Portal de Periódicos da CAPES

An Experience of a Lifetime

2005; Elsevier BV; Volume: 6; Issue: 2 Linguagem: Inglês

10.1016/j.pmn.2005.05.001

1532-8635

Stephanie L. Nyman,

Editor’s Note: The editorial for this issue of Pain Management Nursing is a story told by one of our outstanding members. The experiences of Ms. Stephanie Nyman teach us a tremendous amount about hope and caring. I invite you to sit quietly for a few minutes, perhaps with a cup of soothing tea, and enjoy “An Experience of a Lifetime.”Christine Miaskowski, PhD, RN, FAAN Editor When the December 26, 2004 tsunami occurred in Southeast Asia, I felt a strong calling to help the victims of this horrible natural disaster. The calling felt much like the calling I felt many years ago to become a nurse and the calling to become a pediatric oncology nurse and a hospice nurse. I watched the people of the affected countries on television and felt such a strong desire to help them. I searched the Internet to find an organization that would accept registered nurses as volunteers and send me to the area to provide nursing care. However, I could not find any such organization. I sent an e-mail to the founder of Nurses Without Borders who responded with encouragement to keep searching but did not know of any organization. And then one day an e-mail came from the American Society for Pain Management Nursing (ASPMN) informing members that ProjectHOPE was recruiting nurses and physicians and other health care professionals to volunteer for a tour of duty in Southeast Asia. I immediately accessed the Web site for ProjectHope and submitted my resume and application online. When I read the description of specialties within nursing that were being sought (medical, surgical, pediatrics, operating room, recovery room, intensive care, obstetrics), I was concerned that they would not consider me since it had been many years since I was a pediatric nurse and pain management nursing was not listed as an area of need. My nursing background of 19 years began with 5 years of pediatric oncology/AIDS nursing at the National Institutes of Health/National Cancer Institute, continued on with 1.5 years as a nurse for the Indian Health Service on a rural Indian reservation in Montana, 3 years of home health and hospice nursing in rural Montana, 3 years of hospice nursing in Las Vegas, and currently 6 years of pain management nursing for a medical device manufacturer in Las Vegas. This company manufactures implants for chronic and cancer pain. My role as a Clinical Specialist with the company is to provide physician support in the operating room when the devices are trialed and implanted, to program devices once implanted, and to educate health care professionals and consumers about pain management. So it had been many years since I practiced in a specialty area that was listed on the ProjectHOPE Web site. The first deployment was set for January 26. I received a telephone call from ProjectHOPE with questions regarding my area of practice, passport status, and availability. I answered the questions and was told that I would be contacted the next day with the decision on whether or not I had been selected. The next day came and went and I received no call. I was quite sad that I had not been selected. I checked the Web site often for more information and saw that no decision had been made about the dates for the second and third deployments, so there was still hope. A couple of weeks later, I received a second e-mail asking me to resubmit my resume. So I did but this time with a letter “marketing” myself, my skills, my knowledge base, and what I could offer to the tsunami victims as well as my fellow volunteers. I explained that although I have been a pain management nurse for 6 years, I have a significant amount of experience in pediatrics, not just while working at NIH, but also as a hospice nurse in Las Vegas. I also explained that I had provided grief and bereavement training with both adults and children. Therefore, I could be supportive to the victims as well as my colleagues. I hoped that this letter would spark some interest in selecting me as a volunteer for the mission. I knew I could be helpful and I wanted to help. A few days later I received a telephone call with the same questions as the previous call. I answered the questions and was then informed that I had been selected to depart on February 26. The mission would last until March 20. It was a joint mission with the United States Navy on a Navy hospital ship, the USNS Mercy, where we would care for patients onboard in the hospital. This was the first ever mission of its type with the military so it was somewhat of a test mission. I was ecstatic. My employer was extremely supportive of the volunteer work. I received my paperwork and began the process of preparing for my most rewarding journey ever. I received vaccinations for MMR, typhoid, tetanus, hepatitis B booster, and hepatitis A, and purchased items I would need for the trip. On February 26, I left Las Vegas for San Francisco, then Tokyo, and finally Singapore. In Singapore, we settled into our hotel rooms at 2 am and were told to report to the hotel lobby at 5 am for departure to Banda Aceh, Indonesia. We left Singapore from their Air Force Base on a United States C130 military cargo plane. On our arrival at the Banda Aceh airport, we took US Navy helicopter rides to the USNS Mercy. I had never been on any military aircraft so that was quite exciting. On arrival at the ship, we were given a tour and sent to the berthing area to choose our bunks and unpack. The sleeping quarters, or berthing area, was a very large room that could sleep approximately 150 people in bunks stacked 3 high. Each bunk was like a box with a curtain along one side for privacy. We unpacked and ventured around the ship to become oriented to our new residence. The next day was orientation to the “Navy’s ways.” I found out that my assignment was as staff nurse on ward 1 during the evening shift. Ward 1 was 1 of 2 wards. Both adults and children were treated in this ward. Each patient had as an escort a family member, or a friend if there were no family members, who could accompany the patient onboard. Approximately 50 health care professionals reported for duty. We were joining another group of approximately 50 colleagues who had arrived 4 to 5 days earlier to begin the switch-out with the first group that was being relieved. A few nurses and physicians from the first deployment on January 26 stayed for another tour. The specialties included intensive care, nurse anesthesia, pediatric nurse practitioners, adult nurse practitioners, medical/surgical, labor and delivery, endoscopy, operating room, emergency room, psychiatry, infectious disease, occupational health, and pediatrics. The physician specialties included dermatology, pediatric intensivist, infectious disease, internal medicine, pediatrics, nephrology, urology, surgery (general, oral, maxillofacial and orthopedic), ophthalmology, psychiatry, psychology, and dental. A veterinarian, 2 social workers, and a dietitian were part of the team as well. My first shift was on March 2; I was assigned 3 patients. The first was a beautiful 9-year-old girl with a tumor on her right foot that came up and over her foot to a point (best envisioned in one’s mind as a jester’s shoe). She was able to walk at the time. However, the physicians informed her father that the tumor was benign, would continue to grow, and eventually become so large that she could not walk on the foot. Initially, the surgeons attempted a mid-foot amputation and tumor removal. This procedure was not successful because the skin on her distal foot became ischemic, and a below-the-knee amputation was ultimately necessary. My second patient was a 54-year-old woman with a kidney abscess. She had a nephrectomy and abscess removal that day. The third patient was a 32-year-old man with empyema probably caused by the teeth in his mouth that were abscessed. He had a chest tube using an old Gomco suction machine. I took care of these same patients for several evening shifts, providing medical-surgical care, which I had not practiced for many years since I had worked as an Indian Health Service nurse. It all came back to me quite quickly and I had no difficulty sliding back into bedside nursing. The woman with the kidney abscess was vomiting several times a day. I suggested to her surgeon that she might be having motion sickness. He ordered a scopolamine patch, which was very effective as she did not have any further episodes of vomiting. (The ship was 2 to 3 miles off shore at all times during the day, sailing back and forth, until evening when it sailed 25 km out to sea.) I enjoyed caring for these patients and they and their escorts warmed up quite nicely and quickly while we cared for them. They joked with us through translation by the interpreters and made us laugh many times. In many ways they were just like us, laughing at the same things we laugh at. It just shows how we are all the same throughout the world. After a few days, I also cared for a 17-month-old boy with a benign tumor of the liver and a scalp/forehead wound from tsunami debris. This young boy was sent to Boston for surgery to remove his tumor with great success. Another patient I cared for was a woman in her 20s or 30s with a large tumor on the left side of her face, completely displacing her lower jaw. She had surgery to remove the benign tumor and reconstruction of her lower jaw using a rib and hip bone. She required a gastric tube for nutrition until she could eat using her own mouth. The night before her discharge, I spent 2 hours training her brother on gastric tube care, feedings, and medication delivery through the tube, all translated by an interpreter. The patients we cared for rarely spoke English so we relied heavily on the interpreters who were onboard. We picked up a few words of Acehnese Indonesian, such as sakit for pain. The patients rarely reported pain but would admit to it if asked. Every shift started out with introductions and asking if the patient was in pain and at every encounter we asked the patient if he or she was in pain because otherwise we would not know. Although pain medication was readily available, some of the physicians and nurses lacked knowledge about effective pain management. One order was written for meperidine 10 mg, intravenously, every 3 to 4 hours as needed for pain, in a 19-year-old man after removal of an abscess from behind his eye. Another physician ordered fentanyl, 25 μg, intravenously, every 1 to 2 hours as needed for pain. I was quite thrilled when these 2 physicians were open to education on more appropriate pain medications for the circumstances. Some of the nurses lacked knowledge about pain management. One nurse did not know ketorolac was not an opioid. Another thought oxycodone and acetaminophen (Percocet) and hydrocodone and acetaminophen (Lortab) were the same drug. Some nurses did not know the difference between acetaminophen and codeine (Tylenol #3) and Percocet and also were not familiar with how constipating codeine is. It was wonderful to see how useful it was to have a pain management nurse on board. These episodes are not mentioned to belittle anyone but to show how education and training in pain management remains so necessary in health care in the United States. So much of medicine and surgery involves pain management and, while some people think a nurse with this specialty would not be needed, it was quite evident that the need was there and the specialized training useful in so many situations. Other conditions and illnesses we saw included roundworm, hookworm, neurofibromatosis, cancer, hemangioma, renal failure, broken bones of arms and legs, abscesses in various locations including the spine (at a previous fusion site from years ago), scabies, chicken pox, inactive typhoid, oomphalocele, cleft lip/palate, and inguinal hernia. With several patients, there was a history of an orthopedic surgery years earlier with a wound that had never healed and was obviously infected, yet the patient never had become septic. This was truly amazing. Every day the ophthalmologists went ashore and examined patients for glasses, which were made on the ship, and removed cataracts. The dentists saw many patients and removed hundreds and hundreds of bad teeth. Care was also provided on shore by volunteer physicians and nurses, alongside some Navy and Public Health Service health care providers. Teaching was done routinely on shore to the local nurses still alive after the tsunami. Banda Aceh had 2 hospitals, 1 university hospital and 1 military hospital. The tsunami stopped across the street from the military hospital but completely ruined the university hospital. Everyone, patients and staff, in the university hospital was killed on the day of the tsunami. All of the equipment and furniture and supplies were destroyed. The tsunami deposited several feet of mud in the hospital. Toward the end of the mission, I had the opportunity to go ashore to teach CPR to the local nurses. We had a class of 24 with translation provided by an interpreter who was also a nurse from Jakarta. It was wonderful providing the teaching and having fun interacting with the nurses. They learned quickly and had quite a sense of humor, especially when it came to having a hospice nurse teaching CPR. After the class, we had the opportunity to eat at a local Indonesian restaurant with the hospital’s chief nursing administrators. They then drove us around the area to see the devastation so that we could return to the United States, report the destruction to everyone, “and pray [they] never have another tsunami.” Almost 3 months after the tsunami, the destruction was still devastating. There was a steel barge that had been carried inland 1.5 miles by the tsunami and parked on land. The shopping mall was destroyed and they had not gone in yet to look for bodies. Many people were still missing and mass graves were marked with little red flags. The government is building housing for the people. So much water still remains on the land hundreds of feet inland from the old shoreline. Houses were ripped from their foundations and cement walls were torn apart. There were many sad stories of people who lost up to 300 members of their families. The most rewarding part of this experience was the appreciation that the patients and their families showed us. Every patient was so kind and so appreciative of what we did for them, and even if we could do nothing, they were appreciative of us trying. We found a culture of people who banded together to support one another with such strength and dignity. When a patient was in surgery, the other family members would stay with that patient’s family member to provide support and comfort. When the patient returned from surgery, everyone would gather around to see how he or she was doing. On the ward, the patients and family members would gather together at night to sing and play the guitar with some of the Navy personnel. It was truly a community of love and support. As a hospice nurse, I was truly impressed with the wonderful attitude toward and acceptance of death and dying. Because health care before the tsunami was what we would describe as third world, the people were quite accustomed to not having adequate treatment available to them. Therefore, they accepted a diagnosis and the results of disease progression regardless of how painful it was (emotionally and physically). This was probably due to their strong religious beliefs. As a 90% Moslem community, they believe that what happens to them is God’s will. This probably is what made them so strong in their efforts to grieve and recover from the horrible tragedy of the tsunami. So much could be learned from these strong, hopeful people. It was truly refreshing. So much was learned by this nurse on this journey. I always thought I learned so much from my pediatric oncology and AIDS patients but I learned even more about the human spirit and strength of the human being even in despair during my short time of providing nursing care to these wonderful people. So much cannot be described with words, but it left an empty feeling on return to the United States and a strong desire to return to provide more care.