Disseminated Intravascular Coagulation and other public spectacles

In previous blogs I have teased you a few times by saying someday I would tell the tale of a particular death at Mission Hospital; now is a good time to share.

Oh, I had already been teaching certain specific nursing skills long before 2009 when this particular event happened, and in a way that’s the point; but if you want to know about why I make the choices of emphasis that I do, you are invited to read this.

Short version: at Mission Hospital in 2009 a 34 year old woman with three kids at home, came in to deliver her fourth, but died of Disseminated Intervascular Coagulation (DIC), a rare complication of childbirth. For Mission Hospital it was the first such death of a walk-in mom in ten years (a remarkably excellent record over that time, especially considering the population). Her full term baby also died that day.

Public knowledge: the town was in an uproar and the Mission Hospital community was under siege, reported in the papers and even by the Kathmandu media at the time. I had nothing to do with the incident but I knew there was a big problem, literally an angry mob out in front. The local Maoists seemed to be encouraging anger and resentment.

That’s the barest of all possible bones. In a bit more detail, the team called in their backup and everybody worked for eight hours to fix the D.I.C., (a complicated clotting disorder) and do all the right things to no avail. D.I.C. is often fatal even in USA, and the mom died around dawn. In Tansen women don’t attend cremations, so a public spectacle ensued as hundred of women from the town viewed the body where it lay in the delivery room. I knew something unusual had happened when I saw the line of women as I arrived at clinical. We never had that many people inside the hospital compound.

Death threats were made against two female Nepali doctors, who left town immediately. There was considerable post-event analysis. This event and it’s aftermath consumed everyone’s attention for quite some time. Only a few days later I shared “4 o’clock tea” with the hospital Medical Director, who said “by all accounts the four student nurses who were on duty that night alongside the regular staff, did their role extremely well, and showed remarkable teamwork. Some of the things they did were really excellent. It was clear that they helped prolong the patient’s life and give her a chance.”

I often ate with the students at the TNS canteen, and another day or two after the tea, I had lunch with a group of the students. I told them what the doctor had said. The students said “That was us she was referring to. We were there. We are the ones.”

I said, “Oh, what exactly did you do that was so valuable?”

And they replied: “We responded exactly the way you taught us to respond last year when we did all those drills on Medical Ward. We tried to remember everything you said, and then do those things.”

Okay, so what thoughts would have, if you had been me?

If you said “tears in my eyes” you were correct. As a teacher I know the value of what I do, and here was yet another validation that came my way, a year after I taught somebody something. Also, another humbling reminder that it’s not a joke or a game, people’s lives depend on this.

Maybe this is a bass-ackwards way to tell the story, non-linear, but hey, read from the bottom up if you don’t like it.

What happened in 2007 and 2008?

At first in 2007 I would be responding to an emergency and then get caught up in the usual rapid clinical decisionmaking, doing all the steps. Then after awhile I got smart enough to say “hey, where is everybody?”

I realized that I wasn’t supposed to be doing these things by myself, not getting help from anybody, and it should not be happening this way. So I started looking around during the emergencies at what exactly, the staff was doing instead of helping. The Nepali nurses would find other things to do, and not be effective in resuscitation.

I asked questions, lots of questions. I learned that the Nepali nursing staff was simply not trained to respond to emergencies using the same kind of “swarming” behavior that USA nurses would employ. Due to the usual staffing, there is not enough manpower to “swarm” anyway.

I could not change the nursing staff, but like all good nursing faculty I had an iron grip over the students, and yes, I surely could change the students.

So – in 2008, I developed a personal plan. On those days when it was not busy, I went out of my way to gather the students together and teach them the teamwork skills of dealing with an emergency. We would find an empty bed, (and in some cases it would be in a room where five or six of the other beds were occupied. Yes, other patients could watch us do this. They found it entertaining).

Then I would make up little scenarios, and then assign the group to figure out what equipment they needed, gather it, and pretend to use it. I would sometimes have fifteen students doing this little exercise, taking turns observing and critiquing then doing. We did this on every quiet day, a bunch of times, over and over when we did. Two or three hours at a time, enough to do a dozen or more scenarios. I probably had most of the second years (forty students) take part over the course of 2008. When you are an eighteen year old person you love the team bonding. It’s the same psychology exploited by the US Marines.

And that was what the students were telling me had guided them in 2009. It all paid off. Even though the woman died, we gave her a fighting chance.

Now of course, simulation is not new; neither is ACLS-type emergency response. But from the beginning, whenever I have spoken with doctors in Nepal, both videshis and Nepali doctors, they all express frustration at this phenomenon of nurses lacking confidence and holding back.

The other nursing faculty did not join in; if it was a quiet day at clinical they would go early to their office instead, and busy themselves correcting student papers. They themselves had not been taught to do the skills I was teaching, and so the Nepali faculty could not have led this game if they wanted to. The other foreign nursing faculty tended not to have a background in ICU or ER in their home country, and so they did not have the experience of these kind of drills, either.

This experience contributes to “what drives me” to do what I do, to teach what I teach, the way I teach it.

When I describe this, I want to emphasize that it’s more complicated than simply saying the locals don’t help. It’s a matter of culture, education, staffing and practice. I say this because I don’t want my readers to think that I am disrespecting Nepali nurses. Far from it.

I suppose the bottom line is, my choice of how to go about this is based on numerous personal observations and validated by many other doctors and nurses.

If I can broaden the knowledge of these skills, the next patient who gets a fighting chance, will win.

Now that my teaching marathon is over, Tuesday was just a day of catching up, around here. The Canadian group from Wyecliff Bible Institute left for Biratnagar today, and will only be back briefly to pick up their stuff when they leave the country – they will spend their last few days at a more upscale hotel than the Shalom, as a means of easing re-entry shock.

Last evening one of guys asked me if I owned a Bible (I own three) and made me promise that I would read the Gospel of John in it’s entirety when I returned to Honolulu. “You can’t go picking and choosing what you like and don’t like, from Christianity.”

I always enjoy that Gospel. So – why not? Reading it again will be relaxing. I might skip around a bit though……..

They were pleasant company and I enjoyed the energy they brought to their work. I hope the Guest House is not too quiet for too long, it’s depressing around here when I am alone.

A Day to catch up

I am in a rich cultural area and I feel guilty if I just “veg out” but that is what I did…. Slept until 0600 and puttered around, reading. Took the laptop to Higher Ground, the local coffee place frequented by expats, and transacted business – backing up my BlackBerry, writing a sample for the course certificate, rewriting the LNC letter for One Nurse At A Time, now long overdue; and going through the handouts I will need to take to Bhairawa. Then I went to Yeti Airlines across the street and booked a roundtrip ticket to Bhairawa. It costs $115 each way, about the same as flying from Maine to Boston. Reasonable enough, considering that it would take eight hours by bus.

So the story of Bhairawa is that one of those very TNS students who was in the delivery room in 2009, now works in Bhairawa in their ICU. Monica was dismayed to learn that my plan for Kathmandu was to teach weekly; it meant she could not attend. So she asked me to come there, and spoke with the hospital administrators about me. Monica was a very bright and dedicated student with excellent English. She was a leader when we did the emergency drills during the slow times at Mission Hospital Medical Ward.

I suppose this also illustrates the value to be gained in making multiple trips, investing time and effort in one country. Obviously, I now have a history of known past actions and a reputation. I hope to live up to whatever Monica told them about me.

Joe

There is rumor of a three-day bandh, coming right up. Maybe it will get cancelled. I hope so. I don’t want a monkey wrench in my Wednesday plans…..