I got pushy.

So Thursday I finished up my last day in the ER.

It was another day like the rest, except this time a family brought in a dead person.

I guess this happens often.

It takes time and money to reach the hospital so many people die on the way.

Thursday night Mike and I drank, I needed to drink after those few days.

We attempted to go out, but there is not much to do in Mzuzu.

So we mostly stayed in, I introduced him to Tech N9ne, and we watched "How I Met Your Mother."

Friday we took a cab back to Mwaya.

It felt so good to go home.

It is crazy how quickly a place can feel like home, I definitely am starting to feel at home there.

We had a pretty relaxed weekend.

Mike and I watched "The Lion King" and more "How I Met Your Mother."

I went on a seven mile run, laid on the beach, had some Tonga lessons (I suck), ate food, and drank sangria.

Come Sunday I was headed back to Mzuzu.

The bus ride back was interesting.

It was filled with obnoxious drunk men.

One kept shouting about me I assume, because every time he would shout they whole bus would look at me and laugh.

I was starting to get pretty pissed at him.

Luckily he got off the bus long before I did.

Alcoholism is a major problem in this country. 

People are often drunk at all times of day.

So nobody paid the guy any attention at all.

Monday morning I headed to the Chief Nurse's office to get my next assignment.

She told me I could go where ever I wanted as long as I got them all done.

Well you can just guess what I choose next. 

Peds.

I got to the peds ward there was another woman being shown around.

She is from England and here with an organization to be a clinical instructor.

I then got my tour.

There are essentially six rooms.

The nurses station and treatment room are in the middle.

Next to the nurses station is the burn room.

It is about the size of the treatment room at CMH and contains five beds.

Two of the other rooms which are about the size of two patient rooms put together contain eight beds each.

Then another two rooms which are a bit bigger contain about 14 beds each.

Where there is not a bed there is a mattress on the floor.

The mothers and patients share these beds (calling them beds is generous, they are the size of cribs).

I went to listen to report.

There is a doctor volunteering from the Philippines, his main focus is nursery.

He learned that a baby died in the night and he was very angry.

The baby had central cyanosis and they thought pneumonia so they started antibiotics.

The baby died about thirty minutes later.

I later asked if they have ventilators for any patients in the country, the answer was no.

If they need to they can intubate and the mother can bag.

I think that this does not happen, the baby just dies.

After report I followed the doctor to the High Dependency Unit.

It is basically their PICU.

There were three patients.

One was a kid with meningitis, he had been brought in so late that he could no longer function.

The other was a baby with an abdominal mass.

The third was a baby with now a repaired hernia that had caused an obstruction.

What interested me was the baby with the abdominal mass.

His stomach was so distended.

I noticed the mother was breastfeeding and the patient was not on any fluids.

I later noticed no patients are on fluids, there are also no monitors, and vital signs and assessments are non-existent.

The patient was put on oxygen due to increased difficulty breathing.

Since there are no sat monitors they just go off of clinical signs.

They have oxygen but it only goes up to two liters. 

And they only have that set up at certain places.

I told the nurse to ask if the patient was pooping or passing gas.

The mother said no.

I told the doctor that the mass or something has caused a bowel obstruction.

He agreed and let me put in an NG tube.

But there is no suction, so we had to let it drain by gravity.

I am sure that it was so thick it would not come out.

I asked about IV fluids and he said no it was not necessary because the patient was eating.

I told the doctor the patient should not be eating because he will end up perforating his bowel.

He did not really agree, but I told the nurse to tell the mother to stop feeding.

We then moved onto other patients.

As I was coming around the corner I saw a patient with severe hydrocephalus, it was a four month old and I would guess her head was the size of a volleyball.

Even her face started to look smashed in.

Then the surgery team started to round.

I got right in on this!

They saw many kids with abscesses, hernias, the hydrocephalus baby (which they asked if she had been to surgery yet, I wanted to say, "Do you see an incision dumbass? Because I do not." I decided this would not be appropriate.)

Then we got to the burns.

Talk about terrible.

I have never seen anything like it.

Four of these kids I would guess were at least thirty percent.

I did not see their backs.

They leave their burns open to air, not dressed.

I started asking about nutrition.

Turns out nobody is eating.

Well I got to educating everyone, including the surgeons.

He agreed to put NG tubes down two of them.

Turns out we do not have formula for them.

Did the nurses tell the parents to get any?

Nope.

Then it was time to administer meds.

The nurse calls out the patient's name and the mothers bring their sick kid up to the cart and we slam IV antibiotics in all of them.

Some kids are lucky enough to get either half a tab or a quarter tab of Tylenol.

I am not even sure how they mother's give it to them.

Many of the IV's were bad, and who knows for how long. 

I informed the nurse that they needed new ones.

She agreed and said she would do it after she finished passing meds.

In the afternoon it was slow.

I noticed that kids just lie in their beds and do nothing.

So I took some paper and made a ball, we played catch.

I also gave some kids pen and paper to draw with.

They were having a blast, they were more lively than I had seen any of the kids all day.

At the end of the day the doctor came back and was going to refer the patient with an abdominal mass to another hospital.

He thought that the patient could continue to eat and go by public transport.

I disagreed.

I said that he was for sure a bowel obstruction and should not be eating.

He argued that the patient has not been puking therefor is not a bowl obstruction.

I of course argued back, the patient is also not pooping or passing gas and his abdomen is huge.

He does not need to puke to be an obstruction.

We went back into see the patient.

There was some green output from the NG.

He then agreed the patient was also obstructed.

Well no shit.

I also pushed that we needed at least maintenance fluids to get him through the night.

He was reluctant because of being unaware of kidney function.

 I said yes but giving a very sick kid who has had an obstruction needs fluids, just to get him through the night.

He said he was nervous because night nurses could not manage fluids.

He finally found a syringe pump and said he was ok with it as long as it was run on a pump.

The largest syringe we could find was 30mls, the patient needed a rate of 36 ml/hr.

I knew the pump would beep all night and new fluids would not be started.

But I figured it was the same as not getting any fluids, what else could I do?

I had at least won one battle.

After that I called it a night and headed back.

I was so tired and drained I went straight to bed after going to the grocery store and to the market.

I knew that today was going to be another tough day.

When I got back today many of the patients were still the same as the day before.

I attended some morning rounds, many patients were getting discharged.

I visited my little ortho kids and gave them each a colored pencil and piece of paper.

Then I went to the nursery for a tour.

The babies were so tiny in their bassinets and the mothers all gathered on the floor waiting to breastfeed.

One mother was expressing milk by hand into a medicine cup to feed to her neonate.

It was so impressive to me that these mothers who just gave birth hours before were sitting on the floor.

Then I headed back for some burn treatments.

These kids with terrible burns get no pain medication at all.

They are debrided in their beds while all of the other children anticipate their turn.

It was heartbreaking.

This toddler who is not staff anxious screamed bloody murder at the sight of the gauze being opened. 

Since there was not much I could do, I did what I could.

I showed the mother how to hold the boy straddling her lap and put his face into her chest so he could not see.

I patted and talked to him (not that he could understand me), and held him the best that I could.

I was glad when it was over.

I only assisted with one treatment and then went to meet some of my fellow volunteers for lunch.

After lunch Kate a Ripple volunteer who is a retired doctor from Scotland came back to the hospital with me so she could see around.

The ortho kids proudly showed us their pictures, and we saw the other patients, and then I showed her the burns.

One dad asked me about his child.

He was wondering about debriding the outside layer of the skin off.

I had asked the surgeons the day earlier about surgical debridement.

They said it would bleed too much and they would have to wait until it sloughs off on its own.

I told the father this and then told him to talk to the surgeons.

He said ok, he just thought I was the one in charge of the burn unit.

This made me very sad.

I have only been in that room a couple of times.

I then asked him about the patient's nutrition. 

He said she was not eating much.

I told him she needs a lot of calories and protein, so things like eggs and peanut butter would be great.

I did see another parent later bring back a bag full of food.

I think that my education did some good.

It is amazing how little the medical staff talks with the parents here, it makes me sad.

Later in the afternoon I saw a doctor assessing a patient.

I went to see what the issue was.

It was a baby with severe pneumonia and a pleural effusion. 

Her respirations were extremely fast, but he had just turned up the oxygen and she was crying, so I was not too worried.

I listened to her, she did not sound too bad.

So I let her be.

I later went back to check on her, while she was sleeping I counted her respirations: 114.

I took her temp hoping she was febrile because this would be an explanation and an easy fix.

She was not.

I went and informed a nurse.

He said it was fine the patient had been seen by the doctor.

I said yes but the condition had not improved.

I asked if she was dehydrated, he said no, she was eating.

I told him this was dangerous but also knew that there was no other option really.

I did see the patient breastfeed and she did seem to be able to latch without struggle.

I am just afraid that when kids work that hard to breath they eventually just stop breathing.

I unfortunately know this from experience, fortunately though I learned this in a place where resources and help is plentiful. 

I am afraid this is not the case for this child. 

I am hoping for improvement overnight and that I am wrong in this case.

Being in peds is extremely hard.

But I also know this is exactly where I need to be.

I am sad that I only have one day left.

I think that when I am done with orientation I will be visiting the local hospital.

Kate has told me this place desperately needs my help.

I'm hoping I can be pushy enough to make some changes in practices and care.

As hard as it is, I am so amazed by the kids and the parents.

They are grateful.

Parents do not complain that nurses and doctors do not come see their kids, they are just grateful when they do.

They do not demand pain medication for treatments, they know their child is getting what he needs and they help hold.

They do no demand another nurse come try for an IV, they hold their child still and tell them to stop moving.

The kids may scream but most of them hold completely still, because they know they need to.

Parents have to stay and care for the children.

I think that some parents go get supplies or do washing and other parents watch their children.

I have not seen a single nurse responsible for a child. 

They know they have a responsibility, and that is their child. 

This is something I rarely see at home.

I think the hardest part of my job there is dealing with difficult families and bratty kids.

Here it is heartbreak, lack of supplies, and fighting to get anything done.

I am very interested to see what can be done and how staff will be receptive to new ideas.

There is a lot of work to be done and I am hoping that I can make a much needed change!

I am exhausted and need to head back to get some much needed sleep! 

I will leave you with pictures of the burns.

Just know that they are very graphic and not for everyone!