Good Times by Edwin

A twenty-something year old man came in coughing up large amounts of blood. It started suddenly on Ethiopian Christmas. The coughing was mixed with dark looking vomit. We tested his sputum and it was positive for tuberculosis (TB). Oddly enough, he wasn’t chronically sick like our other TB patients - he looked healthy. We thought he had a big lung cavity caused by TB that was eroding into a blood vessel. After starting him on TB therapy, we referred him to another hospital. My concern was that he would eventually pop a blood vessel with one of his coughs and drown in his own blood. Before going, he went back to his village to collect his things only to discover he had been robbed. He came back to us two weeks later because he ran out of the TB meds we gave him. He told me that he never went to the referral hospital. I told him I was sorry that he was robbed, but he was lucky to still be alive. He is still taking TB treatment at our clinic, and is no longer coughing.

A thirty year old man was rushed into my clinic room by his friends complaining that his throat hurt and he couldn’t eat anything. His neck was tense, his eyes were frightful, and his mouth was open just enough that he was breathing through his clenched teeth. It was hard to ask him any questions. He had no fever. He wouldn’t or couldn’t open his mouth wide enough to look at his throat. I admitted him thinking he had a submandibular or peritonsillar infection. After two days of antibiotics and no improvement, I drove him to our referral hospital in Bonga. The health officer there told me the patient had tetanus. Since there is a risk for respiratory arrest in tetanus, the patient had to be sent to their referral hospital. Since this was impossible for the patient, we took him back to our clinic. We administered the correct treatment for tetanus and he slowly made a complete recovery. If I had been more astute, or if I had known that “trismus” and “lockjaw” are synonyms, we might had diagnosed him sooner and saved him the rough trip to Bonga. Nonetheless, he did get better. And the next patient that came in with tetanus a month later was diagnosed quicker and also got better.

On one of our first weekends here, an eight-year old girl came in with meningitis. She was febrile and her neck was so stiff we could lift her whole body off the bed by lifting her head. She was treated immediately with antibiotics and got better.

We’ve had several children admitted with kwashiorkor, or protein malnutrition. They come in irritable and swollen. Their little feet look like marshmallows, and the skin around their eyes is so swollen that they can’t see. Often times, they will have terrible skin breakdown over their legs and chest, probably from vitamin deficiencies. The first few days of admission they refuse their special malnutrition formula and the parents have to force feed them. Eventually they start drinking without coercion. Around this time their eyes start to open up and they look like they are squinting, or sometimes winking, at you. Sometime in the first week their weight begins to go down, along with the swelling in their little legs. They begin to be more playful. They will drink or eat anything you put in front of them. Their weight climbs and their skin lesions disappear. The parents who were sure their children were dying fall over themselves to thank us and the nurses.

Last week a pregnant woman came in because of prolonged labor. Her abdomen was enormous. I thought she was having twins or triplets, or more. As we stood around her trying to decide whether or not she should be referred, her water broke explosively onto a nursing student standing at the wrong place at the wrong time. The amniotic fluid was meconium stained, meaning that the baby was in distress. Her labor progressed quickly after that. Jessie and the midwife noted that the baby was in a breech position. With a little skill and a little luck, the baby was delivered. Baby and mother, both healthy, left later that day.

Everyday there are stories much less interesting than these, but with outcomes just as wonderful. Everyday the treatment room staff vaccinates children against diseases like tetanus, polio, and measles, which are rare, but still make regular appearances in this corner of the world. They also clean and dress wounds that would otherwise become infected. The nurses treat countless cases of pneumonia, skin infections, typhoid, malaria, giardia, and amebas. Lastly, we have many patients with seizure disorders who rely on our clinic for anti-seizure medications. The importance of this became clear to me only after seeing patient after patient with disfiguring burn wounds from the times they fell into an open fire during a seizure.

It is hard to take pride in the happy moments, because there are so many sad ones competing for our attention. You don’t have to speak the local languages to understand mothers wailing and beating their chest. We had one woman who would yell and scream at us every time we did her wound dressing. One day I finally asked one of the nurses what she was saying to us. She answered, “She says thank you to you, thank you God, bless you.”

Exhaustion by Jessie

The first one died on Monday. She had already been febrile and unconscious for three days when she arrived on Sunday night. We gave her every treatment possible for every possible diagnosis, without proof of anything, but she never regained consciousness. In the early evening darkness, her family bundled up her body. They tied her thumbs together and her big toes together with discarded gauze; her brother grabbed the still-dripping IV tubing from Edwin’s hands and used it to cinch her arms and legs. A shirt was thrown over her face to hide her unseeing eyes and her frothy mouth. It was all done with offensive and heartbreaking efficiency. There were no tears; even the other patients were unusually quiet. The young woman’s father gestured to his chest and to the sky with a wild, desperate look in his eyes and an undecipherable smile.

The second one arrived Tuesday and died Wednesday. Tuesday was a government holiday, so the clinic was closed and only a skeleton crew remained to take care of emergencies. He looked just like the young woman who died the day before – unconscious, with a high fever and respiratory distress from pulmonary edema. He was even from the same village that she was. We worried that the two cases may represent the start of an atypical meningococcal meningitis epidemic, so Edwin performed a lumbar puncture. We read the lab manual on how to prepare thick and thin blood slides for malaria, and then took the spinal fluid and the blood films to the private clinic in town to ask their lab technician to analyze them for us. Back and forth, back and forth, but three hours and 30 birr later the only helpful information we gained was that the patient did not appear to have epidemic meningococcal meningitis. At a loss, we treated him for everything, like we had treated the young woman. And like the young woman, he died within a day.

The third one died in the clinic on Wednesday. I was seeing patients in the exam room next to Bezu’s room. Bezu frequently interrupts me when I am seeing patients, which irritates me, because he is supposed to go the office and find Edwin for questions about patients but he interrupts me because I’m closer. He said there was a baby in his room with no pulse. This irritated me even more, because the last time he had a patient with “no pulse” I ran to his room only to find the “pulseless” patient sitting up in bed talking. Despite the fact that she was alert and complaining, Bezu still insisted that she had no pulse and needed an adrenaline injection. Keeping this history in mind, I reluctantly left my patient waiting and went to his exam room. I placed my stethoscope on the little baby’s chest and heard – nothing. Breathless. Pulseless.

My own heart stopped. For a moment time stood still, and with a snap, everything changed to fast-forward. Infant Ambu-bag from the delivery room, adrenaline from the inpatient ward, a student nurse to do chest compressions, a senior nurse to place an IV line. I remembered seeing intraosseous needles somewhere and thinking I wasn’t comfortable enough to actually use one (I had only practiced on a sheep, never a real baby!) but I searched desperately to find one then. Practice or not, I was willing to screw a huge needle into the baby’s leg bone if the nurse couldn’t get an IV started. But I couldn’t find the needles. And the nurse couldn’t find a vein. The mother sobbed gently, more frightened I think by the flurry of desperate activity than by the still baby in her arms. The child had been alive when it entered the exam room. It seemed there should be some chance, some small chance, to revive it. It wasn’t a sickly looking baby. Chubby, smooth skinned. Tears pushed against the back of my eyes. How long had the mother waited outside the front gate? Why did I respond with irritation when Bezu called me – did my hesitation cost the baby its life? Why didn’t Bezu start CPR immediately? Where were the intraosseous needles when I needed one? I tried to look up saphenous vein cut-downs in our procedure book, tried to cannulate the femoral vein, knowing the baby was dead, but still believing that somehow, suddenly, it would gasp and open its eyes. It didn’t. The infant looked like a perfect plastic baby doll, bow-tie lips slightly parted, glassy black eyes fixed on the ceiling, perfectly still. No blood oozed from the attempted IV sites. Apparently, dead babies don’t bleed. I wrapped the baby’s body in its mother’s shawl and covered its face. She knew, then. Her quiet sobs turned to wails and she beat her head with her fists. The father took the bundle into his arms, and without words, they ran from the clinic. I hid behind the big house and cried. But the crazy busy day continued – I washed my face and went back to seeing patients.

We got word later that day that a child we sent to Jimma for hospital evaluation had died. When I first saw her in the clinic, I assumed she was pregnant. It turns out that her belly swollen with ascites, perhaps from liver failure. We drained liters of yellow fluid from her abdomen. Her family was very poor, so we set them up to go with us for free to Jimma to be evaluated by a specialist. She was actually an annoying patient who cried all the time even though she was supposedly 15 years old, but her father won a spot in my heart. He was an unsophisticated rural man, but he would clearly do anything to save his daughter, even brave the big city and the face the bankruptcy of hospital treatment. My heart fell when I heard that she died. He would have to bury her in Jimma. He would probably never even see her grave again – she was doubly lost to him.

The next death is a presumed death. On Thursday, the family of a 10-day old infant decided to take the baby home to die. The baby was born at home and had developed pneumonia after birth. After four days of IV antibiotics, I was still hopeful that the baby would turn around, but the parents saw little improvement. Not only will I lose her, the father said, but I will lose my farm and my animals if we stay here any longer. He argued compassionately but rationally. The mother sat quietly with the tiny newborn cradled in her lap. She didn’t appear to be paying attention to our conversation, but suddenly she blurted, “I know this baby will die!” Her previous baby had died when it was one year old. Her voice was desperate and hostile and petulant and grieving all at the same time. They said they would bring the baby back for daily antibiotic injections. I knew the baby wouldn’t be back. It wouldn’t survive long off oxygen, and since the mother had already decided in her heart that the baby was going to die, I was sure she wouldn’t feed it every hour with the syringe as we’d taught. But I couldn’t force them to stay.

The last one is still in the process of dying. He arrived last night, gasping for air, gurgling, burping, clutching his chest. He seemed to have an obstruction of his airway. I wanted to scream. It was too much. Too much! It was Friday night. The week had drawn on forever. Already the hospital seemed thick with death. The air was full of souls, like cobwebs, clinging to me everywhere I walked. And here, one more emergency that we are unequipped to handle. One more night spent desperately trying to invent diagnosis and solutions to undiagnosable, unsolvable problems. One more soul, lost. One more set of haunted eyes, one more mother beating her head in grief, one more inevitable, insurmountable obstacle. No money. No transport. No ventilator. No surgeon. And no end, it seems. No end to the parade of dying patients that present themselves at our door. I want to close my eyes and plug my ears and pretend not to notice them. I am exhausted.

Fast like an Ethiopian (Easter in Ethiopia) by Jessie

Easter is hands-down the most important holiday in Ethiopian culture. The Ethiopian Orthodox Church begins Lent earlier and ends Lent later than Christian churches in the US (Ethiopian Easter was one week later than ours). Catholics in Ethiopia follow the Orthodox Church’s calendar, not the Catholic Church’s calendar, and most Catholics here follow the Orthodox Church’s rules for Lenten fasting.

During the two months prior to Easter, the following things are forbidden:
Meat
Eggs
Dairy
Alcohol
Sex
Breakfast (no eating before 2pm)

And the craziest part – everyone does it. Everyone. Anyone seen eating meat products is presumed to be Muslim (or foreign, or heathen). No restaurant will even offer meat products on the menu. The whole country turns vegan for two months. The price of eggs plummets at the market, because there are no buyers. Everyone asks before touching a meal or even a cookie, “is this fasting food?” to make sure they don’t accidentally ingest eggs or milk. After reading a lot of labels, I discovered that most cookies and even most chips have at least milk powder in them. Foiled! It’s a far cry from my half-hearted American attempts at fasting, which mostly involve eating McDonalds fish sandwiches on Fridays.

Good Friday and Easter are national holidays. The streets were empty. Asselevich, a long-time employee of the health center, invited us to her house for Easter dinner. She always invites us for holidays, which is kind because then we don’t feel left out, but extra kind because she is an amazing cook. As time goes by, we have gotten to know her home and her family, so what were at first an awkward and silent holiday offerings are now a festive shared meal of injera, doro wot, tibs, cheese, popcorn, and of course, good strong coffee. After feasting with Asselevich (burp) we went down to wish the orphans happy Easter. They immediately offered us more food – the goat that had been slaughtered earlier that day. The meat sauce was full of pieces of unidentifiable (and unexplainably hard to chew) chunks of meat. Kidney, maybe, liver? Intestines? If one goat is going to feed 13 kids, I guess you can’t waste much.

Later that afternoon, Yibe – one of the orphans – stopped by to invite us to mass. Again. Poor Yibe always invites us to mass, we always say thank you, and we never go. Mass here is too awkward and uncomfortable (and of course, impossible for me to understand). But it was Easter. We were happy. And we wanted to make Yibe happy. So at mass time, we walked over to the small Catholic Church. When we entered, Edwin went to the men’s side and I went to the women’s and children’s side where several of the orphans from our Children’s Home were already seated. A woman smiled at me and scooted over to make space for me on the bench beside her. A random child immediately climbed into my lap as soon as I sat down. Yibe was in the choir, beating the bongo drum, while the choir clapped and danced and sang so loud they seemed almost to be yelling. Suddenly, inexplicably, my eyes filled with tears. I was filled with a tenderness and gratitude that I haven’t felt in a long time. It felt like coming home.

If I ever see another pregnant woman, it will be too soon by Jessie

I stood between the two delivery beds. To my left was a first time mother who arrived in the process of delivering a breech baby. To my right was a first time mother who had been in labor for four days and now had signs of fetal distress – and worse, appeared to be pregnant with twins. And I hadn’t even had breakfast yet. I thought to myself, normally you couldn’t pay me enough to do this - and here I am doing this for free.

The baby that I thought was breech wasn’t. It was a “face presentation.” Normally the baby is face-down and the top of the baby’s head comes out first, but this poor kid was not only face-up but also face-first. What I thought was an anus was actually the baby’s mouth. In my defense, the baby’s skull and face were so deformed from the abnormal presentation that the features were almost unrecognizable. The mother refused to hold the baby until I promised that the swelling and bruising would go away after a couple weeks. I crossed my fingers. The baby did have a really funny-shaped head, more like a bar-bell than a normal newborn cone-head. At least the baby came out strong and crying. At that point, the mother was crying too, because we had to cut an episiotomy the size of Texas to get the baby out.

I was wrong about the second mother, too. The funny bump in her upper abdomen was just… a funny bump, not a second baby. There was only one baby, but the baby was clearly in trouble due to her prolonged labor. Her amniotic fluid was thick and green with meconium (newborn baby poop). The baby’s heartbeat was slow and faint. The guard ran to get the midwife Solomon out of his bed at home. As Bisrat sewed up the first mother’s episiotomy, Solomon vacuum-delivered the second mother’s nearly dead baby. Although it was a plump full-term infant, it lay limp and blue in my arms, not breathing. It was covered with meconium.

We suctioned the baby’s airway as best we could and tried to resuscitate the infant, whose heart was barely beating. I thought desperately of babies born in the US with meconium-aspiration syndrome, about oxihoods and ET tubes with wall suction and mechanical ventilators and incubators and the steady hands of a neonatologist, and I thought there was no way that this beautiful little Ethiopian baby could survive without all those things. And she was beautiful; unlike her neighbor born by face-presentation, the only mark on this plump little baby was the vacuum-ring on top of her head. Her bow lips, her long black lashes, her smooth face, everything else was perfect. But she wouldn’t breathe. The only rise and fall of her chest was caused by the air that I pushed in with our tiny infant Ambu-bag. I knew I couldn’t breathe for her forever. Solomon and I used an IV catheter to cannulate the umbilical stump – not exactly the sterile, precise procedure I’d witnessed in the neonatal nursery in Chicago, but good enough to administer adrenaline and fluids and antibiotics to the baby. The baby’s heart rate rose. She started to breathe. Gasping slowly and irregularly at first, then fast and shallow. We moved her over to the hospital and put her on oxygen. Her breathing during the next 24 hours was so fast that I couldn’t count it; she barely cried; she was too weak to suck. But she survived. By her third day of life, she was breastfeeding well and screaming at the top of her lungs as mom gave her a (cold) first bath.

Here, the baby’s survival is a miracle. A credit. Death and bad outcomes are the norm, so no one would have faulted me or the health center if the baby had died. I think of how different it is in the US, where conversely, survival and good outcomes are the norm. Every bad outcome must be blamed on someone – the OB for not doing a C-Section soon enough, the prenatal doctor for not monitoring the pregnancy closely enough, the neonatologist for not treating aggressively enough, the hospital for whatever, for having a lot of money and employing the people who allowed a bad outcome to occur. Of course, the maternal and neonatal death rates are 60 times higher in Ethiopia than in the US, so there is a reason to expect different outcomes. It highlights for me the shortcomings of the health infrastructure in Ethiopia, and how helpless patients are here if they receive bad care because no one is really held responsible. But, it also highlights how much more gratifying medicine can be when I am thanked more often than I am accused, and when I am free to rejoice (or grieve) with patients instead of fearing them as potential lawsuits. It’s a relief to admit that sometimes bad things will happen, no matter what I do.

Don’t get me wrong though – I still want nothing to do with pregnant women. On any continent.