* Tel.: þ44 16E-mail addr

1355-1841/$ -doi:10.1016/j.j

Journal of Neonatal Nursing (2010) 16, 138e141

www.elsevier.com/jneo

Too much responsibility

Karen Hoover*

40, THE CROFTS, CASTLETOWN, Isle of Man IM9 1LZ, United Kingdom

Available online 10 December 2009

KEYWORDSUnited Arab Emirates;Neonatal intensivecare unit;Babies;Nurses;Responsibilities

24 822610.ess: lkvhoover@hotmai

see front matter ª 200nn.2009.11.001

Abstract 21 years ago, I went to work on a neonatal unit in the United Arab Emir-ates (UAE). Four years before this, I had worked for a year in a British run hospital inSaudi Arabia, where although conditions for women were very restrictive, theworking conditions were excellent, with plenty of staff, no shortage of resources,and a good salary. So when a friend persuaded me to join her in the UAE whereit is much more liberal, I didn’t expect the working environment to be verydifferent. It was.ª 2009 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

New challenges

I went to work in a very busy neonatal intensivecare unit, with a lot more patients, and a lot lessstaff than I remembered from Saudi Arabia; in factit was very like what I had recently left in the UK!

The hospital was staffed mainly by Americannurses, with some British and Australians. Over thenext few years, salaries dropped, and the Ameri-cans left as they earned good salaries at home,unlike the rest of us who stayed a good timelonger! The medical staff came from Arab coun-tries or Africa.

The American nurses had worked in the unit foryears, and were very assertive and dynamic; theywere a good deal older and more experienced thanus, and we learned a lot from them.

l.co.uk

9 Neonatal Nurses Association

They had introduced primary nursing, designedexcellent care plans, and were using develop-mental concepts far in advance of its time. One ofthem bought baby slings so that we (or the mother)could carry around the older premature babieswho were frequently agitated due to being onsteroids for chronic lung disease (usual practicethen). They also dressed the babies, including thesick ones, used brightly coloured sheets and blan-kets, and covered incubators to allow long restperiods. Although I had seen some of this in thevery progressive UK neonatal unit where I did mycourse, it wasn’t common practice at the time.

The American nurses were used to insertingperipheral intravenous (IV) lines, and taking bloodsamples, something I had never done; I stillthought: ‘That’s a doctor’s job!’ I spent the firstfew months asking other nurses to please put an IVin for me, or take bloods, until one day I was told Ihad been there long enough, and do it yourself! Iwas so surprised that I decided to have a go and

. Published by Elsevier Ltd. All rights reserved.

Too much responsibility 139

maybe I could do it, I’d seen it done often enough,and from then on, I rarely had to ask anyone else.I could cannulate, and do bloods on ‘my babies’when it suited them and me, and like all the othernurses, I became very good at it.

However, venous access was often a nightmare;these were the days when preterm babies were ontotal parenteral nutrition for weeks, and becausethey were on endless courses of antibiotics,developed fungal infections. Long lines were notused, so we relied on peripheral access. However,we managed to find the most obscure veins thatprobably didn’t even have a name! If we couldn’tinsert a cannula, the doctor would shrug and say‘well if you girls can’t get one in, I won’t be ableto’, so these poor babies often had to endure hoursof attempts to site a line. Occasionally (and thisreally was occasionally), babies went to surgery forBroviac lines, but these often fell out the next dayand we were back to square one.

It seems unbelievable now, but these were thetimes when surgeons in particular did not thinkbabies experienced pain, and we had some terribleinstances of babies having surgical procedureswithout any pain relief at all. All the nurses werevery vocal about this, and occasionally after muchpersuasion, a surgeon might agree to a dose ofmorphine so small it could only be described ashomeopathic, and although this was better thannothing, it was very unusual. The surgeons’ argu-ment was that babies’ brains were too immatureto experience pain, and narcotics had ‘too manyside effects’. I wonder what they think now, withresearch showing that babies do experience pain,and preterm babies are even more sensitised topainful procedures. The Arabic mothers were verymuch into putting honey on dummies (pacifiers wecalled them) when their baby needed an IV sitedfor example, but sadly at the time we discouragedthis precursor of sucrose pain relief.

Because we had limited medical input, we hada lot of autonomy, and it made us very resourceful.We didn’t use nasal CPAP then unless it was throughthe endo-tracheal tube (ETT) on the ventilator, butthe Australian nurses had experience with it, andthey would improvise and cut the tubes to makenasal prongs, and somehow with a lot of other bitsand pieces, set up a NCPAP system. They used thisa number of times and prevented re-intubation insome of the small babies.

Long deaths

Not long after I arrived, I was sent to collect a babyfrom a small missionary hospital in the desert.

Obviously, it was assumed this baby wasn’t that ill,and I arrived with the ambulance man and a nurseaide to find this little shack type building in themiddle of nowhere with chickens running aroundoutside. Inside I saw an elderly American doctorwith an intubated baby on a table, and I noticedthe baby had odd ‘triangular’ shaped feet, butdidn’t think much of it. This very nice man asked ifI could please put in an IV, but this was way beforeI accepted this was something I could do, andmumbled that I’d only been in the country a fewweeks. So he pleasantly said ‘Well, I’ve nevercannulated a newborn, so he’ll have to wait untilyou get back’, so myself and the nurse aide set offwith this baby whose face was obscured by thebulky, thick pieces of tape holding the ETT inplace. When we got back, and the efficientAmerican nurses decided to re-tape the ETT (afterinserting an IV in less than 10 s), we all immedi-ately saw the squashed, flattened face of a babywith Potters Syndrome (renal agenesis). I wasimmediately grilled by them: ‘Why did you bringback a baby with Potters Syndrome? Didn’t yourealise that’s what he had?’ Well no, and not thatit would have made any difference anyway, I’dhave still had to bring him back. This was a placewhere every baby was resuscitated, we frequentlyhad 300 g babies intubated at birth; as long asa size 2 ETT fitted, it went in. We had conjoinedtwins joined at the chest, and despite them havingdiaphragmatic hernias and being 32 weeks, theywere rushed to theatre for separation, with theinevitably sad outcome. Babies went home onprostaglandin infusions for inoperable congenitalheart disease because no one wanted to make thedecision to stop the infusion and let the baby die.Since there was no follow up care at home, wenever found out what happened next.

The refusal to accept withdrawal of care inbabies who had no hope of survival was very difficultto accept, and we were left to care for these babiesduring their protracted deaths, and support theparents. One of many very sad cases was anasphyxiated baby in renal failure, and on maximalsupport. Over the next few days, she became moreand more oedematous until she no longer resem-bled a newborn. The mother was in her forties andhad about 13 other children, and she spent all dayand most of the night with this child. With a lot ofplanning, and three of us, we would lift the babyonto her knee, and let her hold her, and she cried asshe touched the swollen limbs and stroked her facewhere the eyes could no longer be seen. When thebaby finally died, she was not there, and herscreams as she came in, and saw what she didn’twant to see made us all cry.

140 K. Hoover

Too much responsibility

After 5pm the medical staff went home to theirapartments. There was an on call system, anda doctor would come in if necessary, but it tooktime, and we were left to manage until they did.

The worst were the night shifts when we wouldadmit preterm babies; the doctor would intubate,but would not insert umbilical lines because they’dsay we couldn’t get an x-ray so what was the point?It was very difficult to get x-rays at night due tostaff shortages, and NICU was not seen asa priority. One night, the doctor went home andwe were left with a 28 weeker with no umbilicallines, so one of the American nurses said she’d tryfor a radial line. She inserted the cannula, butwhen the arm blanched as she flushed it (as itnormally does when an arterial line is flushed tooquickly) she pulled it out. I don’t think I helped herconfidence by saying in a panicked tone ‘his fingersmight fall off!’

One particularly nice Egyptian doctor wouldinsert umbilical lines for us, but one night whenthe x-ray was not done as usual, within hours, thebuttocks had turned black, and we removed it. Ithad gone into the femoral artery, and the babyneeded extensive skin grafting.

One evening, a nurse from the postnatal wardcame running in with a baby in her arms saying‘this baby’s dead!’ The baby was completelyapnoeic with a heart rate of about 20, and grey.She was a normal term baby who turned out tohave overwhelming sepsis. We manually ventilatedwith a bag and mask, did cardiac massage, andstarted IV fluids. We had called the doctor, who ofcourse had gone home, and seemed a littleuncertain about coming back. None of us couldintubate, so we just had to bag until he arrived.10 min later, we could see the doctor saunteringacross the car park as if he had all the time in theworld, but acting like he’d run the 4 min mile whenhe did arrive. We couldn’t be too hard on thesejunior doctors; they were very young, much lessexperienced than us, had little support from theirseniors who rarely came in at night, and theyobviously felt intimidated by us. However,although learning to intubate would have helpedus in the short term for cases such as this, in thelong term it would have added to our workload,and the on call doctors would not have come in atnight or at weekends at all. Anyway, the one thingthey were very good at was intubation; after allthey had lots of experience with the little 300 gbabies they resuscitated, something we wouldcertainly not have wanted to take on.

Another night, we had a 30-week baby withsevere pulmonary interstitial emphysema (PIE).This was just before surfactant came into use, andantenatal steroids had not been accepted intopractice, and our sickest babies were the 30e32weekers; below that gestation they often died.This little baby had a chest tube removed that day,but the doctor said there was no need for a followup x-ray (it was after hours of course). I did a bloodgas just before he went home, and felt it justwasn’t as good as it had been, but he wanted to gohome and that was it. A few hours later, the babystarted to deteriorate with bradycardia and fallingsaturations, the gas was much worse, and thensuddenly his chest stopped moving. I had been atthe hospital several years by now and was one ofthe senior staff, and this night I was in charge. Thenurses on with me insisted the tube must beblocked, but I knew it wasn’t as suction andsecretions had not been a problem, and I felt hemust have a tension pneumothorax. The trans-illuminator lighted up the side of the chest wherethe tube had been removed earlier on. However,one of the other nurses had already pulled out theETT and had started bagging. This made nodifference, so I knew it must be a tension pneu-mothorax. We had paged the doctor on call but hehad his pager off, so we called the crash team.They only ever dealt with the adults, and theyarrived with their huge trolley full of huge equip-ment, and stood and looked at us blankly. I wasterrified, but I was in charge and all I could thinkwas: what if he dies? They’ll say he only hada tension pneumothorax, and you did nothing. So Idid something I had seen once during my neonatalcourse; I inserted a butterfly needle into the 4thintercostal space on the affected side and startedaspirating air. I forgot the 3-way-tap, so had toclamp the tubing every time I drew the air out, andI used a 5 ml syringe which was obviously too smallfor the amount of air that had accumulated. But itworked; the saturations came up, and the cheststarted to move. Shortly afterwards, the doctorwho had finally been contacted came in, and thecrash team reluctantly left. This little boy survivedbut he was in and out of hospital with the effectsof severe chronic lung disease. However, from thatday on, the on call doctor slept in the on call room!

We’ve come to take you home

Many of our babies came from Bedouin familieswho lived in the desert, and when we told themthe baby was likely to go home around his or her

Too much responsibility 141

due date, say in 12 weeks for a 28 weeker, theparents would go home, and not visit, and thenaround 12 weeks later they would walk in tocollect the baby. There were no home ‘addresses’as we know it, streets and houses were not namedor numbered, and few had telephones (mobilesdidn’t exist). So we couldn’t contact them, and itwas very difficult if the baby deteriorated, or died,but funnily enough, they would manage to turn upat the appropriate time, so other families musthave been keeping them informed. This wouldexplain that when they did turn up, they acted likethey’d only been in the day before, and smotheredthe baby in kisses and he or she was passed roundall the relatives to be admired and kissed again.And we would get another huge box of lavishlydecorated chocolates. Of course we used theinterpreter to ask them to visit, that we neededbreast milk, we wanted them to hold the baby etc,

and they would nod and smile, but few came backuntil they expected to take the baby home.

I decided to leave after almost three years,when the first Gulf War started, and with the massexodus of western staff, working conditionsbecame even harder. It was time to go back andwork in my own country.

Conclusion

I never had any plans to return to work in theMiddle East, but I did years later when I went toQatar as a Nurse Educator. It was very different;here, the nurses had no autonomy at all. WhileI certainly wouldn’t advocate the responsibilitiesmyself and my colleagues took on in the UAE,I know that what I experienced helped me to dealwith the many uncertain situations I faced in thefuture.

Available online at www.sciencedirect.com