The Week from Hell WARNING: This May be the Most Depressing Post Ever

     This week has royally kicked my butt. It started off with a bang and just never stopped. It doesn't help matters that I've been extremely exhausted for no particular reason on top of it all. I apologize in advance for this depressing post, but it's therapeutic to share it. I don't blame you if you don't want to read it. I will completely understand. Nurses are usually built with thicker skin than most, but this week has resembled my time spent in Haiti and it just sucks, big time.
     Isaac is my senior (attending) on this week. Just as we were about to start rounds on Monday morning an Internal Medicine resident came into the ICU and asked for some help on an emergency. In the US if someone says there's an emergency, you drop everything and go. Here, there isn't the same sense of urgency. I'm not sure why. It may be that they are so resource poor that they often know there isn't much they can do. I don't know. The nurses, students, and physicians are so smart here. They all have more textbook knowledge than I could ever possibly imagine. But from what I've witnessed thus far, there is a disconnect between that knowledge and action. It's just a completely different culture.
     Anyway, when Isaac asked the resident what the situation was she launched into a very detailed history while we all just stood in the ICU. Finally, mainly because we didn't think from what we were told it was that urgent we all walked down to Internal Medicine together. Julie was hovered near the patient in question. We looked at each other and I knew before I even saw the patient that it was going to be helpless. Sure enough, when I turned and saw the patient she was already agonally breathing and unresponsive with blown pupils. Isaac looked at me and asked my opinion. My opinion was to turn down the oxygen and give a dose of morphine after talking to the family. Isaac was exasperated. He said that he was helpless to do anything in this situation and he was right. We were notified too late. I was baffled because we had 4 open beds in the ICU all weekend. After meeting with the family and explaining that while we understood they wanted to take her home (over 3 hours away) to consult traditional healers, she wouldn't survive the journey. They agreed to let her stay in the hospital and I believe she passed away Monday night or Tuesday morning.
     While in the wards Onyema, a short-term HRH Infectious Disease physician who has been coming here since year one of the program, asked if we could take a look at another patient. By the time we got there this patient was also agonally breathing. Isaac decided we could intubate and transfer this younger patient to the ICU. Her saturation when we checked was about 63% (for non-medical people your oxygen saturation should always be above 95% unless you're a smoker). Then came the task of trying to get oxygen. There was none. The first patient who was going to die had way too much oxygen on because they didn't feel comfortable turning it down or off and here was a young twenty-one year old that we could save and there was no oxygen. It was a disaster. I can't even describe it all. We got her to ICU eventually and two hours later she was dead. I spent all day on the unit with Isaac rounding with him. We work well together and he is always asking my opinion, which sometimes I have to laugh because he's the one who went to medical school, not I. But it is very nice to know how much I am appreciated and respected here by others.

Dr. Isaac teaching nursing students about central line placement.

     Tuesday wasn't too bad. I spent a good deal of time in meetings and working on some research and lectures because I hadn't done anything but clinical work the day before. And we admitted another child from surgery. This child (13 years old) for a reason I don't think anyone really knows was suffering from gangrene in all four of her limbs. You can imagine what the treatment for gangrenous limbs is. After a week, her parents consented to surgery. They amputated all four of her limbs. Both arms above her elbows, one leg below her knee, and one above the knee. There are no prosthetics here. And what's worse, the infection is still around, which essentially means that this girls limbs have all been cut off, there is no way she'll ever get out of bed ever again, and she is still going to eventually die. The good news is that my other patient is a very cute 5 year old boy who is improving from his 18-20% burns from a house fire. I didn't realize I would be learning so much about pediatrics when I came here. A few of us also taught the student nurses CPR in the afternoon, which was great fun.

Nursing students learning proper CPR technique.

They had a lot of fun learning.

     Wednesday was just as busy. I spent almost all day in the office working on research and lectures. Emmanuel worked that day and I could tell something was up; he just wasn't himself. Turns out that his 10 month son was having surgery. He is fine and the surgery was minor and went very well and the baby will go home today. But both of us were just tired and off our game. Not to mention that now my 5 bed unit was filled with four patients. My two children from above and two more surgical patients that were unstable. At the end of the day I decided to walk home just to clear my head and relax, which was very nice. Just before I left Emmanuel and I were chatting and I asked him how much surgery costs here. The wonderful thing about Rwanda is that they have health insurance for all that covers 90% of most care and the patient pays 10%. It's really rather remarkable, although it has its faults. For instance, it does not cover contrast for a CT scan at all. We have found this to be problematic, but overall, it's a decent system for a developing country. Emmanuel started to explain, using his son as an example how much some surgeries cost. I asked after he named a price if that was considered expensive to most here. He said yes. I felt terrible. This man is a father of three and works so incredibly hard on the unit, with the students, with fellow colleagues, and me. He comes in extra on his days off and is never compensated for his extra time. He makes roughly $340 USD/month. I handed him just under $30 in Rwandan francs, which will cover most of the surgical costs and told him he deserved it. He almost started to cry, which of course almost made me cry. I felt good but bad at the same time. I know how much he appreciates it, but it is so easy to give money. I feel as though that is something Americans like to do. Let's just throw money at the problem to solve it. And I'm not saying that's a bad thing, but it doesn't help with systems changes. It's a problem that a nurse might work extremely hard here and not be able to afford a surgery that his son needs at the very hospital at which he works. I have fairly advanced technology here, but run out of Morphine almost daily on my unit because donors like to give physical objects, not medication. It's terrible. I am sitting here in the back office and I can hear Violetta, my 13 year old amputee crying because she is in pain. But we have nothing better than paracetamol (Tylenol) to give her.
     This morning hasn't been much better. I walked in and our two unstable patients were even more so. We hadn't even finished nursing report before one was essentially coding and we had a pulse but could not get a blood pressure on the other. The nurses stopped report and just got to work. It reminded me of home. Eventually there was CPR being done on both patients at the same time. The younger of the two was in a shockable rhythm, but by the time we plugged (yes, plugged) the defibrillator (with paddles not pads) in she was in asystole and there was nothing left to be done. They both died within 20 minutes of each other in the first three hours of work. 50% of the ICUs patients are dead so far today. And rumor has it we have another surgical case that might be unstable coming soon.
     I am now hiding in the back office writing this and listening to Christmas carols. It's a habit I formed in nursing school. My hardest semesters were always my fall semesters and my roommates would often find me listening to carols because in my mind if it was Christmas, that meant that classes were over and I was on vacation. Not to mention that Christmas carols are generally peppy and happy. This Christmas will be my first Christmas ever not at home. I will however be going to Ireland to visit my old patient from my DC days and his wife. I am excited for that. And I'm also excited to get away this weekend to Nyungwe National Park with Vanessa and Julie. It will be a much needed break after this week.
     I don't think I've ever prayed as much as I find myself doing here. I am grateful that Christian, my little burn victim is doing well and I hope that he continues to do so. I think the highlight of my week was the box cake I made for Onyema and Peter's last day here at CHUB. They will be missed. I'd post their goodbye speech, but it's a little too big. Time for more meetings. Sorry this post is so utterly depressing. I just really needed to vent.

Lessons Learned:
1) I am so incredibly lucky.
2) Even more so in the US, sometimes there is just nothing else to be done.
3) Living some place else can really open your eyes and make you realize what is really important in your life.