Crash Course

I think I've got a handle on enough of the basics of the Malagasy language to share a little with you all. So here's a quick crash course in Malagasy. If you know a little French, and you know these words, you can get by just about anywhere.

It's a bit strange being in this international microcosm on the ship. While English is technically our official, operational language, if you're working with patients or day crew, their first language is Malagasy. As such, saying "excuse me" might be understood by most of the crew, but EVERYONE on the ship will understand this wonderful word:

AZAFADY!

Azafady is the most versatile, multipurpose word in Malagasy. As a Canadian, I say it a lot, because it equates to "sorry." Or, "excuse me," or, "beep beep! Comin' through!" or, "tough luck." Here are some examples of excellent opportunities to use this word:

You are trying to take medication to your patient, but there are 6 nurses and day crew in your way. 

"Azafady!"

You reach for a napkin and spill your pumpkin spice latte all over your friend. 

"Azafady!"

You have to wake up your patient at 2 in the morning to check their vital signs. 

"Azafady!"

You trip over your patient's caregiver whose legs are sticking out from under the bed (because they sleep on a mattress on the floor under the bed), while trying to check vital signs at 2 in the morning. 

"Azafady!"

You rolled a 7, move the robber, and now steal a card from the person who just picked up 4 wheat. You shrug your shoulders.

"Azafady!"

SALAMA!

Salama is also a fairly versatile word, meaning hi, hello, good morning, good evening, etc. You can also make it more respectful or formal by adding "tompoko" to the end. Or you can say "salamay." Or "salamo." Or just "salam." I still haven't which figured out the significance of these variations, but they all seem to be used interchangeably. 

TSARA BE!

Pronounced, "Chara-Bay." This word means grood. I mean great. And good. Great and good. Literally. Tsara = good and Be = great. It's generally usefull for encouragement and when you're so impressed with something that no english word quite does the trick.

Your 4 year old ortho patient with full-length casts on both legs is walking with their itty-bitty walker and not screaming their head off for the first time? 

TSARA BE!!!"

Your friend manages to carry a loaded plate, bowl of soup, mango, and nalgene bottle to the table without spilling a drop. 

"Wow. Tsara be."

Your colleague knits an entire headband during their shift. It's pretty cute.
"Tsara be!"

It can also be used ironically, like when you trip over the door for the hundredth time (did I mention all the doors have nice beams/lips to trip on? Some even right at the top of the stairs?), and you try to recover hoping no one saw you - but they totally did.
"Tsara be!"

INO VAOVAO

Pronounced, "In vovo?" This literally means "what news?" or, in other words, "what's up?" The appropriate response is usually "tsy vaovao," meaning "no news" or, "not much." At least, this is the appropriate response for me, as I don't know enough words to say anything more than "not much." 

This brings us to the wonderful:

TSY!

Pronounced "teese" (yes, I'm aware that seems backwards, but it's true, I promise). This means "no," and is yet another word that frequently pops up in our english conversations.

You're assessing if your patient is having pain. 

You: "Marary (pain)?"

Patient: "Tsy."

You: "Tsy marary?"

Patient: "Tsy."

You: "Tsara (good)."

Such in-depth conversations we have.

You're walking down the street towards the supermarket, which is a whole 10 minutes walk down the road. 14 tuk-tuk and pus-pus approach you offering a ride.
"Tsy masotra (no, thank you). Tsy masotra. Tsy masotra. Tsy. Tsy. Tsy. Tsy..........Tsy."

You're watching The Holiday and Kate Winslet is about to call the jerk who just got engaged to someone else even though Kate is still deeply in love with him.
"Tsy! Tsy you idiot!"

Your friend wants to try the various condiments and you notice she has a dangerously large amount of mystery green chili sauce on her fork and you yell (unfortunately too late):
"That's...uh, that's maybe a bit too mu-TEEEEESE!!"

True story.


Well, I hope you now feel somewhat aquainted to the language of this wonderful island.

Until next time,

VELOMA (goodbye)!

Here vs Home (An Addendum)

So, my brain stopped working halfway through that last post, and I must mention a couple of things I forgot.

Gravity Drips

In most hospitals in Canada, every intravenous fluid and medication is given through an automated IV pump. In extreme cases, if there aren't enough pumps for each patient, simple fluids can be run by gravity, but ANY medication must be run on a pump. This is A) super convenient/time saving and B) a strong safety mechanism. I shall explain, in case you aren't familiar.

When using an IV pump, one must simply prime your tubing (fill it with saline so there's no air bubbles), stick said tubing into the pump, punch in the rate you want your fluid or medication to run at, program in a volume limit, attach it to the patient, and press start. The pump now knows how fast to infuse the fluid, and when to stop before the fluid runs out. It can also do fancy things like have one medication run then switch back to the fluid line when the med is done, or run both lines concurrently. The pump will stop if it detects air in the line. The pump will not run if you try to run too much fluid too fast. And (if you use the fancy built-in drug library), it will even tell you if your infusion rate is faster than the recommended parameters.

The pump also gives off very unpleasant but helpful BEE-BEEP! BEE-BEEPS! When it requires attention due to any one of the above issues.

Here on the AFM, we have a grand total of...maybe 10 pumps (I might be being generous with that number too). So they are ONLY used for extremely high-risk medications which must be delivered at a precise rate. The rest of our IVs are run by gravity. Meaning, you hang the bag, prime the tubing, and plug it directly into your patient. You must then adjust the rate manually, with a roller clamp, COUNTING the number of drips in a minute, then doing some fancy math (using a standard drip volume - usually 15 drips = 1 mL). This means sitting there for 5 minutes or so, counting for 15 seconds, multiplying that by 4, no that's too fast, ever so slightly close the clamp, count for 15 seconds, multiply by 4, nope. Too slow. Etcetera. It's oodles of fun.

It also requires a lot closer attention, because when your fluid runs out you have to be right there right then to change the bag, or you get air in the line. It also means it's really easy to accidentally run something to fast, or accidentally leave it stopped completely, which (if left long enough), can potentially lead to an occluded IV that no longer works. Meaning you have to poke your patient AGAIN. *sad face.*

Adults Aren't Adults

In the developing world, being 18 often doesn't mean you're an adult (medically speaking, anyways). Quite a lot of our patients (especially the women) who are 20-70 years old are teeeeny weeeny. Most are around 35-40 kg (~75-90 lb). They're skin and bones. Everyone receives multivitamins while here, and many also require nutritional supplements like boost or ensure, or this weird "mana" stuff that's like an entire meal's worth of nutrition in a little peanut-buttery packet.

Mmm. Appetizing, isn't it?

Most of our obstetric fistula patients tend to be small, as their malnutrition is usually a major causal factor in their fistulas. They stop growing very young, due to their lack of nutrition, and as such, their pelvis never fully develops. Many also get married quite young. Trying to deliver a big-honkin baby head through an under-developed pelvis (in an isolated village with extremely limited or non-existant healthcare) equals extremely long labour times (i.e. DAYS of labour). This continuous pressure then causes the fistula to form, and not only do they have to face the horror of a still-born baby, but also a lifetime of shame and ostracism. 

Anyways. The other main reprecussion of this low weight is that we have to use pediatric dosing for the majority of our adult patients. This means calculating each dose specifically for their body weight, and double checking EVERY med with another nurse before giving it. Even a simple tylenol. This seems like a miniscule complaint compared to what these women have been through, so I think I can live with it. 

Everybody's a patient.

I forget if I mentioned earlier, but all of our pediatric patients (the real ones, the ones who are under 18) must have a caregiver with them while they are on board. This is nice, because mama or papa does the great majority of the patient's care. They wash them, they carry them to the toilet, or change their diaper if they're too little for the toilet. Yay! This is great. 

The weird thing about this, though, is that the caregivers often become pseudo-patients. We may notice they may have a cough, wheeze, or rash, so we treat it. Because, uh, we can. So why wouldn't we? We actually have standing orders for tylenol and benadryl that we can give to ANYONE (the patient's parent, the patient's baby brother, the patient's baby daughter, the day crew, etc). They get a little medication record that we stick at the front of the actual patient's chart, and the doctor will sometimes add some orders for antibiotics or some such as well. This seems especially counter-intuitive to my westernized brain, because at home we would have to say, "Sorry, you have to see your family doctor, or visit the ER." 

Prime example. These crazy twins (who were SUPER serious about their UNO game) were here for quite a long time. The one on the left had surgery on her foot. The one on the right didn't. Only one was *technically* a patient. But they were both patients. Both received nursing care, and both received medication.

It's kind of awesome, actually. When you don't have to worry about insurance or tax dollars, caring for people is ever so much simpler.

Here vs Home (A Helpful Guide)

So. You're thinking about working in a developing country. Maybe even, perhaps, with Mercy Ships.
But you're wondering how different it will be, how things are done here vs how things are done there.

The answer: A LOT. So, I have compiled them into this handy list so if you ever decide, "hey! I could do that," you'll have a little help getting started. And for the rest of you, hopefully it's still mildly intriguing?

Number One: Reuse, reuse, reuse.

With limited funds, limited resupply shipments, and little to no reliable local resources for medical supplies, everything that CAN be MUST be reused! This means kidney basins, medicine cups, thermometer covers, ice packs, water bottles . . . I could go on, but I think you get the point. Unless it's irrevocably contaminated, it is washed and disinfected, or saved for the same patient to use again.

Number Two: Destroy, destroy, destroy.

An unfortunate fact in developing countries is that if something can be reused, it will be. This is fine in the above scenario, as long as it's done appropriately, and within reason. When empty medication vials, syringes, IV tubing or bags is scavenged, refilled and sold for cheaper than at a legitimate pharmacy, however, you have a problem. You have a black market. One that is very enticing to people who can barely afford to eat, let alone pay medical bills. People WILL buy their own medication or syringes for cheap on the street, and bring it to the hospital for the staff to use. Yikes.

While I'm all for value, catching HIV, malaria or hepatitis is (by Grabthar's hammer) not worth the extra savings. Therefore, we must destroy anything and everything that could be reused. Lines and bags get cut apart, holes poked in bottles or vials, and labels removed. Any contaminated waste (except glass) is incinerated on the ship.

Number Three: Magnets are your best friend.

Ships are made of steel.
Magnets, therefore, stick to almost every surface on the ship.

We, therefore, use magnets in lieu of nails, screws, and other such fasteners, for just about everything.

Need to hang curtains? Here, use a magnet.

Need a clothesline? Here, tie it to this magnet.
Need to stick your water bottle somewhere? Here, hang it on a magnet.

I  bet you think I exaggerate. 

We have monster magnets.

Number Four: World's shortest commute.

If you're tired of driving 1-2 hours to work every day, as so many in southern Ontario do, then this is the place for you. My commute consists of this: 

• Step out my door.
• Walk 50 meters aft.*
• Enter B Ward.

Awesome.

Number Five: Improvise.

As mentioned, sometimes adequate supplies can be hard to come by. In addition to reusing as much as we can, we also repurpose a lot of things. 

Take this empty medication bottle for example. Garbage, right? WRONG! Cut a hole in the base, and you've got yourself a spacer (aka aerochamber) for an inhaler. A spacer makes it easier for the medication to be fully inhaled, by allowing it to mix with the air. Like so:

Or, say a doctor asks you to check your patient's height, because she looks much taller to him than 169 cm. Just grab a measuring tape, right? WRONG. We don't have those. Of course not, why would we have those? So, we grab some yarn from the knitting supplies (because yes, we have knitting supplies but not measuring tapes), measure the patient with the yarn, then measure the yarn with a 6 inch ruler. Oh look. 169 cm.

Number Six: Your paycheck comes every day.

This is probably the best difference between here and at home. My paycheck here doesn't come with taxes, union dues, and a night shift premium. It doesn't even come with a dollar sign. It comes with ear-to-ear grins and giggles, subtle nods, high-fives, and hugs. And it comes every day, not just every two weeks. It is the best paycheck ever.

Number Seven: All the Nautical Terms!

As this hospital is a ship, not a building, you have to get used to translating things. Not just into Malagasy, or French, or whatever your colleagues' first languages are, but also into nautical terms. The front of the boat is the Bow, or Fore. *The back is the Stern, or Aft. The middle is "midships." Left is port. Right is starboard. Standard stuff. The hallways aren't hallways, they're corridors. The doors aren't doors, they're watertight death traps that will crush you if you get in their way once they start closing (but don't worry, there's lights and sirens to scare you off if that happens). The staff are actually "crew." The kitchen is the "galley." And don't you ever. Ever. EVER call this a "boat." That's like telling a pilot he flies a "plane." Just don't do it.

Number Eight: Be flexible.

You never know what the day is going to hold. You might be working with fistula patients, or you might be working with babies. OR, you might be working with other nurses who got injured while spending time off ashore. You might be staying in Tamatave, or you might be setting sail to escape a tropical storm. OR, you might be STAYING in Tamatave during said tropical storm, to care for our patients who will get moved to the Hope Centre (which is, supposedly, hurricane proof). You might be sleeping for your night shift, or you might be woken up by the BLAZINGLY loud fire alarm: "BWAAAAAAAAAAAAAAAAAAAAA - THIS IS A DRILL, THIS IS A DRILL, THIS IS A DRILL." You might have a hot shower, or you might have no water at all in your cabin. Or in the other 8 bathrooms you try. There's always the pool, right?

Number Nine: "Time off."

So you have a day off. You're bored. You've gone for a swim, done your laundry, done some reading. Now what. Why, visit your patients, of course!

This sounds crazy, and back home the last thing in the world I would want to do is go into work on a day off. But here, it's as simple as popping down the hall, saying, "SALAMA!" (hello), and plopping yourself down next to a patient with some crayons. Or get a group together, spontaneously dress up in wacky clothes, and storm the wards singing "Dimy bey!" in Malagasy (gimme five!). Or run up to deck 7 in the afternoon and tow a giggling bambino around in a wagon (I may have taken a break from blogging to do just that today).

Number Ten: Everyone loves being at work.

This is probably the single, greatest difference between working here, and working at home. Now, don't get me wrong, my co-workers at home are amazing, the great majority of them are AMAZING nurses, and they genuinely love providing good care to their patients. 

Something changes, however, when money exits the equation. When your patients aren't just being treated for an illness, but life-long debilitation. Senority, overtime, scheduling disagreements, grievances, lay-offs, corporate politics. . . these don't exist here. So much stress just vanishes when the job is purely about giving your best for your patients, and getting nothing in return but this:

A day in the life.

I've shared some video snippets of what life is like for the crew of the AFM (Africa Mercy), but I'd like to share what the experience is like for some of our patients.

*Disclaimer* I did not take any of these photos, there are patients in them, and I am not allowed to take photos of patients. These are official photos taken by our media team and used with express permission. So before you go, "WOW! Your photography skills have dramatically improved," nope, sorry, I didn't take these. I am also not in any of these photos, in case you thought I dyed my hair and grew a foot.

So, without further ado: this is what life is like for the average joe in Madagascar.

Life is full of smiles, songs, and often prayer, but is hard. Most eat what they grow, living on around $1 a day, and are very undernourished. All muscle and no fat.

Especially these guys:

The pus-pus (pronounced "poose poose"). Like a tuk-tuk...without the engine.

These guys have MASSIVE calves.

Kids have it tough, and girls most of all, as they often marry very young, and are expected to cook, clean, and tote water and babies long distances. Often doing so at the expense of an education.

Before the ship ever arrives in a country, and most of the time it is there, there are screening teams travelling far and wide to as many towns as they can. They find surgical candidates, match them with an appointment time when the appropriate surgeon is on board, and sometimes return to help transport the patients at that time.

The long wait on screening day.

When the patients finally arrive in Tamatave, they are met by an admissions nurse, who checks them over, does some bloodwork, and some paperwork, and then they are brought on board the ship. Often, they are CARRIED on board the ship. 'Cause it's a long walk up the gangway, and then another 2 flights of stairs down to the hospital. And many of our patients aren't able to walk.

The first day or so is rather overwhelming for most patients, especially the little ones. Many have hardly ever seen white people, haven't heard another language, haven't walked up stairs, and have certainly never slept on a bed that's 2 feet off the ground! But our wonderful Day Crew (local Malagasy hired as translators and ward aids) soon get them adjusted to this weird, wacky, medical world, and our amazing chaplaincy team gets them singing and dancing pretty quick.

Yes, those are bongos, and yes, that's a guitar, and yes, this happens every day.

The first day after a big surgery can be an especially nerve-wracking time, for patients as well as nurses. When our ICU beds are occupied, there's about 20 times more crazy medical stuff; tubes, lines, monitors, and vents. These people are RESILLIANT though. Like you wouldn't believe. Our one patient who lost over double her blood volume during surgery was vented for only 12 hours, and walking out of the ICU back to a regular bed shortly after.

That is cray. They would likely spend weeks in ICU in Canada. We don't have weeks and weeks to spare on the ship though, and somehow, by the grace of God, weeks aren't needed.

Well, the next part of the story sounds a bit boring. It's the part that I do. It's the day to day care on the wards while the patients recuperate. For some patients it takes a day or two, and they're heading home, for others it can take longer. Most require nutritional supplements to help their body heal faster. It's washing, and medicating, and emptying catheters. Yay! Excitement!

But, did I mention this is the Africa Mercy? We don't do boring. We do spontaneous dance parties, and wagon races, and basketball, and arts and crafts, and worship, and movie nights. Yes, WITH our patients. This job is AWESOME.

Deck 7 Sunshine Time!

This tiny wagon is my favourite. It's even better when there's a slightly-too-big kid squished in it.

Eventually, our patients will go home, or they will go to the HOPE Center for a little more TLC, then get home from there. Tiny walkers and all.

Well, I hope this has given you a bit of an idea what a visit to the ship is like from the other side of the stretcher. I shall leave you with this dripping-with-cool photo of a patient who had a hole instead of a nose before his visit:

So. Cool.

Good afternoon, good evening, and goodnight! And...good morning! If it's morning.

Mish-Mash

Wow.

It has certainly been an interesting two weeks. TWO WEEKS!? Has it really been two weeks.

Holy smokes. Time is flying by. Apologies for not writing more updates, I shall try to do better.

Well, I know I said I would working with fistula patients, but as it turned out I spent my first week working on a different ward with maxillo-facial surgery patients. Including BABIES and KIDS.

*gulp*

Now, I know what you're thinking. "But Danita, don't you love kids? What's wrong with kids?" And on some levels, you'd be right. Kids are pretty awesome. They don't judge you, don't hold grudges, and most decide they're your best friend the minute they meet you. The issue is that these kids are in a hospital. They're in a hospital because they've had surgery (some of them very extensively), and they require treatments and medications.

This last part...that's where things get scary, as a nurse with 100% adult patient experience (unless you count camp, but camp is different. My campers hadn't had recent surgery). So, for my first few shifts I had patients of all shapes and sizes, and I was a little terrified. See, little wee ones require much more precise doses of medication, so you don't, you know. . .kill them. So yeah. Terrified.

This, however, is the Africa Mercy. It's a ship full of people who are all here for the same reason, and they are all IN LOVE with this work. Everyone gives 110%, and when the work is all done, we get to play. So everyone works that much harder, because that means more play time* when the work is done. Needless to say, I was well supported, and am now fairly well acquainted with the way things work with other types of surgical patients. Which is fortunate, since our wards are currently a hodge-podge of patients. From orthopedic kiddos with casts on both legs, to tumor patients with bandages holding their face together, to our beautiful fistula ladies with catheters/stents out the wazzoo.

I've quickly learned that life here rarely goes quite how you expect.

And that being an "Adult Ward Nurse" means pretty much squat. You're a nurse and you're put to work where needed, not where you're comfortable. Regardless of your specialty or experience, you're part of a team that is literally the best in the country.

All in all, the learning curve has been steep, and I'm certainly not at the top yet (despite already training local nurses)! I am, however, starting to feel like this is normal, this is the way we do things, this is where we keep the whatchamacallits, this is called paracetamol (not Tylenol), and I ALMOST don't get lost trying to find the library anymore. Almost.

*PLAY TIME: Singing, dancing, jenga, uno, colouring, racing around in wagons or trikes on deck 7, peek-a-boo, etc.