March 19, 2013 - "This is Africa"

For the past week, I have been working in the Special Care Unit (SCU) at Mulago Hospital. The SCU is Mulago Hospital's version of a nursery/NICU (neonatal intensive care unit). Basically, all of the babies who had problems at birth, or shortly thereafter, are brought to the SCU for care.

The SCU is divided in to two rooms: one room for the premature infants (<36-37 weeks) and one room is for the term infants. Each room is probably about 12 feet by 12 feet and contains anywhere from 20-30 babies. The first day I was there, we had 61 babies divided among the two rooms. It was crazy. Literally, there are babies everywhere. There are babies lined up in cribs right next to each other, smushed against the wall. There are babies lined up along examination beds (and yes, I guess we just hope that they don't move and fall off...), and there are oftentimes more than one infant in each incubator (these are small "houses" made for just one infant). There are even babies in wooden boxes (take a look at the following pictures). Sometimes the infants are so covered in blankets that you don't even know that they are there until they start to move or someone moves the blankets...

To care for all of these infants, there are two full-time nurses (staffed 24 hours a day), and various residents and physicians who are sometimes there and sometimes not. How do two nurses care for so many infants? The simple answer? They can't. Infants will often be horribly ill and no one will know until the nurse happens to look at the child or the mother comes in to feed the infant (every two hours) and find that they are not doing well.

The experience has been very sad and a bit frustrating. There are only very limited resources for these sick infants. Most of the premature infants need extra support, which we are unable to offer. We have cPAP (extra pressurized oxygen to help the babies breathe), a small selection of antibiotics, and a caffeine-like medication (aminophylline) that we can give to premature infants who haven't yet developed their drive to breathe.

Many of the term infants are admitted for asphyxia, or lack of oxygen to the infant during delivery. The cause of this isn't always known, but the outcome is usually neurologic devastation, with infants suffering from severe delays (if they even survive). We can only provide them oxygen, antibiotics, and pray. If babies' temperatures are low (as the incubators are all broken and none of them produce heat), there is a single heat box, under which are usually 6-8 infants.

We do have these special "sleeping bags" in which we wrap infants with a warm water bottle to help them maintain their temperatures; however, the water is supposed to be changed every 4-6 hours and infants are lucky if it is changed once per day...

If the infant has jaundice, there is a single blue light that we can use. Other than that, there is not much that we can do.

If an infant is seizing, we don't have any medications available in the hospital for this. So the parents have to go to the pharmacy, purchase the phenobarbital, bring it back, and then give it to the infant (if they can even afford to purchase it in the first place). The infant may be seizing the entire time that they are gone (resulting in severe neurologic problems in the future if they survive), but there is nothing we can do except provide glucose, hoping that maybe the seizure is from low glucose levels (though usually it is from their underlying asphyxia). If an infant needs an echocardiogram, chest x-ray, or even basic laboratory testing, the parents have to pay for it up front, out of pocket. If they can't afford it, the infant doesn't get it. (The same is true in all areas of the hospital, not just the nursery. Such is the case for almost all developing countries).

Whereas in the United States we have so many options for these infants, here we provide the small amount of support we can. And the rest we leave in God's hands. It's really tough. On average, 2-3 infants die in the SCU on a daily basis. They report statistics that, on average, 70% of SCU infants leave with their parents (meaning the other 30% don't make it out alive). I'm not trying to sound morbid or as if I am passing judgement, because I am not. This is simply a resource-limited location. As many Ugandans say, "This is Africa." It makes me feel so very lucky to live and work in a location where we have so many resources for our sick patients.