Another Week In Liberia........

Another Week in Liberia - June 2d

A warm greeting to family and friends, from warm and rainy Liberia. Rainy season has arrived - it has gotten cooler which is welcome. After a good rain - lots of big, brown puddles to skirt on my walks to the hospital, JFK Memorial.
Did I mention - they gave me a "Visiting Doctor Office" here? It has an air conditioner that did not work for the first 3 weeks; now it works and it is awesome! I have a view of the Atlantic Ocean - just 3 blocks away. If i open the window I can hear the sound of the surf arriving on the beach. My view looks over some coconut palms, and over the corrugated metal roofs of the local dwellings in the neighborhood. Anyway - this may be the best office I ever have so I will enjoy it. Also has desk, chair, sink and water that runs most of the time, but spews occasional gobs of green algae-goo.

This Saturday we will have logged 5 weeks in Liberia. The young ones in this home tell me we have 76 days left in Africa. Hey - I'm not counting!

The Neonatal Intensive Care Unit (hereafter - the NICU) at JFK is housed in an acceptable building, recently renovated with a grant from the Japanese government - "Liberian Japanese Friendship Memorial Hospital." Slightly clumsy to say all of that - maybe I will just call it the Friendship Hospital?

I say acceptable because it has power most of the time, running water most of the time, but also contains nuisances. Such as a power cord that drapes across the lower doorway of the main entryway to the NICU (i have asked multiple times for it to be revised). No paper towels except one roll, on one occasion that lasted about 24 hrs. Have not seen another since. The alternative I "inspired" the Nursing/Admin leaders to provide is a cotton towel from Laundry Services that someone from NICU has to pick up, then trade for another when soiled or soaked. Guess I now need to go make friends with the laundry staff! To all my Tacoma NICU friends and associates who help themselves to 3,4,5,6, or more paper towels after a handwashing - I AM WATCHING YOU!

It appears that the way the supply chain works is this: a unit such as this NICU gets an allotment of alcohol swabs; once they are used - they are gone. Thus the lack of absolute basics; hoarding that happens, and no sharing. Disposable gloves - found a box in the closet that holds all the various donated supplies that visiting care providers donate with their trips. It's mine for now - but I mete them out to my cohorts in the NICU when really needed. Alcohol based hand gel for cleaning between patients: spotty supply from the hospital, but better supply if we just buy our own and share it. I have asked for supplies of hand-gel every day from the Nurse in charge - i have seen them arrive once.

Tape is referred to as "plaster". Medications are "served" as opposed to given or administered. Starting an IV = "open an IV". I opened my first peripheral IV in some time today - only one RN of the two assigned RNs made it to work, as the other was sick. So I pitched in a bit more than usual and opened the IV.

Yes - 2 RNs typically, though occasionally 3 will staff this unit which may have 8-12 babies in incubators, on warmers, or in cribs. Plus more on our service who may be rooming with Moms. Today I heard a knock on the side door of the NICU - opened it to find a clinic nurse with 2 parents and a 4 day old baby in tow wanting admission to the NICU. Here I should orient you to the way things are being done here: "newborns" up to even 2 weeks are being readmitted to the NICU if they have a fever, jaundice, are sick in any way. I am opposed to it and have voiced the usual concerns about infecting the babies already born at JFK, but various factors lead to the prior decision to still do this. The newborns come from home/home births (not like we think of home-births; no way to get to the hospital, no way to pay for the hospital, so just deliver at home); clinics where mothers lay-in and deliver; via the Peds Clinic and the Emergency room. Often there is no phone call - they just show up. So now in this instance, Husa was my only nurse. Knowing she was already swamped - I explained to this clinic nurse, the parents, the baby that I would have to divert them back over to the Pediatric Ward at JFK (right next door) as we could not admit him due to staffing limitations. And I explained it a 2d time, and then a 3rd time. I reassured the parents that the ward nurses would take good care of the baby, and called James, the Physician Assistant who sent the baby, to tell him of my rationale (he and I get along well - he is a caring provider, who does good work).

After hearing this, Husa said to me "Dr John - we want you to stay here forever." To which I said - " I will stay if I can have Liberia buy me a mansion on the beach with a pool so we can have NICU pool parties twice a year" She laughed heartily at this!!

Last Friday I performed a procedure that I have not done in several years: a double volume exchange transfusion for a newborn boy whose bilirubin was 39! For my non-medical friends, this is about twice the usual level (20) that strikes fear into the skulls of Pediatricians. So I am now twice as scared, and in a foreign land! But we rallied and came up with a good bag of blood (the father donated his O+ blood to his O+ son), the devices needed to do the infusion (it is done by taking small amounts of donated blood, giving to the baby and taking back now-mixed blood in small amounts, doing this over and over and over…….). I get good venous access, then I conscripted good wife Kim, a former NICU nurse to record for me and watch me in case I was about to commit any fouls! While I am sweating through this (literally and figuratively as the A/C is puttering along), Kim is recording - another baby unexpectedly starts to have seizures, and three more new admissions sneak into the NICU behind my back in the manner described above!
When i finally tucked in all of these characters, finished the exchange of blood, walked home at dusk - I was Pooped! Emotionally, and Physically!

And I have only scratched the surface! Really! I promise to tell more in another installment. Lastly, I must tell you all, as I have told Kim, my children as well as others of you already, death lurks around the families and newborns of Liberia much too much. I have seen many more newborn deaths in 4 weeks of practice here, than I would see in 8-10 months or possibly more back in our Tacoma practice. Some deaths were because of irreversible factors - too late, too ill, no critical care resources. Some deaths seemed like the efforts we put in should have worked, but did not. Birth asphyxia is common as is infection in these little ones. The Liberian people are stoic about the deaths of their newborns - some weep, but certainly not all. I encouraged a mother to hold her baby as life waned, she declined. The intern and nurse in this case tried to tell me that African people do not engage in a lot of drama or emotional energy when babies die or are dying. I am getting the sense infant deaths are common enough that many families are affected by it and inured to it. I have spoken with mothers who have lost 2 babies in their child-bearing years. The medical and nursing leadership I have met are keenly aware of the excess of neonatal deaths and want to reduce it. It will be a gargantuan effort from my point of focus. Kim and I hope to do a bit to improve it by rendering care when we can, teach good care at every opportunity, and promoting Newborn Resuscitation skills anywhere we can get in the door.

We miss you all and we think of so many of you often. Blessings to each of you from our home and family!

John