Tuesday, May 31, 2011
Sometimes I feel like I'm on a bit of a roller coaster here. Things can just change SO fast. One second I feel like I'm ecstatic about a kiddo that got to go home or a good conversation I had and then the next second something makes me so sad or frustrated. Frustrating! :)
The other night I was at work and a kiddo came in who was pretty sick. He was really pale (I'm still learning what pale looks like here with their darker skin but even I could tell this kid was really pale!) His heart rate was 200(fast) and he was breathing 96 times a minute (really fast). I didn't hear anything in his lungs so I assumed that his respiratory stuff was happening because his hemoglobin was so low that he didn't have enough oxygen circulating in his blood. One of the things that malaria does is kill red blood cells (which carry oxygen). Since a lot of times moms will try everything else before bringing him to the hospital, they often come to us with hemoglobin's of 3 and 4. In my ICU in the US we'd start giving people blood transfusions when they dropped to about 8. Mine is probably 14. (Just so you have a sense....these kids come in REALLY low, often on deaths door).
So anyway, this kid came in looking pale and sick. We needed to check his hemoglobin and give him blood. We don't have a lab 24hrs a day but we have someone on call so we called him. His phone was off. So we tried his other phone. Also off. Finally, we sent someone down to his house to get him. He wasn't there and his wife had no idea where he was. Are you kidding me? I was on call all the time in the States. You never sleep very well because you're always waiting for your phone to go off because you know if they call you they really need you. I know the rules of being "on call." This guy is not playing by the rules!
Since we didn't know what else to do, we called the other lab guy who was not on call to see if he could come in. He told us he wasn't on call and said he'd try to call the other lab guy. We waited for awhile, sent someone to his house again with no response and finally called the second lab guy to see if he had any luck. He hadn't and said that he wasn't feeling well and wasn't going to come in. Ahhhhhh. Frustrating.
So we called the hospital manager and told him what was going on and he said we should try the on call guy's wife again. Ok. At this point I'm fuming. I keep thinking "if I was at home right now.....this, this and this would never happen, etc." I don't know what else to do. If I was able to do it myself I would have but I didn't have the keys to the lab and wouldn't have a clue how to go about doing the job.
At the end of my shift we still didn't have a resolution to the situation and I handed off report saying "here's the blood bag, tubing, everything you need. Keep trying to call the guy to see if you can get a hold of him." I woke up at 5am that morning and couldn't go back to sleep going over everything that had happened the night before and wondering if he would still be alive when I went down for rounds that morning. I was also feeling guilty because I wondered if there was more I should have done. What if it was my kiddo? If it was my kid, I probably would have gone down to the not on call lab guy and beat on his door until he came up to the hospital, I don't care HOW sick you feel. Should I have done that?
I've been wrestling with these kinds of questions lately. There are so many things I would change here "if I was in charge!!" No repercussions for people on call who don't show up would be one! Our ambulance driver lost his phone so we couldn't get a hold of him to drive the ambulance for 3 days. There's no way to mark when a chart has new orders and the nurses don't look at the chart so medications will be ordered and never given to patients. They sign of that they gave medications when every pill is still in the box so they obviously haven't and whenever you ask them if they gave it, the answer is always yes. The list goes on and on.
In the three weeks that I've been here I've had so many ideas for how to improve this place. Adding little flowsheets, better documentation sheets, etc. But then yesterday, I kind of had a "come to Jesus" moment if you will. I keep saying to myself "If I was in the States....." But the fact is, I'm not. I'm just not. I've chosen to come work here instead. And I've been here for exactly three weeks. A lot of these people have been here for years. They stayed here to take care of patients when all the missionaries left during the war. They stayed when it was occupied by the rebels and they knew they could be killed at any time.
We have a lot of ex-pats that come to this hospital for a few weeks, a few months. I'm sure they must feel the frustration that I do. I wonder how often they "suggest" things for improvement. I put myself in the Sierra Leoneans' place yesterday. A bunch of strangers come here every few months and tell them how to run their hospital. The hospital that they kept running for a decade by themselves during the war. I think if I was them I'd think "you know, we did just fine without you for years." I don't think I'd really care about the fancy education or experience in a big time medical center. It doesn't matter cause you'll be gone in a few months anyway.
So I've changed my train of thought. Or adjusted it. There are a lot of things that I would change. That for patient safety and better outcomes MUST change. But if I think I'm going to come in with some new charts and accountability and change that overnight, it's never going to happen. I'm accepting that. Slowly. :)
Then what do I do? Well, for now I've decided to be an observer. Learn how things work and why they work the way they do. Also, I want to be the best nurse that I can. Help as many patients physically, emotionally and spiritually as I can. And maybe, depending on how long the Lord leaves me here, help the nurses and nursing assistants see that there are other ways of doing things and why it might be good......but let them take the lead on what needs to change and why.
It feels freeing. I'm sure my frustration isn't going to go away but I've realized that I have to let it go. For my own sanity. I'm going to do what I came here to do which is become a better nurse, build relationships, and seek to love people the way Jesus does. If other things change, it's just icing on the cake. :) Anyway, just a few of my thoughts recently.
**Incidentally that little kiddo was still alive the next morning and is doing much better!! See? Roller coaster. Utter frustration to relief to extreme joy....in about 7 hours :)
Tuesday, May 24, 2011
The hospital I work at here doesn't really have an ER. During the day they have an outpatient clinic which everyone goes through and the man running the clinic decides on the treatment plan and who will be admitted to the hospital, etc. The outpatient clinic closes at 5pm though, so after that the bench outside of the nurses station kind of serves as the ER. The patients that come after five are seen by a nurse and either given minimal treatment and told to return to the outpatient clinic in the morning or are admitted, stabilized and wait to see a doctor in the morning. Since I am working evening shift (3p-10p) my partner in crime and I see the patients that come after hours.
So last night it was kind of slow (I know, the word you never EVER say in the ER). We were sitting on the bench outside the nurses station when we saw a man being carried by a few friends of his coming down the hallway. (Note: small jump in adrenaline here....) :)
His friends sat him down in the bench and I started getting his vital signs while my partner started asking what happened. Here's the story. Apparently this guy was in bush working on his farm. He heard a voice call his name but didn't see anyone....and he got scared. He walked back to the village and his friends found him in this state. Wait. What? Chief diagnosis: being scared?
He is sitting on the bench saying "why, why, why, why" over and over. Vital signs: BP 124/82 (normal) pulse 112 ( a little high but nothing to write home about). He was breathing about 40 times a minute which is pretty fast but his lungs were totally clear. Denies abdominal pain. So his vitals look pretty normal except for his breathing. When I asked why he is breathing so fast, they can't tell me. When I asked if he's in any pain, they said that he was complaining of back pain and then pain all over his body.
So, he was in the farm working, heard a voice, got scared and is now breathing really fast, can't walk and is having back/generalized pain. Huh? I felt like I was missing something.
"So he was scared then, but what is his problem NOW? Why is he here now?" I ask his friend.
"Well look at him, he's sick!"
"Ok, but his vital signs look pretty normal (his breathing had slowed down at this point). You said he is having back pain. Is this new? Did he hurt himself while he was working?"
"Well he had an accident 12 years ago and has had back pain one other time but he did not hurt himself while he was working. He just walked back to the village and was like this."
"So he didn't hurt himself?"
"NO!" (Friend getting a little frustrated with me at this point because I'm just not getting it).
I do a quick neuro exam and look at his pupils. When I open his eyes they are initially looking straight ahead but as soon as I open his eyelids they roll back. He's able to follow commands (like when I tell him to stop saying "why, why, why, why") and when I ask him to stand up and walk he does so, although shakily. Alright, I think I've got it figured out. I've seen it in the States a few times and these patients always seem to come in when I'm really busy with other critical patients. It's called "Take me to the hospital because I want some attention" disease. It drives me crazy.
I know, I know. I need to work on my compassion because obviously something's wrong if they feel like they have to fake a disease to get some attention but I've always struggled being patient with these people because I find it really annoying. God's got some work to do on me yet.
Anyway, cynical ER nurse that I am after I decided what was going on I was irritated. I didn't want to give this guy the attention he what he wanted so I told him that we would give him a shot for the pain and some medicines he could take at home and he could follow up with the outpatient clinic in the morning.
His family did NOT approve.
"You can't send him home like this! He's sick!"
"Ok, what's wrong with him?" I ask. "I can find no medical reason for why he's acting the way he is."
"But he's sick!"
"But WHY??? If you can tell me something else that's going on, I'd love to keep him here but I don't see any sickness!"
"But you have to keep him here!!!"
After going back and forth for a little while my friend decided that we'd keep him here overnight for observation. Fine. Whatever. Faker.
The next morning I was discussing this case with a doctor who's lived here for years and he said that this isn't actually all that uncommon. People will come in after seeing something or hearing something and just be terrified.
Now I felt sheepish. Maybe this guy really WAS just scared! The fact is, that the spiritual world is VERY real here, and very real to these people. In my ignorance (combined with probably a little arrogance and cynicism) I'd brushed aside this guys fear and decided that he just wanted attention. Humble pie for breakfast.
In moving here to practice medicine, I had to add a lot more diseases to my list of differential diagnoses due to the tropical stuff we get here that I never saw at home. And although I have always tried to tend to the spiritual needs of my patients, I think might look a little different here.
I'm happy to say that the patient did end up going home....with no medical diagnosis ever given. Hmm.......
Friday, May 20, 2011
There is one nurse ("senior staff) on evening shift and the rest of the staff are nursing assistants (junior staff). Since there are multiple "senior staff" on days but only one on evenings, I figured I'd ask to be put there so I could help out. Mohommhad is nurse that I work with and he's great!
As soon as we got there, a mother brought in her very sick child. We went through the motions to get the tests done, medications ordered and given etc. The kiddo was really sick and her parents were really worried. We started off the night with a bang and continued that way. The pediatric ward was overflowing with patients and they were all really sick. Around 7pm I had three kids start seizing one after another. I was still figuring out where everything was and how to get medication after hours etc so it was an exercise in frustration trying to find everything I needed to help our patients. By the time I left I was exhausted.
I didn't really sleep much that night though because I kept thinking about the evening and going over everything again in my mind. Should I have started IV fluids on that kid? Did I prescribe the right medicines? I hope that kids fever goes down. I also had several kids who I didn't expect to make it through the night so everytime I woke up I would listen to see if I heard any wailing. You can always tell when there's a death at the hospital because they grieve very loudly here. I wasn't planning on going on morning rounds the next day but I had to check on my kiddos.
I walked into the ward with a slight feeling of dread to see how many weren't there anymore. To my suprise and relief, they were all still there! When we rounded it even seemed like a couple of them were doing a little better. I left around 10:30am feeling hopeful.
When I returned to the ward at 2;30pm for my shift, I was shocked to find that 4 kids had died within about 3 hours. As I scanned the room I saw with relief that P7 (can't share names..you know, HIPPA and all) was still there. That was the kiddo that I admitted at the beginning of my shift and was pretty sure she was going to die that night. I was suprised that she was one of the ones who was still alive. I went over to her bed to check on her. She still looked really sick. I went to look at the rest of the ward and as I did this P7's father came and got me to come see the child again. When I did I could see that the child's breathing had become more labored and she was now having periods of apnea (long pauses in her breathing.) I knew the end was coming. Her parents were looking to me to do something but I knew there was nothing else we could do. Her little body had just been too sick to fight the malaria...even with the treatment she was getting. So I just sat there with her parents as we watched her take her last breaths. It sucked.
I left that night feeling unbelievable frustrated. These kids are so sick. Unfortunately for various reasons, parents often wait to bring their children into the hospital until they are too sick to be cured. Are we even helping? I had busted my butt so much the night before to try and help these kids and it seemed pointless. I was mad. We had had 18 kids in the ward and 5 of them had died within 4 hours. Almost a third.
I had a mild internal crisis at that point. It was the closest I've come to wanting to pack up and go home and wondered how I was going to stay at this hospital for the six months that I've agreed to. It was too hard and I didn't feel like I was doing any good anyway.
This all happened on Tuesday and Wednesday. Today is Friday and I just returned from rounding on the Peds ward. I am happy and excited to say that we sent four patients home and all the rest are looking better. One patient that I've been worried about for the last three days actually cried when we examined him today which was music to my ears! :) All this to say that God is so faithful. He knew that I was at my breaking point and allowed me to see a glimpse of the good side today. And I'm so grateful. I know in my head that we are doing some good....but I was really excited to get to see that with my eyes today.
I feel like I've been writing about the negative aspects of living here a lot and don't want to focus on that! But the truth is, life is hard. Really hard sometimes. But God is still God, and He's good!
Special shout out to my mom who listened to me vent/have a small breakdown over Skype last night. :) Mom's are the best!
Saturday, May 14, 2011
I got a call yesterday saying telling me that there were two women who were fully dilated and would probably give birth any minute. I went down there immediately and found two women in the labor room. One woman had a really small pelvis and you could tell her baby was big! She reported that she'd been in labor for three days so they were going to take her for a c-section. The second woman had also been laboring for awhile but they thought she might be able to deliver vaginally. It was decided that I would go with the midwife to the c-section, until she checked the second woman once more and determined that she was ready to push. I positioned myself...ummm....at the end..... and had a front row view!
We could see the baby's head but the woman was having a hard time pushing. She could not have been more than 17 or 18 years old. Every time a contraction came, the midwife and other nurses would yell for her to PUSH!!!! She would push but....nothing. This went on for several minutes and then they started getting angry and telling her she was lazy. I felt really bad for this girl but had to chuckle a little to myself at the thought of OB nurses in the States yelling at their patients and calling them lazy. Ha! Might not go over so well! :)
After some more minutes of this pushing/hollering the patient told us what the real problem was. She said that there was a devil at the end of the bed telling her NOT to push. Wait. What?? At first I thought she was talking about me! The midwife assured me that she wasn't. Phew. Apparently she had been saying this in the village and that's ultimately the reason that they called the ambulance and had her brought here.
Then the nurses really got to yelling. "This is a MISSION hospital!" "The devil has no power here!! " "There is NO devil telling you not to push." "You MUST push!" Etc. etc.
At this point the tension in the room has gone up dramatically. What started out with nurses chuckling and then getting upset about her lack of effective pushing has now turned into a dangerous situation because we need to get her baby out!
They decided to try a vacuum and brought out a manual vacuum machine. After trying several times without success (I made sure to keep my mouth shut as the vacuum popped off the head multiple times....and I was REAL close and personal!) they decided that they need to take her for a c-section. Since the lights (generator) hadn't turned on yet we knew they didn't have the first girl on the table yet so we sent someone to tell the OR to take this girl first.
I followed them into the OR and pretty much just tried to stay out of the way. They put the girl to sleep and cut her open. As soon as they got to the baby a huge amount of meconium (stool/poo) came out and we knew that baby was going to be in trouble. They also found the cord wrapped around the neck.
As soon as baby came out my friend Patience (the midwife) grabbed baby and took him to the isolette. He wasn't crying and didn't appear to be breathing on his own, although he had a strong heartbeat. They immediately started bagging him and trying to stimulate him to breathe. After a few minutes they checked his oxygen saturation and saw that it was at 21%. (Normal is 92-100%). This was not good. His color was also worsening despite the bagging. He was almost as white as me. They worked on him for about 30 minutes with no real improvement. His oxygen saturations went as low as 5% and never got above 60%. At this time we are about to stop when the surgeon who performed the C-section came over and started bagging. He worked hard for the next 10-15 minutes and I figured his forearm must be geting tired so I offered to relieve him. Then he left.
Now at this point I know that this kiddo is gone and there's nothing left to do but I definitely don't feel like I have the seniority to "call it." So I just keep bagging. They have now brought in the second girl for her c-section, put her to sleep and are getting ready to make the cut. And I'm still bagging. There's no one else around as everyone else is occupied with the second case. I wonder if everyone is just thinking that the apoto (white girl) is one of the ones who thinks everyone can be saved and won't give up. I've seen enough death in the States that I don't really have that perception....I'm just not sure what to do!! So I just keep bagging.
Now the second baby is delivered and they need to bag this one as well so I take it over to them...and my job is over. In hindsight I wish that I would have picked up this little one and held him as his heart stopped beating. He looked so perfect!
I was sad that this mother had lost her baby. I was even sadder when I found out that this was the second dead child she had delivered. But I wasn't devastated. I wasn't destroyed. Although I've seen plenty of death in the States I've never bagged a baby before....never experienced the death of a child before. That was new, and I felt like I should have been more affected. Then I started to worry! Am I becoming too desensitized? Have I lost my compassion? Have I allowed the fact that even if this child was born perfectly normal, he had less than a 75% chance of reaching the age of five make me calloused?
I thought about that a lot the rest of the day and evening. I'm still thinking about it. Today I decided that in order to survive here, I will become slightly calloused. Just like I did when I worked in the ER/ICU. However, I'm begging God to help me not to lose my compassion. I don't want to be destroyed by the pain around me, but I also want to be willing to enter into that pain with the patients that I can. Lord give me wisdom and discernment to respond in a way that glorifies You.
Wednesday, May 11, 2011
Ali sitting and enjoying the view. He also made a little friend that followed him everywhere he went. Ali throwing his bottle into the ocean to see if it will come back
We started seeing the ocean as we were driving along the road and he started freaking out about how big it was. "Eh! It's so big! It's so big! Wow, SO big!!!" When we got the the beach he was initially afraid to put his feet in but I held onto his arm and kind of made him. :) Then he loved it! He asked a ton of questions like "Do the waves do this all the time?" "Do the boats turn over while they're catching fish?" "If we throw something into the water will the waves bring it back to us?"
Saturday, May 7, 2011
My road trip had two parts. Remeber "Ali?" He was the kiddo who broke his leg when the first medical team was here. After a month and a half of the majority of his leg being casted in 95 degree weather, he was ready for it to come off! Last time I went and dropped him off his family asked if I would stay in the village with them but I'd already made arrangements somewhere else. This time I decided to stay there. It was my first time staying overnight in the village so I was excited. Here are a couple pictures from my stay.
Awesome first impression.
Friday, May 6, 2011
In April, we had a medical team from Canada come to Sierra Leone. We operated a clinic in two different sites, both of which I'd been to before. It's always fun going back to places where I've started relationships and to build on them. In addition to getting to build on those relationships, I got to make a bunch of new ones with our friendly neighbors to the North. On our hour long drive to dinner one night I had them attempt to teach me the Canadian national anthem. For some reason I often get this song stuck in my head but only knew the first two words..."Oh Canada." So now I at least know the first 4 lines which will come in very handy during my next hockey game! I'll sing it loud and proud. :)
Clinics like the one we did are alway fun but have their challenges as well. I always hate "the Last Day." This is the last day of clinic when we can't tell people to come back tomorrow and have to turn people who are legitimately sick away because we just can't see them all. I hate that! This time since we did clinic in two different places, we got to have two "Last Days." Yuck.
I think the most memorable case for me was a 10 month old with severe hydrocephalus. I went up to the triage area to try and find the people who were really sick and a man came up to me and said this woman has a baby at home who's head keeps getting bigger. I kind of shrugged it off because we get odd complaints like "something started moving down here (in the stomach) and has moved up to my chest and then my head and now I have a headache" and others pretty often. So I just told her to go get the baby and bring it here becasue I'd need to see it if she was going to get into the clinic.
A little while later I was back in the triage area and she was shielding a baby. I pulled back the blanket and she quickly put it back again. In the short time I saw her I could tell that her head was HUGE! "My baby's head keeps getting bigger" was an absolutely legitimate claim. There was obviously some shame associated with this because she was extremely careful that no one see her baby. I fet so bad for her. I could just imagine some of the things that she'd been told.
I gave her a card to take to the clinic so she could be seen. About an hour later one of the doctors came to me asking me to help find a hospital in Sierra Leone who could put a shunt in this kiddo. (I should explain here that hydrocephalus is a disease in which fluid collects in the head and makes it bigger and bigger, causing brain damage and eventual death. To correct the problem, in the States we put a shunt in to drain the fluid from the head to the abdomen.) I called every hospital I could think of and even called Mercy Ships, who happens to be docked here for a few months, but nothing. Nobody could fix this kiddo's problem. She's going to die. Bleh. Sometimes you just have days like that that stink. No matter how hard we try, there are just limited resources here and we can't fix everything.
Fortunately, although we do have days like that, we also have days that bring great joy at how we're able to help. We found four little kiddos who were unbelievably malnourished and would probably die in the next couple of days. One of the docs with us knew about a hospital run by some Belgiuns who do a feeding program so we put them all on the bus with us and off to the hopsital we went. Hopefully these kiddos will do great after this!