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Therapeutic Cooling in Area of Limited Resources

neonatal-cooling

(pic: http://www.ucl.ac.uk/impact/case-study-repository/neonatal-cooling)

Sometimes, you get amazed at how new technologies are developed to address the prime needs of newborn infants in their compromised states. One such technology developed was hypothermic treatment of infants who were born hypoxic or asphyxiated. It is unfortunate however that such technology is not available in all birth institutions, hence the need to innovate in order to cope up and be at par as far as clinical outcomes are concerned.

A year ago, I attended a workshop on how to provide a whole body hypothermia for babies who are hypoxic-ischemic upon birth. It was so simplified that all you need is just a radiant warmer with a rectal probe, and ice packs. An algorithm was provided on how to bring the baby into therapeutic hypothermia and how to monitor his temperature.

Unfortunately, in my place of practice, the specified ice packs as well as rectal probe (which should be included in the radiant warmer purchased by the hospital) are not available.

One night, I was called to co-manage a baby who was born via emergency Cesarean section to a mother who had eclampsia. The baby came out without heart tones and resuscitation was performed accordingly. However, just few minutes after heart beat was restored, baby had seizures at the operating room. He then qualified to be treated with whole body hypothermia, based on the criteria provided.

radiant warmer

(Ohmeda Infant Radiant Warmer System)

The baby was immediately transferred to the NICU for intensive care. He was placed on the radiant warmer, naked, except for diaper. Temperature was then brought down and tried to be maintained within the recommended range. One ice pack was placed on the back, and another one was placed on his chest. The ice packs were placed or removed accordingly depending on the temperature of the baby.

ice packs.jpg

As we do not have a rectal probe that should be put inside the rectum until the intervention is over, we had to keep monitoring the rectal temperature every 5-15 minutes. After loading dose of anti-convulsant, the seizures did not recur anymore.

After 72 hours, the temperature was slowly increased until normal body temperature. Unfortunately, the mother died after the procedure that the baby was unable to have skin-to-skin-contact with the mother at all.

Baby was discharged after a week from the hospital.

Are you as excited to know progress of the baby’s development?

At 4 months after birth, the baby was referred to a Developmental Pediatrician. As per the doctor’s evaluation, the baby’s developmental milestones are at par with chronologic age. The infant, despite the absence of  bonding with the mother, was also able to show normal affect, thanks to relatives who took turn in taking care of the baby.

This is a testament that babies can be saved, the potentials may still be brought to optimum, with diligence and resourcefulness.

(This blog is dedicated to the Pediatric Residents and NICU Nurses of SLU-HSH who took turn in taking care of this infant.)

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Save Our Trees

What does it make a government agency, tasked to safeguard nature and environment, that endorses killing of trees to allow construction of a cottage for a government official?

On February 24, 2011, PNoy signed EO No 26, which is known as National Greening Program (NGP). This is a massive forest rehabilitation program that aimed to grow 1.5B trees in 1.5M hectares nationwide within a period of 6 years from 2011 to 2016. The NGP is also seen as a climate change mitigation strategy to enhance country’s forest stock and to absorb carbon dioxide, largely blamed for global warming.

Areas eligible for rehabilitation under the program include all lands of the public domain, including forestlands, mangrove and protected areas, ancestral domains, civil and military reservation, urban greening areas, inactive and abandoned mine sites and other suitable lands.

As such, all government employees are required to plant at least 10 trees a year, with the DENR as the lead agency, serving to document, monitor and audit the implementation of the NGP. The Philippine Information Agency has registered the area fronting the Mansion House as their NGP project.

Last May 22, 2017, the Office of the President wrote a letter to the Director General Harold Clavite of the Phil Information Agency (PIA), if the PIA-CAR could vacate the Mansion House Guest Houses Complex, fronting the Baguio Mansion House it presently occupies. This will allow renovation/improvement and refurbishment and consequently convert it to and be used as the cottage of the Executive Secretary “for easy access to the Baguio Mansion House. It will be used as venue for meetings, fora and other official functions.” (Emphasis mine).

Resibo.

Then on November 14, 2017, the DENR endorsed to Mayor Mauricio Domogan the cutting of 32 live planted trees located at the current PIA Compound. CENR Officer Rainier Balbuena is seeking Mayor’s clearance for the processing of the subject application. Resibo.

In 2013 and 2014, WHO studies of Baguio City’s air showed that we had the dirtiest air in the country. Resibo

Of course everyone was enraged and could not easily accept the outcome of that study.

In 2016, CEPMO Head Lacsamana debunked now the claim of the WHO study, stating that through the monitoring of DENR the air quality was good to fair, which means breathable. This was due to the fact that the CEPMO and DENR were never remiss and remained aggressive in the implementation of various programs geared towards improving the city’s quality of air, NGP included. Resibo.

So the question now is, is it more valuable for the government to prioritize a guest house which is NOT occupied on a daily basis over the trees, which are more valuable in cleaning the air of carbon dioxide, releasing oxygen for animals and humans to breath on a millisecond throughout the day, all year round?

A tree absorbs 48 pounds of carbon dioxide per year, and when it reaches 40 years, it would have absorbed a total of 1 ton.

It is in line with this that I have launched an online petition addressing the DENR and now the Office of the City Mayor to reconsider this plan without necessitating the murder of our trees.

i enjoin the citizens of Baguio as well as concerned individuals all around to please click the attached link and sign the petition. Your help will transcend through generations of Baguio residents.

https://www.change.org/p/department-of-environment-and-natural-resources-oppose-building-of-executive-secretary-cottage-that-will-entail-cutting-anew-of-trees?recruiter=17055174&utm_source=share_petition&utm_medium=copylink&utm_campaign=share_petition&utm_term=share_petition

 
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Posted by on December 11, 2017 in Uncategorized

 

prenatal care

(pic: http://www.camelliawomenshealth.com/Prenatal-Care)

The importance of prenatal visits can never be underemphasized. It is a must that all pregnant mothers, regardless of social and economic strata, should receive adequate prenatal care for a successful outcome of the pregnancy.

I was once called to attend to a baby who was born premature at 36 weeks via emergency cesarean section due to uncontrolled maternal hypertension. The baby was having uncontrolled seizure despite the fact that the baby was already seen by a neurologist and on anti-convulsant. I requested some laboratory tests and results revealed that he has low sodium levels (hyponatremia) at a level that can trigger seizures.

Going back to the mother’s prenatal course, she didnt know she was pregnant then because of irregular menstrual cycle. There was a certain period when she noticed that she was having bipedal edema (swelling of both lower extremities). She was self-medicating with furosemide, to no avail. She consulted a nephrologist who noted that she too was having elevated blood pressure. Unknown to both of them, she was pregnant and this was not at all investigated. The mother too was a bit plump and she never noted abdominal enlargement until few days prior to delivery when the abdomen was already large enough to disregard. Furosemide was continued. Abdominal ultrasound revealed a singleton pregnancy. Because of the uncontrolled blood pressure, baby had to be delivered thus.

The mother’s prolonged intake of furosemide, a loop diuretic, lead her to have electrolyte imbalance, particularly sodium. This was reflected to the baby who also had low sodium levels at a level that could trigger seizure. Had she known she was pregnant, and had she been receiving prenatal care, this could have not happened to her baby. The effect of the seizure to the baby’s brain is another story.

 
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Posted by on May 22, 2017 in neonates, Pregnancy

 

When Life Ends Unexpectedly…

Yesterday, 20th of March, was the birthday of one of my god children. A few years ago, that day was very tragic because while the grandfather was grilling some hotdogs for the celebrator, he suddenly collapsed. I was four floors down in my apartment unit, just arrived from work and just took off my shoes when I heard a soft voice, almost a whimper, calling me. “Doc… Doc… nagcollapse si papa” were the words that I heard. Immediately I ran upstairs and checked his pulses. I could not say he has no pulses. That would be the last thing every family members wants to hear. I told them we need to go to the hospital. Gladly, the son-in-law was around, and he drives well, really really well.

The relatives were saying we bring uncle to this secondary hospital but I argued and told them he cannot be cared for properly there as there is no ICU set-up there. Inside the vehicle, I tried my very best still to do chest compressions but I could not do it the proper way with the correct pressure because he was on my lap while I was compressing him; we were at the back seat. Still I tried and persevered. Traffic leading to the hospital was hell, but gladly, I was with the best race driver in Baguio. And thankfully, the vehicles cooperated with the emergency signal and honking he sounded.

We rushed to my alma mater and gladly upon reaching the emergency room, every personnel needed to do cardiopulmonary resuscitation was already there, there was no need to page for a resident. Vitals were 0. After few minutes of trying to revive him, defibrillation, his vitals were back but still comatose. He was transferred to the ICU. Later on, when the other family members arrived, I learned that he already had previous heart operations and heart attacks. Sadly, after few days, when he perhaps bid goodbye to everyone in the household, he left…

 
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Posted by on May 21, 2017 in Personal

 

Kangaroo Mother Care (A Skin-to-Skin-Contact)

Skin-to-skin-contact between a mother and a newborn has indeed offered several benefits especially on the part of the newborn, premature babies most specifically. 

It allows the normal bacterial found in the mother skin to “fly” into the nose/mouth of the baby that he in turn swallows, populating his immature intestinal network. The newborn’s intestinal epithelial cells are full of gaps that a foreign body (allergen, or even pathologic bacteria) can gain access to enter the baby’s circulation system, leading to earlier expression of allergy, or systemic  infection, respectively. But with the presence of the friendly maternal bacteria swallowed by the baby, the immune system found at the terminal ileum, (gut-associated lymphoid tissue, GALT; otherwise known as Peyer’s patch) is stimulated to release secretory IgA, sIgA, that will help coat the cellular gaps and now protect and guard these gaps from being accessed by allergen or pathologic bacteria. Allergy expression, especially among babies with family history of allergy, can be delayed; infection by patholgic bacteria can be nil to minimized.

This simple procedure also provides comfort, relief from pain on the part of the baby, faster transition from gavage feeding to full direct breastfeeding, faster weight gain, and better maternal-infant bonding. As exemplified in the photo above, the baby has 100% oxygen saturation while breathing room air. 

There is also greater proportion of infants who undergo skin-to-skin contact to prefer exclusive breastfeeding. A previous study has established that baby who were breastfed in their infancy were likely to have better employment in their adult life. I guess this stems from the fact that the skin-to-skin-contact promotes a good psychological bond between the mother and the infant. This then will eventually lead to the toddler developing a good sense of security and independence, great trait that enables to have better social relationships with peers, and thus work mates, and intimate relationships. 

(Pictures taken and posted with permission).

 
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Posted by on December 15, 2016 in Uncategorized

 

Giving Birth in the Cordillera Mountains

It has been two years since I started attending the Regional Neonatal and Maternal Death Review in our region, the Cordilleras. I had been invited to be a panelist and as such, it is my duty to critique why such happened, and what should have been the intervention, and what could have been the possible problem that really transpired for such a death. But this forum is not only me and my fellow panelists giving our “expert opinions.” Rather, I in particular had so much learnings and realizations that makes the scenario surrounding each death very painful to accept and embrace as a health care provider. These are some of the few things I came to realize…

GEOGRAPHY

One of the problems identified in our region is the geography. Because of the mountainous terrain of Cordilleras, one pregnant woman would need to hike 45 minutes, some 1 or 2 hours from their house just to reach the road or access a vehicle that will bring them to the nearest barangay health station (BHS), or rural health unit (RHU). Imagine a pregnant woman in labor, walking this distance in between contractions, you would expect a longer time to access the road. Likewise, because of this terrain, some areas are infested with the rebels (New People’s Army) that deters them to go the the nearest health facility, no matter what stage or phase of health emergency they are already in. So if the mother is having post-partum bleeding, they will wait till sunrise before the go to the nearest BHS. And if the midwife at the RHU or BHS would not be able to address the problem, they will have to transfer the patient to the nearest district hospital, which might again take them a while to look for a vehicle that will transport them there.

Another problem that the geography poses is the lack of telecommunication network’s signal. While the nurses, barangay health workers may have mobile phones that would facilitate referral to their superiors for proper advise while patients are being transported to higher centers, the lack of communication signal deters such and thus are only addressed when the midwives or the receiving doctor in the district hospital sees the patient

LACK OF HEALTH CARE PROVIDERS

Another deterrence to full delivery of health care to every household in the rural is the lack of midwives. While there may be barangay health workers (lay people who are not necessarily midwives who can be first line to check on ailing residents), it is the midwives who supervise them and who will ultimately decide whether she can manage the scenario or refer the patient to higher institution. In one municipality alone in Ifugao with 18 barangays, they only have 5 midwives. ONLY 5 midwives. Again, consider the distances of each house, their distance from the BHS or RHU or district hospital. And they usually access these houses on foot. Midwives need to track women who are pregnant, follow them up at the RHU, refer them to higher centers if the pregnancy is high-risk, deliver their babies if unable to reach a birthing facility, follow them up to make sure the mother-baby dyad is in perfect condition, submit monthly report to their municipal health officers.

During the past administration, nurses (nurse deployment program, NDP) and doctors (doctors to the barrios, DTTB) were hired to augment this vacuum of labor force. The nurses were deployed to each barangay or two, to help and facilitate the work of the midwives. Definitely being novice in the community and public health, there are flaws and misgivings, that given more time and experience, these will eventually be addressed. Nevertheless, there was a noted decrease in the number of maternal and neonatal deaths because they were monitored.

Unfortunately, starting next year, these contractual employees will no longer have their contracts renewed, making again the workload of our midwives double, maybe triple or quadruple when the NDPs are gone. Thus a rise again in the number of maternal and neonatal deaths will not be a surprise.

LACK OF SKILLS

We the panelists are specialists and subspecialists. We talk of interventions appropriate to our settings, which is way far up compared to the birthing facilities that the NDPs, midwives and MHOs work at. For one our NDPs, who are mostly first time on the job, still lack clinical acumen to detect subtle signs of disorder in the newborn, or signs of high risk pregnancy. Thus they only become alerted when the severe complications have set in, and thus intervention would be late already. Recognition of these subtle signs and early referral would definitely make a significant difference in these conditions.

Not all midwives are skilled in performing episiotomy. Not a single midwife in the region is even skilled in performing full course of neonatal resuscitation. Even doctors at district hospitals are not specialists to correctly treat these problematic parturients and/or their babies.

CULTURE

One thing that I commonly noticed is the influence of the matriarch of the family or clan. Usually, especially in a place where the house of the parturient is far from the nearest birthing facility, a birth plan is laid out. They assign which (of the limited vehicle) will be used to transport in case she goes on labor. And after birth, how soon they will be visited by the midwive or NDP. In other instances however, the matriarch interferes and alter already the planned contingency. A first-time mother ought not to contradict what their “experienced” seniors dictate upon them. While our health workers are campaigning and encouraging health facility deliveries, some “experienced” matrons insists that their daughters deliver at home, with them helping out. Only then will they call for help when they encounter a major problem. One classic example was when a woman on her third pregnancy delivered at home, assisted by the family members. It took them several minutes attempting to deliver the placenta. And because the placenta was adherent to the uterine wall, as they were tagging the former, the uterus inverted. Only then was the midwife called. And because there was no “birth plan” it took them several hours before the parturient was brought to the hospital. There was massive hemorrhage, with the source not identified, that eventually lead to hemorrhagic shock and her death. Such useless loss of lives would have been prevented had it not been for the “usual practice” that these elder people enforced.

 

Many of these problems presented are often preventable but it takes interplay of so many factors to prevent one maternal or newborn death. Our region as a long long way to go…

 
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Posted by on November 29, 2016 in Deliveries, neonates, Pregnancy

 

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My Cat Tale – 1

By profession, I am a pediatrician, subspecialist in Neonatology. As part of my job, I attend to deliveries of babies whether term or premature ones, at whatever time of the day!

Outside my job, I am a cat owner, now a self-proclaimed (persian) cat breeder. When I took care of a patient sometime last year, the parents gave me a female kitten (10 months old by human age) as a token of appreciation. At the time she arrived, she was manifesting an odd behavior, rolling over at the floor. It was my first time to learn about their estrus. I thought it should be addressed immediately. 



Strange to when is the optimum age when the cat should mate, I immediately searched for a male cat. In short, my kitten at 10 months old got impregnated. And few weeks into pregnancy did I learn that they should be at least 18 months before their first pregnancy. Too late! She was so attention seeking while she was pregnant. We sleep together on my bed. But on the day she was to give birth, she only slept beside me for about an hour and had been roaming around my pad. 


I noticed a greenish like fluid trail till it got to where my kitty was… I just learned that she was about to give birth. I called off my morning appointments because it seems she wanted me to stay beside her. During the active labor, she was heaving, and she wanted me to pet her in between contractions. Then my first kitten was born. 

https://instagram.com/p/7J0pnHDooh/ (Blanca in labor).

 
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Posted by on November 7, 2016 in Uncategorized