Today I really love the patients by Jessie

Of course if you asked me any day, I would say that I love the patients. But. It is love in principle, in a spiritual sense, in theory. Some days there may be a lot of qualifiers attached. “Loving” patients does not imply that I enjoy them or like them at that moment – the same way, I imagine, that parents “love” their children even when the parent is exhausted and the child is throwing a temper tantrum. Love, perhaps, in action – if not necessarily in emotion.

Today, however I enjoyed the patients. I liked them. I liked smiling at them just to see them smile back. I liked saying “welcome, how are you?” in my mangled Amharic just for the joy of hearing them giggle at my attempt. I liked giving diagnoses just to watch the fear drain out of the patient’s eyes as their pain was given a name and a solution. I liked the contrast of white teeth against black skin as the patients smiled. I liked the chubby baby arms and legs pumping the air with unexplainable enthusiasm. I liked the familiar and comfortable feeling of an exam room, sitting across from a patient with a pen behind my ear and stethoscope around my neck and a blank blue patient card at my fingertips. Chief complaint, HPI, exam, assessment, plan. I loved seeing an illness and knowing what to do. It felt as natural as breathing. I really loved the patients.

Not that I loved the patients because they were all really nice. More that I loved them for letting me help, for filling up the empty space in me that I didn’t even know was empty - like not knowing you are tense until you stop and stretch, and it feels so good, the release and the relief of unnoticed stress. I realized after the day was over and the clinic was empty that only seeing patients makes me feel that way. Fills that emptiness, releases that stiffness. And I love the patients for that – for engaging my intellect and my emotions and my spirituality all at the same time – for allowing me into their lives for even the briefest moment – for giving me a purpose.

In the hospital (IV fluid and IV antibiotics) by Jessie

The inpatient ward of our health center is meant for simple things. A child with pneumonia who needs IV antibiotics and oxygen for a day; a dehydrated patient with vomiting and diarrhea who needs some IV fluids, a mother who hemorrhaged after delivery and needs to be monitored overnight for further bleeding. What is actually admitted to our hospital, however, is far more varied, more critical, more surgical, and more chronic than was intended.

This week began with a woman admitted with bloody diarrhea. She was nine months pregnant when she got sick. After four days of illness, she delivered a stillborn baby. She arrived at our hospital five days later, unconscious, with profuse diarrhea and a raw rash across her face. IV fluid and IV antibiotics against dysentery and intra-abdominal infections improved her status somewhat throughout the week, but she still has a tender abdomen and some vomiting, with persistent cough and dizziness. She remains deathly pale and too weak to sit up by herself. There is no fever. When we approach her bed, she asks weakly and fearfully, “how am I doing?” I try to laugh and smile to encourage her, but really, I’m stumped. A blood transfusion may help. So would a CT scan of her abdomen and a chest x-ray and blood cultures. But what we have is IV fluid and IV antibiotics, so that’s what she gets.

She was followed by a similar case – a woman who delivered a stillborn baby at home and then developed a high fever. She was semi-conscious and burning with fever when she arrived. Her uterus was tender. The lab is closed because our only lab technician is gone for a training, so we could only guess at the cause of her fever. She received IV antibiotics against typhoid fever and against post-partum endometritis. Within a day, her fever was gone and her abdomen was less tender. Within two days, she was able to go home. A pregnant mother admitted with hemorrhage after a spontaneous abortion in her fourth month also improved quickly and was discharged home (Edwin removed the fetal parts and treated her uterine hemorrhage – I’m not sure his internal medicine training prepared him for everything he would have to do here!).

One bed has been occupied all week by a baby with Vitamin D deficiency and pneumonia who had been coughing for a month prior to admission. His cough is so violent that he vomits after coughing. The first IV antibiotic failed to improve his respiratory distress; changing to a second IV antibiotic and adding an oral medication failed to cure him also. We tried treating intestinal parasites to see if that may help decrease his vomiting. It didn’t. He continued to cough and vomit. Babies with Vitamin D deficiency are notoriously hard to cure – their constricted ribs and weak immune systems predispose to respiratory infections. Today we discharged him with oral medicines and a follow-up in one week, when our lab is open, to do blood tests. If he is still coughing, we will start him on tuberculosis therapy. Regardless, his prognosis is poor.

The bed beside the Vitamin D deficient baby was occupied by another baby with cough and vomiting, but no vitamin deficiency. The first antibiotic also failed for this child, but fortunately, the second antibiotic worked. Or possibly – the pneumonia was never bacterial at all, it was viral, and it happened to improve at the same time that the second antibiotic was started. Regardless, the baby was discharged home improved. Her bed was immediately filled by another child with severe pneumonia, this one semi-conscious with lungs full of crackles. He was dehydrated because he was too lethargic to drink. Within 12 hours of IV antibiotics, he was playful and drinking normally. He also was discharged home.

The bed beside him was occupied by a chubby 2-month old baby who also seemed to have severe pneumonia – a low grade fever plus a respiratory rate of 112 (try breathing 112 times per minute, it’s pretty hard!) with vomiting and diarrhea and constant crying. CONSTANT crying. We eventually had to move the baby to the isolation room because none of the other patients could get any rest. At first the baby did not respond to IV antibiotics, and I was afraid that the fast breathing and fever and diarrhea were actually due to a surgical intra-abdominal problem, but on the second day improved and the baby quieted down. I wanted him to stay longer because he was so little and had been so sick upon presentation, but all the hospital beds were full. He was actually sharing his hospital bed with another patient who was waiting for someone to be discharged. So the baby was sent home early, with a hundred cautions and reasons to return immediately, and early follow-up in the clinic. His bed was immediately filled by another child with severe pneumonia who had been treated as an outpatient but got worse anyway. The new pneumonia patient was older but equally irritable and crying constantly. He also improved with IV medicine, but is still in the hospital because he failed outpatient treatment and early discharge could easily lead to relapse.

The far corner of the isolation room is occupied by a emaciated chronic alcoholic – the town drunk – who lived by himself, and had been bedridden for 2 weeks before presentation. His neighbors finally brought him in when he stopped eating all together. He was comatose and his wasted limbs were rigid. He was hypothermic and his lungs rattled with cough. Of course, a CT scan of his head and liver function tests and blood cultures would have been nice. But of our quick differential diagnosis list – hepatic encephalopathy, stroke, aspiration pneumonia, and alcohol withdrawal – aspiration pneumonia was the only one we could treat. He was started on (you guessed it) IV antibiotics and IV fluid. Amazingly, he did wake up enough to ask for a cigarette, although he is still quite confused. He has developed a fever and remains hypotensive.

A young, healthy appearing man was admitted the same night as the town drunk. He had been treated for typhoid fever and malaria at another clinic, but still had persistent vomiting and weakness. A preliminary HIV test was positive; we recommended confirmatory HIV testing but he refused because it would cause him “too much stress” if he was found to have HIV. After he left, his bed was filled by a young woman who “fell on a knife” and had an infected puncture wound through her forearm. She is deaf and cannot speak, but she smiles a lot, and the infection seems to be improving. An elderly man admitted with “pyomyositis,” a deep infection of the muscle that I’d never heard of before coming to Ethiopia, also seems to be improving. His thigh is still tender but is less swollen. Needle aspiration of the area did not reveal pockets of pus, so he did not require incision of the muscle to drain the infection. He will limp home tomorrow on oral antibiotics.

Also discharged from the hospital this week was an 8-year old boy with swelling of his entire body and heavy protein in his urine – signs of nephrotic syndrome. Usually grounds for a kidney biopsy, but no one was too keen on sticking a needle into his kidney or trying to analyze the glomeruli under the microscope afterwards, so he was treated empirically with high dose steroids and diuretics. He was so puffy that even his scrotum looked like a balloon, but slowly, the edema decreased. He lost more than 14 lbs as the edema disappeared. In a different bed, another 8-year old boy presented with a swollen abdomen and swollen feet. Unlike the first boy, this child had signs of liver failure. We drained liters of yellow ascites fluid out of his distended abdomen, and then referred him for treatment of possible liver or peritoneal tuberculosis.

We also admitted two children with severe dehydration due to vomiting and diarrhea, both of whom improved with injections of anti-vomiting medicine and ORS (oral rehydration solution). The older child was still vomiting when she left, but she had regained consciousness and was urinating plenty – and we needed her bed. The hospital was full. The family stayed in town overnight and will bring the child back today for a checkup.

The hospital is alternately exhausting and fascinating and frustrating. So many people need so much more than we can provide. So few people have the resources to seek care at a higher level, and the referral hospitals themselves often do not have any more resources than we do. So many patients don’t get better. But – so many do. And being limited in resources stretches us mentally, to think of differential diagnoses without the aid of lab tests and to find alternative treatments. We are limited but not helpless. Who knew that IV fluid and IV antibiotics could do so much?

Garbage by Jessie

There are three plastic trash buckets under the wooden countertop in our kitchen. A red one, for burnable trash, that is emptied into the incinerator every Friday. A blue one with a lid, for food waste that will either be thrown down a compost pit or fed to the chickens. The last one, a green bucket, is for everything else - the plastic wrappers and aluminum foil and broken glass. The “everything else” bucket is emptied into The Pit, a deep hole originally dug as a possible well that did not yield water. Medical waste like used needles and dirty gloves are dumped in The Pit, along with our household trash. During rainy season, The Pit fills with groundwater and the trash inside swells toward to top; now at the end of the dry season the bottom is barely visible. We avoid throwing big things into The Pit, if possible, knowing that it will inevitably fill up and need to be replaced with a new one.

Most trash that would end up in The Pit is recycled. Not put into blue bins with yellow arrow triangles on them – recycled as in reused. The TB patients in the morning take their pills with water in “cups” that are actually empty medicine containers – multivitamins, albendazole, ferrous sulfate, phenobarbitone, amoxicillin. We wash the tin cans and the jelly jars and potato chip canisters and water bottles reuse them as cups for patients or toys for kids. We use flimsy plastic bags from market as barf-bags for patients on car trips to Jimma (most rural Ethiopians aren’t accustomed to car travel!), and if no one throws up, we use the little bags to hold the fruit that we buy from roadside vendors. Staff members fight over the big Nido powdered milk cans with snap on plastic lids. One perk to being the cleaner or cook at our Big House is having first pick of the nice glass jars and cardboard boxes. Any substantial plastic bags are saved and used to carry food from market, since the food is sold by the kilo and bags are not usually provided. I realized the worth of our used tin cans when I saw similar used cans being sold for profit in the marketplace.

Most of our non-burnable, non-compostable trash is from the clinic. There are two trash baskets in every clinic room, one for burnable things like tongue depressors and used gauze and another for non-burnables like disposable syringes and latex gloves. The disposable cardboard “safety boxes” for sharps like needles and razors are first burned in a barrel to dispose of the bulky cardboard box and to melt down any little plastic pieces, and then the charred remains are dumped in The Pit. I am amazed by the amount of trash that our little clinic creates, until I remember hospitals and clinics in the US, where everything that touches a patient is disposable. Most of our household non-burnable, non-compostable trash is not local – it comes from Addis. Ramon noodle packages, candy-bar wrappers, the foil lining from inside boxes of cornflakes. Even more comes from the United States. What else can we do with the reams of bubble wrap that have accumulated over the years? Old CD’s and DVD’s scratched beyond repair, shiny puzzles with missing (or rat-chewed) pieces, broken flashlights, electronics fried by the 220 volt outlets.

There is no litter in rural Ethiopia. I am accustomed to roadsides strewn with plastic bags and wrappers in Central America, or even open fields in the US peppered with plastic pop bottles and greasy fast-food bags. But here, if anything is wrapped, it is wrapped in banana leaves. Most people don’t have latrines so they don’t have toilet paper either – a leaf is used if any cleaning up is needed. And if anyone finds a used magazine or newspaper, they use its pages to paper their mud walls. People are way too poor to buy stuff so there are no fancy wrappers or excessive packaging. People in general do not have cell phones or computers or refrigerators that break and become obsolete and need to be trashed somewhere. There simply isn’t that much garbage in rural Ethiopia. Not yet, anyway.

This week ... by Jessie

… the government threatened to shut down the clinic (again)
… we had to close the TB program because the country ran out of TB meds (again)
… the nurses were not included in a government vaccine campaign (again), a problem which has infuriated the nurses to the point of mutiny in the past because they feel it is their “right” to be included
… we ran out of Depo because the government storeroom was empty
… we ran out of malnutrition re-feeding foods because UNICEF never delivers the supplies to us as they promised they would, and we have to make a four-day round trip drive across the country if we are to pick them up ourselves
… we started re-washing and re-using surgical gloves, because there are no disposable exam gloves available anywhere in the country, due a problem of “under-valued currency”
… the government assigned a random nurse to the clinic, without asking if we want or need or can pay for another nurse (we don’t, we don’t, we can’t)
… our only lab technician got into a loud fight with one of the cleaners, then stopped coming to work
… one of the nurses got into a fight with his wife, which resulted in the nurse crying in the office and his wife being escorted away from the clinic by the police
… Edwin had to drive one of our employees with possible appendicitis all the way to Jimma Hospital because private transport would have cost 1,200 birr (the employee has 2 wives and 5 kids and makes 400 birr per month)
… the hydroelectricity is being rationed, so we have power at most every-other day
… the guy in Addis who was supposed to help us get a new water pump has been sick and out of the office, so we are at risk of using up our water supply
… and to add insult to injury, we ran out pancake mix

But believe it or not, it’s been a good week. Only one death, a baby with severe pneumonia. No OB emergencies that the midwife couldn’t handle. And despite all the politics and drama and exasperating shortages, the clinic still functions. More than a hundred patients still walk through the door every day, nurses and doctors are still busy evaluating sick patients in the exam rooms, babies are delivered, children are treated for pneumonia and diarrhea, medicines are provided for free to the sick and the suffering.

As I look through old records, I see that the problems that Edwin and I face here are in no way new. If anything, we have it pretty good. We have unreliable electricity, but in the past, there was no electricity at all. The government keeps giving us extra nurses that we can’t use or pay, but in the past, there was a shortage of nurses and the number of patients allowed in each day had to be limited. And surprisingly, the patient load was actually higher in the past, even though there were fewer providers here. And even though all the labor and delivery complications make my head hurt, at least we have a hospital one hour away that can do C-Sections. That’s relatively new. And it’s hard to keep the oxygen concentrator running when the electricity is so spotty, but at least we have an oxygen machine to help people in respiratory distress. That’s new too.

It becomes easier with time to let the frustration and the drama roll off our backs, as long as it doesn’t involve people dying. In the end, it is easier to resign myself to working within an imperfect system than to constantly struggle against it. The work itself is so exhausting. Trying to also change the system requires an extra Herculean effort. I have spoken to other volunteers who feel like they really made a difference here. I feel like I’m just surviving, and maybe helping some patients survive too. And for now, for me, that’s enough.

Thumbs up (a small victory) by Jessie

The man walked five days from Chocha to arrive at our clinic. His hand had been pierced through in a knife fight, stabbed at the base of the thumb on the palm side with the puncture wound exiting between his thumb and index finger on the back of his hand. He had been on IV antibiotics for a wound infection for three days. I inspected the wound carefully, and noted a fibrous white patch at the base of the entry wound. One by one, he moved each of his fingers – except his thumb. “He can’t move it because of pain,” the Health Officer explained. I picked up the ragged white fibrous tissue in the wound with a forceps. It wasn’t pain. He couldn’t move his thumb because the tendon was cut clean through.

In the US, hand surgery is a sub-specialty of its own. Hands are pretty complicated, and if they get messed up, it can cause a lot of disability. Especially a thumb. Of course there is no hand surgeon here. No surgeon, period. I asked Solomon the midwife to examine the severed tendon, since he has the best surgical skills of the nurses (anyone who has witnessed childbirth knows why midwives have to be good at stitching!). The problem with tendons is that they act like rubber bands, springing back and retracting deep into the wound after they are cut. Only one end of the tendon was visible. Solomon cut open the palm of the patient’s hand to expose all the thumb muscles, and then he fished around to try to find the lost end of the tendon. He worked patiently, gently, to avoid harming the other fine tendons and nerves that course through the hand. He fished for half an hour. The government will not allow us to buy morphine, so we used local anesthesia and Valium to help the patient endure the procedure. Eventually the missing end of the tendon was found, a subtle white stub buried in red muscle, and the tendon was repaired with two quick stitches of silk suture. “Move your thumb,” Solomon told the patient. The sinewy white rope with two black stitches in it moved like a pulley, and thumb moved with it. Good as new!

It was fascinating to look deep in the dissected muscles and see the inner workings of how our fingers move. And miraculous, perhaps, that this patient had walked five days to the nearest clinic and fallen into good hands. A thumb seems like a small victory, but a farmer or laborer who cannot use his hands loses his livelihood.

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.