I'm home! Where did the last 6 weeks go? I just spent the last 10 days in Italy with my sisters and 24 hours traveling yesterday. Mary flew to Rome last week to meet Catie and I for a celebratory vacation of my ending college and Catie returning to the US. In ten days we went to Assisi, Siena, Florence, Cinque Terre and Rome and it was amazing!
I've posted the last few logs and exemplars I had written for school mainly so I remember to look back on them and as an ending to my experience in Bamenda. The last week was busy and fulfilling and I am only saddened that it went by so fast. The CBC had a huge send off for my sister and me that went on with speeches and presentations for over 3 hours and they dressed us up as "Bamenda Girls" in the traditional Northwest Province ceremonial outfits. Although Catie and I felt a bit ridiculous they thought we looked beautiful. As we walked around the compound, men kept stopping to truly complement us on our looks; no cat calls or marriage offers, they were amazed! I wondered if I would have gotten the same response in NYC had I walked down the street in a headdress and Kaba... anybody want to try it with me? Maybe when I move to Harlem, I can see what the response will be... or not.
In any case, I am currently posting my pictures to Picasa, so they will be available shortly (finally!)
I'm headed back to Charlottesville early next week for graduation celebrations and a presentation to the faculty. My Graduation Ceremonies are next weekend, then I move out and I have absolutely not a clue what happens Monday, May 19th. I have to wait to be given a date to take my boards which probably will not be till the end of June or July and until I have that date, I won't have a formal job offer from the NYC hospitals. So I'm kind of in a secure limbo for now. I'm hoping to move to the city by the end of the July if everything works out but will probably be hopping up and down the east coast from VA to NYC to Maine till then. It's a little scary since I don't have a formal offer (I'm hoping on Mt. Sinai) but then again I'm a nurse and luckily it's one job where I don't really have to worry. So studying for boards, apartment searching, a few safety applications to other hospitals and some source of income to make my car payments for a few months will occupy me a bit till the next chapter begins.
I'll try to write a bit about Italy, there were some great stories... Catie banging on the closed train doors where Mary and I stood with no tickets, randomly walking to St. Peter's square and the Pope just happening to be saying Mass, lots of free limoncello from old restaurant owners, the proposals of beautiful Italian men and Mary having her first few too many glasses of wine... but that will wait for a bit.
Unfortunately it was a rough return to the US. Our dog Bailey, who had epilepsy, went into status epilepticus last weekend and spent a long and rough day and night at the vet with my parents. They were unable to stop the seizures and after many phone conversations to us, we decided that it was necessary to put him to sleep. He was only 3 years old and while we had know for the past year that this could eventually happen, it has been utterly heartbreaking to lose him. The house feels quiet and empty without him and he will never be replaced.
Thanks to all of you for sharing in this experience with me. The blog has been both cathartic and therapeutic, as well as a lot of fun and I've appreciated your responses. I'm glad to be home and can't wait to see you all!
Thursday, May 7, 2009
Some last thoughts
Today was my last day as a nursing student. When I walked out of the clinic at 3pm this afternoon, it was with an awareness that I would never again step into a clinical setting as a student nurse. While I would never go so far as to say that my education is over, in fact I am just beginning, a hard-earned and significant part of my life is coming to an end. After four years of incredibly difficult work with many moments spent unable to see the end in sight, I could not have imagined a more fulfilling or exemplary last day.
I have known, for quite a long time, that I wanted to work in the medical field so that I could work overseas. For as long as I can remember, the idea of working with HIV/AIDS patients in Africa was the apex of the journey on which I hoped to embark. That goal, however, was reached much sooner than I had planned. When I asked Dean Carroll last March if an international practicum would be possible, it was without really believing the answer would be yes. I don’t think I even believed when I got on the plane to come to Cameroon that I was actually coming to do the work that I had not thought would be possible till I was much older. It had taken so much negotiating, planning and stress that when I finally arrived it felt as though I had already beaten the odds. This last month, however, has been truly life changing.
I have always loved clinical; I have looked forward to the days in the hospital despite the prep work and early mornings, because it was the practical application of what I was learning. That being said, I struggled with the US system, because I saw patient care being sacrificed to avoid lawsuits, excessive amounts of waste and diseases that were a direct outcome of poor lifestyle choices, even when the patient was adequately educated. Here, however, each day is more rewarding than all my other days combined.
So often as a student, it has been my job to observe instead of act. I knew that part of my experience here would be spent doing just this, observing. And despite my determination to organize this trip as much as possible, a small part of me feared that I would be forced to spend too much time adjusting to the culture, the medical system and my preceptor before I would do anything practical. I am overjoyed that did not happen. I have learned to think in a new way here, constantly assessing, planning and evaluating; in fact I feel as though my natural thought process has become the nursing process. I have delved into the world of AIDS care and treatment and my days have become a plethora of protocols, international research, and a fight against the social issues that surround this disease. I have not only adapted to the culture, I have begun to feel a part of it. But most importantly, I feel like I have become a nurse in every aspect. As an example of what I learned and where I grew, I would like to share the final interactions I had in my role as a student nurse.
My last patients today were a mother and her three-year-old son. They had come to receive the results of their latest CD-4 and pick up medications. As I reviewed the mother’s chart, I realized that her CD-4 had fallen from 614 to 508 cells/ul in that last 6 months despite ART and regular checkups. When I shared the information with her, she was distraught and wanted to know why it had fallen. As I explained to her possible reasons including poor nutrition, an underlying infection, or stress she asked if it was possible to get sick from sex. Now this is a woman who has been in our clinic for three years, who delivered a child through our program and who is on treatment. I realized immediately that an education deficit was the biggest clinical problem at hand and went on to have a long discussion with her about the HIV virus and lifestyle choices. What I discovered was that the real issue was that her husband refused to wear condoms, despite a negative HIV test last year and an infected wife and child. She wanted counseling on how to talk to her husband and after 45 minutes with her, we had discussed every aspect of lifestyle choices, disease progression, and prevention that I could have imagined.
In my subsequent physical assessment of her, I suspected that she might have TB, as she had begun to lose weight, developed a cough and night sweats. Since she was on the borderline mark of 500 cells/ul that warrants Bactrim prophylaxis and as she had new clinical symptoms, I sent her to the physician for follow-up and then to our social worker for more counseling. While her condition was worsening, her son’s was blossoming. He had an increased CD-4 of 1558 cells/ul, was overcoming his speech delay and just beamed the entire appointment.
Later that afternoon, she returned to my office to share with me what the doctor had said. The physician had indeed agreed with my assessment and put her on Bactrim as well as scheduled a follow-up to monitor the cough. She had spoken with the social worker and she was hopeful of her future as well as prepared to encourage her husband to come to the clinic. She then thanked me for talking with her, and in those moments I see could the transition from a woman who had sat in my office an hour earlier thinking she was losing options quickly to a woman who was praising God for her time ahead.
So often here, my experiences have felt more like stories because they almost don’t seem real. I have never before had opportunities to so directly impact a person’s life in so many ways. What I realized as she left was that I had acted as a nurse in many aspects during that interaction. I was able to provide emotional, educational and medical support and together we addressed the problems of her health, home situation, marriage and work, in just one consultation. And I didn’t have to only hope it worked; I could see it working right there and then.
As I prepare to end college, I realize that this experience is the beginning of the next chapter for me. I feel ready, I am prepared to meet new challenges and I am ecstatic to have found an area of work that fills me with so much joy. Today I may have arrived at the clinic as a student but I left as a nurse, knowing I had made a difference in the lives of my patients, confident in my abilities, and eager to do more.
I have known, for quite a long time, that I wanted to work in the medical field so that I could work overseas. For as long as I can remember, the idea of working with HIV/AIDS patients in Africa was the apex of the journey on which I hoped to embark. That goal, however, was reached much sooner than I had planned. When I asked Dean Carroll last March if an international practicum would be possible, it was without really believing the answer would be yes. I don’t think I even believed when I got on the plane to come to Cameroon that I was actually coming to do the work that I had not thought would be possible till I was much older. It had taken so much negotiating, planning and stress that when I finally arrived it felt as though I had already beaten the odds. This last month, however, has been truly life changing.
I have always loved clinical; I have looked forward to the days in the hospital despite the prep work and early mornings, because it was the practical application of what I was learning. That being said, I struggled with the US system, because I saw patient care being sacrificed to avoid lawsuits, excessive amounts of waste and diseases that were a direct outcome of poor lifestyle choices, even when the patient was adequately educated. Here, however, each day is more rewarding than all my other days combined.
So often as a student, it has been my job to observe instead of act. I knew that part of my experience here would be spent doing just this, observing. And despite my determination to organize this trip as much as possible, a small part of me feared that I would be forced to spend too much time adjusting to the culture, the medical system and my preceptor before I would do anything practical. I am overjoyed that did not happen. I have learned to think in a new way here, constantly assessing, planning and evaluating; in fact I feel as though my natural thought process has become the nursing process. I have delved into the world of AIDS care and treatment and my days have become a plethora of protocols, international research, and a fight against the social issues that surround this disease. I have not only adapted to the culture, I have begun to feel a part of it. But most importantly, I feel like I have become a nurse in every aspect. As an example of what I learned and where I grew, I would like to share the final interactions I had in my role as a student nurse.
My last patients today were a mother and her three-year-old son. They had come to receive the results of their latest CD-4 and pick up medications. As I reviewed the mother’s chart, I realized that her CD-4 had fallen from 614 to 508 cells/ul in that last 6 months despite ART and regular checkups. When I shared the information with her, she was distraught and wanted to know why it had fallen. As I explained to her possible reasons including poor nutrition, an underlying infection, or stress she asked if it was possible to get sick from sex. Now this is a woman who has been in our clinic for three years, who delivered a child through our program and who is on treatment. I realized immediately that an education deficit was the biggest clinical problem at hand and went on to have a long discussion with her about the HIV virus and lifestyle choices. What I discovered was that the real issue was that her husband refused to wear condoms, despite a negative HIV test last year and an infected wife and child. She wanted counseling on how to talk to her husband and after 45 minutes with her, we had discussed every aspect of lifestyle choices, disease progression, and prevention that I could have imagined.
In my subsequent physical assessment of her, I suspected that she might have TB, as she had begun to lose weight, developed a cough and night sweats. Since she was on the borderline mark of 500 cells/ul that warrants Bactrim prophylaxis and as she had new clinical symptoms, I sent her to the physician for follow-up and then to our social worker for more counseling. While her condition was worsening, her son’s was blossoming. He had an increased CD-4 of 1558 cells/ul, was overcoming his speech delay and just beamed the entire appointment.
Later that afternoon, she returned to my office to share with me what the doctor had said. The physician had indeed agreed with my assessment and put her on Bactrim as well as scheduled a follow-up to monitor the cough. She had spoken with the social worker and she was hopeful of her future as well as prepared to encourage her husband to come to the clinic. She then thanked me for talking with her, and in those moments I see could the transition from a woman who had sat in my office an hour earlier thinking she was losing options quickly to a woman who was praising God for her time ahead.
So often here, my experiences have felt more like stories because they almost don’t seem real. I have never before had opportunities to so directly impact a person’s life in so many ways. What I realized as she left was that I had acted as a nurse in many aspects during that interaction. I was able to provide emotional, educational and medical support and together we addressed the problems of her health, home situation, marriage and work, in just one consultation. And I didn’t have to only hope it worked; I could see it working right there and then.
As I prepare to end college, I realize that this experience is the beginning of the next chapter for me. I feel ready, I am prepared to meet new challenges and I am ecstatic to have found an area of work that fills me with so much joy. Today I may have arrived at the clinic as a student but I left as a nurse, knowing I had made a difference in the lives of my patients, confident in my abilities, and eager to do more.
An Exemplar
A Synthesis Practicum in an HIV Care and Treatment clinic located in a developing country is such a unique and wonderful experience that is it hard to pinpoint single moments that stand out as exemplary. I wish that I could share what I learned from each patient, as it is accurate to state that each one of the people I have seen is an outstanding moment in itself. As I start to compare my first days here with where I am now, however, there are a few instances that stand out not only as an example of what I have learned as a nurse but as an experience that changed how I think and feel as a person.
Today I saw the first patient that really pushed the wall that nurses must create to be able to handle difficult emotional situations. I have seen patients die, I have helped their families, I have worked through difficult ethical and social issues with patients and while challenging, none of them have been unbearable. But today, it took all my strength to no break down in tears after I sent one of my patients to the lab.
As a bit of background to help understand how the medical system here operates, each patient has a small notebook that serves as their medical records which they bring to each appointment. In my role as a nurse, when they come to the clinic I review the book to see what has changed since their last appointment. Along with keeping records in our charts, we use the books to make sure the ART regimen is the same, what new prescriptions may have been added and a summary of other appointments they may have had at different facilities. While primitive, it is actually effective because we are able to see every visit and treatment without having to request records from other clinics.
This morning, a mother came in with a 2-year-old boy who was HIV positive. After taking his weight and verifying that the purpose of the appointment was to pick up his ARV medications, I began to review the book as I always do to check whether the CD-4 count is within the last 6 months, plot the weight and height to check the child’s development, and check if he has had to visit any other facilities for any new illnesses. What I noticed first was that his book only went back till January of this year, meaning there were no records of medical appointments from the first year and half of his life. After asking the mother if the child had another book and finding out that he did not, he had not been seen by anyone until 4 months ago, I began to read through the multiple hospital admissions and visits that had occurred since the beginning of this year.
His first visit was to our medical center but with a general physician, not our HIV specialist. This physician had begun the child on ART without a baseline CD-4 count or staging, which is not the protocol for his age group. He was then admitted to the regional hospital with parotiditis, at which point a differential diagnosis of lymphoma was given, but no testing, follow-up or treatment was given. A few weeks later he was seen by our clinic’s physician who renewed the prescriptions, again without a baseline CD-4 and staged him at Stage II with recurrent oral ulcerations. Then he had another hospital visit where extrapulmonary TB was questioned, again with no confirmed diagnosis or treatment. In between all of these visits, our nurses had seen him several times, with one visit by my preceptor who had ordered the CD-4, but the mother did not go to the lab to have the blood taken.
When I finally saw this child he was so clearly and unbelievably sick that I could not help being angry at both the mother and medical staff. His head with dripping with sweat from a fever, his face was incredibly swollen with parotiditis and he cried the entire appointment. Yet the mother was reporting to me that he was fine. My preceptor and I reviewed everything that had happened with the mother, trying to figure out how so many people could have missed so many steps along the way. We immediately sent him the lab and then to the physician, but throughout the morning his case nagged at me through and through. There has not been a patient here yet that I have looked at and thought “this patient is going to die of AIDS”, I try to look instead at the future they will have as a healthy individual, but when the door shut behind that little boy, the reality of the situation hit me hard and tangibly because I knew that someday that would be his outcome and it absolutely should not have been.
It is a fragile system here that operates through a patchwork of disconnected medical facilities, limited resources and social issues of poverty and stigma, but most of the time it works. Today, however, this system failed this little boy and it serves in my mind as an example of how complacency can be deadly. I am grateful that my assessment and thoroughness brought attention to the problem and that I have progressed to a point where I understand the medical system here as well as the disease well enough to function as a competent nurse, but I am saddened that it was even a problem to start.
I have learned so much over the last month. I have seen healthy active members of our support groups who once sat in the exam room so sick they could hardly move. I have heard and seen stories of the amazing abilities of ART to manage HIV and I have learned that just because it looks awful does not been it cannot get better. I am honored to spend my days with HIV positive patients who can find joy and meaning in life and the more time I am here, the more value I can see in the work the other nurses and I do. But today showed what a delicate balance there is here between life and death, how easy it is for someone to slip through our fingers, how we can prevent or promote death through how diligent we are in our work.
Today I saw the first patient that really pushed the wall that nurses must create to be able to handle difficult emotional situations. I have seen patients die, I have helped their families, I have worked through difficult ethical and social issues with patients and while challenging, none of them have been unbearable. But today, it took all my strength to no break down in tears after I sent one of my patients to the lab.
As a bit of background to help understand how the medical system here operates, each patient has a small notebook that serves as their medical records which they bring to each appointment. In my role as a nurse, when they come to the clinic I review the book to see what has changed since their last appointment. Along with keeping records in our charts, we use the books to make sure the ART regimen is the same, what new prescriptions may have been added and a summary of other appointments they may have had at different facilities. While primitive, it is actually effective because we are able to see every visit and treatment without having to request records from other clinics.
This morning, a mother came in with a 2-year-old boy who was HIV positive. After taking his weight and verifying that the purpose of the appointment was to pick up his ARV medications, I began to review the book as I always do to check whether the CD-4 count is within the last 6 months, plot the weight and height to check the child’s development, and check if he has had to visit any other facilities for any new illnesses. What I noticed first was that his book only went back till January of this year, meaning there were no records of medical appointments from the first year and half of his life. After asking the mother if the child had another book and finding out that he did not, he had not been seen by anyone until 4 months ago, I began to read through the multiple hospital admissions and visits that had occurred since the beginning of this year.
His first visit was to our medical center but with a general physician, not our HIV specialist. This physician had begun the child on ART without a baseline CD-4 count or staging, which is not the protocol for his age group. He was then admitted to the regional hospital with parotiditis, at which point a differential diagnosis of lymphoma was given, but no testing, follow-up or treatment was given. A few weeks later he was seen by our clinic’s physician who renewed the prescriptions, again without a baseline CD-4 and staged him at Stage II with recurrent oral ulcerations. Then he had another hospital visit where extrapulmonary TB was questioned, again with no confirmed diagnosis or treatment. In between all of these visits, our nurses had seen him several times, with one visit by my preceptor who had ordered the CD-4, but the mother did not go to the lab to have the blood taken.
When I finally saw this child he was so clearly and unbelievably sick that I could not help being angry at both the mother and medical staff. His head with dripping with sweat from a fever, his face was incredibly swollen with parotiditis and he cried the entire appointment. Yet the mother was reporting to me that he was fine. My preceptor and I reviewed everything that had happened with the mother, trying to figure out how so many people could have missed so many steps along the way. We immediately sent him the lab and then to the physician, but throughout the morning his case nagged at me through and through. There has not been a patient here yet that I have looked at and thought “this patient is going to die of AIDS”, I try to look instead at the future they will have as a healthy individual, but when the door shut behind that little boy, the reality of the situation hit me hard and tangibly because I knew that someday that would be his outcome and it absolutely should not have been.
It is a fragile system here that operates through a patchwork of disconnected medical facilities, limited resources and social issues of poverty and stigma, but most of the time it works. Today, however, this system failed this little boy and it serves in my mind as an example of how complacency can be deadly. I am grateful that my assessment and thoroughness brought attention to the problem and that I have progressed to a point where I understand the medical system here as well as the disease well enough to function as a competent nurse, but I am saddened that it was even a problem to start.
I have learned so much over the last month. I have seen healthy active members of our support groups who once sat in the exam room so sick they could hardly move. I have heard and seen stories of the amazing abilities of ART to manage HIV and I have learned that just because it looks awful does not been it cannot get better. I am honored to spend my days with HIV positive patients who can find joy and meaning in life and the more time I am here, the more value I can see in the work the other nurses and I do. But today showed what a delicate balance there is here between life and death, how easy it is for someone to slip through our fingers, how we can prevent or promote death through how diligent we are in our work.
Clinical Log
I have so much to tell! I’ve been largely without Internet for the last week and a half so I have some catching up for with what has been happening here. The major things were some administrative things that have changed in the clinic as well as a trip to one of our hospitals.
My preceptor and I have been working really well together and since my second week I have been seeing the patients independently. She stays in the consultation room with me to help with some Pidgin translation as well as write prescriptions if need be, but allows me to do the assessments. When an issue comes up she asks my opinion first for what I think should be done, i.e. sent the patient to a lab for a certain test, refer them to the physician immediately, suggest a possible treatment plan or just observe. Although it is not my role to diagnose and treat she really helps me think through what is going on so that I can give a thorough assessment to whomever I refer the patient… and most of the time I’m starting to get it right! She also has been picking out patients from the waiting room for me to do full admission assessments on so that I can see a wide variety of symptoms and practice the WHO staging. Last week I admitted a new patient to our program with Stage IV Kaposi’s all over her body. Really unique symptoms here, I’m actually beginning to be more surprised to hear normal lung sounds than abnormal ones!
One thing that I have noticed is that I have to think very differently in terms of the differentials diagnoses here. Oftentimes in the US if a patient has some GI disturbances it is something viral, but here the first possibility is malaria. I have to remind myself often that these people are so used to the water and local bugs, that if they are complaining something is really wrong!
We also went to the lab this week so that I could practice phlebotomies, which was good to do, but I’ll be doing it differently this week. The system they use here is not so good. The have the old needles that have a twist off cap for the needle and a twist off on the other end for the gray piece that goes into the vacutainer. So you have to attach the bottom part to the vacutainer, uncap the needle, draw the blood, actively recap the used needle, untwist the vacutainer to be re-used and dispose of the needle. I almost stuck myself the first time and so my preceptor and I decided that the risk is too great for me to learn a system that I won’t use the in the US. If all the patients weren’t HIV positive I’d be happy to learn but there is too much anxiety and all I can hear in my head is Reba screaming at me to not actively recap needles, so I’m not going to do it again because it’s one of those situations where my safety has to come first. Luckily I brought butterfly needles with me that have safety devices and pre-attached vacutainers so we decided I will use those to practice so I can still do the skill but more safely.
In other matters, there was a big meeting last week between the directors of all the treatment centers because the CBCHB is losing some of its funding. Until now all PTMTC members have not paid anything and no one pays for drugs or consultations. But Columbia broke their agreement to continue funding and our centers are continuing to grow at a rapid rate. So the decision was made to begin to charge a 300cfa fee (about $0.75) each month for consultation. Last Monday they implanted this fee and so each morning there have been announcements in the waiting room about people having to pay. Although some are upset the reception has generally been good, as they have proposed it from the view of, “we have supported you for the last 5 years but now we need some help to continue to support you, do you think this is fair?” and overwhelmingly the patients say yes!
While everyone was here for that big meeting I had the change to meet Dr. Palmer, a US physician who has been here for over 20 years and is the director of Mbingo hospital (the CBC’s largest hospital). He invited me to come to Mbingo for a night so I could do inpatient rounds with him to see a different aspect of medicine here. So last Thursday after the clinic closed, I took a car to Mbingo and spent the night with Dr. Palmer and his wife. The next morning I went to morning report and rounds with him, then worked in the care and treatment center there to see a rural center vs. the urban one, at which I am normally. I saw things that morning that I will never again see in the US. We saw a women with end stage squamous cell carcinoma in shock, cryptococcal meningitis, gastric aspiration for TB, a trauma patient who had broken 5 ribs, ruptured his spleen, had a lung contusion and subcutaneous emphysema and a man with Kaposi’s from his hip to leg that made his leg over a foot in diameter of solid tumor (the physician is sending me pictures to share). They have to treat largely on symptoms, which usually work out all right but ventilators, accurate lab tests and advanced technologies do not exist here. It’s incredible how bad a patient will get before them come for help. There was a patient that day that had a CD-4 count of two! Two! I didn’t even know that was possible!!!
I was very grateful that Dr. Palmer had invited me and it was great to see how the ward nurses operate (I’m also glad that was not the site I chose for rotation). The ward nurses still do wound care, medication administration etc like US nurses, but the it’s so much more limited that it looked more like nursing 50 years ago in the US.
As you can tell from my exemplar it is still emotionally challenging at times, but this experience has changed a lot about what I want to do and where I want to practice. The need here is so different from the US and I feel like what I am doing helps more here. I only have three full days left in the clinic and I feel like I have definitely met my objectives. I can’t wait to come back and be able to tell more of the story with pictures!
My preceptor and I have been working really well together and since my second week I have been seeing the patients independently. She stays in the consultation room with me to help with some Pidgin translation as well as write prescriptions if need be, but allows me to do the assessments. When an issue comes up she asks my opinion first for what I think should be done, i.e. sent the patient to a lab for a certain test, refer them to the physician immediately, suggest a possible treatment plan or just observe. Although it is not my role to diagnose and treat she really helps me think through what is going on so that I can give a thorough assessment to whomever I refer the patient… and most of the time I’m starting to get it right! She also has been picking out patients from the waiting room for me to do full admission assessments on so that I can see a wide variety of symptoms and practice the WHO staging. Last week I admitted a new patient to our program with Stage IV Kaposi’s all over her body. Really unique symptoms here, I’m actually beginning to be more surprised to hear normal lung sounds than abnormal ones!
One thing that I have noticed is that I have to think very differently in terms of the differentials diagnoses here. Oftentimes in the US if a patient has some GI disturbances it is something viral, but here the first possibility is malaria. I have to remind myself often that these people are so used to the water and local bugs, that if they are complaining something is really wrong!
We also went to the lab this week so that I could practice phlebotomies, which was good to do, but I’ll be doing it differently this week. The system they use here is not so good. The have the old needles that have a twist off cap for the needle and a twist off on the other end for the gray piece that goes into the vacutainer. So you have to attach the bottom part to the vacutainer, uncap the needle, draw the blood, actively recap the used needle, untwist the vacutainer to be re-used and dispose of the needle. I almost stuck myself the first time and so my preceptor and I decided that the risk is too great for me to learn a system that I won’t use the in the US. If all the patients weren’t HIV positive I’d be happy to learn but there is too much anxiety and all I can hear in my head is Reba screaming at me to not actively recap needles, so I’m not going to do it again because it’s one of those situations where my safety has to come first. Luckily I brought butterfly needles with me that have safety devices and pre-attached vacutainers so we decided I will use those to practice so I can still do the skill but more safely.
In other matters, there was a big meeting last week between the directors of all the treatment centers because the CBCHB is losing some of its funding. Until now all PTMTC members have not paid anything and no one pays for drugs or consultations. But Columbia broke their agreement to continue funding and our centers are continuing to grow at a rapid rate. So the decision was made to begin to charge a 300cfa fee (about $0.75) each month for consultation. Last Monday they implanted this fee and so each morning there have been announcements in the waiting room about people having to pay. Although some are upset the reception has generally been good, as they have proposed it from the view of, “we have supported you for the last 5 years but now we need some help to continue to support you, do you think this is fair?” and overwhelmingly the patients say yes!
While everyone was here for that big meeting I had the change to meet Dr. Palmer, a US physician who has been here for over 20 years and is the director of Mbingo hospital (the CBC’s largest hospital). He invited me to come to Mbingo for a night so I could do inpatient rounds with him to see a different aspect of medicine here. So last Thursday after the clinic closed, I took a car to Mbingo and spent the night with Dr. Palmer and his wife. The next morning I went to morning report and rounds with him, then worked in the care and treatment center there to see a rural center vs. the urban one, at which I am normally. I saw things that morning that I will never again see in the US. We saw a women with end stage squamous cell carcinoma in shock, cryptococcal meningitis, gastric aspiration for TB, a trauma patient who had broken 5 ribs, ruptured his spleen, had a lung contusion and subcutaneous emphysema and a man with Kaposi’s from his hip to leg that made his leg over a foot in diameter of solid tumor (the physician is sending me pictures to share). They have to treat largely on symptoms, which usually work out all right but ventilators, accurate lab tests and advanced technologies do not exist here. It’s incredible how bad a patient will get before them come for help. There was a patient that day that had a CD-4 count of two! Two! I didn’t even know that was possible!!!
I was very grateful that Dr. Palmer had invited me and it was great to see how the ward nurses operate (I’m also glad that was not the site I chose for rotation). The ward nurses still do wound care, medication administration etc like US nurses, but the it’s so much more limited that it looked more like nursing 50 years ago in the US.
As you can tell from my exemplar it is still emotionally challenging at times, but this experience has changed a lot about what I want to do and where I want to practice. The need here is so different from the US and I feel like what I am doing helps more here. I only have three full days left in the clinic and I feel like I have definitely met my objectives. I can’t wait to come back and be able to tell more of the story with pictures!
Thursday, April 16, 2009
When you fall off your horse...
Get back on! Ok so the horse story. So Jacabo, the Fulani who let us borrow his horses, brought 5 horses for us to ride on Saturday. Since there were more than 5 of us we decided to have some of us ride to the lake and some follow in the car then switch on the way back. Catie, Neele, Leena, and I rode first with some of the locals accompanying us. Catie was on a female horse, whose mate was one of the other horses. I was on a male horse that was NOT the mate of Catie’s. Although these horses are domesticated for the Fulanis they aren’t domesticated like American horses. So when we got on and started to leave two of the horses got a little touchy with one another and there was a bit of a scramble, but we were assured they were fine. Now, I have ridden horses before… at fair grounds on the pony rides and once in Egypt being guided by the owner, so clearly I’m an expert in this area. Also, my horse did not have a bridle, only a rope to guide it. But why would I ever turn down the opportunity to ride an unbridled, barely domesticated horse through the African mountains? Right?
We all started off and had a lovely first half hour on the horses. Then as we were approaching a hill Catie’s horse in front of me decided to slow down, so my horse (and I) decided to pass it. My horse however just couldn’t keep it to himself and had to approach the behind of Catie’s horse a bit too closely. Not being her mate, Catie’s horse did NOT like this and decided to put my horse in its place… by rearing and kicking it. Naturally my horse reared back and in the process decided to get rid of me as well (obviously it had nothing to do with my poor riding skills). So I learned the hard and very literal way what it feels like to get dumped. Aside from bruising my foot and scraping up my arm I’m fine and I got right back on! Then about 20 minutes later with thoughts of basilar skull fractures (did I mention I landed on my back and head? Oops!), rural villages with no hospitals, and angry University officials I decided that I had proved myself and it was time to let someone else take my horse.
But after the trip to the lake I reunited with my horse that evening and rode him to the caves. I named him Patience for being patient with me and taking his sweet time to get there!
Moral of the story: NEVER get too close to the behind of a taken woman!
We all started off and had a lovely first half hour on the horses. Then as we were approaching a hill Catie’s horse in front of me decided to slow down, so my horse (and I) decided to pass it. My horse however just couldn’t keep it to himself and had to approach the behind of Catie’s horse a bit too closely. Not being her mate, Catie’s horse did NOT like this and decided to put my horse in its place… by rearing and kicking it. Naturally my horse reared back and in the process decided to get rid of me as well (obviously it had nothing to do with my poor riding skills). So I learned the hard and very literal way what it feels like to get dumped. Aside from bruising my foot and scraping up my arm I’m fine and I got right back on! Then about 20 minutes later with thoughts of basilar skull fractures (did I mention I landed on my back and head? Oops!), rural villages with no hospitals, and angry University officials I decided that I had proved myself and it was time to let someone else take my horse.
But after the trip to the lake I reunited with my horse that evening and rode him to the caves. I named him Patience for being patient with me and taking his sweet time to get there!
Moral of the story: NEVER get too close to the behind of a taken woman!
Wednesday, April 15, 2009
Easter in Babanki
Hi! Sorry I have not posted in a week. I was traveling this weekend and had to get some schoolwork done so I was not having time to sit down and write. This past weekend we (Catie, myself, the German girls and Glory) went to Babanki which is a village about an hour outside Bamenda. It is the village of Prof. Tih, the director of the CBC and he invited us to join him for Easter. Most people go to their home villages for holidays and we wanted the real experience so we were excited to get out of the city and relax in the country.
Knowing that we would not be able to have our traditional Easter, my Mom packed a few things for me to bring to make it more like home. One of the things she gave me was 4 packs of Easter egg dying kits. So for a week we were all buying eggs to bring to the village for a huge egg decorating extravaganza and we wound up with over 5 dozen eggs! The only problem is that eggs here are only brown! But we were excited to teach Cameroonians this Western tradition so we were not deterred by the possibility of not having the perfect shades of pink and yellow.
We arrived Friday afternoon and within 10 minutes of our arrival there were 15-20 village kids in the front yard who were there each night till after we went to bed and back before we woke up each morning. (Prof. Tih is an important leader in his village, so his arrival alone is exciting, but then to bring 6 white girls! wow!) That afternoon we went to the fields and learned how to harvest njamanjama, then to clean it for preparation. I attempted to learn how to carry baskets on my head like the women, at which I horribly failed but succeeded in learning how to tie a baby to my back (quite sturdy in fact, I may start carrying American babies this way). We climbed the pear (avocado) and guava trees in his yard and ate watermelon slices the size of our heads! Then we decided it was time... The eggs were boiled, the rain had past and we had enough children around to fill a school.
We decided to make camp on the front porch and everyone gathered around as we set up the dyes, stickers, foam animals (so cool!) and drying racks. We put one egg in the blue dye cup, waited, pulled it out to show and Bam! they were off! The eggs were gone before we knew it (some not to be dyed but to be eaten by small children who were more interested in the eggs as food than as art) and in about an hour everyone was covered in stickers, the front porch was covered in the remains of our project and we had 4 dozen beautifully decorated eggs! They loved it and we loved sharing it with them!
That evening we made a fire, drank palm wine and compared American, German and Cameroonian Easter traditions. The next morning we awoke to the children back in the yard, still with stickers on their faces and ready to play with the balloons and soccer balls we had brought. The front yard was filled with about 6 games going on at once from monster tag to monkey in the middle, duck duck goose (or njamanjama fou fou corn as we re-named it) Then... the horses arrived! Prof. Tih had arranged to have people from the Fulani tribe to let us borrow horses for the day to ride up to the lake and then to caves that evening. You will have to read the next post to hear what happened with the horses, but overall it was an amazing day! Babanki is indescribably beautiful. It is in the mountains and when you are riding down the trails you can see for miles and miles just lush African countryside with distant shadows over the valleys and unreal views. I had to pinch myself a few times to remember that this is my practicum experience! Sorry kids, but I would not have traded this for all the ICU's in the US.
On Sunday morning we all dressed in our African dresses and went to one of the local Churches for Easter services. Even if you aren't Christian, you just wouldn't be able avoid enjoying it. The music, the faith, the overwhelming joy of the people, the kids dancing and the enthusiastic sermon in the local dialect made it my favorite Easter yet. Not to get all hippie and third world on your American lifestyles but you can't be here without perspective slapping you in the face day after day. These people, who struggle to eat, to survive, to get water, to live with AIDS, who will never own an ipod or laptop and may never even leave the 50 miles around their village have more than any people I know. They have true happiness and sincerity in their lives. I envy them.
It was a wonderful and relaxing weekend and one of my favorite memories yet. I can not believe I only have a little over a week left. It feels like I just got here! I want to do and see so much more! Would it really be so awful if I didn’t come back?...
Knowing that we would not be able to have our traditional Easter, my Mom packed a few things for me to bring to make it more like home. One of the things she gave me was 4 packs of Easter egg dying kits. So for a week we were all buying eggs to bring to the village for a huge egg decorating extravaganza and we wound up with over 5 dozen eggs! The only problem is that eggs here are only brown! But we were excited to teach Cameroonians this Western tradition so we were not deterred by the possibility of not having the perfect shades of pink and yellow.
We arrived Friday afternoon and within 10 minutes of our arrival there were 15-20 village kids in the front yard who were there each night till after we went to bed and back before we woke up each morning. (Prof. Tih is an important leader in his village, so his arrival alone is exciting, but then to bring 6 white girls! wow!) That afternoon we went to the fields and learned how to harvest njamanjama, then to clean it for preparation. I attempted to learn how to carry baskets on my head like the women, at which I horribly failed but succeeded in learning how to tie a baby to my back (quite sturdy in fact, I may start carrying American babies this way). We climbed the pear (avocado) and guava trees in his yard and ate watermelon slices the size of our heads! Then we decided it was time... The eggs were boiled, the rain had past and we had enough children around to fill a school.
We decided to make camp on the front porch and everyone gathered around as we set up the dyes, stickers, foam animals (so cool!) and drying racks. We put one egg in the blue dye cup, waited, pulled it out to show and Bam! they were off! The eggs were gone before we knew it (some not to be dyed but to be eaten by small children who were more interested in the eggs as food than as art) and in about an hour everyone was covered in stickers, the front porch was covered in the remains of our project and we had 4 dozen beautifully decorated eggs! They loved it and we loved sharing it with them!
That evening we made a fire, drank palm wine and compared American, German and Cameroonian Easter traditions. The next morning we awoke to the children back in the yard, still with stickers on their faces and ready to play with the balloons and soccer balls we had brought. The front yard was filled with about 6 games going on at once from monster tag to monkey in the middle, duck duck goose (or njamanjama fou fou corn as we re-named it) Then... the horses arrived! Prof. Tih had arranged to have people from the Fulani tribe to let us borrow horses for the day to ride up to the lake and then to caves that evening. You will have to read the next post to hear what happened with the horses, but overall it was an amazing day! Babanki is indescribably beautiful. It is in the mountains and when you are riding down the trails you can see for miles and miles just lush African countryside with distant shadows over the valleys and unreal views. I had to pinch myself a few times to remember that this is my practicum experience! Sorry kids, but I would not have traded this for all the ICU's in the US.
On Sunday morning we all dressed in our African dresses and went to one of the local Churches for Easter services. Even if you aren't Christian, you just wouldn't be able avoid enjoying it. The music, the faith, the overwhelming joy of the people, the kids dancing and the enthusiastic sermon in the local dialect made it my favorite Easter yet. Not to get all hippie and third world on your American lifestyles but you can't be here without perspective slapping you in the face day after day. These people, who struggle to eat, to survive, to get water, to live with AIDS, who will never own an ipod or laptop and may never even leave the 50 miles around their village have more than any people I know. They have true happiness and sincerity in their lives. I envy them.
It was a wonderful and relaxing weekend and one of my favorite memories yet. I can not believe I only have a little over a week left. It feels like I just got here! I want to do and see so much more! Would it really be so awful if I didn’t come back?...
Monday, April 6, 2009
WhiteMan Show
ah the sound of children yelling "white man! white man!" as you walk down the street is music to my ears. Doesn't matter that I'm not a man, it's apparently all the same to them. Last night I was cooking dinner with Neele (one of the German girls) for our friends Glory, Gideon and Kenneth and two little girls walked into our house. Figuring they wanted something, we introduced ourselves, talked to them, asked if they wanted anything but they just wanted to sit there and stare at us while we cooked. And they did, for over an hour. Being white is entertainment enough for them!
It was a good weekend with many people! Catie and I went to the children's support group Saturday morning for HIV+ kids and they are so adorable and educated! 5 year olds were sharing that you can pass HIV through sexual intercourse! Then we went to Mbingo Hospital. Mbingo is a smaller town about an hour away and I wanted to visit the hospital there as it is part of the CBCHB and they have another care and treatment clinic there like the one I work at. It is sooooo beautiful! It's up in the mountains and it looks like it is from a movie. It is also a very well run and clean hospital (still in the 40 people to an open ward, people cooking and sleeping outside kind of African way) but sooo much better than Regional Hospital here in Bamenda.
I should probably tell you about the bush taxis here which is how we travel. So take an old Toyota circa about 1980 with anywhere from 150,000-300,000 miles on it. Put bald used tires on it, rip out the stereo and half the dashboard, break the door handles and windshield, then fill it with people. And by fill I mean 4 adults and one child in the back seat, two in the front passenger seat, one in the middle and one on the LEFT of the driver. Then fill the trunk with bags of dried fish and plantains till you can only tie down the hatch about a quarter of the way and strap a few more hundred pounds of bags on top of the car. Then while you drive, drag the hanging transmission over the speed bumps and be certain to turn off the engine every time you are on any downward grade (don't tell them it takes more gas and energy to turn it on and off so much). It's great! Especially on trips over an hour!
Saturday night my cousin's family got here and we all had a big dinner together. There are now 15 Germans here and the language is getting a bit funny between all the different accents! It's a great time though and I apologize for my continually worsening grammar. I think in pidgin and it drastically reduces the variety of your speech. Example: We done chop all de chop which I done chop for you. Translation: We ate all the food which I cooked for you. Chop meaning food, eat and cook, get my point?
Catie is Yaounde for business right now so I'm going to spend the night with our friend Glory at her house in Nkwen this evening. I'm hoping I get to learn how to make njama jama!
I want to tell you all about contact tracing which I did on Friday in a village but it's a long story so I will save it for later after we go back next country Sunday to do free community HIV testing. But today I got to see patients on my own! woo woo for pidgin assessments! Rest well everyone, I miss you all!
It was a good weekend with many people! Catie and I went to the children's support group Saturday morning for HIV+ kids and they are so adorable and educated! 5 year olds were sharing that you can pass HIV through sexual intercourse! Then we went to Mbingo Hospital. Mbingo is a smaller town about an hour away and I wanted to visit the hospital there as it is part of the CBCHB and they have another care and treatment clinic there like the one I work at. It is sooooo beautiful! It's up in the mountains and it looks like it is from a movie. It is also a very well run and clean hospital (still in the 40 people to an open ward, people cooking and sleeping outside kind of African way) but sooo much better than Regional Hospital here in Bamenda.
I should probably tell you about the bush taxis here which is how we travel. So take an old Toyota circa about 1980 with anywhere from 150,000-300,000 miles on it. Put bald used tires on it, rip out the stereo and half the dashboard, break the door handles and windshield, then fill it with people. And by fill I mean 4 adults and one child in the back seat, two in the front passenger seat, one in the middle and one on the LEFT of the driver. Then fill the trunk with bags of dried fish and plantains till you can only tie down the hatch about a quarter of the way and strap a few more hundred pounds of bags on top of the car. Then while you drive, drag the hanging transmission over the speed bumps and be certain to turn off the engine every time you are on any downward grade (don't tell them it takes more gas and energy to turn it on and off so much). It's great! Especially on trips over an hour!
Saturday night my cousin's family got here and we all had a big dinner together. There are now 15 Germans here and the language is getting a bit funny between all the different accents! It's a great time though and I apologize for my continually worsening grammar. I think in pidgin and it drastically reduces the variety of your speech. Example: We done chop all de chop which I done chop for you. Translation: We ate all the food which I cooked for you. Chop meaning food, eat and cook, get my point?
Catie is Yaounde for business right now so I'm going to spend the night with our friend Glory at her house in Nkwen this evening. I'm hoping I get to learn how to make njama jama!
I want to tell you all about contact tracing which I did on Friday in a village but it's a long story so I will save it for later after we go back next country Sunday to do free community HIV testing. But today I got to see patients on my own! woo woo for pidgin assessments! Rest well everyone, I miss you all!
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