Tamale Accident and the ER

It’s always easier to share the positive things I’m experiencing on this trip. Nothing I’ve posted on my social media has shown the things that aren’t so beautiful, until now. I went from working at the Shakhina clinic, the most peaceful place I’ve ever been, to the Tamale Teaching Hospital where I had my hardest days yet. The three days at the hospital were the most difficult shifts of my nursing degree. However, it’s not all doom and gloom. The shining light in that place was a tall, muscular, brilliant nurse named David. He often didn’t come in ‪until 10:30, but that was the norm. In Ghana, being on time has a completely different meaning then back home. The shifts here are ‪from 7:30am-1:30pm, ‪1:30pm-7:30pm, and overnight ‪from 7:30pm-7:30am (Shorter day shifts due to the heat). Here in Ghana, the staff come when they come and leave only when the next nurse arrives, whatever time that may be. No one seems to be bothered by it either. 

In order to understand the traumas I saw, I need to share a little bit about the people of Tamale. For them, going to a hospital is a last resort. There are other options that are tried first, things like medicine men, juju men, witch doctors, and bone setters. Western medicine isn’t always needed, these traditional services can have some amazing results. I was talking to our instructor Jeanette and she mentioned the research into bone setters was pretty awesome. Another reason people wait to go to the hospital is money, without insurance, everything must be paid for out of pocket and it’s expensive. I also want you to consider the patients are not always treated well by the staff. Back home, learning to communicate and build trusting relationships with patients is just as important as learning the skills, but here that is not always the case. They might be hushed when they call out in pain or scolded for waiting so long to seek medical attention. Now that you have a bit of background, I’ll tell you what it’s really like. 

Day 1

I had been well prepared for this clinical placement. Told what to expect and what I would see. I had made a worst case scenario in my head, but never expected that is what I would be walking into. With our instructor Maggie, Camille and I walked down to dark hall towards the unit. It smelled like a combination of detol, the cleaning solution used here, and urine. Stretchers lined the hallway, and every single bed was being used. There were even people sprawled out on the hard floor of the trauma bay. There had been a bus accident the night before. 

It wouldn’t be uncommon for people to ride on the roof with the luggage.
Traffic accidents are very common in Ghana.

Back home this would be a code orange, this means extra staff and protocols to control the chaos. Here, no one was yelling or running the atmosphere was very laid back, which seemed to odd to me. I was so overwhelmed, walking around wide eyed and not knowing where to start. I’m sure Maggie could sense how I felt, she stayed. 

David met us in the trauma bay and mid conversation his head turned to the door and said “Oh Shit!” My back was towards the door and not going to lie I was a little afraid to turn around. Once I did, I saw a young man covered in blood. He was bleeding from the left side of his head. He was in a motor cycle accident with no helmet. His head had collided with the person on the other bike. We sat him down tried to remove his shirt but it was a struggle, the blood had made it difficult. It was like trying to take off jeans after being pushed in a pool. David put pressure on the wound and wrapped his head as Camille and I tried to do an assessment. Maggie said “what does his heart and lungs sound like?” I’d been so shocked I had forgotten to listen. When I pulled out my stethoscope to listen I remember thinking that I’d never had blood on it before. I’ve never had that much blood on me before come to think of it. Once he was stable, Camille and I left the trauma bay and went to see where we could be helpful. 

A man had come in by ambulance, he was breathing and had a pulse but was unresponsive and had no reaction to pain. His skin was so hot. It felt like he could just burst into flames at any moment. He was triaged as red, critical. 

There isn’t much we could do for him. Even back home with all the supplies at our fingertips. Here supplies were limited. Camille and I did our assessment at supported the family while someone tried to find a bed and move him to the “red zone” on the ward. I knew he wasn’t going to make it.

Another man in the red zone needed the dressing to his hand changed. He had been in the bus accident and his hand was crushed and he was unconscious. It looked like it had been through a meat grinder. I asked if we could get him some pain medicine because I noticed his breathing and heart rate had increased. The nurse said he didn’t need it. She pinched his arm and he had no response. It was only once the antiseptic was poured on his hand and he pulled his arm from her hand did she believe me that he was in pain. We stopped and got an order for pain medicine, but the family couldn’t afford it and that meant we had to keep going. Camille and I watched uncomfortably as she pulled the clots out of the wounds and wrapped his hand in gauze that wasn’t sterile. 

Protocol on how to triage incoming patients

I noticed the doctor starting CPR on the man that was brought in and Camille ran over to help. I was still helping splint the hand after the dressing change and didn’t run over. Camille said the doctor did three compressions and she offered to get the ambu-bag to help him breathe. Finding things on the unit was not easy she asked for help and the nurse stopped to chat with a friend instead of grabbing the bag. Needless to say, we were frustrated. This man is dying and you’re stopping to talk! The doctor called time of death. And then I remembered, this is what the nurses see almost every day. This is their normal.

After that, we helped comfort the man from the motorcycle crash while David stitched him up. (Emerg nurses here have a bigger scope of practice, like rural nurses back home) He was sterile! It was nice to see such good technique after what we had just witnessed. 

Just then another man in the red zone started to choke on the oral airway in his mouth. It was too small. I watched as David pulled out of the patient’s mouth with pliers. I was the one to put the new one in, the correct size is time, with Maggie by my side supporting me.

After this, Camille and I were done. That’s all we could handle for one day. But we spoke too soon, as they needed us to do some teaching before we left. We said okay, and I struggled with the language barrier, trying to explain why it’s important to stay in the hospital with a bone sticking out of a leg. We happened to be next to the family of the man who had just passed. Camille’s eyes met theirs and I heard her say “I’m so sorry” and she had to leave. I felt my heart sink. This was it. Now I was really done for the day and it was only 12:30. 

Day 2

I didn’t really want to come back. I didn’t feel helpful the first day. Camille and I were on our own. We made a good team. I knew I could count on her. 

When we walked in today, there were empty beds! I was so relieved to see that it was a slow morning. We took some vitals in the trauma bay for the nurses. There was one critical blood pressure 220/120 (normal is 120/80). We reported to the nurse and the patient got IV meds to lower his blood pressure within a few minutes. After yesterday, I was impressed with how fast that happened. 

Camille and I found David and went to assess a young boy who had fallen out of a mango tree. He had broken his neck and was paralyzed from the neck down. David found him a neck brace, his neck hadn’t been properly supported until now. Using my finger, I traced a line from his neck to foot to see when he could no longer feel my touch. He could feel everything! This was a great sign Camille and I helped wash him up with the help of two other nursing students. This process took over an hour. Between finding linen, a basin, towels, and all the turning. I noticed that then number one priority around here seems to be keeping the patients clean. 

Just when I thought all was well, in came a man in respiratory distress. He was working so hard to breath. Camille and I jumped into action getting oxygen and doing assessments. The nurse interrupted us and said, “he needs to rest, stop asking questions.” We didn’t stop. He doctors came and ordered a steroid to reduce the inflammation and help him breath. The family member had to run across the street to buy the medicine while he struggled for every breath. 

Just then, a woman was wheeled in also struggling to breath. She looked worse, yet all the doctors stayed with the young man. Camille and I desperately searched for another oxygen mask. We found one, but it had been used so many times the seal was not good. The good mask was being used on the young man. One of the residents came over eventually, we had taken vitals. They were critical. Her oxygen saturation was 64% (it should be above 95% in a healthy individual). We got her a nebulizer to open her airway and a steroid. It didn’t help moments later she stopped breathing and collapsed in Camille’s arms. Her heart stopped Camille started CPR immediately. I had brought over an ambu-bag earlier and I started breathing for her. She started vomiting. The resident hooked up suction and I put in an oral airway. All that was going through my mind was, “Thank God I put one of these in for the first time yesterday. So at least I know what to do.” I was so impressed by Camille, she was running this code. The resident looked petrified. He was learning too and didn’t have support. I don’t think she stopped doing CPR the whole time. We did everything we could with the limited supplies we had, but the resident called time of death. Within ten minutes of being wheeled in she had passed. Camille and I cleaned her up. Camille told the resident he had to talk to the family now. I was proud of her. Usually the doctors do paperwork first but, she made sure this was a priority. This was it. All we could handle for another day. 

All of the equipment we had in the ER

Camille and I left out the main entrance and we’re stopped by the daughter. She hadn’t been with the family when they were told. Camille, without hesitation, told her everything we did and finished with your mom had passed away. She collapsed into our arms. Screaming. Crying. This is not news a nurse would ever have to give in Canada. We held her until a friend came to get her. 

We walked into the parking lot, tears streaming down our faces in silence. I hoped that no one else would notice around us. It was 40 degrees. Maybe I could pass my tears off as beads of sweat. 

Day 3

After a rough couple of days, Camille and I were given the option of not going today. We both felt like we had to be there. 

The night nurse had waited for us to get there to do vitals in the trauma bay again. We didn’t mind. There were also two nursing students from Belgium on the ward today. Yay, I thought, some backup. Camille and I checked on some of the patients we saw yesterday then took a break. On our break we felt that the day was different, it was calm. We even sent a message to our group chat saying………

After choking down another granola bar, Camille looked at me and said “We need to go to the trauma bay.” I asked if her nurse sense was tingling and she said it was. I still don’t know how she knew, but two traumas had just come in. We split up. She went to the head trauma and I went to man struggling to breath. The resident asked a student to bring over a screen to do an assessment. Not again. After three days here I was feeling ballsy! I broke protocol, I told the doctor we’re going to the ward and he can do an assessment there. He needs oxygen, now! While I had to hunt down a mask, clean it, and hook it up, the resident put in a Foley catheter. Ugh! Interesting choice. The basics are the CABs: circulation, airway, breathing. Not urination. 

resuscitation is number ten on the to do list here

Now that the oxygen had helped him breath better, it was time to focus on his blood pressure. It was 65/40(normal is 120/80). This is a critical low. He was bleeding from a peptic ulcer in his stomach. He was in shock. Camille was back now. We took turns sealing the mask to his face, but the doctors had a plan: “Fluids and lots of them. Then to the operating room to stop the bleed.” His brother came by crying and I gave him a hug and let him know what we were doing. This man was young maybe a little older than me. The fluids were taking too long, Camille ran to the pharmacy herself and make them give her bags of normal saline. She put her name down to be billed later. We kept him breathing and running fluids for a couple hours before Maggie, Jeanette, and Vida walked in. They had been saying the official goodbyes and all the other students had left the hospital for the day. Their nurse senses were tingling too and they felt like they needed to check on us. At this point I was in over my head. His oxygen tank had emptied and it had taken 5 long minutes to switch it over to a new one, all while I watched his oxygen levels drop. Hour three, still waiting for the OR. Maggie tagged in holding the mask and decided to stay. I’m so grateful she did. Camille and I were so frustrated at this point. Camille had run to the pharmacy again for fluids and I had paid 5 cidis out of my own pocket for a glucose test strip. 

All of the fluid hadn’t increased his blood pressure. His abdomen was becoming more and more distended. The resident got an NG tube into his stomach to try and suction out the blood. It wasn’t working. It had been too long. David was by our side now. The man’s lungs started to fill. His heart stopped. Maggie instinctively jumped on the bed she straddled him and started compressions. Camille had the ambu-bag and started breathing for him. I grabbed an airway and David put it in. He yelled at Maggie, “Too many compressions! Take a break!” David, Maggie, Camille, and I took turns doing CPR. This was the first time I’ve ever done CPR. The first time I pressed down on his chest, it was such an awful feeling. I wasn’t pressing nearly hard enough. I heard Maggie yell “Deeper!” so I did, I pressed harder. It felt like each rib had broken off from his sternum and I could feel the bones grind with every compression. David yelled for epinepherine. One of the Belgian nursing students started to walk to the pharmacy. Maggie screamed “RUN!!!!” After the epinepherine, we got a pulse back. I was ecstatic. I was the one on the mask. With his heart beating I gave him a breath every 5 seconds. This didn’t last long his pulse faded away and it was back to CPR. The blood oozed from his nostrils, mouth and out of the tube that had been placed. We had an audience. In the quiet ward here were three white women yelling and barking orders at people. I’m not usually one to yell but when one of the other students attempted CPR it looked like she was just slapping him in the chest. Maggie tried to coach her, but it wasn’t working. Every second counts now. I shouted “NO” and shooed her out of the way. It had been thirty-five minutes, decision time. Maggie asked for a decision and the resident called it. 

When I saw the brother after he was smiling. I thought it was the weirdest reaction. He shook my hand and kept saying thank you. Maybe he had watched how hard we tried. No way to be sure. This time when I said we did everything we could. I meant it. 

Witnessing death every day was awful. I don’t know how the nurses do it. It’s nurses like David that I’m in awe of. He works so hard every day, with limited supplies and hustles in an environment when it’s acceptable not to. I learned a lot about myself. I know more then I think I do. I loved seeing how creative they are with the things they do have. I’m so thankful for Maggie and Camille. I couldn’t have asked for better teammates. 

Rachel, David, Albert [head nurse and awesome too], and Danielle

Tamale Teaching Hospital was where Camille and I tried our best to save a life, and we did the best that we could with what we had.

***Don’t worry Mom and Dad we are coping well and heading to Mole to rest and recover! 

Written by Krista Koenig, UBCO 4th year BSN student