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.”


  1. Thanks for writing and sharing with us.

  2. Oh Emily, this breaks my heart! But you totally hit the nail on the head. People ask me all the time how I am a Pediatric nurse and how I deal with the death of my patients (which thankfully is few & far between on my floor) and that's the reason...because you are making a difference...and you are being the hands & feet of Christ even in the death of that child. May God continue to use you in awesome ways & may you continue to encourage the rest of us with your wonderful stories (happy & sad) :o)

  3. Oh i so much agree with you. christ ask us to do for the least of these. he didn't say to quit when we encountered corrupt leaders or lack of supplies he just ask us to give our all. that is why tom and i will be back full time in november. We to will continue giving our all and trusting him to provide the strength we need . God bless you. Drs. Tom and Karen Asher