One Day

A colleague just said to me, "I'm sorry about the tough day you had at work."

To which I replied, "Which day was that?"

Quite honestly, there are so many challenges in the hospital I am at, that there has not been One Day where I, or the Tanzanian nurses, have not faced massive challenges.

So, let me describe a snapshot of One Day for you.

Last week, I came into the labour ward from the Administrative morning meeting, to see an infant born, covered in meconium (this is baby poop). When the baby has pooped inside the womb, there is a good chance they have breathed some of that poop into their lungs. I saw the baby lying lifeless on the delivery table, so dropped my bag on the floor near the nursing table, grabbed the baby, and brought her over to the infant warmer (the warmer part doesn't work - but that is a whole other blog).

I grab one of the electric suction machines to find that there is a convuluted mess of suction tubes, none of which seem to be connected to anything that actually sucks. And the insides of all the tubes are moldy. As I am making my way through these giant, non-working machines, tripping on the cords of the mostly non-functioning equipment, my colleague Macha, motions to the extremely moldy foot operated suction pump that I had tucked behind all the mess yesterday.

You see, I was desperate to help this baby, because yesterday, as I was trying to clean the dusty, non-functioning equipment, a newborn brought in from their home, had gasped their last breath just a few feet from me, but we were all too busy to notice. Other babies were coming, women were begging for a place to lay down their weary bodies, I was trying to organize and understand this plethora of useless equipment. I was too busy to notice an infant dying, just a few feet away from me. And so, on that day, I decided that life takes precedence over cleaning. And then I started to understand why the maternity department is dirty. Life comes first.

Returning to my clumsy, now-swearing-under-my-breath antics, I finally managed to wrangle this antiquated piece of machinery out and attach a too large suction tube and push it down the tiny throat of the lifeless infant. I started pumping with my right foot and holy crap, this thing worked! The mucous had been too thick to bring up with a bulb syringe, the standard piece of equipment, but I managed to bring up what was blocking the airway and the baby gasped. But not safe yet.

With totally irregular breathing, the baby needed help and so I started using an ambubag to try to get more air and oxygen into the lungs (we call it "bagging"). But I will tell you, those CPR classes make it seem a lot easier than it is. Tilting the head back, keeping the tiny, slack-jawed mouth open, making a seal around the mask on the face - extremely difficult, especially when you are internally panicing.

I see the stomach rise and fall - that means the airway is still blocked. Either by mucous or because I haven't positioned the head correctly. Re-position the head, try again. Stomach is still moving.

Get the suction out again - clear the nostrils - they were full of gunk. Trying to bag again. It looks like both the chest and the stomach are moving. Stop bagging. The baby is breathing, but very irregularly.
Another nurse is trying to assist and has some "interesting" approaches, which I have never learned (but maybe they work?). She presses on the stomach and tells me to bag the baby - indicating that if the stomach is pressed, the air will be forced to go into the lungs. I try to explain that is not what I learned in CPR! I bring out my dormant CPR knowledge, and try some back thrusts on the baby while holding their head low, attempting to physically move the mucous up the airway so I can get it out easier. Put the baby back on the bed and  I suction some more, putting the suction tube further down the throat. I am convinced the airway is still blocked with mucous and blood.

I give the foot pump suction another rigorous go (I guess I am getting a work out) and I see the tube fill with yellow and blood tinged mucous. The smell from the moldy water and tubing is pungent and I get briefly nauseous. I get a lot out but realize that I have probably caused some superficial trauma to the tender throat area with the "too big" suction catheter. But the baby is breathing more now and doing it independently. Still irregular, but enough that I think bagging her will interfere with her efforts to breath. I put on some nasal prongs (there is no oxygen mask of the right size) and miraculously, the oxygen concentrator is working.

I wrap her up tightly with the Kanga's (Tanzanian cloth) to try to keep her warm, switch on the exam light and point it at her, hoping the radiant heat will warm up her body temperature. I sit on a stool near her and keep a close eye on her. I can't let cleaning get in the way again.

She is breathing enough times per minute and her heart rate is strong, but she is quite slow to respond and seems to have poor reflexes. The mother and grandmother come in to check on her and I explain in my childlike swahili that she has "water in her lungs" and had a hard time breathing at birth, but that we are doing everything we can to help her breathe. The nod silently and go to the post-natal ward to wait.

She seems stable enough that I can help with a few other things in the labour ward and feel like I am not abandoning her. I work on sorting out the mess of machines. Just as I am plugging in and unplugging machines, I see a tide of water coming towards the 5 electric outlets on the floor. I quickly throw them up on a stool, envisioning death by electrocution, just after I got the baby breathing! I tried to gently explain to the cleaning staff that water and electrical plugs don't like each other very much. Crisis averted and I continue on.

I tell my colleague that I refuse to go home until I am confident that there is a functioning suction machine. I separate out all the tubes and try to see what is working. Two of the electric suction machines have a very weak suction and I can't tell if they are working. The connector to attach the actual suction tube is missing, so essentially they are non-fuctional. I go find the biomedical repair man and tell him that I won't go home until they are working. He jumps right on it and rolls them away for repair. I take the foot pump to the dirty utility room, grab the bucket of bleach, and try to scrub some of the mold out of the pump. I can get the glass bottles clean but the tubes are another story.

I head over to the Medical supply "store" (It is just referred to as "The Store") and explain that a baby almost died today because I didn't have the right supplies on hand and I want some *now*. They let me into the big room and I start going through boxes I had seen on my "tour" a few days ago, and pulling out some much needed oxygen prongs. Unfortunately, there are no suction tubes to be had. Anywhere. The ones for the machine, or the ones to actually suck mucous out. They are "finished" and little interest in finding out when they might come across some others. I reiterate that babies lives depend on this equipment and hope the message spurns them into action.

So, I return to the ward to check on the baby and find she is still breathing on her own and occasionally opening her eyes. I put the suction machine tubing in a big bowl of bleach and just hope it removes some of it, because it is either moldy tubes or no suction. And no suction could mean a life lost.

I get the mother from the ward and bring her to the baby and explain how she is doing and that she might need to drink. I have the mother express some milk into a tiny cup (we use the tops off the IV bottles) and did something I never thought I would do - teach a mother how to fully express breastmilk. I was right in there, expressing it. Oh geez, we never did this in neuro...

I show her how to cup feed and the baby feebly laps her tongue on the milk and we encourage her to swallow. We manage to get a few ml of milk into her, hoping that it will boost her sugar levels. After about half an hour, I try taking her off the oxygen to see if she can tolerate breathing on room air.

The challenge is - keeping the baby in the labour ward on oxygen but having no nurse really available to monitor her and she goes into distress without anyone noticing. Or hoping she will cope on room air and be with her mother and grandmother and they can alert a nurse if her breathing becomes laboured. I opted for the latter.

We go to the post-natal area and I check the oxygen - it's 95% on room air and her breathing is the same it has been all day. I explain in my terrible swahili (and a lot of actions) that if her breathing becomes slow or laboured or she gasps, they have to bring her to the labour ward right away to be put on oxygen and have the nurse look at her. (There is no nurse stationed in the post-natal ward on evenings or nights as there is only 2 nurses for up to 50 patients, and their babies). They seem to understand and agree.

As I step back, I notice that although I had thought the mother had been a bit reluctant and disconnected from everything, she is very gently and tenderly holding her new daughter. As I walk by an hour later, I see her expressing milk again for another attempt at feeding.

It is now almost 5pm and I am exhausted. In between all of the above, I went and did complex dressing changes on several patients with very limited supplies, answered queries from curious families, and was constantly fetching supplies.

I promised the mother and grandmother that I will come on Saturday to check on them. I hoped for the best. I had a nagging feeling that the baby had been without oxygen for just a bit too long - but given that African girls and women are incredibly strong, was secretly hoping and praying that she would pull through.

I headed in on Saturday without a doubt in my mind but found a different mother in the bed. I was so confused. I had tried so hard to keep the baby alive yesterday. They couldn't have been discharged. The baby still needed antibiotics. Maybe they switched beds. Yes, that had to be.

I sought out a nurse in labour ward and asked where the mother of the baby was. She casually replied that the baby had passed away overnight. When she saw my crestfallen face, she quickly apologized for the loss, not realizing how much work had gone into keeping her alive.

I wandered out of the maternity ward and back to my bicycle not sure what to make of this. Is this what Tanzanian nurses do every day? Is this why they seem less shocked when a baby dies, because they are so used to it? Will I get used to it too? Will I stop getting angry at the injustice of it all?

This is but One Day in the life of a nurse midwife in Tanzania.

One Day.

Every day has a heart breaking challenge of its own.

This is but One Day.

I look forward to the One Day in the future when these kinds of stories are in days of the past.