Tantrums & Tibias

Patient "A" (for the sake of this, let's call him 'Andy') was one of a handful of patients in the hospital when I arrived in January. He had had surgery for his bowed legs back in December, but had some unexpected complications which kept him stuck on the ward over the Christmas break. Our team of hospital physicians were initially mystified by his unexplained fevers, but eventually their research, and some test results, gave us a clue as to what was going on.

He was becoming severely neutropenic - his white blood cell counts were far below normal. Essentially, his immune system was compromised for some reason. He had been perfectly fine before surgery; this is something we routinely check for a pre-op baseline. The only explanation our docs could come up with was that it was an uncommon and drastic reaction to a particular antibiotic he had been given. In digging a little myself, I could only find 3 or 4 similar cases mentioned in published literature. As soon as the link was made the antibiotics were stopped, but it took weeks for his system to recover. 

Weeks during which he had to be "reverse isolated:" anyone caring for him had to gown and mask up, he couldn't have visitors, and we kept his side of the ward empty aside from him and his mother. If he left the ward, HE had to wear a mask. Any mild infection could have wreaked havoc while he was so compromised, and he still had an open wound on his leg which was taking its jolly time to heal. He still had casts on both legs, one of which was split so we could access his wound, then wrap it back up tightly together. Because of the risk of infection and his delayed wound healing, "Andy" wasn't nearly as mobile as he should have been this long after surgery. This was causing even more delays in his bone healing. 

WARNING - MILDLY ICKY MEDICAL STUFF IN THIS PARAGRAPH 

I haven't ever talked about our Ortho specialty much because I haven't seen much of it myself - so I'll explain a little what goes on. Most patients we see have a congenital condition that worsens as they grow older, and can become astoundingly severe in our older patients. By older, I mean teenagers. Kids' bones are different than an adult's; they're still growing, and they heal faster. Correcting these windswept or bowed legs requires cutting the bones, over-correcting the deformity, casting them in position then getting the kids to walk. That's the hard part. The weight and pressure from walking actually brings the fragmented bones together. It is a much more complicated and less successful process for adults, which is why our Ortho service is almost exclusively pediatric. Kids' bones have a little bit of give to them, which is why the Ponseti Method works so well to fix club feet. 

ICKY STUFF DONE! 

All this is to say...'Andy' had a rough go of it. He had painful, daily dressing changes, walking was still hurting a lot, and for a few weeks we couldn't even give him a high-five without putting on gloves. The first shift I looked after him, he was absolutely INCONSOLABLE when he saw me getting pain meds for his dressing change. Literally screaming and flailing his arms. His mother wouldn't make eye contact with me as I tried to indicate she should try to help calm him down. She sat, staring at the floor, as tears streamed down her son's face. I was bewildered, and my translator seemed bemused, but we did manage to get the meds into him. After a bit more wailing as I started the dressing, 'Andy' calmed down, distracted by some games on an iPad while I worked. A while later, when another translator was free, I was able to talk to the mother and get a better grasp on the situation. 

Numerous tests had been done over the previous few days, and no one had really told her the results. It had been the weekend, the Orthopedic surgeon was gone, and likely everyone assumed someone else had already explained. It's also possible there was no translator available for her language. The mother, as a result, had assumed the worst she could imagine. Communication mishaps happen enough when there isn't a language barrier. It's so much more likely in this situation. To make a long story short, I was able to reassure the mother, our lovely Dr. Laura also came by to explain the test results in more detail, and mother was much happier - and much more helpful with meds and procedures. And she was always fastidious about hand hygiene, pumping dollops of purell onto her son's hands for him. 

'Andy' remained a bit - how shall I say - moody? He could be your best pal one day then glaring and brooding the next. But I suppose that can be par for the course with a teenager. 

THIS WAS A BROODING DAY. 

THIS WAS A GOOD DAY. 

 

Eventually, as expected, his test results improved enough that we could stop with the reverse iso precautions, and his wound began to heal, albeit slowly. Out of nowhere, too, he got a sudden burst of motivation. He went from refusing to walk the length of the corridor to kicking around a soccer ball and CLIMBING STAIRS a few days later. 

I think the chance to see the bridge was pretty good incentive - big props to Captain Milo for making that happen. 

I didn't see 'Andy' much over the last few weeks before I left, as he was out at the HOPE Center and only coming by for dressing changes and rehab a couple times a week. But I heard from colleagues that his wound is nearly closed, and he's not letting much hold him back now.

The long-awaited day of discharge from the hospital!

Á la prochaine,

-D

Airborne

My time in Guinea has ended, and boy did it go out with a bang.

My last few shifts were...surprising - I think is the best word. 

I started working some shifts as a charge nurse this year. I was a tad apprehensive at first, but after some orientation and a couple shifts under my belt, I felt fairly comfortable about it. I had already completed the 4 charge shifts that were on my schedule, but I ended up trading to help someone out and was in charge again Tuesday evening. 

EVENING ONE - SPORTBALL 

The shift went by without much excitement until about 8:30, when a nurse asked me to look at her hernia patient. "There's a LOT more swelling than there was." In about half an hour, he had gained a softball-sized bulge that was definitely not there before. I paged the surgeon, who came down to look and wrote orders to take the patient back to the OR in the morning. He was bleeding, but it wasn't severe enough to warrant surgery that night. Page back if it gets to be football-sized. Ok, that's what we'll do, I guess. I let the OR team know, got a consent signed, and checked in with the team leader to make sure I hadn't missed anything important. 

Apparently I didn't notice that I had been sweating buckets even just sitting at the computer, because it's HOT in our ward, and a nice little dizzy spell forced me to take a breather and remember to drink water. One of the night shift nurses had made pies, so I got a piece and moved to the air-conditioned office to finish up my work. By the time I updated all the paperwork for the morning shift, I's dotted and T's crossed, I finally left - a round midnight. Slightly uneasy about the still-slowly-bleeding patient, it was even later by the time I fell asleep. No bother, I could sleep in. 

EVENING TWO - DÉJÀ VU 

Arriving on the ward, my team leader said, "Surprise! We need you in charge again!" No problem, I handled last night, and it can't be as crazy as that again. 

The bleeder from yesterday was doing fine, and everything was run of the mill until about 9; shortly after the surgeons had done their rounds. "My kid in bed 1 suddenly has all this swelling." You're kidding me. Paged the surgeon, he took one look and asked, "When did he last eat?" Great. Needs to go back to OR tonight. Once again, notified the OR team, consent, paperwork, find a translator that can explain everything to mama, and he's whisked out of the ward before shift change at 10. 

Just as I'm bringing my print-outs for the morning shift back from the office, around 11, the phone rings. "That was quick," I think as I answer, expecting the news that they're bringing him back out of recovery. 

It's the OR nurse, Melissa. "Did the day nurse say anything to you about a blistery rash?" 

"Wha...?" I double check with the night nurse who got report. "No, no one saw anything..." 

"We THINK he might have Chicken Pox." 

No freaking way. After a moment's disbelief, we discuss what to do and I jog down to D ward to make sure there's an isolation room free. The doctor on call needs to verify before we can do anything - it's a sweet English lady who usually works ashore in Capacity Building. She's never been in the OR and I help her gown up and direct her to the recovery room. "This is what I get for offering to cover the pager," she jokes. 

Sure enough, she's 99% sure it's Varicella. We have to isolate. Once again I track down a Mandingo speaker to explain everything to mum, and escort her to the iso room. It's full of extra ICU equipment which we hurriedly haul out of the way. Shortly after, her son arrives in Melissa's arms, and I help the night nurse get him settled in bed. It's after midnight by now, and our infection control nurse turns up (bless her). We all chat about the plan, no, it's not ideal, we don't have a negative pressure room, but it should be ok, it's more droplets that we need to worry about, they SHOULD be able to go home in the morning. 

Around 1 AM, at the insistance from the night nurse that she would manage (despite having this patient plus 8 more in a different ward), I went off to bed. 

EVENING THREE - MISGIVINGS 

My last shift before I head home. I'm not in charge. Phew. I'll just manage my patient load, no surprises, no problem. Right? Heh. There's some acute patients in D ward, so they've borrowed some of our staff, leaving us with 6 patients each. One of mine is our chicken pox patient. They're from upcountry, and need to stay close by until their 1 week follow-up appointment. We can't send them back to the HOPE center - he's still contagious. Mama doesn't know anyone in Conakry she can stay with, so we're going to try to put them up in a hotel. 

Going back and forth between iso and A Ward (opposite ends of the hospital), I'm trying to get myself organized and make sure I've checked on all my patients when Lizzie, the infection control nurse, tells me they've organized a place for our pox patient to stay. "I've still got to do some teaching," I tell her; she's going to come back with a chaplain who can translate for us.

After about an hour explaining the plan to mama, making sure she understands the medications and can open the stupid child-proof bottles (that is not as easy as you might think to explain in a different language), we finally started to head out. Mama stopped short outside the door and said something to the chaplain. "She wants you to pray for her," he tells me.

"Me? Are you sure? In English? Would she prefer you pray in Mandingo?"

They converse a little, and he says, "Yes, you pray, I will translate."

I don't know what that mama believes, but in that moment she knew she needed someone greater than her to get her through the week ahead. Lizzie later shared that when they reached the hotel, Mama was pleading that they not leave her there. She had lived her whole life in a remote, rural area; being in a huge city like Conakry was terrifying to her. At the HOPE center there are translators and other patients from all over the country; there's always someone you can talk to. It's safe, secure, and familiar. 

She did not want to be alone.

Lizzie and Christopher, the chaplain, were able to find a staff member at the hotel who could speak Mandingo, they helped settle mama in, reassured her that staff from the HOPE center would see her every day to bring meals, and gave her an emergency contact number. It sounds like by the time they left she was more at ease. 

~ ~ ~

Once the two of them were off in Lizzie's capable hands, I rushed back over to A Ward, where I had left a fresh post-op patient for far, far too long.  "Your vitals are done, and I gave bed 7 his paracetamol." My fellow nurses are rock stars. 

I again was in the hospital till after midnight, cleaning the iso room from floor to ceiling with my charge nurse's help. 

~ ~ ~

I don't think I'd trade those 3 crazy shifts for any one shift here at home. They were stressful, but I still walked away feeling fulfilled, effective, and oh so appreciative for the professional team who, despite being from different countries and speaking different languages, work so well together to share the load and show our patients love. 

I'll miss you Guinea,
And you too AFM - but I'll be climbing back up the gangway before long.

À la prochaine,

-D