Nurse in Kenya: November 2014

“Indecision is like a stepchild. If he does not wash his hands, he is called dirty. If he does, he is wasting water.” (African proverb)

"Somewhere along the line of development we discover what we really are, and then we make our real decision for which we are responsible. Make that decision primarily for yourself because you can never really live anyone else's life, not even your own child's." (Eleanor Roosevelt)

I remember how painful and pathetic of a realization it was, one day, to finally notice how desperately afraid I was to make a mistake. I was sitting with my friend Mary, on her neatly made bed, in her warmly and kindly decorated bedroom on an inhospitable, rather unpleasant winter’s day. I had brought myself to her place to chat, as I felt in those times that I had become caught in a stall-formation of stagnated living; I wasn’t sure which way to go next and I was afraid to make a decision. She and I had been discussing my own life at great lengths – what I felt like were my personal successes and failures, what I had done wrong and right in my own eyes, and specifically, ways in which I felt like I had made the wrong decisions and left other people to sift through the aftermath. After a tiresome and really exhausting litany, then exposing a whole host of what I considered to be my emotional liabilities, she looked at me with a restful face. She said something like, “My dear, you are a lovely young lady who simply needs to stop constantly thinking about all of the mistakes you think you have made.”

As a medical practitioner I am required to make decisions about my patients’ care every single day. As the “nurse in Kenya” I have had to learn to trust my guts, listen to my intuition, draw from my experience, rely on my intellectual knowledge, and decide what to do next. Knowing that I am on the front line and similarly at the end of the line of almost all of the medical decisions here at the children’s home sometimes feels like a weighted responsibility. Really though, most of the time I feel like it is a keen and really unique privilege that I cherish. I do have the duty – the sometimes formidable, but actually precious, duty – to decide what should happen next with our sick kids, and frequently even my sick coworkers. Lately decisions come easily as I’ve “learned the ropes,” as they have affectionately tied and knotted themselves around me. It wasn’t always that way, though. Don’t forget – I came here knowing almost nothing about tropical medicine, and having cared for fewer than five children, on the clock, ever in my life.

I think back to a time I was in nursing school. I look back on what it was to appreciate the fact that I was going to be responsible for other people’s lives. It was a frightening and overwhelming notion to realize that the responsibilities I had considered for whole life were finally becoming real.

I knew from what my mother and father had taught me, growing up at a dinner table where medical jargon was passed around with the green beans and the pepper shaker, that medicine was about so much more than passing meds and writing prescriptions. I had been raised with the caring mentality: that house calls were still appropriate, that you took care of the sick even when it made you sick yourself, and that you, as the practitioner, were the end-all-be-all for that ailing or even helpless patient. I remember being in grade school, listening to my mother while she leaned against our white-tiled kitchen counter telling me stories about tough decisions she had to make in her career as a critical care nurse. I remember wondering how it all could have come so easily to her. I visited the operating rooms in which my father would cut people’s eyes open and give them their sight back and I wondered how he could be so confident to take someone’s life into his hands like that. I witnessed my mother tirelessly caring for her own infirmed mother in our home around the clock for nearly seven years and admired her commitment to her decision not to put her back in a nursing home. My parents demonstrated to me what it meant to joyfully embrace the responsibilities of caring for human beings and I looked up to them for it, with every word-almost-too-long-for-me-to-understand along the way.

But then, all of a sudden, I was twenty-two years old and the charts were in my hands. It was my signature at the end of the progress notes, my thumb on the syringe plunger, and my brain doing the calculations to determine how many mLs of a vial of medicine to draw up to equal a prescribed dose. And those patients – it was their hearts beating in my eardrums at the end of the stethoscope, their sweaty palms I held while they pushed their babies out, and their loved ones I was comforting while they died. I remember feeling ill-equipped for the task put upon me, for the career to which I knew I had been called. I remember being afraid that someday I would make a mistake that would hurt someone or that I wouldn’t be able to provide my patient with what they needed, when they needed it most. After all – it is a big responsibility, and I knew I would make mistakes and that I couldn’t possibly meet all of their needs all the time.

When I graduated from nursing school I started in the ICU right away and I felt like I had bitten off way more than I could ever chew. Over time I felt more comfortable being around the critically ill as I learned more about what they needed from me, what I needed from the physicians, and what I needed from myself to get the job done. I went through plenty of struggles coming to accept that I was being asked to, and was also able to, make decisions that would dramatically my patients’ outcomes. I asked a lot – a LOT – of questions. To me, it was worth it to swallow my pride and approach my senior nurses for their experience instead of acting like I knew how to handle every problem my shift could throw at me. I had doctors demand that I be the one to make the decision, even if I didn’t eventually (like that time right before I heard the phone slam down on the other end, ending a two-a.m. call I made to ask for orders when my once-alert patient become unresponsive, when I heard the doc hiss, “do whatever you want.”) After not too long it all got a lot easier and I realized that together, as a team of nurses, we could handle anything together. We had had good nights and bad nights, and some of those good nights were when all we could do was our best to handle horrible outcomes. By the time I left the ICU, I felt like I had been well-equipped to handle what was thrown at me because I had been given, and forced to employ, the tools of critical thinking and clinical decision making: understand what you yourself know, ask questions when you don’t know, get the answers and put them to work for you, do what you can to help your coworkers, and never be afraid to ask your teammates to pitch in when the water is too rough to tread it on your own. I saw many shifts come and go living in that work philosophy, with many people still dying and even more surviving despite the most dire circumstances. I had accepted the responsibility of making decisions in that setting and it worked out.

Then I came to Africa. Here I was (here I am), the sole medical professional at an orphanage of more than a hundred and twenty kids (now more than a hundred and fifty), most of whom were under the age of five (six, now), and I had pretty much no idea how this was going to come off. I was given a set of keys, a computer with all of the kids names and their recent medical histories that also could organize meds to be administered on a daily basis, and a room full of goodies (meds, supplies, and instruments). I would take the kids to the local doctor, and then follow his orders. When emergencies happened in the middle of the night I would call him and he would tell me what to do. Sometimes early-on we had no cell service in our village and I had to figure out what to do on my own. Over the past almost year-and-a-half I can say that it has been quite the journey figuring this thing out, being on the frontier of this children’s home, and equivalently, of myself.

In Kenya, it’s not like it is in the United States. Most practitioners are offended if anyone – especially a “lower” medical practitioner – questions them. It is not appropriate for me to ask physicians their rationale for writing a certain prescription or ordering a certain treatment. I would sometimes have an untoward look or unfriendly tone thrown back at me, but my least favorite response to my still-persistent questioning was an answer that I knew couldn’t suffice for me. I knew even ten or so months ago that my practice was shifting, and that eventually I would be the one making most of the medical decisions, and I knew that I had to equip myself and allow others to equip me for this role. It was a role cut out for me to fill, as many nurses in Kenya prescribe and act as practitioners, “doing everything except surgery,” as my local nurse practitioner reminded me. At the same time, it is not proper for me to work outside my scope of practice, or my scope of experience. So, I had to expand my practice and accumulate experience. I knew I wasn’t going to be able to always rely on the books, the monographs, the package inserts, or even other practitioners for what to do and when. I had to be able to make decisions, and they had to be the right ones.

I have had experiences in Kenya where I knew that I was not willing to trust what practitioners – with more letters, presumably more experience, even if they did have fewer years of schooling than I did – were telling me to do. I’m so thankful that these times have been few-and-far-between, and that I trust all of the providers with whom I regularly collaborate. But in those few-and-far-between times, recognizing my role as the nurse to be the patient’s advocate above all else, I have occasionally, within my scope of practice, had to explore other therapies or treatments for these kids here. They were decisions my directors and my own guts required me to make, and when I learned to be comfortable doing so, things got a lot easier. It was five years ago that I was that twenty-two-year-old nursing student, in a nauseating and poor-fitting teal scrub top, with equally heinous white pants, wondering how she would ever feel comfortable enough with the burden she knew the universe was asking her to lovingly welcome. I guess I’ve grown up as a nurse, if even just a little bit.

Out here I sometimes miss the team I worked with back in New York. I miss being able to ask my other nurses, “does this QT-interval look long to you?” or “can you help me out in room 8? Either I’m not feeling these twitches or my Nimbex dose must be off,” or “I’ve never had many Wound-Vacs to troubleshoot, would you help me figure out why the darn thing won’t stop alarming?” Of course, I don’t have any of those problems here, but I have different ones, and sometimes I have issues outside the scope of what the third-world is used to accommodating. Sometimes I want to be able to ask, “Hey, can you make any recommendations that will dissuade this pregnant chick I’m consulting on to stop eating mud?” (as is the Kenyan way, it is very normal for them), or, “Can you help me get a line in this four-year-old? I really don’t want to have to give this ceftriaxone IM,” or, “What do you think this looks more like, a spider bite or a bee sting?” Sure, I have docs I work with here, and sure, I have a brain on my shoulders, but it was nice to have that safety net. I guess all of this African medicine has made me think harder and faster about certain things, while having to let go of some of the indeed hard-and-fast rules I learned back on the unit. It’s all about decisions, decisions: nursing, medicine, and life alike.

Sometimes, even with all the information we can possibly have, it is still difficult to make a clinical decision. There have been many times I have found myself in the desert of the mind, unable to see the stars, with a broken compass in hand, unsure of which way to go. I usually ask all the questions I can ask, try to find as many answers as I can, get other people’s recommendations, and then go from there. So far I haven’t hit any land mines out in the sand, and a source of water is never too far off. I guess that’s what happens when you know how to ask for directions, even if you aren’t sure how to fold the map back up afterward.

I’m happy to say that I do have support from the States even though I’m thousands of miles away. In upstate New York there is a growing body of generous physicians committed to patient care who have employed a program called iClickCare (visit them at http://www.clickcare.com) so that providers can collaborate with one another through a secure server. Providers can exchange pictures and patient information quickly and confidentially in order to receive expert consultation upon request. I have used this service many times and have been absolutely thrilled with my ability to connect with the first world from far away. It has been a huge relief to be able to be able to pick these doctors’ brains about what they would do if they were in my shoes (or sandals, as the case is usually) in a variety of situations. I can definitely attest to the fact that if I have any kind of first-world medical team it is only through iClickCare. I am deeply grateful to the Drs. Kerr and the whole iClickCare team as they have assisted in several difficult case presentations – they have really made a difference in the lives of our kids over here. If you are a medical practitioner, in the first-world or beyond, I strongly recommend that you consider participating in this service.

Nurses, Nurse Practitioners, Physicians Assistants, Osteopaths and Medical Doctors are all practicing medicine - we can never have all of the answers in and of ourselves. My experience has been that if we think we do have all of the answers, we are headed for trouble. We best serve our patients by continuing to keep an open mind by learning and considering others’ clinical experience, without abandoning our guns that we have seen fire reliably. Their lives depend on us making decisions, that those decisions be sound, and then that they also be executed properly. Making clinical decisions isn’t a cold and detached process either – it might be as important in the long run that we chose the correct dose of the correct drug as it is that we took an extra two minutes to sit on the edge of their bed, take their hand in ours, and just listen to what they need to say.

Maybe one reason why it has become simpler to make clinical decisions is that making my own personal decisions has become equally as simple. As I mentioned at the beginning of this essay, there was once a time that I felt paralyzed in my own skin by a fear that I would make the wrong decision and mess up my life or someone else’s. Indecision, I learned, is as lethal personally as it is clinically. How long did I spend my days worrying about what I should or shouldn’t be doing, instead of doing or not doing without fear, willing to accept the consequences of my actions without regret?

Honestly, when I came to Africa the very first time I remember feeling like life cornered me against a wall and seized me with its fingers around my neck. It looked me in the eyes and talked to me so close I could feel flecks of its spit on my face. It seemed like it wanted to yell, but kept its voice low and hushed, as it explained to me that I couldn’t be afraid of making the wrong decision anymore – that I was not practicing my lines in a dress-rehearsal, but that I had been on the stage of life all along. It reminded me of something I had once knew, but had forgotten since I was a kid: that it was my job to live my life the way I best saw fit. It urged me to confront myself: the desires I tried my best to ignore and dismiss, my brilliantly painted dreams I had left to dry out and flake off onto the floor into a pile of dusty chips that I dreaded sweeping up. It forced me to see, accept, and enjoy that I was who I was. Life got me alone here, long enough in the Rift Valley some two and a half years ago, to make me realize that I had been avoiding it for too long, that it missed me, and that it wanted me again. So I let life have me. I made my decisions and lived them out. I’m still living them out.

We all make decisions every day, mostly without even realizing or consciously thinking about them. The substance of our lives is a conglomeration of the effects of every decision ever made for us or by us. There are times when we need teams of people to help us make decisions, while other times it just takes the actions of one person, even across the world, to change the course of life forever. It has taken me some years to realize that, in a world where many decisions are made for us, it’s critical that we make the decisions that are ours to make ourselves. There are times to ask questions and get opinions and there are others times when this is not necessary or even appropriate. I have come to embrace life’s inevitability of errors, and my own determination to pursue their resolution. Today, the decisions I make in my own life have taken on a new dimension of their own; they are accommodating and generous, warmly lit and inviting. They are mine to make, to enjoy, and to love.

And, oh, how I love them.