Day 07 - Visiting the triplets again

The outpatient department in Annotto Bay - the patients wait outside

I received some bit of good news today when I passed by the pediatric ward in Annotto Bay today. Baby B of the triplets has been able to come off of CPAP and he has been making good breathing efforts. This is the baby who had omphalitis so having one less thing to worry about makes his care a bit easier. I was able to uncover him completely to do a full exam. His omphalitis appears to be under good control. His breathing is unlabored. His right foot is a little poorly perfused and the little toe is looking a little dark. I asked the nurses to place some warm packs on the left leg to improve perfusion. The nurse tried to correct me and asked if I meant the right leg. A great opportunity for a teaching moment!

They are going to try Baby A off of CPAP today. They tried last night but he wasn't quite ready. Dr. Ramos has to make an educated guess as to when a baby is ready to be taken off of CPAP. The babies have never had an X-Ray, because the machine has been broken (since February). We cannot monitor blood gases - they don't have that capability at all.

Triplet C, our sickest one (with possible sepsis), was a little swollen. Dr. Fisher, the senior resident, said that he had low protein levels (hypoalbuminemia) and they had given him some intravenous albumin. This is only going to get exacerbated by the limited nutrition. But at this stage I'm also worried about the kidneys. We have no way of closely monitoring the urine output. On my way back from the clinic yesterday I stopped by two "supermarkets" but neither had a scale. Bobbi - the scales you are bringing will be a lifesaver! Literally. Thank you! Thank you! Thank you! (one from each of the triplets).

Our makeshift NICU has a new addition. A 29 weeker was born yesterday and he weighs about 3 pounds. He's doing well. He is being kept in the nonfunctioning incubator, but at least it is a barrier from infections. He is breathing on his own and he may get fed today.

In the next bed I saw a mother cradling a baby who looked limp. I found out that this is an 8-month old baby with a severely malformed heart - DORV with TGA and VSD/ASD (for my PICU folks). This is a condition that typically requires intensive monitoring and very VERY close observation. He would typically require the collective efforts of a cardiologist, cardiac surgeon, intensivist, and nurses adept at caring for children with congenital heart disease. Yet, he's had no X-Rays.No lactate levels. And he wasn't hooked up to a heart monitor. Dr. Ramos explained that all the available heart monitors are being used. It is a tough decision, but I can't help but agree with the premise. Limited resources must be distributed where they can have the greatest impact. This child's condition is very complicated. He will likely require several cardiac surgeries or even a heart transplant. I spoke with the mother and she barely had enough money to get the first few echocardiograms. She said there is a traveling cardiac surgery team that will be in Jamaica in November. She hopes they will "fix his heart". Dr. Ramos and I talked about how we can prepare him for surgery. We will try to get him to gain more weight. We will monitor his kidneys. We will monitor for heart failure. Dr. Ramos will try to get him transferred to the capital but he's not sure if they will accept him.

Tomorrow is my last day. I will be going to Port Antonio. I'm looking forward to meeting Dr. Fazul again and seeing how he has been doing with our little kid with a severe burn.

Day 06 - Checking in on the triplets

This is where I have breakfast every morning. Yes, it's a tough job but someone has to do it.

Baby A - Note the Zip-Lock bag.

The first thing I did when I arrived to Annotto Bay Hospital is check on the triplets that were born on the day we arrived last week. They are 6 days old today. Dr. Ravi, a pediatric resident, was taking care of them when I arrived and he gave me the update. They can all best be described as stable, but they are having many of the complications that can be expected when they are in an inadequately equipped NICU. Infections are the most worrisome complication at this stage; all the babies had an infection of some sort. Baby A had an eye infection (ophthalmia neonatorum) even though he had reportedly been given preventive antibiotics. Baby B had an infection of his umbilical stump (omphalitis). And Baby C had signs of infection in his intestines (necrotizing enterocolitis) and possibly even signs of a worse infection (sepsis). They were all on adequate antibiotics and have a high chance of cure, however the conditions that set them up for these infections were still there.

Babies B and C sharing a cot - Note the many towels

The temperature irregularities (which actually now may be a reflection of their infections) are being treated by wrapping the babies with nonsterile towels, cotton, and fabric. Last time we were here, we recommended the babies be kept undressed under the warmers, with some plastic wrap covering the cot (acting like a greenhouse). This advice was only temporarily headed, as today they are still wrapped with all sorts of coverings, no doubt havens for bacteria. The use of a Zip-Lock bag in Baby A is ingenious, but clearly it is difficult for the caretakers to stop using additional fabric. Two babies are sharing a cot making it easier for infection to spread. None of the babies are in an incubator. Remember, these babies are sharing a room with other children as old as 13 years old, all of whom have bacterias and/or viruses that are making them sick enough to need hospitalization.

After infection control, nutrition is another top priority in caring for premature infants. However, intravenous total parenteral nutrition is not available. The babies are still receiving simple dextrose water. They will continue receiving this water until they are strong enough to receive formula into their stomach. However, Baby C (who might have NEC) cannot be fed because it could worsen the infection. He will be on sugar water for another week or so. Malnutrition sets him up to be even more easily infected and the cycle continues.

The odds are definitely stacked up against our kiddos, but the doctors are doing the best with what they have. They are using pretty much the same antibiotics we would use in the United States, and everyone is instructed to wash their hands before touching the babies. The bubble CPAP is still working fine. Dr. Ravi told me that he has stayed several late nights at the babies' bedside.

Last week when these babies were born, I remember telling Stacy and Diane that these babies had a good chance of survival. Infants born at 28-30 weeks routinely survive with minimal or no complications. I neglected to take into account that the many facilities we take for granted in our modern NICUs are absolutely necessary for that survival. I'm learning new lessons about what we can do to help. Sure they need equipment like the warmers we donated a few weeks ago. Those warmers allowed the babies to survive the first few days. But the next few weeks depend on education as much as anything else. Nurses would benefit from learning about warming techniques. And someone who has influence needs to see the value of a separate newborn care unit. In a country where the birth rate is 50% higher than that in the United States, there will obviously be enough babies to keep that room filled.

Walking outside of the pediatric ward, I saw the Adolescent and Child Mental Health Building. I suppose this was God's way of letting me know that all is not lost. The goat was the perfect accessory to help put a smile on my face.

Lesson learned
I wish we could get an adequately equipped NICU.

Day 02 - Annotto Bay Hospital

Steve picked us up at the lobby at exactly 8AM. Since breakfast starts at 7:30AM, that gave us enough time to have breakfast and a few cups of the famous Jamaican Blue Mountain coffee. We filled our water bottles, which were provided by the resort and were waiting for us in our amazing suite/villa, with ice water, and were off on our one-and-a-half hour trip to Annotto Bay Hospital. This ride again took us down the same scenic route we took yesterday, but we passed Port Maria and traveled another half hour along the ocean.

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