Learning to Give Thanks Again

Some days I think Kijabe Hospital is the most amazing little hospital in the world, and some days I cannot imagine a more frustrating place to be a surgeon. Today started out as one of the frustrating days…

What I have learned in my brief time working in East Africa, is that the professional culture is very different here. In particular, one of the most limiting factors in my ability to care for patients has been the nursing care on the wards. Part of the problem is that the nurses have too many patients and that their training is limited, but another part of the problem is a lack of accountability or standards in the care they deliver. My orders routinely get overlooked or ignored, and I have no recourse with which to deal with sub-standard care. I never sense any remorse or apologetic attitude for the most negligent care. I have admitted patients who are quite sick, and made rounds on them the following morning to see that not one order was carried out, no IV fluids, no meds, no labs, nothing. In the US, a patient who is admitted and ignored or overlooked for 12 hours would be shameful. The nurse would at least have a very good excuse. When I bring it to the attention of the nurse who was assigned to the patient overnight, the response is one of, “that’s unfortunate”.  Let me be clear...the nurses are not apathetic, disinterested, or difficult. They are kind, thoughtful, and good-spirited. There are systems flaws that make good nursing care difficult, but the attitude of the nurses to overcome or change the system to give good care is absent…bad care just “happens”. Even though they were assigned to that patient, the lack of care or inappropriate care is seen as something that happened passively, not something they were responsible for. I discussed this with my Swahili instructor, and he explained to me how even the syntax of the language is bent toward using passive forms of verbs. (The vase broke vs. I broke the vase.)
So in the setting of this culture, in particular the nursing care, I have had my moments of exasperation.

Today was Thanksgiving in the US, but I felt anything but thankful after rounds this morning. I walked on the floor to see my patients. One woman had sat on the floor for about 20 hours without a crucial order being done…something that was central to her care, and to me obvious that it needed to be done. We went through the usual futile discussion about who was responsible, but as usual, no one was responsible...it “just happened”…or in this case did not happen. I had spent about 90 minutes of precious theater (OR) time debriding and placing a negative pressure (VAC) dressing on her perineum, and this had all been in vain (since the nurses forgot to reconnect the suction). I would have to take her back to the OR and likely cancel an elective case or two for the day, making me fall further behind in my attempts to provide good and timely care to my patients. And here the nurse stood in front of me with a blank expression as I asked why they did not reconnect the suction to her dressing. No apologies, no excuses, no promises that it won’t happen again, just agreement that it was unfortunate what “happened”.   I left the floor frustrated and angry.

I spent the evening thinking about the experience. After my initial frustration, I was able to come to a point where I understood.  The culture here is different, not to mention the low nurse to patient ratio, and limited exposure to surgical nursing training. I can accept that things will “happen”, but it makes it hard for me to invest myself totally in patient care. In other words, why should I give 100%, and work hard for the patients, if all my work will be undone by a health care system that just does not seem to be a 100% health system. For a moment I was tempted to think the way to avoid frustration is to not try so hard…to only give 50 or 75% of my best, so that I won’t be upset by poor outcomes. Why lose sleep, come in at night, wake up early, operate on weekends or evenings only to have my efforts be in vain? Maybe I should just coast a little more. One of the Kenyan physicians even suggested this strategy to me. His attitude is that one should not work too hard to avoid burn out.
But I cannot reconcile this attitude to everything I have been taught. Don’t get me wrong…I definitely make time for myself, and recognize the need for quiet time and time away from the hospital, but for the time and energy one dedicates to taking care of patients, I can’t accept anything but 100% commitment to treating their problems. I am reminded of Paul’s words in Col 3:23 that one must “do whatever one does heartily as to the Lord”. I am here to serve and do my best to care for sick people, regardless of how much the hospital helps or resists that mission. I have to remember that I work for God. There is no reason to get frustrated and lose my desire to serve, because it is God that allows me to do what I do. When my efforts to restore someone to health are successful, it is only by God’s grace that my efforts succeed. So how can I be so incredulous to think that I will only work hard if I think everyone else is meeting my expectations for good care. The patients deserve my best, no matter what the rest of the hospital is able to provide. I have to recognize the limitations of nursing here, and think carefully about what to expect on the floor, but that does not give me the excuse to neglect patients’ problems or give half-hearted attempts to care for them. On the contrary, I may have to spend more of my time doing the “nurse’s job” or educating them, and making sure that they will give good care. (I guarantee I never leave the hospital again without making sure a VAC is on suction.) I must remain invested in patient care, and be an example of dedication, instead of allowing my frustrations to make me succumb to a less than idealistic attitude about patient care.

I’m glad that I had the evening to consider this all. Thanksgiving here in Africa was an afterthought. Only the Americans were celebrating, and most were too busy working to do much except scarf down a bit of turkey in between seeing patients.  But now that the day is done, I recognize that my frustrations this morning were the result of losing the Thanksgiving attitude.  I am reminded to be thankful for the things that do work well at this little mission hospital. It is amazing how much good work is done with so little financial resources. I am reminded to be thankful for what the nurses do instead of what they don’t do. I am reminded to be thankful that I am even well-bodied enough to work at all. To be thankful that I am not a patient. To be thankful that my patients by-in-large get better. To be thankful that I am able to participate in their healing in any way. To be thankful that God has allowed me to thrive in Africa, and live such a rich and full life.
I give thanks today for the privilege and honor to be able serve. If I can keep that attitude, I don’t imagine anything will be able to frustrate me for long here in Kijabe.

Yours in thanks giving,
chad

“The unthankful heart discovers no mercies; but the thankful heart will find, in every hour, some heavenly blessings.”
~Henry Ward Beecher