Tag Archives: healthcare in a developing country

My Experience in the ED

Aug 31, 2017

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August 19, 2017 Saturday

I’m currently writing this in the pitch dark. It’s night time in Tanzania and all of the electricity just went off. A few nights ago after tossing and turning all night because of hearing various sounds throughout the night I woke up in the morning at 5:30am to the sound of heavy rain, electricity no longer working, and a leak in the room. All of the electricity goes out periodically here; both at the house and hospital. There are a lot of things that I’ve experienced here on a regular basis that I wouldn’t typically experience at home.

Sometimes the water goes out when you need to wash your hands or even while you’re in the shower. The toilet will stop working, sometimes the toilet is an actual hole in the ground,

having to hand wash clothes, not having any toilet tissue in any of the public restrooms, constantly having to have bug spray on because misquotes are everywhere at all times, no AC anywhere, etc. However, I can’t even complain. There are so many people here who don’t even have a proper toilet. I’ve seen people washing their clothes in puddles of water and in the ocean. A lot of people in Africa don’t even have electricity. I am very fortunate both here and at home.

When I look back on this week I’m not gonna lie, it has been a really hard one. I’ve just really had my ups and downs. Especially with seeing so many painful and tragic things in the ED. Today as I reached my half way mark I had a mix of emotions. At first I was excited to be halfway done but the more I thought about it, it made me very sad. Of course I miss my dear family, boyfriend, friends, and the little things that America has like oatmeal chocolate chip cookies or AC but I’ve finally made some really great friends with the Tanzanians and feel like I’ve got a good bearing of this city. The people at the Work the World house have been amazing and I’ve been great friends with everyone since day one! However, it’s just different with making friends with the native people. A lot of people come and go at the Work the World house. Everyone that was here when I arrived has left now. The two girls from Belgium that arrived the same day I did just left an hour ago. It’s been so hard saying goodbye to everyone. There’s been people from all around the world: England, Belgium, Netherlands, and Australia. So far I’ve been the only American which has been hard. But everyone has taught me so much about their healthcare systems and cultures.

When I met with the Lumos committee I will never forget what one of the people on the committee told me. He said to be sure to

really make an effort to get to know the local people.

I couldn’t express how it has been the best and most rewarding thing I have done since I’ve been here. The people and culture are literally my ultimate favorite. I’ve never met people as kind as I have here. If you show them a little interest they will pour into you times a million and give you four fold. Everyday is literally a new adventure. I never know what’s in store. Of course I know I’ll be waking up at 5am to get ready for the hospital and it’ll be an hour commute. I may or may not have a seat on the dala dala. But, the hospital is always a surprise. Which nurses or doctors will I see today? What patients will come in? What new friends will I make? What will my evening be like? I hardly ever leave the hospital at the same time in the afternoon/evening. It may be 3:00p or it may be 6:00p. Sometimes a nurse will take me to her home or student nurses will make me dinner and let me come into their hostel. Everyday is literally a new adventure!

My first full week in the ED was extremely eye opening. Everyday felt like I was in an episode of Grey’s Anatomy. I won’t go into too big of detail because I know how some people don’t have super strong stomachs and because of patient confidentiality but I would see patients all over the spectrum: SEVERE motor vehicle accidents, SEVERE burns, accidents with bombs, gun shot wounds, several head hemorrhages, tetanus, TB, malaria, many cardiac arrests, machete accidents, and so much more.

I’ve seen tragic things at the same time. There was a patient who’s blood pressure was 300/200 and was having a stroke. She didn’t have the money to afford a CT scan which is about 170,000 Tanzanian shillings which is about $60 US Dollars so they wouldn’t let her have one. When I asked what’s going to happen to her they said she’ll remain there until her condition improves or worsens. If it worsens she’ll be sent to palliative care. It was midnight and she had arrived early afternoon. Her condition was only worsening. She was struggling for each breath, she was bleeding out blood, and her blood pressure wasn’t dropping. The only thing they were giving her in the IV was dextrose. I was so confused and upset on the inside but I simply had to remind myself of this phrase, “It is what it is.”

I’ve faced a lot of ethical dilemmas while I’ve been in the hospital. There are so many ethical decisions being made that I don’t always agree with or understand but I’ve learned to just observe everything going around and accept what is happening. For instance, my last day in ED there was a patient with 3 wounds to his head. We believe they were gun shot wounds. He started going into cardiac arrest so we began CPR. However, when we would do rescue breathing for him the air would come up through his head and more blood would gurgle out. Eventually he went back to a normal sinus rhythm but shortly after he was somewhat stable his B/P dropped and he went into cardiac arrest once again. Right then and there all of the nurses and doctors began talking about whether they should do CPR again. They stated his pulse was gone and asked if anyone had any issue with leaving him as is. No one advocated to continue so they just left him. My insides flipped over in that moment. I had just never seen that happen before. From what I’ve seen in the US the doctors and nurses will try everything in their power to keep the patient alive unless they have stated they’re a DNR. This patient was probably in his late 30’s. I honestly haven’t seen anywhere on any patients charts if they’re a full code or DNR so I’m not sure if they have that here but I’ll have to ask. This is an example of just one of the many situations I’ve seen where ethics go into play. I could see where the healthcare team didn’t see a purpose in continuing CPR because of the overall outcome of this patient. However, it was just hard to see people giving up on someone to live.
There are two other patients that I would like to talk about that really stood out to me during my time in the ED. I had both of these patients on the same day. Let’s call the first one Rob and the second one Jim. I won’t be able to go into too much detail due to patient confidentiality.

Rob was an older man who has been suffering from various health conditions one of which was cancer. He came into the hospital with a chief complaint of overall malaise and weakness. He didn’t seem 100% orientated and he was struggling to breath. We put a non-rebreather mask on him to increase his 02 level. However, he kept trying to pull it off. The doctors and nurses ended up restraining his hands to the bed so he would keep his mask on. When I was in the SICU at Vanderbilt a patient was so delirious because of the lack of oxygen that he kept trying to pull off the mask, just like the patient was doing here, so the doctors and nurses gave him a light sedative to keep him calm. I thought it was the best thing they could do since they didn’t have the sedatives available. However, he was really having a hard time breathing. It’s always so important to observe your patient and listen to what they’re saying. A teacher at Belmont once taught me that a nurse is nothing without their assessment. However, they kind of just left this man in the corner of the room. About an hour later his breathing stopped all together as they were attempting to intubate him. Due to his various health conditions they didn’t feel it would be a good overall outcome if they attempted CPR. Almost an hour after his death various doctors were still practicing how to intubate. They had the device in his mouth and one after another doctor would practice and clean up their technique. This made my stomach sick and made me so sad. With patients I always try to think of them as an actual family member. This man was just a few years older than my Dad. I wouldn’t want anyone doing that to my father! No way could I do it on this man. Some of the doctors asked if I wanted to practice but I said no. I understand their reasoning so they’d know how to do it on future patients (some American intern doctors were teaching them how to properly do it). But I still didn’t feel right about it. After they all practiced intubating him they just left the room leaving him there. My mind immediately went to what I had learned in my Adult Health 2 class about postmortem care. During my SICU clinical experience back in the US I had experienced my first death of a patient and that was the first time I had done postmortem care. I was incredibly thankful for that experience because it helped me in that moment. Although the postmortem care was a bit different here I was able to do it. One of the hardest things here in the hospital is not being able to speak Swahili fluently. From context clues and simply observing the situation I was able to identify who his daughter was. I wanted to so badly be able to speak with her in her language but all I could say in Swahili was that I was very sorry. It was so interesting to watch how the healthcare professionals treated her. It’s just not what I’m used to seeing in the US. I just kept putting myself in her shoes. If my father had just died I would be a basket case. She called her mother on the phone to let her know. It was all so heartbreaking. To make the situation even worse I was watching what the nurse was doing on the computer screen. She was JUST NOW PUTTING IN HIS TRIAGE INFO and how he presented upon being admitted. She wasn’t even the nurse in the room that saw him once he got there so she was making up a lot of it. It was over an hour after his death and she was just now putting in all of this info that had happened upon his initial admission which was about 4 hours ago. This just surprised me so much. She was documenting on a dead man from when he was alive hours ago because it wasn’t done yet. The situation with this patient really made me sad. What if I had just listened to him when he was taking off the mask. Maybe he was just trying to show us he wasn’t breathing properly with it on and that’s why he was trying to take it off and we should’ve intubated sooner. I’ve faced a lot of situations in the ED that made me question how good my nursing skills are. I don’t have that many clinical skills under my belt since I’m a recent graduate but I just can’t help but think if I maybe had more experience I would’ve been able to save more patients lives.

Later on in the day the second patient that I would like to talk about came in, Jim. He was about my age and was a very fit young man. Looked like someone that nothing could hurt. He was very muscular and healthy looking. Just full of life. However, like many of the patients he was involved in a motorcycle accident and was laying on the bed lifeless. The doctors put me in charge of suctioning and manually bagging him. I did this for about an hour before we transferred him. As we were transferring him I was still bagging him. We took him all the from the ED to the surgical intensive care unit. Which was a good 10 minutes walking distance. They were strolling him and I was bagging him while I tried to dodge running into people. Once we got to the SICU we were able to get him hooked up to the ventilator. However, the SICU was the most eerie place ever. I felt like I was on an episode of The Twilight Zone. The windows were tented with this dark pink/purple tone so you couldn’t see out of them and there were all of these constant noises that would come on every few seconds and play in harmony with one another. It was pure white on the inside and all the patients were lying across from one another in the ward not moving or talking since they were mostly all on ventilators. It was just a very creepy feeling I got. And all the doctors were dressed in a different outfit with white shoes on. The facility seemed great though. It seemed like they had a lot of money going towards that ward which was nice to see.

The teachers at Belmont have taught me SO much! I hold onto everything I learned while at school like a treasure. It’s really helped me while I’ve been here.

Mental Health Ward

Aug 15, 2017

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August 15th

I’m sitting outside with the sun shining on me as it begins to set. This Saturday is coming to an end and as it’s ending I’m reflecting on these last 2 weeks that I had at the hospital. I have been in the Mental Health Ward and it has been such an eye opening experience!!! At first I was really worried because I didn’t know what to expect. I had heard how it was very different in some aspects. However, I absolutely loved it.

I spent my first few days in the male acute ward and fell in love with the patients. In the psych ward they have an acute ward for males, a general ward for both females and males, PPI which are private rooms for people with private insurance, Occupational therapy unit for groups, a day clinic for pediatric and adolescent patients, and a methadone clinic. I had a chance to go to each of these units; however, I spent most of my time in the male, acute ward because I was able to see and learn a lot there!

This is the outside of one of the acute male rooms. It looked a lot like a prison and you had to use a key to unlock the gate to get in

When patients first arrive they are immediately admitted into the acute ward (if they are males) and then when they calm down they’re admitted into the general ward generally after being in the acute ward for 24 hours (sometimes longer). A lot of the male patients upon admission are aggressive. I witnessed quite a few. The family members that bring them in as well as the staff hold them down to the bed and restrain both arms and legs. At first I had a hard time dealing with this. In America, restraining patients is a last ditch effort. We go from least invasive to most invasive. Once they get the patients tied down they then administer medications. Both through the vein and an IM (intramuscular). However, when they administer the medication through the vein they don’t insert an IV cannula. They do it strictly with the needle into the vein. It’s quite a big needle and sometimes the patient is thrashing around on the bed. Typically the needle is jerked out and the nurse re-inserts it several times until they’re able to get it all in. In America we never restick the patient with a needle. This was quite different to see. I’ve never seen medication injected directly into the vein without the use of an IV cannula. It also made me nervous for a needle stick injury. It would be very easy to accidentally stick yourself with the needle with the patient is trying to fight you putting the needle in.

A lot of the patients were admitted with psychosis due to drug use. The most common drug of choice was cannibus. Patients were also admitted because they weren’t being compliant with their medications. Therefore, the patient may come in because they’re being manic from their bipolar disorder. There were also patients there who had schizophrenia, grandiose due to psychosis, aggressive/agitated patients, major depressive disorder, etc. A lot of the patients were highly educated and had a college level education. A lot could speak English as well. In the acute ward there are two rooms. Each room has 6 patients so a total of 12 patients. However, the rooms didn’t really look like rooms. They looked a lot like a jail cell. The male patients wore blue scrubs and the female patients wore red.

Inside the acute ward there was one patient that absolutely broke my heart. He was found on the street (they think his family just dropped him off and left him) and brought to the mental health ward. He is mute and seems to have some sort of mental disability. A lot of patients with mental disabilities are seen as someone who has a mental health problem. They tried sending him to an orphanage but things didn’t work out there so he has been in the acute ward for 2 years now. T W O Y E A R S. I just couldn’t believe it. The rooms aren’t that big and there’s nothing to do inside the room. Every now and then the patients are able to leave for OT but that’s not that often. Since he is mute he’s unable to tell anyone his name. In addition, he’s not able to write so he can’t write his name. He’s literally known as Unknown. They don’t have a name for him. They’ve tried putting his picture in the newspaper, on the news, and on radio broadcastings to try and let his family know he’s at the hospital because he’s unable to give the staff any information about his family and where he’s from. However, know one has shown up. In one regard it’s wonderful that the government pays for him to be there and that he’s not left out on the street but it’s very sad that he’s been there for so long. They’re trying to get him a permanent home but it’s still in the making. I’ve learned that you can’t change things in the hospital but you can have an open mind and just understand that’s the way it is. Before I came here a native had told me to

Be compassionate but not emotional.

That’s the one phrase that I’ve kept in mind over and over again. I’m not here to compare and contrast how we (America) do things compared to how people in Africa do things. I’m here to see how they’re able to manage and use the resources they have here. Countries can learn a lot from one another. Whether that be a developed or undeveloped country.

The man in charge of the acute male ward is named Clemence.

He is SUCH a sweet man and taught me so much!

He’s been there for 10 years and went to college at Muhimbili. He’s such a sweet man with a huge heart and shows compassion to all of the patients. He was so good at explaining how a lot of people in Africa aren’t educated on mental health conditions and people may think the patients are bewitched and such. He also explained how the police force aren’t educated on mental illnesses. A lot of the times the police officers will see a person acting out. Maybe the person is being overly manic and destroying things or acting out in public and the police officers will beat the person and then bring them into the hospital. There was one patient who would scream in pain any time you would touch him and his upper lip was extremely swollen, bruised, and bleeding. When I asked what happened to his lip Clemence explained that he was acting out in public so a police officer bit (yes... bit) him on the lip and they beat him before they brought him in. They did this simply because they weren’t aware that he couldn’t help what he was doing due to his condition.

Moreover, a professor and clinical instructor invited me to a class presentation that his students had where they presented a case of a patient. This was very eye opening! I learned a lot by getting the chance to attend the class. They use a lot of the same terms we use in America for their patients and they also use NANDA! Which is North American Nursing Diagnoses. So a lot of the same nursing diagnoses we use in America they also use in the mental health ward.

Getting to go to the Methadone clinic was a very unique experience. A lot of the patients who have addiction problems to drugs and/or alcohol will go to the clinic to get methadone which is a type of opioid. It is bright green and they drink it at the clinic. It’s in liquid form so the patients can’t try and sell it which they could if it were in pill form. The patients who are seen here have to want to get help and have to no longer use the substances they have been using. Each and every day the patients come to the clinic to get the methadone and then leave.

A lot of the patients who suffer from addiction and have risky behaviors tend to also have risky behaviors sexually. Therefore, a lot of the patients being treated at the methadone clinic also are being treated for HIV. Since they HIV and their immune system is lowered they tend to also have TB. Almost all patients with HIV also have TB. Before the patients can get their methadone they have to come and get their TB and HIV medications. Since the patients really want their methadone, it helps increase the compliance of them taking their other medications first so they can get their methadone. I know back in America it is extremely important for patients with TB to take all of their medications each time. Patients are typically on TB meds for an entire year and take up to 6 pills. At the health department if patients don’t come to take their meds then staff members will call them and even go to their home. It’s so crucial to be compliment with the medication regiment. I thought it was very smart for them to put all 3 medications (methadone, HIV, and TB) in the same clinic. Since there is methadone in the clinic there is a risk for people coming in with guns to try and get the methadone. They said that it’s happened in the past where people have come with guns. So I was extra cautious. However, nothing like that happened while I was there. I also got the chance to see a patient in the clinic get reassessed with how he’s doing with his addiction and no longer using drugs. During the interview there was one thing that really stood out to me. When he was asked what his annual income was he said 350,000 Tanzanian shillings. This is less than $200 US dollars. I just couldn’t believe it. On a typical week here I usually take out 200,000 which is $89 US dollars for food and commuting each day on the bus and tuk tuks. I just couldn’t fathom it.

The methadone clinic was different then any other clinic I’ve been to in America. The experience I’ve had in my mental health rotation and my senior practicum which was in a child and adolescent psych unit back home in America was quite different compared to here. There aren’t rehab programs here or a place for children to stay in patient. The day clinic for children and adolescents doesn’t admit children for overnight. In addition, there is not a problem with self mutilation among pediatric patients here. The most common issue with children and adolescents are drugs. This was a great thing to here! I had to explain to the doctor and nurses how children in America do self mutilate and will sometimes try to kill them selves. It was the first time they had ever heard of self mutilation. However, one of the nurses did tell me that on the adult unit a patient would bite at his fingers and literally chewed them off. Other than that, the patients don’t tend to harm themselves as often as I’ve seen in America. Furthermore, there was also a difference with not having a geriatric unit. The older patients tend to stay in the acute ward and aren’t put in the general ward because the other patients are too intense there and there isn’t as much observation in the general ward. There are about 30-40 patients in the general ward and they all share one room. So the older patients just stay in the acute ward until they are discharged.

Overall, I was able to see a lot of admissions, discharges, and transfers. During my time in mental health I learned a lot! The biggest issue I see is the need for educating others on mental health and imploring more time for the patients to have in OT and getting out of the room on a day to day basis. There are some things they can’t help like being understaffed and not having as many psychotropic drug options as we do in America. However, I was able to learn a lot here from the patients, nurses, and doctors. I’m excited to see what my next two weeks will be like in the Emergency Department! I did a night shift once in the ED already and it was a very interesting experience.