Retrospective thankfulness

Retrospective (adj): Looking back on or dealing with past events or situations.

We had gathered in our customary circle at shift change, taking turns sharing what we were thankful for that week.  "I'm thankful for the things we used to have," one of my fellow nurses confessed.  "I'm thankful for ensure, and 10cc syringes..."  I found myself nodding along, thinking of the intermittent supply challenges and all the things that won't be back in stock until the next field services.  I remembered, too, the other field services when we were short on saline, or tourniquets, or alcohol swabs, and reminded myself that it was good to be thankful for the things we still had, not just the ones we didn't anymore.

It's easy to be retrospectively thankful.  To think back on all the things that used to be an unappreciated and commonplace part of our lives and remember how great they were.  It's been especially easy to practice retrospective thankfulness at the end of this field service.  There are a lot of things I've been glad that we used to have.  In March I wrote about our Ensure shortage.  To be honest, for most of my nursing time here I hadn't thought much about our Ensure supply.  Once it was gone, though, I was thankful we had once been stocked with cans and cans of Ensure.  When the smooth peanut butter ran out, I was thankful we used to have some, and when the blender died two weeks ago I shook Nalgene bottles of milk and peanut butter, hoping to get the chunks small enough to fit down an NG tube, and was fiercely thankful for the blender too.

It extends over into my personal life sometimes, this thankfulness for past blessings.  I'm thankful we used to have hot water, even though we haven't had it much in our cabin since October.  Now that the acid bugs have returned with the rainy season, I'm thankful for the long months without them, and when the vacuum system breaks I remember that we once had a working toilet.

Living a life without can be a good reminder to appreciate what still is.  It can be easy to brush past the everyday, not realizing that sometimes the normalcy of everyday is a blessing, too.

I am thankful for the things of the past, but I am more thankful for the reminder of the present.  How often do I stop in gratitude for a simple meal, remembering those who have none?  I have clean clothes and my own (small) space to store them, a loving family, a safe home despite the riots that are scattered throughout the city.  Shoes that fit and the ability to read, a face that I can recognize in the mirror - not one I have to hide in the dark in shame.  Finding joy and blessings in life, choosing to rejoice in ALL circumstances...this is a choice.

I choose joy.

For each thing I no longer have and learn to creatively and cheerfully live without, I am reminded of all the amazing gifts I have been given that for me have become normal.  Retrospective and expectant, in all times and places and challenges of life, I choose thankfulness.

When the bandages come off

One of my favorite moments of a day shift is that first dressing change...when the bulky bandages finally come off and a new face is revealed for the first time.  What would it be like to see your face for the first time, after a tumor or deformity you had lived with for years was finally gone?

Abraham intently watched through the mirror as I gently peeled back the last of the tape and lifted a drainage-stained eyepatch to show the results of his surgery - a bone graft to the place where he had a maxilla previously removed.  He lifted his mirror to look more closely as I snipped the suture to pull out a drain, and cleaned the dried blood from around his eye.  "What do you think, Abraham," I asked.

He was very serious as his hand reached up to hold the mirror closer to his new cheek, the cheek that yesterday was flat, and he looked up at me with the beginnings of a shy smile.  "C'est bon, Laura," he said very seriously, and then lit up with a huge grin. "C'est tres, tres bon."

It is very, very good.

Rugi refused to watch her first dressing in the mirror, leaving it forgotten in her lap as she concentrated on holding still while I soaked off the places where gauze had stuck, and cleaned the staple line down her half-shaved scalp.  When the last of the gauze came off I encouraged her to look and look again, and she rather uncertainly held up the brand new mirror to examine the steristrips where her eye had once been.  She, too, broke into a smile and reached up a hand as if to touch the tumor she used to have.  As soon as my gloves came off she was shaking my hand over and over again..."merci, merci, merci, merci!"  I winked and called her beautiful, and left her admiring her new face in a small mirror.  There was one thing more that could complete her happiness, and she pointed hopefully at the urinary catheter and asked me a question in Pular.  "She say she can piss on her own," the caregiver from the bed next to her informed me, "if you can just remove this tube for her."

One catheter removal and mad bathroom dash later, Rugi was ecstatic.  She wiggled happily through her vitals check and IV flush, and hugged me over and over, then settled back in bed with her hand mirror to admire her new face once again.

C'est tres, tres bon.

It is very, very good.

Old enough for a nose

November 2011...
We sat together in the back of the church service, listening intently to a three-language sermon.  I was trying to understand the Krio that sounded so familiar, and Kadi was trying out her own bits of Krio.
AAmen, she murmured at the end of the pastor's every sentence, every pause, and every exclamation.  Aaaahhhh-men.  A-MEN-a.   EhyMEN.  Each time she got a little louder, we were starting to get a few looks from the curious patients next to us, and I started to wonder what point is appropriate to shush a 5-year-old's mid-sermon enthusiasm.  Granted we didn't look much like your usual church-goers.  I was in scrubs with my hair pinned up, perched on a high stool next to the crash cart.  Kadi's NG tube was pinned to her intricate braids, out of reach for small hands to pull on.  The center of her face was covered in steri-strips...only smooth skin and suture lines where a nose should have been.  But we were both pretty excited about the sermon and the worship-dance party that inevitably followed.

As our ship sailed from Sierra Leone a few weeks after that last ward service, I often wondered what happened to Kadi.  Would she ever have the chance for a nose?

I asked once why we hadn't made a nose yet for Kadi.  Our doctors have creatively pieced together faces for so many.  The reason was simple, our surgeon told me.  Kadi was too young for a nose.  If she got a new nose then, it would be too small as she grew older.

I reached up a little self-consciously to touch my own nose.  What would I have thought, at 5 years old, if someone had told me I was too little for a nose.  Didn't everybody else have noses at that age, usually?

Fast forward a year and a half, to one morning in March when a tall gentleman came from D9 to greet me enthusiastically in Krio.  I recognized him immediately, but it took a little while longer to recognize the Midazolam-doped girl in the bed as my Kadi, headed to the OR in 5 minutes to finally claim her nose.  She's joined the crowd of Noma survivors and war mutilation victims here on D ward and B ward, with scalps pulled down over faces and bits of face flipped and sutured in a myriad of creative flaps, grafts, and miracle-working.

I was her nurse the next day - one of my treasured pediatric nursing shifts.  Kadi was not even 24 hours post-op, terrified and exhausted from fighting and pretty miserable.  Along with a piece of scalp temporarily down over her face to make a new nose, Kadi also had her tongue sutured to the top of her mouth to close a hole there.  Two long arm splints and a patiently dedicated nursing staff had kept her from pulling out her nasal airway, IVs, and gastric tube.  Still a spunky fighter, Kadi was not a fan.  I used most of my small Krio that night - playing guessing games of what she needed (Yu wan piss?  Yu wan popo?) and making bargains, with a lot of pointing, strict instructions, and a wonderfully serious translator just to make sure (If I remove this, yu no pul am.  Yu sabi?).  By the end of the evening we successfully had both arm splints off with all tubes still intact.  Part of the bargain was me letting her popo (ride on my back) the rest of the shift, and so I finished my paperwork and gave report with her clinging limply to my back and the NG feed running slowly from the bag on a magnet hook over our heads.

We're fast friends again now, and last week she spent the beginnings of each of my night shifts popo as I took report.  I started the shifts off with gigantic drool spots soaking the back of my scrubs, but the cuddles were well worth it.  She's full of fun, inquisitive energy, and great at the pantomime communication so common on the ward now.  We're training her as a nurse as well (7 years old is certainly not too early), and she can turn on and administer her own nebulizers, connect and flush her NG feeds, and do a pretty good oral assessment by flashlight.

Less than a week now, and it will be time for another surgery.  I am excited to hear her Krio-Temne chatter and sweet singing again, and I can't wait to see her new face.  No more waiting; she is finally old enough to have a nose.

Dr. Seuss and the fizzy mango

Dr. Seuss and the Fizzy Mango: A bedtime story from Africa*

     by Heather Klassen, Laura Coles, and Trudi Attema

Travel to the beach and see

How fun my Africa can be!

Would you do what we have done?

Try it, try it, you’ll have fun!

Did you say no boats today?

No public boats today you say?

Are you sure you tell us true?

“Trust me, I no lie to you!”

800,000 we won’t pay,

These Fotay will just walk away!

Bargain, bargain, bargain more,

Check the price with three or four!

Would you could you stay afloat
 Maybe you should bail your boat?

Would you could you keep bread dry

When the waves are splashing high?

Would you stop along the way

With some local children play?

Would you could you go exploring,

Following the ocean’s roaring?

Would you down a cliff backpack-it,

Padded by an orange lifejacket

Camp out on a hidden beach,

Hotel comforts out of reach.

Would you could you in the dirt

Would you could you in a skirt?

Would you could you sleep in trees?

Swaying in the ocean breeze?

Would you hammock in a tree?

Disney princess you could be.

Would you climb in upside down

Eighteen inches off the ground?

Eighteen inches do you say?

No, we’ll hang them high today!

Chase a crab in rising tide,

From your headlamp he will hide.

Gaze at stars up in the sky, 

Rock to baboon lullaby!

Fizzy mango would you eat?

Or some donuts from the street?

Do not eat your street food bland!

Please add spices (and some sand)

Would you could you in the sun?

Coffee on the beach is fun!

Would you could you in a boat, 

Would you could you with a goat?

Would you could you wade through muck,

garbage, fish and not get stuck?

You would not could not, so you say, 

Try it, try it and you may!

Travel to the beach and see

How fun my Africa can be!

 *Based completely on a true story...I promise.

A different normal

More and more often I have moments when I forget I haven't always been here.  It's normal to tie an infant on my back if he's fussy and causing trouble - it doesn't matter that he's not mine.  I'm full of ideas of what to do when the usual procedures don't work, whether it be cutting the end off an IV cannula cap to put together oxygen tubing, or readily offering piggy back rides down the stairs when my patients get tired and the elevator is broken again. And I never, never would think to throw out a bed pan.  I'll probably be peeling the labels off of medication bottles and cutting my IV bottles in half for the rest of my nursing career.

We've run out of Ensure, the versatile canned milky supplement we usually use for NG feedings.  In it's place, our dietician Jess has cooked up a recipe involving milk and peanut butter, vitamins and fiber...and the nurses mix it up in the blender.  There are no Walmarts where we can pick up canned supplements - here we make our own.

This weekend we ran out of smooth peanut butter.  Several of us offered up our personal stash to make feeds with (mine was rejected - too chunky), and some of our nurses tried straining the mixture.  Eventually Jess melted down some chunky peanut butter and strained it, to hold us over until we could get some smooth peanut butter from town.  Even the smoothest of peanut butter has residual though, and when the NG to gravity drips ran slower and slower I fixed one with a pressure bag borrowed from the ICU.

It's creativity on a level I never really needed in the States, and the longer I'm here the more creative I've become.

Sometimes I remember that once I did things differently.  When the baby on my back gets his foot tangled in my patient's IV line and drops the pens from my back pocket all over the floor and I remember that they never told me in nursing school I might have this problem.  The moments when I look down at the working suction unit I've put together with a pair of trauma scissors, a variety of tubing types and sizes, a few odds and ends and a lot of creativity, and realize this wouldn't be considered a "normal" part of a Western nursing job.  Or when I put together pieces from two different blood pressure cuffs when the one we had on the machine didn't fit the patient in ICU.  I realized I had reached a whole new level when I heard myself suggest a partial endotracheal tube as a sterile trach cannula replacement, and realized that the idea actually had potential.

I've gained a different perspective here as well.  I've seen the joy in loving and being loved, in seeing past deformity to the person within, and joined in the worship of the broken.  I've learned pieces of languages and bartered in the market, gotten a wide variety of marriage proposals and comments on my fine African baby-tying technique...

And I've gotten peed on.  A lot.

I suppose it comes with the community aspect of ward life.  Babies are for everyone, and they get passed hand to hand and bed to bed, claimed in turn by each patient and nurse.  It happened to me again this weekend as Ibrahim's mama patiently fed him milk from a spoon and I entertained his baby brother Fala.  As breakfast finished, Fala climbed off my lap where he had been studiously chewing the plastic duck on my name badge and wandered away in his little-girl plastic sandals, leaving a few damp puddles on my scrubs.  Not even 9 am yet, and already I had gotten peed on.  Any American hospital, and this would have been an unfortunate event.  But here?

Me: I think the baby just peed on my pants.

Translator: Laura, this is very fortunate for you.

Me: I remember they said in Sierra Leone that getting peed on was good luck...something about fertility?

Translator: Yes, you will have many children.  Maybe fifteen.

I am wondering though, is that fifteen children total, or one for every time I get peed on..because I must be up to at least thirty by now.

Hear that, Mom and Dad?  Apparently you'll be having a lot of grandchildren.

Sunset Club

 There is an insistent breeze that lifts off of the water, dancing in the gray-gold of sunset and the cloudless dusty blue of harmattan sky.  It whispers poetry to me, cool and steady, weaving between my bare toes, wildly fluffing the skirt I try to hold down, and teasing the wisps of my damp hair.

A small tug sails by slowly, low in the water from fish caught that day, or a few scattered holes. It looks more like a child's bath toy than a seaworthy boat; rust-covered sides make me wonder if it will soon join the other shipwrecks scattered along the sea wall.   Wooden canoes paddle by constantly, and there are a few patched sails of other boats in the distance.  The larger ships leave long wakes in the water, reflective trails there long after a ship has gone, a path of promise to open oceans and distant lands.  I follow their calm wakes out past the rocks and into the sea until they are lost in distant ripples.

When I was a teenager my family would trickle up to our open gazebo rooftop just before maghrib and watch spectacular displays of color surround us as the sun set over rice paddies and red-tile roofs and the call to prayer echoed off the mountains.  Here on ship,

Sunset Club is a tradition that carried over from our outside "family" picnics in Sierra Leone and into the early weeks of the Guinea outreach, one of my favorite evening activities even now.  Almost every evening at the beginning of September found groups of nurses and most of the ward team leaders in a row along the deck facing the ocean sunset.  It was a quiet time away from the busyness of the hospital deck, a taste of fresh air and sunshine and beauty.  Some days the books and ipods came out, while other evenings were filled with lively discussions and back massages.  Attendance began to decrease as life picked up pace, and some days I had sunset club alone with Jesus on the narrow, netted walkway next to lifeboat 3.

 A peace is here, where seabirds wheel and dive, or wing their low way home across the water.  A peace that draws me up to settle with friends every free night after dinner, for chats or chocolate or silence.  No sunset is ever the same, and I marvel at God's endless creativity when the lightning storms crackle through the pink twilights and touch the early stars.

Photos courtesy of Jenny Darvas and Heather Klassen, who documented this amazing beauty while I put my feet up on the railings and drank it all in.

One more

Halima (The previous star of blog posts Looking for you and Yourself again) came back last week for a scheduled outpatient appointment.  Her face is filling out nicely, and the place where there was once a huge tumor is marked only with a small white dressing.  She was feeling fine, blowing kisses through lopsided lips and hugging everyone in sight.  The marketing team had arranged a small photo shoot with Halima, introducing her to some of the many crew members whose blood she now calls her own.

It's come full circle now, from the streets and crowds of her hometown village, and blood tests that I ran on a 6-inch square of clean floor mat in the back of a land rover, to hugs and Pular lessons after surgery on the dock in Conakry.

Every field service there are the patients that stay in my heart long after the ship sails away with us into the open sea.  My feet remember the VVF ladies whose names I don't know but who greet me and walk with me down the hallway to work in the mornings.  My arms remember the small weight of babies once struggling for breath, now fat and grinning the triumphant whiskered grin of a newly repaired cleft lip.  My eyes remember the moments of wonder when bandages are taken off for the first time to reveal the new face beneath.  I watch news reports on the CBS website and I can pick out each patient and each moment I spent with them...and for a few minutes I am in the ICU with Rudy content to sit in my lap and pat my face as he calls me auntie. For a few minutes I am dancing again with Maurice in my arms, teaching wound care or praying with a patient before surgery.

There must be a limit to the spaces I can find to tuck away one more story and one more face to remember.  But there is no limit.  Always there is room for another to be wrapped in sunset reflection and tucked away; always room for another drool spot on my scrubs, another walk down the hallway, another life touching mine.  One of the lasting life lessons I am learning from Africa: there is always room for one more.