Nearing the end . . .

It has been almost two weeks since the all day trauma and mass casualty training and drill and I couldn't be happier in how things turned out.  While I prepared and planned and did my best to make sure I was as organized as possible, I realized that the whole thing could implode and be complete chaos.  I felt strangely calm about it, though.  I did my best and while I had low expectations, I hoped for the best.  And it exceeded all my expectations.  Despite a late start in the morning and a bit of frustration as I waited for attendees to straggle in, the training went really well.  Participants were engaged, answered questions and seemed really excited about the hands-on case scenarios we went through in the morning. After lunch and brief directions on the plan for the mass casualty drill we headed to the Accident and Emergency Department for the actual drill.  There were swarms of people.  Staff from all over the hospital, plus A&E staff as well as University of Washington nursing students, residents and faculty were clustered in groups waiting for instructions and for the start of the drill.  My fellow students and others from the UW were gracious enough to help me by being patients for the drill.  They all had their scripts and were ready to act out their parts.  Some were kids, some patients with minor injuries and even one who was pretending to be dead.  After loading up the fake patients in the ambulances for a simulated arrival of our first mass casualty victims, the staff swarmed the ambulances and started triaging, helping patients out of the ambulances onto gurneys and wheelchairs.  I stood back taking pictures and then as patients were sorted into the appropriate treatment areas I stood by bedsides to listen to the staff talk through the primary and secondary survey and discuss how they would treat each of the patients.  And it was here that I realized how well things were going.  Everyone had a job, the chaos was held to a minimum and patients were sorted to treatment rooms in pretty quick succession.  As I listened to staff talk to each other and think out loud I felt my heart swell with pride. I was seeing that morning's training acted out and being put to use.

Almost all of the feedback I received was positive and I heard staff talking about doing more drills and training in the future.  Seeing staff feel empowered and excited to do more was more rewarding than I could have ever imagined.

A week later while talking to one of the staff, I asked her what she thought of the training and she had pretty positive things to say, and then she said, "I realized how important CMEs (Continuing Medical Education) are," and it was music to my ears.  If I had just one convert, it's more than I could have hoped for.

Be careful what you ask for . . .

The last few weeks have been challenging and I have continued to ride the roller coaster of my emotions, feeling down and dejected one minute and then excited and optimistic the next.  My efforts to implement some sort of trauma training program seemed fruitless after multiple canceled meetings and a somewhat lukewarm response to my questions about what staff were looking for in terms of training or education.  Not really knowing what else to do, I talked with some staff about a good day to do a training, set a time and started working on a presentation.  I wasn't sure how many people I would get, but I hoped for the best.

I stopped going to Casualty on a daily basis due to the MO strike and a low census and stayed at the guesthouse most mornings to work on materials for teaching.  Friday morning I was struggling to stay motivated as I worked on the computer when I got a cryptic text from Kristen.  I texted her back to clarify but suspected I should head to the hospital.  As I was walking out the door she texted that the department head of Casualty was looking for me so I called him on my way to the hospital and arranged to meet him in a few minutes.  Within minutes of our conversation I realized that the small training I had envisioned was growing into a monstrous thing and I would only have four days to prepare for a compulsory, full day training for the entire Casualty department.  Not only did I have to prepare for teaching principles of triage and trauma care, but I would have to lead a mass casualty drill to boot.

The presentation is now two days away and my powerpoint has morphed into a giant beast of a project.  I have now officially learned more about disaster preparedness than I ever thought was possible and still have to prepare for the drill in all of its endless detail and potential for complete chaos.  My best hope is that it's not a complete disaster (pun intended) and at least one person comes away knowing a little more then when they started.

The last two weeks . . .

My friend Kat inspired me to dust off this old blog and write about my experiences while I'm here in Kenya. It's already been two weeks and anything that could happen has happened, both good and bad. That might be a slight exaggeration, but it was definitely an eventful 14 days. Of course, the trip here was a blur of sleep deprivation, endless waiting - in planes, airport terminals, lines and cars. Days of heavy fatigue slid into nights of waking at odd hours unable to get back to sleep till the sun started to peak over the horizon. And with that topsy turvy sleep-wake cycle came a just as topsy turvy emotional state. I swung from excitement and anticipation to despondency and deep loneliness and a sense of isolation. When I first arrived, a first year medical student, Christine, shared the residence house with me and, Jenell, the Chief Resident, was here to get me settled. By Sunday, only three full days in Naivasha, I was all alone - Christine finished her 8 week project and Jenell left for the US to take her board exams. I had 10 days to myself, alone in the house, with only Stephen, the askari (guard) for company.



I tried to make good use of the 10 days I had to myself, but jet lag, coupled with allergies that morphed into a cold, slowed me down and sapped my motivation. I dragged myself to the hospital every day to work with my colleagues at the Accident and Emergency department, to observe, help where I could and teach when possible. It was a slow week with few patients and then the Medical Officers (MOs) went on strike. They, as well as most of the clinical staff, hadn't been paid in over a month. This is not an uncommon occurrence, but without MOs the RNs and EMTs in A&E managed the best they could and just rolled up their sleeves and did what they had to. Which left me with a lot of questions and discomfort about managing care in a low resource and unpredictable setting? How do you manage when there are no doctors and the mid-level providers are overwhelmed in the outpatient department? Do you let the 7 year old with a compound displaced ulnar/ radial fracture sit in pain, refer him to another hospital miles away or just give him some morphine, splint his arm and send him to X-ray?

So amidst the strike, the cold and jet lag, and trying to figure out the details of my project I was beginning to feel pretty low.  Last Thursday I arranged to meet up with Channa, an ER nurse who has lived and worked in Kenya for 30 years training ER nurses in Nairobi. I must have looked as dejected as I was feeling because within minutes of meeting me she firmly "suggested" that I come to stay with her at her farm for the night. There wasn't room to negotiate and I was given no opportunity to change out of my scrubs or pick up a toothbrush, but I wasn't objecting either and for once in my life I was happy to let someone else be in charge. I had been feeling quite overwhelmed and hopeless about the project I came here to do. I was beginning to realize that the pressure and expectations of the grant I received and the requirements of the capstone were conflicting with what I was experiencing. The needs of the hospital and staff didn't seem to fit with this Western idea of a trauma training program when staffing and resources and so many workforce issues made day to day operation a constantly shifting and changing beast. But Chana's motherly demeanor and support gave me a bit of a boost and I enjoyed being cared for, clothed, fed and encouraged to rest while I stayed with her on her farm on Lake Naivasha. Her step-son gave me a tour of their organic vegetable farm and showed me around Crater lake, a small alkaline lake close to their home. We watched the sun set over the mountains with the lake reflecting the last bit of light while drinking gin and tonics.

Lake Naivasha

Chana's Garden

I was returned to Naivasha Friday afternoon while Channa, Jeremy and his cousin headed back to Nairobi. Before we parted Chana gave me the contact information of John, an ER nurse in Nairobi who might be able to advise me on my project. I decided to call him in a few days since he had been ill and in the hospital, but Saturday morning I was pleasantly surprised by a call from him.  We talked for quite a long time about my ideas and frustrations and afterwards I felt significantly better with a clearer vision. John might even come out to Naivasha to help assess the A/E's needs which will be such a huge help.



Friday night while talking on the phone with Mark I heard a loud crash that seemed to be coming from the next bedroom. Too scared to check it out on my own fearing that some animal had fallen through the ceiling I asked Were, the askari, to check it out.  Were was barely able to push open the door because the entire ceiling had caved in.  I woke up multiple times in the night worrying that my own ceiling would drop on me unannounced. All day Saturday the carpenters were at the house repairing it and today they are reinforcing the rest of the bedrooms, thankfully.

I think Jenell must have felt bad for me after the ceiling caved in while she was in the States because she connected me with some of her friends living in Nairobi who had plans to come to Naivasha for the weekend.  I had a lovely dinner with four lovely women (Anjuli, Mackenzie, Jill and Ehete), Mike, their driver and Pete, Jenell's husband.  I unburdened my frustrations and loneliness and the last two weeks of pent up emotions onto them and they all so graciously heard me out and commiserated with me. It was nice to be able to connect with people who understand the struggles of global health and who can offer much needed support and laughter. And beer and good food never hurts either. We also enjoyed a lazy and long lunch at Panorama overlooking the lake before they headed back to Nairobi.

Spending time with Chana and Jenell's friends, I realized the value of accepting care and support. I'm not accustomed to being the "cared-for", and often shy away from it mostly because I've felt that I needed to repay the gift or some how measure up to the kindness offered me. But whether out of desperation, or hopefully some maturing, I've found myself saying yes to the care of friends and strangers without feeling the associated guilt or the sense that I should suck it up and suffer in silence. I find joy in caring for others and I suspect that many of the people I've met in my life feel the same way. And in being cared for I see how I am better able to support others and extend that same kindness. This shouldn't be such a hard lesson, but nurses in particular and type A personalities of which I have been and sometimes continue to demonstrate the qualities of, seem to find this lesson particularly challenging. The need to control and dictate the course of events, including my feelings, often prevents me from being present with or accepting of my emotions, or ask, let alone accept, help from others. Working in global health rips away that false belief that everything can be controlled. Not a single thing I thought I would do or accomplish has happened and may not before I leave, at least in the way that I envisioned it. Often what does come from it is better, full of connections and partnerships with people and an often complex, messy and spectacular understanding of oneself in this big, beautiful world.



Oh, and did I mention that I locked myself out of the house? Fortunately, Stephen and Paul, the taxi driver, helped fish the spare key off the floor that the housekeeper had thrown through the window after she locked up.

The adventures never cease.

Sea Change

In recent months I have experienced an inward shift from an empirical understanding of the injustices in the world towards a desire and motivation for political and social change.  While I feel I am becoming more jaded with each passing day that I work in the emergency room as the slice of humanity that walks through those doors seems ever more base, to say the least, I feel somehow more dedicated to system change.  As an ER nurse working at the bedside I have felt less and less effective as the years go by.  

A recent "This American Life" episode had a short clip where Ira Glass interviewed an emergency room physician.  He asked her what percentage of patients each day did she estimate were in the ER because of  being their own "worst enemies".  Her response, "about 50 percent."  She commented that the uncontrolled diabetics, the smokers, even the car accidents that happened as a result of text messaging, were there because of a life-time of bad choices.  I can concur with this statement, though I think she was being rather conservative in her estimation.  Each day I experience a sense of frustration and impotency as I feel ineffective at educating, influencing or making change where it is most needed.  We are our own worst enemies.  We daily make poor decisions that can have a profound impact not only on our immediate lives but for a life time.  Personal responsibility is important, but as governments, as a society, we cannot rely on each individual to make the best choice for themselves or for the greater good.  The road to hell is paved with good intentions, as the saying goes.  We can all think of a hundred things we intended to do - eat better, exercise more, stop smoking, meditate - and never accomplish, or start and quickly abandon.  How many times have I woke in the morning with the intention to immediately rise and go for a run only to find myself hours later reading the newspaper or surfing the net, still in my pajamas?  Now I'm not saying it's the government's fault for my laziness, but it behooves society to encourage healthy behaviors with subsidies and public spaces that promote exercise, for example.  Is is so radical to think that universal healthcare might also include a subsidy or discount for joining a gym or for local governments to put in place more walking and bike paths, particularly in economically depressed communities?  Why are we so willing to pay for cures and interventions for heart disease and diabetes but we're not willing to pay for education or prevention measures to reduce the behaviors that lead to these diseases?  

In a WHO document, "Innovative Care for Chronic Conditions: Building Blocks for Action" published in 2002, it estimated that more than 50% of the disease burden and mortality in developed nations was due to noncommunicable diseases such as heart disease and hypertension.  This is a reversal in past decades where the threat from communicable diseases such as TB and measles were the highest culprits of mortality.   Many factors can contribute to this reality, but the bottom line is simple - our daily choices can have a profound impact on our length and quality of life.

What this means personally for me is that I see my time is limited working as an ER nurse.  I no longer feel fulfilled by patching up one person at a time, though I believe this is a noble and thankless job, and I don't want to belittle my job or my coworkers.  I want to have a larger impact.  I want to catch people early, before a life time of habits and bad choices have deteriorated their health.  I want to help create policies and influence governments on how to support healthier choices.  And most importantly, I want to help fight against the injustices in the world that prevent, particularly women and children, from receiving equitable pay, rights and services.

John McCain was recently quoted as saying that the "War on Women" is imaginary and a partisan political tactic created by democrats.  While McCain supports the Violence Against Women's Act, others like Republican Roy Blunt pushed a transportation bill that would allow employers to deny contraception coverage for moral reasons and Governor Rick Scott (R) of Florida vetoed funding for rape crisis centers (Huffington Post, Laura Bassett, 4/26/12).  McCain may believe this is an imaginary attack, but I believe it demonstrates a subversive subtext of violence against women.  Some recent research has come to light that the security of a nation is directly linked to it's treatment of women.  Nations with higher rates of violence and discrimination against women (this includes inheritance inequality, preference for boy babies and income inequality, etc) are more unstable then nations with more equitable rights for women.  (For more information: http://www.womanstats.org/).  This is significant as the US does not fair so well in it's representation of women in government, a good indicator of it's treatment and beliefs about women.  In the US, we average lower than most countries with only 17% females in Congress, while countries like Afghanistan and Iraq boast 28% and 25% respectively.  This is significant since the US urged both countries when it invaded that these countries strive for 25% female participation in government.  We seem to recognize the importance of women in power yet we fall so short of even the average.

My own search continues and as I research jobs in women's rights and public health I realize that grad school may be in my immediate future.  I realize that to be most effective I need to educate myself further, though I've been reluctant to incur more debt and head back to school.  But this rising awareness and sense that I must do more is becoming harder to deny and growing so large in my consciousness it seem it won't be easily appeased.  

Adventures of Scoot

Finally, a clear beautiful day in Seattle.  No wind to knock me sideways while driving down Ambaum on the way to work.  No pelting rain to obscure my vision or arriving at the hospital soaked with chilled fingers and raw cheeks.  

The oil in my scooter has been long over due for a change.  After YouTube videos and consulting with Allister and other two wheeled savvy friends I decided today was the day.  With ratchet set in hand, a quart of 10W40 engine oil and 80/90 gear oil, a stack of newspapers, a roll of paper towels and an empty 2 quart yogurt container I proudly marched up the stairs to the drive and set about changing the oil.  Now, I’ve never once worked on anything mechanical.  I’m handy with tools and can put together assembled furniture like a pro.  I’ve helped my sister-in-law wire a ceiling fixture and a couple outlets.  I’ve even put on a new roof with my brother and can swing a hammer like a guy, but as for machines, never.  I’m a little fearful of things with flammable materials and anything that can potentially explode even if that potential is practically zero.  Even at work, I have a secret fear of oxygen tanks.  What if I even gently tapped it on the floor?  Would it shoot off like a torpedo like they say?  I know my fears are not based in any kind of physics or reality, but I can’t help but feel a little unnerved by these things.  So while it seems like I just picked today to change the oil and it was that simple, it’s actually been months of contemplation.  First I had to ask myself if I was capable of such a task.  Did I have sufficient knowledge and experience to do it?  And if I didn’t was I capable of learning to do it without fear of hurting myself or my only form of transportation in the process?  I sat with that for a while.  And as the weather continued to suck, alternating between near freezing temperatures and rain, I could continue to put off the task and the answers.  

But, while slow like the fog that rolls across the Sound, Spring did come to Seattle.  And I felt I couldn’t keep putting things off.  I realized, yes, I am capable and have sufficient brain power to learn how to do it.  A little research, a review of my owner’s manual, and a pre-flight check of my scooter and it’s parts lent me the confidence I needed to finally commit.  

So today it was with confidence that I set off on this task.  Maybe a little too much confidence.  I started the engine, letting it idle for a few minutes, thinking that would be sufficient to warm everything up and get the oil and parts moving.  But when I put ratchet to bolt there was no movement.  That bolt wouldn’t budge and I had visions of having to take it to the service center or finding someone with one of those pneumatic ratchets.  I contemplated “righty tighty, lefty loosey” but i have to be honest, even with that pneumonic, I don’t get it.  I can’t visualize it and when the bolt is not facing me like a clock, but lying in a flat position facing up, it’s really confusing.  So i moved on.  I still had the gear oil to change.  I abandoned the drain bolt for a minute.   I moved around to the left side of the scooter, located the drain bolt and with little effort loosened it and let loose a flood of greenish slimy oil.  Within minutes it was empty. I replaced the bolt, unscrewed the fill bolt and replenished the reservoir.  The fill bolt when back on and off I went to test drive.  To my delight not a drop of oil was to be found when I pulled into the drive.  

My confidence climbed.  If I could just monkey off that drain bolt I could do the same on the engine oil and I would be back in business.  When the bolt felt like it had a little give on my second attempt I wrenched on it with all my gained confidence only to watch with horror as the outer ring of the drain bolt snapped and fell off and sat swinging on the handle of my ratchet.  My heart dropped to my feet as I contemplated what just happened.  Could I be mistaken?  Could this actually be what’s suppose to happen?  Maybe that part wasn’t necessary?  But as I went in for a closer look and saw a rubber gasket exposed I knew this was not suppose to happen.  And then I realized that I had been torquing on that bolt with all my might . . . in the wrong direction. I tightened it so nice and securely I split the ring and broke it clear off.  What was I to do?  I could leave it and take it to the scooter shop and beg and pay for assistance.  I could leave it on, order a new part and hope it would be fine until the new part arrived.  Or I could proceed and figure it out as I went.  Let’s be honest.  There really never was a choice.  I’m practical, but I’m also stubborn and determined.  If I’ve decided I’m going to do something I do it and even if I fail miserably I’ll keep plodding along because damn if I’m not going to see it through till the bitter, terrible, miserable end.  

This contemplation took a matter of seconds and I reversed my ratchet and was busily wrenching on it in the opposite direction now more determined then ever that I was going to do this.  Off came the bolt and kerplunked to the bottom of the yogurt container while streams of black inkiness poured forth.  I wiggled the spring and filter off and accidentally dropped that into the quickly filling container of oil as well.  As it continued to drain I stood on the kick start a couple times to flush the last bit of oil from the engine.  And then I had to fish out all those parts I had so unceremoniously drowned in dirty oil.  I stuck my left hand up to my wrist in that warm mess and came away as coated as the poor seagulls after the Exxon Valdez spilled in the Prince William Sound. 

Of course, this is when I realized if I couldn’t get the bolt back on and refill it with oil with a minimal amount of leakage my scoot was out of service until I could either get it hauled to a service center or I got the part myself and fixed it. I started praying to the Scooter gods and carefully threaded the broken bolt back into place.  Though the rubber  O-ring was exposed it seemed like the connection was secure.  I refilled the tank and again out I went for a test drive.  When I got back there was no visible leaking, no drips or pooling, but the O-ring was slightly slick with oil.  After 20 minutes of sitting still no drips, no obvious leaks.  Another longer test drive and still no leaks.  I think I got lucky but I’m just hoping the thing stays secure till the part arrives in the mail this week.  Of course I’ll have to go through the whole process again and refill the reservoir with another quart of oil, but seeing as the oil was pretty filthy I imagine it won’t hurt anything to give it another flushing.    

Now after all of this I realize how happy things like this make me.  When I got into road biking it was the same feeling.  I liked to ride and in part I started because of a boyfriend and then because commuting on bike was easier than the bus and then because I could exercise while getting myself to work.  All of that was rewarding but what was truly fulfilling was the time and energy I put into making that bike my own, when I taught myself to do my own maintenance or to mount my first bike computer.  And when that very bike was stolen from my apartment building garage I was devastated not because of the money or even the physical bike itself, but because I felt like I lost a friend.  I had put time and energy into it and had learned something new and learned my own abilities while tinkering with that bike.  I replaced the stolen bike, but it’s never been the same.  I don’t own it in the same way.  I don’t feel proud to ride it or have memories of flat tires fixed in the middle of the night or think of riding 45 miles to Red Hook Brewery, the ride back the inner half full of beer and the outer half soaked with rain.  Or of the countless times I fell off my bike in comical slap stick style while trying to get use to clip in pedals.  

It’s all these moments that bring me pleasure and pride when I think about my old bike and these are the same moments I think about as I fix my scooter.  It’s not the mistakes so much as the process.  It’s the stumbling through, the fun of discovery, the pride of accomplishment and the laughter of all those little and sometimes big mistakes.  

I feel real affection for my little scoot.  Not only has she faithfully transported me to and from work in some of the worst conditions but she’s taught me about myself and in that process I feel I’ve become just a little bit better.  

Roots vs. adventure

I spent the day sorting and packing both here at the apartment and in the basement of a dear friend who puts up with my frequent comings and goings and whose husband tolerates my stuff piled (neatly) in his basement.  I keep purging and the footprint of my material life diminishes with each move.  I feel less and less attached and for some reason that both makes me joyful and sad.  I find myself less connected to the things that make up most of our lives and while it feels liberating it also makes me feel a bit removed and lonely.  The question becomes about the purpose of life, and it and the quest to find the answer becomes more pronounced when there's less "stuff" cluttering the path to that question.  I wish I had more answers, but all I find is that the more I keep searching the more questions I have and the less I'm sure of.  But it also leads me to a place of seeing that for me, a life of working 40 hours a week, living for the weekend, slogging through the work week to escape for a couple days into short lived pleasures is not for me. For many, I'm sure, it's not that simple and there are joys in having a family and a stable life that I know nothing of.  But I haven't been fortunate enough to find someone who brings me more joy than the joy I find in living an adventurous life.  I haven't met anyone who is more exhilarating, more fascinating, more thought provoking than my close friends or my travels or the life that I currently live.  If someone were to come along who had that perfect combination of adventurous spirit, intelligence and emotional maturity - the latter being the hardest and most important criteria to meet and the least common, unfortunately - I might find myself singing a different tune.  I might actually dream of settling down and making a home and putting down roots.   But maybe not.  Maybe I'll just take that wonderful man along with me on my adventures and create a whole different kind of life, one that suits us both even if a bit nontraditional.  A girl can dream, can't she?

Photos

P.S. Check out my photos of my travels on my website:  http://gallery.me.com/erinstoy