DAY OFF, BIRTH ON #MISSIONKENYANURSING2018 (4)

It was a Sunday. We all had a rough morning on our respective units. Deaths, lack of supplies, understaffed, sick patients, and the usual list goes on.  It was meant to be a short day, or even a day off, but we are nurses who love what we do, and so on our day off, we spent it nursing too.

After our hectic morning mentoring students on the wards, we took a short break, donned our nursing hats rather than mentor hats, and found the hidden gem of Busia County Referral Hospital. The NICU. The shelter among the Busia hospital storm. 

 In this quiet, warm room, hiding out within the chaos of the African hospital is a nurse walking barefoot, tending to the miracle babies of Busia. Every birth, every living child is a miracle, but surviving any birth complications in a hospital that lacks basic supplies and resources, is a true miracle. So we sat, on our break day, in this serene spot among a bustling, chaotic hospital, cuddling these miracles, and feeling their heartbeats against ours, as we awaited our laboring mothers to give birth. Coming from wards where we battle and surrender to death daily, it was refreshing to inhale the heartbeat and hopefulness of a fresh life... that was until we resuscitated an even newer life on the same table that these two premies lay,  as they struggled to inhale their own miracle of life. But that comes later in this story. 

We held human beings who fit into my palm. Their rapid heartbeat vibrated against my, now calm one. None of these humans had names yet.  Many won’t have a name untill/unless, they earn an exit from this serene, yet enclosed room. Their battle for entry to survive this world was still being fought, and until then they were just a tiny bundle with a heartbeat. Sitting there cuddling the brand new bundles of life,but fighting to keep their life, brought on a feeling too surreal to put into words or images, because it had to be felt.  

Our calmness was interrupted, a 28 weeker was eager to make an entrance into this world. We settled the babies, 3 babies per baby warmer. Fetus was 28 weeks, mom ran away from home, and had no prenatal care. There we were with white rubber boots and green plastic aprons ready for the 8cm dilated screaming 20 year old to deliver. We coached her breaths, we held her while she screamed in pain,we gave her no pain meds because there weren’t any to give, and it took 4 of us to hold her down and hold up her legs,as we guided her through each push. 

Out came the baby, reddish, blue in color, but with a weak cry. Leah and I tended to mom and Ivy followed baby. Minutes later while Leah and I washed up mother, Ivy began resuscitating, baby, who turned bluer and dropped his heart rate shortly after delivery. We joined, Ivy; and it was only us, the 3 mezungus. We teamed up and resuscitated, all hands, all nurses, no docs, and no meds. Kenya has their own rules for resuscitation, we followed them, because we are in Kenya; 5 compressions and 5 breaths. We kept going at it, determined to bring this miniature human back to life. We stood there, each of us focused on our role, yet communicating as a team.  Breaths, compressions and suction. We remained hopeful, and we continued our resuscitation efforts, all while twin premies shared the same baby warmer we were resuscitating on. We were sweating and having palpitations ourselves. After what seemed like ages, baby gave a weak cry, and so did we. Three muzungu nurses and a baby with a cry.  It was an exhausting day off, working, and witnessing the miracle of life, but it felt so well worth it. 

 Our days on the ward are spent fighting for lives, and we  often lose the battle, or can’t even fight. In this Kenya hospital, everyone is DNR, because even if we did resuscitate them, we lack the means to maintain a patient in that state of health once they are resuscitated. We have no ventilation equipment, no sedation meds, nor any resuscitation meds. When a patient dies we let them go. Each day that  we are on the ward, teaching our students, we struggle to keep our patients from hitting that road block that leads them to that DNR state. We teach our students how to care for patients while they are alive, so that we can keep them alive. We can only save them while they live, but we cannot resuscitate, nor can we really teach them how to.  Sometimes I feel like I watch these pulseless patients, and I want do CPR or give them a few breaths,whatever it takes to save a life, but my hands are tied. We had a few patients die because of glycemic issues, which we may have been caught if we had something as simple as a glucometer. But there is one for the whole hospital. So really we try to maintain lives, because even with the minimal supplies, we can still attempt at that. 

So, there we were, finally with the means to save a life we went for it, long as it took, and we finally felt like a nurse, like a life saver. 

We came home in a light mood,and  we debriefed. It felt good to bring a life into the world, and then bring it back to life, only minutes after it entered the world.

That night we each prayed for that nameless baby boy. The next few hours would tell, or at least indicate whether he will win the victory over his nameless NICU sentence to a world with breaths, sunlight and growth; oh, and a name!

We came back to work still thinking about our baby, but got busy on our wards. That day, each of us, working on 3 separate wards, lost patients who had managed to crawl into our hearts. We knew we only had minimal means to try save them, and try we did, as we taught the students to do so as well. After one of the deaths that morning, the family member went to the nurse and with the most genuine, yet heartbreaking words, said “thank you for trying”. Sometimes, try is all we can do, especially in Busia, Kenya. 

Needing some life and hope for the work we do, we went to check on our baby boy in the NICU. Our boy, had no name, no identification band that matched him to the mom who birthed him lay there, still with a beating heart, not great breathing,non impressive color, but alive; and so we went to have our lunch. 

Hours later, we get the news. Our nameless baby boy, lost the battles to his nameless state in the NICU. 

It was a rough day, with lots of deaths, including those who barely had a chance at life. I kept on thinking about our being there to deliver the child, and then being there to resuscitate him. The “butterfly effect” came to mind. We, the 3 muzungu nurses had to be there on our day off to deliver this baby and save him, even if it was just long enough for his mom to meet him and hold him. Long enough for our unnamed NICU baby to be held and cuddled by the human who birthed him. Our being there, allowed this mother to hold a living child, for the short time he was in the world to take his own shallow breath of life. 

Working in a developing country, with 3rd world medical availabilities, we often feel short handed, and often hopeless when we can’t save when we know we can, and want to. Then, sometimes, we are someplace, at the right moment, to breath some air, compress a tiny heart, and allow a mother to meet her child while it still breaths. 

We can’t always save a life. We can always try to in some way. However, sometimes, all we can give is moment in a life, a lesson for a lifetime, create a memory, for ourselves and for others, that may last a lifetime. 

TB X-RAY VIEW; #MISSIONKENYANURSING2018 (3)

A TB X-ray view of a hospital ward  in Busia, Kenya. 

This view  shadows the bustling,vibrancy, the clutter, the  challenges, the struggles and yet the bareness of the hospital conditions. 

A window into a ward that is so busy, and so full of sickness, yet bare of basic life saving necessities. Infectious disease, rampant, wild, deadly, ‘un-isolated’ and unprotected within a small, confined space; Where disease is rampant and treatment is limited. So is the saga of Busia hospital, through the TB rib view, of yet another infected patient

Wards are one big room; beds lined with plastic mattresses, linen-less unless the patient brings their own. All beds are lined close to one another, no matter the severity or contagiousness of the neighboring disease. In some wards, when beds fill up, mattresses are laid out,or patients share a bed (usually in peds). 

1 nurse covers an entire unit. Sometimes 40+ patients under the charge of one nurse. Each patient, a paper chart with multiple handwritten diagnosis and an endless list of illegible medications. Patients purchase medications and keep them at the bedside, and when they can’t buy their meds, they just don’t get them. When a stroke patient can not afford a CT scan, he doesn’t get one.

Nurses work in the barest conditions. Much of the shift involves  deciphering the illegible, handwritten med list and attempting to acquire the meds from the pharmacy way across the hospital grounds. Most medications are unavailable, including life saving meds such as epinephrine, and bicarbonate. I have yet to find a code cart, and 2 oxygen tanks are shared between 4 adult units/wards. 

Nurses must roll their own gauze for dressing changes. Sugar is used for would care. Rubber gloves are used as ostomy bags. Water bottles are used to house iv fluids. Iv tubing are used to hold broken equipment together. Working on the wards, I use nursing knowledge, and I teach, but I must also find a creative part of me to be able to improvise,so that I can provide basic nursing care.

With so much responsibility, the nurse will delegate medication administration to the nursing students. Many who don’t know what the meds are for, why they are giving them, and how to reconstitute the doses. Doctors rarely pass through the wards. Wards are managed by the one nurse, clinician/ medical interns, and nursing students. 

Families are usually at the beside and they help with feeding patients, cleaning, and moving patients from their bed to diagnostic exams or to the restroom. Family will also feed the patients, even the stroke patients and the unconscious. Some family will help feed patients of other families. When a neglected, ill child was abandoned in the peds ward, another patient’s grandmother, would coddle him and feed him with the same tenderness she provided to her own grandchild. 

Supplies. 
What supplies?

We run out of NS daily. Gloves are a commodity. And sanitizers don’t exist, I brought my own from the US.
Infection control, what is that? TB, pneumonia, meningitis, cancer, malaria, AIDS...all together in one room, coughing and touching each other,and sometimes, even sharing food. 

Every patient is DNR, there are no codes, no intubations or resuscitations; there are no supplies, tools, or medications to manage such conditions. When a patient has reached the dying stage, they just go, we hope someone provides a certain level of comfort care. When they do die, they hang out, uncovered in the big ward, side by iside with their still living, neighboring patient, as they await family to come clean them and pick them up.

The last thing I see, as I leave today, is a dying patient with wet breaths, fluid overloaded, and using every accessory muscle to breath. A nursing student scored a face mask, Leah ( my fellow volunteer) adjusts him for comfort. The family is standing around him and they are praying. 

Today was a heavy day, but I also saw my students apply some of what I taught. 

I leave with a heavy heart for the dying and the sick patients I didn’t truly get to today. I leave with some pride when my teaching is applied. In the US, after a hard day I feel power and pride for my part in helping save a life. 

When I leave after a day in Kenya, I sometimes feel pride for the small things I manage to accomplish, but with a stronger sense of powerlessness, for the things I had to let go of, because I had nothing with which to hold it with. 

The shift is over and a dark cloud is threatening to burst in a downpour. So I leave the gates of the hospital, run along the motorcycle, infested streets of Busia, and make it home just as the skies burst into mosquito, swarming downpour.

A STOOP VIEW: #MISSIONKENYANURSING2018 (2)

I sit on a stoop in Africa. 

I watch the people of Busia, Kenya. 
I learn about the humans, who will be my patients.  

The dust from Busia dirt roads, blow in my face, fogging the view from my sunglasses. 

Motorcycles with more than four people riding its padded,tail edge, motorcycles with moms holding babies, Motorcycles whizzing past me, barely missing the humans crossing the busy streets. 

I watch the humans manning the fruit stands, and the families who stop by on their way home from church for a refreshing snack. 

Families on bikes, elders with canes, teens playing hard at soccer, and little boys intrigued by a bike tire. 

One little girl gets pulled down from high bar of her fathers bike, and he instructs her to go greet the Mezungo’s(white
people), she uses her right hand and greets me with “how are you?”. “I am fine”, I reply, as is expected of me. I feel really popular, as almost every child and even adults I see, greet me with same few words in English thag they know to greet a ‘Mezungo’ with. 

I watch from the stoop I sit on, and they wave at us ‘Mezungo’ sitting there, out of place, in their town of Busia. 

How often do we as providers sit back and try to know the humans we treat at the bedside. View them as the humans in the streets, living life, just like you?

Life goes by fast, almost like the speed of those motorcycles, that often fill the hospital beds with their riders. Sometimes it’s nice to sit back, as the outsider, the ‘mezungo’, and watch those lives as they live. 

Today I’m a nurse, an outsider, a ‘mezungo’, watching from be sidelines. 

Tommorow, I will still be a nurse, I will be a teacher, yet still an outsider, still a ‘mezungo’; but I will take it in, from within the inside trenches of the hospital, with the people I see today in their streets. 

Just a nurse in a mission. 

#KenyaNursing2018

#MISSIONKENYANURSING2018 (1)

Traveling to remote, underserved countries, has been a dream of mine since the spark that influenced my career choice as nurse gave its first flicker. 

Now, here I am at 2am, in a deserted airport in Nairobi,Kenya, just myself, my metallic bags and the airport security officer manning this 
deserted terminal, as I wait for my next flight. I m using this time to reflect upon on how I got here, as I anticipate my experience in Kenya for the next few weeks. 

5 years years into nursing, a few months as a certified NP, $3000 of fundraising, and 2 plus days of travel later,  my 4th medical mission is underway. 

Back when I graduated nursing school I had written a proposal for my ideal medical mission that I wanted to start. I had felt that many medical missions that you see in the media function as bandaids for issues in those undeserved countries. Volunteers go and do great work patching up the wounds, but when another wound appears or this one gets infected, that volunteer is long gone. Thus, my ideal international medical mission, was not
 just to patch up wounds but to help the humans 
living in these countries learn to patch their own wounds. 

My past few missions incorporated teaching, but this one is all about it. My vision, together with my friend Leah, and DeAnn, who organized this grassroots organization, is to provide clinical, hands on skills to both nursing students and practicing nurses in this little land at the edge of Kenya, at the border of Uganda. 

This one is my longest mission yet, and I can’t wait to share my experience. 

Lights in the airport are turning on, and suited people are flocking in with their coffee jugs,ready for a new day. Time to give them back their airport terminal that I moved into for the past few hours, and embark on the final leg of my journey for #KenyaNursing2018. 

USA>ISTANBUL>NAIROBI>KISUMU>BUSIA 
   

TRULY, YOUR NURSE

,Your nurse. 


When you live, we strive to keep you alive 
When you die, we respect the life that you  once were.
 
When you need meds, we medicate you
When you overdose, we narcan you.

When you drink, we sober you 
When you bleed, we transfuse you.

When you are  dry, we hydrate you,When you are wet, we dry you.

When you have cancer, we chemo you, 
When you vomit, we Zofran you

When you are bed-bound, we turn you,
When you need to ambulate, we walk with you.

When you  stroke, we TPA you,
When you bleed, we coagulate you.

When your heart stopes we compress you,
When you almost die, we resuscitate you.
 
When you break, we fix you,
When you fall, we lift you.

When you want to give up, we show our faith in you,
When you succum to your illness, we support you.

When you can’t move, we move for you. 
When you are malnourished, we feed you. 

When you are alone, we sit by you, 
When you are overwhelmed, we calm you.

When you are afraid, we hold you 
When you reach milestones, we rejoice with you. 

When you are clean, we maintain you,
When you are dirty we clean you. 

When you wear a hospital gown, we wear scrubs,
When you wear a wristband, we wear an ID badge. 

When you dream of doing something else, 
We can’t imagine doing anything else. 

When you yell at us, we continue to care for you, 
When you thank us, we greatly appreciate you. 

When you are happy we rejoice with you, 
When you are sad, we listen and stand by you. 

When you are struggling to live we fight with you, 
When you choose comfort care, we pain relieve you.

When you are ill, we heal you 
When you are dying, we comfort you. 

From life to death, from joy to sadness, from sickness to health, from dirty to clean, from sad to happy, from worry to serenity, from tears to laughter, from obesity to fitness, from downhill to uphill, from life to living,  from dying to dignity, from your reality to your destiny. We are in it with you. 

From birth to death, and through the rollercoaster of life.  We choose to to lift you, hold you, and guide you through it all.  We live it with you, so you can live. 

This is my 5th year celebrating nurses week, and I’m grateful to be the hand you hold as we tumble through the often bumpy cycle we call life.

In 2013, I took an oath and assumed the role, NURSE. 

I live it. 
I love it. 
I’m proud of it. 
I never looked back and keep looking forward. 

From my green, scrubs to your open backed, gown, 

I am proud to do the work I do, when I care for you. 

Truly. 

Your nurse.

The Right To Hope

Aritle Written by me, for Allnurses.com
http://allnurses.com/general-nursing-discussion/the-right-to-1143472.html

I'm a nurse.

I see a patient.

I see a human blanketed in white hospital linens, and adorned by more wires than an electrician can handle. I listen intently to the rhythmic tunes emanating off the monitors, I examine their awkward, dancing lines. I scrutinize the rise and fall of a chest, managed by a machine nearby, as its oscillating movements mimic a real, independent breath of life.

I see a monitor with its colors, lines and numbers. I hear it beeping. I view the chart, and its whole list of diagnosis. I stare at the labs and test results and I understand the severity, and the magnitude of their values. I read the doctor's notes and comprehend their impression of the prognosis. I then go about my tasks hoping to prove that prognosis wrong. 
I am a nurse, but I am also just a regular human being. I stare back the the human opposite me, in the bed, under the blanket, wearing the wristband. This human battling a complex version of health, stares back at me. What they see at this time, I do not comprehend, but I imagine them before they lay in this bed.What did they do? What did they sound like? What were their passions? What gave them joy? Who were they before they were succumbed to 12 hours of my care each day or night? 

I say health, because as I see it, there is a line of health and a line of illness, and then there is medicine. Thus, my job as a nurse is bridge each of those parallel lines, so that I can help the human under my care cross those lines from illness to health, via the interventions of medicine. 

So, I see this complex picture and I wear both of my heads, my nurse head and my human head. With my nurse head, I fear what the numbers and prognosis are telling me, and with my human head, I hope to paint a cleaner picture and a sturdier bridge for this shambolic, fragile, effigy of a human being. 

With my human head, I stare at the image again, and I spy a tiny flicker, coruscating from the dark walls once enveloping the glim aura of a dark, chaotic, glim prognosis, with a glimmer of light. That flicker is the family and friends at the bedside, holding onto the human wearing the wristband, who appears to be lifeless, under the wires, tubes, and lines. They carry an instrument that I often, inevitably lose as I don my nurse head and manage a patient to help them battle their illness. They may not wear a stethoscope, green scrubs, hold a needle, manage the maze of wires and tubes, or understand the jargon of medical terms, but they carry a vital instrument that is often lost to a human in the battle that succumbed them to this messy picture of health. It's their instrument of hope.

I am familiar with this instrument, of hope. I have used it before. But as a nurse, to get my job done, to help fulfill that beacon of hope, I must lay that instrument aside and deal with the reality of the numbers, rhythms, and complications that are alerted to me with the alarms emanating from the blaring monitors. I must educate the patient and their family of the reality on my side of the parallel lines. I must intervene when needed, even when it may hurt. I must deal with the unwanted bumps in the road, and reveal it with its sharp and painful reality. When on the other side of the parallel lines of health, illness, medicine and the human roadmap it crosses, I am intentionally blinded to the hopeful outcome, because I understand the meaning of the values and the denotations of the jargon it speaks. 

I am a medical provider and yet I am human. I understand, and I want the outcome you want. But, my hope, while wearing the provider (nurse) head, is blinded by knowledge and experience. I think I know the only possible outcome. Providers often challenge that hope, and wonder why the family won't let that patient give up. Won't let that patient go more peacefully. We as providers know the outcome from medicine. What we don't know is the person; who they are, what they would want, and what they are leaving. We also don't know when a miracle might happen, and as much as we may doubt the ability for that miracle. We provide our care via science, research and with medicine, not with miracles; and so we can leave that up to family and the patient, and then we must support their hope for that miracle.

The reality is that many of us want to live, and we choose life. As providers we help reach that choice of life, within our medical means and capabilities, but until we feel we can. Once we feel like our ability to provide the means of life have been worn out and limited by medicine and scientific evidence, we succumb and offer the patient and their family to allow nature to take the patient on its own inevitable journey in a more peaceful way, if that is what they want. The challenge we face, is when our medicine mind sees the ineluctable outcome, but the patient still holds on to the one last string, to keep that straggly line on the monitor from falling into a dreaded straight line.

Do we push our harsh medical reality out there, or we do keep fighting with them and allow them to hold on and hope until there is nothing to hold?

I used to have an opinion on this. The patient is suffering, is it even fair? Why "waste" interventions if we know the outcome?

That right of hope, is for the patient, but it is also the right that lifts the family through the process and allows them to continue living even when the battle of their loved one has been lost. For without it, what do they have when that life has gone?

You see, as a medical provider, your patient is not just the human that the charts, numbers and monitors are slandering about. Your patient is also the people who care for them, who know what we don't about them, other than their physical features and medical history. Sometimes we must consider the other part of the patient in the clinical picture, the one sitting on the side, and holding the hand of the human wearing the wristband with a medical record number. As clinicians we must also uphold to certain standards, and a code of ethics; to do good, do no harm... We must also respect and uphold to our patients rights.

This right to hope, is a patient's right. When I say patient, I mean their family too. Sometimes a patient is too sick, and too busy fighting to hope, and then there is their family who must cope. How do they cope, when there is a strangulating sense of unknown, looming before them? When the fear of loss consumes them? When the trepidation builds up and then falls with every setback throughout recovery? With the frightening new appearance of their once vivacious loved one, now consumed by wires and machines, only a ghostly image of their vibrant lively self? It is with that thing called 'hope'.

With illness, a human may lose everything; independence, ability to care for one's self or others, to wear the clothing they choose to style, travel to places they wish to explore, taste the flavors of food, and the freedom to live the life that living has to offer. What most patients and their family can choose to hold onto, despite every bump and obstacle along the journey towards health, is the hope that they will make it there.

It is hope that allows them to get up each day and be there for their family member. It is hope that guides their decisions for care. It is hope that allows them to comfort their loved one and support their journey to wellness. It is hope that leaks onto the patient themself and helps them put up a fight. But then, when if the fight is not won? Has all that hope been for naught? 

Something in my personal reality, recently clarified this. I have recently witnessed the greatest undeniable faith, hope and belief, that was so admirable, it changed the way I think in this regard within my profession. I have witnessed the faith of family, friends, a community and even strangers. Some even saw the fragile proximity to the straight line, understood the severity of the prognosis, and still held on to hope. They held on even when they were told it was hours, they held on even as the the angel of death loomed over them like a crazed enemy, ready to strike and win a fight. They didn't let go of that hope as the angel of death struck. They didn't blow out that flicker of hope even when there was no breath to prove life; they transformed that flicker of hope into a fire of faith, to carry them forward when death had its way. Their hope was not for naught. Without hope, death may have won the battle over many, with hope it managed to win the battle of one, everyone else won with a flaming fire of faith, to keep them going even when the sheets were drawn and a stone replaced the living human in the bed. 

When a person is sick we hope for them, when they are gone, we hope for us; the people who love and care for that person. Once they are gone, they aren't pained, and they have no battle to fight, of which hope can serve as their armor. Once they are gone, it is the hope that helps those that hoped for them while they were living, to win the battle of their absence. It is this same hope that helps heal those they left with the living.

As a human being and also a nurse, while my medical knowledge helps me save lives with the interventions I perform, that same knowledge strangles the power of hope from within me, as it gets blinded by the facts and numbers of the many unfortunate realities I encounter daily. I lose sight of that right to hope from time to time, and I've judged it from my nurse head, even as I empathized from my human head. While I have challenged that level of hope with my medical head, I now envy that hope as I see it transformed into a valiant leap of faith and strength that helps the living humans left, to cope. Sometimes, I wish not to be blinded by my medicine head and share that hope and belief that things will turn out ok for every patient I care for. When fate has its way despite the sweat and toil of any medical intervention, and when that hope does not transcend to the patient, let it also transcends to those who struggled to save the life and so that they can stay strong and continue to fight more battles to save more lives.

My journey as a nurse is exactly this. To see every challenge in the light of a possible, "hopeful", road towards recovery and life, rather than a road to death, despite what medicine tells me. "The secret is to know that the deck is stacked, that you might loose, that your hands or judgement might slip, and yet still struggle to win for your patients. We can't ever reach perfections, but we can believe in an asympote toward which we are ceaselessly striving (Paul Kalanithi, When Breath Becomes Air)."

Treat each human with the harsh knowledge of medicine; care for that human with the fiery warmth of a human heart.