Daily accomplishments

We went to one of the villages to get heights/weights and screen for malnutrition or other reasons children should see a doctor. We did see some severely malnourished children. One child that is 1 1/2 years old cannot hold her head up or sit on her own yet. We referred these children. I enjoy going out into the villages to assess the children, so I'm glad we got to go. Here at the hospital, I in-serviced on feeding babies, and on the emergency carts we put together and the documentation form we are rolling out. We also made a bulletin board. We just cross out fingers that any of this will have an impact. It's scary to get sick here! Then, we took a ride in the ambulance. That's when we got the low down on the baby. We spent about an hour with them. We didn't get any calls. So, they just took us to several food stands, and didn't seem to understand, "no thank you". So, we tried something they called mango ice cream, but was not ice cream at all. It did have ice in it though. We had some mango juice, and bananas and tried a guava and some other fruit.

Regular Day

We did a few other things between all that! We went to Jeetu's farm and picked mangoes yesterday. Then, in the afternoon, we went to Baroda shopping. We got medical supplies, and also went to the mall for some India attire. We wanted to go to a grocery store to buy some supplies, such as water, stuff for breakfast, toilet paper and chocolate. But, we couldn't figure out how to describe grocery store to our driver. He took us to a fruit stand, then a little shack that sold this and that.  A bakery. We couldn't figure out how to communicate what kind of store we were looking for. So, we just had to get a few random supplies where we could. So much for the chocolate and toilet paper!

Tragedy

There was a birth 2 nights ago. It did not go well. The nurses deliver the babies. The mother was pushing for a long time. After 15 minutes, it is the protocol to call the OB. It probably took him 15 minutes to get there. The nurse said she wasn't properly dilated. I think the babies head was facing the wrong way, and the cervix was probably mis-shaped. The did an episiotomy (they always do). They cut it bigger, but no progress. Dr Mikwana came, the mother was tiring but kept pushing. The baby was finally born after probably 50 minutes of pushing. There was a lot of blood and the baby aspirated and didn't start breathing. They have been taught neonatal resuscitation, so I was auditing to see how they did. The problem was, the equipment wasn't checked ahead of time. I had made sure there was a bag and mask there. But, the oxygen tank didn't work. So, we did what we could. The doctor asked me to prepare a room in the ICU. I ran there, but the oxygen did not work there either. We had to get oxygen from the ED. This all took 1/2 hour. So, 1/2 with suboptimal oxygenation to the brain. And, once the baby got oxygen, we still was really struggling to breath! I was so worried. I stayed with the patient until 1am. And, the nurse in ICU was brand new. Not ideal. I knew the baby had suffered from anoxia, but I was hoping it would be minimal.

 

That doesn't seem to be the case. Yesterday, he started having seizures. Today, I was in the room working on the emergency cart we are putting together. The alarm went off. The baby wasn't breathing. I stimulated the baby, but the baby would not start breathing. I called to the other nurse and asked her to get the bag and mask ready. I called to someone else and asked them to call the doctor. The baby did not breath for 1 full minute. He was very grey. He was breathing when the doctor came, but then stopped again. The doctor had to resuscitate. We ended up sending the baby to Baroda. This is beyond what we can take care of here. It's very sad! :(

 

We heard later that night that the patient passed away at 11pm. It's a tragedy! The hardest part is, knowing this patient would probably have had a better outcome if we had equipment that worked!

Marriage

India is running into a huge problem. Male children are preferred. Because of this, since ultrasound was introduced, abortion of female children is common. Also, families are more likely to seek medical care for a male child than a female. With these two factors, Males outnumber females with a 100 to 70 ratio. The Patel community is struggling with this, because there are not enough women within their community for the men to marry. The leaders had a meeting and made some decisions. They are willing to pay other high caste communities to marry their sons. They are absolutely not willing to allow their sons to marry from a lower caste. And, if their daughters want to marry someone from a lower caste, "honor killings" within families are common. The Patel community held a matchmaking meeting this last week to help with this problem. 400 eligible Patel men were invited. 100 Patel women were invited. The men introduced themselves and told of their qualifications. The women were able to select someone that they would want to marry. Every women was able to find a match. Now, the parents have to get together to discuss this match. There will be another such matchmaking meeting on October 12th. I've been invited to participate. It's no problem that I'm a foreigner! :) Can't wait!

Hindu Culture

Culture. I love it! It is one of my favorite things about traveling! We are coming upon a brick wall in India, because of the Hindu culture. They believe in Gods. Many of them. And fate. Everything is supposed to happen the way it happens. You don't question that. You just accept it. That makes health care a challenge. If you are sick, you are supposed to be sick. If you get better, the Gods wanted you to get better. If you die, that is the way it is supposed to be. You should not try to change these things and mess with fate. So, providing medicine, are medical care or even coming to the hospital, sometimes can mess with fate. You are playing God. That is why they don't feel it necessary to assess and intervene if something is wrong. They have ordered 17cc's per feeding for our Low Birth weight baby. That is less than what is recommended. The baby got 10 cc's today for 3 feedings in a row. I asked the nurse why. She said the baby was asleep. I tried to feed the baby, and she took 22. This nurse did not seem fazed at all when I told her the baby must have more! I'll check back, but am not hopeful. And, they wonder why the baby is not gaining weight! :(

Nurse Education

My purpose here is to Educate the nurses on taking care of Pediatric Patients. But, I have learned my job is much bigger than that. These nurses have gone to nursing school, but the practice here is much different. They have been giving meds and delivering babies. I can't deliver a baby, but I do a whole lot more than give meds to my cute pediatric patients. So, I am teaching vital signs and assessment. Seems so elementary for a nurse, but that is what they need. And, of course, hand hygiene! I have been given a list of educational needs by the Pediatrician. My goal is to get through all of them. That includes: Hand Hygiene, Newborn care, IV, Feeds and temperature. I am adding vital signs to that. I have introduced vital signs in October, taught them in Jan, but found that they weren't being done when I arrived this time. I audited the first week, educated again yesterday, and showed up before doctor rounds this morning to walk around and do vital signs with them. I will continue doing this week. And, have asked the medical students to audit after I leave, to see if they are still being done. I have a nurse coming in July, so I will have her re-evaluate and re-educate. That's the name of the game around here. Re-education about vital signs! The UofU asked me to stay for a year, to tackle some of these problems. I said I would like to, but I also enjoy a stable job at home. And a clean bathroom is a plus! (As a side-note: I asked a sweeper to clean my bathroom. They cleaned my entire room, threw away the trash, and didn't touch the bathroom! I really think bathrooms are considered filthy here, so they are not cleaned. I have never had a clean bathroom here. Makes going into one less desirable. That, and the fact that there is no AC in there.)

Mount Abu

We took the weekend off to go to a cooler climate. We went to Mount Abu. The temperature was still 100 degrees, but it was not as humid. So, it was nice! We took a trek into the mountains, and so where the nomads live. Every day, the Nomads hike their goods out to market. They balance them on their heads. Then, every night, they hike back to their homes in the mountains. The hike was pretty strenuous! They are nomads, because during Monsoon, they have to move to higher ground. We also saw the caves they live in during monsoon season. These people mainly raise grain and milk cows. They also pick berries and fruit. There are many edible berries and fruit in the mountains. We had blueberries, mango's and limes that grow wild. It was a fascinating journey

Visit to the Villages

Today, we visited a small nearby village. Our goal in visiting this village was to see some of the low birthweight infants that have been born at our hospital over the last 2 years. Low birthweight is any infant that weighs less than 5 lbs at birth. There were 4 children from this village. We were only able to find 1 of them. But, when people found out we were there, many wanted their children to be seen. We saw about 15 children and the same number of infants. We set up clinic outside under a tree. We did measurements and vital signs. We assessed for malnutrition. Most looked healthy. There were a handful that were malnourished, but none severely malnourished. We did refer several to the hospital for respiratory problems, diarrhea, malnutrition, and a child that had yellow eyes and a fever. Since it was 113 degrees outside, I thought for sure we would find more fevers! Loved the village visit. Planning to do an another one next week!

Day 1 accomplishments

Held two in-services on using the Open Warmer in the ICU. Had great attendance. Hands on and Return Demonstration.

 

Held 2 in-services on hand-washing. Had great attendance. Demonstration and Return Demonstration. There are no sinks in the old part of the hospital. I spoke to the hospital administrator about putting hand sanitizer in each room. He said the nurses can just bring it with them. Will have to audit.

 

Made 2 bulletin boards on hand washing.

 

Set up an emergency cart for the ICU.

 

 

The Caste System

In India, there are 4 Caste's. The highest Caste (Brahma) are the elite Caste - wealthy and well educated. The lowest Caste is know as the "Untouchables". The Untouchables are very poor, not usually educated, and considered "dirty". They are the ones that live in the blue tarp slums you see on TV. The government as made an effort to equalize the huge societal divide. They have mandated that a certain number of "untouchables" be accepted to colleges and in to programs that, in the past, only Brahma's have been accepted in to.

Our new OBGYN is an  "untouchable". He looked and looked for a job in the City where he was from, but no one would hire an untouchable. I applaud our hospital for being willing to help these people be successful! The problem is, people don't trust untouchables and don't want them to be their doctor.

How do you break this cycle that India has created?

Conflict of Interest

We have a newborn baby (actually, lots!). But, when we rounded on one of them yesterday afternoon, the mother complained that the baby was not eating well, and had not had wet diapers. The nurse said the baby had a fever. I asked what the temp was, and of course, she hadn't taken  it. Tactile fever! :) So, we took the temperature, and it was 102.4. I asked her to notify the doctor and he said to give Tylenol. I rounded again last night, and the temperature was 103.2. I told the nurse to call the doctor. This time, the doctor said to give the baby a cold bath. That's all fine and dandy, but it does nothing about why the baby has a fever. Being from the western world, I was very concerned and felt the baby should be treated for an infection. That can be serious in a newborn. This morning, I explained it to our doc when he arrived. He agreed with me. We weighed the baby and the baby has lost weight. Normal within the first few days of life But not when you only weigh 4 lbs to begin with, you're not eating, have no urine output, are irritable and still have a fever of 101. Unfortunately, not our hospital. Dr. Jha feels like the baby has a fever because it's 115 outside. Healthy infants can still maintain their temp. I don't like it, but the baby was sent home. One more down.

Being a Tourist

I have been to India 3 times in the last 7 months, and have only seen the Hospital. I decided, on this trip, I should venture beyond the borders of Mota Fofalia, and see what other people come here to see, The Taj Mahal!

The Taj Mahal is the resting place of the 3rd wife of Shah Jahan and is known as a "temple of love" because of that. Shah Jahan was married to 2 other women, but the 3rd wife is the only one that provided him with children. I feel sort of bad for the first 2 wives, that are buried outside the walls of the Taj Mahal. Plus, Shah Jahan's son imprisoned him.

Regardless of those facts, the Taj Mahal is incredible! It is one of the most beautiful buildings in the world  and truly a world wonder! Even seeing it in person, it looks absolutely unreal!

On this journey, we also saw the Agra Fort (where Shah Jahan was imprisoned by his son for spending too much money), the monkey temple, The City Palace in Jaipur, the Wind Palace and took elephants to the Amber Palace. All incredible sites.

I also had one other interesting experience in Jaipur. I got a full body massage. And when I say full body, I mean full body! No part of you is untouched! The human body is sure seen differently in different parts of the world! :)

Attract a crowd

I went on a walk through town today. I've done this many times. I enjoy it. And, usually, it is uneventful! A group of men called me to them. I went, wondering if they were going to tell me I didn't belong there. They wanted to speak to me, but in Gujarati. When they found out I speak English, they just smiled and looked at me. And, the crowd got bigger. And bigger. Finally, I asked if I could walk into the neighborhood. They said yes. But, I took a following. A group of kids followed me all through town. I turned around to take a picture, and they scattered. But, pretty soon, they gathered again. After finding out my name, they said "Zulie, photo." and pointed to something. I got all sorts of random pictures of people and things. But, the most fascinating thing was the crowd that followed me! What a site! I felt like a movie star! :)

Funny thing

Our NICU had been opened and is running well, with 1 glitch....  I typically come up to check on the nurses and patients before going to bed. Last night, when I came up, I found the NICU was locked. No nurse was inside. The mother was also coming to feed her baby. I went to find the nurse. When I found her, she could not get into the NICU either. They installed a new security system today that requires a fingerprint. Great idea, but they did not enroll any of the nurses. Not a great idea! So, the baby was locked inside the NICU and all the people that could take care of him were locked out. I went to find the people who run the hospital in their house, and the problem was solved! Luckily! No harm done!

Two Problems

There are two problems we are running into starting a hospital in a rural province in India. First, people cannot afford to pay. We accept and want to treat all patients! There is a nominal fee for cares ($1.50 for a delivery). But, most  people cannot afford to pay that. So, we accept and treat them anyway. It is difficult to figure out where the money will come from to treat these people, but we will find a way.

The other problem is, in other areas of India, people are still very poor. But, they know when to take their child to the doctor. In this area, they don't. They don't bring them until they are very sick. Sometimes, it is too late. I asked the doctor if he thinks they are not recognizing that there is a problem. He said, "no." He thinks they don't bring them until they start interrupting the daily life of the family. This is a farming area. Many families work in the fields 7 days a week. That's the way they earn money to support their family. Any interruption to that can result in them not having money to feed themselves and their family. So, they are hesitant to take the time to accept that someone is sick enough to get care. The quandary is, how do you change that? I, of course, think the answer is education. Which this family is trying to do. They run a school as well as a hospital. But, some poor families don't take the time for that!

Traditional Meal

Last night, I enjoyed a traditional Indian meal. A friend of the Patel's wanted me to have that experience. We sat on mats on the floor. Like every other Indian meal, we ate with no utensils, using only the right hand. The Roti that was served with this meal was very thick. So, it was hard for me to tear with one hand. I have not mastered that art yet. And, it was hard to pick food up with it. So, I ended up scooping. The food in India is spicy compared to what I am used to. I have been able to tolerate it just fine, but there was something served with this meal that made my eyes water. They were all very worried about me, but I survived! They serve a sweet thing with the meal that tastes like brown sugar. They also had homemade butter and milk. I have noticed they don't serve water until the end. Then, they use the leftover water to rinse off their hands onto their plate/bowl. I always enjoy new experiences!

NICU opening

We opened the NICU yesterday. We admitted a patient in Cardiac Failure. The patient came to the Emergency Department with trouble breathing and poor feeding, and was found to have a loud murmur. The patient had been to a couple doctors, but the mother was told the patient had a cold. I was here for the opening of the Pediatric Hospital in October, but there were problems with the NICU area. so, they were unable to use the beds until now. Exciting that I was here for the opening of the hospital, and for the first patients using the beds! I had to read the manuals to find out how to use the equipment, because no-one knew. I taught the nurses how to use them today! Unfortunately, the baby had to be sent to a bigger hospital for an echocardiogram and heart surgery today!

Dinner

We went "out" to eat the other night. When they said, "out" I had no idea where we would end up. Mota Fofalia is very remote. There is nothing that looks like a restaurant in town. We drove for about 20 minutes past the village. I thought we would come to another village, but we didn't. Instead, we pulled off the side of the road by a farm. There was a green tarp that had some lawn chairs underneath. People were harvesting a grain. Then, they served it to you for dinner. It was pretty good. And, like most meals in India, an interesting experience. We ate at the nursing school yesterday. The staff there were anxious about serving me India food. Meghna said, "Don't worry! She's used to it!"

Female culture

We interviewed a perspective new nurse. The "nurse" didn't have any training in healthcare, and wanted twice as much as this hospital is willing to pay. So, they didn't hire her. What I thought interesting is, first, that this girl had not been to nursing school. Second, that a man came with her. I asked Meghna about it. She said it was her husband. She said this is typical in India, because it is still very male dominant. She said if the girl is not married, her father or brother will come with her.

That lead to further discussion of the male dominated society. The things you read are true. Women are getting more education now days. And, they are working outside the home more. But, it is still at the discretion of her family, and husband after she gets married. A very educated women may not be allowed to continue her education or to work once she is married. And, men are still educated more often than women. In India, there is 85 women to every 100 men. There are more men than women. Because boy children are preferred, and ultrasound has been introduced, women will illegally abort a child if it is a female. Also, male children are more likely to get healthcare if they are sick. I think these things are progressing, but they are still happening today. For some reason, the society hasn't realized that if they only have male children, pretty soon, the population  will die. Because, without females, you can't have males. It doesn't make a lot of sense. The good news is, if you are a girl that survives to adulthood, you are more likely to get married than you are in Utah or the US! My problem would be solved! :)

In the hospitals, all nurses are female. They don't do any procedures or assess patients. They are taught assessment, and recognizing certain conditions in nursing school, but really the doctor takes over that responsibility in practice. One good thing is, there are more and more female doctors. In Medical School, there are 4 females to every 6 males. That may not seem even, but in this society, it's pretty remarkable. In my visits, I talked with some female doctors that practice the same as the males.

Museums

Because we were in the city for a wedding, we decided to stay. So, I got to be a tourist for a day. The price for a tourist to get into the museum is 10x that of a resident. I didn't think that was a very good deal. The museum was a typical museum. Nice, with interesting artifacts about history. I ended up being the biggest attraction for many attending. I didn't see any other caucasion people there. Groups of young people kept milling around. Occasionally getting up the nerve to say, "hi" or "hello," and then giggling. Finally, a girl mustered up the courage to ask for a picture. When I said yes, the flood gates opened. I ended up being in people's picture's more than the artifacts at the museum. The girls I was with got a kick out of it. So did I!

Traditional Wedding

I attended a Traditional India Wedding. In India, weddings are still arranged in most cases. There is a lot of tradition that surrounds the engagement and wedding day. This includes the bride's family offering gifts to the groom's family. And, then, a cleansing ceremony that takes place at the Bride's house 2 days before the wedding. The bride cannot see the groom for those 2 days. The bride is then taken to the grooms house is a special carriage just for that occasion. I did not get to participate in that part. I just went to the celebration. We ate Indian food. Then, we were given roses. I'm not sure what you're supposed to do with the roses, but the girls I was with ate theirs. So, that's what I did. It turns out, roses smell better than they taste!

Hospital Work

This is an exercise in patience! I am still struggling with getting the low birth weight baby fed. I've been working with the nurses on that. Today, I scheduled a meeting with all of the nurses to talk about the importance of feeding. It's sometimes difficult to understand! :)

Other things are progressing a little bit. I met with Meghna today to talk about my goals my stay. One of them is educating the nurses. I'm also going to meet with the community Health Care Workers. I'll hopefully go to a Nursing School and government hospital as well. Today, I met with the supply room to find out what supplies they have and what they need. I also followed up with a few malnourished children. 1 is the baby from last time. He has a name. It's Vicar. Often times, people in India don't name their babies until they are 1, because the survival rate is not good. Despite it's advancements, India still has one of the highest infant mortality rates in the world. But, Vicar is doing well. I told some of you that when one of our doctor's followed up with Vicar in November, at 1 month of age, he was almost dead. She brought him back to the hospital, where he stayed for a month. Then, he was sent home with formula. He is now up to about 5 pounds, which is double his birthweight. That's good. They are following him, so it's looking more promising.

Mota Fofalia village

I went into the village this afternoon. I ran across a marriage party! Everyone was so excited to see me! They invited me to come in and eat. I politely declined! But, they insisted I at least take pictures!

Then, I found a little neighborhood. People were on their roofs flying kites for the International Kite festival. I waved and got some little girls giggling. Then, put another little girl in a fit of tears. I must look so scary to some kids!

India in January

I am back in India. And, the saga continues. This is an exercise in patience! We have another low birth weight patient. This time, the mother can stay. The doctor ordered the baby to eat 5 cc's every 2 hours. I checked on the baby in the morning, and the baby had taken 3 cc's, and skipped one of the feedings. I emphasized the importance of giving the baby all that the doctor has ordered. I came back later, and they had placed a feeding tube. I was so impressed! I thought they were learning! Then...the baby only took 3 cc's the next feeding. They didn't use the feeding tube. Sometimes, I don't understand! So, I tried to be very clear. I hope that they understand, and that the baby continues to get fed. It's really not right that a baby should be born healthy, although small, and then starve to death. That shouldn't happen!

Indian adventure

During my first visit to the Mota Fofalia hospital, I found that the nurses and facility were unprepared to provide care to Pediatric Patients. The structure is beautiful! But the nurses are untrained. I taught them how to do vital signs. That's right, they didn't do them! I taught them how to count a heart rate, a respiratory rate, and take a temperature. And, what these numbers mean.

We ran into some bumps. The most significant to me was a low birth weight baby that was born while I was there. This baby weighed less than 3 lbs. The mother started coughing up blood, so we knew she likely had TB. The hospital was not equipped to care for a mother with TB, so she could not stay there. We knew that if the baby did not stay, he would die. He was too weak to breast feed. This was against the culture. In India, family members are required to stay with the children to care for them. We talked them into going against the culture. I tried to teach the mother that she must keep hand expressing breast milk, or she would loose her supply. The grandfather insisted he take the baby and mother home, but we convinced him that wasn't a good idea. So, the baby stayed. The doctor ordered a minimum amount that the baby must eat. The baby wouldn't eat that amount, but the nurses didn't realize that was a problem. I reinforced time and time again that the baby must eat that amount!

That's not the end of the story. The doctor followed up a month after the baby left, and the baby was almost dead. Mom hadn't pumped and lost her milk supply. They couldn't afford formula. It's really sad that a baby born healthy could die.

India Adventure

In October, I learned about a new charitable hospital that was being built in a small town called Mota Fofalia, India. The next week, I booked my airline ticket. The hospital was built by a family called the Patel's. Their father worked really hard, and saved enough money to send his kids to the US to study. All 3 boys stayed in the US. the father then built a small school in Mota Fofalia, so that other children could stay there and get an education. The father had a dream of a bigger school. He finally got permission from the government.Then, he had a stroke. He told his children, before he died, that they had to fulfill his dream. After he passed away, His oldest son took out a loan on his house to build the school. They were very poor. But, after the school was built, he believes God blessed him. He sold a business for 1.5 billion dollars. He then went on to buy and sell more businesses. He is now a multibillionaire. So, he didn't stop with the school. He built a hospital. Then, a children's hospital.
That's where I come in!