Multiple Choice...

If a three year old comes into your ER in respiratory distress would you:

A. Give him paracetamol...US tylenol (without knowing if he has a fever or how old he is/how much he weighs)

B. Decide we should try normal saline nebulizers every 20 minutes for an hour (when you have been told that salbutamol nebulizers did not help him this morning)

C. Start IV fluids but when they stop halfway through just leave them that way

D. Wait 5 hours until you decide oxygen is needed

E. All of the above

In the best hospital in Mozambique today I watched them choose E before ever thinking oxygen or an oxygen saturation might be a good idea. Here's how my day panned out...

It's been one of those days. My alarm went off and I decided I'd sleep a bit longer and take a shower later in the day. Apparently that was a mistake because before my alarm could go off again there was a faint knock at my door. Aleya (my roommate) was on call for the baby house last night but knew I'd was working today. She had just taken a call about one of our little guys who wasn't breathing well and needed to go chase down some other kids for GATV stuff (the program that sees all of our HIV+ kids on a regular basis) so wanted to see if I could help out.

So I threw on some clothes and headed up the baby house to find Dino in respiratory distress. I had seen him yesterday after church, and he wasn't looking great but wasn't terrible and certainly did not look how he looked this morning. I tried salbutamol nebulizers...2 in a row didn't change a thing. Next I called Jannie (another nurse) to come take a look at him and we decided together he probably needed to head to the hospital. In the midst of getting all of that sorted I discussed the situation again with Erin and Jannie together. We decided since we do have an ER doctor on base at the moment visiting that it would be good to have her look at him.

So I found Kim (the ER doc) and brought her to see Dino. We decided waiting an hour to see if we could get rehydration fluids into him and see if that made a difference (he hadn't held anything down without vomiting since yesterday morning really) was worth a try. About 45 minutes later I had gotten a little over 200mls of rehydration fluid in him but he started not making great sense. Erin took a look at him and we just decided the hospital was our best bet.

So, Tracey (one of the missionaries who works in the Baby House who has a great deal of experience at the hospital), Kim, and I headed into the city. The hospital is a good 35-45 minutes from our center. Upon arriving I quickly learned that you can't just sign in you have to go be seen in the treatment room (where I think no medical people work)...they gave us a small square of cardboard that said asthma (not his problem but at least they got it was a lung issue right) on it and asked if he had a fever. I said yes and they promptly gave him paracetamol...I have no idea what dosing they used considering they hadn't weighed him, didn't ask if I had already given it to him (which praise God I had given him ibuprofen in the car not paracetamol).

Next he went to go see the doctor. I did not go on this adventure because Tracey's portuguese is much much much better than mine. But, he was seen by 2 doctors, oxygen was discussed, along with nebulizers, blood work, and a chest x-ray. Ok...sounds pretty positive right? So Tracey called me because in the midst of blood work Dino decided he needed to pee...and soaked the exam table. I sunk my little way back (because only one person can stay with the kid) with diapers for Mr. Dino. Well they had started an IV (in his hand praise Jesus...usually they just go for the neck), drawn blood work, then we were taken back to another area (I guess I could describe it as our ER rooms). They started giving him normal saline nebulizers and inhalers of ipratropium. Here comes the best part...they weren't using a spacer for the inhaler...instead their make-shift idea was to use a cut in half water bottle. So they had cut it and were using the cap side for the inhaler to go into and had put tape around the cut off part so it wouldn't cut your face when they put it on you like a mask. WOW! Well he never got any of the meds because they would spray the inhaler and immediately take the "mask" if you could call a cut off water bottle a mask off his face immediately.

Alright so for the next 4 hours we sat...they gave him nebulizers...which really meant we held him down and held the mask on his face and then inhalers (where he got no medicine). Absolutely nothing changed. His respirations remained 60/minute, nasal flaring continued, he was grunting sometimes...altogether not good. Oh and another situation...they started an IV drip of glucose but about halfway through it stopped. I even asked the doctor/med student/intern that was attending to Dino, "Doesn't he need that?" His answer was only one time...WHAT? Well in another hour or so we got another attending doctor/med student/intern who finally noticed it had stopped, had a nurse flush out his IV (which was infiltrated), and start a new one so he could get the rest of his fluids. Starting the new IV was a situation...I'm pretty sure the first nurse stuck him 5 times (several times with the same needle) before she finally called someone else who got it on the first try. But I was amazed that after stick #3 she went to get me gloves since I was holding Dino's arm for her and cleaning up the blood from the other sticks was not her strong suit. So on we continued with no change. This new doctor also noticed his fever was up again and ordered 4mls of paracetamol...I got a little excited thinking they are actually going to give this kid liquid, a novel thought. Well they did give him liquid but who knows what the dosing in 4mls is because liquid means yet again another water bottle filled with crushed up paracetamol in water/sugar water. Yea...great idea. Anyway we got that down him...ok no I got that down him because of course the nurses don't give medicine they just pull it up.

Well then a miracle of God happened...someone called a pediatrician!!!!!!! Praise the Lord! She walked in and immediately said...he hasn't changed...why's he not on oxygen and where is his chest x-ray?? So we were rushed back to the baixa (or ICU), he got his chest x-ray taken (something that usually you would have to walk to the adult hospital, wait in line, wait for it to be printed, and return with) right there in the baixa. AND HE GOT STARTED ON OXYGEN...only 5 hours after we arrived. Mind you it was 10L of oxygen...a bit much for a 3 year old but oxygen nonetheless. What a situation?!

So I'll ask your prayers for Mr. Dino who is still in the hospital. He was admitted, and we assume will at least stay the night in the ICU and possibly be moved to the peds floor tomorrow. One of our tias is with him...her name is Tia Sandra if you would pray for her as well. The care takers in the ICU are not allowed to sleep or keep any personal belongings with them. They just have to sit at the patient's bedside and wait for instructions. I have also heard they are not allowed to sleep. So please keep them both in your prayers. I will keep you updated as we hear more this week.

Blessed by the pequeno (small) things...

First...I'll admit you are probably going to laugh at this but I had to share. I've had a rough few days...all I can say is that I think I am beginning to understand what "culture shock" really is. Up until this point I've been able to pass everything off in my head as...well that's just how they do it...they aren't Western and I can't expect them to be...what did I think was going to happen coming to a developing nation. Anyway this week I've just gotten frustrated. It's the little things that make me boil over.
Perfect example- Last night I jumped in the shower. It was cold because of course we're out of gas and the center doesn't have any more right this minute. So I'm trying to go as fast as possible because last night it wasn't really that hot outside so a cold shower was not that exciting of a notion. Anyway I looked down at one point and there was a ROACH on my leg. Ok, I can deal with a lot but the fact that a roach could have crawled half way to my knee without me feeling it just pushed me over...tears rolled down my face.
Ok...so that's what it's been like. The little things just do me in. But tonight I was in my bathroom getting ready for bed and there was a pequeno...I mean smaller than my big toe...gecko on the floor. It was maybe the cutest little thing (other than adorable African children) I've seen in a long time. All I thought was...what a blessing?! So all of that to say...thank you Lord for blessing me with a baby gecko!
Good night to all!

Eu sou uma enfermeira.

I am a nurse. What a HUGE statement to make? Some days it overwhelms me, others it makes me feel accomplished, others it brings about fear and worry, others I sit at the Lord's feet in utter surrender or thanksgiving...today it brought about questioning...

I just spent some time looking up the definition for nurse:
n. a person formally trained to care for the sick or infirm
v. to tend or minister to in sickness or infirmity, to look out for carefully so to promote growth and development, foster, cherish, to keep steadily in mind or memory, to bring up, train, or nurture, to clasp or handle carefully or fondly

How many times in school did we define what/who a nurse was? I can't even count (yep that's right I did listen all those days!). Someone who cares; the number one trusted professionals in the US for so many years running. The one part of the definition I'm stuck on today is...a nurse always does good and never intentionally does harm. What does that mean when you live in a developing nation? What does that mean when you have access to some things and not others? What does that mean when you live, eat, and breath your work place and therefore your patients?

So this afternoon I was called and asked to fill a few prescriptions for a community lady (a mother of two boys here at the center) who had just given birth. She had a c-section a few days ago and has had no antibiotics or pain killers since she left the hospital yesterday. I headed over to get her prescriptions and encountered about 4 drugs I had never heard of, amoxycillin, and no pain killers (at least none I recognized).

So let me just throw some stats at you about Moz:
~Only 2% of births are done by c-section and over 50% of deliveries are done at home.
~Less than 50% of births are attended by a skilled delivery specialist.
~Infant mortality rate is 11%
~1 in 45 women will die from childbirth during their lifetime.
~Contraceptive use is 21% (much less in some populations).

Where I struggled was in the fact that a nurse who has been here much much longer than me and knows this particular lady from previous issues wanted to send her away until tomorrow when we specifically see community members and the clinic is open. So where does my responsibility as a nurse come in? What call do you make? Do you send her away and pray that she has the money/energy to come back tomorrow and that antibiotics tomorrow will be enough to fight against whatever infection she already has (I'm just assuming her incision is infected after seeing the hospital the other day)? Do you follow leadership or the gut feeling you have that this particular lady needs antibiotics (she surely didn't look great) and is not going to adequately feed her baby without some painkillers as well?

Here's what I've learned so far as a nurse. You go with your gut. The Lord has given each of us that still small voice that speaks to us and nudges us in one direction for another. When in doubt go with the safest route (the one covering all bases) and just go with your gut initial reaction. So...for those of you wondering...I packed up 7 days of amoxycillin, ibuprofen, and paracetamol (that's US tylenol) and let her know if she did want to take the other meds as well to come back tomorrow. As for those wondering...the baby was GORGEOUS! And he weighed 3.61 kg (almost 8 pounds) on delivery!!! So great; praise Jesus!

So...that was my day...I still don't have answers to my questions but I'm praying God will reveal them in His time.

Border Run Adventures...

So tomorrow it will have been another 30 days that I've been in Moz. And since every 30 days I have to be out of the country, Sharon (another missionary) and I took off at 6am (stupid o'clock if you ask me) for the border. All was well for the first hour of our trip. Then we decided to stop to pull some money out of the atm on the other side of the city before you're pretty much in the middle of nowhere for awhile. Sharon got her money just fine...but I put my debit card in and the machine said processing and I got nothing in return...
I turned to Sharon and said, "That machine ate my card!" I've heard of this many many times from other missionaries but prayed it wouldn't happen to me. Well we pushed cancel, clear, and anything else we could think of to rectify the situation. Nothing helped. Finally, we decided since it was 6:50 in the morning and obviously the bank was not open we would just head to the border and come back to deal with this. We did stick around to watch another man attempt to use that machine...I wanted to make sure that the next person wouldn't get my card back with their own or something strange like that...I mean this is Africa after all.
At the border our only adventure was the fact that we ended up on the wrong side of a rope barricade. I ended up taking it down, letting Sharon drive over it, and then putting it back up! When we got back to the back about 2 hours later the line filled the ENTIRE bank. I'm not exaggerating at all! So I stood in the back of the line for a few minutes and finally decided that if someone who worked their squeezed by me I would ask him if I even needed to be in this line. Well it turns out me and the rest of the world didn't have a debit card. The bank guy started handing out these packets of pages and pages of information you needed to fill out...but somehow me the white girl, who didn't speak great Portuguese didn't need one. He just took my passport and starting trying to look up my debit card information. Then he thumbed through a stack of debit cards higher than a deck of cards...RIDICULOUS! None of them were mine. Finally, I told him it was blue and said Wachovia on it...he said, "Oh!" and left for a few minutes. He came back with 2 blue debit cards...neither of them mine. Fail!
Next we were ushered into a little side room and someone who spoke English started asking me questions. After another time of waiting...the guy showed back up with nothing. The whole time I was thinking, here we go I'm going to have to figure out how to cancel my debit card from Moz and go through getting a new one...what a hassle. He said..."Could you just look in your wallet one more time and make sure you don't have?" Sharon and I both said..."I don't have it...the machine ate it". He insisted I look again. And...THERE WAS MY DEBIT CARD RIGHT WHERE IT ALWAYS IS. I still have no recollection of it coming out of the machine and putting it back into my wallet. I think that proves I'm exhausted and stressed. What a day?!