Diary: Sharing skills with nurses in a Pacific paradise

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Angie Gittus and Bronwen Griffiths from northern NSW recently flew to Kiribati in the Pacific to provide education and support to the nurses working in the Emergency Department at the Tungaru Central Hospital, Tarawa.

Here’s Angie’s diary.

flying-inDay 1 – Arrival: Thursday morning we flew from Fiji to Kiribati – three hours flying over the Pacific Ocean. Coming into Kiribati was beautiful, we flew over a very picturesque lagoon and landed in the most ramshackle but endearing “international” airport I’ve ever been in. After a rather mad scramble to reclaim our luggage, we were very soon on the other side of the barrier and stamped into Kiribati.

(For those that haven’t yet, I encourage you to Google-map Tawara, Kiribati. It’s essentially a long narrow strip of land in a sideways V shape that makes a triangle where the lagoon entrance is the third side. The two land edges are approx 24km in the south and 36km in the north. It’s an obtuse angel and the watery third side is the longest edge – 40-minute trip in a very fast boat.) [Please note – all statements that include numbers could well be wrong, as those that know me will know that countilating is not my strong suit!]

On arrival we’re met by Brady, the doctor we’ve been communicating with via email. He took us for a welcome lunch with his family, who are lovely, then a quick tour of the hospital and meeting of some staff and back to our lodgings to get settled. He then very generously invited us back for dinner so we didn’t have to find food on our first day.

angie-at-hospitalDay 2 Kiribati: to the hospital. Morning shifts are 8am-4.15pm and that seems the best time for us to be there. We walked to work, about 20 minutes at a very leisurely pace. [Angie on right.]

Work was busy. Kiribati is similar to emergency departments across the world and has to deal frequently with bed block – waiting for patients to be discharged from the wards so that new patients can fit in. Makes for an even busier emergency department as the new patients keep arriving and everybody needs to be cared for.

We spent the day watching the way the staff and department as a whole operated. Trying to get an understanding of how things worked. We managed quite a bit of ad hoc education as we went and made the arrangements for the formal teaching sessions as well.

Lots of things seem to be done well, but we can also see the challenges of trying to provide excellent care in a resource-poor environment.

By the end of the day we were both hot, tired and sticky and well covered in alcohol hand rub, but with a better idea of how we might approach the next few weeks.

Day 3 – the weekend!
I must confess, I almost feel a bit guilty about how fantastic our day was today. I kinda feel like we haven’t worked hard enough yet to deserve such an amazing day off, but what can you do about when the weekend falls?

Today we were invited to join a group of the hospital ‘extras’ on a boat trip. Organised by one of the doctors from Taiwan, there were Taiwanese staff (there’s quite a cohort from Taiwan, including a lovely Taiwanese Emergency nurse who has also just arrived to volunteer) and a bunch of other non-local staff.

island

We took a boat to an outer island. A beautiful, quiet island that looked like something from a travel brochure. As we boated into the island the water was the most incredible blue I’ve ever seen. Almost fluorescent aquamarine.

Standing on the beach there were three distinct shades of blue, each a different depth. All were the kind of blue that’s only ever seen in swimming pools with blue tiles. The water was pristine and shortly after landing we were all face down with goggles and snorkels watching the fish. We swam, snorkelled, wandered the rock pools and beaches, were served a fresh cooked array of seafood, chatted with interesting people and just sat and gazed out in wonder. Then late afternoon we loaded back into the boat and were whizzed back to Tarawa, filled with the buzz of an absolutely perfect day.

Day 4 – Sunday: Today we headed off early for a “quick” bus trip to Betio (Bess-o) at the southern end of the island. Yesterday we heard stories of grocery shops down there that had a wider variety of food.

Well, it took us from 10.00-16.00 to travel 40km to get some shopping, but after a swim and a rest, a gift of some eggplant and capsicum and our very delicious home-cooked dinner, it was still a great day.

teachingMonday: Today we delivered classroom teaching for a group of nurses. We had a great day, with very keen staff who came in, unpaid, to hear us talk about emergency care, recognition of sick or deteriorating patients, cardiac monitoring, ECG rhythms and ALS, paediatric assessment and asthma. [Bronwen teaching.]

A few favourite moments from the day for me…..
1) realising that the very proper nurse caps some of the staff wear are actually origami paper. One of the nurses had made hers from a hospital fluid balance chart!

teachingcprkiribati2) anyone who’s done first aid recently will know that Staying Alive is often used as a guide to keep time for cardiac compressions. Hiro, the wonderful volunteer nurse from Japan, has found an ikiribati song with the same timing. So while practising CPR we had a fantastic Pacific island chorus with clapping to get the rate of compressions right.
3) the laughter. Although there were a lot of intense thinking faces and note taking, there were also loads of good belly laughs.

Wednesday: worked in the ED alongside the staff. Busy day trying to stretch inadequate resources further than they can go. It seems the flow of patients with needs never ends but the resources frequently run out.

It’s good working after doing the education sessions as there’s so many moments to put the theory into practice in context to consolidate the learning and hopefully continue better practice.

Wednesday after work we had a girls night out. Michelle (Brady’s wife), Margie (a fantastic Aussie optometrist) and Bron and I went out for dinner. Michelle drove us to a fantastic cafe/restaurant/resort in the northern part of South Tarawa. It was so peaceful. We had to wade across the causeway to get there. On the way home in the dark we caught a boat for 50c. Gliding across the moonlit water with three fabulous women and the softest of breezes, our feet dangling just above the water – memory to be cherished.

Thursday: more teaching. We’re running the same sessions for all the staff. A bigger group this time (so we assume no one said the first session was dreadful!)

Really great to see the staff so keen and asking thoughtful and reflective questions.

Then, after teaching it was back down to the ED to work the rest of the afternoon. Things got really busy and Bron and I, as well as Brady and Teitinana, the NUM, stayed back late to care for a very unwell patient. Teitinana was still working hard when we eventually decided to go.

origami-hatsFriday: back to the ED and another busy day. This time two very sick babies, both needing lots of care. Bron and I usually work with the nurses who are caring for the sickest patients, helping them understand why it’s so important to identify and treat them early, to think back to what might be causing the problem and how to fix it and forward to what might happen next and how to prepare for that. [Right: Ange and Bron wearing their origami caps.]

Then we left work and jumped on an 18-seater plane and flew to a deserted island!

We’re here for the weekend and it’s paradise beyond description. I feel immensely lucky to be here. It certainly wasn’t part of the plan when coming to Kiribati to be soaking up idyllic island life! When Margie found out it was Bron’s birthday this weekend, she decided a weekend on Abiang was essential and set about organising all the details. Thank you Margie!

Another busy week working and teaching

Monday: worked in the ED and rolled out the new asthma management plan we’ve been teaching. Change is never fast or easy (I know lots of nurses will remember being resistant to changing from nebs to spacers!) but here that change has so many benefits. Using spacers means people are less likely to be admitted, less likely to get an infection from cross-contamination of masks, more likely to manage their asthma better at home and hopefully stay out of hospital. Also with frequent power outages and O2 shortages it means Ventolin can still be given to patients.

Tuesday: back into the classroom for more teaching and down to ED after lunch to work the arvo. In the emergency department was a young man from an outer island with a nasty leg injury. He’d fallen from a coconut tree and badly injured his leg. His management of the injury was to stay home and use traditional massage. After more than two weeks it was clear his leg was getting worse. The clinic on the outer island arranged to transfer him to Tarawa for treatment. His injury was a complex fracture of his lower leg that in Australia would have required extensive surgery. The fracture was compound and was now complicated by severe infection.

As soon as he was seen in the ED he was scheduled for an above knee amputation. An incredibly stoic man, he refused all treatment. After many discussions a social worker was called and he eventually consented to surgery. The loss of his leg is devastating. He lives a subsistence life on a small island. His family, and likely extended family, are dependent on him to provide for them. Delayed treatment, limited options for care and a health service struggling to provide care for a large geographical area make illness or injury so much harder to treat and the consequences are deeply felt.

Wednesday: back in the ED. Today we’re bed-blocked. Every bed is full, the outside area is chaotic. There are people down alleys between buildings and around corners we can’t see. It’s hard to keep track of patients. The staff are busy. I work outside most of the day, Bron works inside. The nurse Bron works with is tireless, she doesn’t have a break all day, there’s no one to fill the void if she does (the other nurse who was working with her was called away to do something else).

Thursday: we are to visit the smaller hospital in Betio. It takes an hour on the bus to travel less than 30km. The bus we catch is “the Ministry bus”, provided by the Ministry of Health to get staff to and from work. We’re on the bus taking the night shift staff home. There’s plenty of giggling and chatting and goodbyes as each nurse gets off at their stop to try in sleep in the hot and noisy day.

Betio is a much smaller hospital and on the day we arrive, not too busy.

They have an ED, a general ward with one end reserved for paediatrics and a very new and impressive maternity unit, provided by DFAT. Betio hospital flooded spectacularly last year during a high tide, requiring evacuation to the sports oval. Since then they’ve raised the sea wall between the building red-seaand the very close shoreline.

From the sea wall you look directly over the “red sea”, the site of a huge loss of lives during the 2nd World War, where apparently the sea ran red with blood. There are still wrecks in the water from then.

Friday – a really positive day.
First Bron and I gave a presentation to all the junior doctors about the asthma protocol nurses are now using. About its importance and how they can support it and help it succeed. Later in the day Charlie the Glaswegian med student told us it was well received by all doctors.

While we were sitting with the doctors waiting to present, one of them gave positive feedback about the night shift nurses having done an ECG and identified a problem and brought it to her. When she acknowledged their pick-up they said it was because they’d been at one of our workshops.

bronwen-and-angieThen Teitinana (NUM) and Bron and I had a meeting with the Director of Nursing and the Principle Nursing Officers (the PNOs). Discussion focused on the challenges the ED nurses face and how to improve them. It seemed we reached agreement about some things and others still need more work, but overall Teitinana said he felt like it went well and is hopeful for future change.

After lunch we went to the School of Nursing and taught a group of very enthusiastic third year students Basic Life Support.

hiroteachesdefibBron and I did the teaching with Nina, a Taiwanese ED nurse who is volunteering in Tarawa for two months and Hiro [right], Japanese ICU nurse and volunteer in the ED for 18 months. Nina’s partner Pedro is a doctor from Taiwan volunteering. He’s an incredibly energetic and enthusiastic man who spreads cheer wherever he goes. He made the link with the nursing school and organised the BLS teaching.

It’s been a really heart-warming experience meeting so many wonderful people while we’re here.

Conclusion: Before leaving to come home Bron and I made a commitment to the nurses in the Emergency Department that we will return to Tarawa and continue to support them as they work toward developing the specific skills needed by emergency nurses. Since getting back we’ve been busy planning the “how-to” of ongoing education and funding for the project.

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