Mission, Zambia, Africa 2017: A Day and Night In Action

Some days I was greeted with a hug, a formal hand shake or a high five, and often I had herds of kids pushing to clutch my hand, feel my curls, and even jump on me to get a selfie. There is nothing these children wouldn't do for a 'sweet' or a ' selfie', and it was seldom that they didn't win my heart and have me give in. 

The daytime hours were spent screening hundreds of children for their basic health assessment, all while addressing the aches and pains of last year, yesterday, or even tomorrow; thank you language barrier. It went beyond  a nursing degree or even my pending NP degree to find a differential for  headaches presenting on a knee; or just a basic interpreter would suffice. I've listened to hundreds of heartbeats, and heard so many variety of arrhythmias, I can practically orchestrate an intricate tune if I combined all those rhythms. I looked into hundreds of ears  and saw landscapes of wax, dirt and often insects lining their ear canals, paving a bumpy, odorous, road to the frequently infected eardrum. Exploring their mouths as part of our general screening, consisted of a visual venture into the tunnels and pot holes of the cavities and rotten teeth scattered within their gums. Sometimes, it was a large hernia, other times an interesting rash or an infectious disease, but each day there was something we came home talking about. We also performed some eye assessments, and fitted kids with glasses. Using a water adjustment system in the lens; we adjusted the lens on the spot based on our assessment of how they did on the eye exam. We used up and down pictures and had the kids move their hand in the direction of the picture we pointed at instead of them reading letters, since many cannot yet read. 

Everyday, I looked into hundreds of eyes, each one deep, dark and soulful . Each one is a life, with a story, with aches and pains that I don't always understand, but with deep soulful expressions that will melt the heart of anyone catching a glance.  

Nighttime in Zambia is spent awake, because, why sleep when you are a night shift nurse?!?

Enter the labor ward in Zambia clinic. 

We have  a few clients in labor.  Some are first time moms. One is in active labor, one has been having contractions all day, but with no progress. One mom needs IV fluids, I offer to place an IV, but the clinic is out of IV bags. Scratch that, we improvise; we send the patient's mom and aunt to go buy some drinks; and we give some oral rehydration. We encourage her to continue walking with hope of progressing her scattered contractions into active labor.  Another mom is in preterm labor at 26 weeks, so we called an ambulance to come take her to hospital; 45 minutes later we are still waiting. 

 Soon another mom shows up. Her name is Giveness, and she is expecting her 4th child. She says that she has had pains since 1000, it is now 0300. Lacking proper electricity and power, the lighting in the clinic relies on a combinations of sponsored solar powered lamps that intermittently work, candles, and the headlamp I brought from America. We do a pelvic exam, and we listen to the fetal heart rate. There are no monitors to attach the mom to, and no fetal heart waves to examine. We use a manual fetoscope that we place on the moms abdomen to measure the fetal heart rate. I put my ear to the fetoscope, and I hear the fetal heartbeat.  The midwife does an internal exam, and she is fully dilated.  It has been about 10 minutes since she arrived in the clinic; and it's time to begin pushing and deliver the baby. 

One of the lamps are beginning to dim, I pull out my head lamp, the midwife lights some candles and we prepare the delivery equipment. 

 There is no such thing as pain medications or epidurals in this birthing ward. The women just wing it. They also pull themselves up onto the elevated bed. No machine adjusts the bed's height to convenience a body with a huge, painful abdomen. They climb onto the beds on their own. The bed is clothed in linens that the expectant mothers bring with them. We layer the bed with plastic garbage bag that the laboring women bring from home and layer it with their "Chitenga", a traditional designed cloth that has a multipurpose usage as skirts, dresses, hair wraps and baby carriers. Here it is used to dress the bed that they will deliver their baby on.  We prepare the baby warmer that is not working, we layer it with blankets brought from home. 

 We don our gloves and aprons, the midwives and I, and we are ready to deliver. Giveness (the mom) climbs onto the bed, that she made. There are no stirrups to secure her position. I hold on one side and the midwife assists with the other. She has no family there for moral support, so she squeezes my hand with every push. She is crowning. The midwife turns to me, "Sister Devorah, are you ready to deliver a baby?” Not in the least bit, was I ready. The last time I delivered a baby was a year prior in pure candlelight, in this very clinic, with the same midwife, 'Mwamba', as they call her. However, what changed in the past year is that now we have some light, I have done this before, and I have since become an ER nurse; which means whether I am prepared or not, I must deal with whatever situation faces me at that moment. As an ER nurse,  I have learned that I must always be ready to deal with the unexpected, if not physically, then at least mentally, because no one plans an emergency.

She begins to push, and she is definitely in pain, but she doesn't make a peep. The bed is flat, there are no pillows, and she is laying on her back, so as we hold her legs She holds up her own head as she pushes. Before I can blink, the head is out and I begin to position it and guide the shoulders. The cord is wrapped loosely around the neck, I fumble my fingers through it and hold it down as the midwife helps pull the baby out. It is a tight squeeze, but the baby is out. We dry her off with a towel, she yells out in a strong, loud, shrill and we place her on the mom for skin to skin. I give a proud sigh of relief, we are done; a new life is born. Still slightly holding my own breath, I clamp and cut the cord with a sharp needle because, the razors which they usually use, are out of stock. With a candle, still flickering in the background I hold the baby up to the mom so she can see the miracle that she just painfully but bravely delivered. 

It's a  girl!!!

As we are cutting the cord, I mention to the midwife, that the cord seems a bit short. She looks at the cord and touches the mom's still firm belly, and says " Sister, there is another". I quickly take what has now become baby #1, weigh her, 2.0kg, wrap her in layers of blankets and head back to the mom. 

The mom is not aware there has been not one, but two humans growing inside of her. When  we used the fetoscope to listen to the heartbeat we didn't think to listen out for another. As Mwamba does an internal exam, she says that she feels a limb, and the baby is in a breached position. However, because the membranes are still in tact, and we have no ultrasound or other diagnostic tools to assist us, she has difficulty determining the exact position. The midwife wants the place a urinary catheter, because she needs an empty bladder to allow for more  space to assess and maybe reposition the baby internally. Slight bump in the road, we are  out of catheters. Mwamba thinks fast and grabs the IV tubing we had out for the mom who needed fluids, but had no IV bags. She tears the tube and places it inside the urethra as she would with a catheter. The bladder drains, and she begins an internal exam. However,  before we can think further, the membranes open, and the mom insists that she needs to push. Before, we can do anything else, she gives a strong push, and I look down at her vagina to see what looks like feces squirting out of a butt, and a miniature vagina, as well as a tiny hand, staring back at me. The little girl, baby #2, made her surprise entrance into the world, butt first! 

We fished around a bit to find the other arm to pull out, and the mom continues the hard work of pushing. Soon the head is revealed with the cord around her neck, we untangle it, perform aggressive suction, and hold our breath, until baby #2 reveals her voice, and ability to breath with a loud cry. Now, we breath. 

As I fumble to find oxygen and tend to babies, Mwamba tends to the mom, to deliver the placentas and to stitch her up. Baby #2 is 2.1kg. 

 One of the overhead lamps that was flickering a dying light, suddenly comes back to life with  a brighter shine. Once she is stitched up and cleaned, the mom then gets up, carries her bucket of belongings and sets herself up in the postpartum room. A short while later, after we cleaned, dressed and wrapped up her babies (in layers of blankets and mini towels as diapers), the mom rests in bed, sheltered by her mosquito net, we hand her the babies to be fed and stay with her for the next few hours until she goes home. 

Not one crib exists in the postpartum room, babies all sleep with the moms in the same bed. Most mothers stay in the postpartum room for six hours until they are discharged. Since it is late at night this mom will stay until the morning. 

We now refocus our attention to the other laboring moms. The ambulance finally came to retrieve the mom in preterm labor; 1.5 hours after it was called. The mom who had been drinking fluids is reassessed and she is more dilated; success, labor is progressing. We allow her continue resting and walking in the postpartum area until she is ready to push. We can't bring her to the delivery area, because we have only 2 beds there, and both have been filled by two moms who have just walked in in active labor.

 It's nearly 0500 (5AM). The midwives of G'Nombe Clinic didn't get to jump into their on-call bunk beds for a nap tonight, because it was just too busy. As the sun is beginning to rise, and I am preparing to leave so that I can go home, change, and take a quick nap before I return to schools and the clinic for my day time role, two more babies are born. One of those babies, is born in the postpartum area, our lady with the 'slow' labor progression, caught up pace rather quickly. 

I head out of the compound just the roosters are crowing in their morning tunes. The sun is beating strongly. Patients begin to flood the lines of G'Nombe Clinic, and new day has begun  in a little compound in Zambia, Africa.

Striving Novice On A Mission, Zambia, Africa 2017: What Am I Doing There?

Hundreds of schoolchildren, many clothed in similar uniforms, some wearing shoes, some barefoot, form lines leading to the large tented area in the center of the school yard. Some waiting more patiently, and others, well, less patiently, for their turn to express all their aches and pains to any of the health clinicians who will listen. The process of this system will entail, baseline health screening for the students, referrals as needed and medication prescriptions and administrations as necessary. But how can we ensure that the prescriptions will be filled, that the meds will be taken as prescribed, that follow ups will be carried through, and that our interventions are helping to heal the symptoms?

To make this scenario more applicable, in a world where a 6 year old child is more literate than his mother or father, where the nearest health clinic, may be miles away but transportation unavailable, and where disease and illness are rampant and deadly; how can this continuity of care be maintained? How can one ensure that the child who came to clinic with an ear infection will actually pick up medications and receive follow up to assess whether the infection has healed? 

Here in Zambia, the focus is on the educational system, the most steady and reliable atmosphere in most villages. We recruit some of the more  literate populations, the teachers and the students mostly, with occasional medial professionals or medical professionals in training to participate in health maintenance programs. Many of the teachers undergo a basic health training session, and serve as the pioneers who maintain the connection between the students/patient,the parents and their healthcare interventions, as well as assessing outcomes of interventions and intervening when necessary. The teachers help the medical staff by gathering the children, collecting basic information and bringing their students to the clinic. The role of the teachers who participate in this program, is to help facilitate some sort of continuity of care, via serving as the string that holds the patient and their healthcare resources together. 

This program produces a multifaceted outcome, since many who participate also acquire health education and knowledge through the process of receiving actual medical care. The teachers learn through their training and interactions. The students learn from their teachers and through the health screening programs. And some parents even learn from their children. Even the foreign nurses, such as myself, who travel across the world to participate in this incredible operation learn so much through working in the screening process or just seeing patients at the local clinic. As a nurse, my assessment skills have sharpened, since I assess so many patients each day. I have heard more heart murmurs than I heard when I worked on a cardiac unit, I often make decisions that are way beyond my scope of practice in the states, and I see cases that I would never see working in a large city hospital. 

Everyday that I wake up in Zambia, Africa, to be a part of this project, is like waking up to a new learning experience, and a new world of medicine to experience and acquire knowledge from. It is like waking up to a new, fabulous, brain stimulating adventure each day. 



Devorah Goldberg RN, BSN

Sent from my iPad.

StrivingNoviceMissionZambia2017

From paved roads and sturdy bridges which compile the concrete jungle  that I call my home; to a rocky unpaved African village with rickety wooden bridges, and hand made, cardboard structured homes. My nursing journey will once again take me across oceans on to another continent where I get to combine my various passions for travel, adventure, nursing and of course meeting new people and exploring new cultures. Entering this other world of living, health, and nursing is like the spark that rejuvenates my passions for the work I do and live for.  That passion that sometimes drifts into my daytime naps and sleepless days, and but is so needed to help uplift my stamina to provide care with a full heart and complete devotion. Volunteering and using my nursing skills in such an arduous setting serves as an energy boost that simultaneously humbles my everyday practice and revives the spark of interest of a #strivingnovice to challenge my nursing spirits and to humble myself in the work I do.

Last year when I scored the opportunity to travel on a nursing adventure, to practice the work of my passion, in a foreign country that was lacking the essential necessities that I use each day at work, but often take for granted, the accessabilities which myself and my patients are privileged to attain; my thirst for another opportunity to combine my two passions of traveling and nursing, only became more parched. Before I ever went on a travel mission, the idea was more like a freign dream, something similar to my once imaginary vision of nursing, that consisted of a hero shocking pulseless humans and performing compressions. A dream that was void of disgruntled, odorous patients yelling, demanding and requiring the little bits of my nursing capabilities. That hero nurse fizzled into the air as my life became consumed with the real life world of nursing, school, and my ongoing attempt to fit life, health and some sleep hours into the almost non existent time slots in my schedule. But I learned, that everyone has a busy life; even people with the passion to creep outside the lines that mark their schedules, and which overtakes the minutes we hope to sneak into our limited lifetime to make some of our dreams come alive. So if it meant giving up on sleep for the few days before the adventure, some extra organizing, and pleading emails to be granted time off, I was going to  give one of my dreams some life for the second time.

So,it is just a few weeks into my second to last semester of NP school, and after completing 3 ER night shifts and 3 NP clinic days;and after few flight cancelations and other airport drama- thank you- #winter2017snowstorm, I have finally embarked on what will hopefully be another educational, fun and fulfilling adventure; as I fly across the some continents to dive into a world of nursing and healthcare that is void of computer systems that dictate what I did and what I can do, lacking essentials such as power and electricity, and bare of what I used to think is essential in the life of healthcare and life saving environments. With vaccines ingested, and injected, bags packed with random basic items to fill the bare supply rooms in the small clinic and labour ward,such as lights ( as in candles and electric headlamps), gloves, resuscitation devices, and sanitizers; and some kosher food; a tired but adrenalized #StrivingNovice, with a newfound energy obtained from the mare exhilaration for what  will greet me after my 20+ hours of travels, as well as ambition; to bring light, smiles, candies and healing to some remarkable human beings inhabiting some small, rocky,  unpaved villages in Zambia, Africa.-#StrivingNovice takes on #MissionZambia #2.

#alwaysstriving

#StrivingNoviceTakesZambiaMission2

#ERNurseDMissionZambia2017.

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#StrivingNoviceMissionZambia2017.

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Devorah Goldberg BSN, RN