[Ann Emerg Med. 2008;51:328-329.]
“We have no ICUs here, only the hand of God.”
—Local physician in Dire Dawa, Ethiopia
She was still diaphoretic and wide-eyed, but looking slightly more comfortable today than she had when we saw her on yesterday’s evening rounds. We looked on as the young lady sat forward and answered the head physician through an oxygen mask stained from multiple recycled uses and dispensing a very rationed supply of oxygen. He translated her short responses to us, and after a brief examination we moved on, with some relief from the feeling that her condition had improved slightly overnight. My wife, a pediatrics resident, and I, an emergency medicine resident, were in Dire Dawa, Ethiopia, midway through a month of working side by side with the local physicians, and here again we were experiencing firsthand the daily battles they fought to provide medical care with the limited and strained resources at their disposal.
The patient, a very slender woman in her early twenties, had a history of HIV and a respiratory infection we had presumed to be Pneumocystis pneumonia. We were still a few days from getting her CD4 count back from the distant town with a working laboratory machine, and without local availability of silver staining, treatment was based only on presumed local epidemiology and the bilateral infiltrates on her single radiograph that we daily held up to the window to discuss and debate on rounds. She had arrived 3 days earlier and had steadily been deteriorating despite the regimen of oral trimethoprim/sulfamethoxasole she was receiving. When we had last seen her, last night after evening rounds, she had looked strained and worn out, breathing with deep retractions and looking at us through tired eyes. We had left reluctantly, not knowing what daylight would bring, and this morning’s improvement was a welcome and heartening sign on a day that had already begun with 2 deaths on an inpatient floor of just 23 beds. However, this respite was not to last.
Less than 10 minutes later, when we had progressed no more than 2 rooms farther into rounds, one of the nurses motioned to one of the local physicians from the door and said calmly in her broken English, “Come, she is worse.” The more junior of the local physicians left with the nurse and shortly returned to lean in the door, informing us that “she is gasping now.” The rest of us then broke off and returned with him to her bedside.
The deterioration in the 5 to 10 minutes we had been away was marked and immediately alarming. Where she had previously been sitting forward in the bed, she was now collapsed back against the pillow, and her breathing was shallower and slower, still involving all accessory muscles. Within her frightened diaphoretic face, her eyes had begun to gain a disquieting lid-drooping calm, signaling acceptance and resignation in the face of end-stage respiratory distress. We examined her quickly and discussed possible reasons for her sudden deterioration. Physical examination ruled out pneumothorax, and lack of diagnostic and therapeutic possibilities ruled out the possibility of considering pulmonary embolus. Without resources for blood gases, portable radiography, or other urgent diagnostics and therapeutics, we dialed up the knob on the hospital’s single rationed cylinder of oxygen to 2 L per minute and stood by feeling inadequate and helpless as her responsiveness continued to decrease.
The nurse in the room gathered the multiple family members, and speaking to them in Amharic, she ushered them from the room. In response to my wife’s inquiry about what they were told, the head physician told us, “She tells the family she is fine; otherwise, they will start screaming and become hysterical.” Coming from the environment of our residency training, where family presence at resuscitations is often encouraged, this was a difficult cultural difference to accept. However, as the visitors, we had learned to try to work within these differences and to try to understand them as we encountered them, so we solemnly watched the family file from the room, hoping our expressions didn’t give away the truth of the events unfolding. As had happened many times already during our visit, we again found that the one tool we had to offer in this case, comforting words and support, was not available to us, because of language barriers and cultural differences.
By this time, it had become clear that our patient’s respirations were becoming inadequate and would not sustain her much longer. By the time a bag-valve-mask appeared, she was only minimally responsive to pain, and her bradypneic respirations were barely audible. I instinctively held the mask and the junior physician began squeezing the bag at a regular rate as we began delivering breaths of ambient air; the recycled bag-valve-mask had long ago lost any connections to allow the direct attachment of oxygen. As we continued our resuscitation efforts, my emergency medicine training kicked in. I wondered at the inaction of the senior physician as I began running through the short list of available sedation medications in my mind and asked if we could get the airway kit from the OR to get the badly needed intubation under way.
The senior physician, watching our efforts from the foot of the bed, shook his head calmly, quietly stating, “We have no ventilator, and her family couldn’t afford one if we did.”
“There is nothing left we can do,” he finished with resignation.
The reality and weight of these words set in slowly, and our efforts began to weaken. I have worked in end-of-life situations many times at home, in high-tech ICUs or well-stocked resuscitation rooms. I have been faced with irreversible situations, but it was something new to admit that we had reached our boundary when it was purely resource scarcity limiting the care of someone so young with a process that could have been reversible. Wordlessly, our inadequate ventilation efforts ceased, and the junior physician and I stood next to the bed. We realized he was correct, yet didn’t want to admit we were only prolonging the inevitable with our reflexive yet futile efforts. As her last breaths faded, I took her right hand in mine and put my left on her pulse until it faded and quietly left her wrist.
“Wow, 3 deaths in 1 morning,” the senior physician softly said. With that thought hanging in the air and on our minds, we pulled up the sheet and filed from the room with a reinforced appreciation of what we take for granted daily in our practice back home. We returned to rounds and filed by the family without saying a word. We tried to keep our faces from giving anything away, so as to obey cultural norms that we didn’t understand and in which we didn’t necessarily believe.
After rounding on 2 more patients, we heard a tremendous commotion outside in the street, and the lead physician motioned us to the window. “Now you will see how we grieve here,” he said. The nurses had ushered the family outside to inform them of the patient’s death. We now looked down onto a heart-wrenching scene of family members wailing, screaming, and rolling around in the dirty street in their grief. Suddenly, we had a better understanding of why the death-telling happened the way it did. We tried to close our ears to the emotional sounds drifting through the open window, turning our attention to the elderly gentleman in front of us. He was dying of a large abdominal mass we could feel but not diagnose.
And so continued our month, working with and learning from the awe-inspiring physicians who became our colleagues in Dire Dawa—colleagues who still struggle within that system daily and who taught us how to do what we could, with what we had, for whom we could.
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