RESOURCE CORNER

One Small Step Today, One Giant Leap IntoYesterday

Debbie Sandlin, RN, CPAN

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THIS COLUMN IS a startling look at how farinto the past one can travel by taking a smallstep today into a third world country to deliverhealth care. When considering resources forcontinuing nursing education, one seldomthinks of opportunities presented by volunteer-ing in a poor country. No contact hours orcertificates are awarded, yet the rewards can beoverwhelming and intangible. From snakes andscorpions in the PACU, to the most beautifuland most appreciative patients, this experiencehas it all.

Machine Guns at the Airport

Seeing guards armed with machine guns in theairport reminded me immediately that I was nolonger in America. At the baggage claim area, Iwas met by very large dogs that were interestedin my luggage. Thankfully, I was carrying noillegal drugs, so they passed after a quick sniffand continued to the next passenger. Guate-mala City, a huge, bustling city, very modernand progressive, is like most American cities,with tall buildings, many shops, and restaurants.Parts of the city were spotless and beautiful, andothers were dirty and cluttered. The traffic re-minded me of America as everyone drove sofast and no one seemed willing to yield. Lots ofhorn honking and rude hand gestures passedbetween drivers. I joined the mission group at aseminary, a large compound hidden behind tallconcrete walls topped with razor wire and agate guarded with machine guns. I began towonder what I was getting myself into. It wasterrifying that a religious seminary had to be

guarded so heavily.

Journal of PeriAnesthesia Nursing, Vol 21, No 1 (February), 2006: pp 43-47

ravel Day

fter getting up at 4 AM, we boarded a dilapi-ated old bus with our luggage loaded on topor the trip to Chocola, Guatemala. The bus waslled with cheerful and laughing volunteer med-

cal staff, all anxious to get started. The busriver advised us to refrain from drinking liquidsecause we were not going to be able to stopuring the 4-hour trip. He explained that weust travel the highway where a recent tourist

us was overtaken, and the women were rapednd the men shot. He explained that it was notafe to stop for breakfast or a bathroom breaklong the way. I took a deep breath and said amall silent prayer, again wondering what I hadotten myself into, then promptly went toleep.

e Arrive

was awakened suddenly by severe bumpingnd jostling. Apparently, we had been travelingor almost 4 hours. It was a struggle to remain inur seats because we were on an unpaved,uddy, one-lane road with lots of deep holes.e were surrounded on both sides with lush

reenery including coffee plants, and bananand avocado trees. The road conditions gotorse. Several purses flew down the aisle, and

Debbie Sandlin, RN, CPAN, is Manager of Outpatient Sur-ical Services, Southern Hills Medical Center, Nashville, TN.Address correspondence to Debbie Sandlin, RN, CPAN,

outhern Hills Medical Center, 391 Wallace Road, Nashville,N 37211; e-mail address: debbie.sandlin@hcahealthcare.com© 2006 by American Society of PeriAnesthesia Nurses.1089-9472/06/2101-0009$32.00/0

doi:10.1016/j.jopan.2005.11.002

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our lively group grew silent. The bus had almostoverturned several times and was lurching fromside to side when we hit a very deep hole, andthe bus tilted precariously to the left. It felt likewe were turning over in slow motion, butstopped just short of rolling over. While teeter-ing precariously on the left wheels, we wereinstructed by the driver to move to the rightside of the bus to attempt to balance it andhopefully make it fall back onto all 4 wheels.When that plan failed, we were told to abandonthe bus. Because the bottom step of the bus wasnow about 5 feet off the ground, the men gotoff first and assisted the ladies. We eachplopped down firmly into the mud and startedwalking. The men stayed behind and tried val-iantly to push the bus out of the hole while thedriver revved the engine. The bus stayed put,and the guys were covered with mud. Walkingcarefully proved impossible for some of thegroup and several people fell and were humor-ously muddy. We walked a mile and a half toour destination, a couple of old concrete blockbuildings. Probably 200 people, clothed in thevery colorful hand-woven Mayan fashions typi-cal to the area, were there to greet us. Theysmiled and uttered greetings. I had learned sev-eral Spanish words and phrases over the lastfew weeks in preparation for this trip, but notenough.

We were miles away from the nearest city orvillage, and there were no shops or vendingmachines because this was the jungle. We en-tered one of the concrete block buildings andfound it to be a pleasant eating area with severallong narrow tables. On the back wall was ahand-painted mural of Noah’s Ark. The buildinghad electricity, so there was limited lighting, butno air conditioning, hot water, or drinkablewater. There were 2 urns of coffee and a largetub of pancakes and some watermelon slices.The coffee, juice, and food soon ran out, andthere was no more for this meal. We were toldin advance to bring bottled water and somenonperishable snacks. The showers were icy

cold, and there were no showerheads, just e

ipes that gush water. Several of us had camphowers that we left in the sun to warm daily.

ur cots were covered with a white cottonospital blanket, 2 sheets, and a tiny pillow

abeled “American Airlines.” We were very pop-lar with the children because we had broughtreats. I took about 15 pounds of chocolateandy, gum, and small toys for them. Our cur-ains were bed sheets hung over crude rods, buthey served their purpose. Being very tired, Iaid down on my cot and the entire middle sunkown, leaving me in a jack knife position, but ittill felt good to lie down. Looking up at theeiling tiles, I noticed that they appeared to beade of dried plant material and glue, and

ontained long slender leaves and blades of longrass. The ceiling color was black, which I laterearned was caused from bat excrement leakinghrough from the attic. The intense heat andumidity were overwhelming.

he Hospital

went into the hospital, and the first thing Ioticed was an 8-year-old boy sitting in a foldinghair alone. He was being prepared for surgeryn the “holding room” where other patients

ere sitting in 6 folding chairs as their intrave-ous (IV) lines were started. Each patient hadet hair because they were required to showerefore surgery, also in icy cold water. The littleoy was scared and was sitting wide eyedringing his hands. He was to have an inguinalernia repair. We used what we had available,lass and plastic bottles of assorted IV fluids.he patients were grateful to be there and wereery cooperative. The lighting was terrible, andt was difficult to see to start IV lines or to read

edication labels. Surgical permits were signedy the patients with a scrawled “X.”

urgical Suites

atients walked barefooted down the surgeryallway and climbed up onto the operatingoom tables. Some were having general anesthe-ia and others a spinal. The 2 rooms were

quipped with outdated operating tables and

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ONE SMALL STEP TODAY, ONE GIANT LEAP INTO YESTERDAY 45

other sparse ancient equipment such as anes-thesia machines and cardiac monitors with nopulse oximeters and no printout capability.Each room had a window air conditioner, al-though no other part of the hospital did. Thesurgeons brought their own instruments thatwere sterilized in an old autoclave by a volun-teer who is a farmer in the United States. He isan old pro at this, having done it for years onmany missions. The temperature was above100°F, and it was brutally hot inside the build-ing. The humidity was very high, and there wasan abundance of mosquitoes and flies. Whenthe first patient was placed in lithotomy posi-tion in the operating room, her uterus wasprolapsed outside her body and just hung there.These patients needed surgery so badly that itwas unbelievable. Another patient’s inguinalhernia sac was so large, it almost reached hisknee. Patients were delighted to have beenselected to have their problems repaired by alocal physician who had chosen those whowere to receive our services.

Most of the surgeries planned were hernia re-pairs and hysterectomies. I looked at the mea-ger medicine cabinet and noticed there was nodantrolene. I asked what happened if we had acase of malignant hyperthermia, and the Certi-fied Registered Nurse Anesthetist just gave me asad knowing look and shrugged his shoulders.There was no ice either. Our medications con-sisted mostly of antibiotics, meperidine, andpromethazine. A young girl with our group, ahigh school student, was able to act as a trans-lator. She was also shown how to circulate inthe operating room despite being a little afraidof the sight of blood.

Sterile Supply Room

A dark, dusty “supply room” consisted of as-sorted donated supplies on open woodenshelves. There were various brands of foleycatheter sets, dressings, tapes, syringes, andnonsafety needles. The supplies were reason-ably well organized but a real hodgepodge of

brands. There were still many supplies in old s

uitcases and boxes that were as yet unpacked.noticed boxes full of shoes, but most of ouratients did not want them.

ACU/Post Op Ward

he Post Anesthesia Care Unit, also the over-ight hospital ward, had no nurses’ station, noardiac monitors, no oxygen, no suction, ando pulse oximeters. We only had one stetho-cope and one blood pressure cuff with a gaugettached. We had gloves because we were toldo bring them with us. There were 27 mis-atched twin sized beds, cots, or old hospital

eds. The hospital beds were no longer opera-ional, so the beds were all different heights,ome very low and some very high. All wererowded close together, and there was no pos-ibility of Trendelenburg position or elevationf the head of beds. All of them were made upith colorful unmatched sheets and each had aillow and thick wool blankets. I wonderedhy anyone would possibly want thick woollankets in this blazing hot room. Our scrublothes were already soaked with perspiration.here was one stretcher to transport patients

rom the operating room to the PACU, and itas not height adjustable. Postoperative pa-

ients were pulled from one bed to another,ometimes bouncing downward as much as 2eet. There were no privacy curtains around theeds or windows, and each window wasrowded with people pressing their facesgainst the screens to see inside.

he child with the hernia repair was our firstatient brought out of surgery. He was post–eneral anesthesia, and the family quickly cov-red him up from head to toe with the heavyool blankets. He was asleep but breathing so Iut him on his side and positioned his head andeck to facilitate an open airway. He soundedwet” and gurgling, but I had no suction, noonitors, and no oxygen. He was really hot, but

very time I uncovered him, the family imme-iately replaced the wool blankets. I learnedhat they believe that the blankets keep the “evil

pirits” away and should be placed around all

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sick people. He took liquid acetaminophen likea champ, and when we asked him to take deepbreaths in Spanish, he understood and com-plied readily. His bed was surrounded by terri-fied parents and other relatives. Someone ar-rived that could translate and told the familythat the child was “okay” and that the medicinewe gave him should help his pain. Theybreathed a collective sigh of relief and smiled atus, nodding their heads. They held hands andprayed as a group, with silent tears of joy run-ning down their faces. My heart was in mythroat, and I was touched to the point of tears.This happened with each patient when thefamily realized that surgery was over and theirloved one was okay.

The Hospital Bathroom

The PACU/overnight hospital ward had onetiny “bathroom” with no toilet, no door, and noprivacy curtain. What it did have was a com-mode chair with a bedpan sitting on the floorunderneath it. Urine and feces splattered pa-tients’ feet and the floor when it was put to use.We had one other plastic bedpan and urinal thathad to be used for all nonambulatory patients. Arusty 5-gallon bucket was used to empty urinals,bedpans, foleys, and emesis.

Families played a large part in patient care. Theyhelped the male patients with the urinal andthen passed it to the next male bed. The urinalwas only emptied when full. Each of the 27patients had 6 to 10 visitors crowded aroundthem. There were no chairs or bedside tables,and at mealtime, families fed the patients. Mostpatients could not talk to each other becausethere were so many different dialects repre-sented and there was very little actual Spanishspoken.

Nursing Care and Assessment

Documentation was easy . . . no JCAHO orASPAN standards. We used simple forms anddocumented brief assessments, vital signs, andmedication administration. We did vital signs

every 15 minutes times 4, then just whenever c

e could. We were told not to do vital signs atight unless we suspected a problem. Eachatient had a clipboard hung on a nail at the endf the bed and a handmade sign at the head ofhe bed with their name and operation listedno HIPAA here either). Another patient wasoming in, and I turned my little patient over ton Emergency Room Nurse. This new patientad received a spinal for an open abdominalysterectomy and we easily moved her to a bed.one of the beds would lock, but the beds were

o close together that there was little chance ofalling between them. She was awake, breath-ng fine, stable blood pressure and pulse, andovered up head and ears with thick woollankets. I could not assess the spinal levelecause I could not ask her. She did not speakpanish or English and neither did the 9 familyembers crowded around her bed. I pincheder toe with no response, so I assumed that sheould not yet move her legs. Her foley was inlace and draining clear yellow urine in ade-uate amounts. I was surprised because Ihought she would be dehydrated from the longPO status and this hot, hot climate. Because ofur limited supply, we had to conserve IV fluidso that each patient only received 2 liters duringhe course of surgery and the following postop-rative days. I had 2 more nurses now, bothB-GYN office nurses, and more patients com-

ng out of surgery.

he First Explosion

had finally drifted off to sleep when I waswakened suddenly by an explosion. The roomas extremely dark, so I felt around the wallntil I located the light switch. When I flipped

t, nothing happened. I took my flashlight andent across to the hospital building where theyere in the dark also, except in surgery. A little

as-powered backup generator allowed surgeryo continue. Several people in the PACU hadashlights, and we quickly located some can-les and stuck them into empty soda bottles.he explosion was caused by an overloadedlectrical box on a pole outside. A local villager

limbed the electrical pole and somehow re-

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ONE SMALL STEP TODAY, ONE GIANT LEAP INTO YESTERDAY 47

stored the power. This scenario of explosionsfollowed by blackouts and the villager climbingthe pole was repeated 3 times during our week.

The Pantry and the Outdoor KitchenHut

Another small hot room contained cartons ofunrefrigerated eggs, bags of black beans, corn,potatoes, onions, peppers, flour, sugar andother “grocery” items. These were used to pre-pare the food we ate. Our food was cooked bylocal volunteers over an outdoor wood fire thatwas covered by a little hut. There was one largesink that was used not only to soak the corn forour daily tortillas, but also to hand wash thebloody linens and towels used daily. It was verycomforting to see gallon jugs of Clorox Bleachin the area. A typical meal consisted of blackbeans, meat or chicken, potatoes, tropical fruits,and fresh hot tortillas.

Snake in the PACU!

I heard squeals, screams, and a great commo-tion and realized that the visitors had jumpedonto the beds with the patients and were point-ing to the floor. I saw a small side-winder snakeand because everyone else had run away, Ididn’t know what else to do but try to kill it. Ishouted for someone to get me a hoe, meaninga garden hoe. Being from Tennessee, I have apretty pronounced southern accent so a gardentool is not what the native people who spoke alittle bit of English thought I was asking for. Itwas funny later. I stepped on the small snakewith my left foot and managed to kill it with myright foot. We hoped no larger snakes wouldcome in through the gaps in the walls. Luckily,

ouple of scorpions, and one night a flyingnsect the size of a humming bird flew past myar and became tangled in my patient’s hair. Noack of excitement here.

Little Medication Error

was feeling very proud of myself because Ihought my communication skills had improvedramatically since my arrival in this country. Aatient complained of nausea and I gave him anntiemetic. Almost immediately, I realized thate had been trying to tell me good night andas not complaining of nausea. I gasped whenrealized it and a little elderly female patientearby started giggling. I looked at her and said,You speak English don’t you?” Grinning, sheodded her head and said, “He no get sickhough!” She had a good laugh every time sheaw me after that. We helped 67 patientshrough their surgery that week.

n God’s Hands

hen these patients were discharged with amall package of acetaminophen for postoper-tive pain, they were so grateful to us. Theyugged us and sobbed thanks to us before

eaving to walk as far as 5 miles back home. I feltery small and undeserving of their gratitude. Iruly felt God’s presence during this entire ex-erience and felt blessed to be allowed to playven such a small part of this mission. I amore thankful now for the little things in my life

hat I take for granted each day. I don’t everemember working so hard or enjoying work souch. There were no contact hours and no

ertificates of attendance, yet my reward was

no more snakes appeared, but we did kill a indescribable and priceless.