[Written about Tanzania]
This is a guest post I wrote one year ago with my friend/colleague on his blog: https://fracturedfablesandtachytales.com/2016/04/14/the-irony-of-nursing-my-journey-into-the-third-world/. I just wanted to put it on my own site too. It was a therapeutic process for me to write about a traumatising event whilst volunteering in Tanzania, and my reflections afterward upon returning home to Australia.
Wrapped up in a ‘kanga’ cloth in the arms of his mother, the baby’s tiny head only just pokes through the top of the colourful bundle, with tubes coming out of his nose; one to feed him and one to supply him with oxygen. His eyes are closed tight and the skin of his forehead is stretched so thin that it’s obvious he is very sick.
“Let’s have a closer look” said the doctor who is doing her rounds on the Malnutrition Ward at Muhimbili National Hospital in Tanzania’s most populated city, Dar es Salaam. I watch with bated breath as the mother unwraps the cloth around her child.
Chronically undernourished, at three months of age his frame resembles that of a baby bird. He looks so fragile and vulnerable that I’m scared if I touch him he will crumble beneath my fingers. He is suffering from a nutrition deficiency condition called Marasmus (from the Greek word meaning ‘decay’) and that is exactly what he looks like. A living body which has already begun to decompose.
The doctor turns to me and bluntly states, “this one is the sickest on the ward," as she takes out her stethoscope and listens to his heart and lungs. The mother holds the child and looks up at us all expectantly. She doesn’t speak English so she is unaware of what we are saying, but there is a certain weight that is held here amongst the Tanzanian locals with English speaking foreign aid workers and it’s an uncomfortable pressure I feel everyday in this place: wanting to help but not having the resources to do what I know I can, while every patient expects miracles from me. I am a volunteer Registered Nurse from Australia and I am only spending one day on this ward, but I am keen to learn and help out as much as I can despite the limitations.
As I study the patient, I can see the malnutrition has left his fading, failing body to waste away. His sunken eyes no longer show the pain of hunger or thirst. It’s almost as if the those feelings have been dampened by exhaustion. Hunger is so intrinsically wired in his tiny brain that it is unable to register it anymore.
The Tanzanian doctors briefly discuss the patient amongst themselves before swiftly leaving to see the next one. They see dozens of patients like this one everyday so it doesn’t phase them anymore, but I have never seen a child as sick as him and I shuffle my feet uncomfortably not knowing what to do next, but feeling compelled to stay in this room a bit longer and assess this patient more thoroughly myself. I’m here in Tanzania as a preceptor for four Australian student nurses, and they are all in the room with me now, looking at me for instructions.
“Jina langu ni Kam. Mimi ni nesi kutoka Australia,” I say in Swahili to the mother who smiles wide, “my name is Kam. I am a nurse from Australia.” “Nesi mwanafunzi” I say, pointing to the four girls standing behind me, “student nurses.” I gesture toward the infant to imply that I would like to assess him, realising the difficulty I face as my basic Swahili knowledge means I now have to rely on improvised sign language to communicate.
The mother nods and places the child on the bed and gets up to leave, probably to take a much needed break for herself. I bring the students in closer to discuss the assessment process for a patient like this, going through basic observations and noting on the limitations in comparison to a hospital we would work in back home. The child looks around through a small slit in his eyelids, not really focusing on anything or engaging with us as he should at this age. He feebly moves his limbs in protest while we gently place our stethoscopes on his bony chest.
Measuring his blood glucose level by drawing a drop of blood from his heel, a daily routine on this ward, it reads 1.2, a low number that raises an alarm. “Shit shit shit” I think to myself, “this is bad.” The familiar adrenaline rush that I feel everyday in my job back home as an Emergency Nurse begins to build through my body as I look around to see how to best manage his deteriorated state.
Like a wilting flower, his short time on earth has been a struggle for survival. Without enough food or water, his life is just another symptom of an impoverished third world. He is now showing signs that he simply cannot compensate any longer with the lack of basic human needs he was so unjustly deprived of.
“Someone get the doctor” I called out to a passing nurse, who comes into the room and asks what is going on; luckily the nurses here speak English well. I quickly explain the patient needs glucose to increase his dangerously low levels. The nurse walks over to the trolley next to the bed which haphazardly holds basic equipment in old boxes, and uses a syringe to measure out a therapeutic dose of oral glucose which she squeezes through the tube in his nose that leads down into his stomach. The nurse promptly walks out of the room leaving me and my bewildered students alone again with the child. After a few minutes of anxious waiting, it seems that the intervention has not had the desired effect, and I feel my stomach drop. With each breath requiring more effort than the last, the baby’s body has already begun to shut down. And suddenly he is still. Silent. Without breath. His head now limp on its side with a vacant expression is his eyes.
I now feel more alone than I have ever done in my whole life. My basic life support training skills kick in and I decide to intervene in the only way I know how right now. I sit down on the edge of the bed and reach out to the tiny patient. As my cupped hands wrap around the child’s chest, his entire body fits neatly inside my palms. I have held bigger newborn babies than him.
With my thumbs at the base of his sternum, I begin to put regular even pressure to help circulate blood around his body since his heart is likely no longer now doing it for him. It requires hardly any physical effort at all, but it’s mentally exhausting even though I don’t realise it yet. “Can we increase the oxygen and do a set of obs please?” I calmly ask of a student nurse who fumbles around the machine next to the bed for a minute before eventually realising that it doesn’t work. This machine, we find out later, is merely an ornament in the room and hasn’t worked for weeks. “Can we get IV access and adrenaline 1:10000 and intravenous 10% glucose” I address to a bewildered intern who has walked in the room, recognises what I am doing, and quickly grabs a cannula from one of the boxes on the trolley. “Can you two go to the critical care ward upstairs and ask if we can borrow their obs machine, and see if they have a defibrillator we can use as well,” I ask of two of the students who turn on their heel and rush out of the room. Sweat begins to build on my forehead as I realise how grave the situation is, but I take a deep breath and continue compressions anyway.
The junior doctor desperately fumbles to find a vein in the skeletal wing of the child. All the while, the futility of the CPR is becoming more and more evident. With each compression, a clear fluid bubbles from his nose and mouth. The glucose solution that was syringed in his nasogastric tube earlier is now appearing again and I can feel the sting of a tear in my eyes as I realise what will happen next.
The word ‘nurse’ is both a noun and a verb. In this desperate situation, I feel a world away from both meanings. At times in my career so far, I have felt like a fraud, because I wasn’t able to truly nurse someone back to health. I wasn’t able to give them comfort despite my best efforts. I wasn’t able to take away their pain or suffering. I was just a spectator. This is how I feel right now, and it’s the most helpless feeling in the world – when life is being pulled away so violently from your very own fingertips and there is nothing you can do to stop it.
I turn to the remaining two student nurses next to me and ask them to go and find the baby’s mother and bring her in the room. I know the evidence shows that people who witness the resuscitation efforts of their loved ones psychologically cope better after the event, and this setting was no exception to that. The mother must have been nearby as the students return shortly after with her between them. She stops in the doorway and looks at me and sees what I’m doing to her child, and immediately collapses onto the floor, wailing viscerally in Swahili. The noise is chilling but it doesn’t break my focus as I ask the doctor if they have equipment to insert an intraosseous needle or central line to administer the emergency drugs that cannot be accessed peripherally, despite many attempts.
The doctor shakes his head and gives me an incredulous look as if to imply that I should know by now that kind of equipment doesn’t exist in a place like this. In fact, the drugs I need to resuscitate this child aren’t even readily available even if we were to somehow get access into his feeble veins. The student nurses return from upstairs and tell me in a defeated tone, “we can’t borrow the machine, it’s being used on someone else right now, and there is no working defibrillator here.” So I direct them to find water for the mother and comfort her with the other students in any way they can.
The reality of the outcome of this situation has now sunk in, but I am not qualified enough and am unwilling to make the call to stop CPR, so I turn to the intern again and ask him to bring the senior doctor into the room to manage this case. She walks in moments later with the same blasé expression she left with and I quickly explain what has happened, fumbling over my words nervously as I try to hand over the sequence of events in a succinct manner, finally asking the doctor if she thinks I should continue CPR or stop all interventions. The doctor looks at me with wise but tired eyes and sighs before saying,
“Stop… What do you expect anyway? There is nothing we can do for this child.”
A moment passes that feels like eternity as I stop moving my hands that have been helplessly trying to save the life of this little innocent being for the last 20 minutes. I take one last long look at the boy who has died in the most undignified way and resist the temptation to gently pull out all the tubes and tapes and needles in his body and hold him close to me to provide some compassion and comfort for a life taken too soon. I get up from the bed and see the Tanzanian nurses and doctors filling into the room and taking over the care, doing what they do so well because of the conditions they live in.
I now strongly feel the stark cultural differences between the Australian and Tanzanian medical staff in the room and that I don’t belong here anymore, and maybe never did to begin with. I start to feel the same stinging behind my eyes again and a sickness in my stomach that compels me to respectfully leave. But first, I walk over to the mother, still crying on the floor making haunting pleas to someone I can’t see. I gently touch her back and quietly say “pole sana mama,” “I’m so sorry,” an expression often heard here in Tanzania used to show sympathy. In a place like Dar es Salaam, children die unnecessarily all the time, and you would think the mother would’ve been prepared, that she would’ve seen how sick her child was and she would’ve known his inevitable fate. But no matter how many babies have died around her before, and how sick her baby has always been, losing a child is still the most horrific grief someone can experience that I can never even imagine.
I don’t know anything more that I can say to comfort her, but in a moment like this, words are irrelevant anyway, so I silently share a moment of my compassion and grief before indicating to my students that it’s time to go. We quietly get up from the floor and walk out of the room, leaving a bit of our broken hearts behind. ——————————————
Months later, I am back in the same emergency department I was working in before my experience in Tanzania. Nothing around me has changed and I slipped right back into the daily grind as if I had never even left. I still see the same type of patients and fill in the same type of paperwork, but I probably am a different person now, and I’m definitely a different nurse.
Eventually I started to forget what it was like back in Tanzania, and I also started feeling frustrated by what I call, ‘First World Problems.’ But what I notice in me now is that I so vividly see the injustice of the world around me. I see how my patients are coming into the department sick with preventable diseases that are caused by poor lifestyle choices. I feel frustrated because I work in a system so stretched that it doesn’t allow me to spend enough time with my patients and doesn’t encourage me to teach them to live healthier even if I did, and instead I am treating every problem or symptom they have with drugs, like a bandaid on a chronic wound. The irony of it all is that while we are on the opposite end of the spectrum from the people in Tanzania, we are still suffering in other ways and end up with the same sad outcome: an unnecessary, undignified, and often early death.
I became a nurse because I wanted to help people, but it seems that no matter where I go in the world I cannot acheive this dream. Whether it’s working in a resource deficient malnutrition ward or a pharmaceutical driven emergency department, I rarely feel that I am doing enough to fully nurse any of my patients back to health.
But because I am a nurse, people let me into their most vulnerable space every single day, and for that I am truly privileged and will never take it for granted. I know that with all the challenges and limitations I face from the inequality and injustices of the world, I still have the potential to bring thriving health to at least some of the patients I will look after in my career, and that tiny glimmering notion is enough to keep my feet planted firmly in this role for the rest of my life.