Training to Take Care of our Tiniest Patients

You have heard the stats on this blog before - babies, and a lot of them, are dying here in Indonesia and around the world just shortly after they were born. The stats I heard recently, said it was one every 3 minutes or almost 500 every day in Indonesia. It is hard though living those stats every day.

There are many things we lack here in Indonesia including equipment, supplies, and in many cases well-trained people. In many cases however that is just because they have not had much training. Education in Indonesia is heavy on the theory and short on the practicing. Our staff have hearts that are eager to serve and a desire to learn.

A couple of weeks ago, our hospital hosted an updated neonatal seminar and workshop for not only our hospital employees but also for staff of government and private clinics and hospitals throughout our province. The main speaker was an Indonesian neonatalogy doctor from Jakarta. It was a great review for me and a great chance for my Indonesian co-workers to learn some of the newer methods and skills for caring for our tiniest patients.

One of the big draws was the opportunity to practice some of the skills like neonatal resuscitation. This has been one of my biggest concerns in observing the care we provide here - I would walk into a delivery room that had no equipment set-up and ready for baby, even though baby was close to crowning and was known to have meconium stained amniotic fluid. Today I walked into the delivery room to find a similar patient story but this time the ambu bag was ready to go and the suction was all set-up! We still have lots of work and practicing to do but it is a big step in the right direction!!

For fun here is a video of the first group to practice neonatal resuscitation during our workshop. They completely failed but in their defense it was an ICU nurse and ER nurse and they don't do many neonatal resuscitations on a regular basis. In the video, they are simulating receiving a premature infant who had just been born by c-section. The baby started off crying but then quickly started grunting with nasal flaring and the oxygen saturation did not increase as it was suppose to, so they should have started giving the baby oxygen but didn't.

One of my goals is to do regular simulations like this with all of the staff, so we know that all the equipment works and it is as routine as possible.

Sorry it is an Bahasa Indonesian and a video of the simulation being shown on the big screen, so everyone can learn from the process :)

Baby Bulan and other little ones

Baby Bulan

They say things come in threes and that is true for us this week. We had three 1500 grams (a little over 3 pounds) babies admitted to the hospital this week. Baby Atna was born at a local government clinic and then transferred to us for higher level care. Baby Gabriel was born at our hospital and has a heart defect. Baby Bulan is one month old and was admitted with several malnutrition.

Baby Bulan (moon) was admitted earlier week. He and his twin were born in a village about a month ago and he weighed 2.3 kg at birth. Unfortunately, his parents seem to be lacking in knowledge or skill to care for their new children. Bulan's brother died last weekend and that caused their community to intervene and they brought Bulan and his mom to the hospital. Those first few days were touch and go as he battled infection in a very weakened state. But with IV fluids, antibiotics, and milk he has turned the corner. Those first few days he alternated between being lethargic and very fussy. Now he is sleeping a lot although if you waken him he will lie there contently. I imagine it is the first time in a long time he has had a full tummy. This morning his weight was up to 1650 grams. 

He still has a long way to go as currently all of his milk is given through a tube that goes through his nose and into his stomach. We will start with a dropper and work our way up to a spoon. He is now transitioning out of the ICU and hopefully soon out of the incubator. It will take awhile though before we feel comfortable sending him home and hopefully can also arrange good follow-up for him. 

Baby Gabriel (the baby with the heart defect) was transferred to our provincial capital city in hopes of getting at least an echocardiogram and seeing if his heart is something that could be fixed. Unfortunately, he passed away on the way there.

Last but not definitely not least is little Baby Atna. She is a tiny one and like most babies has lost weight after being born but so far there are no signs of infection or major problems with her heart or lungs, so we are hopeful that with good care she will soon start gaining weight.

Baby Atna - weighing 1.3 kg (just under 3 pounds) this morning. 

Back in the Trenches

Who would think checking cervical dilation would be exciting but after more than a year sitting on the bench, as I completed language study and waited for work permit, that simple skill felt good to be doing again. Funny, to think just 7 years ago I barely could find a cervix let alone tell you how far it was dilated. I had some awesome teachers and preceptors guide me to this point and hopefully now I can do the same for others. For several months now at the hospital, I have reviewed charts, shared advice as I was able, and talked through situations and problems with our medical and nursing staff. Occasionally, I would help out with a precipitous delivery or CPR in an emergency.

This week though I finally have my work visa and so can start working with and training our staff here. Today, it was a first-time mom with spontaneous rupture of membranes with no signs of labor and an OP baby. After checking her cervix and placing misoprostol, I spent time talking the staff through different positions the mom could be in that might help the baby turn. Typically laboring moms here spend most of their time on their back and occasionally on their side.

Then I went to see the mom who had an emergency c-section on because she came in seizing from eclampsia. She had a little 35 weeker who weighs just over 2 kg (4 1/2 pounds). He was busy being very upset at the lack of mommy time and breastmilk and since mom was now conscious I took him to the ICU for a visit where he promptly latched on and breastfed for close to 30 minutes. I wish I had been able to take a picture because he was so cute as he ate but my hands were busy holding him close and plus it felt like an invasion of their privacy.

There are two other little ones in the ICU and I don't know whether they will make it. One is a 32-weeker who weighs 1500 grams (just a little over 3 pounds) and the other is a 1-month old who only weighs 1600 grams (almost 3 1/2 pounds). He is obviously failing to thrive and his older twin has already died. Finally, there is also a toddler from an interior village with a very bad pneumonia who has been on the ventilator for almost 20 days now.

So just because I can finally get back in the trenches doesn't mean all the days are going to be happy ones. But I do have to admit I am glad to be getting my hands dirty again and soon the new school year will start and I will have a chance to shape some young minds and skills from the beginning.

Oh and by evening the laboring mom had delivered after a trip to the toilet (squatty potty) resulted in baby turning and a rapid delivery for a first time mom. :)

And so it begins...

Ibu Deen

This handsome fellow was born yesterday at our hospital via c-section. His mom, Ibu (Mrs.) Deen, has been a patient at the hospital for almost a month now. She is from an interior village about 4-5 hours from the hospital, 2 of those hours on dirt and very bumpy roads.

About 30 weeks into her pregnancy she started having vaginal bleeding and her local midwife sent her out to the government hospital nearest their village. She was then referred by the government hospital to us because they do not have an obstetrician/gynecologist on staff right now. An ultrasound showed that she had a complete placenta previa, which is where the placenta is implanted right above the cervix, which blocks the exit of the baby when it is suppose to be born. This complication can cause both mom and baby to die very quickly if she goes into labor or starts to bleed. 

After she was admitted to our hospital we found out she was contracting, so she was given medication to try and stop those contractions. She was also given a steroid injection to speed up the development of the baby, specifically his lungs, because if he was born then he would have been too early and most likely would have died. The bleeding slowed down, so for the next several weeks she laid in her bed in the ward on complete bedrest. Finally she reached 36 weeks (8 months) and we let her go a relative's house in a nearby town (her village would have been too far away and with the bad roads would have been a huge risk). But less than 24 hours later she started bleeding again and she was readmitted to the hospital. The decision was made to do a c-section.

So at 36 weeks and 2 days this little one was born. He weighs 2.5 kg (5 pounds 5 ounces) and after needing a little help with oxygen during transition, he is hanging out with mom in the ward. Because he is early he is having some problems with his temperature and with breastfeeding but overall he is doing great and will hopefully work through those issues quickly. Mom is doing well also, did not bleed too much during the surgery, and is now recovering.

This one will go down in the books as a life saved from a complication that could have taken both the mom (leaving two other kids without a mom) and baby. The system worked like planned. Just a few weeks after I arrived, we lost a baby just like this one. She had started bleeding a lot and the baby had passed away before she even got to us. The baby was perfect and almost at its due date. We did a c-section and she lived but it was a close call.

Listening to the Stories

So this is one of those blog posts that should have been written a couple of months ago but I just haven't gotten around to it. It is about my visit to Bethesda Hospital in October. I knew I was only going to be there for a couple of days, so my biggest priority was seeing old friends and making new ones. It was also a chance to listen - to hear the stories of current joys and challenges of the ministry there. Honestly, it could have been more encouraging because there are a lot of challenges right now but it was also a blessing to see so many serving every day.

I had the brief chance to talk with our current Indonesian obstetrician/gynecologist, who at the moment is also the director of our nursing school. He gave every indication that he is looking forward to partnering in the work together. I am not sure exactly what that will look like but am hopeful. He and others shared a few stories with me from Zaal Bidan (OB Unit). 

One was a patient who had come in that week. Many of our patients are referred from clinics and even other hospitals for a variety of reasons. This patient had been referred to us because of a post-partum hemorrhage (heavy bleeding after the birth of the baby, which can be fatal if not treated quickly and correctly). It turned out her uterus had prolapsed into her vagina. Thankfully it was able to be returned to its normal location and with a blood transfusion and antibiotics she was expected to fully recover. 

Another patient though did not have as good of an outcome and she was also a transfer. Apparently during the birth there had been a shoulder dystocia. The head of the baby had delivered but the shoulders got stuck. This is one of the emergencies of OB medicine. So she was transferred like that and the baby died during the transfer. There are number of maneuvers that can be tried to correct the problem and help the baby be born. We are not sure if any of those were tried or what exactly happen. Once she arrived at our hospital, we were able to start her on Pitocin, to make her contractions stronger again, and with one of those maneuvers the baby was born. 

These are just a couple of the stories I heard during my few days at Bethesda Hospital. One of the doctors after telling me some of the stories, asked me if I was going to run away and never come back. I have to admit the thought did cross my mind but it was also a good reminder of the great needs that still exist here in Indonesia and around the world. Moms and babies are dying and many of these deaths could be prevented!  

I will be moving to the hospital in March, after I complete my language study. I anticipate the first few months will be spent learning more about the situation and how I can best use my skills to fit the needs. I do know that this is going to be a very stretching and challenging ministry!