A long two days by Jessie

It begins with a cord prolapse. The laboring mother had been in the hospital overnight and still there was no progress in her labor. We arrange for her transfer to Bonga for C-Section. She is fine, the baby is fine. The baby just won’t come out. The problem now is money – the family goes out to gather the necessary funds to pay for a C-Section. Then without warning the mother’s water breaks, and the umbilical cord floats down beside the baby’s head. I have a sudden flashback to residency, to seeing my OB attending doctor discovering a cord prolapse – never removing her hand from the birth canal, trying to elevate the baby’s head so that it would not crush its own blood supply, getting on the bed with the patient and the whole bed being rolled down the hall to the operating room. Six minutes from incision to delivery of the baby. My attending crouched beneath the sterile drape in the OR, keeping the baby’s head elevated even during the surgery. Six minutes – standard of care. I look at the mother in front of me now and feel despair, knowing that at minimum there are 1-2 hours between her and C-Section. The baby’s heart beat is weak and irregular. And still, no money. Edwin and I dig into our pockets and ask the Program Director for the rest. The Land Cruiser takes off for Bonga Hospital, but in my heart I am sure it is too late. Emily asks what’s going on, and I collapse against her side and cry.

A healthy 12-pound baby boy is delivered by C-Section at Bonga Hospital. I wonder briefly exactly what happened, but I quickly decide that it doesn’t matter anymore. I feel a little bit like a wrung-out rag.

Ten pm. A knock on the door, “Bisrat, delivery,” says the guard. I don’t bother getting dressed. I put a sweater on over my pajamas and walk with my flashlight to the hospital, not surprised to discover that it’s not a delivery (the guard’s English vocabulary consists of about three words, one of which is “delivery”) just a drunk man with a big head wound. Bleeding. And bleeding and bleeding. I roll up my pj pants and wade into the puddle with Bisrat, the nurse on call, and together we try to capture the pumping artery in the patient’s open wound. Hard when the cut keeps filling up with blood, and my freshly-washed hair keeps falling into the field (guess those disposable surgical caps aren’t as silly as they look after all). I avoid the instinct to hold down his bloody flailing hands with my sterile ones. “I have disturbed you,” Bisrat says apologetically as he notices my wet hair and pajamas. No, I reassure him, this is why we’re here. And I meant it.

Back to bed and then up for another day, starting with good teaching rounds in the hospital. The morning is sun-drenched after a night of furious storms. The malnutrition baby that seemed sure to die is looking better, despite the NG tube taped mercilessly across her face. Her mother and sister, however, are covered with hundreds of bites. Mosquitos or fleas? I’m chagrined and embarrased that they were eaten alive in the hospital of all places, which seems it should be cleaner and safer than that. Up with the bednets. Off with the old clothes, on with new poorly-fitting inappropriate American cast-off T-shirts. I make a mental note to leave money behind for the charity clothing fund.

Then comes the man with an obstructed abdomen, vomiting blood as the NG tube is placed, wretching and grasping his bloated belly. His family is terrified and demanding when we tell them that he needs to go to Jimma for surgery. I explain for the millionth time that we can’t drive patients all the way to Jimma. They gesture angrily at the Land Cruisers parked in front of the office. I wish we had a garage to at least hide those beasts from public view. They can’t afford to go to Jimma. Stay here, I try to persuade them, at least we can give him antibiotics and IV fluid and see if he gets better. His chances certainly are no worse here than they are at home. But still, they bundle him up and take him home to die. We quickly run in a bag of IV fluid so at least he doesn’t leave dehydrated.

Tigist admits a baby with malnutrition, a one-year old child who weighs only 9 pounds. His eyes are glazed and breath is gasping. Poor baby has not only malnutrition but also pneumonia. Tigist manages to place an IV in his shrunken arm. He dies at lunchtime when the nurses are all away. Edwin and I remove the IV from his hand and wordlessly kiss his mother and father. I try to close the baby’s eyes but the lids unnervingly spring back open each time. We tell the guards that the family can go home without waiting for the nurses to return to talk with them. What is there to say?

After lunch, we decide to admit the mother who arrived in pre-term labor. Her cervix is open and the amniotic sack is bulging through. It seems only a matter of time. Her belly measures 25cm, so she is roughly 25 weeks pregnant. Impossible for a 25 week old baby to survive here, but she isn’t having contractions, so maybe she won’t deliver yet. We give dexamethasone to make the baby’s lungs mature faster. It feels like a remarkably “first world” thing to do. Futile, really. But the right thing. The clinic is closed and quiet when the amniotic sack breaks and blood comes pouring out. Half a liter by the time I make it down to the room. Bright red blood pours out of the speculum. One liter, in the basin, on the floor. I try to pack with gauze to staunch the bleeding. The force of built-up bleeding behind the gauze as she tries to sit up causes an explosion of blood and clot, and again, I find myself standing in a red puddle. A liter and a half. The nurses try to place IV’s while the guard runs through the town looking for her husband. He starts to cry when he enters the room and sees the red puddle. He only has 20 birr. A C-section costs 350 birr. “Only 20 birr?” Edwin exclaims as we raid the clinic cashbox to come up with enough money. “What do they live on?” The answer is, of course, nothing. The land. We bundle them into the back of the Land Cruiser and I hope that Bonga hospital doesn’t turf them to Jimma because she’s bleeding and they can’t do blood transfusions in Bonga. I send Solomon the nurse with Edwin because Solomon is the most persuasive, and if anyone can convince them to operate in Bonga instead of referring, it’s him.

As they drive away the sun is already lowering on the horizon. Edwin will be returning in the dark. I’m grateful he’s such a good driver. I worry a little less. Tigist shrugs and comments as the car drives away, “only God can say.” At that moment, I realize I’m furious. Not at Tigist. Or at the patient. But at my helplessness while I watch liters of blood pour out of a pregnant woman. At my inability to do C-Sections. At a country where there are no ambulances. At poverty that reduces people to literally having two dollars to their name. At the necessary, indifferent helplessness of a broken system that watches people die every day and blames it on God. “Then I will have a word with God,” I reply to Tigist. I do believe. I see God’s hand in everything, in all of it, I see God’s sorrow and I feel God’s command. I see God in my hands and I realize that maybe “only God can say” but only I can do.

Edwin returns safely and says the patient was accepted at Bonga hospital. The night again is filled with furious storms and pounding rain. The morning again dawns fresh and cool. The sound of birds and wind in the treetops along with the dewy smell of wet grass almost makes me think for a moment that I’m in Minnesota again. Almost.

Vacation by Jessie

Part of me understands why people may want to vacation in Ethiopia. Lots of history, lots of scenery, possible adventure. BUT. No toilets. Bad roads. Harassment from the locals. Big spread out country that takes days to cross by bus. Heat and dust. Rain and mud. All things considered, our home in Chiri usually looks much better than any vacation we could possibly take here in Ethiopia, especially given our current budget (salary = $0). Here in Chiri, we have hot water and clean sheets and flushing toilets and sinks that work, which is more than I can say for 90% of the hotels in Ethiopia. The downside is that we live where we work. My ears have become hyper-sensitive to the sound of guards and nurses walking up the gravel path to our door at night. A delivery. A dying patient. Even if we aren’t technically on call, any major event ends up in our laps. As rightly it should. But after a while, you just really need a vacation.

We had already visited all the sights and small cities within driving distance. Vacation would mean either a bus ride or a plane ticket. We researched tickets to Zanzibar, a nearby tourist location off the coast of Tanzania that volunteers visited in the past, but the plane ticket for one of us alone exceeded our budget for the entire vacation. So we thought we’d look closer to home. To the west – Sudan. Hmmm, no. To the east – Somalia. Hmmm, not so great either. To the north, Eritrea. Not exactly a tourist destination. To the south, Kenya. Sounded better, but the Masai Mara game reserve is not for the weak of pocketbook. So, we decided to explore Ethiopia.

We made the 9-hour drive to the capital Addis Ababa, where we stayed overnight. We sometimes go to Addis for business, but this time, we set out to have fun. We found a movie theater and watched “Slumdog Millionaire” on the (sort-of-big) big screen. Early the next morning, we caught a flight out to Lalibela. Lalibela is a famous tourist destination in northern Ethiopia, known for its “rock-hewn churches” – ancient Christian churches excavated from the rock so that the whole church is one solid stone, no seams. King Lalibela apparently built them in the 11th century to create a “second Jerusalem” so that Ethiopian Christian pilgrims wouldn’t have to make the long journey through the Sahara to get to Jerusalem.

I was struck immediately by the difference in scenery – hard brown rock everywhere, spotted with green bushes, very desert-like compared to our home in southern Ethiopia. We stayed at a nice hotel with hot water and (yes!) clean, functional western toilets. The view outside our door was breathtaking. No TV, but who am I to be picky? We were fleeced and scammed every time we left the hotel, since most people in Lalibela seem to make their living by separating tourists from their money in one way or another.

The churches themselves were interesting. They are undeveloped except for the ugly scaffolding that some European historic society built over them as protection from the elements. Most are still used as Orthodox churches. As we removed our shoes to enter the first church, I got caught in a flurry of nuns and priests that were leaving the building. They settled themselves on the rocks outside, perched like doves in their white prayer shawls, eating the holy food offered after mid-day prayer during Lent. The church was dark and muffled inside, and disconcertingly, the ancient rock was draped with gaudy carpets and curtains. Huge iconic poster-paintings of Jesus and Mary were propped up against the walls. Empty water bottles spotted the floors. None of the curtains or carpets matched each other or anything else. Wires leading to lone light bulbs crossed the ceiling. It was all done to make the space a functional Orthodox church, but to me, it seemed tacky at best and sacrilegious at worse. Either way, the majestic stone churches all looked like forgotten tree-houses inside. Fortunately, there were enough secret passageways and mummies (no joke) to make me feel like Indiana Jones anyway.

After a couple of restful days exploring Lalibela and eating fancy food at the hotel restaurant (well, their version of fancy food), we returned to Addis. We went to two great museums in Addis, bought some souvenirs, and ate at some more nice restaurants. By that time, I’d given up on main dishes and was just eating ice cream and/or french fries for every meal. Ice cream is rare in Ethiopia. I didn’t intend to let my one opportunity to eat ice cream go to waste. I ended up with strep throat and traveler’s diarrhea, but it was worth it.

We made the nine hour return drive today. The clinic is still standing. Apparently the patients survived, although two of our chickens were eaten by ants. As I return, I am grateful for the chance to vacation, but I’m also grateful that Edwin and I have the chance to experience Ethiopia in a way that tourists never can. Living and working in Chiri is (for better or worse) as close to a real-life Ethiopian experience as a white foreigner can get. No museums or rock-hewn churches, true, but we are involved in people’s day-to-day lives, their relationships and sicknesses and struggles. And, we have a flushing toilet. For Ethiopia, I think this may be as good as it gets.

Grief by Jessie

I don’t know the right reaction for a doctor to have toward the death of a patient. Especially here.

It seems that doctors should have a kind of detached compassion, a wisdom formed by constantly dealing with life and death and the inevitabilities of both - like we should somehow be sympathetic while still being above the fray. But today a patient died. His wife was fighting for us to give his corpse a free ride back to their distant hometown. She had their baby strapped to her back. The baby cooed and babbled happily without any understanding of the situation. But I understood. Here is a young mother with a young baby. She has no education, she is looked down upon because of her darker black skin and coarser features, she is miles and miles from home, and now she has no one to support her and her child. And worse, she somehow has to get the stiff cold body of her dead husband back to Dishi. There was no softness or grief in her bearing. Her face was impassive; her tone was hard and insistent. She must understand, I think, the desperation of her situation.

During hospital rounds we had talked scientifically about the likelihood of the patient’s survival. Tuberculosis pericarditis, 90% mortality without treatment, and still a 30% mortality with medication and surgery. So, no heart surgery at our clinic – that just left TB medication. I found myself wanting less and less to even try to save him. In my heart, I just wanted to get him back to Dishi before he died, knowing that transporting a sick person all that way was hard but transporting a dead body that far was almost impossible, knowing I would have to argue with the family about transporting the corpse in our car. I was shocked and disconcerted at my own reaction – giving up, avoiding. We continued his hospital care until his wife insisted on renting a place in town and coming to the clinic every day to pick up his TB medicine. I was grateful when they left, but quickly, ashamed of my gratitude. He died the day after he left the hospital. I was surprised – he didn’t seem one day away from dying when he left. I wondered if his wife knew something I didn’t. Maybe she knew with the uncanny foresight of people here that her husband was dying despite our efforts. His friends had tried to take him home as soon as they saw how his body was swelling. “People always swell up before they die,” they said. We convinced them that the swelling was from heart disease caused by TB, and there was a chance of cure. It seems that they knew more than I did.

So I stood at the gate, offering profuse sympathy to the stony-faced wife, gently embracing her without being embraced back. I refused her request to drive the body back to Dishi, per policy. Then I beat a hasty retreat back through the gate with tears in my eyes, hoping the nurse wouldn’t try to talk to me or the tears would spill over. Part of me knows that some measure of detachment is necessary to stay sane here, but part of me rebels and asks, what kind of doctor doesn’t feel true sadness when her patient dies? How coldhearted would I be to watch a widow and her infant walk away into an uncertain future without aching for them? How callous and unfeeling will I become if I ignore my grief? But at the same time, how can I afford to be struck down by every death and bad outcome? The balance is always difficult. I will always cry when a patient dies. But I will not – I cannot – be paralyzed by sadness or hopelessness. I cannot give up.