Pneumonochrome

We went to church at one of the two branches in Addis Ababa today. My word, these people are soft spoken. I didn’t hear a word that was said, and I was sometimes only a couple of feet from the translator. They must think we are the loudest people in the world.

After church we visited the “Missionaries of Hope/Mother Theresa home for the sick and dying destitute.�? Oh, my. It was like a concentrated version of the worst cases we saw in the village. One man was as thin as I’ve ever seen anyone in my life. His arms were maybe 1.5 inches in diameter, and his legs at the thigh were no more than 2.5 inches. We saw a room full of mothers who were critically ill being treated in a room with no working lights at all, children with disabilities (including the worst case of hydroencephalitis I’ve ever seen), everything you could imagine in buildings that looked like they’d just been gutted out and then moved into.

They said people were brought to them by Police, hospitals (when their family abandoned them), friends and relatives, etc. Sick people stay only until they are well, then are back on the streets (most of the time) because they just don’t have room for people who aren’t sick. I don’t feel nearly so bad about my job over the course of the last week now. The conditions are poor at best, and they have a clinic that serves a population of about 600-700 people with 2 doctors. I don’t think I’ll ever be able to complain about case loads in American. After that, we visited a Franciscan Sisters of the Heart of Christ orphanage. The conditions here were much better. The children were in good health, clean, and seemed happy overall. The two sisters who run the orphanage were SO good with the children and SO happy in what they were doing. It was refreshing to see children in fairly good shape for once, and to be able to smile and talk with them instead of just checking for triage marks and beckoning them in or sending them away.

After that we went back to the Sheraton, checked out, ate, said good-byes to the group members who weren’t leaving yet, and headed for the airport. When we got there, Dr. Burton found he didn’t have his ticket, so the rest of us checked in and waited. After about an hour he was re-issued a ticket, and now we’re waiting to board the plane and start the 25 to 30 hour journey home. It will be a relief to get back home, see my wife again, and get back to a much less stressful job.

We packed up the clinic this morning, cleaned up the building and visited the village. I only went to the village briefly, and didn’t see many adults, but the ones I did see weren’t eager to see me. I don’t blame them, really. From their point of view I’m the terrible person who didn’t think they were good enough to see the doctors. So I went back to the compound. Even though no one was being let in today, there were still 30 to 40 people at the gates hoping to be seen. We gave out a couple of wheel chairs, said good-bye to the locals who worked as translators for us, and locked everything up. A few of the translators seemed to like me, which was nice.

Most of the other group members had a “special person�? that was the “reason they came�? who they worked with or treated or otherwise met on the trip. It was really fun to see them saying good-bye to each other today. The group really is able to improve a lot of lives. I was also surprised at how easily I came to terms with the fact that I had not found such a person, because I had not been spending any time with individual people. I was okay with it today, perhaps because I didn’t have to do it today. A group of villagers had been practicing an acrobatic/circus type performance all week that they performed for us today, then we left.

I slept through most of the drive back to Addis Ababa. When we got back to the Sheraton, with its clean water, I shaved and showered. Some of us went to a restaurant tonight where everything was authentic Ethiopian: The food, the seats and tables, the entertainment, everything. The food was really good, spiced thoroughly but not overwhelmingly. We sat on wooden stools and ate from little squat, round platform type tables. A live band played cultural music and dancers performed traditional dances. At one point DJ got up and danced with the dancers, trying to learn, and a bunch of other customers followed suit. It was a really fun time, even for those of us who just sat there and ate. It was a really good way to end an amazing, though difficult week.

I’m going to have to get a new suitcase when I get home, as one of mine had both zippers ripped off of it while it was holding medical supplies in the clinic. I wish it hadn’t been broken, because it was a good suitcase and didn’t need to be replaced any time soon until it lost its zippers, but it did, so oh-well.

We just got back to the hotel, and it’s 11:40pm here. I’m tired, and I think I’ve written everything interesting about today, so good night.

PS-They still play “Knight rider�? on TV here! How cool is that?

Last day of clinic, and I triaged again for most of the day. Things were more difficult to manage today at their best than they were any other day at its worst. DJ sent people over in groups of 5 to 10 most of the time, and there were usually more than 50 people at the gate when we would open it. As soon as the gate-door opened they would all try to rush in, almost trampling me in the process. There were a couple of times I thought I was going to be knocked down and trampled. To get the people through at any reasonably safe rate, I had to yell and holler until they quieted down enough to tell them that people would come in one at a time, or not at all. We never did achieve “one at a time�? but it made the flow of people more manageable anyway. There were people that argued, people that begged, people that went quietly to the village, and people who stood there, arrogantly staring at me and refusing to either speak or move.

I hate doing this. I feel less like a caring person and more and more like Javier from “Les Miserables�? every hour I spend doing this. I feel like I have to leave any compassion I have back at the hotel room in my suitcase, and I, ironically, came out here expecting this to be a compassionate work. If it weren’t for the fact that I count the charts every night to know how many patients we saw, and got a chance to see what we were treating, I’d have probably burned out already, or given over to hating myself for a miserable, heartless excuse of a human being.

I thank God that there have been little reminders of why we have to turn all these people away throughout the day. I’ll really get to look for a minute at a patient that gets in, or hear the doctors discussing a difficult case, or something else will happen that will remind me that we’re not turning everyone away; we really are helping a large number of people. There’s just so many more than we have the ability to help. The hardest thing about it was that they all have legitimate medical problems. Most of them had problems we have materials and expertise to help, just not enough time. I was often near tears about how much the situation just sucked. There are few things in my life I’ve been so glad to be done with. I couldn’t do this on a regular basis, I’d hate myself all the time.

I’m really ashamed to say it, but I was SO glad when it was time to stop triaging. Over lunch we went to visit the hospital in Shashemene (the nearest city). It was a compound of many 1-story buildings in various states of disrepair, filled to over flowing with people in various states of disrepair. The hospital has 5 doctors and serves a population of about 1,000,000 people. They have no anesthetists, so emergency operations (i.e. emergency C-sections) are done without anesthesia. I can’t imagine…

The buildings, in parts, made the old milking barn I used to work in look sterile. In the labor and delivery room, the walls were dirty with cracked and chipping or peeling paint. They told us they couldn’t clean the walls because every time they did, more (lead-based) paint chipped off. The beds had no stirrups, and were quite old and dirty, and they had a couple of rusting old commodes in the room. The pediatric ward seemed right at home with the delivery room: old, rusty steel-framed beds, old bedding, dingy walls, etc. We also saw their O.R. I’ve never even dreamed that something like that might pass as an O.R. There was little in the way of equipment, and what they had was often broken. There was an unused anesthesia console that looked like it might have been used to administer Ether back in the early days of general anesthetic.

Next we visited the leprosy ward. There were so many people there. Apparently there was an outbreak of leprosy a couple of years ago, and they’re still dealing with it. There’s a small village attached to the hospital where the lepers live while undergoing more long-term treatment. It really made me think about just how much we have in America, and how much they don’t have here. After lunch I helped wash a few patients for scabies to help with a large backlog of patients to be washed, dealt with some more triage problems, and shadowed Dr. Burton at the very end of the day. The shadowing helped me get out of the funk of having been triaging for three days straight, 9 to 10 hours a day. We closed up shop and went back to the hotel, we’ll return tomorrow to break down everything and put it in storage.

After dinner I counted the total number of patients we saw. Tuesday we saw 120 patients, Wednesday we saw 240, Thursday we saw 140, and Friday we saw 230. For the week we saw a total of 730 patients. That was just the ones we had records for though. There were some lost records, and some families with only one record, so my guess is that we saw more like 750 to 775 patients.

Despite all my complaining, this has been a good experience for me. I’ll be very glad to go home and see my wife again. The trip really has changed my perspective on medicine. I think those of us who “have,�? really have a responsibility to those who “have not.�?

I’ve also learned that tough decisions are sometimes deciding who you can see and help, and who you don’t have time or other resources for. I’ve learned that I’m capable of making and enforcing those choices, even if I don’t enjoy doing so, or hate doing so. I’ve learned that knowing how many people you are helping only marginally lessens the bitterness of how many you can’t help. I’ve learned that I really do wish I could help all of them.

I’ve tried, unsuccessfully, to learn to crack a whip, speak Oromo and Amharic, and do more things at once than I have limbs. I learned that some people will try to take advantage of even the most charitable causes, and that nothing can convince a mother that anyone else’s baby is in more need than her own. I learned that extreme poverty polarizes people in the area of selfishness: Some people become quite selfless while others become unbelievably selfish, but very, very few remain in the middle ground. I learned that people will attempt to argue even with something as immutable as the passage of time. I learned that a bleeding heart or extreme compassion for an individual is a liability we can’t afford in the practice of mass medicine and emergency medicine, and I learned why medical schools like applicants to have done this sort of thing: It changes your view of what medicine is, and how to administer it. It changes your view on what “caregiving�? is. It teaches you to deal with not being able to help everyone, and to be glad for those you can help. It’s been a very difficult, but amazing and eye-opening week.

Triage again today, though it went much more smoothly. There are still a lot of people that don’t like me because I prevented them from getting in because we just didn’t have time to see them. Around lunch time there were four separate, unrelated roll-overs from the road that runs between the village and the compound. I say unrelated, but there’s probably two things they have in common: It started raining pretty hard around the time of the first rollover, so the road was at its slickest for the next hour (the same period of time in which all of the rolls happened), and the drivers here in Ethiopia. There were no injuries in the 1st, 2nd or 4th rollovers, but there were in the 3rd. The 3rd rollover was a 50 passenger bus.

I was on my way to the village to get some more patients shortly after it happened, and was the first person with any medical knowledge on scene. The bus had rolled 1.5 times, through a retaining wall made of local vegetation and into a village’s open, green area. It seems the driver was swerving to miss a mule that had wandered into the road. He hit the mule anyway, lost control and rolled into the village.

I was the first person on the scene, and it was the first time I’d actually used my EMT certification. I didn’t have the equipment I’d have had if I’d been working on an ambulance back home, so I did what I could with my first aid kit. I caught one kid away from the crowd with fairly bad lacerations on his arm and head. I bandaged his wounds with the sterile compress I had and some roller-gauze, and sent him with a group member back to the village for stitches.

I got to the scene and there were about 200 people milling around in mass confusion. Crowd control was made even more difficult by the fact that none of them spoke English, so I was dependent on interpreters from the village who weren’t handling the situation well themselves. By the time I began to get through the crowd, they’d already stopped a passing van and loaded a few of the injured on. One woman had an open head wound and was looking in extremely bad shape. Others didn’t look much better. I caught a few with large lacerations but no other visible injuries and sent them on to the van. The van took them all to the hospital. I found out later that two patients died (one on the way to the hospital), 5 had been released already and 1 was in critical condition. That was one of the most helpless feelings I think I’ve ever had, to be faced with so many injured people, and have only myself to try to handle it while trying to communicate with a bunch of people who didn’t speak the language I speak.

I radioed for some help as soon as I knew what was going on, and all the doctors and nurses came out, about the time the last patients were being loaded on the van. Given the mood of the crowd, we decided it was time to get all of our people back within the compound or the village we’d been working in, so I started looking for our group members and sending them back.

When I got back to the compound things were quieting down in there and we broke for lunch. Immediately after lunch I got to see some minor surgery performed on a child who had a 6th finger on both of his hands. The fingers had no bone, but were hanging off of the little finger by a strap of tissue. The doctors numbed the fingers and cut off the extra ones so they wouldn’t be torn off later and result in extreme infections. They were also finishing treat a patient with a lot of gangrene on his right leg about the same time. The child had received an injury some three years earlier that had never properly healed. Infection set in and got so bad that the limb became gangrenous. The poor child was terrified when he came in that they’d need to amputate his leg. After a long time washing the kids leg, the doctors were reasonably certain that the wounds would heal if dressed properly, and he’d keep his leg. He’ll probably have some pain in the leg for the rest of his life, but at least he’ll have the leg. Another woman was brought in with a huge abscess on her neck that the doctors drained and determined might have been cancerous, and another came in with a large abscess in the mouth. We also saw a patient with bronchitis.

I mention the bronchitis patient because I’m still a bit frustrated about the whole situation. He was found by one of the teachers who was going into homes in a neighboring village. They (the teachers) determined he needed to be seen immediately, and gave him a 3×5 card to get him in through the gate. That was yesterday, and he told them he could come until today. She mentioned the guy to my last night and I told her I’d try to watch for him at the gate, but that he really needed to be triaged to be sure he’d get in.

Today she asked if I’d seen him and I told her again that the gate wouldn’t have let him in with the 3×5 card because we had to really tighten down gate entrance to control the crowds that are building up at the gate now without having been triaged or after having been triaged as not sick enough to come to the clinic. I also told her I’d go with her to find and bring him in later. At this point all we knew was that they thought he was mortally ill. We went at lunch but the village he was in is the one into which the bus had rolled, and we had been instructed to stay away from it until the crowd had dispersed. They hadn’t dispersed yet, so we went back and I told her we’d go in a couple of hours.

After about an hour she decided she didn’t want to wait any more and went over my head to the director of the group, and got permission to bypass both triages and bring him straight in, annihilating the things DJ and I had done to control the crowd. We set things up this way for a reason, which reason was controlling the number and severity of cases that took the doctor’s time. We had a nurse decided which patients were sick enough, but apparently this guy didn’t need to be screened, and could come straight in.

It drives me nuts to be asked to solve a problem, find a working though extremely unpleasant solution, institute it, and then to have that solution completely disregarded by someone who doesn’t know how we’ve made things work. I felt like pulling the head of the group aside and saying, “If you want me to fix something, then give me complete control of it and let me fix it. After I do, please stick with the solution so that it can work.�? It just adds salt to the wound that not only did this guy only have bronchitis, but that the solution we came up with was so amazingly hard on those of us who administered it emotionally. It’s a lot easier to do something draining when you know it’s both necessary and appreciated, but when someone’s actions tell you that this thing you hate doing is neither appreciated nor viewed necessary, it’s really, really hard to keep doing it.

It’s really hard not to hate myself when I turn some of these people away. They’re genuinely sick, and we could almost definitely help them, but there are so many sicker people that we can’t lose time on any but the sickest, and I spend all day long telling people that if they weren’t chosen to be treated by the triage nurse, then I can’t let them in, regardless of what the problem is. I’ve turned away young men and women, old men and women, children, generally anyone who isn’t on a death bed, or who isn’t a mother or infant. We’re focusing on Mothers with infants right now, because they are the “future of Ethiopia.�? It makes sense to do this, but it doesn’t make it any easier to turn hundreds of people away every day.

It also looks like no one else will be willing to do this job, which means I’ll be doing it tomorrow as well. I’d really hoped to get back into the clinic. Ultimately, though, this trip isn’t about what I want or don’t want; what I like doing or hate doing; what is fun or isn’t fun; it’s about helping these people the best we can, and to do that we need someone who will be firm, or cold-hearted, enough to only admit the sickest people and to not make exceptions for the heart-breaking-yet-less-serious cases out there. I’ll be happy to be done with this job.

Today was an exhausting day. I was assigned to work a secondary triage with Vickie Taylor, one of our RNs. The way it was supposed to work was: Villagers who had gone through all the health fair clinics were allowed into the triage group where DJ would triage them and then send them over to the clinic. When they arrived at the clinic, Vickie and I would briefly interview them and set them in one of three groups. Once assigned to the Doctor’s group, meds group, or scabies group, they were either registered to visit the doctors, given the meds we couldn’t give them the day before, or sent back to be washed for scabies.

In the doctor’s group we determined which patients actually needed to see the doctor and which were there only because their families were. This was to streamline the work and help the doctors be more efficient by not having to interview those who weren’t sick in the first place.

We soon learned that many people were making it in to the second triage who had never been through the initial triage. We found that the gate guard was letting anyone in, such that by lunch we had about 100 patients waiting to be seen, and more coming over. So I went and reminded the gate guard to only let those marked from today’s triage or who had an appointment paper from previous days.

That slowed down the “self admits,�? and I had to turn the rest of them back and tell them that tomorrow they needed to go through triage in the village first. There were a lot of people mad at me for that.

Ultimately we found we were still getting too many patients, so we only had DJ send over the absolute emergencies. We started seeing some REALLY sick people at that point, and finally began whittling away at the huge numbers of patients we had waiting to be seen.

Even with that, we just weren’t seeing them fast enough, so we (I) had to send about 40 people home to come back in the morning. This really didn’t make me any friends, and was a bit difficult for me to do. I wish we’d been able to see them all, but we simply ran out of time.

I did find out that yesterday we only saw 120 people all day long. We’d seen that many before lunch today and my guess is that we saw a total of about 250 people today. That’s really a huge increase in the number of people we saw, and a lot of people overall, considering we had 4 doctors.

It was really hard to have 250 people come through that didn’t particularly like me, because I’d turned so many others away, and made many of these people go to the village before we could let them in. It was even harder that all of them loved everyone else they had to deal with. It’s hard to feel good about yourself in that situation, especially when you spend all day sending sick people away because they aren’t sick enough.

At the end of the day there was an old woman I didn’t recognize, so I checked to make sure she wasn’t waiting for a doctor and getting passed over. It turns out that she’s the grandmother of the adopted children who started all of this, and was the Kennards (the adoptive parents). She told Lon Kennard how grateful she was that I was paying attention and wanted to make sure she was not being missed. It helped a lot to have someone happy with me.

I think we’ve got some good ideas about how to make the triage process run more smoothly in the future, and we’ll see tomorrow if they actually work. I’m hoping to get the system working smoothly and get back to shadowing the doctors, as that was very interesting, and much more enjoyable than being the bad guy. I can’t really say that I enjoyed today, though I didn’t really hate today either. It was just a long and very tiring day. I’m glad to go to bed now.