8E shoutout

Hey ladies. Have, in the last few days, been "friended" by a few of you on facebook which gives me hope that you haven't disowned me for my lack of communication :P Lack of communication does NOT equal lack of thought! In fact early this week I thought about all of you a lot. Let me tell you a little story...

Biira was a 3 or 4 year old girl, a bit older than most of the kids we see with malnutrition...developmentally delayed, she says "mama" and that's about it, came in with LE swelling, skin peeling, mouth cracked in the corners, typical presentation of Kwashiorkor. She never smiled, always irritable. She was started on F75, the starter formula for severe acute malnutrition supplied to us by UNICEF, and she began to loose weight. We actually like for this to happen with Kwashiorkor kids because their weight should drop as they loose their edema and then they turn the corner after a week or two and begin to gain "good" weight (without edema). Anyways, for the first week she continued to loose weight, the second week we moved her up to the "maintenance" formula, F100 (higher caloric density) - she continued to loose weight. Knowing that it takes some kids more time to turn the corner than others, we continued to support her with various treatments for her diarrhea including vitamin enriched oral rehydration solution for severely malnourished kids. She kept taking the milk, and kept loosing weight. Into her 4th week she was beginning to waste away after making a brief improvement late in the 3rd week...Friday when I left she had IVF going through a scalp IV that the supervising nursing officer placed and I didn't think I was going to see her Monday morning when I came back.

Monday morning her mom had packed all of their things up, and Biira was lying on the bed wrapped in a kitenge unconscious and walking that precipice between life and death...Jennifer and I were alone on the ward without any Ugandan staff. We looked at each other, each took a deep breath, she put her pen to the page and I reached for another bottle of IVF. Now, none of my 8E coworkers will be shocked to learn that I was quite relieved to see that the scalp IV Mr. Mwonge had placed on Friday was still there. I strung the IVF and drew up some saline to flush the line before starting the fluids...*#$@! It was swelling when flushed - ie. the IV was no good; there but not really there. Remember how I said we were alone on the ward without any Ugandan staff? You know what that means..."Heidi, you're the one!" I thought to myself. I gathered all of my supplies, hoping that someone would miraculously appear by the time I got it all together...nope. Well, there clearly must be another solution...so I went searching for another nurse. I searched in vain. The only one around was Mr. Mwonge stumbling out of his house on his way to the cho...I clearly was not going to interrupt him. So back to the ward I went, steeling myself for facing the challenge awaiting me in the treatment room...a 4 year old very dark skinned little girl who has had diarrhea for weeks in need of an IV..."There are no IV teams, Heidi, no transport teams, no NICU nurses, no no one...you're it. She's going to die if you don't do anything (and still probably will die even if we do, but that doesn't stop us)" (all of this of course swirling around in my head in a matter of seconds...)

So, I rip off the curled hem of a glove before putting it on, tied this rubber band "tourniquet" around Biira's wrist...nothing...the other wrist...nothing...gently slapping her hands, trying to make a shadow of even the smallest vein pop up...nothing...trying to reposition her and myself around the bed so that I could get the best light from the open window...both feet...nothing...so I put it around her head and there was one...nope, look closely, it's pulsing...that's an artery...no go...I tried 3 times, trying to leave room lower for someone else to try when all I got was a quick flashback and then each would blow...I kept looking...from one side of her scalp to the other...and that's when I heard Asussi's voice...ah! another nurse...praise God! She tried a few times, and couldn't find anything either...Mr. Mwonge came eventually and tried without success...Even NGT placement was not successful, kept coiling inside her mouth...no ice to try to stiffen the tube with...what to do? How to hydrate this child?

Asussi recommended the mom heat some water and we would fill a few gloves with water and place them around Biira as she lay in bed, to try to create some vasodilation to ease IV placement...the family complied immediately. When I left for the day there were 3 experienced nurses around and Biira was warming up.

Tuesday morning the night report said she was finishing her IVF, and there was the bag hanging...Agnes had successfully placed an EJ...you gotta do what you gotta do...We were a half hour or so through rounds and I heard a mother begin to cry..."uh oh" I thought to myself...Jennifer looked up from the patient she was seeing and a crowd was begining to form around Biira's bed. We went over and found an aunt or grandmother closing Biira's eyelids, as Biira's mom cried with her hands over her face...Jennifer put her stethescope to Biira's chest...nothing...the crying grew louder...I handed Kasareka, who was already gloved, a stack of 4x4 gauze for tying her chin closed and wrists/ankles...the crowd grew around the bed....as they got things packed up, mom was helped out to the front porch of the ward. I glanced up from the patient we had returned to seeing and the mom's tears had grown to full blown wailing and she was writhing on the floor in mourning, with other women trying to help her up to no avail...I took several deep breaths, accompanied by heavy sighs.

So, even though we finally got a line, we could do nothing to stop this little one from drifting off...but just goes to show you that not much has changed...I'm still a wuss when it comes to putting IV's in...it's not for lack of knowledge, just lack of courage...poking children when there are people around who are better skilled seems cruel, but what has that led to? No skilled experience base when there is no else around...This place doesn't so much allow for lack of courage...I keep telling myself one of these days I just need to take a whole week and be the go-to for IV placement and blood draws...practice makes perfect (although I'm sure none of you non-nurses like to hear that - it's for sure the truth). So, thanks to all of you who saved my rear countless times on 8E with putting in lines/drawing blood, and thanks to all of you who made me do it myself (BW, BM, MK, MH, LH). I miss you guys so much!