Danielle Dhaliwal (PL3) Describes A Care Delivery Experience

Posted on behalf of Danielle Dhaliwal (PL3)

Medicine at Selian hospital in Arusha has truly proven to be an exercise in delivery of care to children in a resource limited setting.  I have several cases to share that I have experienced while here that I believe demonstrate this concept well.

The first case was of a child who was born prematurely at what was estimated to be between 26 to 28 weeks gestation.  The mother presented with premature onset of labor and, despite bed rest and tocolytics, she dilated quickly.  She was able to receive two doses of prenatal steroids prior to delivery of the infant (hydrocortisone is used here vs betamethasone - not sure of the difference in lung maturity outcomes with this).  We were called to assess the infant soon after delivery knowing that it was possible, and likely, that if the infant was 26 wks it would likely not survive.  But also knowing that dating was just as likely to be inaccurate.

Immediately after the infant was born she was cyanotic, hypotonic, and grunting with poor respiratory effort and an initial Apgar score of 4.  For me previously in the NICU this would be a routine resuscitation requiring temperature stabilization, blood cultures and antibiotics, close oxygen monitoring, CPAP, possibly some manual breaths, and likely surfactant administration.  Here these options were not readily available so creativity and temporary stabilization until the infant was able to transfer to higher level of care was all we could hope to achieve.  

Our infant ambubag was broken and we had no ability to titrate the oxygen percentage so could only deliver 100% oxygen.  Despite giving the best breaths we could the infant's perfusion was worsening and her heart rate began to decline.  Joseph (the pediatric registrar) began doing CPR while I continued bagging the infant.  We did not have any umbilical catheters and instead used a small 4 fr nasogastric feeding tube and gave a 10 mL/kg NS bolus.  I attempted to draw up epinephrine to give however noticed that the only vials we had were 1:1000.  To deliver the correct dose I needed to dilute this to 1:10,000 - I learned to never do math under pressure!!!  (by the way, mix 1 mL of 1:1000 epinephrine with 9 mL NS and this makes 10 mL of the 1:10,000 concentration - estimating the weight at 1 kg you would then give 1 mL of this solution)    The infant's glucose was also low so we wanted to give a dextrose bolus.  We had D50 so Dr. Swanson had to quick figure out how to dilute to the proper concentration while Joseph and I continued CPR.  Thankfully the infant's heart rate and color improved and she began spontaneously breathing although she continued to have significant grunting and hypothermia and so we decided to transfer her to ALMC where they have a NICU and ability to do CPAP.

Me warming the baby until she was stable enough to go skin to skin with mom

Getting ready to transport infant to ALMC 

In prep for transport I ran through a checklist:

• Oxygen - check, no,wait - tank is empty and need to get a new one. 
• Ambu bag- check. 
• Pulse ox - check. Adult sized but will fit over entire foot and work, hopefully.  
• Thermometer, check. Given disease rates and reuse of thermometers between patients, only rectal and oral temps are taken. 
• Planning to have mom do skin to skin throughout the bumpy ride.  
• Stethescope - check.  
• Unfortunately our low UVC fell out so I had IV epinephrine in my pocket ready to inject directly into the heart if CPR and bagging were not working.  

Thankfully HR and sats were stable the whole ride!

I checked on this infant yesterday and she is doing great!  Still below birth weight but otherwise a successful resuscitation and one that reminded me of the basics of infant resuscitation and taught me how to do so with limited resources. Helping Babies Breathe was a great resource as well.

Here are some closing pictures of the hike I mentioned in my last blog post to Mt. Meru.  

View of Kili from top of Mt Meru