"You Come To My House And You Will Be Better"

I've been sick again (this time tonsilitis, which I am prone too) and my illness has been causing a few cultural snafus.  Just like the local belief that a stomachache apparently needs to be treated with food, a sore throat (and other respirtory illnesses) need to be treated with a journey out of the city and into the country.
So, when news hit the hospital that I was sick, a "rash" of invitations came rushing in, each to a villiage more distant then the last.  Although it's rude to refuse an invitation to another's home in this culture, I tend to put my foot down when I am not feeling well and just want to rest.  Unfortunatly, the invitations do not appear to be voluntary, and I have taken to hiding in my room to avoid them.  The first one I thought that I would be able to perry with an excuse, but the lady said that if I came to her house I would be better.  I laughed at her joke, then realized that she was serious.  At that time I had a slight fever and I was an hour from the end of my shift and an hour from bed.  Unlike milky food which can be hidden in the trash, I have had a harder time trying to convince people that I just don't want to travel or meet a ton of people when I have a fever.

For me, it seems unreasonable to make any type of demands on someone that doesn't feel well, and I am trying not to feel frustrated that people will not just accept my "no thank you, I don't feel well, perhaps another time" and drop it.  I am trying to imagine my own reaction if I found out that someone was continuing to smoke during a nasty chest infection-- I would not take a "no thank you" to my advice to stop smoking if I really cared about the person, no matter how polite.  I think that people here feel the same way about getting me some fresh air.  But, after working for eight hours, I really just want to rest and spending another four hours trying to stumble through a conversation with my weak Arabic is just not an option. 

I have been transferred to the NICU, where I have been for the last few days.  The plus sides is that I don't have to try to talk to scared parents that don't understand my English.  The con side is is that I am working with men who don't really know how to react to a woman like me, but I think that we will all learn.  People of opposite genders are not friends here, unless they are also family.

Water Water, nowhere?

I was talking to some NGO workers the other day, and I learned about the problem in Hebron that involves water.
You have probably heard at one point or another that the water is not divided equally amoung the groups here.  There are basically two governments, the Israeli government and the Palestinian Authority (PA), which is below the Israeli government.  The Israeli government decides who gets the water and how it is devided up amoung the people, and the PA who rations out the water that the Israeli government decides that they get.

Needless to say, there isn't a water problem that I know of in the settlements.  The area of the city outside the settlements is another matter, however.  Most of the Palestinians have water tanks that are on their roof.  The PA gives each house 2, and richer families will buy more.  The water is rationed to different areas during the month.  When it is your month, you fill up your tanks and that is all the water that you get for a few weeks.  This means that water usage that it not considered "vital" will have to wait.  Some couples will even have to forgo sexual activity as they are unable to properly wash afterwards to pray.    (I also heard that during the Intifada, bored Israeli soldiers guarding the settlements would shoot at the water tanks to rupture them, and leave the families without water.)

This is obviously not an issue here at the hospital, where we are able to have all the water that we need.  But after learning this, I have taken steps to conserve.

A Sad Day

Beleive it or not, the hospital isn't all
dying children and crazy staff.
There are good days, too. 

The day before I got sick, we admitted a little guy with Down's Syndrome who was having respiratory problems. I had not been able to determine what exactly was wrong with him, but he had obvious cardiac surgery, acidosis (probably respiratory), and was gray. I guessed that he was about less then a year-- age was hard to judge because of developmental delays. We did the same respiratory resuscitation efforts that we had done on Farah the day before and he was admitted to our pediatric ICU.

He wasn't doing very well when I came into today, with bruises on his body from what looked like DIC. I found out that he had been coded during the night. He was on a respirator and a heart monitor that was showing periods of apnea. I think that the heart monitor may have also been a defibrillator that was keeping him alive, but I wasn't able to find out. I worked in another area for about an hour, then when I went in to see how he was doing I saw that he had died. He was wrapped in a sheet that was taped closed, and someone had written something (probably a prayer) in green. I am not sure why the child died, or if he would have died had he been in the States. Down Syndrome kids tend to have pretty significant cardiac problems, so it was probably related to that and may or may not have been fixable.

About an hour later, the family started to congregate. I didn't take much notice of the men, but a young woman came in and sat in a different set of chairs and started to cry. Everyone was busy with rounds at this time. Now, the problem with working with families that have lost someone is that death rituals differ greatly, including among different areas and classes. So although my first instinct was to take this women in to see her son, I wasn't sure if that was appropriate.

I did know that, regardless of culture, it wasn't appropriate in any situation for this women to have to quietly sob while people were laughing at the nursing station five feet from her. I tried to get someone to take her someplace private (I didn't want to lead her away without telling her where she was going, and I didn't have the words to explain) and they started to take her into Farah's room (the young baby I've been caring for). Knowing that the last thing that women needed to see was another women holding a living baby, I intercepted the her and took the bewildered women into the nursing break room. I gave her some tissues and a glass of water and then demanded that she be allowed to see her son. 

Finally, two nurses took her into the PICU and unwrapped her son for her to see and touch. She cried,touched his face, and asked that he be covered up. The family wrapped up the youngster in a blanket and took him away.

Code Bleah

Been sick for the last 24 hours with some sort of stomach virus that has been going around.  I think that I am finally over the worst of it.  The staff here have been really great about taking care of me, although mostly they come into my room to try to talk me into eating food that I can not digest.  I am going to head out in a bit and try to find a store that sells ramen.  Instant ramen is a pretty universal food, I am hoping.  I keep trying to explain to the housekeepers that I would rather be punched repeatedly in the stomach then try to digest the oil-laden hummus, flatbread, and yogurt that they keep bringing me.

My one (and only) patient, Farah, went down a few days ago to have a gasto tube placed as tube feedings unfortunatly seem to be a part of her permenent future.  While she was down there, I got to wondering what would happen if a patient coded while on the unit.  I had not been shown a crash cart, paddles, or anything like that.  And I came pretty close to finding out.  About an hour later, one of the nurses got a call to pick her up.  I was behind the nursing station when the doors opened and Nabila called out that we needed O2.  I wasn't able to figure out what happened exactly, but Farah was grey as stone and her mother was in tears.  We took her into the room and I used a nasal cannula that was there to give her O2 until someone brought a vent.  We got an O2 monitor at her and she was running at 76% O2 (normal is 95-100).  We manged to get to O2 stats up, but she kept on stopping breathing on me and I had to shake her awake.  It took 20 minutes to get her color back, and I insisted that the doctor be called when the poor little girl wouldn't stop gasping for breath.  Normally, I would have called a rapid responce the second that she had gotten off the elevator, and reamed surgery for sending what obviously was an unstable patient on an elevator without supplimental O2.  On that note, I don't think that I have seen any portable O2 anywhere in the hospital.  We do the best that we can with the little amount of equiptment that we have.
Anyway, she is doing a lot better now.

Salami Legroom

Nabila, my preceptor, hasn't been paid in
three months, yet here she is diligently
showing how we get a flush

As Friday is a Muslim holiday, Thursdays are basically Fridays here in Hebron.  As a result, there is a fireworks show going on at some big place about 200 yards outside my window.  They shoot off about 20 or so every hour.  It was cool at first, nows it's starting to get annoying. 

Life at the hospital goes on.  I found out today that no one here has been paid for a month. One of the nurses told me that since there is no money for the Ramadan feast (Ramadan is in August) she is planning on eating her children for the Iftar, or breaking of the fast. I think that the joke might have lost something in the translation.  (There go the damn fireworks again.)

My patient, Salah, whose name is actually Farah (Salah is the mother) is still here.  The doctors said a week ago that Farah could go home as soon as her parents buy a home suction machine.  I am starting to wonder if the parents know that. I have tried to get the other girls to ask the mother if she has questions about this request, but the baby is still here.  Not that I mind, I enjoy taking care of her.  (That is us in the picture.) 

Me and Farah

But I am really worried about her.  I think that I mentioned that her mother and father are older, which is probably why she has so many congenital defects.  She was also an IVF baby.  With the baby being likely developmentally delayed (I suspect Down's Syndrome), deaf, and mute from the trach, she will need much more stimulation then most babies to help her mind grow. She will cry, but it is completely silent, so she can't even ask for attention. 

Farah and her mother, Salah

And there go the fireworks again...

Hebron



Unrelated note, what is up
with this picutre?

For my first day off, I took a walk into the old city of Hebron. Hebron is unique in that it is the only area in Israel and the occupied territories to have a settlement in a major city. Hebron is divided into two areas, H1 (under Palestinian control) and H2 (the Israeli settlement.)

Guard tower at the separation
between H1 and H2

As a Red Cross/Red Cresent volunteer, I have made it a goal not to become involved in the politics of the situation. Although I have my own beliefs, I am not here as a protestor to to serve some agenda, at least I am trying not to. It is hard when everyone wants to talk to me about politics, or you walk around in Hebron.

I am willing to consider arguements about Israel's right to be here and it's founding, etc etc, but do firmly beleve that the settlements are wrong. Supported and populated mostly by the most extremist populations, it is generally believed that they serve simply to increase the land holdings of areas that are not under Palestinian control. They are akin to people moving into the “Green Zone” of Iraq, and are not only agaist international law, they are against Israeli law as well. They are tolerated in this country for the same reason that the US tolerates things like Abu Ghraib and Gitmo-- it is thought that they are necessary.

Hebron old city market, with the covered to catch garbage.
Can you imagine living here?

A lock to a shop soldered shut

In the case of the settlements in Hebron, they have causes the old city and it's holy site – Ibrahimi Mosque-- to become heavily fortified by Israeli solders. Lonely Planet states that there are 4000 soldiers to protect the 500 settlers (no, that isn't a typo, in fact I just looked itup again to be sure.) After eeing the rooftop lookout points and walking through three checkpoints to get to the mosque, I did not find this hard to believe. The settlement houses are across a small alley from the Palestinian houses, and the Palestinians have had to put webbing over the roads as the settlers will throw trash out the window. In one house that I visited, my host said that he had to keep his windows closed and locked lest his neighbors from across the way toss rocks and Maltov cocktails into his home. (I did not believe him about the Maltov cocktail part until he showed me a area that had been bombed by such a concoction.) He also showed me that many shops were forcefully closed and their doors welded shut to prevent the re-opening of the shops. The shops were too close to the settlements (often, they were in the first floor of the building) and so they were taken away. Resisters were arrested.



The old city

Hebron's recent history includes a massacure in the Ibrahimi Mosque, were a settler (who happened to be a doctor) walked in and killed 29 men and boys while they prayed, injuring another 200. This is most of the reason for the security to get into the Mosque. After walking through two remote controlled locked doors and being searched by two guards, I could start to feel the irritation. My irritation reached its peak at the last Israeli solder who searched me. She was blonde with an American accent, and when she asked me: “Where are you from?” I couldn't help but answer “America. And you?” She gave me a dirty look and let me pass.  So much for not getting involved politically.

Praying at the tomb of Abraham

 

Heartbreaking

I am continuing to work with Salah, the little girl that I spoke about yesterday with the congenital defects.  She is still needed almost constant suctioning.  Today the doctor ordered that we try and perform feedings with the bottle, but she will almost immediatly start to choke, and she doesn't try top suck (probably because she has never successfully fed from the bottle or nipple.)

Her mother is an older lady (40+) who is having a very hard time dealing with her daughter's medical needs.  I noticed that she has had no visitors, which is rare in Palestinian culture.  I learned today that she is actually from Bethlaham, so she is a long way from home.  She also doesn't have any other kids.  She is trying to be positive about her daughter, but when little Salah vomitted everything that ws given her, the mother broke down and stated to cry.  If the child survives, then this women's next few years is going to be spent caring for a child that can not even eat.  The mother has been very good about doing the suctioning and feedings herself, but today I had to take over when she was threatening a nervous breakdown.  Even if I could speak English, there would be no words of comfort that I would be able to give her.

She must have been looking forward to having a child very much. Of course, there is no guarentee that any child will be born healthy, but I am sure that she was not expecting to suddently take care of a child that is so ill.  I tried to get her to leave this afternoon, even for a few hours.  She left overnight a few days ago, and returned in much better spirits, but the mother didn't want to leave.  The child will be discharged soon, and hopefully will some day be able to have surgery to correct some of her defects. But I worry that the baby will die much before that.

We also got a terrible case of meningococcal meningitis. I was horrified to see that he was not put on droplet isolation, but they did have contact isolation (of sorts).  He was covered with sores due to a very high PTT that was probably caused by DIC.

Days 2 and 3

Nursing Station

Well, I have completed day 2 and 3 of my hospital work. Today was very slow, we didn't have any admissions. I am starting to remember what I found most frustrating about working overseas, and that is the slow pace of life.  Honestly, the workload of the entire unit could be done by one nurse from the hospital that I used to work at.  The parents do most of the care, leaving the nurses to just administer medications.  There were four nurses today, including myself.  That means that there is about only one patient per nurse.  Much of the day is spent talking and eating.  There is a special concern over my eating habits to the staff, and the kitchen will often call the floor to tell me to come eat.

Intake/med room/1 of 2 sinks

I did get my own patient today.  Little Salah is a little girl who was born with severe congenital defects.  You can see in the picture that she has a trach, 6 fingers on her right hand, and deformed ear canals.  I have not been able to find out more about her condition, but I think that even in America there would be little that could be done for her.  She requires almost constant suction, feeding through her NG tube, and is on an antiepeleptic drug phenobarbitol.  She is going to stay until her mother "psychologically accepts her condition" and has learned to care for her.  I think that this will happen soon.  The mother would not allow me to touch her or play with her two nights ago, but today the mother picked her up and cooed to her and was able to perform feeding and suction.  At the end of shift, I was told to give report.  Sif, the head nurse, was there for report and I assumed that he would translate.  I said that the infant was stable, was not needing suction as often, but that the mother needed to understand the importance of checking residue prior to feeding.

An empty patient room

I am learning a lot.  I inserted my first NG tube, although I wish that it had not been on a baby of a month old.  All patients get an IV, and scalp IV's are not inserted by the doctor, so I am terrified when I will first do this.  There are only two sinks on the floor with liquid soap and paper towels, so I carry a bottle of Purel which I share with the other nurses.

What I wouldn't give for my maternal and child textbook! 

Day One

No pictures, I am afraid, I forgot to bring my camera.  I should have some tomarrow.
I am hoping that this is just first day jitters, but I am actually not sure if this is going to work, but I am certainly going to try.  The language barrier is a real problem.  All the people that work are Palestinians and have only a very basic skill of English.  I think that they thought that my Arabic was better, but if they are willing to give it a go, so am I.
I am working on the Pediatric ward, and my preceptor probably has the best English there.  The kids that were there involved a few babies with hyperbilirubin, a baby with terrible congenital defects, and a few older kids with chronic health problems (respiratory).
The worst part was that I couldn't answer the questions of the parents or even explain what I was doing when I went in to take vitals.  At one point, a mother went to the door and motioned to me.  I told my preceptor, who was charting, that help was needed and she told me to go in myself.  I did, but obviously couldn't understand what she needed.  I mean, how awful is it to have a sick kid, and a nurse who can't talk to you to boot?  Communication and teaching is such a vital part of nursing, and this is why I am not sure if I will be successful here.  Even asking a simple question like "do you want some tea?" is rewarded with a barrage of Arabic rather then a yes or a no.  I am not very good at learning languages in the first place, and I don't think that I can raise to a level where I can be a helpful worker.  But, as I said, I will try.
There was rounds in the morning, and for some reason they would switch to English when the doctors would announce what his plans were for the child.  At one point he pointed at a premature (29 week) newborn and asked everyone what we should be concerned with regarding the eyes.  No one there knew, and he was very pleased when I finally said that we should watch for retinopathy of prematurity, so maybe I will be able to help after all.

We will see tomorrow, maybe it will go better.

Hebron

Well, I finally made it to the hospital. I am in my new room listening to call to prayer. My room faces west and I am able to watch the stunning sunsets over the city of Hebron. The strangest thing is that it feels like I never really left.

Yesterday, after a very brief argument over the day of the week in a Tel Aviv bus station, I discovered that it was actually Friday, not Thursday. This meant that the offices of the Red Crescent would be closed, and I would not be able to travel that day. This was actually pretty good news, as it meant that I would have a day in Jerusalem, although I was eager to start my work. At the bus station, I met a guy from Holland, Jaap, who was coming in to volunteer as well. It turned out that he was not only going to Damascus Gate, but he was also planning on staying at the Palm, which was the same place that I was last time.

We actually met due to the extreme rudeness of the Israeli citizenry that I have encountered here. We had been waiting for about 30 minutes in the searing heat for a bus to come. When it finally did, Japp helped me to load our luggage onto the bus while the rest of the people got on. When he started to get on the bus, the driver told us that there was no more room. We had to grab our bags from the bus, which drove away almost the second that our bags hit the pavement. Although this behavior was what I may have expected in America, I was used to the hospitality of the countries that I had been in and was pretty shocked. But it did give me a traveling companion, and we spent the day in Jerusalem together, visiting the tomb of Jesus and watching Shabbat at the Western Wall.

Ack, I am so tired. Will write more later.   But here is a picture of the Seperation Wall for your viewing pleasure.

They're not buying it, Chewie

Made it in!!!
I didn't think that I would.  I got into the airport having made a few friends on the plane and was chatting with them in an attempt to look casual as I approached the passport station.  I had read somewhere that whistling people appear to be less worrisome, so I whistled a silent toon and tried to look tired but excited.
When I approached the customs person, I think that my first mistake was answering a little too pat.  On the plane, I talked to a few Israelis who all expressed a good deal of shock when finding out that I was planning on asking for a three month visa.  I was told by all of them that there really wasn't enough here to have a three day stay. I also found out that there really isn't an age limit for working on a Kabutz.  So when they asked what I would do here, I said that I wanted to start in Jerusalem and move outward to see everything, and maybe volunteer in a Kabutz if there was time.  She nodded, hit a few more keys, then asked me to go to the office "for security reasons".

When I went to the office, there were a few people of obvious Arab decent there (the women where wearing scarves) and no other white people.  I waited patiently, trying very hard to stay calm.  I felt a little better when another white woman was shown in.  She was irate, swearing under her breath.  I folded my hands and tried to look polite, feeling a little better.  I felt a lot worse when she was was told a few minutes later that she was free to go. 

All the people  I was waiting with (and a few new people) were cleared and I started to feel screwed.  An hour later, I finally noticed that one of the security men were looking at my passport.  My stomach sank when he started to key my name into a computer.  I basically gave up hope when he picked up the phone and told the listener my name.

I was called in a few minutes later, and the minute I stepped in a second man who looked like a policeman walked in behind me.  Great, I thought, they are going to arrest and deport me on the spot.  The computer guy asked me if this was my first time in Israel.  Knowing that he knew the answer anyway, I said that it wasn't.  He asked what I had done during my last trip, and before I could answer the two men started talking.  I wished that I knew Hebrew.  Mr. Computer then asked me about money, and asked to see my credit cards.  I handed them over, with a glimmer of hope.  He dashed that when he then asked me if there were any "problems" during my last trip.

In a move that probably allowed my entrance, I told him flatly that yes, there were problems, I was arrested and deported during that last trip.  Hegding my bets that his computer didn't have any details about my arrest, I said (very somewhat truthfully) that I was following "a guy I met" from Denmark.  I said that I stayed with a group of international women, and that I was arrested "for being in the wrong place".  I said that it was stupid.  I also told him that I was planning on volunteering during my stay.  I told him that I was in contact with the Red Crescent and was also hoping to work with the Israeli version of the Red Cross, and perhaps a Kabutz.  I said that I was a nurse.

He then asked me many times if I knew anyone here.  He asked if I was still in contact with the women or the man that I was "following".  I laughed a little and said no, I didn't even remember their names, I think it was Gustov or something.  I talked with a few others later who had been held, and questions about people that we knew in the area were a common theme.  Finally, I was asked to wait somewhere else.  I assumed that they were holding me so that they could get the right people to escort me out of the country.

My hopes dashed was actually a bit of a relief, as was the coke machine that was in the new place I was waiting.  I got a coke and watched some football on TV while I waited my fate.  After about another hour, a women said my name, handed me my passport, and said that I could go.

"Uh, where?"  She pointed to customs.  I opened my passport and saw a three month stamp.  It was a beautiful moment.