Again Valerie, Beverley and I went to placement for my second day while the other 3 were away on an excursion. Everyone was quite bright on the journey to the hospital with jokes, laughs and reggae music which came to be the theme of the trip thanks to Fred and Tom's love of reggae. We all sang along to Bob Marley's "Three Little Birds". Not long after we arrived it was Valerie's turn to go and observe a caesarean. There were 2 labouring women occupying both beds. After we'd done some mopping I spotted a piece of equipment humming away that I'd not seen before, when I went over to look I noticed that one of the incubators was occupied and the machine was an oxygen pump. Beverley looked in and said it didn't look well, we asked what was wrong with this baby and we were told that it needed help breathing.
The baby from the caesarean returned from theatre and was placed in the incubator next to it. As this younger baby had been carried from another building where the theatre is, I decided to check it's temperature, it was cooler than it should be. At the same time Beverley felt the cheek of the first baby and said it felt cold, she felt the chest as this gives a truer indication of the core temperature. Still cool, got a thermometer and it was at this point we found the kanga closest to the skin surface of this infant was damp, I tried to listen to the heart but couldn't even make out the sound due to the sound of the lungs- which sounded very crackled - clearly had a lot of mucous on the chest, temp of 35.3•C and visual signs of respiratory distress. We reported this to the sister who suggested we get more blankets to keep both infants warm. We asked if this first baby had been fed since delivery and were told no as it needed oxygen so couldn't go on the breast. Beverley and I moved quickly to get a fresh dry kanga, get a hat and knitted cardigan around the baby, turn the incubator temperature up, from 'low' to 'high' as skin to skin wasn't an option due to oxygen therapy. The mother was asked to hand express some breastmilk to give the baby some energy and she managed some that was put into a syringe. Beverley tried giving this to the baby, it had no suck reflex so the tiny drop of colostrum remained in the cheek. I rechecked the temperature after 15 minutes and it had dropped to 35•C and all other observations sent alarm bells ringing. We got hold of one of the midwives and told her this infant needed reviewing by a pediatrician but she told us there wasn't a pediatrician in as it was a public holiday and that they didn't have any NG tubes on the maternity unit. We asked if we could bring the mother through to see her baby (we were convinced the child wouldn't survive) but were told this can't happen while there are 2 women labouring-as soon as they were delivered we could bring her through. The midwife rang the obstetrician for us who came and agreed the baby was hypothermic and needed transferring to the neo-natal care unit. He went and made a care plan of warming the baby, NG feeding of EBM every 2 hourly and IV antibiotics. We took the infant over to NCU on the pediatric ward and the mother soon followed. the NCU was behind a tinted glass door, we had to put hair nets on and change our shoes as part of their infection control. Once through this door there was 2 rooms, to the left was a room where the mother's nursed their poorly infants and things like hair nets, shoe covers were stored. The room to the right was where the infants stayed, this room was maintained around 30•C by two heaters mounted on the wall; it had a large bed that had been converted into 4 small cots and a resuscitaire - where our infant was placed. I was quietly glad to see a piece of equipment I recognised! However although the resuscitaire appeared familiar I soon realised that it was really only a matress with an overhead heater. But this couldn't be used, nor the electronic thermometer probe attached, as the machine didn't have mains socket. The air, oxygen, suction, heat etc were all controlled by separate pieces of equipment in the most basic of forms.
The nurse had taken some time to gather the equipment to site a cannula but did appear to have a sense of urgency, the first I'd seen that day. The poor woman even apologised to us for not being able to find the equipment sooner. It took her a few attempts but she soon got a cannula sited and administered the first dose of antibiotics. She also periodically used foot controlled suction to clear the mouth of mucous, this reminded me of a camping bed foot pump in reverse - it had to be controlled slowly and steadily by foot-no suction rate/pressure on a dial like we would set on the resuscitaires at home. This was also much more complicated than expected as it took at least 20 minutes for her to find tubes that fitted together, then they needed sterilising as they have very limited single use equipment. In the end I had to hold two mismatching tubes together to ensure an airtight seal and she used an NG tube with the end cut off as there were no other tubes small enough to use in the mouth of this infant or a yankauer. During this time the baby began to feel warmer by touch and the skin colour was improving but the nurse didn't have a thermometer available to check.
It was now 1pm and Valerie and Beverley were leaving, I was due to finish with them but I couldn't leave that baby so arranged for Tom to come and collect me a few hours later.
The nurse had taken some time to gather the equipment to site a cannula but did appear to have a sense of urgency, the first I'd seen that day. The poor woman even apologised to us for not being able to find the equipment sooner. It took her a few attempts but she soon got a cannula sited and administered the first dose of antibiotics. She also periodically used foot controlled suction to clear the mouth of mucous, this reminded me of a camping bed foot pump in reverse - it had to be controlled slowly and steadily by foot-no suction rate/pressure on a dial like we would set on the resuscitaires at home. This was also much more complicated than expected as it took at least 20 minutes for her to find tubes that fitted together, then they needed sterilising as they have very limited single use equipment. In the end I had to hold two mismatching tubes together to ensure an airtight seal and she used an NG tube with the end cut off as there were no other tubes small enough to use in the mouth of this infant or a yankauer. During this time the baby began to feel warmer by touch and the skin colour was improving but the nurse didn't have a thermometer available to check.
It was now 1pm and Valerie and Beverley were leaving, I was due to finish with them but I couldn't leave that baby so arranged for Tom to come and collect me a few hours later.
After they left, Marley's song was stuck in my head, hoping he was right-hoping this little thing would be alright, I started humming the chorus to myself repeatedly, almost as a prayer...and my sight became blurry as my eyes filled up. I was so upset, angry, scared, frustrated. This poorly baby had been in the hospital since about 7am and a formal plan hadn't been made until nearly lunch time. Midwives were so overwhelmed with caring for labouring women and new admissions that they hadn't had chance to do any checks on this baby. There were less staff available due to it being a public holiday. The baby had had breathing difficulties for so long what if it was too late already? This was my first encounter with an infant where I thought it may not survive and I felt absolutely helpless!
I went to find the nurse to see if there was anything else I could be doing. I couldn't find her and when I asked a parent of another patient if they'd seen her, they said she was searching for equipment. I asked if another nurse was around and was told no, she was on her own. My heart sank as I realised this nurse who'd dedicated so much time to the baby we had brought over was responsible for all the other patients too - at least 3 other neonates, 5 children in the diarrhea unit and minimum of 3 other inpatients.
I went to the mother of the infant I was with and with the help of another 'NCU Mother' who knew a little English and a lot of gestures, she finally understood my request of her to express some fresh colostrum. As I thanked her and turned she reached for me and started speaking to the other woman who'd managed some translation. They both looked at me and seemed to be asking something, I told them 'Sielewi. Pole' - 'I don't understand, sorry'. The second woman then asked 'girl? boy?' It was now that I realised the woman didn't know if she had a son or a daughter, she hadn't seen her child since they were transferred in immediately after delivery at 6am this morning! My heart dropped for her. Without saying anything I took her hand and led her after me, gave her a hair net and pair of shoes and ventured into the warm room where the babies were all asleep. I introduced her to her baby while she whispered 'asante' 'thank-you', I carefully unwrapped part of the kanga and showed this woman that she had a daughter. She kept her distance while continuing to whisper 'asante'. I pulled out my hand gel, squirted a bit onto my hand then motioned to put some on her hands, we rubbed our hands dry then I took her hand again and placed her finger in the palm of her daughter's hand. After a couple of minutes the woman stood up straight, said something to me I didn't understand (again) but from her gestures I gathered she was going to the other room to express milk for her baby girl.
I went to find the nurse to see if there was anything else I could be doing. I couldn't find her and when I asked a parent of another patient if they'd seen her, they said she was searching for equipment. I asked if another nurse was around and was told no, she was on her own. My heart sank as I realised this nurse who'd dedicated so much time to the baby we had brought over was responsible for all the other patients too - at least 3 other neonates, 5 children in the diarrhea unit and minimum of 3 other inpatients.
I went to the mother of the infant I was with and with the help of another 'NCU Mother' who knew a little English and a lot of gestures, she finally understood my request of her to express some fresh colostrum. As I thanked her and turned she reached for me and started speaking to the other woman who'd managed some translation. They both looked at me and seemed to be asking something, I told them 'Sielewi. Pole' - 'I don't understand, sorry'. The second woman then asked 'girl? boy?' It was now that I realised the woman didn't know if she had a son or a daughter, she hadn't seen her child since they were transferred in immediately after delivery at 6am this morning! My heart dropped for her. Without saying anything I took her hand and led her after me, gave her a hair net and pair of shoes and ventured into the warm room where the babies were all asleep. I introduced her to her baby while she whispered 'asante' 'thank-you', I carefully unwrapped part of the kanga and showed this woman that she had a daughter. She kept her distance while continuing to whisper 'asante'. I pulled out my hand gel, squirted a bit onto my hand then motioned to put some on her hands, we rubbed our hands dry then I took her hand again and placed her finger in the palm of her daughter's hand. After a couple of minutes the woman stood up straight, said something to me I didn't understand (again) but from her gestures I gathered she was going to the other room to express milk for her baby girl.
The nurse returned with equipment for siting a naso-gastric tube. As I'd already seen that they have very little single use equipment, I was intrigued as to how this would be done. She had a tube as we would have in the UK and some cooled boiled water in a sterilised cup. As she was preparing she asked me how we site an NG tube in the UK, I felt relieved that this was something I'd learnt to do on placement a couple of weeks before going to Tanzania. I told her how we measure the tube for the infant, how it's inserted and how the pH of the aspirate is checked before each feed to ensure it hasn't been inserted into the lung. She was very interested in what I told her and again apologised for not having such advanced equipment. I told her not to apologise, she's doing a wonderful thing and us mzungu are just lucky.
She dipped one end of the tube in water to lubricate it then asked me to hold the other end of the tube in the water, keep it there and tell her if I see any bubbles. She began inserting the tube in the right nostril and told me that if the tube is sited in the lung then as the baby breathes out bubbles would form in the cup. This was how she checked it's location. While I did think this was an interesting way, I did think that this technique must also carry the risk of an infant inhaling water via the tube. The tube was sited, there had been no bubbles and the water level in the tube had not moved either. The mother had brought some colostrum and I drew it up into a fresh syringe. The nurse gave the feed. Finally! Her chest sounded clearer, heartrate had improved, skin colour was better and there was no longer any nasal flaring! The nurse had got hold of a thermometer and while I can't remember it, it had improved, thankfully!
Time had flown and Tom was waiting to take me home. It had been a long, tough day. Now I was hoping the little thing was gonna be alright overnight and kept on humming the tune which soon became the theme-song to my time in Tanzania.
She dipped one end of the tube in water to lubricate it then asked me to hold the other end of the tube in the water, keep it there and tell her if I see any bubbles. She began inserting the tube in the right nostril and told me that if the tube is sited in the lung then as the baby breathes out bubbles would form in the cup. This was how she checked it's location. While I did think this was an interesting way, I did think that this technique must also carry the risk of an infant inhaling water via the tube. The tube was sited, there had been no bubbles and the water level in the tube had not moved either. The mother had brought some colostrum and I drew it up into a fresh syringe. The nurse gave the feed. Finally! Her chest sounded clearer, heartrate had improved, skin colour was better and there was no longer any nasal flaring! The nurse had got hold of a thermometer and while I can't remember it, it had improved, thankfully!
Time had flown and Tom was waiting to take me home. It had been a long, tough day. Now I was hoping the little thing was gonna be alright overnight and kept on humming the tune which soon became the theme-song to my time in Tanzania.
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