I teamed up with two other nurses this week, "K" and "M" to hold a 3 day seminar to teach nursing instructors what they need for their nursing students in their clinicals. It was quite the eye opener! "K" started by giving an introduction to the expectations. They have to show up for their clinicals, or they will be out of a job. Period. Sounds silly to have to say? Well, several of the instructors never show up, so the students drink a bit of tea, then leave. They then graduate and start working in the hospital with no clue of what to do. We would like to stop this practice, so she also gave some expectations for the students. If they don't meet those expectations, they don't graduate!
I then gave a lesson on "Comfort measures". These range from fluffing pillows (yes, some nurses still do that) to getting the patient to do deep breathing , coughing, and leg exercises to prevent pneumonia and blood clots. They had no idea that patients on bedrest were at risk for these things. I also said that a patient should get up and walk ASAP after surgery, and they thought I was crazy (they still think you need to wait 24 hours...a practice that is not long ago in our past). So they couldn't believe that I had surgery this summer, and walked out of the hospital less than two hours later!
The next day, I gave a lesson on assessment (many new things there!), and "M" gave a lesson on medication math. The assessment went well, and I had found this great program on "lung sounds" on the internet, and because I am an aid worker, they gave me a 30% discount! So we got to hear a lot of crazy sounds. They were upset that I didn't have any heart sounds to listen to. I told them, that they had enough new and important stuff to learn, and that if they heard anything different than lub-dub, they should tell the doctor.
Here is where it went crazy. "M" introduced them to medication math. What the doctor orders is not necessarily how the drug is supplied, so you have to do some calculations to figure out the correct dose. For example, the doctor may order 15 mg of something, but it comes in a bottle labeled 30mg/ml. So, you have to give 1/2 ml. That is an easy one. They aren't always that easy. These nursing instructors are the creme of the crop, some with 20 years experience, and they had never calculated a dose! They draw medicine up into a syringe and just give it without knowing how much of the drug is actually in it! Oh dear.
Then, we went on to drip rates for IVs. That was even worse. They just eyeball it and give a little or a lot (no kidding). That is dangerous for an adult, it is lethal for children. In the States, though we learn how to do a drip rate, we have machines now that do it for you. here they have nothing mechanical at all, so it is up to the nurse. When a patient gets up to go to the bathroom, they shut their own IV, then open it back up when they get back to bed, and usually, they open it all the way up and get flooded with fluid! So crazy.
So, we have decided to have another "mini" seminar just for medication math for these poor instructors.
The instructors were eager to learn though, and that was very heartening. The students come back to school jsut after New Year (which is March 21 here!) So, we will have our work cut out for us!
Showing posts with label Nursing. Show all posts
Showing posts with label Nursing. Show all posts
Saturday, March 1, 2008
Tuesday, February 19, 2008
a light at the end of the tunnel
Well, I can still see my breath in my house, but it is no longer painful! Spring looks like it may come early this year, but you never know what is around the corner. The BBC is still calling for snow. We shall see. In the meantime, over 1000 people have died as a result of the coldest winter on record in Afghanistan, and over 300,000 livestock have died, with as of yet unknown repercussions. Here are a couple of links to download video of this Afghan winter.
Last week, a friend, "F", who runs a kindergarten here called and asked me to see a couple of siblings of one of her students (ages 3 and 1.5). She said that their hands and feet were black and swollen from frostbite and one had a blister that was open. My heart froze, and the chill ran through my entire body as I thought of having to take small children to the hospital to have their fingers and toes cut off. I gathered all I thought I would need to try to thaw them out, along with some ibuprofen and codeine for the pain. As soon as I walked into the room, I could tell it was an extremely poor family. They had next to nothing. And there is a certain smell that a room picks up with the family is poor. I can't describe it. I call it the smell of poverty. It is the same smell that was in the orphanage I worked in in China. It is a smell that I am becoming more and more familiar with.
F brought them some cushions to sleep on and a blanket and some coal for heat. I brought a thermos of warm water to thaw out the children (it takes fuel to heat water and I was afraid that they wouldn't even have that.)
I looked at their little hands and feet. They were black, and they were icy, but they didn't seem as bad as they had been described. F said that they weren't as bad as when she had seen them earlier. So, I gave them both some medicine, and placed their hands and feet int he warm water. I also took out a bar of soap to wash them (some of the black was simply dirt). As we waited for them to thaw, I passed out gummy bears to all of the children (lost count when the whole family was in the room), and we sang children's songs to them in both English and Dari, and told stories. When the two that I was treating started to cry, I went to plan B and brought out the beanie babies I had brought them. They really enjoyed that too.
It takes a long time to thaw frozen body parts, so as we continued to wait, I went around the room to feel everyone else's toes and fingers...There were at least 6 children and 4 adults in the room (the size of an American bathroom!), and not a single one of them had a pair of socks...need i remind you that the average temperature during the day in the month of January did not get above the teens? It was too late to address that issue, but the next day, we sent them all socks and gloves. We also reinforced that once the children's fingers and toes were thawed, they had to keep them warm, or it would be even worse, and they would lose them.
In the Afghan culture you are not supposed to say anything bad may or will happen. They think it will cause it to happen, and if they do say it, they preface it with KhudA nakuna (God forbid!) But I have found that they simply will not follow my instructions unless I scare them into it. So, I told them that if their hands froze again, they could get infected and would lose them and if they weren't cut off in time, they could die. Harsh, but true. I can only hope they listened. When we left, the little fingers and toes were warm and pink. God was smiling on those children that night. I have no other explanation.
Today, as I was walking to the office, I GOT HOT! I couldn't believe it! The sun was shining and I got hot! There is hope.
Last week, a friend, "F", who runs a kindergarten here called and asked me to see a couple of siblings of one of her students (ages 3 and 1.5). She said that their hands and feet were black and swollen from frostbite and one had a blister that was open. My heart froze, and the chill ran through my entire body as I thought of having to take small children to the hospital to have their fingers and toes cut off. I gathered all I thought I would need to try to thaw them out, along with some ibuprofen and codeine for the pain. As soon as I walked into the room, I could tell it was an extremely poor family. They had next to nothing. And there is a certain smell that a room picks up with the family is poor. I can't describe it. I call it the smell of poverty. It is the same smell that was in the orphanage I worked in in China. It is a smell that I am becoming more and more familiar with.
F brought them some cushions to sleep on and a blanket and some coal for heat. I brought a thermos of warm water to thaw out the children (it takes fuel to heat water and I was afraid that they wouldn't even have that.)
I looked at their little hands and feet. They were black, and they were icy, but they didn't seem as bad as they had been described. F said that they weren't as bad as when she had seen them earlier. So, I gave them both some medicine, and placed their hands and feet int he warm water. I also took out a bar of soap to wash them (some of the black was simply dirt). As we waited for them to thaw, I passed out gummy bears to all of the children (lost count when the whole family was in the room), and we sang children's songs to them in both English and Dari, and told stories. When the two that I was treating started to cry, I went to plan B and brought out the beanie babies I had brought them. They really enjoyed that too.
It takes a long time to thaw frozen body parts, so as we continued to wait, I went around the room to feel everyone else's toes and fingers...There were at least 6 children and 4 adults in the room (the size of an American bathroom!), and not a single one of them had a pair of socks...need i remind you that the average temperature during the day in the month of January did not get above the teens? It was too late to address that issue, but the next day, we sent them all socks and gloves. We also reinforced that once the children's fingers and toes were thawed, they had to keep them warm, or it would be even worse, and they would lose them.
In the Afghan culture you are not supposed to say anything bad may or will happen. They think it will cause it to happen, and if they do say it, they preface it with KhudA nakuna (God forbid!) But I have found that they simply will not follow my instructions unless I scare them into it. So, I told them that if their hands froze again, they could get infected and would lose them and if they weren't cut off in time, they could die. Harsh, but true. I can only hope they listened. When we left, the little fingers and toes were warm and pink. God was smiling on those children that night. I have no other explanation.
Today, as I was walking to the office, I GOT HOT! I couldn't believe it! The sun was shining and I got hot! There is hope.
Saturday, January 26, 2008
Winter part three-the never ending story
Yesterday, I was sitting on cushions, with two heaters on, and I could still see my breath. There was no electricity, and our water had finally frozen. I hit rock bottom. I can't imagine how it must be for the Afghans who can never get warm. Our guard came in with a blow torch and heated our pipes for about 30 minutes, seemingly to no avail, but a couple of hours later, we suddenly had water again! Today we had running water and electricity the whole day! A blessing without precedent!
How do you walk with the poor when you are not one of them? This is the question I have been asking myself the past week, as things have gone from bad to worse. The Afghan people have made great strides in trying to move forward after generations of wars and tribal conflict. But, they hang by a precarious thread. They have a little now for basic survival, but there is still nothing in reserve. Any disaster can take them down, and that is what we are seeing now.
What does poor mean in this society? My friend and I went looking for the poor the other day. We have a fund set up in America to use to buy food, medical care, blankets and heating fuel for the poorest of the poor. There are many poor here, but there are some who are simply desperate. We asked local Afghans to introduce us to the people that they think are poor.
My friend's house helper picked out two families. We went to the first and saw a weird scene. It was almost like it had been set up. (Yes, there are people here who would scam a foreigner to get whatever they can). It was a concrete house (you really want to live in a mud house here, warmer in the winter and cooler in the summer). There was no heat what-so-ever. It was absolutely frigid! It was a widow, with nine other people in her house, including two healthy working age sons. Now, at the moment, it is difficult to get a job, but if you are desperate to eat, there are some things you can do. We asked what they needed, and they said everything, and the quantities that they asked for were huge. We looked around though, and there were two chickens in the yard, two bicycles, and a small generator. That doesn't sound like much from a western standpoint, but there are people now who are tearing up every scrap of wood they can find to heat their house, and their children are starving. This family was not that desperate. If they were, they could sell the generator, the bicycles, and they could eat the chickens.
We went to the next house. This family was different. There were two families living in two rooms of a house. In one room, there was a woman, her husband, who was disabled from kidney problems, and two children. The other room housed a widow, her daughter and several children. This is the room in which we sat. Two of the children sat in the coldest corner. One slept while the other looked at us with big haunted eyes. As we spoke with the woman, she said that she peels chickpeas for 20 afghanis a bag (40 cents). This will buy bread for her family, but not much else. Suddenly, a metallic cough rang out from the little girl, which went right through my bones, then the tell tale whoop during the intake of air, which indicates whooping cough. Yes, this family was hard up. We made a list of things to bring them, including antibiotics for the children.
The third family we visited was recommended to us by my house helper. There was an older woman, her son, his wife and their 1 1/2 year old daughter. The man was out, presumably looking for work. They lived in the basement of their landlord. It was about 14 feet by 7 feet. They owned nothing but a teapot and the clothes on their back. Their neighbors had loaned them a little gas bottle to cook on, and a carpet to keep the cold from seeping in through the dirt floor. They had just moved here from Bamian (the city with the ancient Buddha statues that the Taliban destroyed in 2001). We asked why they moved away from their qaom (relatives...all Afghans live in a neighborhood surrounded by family). They said they heard that it would be better in the city. I don't know what drove them to think this, but it was so strong, that they hitched a ride on a potato truck and sat on bags of frozen potatoes for probably two days of driving. They were desperately poor. We also made a list of things to bring them, including cushions for the floor, so they are not sleeping on the bare cold floor, one more blanket (two had already been donated), and some basic food necessities to get them through a few weeks. (Usually this includes flour, rice, kidney beans, and oil). We also ask neighbors to pitch in with what they can, a cooked meal, a bag of potatoes, an extra floor cushion... We cannot save Afghanistan, but if we work with the Afghans and show them that they can help their own country, it is a step forward. Hopefully in the process, we are alleviating some of the suffering.
How do you walk with the poor when you are not one of them? This is the question I have been asking myself the past week, as things have gone from bad to worse. The Afghan people have made great strides in trying to move forward after generations of wars and tribal conflict. But, they hang by a precarious thread. They have a little now for basic survival, but there is still nothing in reserve. Any disaster can take them down, and that is what we are seeing now.
What does poor mean in this society? My friend and I went looking for the poor the other day. We have a fund set up in America to use to buy food, medical care, blankets and heating fuel for the poorest of the poor. There are many poor here, but there are some who are simply desperate. We asked local Afghans to introduce us to the people that they think are poor.
My friend's house helper picked out two families. We went to the first and saw a weird scene. It was almost like it had been set up. (Yes, there are people here who would scam a foreigner to get whatever they can). It was a concrete house (you really want to live in a mud house here, warmer in the winter and cooler in the summer). There was no heat what-so-ever. It was absolutely frigid! It was a widow, with nine other people in her house, including two healthy working age sons. Now, at the moment, it is difficult to get a job, but if you are desperate to eat, there are some things you can do. We asked what they needed, and they said everything, and the quantities that they asked for were huge. We looked around though, and there were two chickens in the yard, two bicycles, and a small generator. That doesn't sound like much from a western standpoint, but there are people now who are tearing up every scrap of wood they can find to heat their house, and their children are starving. This family was not that desperate. If they were, they could sell the generator, the bicycles, and they could eat the chickens.
We went to the next house. This family was different. There were two families living in two rooms of a house. In one room, there was a woman, her husband, who was disabled from kidney problems, and two children. The other room housed a widow, her daughter and several children. This is the room in which we sat. Two of the children sat in the coldest corner. One slept while the other looked at us with big haunted eyes. As we spoke with the woman, she said that she peels chickpeas for 20 afghanis a bag (40 cents). This will buy bread for her family, but not much else. Suddenly, a metallic cough rang out from the little girl, which went right through my bones, then the tell tale whoop during the intake of air, which indicates whooping cough. Yes, this family was hard up. We made a list of things to bring them, including antibiotics for the children.
The third family we visited was recommended to us by my house helper. There was an older woman, her son, his wife and their 1 1/2 year old daughter. The man was out, presumably looking for work. They lived in the basement of their landlord. It was about 14 feet by 7 feet. They owned nothing but a teapot and the clothes on their back. Their neighbors had loaned them a little gas bottle to cook on, and a carpet to keep the cold from seeping in through the dirt floor. They had just moved here from Bamian (the city with the ancient Buddha statues that the Taliban destroyed in 2001). We asked why they moved away from their qaom (relatives...all Afghans live in a neighborhood surrounded by family). They said they heard that it would be better in the city. I don't know what drove them to think this, but it was so strong, that they hitched a ride on a potato truck and sat on bags of frozen potatoes for probably two days of driving. They were desperately poor. We also made a list of things to bring them, including cushions for the floor, so they are not sleeping on the bare cold floor, one more blanket (two had already been donated), and some basic food necessities to get them through a few weeks. (Usually this includes flour, rice, kidney beans, and oil). We also ask neighbors to pitch in with what they can, a cooked meal, a bag of potatoes, an extra floor cushion... We cannot save Afghanistan, but if we work with the Afghans and show them that they can help their own country, it is a step forward. Hopefully in the process, we are alleviating some of the suffering.
Monday, January 21, 2008
Nursing clinicals
When I took this new job helping the nursing students with their clinicals, I knew it would be a challenge...yesterday, I got a reality check.
Definition: clinicals are when a nursing student goes into the hospital and puts the theories they have learned in the classroom and the lab into practice. The instruction that the students receive here is pretty equivalent to what they receive in the states, and they have a good lab in which to practice...but clinicals. I hardly know where to begin.
First, we are supposed to be supervising the instructors who are teaching clinicals. This is difficult to do when the instructor never shows up. So the poor students are unleashed into the hospital setting with no goals, and no supervision. So, mostly they just stand around for a while, then drink a cup of tea and leave. These students are in their last year of school. In a few weeks they will graduate and get a job as a nurse, having never once even touched a patient!
So, we are teaching the clinicals. We arrived at 8 am and I got a tour of the hospital...please lay aside your expectations of what a hospital in the west looks like, and step back several hundred years. Now, the students who were meant to show up at 8:30 started trickling in about 9:15. Oh dear. I assigned one patient to every two nursing students, instructed them to go over their chart, examine the patient, and see what medications they were on, and I would come and see what they had done. (we were in the "ICU" where there were about 5 patients in the room). I stood back and watched for about 10 minutes as they looked at the charts, then they just stood there staring. So, I went to the first pair and asked what they had found out. They said that she was there for Nafas tangi. (literally tight breath). That is a generic diagnosis given to anyone having trouble breathing. Could be asthma, emphysema, bronchitis, anxiety, heart failure, etc... I looked at the chart though, and she was on all sorts of heart medications. The problem is, that the drug names are all written in English...the nursing students don't know English. Sigh...
So, I asked if they had done a physical assessment (examination). No. Ok, first take the vital signs. No blood pressure cuff or stethoscope to be found. Well, you can at least take pulse and respirations. Those are important if the patient is having trouble breathing and has heart problems and is on heart medications. So, one student put her hand on the patient's wrist to count the pulse. I asked her if she had a watch. Oh, no...well, how do you know how many beats per minute? Oh, I have a cell phone she said. Does it have seconds? no. Ok, here is my watch. So, she counted on one wrist, while I counted on the other. she got 60. I got 144. Granted it was an extraordinarily weak pulse that was very difficult to count but the extreme difference told me she had no idea what she was feeling for. So, we worked on that for a while. In the meantime, all 7 of the students had crowded around me and the patient and were leaning on me trying to see and here everything. I think they were nervous and just didn't know what else to do!
After we got the pulse down, I told them it was important to look at the whole body, especially the feet. The woman was 70, and had been in the hospital for 9 days. She was at an extreme risk for a blood clot. there are no PTs here to come and walk with the patient. So, we went to check her feet, and they had 2+ pitting edema (very swollen). Even so, her little legs were about the size of my wrist!
When we finally got through with that patient, I wanted to make sure that I set a good example, so we set out to wash our hands. We finally found THE ONE sink in the hospital...I though I might be sick in it. It was so gross, that I felt it may be better to not wash after all. Turns out that we couldn't anyway, because the pipes are all frozen, and there was no soap to be had. We finally found a pitcher with warm water and we poured it over our hands and rubbed hard. (hopefully the friction removed a few germs...sigh again).
We went on to the next patient, and it went much as before. The chart was nearly unreadable, it was half English and half Dari, and the students hadn't done any kind of exam.
At the end of the day, I had a post conference with them. You know, for what they had available to them, they had actually done ok. Here are the instructions that I gave them.
1. Your patient is a person, not a thing or a body part. When you go up to them, talk to them. They are sick and scared. They don't know who or what you are (doctor, nurse, student, weirdo off the street), and they don't know what you are doing to them. Tell them who you are and what you are going to do. Treat them like a person.
2. You must take vital signs. This is important. Who has a watch? All raised their hand. Bring it to the hospital every time you come! If you don't have a BP cuff, at least get the pulse and respirations, and we will come up with a stethoscope so that you can listen to lungs.
3. To examine a patient, you must touch them. You cannot do a physical exam without touching the patient. (this is a public hospital which means that the patients are very poor. Though you don't have to pay to go to nursing school, you do have to have some sort of money to pay for food and lodging while you go to school, so typically the students are of a higher class than the patients, so they disdain them, and don't want to touch them).
4. Wash your hands. I know that sometimes there simply is no way, as there is no soap or water, but try your best to find some and when you can, wash.
5. Many of these patients have been here for days/weeks. They are at high risk for pneumonia and blood clots, as they just sit and lay around all day. Go to them every hour and have them pedal their feet and take deep breaths and cough. Even that may save a life.
I came to a quick realization that this hospital will never be UAMS or Good Sam, and we will not be able to get the nursing students up to the level of a Western trained nurse. But if I can just get one to wash her hands, we will have saved a life. If I can get one to treat a patient like a human, we will have given someone dignity. If we can make one step forward, lives will be changed, and then we can prepare to take the next step.
A few more notes about the hospital. It is a big, cold concrete building with concrete floors that are caked with mud. When we arrived, someone was mopping, and it was so slick that I thought if I can just keep from falling down today, I will have accomplished something big. The wards are full of flat beds, and patients just sit in them all day. There are no food trays to be passed. Families must provide sustenance for the patients. The patients are dirty, with no place to wash. They must go to a bathroom down the hall, that I would go into kidney failure to avoid.
The doctors come in, treat the patient as an inconvenience, and never touch them (I say again, how can you examine a patient without touching them?) The charts are just a bunch of papers stapled together, with instructions written in English, and no orders are ever discontinued, so when it says Dopamine (an IV medication used to treat extremely low blood pressure), but your patient doesn't have an IV, you wonder what is going on. On the next line, you see Enalapril (used to treat high blood pressure), and you realized that someone lost their mind. But, everything is extreme here. Someone has low pressure, so they give dopamine is such a large quantity that the pressure spikes and they give a medication to bring it back down.
On several of the charts the blood pressures on admission were written as 65/0 or close to it. Then, though they were on dopamine their pressures were not monitored. Now, in the States, with that kind of blood pressure you probably won't survive, though you may. Here, there is no way... NO WAY! I think the pressures are made up by people who cannot here on the low grade stethoscopes they have here. Sigh...
One of our patients had been admitted because she had not urinated in several days. She had been in the hospital for a number of days, but there was no clear diagnoses to be found on her chart. As we started our exam, the doctor came in with her son (you must quickly get out of the way when a doc comes in, as they view themselves as gods, and nurses as roaches). The son had a handful of x-rays with him, showing that his mother had TB and had been treated for only one month, then quit treatment. Treatment for TB is 6-9 months, and antibiotic resistant TB is so rampant here, that if you miss one dose, there is nearly no hope. This woman had been laying in a crowded room for days coughing and exposing every other patient, doctor, nurse, student and visitor to resistant TB. Big Sigh... At least the students recognized that she needed to be wearing a mask.
While we were there, a lady was admitted and the women with her sat beside her and sobbed. I put my arm around her and said, Auntie (a proper form of address for an older woman whom you do not know), is this your mother? She said yes. I asked what was wrong. She said, her blood pressure is 0. I looked at the woman MOVING AROUND IN THE BED AND OBVIOUSLY BREATHING, and sighed yet again.
Definition: clinicals are when a nursing student goes into the hospital and puts the theories they have learned in the classroom and the lab into practice. The instruction that the students receive here is pretty equivalent to what they receive in the states, and they have a good lab in which to practice...but clinicals. I hardly know where to begin.
First, we are supposed to be supervising the instructors who are teaching clinicals. This is difficult to do when the instructor never shows up. So the poor students are unleashed into the hospital setting with no goals, and no supervision. So, mostly they just stand around for a while, then drink a cup of tea and leave. These students are in their last year of school. In a few weeks they will graduate and get a job as a nurse, having never once even touched a patient!
So, we are teaching the clinicals. We arrived at 8 am and I got a tour of the hospital...please lay aside your expectations of what a hospital in the west looks like, and step back several hundred years. Now, the students who were meant to show up at 8:30 started trickling in about 9:15. Oh dear. I assigned one patient to every two nursing students, instructed them to go over their chart, examine the patient, and see what medications they were on, and I would come and see what they had done. (we were in the "ICU" where there were about 5 patients in the room). I stood back and watched for about 10 minutes as they looked at the charts, then they just stood there staring. So, I went to the first pair and asked what they had found out. They said that she was there for Nafas tangi. (literally tight breath). That is a generic diagnosis given to anyone having trouble breathing. Could be asthma, emphysema, bronchitis, anxiety, heart failure, etc... I looked at the chart though, and she was on all sorts of heart medications. The problem is, that the drug names are all written in English...the nursing students don't know English. Sigh...
So, I asked if they had done a physical assessment (examination). No. Ok, first take the vital signs. No blood pressure cuff or stethoscope to be found. Well, you can at least take pulse and respirations. Those are important if the patient is having trouble breathing and has heart problems and is on heart medications. So, one student put her hand on the patient's wrist to count the pulse. I asked her if she had a watch. Oh, no...well, how do you know how many beats per minute? Oh, I have a cell phone she said. Does it have seconds? no. Ok, here is my watch. So, she counted on one wrist, while I counted on the other. she got 60. I got 144. Granted it was an extraordinarily weak pulse that was very difficult to count but the extreme difference told me she had no idea what she was feeling for. So, we worked on that for a while. In the meantime, all 7 of the students had crowded around me and the patient and were leaning on me trying to see and here everything. I think they were nervous and just didn't know what else to do!
After we got the pulse down, I told them it was important to look at the whole body, especially the feet. The woman was 70, and had been in the hospital for 9 days. She was at an extreme risk for a blood clot. there are no PTs here to come and walk with the patient. So, we went to check her feet, and they had 2+ pitting edema (very swollen). Even so, her little legs were about the size of my wrist!
When we finally got through with that patient, I wanted to make sure that I set a good example, so we set out to wash our hands. We finally found THE ONE sink in the hospital...I though I might be sick in it. It was so gross, that I felt it may be better to not wash after all. Turns out that we couldn't anyway, because the pipes are all frozen, and there was no soap to be had. We finally found a pitcher with warm water and we poured it over our hands and rubbed hard. (hopefully the friction removed a few germs...sigh again).
We went on to the next patient, and it went much as before. The chart was nearly unreadable, it was half English and half Dari, and the students hadn't done any kind of exam.
At the end of the day, I had a post conference with them. You know, for what they had available to them, they had actually done ok. Here are the instructions that I gave them.
1. Your patient is a person, not a thing or a body part. When you go up to them, talk to them. They are sick and scared. They don't know who or what you are (doctor, nurse, student, weirdo off the street), and they don't know what you are doing to them. Tell them who you are and what you are going to do. Treat them like a person.
2. You must take vital signs. This is important. Who has a watch? All raised their hand. Bring it to the hospital every time you come! If you don't have a BP cuff, at least get the pulse and respirations, and we will come up with a stethoscope so that you can listen to lungs.
3. To examine a patient, you must touch them. You cannot do a physical exam without touching the patient. (this is a public hospital which means that the patients are very poor. Though you don't have to pay to go to nursing school, you do have to have some sort of money to pay for food and lodging while you go to school, so typically the students are of a higher class than the patients, so they disdain them, and don't want to touch them).
4. Wash your hands. I know that sometimes there simply is no way, as there is no soap or water, but try your best to find some and when you can, wash.
5. Many of these patients have been here for days/weeks. They are at high risk for pneumonia and blood clots, as they just sit and lay around all day. Go to them every hour and have them pedal their feet and take deep breaths and cough. Even that may save a life.
I came to a quick realization that this hospital will never be UAMS or Good Sam, and we will not be able to get the nursing students up to the level of a Western trained nurse. But if I can just get one to wash her hands, we will have saved a life. If I can get one to treat a patient like a human, we will have given someone dignity. If we can make one step forward, lives will be changed, and then we can prepare to take the next step.
A few more notes about the hospital. It is a big, cold concrete building with concrete floors that are caked with mud. When we arrived, someone was mopping, and it was so slick that I thought if I can just keep from falling down today, I will have accomplished something big. The wards are full of flat beds, and patients just sit in them all day. There are no food trays to be passed. Families must provide sustenance for the patients. The patients are dirty, with no place to wash. They must go to a bathroom down the hall, that I would go into kidney failure to avoid.
The doctors come in, treat the patient as an inconvenience, and never touch them (I say again, how can you examine a patient without touching them?) The charts are just a bunch of papers stapled together, with instructions written in English, and no orders are ever discontinued, so when it says Dopamine (an IV medication used to treat extremely low blood pressure), but your patient doesn't have an IV, you wonder what is going on. On the next line, you see Enalapril (used to treat high blood pressure), and you realized that someone lost their mind. But, everything is extreme here. Someone has low pressure, so they give dopamine is such a large quantity that the pressure spikes and they give a medication to bring it back down.
On several of the charts the blood pressures on admission were written as 65/0 or close to it. Then, though they were on dopamine their pressures were not monitored. Now, in the States, with that kind of blood pressure you probably won't survive, though you may. Here, there is no way... NO WAY! I think the pressures are made up by people who cannot here on the low grade stethoscopes they have here. Sigh...
One of our patients had been admitted because she had not urinated in several days. She had been in the hospital for a number of days, but there was no clear diagnoses to be found on her chart. As we started our exam, the doctor came in with her son (you must quickly get out of the way when a doc comes in, as they view themselves as gods, and nurses as roaches). The son had a handful of x-rays with him, showing that his mother had TB and had been treated for only one month, then quit treatment. Treatment for TB is 6-9 months, and antibiotic resistant TB is so rampant here, that if you miss one dose, there is nearly no hope. This woman had been laying in a crowded room for days coughing and exposing every other patient, doctor, nurse, student and visitor to resistant TB. Big Sigh... At least the students recognized that she needed to be wearing a mask.
While we were there, a lady was admitted and the women with her sat beside her and sobbed. I put my arm around her and said, Auntie (a proper form of address for an older woman whom you do not know), is this your mother? She said yes. I asked what was wrong. She said, her blood pressure is 0. I looked at the woman MOVING AROUND IN THE BED AND OBVIOUSLY BREATHING, and sighed yet again.
Winter part two
I cannot describe the pain that winter has caused here. Last week, a building in our bazaar caught fire, it spread, consuming two of the biggest retail buildings in our city, and damaging 7 others. ISAF (the international security assistance force) came to help put out the blaze, but it was too far gone to save the two buildings. As a result, 500 people were directly put out of business, and tons of others were affected (for example the people who make the clothing that is sold in those stores, and the people who sell the fabric to make the clothing, etc...on down the line). If you would like to see pictures and hear news of this fire, paste this link into your browser: http://the-rumi.blogspot.com/2008/01/balkh-city-on-fire.html It has really devastated the city. When you drive or walk past, it looks like two burned skeletons and the shattered dreams of people who are just trying to make life better here.
There are all sorts of rumors that go around here when something like this happens. Some say it is the wrath and judgment of God against materialism. Others say it is certainly Al Qaeda or the Taliban. I think someone just got careless with their open flame gas heaters and poof the building went up in flames. There are no building or fire codes here, so of course there were no sprinklers or fire hydrants.
It sounds terrible that the laws haven't caught up here yet, but less than 100 years ago, The US was in the same boat. It took tragedies of children dying in factories to get child labor laws passed. Many people died in clothing factories and tenement fires before building and fire codes were passed into laws. These are Afghanistan's growing pains. Hopefully this suffering will not be in vain.
In the meantime, the cold seems to be unrelenting. We have managed to get a bit of a handle on it. Last night we hung parachute fabric on the inside of our door. You can still see your breath in our hall, but now, there isn't such and arctic blast coming in.
The cold managed to get me first though, and I am down with bronchitis and a sinus infection. So, since I can't smell, I didn't notice the gas leak in my room until my guard came in to change the gas bottle. He said, dear, I am very worried about you. The smell is bad. So, I called my two friends in and sure enough, it was bad. So I had to open up my room to the arctic and air it out. We didn't have electricity, but a dear friend had given me a battery operated fan for the summer, and it happened to be charged up and working! So, my room is now filled with fresh air, albeit cold.
They say that 14,000 sheep have died in the mountains. Simply froze. Also 200 people have died. In the States the sheep wouldn't be that big of a problem, because the government would come in and subsidize. But here, that means the shepherds are out of business, and thousands of people will not have meat to eat in the spring.
As you go through your day, let me encourage you to count your blessings. Toilets that flush. Water that comes out of the faucet, furnaces that come on with the touch of a button, buildings with fire codes and sprinkler systems, and smoke detectors. Fire hydrants that actually have water and firemen who show up and sacrifice themselves to save others. Electricity that is powerful enough to run your refrigerator, hot water heater, electric blankets, computers, stoves, ovens and microwaves. Police who are upright and enforce the laws, instead of breaking them, the freedom of women to get into a car and drive anywhere at will. Grocery stores that are full of food, and jobs that provide enough to eat with. We truly are blessed.
There are all sorts of rumors that go around here when something like this happens. Some say it is the wrath and judgment of God against materialism. Others say it is certainly Al Qaeda or the Taliban. I think someone just got careless with their open flame gas heaters and poof the building went up in flames. There are no building or fire codes here, so of course there were no sprinklers or fire hydrants.
It sounds terrible that the laws haven't caught up here yet, but less than 100 years ago, The US was in the same boat. It took tragedies of children dying in factories to get child labor laws passed. Many people died in clothing factories and tenement fires before building and fire codes were passed into laws. These are Afghanistan's growing pains. Hopefully this suffering will not be in vain.
In the meantime, the cold seems to be unrelenting. We have managed to get a bit of a handle on it. Last night we hung parachute fabric on the inside of our door. You can still see your breath in our hall, but now, there isn't such and arctic blast coming in.
The cold managed to get me first though, and I am down with bronchitis and a sinus infection. So, since I can't smell, I didn't notice the gas leak in my room until my guard came in to change the gas bottle. He said, dear, I am very worried about you. The smell is bad. So, I called my two friends in and sure enough, it was bad. So I had to open up my room to the arctic and air it out. We didn't have electricity, but a dear friend had given me a battery operated fan for the summer, and it happened to be charged up and working! So, my room is now filled with fresh air, albeit cold.
They say that 14,000 sheep have died in the mountains. Simply froze. Also 200 people have died. In the States the sheep wouldn't be that big of a problem, because the government would come in and subsidize. But here, that means the shepherds are out of business, and thousands of people will not have meat to eat in the spring.
As you go through your day, let me encourage you to count your blessings. Toilets that flush. Water that comes out of the faucet, furnaces that come on with the touch of a button, buildings with fire codes and sprinkler systems, and smoke detectors. Fire hydrants that actually have water and firemen who show up and sacrifice themselves to save others. Electricity that is powerful enough to run your refrigerator, hot water heater, electric blankets, computers, stoves, ovens and microwaves. Police who are upright and enforce the laws, instead of breaking them, the freedom of women to get into a car and drive anywhere at will. Grocery stores that are full of food, and jobs that provide enough to eat with. We truly are blessed.
Saturday, January 19, 2008
Winter
This is the coldest winter in Afghanistan in at least 10 years. It has even snowed in Herat and Kandahar, where there is usually no snow at all int he winter. They say that 60 people have died in Herat due to their roofs falling in from the heavy snow.
There is no such thing as central heat in Afghanistan. Most Afghans use something called a 'sandalee" to keep warm.
There are various forms of the sandalee. Traditionally, there is a small hole dug into the middle of the floor (easy to do when your floor is dirt). Hot coals are placed into the hole, then a table is placed over the hole and thick heavy blankets are placed over the table and overlap the cushions the people sit on. You sit on the cushions and put your body under the heavy blankets. It is a very quick way to get warm, but you can imagine the dangers. Almost every family has a story of a child rolling down into the coals and burning to death. Other children have suffocated under the heavy blankets, others have been the victim of CO poisoning.
Nowadays in the city, there are more sophisticated forms of the sandalee. The heat source may be put into a big metal bowl, so that children don't roll into the hole. Others use electric heat sources (though electricity is often scarce here). The problem is, that you cook and clean in an unheated room. Imagine washing dishes in water that is straight snow runoff and the temperature in the room is 25 F.
There are other forms of heat. There are old-timey type wood burning stoves like your great grandmother used, but for the most part, there is no wood in Afghanistan. There are diesel drip heaters. Basically diesel is in a can on the side, with a spigot. You turn the spigot on, diesel drips down a tube into a small barrel type container and you drop a match into it, and it slowly burns. I know many people who have had fires in their houses due to this type of heater. And, diesel in expensive. In the two weeks since I arrived, my roommate and I have spent over $60 in diesel. I have a German made diesel heater. It is basically the same principle, but a bit safer and more controlled. I also have a gas heater in my room. I have had fun dancing with the two heaters trying to make my room bearable. I get it to where I can function as long as I am wearing a lot of layers.
A few people have sawdust heaters. They tend to keep the room comfortable as long as they are burning properly.
All this to say. Winter is hard on the Afghans. Their hands and feet are always bright red and swollen with the cold. They spend most of their time being cold and only get warm when they have time to get under the sandalee.
I wonder if there is ever a time when Afghans are not suffering...
There is no such thing as central heat in Afghanistan. Most Afghans use something called a 'sandalee" to keep warm.
There are various forms of the sandalee. Traditionally, there is a small hole dug into the middle of the floor (easy to do when your floor is dirt). Hot coals are placed into the hole, then a table is placed over the hole and thick heavy blankets are placed over the table and overlap the cushions the people sit on. You sit on the cushions and put your body under the heavy blankets. It is a very quick way to get warm, but you can imagine the dangers. Almost every family has a story of a child rolling down into the coals and burning to death. Other children have suffocated under the heavy blankets, others have been the victim of CO poisoning.
Nowadays in the city, there are more sophisticated forms of the sandalee. The heat source may be put into a big metal bowl, so that children don't roll into the hole. Others use electric heat sources (though electricity is often scarce here). The problem is, that you cook and clean in an unheated room. Imagine washing dishes in water that is straight snow runoff and the temperature in the room is 25 F.
There are other forms of heat. There are old-timey type wood burning stoves like your great grandmother used, but for the most part, there is no wood in Afghanistan. There are diesel drip heaters. Basically diesel is in a can on the side, with a spigot. You turn the spigot on, diesel drips down a tube into a small barrel type container and you drop a match into it, and it slowly burns. I know many people who have had fires in their houses due to this type of heater. And, diesel in expensive. In the two weeks since I arrived, my roommate and I have spent over $60 in diesel. I have a German made diesel heater. It is basically the same principle, but a bit safer and more controlled. I also have a gas heater in my room. I have had fun dancing with the two heaters trying to make my room bearable. I get it to where I can function as long as I am wearing a lot of layers.
A few people have sawdust heaters. They tend to keep the room comfortable as long as they are burning properly.
All this to say. Winter is hard on the Afghans. Their hands and feet are always bright red and swollen with the cold. They spend most of their time being cold and only get warm when they have time to get under the sandalee.
I wonder if there is ever a time when Afghans are not suffering...
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