Sorry for the long delay in posting to the blog. We've gotten really busy with our research project in the past few weeks. So, now that you've gotten and introduction to Nairobi and Kisii, I thought it would be good to share a little bit about my experiences in the hospital here and about the project that Noela and I are working on...
On our first day at the KEMRI-UW office in Kisii, we were told that we needed to have Kisii names for when we went out into the local villages to meet with community health workers and traditional healers. Noela said that she had already been given a Kisii name by one of her friends from the area - "Kwamboka" - which means someone who has crossed over rough waters to arrive where they are today. But I was still name-less. Luckily, Peter, one of the office staff, came up with a name for me - "Moraa" - which means always happy & smiling.
Armed with our new names, we set out to see the hospital and brainstorm about our research project. We got a tour of the hospital wards and met some of the nursing staff. Kisii's hospital is a Level 5 facility, which means that it is supposed to be a referral hospital for the Kisii District and just one level below the national Level 6 referral hospitals - Kenyatta in Nairobi and Moi in Eldoret.
However, Kisii Level 5 has no pediatric ventilators or ventilators for newborns. It actually has no pediatric or neonatal ICU. There is only one certified pediatrician on staff, who is supposed to supervise the care of the entire pediatric ward and newborn unit. She works with several medical officers and clinical officers -- mid-level health care workers who have some general medical training but have not gone to medical school or completed a residency. These MOs & COs provide the majority of the care to the children who are admitted to Kisii Level 5, and actually to most patients admitted to government health facilities all over Kenya. There is a critical shortage of qualified medical providers in Kenya - both doctors and nurses.
On the day we arrived in Kisii, the pediatrician was away in Nairobi for a meeting. That meant that Noela and I were the most highly trained pediatricians at the hospital. The pediatrician had communicated with our mentor in Kisii - Jackie - that there was a newborn recently admitted who was very sick.
Baby E. was a 10 day old girl who had been born at home and whose mom had not gotten any prenatal care. Her mom brought her to the hospital because she had developed jaundice. Once she was admitted it was also clear that she had a serious infection (sepsis) and probably meningitis. But the jaundice was the most concerning issue because it was not responding to the phototherapy that been used for the past 3 days.
The next step to try to prevent the jaundice from leading to permanent brain damage was to do an exchange transfusion. For the non-medical folks that's a special type of blood transfusion where a baby's entire blood volume is removed and replaced with fresh donor blood. Replacing the baby's blood helps reduce the level of bilirubin, the chemical that causes brain damage in jaundice.
Obviously, it's not a procedure you do every day. It can be very dangerous and can even kill a baby. It has to be done under sterile conditions and you need to monitor the baby very closely and check lab tests frequently. I was pretty apprehensive about attempting to do this procedure because the newborn unit had no electronic monitors and I didn't think they could set up a truly sterile area for us to do the transfusion. The unit is chronically overcrowded and they usually have 2 or 3 babies in each crib, and up to 4 under each phototherapy light.
But it turned out I didn't have to worry because we didn't even get that far. First of all, the blood bank didn't have enough blood for the transfusion. And secondly, we were never even able to check the baby's bilirubin level to confirm if it was high enough to cause brain damage and thus worth the risk of doing the procedure. Why were we not able to do this basic lab test? Because the machine in the lab was broken and kept giving us the wrong results.
So in the end, we just continued to treat the baby with phototherapy and antibiotics. Her jaundice eventually improved, but over the next couple of weeks we watched her develop the signs of brain damage from her initial severe jaundice. She started to have episodes where she stopped breathing. And then one day, we came in morning and heard that she had passed away overnight. It was really heartbreaking to watch because it should have been prevented. If her mom had delivered at a hospital and gotten good prenatal care & health education, if she had brought the baby to a doctor just a couple of days sooner, if the hospital had a working laboratory and a functional blood bank, if the newborn unit had monitors and enough space and staff....if any of those things were true, Baby E. could have lived.
Baby E.'s story inspired us to focus on newborn babies for our research project. We decided to look at neonatal infections and how the outcomes differ between babies who are born at home and those who are born in a hospital. So far we have interviewed and surveyed health care workers, community health workers, traditional birth attendants, and mothers about their knowledge of neonatal infections and proper newborn care. We're also investigating the outcomes for newborns admitted to Kisii Level 5 with infections based on where the baby was delivered. Hopefully we'll end up with some useful results!
Ammu
On our first day at the KEMRI-UW office in Kisii, we were told that we needed to have Kisii names for when we went out into the local villages to meet with community health workers and traditional healers. Noela said that she had already been given a Kisii name by one of her friends from the area - "Kwamboka" - which means someone who has crossed over rough waters to arrive where they are today. But I was still name-less. Luckily, Peter, one of the office staff, came up with a name for me - "Moraa" - which means always happy & smiling.
Armed with our new names, we set out to see the hospital and brainstorm about our research project. We got a tour of the hospital wards and met some of the nursing staff. Kisii's hospital is a Level 5 facility, which means that it is supposed to be a referral hospital for the Kisii District and just one level below the national Level 6 referral hospitals - Kenyatta in Nairobi and Moi in Eldoret.
However, Kisii Level 5 has no pediatric ventilators or ventilators for newborns. It actually has no pediatric or neonatal ICU. There is only one certified pediatrician on staff, who is supposed to supervise the care of the entire pediatric ward and newborn unit. She works with several medical officers and clinical officers -- mid-level health care workers who have some general medical training but have not gone to medical school or completed a residency. These MOs & COs provide the majority of the care to the children who are admitted to Kisii Level 5, and actually to most patients admitted to government health facilities all over Kenya. There is a critical shortage of qualified medical providers in Kenya - both doctors and nurses.
On the day we arrived in Kisii, the pediatrician was away in Nairobi for a meeting. That meant that Noela and I were the most highly trained pediatricians at the hospital. The pediatrician had communicated with our mentor in Kisii - Jackie - that there was a newborn recently admitted who was very sick.
Baby E. was a 10 day old girl who had been born at home and whose mom had not gotten any prenatal care. Her mom brought her to the hospital because she had developed jaundice. Once she was admitted it was also clear that she had a serious infection (sepsis) and probably meningitis. But the jaundice was the most concerning issue because it was not responding to the phototherapy that been used for the past 3 days.
The next step to try to prevent the jaundice from leading to permanent brain damage was to do an exchange transfusion. For the non-medical folks that's a special type of blood transfusion where a baby's entire blood volume is removed and replaced with fresh donor blood. Replacing the baby's blood helps reduce the level of bilirubin, the chemical that causes brain damage in jaundice.
Obviously, it's not a procedure you do every day. It can be very dangerous and can even kill a baby. It has to be done under sterile conditions and you need to monitor the baby very closely and check lab tests frequently. I was pretty apprehensive about attempting to do this procedure because the newborn unit had no electronic monitors and I didn't think they could set up a truly sterile area for us to do the transfusion. The unit is chronically overcrowded and they usually have 2 or 3 babies in each crib, and up to 4 under each phototherapy light.
But it turned out I didn't have to worry because we didn't even get that far. First of all, the blood bank didn't have enough blood for the transfusion. And secondly, we were never even able to check the baby's bilirubin level to confirm if it was high enough to cause brain damage and thus worth the risk of doing the procedure. Why were we not able to do this basic lab test? Because the machine in the lab was broken and kept giving us the wrong results.
So in the end, we just continued to treat the baby with phototherapy and antibiotics. Her jaundice eventually improved, but over the next couple of weeks we watched her develop the signs of brain damage from her initial severe jaundice. She started to have episodes where she stopped breathing. And then one day, we came in morning and heard that she had passed away overnight. It was really heartbreaking to watch because it should have been prevented. If her mom had delivered at a hospital and gotten good prenatal care & health education, if she had brought the baby to a doctor just a couple of days sooner, if the hospital had a working laboratory and a functional blood bank, if the newborn unit had monitors and enough space and staff....if any of those things were true, Baby E. could have lived.
Baby E.'s story inspired us to focus on newborn babies for our research project. We decided to look at neonatal infections and how the outcomes differ between babies who are born at home and those who are born in a hospital. So far we have interviewed and surveyed health care workers, community health workers, traditional birth attendants, and mothers about their knowledge of neonatal infections and proper newborn care. We're also investigating the outcomes for newborns admitted to Kisii Level 5 with infections based on where the baby was delivered. Hopefully we'll end up with some useful results!
Ammu
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