Guyana Nurse Training Program: Blowing Smoke

"Tobacco glyster (enema), breathe and bleed.

Keep warm and rub till you succeed.

And spare no pains for what you do;

May one day be repaid to you."

This nemonic, created by a physician in the 1700s, is the process of remembering the steps to take when reviving someone. First, give them a tobacco enema (aka, blowing smoke up the arse) which they thought would stimulate the cardiac system. If that didn't work, resuscitate by blowing air into the lungs via the nose/mouth. I'm glad that modern medicine finally figured out that the second option was actually the best, mostly because tobacco is actually a toxin to the cardiovascular system and will cause more harm than good. Because of the practice,we still use the expression "blowing smoke", today referring to the figure of speech in which a person talks big, and usually insincerely, in order to inflate one's ego.

Understanding this phrase helps start to explain why we have problems getting the NICU in Guyana to be fully functional. People love to promise you something and fail to follow through. They'll talk a big talk about how important something like hand gel is, yet after a unit walk through with infection control, a 1.5 hour face to face meeting with quality control and numerous phone calls, we still have not gotten our hand gel bottles filled 3 days after the initial "promise". I have to resort to telling my boss, the founder of the organization which gives money, time, and resources to the hospital, who then emails the CEO of the hospital, who again promises he'll get someone on it. We'll see if he's just blowing smoke. Same thing goes for improving the process of communication between OB and NICU physicians. They have joint meetings monthly to discuss patient cases and come up with solutions to the problems with communication and resuscitation of newborns. They all say they care, that they should be improving measures, but there is no action plan...just smoke. No one wants to take ownership or leadership to develop a plan and implement it. Whether it's because staff are overworked, tired, unable to get resources or support, don't care or a combination, it never gets done. So years later, we're still battling the same issues. Thermoregulation, neonatal resuscitation, communication, collaboration. Physicians and nurses will give us input, our NCH team will make suggestions for what we think will work with their resources and needs, we start to implement when we're on the ground, and when we leave, management doesn't take initiative to uphold the plan. So things fall apart, communication is lost, and babies die. They blow smoke to placate, to make it seem like they care, to make it seem like they will actually utilize our plans. But I now see that it's all smoke and mirrors- make me believe what I want to believe, until I come back and want to beat my head against a wall because it would be a better use of my time. After this week, and really talking to the staff-they agree the talk is all smoke. They know they can do better, they want to do better, but they don't know how and they're overworked. Hallelujah! I can at least work with this attitude...I just need to recruit the right people. As Nar said before, I can teach anyone willing to learn how to take care of a baby, but I can't teach people how to give a sh*t.

One thing I have learned...people respond to checklists, logs, and visual cues. Why I haven't thought of this sooner, I really don't know. But, after 3 years of talking about thermoregulation and having people blow smoke at me about how they are going to keep the babies warm, I decided to try a new tactic. I noticed that some infants had a piece of paper hanging at their bedsides to record abdominal girth. The nurses respond well to visual cues- they all write down the measurement at the exact times specified. Why not try this with temperature monitoring? Kate made a great log sheet to hang at each bedside to record time, temperature, which intervention was done if the baby wasn't in normothermic range, and nurse/pca signature. We asked nursing and physicians if they liked this, and they said yes it would help. We started Thursday during rounds, and as of this morning when Randy went in to the unit at 7am, they were all still using it, and the babies were warm! Holy hell I almost cried. It's so simple, but if we use a piece of paper to reinforce the habit, I'm hoping over time the practice will be so ingrained that we won't need it anymore. Ironically, when I was in my "office" friday afternoon (aka, Ruth's office, the OB resident coordinator, who is in the states for her maternity leave), there was a book by Atul Gawande called "The Checklist Manifesto", where he describes how the use of a checklist in the medical field can help increase compliance and reinforce safety. I'm excited to read his suggestions. I guess there is light at the end of this smoke filled tunnel...