Brienne Johnson, RN, and Jenn Porkka, RN, deliver Children’s care 9,000 miles from home.
Care for Cambodia
Nearly 9,000 miles from Children’s Hospital Boston, Sue Gray, RN, is setting up a monitor for a young patient in the pediatric intensive care unit (PICU) at the National Pediatric Hospital (NPH) in Phnom Penh, Cambodia. The instructions and controls on the monitor are in French. Gray takes a deep breath. She knows some French—she can do this. She finishes setting up the monitor and moves on to the next patient. His monitor is in Russian.
This is the least of the challenges faced by the group of Children’s nurses, physicians and respiratory therapists who have dedicated themselves to establishing a “sister PICU” at NPH. The team— named C4C, after their Cans for Care fundraising program—has been partnered with NPH’s PICU almost since it first opened in 2007. Inspired by a presentation she saw at the World Congress on Pediatric Critical Care in Geneva, Gray was looking for a way to challenge herself and her colleagues at Children’s to use their expertise, experience and influence to improve the healthcare outcomes of children around the world. With the approval of the World Federation of Pediatric Intensive and Critical Care Societies, the Children’s Medical/Surgical ICU was selected to partner with the PICU at NPH.
In a country with the highest youth mortality rate in Southeast Asia, NPH’s 225 clinicians serve a population of approximately 2.7 million children, most of them suffering from treatable ailments such as Dengue fever, meningitis, bronchitis, asthma and diarrhea. Lack of formal medical training and limited funding have resulted in a shockingly low standard of care. Forty percent of the children admitted to NPH’s PICU don’t survive their stay. That rate leaps to 70 percent for respiratory problems. “The sense of desperation is huge,” says Brienne Johnson, RN. “This is a population that’s accepted its own mortality.”
Gray led the first trip to NPH in December 2009, along with Kim Cox, RN, and Traci Wolbrink, MD. What they found was as far from Children’s as they could imagine. None of the NPH staff had worked in a PICU prior to the unit being founded, so clinicians had no experience providing critical care for pediatric patients. The C4C team was met with a PICU consisting of two rooms with six beds each, barely enough staff to support half of the unit and no basic equipment such as code carts, syringe pumps or bedside monitors. The hospital had one incubator to cover all premature newborns.
On a 107-degree day, they found an open-air unit with no fans, IV bags hanging on sticks and equipment and medication labeled in multiple languages. Donated from supplies that other hospitals were throwing away, some items were received with stickers declaring them “For disposal only—not for patient use.” Despite the equipment issues and language barrier, the NPH staff was—though inexperienced—eager to learn. “You’ve got to suspend your understanding of medical practice at Children’s in order to simply function,” says Posey Veator, RN, who joined Cox, Johnson and Virginia Leon, RN, for C4C’s second trip in March 2010. “You discover the importance of universal conversation methods— nodding and pointing.”
They also found a culture of community support, even in the most trying situations. During one code, the father of the child in the neighboring bed pitched in to prep syringes for saline flushes. Families are responsible for purchasing their own supplies—tissues, cleaning wipes, water—but people share what they have. Johnson recalls one mother whose child died; the grieving mother distributed all of her supplies to other families before going home.
A third team visited in October 2010, adding Jenn Porkka, RN, David Kantor, MD, PhD, Fritz Perry, Tricia Meehan, RN, and Kammy Marine, RN, to the roll of honor. The challenges they’ve faced have made the victories even sweeter. When the first team arrived, all supplies were kept locked in the director’s office, for fear that someone would steal them. During their first visit, C4C created the PICU’s first fully stocked code carts. When the third team arrived, the carts were still stocked.
With funds raised by C4C, Wolbrink purchased a laptop for the unit and arranged Internet access for email and Skype remote conferencing. Prior to this, medical staff had to drive to the city and pay for access at cybercafés. C4C recently donated a printer, providing some patient families with the first pictures they’ve ever had of their children.
In March 2010, a C4C team aided the NPH staff in achieving a lifesaving milestone: the first use of Bi-level Positive Airway Pressure—an apparatus that forces additional oxygen into an infant’s lungs—in the hospital’s history.
C4C continues to push basic safety—things like setting alarms and proper monitor setup. They’ve also created the first safety list in Khmer, the official language of Cambodia. By the end of their third trip, all of the NPH PICU’s patients were on monitors.
Gray will bring C4C’s journey full circle in March—this time, she’ll be the one presenting at the World Congress on Pediatric Critical Care in Sydney. Though she hopes to inspire others with the continuing success of Children’s sister PICU, what the program truly needs is to attract financial support. Their Cans for Care recycling program raises some of the funds needed for travel, supplies and NPH’s ongoing Internet access, but not all.
The members of C4C pay roughly $3,500 out of their own pockets for each trip to NPH. Between the financial burden, the three weeks of vacation time needed for the trip, and the challenges of finding coverage for their Children’s duties while they’re gone, making one trip to Cambodia is beyond the means of many—let alone returning to finish the work they’ve started.
Cox will return to Phnom Penh on her third trip in March, accompanied by Maureen Hillier, RN, who will be experiencing pediatric care in Cambodia for the first time. Despite the financial challenges facing C4C, Gray knows that keeping the ball rolling is critical. “It’s hard for NPH to hold onto good nurses and doctors, when they know they could be making more money selling scarves down in the Russian market,” she says. “Sometimes, the best thing we can deliver is inspiration. They’re invested because they know that we’re invested—that’s what a partnership is all about.”