Trying to Understand Malnourisment at Save a Life!

The Save A Life Clinic was kind enough to host Gillian and I (Johanna) this past week. We were excited to utilize our paediatric assessment skills on several of the admitted patients. One particular case that stood out for us was a small boy that we will call Nawa for the purpose of this blog. He was a severely malnourished patient who looked no more than 6 months old. We were astonished to find out he was actually a child of two years and one month after discussing the patient with Dr. Lisette. We realized it was difficult to guess the age of many of the children because malnourishment can cause severe developmental delays. According to the WHO standards for acute malnutrition, the weight to height ratio of this boy was at -3 SD's which is categorized as severe malnutrition. This level of malnutrition can increase a child's risk for death by 9-fold. Due to Nawa's severely dehydrated status and his inability to drink, he required IV fluids. His deterioration led to an admittance to the hospital as Save A Life did not have adequate equipment. We soon found out supplies were limited at the clinic as the clinic runs on donations and sponsors for their resources. Unfortunately, we were informed the following night that little Nawa had passed away at the hospital. Nobody knew the exact time of death and by the time Dr. Lisette arrived he was already gone. Dr. Lisette had to inform the mother as she was not aware of his death. Many thoughts went through our minds such as, "Would this child be still alive if we had the right supplies? If someone was around the child at the time of death would he have been given another chance? Did we do all we could to save this child?" With the knowledge and abundance of resources we have in Canada, we felt guilty because perhaps this life could have been saved. Unfortunately, this is just an example of many cases of malnutrition throughout Mongu.

         Another part of our week were the home visits regarding outpatient follow ups. The clinic follows each patient and their family for six months after discharge to ensure proper feeding. What we witnessed on these visits was surprising. Even though the mothers are being taught about nutrition and the importance of feeding, there was a disconnect between understanding the teaching and actual feeding practices. A lot of these women were not feeding their children appropriately, such as on a schedule or throughout the day. The mothers seemingly had all the supplies amd resources needed-because the clinic provides teaching and free food-and yet the children were not being fed appropriately. Although this might seem unbelievable, we attributed this to deeply ingrained cultural practices. We found it frustrating to know that some children are not being fed however we realize that in Canada we are fortunate to have loved ones around us to teach us basic life skills such as mothering. We also have a great health care system that supports and educates expecting mothers from the beginning of their pregnancy to post pregnancy. A lot of these mothers are young, such as age 15, and may not have the support or family alive to help teach basic life skills. This was a big culture shock for us as it was hard to not only understand their lifestyle but be compassionate towards it. Mostly we have learned that we take for granted the simple things in life, and not realize that these simple things can have such a big impact. We are feeling especially thankful for our friends and family back home. :)

Dr. Lisette and Gillian assessing Nawa.

A typical scene during the home visits - we would meet outside of their houses that were made of straw or mud.


Doing some teaching on TB while the patients wait in the clinic.

         

Meet the family- By Natalie and Rebekah

If you have ever found yourself frustrated with the Canadian health care system, remember and consider this as you read our blog today. Rebekah and I (Natalie), now have a new appreciation for the resources we have in Canada after working on the paediatric ward in Mongu. 

This week it was particularly challenging to find our places on the paediatrics floor. The floor is very busy, with many sick children surrounded by families at the bedside. It was very difficult for us to hear the doctor during morning rounds as the ward was very noisy with children's cries and screams. The ward was dirty, muggy, and hot- we felt very overwhelmed by this environment initially. However, our incredible journey with a sick child and his family was about to begin and impact our nursing practice forever. 

This is the beautiful family we had the pleasure of working closely with this week.

I (Natalie) first met the family, when I sat at the bedside of a sick boy with his mother. The mother was very concerned about her child's condition. He was diagnosed with severe malaria, but was not improving despite treatment. Malaria is a common yet preventable disease that is prevalent among many children living in Africa. According to the World Health Organization (WHO) most fatalities from malaria are found among children in Africa, with a child dying from malaria every one second. We both saw first hand the devastating effects of malaria during our first day on the ward. Unfortunately, this sick child had received all his malaria treatment and was not showing any signs of improvement. Dr. Idi, (the doctor overseeing this case) became concerned about the possibility of meningitis.

The diagnosis of meningitis is made through a procedure called a lumbar puncture. This is a diagnostic procedure where a long needle is inserted between two lumbar bones (vertebrae) and a sample of cerebrospinal fluid is extracted to determine the presence of meningitis so treatment can be started promptly. The mother had been refusing to consent to the procedure for a few days now. When talking to the mother, I discovered that she was scared to consent to the lumbar puncture because her uncle recently passed away preceding same the test. The mother had also lost her son in 2013 and the thought of loosing another child was unbearable. The mother said to me "some days I open my laptop and see my sons face and I ask myself why? But then I tell myself I have to be strong, I have other children to be strong for." I had tears in my eyes listening to her story. I knew that this was our opportunity to advocate for this family and make a difference. Both Rebekah and I told the mother that we would find her some more information about lumbar punctures so that she could feel confident making an informed decision. The mother said to us "before I make a decision I most call my husband...we are a team". This was incredible to hear from the mother because I have noticed that many fathers are not involved in the care of children (unlike in Canada).

Rebekah and I collected all the information we could find on meningitis and lumbar punctures at the nursing library. It was very informal, all our information was written on a piece of scrap paper (this is what you do in Africa with limited resources available). We went back to the ward and were pleased to see the child's father and grandmother at the bedside. 

We took this opportunity to speak with the family about the serious nature of meningitis and the importance of a lumbar puncture. We also addressed their concerns around the risks of the procedure.  We asked the mother if she understood our teaching. Our biggest fear was that the child may pass away from meningitis shortly after having the lumbar puncture, and that the mother would think we lied to her. Fear is one of the reasons why many people refuse  lumbar punctures in the hospitals here in Mongu. Many people associate medical procedures with death even though the procedure did not cause the death. This is problematic as many people avoid hospital visits or medical procedures because of their fear of dying and they often present at the hospital in the late stages of their illness. 

After our teaching, the mother gave her consent for the procedure!  She said "we have tried the treatment, and it's not working. It's time to take the next step." We were relieved that we received  consent and knew that we needed to advocate  to have the procedure done immediately. With some strains of meningitis, particularly in bacterial statins, the child may only have 24-48 hours after symptoms appear to receive treatment before it becomes fatal. We called Dr. Idi and requested that he come in to complete the procedure immediately.  The doctors here are incredible! They work very long hours, and are always willing to teach and support your concerns. We left that day feeling like we accomplished something. 

We came back to the ward pleased to find out that the lumbar puncture was negative for meningitis. However, we were stumped. The child had completed his malaria treatment, but his condition was not improving. He was very weak, his vision had recently become blurry and he could not speak or walk. On morning rounds we told the doctor we were worried about his neurological status. Could this be a tumour or something that resulted from the malaria? Dr. Idi said that it could be cerebral edema from severe malaria (swelling of the brain). In response, he prescribed mannitol, a drug that would bring fluid from the brain back into the vessels and decrease the swelling. 

We set off on our next challenging journey to find the medication in Mongu at the local pharmacies. With no success, we put in a request for the medication to be sent from Lusaka (a city 10 hours away). In this moment we felt frustrated and hopeless. In Canada we have all the medications and diagnostic equipment we need at our fingertips, and here in Africa we had nothing we needed to help this boy. 

The pharmacy we went to looking for the mannitol. How do we get inside? 

With no diagnostic equipment, we knew that we needed to continue ruling out diseases to find answers. Later that day, we took the boy to the eye clinic to rule out optic nerve damage as a result of cerebral edema. The ophthalmologist found no signs of optic nerve damage that would explain the blurred vision. 

The little boy with our sunglasses. We gave him these to wear to protect his dilated eyes from the sun as his mother carried him back to the children's ward. 

On our final day, we started the day feeling very defeated. The child was still very sick and we had no medication or diagnostic equipment at our disposable. To our surprise, two bags of mannitol solution arrived on the unit from Lusaka. Natalie and I (Rebekah) brainstormed ways to administer this medication in a safe way without the medication resources and IV pumps we have at home. At home we would never administer a medication to a child without precise measurements and syringe pumps to administer the medication. It was scary working with unfamiliar and limited resources, but we knew that this medication needed to be given and we had no choice but to find a way to do so. We were able to calculate the medications and drip rate to successfully give the medication through a gravity IV drip. We felt a sense of accomplishment knowing that we administered this medication to the child!

Natalie drawing lines on the medication bag so we knew when to stop the infusion. 

Natalie's highlight:

This week was the highlight of my of my nursing education. I felt like I  truly experienced the reasons why I chose to become a nurse. I met the most amazing family. Within the first five minutes of talking to the mom of the young boy who had severe malaria, I felt empowered to do everything I could to help her son. When she smiled at her son, it made me smile. It was a special bond, one I simply cannot find the right words to explain. This week I did not only help her, but she helped me. If anything, she showed me what family really means.  I have never poured my heart and soul into nursing as much as I did this week. I found myself doing things I never imagined I would do for a patients family, like taking a cab into town to find a drug and tearing up when it was not available. I would go home at night and be constantly reviewing his case. I would even call my teacher in excitement when we achieved progress. I just couldn't and wouldn't give up for this family. 

It wasn't  just the relational part that I loved. I really challenged myself this week to learn, and to use the knowledge I had to critically think this case. Even in moments of total frustration and lack of resources, Rebekah and I did what we could to make do with what we had. This week made me love nursing because I learnt the depth of what I am capable of. I felt appreciated, and valued for my efforts. 

I came to Mongu hoping to make an impact on the lives of others, but what I didn't realize is that their people could make a tremendous impact on my life. I will never forget this week, and I truly will never forget that family. In nursing you don't always give, you receive lots as well.

Rebekah's highlight 

During my time on the paediatric ward, I have learned that you can not nurse in Africa like you do in Canada. This week I was challenged to think outside the box and practice nursing in a way I had never done before. I learned this week that nursing is more than giving medications, charting, and assessments. I realized that when we nurse in Africa, we nurse in unique and small ways that can make a big difference. 

During the difficult moments this week when I began to feel hopeless, I found joy in playing with the children. I unlocked the toy box on the ward  (yes it is locked) and got the children playing and colouring. It amazed me how many of these children never had coloured before (including their parents). There was one father who asked me if he could have a crayon and a colouring sheet so he could colour a picture for his home. At the end of my day, I remember looking back at the ward and was so pleased to see children and parents colouring together. These children and families were laughing, having fun and just happy. In this moment I knew that that is nursing in it's purest form. 

I will never forget my experience with these beautiful children and families this week and hope to continue to find the joy among the great sadness. 

Natalie and Rebekah 

HIV: Facts and Figures (ART)

The Anti-retroviral Clinic (ART)

This week, Nicole and Sue spent some time at the ART clinic attatched to the hospitial here in Mongu. In Canada we would probably call this the H.I.V. clinic.

In our four years of nursing school Sue has only encountered one person that was HIV positive taking anti retroviral medication and Nicole has seen none. In one day we saw over 200 people. Over the week, we saw almost 1000 plus infected people lined up waiting to be seen for treatment. In 2012, 12.7% of adults in Zambia were living with HIV. Compare this to Canada's 0.002% (as per the public health agency of Canada). The clinic we were at sees 20,500 citizens alone for anti-retroviral medications and treatment. It is the second largest treatment centre in Zambia with Lusaka being the first.

(The filing system at the ART clinic)

Since they started reporting HIV cases in Canada in 1985 there has been a cumulative total of 75,000 HIV cases. Based off these numbers it is evident how drastically our countries differ in the prevalence of HIV. 

When sitting in with the pharmacist who administers medications to about 200 people a day, we were told that HIV is "normal here". She asked us what would be normal in Canada. In thinking about it, patients with high blood pressure came to mind but as a nurse we would still never see 200 people a day with hypertension. There also wouldn't be the incredible stigma on these people that comes with being HIV positive. Reflecting a little later, we thought how often we see diabetic patients. These patients must check their blood sugar sometimes up to 3 times a day and have insulin injections to maintain their health for the rest of their lives. People living in Zambia that are HIV positive must have blood drawn once every six months and take a pill every day for the rest of their lives. 

(Nicole stocking anti-retroviral medications)

Nurses in Canada talk about how abnormal it is to not have a diabetic patient on their team. Imagine if those patients where instead HIV positive and living in Canada. This is what the nurses face in Zambia. Not having any patients with HIV would be abnormal for them. 

HIV and AIDS takes 30,300 lives in Zambia a year according to a study done in 2012. Compared to less than 1,000 in Canada.

Although we were seeing these people with our own eyes it was still very difficult to wrap our heads around the fact that everyone we saw was positive. Some of these people were visibly very sick, while others appeared healthy and HIV free. It allowed us to see how on one hand this disease has the potential to be managed with adherence to medications but for those who do not have the access to aid, the disease can be easily masked and unknowingly transmitted between people. 

Sefula Part Two: Baby

This will definitely be one of the hardest blog posts I anticipate having to write. 

This week, Rebecca and I (Danielle) were placed at a small rural health clinic in a village called Sefula. Though excited, I was hesitant to be placed here. I had seen the lack of resources at the hospital in Mongu, and had seen instances in which the care patients received was limited. It's not that the nurses and doctors here are not smart, or that they don't try there best. They do their best with the resources they have. And sometimes their efforts are enough. And sometimes they aren't. Even in Canada, our best is sometimes not enough. But I couldn't imagine what health care would be like in an even smaller clinic with less resources. And as hard as I tried not to, everyday, I found myself thinking of home. Of how the care these patients were receiving would be different in Canada. And I know that type of thinking is counterproductive. But it's hard not to imagine if a patient's outcome could have been different if they were back home. Enter: this week.

My week started off good. My first day, I shadowed an extremely intelligent nurse as we conducted small pre-natal clinics for the pregnant women in the village. I was actually surprised at how thorough the nurse was - every woman received a full head to toe assessment, was tested for HIV and STIs, and was given deworming medication. I was already learning so much. This first day provided me hope for the rest of my experience here - if they could provide excellent nursing care in a low resourced, small community clinic, then maybe I could as well.

My second day was my ultimate high. Most of my friends and family know that before I left, I dreamed of being able to deliver a baby in Africa. I didn't just want this experience, I craved it. Not only would it put so much of my acquired nursing knowledge to the test - it would also allow me to be the first hands to welcome a baby in to the world. This is what drove my desire. And when I arrived that day and saw a labouring mom, I knew my day had come. There were no doctors in this clinic, no midwives. There was only myself, the nurse, and Rebecca responsible for this woman's wellbeing. And I felt up to the task.

The woman was a gravida 5 para 4 - this means that she had been pregnant 5 times (including this pregnancy) and had delivered 4 babies already. It made me feel better that the mom maybe knew what she was in store for with her labour, because I certainly did not.

Though this woman could not speak English, the nurse taught us some important key phrases to help with the delivery. And after a few minutes, we were yelling "Kasha Ahulu Mama!" with every contraction. Roughly, this translates to "Push hard, Mama!"

The woman had been labouring since midnight, and actively pushing for two hours when I started to get worried. Rebecca and I couldn't hear Baby's heart rate. The nurse listened, and said she could hear it, but it was irregular. We knew Baby needed to come out quickly. We knew the labour wasn't progressing fast enough. We knew we were in trouble.

Back home, this lady would have been rushed for a c-section. Especially since this was her fifth baby. By this point, her body should know what to do. The baby should have been delivered hours ago. But Baby wasn't. And there was no operating room. No doctors to preform a c-section. There was only us.

The labour continued. At one point, a piece of the placenta was pushed out. This is extremely bad - the placenta needs to stay entirely intact or a woman is at risk of post delivery bleeding so severe it can often lead to death. It can also be bad for the baby.

At this point, Rebecca and I still couldn't hear Baby's heart beat, but the nurse assured us it was there. I began to wonder if it really was, or if the nurse was just trying to keep the situation calm. And at that point, I realized it didn't matter. Heart beat or no heart beat, all we could do was deliver the baby. We had no interventions we could preform. We had to let nature take its course.

Finally, after hours of active pushing, the baby started to descend. I could feel swelling on its head, and the nurse explained to me that it was called Caput - and it happens when the labour is prolonged and the baby's head starts bleeding. Was anything going to go our way?

And then the moment finally came. At 1:04pm on March 25, 2015, I delivered a beautiful baby boy into this world. The feeling cannot be described, the beauty of the moment never replicated. I felt so blessed in that moment.

And I wish the story could have ended there.

Most babies don't come out immediately crying. But after dried off with a towel vigorously, having their mouth cleaned, and having the cord cut, babies are normally stimulated enough to start stirring. However, our baby did not. And I paused as I realized a small, blue baby laid in front of me, not breathing.

We cut the cord, and rushed Baby to our work station. The nurse remained calm as she tried to rub Baby more to stimulate him awake. But my heart felt like it was beating a thousand times a minute. I became frustrated - how was the nurse so calm? And as I lifted my stethoscope to Baby's skin, all I wanted was to hear his heart beat mimicking my own.

I listened to Baby's chest, found a heart beat, and sent up a thank-you prayer. Though slower than it was supposed to be, it was there. But I knew that unless I got Baby breathing, it wouldn't be there for long. I re-cleaned Baby's mouth with a cloth and asked for an infant resuscitation mask. I began giving Baby breaths. With each pump of the mask, I was desperately trying to force Baby's airways open.

Give two breaths, check for breathing. Give to breaths, check for breathing. I frantically followed this pattern for three rounds. Then, it happened. Baby began to breathe on his own. And I swear, that first breath he took was the most beautiful thing I had ever seen.

Baby then started to pink up and move. And I will never forget the moment, as I checked Baby's reflexes (to check for brain damage), that Baby's little hand wrapped around my finger. And that squeeze was the only thank-you I would ever need.

When it was time for us to leave, Baby still hadn't cried. But he was moving. He was breathing. The nurse told me that he was possibly just tired from the long labour. I asked if we could check to see if his blood sugar was low (somewhat common in big babies that are tired), but there was no blood glucose monitoring machine. And even though my worry for Baby's condition was not completely gone, the nurse told me that she thought baby would be just fine. And as I started down at that adorable little chubby face, I knew that in that moment, there was little else I could do here. Baby had made a miraculous recovery. And I had to believe that overnight, he would continue to do so.

That night, I went home on a high. Not only had I successfully delivered a baby, but I had successfully resuscitated one as well. As I am sure some of you saw from my Facebook post, I was happy. And every time I looked at that photo of me staring down at that cute little baby I felt warm inside. All the support I received was amazing. It was a great day.

Again, I wish the story could end there.

The next day, I returned to Sefula. Rebecca and I had brought a package for Mom containing baby clothes, socks, slippers, and receiving blankets to adorn our new babe. When we arrived, I couldn't find Baby, but I assumed he was being greeted by extended family somewhere else in the clinic. However, I found Mom happy as ever, and gave her our gift. She was so grateful. We were so happy she was doing well.

I then went to the OPD section of the clinic to get my fix of Emergency Medicine for the day.

About an hour in, Rebecca, who was working in Maternity, showed up in OPD and beckoned me to come see her. I knew by the look on her face that the news was not good.

Tragic words came out of her mouth: "Baby died this morning."

My heart stopped.

Shock and grief overwhelmed me. I don't even remember walking to the Maternity area, but when I arrived, the nurse brought me into a small room. She unwrapped the blankets, and there on the bed, Baby lay still. And I knew he was gone.

I tried hard not to cry. I tried to be strong. But as I stared at the small, lifeless babe, I broke. The hand that squeezed mine, the lungs that I inflated, at rest. Baby's sweet, little eyes, closed. It was true. Baby had passed.

As I walked out of the room, there was Mom. She had heard the news too. She was crying hard.

I asked the nurse to tell her in Lozi that I was sorry for her loss. And then I sat down with her, and we cried.

I later found out that through the night, Baby spiked a temperature of 40 degrees. Baby had gotten an infection.

I knew that Baby had been given antibiotics, that they had tried to treat him. But it was the things I didn't know that were eating me inside. Was Baby properly hydrated? Was he cooled? Did they attempt to resuscitate him? I don't know the answers to many of these questions. But I do know that the nurses at Sefula are amazing. And I like to think they gave Baby a good shot at life.

Looking back on this experience is hard. Even now, I wonder if this was something I could have prevented. If there was something more I could have done. If I should have stayed overnight with Baby and Mom to make sure they were ok. And everyone says not to blame yourself. But when your heart hurts, it's hard.

In Africa, one of the sad realities is that they lose so many babies, they wait to name them for a while to see if they survive. Baby never got a name.

It was this experience that made me fully grasp the phrase of "This is Africa."

The other girls that I am here with have been great. And I am doing good. They are making me laugh, smile, and letting me vent. I really don't know what I would do without them.

And every day, I come more to terms with what happened. And I am learning that some things are just meant to be. And I have to trust in that.

But still, every time I stare down at my phone and see the background of that little babe, and miss him with all my heart, it hits me again that I am in Africa. And there are highs, and there are lows. And though the lows are low, the highs are high. And in the end, I hope they will come to balance each other.

I know I will never forget Baby. His life was one of my life's best parts. Though his life was small, it was a big part of mine. And I felt honored that I got to spend it with him. And happy that he got to spend it in the loving arms of his mom. Really, I guess that's all he could have asked for.

- Danielle

Sefula Part One: The Clinic

This week Danielle and I (Rebecca) worked in a rural clinic in Sefula, about 40 minutes from our home at Liseli Lodge. This clinic is divided into two main sections: an outpatient department combined with an ART clinic (for HIV patients) and a maternal-child health clinic. Almost all of the patients spoke Lozi, making it very difficult. The staff knew English and were able to translate, but it is hard to make connections with the patients. We definitely picked up some words and phrases along the way and the locals, who don't often see Mukuwas like us, loved that we tried to integrate ourselves into their world!

Main Street, Sefula

We were very impressed by how the clinic was run and we can attribute that to Barbara, the charge nurse at Sefula. She was very organized and made sure things were getting done. All of the paperwork was up-to-date and medications were labelled. It may not seem like much, but it was a drastic difference compared to the hospital. There were motivational signs and statistics from their clinic posted as well. One of the most notable was how the rates of HIV have diminished since antiretroviral medications have been in place. One of the counsellors said about 1 in 10 people tested would come back positive before. It is now closer to 1 in 20. With the success of the ART clinic comes challenges too. As the patients live in very rural villages, some of them do not have contact information. When people miss their appointments, the staff try their best to find them and make sure they are staying on track, often by calling the village chief or bicycling over to see them.

Barbara also told us how there are quarterly meetings to get feedback from the communities in their catchment area. This assures that problems are being addressed and they are meeting the needs of their clients. This was something that we don't even really have implemented in Canada. These meetings are also a way to communicate back to the communities, such as by encouraging women to come in to a facility to give birth instead of at home.

Sefula Clinic

In addition to the administrative side, Barbara worked in the clinic. She assessed, came up with impressions and diagnoses, and developed treatment plans. While doing this, she treated the patients with the utmost respect. 

We spent a good part of the week with Precious in the maternal-child clinic. We spent time with her doing antenatal assessments on pregnant women and working in the under-5 clinic doing vaccinations. We learned so many new skills and she was incredibly encouraging. We felt the mothers' bellies for the position of the babies and listened to their hearts using a fetoscope. We felt like she really appreciated our help and was excited for us to be there.

Vaccination Clinic

We have both experienced vaccination clinics in the Okanagan and it is very different here. They are so busy because there are so many children and it seems hectic from an outsider's perspective. Although it might not be as regulated as home, the most important thing is that women are bringing their children in to be protected against illnesses that are more common place here.

Rebecca and one of our Favourite Nurses, Precious

The biggest thing we learned working in a rural clinic is that you have to work with what you have available. This really hit us when we assisted a mother giving birth to her baby. In Canada under her circumstances, she probably would have gone for a c-section, but that was not an option at Sefula. There were limited supplies and limited people available to have a birthing experience like back home. Instead, we helped the mother with support and encouragement, something that is readily available no matter where one is nursing. 

- Rebecca

Makuwas in Makilipwe: A Tale of Rural Outreach Nursing

This week Karen, Jessica and Courtney headed into the wilderness of Africa on a medical outreach. In this rural remote nursing experience in Makilipwe, we set up tents, cooked over a fire, and built a pop up medical clinic made of reed mats and chintenges (a traditional piece of fabric the women use for everything, from skirts to baby wraps).

Jessica dispensing medications.

The church we held our clinic in.

An average house in the village.

Our bathroom facilities.

Straw huts we strung chintenges across and boiled water over the fire to put in a small basin to wash with.

Makilipwe is a small village 2 hours outside of Mongu in the floodplains of Zambia. Homes are made of mud and straw, and there is no electricity or running water.

On this outreach our role was similar to that of a nurse practitioner in Canada. Under the guidance of Nilene, a South African doctor, we assessed, diagnosed, and dispensed medications to patients. We were also lucky to have our translator, cultural guide and impromptu little brother, Muyunda. During this week we realized just how important it is to work together as a team, all of us quickly becoming a family.

Muyunda, Courtney, Jessica, Karen & Nilene ready to head out to outreach.

Our camp site was set up near the community church, and the villagers welcomed us the first night, inviting us to sing and dance around the fire. As the villagers danced the Milky Way was shining brilliantly above us, and across the floodplain, lightning was flashing. The people danced to the drum, and sang biblical songs in Slozi, and soon we were joining in. It was an experience that we will never truly be able to describe in words, this was the real Africa. This experience was relived for roughly three hours each night of our visit until the last night, when we treated the villagers to a play in Slozi. (That was a first.) 

Our days would start bright and early at 6 am, prayer was at 8, and clinic started soon after. During clinic it became apparent that lack of access to medical care in this village had a great impact on the health of the people. Medical outreaches like ours may only visit them once or twice a year, the nearest medical facility is a four hour walk, and the nearest hospital a two hour drive away!

Jessica working in the clinic.

Courtney and Muyunda attempting to fix a shoulder dislocation with manual traction.

Courtney manning the outdoor clinic. 

Reed mats used for patient privacy.

Social determinants of health, here, and in many other communities in sub-Saharan Africa, have a large impact on the mortality and morbidity rates. Makilipwe faces challenges including extreme poverty, lack of resources, and its community members lacking formal education. Social determinants of health, according to the WHO are described as the "conditions in which people are born, grow, live, work and age, and these conditions are shaped by the distribution of money, power and resources." For example, we encountered many late stage cancers, where it was evident that the patient had been exhibiting symptoms for many years. For these patients to get diagnosed living in a rural village such as Makilipwe, they would first have to get a referral from a clinic, meaning walking several hours to the nearest clinic. After receiving a referral they would then have to figure out how to get to the hospital in Mongu, which is a logistical nightmare. At the hospital in Mongu if it was determined that the patient has cancer, they would have to take a bus to Lusaka for treatment (a nine hour trip, which is too expensive for the average villager). 

A Grandfather talking his granddaughter into trusting us at the clinic. We loved the bear she carried around in her chintenge on her back. 

As we saw more patients we realized that while we could give them medication, in two weeks that medication would be gone and they would be back at square one. Initially we felt like we were putting a small bandaid over a huge problem, each of us struggling with this conflict. We questioned if we were truly making a difference. However, by the end of the practicum we realized that through providing education, being present and forming strong relationships, that we were making a difference in this community. Our presence in the village brought more than medical care, but also hope and a reminder of the importance of unification. Although we couldn't speak Slozi, and they couldn't speak English, we were able to form strong relationships with the community and its members.

The villagers called us makuwa (literally translates to 'white man'), and the difference in privilege between us was apparent, as many of our phones were worth more money than they had ever seen, or would see in their lives. Ultimately the differences between us were pre-determined by where we were born. By making personal connections with villagers and integrating ourselves into their community we felt that we were able to overcome some of those differences, and for the week unify with the common goal of improved community health and health education.

-Courtney (center), Jessica (right) and Karen (left) ❤️

Life Lessons in OPD

I have spent my last week in the OPD, which is the Zambian equivalent of our Emergency Department. I have never had a chance to experience emergency medicine back home so this was an entirely new experience for me. 

Walking through the OPD looks like pure chaos. Patients are crammed together on benches waiting to get their vital signs taken, another swarm of people fill the hallway clutching their crumpled files as they wait, and healthcare professionals call out for patients in what appears to be an order without rhyme or reason. I remain bewildered at the lack of triage and don't understand how  patients know which room to go to or which clinical officer to see, but I quickly realized the staff in OPD is extremely efficient and amidst the chaos they manage to spend quality time with a very high volume of patients. 

Here I am performing a knee tap on a patient with extrapulmonary TB in his knee joints. This was awesome - I would never get to do this in Canada! 

The x-ray board was smoking so we were unable to properly read any films. The staff at Lewanika are very good at figuring out solutions in low resource settings. 

I spent my week with a medical officer named Kwibisa who is one of the best teachers I have ever worked with. He quizzed me, pushed me, observed me, and coached me through a myriad of situations. Under his guidance my knowledge and confidence in myself grew exponentially. All of his work was done with genuine compassion capped with a huge smile and observing him as he worked was a powerful reminder of the kind of healthcare provider I have always aimed to be.

Still, despite the experience I was having, I began to grow frustrated. I was observing great things but I wanted to be doing! I kept thinking that I came here to help and to make change, yet I was doing neither. Sure I was advocating for my patients, lending a kind hand in a scary moment, or donating items to those in need, but that is no different than what I would do as a nurse at home. I struggled with these emotions all week. 

In an attempt to shake my frustration and dive into "the experience" head on, I decided to work a night shift in OPD with Danielle (she was in OPD last week). We ended up having a very tough shift and dealt with some situations that only perpetuated my frustration. 

We were taken to the male and female psychiatric wards, which we were blissfully unaware of until then. Seeing the conditions these patients were kept in was traumatizing. The ward resembled a prison and all patients are kept together in a dark cement room behind locked bars. Some had mattresses and clothes, some did not. I could not fathom how any patient would be able to heal in such an environment and we were informed that some patients are there for so long with nowhere to go that they become "property" of the hospital. I struggled to process what I saw and again grew frustrated that I was unable to help change this. 

The second part of the night was spent on the maternity ward with a mum in labor. I have been told by my peers that the situations for women in labor is very different here than in Canada yet I still had a hard time seeing the mum all alone, naked on a bed in the back room, without so much as a kind word of encouragement or a hand to hold. Provision of holistic care is a large aspect of nursing in Canada, but I have learned that I cannot judge the practices here and say they are wrong simply because they are different. However,  what I cannot accept is the way the woman was treated throughout her birthing process. She was repeatedly pinned down on the bed to get her to stay still, she was shamed, and she was physically forced to lay in positions that were clearly causing her discomfort. I did everything in my power to make her feel loved and supported and I believe I helped make her birthing experience more positive. I may have made a difference for one woman, but patients will continue to be treated this way and I realized it is my inability to change the big picture that frustrates me so much. 

Through a lot of personal reflection and some powerful conversations with Jackie and Jess I have come to terms with my frustration and sorted through the emotions I was struggling with. Yes, we are here to help where we can, but we are not going to be able to change the way the system works. That takes years of effort at many different levels and unfortunately change is slow. I have to do my best with every patient I interact with and know that I've still made a difference - an effect on some lives are better than none! Jessica and Jackie are working hard to help implement change on a bigger scale, and I have realized that for now I am just a piece of the puzzle.  

As Jessica reminded me, it is important to bear witness to these global issues. I  am participating in healthcare on a global level, which is the underlying reason this practicum is an option for us. My frustration has subsided and instead I find myself inspired and recharged. I am ready for the next challenge that lays ahead. 

- Marissa 

Maternity nursing in Mongu

This week Liona and I were on the maternity ward. While there was some difficult moments during our time there, there were some great moments that we will always remember. 

The highlights for both of us was the opportunity to deliver babies with the skilled midwifes at our sides to guide us. This was an amazing experience that we would have never gotten in Canada. We were apprehensive at first, due to it being our first time delivering a baby but having the midwifes there eased our fears and we were glad we jumped in! Being there for these happy moments in the moms lives was extremely rewarding. Thankfully both the babies we delivered were healthy and happy and the moms were very thankful for the patient centred care and support we gave them. We both came to Africa with the dream to deliver a baby and our dreams came true! 

Although much about the maternity ward was amazing we had a few difficult moments that reminded us where we are. There are little resources here and some practices that would never be done in Canada. We saw some aggressive pushing on a moms abdomen to force her baby out faster then natural without giving mom time to progress. The midwife present seemed to give no thought about the wellbeing of the mom. He seemed like he was just in a hurry to move on with his day. It was very hard for us to watch. Pushing on a pregnant woman's abdomen increases the chances of a ruptured uterus, post-partum hemorrhage or other complications, and is never done in Canada. Why this was done here may be is due to an education gap, lack of research based practice or lack of patient centred care such as we are accustomed to back in Canada. Patients are very low on the hierarchy here which is completely different than what we are used. We  feel that the meaning behind nursing and the reason for healthcare is the patient. We originally went to nursing to help people so it was incredibly difficult to see the lack of respect for that patient. Although it was traumatic to watch this practice being done we were relieved to hear from the midwife students and the obstetrician that this practice is no longer being taught and is not condoned to perform. Our only regret from this past week is that we did not adequately advocate for that patient because we were so shocked by what we were seeing. 

On our last day on the ward we saw first hand the lack of resources here. There was a woman that needed emergency intervention to assist the delivery of her baby, and all that was available was minimal amounts of very basic and outdated equipment. Despite this seeming primitive to us the reality was this was  the best care that the mom could have received here. What would have been less then basic care back home, was high level care for here. According to the WHO only 42% of women in subsarahan Africa give birth with a medical personal present to assist the delivery and only one in three women requiring emergency intervention receive it. Each year in Africa a quarter of a million women die due to pregnancy and childbirth complications. This particular mom was very lucky to get the care that she did, and could have easily became one of those statistics. It was an eye-opening experience for us that made us feel very grateful for the level of care we can receive at home, which is very easily taken for granted. 

After our week we are so grateful to have had the chance to work with the amazing midwifes on the maternity ward. They do so much with the little they have to work with. We wish we could stay on the ward to support the incredible strong moms during those amazing moments in their lives. This experience may have turned us into maternity nurses! 

"That's it"

       "That's it". We have never experienced these two words in all four years of our practical nursing experience in a Canadian setting. We have been fortunate enough to be surrounded with diverse resources and treatments that are easily accessible in the healthcare setting.  When a particular treatment has failed, there has always been an alternative protocol to follow. 

In Canada, birth is considered a celebration of life. Families experience overwhelming feelings of joy and love upon the arrival of a newborn child. Child mortality in Canada is not as prevalent as it is in some African countries. According to the UNICEF organization infant mortality is 6 times more likely to occur in Zambia than in Canada, which was a culture shock in itself to us. Families tend to dissociate themselves from children as some are not expected to live past the age of 5 (119 deaths per 1000 live births). A large majority of people, in one way or another, have experienced the loss of a child to the extent that it has become a part of life here in Mongu, Zambia. Here, on the postnatal ward, the families are not as involved with the birthing and postnatal period as they are in Canada.  This leaves the mother to become her own support system. The lack of unconditional love and support for what we know to be a "creation of life and happiness" is a hard concept to grasp.

So precious.... so small... so weak... a little human being trying to hold onto its place in this world, is what we saw through the walls of a neonatal incubator one morning. The babe was severely dehydrated due to poor feeding that unfortunately led to hypovolemic shock (hypovolemic shock is an emergency condition in which severe blood and fluid loss makes the heart unable to pump enough blood to the body).The babe appeared to have poor muscle tone, had a mottled appearance, and her chest was retracting with efforts to breathe. In order to receive proper hydration the babe needed intervenuous access, which had gone interstitial earlier that day. In efforts to save this babe we decided to call the physician. It was in that moment, after the physician had tried the veins in the hands, arms, feet, clavicle, and  shaved a portion of the head with attempts to start an IV, that we lost hope. The physician then explained "that's it". 

The strong front that people here in Zambia put forward with regards to pain, loss and suffering is unbelievable to us. Woman are taught to be "tough as nails" and mask their emotions. The mother was devostated when explaining the prognosis of her baby girl. Although there was an existing language barrier I comforted her, held her hand and let her know it was okay to cry. Rubbing the father's back and hugging the grandmother were moments that I take away from this emotional but remarkable experience. Palliative care is not part of common healthcare practice in Zambia. We, as a team, were able to advocate for this family who needed palliative support more than anything in this difficult time. This advocacy allowed the mother to feel supported and hold her babe during this emotional situation. 

Due to a lack of resources something as simple as dehydration, which is preventable in Canada, is a common reality in Mongu. Perinatal and early child mortality rates in Zambia are among the highest in the world (Hyder et al. 2003; Madise et al. 2003; Stanton et al. 2006). It is difficult to accept this reality as we are used to seeing and practicing health care in such a different way back home. Upon reflection, we came to the realization that the physician was well aware of the pending prognosis, but went out of his way to attempt to start an IV on this babe to emotionally support us as students.    

At the end of this experience, we recognized a great need for a balance between being empathetic and accepting the current reality here in Zambia with relation to postnatal and maternity care. We never would have expected that the words "that's it" could lead us to a new perspective of life, and open our eyes to cultural differences.

Prayers and love to the family we cared for this week. 

Love 

          Trisha and Amanda 

This is the grandmother and mother during our last day on postnatal

This is the twin sister of the neonate that passed away

Celebrating World TB Day!

This past Wednesday, March 24^th Jessica, myself, and 13 of our nursing students (3 students are away doing rural outreach work this week) had the privilege of walking in the March for World TB day in Mongu, Zambia. This year Mongu gained the honour of being chosen as the site for the National Zambian world TB celebrations.  Honoured guests included the World Health Organization (WHO) regional director and the Minister of Community Development – Mother and Child.

 

This was quite the experience. I have never marched for a cause and what I felt was truly a sense of empowerment. Hundreds of people joined in on the march, including school aged students, nursing students, nurses, marching bands and many other local groups and organizations. Following the march we got to observe several cultural performances that included traditional dancing, singing, and ‘dramatic acts.’ It was truly a pleasure to get to see how other countries come together to raise awareness about important causes.

        The UBCO 2015 Nursing team in Zambia

 World TB day happens each year in March. The aim of the day is to enhance public awareness of the ongoing epidemic of Tuberculosis that continues to impact many areas of the world. TB remains a major health challenge in Mongu and throughout Zambia. The high prevalence of TB in Zambia is largely the result of a number of factors, which includes high prevalence of HIV, low socio-economic status, inadequate housing, transit systems that lack adequate ventilation, and a health system that continues to fall behind on the resources needed for education, diagnosis, treatment and prevention.  

Although we see TB in British Columbia it is not an epidemic, nor is it a leading cause of death in Canada, as over 95% of TB deaths occur in low- and middle-income countries (World Health Organization, 2015).  According to the WHO, in relation to infectious diseases, TB is the greatest cause of mortality next to HIV worldwide.  In 2013, 1.5 million of the 9 million people with documented new reports of TB died from the illness.

However there is progress; the death rates of TB from 1990-2013 has declined by 45% and approximately 37 million lives were saved through increased resource allocation, diagnosis, treatment and public awareness (WHO, 2015, Key facts).

After the celebration Jessica and I were invited to a luncheon with 200 local and out of town guests to complete the day. We had the opportunity to meet new people and re-connect with people we’ve met working here in the past. We truly see a solid partnership formed here with our Zambian colleagues. The day raised a lot of awareness and showed the great strengths and efforts Mongu has made to reduce the incidence and deaths caused by TB!

Jackie and Jess A.K.A. J&J