Therapeutic Cooling in Area of Limited Resources

(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.

(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.

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.

UPDATE:

At 18 months, the baby was seen by a Developmental and Behavioral Pediatrician, and finally cleared baby of any neurodevelopmental deficits. CLEARED! NO NEUROLOGIC DEFICITS!

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

 

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

 

(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.

 

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…

 

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).

 

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…

 

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).

 

The Curious Case of Miriam

Few months ago, Sen Miriam Santiago announced she has stage 4 lung cancer. Some went sad because they, myself included, saw in her someone who could be their leader for a better governance.

Then afterwards a few months, in a press conference she announced that she has been cured, “I licked cancer.” She was cured! And now she is ready to accept the challenge to lead the country to a better future. Many, especially those from the medical field got baffled how easily would she be cured, in barely three months. Between her announcement of having a cancer and getting cured, you see her occasionally attending functions and delivering speeches. You never saw her wear a wig, get bald. She said her doctor had been giving her a new kind of treatment modality. Alright, fine. Perhaps that is someone I am not familiar too as oncology is not my field of specialty.

Then she declared her candidacy. People are used to her giving several pick-up lines of one liner jokes before her main speech to the amazement and entertainment of her audience. Even in her sorties that I have attended, she always commanded and drew attention to her with those jokes she never failed to deliver. But during this time, there were no pick-up lines, one liners. The speech was only a short 5-min run. And then she sat down and allowed photo ops with her followers. A very very unusual thing to happen.

People became skeptic. Did she really beat cancer in mere three months? Why the sudden change of her speaking style? Did she not really get cured and now cancer is taking its toll?

A doctor challenged her to present her case, whether it be a medical certificate or medical abstract to prove her claim of cure in barely three months. She is running for a sensitive position and as a voter we ought to know her health status, she claimed. But Miriam was so adamant that she invoked her right to privacy. Okay, so we respect that, but that leaves us hanging as to how she really is… cured? in remission? or worse, did she just make up stories to gain sympathy? I hope not.

We know that lung cancer, stage 4 at that has a very low survival rate. In fact, a 5-year survival rate of if the lung cancer at the time of diagnosis is already stage 4 is nil, barely 1%. Many of them would not even last six months from the time of diagnosis. We usually use the terms survival rate, in remission, but we rarely use the term “CURED.” I know of one patient (a relative of one of my patients) who had full remission, but being workaholic, he wanted to resume his stint in the government service. His doctor however advised him not to because the stress might just trigger relapse, causing expression of genes for replication of cancer genes.

If indeed her claim is true, personally I wanted to congratulate her for beating a stage 4 lung cancer. Such is not an easy feat.

The doctor wanted to know the state of health of MDS as campaigning and sorties would be energy-draining and stressful. But without really her medical abstract or certificate of full remission one in the know would cast doubt as to the authenticity of her claim. Her case is a curious one, I would say it is worth discussing in a medical conference. Her case is a statement that a stage 4 lung cancer is curable, inspire others not to lose hope.

Then recently, she changed her story… she is currently on chemotherapy, but her cancer is “stable.” Wait, whaaaat? So what happened now to “she licked cancer?” Was she really cured at all?

And what were the implications of her presumptive “cured” statement? She actually demoralized patients or relatives of patients who died for receiving a different treatment regimen. The indigent people would despair “pwede pala tayo mabuhay sa stage 4 lung cancer kung may pera lang tayo kagaya ni Miriam.” Chain or heavy smokers can say “why quit from smoking when stage 4 lung cancer is curable?”

She was just so hasty to let her audience know that she still can run for presidency. Wrong move though I must say…

 

 

 

 

My First Case of Congenital Cytomegalovirus Infection

I have this opportunity to demystify an infant’s case of long standing jaundice…

The mother’s prenatal course was apparently unremarkable, save for gestational diabetes that was controlled. The mother cannot remember any other symptoms such as flu-like illness, skin rashes, nor was she hypertensive during the prenatal period. Baby was delivered via repeat cesarean section, small for gestational age. He stayed quite long in the hospital because of infection. He was purely breastfeeding. His newborn metabolic screening result was normal. I was not the attending then.

At home, baby was quite fuzzy and irritable. Baby has been being attended to by the original neonatologist. He was jaundiced. In cases of purely breastfed babies, sometimes jaundice can be expected to last for about 3 months but the intensity is not that much compared to that during the first week of life. His stool color was still yellow. He developed umbilical hernia. The skin texture was fine; tongue was normal in size; hair was not coarse; there was no hypotonia; nor was there any constipation (something that is a remarkable findings among babies with hypothyroidism). Baby was worked up for possible hypothyroidism. Thyroid function test was normal. They were advised to go to a pediatric endocrinologist for evaluation.

Mother brought baby to my clinic for second opinion. I saw the laboratory result, it was normal. But what is puzzling is the jaundice that was quite intense. I could not evaluate baby well, especially the abdomen, because he is irritable. I advised mother that baby needs further test and treatment thus they agreed to be confined in the hospital.

I repeated the thyroid function test, it was normal. That reassured me baby has no congenital hypothyroidism which is one dreaded condition a baby can have because of life dependency on thyroid hormones for better quality of life and to attenuate whatever cognitive impairment it has already caused. I still called up an endocrinologist friend to confirm my understanding of baby’s thyroid function test result and she agreed baby is not a case of metabolic disorder.

I treated the baby as a case of sepsis pending work up results. Ultrasound of the abdomen showed the liver is enlarged, the biliary tree is intact. I am not afraid that this baby has biliary atresia which is another “lethal” condition that usually leads to baby’s death in a slow fashion.

Liver enzyme, alkaline phosphate and bilirubin were all elevated (it was a direct hyperbilirubinemia). I started the baby on ursodeoxycholic acid to help eliminate the bilirubin that could also cause inflammation of the liver cells.

After a week in the hospital, baby’s jaundice has significantly decreased and yet the direct hyperbilirubinemia (50%) was still persistent, and alkaline phosphatase level was still significantly elevated. I have discharged baby with instruction to undergo karyotyping and TORCH screening as I haven’t ascertained yet what was causing the baby’s jaundice.

A week later, mother brought back the results of baby’s tests. Karyotyping was NORMAL (thank God). On the other hand, TORCH panel revealed (+) IgM and IgG for cytomegalovirus. I referred the baby immediately to an ophthalmologist for chorioretinitis screening, and to a pediatric infectious disease specialist for further management. CT Scan of the head showed that there were periventricular calcifications near the parietal areas of the brain.

Baby is still jaundiced although the intensity is no longer that dark. He is on supportive treatment.

He will undergo repeat head CT scan as well as chorioretinitis screening one month after the first.

 

My Struggle Continues…

I was the happiest person last August of this year (2014) when I finally had a normal cholesterol level. This was accomplished through several means. First: I went hard on my diet. I literally had been eating veggies more often than not, and only taking meat 2 days in a week, in the form of chicken or fish. Second: the dose of my ruosovastatin was increased from 20 mg to 40 mg daily. My exercises were still zumba once to twice daily for 5-7 days.

My doctor as well was very elated with the result. So on that day, she decided to a) decrease my ruosovastatin back to 20 mg daily, b) decrease my ezetimibe to one tab every M-W-F, c) asked me to come back with repeat lab test after six months. On a personal basis, I tried now to enjoy eating some chicken more frequently, but not on a daily basis. I happily complied with decreasing the ruosovastatin (as it is very expensive) but I was on doubt of decreasing my ezetimibe to thrice weekly, so I secretly kept it daily. In my mind, I think six months is a long wait for my repeat lab tests, so I decided to have a repeat test after two months.

The repeat tests shocked me. My LDL went above the acceptable value for a post-bypass surgery patients like me. My total cholesterol went up from 120s to 180s, although it is still within the normal value. I got sad. I felt guilty for having a go with my meat intake just because I was getting bored with merely veggies daily.

I informed my physician that I will be increasing back my ruosovastatin to 40 mg daily and go back to mostly veggies diet (no matter how lifeless it seems).

I havent done yet my thyroid hormones as of posting but I plan to do it in the next few days to see if I might again need thyroid hormone supplementation.

On the other hand, I noticed that I got thinner again compare to two months ago. So I am guessing that my thyroid hormones are still within normal limits. Otherwise, I should have gained weight again. So if I am still losing weight, and yet my cholesterol is increasing, then I am guessing that I really had a very very bad gene for this disorder that I really need a strong dose of my anti-cholesterol. Because if I am gaining weight at the same time my cholesterol is rising, then it would mean that my cholesterol elevation is related to hypothyroidism, which causes a decrease in metabolism.