Wednesday, January 9 Part 2

Wednesday, January 9 Part 2

The nurses went to Ibanda Hospital, about 55 km north of Mbarara. We visited there last year, but yesterday and today got a first-hand look at how difficult health care can be in a developing country. The hospital is run by the Sisters of Our Lady of Good Counsel, an order that focuses on teaching, health and social service.

Joanne was dispatched with Sister Stella to an immunization/prenatal clinic in Ruyonza, which took place in a tiny brick church with no glass in the windows, and a very small adjacent mud hut where the expectant mothers were examined and counseled. The rest of the team spread out through the pediatric units of the hospital. It was a very difficult and discouraging visit.

The hospital is critically understaffed, and very heavily dependent on the labor of students from the adjacent nursing school. Thus there are portions of the hospital where very sick children receive little monitoring from fully trained medical staff. An example that touched all of us was a four-day-old infant brought to the hospital the night before. The child was blue at birth, had never cried or breathed properly, and had yet to feed from her mother’s breast. The political unrest in neighboring Kenya has driven the cost of gas up to $15/gallon, putting motorized transport out of the reach of most people. The child’s parents were unable to get her to the hospital, and after four days without adequate respiration she was presumed to be brain-damaged from hypoxia, or lack of oxygen.

We found her in the “premature unit,” or what we in the US would call neonatal intensive care. She was lying flat in an isolette, barely breathing and with a very slow, irregular heart rate. Her lungs were full of fluid. No nurse was present; we learned that the nurse in charge of the premature unit also had responsibility for the laboring mothers in the next room. A new mother had arrived and the nurse was busy admitting her. Thus she was forced to leave a critically ill child alone. When she returned Kathy, our neonatal intensive care nurse, suggested elevating the baby’s head, suctioning her airways and reapplying supplemental oxygen. (The child had been receiving oxygen but the power went out overnight and it was discontinued. When power returned, the single nasal cannula on the unit was applied to another baby. By morning, the second baby was doing well enough to breathe on his own, but the cannula had not been returned to the sicker baby. Now she was near death.) With a little help breathing, the baby perked up and moved a little.

When the team returned, the baby was back at the brink of death. The nurse concluded that since the mother had not returned to the baby’s bedside for hours, she had resigned herself to her child’s death. They decided to discontinue the oxygen and let nature take its course. Sister Margaret quickly baptized the child and the mother was sent for, for a last good-bye. It was a very difficult moment and, to be honest, some of us could not remain in the room. Some of us were thinking the thought that inevitably occurs in the developing world, “If only the child were in the US . . .” But we weren’t at home, and decisions are different here.

Anita Hunter picked up the baby to hand it to its mother. With the touch and movement, the baby aroused again. When the doctor arrived, he prescribed hydrocortisone to reduce inflammation and swelling, and thus help the child breathe. Kathy showed the nurses a technique used at her hospital, adapting a nasogastric tube with a syringe from her backpack to perform deep suction and clear the child’s lungs at a lower point than can be achieved by shallow bulb suction. The child again revived again but was still cyanotic.

We discussed the situation with Dr. Emmanuel, Ibanda’s medical director. Our question was, when the power went out and oxygen was no longer available for the child, could the hospital’s diesel-powered back-up generator have been turned on? His answer was no; it is the hospital’s policy not to turn on its generator for a single patient, no matter how ill. It cannot afford to. We left with heavy hearts and, to be honest, a significant amount of conflict among us as to what would have been the right course to follow. We don’t know the child’s fate.

What happened at Ibanda raises some tough choices for the Holy Innocents project. First, the child’s condition -- extremely fragile to begin with -- was made worse because the hospital cannot afford to be adequately staffed. Had a nurse been assigned solely to the premature unit, the baby’s deterioration would have been discovered sooner. What will be possible at Holy Innocents?

Second, the premature unit had only the most basic equipment, an oxygen concentrator to give supplemental oxygen to a single baby, and a suction machine operated by foot pedal. There was no heart monitoring equipment or any resuscitation gear other than an ambu-bag (like TV doctors use when the order is “bag ‘em”). Will Holy Innocents be able to go further? Is it appropriate to go further? These are decisions for the Mbarara community and its supporters to make.

Your comments are welcome.