African Triage

I have been a nurse for many years, the majority of that has been working in an Emergency setting where triage is always a part of my job. The concept of triage, choosing who is sickest among the sick is one that is developed over time through practice and experience. Comparing triage from when I worked in Trauma in San Francisco to here in Mozambique brings much obscurity because of the blatant differences that I see. It is hard for me to fathom triage in the Africa hospitals, hard for me to imagine walking with those nurses every day through the grief that they see. I had the opportunity to visit a hospital again the other day, and both times that I was there, my heart was torn is so many ways, as a nurse and also as a person. The first triage challenge that I was met with was the previous day at a way in clinic out in the rural communities where I met a young woman and her daughter who was very ill. The white cold toes, the bulging little eyes, and the fragile hair caught my attention even before I started hearing the history of the child. She was almost 2 years old, and was under 6 kg, had been sick with Malaria many times and was just not growing. The mother explained that the she had been told that her child needed blood and I could see the evidence of that as I looked at her girls face. Instead of seeing the dark, brown skin that I have grown to love so much, I saw discolored patches across her face that told me that her blood levels must be really low. Anemia in Canada is a problem just like it is in Mozambique, but finding blood to transfuse in Africa becomes a problem for the family as they have to supply the blood. I sat there looking at this little girl going through the many reasons why she would be so low on her blood levels…malnutrition, liver damage from the malaria, underlying disease such as AIDS and I was challenged by my perspective of triage. Despite my first instinct of packing the child up and taking her immediately to the hospital, I relied more on my Africa triage knowledge, and made a plan to provide transport in the next day for her to go. With many other women looking on as I assessed the little girl, it was hard to believe, but so true that there were sicker children that this little one that needed blood. Despite the obvious problem, she was breastfeeding well, and wasn’t fighting any infection at this point. She was alert enough to voice her discontent for this white woman who was trying to touch her, and I could see that she had lots of fight left in her. As the team continued to work through weighing all of the children, it became even more clear that triage would be needed because more that 90 percent of the children present were underweight and fighting illness. Challenge just doesn’t seem enough of a word to describe what I felt.
Thankfully we were able to bring the mother and babe to the hospital the next morning and as we talked with the health director, I was quickly reminded why the hospitals of Mozambique have always raised the hair on the back of my neck. I heard the sound the minute I stepped into the hallway, the sound that has always made me instantly nauseous, the sound that brings goosebumps to my skin and tears to my eyes, it was the sound of a woman wailing. As we rounded the corner, I saw a woman sitting on the floor holding her face in her hands and wailing. At first, it was difficult to know what to do, and it was so hard for me not to just run to her and hold her as she cried. Eventually the story was explained that she had just been told that her daughter had died, and if that wasn’t enough to rock my emotions, one of the women pointed to a little baby and explained that the mother of the child had just died. As the baby looked curiously at me, and as I reached out and let his little hand grasp my fingers, the sound of the mother wailing for her daughter brought waves of despair. This precious baby didn’t know that his mother would no longer be holding him, would not longer be feeding him, would no longer be keeping him warm. But just when I thought the grief of it all would overtake my ability to cope, a woman came and gently lifted the baby onto her back and began binding him to her for the journey home. I don’t’ know who the woman was, I imagined it could have been the babies aunt, or other family member. It could have been a neighbor, or perhaps the woman’s friend, but it blessed my heart so much to see someone come and start loving that baby. There were no words from the grandmother, there was no formal process, it was just a silent way of ministry, a form of love like I have rarely seen. Even though that baby would never know his mother, he would know love, he would know care and he would know he was wanted. Again, just as many times previous, peace overcame my soul and enabled me to continue on with the other challenges of the day.

Later that day the triage aspect of my nursing was challenged again as we returned to the hospital. As I walked toward the entrance, there was a crowd or people and we heard that a young boy around 6 years had just been struck by a car. Given my previous experiences with the hospital, and know that they Emergency room didn’t even have basic supplies like oxygen, I felt the difficulty of the situation. I walked toward the ER and I heard his little voice as I stood outside in the hallway. I couldn’t understand what he was saying, but I did recognize the fear that I heard. As I stood and listened my heart sank as I heard the room go silent which never is a good sign when you have a pediatric trauma patient. When I am thinking about triage at home with children, a crying child is always better than a child that is difficult to rouse or is too weak to cry. As I was invited into the examining room I was met with a sight that broke me. This little boy, the size of my nephew, was being restrained on a plastic mattress with blood coming from his head and nose. He had obviously been struck on the back of his head and his forehead had been driven into the pavement. By the time that I started to assess him, he became agitated again, and was repeating words in his local dialect. I discovered that the boy at the end of the bed holding his legs down was his brother, and so we encouraged his brother to go and talk with him to try and lessen his fear. My heart sank again as I watched the little boy barely respond to his brother and continue to utter confused phrases. Even my placing a blanket on the little guys legs was terrifying for him, and I recognized that many of the things that we were seeing were evidence of a head injury. I then turned my energies to what the plan was and learned that the nurses wanted to transfer him to a bigger hospital. The only ambulance that was available was heading there way in an hour, and so my triage mind continued to deliberate what would be best. I thought about trying to pack up the child and drive him to the next hospital 40 minutes away, I thought about the pressure that could be building in his head, or the bleeding and injuries that I couldn’t see. I thought about the fact that this little man was alone without his parents and how scary that would be. As the cry changed, and they told me that the child was crying because of pain, my tears started to build, because I knew that the hospital didn’t have more than Tylenol to offer. What was the best plan? Was there such a thing as a best plan, or the most appropriate triage choice? What would I do at home? Well, at home, this child would have had an Ambulance present at the accident, he would have been assessed and most likely flown to Children’s hospital via helicopter, he would have been met by Emergency and Neurosurgeons, and most certainly, he would have had his mom or dad at his side. Here, he was afraid, confused, and without any parents to comfort him. The decisions fell to an older brother that was equally terrified of what was going on. I stood at the side of the bed and quietly told the little boy my name, that I was a nurse, and that I wanted to help, all the while trying to figure out what I was going to do. After thinking in an Africa triage mindset, I realized that even the next hospital wouldn’t have what the boy really needed, nor would any hospital for that matter. I realized that this little boy would lay on a bed and wait for hours by himself if we were to take him to the next city, and wouldn’t get any better care. I realized that in taking him, he would be without his family, and his parents wouldn’t be able to see him for an extended period of time. The decision that I made was one of the most difficult ones, as I chose to pray for the little boy, to leave a blanket on him and to walk away entrusting his care to the medical system that he was a part of. As the prayers of others went up from that place, my hand remained on his leg and I continued to whisper words of comfort to his little spirit. Although it felt like we were doing nothing, like we were just standing by and allowing this little boy to get worse, and even die, I knew in my spirit that wasn’t the case. Jesus was in that room, He was whispering to that little boy, His arms were holding him, and there was peace. As I walked out of the little Emergency room, I glanced back and saw the little boy close his eyes, his crying stopped, he stopped fighting, and one way or the other, I knew that his little spirit had found rest and peace.