Thursday, December 30, 2010
As the end of the year sets and the New Year dawns we often think of the year gone by…at least I do…it seems to me that the years are getting busier and time is flying bye…this could be a reflection that I am getting older however I don’t feel older, but sure as hell my body keeps reminding that I am….
As this has been a humongous year in line with my recent trip to Tanzania I am going to list the 10 highs and lows of the year: it is so handy having a blog to look back on to jog the memory when so much happens in a year.
Top 15 highlights for 2010 – the order is not significant
Meeting the Prime Minister (K Rudd) & Health Minister
Listening to proceedings in Parliament and hearing the words 'midwife' 'midwifery' continuity of care' spoken so many times and in a positive light
Teaching in Singapore / Meeting up with friends in Sydney
Putting in Submissions / politically lobbying
24hr Virtual IMD Celebrations (Sarah Stewart)
Linda’s Holiday – Perth to Carnarvon – (being a Skype Midwife)
Sitting on Uluru….breathing in the atmosphere
Making a decision about my study – starting a new degree
News of a new Grandchild (April 2011)
Medicare Provider Number for Midwives
Starting Centred Midwifery Group Practice Inc (CeMGP)
My Tanzanian experience
Family, friends & some great work colleagues
Jasmine started Yr 1, Dylan Pre-Primary, Jessica Kindy
Talia coming into her own, starting to stand up for herself,
Sam, Isabella and Logan all going through the terrible two’s
Top 11 Disappointments:
The division over collaborative arrangements and the Determination 2010
Homebirth debate / Insurance issues
Miscarriage in the family
Election dirty politics
Factions within Midwifery
Lack of team work and loss of integrity from esteemed colleagues
Muffin passed away
A better disciplinary process (Hospital) for midwives using their piers
son-in-law having a back operation
Seeking & acting on legal advice for defamation
As you can see the highs thankfully outweigh the disappointments….and my lists are not exactly 10…. See you have to be adaptable in life…best laid plans of mice and men...lol.
Wishing everyone that reads my blog a happy, peaceful, safe and successful 2011:
Sunday, December 26, 2010
I have not felt much like Christmas this year, partly I think it is that I have not had much lead up to Christmas: This is the first year I have not taken the grandchild to carols by candlelight.... something I really do enjoy:
Midnight Mass was uneventful, the Church was not over flowing... usually it is standing room only....but this year it was 3/4 full... there was a new priest...and I was not use to him,... I was not inspired by his sermon.. another first we sang Happy Birthday to Jesus... a strange concept for me... in all the years I have gone to Midnight Mass this was a first...I was less than impressed.... again I am not sure why....
Christmas morning for me is relaxing...the family come over late afternoon, however my daughter Kirsten (who stayed over to help) stated..."I've never known Christmas morning to be relaxing... preparing for Christmas dinner for 20 plus".... different concepts on what is relaxing... but you see for me that is relaxing....the thought of preparing a feast....pleasing all the children with a banquet of wonderful food, Turkey that melts in your mouth.... beef fit for a King, ham, asparagus salad, peas with pancetta,cauliflower gratin (made by Margaret K)green bean and broccolini balsamic salad, roast potatoes, pumpkin, stuffing balls, onions and of course Yorkshire puds and gravy: Fruit salad, Christmas cake, panettone, chocolates, ..wine,juice, beer.... etc.
Most of all I love it when Santa comes and gives all the children there presents... I love watching the excitement when they open their presents...it is such a delight. Christmas for me is about family, friends, children, love, giving, good food, laughter and fun....I had the best Christmas ever and I am so grateful for a wonderful family: God Bless You All......love mum xx
Friday, December 24, 2010
At last on my return from Tanzania I received a letter from AHPRA (16th Dec) that they had met on the 2nd December and have approved my application:
"An eligible midwife competent to provide pregnancy, labour, birth and post natal care and qualified to provide the associated services and order diagnostic investigations required for midwifery practice. In accordance with relevant State and Territory legislation.
Eligible midwife, but NOT qualified to obtain endorsement under section 94 to prescribe Schedule 2, 3, 4 & 5 medicines required for midwifery practice in accordance with State and Territory legislation".
It goes without saying that all midwives once you have successfully completed your course are by definition eligible midwives, we just have another criteria to get now for legislation and that is "eligibility" (three years experience post registration across the full scope of midwifery).... see the AHPRA website for more information.
A notation goes on the public register so that anyone can see if you are eligible or not.....
Next step is applying for a MBS provider number, I will be doing this between Christmas and the New Year;
One of next year's plan is to complete the Prescribing and Diagnostic courses....which are not up yet.....but will start following this up... Roll on the New Year..... NOW come on all you WA midwives start applying for eligibility:
ref pic: henry.k12.ga.us
Wednesday, December 22, 2010
This is a snapshot of midwifery in Tanzania from my perspective, it does not refer to anyone specific, the judgements are made from my personal observations:
Tanzania a country in which health resources are minimal and much help is required: the lack of staff, general caring and privacy being high on the agenda.
In the public hospital the labor ward has approx 12-14 beds; the beds are hard and there is no visible linen, the windows and doors remain open and there is a problem with flies. I did notice curtains around some of the beds, but they are rarely used. The ward is split into three sections, with a resuscitation area for the babies, however I did not see any resuscitation equipment.
There is a long wooden bench for the women to sit on after birth; and there is a clean and dirty room, however it is a stretch of the imagination. There is a small room attached that has four beds and this is called the eclampsia ward...... the incidence of eclampsia appears to be high, and the antenatal care is insufficient in the prevention of the condition... this could be due to the low resources therefore not enough education. There are some rudimentary posters on the walls for treatment of PPH and Eclampsia, generally the ward is constantly busy, noisy often used as a thoroughfare.
A normal 24hrs could see anywhere from 74 – 120 births; on the days I spent there the average birth rate over 24hrs was 75-85 births a quiet time; the lack of staff is a massive problem and the ward is laden with students; as I commented in my nursing in Tanzania blog.... the structure of nursing is very different to Australia.... nursing and midwifery are together in every course and I suppose this also will assist with the shortage of staff.... just to remind you of the career structure..... enrolled nursing & midwifery is now a 2 yr course ( previously 4yrs) entry level is equivalent to yr 10 (form IV), as student midwives these students conduct 20 normal births and 10 high risk (breach, face, brow presentations etc) supervised by a qualified midwife. Diploma nurses and midwives if they have moved up from enrolled nurses will do a further 10 normal births and 5 high risk, and this takes a further 1 yr, also supervised by a qualified midwife. Diploma nurses/midwives straight from school good scores for form IV, three yr course. These nurse/midwives if they want to convert to a degree course will have to do another 3 yrs (6yrs in total). Lastly there are degree nurses and midwives (3yrs course) entry level form VI (TEE / TER level) these students require 30 normal and 15 high risk births. Confused......it took me a while to work it out.....
Part of the problem is that students outnumber the registered staff... and you don’t know who is an enrolled /diploma or degree nurse/midwife student until you ask and then I was still not clear who is accountable for what. On my shift there were 6 students and 2 registered nurse/midwives and a doctor........ at one stage I had four labouring women at fully with just me myself and I.... oh and my nursing students (as if in a maternity setting) it was frantic.....The African women need to bring with them 4 Kanga’s..... these are traditional cloth /dress, pieces of material (2 meters long) one piece is cut in half... so there are two for the baby.....the women use one as a sheet on the bed, they often have one they are wearing and the others are for after the birth and the baby.....often the women are naked, privacy does not seem to be an issue..... People walking in and out of the labor ward as if it was a thoroughfare.... flies were annoying.... it was hot/humid everyone was sweating, no way of cooling down.....there was no visible water anywhere, at times I felt useless and helpless.....I allocated my nursing students to stay with each woman attempting to provide some comfort.... and encouraging them to drink some water, which the women bring in themselves; I found a pinard on the desk, so was showing the students how to use one....there was no electrical fetal monitoring.... (not such a bad thing).
Two women had syntocinon running, so I listened to their fetal hearts first.... all seemed well.... then I moved to the second two women..... These two seemed to be going head to head as to who was going to deliver first..... I called out for some help..... and a doctor came forward.... he was less than helpful....however he did yell for someone else to assist.... whilst he was with me I asked if he could translate to my women as I wanted her to stand up or turn over to aid her birth..... his response was “no we like them on their backs so we can see what is happening” he promptly called for a student midwife to assist me and yelled at the women to push harder......I regretted asking him to translate..... as we were preparing for birth.... I found the delivery pack.... but could not find a cord clamp..... by now the woman was pushing well the student midwife had disappeared momentarily ..... so I asked my favourite doctor who had taken his spot at the desk... watching the events...no curtains.... three naked women in the room all pushing....”excuse me, I can’t find a cord clamp I ask”.... “ ah you want a cordie clampie ask the woman or look in her bag, she has them”..... now the student has returned... and I am informed that the women bring in a cord clamp, a roll of cotton wool for the birth and her kanga’s, food and water for herself. If the woman does not have a cord clamp you find some cotton or tear a piece of material to tie the cord.... thankfully the woman has purchased a cordie clampie.....I could not find the scissors to cut the cord.... emm that’s because we use a blade....at one stage I needed to clean around the perineum and asked my student nurse for a paper towel..... forgetting where I was (the poor student went looking for one until I called sorry forgot where we are, we both nervously laughed) it was tough to use cotton wool for everything....it is hard doing a vaginal examination using cotton wool....it was a beautiful birth....a truly special moment...third stage went well, syntocinon given as usual.... the woman was exhausted...now it was time for her to get up and go and sit on the bench... I had taken too long and the student midwife was hurrying me along.... it was only 40mins after the birth..... the student midwife cleaned the bed with the two dirty Kanga’s, “I asked what happens to them now” she continued to clean the bed, rolled them up and put them in a plastic bag and gave them back to the woman...... no laundry required.... the woman sat on the bench drank her water and had a bite to eat (a piece of bread I think)... and started breastfeeding....
We then weighed the baby..... the woman was then transferred to the postnatal ward (we walked her across) within 90mins..... she then stays on the ward for 6hrs and walks home or catches the bus with her baby..... the postnatal ward may have two or three women to a bed.....I counted 12 beds, saw no baby cots...... the women lay exhausted on the bed with their babies...some crying...soulful eyes watching you... they have a resigned look on their faces...as if this is my life.....the nurse is sitting at the desk......the ward is packed a sea of faces.... there were be a couple of nursing assistants walking around assisting with breastfeeding.....it was heartbreaking, poignant and I was sadden by the obvious pain of life.
It wasn’t long before there were two more babies..... All healthy and well.... the last woman was having difficulty and was going for a Cesarean section..... they don’t have forceps or ventouse births in this hospital, however I could see the benefit of using a kiwi cup ...... but that’s a different story.....the Cesarean section rate is about 20% and on the increase......only about 40% of women birth in the hospitals, the rest are out in the rural areas.....
We did visit a dispensary that was well equipped for births and I did meet some traditional birth attendants..... who also state they birth women on their backs on the floor... I did find this interesting.... I tried to share my experience of changing positions and it was met with great laughter.....
In the rural clinic the women come whenever they have time or feel they need to attend.... with their first babies they seem to be more vigilant and clearly the more babies they have the less inclined they are to come to the clinic early they normally show up at about 32 weeks.... the clinic we visited was 2.5 hours away from the hospital.... and transport if things go wrong is difficult..... they often have to cope or find alternative ways of getting to the hospital.....
My students really enjoyed this placement and I am sure that 4/5 students will go on to do their midwifery; for me I was dismayed and the visions stayed with me for days and I am still troubled by the conditions that women are in.... and I would be keen to be able to help in a more substantial way.........The issues that struck me most: Technology v no technology: Caring / compassion v no caring / compassion: women being totally alone with no support: the total lack of staff: Birth flat on their back in bed:
There was a complete contrast in the private hospital.....the birth rate for November was approximately 50 for the month, there were no patients on the day we spent several hours there.... privacy is still an issue with three labour beds in the one room... the labor ward has just been renovated so was very modern ...
.....there were brand new beds.... however I was dishearten when I saw the strips remain in place on the bed.... for me this would mean because they are there they will be used..... There was a CTG machine...... in another room there were two labor beds... and there was one private room....( the executive room of course at a price). What was surprising was they had a spar bath.... it was great to see... however would need education re its use..... (I was asked to give a lecture on waterbirth that’s another blog). There seemed to be more staff here and they did seem more caring...and providing one-to-one care... but this was only a snapshot so I really could not give an accurate account......it was reassuring.... but sad at the same time.... because most women could not afford this care.......
My maternity time was an experience,as was my whole Tanzanian clinical practice....... I met some phenomenal people and some I hope to continue to keep in contact with...... more in my next blog......
Sunday, December 19, 2010
Last night I dreamt that I was swimming in the ocean, it was a beautiful clear ocean, I love the sea.....my husband was standing on the shore as he normally does..... I was a little afraid a healthy respect of the ocean, it was a nice sunny day and I just love to swim in the ocean, so continued to swim. I then noticed some fish middle size fish... this frightened me a bit more but they seemed non threatening..... so I continued to swim...... more and more fish came.... they seemed to have their mouths open and looked half out of the water.... I was starting to panic the more fish that I sore... and then there seemed to be snakes and eels in the water, now I was terrified and swam for the shore completely panicked...... I woke in a sweat.... afraid there were just too many fish and eels in the water.......I was out of breath and afraid..... I looked around and thought “thank God I am in my bed, it was a dream”.......
In trying to make sense of my dream, I thought is must be that I have been a busy the few months, in fact an extremely busy year; certainly ending in a big way, in many ways very difficult I have to say I am tired, and sadden by many great women being wounded and continue to be wounded all in "the best interest" of midwifery, women, life, work.....I have to ask the question is it worth it? But deep down I know it is for the sake of all women and midwives, not just one or two groups... the one’s who shout the loudest.....and care the lest for all women and midwives.
The poverty and lack of resources in most parts of Africa - the uncaring of our fellow man/woman/child......it leaves me feeling completely drained...however hopeful of progress with help and resources.... I enjoyed teaching in Singapore.... it is was worlds apart shopping on Orchard Road v Dar Es Salaam .........it really is food for thought!
A dear friend of ours, not so close these days but from the past, well thought of & loved, lost their son of 34yrs (Peter); our boys all use to play soccer together: Peter was larger than life, enjoyed life to the fullest; listening to his eulogy it was a full life packed into 34yrs, but oh so young to die & so suddenly: the memorial service was packed and there was not a dry eye, men, women and children all crying........as we sat in the Limerick Bar at Rosie O'Grady's celebrating Peter’s life " I pondered as you do on your own life" what would they say about me? I have so much more to do.... so much more to give.... so much to share.... the energy spent on nonsense is a tragedy.... I want to yell from the highest mountain...pull your heads in......get on the same page!!!!!!!
The Kids putting up the Xmas tree....
Family is most important.... letting them know how much I love and am proud of them, watching the grandchildren grow up and being able to influence that growth....sharing the passion of life...teaching them to reach for their dreams and passions......everything is possible.....not to get bogged in the minutia of bullshit......listen to your inner voice and you will know what are the correct things to do in life.... that is really one of the most important lessons..... That is to trust your own judgement...... listen to and trust your inner judgement..... then follow that ...... you can’t go wrong........
It is times like these I like to go back to a favourite poem of mine Desiderata:
Go placidly amid the noise and the haste,
and remember what peace there may be in silence. .......... Avoid loud and aggressive persons;
they are vexatious to the spirit.......... Exercise caution in your business affairs,
for the world is full of trickery....... Take kindly the counsel of the years,
gracefully surrendering the things of youth.
Nurture strength of spirit to shield you in sudden misfortune.
But do not distress yourself with dark imaginings.
Many fears are born of fatigue and loneliness.......... Beyond a wholesome discipline,
be gentle with yourself.
You are a child of the universe
no less than the trees and the stars;
you have a right to be here.
And whether or not it is clear to you,
no doubt the universe is unfolding as it should.
Therefore be at peace with God,
whatever you conceive Him to be.
And whatever your labors and aspirations,
in the noisy confusion of life,
keep peace in your soul.
With all its sham, drudgery, and broken dreams,
it is still a beautiful world.
Be cheerful. Strive to be happy
Sunday, December 12, 2010
It is hard to know where to start with this blog... as there is so much to tell, therefore I think there will be several blogs relating to Tanzania; The main focus of the trip was to take 20 nursing students from five different universities to experience nursing in Tanzania. My first impressions were biased with a preconception of what things would be like, having already lived in Africa, however some things still were confronting and the total lack of resources, water, infra-structure (in rural areas) and medication still came as a surprise:
The process through customs, immigration is the usual for any African airport, slow, hot and humid, confusion as to which forms to fill out, eventually we all got through.... the main currency for Tanzania is shillings..... 1000.00 approx for each $1.00.... we changed some currency and got some local sim cards for our phones, we were met at the airport which was fantastic.... we were all bundled into cars and buses, with our luggage perched preciously at the back of the bus. Our hotel was about 35 mins from the airport, the first thing that struck me was the amount of cars on the road.... it did not take long to realise that they all drive like lunatics.... it was equal to Egypt which I thought have the worst driving in the world. There were hundreds of people milling around, over crowed buses and many street markets......
Health care in Tanzania is dependent on social status and level of income is the most predominant social determinant of health for people. This means access to clean water, sufficient food and reasonable health care. Health care access is further compromised due to issues of geographical location and distance to services as well as lack of resources and technology. It was interesting to note that everyone has access to mobile phones even when electricity was not available.
We arrived at our hotel ...... pleasant, clean, small, friendly staff.... the first thing I noticed was there was no bar fridge.... now I know what you are thinking....no not for alcohol... I wanted a cold drink of water.... alas this was to be one of my biggest complaints.... a must in a hot humid country....the availability of cold water and tea and coffee making facility.... minor things really, just shows how spoilt I am. Every day began at 0530... the bus collected us at 0645 to get us to both hospitals..... we would split into two groups, two supervisors and 10 students in each hospital: one to a private hospital and a government hospital.... then the following week we would swap. Mine was the government hospital first.... this was a baptism by fire.... it was a culture shock for all, I was a acutely aware of how the students would be coping, sights, smells, queue’s of people, sad hollow eyes watching our every move....we stood out like beacons in our stark white uniforms; at times I felt like the fish in the fish bowl..... Intruding into the lives of people I could not really make a huge difference to....We would attend the hospital handover, all given in English we would then go to our allocated wards.
I had to focus on the task at hand..... once orientated to the ward we would begin to assess the situation and decide how to move forward.... each ward had a notice board which listed the 10 most common disease and drugs used, together with the tasks for the day: There was no surprise to find No 1 condition in the medical ward was HIV (there are medications and treatments for HIV which was good to see), I learned about the finger test for HIV.... great idea quick and efficient, next condition was Malaria, hypertension, anaemia and diabetes: each ward (medical & surgical male and female) consisted of approx 30 beds, sparse furniture, a single sheet on the beds and some ceiling fans, however the wards were stifling hot.........patients bought in their own food and water; sometimes it was hard to know where to start.... so often I would get students to take vital signs, as this was something I knew they could do well and would start the two way conversation... however our Swahili consisted of “Jambo” – Hello, or “ Hujambo” – how do you do, “Jina langu ni......Pauline – my name is....
The nurses work very hard and are short staffed, often 1 RN to a ward, a couple of student nurses and nurse assistants; doctors milling around, completing ward rounds, barking orders, nursing assistants scurrying around to get tasks completed. There was often only one oxygen cylinder and the ethical decision would be who needed it the most... and sometimes someone would come urgently from another ward requiring the oxygen cylinder ..... what do you do?
The sister's desk:
The drug cupboard was sparse, patients are ordered medications and it is a pay as you get service.....the students coped remarkably well.... all equipment used for patients are paid for by the patient, such as IV cannula’s, drips, catheters, tests etc, everything we take for granted here.... it really makes you appreciate the excellent health care service we have.
We witnessed some interesting procedures and dressings, at times did some teaching as well as sharing experiences and ideas.... it was an interesting journey: documentation, nursing notes, filing cabinets, policies were all nonexistent in the literal sense.... there were two cardboard boxes... marked “discharge notes” a stark reminder of where we were....... Pain seemed second nature to patients....as well as lack of dignity and privacy due to overcrowding and lack of resources..... the hard working underpaid nursing staff and health workers, were not well respected......they do the best they can in these harsh conditions, always with a resolve that things would get better. Also acutely aware of how the situation must look to us the ‘foreign nurses’ apologising for the bad conditions and stating they just do not have enough staff or resources to treat all these patients.
I was amazed at how long people wait to see a doctor or nurse; they have walked for hours and sit patiently in the sun until they are seen, with not a word of complaint.... just happy to be seeing someone and getting some treatments. Our challenge was often to think of cheaper effective ways of treatments, dressings etc choices of medications were limited to bare essentials.......families assisted with patient care, feeding and bathing.......traditional medicines were popular and the stigma of HIV was an issue: I was surprised to see that bowel obstruction was very common – top 10 surgical conditions were: Intestinal obstruction, peptic ulcer, pyomyocties (infection of the muscle), hernia, haemorrhoid, hydrocele, osteomylitis, burns, diabetic wounds, and motor vehicle accidents (no surprise there with the driving we witnessed).
The nursing system is three tiered; enrolled nurses (2yrs training nurse/midwife), registered nurse/midwife (degree course 3yrs), diploma registered nurse/midwife (3yrs or 1yr after EN course): nursing assistant (2yrs – can go on and do diploma RN 3yrs); a diploma RN/M can go on and complete the degree course 3yrs – equal to 6yrs: Their scope of practice is wide and varied........the medical system is equally complicated: from medical assistants to degree MD’s. The graduation I attended had only 10 degree RN/M’s, 20 diploma RN/M’s and 40 Doctors graduating....... nursing is not considered a prestigious career, parents try to discourage their daughters from doing nursing if they are going to do a degree.......nursing assistants and diploma nurses usually complete form 1V (equivalent to year 10).
The question I ask is how do we make a difference? Some of the students who travelled will travel again, they have all be touched by the experience, maybe two or three will go back to Africa and help make a difference; I think you need to stay in one area for a two – six month placement and introduce structures for change; working alongside our fellow nurses exchanging ideas and promoting change: providing mentorship, support for the new students, therefore providing for the future..... Fundraising for essential equipment (gloves, alcohol gel, fob watches, thermometers etc); now that this will be an ongoing project I am hopeful that we will be able to make a difference in some small way:
On our last day we met four first year nursing students, all straight from school, they were so young, full of enthusiasm, our students took them under their wing and taught them vital signs, it was delightful to see, gave them some text books, our equipment, stethoscopes, thermometers etc... and we wished them well. I have promised to keep in touch with one student and provide some mentorship from a distance. If I am to return I will ensure to follow her up.........This has been an incredible journey for me and I will be forever touched by the courage of the patients I have met and for some of the brave nurses I worked with....... I am eternally humbled from the experience.......I have met some fantastic students who are know RN’s and also have made special friends with the other supervisors from our trip........partners in crime.......next blog..... Midwifery!
Good luck to all my students (now RN's)as well as the new students starting....life is a continuous journey which we are all learning.....