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

Danielle Dhaliwal (PL3) describes her time in Arusha

Posted on behalf of Danielle Dhaliwal (PL3)

Jambo from Arusha!

The house we are staying in in Arusha is up a steep hill away from town but it is on a bustling street - between barking dogs, nightly music, honking horns and pouring rain we are thankful to have ear plugs to allow some quiet sleep .  The house is adorable and we are currently sharing it with a 3rd year medicine resident from Denver, CO.  A medical student from Australia will also be joining us this week. 

 

The living room in the Exempla House where we are staying.

In Arusha we began our time at Selian Hospital.  As Danielle and Emily mentioned, it is about an hour and a half walk up a muddy hill but, fortunately, there is a retired Medicine physician from MN, Ron Eggert, who is here for the next year and he and his wife are kind enough to pick us up and drop us off on most days.  

 

The walk to work this morning.

Ron's wife Ingrid works at the Plaster House, and we had the privilege to get a tour of the facility the other day - what a beautiful and inspiring place.  The Plaster House is a home in Arusha for children from around Tanzania to recover in after they have had corrective orthopaedic surgery, plastic surgery or neurosurgery for a disability.  The Plaster House is particularly busy this week - a group of surgeons just arrived last evening and will be performing a number of complex surgeries over the next 4 days.  

The Plaster House

Today was the screening clinic and Dr. Swanson and I helped in seeing some of the pediatric cases to ensure they were safe to proceed with anesthesia.  We saw so many children today who will benefit immensely from their being here, I was so happy to be a part of it.  A majority of the cases were cleft lip/palate and burn contracture revisions.  One of the cleft kids was referred to us for a heart murmur.  Not only did she have a 6/6 holosystolic murmur but she had a webbed neck, short stature, shield chest, and other features possibly suggestive of Turner's syndrome. Another child had fallen several months ago onto her chin.  She had fractured her mandible at bilateral TM joints and without proper physical therapy her TM joints fused and she was unable to open her mouth and her mandible growth had been stunted.  Another child had sustained burns to the back of her legs and sadly developed severe burn contractures and was only able to walk with both of her knees bent.  

One patient had been seen by the plastic surgeons however was referred to us because of severe and poorly controlled atopic dermatitis.  The patient had been seen in clinic before and was diagnosed with urticaria but had not received topical steroids and has since developed superinfection of many lesions and possibly eczema herpeticum.  

 

Poor guy was so itchy and uncomfortable and so inflamed that I could feel almost every lymph node he had.  It was my first time feeling epitrochlear nodes.

We prescribed a number of medications and to ensure that this infant received what we had prescribed I walked with her and her child to the pharmacy down the street.  Between the topical steroids, antihistamines, emollients, and antibiotics the bill at the pharmacy was 45,000 Shillings (the equivalent of ~$30).  Given that most Tanzanians make less than 5,000 shillings a day this family was unable to pay and so Dr. Swanson and I split the cost for the medications.  I only hope that when the time comes for refills they will be able to do so on their own.  I am having them follow up with me in two weeks so I will let you know how he is doing. 

We do often walk home and when we do we are always called into the home of an elderly man sitting on his porch.  He has severe bilateral lower extremity pitting edema, JVD, and a necrotic ulcer on his calf.  We gather from these findings and what we can understand of his Swahili that he was diagnosed with diabetes, hypertension, and heart disease but only was able to pay for one month of his medications and has not been seen in clinic since.  He is such a sweet man and clearly is suffering despite the fact that the hospital is a 20 minute walk from his house.  Treatment and monitoring of chronic medical conditions is something that we struggle with even in the US, however in Tanzania it is profound.

We spent our first weekend here in the Zanzibar archipelago.  Stone Town is the main city.  It is a UNESCO World Heritage Site due to its being a former center of spice and slave trade and it is rich with diverse influences of Swahili culture with a mix of Arab, Persian, Indian and European influence.   We spent most of our time soaking up the perfect weather and relaxing on the beaches of Jambiani. 

 

This is actually a real picture I took

I have so many more stories to tell but I need to finish packing.  Tomorrow morning we head out on a three-day hiking expedition up Mt. Meru, a volcano that looms in the distance at 14,800 ft. Can't wait!

-Danielle