Day 19-22

When one door of happiness closes, another opens; but often we look so long at the closed door that we do not see the one which has been opened for us!   ~Helen Keller

At the beginning of the week, I started my rotation in the NICU. It clearly isn't up to date with the level III NICU of Sacred Heart Medical Center in Spokane, where I completed my senior practicum during nursing school, but definitely gave me the perception of how critically ill neonates are cared for in Ghana. With only one incubator, two phototherapy lights, two heat lamps, a couple rusted oxygen tanks, and absolutely no ventilator, obviously the limit on equipment restrains the type of treatment that can be provided. There was also no refrigerator on the unit so the breastmilk for each baby was stored in a bottle sitting out on a table all day. I later found out they throw it away after 8 hours, but even this amount of time allows a significant amount of bacteria to probably grow and the milk already has evidence of separating components, with a thin layer of oil like film on top. One thing that surprised me though was a makeshift code cart set up on a metal tray and covered with a sheet. It included ambu bags, face masks, a few medications, ET tube, and bulb suctions. The main room has up to 8 babies lined side by side and crammed into a small space. There is barely any room to even walk and observe them. There is then a narrow hallway that has about 6 cribs lined on the right hand side, leading into another small room where there are currently no cradles. Staff are supposed to change into scrubs on arrival to the unit as an attempt to maintain a sterile environment, however the realistic aspect of anything being sterile in the hospital given their limit on supplies and training, it's unlikely whether I changed at home or at the hospital would really make any difference.

Main NICU room

No cardiopulmonary monitors exist unlike the NICU in the states. Therefore there are no alarms but also no close monitoring of vital signs. I take temperature, pulse, and respirations manually everyday at 10 and 2. There are only two good stethoscopes- the doctors and one other; I noticed the other two have cracks in the bell so there is no way to even hear out of them well. I have had the pleasure of being a teacher while on the unit as well. There are two pre-med students working as volunteers from another program and neither has had any medical training so far, so it feels good to use what I know and give them tips. I explained I am still learning myself and am no expert but would be willing to answer any questions they had. I also took the opportunity to teach about taking vital signs, the purpose of phototherapy and what jaundice is, and a bit about noticing respiratory distress in the newborn.  Our job is also to participate in feedings. They don't use bottles and nipples so the babies unfortunately don't learn how to suckle for when it comes time to breastfeed at home. Instead they use 30 cc medicine cups and basically pour the milk into the babies mouth. Some swallow fairly well but others pretty much choke. My first time more milk went onto the gauze bib than in the baby's mouth but after a few times I am now mastering the technique. It's a lot of fun to participate in care and hold such precious babies in your hands!
 
The doctors estimate the gestational age of each baby by using the Ballard Scoring system which looks at different signs i.e. the square window, scarf, creases on the sole, presence of lanugo, etc. The most shocking case to me is a 27 week baby who weighs just 1.85 lb. I am honestly amazed he is still living without a ventilator. The only respiratory support he has is oxygen via nasal cannula and he lays in the only incubator. He also has an NG tube placed for feedings. He is experiencing respiratory distress as I could easily count every rib in his body due to the sternal retractions with each breath. He is the first patient I have seen receive any blood thus far. I guess they have a blood bank at the hospital but the blood they transfused was just stored in a picnic cooler for at least 3 hours before it was given. They thankfully established a new IV site and primed some new tubing that also had a filter in the chamber, but the only way to run the fluid is to gravity as no pumps are available. Nobody confirmed the correct blood with the RN and type and cross obtained. No vitals were checked either to identify any adverse reaction or complications until I asked. I then notified of the results and they told me there was no proper place to record until the next set of vitals were due at 6 in the evening! I hope by the end of my three weeks in this unit I will watch him grow stronger.
Another case I found interesting yet sad was that of a four day old who was admitted. The mother noticed he was cyanotic, not feeding well, and just was lethargic. On further examination and through echocardiogram (which I was shocked they even had available), it was determined he only has one ventricle, atrial septal defect, and one vein leading out of the heart so the blood is a mixture of oxygenated and not that has to supply the lungs and the rest of the body. There is no treatment available other than surgery and the parents don't have medical insurance. It is very costly and only available in Accra so they would even have to travel. The doctors don't expect him to live past toddler age. There was also a baby who has seizures as a result of a complicated delivery. She was born via vacuum assisted vaginal delivery which resulted in either a subgaleal or subarachnoid hematoma. They are unsure whether blood entered the cerebral spinal fluid but the baby has a hyperextended neck, is very irritated with any movement, and has some neurological damage evidenced by the eye movement. I questioned the possibility of meningitis but was told she just has cerebral irritation and it's a waiting game to see if any improvement is made in her condition. 

I learned that it is tradition in Ghana to not name babies until at least one month of age when a special ceremony is held. It is practiced differently by each region. While in the hospital, the baby is called after his or her mother's name. That explained a lot as I looked at the chart and noticed all girls on the unit then found differently when I went to change diapers! They don't have baby wipes either so just use normal toilet paper to wipe which shreds into small pieces because it's cheap. Each baby is only allowed 10 diapers per day so you will find them prolonging the changes also.

At the leprosy camp, I changed Majua's dressings today. We figured out a new technique to help restrain her but also calm her down and she can't see what is going on. She lays across the lap of two volunteers on her stomach and gets rewarded with a juice box. It doesn't seem like the wounds are healing and are actually increasing in number. They are all oozing pus and blood around the edges. Some of the skin surrounding each area is dead and peeling away so it has to be cut back. I feel so sorry for her! The only supplies we get are the gauze, iodine, and tape so there isn't much more we can do unfortunately. She already completed the round of antibiotics obtained from the local clinic near the camp but another visit there might be beneficial. Onasis also has a wound on the lateral aspect of his knee. It proved to be a difficult spot to keep a bandage around. He is such a busy boy and due to his developmental disabilities, he kept peeling the wrap off. We decided to attempt bandaids as well but after going through three, we came to the conclusion it wasn't worth the hassle and use of supplies but at least the wound was cleaned. He later tried to leave with me, holding my hand the entire way to the road until I had to catch a taxi back to the hospital. He didn't understand why we had to leave and I kept saying bye but he never left. Finally a man yelled something in Fanti and off he ran into the distance. I also completed the dressing for a younger man I have never seen before. On the surface it looked decent and healed but then you noticed the tunnel and depth of the wound where pieces of iodine soaked gauze could be packed in about one inch into the bottom of his foot. There are two women at the camp who cannot walk so we go to them. They are always so friendly and grateful for our service.

Village of Akwidaa

You give but little when you give of your possessions. It is when you give of yourself that you truly give...