When The Lines Blur

This week we had our very first Zambian rotation in Lewanika General Hospital's Special Care Baby Unit (or SCUB). After talking to our instructors and nursing peers about the lack of hospital resources for neonates, we where nervously anticipating our days in the SCUB. After spending ten minutes in the 40 degree 60 square foot room, we both realized that it was going to take a lot more courage than we had prepared for. We began our day damp dusting the unit (different from our usual morning safety checks), while dusting we were faced with the challenge of keeping the unit clean and bug free, including trying to keep ants out of the incubators and off of the babies. This made us reflect on how, and if, staff are able to maintain sterile environments, and if it causes and increase in infection. 

While we were damp dusting our instructors popped in and noticed that one baby was very low on oxygen and in need of immediate attention. We put down our cloths and dug through a bin of oxygen tubing and found a mask so we could began giving supplemental oxygen. Throughout this shift we noticed that the baby had a lot of deprecate health issues and realized he had been through a surgery to fix a congenital defect. One that often comes along with additional defects and health problems. While we provided the best care we could with the supplies we had, resources were low, and even though the baby had had surgery we didn't know if the hospital or the community would be able to support him. We came to beg the question, "just because we can, does that mean we should?"  

Although our first day was hard and shocking, the day that we both want to, and don't want to, discuss was our third and last SCUB shift. Initially we decided to spend most of our day on the post-natal ward, because of the many Zambian nursing students who were also assigned to the SCUB. Half-way through the day we found ourselves having a hard time keeping busy in post-natal, so our instructor suggested that we go assess the babies in the kangaroo care room (a room where mothers can provide intimate skin-to-skin care with the newborns). Upon entering the room we immediately noticed that one little baby tucked beneath a large fleece was grey in colour. We ran over and began assessing and found that he wasn't breathing, so we rushed him into the SCUB where the nurse began mechanical ventilation. As this was happening, we looked over and noticed a premature newborn in the incubator beside us was grey and very sick. We quickly realized we were in over our heads and Mckinnley called our instructors. When they arrived and we had stabilized the first baby for the most part, we turned attention to stabilizing and getting a doctor for the second sick newborn.  We both ended up having to mechanically ventilate the second baby while the doctor preformed chest compressions and our instructor gave medications. After many heart-racing, sweat dripping minutes we where told to stop mechanical ventilation. For us this became difficult and confusing because we were still providing life saving medications, and hadn't moved to get the baby's mother. In Canadian culture a nurse would clean up the baby, wrap them, and pass them to a parent so they could be held while they pass. In anticipation of this Kristen ran to grab a blanket. Even though there was nothing more to we could do our Zambian colleagues didn't want to completely withdrawal care, and in a heart wrenching moment we were told to put the baby back into her incubator. Later we found out that in Zambian culture holding a baby while they pass for comfort can be seen as giving up. Instead we did our best by bringing the baby's mother in and sitting her down so she could hold her baby's hand for her last few breaths. 

What we both learned from both these tragic days was that like Canadians, Zambians struggle knowing where to draw the line between acute and palliative neonatal care. Everyone wants to do all that they can to save the life of a baby, but this sometimes means that our needs and hopes come before that of the baby's needs. Choosing to move to palliative care is a tough decision, but in a newborn it's just that much harder. We don't know who is qualified to make these decisions. Parents? Health care professionals? Whoever does often makes the decision between hope and practicality. In those moments neither of us felt equipped to make that call and we aren't sure if we ever will.

Leaving the SCUB that day was a heart wrenching moment; but we did it knowing that we were a part of saving the life of one baby, and had done everything we could have possible done for another. Neither of us will ever forget that little baby, or any of the other SCUB babies and will carry the lessons they taught us for the rest of our nursing careers. 

- Kristen Monz and Mckinnley Massey 

SCUB at LGH