AACN News—August 1998—Beyond Our Borders: The Nicaraguan Experience

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Vol. 15, No. 8, AUGUST 1998

Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it’s the only thing that ever has.
—Margaret Mead

By Denise Guaglianone

I am always looking for a new adventure, but the one I am sharing with you surpassed my expectations—both professionally and personally.

Imagine what it would be like to work in an ICU with minimal technology, and where medications are a luxury and every task presents a challenge in problem solving. Throw in a foreign language, put it in a third world country, and you have the main ingredients of my experience.

It started when I visited the CardioStart booth at last year’s National Teaching Institute™ and Critical Care Exposition. CardioStart is a nonpolitical, humanitarian organization with a mission to provide compassionate medical assistance in underserved areas of the world. In addition, the organization provides continuing education and support for the development of a fully functioning cardiac surgical unit, as well as immediate and ongoing medical supplies and support to orphanages, hospitals, clinics, and feeding stations.

I had been searching for an organization like CardioStart for years and was impressed by its mission to provide not only care, but education. CardioStart’s mission is congruent with the mission of AACN: a healthcare system driven by patient need, in which critical care nurses make their optimal contribution.

I signed on and found myself traveling with 25 strangers to Fonseca Hospital in Managua, Nicaragua. My team members—RNs, physicians, perfusionists, respiratory therapists, a dietitian, and administrators—became close friends, as we did with many of the Nicaraguan people.

Our first task was to unpack and separate the freight. CardioStart collects donated used and new medical equipment and supplies for these countries. We then set up the area as a cardiothoracic ICU and operating room.

We also assessed how a separate ICU, set up by CardioStart on a previous visit, was functioning. It appeared that all equipment were in use. I was surprised to find that only 1 RN and three nurse aides were available to care for nine patients. In our new unit, we worked with 15 RNs, who were studying for an advanced specialty in critical care, similar to our bachelor of science in nursing programs. These nurses traveled from all parts of Nicaragua to work with, and learn from, us—as we would learn from them.

Even though I viewed Fonseca Hospital as poorly equipped, these nurses reported that it was better equipped than their own hospitals. I was repeatedly reminded over the next 2 weeks that it is not machines and technology that make good ICU nurses.

As I surveyed the room that would become our ICU, I remember thinking that this was the best we had, so we needed to make it work if we were going to help these people. This was the ultimate challenge in change projects. We had many environmental obstacles to overcome, such as lack of soap or paper towels with which to wash or dry our hands.

Side-By-Side Mentoring
We worked side by side with the Nicaraguan nurses. Our goal was to enable them to become independent. As we unpacked supplies, I quizzed the nurses on different medications and their actions. They did well, even though many drugs had never been available to them. This was mentoring in the most challenging form: in a foreign language. Remember the last time you mentored someone and were frustrated when your pupil asked a million questions? Try answering in a foreign language! Although this was a challenge, it gave me an exhilarating sense of who I am and why I became a nurse.

Nurses were not the only ones to be trained. Doctors and x-ray technicians among others needed mentoring. The MDs never quite understood what a nurse practitioner does, as a lot was lost in translation, but I know they respected the other ICU nurses and me, as they sought our opinions about patient management.

I spent time trying to get the x-ray technicians to take chest films with the film upright instead of sideways. It was easier not to center the film on the patient, even though it was impossible to visualize the upper lobes of the lungs! But by the end of the first week, with much encouragement from the Nicaraguan nurses, we got adequate chest films.

The mentoring process continued in all aspects of patient care. The surgeons, operating room staff, anesthesiologists, perfusionists, respiratory technicians, and step-down unit nurses were mentored by the respective members of the CardioStart team.

Reaching Out
The patients themselves would have broken your hearts, as they did mine. All patients were younger than 40 years of age, with hearts the size of watermelons. Rheumatic heart disease had destroyed their valves. It is difficult for us to comprehend the enormity of this public health problem, because antibiotics have made it rare in the United States. In Nicaragua, where the average person makes the equivalent of $20 per month, $3 or $4 for antibiotics is an extreme luxury.

Following the death of her parents, one patient in her early 20s, who was raising her brothers, asked if we could leave our pens for them. It is difficult to learn at school when you have no pens or paper, she explained. We took a collection that day and presented her with a bag full of school supplies. There were tears in the unit that day. This was not the only time we reached into our pockets. Sometimes it was for a taxi ride home from the hospital, instead of a 2-hour bus trip, or money to buy something for the children, because money would be scarce until these patients could return to work.

Teamwork was the name of the game, and this was the best team of people with whom I have ever had the pleasure of working. We were brought together by the man behind every mission, Aubyn Marath, MD. In addition to being a compassionate physician, his surgical skills were exemplary. We accomplished goals to which most US surgery centers only aspire. The majority of patients came out of the operating room extubated and thankful for the great effort of our anesthesiologists. Patients were out of bed and the hospital sooner than expected. It is amazing what you can accomplish, even with minimal resources.

Outside the Hospital
Our hospital work was only part of our mission in Nicaragua. We also supported an orphanage, to which we delivered boxes of donated clothes, toys, food, and medical supplies. Nuns a this orphanage were caring for 80 children and received no government support. One of the nuns said there are many weeks when the children go to bed hungry, and all they can do is pray for the next donation to arrive.

The children were like any other children. They were curious about us and even more so when bags of Halloween candy brought from home were opened. I remember wishing I had something more nutritious to give them. The nuns educate the children and provide their most basic needs. They seemed relatively happy, not knowing what they were missing. Each child received a stuffed animal donated by the class of one of the nurse’s children. For most of these children, this was their first toy. My trip to the orphanage put a face to the problem of world poverty.

I can go on with stories, such as the one about the feeding stations that had only enough supplies to provide three meals per week. This is a poverty that few of us can understand, though we all have the ability to make a difference.

You Can Help
Every day we health professionals waste so many things that are like gold to these people. Just think about it! You open a central line kit, but don’t use the novocaine or the sterile needles. These items are precious to CardioStart. We rely on these donations to make our missions possible. Maybe you have some equipment in storage that could be donated. If you are unsure whether we can use it, call or e-mail me. No matter where you are, we will find a way to ship supplies to our warehouse in Tampa, Fla, and then to their final destination. What a great chapter or unit project this would make.

CardioStart especially needs pediatric and adult ICU nurses. But you don’t have to participate in a mission. Many people volunteer by doing what they can to collect donations.

For more information about volunteering with CardioStart, call (813) 689-3289 or (203) 876-7558, or e-mail me at deniseguag@aol.com, or Chuck Mulhern, our administrator, at CardioStart-Intl@msn.com.

Denise Guaglianone, RN, MSN, CCRN, CS, APRN, is an acute care nurse practitioner at Bridgeport Hospital, Bridgeport, Conn. She is a member of AACN’s Advanced Practice Work Group.
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