That moment when my Lubwisi failed me
The NICU was insanely busy on Monday. I walked in at 8 am and looked around for the night nurse. I asked one of the mothers where she was, and she told me she left at 4 am because one of her family members had died in the night.
On a good day all of the babies are weighed and caught up on their medications by the time I get to work. I usually get a head start on vitals and assessments before Dr. Jennifer comes in after the morning staff meeting. But Dr. Jennifer was in the US this week so it was just me, my interpreter and whichever other nurse was on for the day. I was uncertain if a doctor would round or not, since this hospital doesn’t have many doctors.
There were 25 babies admitted, some were cuddled together sharing the phototherapy lights, our 1 oxygen cylinder that was close to empty was being spliced four ways, a baby was sleeping on the floor because there weren’t any more cribs. The electricity kept cutting out during all of this. I quickly discovered we were out of all syringes, which meant I couldn’t draw blood or give any medication. Someone had hid the key to the closet that contained all the gloves and NG tubes. And to make the morning even more challenging, we had a number of newly admitted very fragile babies under 1 kilogram (2.2 pounds). One of them had no chart, no history recorded, and not been seen by anyone.
I was officially overwhelmed, feeling trapped with each failed action I tried to take. My throat was hot with a storm of tears. I had to pull it together. I would get through this day. Another nurse would hopefully be coming soon and we would work this out together. I walked to the bathroom and a sign on the door said ‘no longer in service’. A flash of rage cursed through me. Nothing was working. I would have to hold it.
I started at the first bed of a premature baby with microcephaly. This child was slowly gaining weight with stable vitals and a good report from his mother. Dr. Jennifer wrote a note from last week and it was of course, incredibly thorough. We made a plan to start the baby on iron and a multivitamin (once we stocked up) per her notes. There were no huge issues to address that I could see, so I wrote some nursing notes and moved on to the next bed.
“Kacie?” My interpreter Scovia whispered in my ear. “This mother over here said she isn’t making any breastmilk for her twins.”
She pointed down the line of beds.
“Okay, let’s see all these babies first and then we can see them and talk to the mother.”
The day nurse arrived but when she saw the situation on the ward she put her arms up in the air and walked back and forth saying, “this is too much, this is too much.” I like this nurse because she’s hard working, smart, intuitive and has a really outgoing personality. She narrates out loud everything she does, which is opposite to me. I’m more on the quieter side as a nurse. In the medical environment it is helpful to be vocal and it is something I try to work on. But in this moment I wanted her to just start somewhere.
“We can do this.” I said. “Bed by bed.”
But we were in over our heads, for sure.
She threw her arms out in a gesture of ‘where? Where do I start?’
“Start in the room with the babies who have sepsis, and I’ll work in here with the prematures. Then we can meet in the middle room.”
Moms were sitting everywhere with barely any walking space on the floor. Most of the mother’s spend their time expressing breastmilk with their hands into plastic cups, preparing for their babies next feed. In between that they nap, sitting up against the walls. Or they hold their babies skin-to-skin. They talk and laugh with each other. It’s a very mother-friendly environment, which includes a lot of shirtless women.
It took me A LOT of time to assess and write notes on the first row of babies. Hours. I think the nurse I was working with thought I was too slow. I was being meticulous and signing every note with a final line of “MD review please”, which felt hopeful but also like my own mini personal joke.
I calculated dosing for IV fluids and NG tube feeds, and tried to wrap my head around what it would be like if this is how it always was. If Dr. Jennifer didn’t work here and if the hospital was always too busy to get a doctor consistently into the NICU. I know that I make a difference being here. I know that every nurse who I work with changes the trajectory of these babies lives. They don’t all survive, but many of them do. Many of them are completely dependent upon the diligent work of overwhelmed but committed nurses, and the tireless efforts of Dr. Jennifer and Dr. Amon. But this place could use a lot more help.
It was lunchtime and I hadn’t eaten a great breakfast that morning. I could tell Scovia was fading too.
I asked her, “Can you run and get us each a rolex for lunch? I’ll finish up with these twins and then we can take a break and eat.” (a rolex is a chapati and egg rolled together, delicious)
She left the building and I was officially on my own with my Lubwisi.
I said my greeting to the woman sitting next to the twins, and she greeted me back.
The twins looked dehydrated and I remembered these were the babies that I was told weren’t getting enough breastmilk, so I asked in Lubwisi… ‘are the babies breastfeeding well?’
She patted her breasts and what I thought I heard was “I have no milk”.
I figured my next assessment was to try to assess her milk supply, but I lacked a graceful way to communicate- so I did the best I could with what I had. People here are very matter-of-fact and often use command in a non-offensive way, so I said, “Take off your dress.” (If you say ‘please’ here, you are stressing a word that makes it sound like you are starting to get annoyed. So out of patience and kindness, most people don’t use please right away.)
I thought her dress was a really poor choice for a breastfeeding mother. I’m not sure if she had many options, but it was a full turtle neck of a dress, that was tight, and her breasts weren’t easily accessible for two hungry babies.
She wiggled out of it and tossed it on the ground.
I motioned for her to remove her bra, so she did. She unhooked it and added it to her pile.
Another cultural note here: exposing ones breasts, especially in the context of breastfeeding, is a natural part of life here. Breasts are more functional, and less sexual. Almost like how Westerners consider their knees.
However, exposing your thighs or any skin from your knees to your waist is considered highly provocative. This woman had on a slip underneath her dress that kept her bottom half covered, but from the top up she was bare.
I sanitized my hands and put on a glove. Then I showed her how to make a C with her hand to express her milk. I reached my hand out and began to move my hand in the way one does to get those first drops of milk to release. Her breasts were deflated and wrinkled, I could easily see there was no milk, but I thought I should try to help her for at least a little longer before suggesting metoclopramide to help with her supply.
She stood there calm but quizzical as she watched me.
I felt someone standing behind me and I turned to see Scovia, with a black plastic bag full of 2 hot Rolex in hand.
“Excuse me Kacie. What are you doing?” she asked.
Sometimes I explain the medical side of things to her, if she asks. But mostly she interprets and doesn’t ask a ton of questions.
“I’m trying to get her milk to come out, by hand expressing.” I said, matter-of-factly.
She pointed at the woman and said, “But that’s not the mother.”
I stopped what I was doing.
“That’s not the mother.” She repeated.
“Who is this?”
“The mother’s friend, she’s just watching the babies right now while the mother went out.”
I looked at the shirtless woman. “Oh. Um. Okay. How about she puts her clothes back on.”
I ballooned in embarrassment and then erupted in laughter. “I thought she was the mother!? Please Scovia, tell her I thought she was the mother. And I’m SO SORRY!”
Scovia explained the situation to her and everyone in the room, including the woman, let out a good belly laugh.
“Okay. I think it’s time to eat.”
I slunk off to a small room to shove some food into my face with Scovia. Every few seconds I had a new question to help me understand the situation, but she was just as perplexed. I’d take a bite of food, and remember what I just did, and then we’d both start laughing from the awkwardness of it all.
“Wait, I thought when you put “ta” in front of a word it turns it into a negative?” I said.
“Tell me what she said exactly.”
I told her.
“No” she corrected me, “she was saying ‘she doesn’t have any milk’, referring to the mother. ‘Ta’ meant the mother. If it was her she would have used ‘Tin’, saying ‘I don’t have any milk’.”
My language teacher had taught me that months ago, but clearly I had forgotten.
Thankfully Scovia isn’t afraid to be honest with me. She confirmed that the woman had a good sense of humor about it and didn’t appear to be bothered.
“Okay thanks for this debrief.” I said. “I won’t ever forget this cultural mishap. Or Tin and Ta.”
The doctor was able to round after he finished seeing about a hundred children in the pediatric ward. He was pleased with our work for the day. I was reassured that the care of these babies wasn’t left entirely up to the nursing staff, because in my exhaustion I may have ended up milking every stranger there.