Be the change you want to see in the world. ~ Ghandi

Friday, November 27, 2015

Amanda Judd tells about her mission with Refuge International

We arrived excited to get the San Raymundo temporary hospital up and running. We had lost time with flight delays and reroutes due to Hurricane Patricia, which was pounding Dallas with an unexpected wallop and caused baggage to be delayed and people to be stranded. Fortunately, thanks to the well-oiled machine that is Refuge International, we were up and running by Sunday afternoon. 

The San Raymundo facility is run by a local group of citizens who open up the compound about every 2 months to Refuge International's medical staff and alternately with a group of Italian medical staff who helps in the San Ray facility. While unpaid volunteers provide all of the care, the local group charges a very nominal fee to the patients to cover the costs of the building, maintenance, and upkeep. Having vested interest in the medical care for the community, the locals seem to respect and appreciate the volunteers from Refuge International. The community organization provides Refuge with a locked storage room to keep supplies safe when Refuge is out of the country. This was a good thing, too, since many of our supplies were delayed for 5 days with all of the reroutes. 

This is a view from the roof of the temporary hospital, overlooking the cafeteria, the adjacent school (in green), and some of the sleeping quarters.

Early morning OR setup.

This is me, ready to go on day 1.

As an ICU nurse, I was assigned to the PACU, and I was able to observe some of the earliest procedures prior to having patients. I was lucky enough to be on a mission with Dr. Cockburn, a urologist, and his lovely wife Judy. Judy was such a warm, inviting person. She managed intake flawlessly while Dr. Cockburn did consults and surgeries. 

One of the first patients to get a procedure was done by Dr. Cockburn and had a softball-sized fatty tumor removed from his buttock. Dr. Cockburn and the patient allowed us to watch the procedure. The patient was numb but awake. He remained very stoic throughout the procedure and was hesitant to admit that he could feel the removal, at times. It's interesting how different pain is perceived culturally. As Americans, we would probably yell out and make them stop the procedure until we were completely numb, this patient tolerated it until we asked him and was grateful once the procedure was done.

Dr. Cockburn operating.

We did many procedures throughout the week. Of course, the kids always capture your heart. The little boy seen below was named Franco. He awoke quite confused from anesthesia but was quickly captivated by one of the games on Eleanor's phone. He was excited to tell us a story about his "pets". He has 2 chickens and 3 fish. One day he decided to take one of his chickens to school for show-and-tell, but was bemused to find that the chicken had laid an egg at the school. In some ways, I think that it's the sharing of experiences that may have a more lasting impact than the medical procedures themselves.

Franco with Eleanor, the NP who worked as an RN in the PACU, and Ashley, the translator. 

A beautiful little girl who had a tumor behind her ear removed. She and her mother were an absolute joy to care for. She awoke from surgery happy, smiling, and full of giggles. 

San Raymundo at sunset.

Of course, there are stories that are gut-wrenching, and make you wonder if our best intentions are not always in the best interest of the people.

With the exception of my luggage showing up, this day was fairly routine in the way that medical clinics become very routine after a few days when everyone knows their places and jobs. I had retired early to enjoy a shower with my own bath products and had crawled into bed to read my newly arrived book when Nancy (the trip leader) came in and asked Dr. Janet Sweetman, ER doc, to please come to the PACU where a baby that had just been delivered today was retracting with an SpO2 of 50%. For those that don't know this is bad, very bad. 
Evidently, the baby was not trying to latch a number of hours after she was delivered by c-section. Eleanor, the NP working in the PACU, is a lactation specialist at home. Her gut told her something was wrong, so the baby was hooked up to a pulse oximeter. That was when the dangerously low O2 levels were discovered. 

This is when teamwork and ingenuity become really important in a resource-poor environment. 

We managed to get a modified O2 hood on the baby, but had to figure out how to transport the baby to the nearest hospital for more intensive care. Someone was able to get an ambulance, which was more of a regular vehicle than what we think of as an ambulance, to transport the baby The final piece of the puzzle was how to keep the baby warm on the 20 minute transport to the hospital. We all looked at each other and collectively said, "Skin to skin, " but who was going to do this? The mother was unable to travel with the baby because she was still recovering from her c-section. One of the midwifery students immediately volunteered and we quickly moved to the other room where I held up a sheet for her to tuck the baby into her shirt and they were off in the night to the hospital.


It is a very helpless feeling to do all that you can do and still know that it might not be enough. To know that the randomness of birth would likely give this baby every chance in the world at home but here life hangs by a thread. That Guatemala has the worst newborn mortality rate in the Western Hemisphere and how none of that matters when the mother is looking at all of us wondering if her baby will die and all there is to do is pray. And you pray regardless of what you believe because that's all that you can do. 
When a nurse volunteers to take the baby to the nearest hospital on her bare chest because that's the best chance to keep the newborn warm and alive until it arrives. And it is all that we can do to not break down and cry because of the life that hangs in the balance. 
We were all restless in bed while holding our breaths waiting for news of the baby. 
I always think of things that I have read when I have experiences like this.
"so much depends
a red wheel
glazed with rain
beside the white
-William Carlos Williams

In the morning, after transferring the baby to a local hospital, along with some of our L&D and neonatal nurses who stayed for a few hours, the baby did well and was nursing. 


This baby was the 7th daughter of a couple who had so desperately hoped for a son. The only son that they had was stillborn. You couldn't help but notice the tears and ambivalence of the father when he found out that it was a girl. The mother had opted to have a procedure so that she would no longer get pregnant, so this baby was their last chance for a boy.
A few days later, the father came back to the hospital desperate because the nearest hospital was a private hospital. The hospital was pressuring him for money that he didn't have before they would release the baby. The baby wouldn't have survived to make it to the government hospital over an hour away. We couldn't help out the father with money because that would set a bad precedent and be unethical. 
This brought up many ethical questions. Should we have even tried to help the baby, if the parents couldn't afford the care and we couldn't give them money to help? Had the baby taken an anoxic hit that would cause complications for life? The issues of ethics comes up in one way or another while doing medical work in underserved areas. It is a tough thing and lends itself to criticism and the concept have having an overall code of conduct on these trips.

Guatemala is such a beautiful country but it's tough here. Really tough. We have people coming from Altaverapaz- a few hundred miles away. The national cancer center is not functioning. Treatable cancers are now a death sentence in Guatemala. People in government hospitals are expected to pay for and bring their own suppose including sutures, etc. If you cant afford private care, you are up a creek without a paddle.


And then there is happiness:

One of the days midweek was a 14 hour day today with one amazing highlight. A woman walked in with imminent labor and delivered her baby within about 20 minutes. She rested in recovery for about 3 hours and she walked home with her husband, mother, and healthy baby. This was a picture of the beaming abuela with her new grandson.
Joy is contagious. She hugged and kissed all of us even though we had nothing to do with the delivery. This work is the antidote to compassion fatigue. 
I thought of a book that I read, "Maybe that was how to heal. I told myself stories and learned that I could be made of the ones I chose to tell, not simply the ones that life had laid haphazardly around me."-Francisco Goldman, The Long Night of White Chickens

Abuela with her newborn grandchild.

San Raymundo, Guatemala
San Raymundo, Guatemala
San Raymundo, Guatemala
San Raymundo, Guatemala
San Raymundo
San Raymundo

The improvisations:

One of the nurse anesthetists had to give a patient a nerve block. He rigged a machine that was like a train of four to a long needle to locate the nerve. He injected the patient and it worked beautifully.


We needed some y-tubing in the PACU because we had only one air compressor and 2 patients that needed O2. Some tubing, a syringe, and a few minutes later, we were in business.


The last day during the last surgical recovery, the power went out. Cell phones lit the OR. Iphones were finally used for a greater good.


We wrapped up after 4.5 days of clinical. Hopefully some lives were changed and maybe made better with this Refuge Mission. The team was a huge part of the success of the visit. It was a great experience and I hope to do it again.

Final tally:


And a great team:


Thanks to One Nurse at a Time for giving me the scholarship and the opportunity to participate in this great mission with a wonderful organization. I will definitely work with Refuge again and I would highly recommend them for future scholarships.

Happy Thanksgiving,

Amanda Judd

Monday, September 21, 2015

Jo's Nurses work in Chocola, Guatemala

2015 Jo's Nurses with Refuge International

Chocola is a remote village in the mountainous southwestern region of Guatemala where there is no government assistance in education, health or roads.  Sadly because of the country's political climate there is no help for the indigenous people.  They're abandoned.

Dr. Sergio Castillo and his wife Veronica first visited Chocola about 15 years ago.  They were shocked to encounter villages in deficient conditions with advanced illness including malnutrition, infection, and waterborne illness.  They found an abandoned building in the heart of the community and started a hospital catering to the indigenous Mayan people.  In 2005, after the devastation of Hurricane Stan, Dr. Castillo partnered with Refuge International to help expand the care to the region. "To have a complete team of surgeons, nurses, anesthesiologists armed with medicine was like the answer to our prayers.  For me, it's an honor to be able to help our people.  Refuge allows me to help others.  I'm like a bridge for the people with extreme needs and the services of Refuge." Says Dr. Castillo.

Dr. Castillo is a very positive, inspirational, humble man.  He remembered all of our names and always greeted us with a big smile, thanking us constantly for helping his people.  I will never forget our second night there.  It had been a busy day, the usual torrential thunderstorms where playing their symphony on the tin roof.  After a delicious dinner cooked by Veronica we made our rounds in the hospital.  To our surprise the Inn was full.  Dr. Casillo had invited all the families to spend the night because they live so far away and the thunderstorms were so bad.  We had families sleeping in preop, postop, and even in the courtyard.  It warmed my heart to see such a gracious, giving spirit in action.

I would have to say that our first case was one of the most memorable and inspirational to me. He was an 80+/- (they don't know their exact age) old hernia case.  Hernia's are very common because they work so hard and do a lot of heavy lifting.  While I was caring for him his son came back and told us through the interrupter that he walks 8 miles two times a day to carry wood back to the village for cooking and their campfires.  Wow, was he in good shape.  He always smiled, never complained, took no pain meds and was so grateful for all we did.  On so many levels I feel that the indigenous Mayan people of Chocola have a lot to teach me.  They are truly an inspiration.  They are intelligent,
hard working, disciplined, humble, respectful, compassionate, loving people with a strong sense of family and community.  I feel that as we work together we can learn and help each other.  We can help them with our medical/ surgical and technical expertise and they can help us take a step back and realize what is really important in life.

Thanks again One Nurse At A Time for the scholarship that made this amazing opportunity possible to serve the people of Chocola, Guatemala.  Thanks also to Refuge International for their wonderful work in helping to provide healthcare, adequate nutrition, clean water and education to those in need.  I hope that other nurses will hear the call and want to help with the wonderful work that Dr. Castillo and his family are carrying out in Chocola.  Thanks again 

Bonnie Madeja

Thursday, April 23, 2015

Update on Emily Scott's experience in Sierra Leone

Filling In The Blanks
My colleague who was infected has tested negative for Ebola and been discharged from the National Institutes of Health. The 16 Americans being monitored as “high risk” contacts have all passed 21 healthy days. My cohort – the clinicians with whom I trained, traveled, and worked – are all home and well past their 3 weeks of monitoring. I am back at my day job. By all accounts, my experience as an Ebola responder has finally come to a full stop. But issues still linger, and details of what we went through are still coming to light. I know a lot of you have questions, because I’ve heard them from you, the most common one being: “All of a sudden you just stopped writing… What happened?”
Since many of the details have come out in the news, and because all of the clinicians involved are home and healthy, I think now is an appropriate time to fill in some of the details. I would never endanger the privacy of anyone I worked with, so some aspects of the story will be vague. Most of it you could piece together by picking through the news over the last several weeks, but I can share with you how it felt to be in the eye of the storm.
My last good day in Sierra Leone was a Tuesday, the day before I found out that our colleague had Ebola. It was my first day off since arriving in country, and I had plans to meet some friends from my cohort at the beach. After a few days of training and working at Maforki Ebola Treatment Unit, the twelve of us had been split up to work at different facilities based on where Partners In Health clinical leaders thought we would be most useful. Most of my cohort had remained in the Port Loko district to either continue working at Maforki or to help out at Port Loko Government Hospital, where patients with non-Ebola related health issues were treated.
While it may seem like Government Hospital would be an ideal place to work since you wouldn’t have to worry about Ebola, in reality many of us felt that working there seemed more dangerous than suiting up at Maforki each day. In an Ebola Treatment Unit, at least you know for sure that your patients have the deadly disease, and each time you interact with them, you take the proper precautions. Government Hospital was more of a gray area. It was expected that no patients with Ebola would enter the facility, so clinicians had no need to don their full Personal Protective Equipment (PPE) when entering the wards. Just like in the States, if you’re treating a patient for cancer or malaria, there’s no need to wear a hazmat suit to do it.
But what if a patient slipped through the imperfect triage system and was admitted to the hospital with Ebola, under the assumption that it was a different disease? Or, what if someone was admitted while incubating the virus but before becoming symptomatic? Ebola has a 21 day incubation period, meaning that if I am exposed to the virus, I could walk around for up to 21 days without showing symptoms and without being contagious. I often wondered how strictly the patients at Government Hospital were being re-screened after admission. If a patient was admitted with malaria and a few days later started showing symptoms of Ebola, would it be caught in time to protect the clinicians who had been treating him without full PPE?
I never worked at Government Hospital, so I really can’t say for sure. I have heard varying opinions from the doctors and nurses who served there: Some say they felt perfectly safe, and others say they had serious concerns from their first shift there. It was at Government Hospital that our colleague who turned out to have Ebola collapsed, and several other clinicians came to his aid, assuming he had fainted from heat exhaustion.
I never saw Government Hospital for myself because, as you know, I was sent back to Freetown to work at Princess Christian Maternity Hospital, the Ebola Holding center for pregnant women. I loved the work. The plight of pregnant women in Sierra Leone was like nothing I’d ever seen; I felt my skills were sorely needed, and I woke up excited to go to work each day. I noticed imperfections in infection prevention and control policies from day one, but I did my best to protect myself while I worked with my colleagues to address them. While I wished my concerns had been taken more seriously, my desire to continue my work completely outweighed the level of risk I felt I was taking.
So when my day off coincided with that of a good friend who worked hours away at Maforki, I jumped at the chance to meet him at the beach to decompress and share our experiences. It was a fantastic day of swimming in the surf, sunning ourselves on the beach, and unloading difficult stories of our work over a healing beer or two. It was jarring to turn back from the gorgeous turquoise waves and think that a short drive away, people were fighting a deadly disease in horrific conditions. But we put Ebola aside just for the day, and lingered as long as we could while the sun sunk lower and lower toward the water, until we knew it was time to head back to reality. I felt recharged and excited for the next day at work.
Among the stories my friend shared with me that day was the news that our colleague had collapsed while working at Government Hospital. To be honest, we thought nothing of it. Sierra Leone is very hot and clinicians are working very hard; it didn’t surprise me to hear that one of us had passed out from the effort. If you’re used to working in an air-conditioned hospital with plenty of staff, it would be a shock to the body to run from one emergency to another in a poorly-ventilated ward in 90-degree heat. I told my friend to give our colleague a hug and a stern talking to about taking better care of himself when he saw him next. Without going into the details of his situation, I simply did not feel we had any reason to worry about him.
I was still in my pajamas the next morning when a PIH staff member knocked on my door and asked me to get dressed and come downstairs for a meeting. Again, I thought nothing of it. It wasn’t until everyone was assembled and leadership started telling us that in four months of working in West Africa, PIH had never had a clinician become infected with Ebola yet, that I started to feel the weight of what was coming. It settled in heavy on my shoulders, and I knew what he was going to say before he said it. Our colleague had tested positive for Ebola.
It was a difficult moment to process because most of my friends were hours away in Port Loko. Almost everyone else in Freetown at that time was from a brand new cohort that had just arrived in country. I was one of only a few people there who even knew who the infected clinician was, and I certainly wasn’t going to share that information. I went back upstairs, put on my scrubs, and went to the unit to work. I donned my PPE and went into the Red Zone, trying to focus on the task at hand rather than the questions swirling through my head.
The next few days were a whirlwind. I don’t feel it would be helpful right now to share every detail of how things played out, or to pass public judgment on how PIH handled the situation, whether positive or negative. As you know from the news, one of PIH’s Sierra Leonean clinicians fell ill with Ebola shortly after our colleague was diagnosed, and in the end 16 American clinicians were sent home on chartered flights after the CDC deemed them “high risk” for having had physical contact with the infected clinicians after they became symptomatic. It was a frightening few days, and more than a few times I thought to myself, “Am I next?” I have complete certainty that our American colleague followed procedures exactly, just as I felt I had. Where was the breach that exposed him? Had he and the Sierra Leonean clinician made the same mistake without realizing it? Had I?
An investigation into infection prevention and control procedures at PIH facilities was of course initiated by PIH leadership. My colleagues and I stepped forward with issues and suggestions, while we waited to see what the next step would be. After a few days, myself and several members of my cohort reluctantly decided that it was no longer safe to continue our work there. Please don’t think for a moment that we took this decision lightly. I can say with certainty that absolutely no one I worked with wanted to leave. Least of all me. I felt that the work we were doing at PCMH was incredibly important, and I honestly wish I could still be there. In dark moments I think about the women I could have helped if I had stayed longer, and hope I didn’t abandon someone to die because I wanted to protect myself. Again, I won’t go into the specific details of what made me feel I needed to leave, but I was (and still am) confident in my decision, although it broke my heart to walk away.
I don’t doubt the good intentions of Partners In Health. They leaped into the fray in West Africa several months ago when the outbreak was at its peak, when they certainly didn’t have to. The first teams of PIH clinicians bravely provided care at Maforki when there were 100 patients in absolutely horrific conditions. Having been there when we had 10 patients, I am in awe of those first teams. But could things have been done better, made safer, the level of care improved more in the interim between those first days and now? I think so. The events of the last several weeks have shed some light on those issues, and on what changes need to be made.
Since I left Sierra Leone, I am hopeful that PIH has been addressing infection prevention and control issues and improving the safety of their clinicians while continuing their commitment to the people of Sierra Leone. By their own admission, emergency response isn’t PIH’s specialty; they are an organization that normally works on long-term development projects. As cases of Ebola drop to the single digits in Sierra Leone and to zero in Libera, PIH’s real expertise will come into focus: Health system strengthening. After the last case of Ebola is over and emergency response groups have left, Partners in Health will remain in Sierra Leone and Liberia for years. They will continue to work in government hospitals and rebuild health systems that were ineffective to begin with and completely destroyed by the outbreak.
Here’s a perfect example: In Sierra Leone, when a person is admitted to the hospital a family member normally stays with them. This family member does much of what is considered to be “nursing care” in America: feeding, bathing, turning the patient. Sierra Leonean nurses do not regularly assist patients with these activities because there is always a family member at the bedside to do it. After Ebola ran rampant through hospitals, spreading from patient to patient and killing healthcare workers, no one wanted to set foot in a hospital any longer. No one can sit by the bedside of a family member with Ebola and expect to escape infection themselves. Even when Ebola patients were isolated to separate Ebola Treatment Units, and regular hospitals began to resume care for other illnesses, the fear remained. It will be a challenge to convince Sierra Leoneans that it is safe to bring sick people to a hospital, and to visit and care for their loved ones there.
In the meantime, Sierra Leonean nurses will have to learn to care for patients in ways they never have before. I heard from many American clinicians who were shocked by what appeared to be the apathy of the nurses, who didn’t bathe or regularly turn ill patients, leaving them to develop bedsores. But these nurses have been risking their lives to provide care during an Ebola outbreak in exchange for a pittance from the government that may or may not arrive; they are worn out, and afraid for their own lives. It also helps me to remember that they have never witnessed care being given at the level that we provide it in the United States. They have nothing to compare to. What seems inhumane and unacceptable to us is the status quo for hospitals in Sierra Leone. Education can change this. PIH will tackle these issues, and more, for years to come.
Shortly after I left, I heard that another facility in which PIH works had received its first case of measles. It won’t be their last. With vaccination programs shut down for nearly a year during the Ebola crisis, West Africa is a measles outbreak waiting to happen. Care of pregnant women and newborns was abysmal before Ebola, and even worse now. Everyday illnesses like malaria, typhoid, cancer, heart disease… you name it, and I guarantee you wouldn’t want to be treated in Sierra Leone if you came down with it. PIH is staying in West Africa to try to change that.
For more on what occurred in Sierra Leone surrounding our colleague’s infection, check out these articles. I’ve included one by the New York Times and a couple of others from Partners In Health’s perspective. I find some truth in all of these articles. Very little in global health is ever completely black and white, including my experience in Sierra Leone. My hope is that everyone involved will learn from this situation and continue to improve our efforts as humanitarian responders. I know I have.
Article by PIH clinician: All Lives Matter
Letter from PIH’s founder: Redoubling Our Efforts