Cameroon letter #3 - orienting to MercyShip ward nursing

Dear Ruthanna,

It’s been a really busy week. The last day I wrote to you was Monday. On Tuesday I started ship orientation. In the morning all the new people – about 20 of us from places as far apart as Oregon and Queensland. Then they split us up by departments and we met our supervisors. My nurse educators are three young nurses who’ve been on the ship for several years. They are smart and enthusiastic and I liked them right away. In the afternoon we toured the ship’s four wards – A, B, C, and D – and looked briefly at the ICU. The ship is basically a several-decade-old 8-deck cruise ship, with staff housing scattered across all levels, a cafeteria on level 5, and the hospital wards and operating rooms on level 3. A Ward has mostly pediatric patients, B Ward is populated by women recovering from fistula surgeries, C Ward is currently empty, and D Ward houses maxillofacial repair patients of all ages. The ICU here contains only two beds and is rarely occupied; I’ve been working on D ward, with 3 patients each shift.

View of one of the rehab shelters through the netting on the side of the ship (I don't work there but some of my friends do)

The wards are so different here from the US, small rooms with narrow cots side-by-side, separated only by curtains that are rarely drawn. Privacy and accuracy of measurement are both very limited. The patients share a bathroom because most of them are ambulatory. The patients wash themselves, or are washed by family members. Accurate intake/output measurements are limited because patients do their own care, frequently refill their own water pitchers, and dispose of waste themselves. We give the patients a narrow range of antibiotics, antiemetics, and topical agents – I have yet to see Zosyn, Meropenem, Protonix, or Vancomycin. There is only one desk in the unit, immediately below the cupboard where we keep medications, so most of the time I have to prop the patient’s chart on the shelf at the foot of the patient’s bed to write in it. Narcotic meds are kept in a little safe, but all the nurses know where the key is. We cosign them in a binder. Other meds are kept in an unlocked cupboard. Patients who have had oral surgeries return from the OR with NG tubes sutured into their nares through which they receive tube feedings every 3 hours, following a laminated protocol contained in every chart. A nutritionist mixes the feeds daily and stores them in baby bottles in the fridge. For patients who can drink, we blend milk and Mana – a peanut-based supplement that reminds me of PlumpyNut.

Sometimes I have enough time to draw and color with my patients (I signed these with my very limited French and Fulfulde)

The patients are different from patients I care for in the US, too. None of the patients is anywhere near US ICU acuity – partly because MercyShips carefully screens patients, and can’t operate on unstable ones. We can’t tangle ourselves in the kind of clusters the US healthcare system caters to, the hurricanes of futile interventions leading to an inevitable death we make increasingly ugly by our inability to accept it and meet it with grace and dignity. Although patients present to MercyShips with disease processes far advanced beyond what I’m used to seeing in the States – in the US we operate to remove parotid glands when they are just slightly enlarged, not the size of a baseball – they are younger and stronger than many patients in the US. I mean, they have to be, to tolerate a cramped twelve-hour bush taxi ride along pot-hole punctuated roads, intermittent malaria, and the malnutrition that is aggravated by a cleft lip/palate or large facial tumor. 

And the patients are nice, they are so nice. I’ve had some nice patients in the States, but these patients eclipse everything I’ve known – except Niger. Although patients in the States would probably throw tantrums about sharing such a small space, MercyShips patients seem pretty gracious about it. They throw a sheet over their heads and sleep through loud noises. They sit up at the foot of their beds, their heads wrapped in cotton gauze and Kerlix, playing cards and Ludo together. They watch in quiet fascination, muttering soft commentaries to each other, when any of the other patients is in distress, taking meds, or having a dressing changed. Sometimes, when we can’t find a translator who speaks one patient’s language, another one steps in as translator. Their designated family members/caregivers sleep under their cots and become friends with each other and with other patients. They don’t question what medications I hand them, and they don’t attempt to refuse anything. They thank you constantly. They rarely ask for things; I have to ask at length to find out what they may need. I have to probe when they say “yes” to make sure they’re not just lying because they want to seem agreeable. I have to tell them, “your face looks like you are in pain,” to get them to rate their pain higher than a 0/10. When they are asked to wait, they typically do so. Their families accept the end of visiting hours without complaint, even though visiting hours are less than 2 hours daily. 

On Wednesday I worked an 8-hour day shift (0700-1530) with Kevin, an energetic, friendly ER nurse from California, as my preceptor. Honestly, everyone I’ve met here is friendly. Kevin had that great nurse vibe of being chill and also thorough, which made my first shift a lot easier. It was hard to switch to paper charting, paper medication lists, and paper order sets. I was thankful that I worked with all three during my first job at Reston; nothing was completely new. At the end of the shift we took the patients upstairs to a net-enclosed section of deck 7 where the children can play safely while the adults sit and enjoy the fresh air and the rivermouth view. Many of the adult patients are women who had fistula repair surgery, and I’m finding that right now most of those patients are Fulani women from the Northern (Muslim) areas of Cameroon. They speak a slightly different dialect of Fulfulde than the Wodaabe (the subgroup my parents worked with) did, but we can patter along and try to understand each other. I never spoke Fulfulde well, but I understood it, and now that we often don’t have an interpreter for it I am actively trying to learn it. The patients enjoy my attempts, and it’s good to see them laugh when I fail. They are pleasant, but life has been hard to them and I don’t see them laugh often.

On Thursday I worked an 8-hour evening shift (1400-2230) with Kirsten, a warm, detail-oriented nurse from Pennsylvania. It turns out her last job was at my last place of employment – HMC. What a crazy small world! She helped me fine-tune my charting and figure out nuances of working on D Ward. At the end of my shift I felt mostly prepared to come off orientation. Orientation on the Africa Mercy is short, only 2 shifts, but it felt adequate for what I need to know to do the job. It would be much harder to adjust if I was a new nurse without previous experience. I also began recognizing patients on the ward. One lady in particular, Amina, has been in the Mercy Ships hospital for months because her cleft palate was very complex to repair. Despite many complications, she remains sweet, friendly, and patient. She is primarily Fulfulde-speaking and is extremely amused by my weak attempts to string sentences together. Because I’m one of the only Western staff members who knows enough Fulfulde words to try to put them together, she has decided I’m her special friend and she likes to stroke my hand, like the Wodaabe women used to, and repeat, “Tabi is my friend, she speaks Fulfulde to me.” When she kept repeating it, I finally said, “My Fulfulde is limited and it’s the Fulfulde of the Bodaados, the Bororos.” (“Bodaado” and “Bororo” are terms the Hausa and other tribes sometimes use to tease or mock the subgroup my parents worked with because the Wodaabe have a superiority complex and like to sequester themselves from interacting with other tribes.)  Amina is not Wodaabe, and she thought this was hilarious. She and another Fulani lady spent the rest of the afternoon joking over it. They then decided to call me “Auntie,” because Amina said I look like I’m at least fifty years old. I think that may also be a joke. I’d like to think so, at least…

On Friday my bunkmate Jill and I got up early to have breakfast together. I was still a little jetlagged, so I spent the morning napping. I worked my first evening shift on my own, and it was wildly busy. I was thankful that of my three patients, two spoke Hausa or Fulfulde and the third had a sheet of phrases I’d copied from a Mafa interpreter (while we still had one the day before) that I was able to use for basic communication. We had several postop patients come out from PACU, a baby we’ve been caring for kept vomiting and pulled out her IV, a pediatric patient was also vomiting but her jaw was wired shut and we were struggling to calm and suction her, Amina was feeling worse, and my Hausa lady patient became very annoyed with me because she wanted to lay the head of her bed flat but it wasn’t good for her recovery from a parotidectomy to lower her head. We have to mix all our own IV meds and we don’t run most of our drips on IV pumps (we use drip rate calculation) so it was hard to stay on top of my hourly intake and outputs. Thankfully, the patients who were feeling well simply amused themselves playing card games, or sat at the foot of their beds staring silently at the patients who weren’t feeling well while the nurses rushed around or hovered over the vomiting children. 

The main thing I’ve concluded after my first three shifts here is that I wish patient rooms in America weren’t private. The patients here are less lonely, they act as advocates for each other and develop friendships, they seem to have a much better sense of their own relative illness and urgency of their needs when they can observe other people, they are easily entertained watching each other, they are motivated to keep up and be mobile as they watch each other move and improve, and they help each other out, which seems to improve their own sense of self-efficacy and autonomy. When the nurse isn’t at their bedside, they can see that the nurse is either preparing a medication or helping another patient and they respect how busy we are. I wish patients had to share rooms, or bunked in large wards, in the US, too. It might be an infection control issue on some levels, but I think its benefits would outweigh its risks. I think its effect on selfishness and lack of initiative would be one of the most significant ones. 

Now that I’m gone, it’s just you and Sarah. You might move into my room. So:

A)                         I forgot my swimsuit in the top drawer. Please don’t wear it, it’s mine, I paid for it, I want it. Please put it with my things in the attic. I’m going to need it in Florida. 

B)                          Sarah is the only real sibling experience you have now that the rest of us are gone. I would have envied you so much when I was your age – getting to share your room with a sibling only 4 years younger than you, or having my own room. But now I think you actually have much less opportunity than I did - while you have more freedom and privilege, you have fewer close family relationships to teach you how to love with grit and sacrifice in the mundane. Living together as siblings is, for children, what sharing a ward with other patients is for patients. It teaches you virtues – humility, collective identity, sharing, resourcefulness, responsibility, patience. Don’t waste the one opportunity you have – Sarah – to learn, in a profound, incredibly effective way, how to be an enduring giver to society and not a whiny taker. There are enough individuals in this world, enough isolated selves. Don’t become another deceived island floating with your margins across everyone else’s pretending you are alone in the sea. You are here in this world to overlap, and to do it in a way that makes everyone else shine brighter, live fuller, feel safer, love more deeply. You don’t make that happen by demanding your rights. You make it happen by sharing your waffles, complimenting her outfit, helping another patient hobble to the bathroom and showing them where to get a new washcloth, translating Mafa for me, the struggling American nurse. You make a beautiful world possible when you are faithful enough in little that much trust is given to you, and as you look at the trust that has been laid in your hands you realize that all the little faithfulnesses have made you strong enough not to break this great great thing the world rests on. Remember that the one you are called to look like is the one who was actually entitled to everything but didn't resent losing all of that, being demeaned and belittled, being treated unfairly and unjustly and ultimately killed, because he was set on the glory of making humans understand that God loves us enough that we can rest our worlds on trust. 

Love you, Tabi