Beauty Amidst Sorrow

4:30 pm hits and the patients roll in thick and fast. Floppy children carried in their parent’s arms, pale and lethargic. They are laid naked on a bed in REA (emergency), feverish and dehydrated. After a month here I cannot count the number of children I have seen and cared for like this. Some pull through and others don’t, despite our best efforts.

This week we had a small child carried into REA unconscious and unresponsive to pain with irregular eye movements. His heartbeat was steadily drumming away, too fast for his age. We acted quickly to monitor him and get an IV in. I had a bag-valve-mask (ambu bag) ready because I’d learnt from my prior experience.

As I looked over him, assessing him without even realising I was doing so, I noticed his breaths were shallow and sporadic. He wasn’t filling his lungs and moving air to oxygenate his body. We grabbed the bag-valve-mask and started bagging him for support.

After about 15 mins with no change in his respiratory effort the Dr told us to stop and just put an oxygen mask on and go to look after the other sick kids. I looked up at her and the other nurse standing with me at the airway. Did she mean what I thought she meant? I understood why. We have to work as if this is disaster triage. You save the ones you can and let those who are going to die, die. Everything in me screamed out to not walk away though. He would die without airway support. How could I walk away from him and just leave him there? I looked at the relatives faces, knowing it’s their faces that I remember long after the child has died because it’s their hearts I see break.

So we stopped what we were doing and left him there on the bed, naked, with an oxygen mask on his face, IV dripping, cardiac leads on his chest and a relative at his bedside. I prayed the same prayer I say multiple times a day, Jesus help. It was awful just walking away.

He hung on though, despite barely breathing. Overnight he regained consciousness and started moving. By the morning he could sit up and when I came back on shift he cried for two hours saying he wanted to go home! He perked up so much he was able to sit on his mama’s lap and eat spaghetti for breakfast. Amazing!! Seriously miraculous. We have no idea how he’s still alive, except for God’s power.

In the paediatric ward and ICU I’ve looked after a lot of different types of patients but there has always been at least one premature baby. I had no idea when I arrived that 2 shifts in special care nursery in the hospital at home in Australia would be so helpful now. I’ve now cared for 5 different premature babies, all weighing less than 1.5kgs. It has been a learning curve complicated by lack of clean sheets, no nappies, limited neonatal IV supplies and most of the isolette cribs need a service and so don’t heat well or at all. But I love these babies and have enjoyed seeing them and their dedicated mamas every day. They are a rainbow of beauty in the midst of the shadow of pain and loss of some of the other patients. We are struggling with some of these precious babies to gain weight. Please pray for these little ones. None of them are given names until they leave the hospital.

Thank you so much for praying and walking this journey with me. After so much grief and loss a couple of weeks ago, I was lifted by your prayers and comments of support and love. Please continue to pray, not just for me but the team here and those who work and live in Mango and face the reality of life here every day. It is a truly beautiful country, with friendly, strong, courageous people.

Loss

I have been thinking a lot about the two weeks I spent in Masanga, Sierra Leone in 2013. I felt like I was working in a disaster area because multiple children arrived every afternoon with severe malaria that were half dead. It was there that I did CPR on a baby and child for the first time. It was there I saw a child haemorrhage who died while I was away eating lunch. It was a shock to my sheltered nursing career and love of people. I thought it might be unique to that area because it was remote. There were still wild monkeys jumping around the trees. But I have realised this week that my experience in Masanga, Sierra Leone is not unique to that area.

It is currently malaria season and you know the season is upon you when there is multiple small children lying in beds in emergency or ICU, febrile and severely anaemic. These patients are very lethargic and flat. Some have advanced cerebral malaria to the point of seizures. Yesterday a baby seized for over an hour which could not be reversed by medications. His nurse came to me for advice since she is not a paediatric nurse. She told me his respiratory rate has dropped significantly and she was worried. I could see from the monitor at a distance that his heart rate was close to 200. I told her that if his respiratory rate was dropping then he was probably going to have a respiratory arrest so to be prepared. (Unless children have a previous cardiac history, they will have a respiratory arrest before a cardiac arrest.) She went and told the doctor the baby’s vitals and then got the appropriate equipment- simply a paediatric bag-valve-mask (ambu bag) and age-sized face mask. That is all we have. The saddest thing to me is that I didn’t even have time to help her because I had 3 premie babies (all weigh less than 1.5kg/3.3lb), 2 3month old twins who weighed 1.4kg and 1.52kg with malaria and malnutrition and a toddler with malaria who had barely moved. I didn’t have time to get heavily involved with a baby potentially needing CPR. There were multiple reasons for me not volunteering to assist. Firstly, the staffing ratio to patient numbers are often barely manageable because people need care so come to the hospital, but we only have so many staff to work. On Saturday I had a nursing student help me in the morning (he was supervised by a Togolese nurse) but after lunch my patient load was 6 babies that weighed less than 2kgs each, all feeding every 2-3 hours and 3 children. We always have a nurse-aid caring for our patients who are super helpful but there is only so much they can do. More children were admitted who I should have taken care of but I physically and mentally couldn’t pick up any more than I was carrying.
Secondly, I wasn’t sure I had the mental strength for potentially doing CPR on a baby. After losing the 6yo girl earlier in the week due to malaria, the following day I had worked really hard with another severe malaria baby boy. He looked ok but I came back to work 2 days later and the night shift nurse told me he had coded overnight. They had managed effective CPR, but then he died a while later. Oh how I wanted to burst into tears. His little body was still on the bed and his mama was still wearing the yellow shirt from the day I met her. She picked up his limp little body that fit perfectly in her arms. He was wrapped in her fabric. She had a bewildered look on her face and tears pooling in her eyes and streaking her cheeks. She had to pay the hospital bill before she left but she didn’t have enough money.
Caring for children who are on the verge of dying is mentally, emotionally and physically exhausting. That day I had already helped a team do CPR on a woman who had come in the door and arrested immediately. She didn’t make it either. I was standing at the head of the bed when we stopped doing compressions and the doctor checked the pupils. No reaction to light. The female relative was distraught and quickly covered up the patient’s lifeless face after closing her half open eyelids. I choked back tears.

I know death is a part of life, more so in low income countries than high income. At home we hold on to life for too long sometimes. But I am struggling with how quickly we lose life here. It just feels so fast. I wrestle with knowing God cries with me and more, for the loss of his children but I wonder why He hasn’t answered some of our prayers. Why do these communities suffer with so much needless loss? It is just so unfair.
I’ve been wondering, how is this life sustainable? The only answer I can find is to look for the good. See those who survive because there is a hospital. There are countless patients who come in, get treatment and not only survive but thrive. All those premie babies are surviving and getting fatter and closer to going home. That is beautiful to see and be a part of. Also, the Togolese nurses who work in this hospital are amazing!! They are heroes who deserve so much praise.

For a period today though, I just need to cry and grieve the losses of the week because they are so real and heartbreaking and if I don’t cry now I never will. I put some music on this morning, my favourite album Let There Be Light by Hillsong Worship and just let the words wash over me and sink deep into my soul.
Thank you for praying for me. I can tell you are because some days in the midst of a situation where I might feel swapped and completely overwhelmed, I’m calm. Please also pray for this community, that they would come to know Jesus. Pray that despite severe loss and grief, they would know hope. He is the only one who can truly save them.

Malaria

I walked over to her bed with the malaria meds prepped and ready to inject through her IV. I set my little tray of medications on the table near the trolley she lay on in emergency. I had seen her from a distance while I was in the nurses’ station but hadn’t been a part of her bedside care yet. It had been a busy nursing shift but I’d caught up and was helping out my friend and co-worker Vivian.
The papa was sitting by her side on a heavy wooden hospital chair. This 6 year old girl had been admitted with severe malaria and her colour was terrible. Malaria destroys your red blood cells causing death if untreated and children are especially vulnerable. I could see the pale soles of her feet, her pale face and lips and identified immediately that she was terribly anaemic and needed a blood transfusion. Viv was just preparing it as I came to give these meds. Her papa had previously taken her to another hospital but they were unable to give a blood transfusion which was what she really needed, so he had brought her to us.
As I neared, I noticed she was staring straight ahead, eyes half open, not blinking. Her face was a terrible greeny-grey colour. I glanced up at the cardiac monitor. Her heart rate was only 35. I recognised the signs immediately and tried stimulating her by sternal rubbing but she didn’t respond. I called out for Viv and placed the palm of my hand on her chest and started pumping like I have done so many times in practise, but this was a girl who had very much been alive a few minutes ago. She was not a manikin. Her skin was warm and the contours of her ribs showed through her skin. Her eyes, half open, had beautifully curled black lashes. Her ears were pierced and adorned with gold earrings as per the custom here for girls. I kept pounding her heart with my hand while consciously thinking of the rate and depth of compressions. Right then I wanted to cry. We train for these things but never really want to do them for real. I grit my teeth, swallowed back the tears that threatened to spill and I concentrated on compressions while a team formed around me, airway, suction, squeezing the blood transfusion in and more IV access. The trouble is, we are in a low income country and our hospital doesn’t have a ventilator or intubation gear. We have an oral airway and can bag her with oxygen but that is it.

I continued compressions. I swapped to airway. I changed back to compressions and back to airway while the team gave adrenaline and put down and NG. I’m not sure where her papa had gone, but I continued to concentrate on pushing the little blood she had around her body.
After some time passed and there was no response in the girl, I kept looking up at the doctor. She was trying to decide when to stop. I could see her hesitation. No one wants to be making that decision but this little girl’s spirit had already gone leaving behind a washed out body.
The doctor called us to stop. We took our hands off her small, still body and I looked around at the 3 other white faces, all were streaked with tears. The Togolese who were helping, cleaned up and moved on to their other jobs with stoic emotions. No doubt this was another of uncountable deaths during their time in healthcare (which doesn’t mean they don’t feel it, they just don’t tend to show their emotions outwardly like we often do).
Her papa walked forward from where he had been watching us and asked if she was dead. “Yes she is.” The doctor replied in French through her quiet tears. “Bon courage,” her papa said to the tear streaked faces surrounding his daughter’s body.
We removed the IV lines and things from her body and wiped her clean. She was wearing just a skirt so one of the nurse-aids got a small child’s gown to put on her and once they were ready, papa picked her up and her head rested on his broad shoulder as if she were just asleep. And then he walked away with her body. The very opposite of every hospital admission I hope for.

The strange thing is after that situation you just have to carry on with caring for your other patients, even though your heart is crying. It cries for every parent, sister or brother who loses a child or sibling to malaria or sickness that is totally treatable or preventable. It cries for the injustice and disparity here and across many countries in the world. It cries, hoping and praying that next time we’ll be quicker and can save them.

A Taste of Mango

I wake up but keep my eyes closed because my eyelids are so heavy with sleep still. I know the power has gone off because my ceiling fan directly above my bed has stopped, causing me to wake feeling overheated and sticky. With the white noise off I can hear people laughing and talking in a different language outside my window across the sandy, red dirt road. The air in my room is still. Too still to be comfortable. I guess it’s about 32C in here. The dependance I live in is just two rooms and sits across a small courtyard from the house my friend Miriam lives in. We are in Mango, Togo, 475km (295 miles) north of Lomé.

The power comes back on and my fan restarts but now I’m fully awake so I wrench myself out of bed and dress with my shoulders covered and a skirt that reaches my ankles in respect of the Muslims who populate this area of northern Togo. I unlock my door from the inside and head across the dirt courtyard to the house. The sun is blazing and a warm breeze rustles the pink bougainvillea on the wall surrounding our house block and the mango tree in our yard. The house is simple inside and a very fine layer of red dust coats everything. The Harmattan winds that blow from the end of November to the middle of March create most of the dust but also the red dust is kicked up from the village streets as only the main road is paved. 

I head to the kitchen to get a drink of water as I wake thirsty every day. The tap water is dirty so we have a big water filter and keep clean water in bottles for when the town water is switched off, which is frequently.

The next step of the day is making coffee. The power is back on but I need to switch off the kitchen fan to light the gas stove to boil water in a saucepan as we have no kettle. I mix up the powdered milk while I wait for the water to boil. There’s seems to be an extra step for everything here.

Coffee cup in hand I sit on the couch and check messages on my phone. At least Miriam’s house internet is reliable when the power is on. It’s nice to still feel somewhat connected despite being miles away from anywhere. I start replying to messages people have sent asking me how it’s going over here.

I’ve worked a few shifts in the hospital now and have an idea of what each day might look like. The hospital is run differently from other hospitals. Patients must come between 0700-0800 and wait at the front gate to be triaged and sent to the clinic for outpatient appointments, surgery appointments and new presentations. Not everyone will be seen each day as there are limited staff members and hours in a day to work. Patients are sent to the laboratory, pharmacy, radiology or up to the hospital from the clinic. The hospital has areas for emergency, men’s ICU, men’s ward, men’s infectious, women’s ICU, women’s ward, women’s infectious, isolation rooms, paediatric ICU, paeds ward, maternity/labour and delivery and neonatal ICU. The nurse’s station to all these areas (except maternity/labour and delivery) is central so it’s set up in a cross shape. There is also an operating room wing with a recovery room area, although if we are under staffed the emergency nurse will recover the patient.

The hospital is run by expatriate Baptist missionaries but employs many Togolese who work in all areas and are the team leaders and nurses each shift. There is a nursing school on the compound and the 15 nursing students work in the hospital 3 times a week putting into practise what they are learning. Each registered nurse is assigned a Nurse-aid who takes the patients’ observations, helps with tasks, restocks and also helps translate for the expat nurses like me. A patient’s relative stays with each patient. They are responsible for providing all meals for themselves and the patient. There is a place on the hospital compound where they can go out and cook their meals (cuisine). They must bring all pots and pans and essentials for cooking. They normally bring a mat or piece of fabric and sleep on this flat on the tile floor near the patient’s bed. When a patient is ready for discharge the family member goes to the caisse to pay the bill and if they don’t have enough money they must stay until they can pay. For one more night they can sleep in the hospital but after this, there is a place on compound for families to stay until they can pay their bill.

The patient population here is mostly different to Australia. So far I have seen or cared for patients with eclampsia, HIV sepsis, chronic osteomyelitis, fractures, malaria, abscesses needing incision and drainage, Burkitt’s Lymphoma, infantile fibrous sarcoma, snake bite, CHF, nephrotic syndrome and premature birth (33 weeks gestation). Most of these conditions I’ve never cared for so I have a lot to learn.

The nursing shifts are from 0700-1930 or 1900-0730 with a 2 hour lunch break, 4 shifts per week. Miriam had the bike man put new tyres on her bicycle and this is now my transport to and from work and around town.

One night last week I barely slept as the power was off and it was unbearably hot and then at 0430 the wind picked up and a storm blew over, battering my little home. The sky opened up and dumped down rain. I was fully awake despite minimal sleep and prepared to ride to work on my bike in the downpour through sandy unpaved roads. I put my work uniform and gear in plastic bags but by the time I left the house the rain had stopped, much to my relief. The cycle to the hospital required quite the effort through sludgy red mud, avoiding goats wandering in the streets, kids walking to school and motorbikes zipping past, all keeping an ankle length skirt out of the wheels and covering at the very least my knees. 

As I drink my coffee Miriam hands me the Mango + 1 recipe book. All recipes are ingredients that can be found in the small market in Mango plus 1 ingredient from a big city such as Kara (2 hours drive south) or Lomé (9 hours south). I page through the book deciding which recipes I could try this week according to the food already in the house, thankful for the recent 18 months I had in Australia cooking each night and knowing those skills will come in handy for the weeks to come.

From Ship to Shore

I’m not really sure what I should be feeling right now. After arriving to the ship at the end of January and jumping into work as Maxfax team leader, I felt like I was running a 4 1/2 month marathon. Then when we were 2 days away from closing the hospital, unforeseen circumstances caused us to extend the closing by 3 days. Oh how I wanted to cry from fatigue! But we managed with nurses offering to work and the other team leaders kindly took the extra days on-call so I didn’t have to. Then on Monday just gone, we finally discharged the last patients and we sighed a massive sigh of relief. The nurses blitzed the hospital cleaning, packing and tying down while I finished projects I had been working on and tied up loose ends for the next team leader. Before I knew it, Friday morning was here, I said a lot of goodbyes and I hopped on a plane to Togo. (The most expensive flight I’ve ever been on but it was direct and uncomplicated which I appreciate.) Now I’m sitting at a beach-side hotel restaurant in Lomé, Togo listening to Kenny G on repeat and drinking Nescafé coffee (not my favourite but it’s the only option). So, in the next few days comes the big gear shift to remote African living.

Yesterday I was met at the Lomé airport by my friend Miriam who I lived on the ship with me for almost 3 years a few years ago. She’s a pharmacist and has worked at the Hospital of Hope in Mango now for 3 1/2 years. She took the 8 hour night bus journey from Mango to Lomé with another missionary Susie, in order to pick me up and shop for supplies in the bigger stores. The shopping list has things like 10 boxes of Honey Puffs, 20L of soy milk, pancake syrup and a cross trainer exercise machine to name a few. She only comes to Lomé about every 6 months on average so it’s sort of shop until you drop and get a taxi not a motorbike back to the beach hotel. 

I only have the rest of this day and the 9hr taxi ride tomorrow to shift my mind to the 2 months of hospital nursing and village life ahead of me and to process the 4 1/2 months of working and living life on the AFM with Mercy Ships. I know it will take longer than the next 36hrs but I have to start somewhere.

The night before I left the ship the communications team gave us access to some photos from the previous month, a time when my ward was full of one year old cleft lip or palate repairs. The first few days were miserable for them and there was so much crying but by 4-5 days post-op their pain had decreased and they were smiling and happy. One little one named Oslima showed her joy by sticking her little tongue out all the time. We all poured out so much love on these babies and their mamas. What a special time.

 

There was also a woman on the ward we called Mama Sabine. She is such a special woman who loved on each of us as if we were her grandchild. Someone asked her if she was looking forward to going home after her surgery. She said, “This place is just an extension of my home.” When I went to greet her each morning she’d give me a big hug and kiss on the cheek and tell me how her night was and ask me how I was. We all adored her.

 

Another patient who was with us to the end was Lawrence. He had a bit of a hard trot with delayed wound healing and several returns to the OR which caused him to be quite downcast on the ward but by the last few days of his stay he was happier and doing well.

I wish it was easier to know how my patients do after they leave from our hospital and the ship sails away. So often I think the same as Mama Sabine said as she walked out and down the hospital hallway towards the stairs to the gangway, “See you in heaven!” What a party it will be to see each other again.
 

I leave the ship knowing I will return in the next while but waiting for God’s direction. In the meantime I follow the steps laid out in front of me, knowing a hospital on land will stretch me in different directions than the ship did but I’m looking forward to a different way of life and sharing the journey with you.