Children's global health: Cambodia Days 4-6

Since December 2009, a group of nurses, physicians and therapists from Children’s Hospital Boston has dedicated themselves to setting up a “Sister PICU” (pediatric intensive care unit) program between Children’s and the National Pediatric Hospital (NPH) in Phnom Penh, Cambodia. Read about the C4C team–named for their Cans for Care fundraising efforts–here, then read the first in a series of posts from Maureen Hillier and Kim Cox, two Children’s nurses who are spending the next two weeks 9,000 miles away, in Phnom Penh. Last week we shared their first 3 days in Cambodia, here we learn more about their efforts.

This small structure is the family waiting room, laundry room, and cafeteria at the National Pediatric Hospital (NPH) in Phnom Penh

Day 4: Today, when we enter the unit, we find a newly admitted one-month-old baby with moderate respiratory distress. This is great timing, as one of the main objectives of our visit is to enhance the NPH PICU nurses’ knowledge of the respiratory and neurological system.

I continue to be stunned by some of the things we’re encountering in Phnom Penh. I’m boiling when I find out nurses aren’t allowed to use stethoscopes—only the doctors! Our hands are tied, so Kim and I start by reviewing the most straightforward respiratory assessment items like respiratory rate, saturations, retractions and nasal flaring. Operating under the premise that some rules were made to be broken, we help ourselves to the four stethoscopes sitting idly on the E-Trolley (an emergency cart, created by the Children’s team two visits ago. How did a PICU exist without an emergency cart?) Since there aren’t too many doctors around, we encourage the nurses to put on stethoscopes and take a listen! After an hour or so, they have a sound understanding of stridor and more specifically on this baby who has wheezing, crackles and decreased aeration on one entire side. Lots of reinforcement will be needed here. The nurses need to be able to use stethoscopes and this will be an agenda item to discuss with the medical director, but Kim warns that this is a big issue that will likely not be resolved on this trip.

After lunch outside in 100+ degree weather (it’s worse inside since we have no air conditioner), we return to the unit and get into teaching mode. Mr. Barach, the unit educator, wants to learn more about the newly donated CPAP (continuous positive airway pressure) machine. Since CPAP has only been used infrequently here, and we have no patients currently in need of noninvasive ventilation, Kim will be our subject. What would be straightforward process to our colleagues at home takes twice as long in Cambodia because all information must be translated. In addition, more information is needed than home, because this ICU doesn’t have the luxury of a respiratory therapist as a resource.

Day 5:

Today there are two patients and one admission in the PICU. All of the patient alarms are on, a few needed revisions, but alarm fatigue remains a critical issue. Some of the nurses seem to resent us asking them to get up to see why a patient’s alarm is going off. We review the patients in-depth, but nursing assessments aren’t done on a daily basis, even for a child who’s newly admitted.

With less than a week left, we need to start focusing on some housekeeping items. The Emergency Code list which the Children’s team created last year needs updating and laminating. The computer that we bought last year has multiple viruses and needs a current virus scanner (looks like the medical students found where the computer was kept). Many of the nurses still don’t understand how to log on to the internet, which brings up another critical issue. On our very limited budget, we need to decide how much money we can realistically continue to send to the NPH PICU for their internet service.

Day 6:

The nurses are making progress learning how to set monitor alarms, but it continues to be a work in progress. We share one of our PICU secrets about putting a drop of Saline under an EKG lead to extend its life. It works! There are folks from KKH hospital in Singapore here, who also donate their time, providing lectures to the staff, twice a year. Unfortunately, all the lectures are in English and not Khmer—the primary language in Cambodia—so most of the nurses aren’t able to understand the full content. Doctor’s orders are hand printed in French, further complicating the nurse’s work. The unit staff tells us that they “like the hands-on approach better.”

With the help of our wonderful interpreter friend, Mr. Bon, we feel like we’re really connecting with the unit staff, and having some fun along the way. Today, after morning rounds, we performed a two-hour, in-depth, head-to-toe nursing assessment on a baby. It’s so rewarding because, not only do nurses and nursing students attend our bedside teaching, but a regular group of medical students attend now, as well. Fortunately, the parents don’t mind—they appreciate the extra attention and learn a bit, too.

As a nursing instructor for Curry College and Northeastern University, I now realize how fortunate our students are to have at such wonderful, supportive clinical sites in the Boston area. In Cambodia, a four-year Bachelor of Science nursing education offers observational experiences only. It’s not surprising that nurses continue to take on a more passive role upon graduation.

This afternoon, we learn that the NPH Medical Director will start to adopt our suggestions to modify the ICU flow sheet. This is great news and will make the nurses more responsible for raising the standard of nursing care. IV sites will be more closely monitored, all head of the beds will be raised 30 degrees, intakes and output will be closely measured. Kim first suggested flow sheet amendments on her first visit to NPH more than a year ago, but change moves slowly here. Nevertheless, the change did occur, and that’s positive progress.

Maureen, Kim and Pretheory

Both the number of patients and the severity of their symptoms is lower now than on past visits, but that leaves time for what the nurses truly need—great teaching opportunities. It has also allowed us additional time to know Pretheory, who’s one of the younger nurses, but very self-motivated. She was asked by her nurse manager, Socheata to prepare a brief lecture on ARDS (Acute Respiratory Distress Syndrome) to deliver to the Singapore team when they make their final visit at the end of the month. She quietly and politely declined, believing she couldn’t do it because it was never part of her education. On one of the previous visits, one of our nurses created a nursing library, and on our first day, Mr. Barach showed us how neatly he organized all of the donated books. Sadly, they haven’t been touched since! We showed Pretheory how to use the library, and after two understanding to provide a lecture. Tomorrow, we’ll show her how to create a PowerPoint, pull some pictures from the internet, review her material and she should be ready to go by the end of March! Because Protheory has started to believe in herself, I think this is one of our best days yet.