2018 AMRI Scholarship Program by Sarah Arosen
Author: Sarah Arosen
School: Ball State University
Area of Study: Master’s of Science in Nursing
Introduction
In May of 2016, I traveled to Honduras, Central America, for the first time with a small group of medical personnel to run medical clinics in a few rural villages near the capital city, Tegucigalpa. I came home absolutely in love with the country, the people, and the way I had been able to use my skills as a registered nurse to serve those with such limited access to healthcare. At the time, I was working in a cardiac intensive care unit in a hospital in Indianapolis, Indiana, and I thought this is where I would remain, first as a nurse and then one day as an acute care nurse practitioner. I welcomed the challenge of caring for the most critically ill patients and using both my knowledge and skills, particularly my advanced cardiac life support (ACLS) skills, to be a part of saving lives and helping people recover from serious cardiac events and surgeries. Little did I know that three months later, an opportunity would basically be laid in my lap to serve with an American-based non-profit organization that sends medical and dental teams to impoverished locations in Honduras every other week. It should have been a difficult decision, given my love for cardiac intensive care, but after my experiences caring for people who had no one to care for them, it was not. Though I still had a desire to care for the sickest patients, an even deeper compassion for those with so little now burned within me. In blind faith, I stepped out on a limb and accepted the job, not knowing exactly what my work or my life would look like in the next phase of life.
Making a Difference in Honduras
I started working with the organization, called Honduras Baptist Dental Mission (HBDM), in January of 2017 as the first medical personnel to ever be part of the paid staff. In the past, the staff had always been more of the administrative and management type, helping plan for and lead the teams, and the medical personnel had been from the teams that were visiting the country to serve on a temporary basis. Because of this, I had the freedom to create my role as I saw fit and to use my skills in a variety of ways. The job required me to spend a majority of my time in Honduras, working in the field with teams and on the HBDM compound, but I would remain a permanent resident of the state of Indiana. I spent much of my time in 2017 assisting in the treatment of patients alongside the medical and dental teams, and also in creating methods to bridge the cultural gap between the Americans and Hondurans so that the teams could serve in ways that most benefitted the Honduran people. Additionally, a large portion of my time was spent seeking the best ways to provide care for the local community of El Plan, where the Honduran-based HBDM compound is located. I created and conducted a community health survey of over one hundred families in the community, in which I sought to discover each family’s views of health and wellness as well as what they considered to be the advantages and challenges of living in their community. I quickly determined that one of needs of the community was for medical care that was affordable and accessible. The community only had a government-run health clinic, which was often out of medicines and very understaffed. Other health clinics were located in nearby communities but the people of this community had trouble affording them. Fortunately, HBDM already had a medical facility on the property, but it only operated a few times per year, when select teams stayed on the compound and ran brigades locally. I made it my goal to have the clinic open regularly by the end of 2017.
Opening a Clinic Overseas
It was not an easy task to figure out all the logistics behind opening up a medical clinic, especially trying to do it in a language that was not my first language. Early on in planning phase, I decided to charge a very small cost for care, primarily to help promote self-sufficiency rather than the attitude of relying on the charity of others for one’s wellbeing. Though I saw the great physical and medical needs of the community, I also wanted to help in a way that would promote long-term development rather than just short-term relief. This complicated the process a bit because HBDM had never charged for care before. I had to write a proposal to the board of directors of the organization, detailing how everything would work and asking for their approval to use our resources to open the clinic regularly and to charge a cost for care provided. I also had to work through the legal paperwork of operating a medical facility and hiring a doctor and other staff. On September 30th, 2017, we opened the clinic for the first time at a low-cost and we had a grand total of four patients. Small in number, but enough to encourage me that we had made a difference in even a few lives that day! Since then, we have had a few more low-cost clinic days, and in 2018 the clinic will be open every first and third Saturday of each month, and most likely more often as word spreads and demand increases.
Continuing to Serve Underserved Populations
It was through the culmination of these experiences, both in the United States (US) and in Honduras, that I saw the great need for and great relief a practitioner, with diagnostic and prescriptive capabilities, can provide to underprivileged persons or communities. Though I was able to help so many through nursing alone, I realized that pursuing an advanced nursing degree would allow me to make an even greater difference, especially in our clinic in Honduras. I would be able to see and treat patients on my own and I would be able to make a profound impact on the high prevalence of chronic diseases, such as diabetes and hypertension. So many people go untreated because they cannot afford treatments or because they do not understand how to properly manage their diseases. The level of medical education, and of education in general in Honduras, is very low. I have already seen the difference we have made just by taking the time to teach people simple ways to monitor and improve their diseases, such as having diabetes patients regularly check their feet for wounds. I want to be the best I can be for my community, and I want to be able to offer patients that come to our clinic the best care that I can provide. For me, this looks like pursuing a Master’s of Science in Nursing, with a family nurse practitioner concentration, through Ball State University. I know this degree will not only benefit the people of my community in Honduras, but that I will be able to use it wherever I may go, whether that be home or abroad, to help those living in disadvantaged communities.
Using My ACLS Training to Save Lives
Part of being a practitioner, especially in locations with limited healthcare, will mean maintaining my ACLS certification and remaining up to date on the latest evidence-based techniques to treat cardiovascular and pulmonary emergency situations. Thankfully, I have not personally encountered a situation outside of the hospital in which ACLS intervention was necessary, but I believe there are a few factors that could make applying ACLS techniques in underprivileged locations difficult.
Based on my experiences in rural clinics, both home and abroad, I believe the greatest difficulty in applying ACLS techniques in these types of locations would be the limited number of medical personnel, particularly personnel that are ACLS certified, as well as the limited experience of those personnel in handling emergency situations. Ideally, in an emergency situation, there would be someone performing chest compressions, someone giving rescue breaths, someone giving medications and intravenous fluids, someone managing the automated external defibrillator (AED), someone supervising and directing the situation, as well as someone recording the timing of medications, cardiopulmonary resuscitation (CPR), and defibrillations. In our clinic in Honduras, and in similar clinics in rural settings, there may only be one practitioner present, one other medically trained staff member, such as a nurse or medical assistant, and an ancillary staff member, such as an administrative assistant. The practitioner is most likely to “run the code” since he or she has the highest level of medical training, and in the case of only having a few other personnel on hand, he or she will most likely have to take on another role as well. Nevertheless, this requires that the other personnel are capable and comfortable with CPR and defibrillation. Additionally, emergency situations, such as a cardiac arrest, are intimidating, especially if someone has never experienced one before. Even in the hospital with code teams, physicians, and numerous medical personnel present during emergency situations, it can be easy to lose one’s nerve or momentarily forget because the situation can stun even experienced professionals. Imagine this happening in a rural clinic with only a few staff members on hand who may or may not have experienced a medical emergency before. Properly and efficiently applying ACLS techniques would be difficult.
Second, I believe the limited amount of supplies, equipment, and medications as well as the quality of these items in remote clinics could be a hindrance to applying ACLS techniques. Though it may not be the case in most medical facilities in the US, many clinics in third world countries have the bare minimum in terms of equipment and supplies, and often what they do have is old and has been passed down from the US once newer equipment has been invented. Additionally, primary practice and outpatient clinics both home and abroad may only be stocked with enough “emergency medications” for one emergency. It is unlikely that more than one medical emergency requiring these medications would occur in a small time span, and clinics should be regularly checking and replacing their stock of expired or empty medications, but this is not always the case. Errors can happen and if, for example, a clinic’s supply of epinephrine has expired or been even partially used, this could create a huge hindrance to saving the life of someone in a cardiac arrest situation. Additionally, if for some reason the AED equipment, intravenous catheter equipment, intraosseous access equipment, or bag-mask is old, hard to use, malfunctioning, or limited in supply this could greatly detract from the quality of ACLS techniques applied in an emergency situation. It may seem like a stretch to argue that these factors would really be a barrier, but in a clinic where the primary focus is not on emergency situations, and where funding and supplies are limited, these can be real causes for ineffective attempts at applying ACLS techniques.
Lastly, distance and accessibility to a medical facility in which advanced interventions can be continued after ACLS is required outside of a hospital can be a mental hindrance to applying ACLS techniques. In 2016, the overall survival rate for persons that needed CPR outside of the hospital (in the US) after a cardiac arrest was only 12% (“Cardiac Arrest Statistics”, 2017). Imagine living a great distance from a hospital with the equipment necessary to sustain life after a cardiac arrest, and facing a situation as a provider in which you have to apply ACLS techniques. Your motivation to continue or possibly even start ACLS in light of these factors may be greatly decreased if you thought your patient was not going to survive in time to make it to the hospital. Especially in third world countries, such as Honduras, where a hospital with the technology to provide intensive medical treatment is few and far between, the likelihood of surviving or having a decent quality of life after an emergency situation in a remote location is very low. Unfortunately, people living in these types of locations often have a much different view of life and death, than those living with easy access to dependable healthcare. If an emergency is to happen in this type of setting, even practitioners may believe that it is better to let a patient die somewhat comfortably than to try to start ACLS, which is in itself a trauma to the patient’s body, and hope that they make it to a dependable hospital before the patient’s body gives up. It is not pleasant to think about having to be in situations such as these, but much of the world lives with the reality that an emergency medical situation is unlikely to end well. Thus, there are many mental and even rational hindrances that might keep one from applying ACLS techniques in a remote location.
Recognizing that a limited number of medical personnel, a limited amount of supplies, and limited accessibility to a hospital may make it difficult to effectively apply ACLS techniques will allow me to be a better nurse and, in the near future, a better family nurse practitioner. I embarked on my journey to be a nurse with a desire to help the hurting and my ACLS skills literally allowed be to be a part of saving lives in my job in the cardiac intensive care unit. Though I no longer work in such an intensive area, I still feel confident in my ability to handle an emergency situation, whether that be in HBDM’s clinic or in a remote community in the US. I now begin a new journey towards becoming a family nurse practitioner, where I will have more responsibility, as well as the capability to provide more complete care for my patients. My ACLS skills, however, will be no less useful than they were in my job as a nurse, and in fact, I will have the capability to order life-saving medications and interventions in an emergency situation. I am grateful for this opportunity to further my education and for the doors it will open to provide care to underprivileged populations wherever I may go. I am also grateful for my ACLS skills and I recognize that they have been and likely will again be the difference between life and death, despite the barriers encountered along the way.