Day 11 - Code Black

The morning started off slow, then we had a mass casualty. One patient walked in with a head injury from a road traffic accident (RTA) and we started to evaluate him.  Auna was asking questions and getting the ultrasound for a FAST exam and when I turned around, suddenly there were two more young men on stretchers behind us.  They were from the same RTA, a lorry carrying oxen collided with a car.  One of the men was drowsy, very difficult to wake up, and wouldn't answer questions.  The second was alert and talking with abrasions to his arms and legs.  I started to evaluate the drowsy patient, when another young man from the RTA was rolled in on a stretcher in worse condition than the drowsy guy. This one was very difficult to wake up as well and was initially talking, but then stopped. Then, two more men walked in and sat in chairs, both from the RTA but in better condition than the 4 we had on beds. We saw each patient, did a FAST exam, wrote radiology and lab orders on each, and laid the paper slips on their beds.  We had no names, no charts.  We started each note and left those on the stretchers too.  We thankfully had extra nursing hands and one GP from the room next door to help carry some of the load. The two sickest patients, with altered mental status, each needed a CT scan but the friends with them only had money for one of the two patients.  The most altered went to CT scan and had a severe fracture of his C1 vertebra. It is a miracle he is not paralyzed.  He had to be transferred to the capital as we do not have a neurosurgeon here.  We don't know what kind of injury the other altered patient has (maybe a concussion, maybe a head bleed) but we could not get imaging. Maybe he will be observed in the hospital, maybe he will go home with his family if they can't afford the hospital stay. 

As soon as things started to calm down after the mass casualty, another patient was wheeled in on a stretcher salivating, vomiting, and lethargic.  He smelled of pesticides and his friends said he "drank poison."  Our first organophosphate poisoning!  The nurses immediately put an NG tube in the patient and started gastric lavage with normal saline (we don't intubate for airway protection here) and we gave him 2 mg atropine IV (we also don't have 2-PAM here).  His secretions cleared up almost immediately and he stopped vomiting.  We admitted him to the ICU for close observation and more atropine as needed. 

Our lunch break was much needed after a ridiculously busy morning!  The afternoon was much quieter at least in the ER, but a crowd of people gathered outside on the hospital grounds to watch a helicopter land and stood staring until long after the passengers left.  We ended our work day with an airway lecture and intubation practice with the GPs and some nurse anesthetists at the hospital, with an encore lecture/lab planned for Friday.  Then, we celebrated our first of two Thanksgivings with the family with whom we share our house.  Our second celebration will be on Saturday, and the word is we will have a Butterball turkey thanks to a staff member at the American embassy!

Happy Thanksgiving friends and family!

Day 11 - Lessons

Waste not, want not. It is amazing how little is wasted here, in the hospital particularly. At home, when we do a procedure on a patient we grab extra supplies (needles, syringes, gauze, gloves, IV cannulas, etc) and whatever remains is more often than not just thrown away. Because our sterility and cleanliness is scrutinized.  We are so afraid to risk contamination of another patient that we don't want to use supplies that have potentially touched another person. We repeat the mantra "foam in, foam out" so often that I find myself washing my hands with sanitizer or soap and water nearly every 5 minutes, sometimes if I am just talking about something that seems dirty or if I feel like it has been too long since my last dose of sanitizer.  I frequently don gloves at home to examine patients, even if I will not be touching body fluids or a wound.  All of this has gone out the window in Ethiopia. We brought with us one box of small gloves and 3 small bottles of hand sanitizer.  Our first day in the ER/ICU, we shoved a handful of gloves in each of our white coats. We were examining patients and using the ultrasound and Auna used about 2 pair of gloves within 15 minutes. We quickly realized we would not have enough gloves for the month if we continued to use them like we do in America.  We were also using hand sanitizer after touching patients, doors, dialysis solutions, charts, etc on the first day.  There is hand sanitizer on the walls in the hospital, but when Auna used it initially, the smell was pungent and irritating. By halfway through the first day in the ER, we realized our sanitizer from home was not going to last.  Yesterday, I reached in my pocket for the hand sanitizer when Auna said "Stop! You haven't touched anyone, you aren't dirty! Save the sanitizer!" It is just habitual. I had touched a door and elbowed through the busy hallway outside the ER, and I felt dirty.  The smell of the local sanitizer is now comforting in its cleanness.  When patients buy medication from the pharmacy and it comes in a vial, they buy the entire vial not just their dose. At home, we throw away nearly full bottles of lidocaine and other medications in glass bottles that are now deemed "single use."  Here, we put a piece of tape over the top and hand the vial back to the patient or family to keep for when they are due for another dose, if it is a medication that will be repeated. Patients also have to buy each syringe, IV cannula, and even sterile gloves for procedures.  Not just pay for the materials we use, but actually physically walk to the pharmacy to purchase the supplies.  There is no room for careless use of supplies.  There is no waste here because our patients, and the hospital, cannot afford it. While our hands our tied by CMS and hospital standards at home, and we cannot reuse or recycle much, working and living in this environment will change how we use medications, supplies, and materials at home. 

Random photos...

Macchiatos in Soddo

Neighbor dog, Peanut

Lawn trimmer, blood agar supplier, and Peanut-chaser.  There are three sheep, we call them all Dexter.

Pretty flowers outside our house

Day 8, 9, & 10

Happy Thanksgiving from Ethiopia!  We had a full day at work today, followed by a great dinner with the family we share the guest house with, the Wegners, and a few other staff from the hospital.  We are thankful for the friends we've made here and the hospitality of everyone at Soddo Christian Hospital, the wonderful nurses who translate for us and help us take care of patients, Jeremy and the GPs who teach us something new daily, and for all of the great experiences we are having in Ethiopia! Our gift to all of you at home is three new blog posts...enjoy!

Every morning, one of us rounds in the ICU and the other starts seeing patients in the ER.  Monday was our first official day at work.  I started in the ER and was waiting for Kelsey to return from the ICU so that I could hear an update on our dialysis patient. It was only the first hour and a little slow. I had seen a couple of fractured wrists and nasty nasal abscess when a man ran into the room with a pile of blankets in his arms -- "Please, emergency, I need oxygen."  I looked into the bundle of bloody blankets and there was a newborn baby...a blue newborn baby. I grabbed the baby and began to dry him off with the blankets. The nurse told me he was born across the street at the health center immediately before arriving at the ER across.  I asked for oxygen and a bulb suction. "We don't have here for him" was the response (in other words: we don't have baby stuff in this room). The baby began to look a little less blue with the vigorous drying and let out a whimper, the first noise he had made since he came through the door. Luckily Jeremy was nearby and suggested that we go to the L+D ward where there is an incubator. I wrapped the baby up and ran across the hospital grounds in the rain. Once we were in the delivery room, we got him under the warmer and I was able to suction him. With oxygen he started to pink up and became a little more responsive. The baby's father stood with us with tears in his eyes, his first baby. It was only then that I heard screaming. They had brought another woman into the delivery room and she was giving birth about two feet away from us. As I looked up, the new baby was crowning. Now that my baby was looking better, I left to write for dextrose (the glucometer is not working so we just treat), fluids, and antibiotics.  Jeremy called the pediatrician who would come see the baby once he was done with his clinic. Welcome to the ER.

The ER at Soddo has four small beds and two nurses who translate for us and complete all medication administration. We see one or two patients at a time in chairs (sound familiar?) and then move them to a bed for examination. Some patients are walked back and placed directly on beds without a card (chart) and are called "emergencies" but the triage system is unclear. Long bone fractures are the only things that are reliably walked back to a bed.  And people who cannot stand on their own.  We write lab and radiology orders on slips of paper that are handed to the patient.  The patient then takes the slip of paper to either lab or x-ray, where they pay for each service, have their blood drawn or films taken, and then wait for the results.  Sometimes x-rays (on actual film) are brought back to us by the patient, sometimes by a porter who carries both the lab and radiology results.  The only patients that don't go to the lab themselves are the ones that are too sick to walk. In this case, the family is responsible for carrying or wheeling in a stretcher or wheelchair the patient to lab/X-ray. Sometimes our nurses will draw labs and have a family member walk the specimen to the lab.  Needless to say, sometimes the blood or other specimens don't actually make it to the lab.  It is shocking who we send out of the ER by foot to lab or x-ray.  Kelsey had a hypoxic patient with saturations of 76% who actually looked clinically well (walking and talking without problems) who we sent to radiology and didn't see for 4 hours. She, like many of our patients, will leave the hospital grounds for breakfast, lunch, church, etc. Some will even leave completely and return the next day for results (a 24 hour ER stay without actually staying in the ER building).

We have learned so much in this first week. We each had a patient with large painful knee effusions. Both knee taps came back as septic arthritis and tested positive for tuberculosis. We have come to realize that anything here can be (and often is) tuberculosis (as Jeremy said, we "are starting to get the hang of it!").  We've seen things here that we rarely even think about in the US.  Kelsey saw a 14 year old girl with right lower quadrant abdominal pain. She had never had a period.  Her belly looked big when she stood up to walk to an examination bed.  Pregnant?  We took a look at her abdomen with our ultrasound and she had a large fluid collection in her right lower quadrant and her uterus was huge. It didn't look like a pregnancy, but it didn't make sense. Kelsey did a pelvic exam and the girl had an imperforate hymen.  Thankfully Jeremy was around to even suggest this diagnosis as it is not uncommon here.  We sent her to gyn clinic for a curative operation.  A toxic looking four year old came in with a high fever. He had been vomiting for one day. He was seen the day before in the ER and his family took him home to wait for results. He looked terrible when he returned.  His malaria test had been positive a week before. Chest x-ray and urine were negative for infection.  His WBC count was 28. One of the Ethiopian residents asked if we had performed a lumbar puncture. She agreed he didn't have meningeal signs (a stiff neck) but she said sometimes they have outbreaks and his parents told her that the child was having a severe headache.  They performed the LP and we started him on steroids and antibiotics and admitted him to the hospital. While he was waiting for his bed, his LP results returned -- gram negative diplococci on the gram stain, likely Neisseria meningitidis.  We wrote prescriptions for our nurses/staff for ciprofloxacin meningitis prophylaxis and took our own cipro at home.  Jeremy called the zone medical board to report it and informed us that he has never had a patient survive bacterial Neisseria meningitis. Hopefully, our patient will be the exception.

There have been a lot of ups and downs this first week. The first afternoon was overwhelming and I needed a break. I ran to the house to refill my water bottle and on the way back I went to check on our dialysis patient. There was wailing in the ICU. I walked in and told the nurse that I was working with Dr. Kelsey and Dr. Jeremy on the sick patient. She responded "Oh, he has died." The wailing was the family. I must've looked shocked and asked her when it happened. "I don't know" she replied.  I asked if she needed anything and she said no. I didn't say much else--we all knew that even if he was in the US he probably would've died. I walked back to the ER and told Kelsey. We both didn't say much...and then we got back to work. Some things are the same no matter where you are.

Auna and the blue baby

Our Thanksgiving table

Day 7

Nerd alert! The following post is awesome, if you are nerds like us.  You have been warned!  This is the follow up to the sick patient in the ER we saw on Saturday night.  Jeremy's late night text message said "I had to tap (lumbar puncture) that guy, lots of WBCs (white blood cells) but not enough fluid for GeneXpert (TB test)."  Basically, his LP showed meningitis.  His CT scan from that night did not have a mass or a bleed.  He did have bilateral pulmonary infiltrates (pneumonia or possibly fluid in the lungs) on his chest x-ray.   He did receive antibiotics in the ER, but there were not any anti-fungal or TB medications available to give him at the time.  When we woke up on Sunday morning, our only plan for the day was lunch with two NPs from the hospital who invited us out to a restaurant.  Little did we know we would be working all day.  We were literally, again, laying on the couches in the living room drinking coffee when Jeremy texted and asked us to go to the ICU and do another LP on the patient so that we could test for TB.  Neither of us like doing LPs (they are often difficult) but we figured we'd head over and get it done quickly, then come back to finish our coffee and breakfast.  When we arrived in the ICU, our patient was in the very last bed beneath the windows.  He had nearly no urine in his catheter bag from overnight, and what was there was brown.  He was breathing fast and deeply, a sign of his severe acidosis.  Jeremy was at his bedside, brow furrowed with concern.  He gave the family two options -- drive the patient to Addis Ababa immediately for hemodialysis or stay in Soddo and we would continue to try our best to save him.  His family could not afford the ambulance transport to Addis, and there was no way he would survive a car ride there by personal transport.  There is currently no option for dialysis in Soddo, but Jeremy has been researching how to do peritoneal dialysis in hopes of someday being able to offer at least some solution to patients in acute renal failure at his hospital.  Peritoneal dialysis (PD) was both our, and the patient's, last hope for survival.  Here's the catch -- none of us have ever done PD on a patient.  We've all taken care of PD patients in the ER, but we usually aren't responsible for placing a PD catheter (a catheter that inserts into a person's abdomen to allow fluid exchange) or for making the dialysate solution used in the exchanges.  Although we had basically zero experience, and the procedure has never been done at Soddo hospital, this patient was a great candidate and we had no other choice.  Jeremy sent us off to research how to best do PD in this setting (thank you Navy Emergency Medicine) and after about 30 minutes of googling, PubMed scrounging, and brainstorming we came up with a plan.  Jeremy had a recipe for the dialysate from a nephrologist friend, but it had to be made from scratch.  We quickly became mixologists -- a liter of saline, a little dextrose, two parts bicarbonate, a touch of calcium, a pinch of heparin and top it off with ceftriaxone (I promise, we were much more precise than this sounds) and we had homemade dialysis solution.  It sounds like a simple recipe, but nothing is straightforward here, not to mention we hardly ever mix medications (or even handle them for that matter).  Each component had to be purchased by the family and brought to the ICU.  So did every syringe.  Making the first 2 liters of solution took forever.  Next, we had to place a PD catheter.  We rummaged through the medical supply store room (an outdoor shed with donated supplies) and found 14 gauge single lumen central venous catheter, which seemed to be our best option. We placed the catheter into the peritoneal cavity at bedside using Seldinger technique.  Then our homemade fluid was instilled into the patient's abdomen through the catheter to begin the exchange. We repeated this process twice on Sunday, taking breaks only for half of the church service held in our guest house and a potluck dinner with other visitors to the hospital.  After dinner, we went back to the ICU one more time to check on our patient.  He was alive, looked slightly improved, but was still in very critical condition.  It is amazing how few resources we have here to practice critical care, but it was extremely rewarding to work together to do something brand new, to creatively make use of our scarce resources, and to try everything in our power to help a patient in extremis.

That was Sunday, our day "off."  Bring it on, Monday!

Also, we only brought a small amount of hand sanitizer...here is hoping it lasts the three weeks!

Day 6

Another beautiful sunny day in Soddo!  We planned to hike Mt. Damota, the highest point in Wolaitta Zone at 2738 meters, with Jeremy and Pastor Daniel (a visitor from Chicago) this morning.  We met at 7am and took a hired bajaj (basically a motorized tricycle) through town and up the base of the mountain on bumpy dirt roads to a seemingly arbitrary "trailhead."  We had two local boys along, Ebenezer (15) and his little brother (12) whose name I still cannot spell or correctly pronounce, as our guides.  The trail up the mountain is a well worn, deeply rutted path used frequently by the families that live up in the hills and atop Mt. Damota.  On market days, women and children carrying palm-leaf wrapped bundles on their backs or mats on their heads and men driving mules and horses with similar packs upon their backs come streaming down the mountain.  The higher you climb, the less Amharic is spoken and the more Wolayta you hear.  People live in straw huts tucked away among the trees and farm on the hillsides.  Little kids either stared at us, tried to touch us, or ran away.  Occasionally they threw rocks, but Ebenezer was proficient at chasing them away.  He also indulged us by answering many of our questions -- "what are they saying?", "what plant is this?", "what are they carrying?"  At the top of Mt. Damota is an old Ethiopian Orthodox church.  When we were nearly to the summit, we met a young man on his way down who explained some of the history of the area and the church to us.  Apparently a missionary in the 12th century brought Christianity to the area and the church has become a sort of pilgrimage site for some Ethiopians in the Orthodox church.  He was from Addis Ababa and clearly had made this steep, high-altitude climb with no food or water as he was only carrying a Bible and a walking stick.  We weren't clear from his story if the church itself had been built in the 12th century, but it certainly looks newer than that with its wooden roof and bright yellow walls.  There is a second church site, a blue older church, at the summit sitting across the valley from the yellow church that is in shambles, but again does not look 12th century old.  The doors were locked on both churches so we couldn't go inside unfortunately.  We shared some snacks at the top while sitting on wooden benches outside of the yellow church with about five kids under the age of 9 watching us from the nearby tall grass.  The trek down was filled with even more locals headed to market, near misses by out of control mules/horses reeling down the slopes, and many women and girls surrounding Auna--some helping her with her footing and others trying to touch her or talk to her in other languages.  Because of this, we learned a new very important word: "inenga" or "I don't know!"

After the hike, we were exhausted.  We had lunch at the hotel Nega (fries and papaya juice) and then headed back to the guest house for a much needed shower and nap.  We were lounging on the couch and about to fall asleep when Jeremy came to the front door in his white coat.  We knew that meant work! He told us there was a sick patient in the ER, a young guy with altered mental status and renal failure, who was waiting on a CT scan and then would be going to the ICU.  Pulling on our white coats, we headed up the hill to the ER to see him.  His eyes were open but unfocused, his mouth was dry, and he was grunting.  He had only received 1 liter of IV fluids, so we suggested the GP give another 2-3 liters while he was waiting for the CT technician to come in from home.  Knowing that things here rarely happen quickly, we went back home to make dinner and to wait to hear from Jeremy again if there was anything else we could do to help.  A text message at 11:30 pm woke us from sleep...but we'll save the rest of that story until tomorrow!

Pictures below are of our hike to Mt. Damota.

Day 5

We're still not really sleeping through the night, waking up between 1-3 am followed by taking "naps" between about 5-7 am.  A little surprising for a couple of EM residents who routinely "flip."  We took a tour of the hospital with Jeremy to start off the day.  He explained the history of hospitals/medicine in Soddo (originally the medical mission was in a different area of town, but the founders were forced out by the communist government in the 1970s and the hospital was run by the government; when the government offered the hospital back to the missionaries, it was in shambles so they started a new hospital on the current site) and then we walked through each building on the campus.  The card room, or registration, consists of 3 outdoor windows where patients line up to pay a fee to see the doctor.  Then they enter the Outpatient Department (OPD) where the ER and clinics are, have vital signs taken at triage, and then sit in a small waiting room.  The OPD has a few clinic rooms, a dental room staffed by a couple of dentists, and a 4 bed ER.  The ER is sparse -- one bed has a vital sign monitor, there is a soon to be filled (by us!) airway cart, and a small Sonosite ultrasound.  That is about it.  We also saw the inpatient wards, including the ICU/recovery area where they have a brand new ventilator that can work with low pressure oxygen sources, the Ob/Gyn ward where a new baby had just been delivered, and the Ortho/Surgery ward (which is being expanded to about twice its current size).  There is also a medical and pediatric ward.  Each ward is a separate long, low-slung building with surrounding green grassy areas where family members of patients set up camp, sprawling in the sun and eating lunch.  We visited the ORs also.  There are 4 rooms, the ortho/surgery clinics are housed in the same building for convenience of location to the surgeons, and there is a call-room for the general surgery residents.  Anesthesia is done by nurse anesthetists frequently using ketamine and nerve blocks, although they have the capability to also use general anesthesia.   There is a kitchen on campus as well, which smelled amazing on our walk by, where they make food for all of the patients.  This is uncommon in Africa, where most hospitals require family members to bring food to patients, but because nutrition is so critical to healing the staff at Soddo feeds the patients healthy, high-protein meals.  Rounding out the campus is an eye clinic, a pharmacy, a chapel, and many residential buildings for missionary families, guests, and resident physicians.  Oh, and three sheep who are phlebotomized for blood agar in addition to keeping the grounds trimmed.

After our tour of the hospital, we attempted to eat lunch at a nearby hotel called Nega, but we went into the wrong "tall yellow building" right across from the hospital which was actually the cultural center.  Turns out they have a cafe, but there were no menus so we pointed at the food on a nearby table and asked for the same.  It was pretty good food, although we have no idea what kind of meat we were eating.  We tried to order coffee with milk, but hadn't learned the Amharic words for this yet, so we ended up with a popular drink in Ethiopia -- shai-buna or tea and coffee combined.  Yuck.  Just before we got up to leave, an older Ethiopian man stopped at our table and said in very good English "I used to live with Americans and every time I see Americans I stop and say 'how do you do'?"  According to Jeremy, many Ethiopians know the English phrase "Are you fine?", which is a direct translation of the Amharic "Dehna neh?" and like to try it out on English speaking "ferenji."

Next was a tour of Soddo (e.g. grocery store, bank, good restaurants, cafes, etc) by van with a group of other visitors to the hospital and a little street shopping for football jerseys where we attracted a large, gawking crowd.  The day ended with pizza at the Gabrysch's house while watching "The Lego Movie."  Auna fell asleep at the table.  She woke up between 3-4 am again.  Someday we'll get this sleeping thing worked out!

Day 4

The battle with the mosquitoes has begun. I can't tell yet if we are winning or losing. I just hope I didn't wake the whole house when I jumped from bed to bed slapping the ceiling with my shoe. It's 3:00am. This is becoming a routine as we haven't been able to sleep through the night yet. Maybe if we stay up tomorrow without an afternoon nap or dozing in a plane or car we will finally be able to adjust to the time change. We are staying in a beautiful guest house surrounded by palms and flowers. It has two floors, a kitchen, two bathrooms, a large dining and living area and multiple bookshelves full of abandoned books. So far, we found the Village Medical Manual which is a layman's guide book to village medicine and is a dry but useful read. We are sharing the house with another family. We met them last night after waking from a nap. They were having dinner with a retired couple from down the path. Their accents were clearly American but when we asked where they were from we got the answers "here" and "The Congo". They were super friendly and offered us their flashlights and dinner before we told them we were eating with Jeremy and Christina. Almost as an after thought as we were walking out of the door one of them asked where we were from. Dallas. That was the end of the conversation. You could tell it didn't really matter where any of us were from - we are all here now. Surprisingly, there are a ton of young children of volunteers here, at least 10 of them ranging from ages 3-12. We ran into them last night as they were chasing a mongoose with their dog, Peanut. We were told you can see the mongoose eyes at night glowing red in the darkness. Soddo is beautiful and a welcome change from the capital city of Addis. It is green and dotted with palms. Hills rise from the ground and dip into deep valleys covered with farms and small huts. The people, the sun, the clothing are all brighter here and everything is more relaxed. Jeremy and Christina are amazing. They opened their home to us immediately and did not hesitate to show us around and insisted that we join them for dinner. Before we could even finish unpacking, Jeremy came back to the guesthouse and called up the stairs for us to grab our white coats and come to the ER to see an interesting case.  We dropped what we were doing and hurried down.  He explained on the short jaunt to the ER entrance the history of "mossy foot" (a form of Elephantiasis caused by lymphatic obstruction due to volcanic soil) in Ethiopia and the physician who formerly lived in Soddo who, in his 80s, started a foundation to promote foot care among Ethiopians suffering from mossy foot.  We actually saw two patients in the ER with mossy foot, each with edematous discolored feet and ulcerations carrying the scent of infection.  It was a brief and unexpected introduction to both tropical medicine and medical care in Soddo.  Jeremy and Christina also invited us to join in on their plans for this weekend including touring the town, hiking up a nearby mountain and eating pizza with them tonight. They are so honest and emanate a sense of peace which is calming and familiar.  They answered all of our questions, told us funny stories of travels, and explained some challenges with the small hospital. We filled them in on Dallas and the new hospital. The dinner ended with us walking back to the house with Jeremy who was going to check on one of the other physicians, a pediatrician with a fever of 103F. He was heading to the hospital after that to see if he could get the wifi running. It has been down on and off for the past 3 weeks so likely multiple posts will show up at once when we have brief periods of connectivity!

Day 3-4

We arrived in Addis Ababa, the capital of Ethiopia, on Wednesday.  Where Dubai felt western, Addis is definitely African.  There are abundant similarities to a county hospital here.  It is controlled chaos -- everything works, but not well.  In the airport, we had to first stand in what you could loosely describe as a line to undergo an Ebola screening.  Getting a visa, exchanging money, and finding our bags all went smoothly.  But then we had to get through customs.  One of our bags was flagged for inspection.  We decided to separate that bag from the rest after watching a few Ethiopian women have to remove every article of clothing from each of their bags.  Auna spent about 2 hours emptying everything from the bag, explaining why we had medical supplies and what each item was used for, and shuffling papers between 3 different customs agents.  We were carrying an airway mannequin (basically a plastic human head with a cross-sectioned neck to show the anatomy) and two deflated plastic CPR dummies in this particular bag.  The man inspecting the bag looked with disgust at the mannequins and quickly closed the case back up.  Thankfully, he let us leave with the head -- it was definitely the most difficult item for us to get back home!  In hindsight, we probably could have just walked out of the airport without even stopping at the customs inspection stations with all of our bags given the total disorganization of the entire process.

Another perk of the controlled chaos is being on "African time" -- even after an unexpected two hour delay, our driver to the guest house we were staying in was still waiting for us.  The roads in Addis are crazy.  No lights, only roundabouts.  We felt a little like we were in a Mario Kart game, dodging other drivers, honking to get people to move, no regard at all for any lines on the road.  The roads here are the epitome of "shared" -- cars, 10+ passenger vans, horse-drawn carts, donkeys, cows, goats, and PEOPLE everywhere.  Its a bit shocking that we haven't actually seen anyone get hit so far.

The guesthouse was fantastic.  Clean, fast wifi, lots of space, wonderful staff, and a friendly house dog named Max.  Lee, the manager of the house, arranged a reservation for us at an Ethiopian cultural restaurant (Yod Abyssinia).  We had a buffet of Ethiopian food (amazing!), St. George beer, and watched traditional dancing and singing during dinner for entertainment.  The dining room was packed with people, a mix of European and African tourists as well as Ethiopians, sitting at low tables crammed into every inch of space available.  People sang along with songs they knew and even went up to the stage to dance along with the performers.  There was a European family sitting next to us with a little boy, probably about a year old, who was bobbing his head along to the music the whole time.  It was a fun introduction to the culture of Ethiopia.

Today we are headed to Soddo, where we will be spending the rest of our time here.  It is a five hour drive from Addis (we're in the van as we type).  Our driver, Silas, is a pro at dodging wandering livestock and potholes on the road (he leaned out the window once to scold a cow).  We just stopped at Butajira for a much needed macchiato break -- the coffee here is delicious (thank you Ethiopian grown beans and Italian brewing influence)!  We are looking forward to finally getting to the hospital after nearly 4 full days of travel.  Pictures to come!

Day 2-3

Only a couple hours until we land in Addis Ababa. It's been almost three days since we left Dallas and we still have another 24 hours until we arrive in Soddo and begin to work. In a sleepy haze we were able to explore Dubai for half a day. We enjoyed a nice lunch in the sun at the souk and then took a true coffee nap at a cafe on the Arabian gulf. Next we went to another mall (all of Dubai felt like a mall) and the tallest building in the world, the Burj Khalifa. The open air viewing of the city below from the 124th floor was frightening and amazing. This was followed by a fountain show three times the size of the Bellagio fountain. Our evening culminated with a wonderful Arabic dinner under a very different set of stars surrounded by sweet hookah smoke and foreign tongues. I have to admit, the highlight of our day was our driver Mohammed. He was a friendly petite man with a slightly wrinkled shirt from sitting too long in one position during an afternoon sweat. His demeanor was earnest... and mostly confused. He didn't trust his new Mercedes' GPS and called every location we wished to visit to ask for (and sometimes confirm) his route. You could sense he was uncomfortable with the size and congestion of Dubai. I have to agree. The city was such a strange mix between what seemed like a very ancient world and a very flashy new world. It might be a fault in my perception of Arabic culture which I see as so old and rooted. Dubai seemed out of place - a teenager wearing a leather skirt and red lipstick at church. Women in full Burqas wearing sparkling stilettos that were only visible every fourth step. Stuffed dates and honey covered apricots in cases next to the Coach store. Even the floor of the viewing room at Burj Khalifa, a modern work of art and steel, was wooden and moaned under your feet as you edge towards the viewing windows. That being said, I can't wait to explore this part of the world again when I have more time to take it in. Now, on to Africa.