wake up with a start. It’s 3:26 a.m. The nightmares are back. They always take a different form, but with the same theme. I’m running from some nameless terror.

 

I desperately want to sleep, but the headaches continue. There’s also a lurking fear that when I lie down, I won’t be able to sleep. So I watch a movie, read a book, wander around puttering till the inevitable stop of the generator forces me to hit the sack.

 

Finally, I lie down. I start off with the illusion of falling to sleep immediately. Instead come the slow, persistent memories from the day’s work: strategies, plans, ideas . . .

 

Above all, it’s the thoughts of what I shoulda, woulda, coulda that surface. And working at a small bush hospital in sub-Saharan Africa as the only physician leaves plenty of fuel for that fire.

 

I should’ve cut an episiotomy sooner. The baby was already stressed. Sure its heartbeat was fine. But the 14-year-old mom had been in labor on that small pelvis for too long. If  I’d only got him out a few minutes earlier he might have made it.

 

If I’d recognized that meningitis a day sooner instead of treating only her malaria, maybe that little girl would’ve lived. I’m sure we did everything we could: IV fluids, glucose, steroids, appropriate antibiotics. What did we miss?

 

Did I speak too harshly to the boy whom we’d amputated, and then had almost healed his wound when he left against medical advice? When he came back with a huge infection needing a higher up amputation, I should’ve spoken gentler.

 

How could I have thought it was an ectopic pregnancy? An unnecessary operation on a woman with a normal intrauterine pregnancy. I could’ve saved myself the trouble, and her a dangerous procedure.

 

Are Israel and Paul overworked? They are volunteer nurses, after all. I want them to have a good time so they’ll encourage others to come. Am I assigning them too many night shifts?

 

Words in Arabic, Nangjere, and French wind themselves around my thoughts as I relive my frustration at being able to communicate only on the level of a child. My deep desire to learn Arabic and Nangjere clashes with feeling so overwhelmed that at any break I just want something to temporarily

distract me . . .

 

Finally, I fall asleep, and the nightmare begins again. My throat is sore; my lips are dry. I grope for a flashlight and take a drink of water in the bathroom. A flashlight appears outside the window, rapidly followed by a rap on the metal door. I unplug my ears, grab my headlamp, pull on some shorts and a T-shirt, and go to see Clarice and David.

 

Clarice is in her 10th pregnancy, under oxytocin to augment her labor. She has been completely dilated for three hours without delivering. I change into scrubs, find my keys, head to the OR, snatch up the oft-used disposable hand-pump vacuum, and head to Labor and Delivery.

 

I put on gloves and examine the woman. The head is high up but there seems to be room. I wet the vacuum and slide it in over the baby’s crown. She has a strong contraction. I pump up the vacuum and slowly pull. The head descends and twists to the left as the eyes, nose, and mouth pop out slowly over the perineum. I use the bulb suction to clear the airways, release the vacuum, and pull the head down to free up the anterior shoulder. That’s quickly followed by the squirt of slimy child, arms and legs firmly contracting, already wanting to scream her anger at the world. We quickly dry her off and wrap her up against the cold. The placenta follows quickly.

 

I go home, hoping for at least a few hours of nightmare-free sleep . . .