Thursday, July 25, 2013

African ICU

Yesterday was one of those days that I think might be imprinted in my mind forever.  I went down to the pediatric ward in the morning to round on the kiddos.  Rounds were pretty benign (which means I didn’t stumble upon a kid that was barely breathing and end up spending an hour literally running (always gets a “heeeeeeeeey….look at the white lady run!) up and down the hospital trying to save them.  The kids were all stable.  I wasn’t sure what to do about two of the kids so I went and talked to the new doc (he’s awesome!) about them.  He said he’d go take a look at them and I headed up to the house.

A couple hours later I was doing some homeschooling with Marie (which no doubt meant that I was inwardly beating my head against the wall while outwardly calmly pointing out ONCE AGAIN the difference between a straight and curved line) when the doctors wife came up to ask me something. She told me that they were bagging a kid (“bagging”= placing a mask over the kid’s face that’s attached to a bag of air that you squeeze to breath for the kid when they can’t breathe on their own) and wanted me to teach the family how to do it so they could all rotate.

Ok. Pause. What? They’re bagging a kid?  I didn’t think we did that here? The ICU nurse inside of me got really excited. When I moved here one of the most difficult things to get used to medically (don’t get me started on the food, bugs, larger gross animals, shirtless women, etc) was that we don’t do any “heroic measures.” That means when a person stops breathing, we just let them go.  (We do make exceptions for newborns who need a little help to get used to living outside the womb). This flies in the face of all I’ve been taught as an ICU/ER nurse.  When people are dead, we do our darndest to reach out there and snatch them back. 

I digress. I went down to the Peds ward to see what was going on. When I walked into the ward I saw that not only were they bagging the girl, but the doc had intubated her. This means that she had a tube down her throat into her lungs which allows the air to easily pass through.  She was about 12 years old and had been bitten by a snake approximately 30 minutes before coming to the hospital. When she came in she was crying and upset but then started vomiting, seizing and eventually stopped breathing. Hence the intubation. 

I showed several family members how to bag and went to find a suction machine to try and suck some of the junk out of her lungs.  I proceeded to accidentally fry our suction machine when I plugged it into a 220 socket. I’ve been here for 2 ½ years. I still do that. Darnit. I started heading back to the house to e-mail my dad and ask for one on the container that’s coming when I noticed a little bit of commotion in the peds ward. I turned around and went back. (Incidentally, praise the LORD we had several other suction machines in storage….so I was able to sleep that night).

When I got there, the doctor and his sister (a nurse that just got here and is visiting for a couple weeks) were at the bedside of the little girl.  He explained that in the bagging, we’d essentially collapsed a lung. (Air was on the outside of the lung and was pushing against the lung, not allowing it to expand).  He said that this is inevitable with this kind of bagging which is why we always put patients on ventilators that regulate the pressure that’s used to push the air into the lungs. When I’d left the girls oxygen saturation had been 99% (we want it over 90%). Now it was 50%.  He proceeded to stick a needle into her chest, letting the air out and allowing the lung to inflate again. The dilemma was what to do next. We needed a one way valve so the air could come out but not go in. He said, “well, in the books they do this…” and proceeded to take a rubber glove, cut off the tip of a finger and put a slit in the end. Then he taped the tip of the glove to the end of the needle.  It’s a valiant effort….but not a long term solution. She needed a chest tube.  This is a tube that’s inserted into the chest to allow the lung to continue to inflate and deflate. So how do we make a chest tube here?

The next hour was spent trying to find supplies to see if it would even be possible.  And if not, how can we jimmyrig something so it would work.  We found a contraption called a “pleuraVac” which is what we use in the ICU for our chest tubes.  But as we’re talking this all out and the doc is making sketches of exactly how we could make this work, we’re overcome with our limitations. I don’t know how many times the words, “if we were in America…..” were said. 
The fact was, even if we could get this to work, the chance of this little girl surviving was very slim.  We needed 24 hour electricity in order for the chest tube to even work.  Our solar usually goes off around 11pm at night. There’s no way the patients family could afford to pay to run the generator all night and the hospital doesn’t even have enough money to run it for 2 hours a night to give the staff homes a little electricity in the evenings.  Things are VERY tight right now.  He said that she would need the chest tube for at least 3 days. Then there was the issue of the ventilator. We don’t have one. Someone would need to bag for 24 hours. And the same thing would happen again. The air would start going into the wrong places and she’d blow up like a balloon….and then die.  There just wasn’t anything we could do.  Which as health care providers is VERY frustrating!!!  As we hashed it out between ourselves we realized there was just no way this was going to work.  So I prepared to do something that I haven’t done in years.  Withdraw life support. Only this time it wasn’t on an 87 year old man who’d coded in the nursing home, it was on a 12 year old girl who was helping her family on the farm and was in the wrong place at the wrong time and got bit by a stupid snake.

We went back to the ward and asked to see the girls mom and dad.  When we were told that the mother had left, the doc asked them to go get her. In that moment I realized that I’ve been here for awhile.  I put myself in this doc’s place (newly arrived) and of COURSE you have the parents come. They’ll sit with their child and say goodbye while she goes.  That’s what we do.  In America. Not here. Here, the parents usually leave when it looks like the child is going to die. They can’t bear to watch.  (Incidentally I was talking about this with my friend Peter (Sierra Leonean) and he was equally horrified by our culture’s need to be present as I was at the parent’s absence here. “How could you sit there and just watch your child die?!?!!) 

So I knew that asking for the parents and waiting until they got back was not going to work.  We had asked for the parents, but the family brought us the grandfather. They said he was the “strongest one.”  The doctor proceeded to explain everything. He explained what we’d done, what our goal had been in intubating her to begin with (see if we could breathe for her long enough for the paralyzing poison to wear off) but that we’d reached a point where we just couldn’t do anything else. And we were suggesting removing the tube….which meant that the child would die.
The grandfather agreed.  We removed the tube.  She had absolutely no respiratory effort of her own. And we sat there and held her hand, touched her foot and cried with her mother….wherever she was, as her child slipped away. 

Later that night I went down to the doctor’s house to see how he was doing. Both he and his sister had taken off (totally know that feeling when you just have to get away).  I started talking with his wife about what happened that day and she asked me how I do it. How do I stay here and keep working with no supplies, so much death, etc. She’d asked me that before so I’d been dwelling on it for a little while. I think the answer is probably different for everyone, but mine is pretty simple.  Number one, I STILL get frustrated with the death, the lack of supplies, etc.  It’s a DAILY struggle.  Number two, I think some of it is just time. It’s a BIG jump to go from working in a country with some of the best medical care in the world to working in a place that has one doctor for how many tens of thousands of patients.  A BIG jump.  But this is my reality. And at some point you have to start accepting your reality or go crazy. I’ve been here for almost three years. They just got here. They didn’t see me when I first arrived!! J

But I think the biggest thing the enables me to stay here is that medicine is not my end goal. If it was, I absolutely would go crazy.  When I saw that little girl intubated yesterday, the ICU nurse in me got really excited.  We were going to get to radically try to save a life. But in the end, we failed. As we were sitting there holding her hand while she passed away, her grandfather had tears in his eyes but looked repeatedly at the doctor and said, “You tried. You really tried.”  And we did. We did everything in our power to save the little girl but in the end it wasn’t enough. And while I get SO frustrated and tired of death, I know that while we couldn’t save her, yesterday we showed her family that their child was important. We loved them by loving their child.  I can’t save everyone. I believe that ultimately, God is the giver of life. So I’ll work as hard as I can for them but whether or not I can save them, I will love them. And someday when I stand before God, I think He’ll say it was enough. “His grace is sufficient for me.”

Wednesday, July 10, 2013

A time to live.....a time to die....

Death is something I deal with on a weekly, if not daily and sometimes hourly basis.  For that reason I was surprised to realize yesterday that in my two and a half years here, I have never been to a funeral.  I’ve pronounced plenty of people dead, I’ve used my car as a hearse many times, but have yet to observe the whole thing. Until yesterday.

Two nights ago my friend Peter called me to tell me that one of his employees had lost his mother. It was unexpected because the woman had been pretty healthy and suddenly keeled over and was dead.  She had been visiting her family in this village so they needed to get her body back to her own village and I volunteered The Colonel (my car).  They decided to wait to take the body until the next morning. 

The next morning Peter and I took the body, along with as many other people that could cram into my car to a village about 7 miles away.  The women in the back periodically started wailing and singing woeful songs.  After a few miles Peter told me to start blowing my horn continuously every time we reached a village.  Not liking to draw attention to myself I asked why and he explained that this way people would know they were coming with the body and would come for the funeral.  “How do they know who the body is? How do they know what village we’re going to?” “They just know. People have told them.”  The information that is passed to people in the middle of nowhere still amazes me.

We arrived to an assembled crowd in the village, all wailing. I wish I could convey the sound of this wailing through a blog.  I’ve heard it countless times, but it never fails to take my heart and give it a good twist!  I started tearing up.  Death is just so hard!!

 They took the body into a house. When I asked Peter what they were doing, he said that they were washing the body and dressing her in a white dress that had been made that morning by the tailor. She would then be wrapped in the same white material, with her hands and feet tied together.  The wailing continued to come from the house.  While we were waiting someone started beating a drum signifying that the woman had been related to the chief.  A small boy started beating on a tire rim that was strung between two trees, the signal to begin coming to the church. 

After thirty minutes or so, the women came out of the house with some male pallbearers carrying the body.  They made a procession into the church where we had the service.  There were no children present.  They don’t come to funerals.  The pastor briefly spoke about the woman and her faithfulness to the church and then spent 20 minutes or so challenging the congregation to begin financially preparing for their own funerals so they would have nice ones.  No comment. 

The pastor did preach a nice message to we who were left about our life being a vapor and encouraging us to make the most of it.  We sang several mournful songs and the mood was sober.  After the service was over we took up the rear of the procession as they took the body to the cemetery, singing the whole way. 

Cemeteries.  I love cemeteries ( I know, I'm kind of odd) at home but when I came here I noticed that I saw very few.  I think I’ve seen two.  So where do they bury their dead?  I’ll tell you. In the middle of the bush.  We went down a path to the “cemetery” which I definitely wouldn’t have known was there.  It felt like something in a novel....from a hundred years ago. The trees were hung low.  People were gathered around a 4 foot hole that was clearly a grave, and the body was placed beside it.  As I looked around, I noticed mounds of dirt near the grave.  One had the mark of a wooden cross. The other had no marking.  When I asked Peter where the other graves were, he explained that they were all around us, but were in various stages of being reabsorbed into the ground.  No markings. 

The pastor shared a few words and then opened it up if someone else wanted to share.  After the sharing, the singing started again and the body was lowered into the grave. At this point there was some confusion about who was supposed to lower the body into the grave. Some said that women had to lower a woman down, but others said it didn’t matter. A man beside me muttered “Those Limbas. They have too many traditions!” (Limba is one of the tribes here).  Since three men had already descended into the grave, they let it slide and moved on. The pastor remarked that the younger generation was so bold, but the older people were still afraid to touch a dead body.

After the body was laid into the grave (no casket….just the covered body), her oldest son (Peter’s employee) took a small amount of dirt and threw it into the grave.  Then the men took large sticks, some looked like small trees, and put it over the grave.  They covered the opening completely. Then everyone started taking branches and leaves and putting them over the sticks.  Peter explained that they wanted to make sure that the dirt wouldn’t be directly on top of the body.  Then, as the sticks start to decay they will fall into the hole and all will be absorbed into the earth.  After they packed the dirt on top, we began the procession back to the town.

When we arrived, there were many people assembled under a tarp.  Peter explained that they were deciding when they would do the next gathering.  Because we don’t have refrigeration here, funerals must happen quickly to prevent well….you know. For that reason, they often have another time of remembering for the deceased either 3, 7 or 40 days from the funeral.  The family originally decided on 40 days until someone reminded them that that would be right after Ramadan and they would be spending a lot of money during Ramadan. Would they have money for the funeral then?  See, as I learned….funerals here are a big deal!  If a funeral isn’t done correctly, people will talk!   As the eldest son, Peter’s employee was responsible for paying for most of the people to get to the village and was expected to feed them as well. He said that in big towns some people rely on funerals for their daily bread. They will listen for the sound of a funeral and go there for the food, occasionally hitting up more than one in a day!

As Peter and I were waiting for the meeting to finish, a woman passed by and said, “Thank God that woman gave birth to Idrissa (Peter’s employee). If it wasn’t for him they would have had nothing!!”  I asked Peter why people wouldn’t just be able to understand that they were poor and didn’t have money to feed all these people but he said that if they didn’t have the money they would need to borrow it in order not to bring shame upon the family.  Yikes!!  That's a lot of pressure in your time of grief!

When the meeting was over we crammed about 15 women into my car and headed back.  Not to waste a trip, I loaded up 20 bags of charcoal on the top of my car for another friend of mine. When we stopped to pick up the charcoal I realized that one of the women we had with us was…..rather intoxicated.  The other women said that she had been drinking most of the time during the funeral.  Well, they took to goading her and she didn’t love it. She got so mad that she started yelling and saying she wanted us to just leave her there, and she was going to walk. When Peter told her he couldn’t do that and shut the door, she started cursing us and telling us she was going to take Peter to the chief.  The women kept goading her and she ended up slapping a bunch of them.  They started agreeing, saying we should just drop her on the road! J  We made it back without further incident and I was glad I got to help out a friend and witness my first Sierra Leonean funeral.  I wonder if things here will ever start to feel "normal."???

Tuesday, July 2, 2013

An EYE for an EYE

Well, it’s been a little quiet on the blog front this month. Part of that is because I haven’t been able to see. Literally.  Several weeks ago I went to bed….like I do every night.  When I woke up I could feel that my left eye felt dry and was a little sensitive to the light. This isn’t the first time this has happened so I didn’t think much of it and headed off to work.  As the day progressed, my eye started getting worse and worse.  It didn’t help that that day, of all days, when I was now struggling to keep my eye open due to the light sensitivity that I had the worst. Labor. Patient. Ever. 

Now I’ve never been in labor.  So there’s no way that I can fully empathize with the pain that you ladies are going through. And Sierra Leonean pregnant women, I’m with you! When you’re crying in pain and the men around you tell you you just have to “bear” the pain, I want to slug them right along with you. But this particular woman took the cake for most dramatic labor to date.  At one point I walked in the labor room and she was STANDING on the labor bed (which is much higher than a normal bed AND HAS WHEELS!! Even if they’re locked, they still move a little).  Up to that point I’d been the picture of compassion and patience  so I think it startled her when I very sternly and loudly said: YOU SIT DOWN RIGHT NOW!!  She was on her best behavior. For about three minutes.  Then
it was back to screaming, pulling IV’s out, etc. 

And my eye! My stupid eye was getting worse and worse.  I was working a double shift that day and by the time the OR team got there for this patients c-section (she wouldn’t stop pushing so everything got really swollen and the baby started getting in trouble) I could barely see.  One of my beloved friends who’s always looking out for me called the night shift nurse to come early and as soon as I caught the baby, I went home. 
Attractive.....I know
The next morning I woke up and couldn’t open my eye. Thank you Jesus we have a new doctor that had arrived the week before and as soon as he saw me he said that I had an ulcer on my cornea.  When we were discussing treatment options, he told me that if I was in his ER in the States, he would send me straight to an ophthalmologist.  Well, not so much an option here.  He started me on some antibiotic ointment and we decided we’d watch it.  One of the kickers was that my friend was getting married in a few days and I REALLY wanted to be there for it! Since I didn’t know any ophthalmologists in Freetown, I decided to just stay in my village and see. My mom wasn’t thrilled about that. :) 

I was putting the ointment in for a day or so and went to see the doctor’s wife to talk about a little bridal shindig for my friend.  The doctor happened to be there and when he saw my eye he was….concerned. Apparently it looked way worse. I couldn’t really tell because I literally couldn’t open the eye, which made it really hard to open my other eye so had basically sat on my couch for the last day, listening to movies.  When he asked me to count his fingers, I couldn’t. I could see his hand waving, but my vision was bad enough that I couldn’t distinguish how many fingers he was holding up. Shoot. I’d thought it was because of the ointment I was putting in, but apparently not.  Now it seemed like it might be a little more serious. 

Fortunately I have some great friends and a great God!  My in country director e-mailed an ophthalmologist that used to work here but has since returned to the UK.  He ended up calling me that night and after discussing everything with him put me on an antibiotic regimen of eye drops every 30 minutes for 2 days.  Then I decreased it a little bit. He also gave me the name of an ophthalmologist from the States who was working in Freetown!!  I did the drops as prescribed, got to see my friend get married, and then headed down to Freetown to see the eye guy. 

When I saw him that morning, he said that I was pretty lucky. Apparently these things can ulcerate and perforate the eye (put a hole in it) within 48 hours. Ummm….scary.  He said that it had headed that way, but that it was starting to heal.  Unfortunately it’s going to take months to fully heal and he said I may never get all of my vision back.  Right now my vision in my left eye is about what it is when I’m not wearing my glasses.  But I’m SO thankful for how things turned out!! It’s been several weeks now and my eye still bothers me, especially in the bright sun, but it could have been so much worse!!  And I was so blessed to have my awesome roommate Valentina who was there to take care of Marie when I was sitting on the couch like a lump for several days.  Vale, you're awesome....and missed!!!! :)