Fall Funk

     Well it's official. After being out of country for just over 60 days I had my first (and I'm sure not my last) cathartic sob fest. Let me fill you in because yet again time has gotten away from me, though partially this time because I just didn't feel like writing. It's been a dark couple of weeks and I really didn't feel like bumming everyone out again.
     Two weeks ago, I walked into the ICU thinking it was just going to be like any other Monday. Granted, it would be like any other Monday here in Rwanda so never the typical Monday you're thinking of I'm sure. In fact, that particular Monday was Columbus day, so the mere fact that I was at work and some of you weren't makes it special. Anyway, it wasn't long before my tired, groggy, un-caffeinated body that hadn't slept well over the weekend, found out that our newest patient happened to be my Head of Department (medical director)'s mother. When Claude, the Senior taking over that morning found out his eyes became as big as saucers. I had an uneasy feeling.
     Tuesday morning was worse. Théogène was on his flight back from Sweden where he had been for a month working on his PhD. His mother had taken a turn for the worse and it was not looking good. I kept checking to make sure she had a pulse I was so nervous. The unit was hectic and I pushed lecture to the afternoon because otherwise I'd be lecturing to myself about the importance of calculating patient's fluid balance. The next thing I knew a different patient started to code. I don't even remember his patient story. It all happened so fast. The code ran extremely well and I was very proud of the nurses and of the doctors. We have a new General Practitioner for the ICU, Oscar, so he's still getting his feet wet, but he, Claude, and the nurses did a very good job even if in the end they were unsuccessful in reviving the man. I will say that I was able to cross another first off my list though... I thought they only used paddles on defibrillators in old tv shows (think early years of ER) and movies. Nope! They use them here too. I was the one who squirted the gel onto them. I felt as though I was in a time warp.

Claude working hard to save a life.

     Meanwhile, we were all hoping and praying that Théogène's mother would hang in there until Wednesday when he'd be back in Butare. I finally I had to leave the unit to have a bite to eat and when I came back about 25 minutes later I discovered that they had started to code her. Claude and the nurses worked tirelessly and I will admit to doing some CPR as well. But all efforts were to no avail. She died at 2:05 pm Tuesday afternoon after 30 minutes of coding. It was terrible. Théogène's brother works at the hospital as well and the rest of the family was present, but it was just awful that he wasn't there. We all felt terrible, but they had done everything that they could to save her. I went back to the cafeteria and bought everyone in the ICU a Fanta as a little pick me up. It helped a little. I didn't sleep well for the rest of the week. Nor was lecture very successful for the rest of the week. I had 11 of my 15 staff nurses come in the first week and 5 of the 15 the second.
     Friday was the funeral. Not sure if I could really handle the depression I was happy to walk up to the post office in the morning and pick up a care package. The box was almost falling apart, but it arrived, in one piece from good old Monkton, Maryland and my friend Dan and in it was a wonderful surprise... CHEERIOS! I LOVE CHEERIOS. I'm just sad that the milk here isn't fabulous, but I'll eat the entire bag dry. I don't mind. I also received more Berger cookies that at this point my housemates have fallen in love with as well and we enjoyed them very much. This prompted a super excited Facebook post, which resulted in a very funny status from my friend Kara, who is one of the sisters I met two years ago in Croatia. Unfortunately, my enjoyment of my care package was quickly brought to an end as I attended the funeral.

 

     I wasn't sure if it was appropriate for me to go initially, but everyone said that I should so I went. Out came my black dress (though I spiced it up with my red heels, color does not matter here for funerals) and I walked up to one of the churches in my neighborhood for the service with Melody. There we met Jessie and Beth (an ICU physician from Kigali) who had driven down in the morning for the service. It almost started on time and was a very nice service. The music was very beautiful. One of the things I've always appreciated about the Catholic mass is your ability to follow it no matter what language it is said in. Well... Kinyarwanda might be that exception. It was very difficult to follow, but I think I said the proper English responses where appropriate. Actually probably not. I probably said the old English responses that are reflexive and not right anymore. There were about five words of Latin that I understood for the 2.5 hour mass. When Théogène's aunt stood up to speak I got this feeling, a feeling I understood all too well. Ever since my brother died when I was 13 I get these feelings. It's of shear terror and panic revolving around death, which is an odd thing for an ICU nurse to experience I suppose. I hadn't had that feeling for a very very long time and when it hit me, I felt as though there was nothing I could do to stop it. Here I was sitting in a church and I was about to have a full blown panic attack. Fortunately, it was afternoon at this point in Rwanda so I quickly pulled out my phone and text Meredith and one of my best friends who has always known about this visceral gut aching, take your breath away feeling Luke. Dith responded as she fell asleep. Luke was able to distract me enough that I didn't end up completely freaking out. Disaster averted. But I hate that feeling.
     After the service we went to the burial. That was a very new and interesting experience. First off, the grave yard was on a beautiful hillside that overlooked rice paddies and appropriately in my opinion, the hospital is across the little valley on the opposite hillside. It was quite picturesque. However, the experience was very different than the US. First, there were prayers and singing and then they lowered the casket into the ground. That's not typically done in the US, but it didn't stop there. While we were praying and singing they started to build the gravesite. There was no dirt thrown on top of the casket, just Holy Water, but they then took boards and covered the site. Then laid down paper, and then a grid, and then concrete, and then made a headstone from brick, and then placed a cross with her name and dates on it. They entombed her. I'd never seen that done and it took me by surprise. But it certainly solidifies that she is gone. It was beautiful that her family was there until it was all said and done, but it was also immensely depressing.

Beth overlooking the valley

ICU nurses laying flowers at the gravesite

    Afterwards I went home extremely exhausted about six hours of funeral. I was home alone and just wanted to curl up and watch a movie. But of course, there was work to be done. Emmanuel and I needed to finish our goals for the year. So he came over and he wrote his goals out with my help and I cooked dinner. I made him stir fry. He'd never had it before and he claims he liked it. I hope so. It was a good bonding evening for us, even if I gave him too much wine to drink. I finally crawled in bed, couldn't sleep of course, and got a couple of hours of sleep before I was up and ready for a better day because I was off to Nyungwe Forest again!
     One of our pediatricians, Emily had a birthday and we decided to go hiking and then to the Forest Lodge for an evening of relaxation and fun. The hike was amazing! We climbed the highest peak in Nyungwe where at the top you can see Burundi to the south and Lake Kivu and the Congo to the west. Pretty amazing views... Ours looked more like this...

View from the top.

Yep... it was a little cloudy and mysterious so it didn't result in the best views. It did result in the spotting of some monkeys and interesting birds and some white wine with our picnic lunch and a lot of laughs as we played a game called Contact, which became infinitely more fun and difficult as we consumed wine. On the way down it started to rain. And then POUR for about 2 hours. By the time we got back to the car we were soaked, freezing, and the wine buzz had worn off.

Jared carried the white wine to the top

Mountain monkeys just hanging out

Hiking through the jungle/rainforest

By the time we got to the Lodge I also felt as though I was going to vomit. The last 30 minutes winding through the forest is gorgeous. It's also the worse part if you tend to get car sick, which I do. It was bad. I was so excited to get to my lovely room and take a very long hot bath and/or shower. You can imagine how I felt when I discovered that I had somewhat lukewarm water and that almost all of my clothes for the weekend were not only wet, but stained from my no longer waterproof day pack. So to recap, I'm soaked to the bone, freezing, feel like I might vomit, exhausted from lack of sleep for about 10 days at this point, have almost no dry clothes, and basically no hot water...

     Yep, you guessed it, cue the completely ridiculous breakdown. I could not stop crying for about an hour and a half. I FaceTimed my mom and when she asked me what had happened I even admitted that nothing had happened. I'd just had a fabulous day with my friends. And yet there was I bawling my eyes out and saying I wasn't going to go to dinner. I was being completely ridiculous. Julie and Vanessa finally were able to coax me out of my room and put me in a hot bath in Julie's room and scrounged up some dry jeans and a shirt. Fortunately, the dress I had packed for dinner was remarkably dry and unstained and I put it on and rallied for drinks and dinner and we all ended up having a really great time celebrating Emily's birthday.

The Butare Gang (L to R): Jared, Tiffany, Veronica, Emily, Julie, Jim, Vanessa, Steph

The birthday girl and her homemade cake with sparkler!

     Things have gotten a little better. The initial excitement of moving here has officially worn off though so last week was still a little rough with a lot of "I wish I'd never come here" and "Why did I leave San Francisco?" going on in my head. I was still having trouble sleeping despite Benadryl and Dramamine supplements so I worked from home on Tuesday because I just couldn't for the life of me wake up and I ended up sleeping in until 10 am. It was much needed. The end of last week I went to Kigali with Emmanuel and Cécile the In Charge of the unit and visited the three hospitals there and the ICUs to get some ideas on what we can do to improve with accreditation. I think it was very successful.

     Friday night Vanessa and Julie decided that I still needed some cheering and so I hadn't been home for five minutes before a tasty adult beverage was in my hand. We went to Chinese dinner with a group and Emmanuel joined us, which was very nice. I like treating him to dinner and such when I can. And oddly enough, Chinese has become quite the comfort food. Who would have thought. Especially since I haven't regularly ordered Chinese since I was 20. Of course it started to torrentially downpour during dinner and geniuses that we are decided to walk home... we were slightly damp by the time we reached the main drag and hopped a taxi so that we wouldn't have to slosh through the mud.

Emmanuel and I at Chinese dinner.

Vanessa, Me & Catherine in the pouring rain post dinner.

     The weekend was quiet as Julie has officially gotten me addicted to Downton Abbey and I couldn't resist watching several episodes... ok, I will admit that I managed to get through both Season 2 and 3, but it was a quiet rejuvenating weekend that I needed. We did purchase some awesome whicker furniture for our back veranda that we are all really enjoying, particularly in the morning. It's in the perfect spot to enjoy the sunrise.

The newest addition to the household

It's good to be back at work and busy. The busier I am the easier it is to keep my mind off things. Today is my 70th day in country according to the IRS. Which really means I only have 56 days to go until my Christmas vacation in Ireland with my former patient and his family. Sorry that this post is so long, but I wanted to catch everyone up. Thank you to my good friends Em & Emily who have respectively sent me a funny postcard and care package. I really appreciate how much support I am getting from back home. Keep the emails, notes, packages, texts, Facetime, and any other form of communication you can think of coming. It really really helps. Love to all!

Lessons Learned:

1) Everyone needs a cathartic breakdown session every now and then.

2) I must be one of the most truly blessed people on this planet.

Class is in Session!

     Well, last week I started lectures in the ICU for the course I'm teaching (that I'm making up as I go along) aptly named the ICU Accreditation Course. So far so good! 11 of my 15 nurses currently working (I have one out on maternity leave and another in school) came to class last week. They are very interested in learning. Sometimes it is a bit of a negotiation to get them to come to lecture, but once they're there, they are very engaged.
     Last week I taught two lectures. One on accreditation and the other clinical audit results for August and September that I had done. If I haven't mentioned it, CHUB (we do not say chub instead we pronounce each letter in French, so it sounds like Say-Ach-OO-Bay) is working towards accreditation by the South African group called COHSASA (Council for Health Service Accreditation of Southern Africa). It is quite the process, for instance, just a few weeks ago the first hospital wide policies were rolled out... there isn't a single policy written for ICU care... yet. Next week I am going to start working with my In-Charge (manager) for ICU on writing simple policies. We'll see how that goes! The clinical audit that I did was compliance of charting. Jessie (predecessor) worked hours upon hours on end last year in developing an ICU flowsheet for the nurses to chart. They rolled it out in July and I wanted to see how well the nurses were doing with the new material. Turns out, they aren't doing so bad! They document everything about 50% of the time, which I realize isn't perfect or anywhere near perfect, but considering that prior to this flow sheet they didn't chart an assessment ever... I think we're doing pretty well. Lots of "areas of improvement/opportunities" as I keep positively referring to them, but that's ok. Baby steps it is.

Make-shift classroom in the corner of ICU.

     This weeks lecture is on our October Focus Points, specifically Intake and Outputs/Calculating a patient's Fluid Balance. Each month, based on the audit results I am picking goal(s) to strive for and essentially bribing my nurses with a surprise if the goals are met. I am then doing follow up lectures to clarify and educate on weaker areas that we are focusing on. Already I've witnessed improvement, but I've also witnessed some set backs that I didn't see coming. The ethic of teamwork here is incredible and it puts US nursing to shame. Never does someone complain when another asks for help, nor do they ever complain about listen for all the patients for each others 2 hour lunch breaks (the majority of my nurses go home, eat, and return and they live a distance). However, I've discovered that while fabulous, it hinders a few aspects of nursing. Mainly, they don't like to see each other fail so they cover for each other. The idea of individual accountability is non-existent. So when I mentioned that one area of improvement for the future would be to update our nursing assessments on night shift (or indicate clearly that nothing has changed overnight) I never expected to catch a dayshift nurse putting lines through the night shift assessment, thus indicating that there had been no changes overnight. I have no idea how I'm going to approach this topic. May need to consult some higher ups in the hospital organization to figure it all out and to have a better understanding of the practice. Always hiccups when you're teaching. I never expected this one and it will be hard to develop a solution without damaging the fledgling relationships I am building here.
     Anyway, last week was successful and the weekend fun. Our newest roommate Joe who is living in the guest house had a grill made and we had a little BBQ Sunday evening. It was very nice to have other faculty over to hang out for beers and brats!

Facetimed my dad to check in while mom was away.

Sunset from our yard.

Moonlit clouds

A fly really liked my Coke one day at lunch.

Sunrise from my bedroom window.

Afternoon rain at the hospital.

This is short rainy season (hospital)

Storm clouds clearing as I head home from work.

Joe BBQing

I'll write another post about this week later today if I can. Love to all at home!

Lessons Learned:
1) It's best to give the same lecture multiple times... you learn quickly what needs to be edited as I was informed that my phrasing of "print and sign names" is incorrect. To print is to print something from a computer :)

2) Again, hiccups will occur that you never expected. It's good to always look for solutions!

It is Every Girls Dream to have a Waterfall in Their House

     Friday night Julie and I were hanging in our living room enjoying each others company as Vanessa had callously ditched us for Kigali for the night (ok not really, she had a meeting and did some shopping for us). We had both just commented on how hard it was raining, that we were impressed we still had electricity, and how slow the evening was dragging. We had already watched the second episode of The Good Wife (I've discovered I can use the hospital Wifi to download from iTunes) and were reading our latest novels.
     I was about to say just how loud the rain was pouring off the roof when it dawned on both of us that that wasn't what we were hearing... earlier in the week as invalid Julie was home we had some crazy rain and a leak appeared in our guest room, which happens to be on my side of the house. Julie had told us that it was pretty crazy and we sent an email to the Colonel letting him know. By the time Julie and I got to the guest room it was way too late. Water was POURING in from two corners of the room and from all the walls. The water had spread across the room, down the hallway, and half way into my bedroom. Thankfully, my shag carpet proves to be very good at soaking up dirty roof water. We grabbed our laundry tubs and started to squeegee the water into my bathroom which has a drain in the middle of the floor. Good design. At one point the water was coming in so quickly I couldn't dump the tubs fast enough into my shower. Our guard Charles didn't know what to do. Then the light fell and water started to come from the fixture. We turned off the electric to that room. Then the waterfall came. A legit waterfall from a new place all down onto the bed.
     Thankfully, the rain finally stopped. We shut all the electric off to be safe and opened a bottle of wine. It was quite the experience. I slept in Vanessa's bed just to be safe that night too. Hopefully the Colonel's maintenance man, Robert will be able to get here today and see what he can do. I think this was to make up for missing out on the waterfall hike last weekend. Every girls dream is to have a waterfall in their house.

Waterfall entry point

The aftermath of night one

That is indeed a water spout coming into the room.

A second (or third or fourth at this point) water spout.

     Well, I didn't get around to posting this before the weekend was over due to African internet, however we had a second waterfall in the guest room yesterday. Seriously, who knew I'd be living the life of someone rich enough to have an established waterfall to decorate their house? Thankfully, Robert was present during the second waterfall and agreed that we were not making it up or exaggerating in the least when we stated we had a waterfall in our house. He climbed up onto the roof in the middle of the torrential downpour/thunderstorm and discovered that indeed we had a plastic container blocking the drainage pipe of that section of roof. So far, we have had no more leaking or waterfalls, but I'm keeping my yoga mat at the base of my door just in case.

Lessons Learned:

1) Every bathroom should have a drain in the floor... it was a godsend this weekend.

2) Always be prepared... you never know when you're going to need an extra laundry tub to catch a waterfall.

Nyungwe Weekend

     Well, when you last left me, I was having a pretty terrible week. I am glad to report that the weekend was much nicer, though didn't exactly go as planned. First thing Friday morning I received a text from my dear friend back home, Marcus, asking me if I had really not received my care package from him yet. Well this got me excited because I hadn't checked out post box yet but now I had reason too! I told him I would check before I left town for the weekend but I was very doubtful it would be here after only two weeks. We were headed to Nyungwe National Forest and we were seriously excited.
     Anyway, off to work we went where Julie and the other nurses and I had a meeting with our Director of Nursing, Naasson. Naasson is a very sweet, educated man. He was finally able to sit with us and discuss the hospital goals for this year. It was very helpful and I was so glad to see that many of the ICU specific goals I had already figured out from my nurses and head of department matched his. After our meeting, Julie and I walked home to pack. Vanessa was able to wrap up her duties earlier than she originally planned and by 1 pm we were on the road!

Roomate selfie to start the trip!

First stop, the post office, where indeed I had a package slip awaiting me in the box! And what a package it was... Marcus, knowing me so well, sent a request for me to send him a gazelle in exchange for my English Breakfast tea, Walkers shortbread cookies, Swedish Fish, and Ghiradelli's dark chocolate with salted caramel centers. I'm not sure if I can live up to the request for a gazelle, but Vanessa, Julie, and I certainly made short work of the candy (this may have contributed to a little car sickness later) and I have enjoyed my tea every morning thus far this week. It was a heavenly surprise for all of us and a fabulous way to start our weekend getaway.

 

Terraced hillsides

     Nyungwe is a 2-3 hour drive from Butare depending on the road work within the park. Our final destination was the Nyungwe Forest Lodge on the far western side of the park, which is a five star lodge with a spa. We were dying for comfortable mattresses (not sure if I've mentioned that the mattresses are rather hard here), a variety of food, a little spa treatment, and some good hikes. The forest itself is absolutely gorgeous. It's a jungle, not a forest and it was pretty odd to see so many trees. As previously noted Rwanda is so fertile that the majority of land is farmland. They have terraced all the hillsides to enable for more cultivation, so to see the jungle spring up before us was surprising and lovely.

Country hillsides

     When we arrived at the lodge, we had just missed the afternoon rains. They greeted us at the car, offered us hot towels and a fresh passion fruit juice spritzer and offered us all a seat in the plush lobby area. They then brought us our registration and our keys and showed us our little "pod" of rooms where we were going to stay. See below for details... it was LOVELY and I confirmed that I really will have no problem sleeping on a soft mattress after adjusting to my hard one.

Our pod of rooms

Private forest facing deck where I observed multiple monkeys

We settled and met back at the lodge for a real drink and sat next to the heated infinity edge pool. Life was looking much better and relaxing after the week at the hospital. The hotel staff seemed well versed in the wazunga staff of CHUB and were more than happy to comply with anything we needed. It was fabulous.

However, our exciting weekend took a turn Saturday morning just after breakfast. We were advised to do the waterfall hike that other staff members have done. We were very excited because we assumed with the pouring rain we had gotten the night before, the waterfall would be spectacular... unfortunately, we never saw the waterfall because Julie decided to meet the deck up close and personal. The deck in our pod of rooms was slick from a morning dew/night rains and she slipped dashing back to her room for her glasses and went down hard. She has broken a rib and has been on home rest this week the pain has been so bad. we offered to come home, but she made a valid point that her bed was much more comfortable and she could curl up and watch a movie or too. It ended up been a rather rainy weekend anyway, so Vanessa and I enjoyed some tea in the main lodge by the fires and did some work.

     While it wasn't planned, the weekend was still relaxing and beautiful and we will certainly be back for a little pampering when our stress level reaches the maximum. We can always hike next time and do the canopy walk that everyone talks about. It is getting late here and honestly there isn't much else to say other than we enjoyed our quiet time, great food, and a soothing massage. Look forward to going back when our patient is healed!

Lesson Learn: Don't get hung up on what you have planned... it's bound to change without warning.

P.S.- Thank you to all the emails, text messages, FaceTime, calls, and Facebook love I received after my rough week. It was very much appreciated. I am so grateful to have such an incredible support system. Thank you.