Goodbye Mango

I’ve worked my last shift. I’ve packed up my things and left my white nursing scrub tops and stethoscope behind in Mango. I hugged my friends goodbye, hopped in a vehicle early in the morning and arrived in the capital, 295 miles away from a place that became home.

Right now I’m traveling for a short time with my sister before heading back to Australia. So far we have visited two of her Compassion sponsor children (one in Togo and one in Ghana) and have been very impressed by Compassion’s work in the lives of the two children and the children in each project.

In between visiting kids and being a tourist, I have been trying to process and debrief what happened in my life over the last two months.
I don’t really know where to begin. Before working in Mango at the Hospital of Hope I had never worked in a place where I felt so consistently stretched and stressed that my patients were going to die. Sometimes in other places I’ve worked, after a busy shift we joke that everyone is alive so that’s our nursing job done, but in Mango so often you can’t even say that. Instead we joke that if everyone survived our shift it was a good day. Of course there are good and bad moments of every shift but with so little staff, such high patient to nurse numbers and high acuity (very sick patients), it really takes nursing to a new level of stress.

One shift I had an admission of a boy who was writhing around on his bed, gasping for air, dripping saliva. It was during the afternoon when we take our mandatory (by Togolese government) 2 hour lunch break (the only break we get from 0700-1930). During this time we take over one other nurse's patient load which end up being half the hospital (your patients plus theirs). So, not only did I have a boy who was the definition of a hot mess (an American term which I have wholeheartedly embraced), but I had a bunch of other sick and unconscious kids too.

Before I let the other nurse go on break, I went to assess this kid and give him some medications. He was doing circles in his bed. The leads from the cardiac monitor was pulled off and stuck to his stomach, his IV line was pulled tight across the bed, the non-rebreather oxygen mask was around his neck and not on his face. What a mess! It wasn't simply a matter of reorganizing the wires and tubes, because this kid just simply couldn't stay still, but to make matter worse, it sounded as though he was choking to death. I went out to find a doctor but couldn't find her. I found the other nurse and she said that he sounded like that previously but she would help me try to settle him. I walked around trying to find the doctor while inside I was panicking thinking that any moment he would have a respiratory arrest and I would have to do CPR and we would lose another child. My stress response is crying, which is super unhelpful. So I choked back tears, clenched my teeth and did what I could.

Eventually I got him calmed down and when I saw him touch his mama tenderly on the face, I repented of my frustration towards him, realising that it wasn't him, but his sickness that was making him so hard to care for.

When I handed over to the nurse that evening, I was fairly certain that he wouldn't last her shift. After she assessed him, she didn't think he would either.

What I have come to realise is that I just don't know what God is doing and why some children survive and others don't, but this child managed to pull through. Several days later when he was much more healthy, I asked his papa if I could take a photo so that I could remember that despite the situation looking hopeless, he is alive and well.

 

On my last day of work I had a premie baby have 3 apneas and a young boy (cared for by another nurse but in the same room as my patients) drop his pulse too low several times, requiring a long sternal rub (it causes a pain response) to increase his heart rate and a baby have no urine output and an increasing heart rate all before 11:00. Thankfully we had an extra nurse that day because the previous day I had all the kids (the regular paeds ward and paeds ICU) and I couldn’t keep up and then throw in a baby who is very sick and I wondered how on earth I would keep them all alive. The crazy thing is, we have nurse aids that do all the vital signs. Nurse friends- you know how much time recording and paper charting vitals take, remove that from the equation and I’m giving meds, fluids, feeds, doing assessments and trying to keep up with charting everything (which is way less than a western hospital). Often at work in Australia I feel like all I ever do it vitals, hand out food, showers, make beds, fill out paperwork and a few meds. You could not find two nursing jobs more different.

Aside from the work in the hospital, I met some really amazing people who became friends and it’s hard and sad to walk away from it all. Also knowing I can’t be there to shoulder any of the heavy workload for them. The best I can do is pray.
 

I walk away having very mixed emotions. On one hand I’m excited to see my family and friends in Australia and somewhat relieved that my stress level is dramatically reduced by returning to a job that has equipment and drugs to keep children who are dangerously unwell alive and treated (for the most part).
One the other hand I have left behind friends with whom I now share experience of deep emotion. I have left a town of Togolese that I have shared precious moments of life with; the beginning for some and the ending for others.
I’m also afraid that when I return to work in Australia I’ll be frustrated and bored. I know there’s no fix for this and I do realise I’ve just written about how stressed I was, but there has to be a happy medium!? I don’t know what that looks like.

So, friends who are welcoming me home, be patient with me. Don’t be afraid to ask me questions, even if it feels like it could be a sensitive topic. I know I’ll feel sad and want to cry. It’s not personal. It’s not because you are not enough.

I sent a message to one of my nurse friends I left behind in Mango asking how one of the babies I looked after was going since I’d been gone. She replied saying that he passed away.  He was 8 months old. His mother had died at his birth and his grandma was caring for him. He was severely malnourished and had other things going on that we couldn’t test for or figure out treatment to cure him. I believe he’s now held by Jesus, but that doesn’t stop me from feeling sad.

I don’t know how to wrap this up and I don’t know what my next step is, but I’m on a journey like you, taking each day at a time and asking God to direct my path.

The Good Things

I was on night shift a couple of weeks ago and I wrote most of this blog on one of them but never posted it because life was busy and then I got sick.

I have been on night shift this last week. My housemates have graciously given up their beds for me to sleep in at various times because the house is far cooler and quieter than my little dependance. Other than the usual trials of sleep and feeling generally gross (retrospectively I actually had malaria) my 12 hour nights have been filled with the usual work. I have been feeding my premie babies every 3 hours, putting up IV antibiotics, giving malaria medications and checking IV drop rates. The calmer hours of the night give extra time for letting mamas sleep and sitting in the ward feeding the babies.

The paeds ward I have worked in almost every shift since I have been here is one large room and is ever changing with the number of beds, cots and baby isolette cribs. My first night shift I had the whole 10 patients. By the time the lights were dimmed I barely had space to walk between the relatives sleeping on the floor. Interestingly my three patients who had beds (not cots or isolettes) all slept on the floor next to their mamas so all their actual beds were empty.

I end up spending quite a bit of time on the floor, reaching for patients between their bed and mama or other sibling or sitting on a stool while a mama gravity feeds her baby breastmilk through the nasogastric tube.

Some of these nights I had spare time and was able to let the mama go back to sleep and I would sit on the stool and continue feeding the baby, looking over the ward and admiring the beautiful, tiny baby in my hands. The premie babies are such sweet little things. We have worked so hard trying to fatten them up. Our work is paying off because 2 out of 3 of the original babies have reached 1.5kg and have now discharged! They will come back for appointments to check their weight gain.

Tonight for the first time since I arrived I have no paeds patients. Instead I have a collection of adults- snake bite, gastric cancer, fractured femur who is very confused, pulling at her dressings and not sleeping, peritonsilar abscess and abdo pain. I feel like I’m back at home in a medical ward! Thankfully this is because in the last day we have discharged many kids who are now healthy because they got treatment in time. You have no idea how relieved I feel about that. We still have several severe malaria admissions into REA each shift but most of them arrive before it’s too late. I often see them laying on their backs with their eyes open but a vacant stare or even asleep but their eyes aren’t closed. I think every time of the girl with malaria who I came across who had already stopped breathing, her eyes half open but no one was staring out of them. I don’t think that’s something I’ll ever forget.

This place has certainly changed me. I don’t think I can sum it up quite yet, if ever. It has been an eye opening time in many ways. I have the utmost respect for the missionaries who came out here and pioneered the way and continue to work so tirelessly at serving God through their various jobs (Christian radio station, village bible studies, nursing school, running the hospital and more). I always wondered if I had what it takes to live in Africa.

Tonight the termites are out flying around the lights and crawling on the floor. They are big winged, big bodied bugs that are continually being zapped on the bug zappers, sometimes for so long that you can smell them cooking. They aren’t the only bugs walking these hospital hallways. There are these other big beetles that also fly and crawl around. I usually give them a light kick to the side if they’re in my way. The flies are insistent too, relentlessly sitting on my patients, crawling over their faces, dressings or somehow getting into the baby isolettes. I think Australia’s insects prepared me well for being here.

 Fast forward through one week of sickness and first ever diagnosis of malaria:

I now only have 5 days left of my two month stay here. I have learnt so much and continue to be amazed and warmed at the family units I have seen caring for each other and community around them. I have seen severely malnourished kids get chubby cheeks and tiny premature babies get bigger. I have seen a miracle and heard of more. I have been so impressed by the skills and willingness of the Togolese nurses and nurse aids to help me again and again. (I’m looking forward to the day I can speak English to my patients!)

Life on my days off has been fun too. I love my little home and can always find something to do, cook, create or learn. I have grown to love the character of my home, the peeling paint and dark concrete floors. There are happy memories made here, from movie nights to housemate dinners to the constant electric shocks I get from my computer keyboard when it’s plugged into the Togolese power supply. 

Behind that wall is my house

My little dependance

My friends here have already asked if I’ll come back (or just stay). I have been wondering the same thing myself. At this stage, let’s just say God will have the final say.

Nothing Pretty

It is 0500, it’s still dark and I’ve given up trying to sleep. There is a lady who lives somewhere near us that has a mental illness who throws a large rock to the ground repeatedly every morning and sometimes in the afternoon. The force of her throw sends vibrations and a thud through the nearby houses. I can hear her powerful throw as she chases away whatever torments her.

I’ve been awake a lot overnight. I was getting a lot of headaches so finally decided to get checked for malaria, despite having a cold and feeling like I was probably overreacting. I tested positive for malaria, much to my surprise and relief that the headaches will be treated and disappear. After I got home from work I started the oral treatment which side-effects apparently give me insomnia. It was also a rough day yesterday and I’ve been reliving my day at work while trying to sleep.

I didn’t want to write every time I had a terrible work day and I haven't but it does help me to process and so here I am again, thinking of my day, tears spilling and blurring the screen in front of me. 

I was on nights last week but returned to day shift this week and started off the week looking after a baby boy who I had met on a previous admission. He was only a few weeks old with a very attentive mama and grandma who cared for him and his twin sister so well. He had gotten sick at home and his mama had brought him into the hospital where he’d gotten worse despite treatment. I assessed him throughout the day and didn’t like how he looked but he hung in there. I was worried though.

It’s so hard working in a country where you don’t speak the language and you don’t know the culture well enough to know what you’d even say to the parents of a child or baby who is very sick. In some African cultures you cannot tell them someone is dying because it removes all hope. Thankfully the expat doctors here speak French and working with the Togolese nurses and chaplains, we try the best we can.

I arrived at work in the morning to find out the baby boy didn’t survive the night. I felt so crushed for the mama. They had already left the hospital which I was selfishly glad of because I didn’t want to see that mama’s heartbroken face.

I was looking after the paediatric ICU again that day, along with the nursing students sharing the load and I was also orientating an expat paediatric nurse. Before we had time to do much the nurse aid called me to our 4 yo girl with severe malaria. She was seizing. And so began the day. We gave medication after medication, blood, antibiotics and airway support. We threw everything we possibly could at her and hoped it would be enough. There were wires and tubes everywhere but when I wasn’t next to her cot, there was a relative at her side. At one point I put in a foley catheter and was surprised when the ‘urine’ that came out was the same colour as the blood transfusion going in. We called the doctor over for the hundredth time that day. She said she’d only seen one other patient with urine that colour in all her years working there.

Conversations were had with the family as we waited to see how she would respond to treatment. I looked at her vitals and knew that it would take a miracle and prayed so but I also felt at a loss for words. Jesus. Jesus.

We made a plan before I went for lunch and I wasn’t sure she would still be alive when I returned, but she was. She kept going for hours. Her little chest heaving breaths through crackly lungs. We hadn’t been able to get a blood pressure reading on the monitor or oxygen saturations for hours and then I couldn’t palpate her peripheral pulses. I stayed by the bedside with the family as I watched her little body stop working. There was no hope in coding her and prolonging her death so we let her slip away but the thing is, it wasn’t pretty. Her mama was sobbing and I stopped being brave and just let the tears fall. We stood there while she breathed her last gasping breaths, the CPAP still blowing air down her throat. And then her heart slowed and stopped and what I knew was going to happen, happened. She was still and lifeless. I stood there wondering what she had been like. Had she been a bubbly, lively little girl?

I stood helplessly next to the family, so desperately sorry that we’d lost another child. Another beloved child. I felt so angry that kids and babies are dying of something that’s been eradicated in other countries but also an element of hopelessness. When will it ever end?

There’s nothing pretty about this. No nice way to tie this up. I know Jesus walks with them in sorrow and oh how deep that sorrow is. I asked God to give me a heart that breaks like His and I think this is what it looks like.

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.