Operation Malawi: Part 2

Operation Malawi part 2

Monday, September 2: 

 I need to begin this by starting with last night.  Last night around 2200 I got a call from Shymol stating that there was a vent in the ICU now, asking if I would come in.  So I said sure, I’ll be there as soon as I can.  So I go in and take a look at the ventilator and all the settings were good (Dr. Saunders and I had already discussed initial vent setting and such).  I talked to him about the plan and the history (patient had been drinking a little too much, vomited, and developed aspiration pneumonia) of the pt and everything looked good for now, so I went back to where I was staying.  This morning I went in and the pt was doing OK at best.  Oxygenation was good.  But we were still suctioning out a lot of secretions.  He was also sounding very tight and wheezy, I would have sworn that he smoked but family kept denying that he smoked.  We got a gas and it showed metabolic acidosis with partial respiratory compensation.  So Dr. Saunders and I talked and decided to start him on Salbutomol and Methylprednisolone.   The question was how were we going to give the Salbutomol?  I couldn't find any t-piece adaptors for a nebulizer.  I did, however find an in-line spacer.  So I taught them how to give an MDI in-line with the ventilator.  I also got to go more in depth in the ventilator education with the nursing staff.  Now they could see the ventilator working on a patient and put together the settings with what they mean.  Now they could see how they affect the patient.  I was able to see a lot of light bulbs turning on and that was AWESOME.  I also worked with them on suctioning technique (bizzing the patient to loosen up secretions) and started teaching them breath sounds and how to properly listen to the patient.  I stressed to them the importance of securing the ETT when repositioning the patient and suctioning.  Though something that did drive me nuts, and I didn't say anything to them about it because there really isn't anything that they can do about it, is that they don't practice sterile suctioning and they re-use the same catheters.  The reason for this is due to cost and to preserve equipment.  So I didn't even bother trying to fight that fight.

Tuesday and Wednesday, September 3-4:  

These three days were pretty much spent all doing the same thing.  I was sitting in the ICU helping to take care of the ventilator patient.  I kept going over with the nursing staff about listening the breath sounds, taught them how to do ventilator checks on a flow-sheet that goes in the chart (they actually already had one, they were just inconsistent with it because they didn’t know what it was for and what they were writing down), suctioning and care of and minding the ETT.  It was amazing seeing the information click in their heads.  I also had them teach each other, every time a new shift would come in I had the old shift teach them.  It was awesome seeing the info click and seeing them share it with their co-workers.  I also spent this time teaching the nursing staff about non-invasive ventilation.  The ventilators that they have actually have non-invasive mode on it, and I was asked to try and figure out how to use it and teach them how to use it.  They had been having problems with patient comfort and synchrony.  So I figured that out for them and taught the nursing staff how to use it and how to care for a patient on non-invasive ventilation.  I even made them all put the mask on and discover how it feels to be placed on non-invasive so that they could understand how the patient feels and why they may fight it.  The only issue I was having is that for some reason the machine kept cycling itself when it shouldn’t have been.  I will have to work on that some more to figure out what was going on there.  On Wednesday, September 4, a team from Loma Linda University Medical Center’s Emergency Department arrived, though nobody got the meet them till Thursday.

Thursday, September 5:  

Today, the morning went pretty much like the rest of the week did.  Went to the ICU to and helped to take care of the vent patient.  He is coming along very well and I am having a blast taking care of him and teaching the nursing staff to take better care of him.  I also got to meet the team from Loma Linda, they seem very nice.  Anyways, this morning when I went in the patient was on CPAP, Dr. Saunders just wanted to see how well he would do.  He seemed to do pretty good and we kept him on it most of the morning.  In the afternoon I was asked to do another CPD class.  This one was on trach care.  They had asked the trach patient to come in special just for this class so that I could teach the nursing staff how to do trach care and what special precautions are needed when taking care of a patient with a trach.  The issue here was that my demo patient was late in arriving so I had to kill time talking and trying to get them to ask questions.  I even resorted drawing a neck on the white board and demonstrating trach care on the white board.  But my patient finally arrived and we got it done.  It was awesome being able to see things click with them.  Right before the CPD, though, Shymol and I were called to the ED to help take care of a critical patient that had arrived from an outside clinic.  We arrived to a patient that was unresponsive doing Biot’s respirations.  He was just responsive enough to take the oral airway out and occasionally pulling on the NRB mask.  They kept trying to put the oral airway back in, finally I was able to convince them not to.  It was obvious that he still had a patent airway and didn’t need it, plus if he kept pulling it out that means that he may still have a gag reflex.  So I ran to get a nasal trumpet and put it in to make everyone feel better.  He was so clamped down, though, that we couldn’t get a SpO2 reading on him anywhere and it was very difficult to get a peripheral pulse and blood pressure on him.  When I got done with the CPD we went back to the ICU and the stroke patient was in there with the Loma Linda team working on him.  I was talking to Dr. Saunders and he told me that normally in this case they would just provide palliative care and let the patient pass.  There was really nothing they could do for him, didn’t have the right supplies/equipment or the knowledge to take care of his condition.  The CT scanner was down so they couldn’t do a scan to find out if it was hemorrhagic or a clot.  Plus the patient was HIV+, not that it makes a difference, but that means that the patient likely had other issues going on as well.  Though they were letting the residents from Loma Linda do what they could for him just for the experience and so they could say they tried to save him.  Anyways, they were trying to put a central line in him.  It took them a long time, but they did finally get one in him.  The entire time, every time they would get it, it would immediately clot off.  It was no wonder he stroked out. 

Friday, September 6:  

Today I arrived in the ICU to see that our stroke patient had passed in the night.  It was expected.  The vent patient that we had been taking care of all week was on CPAP/PS again, and doing amazingly.  I started experimenting with the vent and looking at how it did respiratory mechanics to get weaning parameters.  This vent is able to do the RSBI, VC and NIF.  Though it had a little quirk that the only way it would calculate the RSBI was to turn off the pressure support and leave the patient on CPAP without any pressure support.  I didn’t really care for that, but I did it just to see how well he would do.  He actually tolerated it for a while.  Then he started to putter out and started to breathe fast and shallow.  So I put the pressure support back on.  That helped a little bit, but not enough.  So we started to suction, and he was rather difficult to bag and we weren’t able to pass the suction catheter.  We had to bizz (they were still having a difficult time grasping that concept) and he ended up hacking a big ole mucous plug into the bag.  It was AWESOME!  After that we suctioned him out a little bit more then let him rest for a few more hours.  At this point in time I was getting nervous, and I think Shymol was getting nervous as well.  I was getting nervous because I felt that my credibility with the nursing staff and physicians was on the line.  Shymol was nervous because her reputation and the reputation of the hospital was on the line with the community that this patient was a part of (they don’t trust the hospital and the care provided, even though it is the best hospital in the country.  Being from India, they were used to first world care).  Later that afternoon we decided to risk it and extubate him.  Turns out there was a huge dried mucous plug at the bend of the tube that causing him his problems.  Shymol was getting on the nurses pointing it out to them saying that this was why they needed to suction and why suctioning was important.  Placed the patient on a mask initially and quickly weaned him down to a cannula.  I don’t know much about what the Loma Linda team was doing today, other than teaching BLS classes to the nursing staff.  I was able to attend a little bit of one of the classes.  They were doing a good job.

Sabbath, September 7:  

Went to church today.  But after church there was a huge gathering at one of the physician’s houses.  The pediatrician, Dr. Varona, invited a lot of people, new people old people, birthday people, pretty much everybody, over to her house for Sabbath Potluck.  Also today Dr. Priester returned from South Africa where she was attending at continuing ed conference the past week and a half.  It was fun eating good food (not hospital food) and fellow-shipping with everyone. 

Week Recap:  This week was much better.  I felt like I was finally doing what I was there to do: teach and help take care of patients.  I had fun this week doing what I love to do.  I really do need to thank and God for helping me get through the slump I was feeling during the first week and Jewel for putting up with me and helping me through that first week.  I also need to thank Shymol for helping me into this week and helping to instill confidence into her nursing staff so that would trust me.

Operation Malawi: Part 1

First I want to apologize for taking so long on getting these up.  Please hang in there with me as I try to find time to go through these and get them posted.  Thanks!

Following are my daily thoughts on the first week I spent in Malawi.  As you will tell, it was kind of an emotional roller coaster of a week.  This was due to several reasons, culture shock, missing my family, lack of confidence in myself and lack of faith in God, uncertainty and hitting the "wall."

Monday, August 26: I just arrived in Blantyre, Malawi.  Going through customs was easier than I thought it would be.  They just asked me what I was here for, where I was going and if I had anything to declare.  That was pretty much it.  Fortunately there was a driver waiting for me in front of the airport.  So we hop in the truck and he drives me to the hospital.  I knew to expect it, but I was a little thrown off by them driving on the “wrong” side of the road, and they really don’t pay that much attention to traffic laws, if there are any at all.  So I arrive at the hospital and from there I am handed over to a young American lady named Jewel.  She has been one of my e-mail contacts.  Fortunately from there they just let me rest and relax and get cleaned up from the long trip over.

Tuesday, August 27:  Today was kind of the orientation day. Went to morning worship and was introduced during the announcement section.  Fortunately they didn’t ask me to make any big speech, like I was warned that they might.  Then from there I was shown around the hospital and the outpatient department.  The general floor is comprised of just a bunch of wards.  There is a pediatric ward, labor and delivery ward, maternity ward, post natal ward, a nursery (comprised of two isolettes, one radiant warmer and I saw what I thought one old bubble cpap machine, turns out it was just a blow-by for humidified oxygen), then a few med/surge wards.  There is also an ICU, which looks much more advanced than the rest of the hospital.  One of the doctors, a pediatrician, didn’t waste any time taking advantage of my presence.  She immediately called me in to talk about an asthmatic, she wanted to me to do a water bottle “spacer” instruction with this boy and his family (turned out they already had one).  She then wanted to go over another child with me that presented like CF, but everything kept coming back negative and she asked me to do pulmonary toilette training with the mother.  Then I start getting a list of everything that they want me to teach the nursing staff and physicians while I am here.  Now I am starting to feel very overwhelmed and worry that I am not going to be able to meet their expectations.  I still have that fear, another fear that I have is that they don’t have the proper equipment do what they want me to teach.  For instance they want me to teach NICU stuff, I am not a NICU therapist, yet, so I don’t have that skill.  How am I supposed to teach something that I don’t know?  Then I look at the equipment and it is so archaic that I don’t even know how to use it.  Then in the ICU looking at their equipment drawers, they don’t even know what they have and if it can be used.  But they make do with what they have.  So needless to say, I am very nervous and am wondering what I got myself into here.  I just hope and pray that the Lord will bless and use me.  Because I know that I can’t do this without Him.  I am really missing my family right now…Happy anniversary deary!

Wednesday, August 28:  Today, so far, has been a mixed day.  This morning I was sent to the ICU, which doesn’t have any patients right now, with no instructions.  So I took it upon myself to start organizing some of their respiratory equipment.  One of the problems that they are having is also a blessing.  They rely primarily on donations for equipment.  They had a lot of equipment that they can’t even use.  So we (the ICU nurse manager came in and helped also) went through and took out what they couldn’t use and organized what they could.  Yesterday I was able to figure out a way to make their ventilator (Respironics Esprit) work as a CPAP/BiPAP as well.  So that helped to weed out the types of circuits that they could and couldn't use.  Then I was called to meet a pediatric patient that had come in for an outpatient visit.  He was trached (I was rather surprised to hear that they had a living trach patient here) and was feeling very self conscious and his family was worried that it was permanent.  Being that I was used to be trached they thought that it would be a good idea for me to meet him and give his family hope.  They also wanted me to go over trach care with the family.  The family was so grateful to see that I was trached and am now without the trach and doing very well.  Grandma (primary care giver) stated that I gave her hope. The plan was to do an surgery on this boys airway to remove some polyps that grew rapidly in it, then from there start weaning his trach to decannulate him. 

From there I just kind of wondered around exploring the grounds, trying to figure out how to get to certain places, trying to keep from getting bored.  When I finally found the ICU nurse manager again I asked her if there was anything else I could do for her.  She called in her staff that was working today and had me give a brief in-service on ventilator management and care of the ventilated patient.  That was fun and I really enjoyed it.  Tomorrow they want me to teach oxygen therapy and trach care.  They say that they have blocked out 2.5 hours for this, I don’t know if I can take up that much time, but we shall see.  Maybe they’ll ask a bunch of questions.  Still missing my family, A LOT.  Wishing I hadn’t taken so much time.  I believe I could have crammed in what they want in a much smaller amount of time.  Oh well, God will bless.  I’m praying that he will guide me to be the most service to these people.

Thursday, August 29:  Today seemed to go better.  Right after morning worship, the ICU nurse manager and I went to the ED to do some BLS instruction (Loma Linda is sending an ED team to go over ACLS in detail next week).  That actually took up about two hours, I think.  We went over how to do proper compressions, bagging and defibrillator use.  We touched a little on ACLS as well since we also included the advanced airway and the defibrillator was not an AED.  We had a manikin that they could bag, but they couldn’t practice compressions on him as it was designed for airway training.  So we had them practice compressions on a pillow with a backboard under it.  Then in the afternoon we had a CPD (don’t know what it stands for, but it is essentially an in-service, or continuing ed class).  There was a lady there that taught an EKG class.  She basically went over the parts and meanings of the different parts of the EKG’s.  Then they had me give a talk on oxygen therapy.  So I went over the different oxygen delivery devices that they had (nasal cannula, simple mask, non-rebreather mask and they had just gotten some venturi masks as well).  I also told them how to use them properly and how to titrate up and down.

From there I went grocery shopping.  That was definitely an experience.  The store really wasn’t all that different from a grocery store in the States, it was the prices.  It was difficult to judge how much money I needed.  Thankfully the store was able to take Visa.  Over all, today was a very good and productive day.

Friday August 30:  Today I found out that the ICU nurse manager (from here on out I am going to use her name, Shymol) had today off.  So I was a little nervous, as she was the one that has been taking the responsibility to organize and get times for me to educate the nursing staff.  But the ED charge nurse (Tina) stated that we were going to just do another BLS teach with the ED nurses and OPD (Out Patient Department) nurses.  So we went over the same thing we did yesterday with another group of nurses.  It was still fun.  This time I decided to also go over how to insert an oral airway.  I decided after thinking about yesterday’s session that it would be important for them to learn as well.  It is really quite interesting.  Some of their equipment is very nice, such as their laryngoscopes and blades, and their ventilators are decent, but other equipment is extremely archaic, like their defibrillators and infant bubble CPAP machine.  I guess that’s what you have to do in a third world country, you work with what is being donated to you.  Anyways, after that I asked Tina if there were any other nurses or education she wanted me to do.  She said no, that they only work a half day on Friday and that I was pretty much done the rest of the day.

So from there I went around twiddling my thumbs until my roomy, Jewel, asked if I would be willing to go to their their NICU/Peds respiratory equipment.  So I jumped on the opportunity for something to do.  So I went through all their equipment, attempted to organize it and weed out some stuff that would be useless.  I also went through their emergency (Code) boxes and made sure that the right respiratory equipment was in those.  That was fun and took up some time.  From there I just went out to the nurses desk and talked to Jewel, some.  She told me about a miracle that had happened with a micro preemie that was born there and by the grace of God survived and is still alive to this day.  The baby was born at 28 weeks was taken care of at that hospital and was released to go home six weeks later.  That is virtually unheard of!  The baby is still doing well and thriving today.  PRAISE GOD! 

Sabbath, August 31:  Today was a true blessing.  I love the Sabbath!  I got to sleep in (hurrah!) and then got up to go to church.  Though, I was slightly disappointed in the church service.  I was kind of expecting it to be different, but it was pretty much the same type of service that we would have back in the States.  Oh well.  After the church service I was invited for Sabbath lunch to a couple that were in Africa as Maranatha (if you get a chance check out www.maranatha.org) workers.  They go around with teams and build one day churches, schools, hospitals, and drill wells for water.  It was amazing to hear their stories and how God is working through them to spread the message of the gospel around Africa.  They cannot keep up with the demand for churches!  It was truly uplifting and encouraging to hear them talk.  If God has in His plan for me to come back to Africa to work, I would like to do it with Maranatha, if it is in His will.  Thank you Lord for such an uplifting and encouraging Sabbath!

If you missed my intro post on my trip to Malawi Africa, you can read it here.