – but the Sisters help care for the patient and help them get treated at the hospital. The patient still has to pay the hospital fees, but they can request a “free letter” from their kebele chairman (mayor) that says they are too destitute to pay for their medical care. And they get treatment for free. Ethiopian Medicaid. Then, the next time we are in Jimma (every 4-8 weeks), we pick up the cured patient and bring them back to Chiri. Jimma Hospital and the Sisters of Charity are our hope in hopeless cases. Not hopeless medical cases – all are cases that could be diagnosed and usually cured – hopeless social cases, patients who require more than we can do here but have no means to access the care they need.

I sat next to the patient with the goiter as we bounced over the washed-out dirt road to Jimma. She looked scared - I don’t know if it was because of the road (which terrifies me), her difficulty breathing, or her journey alone into the unknown. I wished I could speak some word of reassurance but I can hardly say “good-morning” in Kafinoono much less say anything comforting, so I just squeezed her shoulder and patted her face with my hands instead. When we went over a big bump, she grabbed my leg to steady herself. I put my hand on hers, and held it. For a while. When I let go, she held on. For four hours, she clutched my thigh. For steadiness, for comfort? I didn’t mind. Every time her grip tightened or changed I knew without looking that she was still awake and breathing. I imagined that somehow my hope and reassurance could flow through that point of physical connection.

The Missionaries of Charity courtyard in Jimma was beautiful. Clean, stone instead of mud, flowers around. I was relieved. I didn’t know what to expect, but if I were a scared patient, it would comfort me to be welcomed into a clean, well-organized place. The Sisters knew what the patient needed within three seconds of seeing her. And, they knew she wouldn’t get it. “Oh goiters, they have to wait a year to get into the hospital, even if they’re suffocating.” A tiny white woman in a blue-trimmed sari spoke to us bluntly, in an eastern European accent. There had been an Ethiopian surgeon who came on Saturdays to the compound, but he left. The Swiss surgeon, the Belgian – they were gone too. She shrugged and smiled, and whisked the patient away to what I assumed was the sick peoples’ residential area. My heart sank. This was the pinnacle of our hope? The sign did say “Home for the Destitute and Dying.” Maybe it really was hopeless after all. All that time, I held in the back of my mind for so many patients, “if we could just get them to Jimma.” Apparently getting them there was only half the battle. And really, one university hospital for all these destitute patients who can’t afford to pay a thing? In Ethiopia of all places? What was I thinking? What was I expecting? I self- consciously touched my thigh, where the paitient’s hand had been. Did I bring her all this way to die alone?

But there is no other option. I understand that we will have to send incurable patients home to die. “Take him home and pray.” But curable patients? They deserve every chance, even this slim chance. Maybe next month we will pick her up on our way through and bring her home, untreated. Maybe by the time we leave Ethiopia we won’t bother taking goiter patients to Jimma anymore. But for now, we have done all we can. And for now, there is still hope.

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Today I sent a child home to die by Jessie

A three year old girl. She arrived a few days ago, referred from the local surgeon because of burns and severe malnutrition. Burns are common, since most people light their homes with kerosene lamps and many cook on open flames in their houses. This child had clearly fallen backward and landed with the top of her head in the flames. Her father cradled her little body with such love, such tenderness, that at first I didn’t see her cachexia or her wounds. Just a little girl, clinging to her dad. When he unwrapped her, however, her chronic malnutrition was obvious. Her face was gaunt and looked older than three years old; her body was wasted and weak and seemed younger than three years. The skin hung loosely from her emaciated arms but seemed stretched tight over her visible ribcage. Her belly and legs were swollen with the edema of protein deficiency. A swath of gauge wrapped around her head like a turban hid the extent of her burns.

Until this morning. The treatment room staff who normally do dressing changes on burns came to me, saying, “this is too much. To severe.” I asked the senior nurse, Tariku, to come with me to evaluate the injury. What do I know about bad burns? I was in a burn unit one time. I scrubbed my hands and arms like I was going to do surgery, donned a sterile gown and mask and gloves, and entered the restricted burn area at HCMC. The patients were hidden in individual glass rooms. I didn’t know what I could touch and couldn’t touch. I couldn’t find the chart I needed. I left.

The baby, or rather, the child – she was so tiny and helpless that I keep mistakenly thinking of her as a baby – was awake but seemed ill. She would meet her father’s gaze, briefly, and then her eyes would roll back into her head so only the whites were visible. It was unnerving. Tariku bent over the baby and gently rubbed the burned skin on her head with gauze. The skin came off. Nearly all of it. Down to the bone of her skull. She barely whimpered. The smooth ivory of her skull was marred with reddish purple spots where the bone was necrotic. It seemed impossible that she was still awake, but she was, clinging as always to her father. Exposed bone, her whole scalp, far more than could heal over without a skin graft. Even if grafting were possible, where could that much skin be harvested on this emaciated frame? How much good would IV antibiotics do at this point?

I wasn’t shocked by the sight of the baby’s exposed bone or burns, which surprises me. All I could think about was her father, who continued to cradle her body in his lap and support her head and neck in his hand as the charred skin of her scalp fell away. He never flinched, he never looked away. He didn’t ask any questions. His eyes were wet but he didn’t cry. Two of his five children died of diarrhea. I would like to think he was somehow hardened to loss, but when he carried his daughter back to the hospital bed, he laid her down so gently and swaddled her so carefully that it was clear how much he loved her. Still he didn’t speak. Tariku took the dad to a separate room to offer two options: she likely will not survive, but we can try IV antibiotics and re-feeding and see if she heals, or, you can take her home. Implied, take her home to die. I discovered the result of their conversation later that morning when I went to the hospital and the baby’s bed was empty.

I need reassurance – I need an attending to tell me that there was no way the child could have healed a burn that extensive, especially in her malnourished state. I need to find that father and somehow tell him I’m sorry, I’m sorry that he has to watch another one of his children die. I need to tell him that I don’t think he is a bad father. Projection, I guess. I would be afraid that the doctors thought that somehow my negligence or carelessness caused my daughter’s death. I want to ask his forgiveness – maybe he’s the one who thinks it’s my fault, since I couldn’t cure her. I want to ask him to stay in the hospital just a little bit longer, just to see if maybe she could gain a little weight, to give her antibiotics while we did daily dressing changes. Who am I to say that she had no chance?

Today I saved a child’s life by Jessie

I was walking back into my clinic room mid-morning when I saw a father and his son sitting among the patients on the wooden bench outside my door. The boy seemed to be barely breathing. Normally, the guards at the front gate are good at spotting the sickest of the sick and sending them to the front of the line. This boy, however, was so ill that he did not appear to be in distress. Just asleep in his father’s arms – unconscious, unarousable from hypoxia. I could hear his wheezing without even putting my stethoscope to his chest. The interpreter seemed rightly confused when I skipped my normal interview and physical exam, and instead put the child in his arms and told him to take the boy directly to the inpatient ward while I went to the pharmacy for medicine. Albuterol, intramuscular hydrocortisone, epinephrine.

The boy’s oxygen saturation was 75% after we placed him on oxygen and gave him a nebulizer treatment. He was breathing 40 times per minute; a little fast for a normal four- year-old, but not nearly fast enough for someone who was so hypoxic. He didn’t respond to voice, or to the intramuscular injection of hydrocortisone. He woke up with a cry when Membere injected the epinephrine subcutaneously. His O2 sat surged to 94 percent. Finally, after so many hopeless or uncertain cases, here was a child who could be saved! His case was by no means rare in the pediatric world – the ER at any children’s hospital probably sees a patient like him every day (and intubates him, which we cannot do here). And it’s not that a severe asthma attack is hard to diagnose or to treat. But I go through every day guessing the diagnosis, trying one treatment and then another, hoping that at least I’m doing no harm. How rewarding to finally recognize a problem and to know immediately what to do.

That is, until the epinephrine wore off.

One hour later, I returned from the clinic to the hospital to check on the patient. The nurse reported that he was sleeping comfortably. Sleeping – half dead! He was again unresponsive, breathing 15 times a minute, with an oxygen saturation of 80%. More epinephrine. More albuterol. But he clearly needed something more. The protocol for severe asthma at the clinic suggested an IV aminophylline drip for patients who did not respond to first line treatment – which I had never heard of, and none of the nurses had done before. So we got out the aminophylline and the peds ER book. Mix the right concentration, figure the dose per hour based on weight, count the drops in the IV tubing. Add ceftriaxone in case of underlying pneumonia. That was literally every trick in my book. And he got better. And this time, he stayed better. Not great, but awake and breathing.

In the bed to the left of the asthma patient is a malnourished one-year-old on oxygen who has no firm diagnosis, but appears to be slowly getting better. He was on every antibiotic we have, and we entertained a hundred different (unprovable) diagnosis, but in the end, re-feeding and oxygen therapy seem to be working. I have no idea what’s really wrong with him. To the right of the asthma patient is a nine-year-old boy who came in with a big spleen and a fever. His blood smear shows 140,000 immature white blood cells. Leukemia. So at least he has a diagnosis, but for him, there is no treatment here. So I focus on the patient in the middle, with asthma, potentially fatal but both diagnosable and treatable. Awake and breathing, getting better.

Leaving AMA (against medical advice) by Jessie

It’s hard enough to explain diseases and their treatments to people in English in the United States. Every now and then, an angry patient will leave the ER or the hospital “AMA” – against medical advice. Sometimes it’s the asthmatic heroin addict who was intubated for respiratory distress, and then wakes up and extubates himself in the ICU and leaves barely breathing, searching for another heroin fix. Sometimes it’s the pregnant woman in OB triage who’s tired of waiting for the doctor to see her, or a drug-seeking patient who is denied narcotics, or the demanding family who feels that not enough is being done for them, or the patient who refuses to stay for further testing because they’re sick of being in the hospital. The confrontation between the patient and the doctor is often tense, defensive, desperate, exasperated, and irritated all at once. It’s about power and powerlessness, about fear and trust.

Then there is leaving AMA in Ethiopia. Our first meningitis case was an 8-year-old girl who responded rapidly to antibiotics. It was so rewarding to see her improve. The second patient was already near death when he arrived – obtunded, seizing, febrile. One day of IV antibiotics did not change his clinical status. That’s expected; it may take 48 hours for the antibiotics to work, and that’s if he got the antibiotics in time. It is still possible to die from a severe case of bacterial meningitis, despite appropriate treatment. When his family saw his lack of improvement in one day, however, they decided to take him home. I was stunned. I thought they must be angry, they must think we are delivering inappropriate therapy and that’s why he is not getting better, they must not understand the concept of a bacteria invading the central nervous system. What I found, however, was a calm and grateful family. They thanked us for the excellent care, but explained that they wanted to take him to a priest for traditional healing. They said it would be ok for a nurse to go daily to their home and give a dose of IM antibiotics.

Our second patient to leave AMA was an elderly man who had been hit by a bicycle while limping across the street and sustained an open fracture of his lower leg. Both the tibia and fibula were clearly shattered. We pulled loose fragments of bone and dirt from the exposed muscle of his leg. Open fractures are orthopedic emergencies – the rate of infection and death are high. Unfortunately, he needed orthopedic surgery to fix the bone, or more simply, a below-the-knee amputation. We racked our brains trying to figure out how to get him to the nearest surgeon, four hours away. Everything was set – and then they took him home instead. For traditional healing, with the bone-setter. We begged him to stay at least for a complete course of IV antibiotics to prevent infection, but he declined. Again, no anger. Just resignation.

My greatest frustration was with a 13 year old boy that I feared had appendicitis. I tried to explain to the boy’s father that I wanted to keep in the hospital for observation and antibiotics, but that he may need to go to Jimma for surgery. The dad had never heard of appendicitis, so I tried to explain it through an interpreter, but he seemed more scared instead of more at ease as I talked. Again, a four-hour journey to reach a surgeon. An insurmountable amount of money for a poor family. The family left to get lunch and never returned to the hospital.

Part of the phenomenon seems to be lack of resources – people simply cannot pay for surgeries or transportation to a higher level of care, so they accept bad outcomes. Families take their loved ones home knowing the patient will die. Resignation. There is some trust in traditional healers also. Most patients have already tried traditional remedies when they arrive to the hospital. Lastly, people don’t want to die in the hospital. Of course, no one plans to die in the hospital in the US either, but statistically, most of us do. In Ethiopia, any sign that the patient is taking a turn for the worse is grounds to get them home before they’re dead. There is no angry confrontation here. The scientific and medical risks are presented, but they rarely seem to make a difference. The family thanks the hospital, and they carry the patient home.

Change of address by Jessie

I love our new house! When we arrived, we stayed in “the tukel” – the only traditionally African dwelling on the clinic compound. It is actually a step up from a traditional tukel, because it has indoor plumbing and electricity and a cement floor. Before arriving in Chiri, I secretly hoped that we would get to live in “the tukel.” It seemed like part of the experience. Living in Africa, like an African. Why come all this way to stay in one of the other square cement ex-pat houses? It seems, however, that I am truly an American, living like an American! The tukel seemed dark and dank and musty. It has only three small windows with obstructed views looking directly into the hillside. The single overhead lightbulb threw uneven light into the center of the room, leaving shadowy corners. The cement floor is damp and cold. Also, the tukel is somewhat isolated from the rest of the clinic compound. Monkeys playing in the trees and shrubs at night always sounded like someone walking down our path in the dark. Perhaps living like an African in rural Africa is over-rated! Even the American-ized tukel seemed claustrophobic and spooky to me.

So, when the former volunteer clinic manager left last week, we moved right in to her old house. It is an ample square cement room with a bathroom – a bathroom with its own electric light and toilet that doesn’t have to be convinced to flush! – a bed, a table, a dresser, and a bookshelf. A wooden leisure chair is tucked into a sunny corner. Light comes pouring in the windows on all sides. No shadowy corners, and no scary spiders, only friendly daddy long-legs. Most of the windows overlook the African countryside, over the valley to layers of hazy green mountains in the distance, and tall piles of clouds on the horizon. The front of the house faces west. Every night, the African sunset kisses our little front porch. It’s breathtaking. The other window conveniently looks toward the clinic compound, so we can see who is approaching and see if the clinic’s Land Rover is parked in the drive or not. Tonight rain is pattering down on the tin roof. I’m wrapped in a blanket, drinking hot water from a Nalgene bottle, feeling 100% at home.

But then I imagine our former tukel, African style: with a dirt floor, with a fire for warmth and cooking in the center, smoke rising up to the thatched roof and filtering out between the palm branches. Animals in one corner, five kids in the other corner. No bathroom. A little water stored in gallon-sized jerry cans hauled every day from the community spring. Kerosene lamps for lighting. No shoes, just bare feet on the damp packed mud floor. No windows, or few small windows, closed with wooden shutters to keep the nature out. When I picture this, I am ashamed of my discomfort in our former Lalmba home, the beautiful tukel.

I wonder if it’s wrong to travel to such an impoverished place and then live in such comfort, better than the community. I have always felt a nagging, uncomfortable contrast between my privileged life and the lives of the poor. I thought that moving to a third-world country would diminish the contrast. Make me feel closer to the poor, more comfortable in my own skin. But the contrast is only sharper now. And even if I choose to live in town in a mud house with the community, the contrast will remain – because I could choose to leave any time. And even if I gave away everything I own here, and I lived among the poor, I would still have my personal wealth of education and experience and health. I would never be truly poor. I will have to find another way to reconcile the contrast. I hope Ethiopia can teach me!

Introduction to tropical medicine – part 2 by Edwin

When I finished my internal medicine residency, I felt pretty good about what I was supposed to know as an internist. Diabetes, high blood pressure, heart disease – I knew that stuff like the back of my hand. I figured that the type of medicine I would need to know in Ethiopia was going to be a little bit different – and I was right!

Fortunately, my first day in clinic was a gift from the “internal medicine gods.” I saw patients with headaches, joint pains, “colds,” and dizziness, which are the same sort of ailments that I would see in any acute care clinic in the US. However, after that first half-day of clinic, things have been more out of my realm of comfort. Every time I see a young woman or a baby walk into my clinic room I feel like I’m about to take a jump off of a high-dive platform – I close my eyes, hold my breath, and hope for the best. But like I mentioned before, a lot of things we see are typical of any location, and so I can remember back to medical school and figure out what is likely going on. And fortunately, Jessie usually isn’t too far away for a consult (as a family practitioner, she has a lot more experience with kids and young women that I do).

Now, normally, when I see someone in the hospital or clinic with a complaint, I generate a “differential diagnosis” in my head of all the most likely causes of their complaint. Then I’ll interview the patient to narrow down my “differential” to a handful of possibilities. Finally, I’ll do an exam and maybe order some tests to clinch my suspicion. After about 5 years of clinical experience I’ve gotten better at this, and feel like I’m pretty competent at diagnosing a patient’s complaints. Here in Ethiopia, however, my competency is really being challenged.

First of all, I’m dealing with a lot of diseases I have never seen before, so my “differential” now includes things like malaria, leshminiasis, filariasis, hookworm (or really, any kind of worm), leprosy, measles, mumps, and podoconiosis (I just learned about that one). Then there are things that I’ve seen before, but are more prevalent here such as giardiasis, tuberculosis, syphilis, and HIV. I’ve probably ordered more AFB stains (a quick and easy test for tuberculosis) in 3 weeks than I had in all of residency, and I’ve definitely had more positive results.

Second, my interviewing skills are seriously handicapped. I feel that about 50 percent of the clinical training I’ve had thus far is learning how to talk to patients and get relevant information from them. I say that seriously because it takes a certain skill to ask questions the right way. Now I have an interpreter, which makes me feel like I’m starting all over again. My first day, whenever I asked someone why they came to the clinic, they would say because they were “ill,” not that their head hurt or they had a cough, but because they were “ill.” Follow-up questions usually entail a long conversation between the interpreter and patient, resulting in an answer to something else completely; but by that time I usually forget my original question. Another difficulty is that people can be very suggestible. I can ask anything, such as, “do your eyes turn green in the dark?” the answer will invariably be, “yes, and my joints hurt.”

There’s an expression in medicine that goes, “common things are common.” So generally we treat people here for the most common cause of their ailment. And the treatment is often dictated by what we have in the pharmacy – if it sounds like an infection, treat with antibiotics; if it sounds musculoskeletal, give ibuprofen; and if that doesn’t work, try something else. We have a lab, but the tests we can run, and thus the information we get from them, are limited. I’m slowly learning about what is “common” here and how to recognize different diseases. There are many knowledgeable nurses here that help out in this respect. Most of my nights are spent reading about different tropical and childhood diseases. Fortunately we have a small collection of medical books here that we constantly use, including one book called, “Principles of Medicine in Africa,” which gives a great perspective on the unique problems that Africans suffer (e.g. the section on malnutrition is much larger than the section on type 2 diabetes).

Practicing medicine in Ethiopia is a challenge. Part of this is due to the different selection of diseases in this part of the world (another part is the lack of resources, which I won’t go into now). Sometimes I feel that I can’t learn this stuff fast enough to be helpful. However, seeing sick and helpless people everyday has been a great motivator.

Introduction to tropical medicine

My first day in the clinic, I saw a man shaking with fever from malaria. Singay the lab tech showed me the schizont ring form of the Plasmodium Vivax on the patients blood smear. I saw a baby with severe respiratory distress from pneumonia, lethargic and breathing 60 times per minute. A pregnant woman with intestinal parasites, a pregnant woman with gonorrhea, a child with chronic tinea capatis. My head was spinning. The drug formulary at the clinic is limited, and worse, even the familiar medicines have different names. I was grateful to have the outgoing health officer Admasu (the equivalent of a physician assistant) translating and showing me the ropes.

Then came the weekend. A 12 year old girl who stepped on a splinter and got an infection in her foot – we sedated her with ketamine and opened the wound, only to discover a deep abscess with exposed tendons and liquid necrosis of all the tissue between her first and second metatarsals. Then a six year old child with the sudden onset of high fever and a rigid neck. Of course, I have read about meningitis but I was not prepared for the severity of her presentation. I could lift her entire upper body by lifting her head, because her neck was so rigid. The next day a 25 year old man presented with similar sudden high fever and neck rigidity, but he was worse off – already unconscious and seizing. Edwin had attempted a lumbar puncture on the child, but was unable to get CSF. Now it seemed even more important to get a CSF sample for gram stain, since two new meningitis cases so close together indicate the possibility of a neisseiria meningitis outbreak in the community. The seizing patient was sedated with diazepam and positioned on his side for the LP. Four relatives held the patients trembling body still for the LP. Edwin knelt on the cement floor, and with flies landing on his sterile gloves, he inserted a spinal needle into the patient’s back. With one stick, he got a return of cloudy, purulent CSF.

I was called away at that moment to the next room where one of the children with pneumonia was dying. He stared with glassy eyes at the ceiling, unresponsive. His breathing was agonal at a rate of less than twenty, a marked change from his prior irritability and respiratory rate in the 60’s. His mother held him with one hand and beat her chest with the other fist, wailing, rocking back and forth. His father leaned over the bed, sobbing freely, his face wet with tears. What more to do? Already on antibiotics. On steroids. Tigrist, the nurse on call for the weekend, injected epinephrine subcutaneously, and we gave an albuterol neb treatment. It seemed almost cruel to prolong the baby’s inevitable death, but how could we do nothing? The baby’s respiratory rate picked up, due to the epinephrine. After the neb treatment we put the oxygen back on the child. I didn’t know if I should stay with the family or leave. I couldn’t talk to them. I touched his mother’s face and she met my eyes, pleading, begging, without saying a word. Please save my baby. Please save my baby. I left. When I returned an hour later, the baby was still alive. Two hours later, he was improved. That night, he was again crying and breastfeeding, still in respiratory distress, but alive. Tigrist translated as his father spoke with a bright face and eager smile, he says thank you for saving his child. I wanted to dampen his enthusiasm, to point out that the baby was still critically ill and may still die. But I just smiled and bowed toward him, saying, it is in God’s hands. Because it really is. I don’t know what else to do to make the baby better.

Meanwhile, Edwin and David Leanord were in the lab trying to remember how to do gram stains. The meningitis patient’s cloudy CSF sat in a test tube on the lab desk. The CSF showed inumberable PMN’s, consistent with bacterial meningitis, but they found only one area across several slides that showed gram positive cocci in short chains - consistent with strep pneumonia meningitis. But it could easily be a contaminant, and neisseira meningitis could not be conclusively ruled out. Exhausted from working straight through the day, we stopped for supper. Then a 5 year old girl with a snake bite came in. Her father carried her for 7 hours from an outlying region. Edwin showed him pictures of different snakes to see which one bit the child. He pointed to black mamba. For better or for worse, if it was really a black mamba bite, the child would probably have been dead already. Regardless, the bite was infected so antiobiotics were started. No anti-venom is available at the clinic. Later that night, the nurse delivered a breech baby without even waking us up.

Quite an introduction to tropical medicine.

So now what? - by Jessie

We have been in Ethiopia for nearly two weeks now.

Kay, the previous clinic manager, is trying to teach us to do her job. She’s leaving next week. She is responsible for government reports, keeping the pharmacy and the storeroom stocked, vacations, on-call schedules. She seems to write a lot of letters. The Ethiopian staff approach her often with questions, but the most common question these days seems to be, “who do we talk to about such-and-such after you are gone?” Kay has a million different stories about different personalities here and about how to get things done. We’ll take over her job when she goes, but despite our orientation, I still feel unsure of what exactly she does all day. If I were to start right now, I wouldn’t know what to do. But I do know it seems to be a full time job.

Guy was the outreach coordinator. He investigated the state of latrines at surrounding schools as the footwork for a water and sanitation project. He arranged twice-weekly trips to nearby kebeles (villages) to do routine vaccines, HIV testing, and patient education. He also ran the tuberculosis DOT (directly observed therapy) program. The water and sanitation part seems to be on hold, and the outreach trips are scheduled up through November. Edwin has taken over the TB program. But everyone seems to think that outreach should be more than it is. In what way, I don’t know. Guy left just as we arrived.

The clinic seems well-staffed with nurses to take call at night/weekends and to see outpatients on weekdays. There are four nurses who rotate call Q4, and two senior nurses who alternate “backup call” to come in if the on-call nurse is overwhelmed or unsure. The outpatient area is slow now because of the rainy season, about 40-60 patients per day. The inpatient census varies from 2-10 patients; all the nurses plus the lab tech and the pharmacist and the attending doctors (that’s us!) round at 8:30 in the morning and again at 3:30 in the afternoon. Edwin and I teach and offer guidance during inpatient rounds, and once a week give a lecture. Guiding and teaching the nurses seems to be one of our main functions. The nurses are very smart people with minimal medical education, eager to learn more. We are encouraged to sit with the nurses in the outpatient clinic to learn the local diseases and treatments. Sometimes we see patients on our own with a translator, but there is usually enough nurses to handle the rainy-season patient load without our help. We see patients mostly for fun.

So here we are. There seems to be a million things to do and a million things to learn but I still feel uncertain of my role. The goal seems to be for each of us to spend half a day in the clinic and half a day doing administrative stuff. I still find myself often with nothing to do. So I read. I make feeble attempts to learn Amharic. I wander into the treatment room where patients come for wound care, I wander through the Big House where Amaz the cook is preparing lunch for us, I prepare lectures. It sounds like some volunteer physicians before us worked so hard that they were nearly overwhelmed; currently I am quite underwhelmed. What was I expecting? What was I hoping for? Getting started in a new place is so hard.

I remind myself to have patience, openness, and courage. Surely God called us here, so surely God will reveal whatever he had in mind, little by little, piece by piece. Surely we will find our place in this experience. Surely we will find that we have things to give and things to learn. Right?

So now what?

home sweet tukel

Many Ethiopians live in tukels, one-room round mud huts with thatched roofs. Their fire for cooking is inside the tukel, and the animals often live in the tukel too. Our tukel is the deluxe version. Cement floor, windows, electricity, and a low wall dividing off an area with a toilet and a sink. All the other volunteers live in small square cement houses – this is the only tukel on the clinic compound, and it belongs to the founders of Lalmba who now live in Denver. So naturally, the first night we moved in, we almost destroyed it!

We entered with our suitcases and immediately I cut my finger on something and starting bleeding all over the cement floor, then bleeding all over the luggage as I tried with one hand to unearth the bandaids that I was positive we packed in one of the four suitcases. Meanwhile Edwin used the toilet and discovered that it didn’t flush, so he turned out the water at the base to fill the tank. The overhead light didn’t illuminate the toilet very well though, so he tried to light a candle with the so-called “safety matches.” The lit tip of the match broke off and landed on the rug. Edwin stomped it out. The next match didn’t light at all, and third one threw sparks all over Edwin’s shirt so he tried to put out the match with one hand while extinguishing the sparks on his chest with the other. By then I’d found a bandaid but bled through it. We realized suddenly that the water was still running into the toilet. Fortunately the toilet hadn’t flooded yet so we turned the water off and decided to figure out how to flush the toilet in the morning. So, that is how we tried to flood and burn and bleed on the tukel all within the first hour of arrival. Fortunately, it is one week and the tukel is still standing. And we figured out how to flush the toilet.

going to church

Ethiopia is about 30% Muslim and 50% Ethiopian Orthodox, with the rest being a random mix of animist and Catholics. We approach the small Catholic church on Sunday morning, walking through morning mist and under low clouds, across a wet grass field. Women and children are standing on one side of the church and men on the other. Their voices rise and fall across the aisle in familiar cadence as they pray the rosary. I can’t understand a word, but I know what they are saying. Kay, fearless Kay who is not only the sole white woman to attend the church but also the only woman of any color to give homilies there, pulls me over to the end of a rough wooden bench. She tells me which part of the Hail Mary they are reciting. She joins in softly, speaking the prayer in English under her breath. She shows me how to kneel on the floor and bend my body over the bench in front of me at the right times. We read along in English in her Bible as the scriptures are read aloud in Kafinoono. There is no priest this week, so there is no communion.

The choir is strong and rhythmic, clapping and beating the bongo drum. There are no music books, but everyone knows the words and sings and claps along. The joyful music is a stark contrast to the dark, humble church and the somber sky outside. Rain falls on the tin roof, which makes it feel cozy inside, but it also makes me dread the wet and muddy walk home. It’s hot and close in the small church and I feel faint. I’m relieved when mass is over. I feel so obvious and so lost even in this familiar ritual.

Mass ends and everyone pulls the benches outside and rearranges for boona, for coffee. The sky has cleared and sun is beginning to shine through. A boy hands out small ceramic cups to every parishioner, then fills them with coffee. Another child brings around a shallow bowl full of chewy roasted corn for everyone to sample. People seem to be having a heated discussion, and praying. There is chatter and laughter. The deacon, a friend of Kay’s, introduces us as the new doctors in town. People smile at us and respond to him in Kafinoono. I ask what they are saying. He smiles and translates, “they say welcome, that you are welcome to come and pray with us at our church.”

the road to chiri

Karen’s hands are tight on the wheel. The veins on the back of her hands stand out, and the muscles of her forearms are tense ropes. The steering wheel shakes violently in her grip. We are all bouncing. The road is washboard dirt that was maybe paved with rocks at some point, but after seasons of rain and traffic, it’s just a scar of uneven dirt. Karen avoids the biggest holes, but barrels on through the smaller water-filled pockmarks since it’s impossible to avoid them all. A small river of water winds unpredictably back and forth through the road. Our wheels smash in and splash out again and again. Karen seems to be going fast. Maybe it’s like ripping off a bandaid; it’s better to just go fast and get it over with. I try to plant my feet wide for balance. My chest and my bottom ache. I wish I would have worn a sports bra. We hit a pothole hard and momentarily I’m airborn, held down only by my seatbelt. The cargo in the back stops rattling as it too is momentarily suspended and for a split second, it’s quiet. We hit the ground hard and rattle on.

Despite the recent rain and the water-filled potholes, dust rises like steam up off the winding road. Shrubs with yellow flowers standing at attention and torch trees with flaming red flowers line the road. Round wooden huts with thatched roofs dot the roadside. Acacia trees raise their flat umbrella branches up to the sky like storm clouds that hit the jetstream and flatten out on top. They look like Africa. The valley is verdant green, a patchwork quilt of square cropland across the low hills. Heavy clouds hang low over the valley, and when the sun breaks through, the valley is zebra striped with sun and shade.

The bumpy road is filled with animals – cattle, goats, sheep, donkeys, occasional chickens. Some of the donkeys are nearly hidden under mountains of hay piled on their backs; those without cargo lay down in the road and scratch their backs in the dirt. Whole herds of cows meander in the road, seemingly unbothered by the traffic, slowly parting as the vehicles push through. A dozen baboons freeze at the roadside and watch us with dark, unblinking eyes. Bright yellow basketweavers dart through the air with twigs in their beaks and weave perfectly round globe nests in the trees. We constantly stop and start and dodge and honk to make our way through the menagerie.

The road is also full of people. The small children light up and smile, waving frantically as we pass. Older children watch us impassively, with unreadable faces. I imagine hostility in their distant eyes and still bodies. A man on the roadside shakes his shoulders up and down in a silly imitation of our bouncing vehicle then gives us a wide smile and a thumbs up sign. His gesture is so silly and friendly that I forget any imagined hostility. Later a crowd of schoolchildren mob the car, beating the doors and windows and shouting, “money, money!” They are laughing and screaming. Karen is visibly shaken as she tries to navigate the vehicle through the throng of children without running anyone over. Most pedestrians continue their slow trek without paying much attention to the traffic. Some wave cobs of roasted corn that are for sale; others motion with wide gestures that they have charcoal to sell; some place their hand out for a ride.

As we near Chiri, the dark purple clouds press down and it begins to rain. The richochet of hard rain obscures the road in wet haze and the road fills with muddy water. Our bouncing is now complicated by sliding in the slick mud. Karen is focused; she wants to make it home before dark since the headlights do little to illuminate the unpredictable road. The sun has begun to set. The vegetation is vibrant green and steaming all around us, and the road has become more deserted. We pass many huts and homes, but fewer animals and people. It is nearly dark when we reach the gates of the Chiri Health Center. A smiling guard emerges from the semi-darkness and opens the gate, welcoming us. We drive straight over the grass to the Big House, where we unload the Land Cruiser and sit down to a meal of rich vegetable soup that sat simmering on the stove, waiting for us to arrive. The hot soup and warm bread are perfect. After supper, we walk down a dark path lined with flowers to the tukel, our new home. We unpack enough to find our pajamas and flashlights. For the first time since arriving in Ethiopia four days ago, I sleep through the night.