You give me love...crazy love...

 At the beginning of my two weeks in Guyana, I told the students that I always learn as much from them as they (hopefully) do from me.  I have always believed education is a continual learning process for both the student and the instructor (I actually prefer facilitator or guide over teacher for this reason).  So naturally, at the end of the two weeks, the students wanted to know what I've learned.  Here is my response, in no particular order of importance:

I've learned:

* Trust in the basics- no amount of technology can substitue for a good physical assessment, intuition and common sense

* The simplest changes really do make a difference- I know it's a cliche, but handwashing and a good clean environment can drastically improve outcomes (and on that note, thank you to all of our housekeeping staff who work their butts off everyday- you are as vital to our healthcare team as any nurse or physician)

* You CAN calm an infant without a pacifier.  

* A mother's love is universal- no one knows their infant or child better than their mother- our job as nurses is to embrace this and help nurture this already amazingly tight bond, no matter what age, economic status, or ethnicity 

* Politics are everywhere- they don't just exist in your place of employment.  The challenge is to learn to ballance all the powers that play into creating a better outcome, because in the end, good really does trump evil (or at least I still have hope!), and most people really want the best outcomes for their patients and hospitals

*It all comes down to communication- clear, open, honest communication.  Whether this is between staff and families, members of the healthcare team, or your own personal relationships.  The communication between physicians and nurses in the NNU has grown by leaps and bounds from the first time I stepped foot in the unit, and while it's not always perfect, they are making the effort to make it less rigid/structured and more professional and open than before.  While the same cannot be said between members of the whole perinatal staff/maternity block, change is always best started at home, and I am so proud of how far the NNU staff has come in a short amount of time. 

* Never give up on your students (or staff)- just when you think they are not listening to a word you say, when you think they will never "get it", you find amazing changes being made one person at a time (after an entire environmental lecture of which I didn't think anyone was listening, the next day a couple students came in with signs they made to post all over the unit about handwashing, using alcohol before accessing multi use vials, changing IV tubing every day, etc).  

Most importantly, every time I travel to deliver education and/or nursing care outside of my permanent place of employment, my passion for my profession is renewed.  Maybe it's the thrill of testing myself and my skills in a resource poor environment, maybe it's the rush of traveling and seeing something new or having your eyes opened to a different way of thinking, or maybe it's just realizing that the heart of nursing exsists beyond political, economic, religious, racial, and ethnic lines.  We are all striving to provide a little bit of comfort in what is normally a challenging and sometimes painful situation, and we give of ourselves not for the money (although it does help), but because we love the human condition in all forms and couldn't imagine ourselves doing anything else with our lives.  While we hope to be healers of the body, if at the end of the day we are only healers of the spirit, then it's all worth it.  

So thank you to all the people of Guyana, and for my travel mates and project dawn housemates, for helping me grow in many ways over these last 2 weeks.  My body may be back in Ohio, but a little piece of my heart will always remain in Guyana...

Teach me how to...

The unit was fairly quiet today, as they discharged several infants yesterday and were left with only 16-17 patients, which gave us some much needed time to have the students in class talking about environmental infection control management, specifically about IV care and ETT care.  Randy again went over how to set up and troubleshoot a ventilator with a couple of students and included Bennett (our biomedical guy) in the teaching.  

Appologies for the brevity today...just a normal average day in the NNU. More reflections to come tomorrow, as we take on our last day, which to me is extreamly bittersweet.  I am just now getting in the flow of the unit, and could easily spent another month here with these amazing students!

 Randy and Bennett

A group shot from last night...thanks for the pose Kate :)

I'm picking up good vibrations...

First, sorry for the delay in posting- the UK boys fixed a large dinner which ended in some late night balcony sitting...but more on that later.  

The morning (Wednesday) started off with a buzz.  One of the babies on bubble CPAP was very "chesty" and Kate mentioned to Randy that the baby needed chest physiotherapy with one of our handheld vibe machines.  Being that we didn't have one, Randy decided that he wanted to go out and buy a device that would give the baby vibrations...at an adult toy store.  This purchase has brought much needed laughter from all of the staff, and allowed us to break up the large amount of secretions in the baby's lungs.  Definitely a win for all involved :)

The rest of the day was spent discussing nursing documentation and setting up for an admission- which was very appropriate because we received a baby into the unit that afternoon, with a suspected diagnosis of pulmonary hypoplasia (xray is across the street, so to get a confirmation, a nurse has to walk the baby over, which is a little difficult with a ventilator).  It gave the residents and students much needed practice with taping ETT and using bag mask ventilation.  

Our night was a big feast cooked by Joe and John mostly, with help from Conor and Graham.  We had sauteed bora beans (they look like skinny green beans), steak, cassava mash, sweet potatoe casserole, and chocolate cake for dessert.  Oh, and Rum.  Lots of Rum.  Which is why the blog never got posted :)  But it was all in good fun and we showed up on time (although with a large need for coffee) the next morning to greet another day in the NNU.

 Shaheen and Dr. Arifa Alladin Karan

 Terrance taping the ETT

 Dewon and Laurel set up the ventilator

 Rachel performing an assessment

 

Jonelle obtaining a random blood sugar

 Michelle working on Charting

 Tamacia working on charting

 Kate and baby

 Shaheen and baby

 Conor and baby (we are trying to turn him into a neonatologist!)

Shaheen in rounds with Dr. Sarah Singh and the GMO's while Michelle and Rachel provide a nursing presence

Randy (and Kate and Cait) get schooled

Finally, after 7 days on the unit, things are clicking into place.  I feel like the episode of the TV show Scrubs where everything is falling in line for JD, IVs are done on the first try, you have a good rapport with the staff, and you generally know the flow of how things are done and where everything is located.   I sometimes forget that I am not a permanent part of the saff...the doctors ask for a piece of equipment and we know the general vicinity of where to find it (there is no organization what so ever on the unit or in the store room...we're working on that!), orders are placed and we help implement them, heck, I even calculated an actual drip rate for the first time since nursing school (see...those labs weren't a complete waste of time even though we complained through the whole thing...thanks Prof. Diane Patterson for making us stick with it!). Despite all of this comfort, we are still learning a lot from the nurses, especially language, here's a couple of our favorites:

"Just now"- does not mean they are doing or going to do something immediately- means whenever they get around to it, or whenever there is time.  I had a student ask me to explain something "just now' meaning whenever I had a moment.  

"having wind"- gas

"Chesty"- meaning the patient sounds congested or lung sounds are crackly/wet- Randy thought the nurse ment that the patient had a huge chest or huge breasts- they had a good laugh at that.  So Randy decided when the baby had a lot of nasal congestion that the baby was 'nosy'

"have a lime'- to hang out

There is also the random stringing together of words, which here they call 'creole'- such as if you wanted to tell someone you'll be back shortly, you would say, "Igocomebakman"- makes it a little difficult to understand what people are saying, as there is very little annunciation and they speak softly.

Also today, Randy and Kate got a lesson from sister Khirodhar, who is the most senior nurse in the NNU and a midwife. When we have come before, it seemed as if the sister reallly didn't want to change practice and didn't care about the improvements to the unit or really even care if the babies did well.  They got the full story as sister opened up to them in the unit today, saying that due to staffing she didn't feel they could give their full attention to the sicker infants, and therefore had to concentrate on the infants they knew had a good shot at survival, such as the term breastfeeding, no IV fluids babies.  She said that she wished they had better supplies because she feels terrible that she isn't able to give the best care.  Hearing this broke my heart, but also filled it with hope, as I found that it isn't that the nurses don't care- they care very deeply for these babies and their outcomes.  I hope that we can help to get them the resources and training needed to do the job they would like to do, along with the training to know how to do it.  

Today was just your average day- Cait taught a lecture about problems with the GI system, along with some NRP training to the emergency medicine residents, Randy went about helping suction and position the CPAP babies (no more ventilated patients- we have 2 on CPAP!), Kate helped reinforce our schedules, developmental positioning, thermoregulation, and IVs (we had 2 more nurese today get their first IVs!), and Shaheen rounded with the residents reinforcing feeding and nutirition principles.  Despite what we perceive to be routine, it is amazing to see how far this unit has come.  The neurological baby that was ventilated when we first arrived last monday has since been weaned to CPAP, then to an 02 mask, and was discharged yesterday evening eating by breast and doing well.  The nurses overnight set up the CPAP and tured a plugged ETT into an opportunity for extubation.  The students are getting IVs started with great success.  I even learned that they managed a baby with an omphalocele for about 3 months prior to our arrival, in which the infant is doing very well and was discharged home with just a little skin yet to grow over  the site.  While it is easy to concentrate on the frustrations, it is even better to see the small victories happening all around us.  The unit may be taking preemie steps, but at least they are headed in the right direction.

Runnette attending to a hyperbili baby

Laurel attending to twin #1

Samantha attending to twin #2

Randy helping Desmine set up and trouble shoot the ventilator

 Trudell setting an IV pump

Shaheen attending rounds

Cait assisting Dewon with suctioning of a baby on bubble CPAP

Randy getting schooled by Sister Khirodhar

Overview of the middle room (the white door is the main entrance to the unit)

This is hanging in a prominent spot, encouraging all mothers to breast feed and keep a committment to a baby friendly hospital

Get on your bikes and ride...

   Our day started out with a very unusual sight- A sister on a bike.  Before you get all excited, it wasn't a Nun type of sister.  In Guyana, nurses that have superior status, such as nurse managers and charge nurses, or just nurses that have worked on the ward a long time.  All the sisters usually wear all pink instead of the traditional white uniform, making them very noticeable.  So this was sister on her bike: 

Needless to say, this made my monday :)  

Today's focus was on ventilation and CPAP.  Randy gave demonstrations of how to set up both the ventilator and CPAP tubing from the base parts and had each student give a return demonstration.  He also led them through scenarios to trouble shoot alarms and if the system isn't working.  Kate and I ran through how to structure care for a baby on ventilation, emphasizing suctioning and oral care to prevent VAP.  We learned that overnight a baby had to be reintubated because of a plug in the tube, which most likely was due to not refilling the humidity chamber and suctioning the baby over the weekend.  While there has been resistance to doing "scheduled" cares in the past, we asked the nurses just to place babies on a schedule who are on a ventilator or CPAP, as this most likely would only be a max of 4 patients currently.  This would ensure  that these babies received more direct monitoring and  care to prevent unnecessary intubations or further respiratory distress.  

After yet another amazing lunch from Shanta's (red snapper curry!), Kate and I worked with the students in their direct care, making sure they understood their IV rates and orders, and helped 3 get their first IVs!  I think most nurses can remember the first good IV attempt...mine was in a 28 weeker with the help of IV goddess Renee C...and there is no better feeling in the nursing world, no better boost to your self esteem, and it was great seeing the rush these student's got with theirs.  

Back at the house, Shaheen got a tutorial in how to "wobble", which led to me and Randy performing a very white wobble for Kate and Shaheen :)

Also enjoy pictures from our dinner at the "house" last night!

Oh Randy :)

 Jonelle and Rachel practice setting up a CPAP with Randy

Onika and Sheba

Onika admitting a new 34 weeker with mild respiratory distress

A mother admiring her daughter

 

Kate and Terrance working on an IV

 Shaheen teaches Claire and Conor, medical students from the UK

Randy's tropical fruit salad- grapefruit, starfruit, passionfruit, pineapple, bananna, and star apple

Sunday night dinner with our growing family...from Kate going clockwise, Kate, Shaheen, Randy, Charlie, Jenny, Graham (all from the UK), Dr. Kaino, Conor, John, Joe, and Sherrie (OB from Chicago)

Take it easy....

Lazy sunday in Guyana.  Randy and I went to church with the new OB physician, Sherrie, who arrived yesterday, then to lunch at the Roti hut and grocery shopping at Naigel's.  Kate and Shaheen took a little walk to the seawall, and now the group is sitting around with our UK bunch discussing differences in our medical systems.  We directed Joe to the Time article, "Bitter Pill" from last year that dived into the financial issues people face in the American medical system.  If you haven't read it yet, I really suggest to look online (you can read about 75-80% of the article there), as it really was an eye opening article.  

As all holistic nurses know, we can only care for others once we have cared for ourselves, so we are all lounging today in preparation for a busy week ahead.  Enjoy some of the pictures from Friday night at the Brazillian steakhouse and gravity bar!

Mike, a little afraid of the meat man and his knife

Mike and Conor in awe of the chicken

Our new little international family...Mike, Conor (Irishman), John (UK), Dr. Michael Kaino (Tanzanian in training for anestesiology), Joe (UK), Cait, and Kate

Yet another Kate/Cait sandwich with Mike at the Gravity Bar (yes, the palm tree is on the roof)

Mighty Kaieteur

Today we were able to see why the national anthem sings, "Oh, beautiful Guyana", as we took a trip to the mighty Kaieteur falls.  While our final destination was the highlight of the trip, we enjoyed the 55 minute flight to the falls in a 13 passenger cessna where we watched the geography go from the low costal plain of Georgetown, past rice and sugarcane fields, up the demerarra and essequibo rivers to the potaro river and the highland region with dense rain forest canopy to Kaieteur falls.  We passed bauxite and gold mines in route to the river, which was difficult for me to see as a preservationist, thought I know it brings in much needed money to the country as 2 of Guyana's biggest exports.  

As the mountain peeks rose up out of the forest, so did the falls, which we passed by twice before landing in Kaieteur national park.  Our tour guide lead us to 3 spots at the falls to take pictures, pointing out flora and fauna along the way.  Enjoy the pictures and this poem by Alex Morritt.  

"Mighty Kaieteur"

Gentle meanderings a little way upstream.

The Potaro River, tranquil and unassuming, 

Head down river, have cause to wonder,

The booming tremor of approaching thunder,

Draw closer still, a deafening roar,

Hints at the imminence of the mighty Kaieteur,

A rising crescendo of earth trembling rumbles,

As a mammoth cascade in freefall tumbles. 

Thousands of gallons form a giant aqueous wall,

Rendering this the world's premier waterfall,

Descending several hundred metres in height,

A colossus with an awesome display of might,

Guiness couloured torrents of frothy tan and cream, 

Crashing down on boulders, billowing clouds of steam,

Showering mossy banks with a fine mist spray,

Caught in the crossfire of the sun's dazzling rays.

Behold the bright arc, a perfect rainbow,

A befitting crown, a majestic halo,

Adorning rocky outcrops perched all around,

Jaw dropping vistas with true surround sound,

Gaze at that deluge and be mesmerised,

Humbled by Nature, her sheer power and size,

Soon to reassume a far gentler pace,

Vanilla swirls atop a dark chocolate surace.

Snaking her way down beneath jungle clad peaks, 

As the rainforest echoes with all manner of speech,

One last glimpse of the mighty Kaieteur Falls,

now a faint murmur that perpetually enthrals.

Field trip!

The best days of school were the ones where we got to step outside the doors to discover new ideas outside of the traditional classroom.  All of us were able to have some kind of field trip which helped us to go more in depth into the resources and relationships available for the NICU and our program.

The day started out with Kate and I making morning rounds with the students and checking on all the babies.  Two of the infants needed IVs so Kate and I were able to work with 2 of the students directly to insert.  Next came Cait's first field trip of the day, which was to observe a meconium stained fluid c-section.  I was impressed that the delivery room staff had everything they needed and that the radiant warmer was on and functioning when the resident and I arrived.  Baby came out a little unresponsive, and the one midwife knew not to stimulate him, but didn't know how to hook up and use the meconium aspirator with the ETT.  It was great to be able to teach/ show them how to effectively use this device, as it is a common problem here.  The baby did well, we transferred him to the NICU for further monitoring, but was breathing better by the end of our day today. The one thing of note was that there was no timer to assess the APGAR score, and at the end of the resuscitation, the resident had to use her best judgement as to what the scores were.  I'm hoping to talk with Ruth ( the OB resident coordinator) about my observations and to plan an NRP class with the midwives next week.

Kate's field trip was next.  She was able to travel to the lab to talk with the physician in charge about their equipment and how we can best obtain lab tests on our babies.  They both agreed that point of care testing would be the best, as currently their machines are unable to process small volumes of blood like in the U.S.  Kate is going to solicit advice from NCH laboratory staff about feesability of POC testing upon our return.  

Finally a field trip for Randy, Mike, and Cait while Kate stayed back to teach the students about nurse to nurse handoff reports had how to structure the work day to best care for infants based on our scheduling system for NPO vs. patients that are eating.  Our field trip was to the hospital in West Demerrara, which is a site that Guyana Help the Kids wants to equip with physical resources and nurses for a NNU ( neonatal unit).  Having an offsite in this location would be a significant help, as babies that require minimal care, such as preemie grower/ feeders, babies needing phototherapy or antibiotics, or babies transitioning would've have to make the trip to GPHC.  The unit was still under "construction" as they were putting in electrical outlets and oxygen hook ups, but it was a nice space that is directly in the post-natal unit where the NNU nurses could have direct observation and early identification of infants who need additional monitoring.  The unit is almost complete, so now we just need nurses who are willing to sign the contract with the hospital and enroll in our program.  We met Dr. George, the medical director, who said that a shorter orientation program (4-6 months) would help recruit nurses as many of them said that a year training was too long for them to commit.  Now that I have heard this from several sources, that will be a priority upon my return. 

Driving back to GPHC, we stopped at a roadside stand for fresh coconut milk and to pick up some lunch at one of Aruna's favorite drive ups ( excellent BBQ chicken and fried rice!). 

Out week rounded out nicely as the students practiced giving a finally report on their patients while Dr. Mike discussed/practiced NRP with the pediatric/ neonatal residents.  We were able to leave the unit happy with our progress this week and with Hope for a quiet weekend.

Tonight we are all headed to a Brazilian restaurant with our flat mates from the UK, then to gravity bar (a rooftop bar) for a drink overlooking the city.

Kate and Randy were brave and rode in the back of the pickup truck on our way to the hospital this morning 

Crossing the Demerarra river on the floating bridge- this view overlooks the city towards the outlet to the ocean.

Outside entrance of West Dem hospital..the sign talks about how fathers should be involved in feeding their infants mom's breast milk and supporting/ encouraging moms to breast feed

Cait and Dr. George in the new NNU space in West Dem

Coconut milk drinks...they deliver right to the car...hand chopped upon our arrival ( you should have seen the size of the machete!)

Kate and nurse Trudell