Upon arrival to Annotto Bay hospital, it is difficult to imagine that this hospital was recently upgraded to a level B hospital. It is a group of small one-story buildings connected by a web of outside sidewalks that you find yourself sharing with goats, dogs, and chickens. We were received by the CEO of Annotto Bay hospital, a wonderfully charming lady named Ms. Mighty. In her office, we got a glimpse of the inner workings of administration. Communication is almost entirely by cellular phone. It is not uncommon for you to be having a conversation with someone and have them stop, mid conversation, and start talking on the cellphone. Calls appear to be business-related and are usually kept as short as possible. We quickly learned not to be offended if someone picks up their phone while we were talking with them.
Ms. Mighty contacted Dr. Melissa Fisher who came to greet us. She told us she was caught up in the pediatric wards because they had just received a set of triplets, each weighing a little over one pound. We (Dr. Fisher, Dr. McConkey, Diane, and I) were led to our clinic for the day. We were given the two nicest offices, the only ones with air conditioning, in which to work. Stacy set up her work space in one office, I left my stuff in the other and asked Dr. Fisher to take Diane and me to the pediatric ward where I could see if I could offer any help with the care of the triplets.
The ward is a single room, about ten-feet by 30-feet that is crammed with beds of several sizes, a few cribs, a few nonfunctioning incubators, and a nurses' desk. There is barely enough room for the beds and I'd find it very difficult to even walk around the beds. Luckily the infants were close to the entrance. They had been born about 5 hours before we arrived, and were estimated at 28 weeks - there had been no prenatal care and the gestational age was an estimate based on maturity rating.
Two infants were in an incubator, and one was in a crib. All were attached to a wonderfully simple, but functional, bubble CPAP system (see how it works here). The oxygen comes directly from tanks at the bedside, and there is no warning system in place to indicate low oxygen reserve. Someone has to check the gauge frequently, and bubble CPAP necessitates that the flow be turned up as the supply pressure drops. We were giving the infants CPAP at about +8 and they seemed to be breathing fine. The attached pulse oxymeters were reading 100%.
All of the infants were hypothermic with a temperature of 92-93F. None had an infant warmer in place. Diane asked Dr. Fisher about the warmers that Issa Trust had donated but Dr. Fisher did not know they even existed. Diane left to address this issue as Dr. Fisher and I tended to the infants. The nurses had wrapped the babies with several layers of insulation - one layer of 1-inch thick cotton, three blankets, saran wrap, and another blanket. The ambient temperature was close to 100F, yet an axillary thermometer read 92.6F. They were not monitoring internal temperature (they had neither probes nor a monitor), but were monitoring pulse oxymetry and heart rate. They did not have newborn size blood pressure cuffs.
I did not like having the babies wrapped to the point where I could not see them. If the babies were to survive, then these warmers that Issa Trust had donated only a few months ago were absolutely crucial. I examined all the infants - no heart murmurs, good air movement, no apnea. So if we could warm these infants up they had an excellent chance at survival. I unwrapped one infant and found that the inner cotton layer was soaked and so probably was doing more cooling than warming. I wrapped the baby directly with saran wrap, and then with a blanket. I layered some cotton above and then watched the temp gradually go up to 94F.
Diane arrived and told Dr. Fisher that she had found the warmers. The head matron (similar to our nurse manager) had received the donations and decided that the pediatric ward did not have enough space for them! Dr. Fisher was never even asked! That's when Dr. Fisher called the head matron and asked that two warmers be brought to the ward. I heard her having to argue with the head matron about space. The warmers arrived within minutes. They did not have any temperature probes so the babies' temperatures had to be manually checked every 10 minutes and then the warmers cycled on-and-off, but they were all normothermic within a couple of hours. Their heart rates stabilized, their breathing became less labored, and their mom was allowed to visit them. She asked if the hospital could inform the media about them - perhaps as a way to spread the word that she was going to need help with baby supplies.
I went back to our clinic site. I saw 5 patients in the clinic that day. Stacy had seen 12.
Lessons learned:
1. Inform the local doctors about the incoming donations
2. Get probes for the infant warmers
3. See if we can get newborn size blood pressure cuffs
4. See if we can get CPAP pressure monitoring systems
Thank you for your posting and the good work. It's always a struggle to advocate for the LBW / premie in a low resource environment. I will try to get some newborn BP cuffs
ReplyDeleteDr Arleen Haynes-Laing
Keep it up guys, Well done. Ava.
ReplyDeleteYou are right on the spot, Dr. Rabi !!!!As you detail only a few of our many challenges.
ReplyDeleteAs you know, it is a cumbersome and intricate task to care for premature neonates with or without respiratory distress, with all the complications they can develop.
Preterm delivery is associated with a high mortality rate even in the best environments. No doubt,a higher mortality rates are expected in our third world countries.These disadvantageous outcomes are not necessarily related to lack of knowledge or dedication of the staff members.
Babies (like our fighting-triplets) are very often conceived, delivered and managed in less than optimal conditions.
Besides of the shortcomings that you have underscored, there are yet many others that we face , like:
a) No Specialized/Pediatric nurses
b) Not enough staff, to keep the recommended nurse-to-patient ratio. One that could satisfy an intensive care for high-risk-of-dying-patients (as our triplets).
c) No working incubators.
d) Lack of necessary monitoring equipment.
Therefore our nurses and doctors have to make an extraordinary effort with an amazing display of clinical skills and dedication, to achieve hour after hour, day in and day out, all year-long,what machines and equipment do in the first world.
I understand that what you have seen and what your staff will see in the upcoming months might be shocking.We realize that our setting is suboptimal. That is why, we are so desperately in need for support, in terms of equipments.
I should probably let know the fact that our Early Neonatal Mortality Rate in Annotto Bay Hospital for the last five years has been below 8 per 1000, and a Late Neonatal Mortality Rate less than 1 per 1000. Beyond the neonatal period (infancy) we have only had 2 deaths in the last five years.
Features these that can only be atributed to the hard work and sleepless hours of bedside monitoring dedicated to these extremely ill patients by our nurses. And also to the fast pacing work, quick wit,relentless spirit, high clinical skills and accurate pediatric knowledge of our team of doctors, whom more often than not have to rely only on clinical judgement to make diagnoses and discover complications, that in high technology working environs are made within minutes by echocardiograms, sonograms, ABG's, chest-X-Rays, CAT scans and MRIs.
But we will keep doing what we do best, even with a minimun at hand. With all heart.