Our first shift on the Female Ward at Lewanika General Hospital has proved to be an eye opener for the both of us; again, a shift full of the ups and downs of triumph and frustration. The emotional rollercoaster here is nothing like we have ever experienced before…the joy and happiness felt one moment by holding a newborn baby is quickly overtaken by a moment of anger when something as basic as a needed blood pressure cuff or a pain medication cannot be found. Every laugh of a child seems to be shortly followed by the haunting wail of a woman who has lost a loved one; with each feeling of triumph after helping a patient regain stability comes the feeling of helplessness of a patient who you cannot help.
From a young age we are taught to take care of our things, and to fix them when they are broken. When a toy breaks, we attempt to fix it before rendering it garbage; when a shirt gets a hole, we sew it. In nursing school, again, this mentality is driven into us. When a patient has an injury, we heal it; when someone is coding, we bring them back; when someone is broken, we fix them. Today, we truly realized for the first time that not everything that’s broken is meant to be fixed.
The first patient we saw upon walking into the ward was a 40 year old woman, bordering on the line of consciousness. She looked like nothing we had ever seen in person before, but instead like a photo of a Holocaust victim in an old textbook. She was so incredibly skinny, that we could see her heart’s struggle as it exhaustedly beat through her ribcage. We noticed an NG tube hanging from the loosened tape around her nose, and that her bedding was drenched in days’ worth of stale urine ad sweat. After noticing that she hadn’t been getting her tube feeds regularly, she wasn’t hooked up to an IV and she hadn’t been bathed or turned in bed for probably days, we realized that we had our work for the next couple of hours cut out for us. We took turns feeding her the dose of 300mL from a 5mL syringe (all they had). It took the two of us almost an hour to get through the feeding, so it was easy to see why a nurse hadn’t been doing it every 3 hours as scheduled, when there were 30-40 other patients to attend to. After looking through her chart, and performing an assessment, we came to the conclusion that she was beyond the point of fixing, and that comfort was the only measure for this palliative patient. As we made plans for a potential code, we both felt a dilemma in what we should do. Would we resuscitate-would it be fair to thump on this 60lb woman’s ribcage? Would she want to be brought back to life only to live another few more days of pain and suffering? Who are we to decide that for her? In Canada, her chart would no doubt bare a “DO NOT RESUSITATE”, but here we feel obligated to try everything.
Our assessment found that she was probably suffering from pneumonia (most likely aspiration, as they fed her lying flat on her back), severe malnourishment and dehydration, septicemia (her original diagnosis), and a pressure sore on her heel after days of neglect and not being turned properly. She was just 40 years old. After realizing that there was nothing we could realistically accomplish for this woman in regaining her health, our focus shifted to making her as comfortable as possible. This was possibly her last night, and we were not going to let her die with no dignity, soaked in her own urine.
Fallon: This number really hit me, as my own mom is just over 40. This tiny, frail, and neglected woman was a person with story, somebody’s mom. After the daunting task of cleaning her up and changing her soiled linen, I asked the silent woman who was helping us what her relation was to this patient. She pointed to her womb, and then back to the patient. This was her daughter. My heart sank, and I began to see this patient in a new light: Not only is this someone’s mother, this is somebody’s daughter. I was embarrassed that I hadn’t even thought of that before…of course she was someone’s daughter. I asked the mom if she was okay, if she wanted a granola bar, or needed to go get some fresh air. Her response, with watered eyes (it is not acceptable to cry here, until after someone has died) was “Not okay”, and she pointed to her womb and back to her daughter. After another one of those “I have nothing to say” moments as I was chocking back my own tears, I said “you are a good mom”, and smiled at her. I wasn’t sure if she could understand them, but I felt like I needed to hear myself tell her those words. I remembered that sickly feeling of helplessness that I felt earlier, and wondered how much more helpless the mother must have felt. She gave life to this woman, nursed her, healed her childhood scrapes and bruises, but could not stop her from dying. She said a sincere thank you, and went back to sitting on a hard plastic chair, dedicatedly sleeping at her daughter’s feet. She appeared to be praying, desperately pleading with some higher force to watch over a situation that was far beyond her own hands. This sight made me feel heartbroken, and reminded me of the women I love and care back home in my own family (this made me miss you guys even more!), who are a similar age. How could they let someone’s mother, or someone’s daughter sit in her own urine-drenched bed for days? How could they neglect her and not give her the scheduled tube feeds? What an inhumane way to let someone die. With tears in my own eyes, and now partially motivated by anger, I became even more determined to make this woman’s death comfortable and with dignity. I am a nurse. As I had just learned, clearly some broken things in this world are not meant to be fixed. However, these broken people should still be handled with care, respect, and be given the right to a peaceful and dignified death-and that was exactly what we were going to give her. There might not be any supplies, no quiet room or comfortable pillows I can offer, but I have love, compassion, and one hell of a determined/stubborn mindset. I looked at Sam, and instantly knew we were both on the same page.
Sam: Some days here it easier to forget that these patients are in fact people. I feel like we are so overwhelmed with their diagnosis’s, and forever haunted by the images of these patients engrained into our minds as we sleep. So unbelievably sick, it’s nothing like we have ever seen before. So we separate ourselves from the actual patient, especially in times of emergency when their immediate medical concern is our focus, so it is easier on us when you know there is nothing that can be done. And here I stood at the side of this patient’s bed, looking at the extremely frail woman, and for a moment we remember. We remember that this is a person, we remember that this person has a child, we remember this person has a mother who has been sitting by her daughters feet for who knows how long just waiting. And then it hits you, you see them laying drenched in their soiled linen, you see them being neglected, surrounded by flies, and you know you must intervene. This is a person, who should never be treated this way. There comes times in our career that make everything we do (even the horrible things we see) worth it. That shift was one of those reminders. This woman could barely open her eyes, she was too weak to move and she did not respond to verbal or physical stimuli. She was probably not going to make it through the night. However, when I was feeding her, she looked so peaceful, like she was ready to go at any moment and so I held her hand… and I felt the slightest squeeze back. I remember almost laughing I was so taken back, I yelled for Fallon and told her she squeezed my hand! She knows we are here! She knows were trying to help her! That is when I knew that we did everything we could for her, and she was okay with it. “You may not be able to change the world, but you can definitely impact the people within it”-a quote we seem to be reminding ourselves of often here.
We remembered the 40:2 patient to nurse ratio, and thought of how unrealistic it is to expect them to be able to attend to this woman with her time-consuming needs. After an episode of convulsions (she had been having them frequently), we tucked her in, got her comfortable, and made our way to check on the other highly-acute patients on the wards. Someone had an IV that went interstitial, another was calling out for pain meds (that the hospital ran out of), and another severe chemical burn patient was spiking a dangerous temp. We felt stretched and restrained by both the language barrier and lack of basic supplies. There was no nurse on the ward to help us for at least half an hour; it was just us and these frustrating obstacles.
At least 2 patients die each night in this ward, and knowing this we tried to prepare for a potential code. We checked for oxygen, there was none; we searched for an ambu-bag, there was none; we went to draw up epinephrine; the drawer was empty. In the pitch black of the night with thunder and heavy rains loud against the windows, the lights and power flicking on and off, rats darting across the floor, and us running in the dark outside from ward to ward searching for basic equipment, we were reminded, ONCE again, that “this is Africa”-another quote that is mentioned repeatedly each day here.
While searching for our nurses before their shift change, we remembered that the much-anticipated Zambia vs. Ghana soccer game was on. Apparently it was taking priority over the patient’s and their needs. We were reminded of this frustration every time we heard people (nurses too) cheering from an adjacent ward as the Zambia team scored. There are people not getting their scheduled tube feeds, linen changes or pain medications, but our soccer team is winning. This extreme shift in priorities was definitely not something we are used to in Canada, and it left us both resentful and frustrated. (On a high note, Zambia beat the odds and won the game against Ghana last night. We heard the cheering and the energy while we were working).
At the end of our shift (which ended up being almost 3 hours overtime), we made the decision to go home. We were content in knowing that there was nothing else that we could possible do for the patients, our little lady in the “acute bay” in particular. We came to realize that not everything broken is meant to be fixed, and we were actually okay with leaving her knowing that she will probably die sometime during that night. She was clean, in fresh sheets, with a full belly, dignity, with her mother at her side. She looked at peace. There were no more flies on her body. As a nurse if we are unable to “fix” a patient, our duty turns to providing comfort measures, love, compassion, and advocating to making sure they receive their God-given right to a humane death. As much as we felt restrained and frustrated by our resources, and challenged as a nurse, we felt like more of a nurse that night to this frail patient, than ever before.
Team Sam and Fallon
(Apologies for the excessively long blogs!)