August 19, 2017 Saturday
I’m currently writing this in the pitch dark. It’s night time in Tanzania and all of the electricity just went off. A few nights ago after tossing and turning all night because of hearing various sounds throughout the night I woke up in the morning at 5:30am to the sound of heavy rain, electricity no longer working, and a leak in the room. All of the electricity goes out periodically here; both at the house and hospital. There are a lot of things that I’ve experienced here on a regular basis that I wouldn’t typically experience at home.
Sometimes the water goes out when you need to wash your hands or even while you’re in the shower. The toilet will stop working, sometimes the toilet is an actual hole in the ground,
having to hand wash clothes, not having any toilet tissue in any of the public restrooms, constantly having to have bug spray on because misquotes are everywhere at all times, no AC anywhere, etc. However, I can’t even complain. There are so many people here who don’t even have a proper toilet. I’ve seen people washing their clothes in puddles of water and in the ocean. A lot of people in Africa don’t even have electricity. I am very fortunate both here and at home.
When I look back on this week I’m not gonna lie, it has been a really hard one. I’ve just really had my ups and downs. Especially with seeing so many painful and tragic things in the ED. Today as I reached my half way mark I had a mix of emotions. At first I was excited to be halfway done but the more I thought about it, it made me very sad. Of course I miss my dear family, boyfriend, friends, and the little things that America has like oatmeal chocolate chip cookies or AC but I’ve finally made some really great friends with the Tanzanians and feel like I’ve got a good bearing of this city. The people at the Work the World house have been amazing and I’ve been great friends with everyone since day one! However, it’s just different with making friends with the native people. A lot of people come and go at the Work the World house. Everyone that was here when I arrived has left now. The two girls from Belgium that arrived the same day I did just left an hour ago. It’s been so hard saying goodbye to everyone. There’s been people from all around the world: England, Belgium, Netherlands, and Australia. So far I’ve been the only American which has been hard. But everyone has taught me so much about their healthcare systems and cultures.
When I met with the Lumos committee I will never forget what one of the people on the committee told me. He said to be sure to
really make an effort to get to know the local people.
I couldn’t express how it has been the best and most rewarding thing I have done since I’ve been here. The people and culture are literally my ultimate favorite. I’ve never met people as kind as I have here. If you show them a little interest they will pour into you times a million and give you four fold. Everyday is literally a new adventure. I never know what’s in store. Of course I know I’ll be waking up at 5am to get ready for the hospital and it’ll be an hour commute. I may or may not have a seat on the dala dala. But, the hospital is always a surprise. Which nurses or doctors will I see today? What patients will come in? What new friends will I make? What will my evening be like? I hardly ever leave the hospital at the same time in the afternoon/evening. It may be 3:00p or it may be 6:00p. Sometimes a nurse will take me to her home or student nurses will make me dinner and let me come into their hostel. Everyday is literally a new adventure!
My first full week in the ED was extremely eye opening. Everyday felt like I was in an episode of Grey’s Anatomy. I won’t go into too big of detail because I know how some people don’t have super strong stomachs and because of patient confidentiality but I would see patients all over the spectrum: SEVERE motor vehicle accidents, SEVERE burns, accidents with bombs, gun shot wounds, several head hemorrhages, tetanus, TB, malaria, many cardiac arrests, machete accidents, and so much more.
I’ve seen tragic things at the same time. There was a patient who’s blood pressure was 300/200 and was having a stroke. She didn’t have the money to afford a CT scan which is about 170,000 Tanzanian shillings which is about $60 US Dollars so they wouldn’t let her have one. When I asked what’s going to happen to her they said she’ll remain there until her condition improves or worsens. If it worsens she’ll be sent to palliative care. It was midnight and she had arrived early afternoon. Her condition was only worsening. She was struggling for each breath, she was bleeding out blood, and her blood pressure wasn’t dropping. The only thing they were giving her in the IV was dextrose. I was so confused and upset on the inside but I simply had to remind myself of this phrase, “It is what it is.”
I’ve faced a lot of ethical dilemmas while I’ve been in the hospital. There are so many ethical decisions being made that I don’t always agree with or understand but I’ve learned to just observe everything going around and accept what is happening. For instance, my last day in ED there was a patient with 3 wounds to his head. We believe they were gun shot wounds. He started going into cardiac arrest so we began CPR. However, when we would do rescue breathing for him the air would come up through his head and more blood would gurgle out. Eventually he went back to a normal sinus rhythm but shortly after he was somewhat stable his B/P dropped and he went into cardiac arrest once again. Right then and there all of the nurses and doctors began talking about whether they should do CPR again. They stated his pulse was gone and asked if anyone had any issue with leaving him as is. No one advocated to continue so they just left him. My insides flipped over in that moment. I had just never seen that happen before. From what I’ve seen in the US the doctors and nurses will try everything in their power to keep the patient alive unless they have stated they’re a DNR. This patient was probably in his late 30’s. I honestly haven’t seen anywhere on any patients charts if they’re a full code or DNR so I’m not sure if they have that here but I’ll have to ask. This is an example of just one of the many situations I’ve seen where ethics go into play. I could see where the healthcare team didn’t see a purpose in continuing CPR because of the overall outcome of this patient. However, it was just hard to see people giving up on someone to live.
There are two other patients that I would like to talk about that really stood out to me during my time in the ED. I had both of these patients on the same day. Let’s call the first one Rob and the second one Jim. I won’t be able to go into too much detail due to patient confidentiality.
Rob was an older man who has been suffering from various health conditions one of which was cancer. He came into the hospital with a chief complaint of overall malaise and weakness. He didn’t seem 100% orientated and he was struggling to breath. We put a non-rebreather mask on him to increase his 02 level. However, he kept trying to pull it off. The doctors and nurses ended up restraining his hands to the bed so he would keep his mask on. When I was in the SICU at Vanderbilt a patient was so delirious because of the lack of oxygen that he kept trying to pull off the mask, just like the patient was doing here, so the doctors and nurses gave him a light sedative to keep him calm. I thought it was the best thing they could do since they didn’t have the sedatives available. However, he was really having a hard time breathing. It’s always so important to observe your patient and listen to what they’re saying. A teacher at Belmont once taught me that a nurse is nothing without their assessment. However, they kind of just left this man in the corner of the room. About an hour later his breathing stopped all together as they were attempting to intubate him. Due to his various health conditions they didn’t feel it would be a good overall outcome if they attempted CPR. Almost an hour after his death various doctors were still practicing how to intubate. They had the device in his mouth and one after another doctor would practice and clean up their technique. This made my stomach sick and made me so sad. With patients I always try to think of them as an actual family member. This man was just a few years older than my Dad. I wouldn’t want anyone doing that to my father! No way could I do it on this man. Some of the doctors asked if I wanted to practice but I said no. I understand their reasoning so they’d know how to do it on future patients (some American intern doctors were teaching them how to properly do it). But I still didn’t feel right about it. After they all practiced intubating him they just left the room leaving him there. My mind immediately went to what I had learned in my Adult Health 2 class about postmortem care. During my SICU clinical experience back in the US I had experienced my first death of a patient and that was the first time I had done postmortem care. I was incredibly thankful for that experience because it helped me in that moment. Although the postmortem care was a bit different here I was able to do it. One of the hardest things here in the hospital is not being able to speak Swahili fluently. From context clues and simply observing the situation I was able to identify who his daughter was. I wanted to so badly be able to speak with her in her language but all I could say in Swahili was that I was very sorry. It was so interesting to watch how the healthcare professionals treated her. It’s just not what I’m used to seeing in the US. I just kept putting myself in her shoes. If my father had just died I would be a basket case. She called her mother on the phone to let her know. It was all so heartbreaking. To make the situation even worse I was watching what the nurse was doing on the computer screen. She was JUST NOW PUTTING IN HIS TRIAGE INFO and how he presented upon being admitted. She wasn’t even the nurse in the room that saw him once he got there so she was making up a lot of it. It was over an hour after his death and she was just now putting in all of this info that had happened upon his initial admission which was about 4 hours ago. This just surprised me so much. She was documenting on a dead man from when he was alive hours ago because it wasn’t done yet. The situation with this patient really made me sad. What if I had just listened to him when he was taking off the mask. Maybe he was just trying to show us he wasn’t breathing properly with it on and that’s why he was trying to take it off and we should’ve intubated sooner. I’ve faced a lot of situations in the ED that made me question how good my nursing skills are. I don’t have that many clinical skills under my belt since I’m a recent graduate but I just can’t help but think if I maybe had more experience I would’ve been able to save more patients lives.
Later on in the day the second patient that I would like to talk about came in, Jim. He was about my age and was a very fit young man. Looked like someone that nothing could hurt. He was very muscular and healthy looking. Just full of life. However, like many of the patients he was involved in a motorcycle accident and was laying on the bed lifeless. The doctors put me in charge of suctioning and manually bagging him. I did this for about an hour before we transferred him. As we were transferring him I was still bagging him. We took him all the from the ED to the surgical intensive care unit. Which was a good 10 minutes walking distance. They were strolling him and I was bagging him while I tried to dodge running into people. Once we got to the SICU we were able to get him hooked up to the ventilator. However, the SICU was the most eerie place ever. I felt like I was on an episode of The Twilight Zone. The windows were tented with this dark pink/purple tone so you couldn’t see out of them and there were all of these constant noises that would come on every few seconds and play in harmony with one another. It was pure white on the inside and all the patients were lying across from one another in the ward not moving or talking since they were mostly all on ventilators. It was just a very creepy feeling I got. And all the doctors were dressed in a different outfit with white shoes on. The facility seemed great though. It seemed like they had a lot of money going towards that ward which was nice to see.
The teachers at Belmont have taught me SO much! I hold onto everything I learned while at school like a treasure. It’s really helped me while I’ve been here.