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.
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.
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.
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.
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.
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