Female Ward Week #1

I think that the best way to illustrate what life is like for me as a nurse in Africa is to first paint the picture of my life as a nurse in the states. Read on and I think it will make sense.

A day in the life of Nurse Julie at a government run hospital in the USA:

I arrive to work and print out a list of the patients I will be caring for. The list will include; diagnosis, allergies, latest recorded vital signs, the medical specialty the patient is under, and space to write my notes for the day. There will be as little as 5 and no more than 10 patients that I am assigned to. On the worst day I will have 10 patients, but I will have someone on my team to assist with giving medications, checking blood sugars, documenting intake and output, and taking vital signs.

After getting a thorough report from the nurse on the previous shift I look up each patient in their electronic medical record to check for new orders. If a patient needs an intravenous (IV) cannula placed, I inform the IV team and expect it will be done within 1 hour or sooner if it is urgent. When I see that a lab needs to be drawn, I print out a request and send it to the lab, and anticipate that the phlebotomist will come to draw blood. I will see the results in the computer within my shift. Chest x-rays are easily obtained with a portable x-ray machine brought to the ward soon after the order is put in. Sometimes a medication is not available, so I phone the pharmacy and they will have it sent up. The amount of time I have to wait for these things when I have an unstable patient can seem like an eternity.

Before I enter a room to check on a patient I look at the flow sheet outside the room to see if the vital signs are stable. Any abnormal vital signs will give me clues on how to assess the patient. I may be exasperated if I see that there are no size small gloves for me to use outside the room, but I will go to the supply room down the hall and grab a box from the huge stack that are available. When I return to do a full head to toe examination, I first clean my stethoscope with an alcohol swab. If a patient has an issue, such as uncontrolled pain, I will page the doctor on-call. The doctor will return my phone call within 10 minutes, and a new order will be activated in the computer within minutes. When I sign out the medication electronically, I can check to see when the medication was last given, the dosage, and how much pain the patient was in at the time. If I need to give insulin for a diabetic, I can check in the computer to see what the latest blood sugar was. Of course, syringes and insulin are always readily available.

Antibiotics are premixed by the pharmacy in bags with carefully cross-checked patient information printed on them. I retrieve IV tubing from a giant bin and set up the antibiotic by programming into the electric infusion pump how many milliliters/hour it should run. I walk away and expect the machine to alarm when it is finished. When I return with a premixed 10ml normal saline syringe, (found by the hundreds in the supply room) I push normal saline into the patient’s vein, so that the IV line will remain patent. At this point I may notice that a patient needs a dressing change. If I go to the supply room and I can’t find what I need, I call the supply department and they bring me anything I request. On any given shift I will use approximately 100 pairs of gloves, 50 alcohol swabs, and 25 normal saline syringes. It is very rare that a medical supply cannot be obtained.

During my shift, I carefully document everything that has been done with the patient including the results of the head to toe assessment and how a patient responded to treatments. Then I pass the information on to the next shift. I am busy during the entire 8.5 hour shift, and barely have time to take a ½ hour break. Of course there are many variations to each day, but most days I can go home knowing I worked hard and my patients were well cared for.

A day in the life of Nurse Julie at a government run hospital in Uganda:

I arrive to the female ward at 8:30 in the morning and put the handwritten patient charts in the order of the bed numbers. The ward has no privacy, with all of the patients in one room together. The night shift nurse, who signs off to me, tells me very basic information about a select few patients such as the new admissions, who is on IV medication, and when their next dose is due. There will be 1 nurse caring for the entire ward, with no assistance. There are usually no less than 24 patients. Fortunately, on the female ward a lot of the patients are stable enough that they don’t need to be closely monitored. The common illnesses that I have seen so far are malaria, typhoid, random parasitic induced infections, ulcers, bowel obstruction of unknown etiology, newly diagnosed HIV/AIDS, tuberculosis, pneumonia, heart failure, uncontrolled diabetes, post-partum depression with psychosis, and osteoarthritis in the elderly.

The tricky part to the beginning of the shift is figuring out which patients need to be closely monitored. It is not protocol for a nurse to take a patient’s vital signs or document their intake and output. Not knowing this information negates important clues as to which patients are the most critical. The best I can do is to go and look at each patient, and try and prioritize/triage that way. First, though I flip through the charts and try to decipher the messy handwritten diagnosis and orders on random pieces of paper in each chart. I admit that I am not very good at it yet, as the types of illnesses and medications are much different than the ones I am used to at home. Not to mention I am accustomed to neatly type-written orders. It is a relief when my interpreter Peninah arrives and she helps me read through charts and then we go and do rounds together.

In Africa, it is customary for a patient to bring an attendant to the hospital with them, and it is usually a family member. The attendant is responsible for feeding, bathing, and laundering the patient’s linens. Washing linens is done by hand out on the hospital lawn. If the patient even has linens it is usually just a wrap they have brought with them, otherwise they are lying on the plastic mattress. The cleaning of each bed after a patient leaves is the responsibility of the attendant and usually does not get done. The patient and attendants are often from far away and therefore the attendant is forced to sleep on the floor under the patient’s bed. When a patient has a baby, (which is often) and the attendant is away, babies are found crawling around the ward. The attendants are a valuable and crucial resource, not only in caring for the patient’s basic needs, but also in providing important patient information to the health care providers.

I am still trying to figure out the best way to conduct my day, but so far I have chosen to attend primarily to the patients whom I think to be the most sick. I start by asking them what their primary complaint is, then ask if and how much they have been eating, drinking, peeing, and pooping, and then I take their vital signs. At home blood pressure, heart rate, and oxygen levels can be determined quickly using a battery powered machine. Here I take blood pressures using a manual blood pressure cuff and stethoscope. Checking their heart rate requires finding the radial pulse and timing it with a watch. At Kisoro Hospital there is only one oxygen tank for the maternity ward, so we do not check oxygen levels. A thermometer is usually hard to find, so I began to bring my own. To obtain a blood glucose level requires going to the male ward and borrowing their machine. These processes can be time consuming, which gives me some indication as to why they are not done routinely by the other nurses.

Sometime during the period where I am assessing the most sick, and passing by the least sick as they look expectantly at me, the 1 doctor on duty may request a lab to be drawn, an IV cannula to be inserted, IV antibiotic or fluids to be started, or an x-ray to be done. This is where it gets interesting. To draw a lab or insert an IV cannula first I have to find gloves. During the 5 days I’ve been on the ward, there was only 1 day where there was one box of gloves on the ward. Fortunately, I brought gloves with me, and I am not sure what I will do when I run out. I also brought alcohol wipes to clean my thermometer, BP cuff, and stethoscope between patients, but that supply is limited as well. Besides the gloves, the most useful thing I brought with me is hand sanitizer. There is only one sink with a bar of soap and often no hand towel. There are certainly no electric paper towel dispensers here.

Drawing blood and inserting IV cannulas is something I know how to do, but have practiced very little. So usually I have another nurse come to assist me. One always hopes when inserting an IV cannula you will be successful on the first try so as not to cause the patient any extra discomfort. Another thing that has to be considered here is that many times there have been no IV cannulas available at the hospital and the patient’s family had to spend what precious little money they have to buy one. It is therefore important to use such medical supplies sparingly and carefully. Once the IV is placed there is usually not enough syringes around to flush the line to maintain the patency, which makes the IV not last as long. The other problem with starting IV fluids and antibiotics is that there are rarely enough “giving sets,” (IV tubing) which forces the attendant to go buy that supply as well. More than once I have seen a patient or attendant unable to afford these supplies and despite the fact that the patient is very sick we are unable to administer the necessary fluids or antibiotics. Sadly, last week a patient on the male ward with cerebral malaria died because the patient’s attendant was unable to return fast enough with a “giving set” to give the antibiotic that would have easily saved his life.

The most common labs that are taken are for malaria, HIV/AIDs, and tuberculosis. The other lab values are either not available, inaccurate, or take such a long time to process, that it is often not worth it. An ethical issue here is that sometimes they draw a lab which is called a “blind serum.” It is an HIV/AIDs test taken without first getting the patient’s consent. Even more odd, is that the patient will often not be informed if the results are positive. This is at the discretion of the local health care providers, due to the fact that the patient may become depressed or they are not ready to hear the results. The point is that the health care provider will better be able to diagnose the patient. Interestingly, the patient cannot be put on an anti-retroviral treatment without first consenting.

Getting an x-ray has been near impossible since I have been here. The two reasons I have heard are the radiologist is not around or they were out of film. The residents are often frustrated that they do not have access to a CT scan which would, in many cases, make diagnosing a patient much more definitive.

When it comes time to pass medications a cart is rolled out to the middle of the ward and each patients name is called out. The attendant comes to pick up the medication to give to the patient unless it is an IV medication. The IV antibiotics are diluted by the nurse and the rate is set manually. There is no electric pump to program the rate. The oral medications have only the name and sometimes the dosage of the medication handwritten on the bottle. This fact and the fact that the medication orders that are handwritten in the chart are often unclear, leaves a lot of room for medication errors. It is common for a medication bottle to be empty and in that case, we document that the medication was not given and write instructions for the attendant to go buy it at an outside pharmacy. In the 3 weeks that I have been here the hospital has been out of insulin, and often they are out of other important medications, such as the diuretic lasix.

As soon as the medications are given it is around 2:30pm and the day shift is essentially over after the nurse jots a few notes in the log book. I’ve learned that only the bare necessities can get done in the allotted 4-6 hour shift, which depends on when a nurse arrives and how long they take for a break. By then I also am mentally drained and ready to go home. In a way the frustration nurses have cross borders. Things such as under-staffing and systemic issues continue to make nursing a profession that has a low retention rate and a high level of burnout. The nursing and medical administration here would like me to implement some new processes. One of the difficulties is that nurses rightfully may not trust me and may be resistant to change. We will see what I can do given the limited amount of time and resources I have.

Fun Things:

My main activity this week was taking a two hour hike up Nyagashinge Hill right in front of my house. I went with Morgen and the new resident and my new housemate Baback. It was a short and steep walk up the hill, where we had a sad little boy named Gillard who decided to lead us the entire way, on his own volition, without a request for payment. At the top of the hill we found smoke rising, and discovered a boy, about 5 years old, roasting maize in the ground, and tending goats. As we meandered down the other side of the hill, we heard the loud call of dozens of weaver birds. I found the source of the calls in a tree full of nests dangling like ornaments. This is where we passed through a small village and collected an entourage of children. When we took pictures of them and showed them on our cameras they would scream with glee. One little girl name Rosette took my hand and held it until we reached town.

After our hike we stopped for dinner at the Golden Monkey where Morgen and Jay are well known. We were invited into the kitchen to hang out and watch our meal being prepared as everyone chomped on roasted maize. Tomorrow if it doesn't rain I may go with my new colleagues and attempt to climb the jagged Sabinyo volcano, a rugged 3669 meter hike. Now I’m off to popcorn and beer gathering at Peggy’s house.