Guyana Nurse Training Program: Reflections on the way "home"

Many times while I am in Guyana, I catch myself saying to someone, "I left it/forgot it at home". The home I am referring to, though is not the U.S., but my home away from home, Project Dawn, a dormitory style living space on the second floor of a clinic, which was purchased and equipped initially by a nun from the U.S. for a place to do same-day surgeries for medical teams visiting. Now, it is mostly just used for housing medical teams and for medical education. It has all the necessities of home- a large kitchen (see my March/April posts for our big group dinners) with cooking utensils, a living room with couches and a TV, an amazing balcony with a great sea breeze, and 14 individual bed/bath rooms. While it may not have all the comforts of home, after awhile it becomes a part of you, and just like a "home", it is not complete unless you have amazing people to share it with. The housemates from the march/april trip were truly like family- we ate, laugh, drank, shared stories, played games, and enjoyed each other's company. This time, our "home" is more like having a bunch of extended family you haven't seen in quite awhile- just trying to get to know each other with a little awkwardness and over-the-top politeness. We have an emergency medical do from Vanderbuilt, 3 pediatric oncology attending/residents from Buffalo, 3 echocardiogram technicians from Canada, and Cenise, our neonatal educator (staying monday-wednesdays). Every time I come to project dawn I am amazed with how many people are so dedicated to learning and sharing their knowledge with others to help improve health care.

Random pictures from my ride from the hospital to Project Dawn

Above-ground graveyard

typical housing- Georgetown is in a flood plane (they are 2 feet below sea level), so all the houses are on stilts. Also, most have a water reservoir because the city water is frequently shut off by the government)

Turning into the driveway at Project Dawn in the dusk

Project Dawn is located about 20 minutes drive from the hospital, depending on traffic. Most days, the car ride becomes a place of quiet contemplation about the day. And today, there was a lot to contemplate. So, I will have to warn you that what I am about to say is not pretty, inspirational, uplifting ideas that are mostly shared on this site. Today was just a disappointing day, which highlighted a lot of the issues in the NICU. However, I feel it is important to discuss the negatives to shed light for the positives that are taking place, so I hope you will stick with me.

Ok. Let me shine you (a local term meaning let me shine some light on the subject) for a moment about my day...

Kate and I arrived on the unit around 8am. We usually come in and do a general survey of the unit- who is working, which babies became sick overnight, what babies were admitted, the energy level, and what equipment is being used. We use this information to gauge our goals for the day, and which babies we need to pay extra attention. The first thing I noticed was that all of the IV buretrols were taken out of the IV pumps and placed back to a general drip rate (it's important for IV fluids to be delivered on a pump, as it more accurately calculates how much fluid is given, which is extremely important for infants who are susceptible to damage from fluid and electrolyte imbalances due to immature brains and kidneys). I asked the nurses why the IV buretrols were not loaded into the pumps, as they were all working fine when we left the unit yesterday afternoon. The response was that the night shift nurses believed the infants were getting too much fluid because the drip chamber was dripping too fast (which has nothing to do with how the pump functions) and because one of the babies had edema and hypoglycemia (this baby has adrenal insufficiency and sepsis creating third spacing of fluid into the tissues). So I talked with Cenise about the problem, and she said this is a common complain of why the nurses don't use the pumps. So she explained to the nurses the issue, helped provide education, and together re-set all of the pumps. Why this story is important is that it highlights a major issue that we have been dealing with for the entire time I have worked in the NICU (since August 2012); You cannot provide equipment without education, specifically background information about why you use the equipment and how to troubleshoot problems. What has happened is that equipment is purchased and sent to the unit, someone may show the nurse how to turn it on and generally operate it, but there is no follow up. So, as these pumps arrived in a large shipment in the middle of August, and no one was there until September and only for a week, the education and troubleshooting was missed. Because of this, many pumps were said to not be working and either discarded or placed on a shelf marked "broken". When you have an organization spending millions of dollars on equipment, this is not what you want to see. Luckily, after Kate's investigation yesterday and talking through the problem with Cenise, we were able to educate the staff appropriately, but this will have to have continual reinforcement, which is not always feasible when you are here for a week.

Cenise providing education about the IV pumps

The second major story I will share highlights the inadequacy of the communication between nurses and physicians (mostly the GMOs, general medical officers, or genmed residents in the states) and how hierarchies will not help us achieve better infant mortality rates. One of the nurses noticed that a 30 week infant who was in mild respiratory distress yesterday and on CPAP was working harder to breathe today and had O2 sats drifting into the 70's on 100% FiO2. So she called the GMO over to look at the baby. The GMO started bagging the baby, but was using a technique appropriate for an adult (large pressure volumes and very slow rate). Kate noticed this and said to the GMO that it would be more effective to use smaller volumes and faster rate appropriate for a neonate. Her suggestion went ignored. So I went to the GMO and said that it looked like the baby was trying to breathe on it's own, his heart rate and O2 sat was improved, we should try O2 blowby instead and let the infant recover. This also went ignored after several attempts to say the same. After some time, it was decided that the baby needed intubated. The GMOs tried, and finally a 2nd year resident intubated the baby. However, when Kate took over bagging, she noticed that the abdomen was rising instead of the chest, that the infant was struggling to breathe, the sats were in the 50's, and the nurses were pulling large amounts of air from the abdomen. She suggested to the GMO that we check an X-ray or tube placement as it seemed the infant was not intubated. After an hour and a half, an X-ray was obtained and seen that it wasn't in the right place. The infant went on to struggle in this way until he passed around 3pm. It's a sad story, but unfortunately one that happens too often because of physicians not working as a team with the nurses. As soon as Kate started talking the nurses through what she was seeing, and why she felt the infant was not intubated, the nurses did their own assessment and agreed with their own input into the case. Yet, after several hours, and an X-ray confirming that the tube placement was incorrect, the physicians still refused to say that they did not provide the correct care, which cost the infant his life. If we want to improve neonatal outcomes, we have to educate the GMOs on resuscitation, and we have to instill the attitude of teamwork. Ending this story on a positive note, the nurse in charge of the baby was doing an excellent job of delegating to the PCAs to help retrieve supplies so that she could stay with the baby at all times. She even had one PCA writing notes about vitals, interventions, and assessments so that she could accurately chart the event afterward. This makes me proud to see the nurses being so attentive to their patients and their documentation.

GMOs standing with the 2nd year resident attempting intubation

Because of this, Kate and I left with a feeling of discouragement about our work. It's amazing how one bad day can negate all the good ones (or at least encouraging ones) that have come before. Yet, I know that tonight, after an amazing meal (the guyanese buffet at the grand costal hotel) with lots of amazing colleagues, I will go right back tomorrow to start a new day. Because as health care professionals, that's all we can do. We pick up, learn from the situation, and move on because we ultimately love what we do, and no matter how bad we get beat up and torn down, we will always go back for what we love and the hope of a new day.