Dilemmas
Blijf op de hoogte en volg Anna
11 Februari 2013 | Ethiopië, Bahir Dar
A few days ago, we got a new staff member at the hospital here in Mota.
Tenaw is a health-officer. Health officers have more training and responsibilities than nurses, but less than MDs. The special thing about Tenaw is that he has been trained in emergency surgery. He can do emergency cesareans, bowel operations and other surgery. Furthermore he has a more thorough training in obstetrics and can do ultrasounds.
So we are very happy to have Tenaw. This means that we “ferenjis” will no longer be needed in the near future. And that was the plan in the first place.
Tenaw comes to our ward rounds in the morning, starts doing procedures, and helps finding solutions.
That is where the dilemmas begin. Obviously he is trained in Ethiopia and has another perspective than we ferenjis have. Very often that is most helpful and gives us insights in how things are, and why they are like this. He is very well aware how things should be done according to current evidence, and about how we handle things “in the developed countries”.
Only that the conditions and circumstances here are sometimes too different from the theory to apply that modern knowledge straight away. At least, that is our point of view as ferenjis.
On example are pre term babies.
Yesterday we had a twins being born after a pregnancy of surely not more that 32 weeks, probably less (the normal is 40 weeks). In our setting the mother would have come as soon as she had contractions. We would have given medication to stop labor. She would have gotten medication to ripen lungs and bowels. The babies would have gotten directly into an incubator, with oxygen, IV lines, monitoring of heartbeat, Oxygen in their blood, respiration and so on. The would have gotten special formula milk for preterm babies while the mother would have an electric pump to stimulate her breast and have some “real” milk for those little ones. (And I am sure and neonatal nurse reading this can think of 100 other things done specially for those early born babies!) They would be in hospital for several weeks.
When we arrived at the ward, the babies (1,3 an 1,5 kg) were 2 hours old, wrapped in old blankets, laying somewhere in the bed on a distance of their mother. They where grunting (a sign of unripe lungs, worsened by low temperature, lack of blood sugar etc).
Now here is the dilemma:
Usually here I would have the babies in skin to skin contact with the mother, and they would have to rink from mommy’s breast or being fed with a cup or a little syringe with mother’s milk and nothing else. If they would be strong enough, they would survive. Otherwise they would die. If they would survive the first days, it would still be very questionably if they would be alive one year from now, due to an underdeveloped immune system in combination with poor hygiene. – The survival of the strongest!
Tenaw is very eager and wants to improve things here. We found an old incubator in the storage room. The heating works more or less (the babies by then had a temperature of 33,5 degrees). There is no oxygen (and nobody bothered to get the oxygen concentrator from another ward, which anyway could only supply one of the babies). The babies have NG tubes going into their stomachs to feed them, as they are not sucking. They get normal formula milk, because there is no special mile for preterm babies. The mother can only express her milk by hand but does not seem to be eager to do so. I have seen her trying once. The babies still have breathing problems and first signs of NEC, condition that effects the unripe intestines when they are unable to digest the food, and which might kill them very soon.
In our countries they would be treated with IV antibiotics in an intensive care unit and would be fed through an IV line to keep the bowels empty.
And so I wonder if doing al this stuff, without proper equipment and without any specialized nurse or doctor, is the right thing. I do what I remember from my time at the neonatal unit in Assen and from midwifery school. But none of the midwives here has ever seen an incubator before. They have never inserted NG tubes or fed babies through them. Taking temperature regularly, preparing the meals and all those things are a lot of extra work on an already extremely busy day. While they probably realize that it is of no use. So they are not very interested. Which I can fully understand.
Maybe it sounds harsh, but I am sure these babies won’t survive, and I am sure the mother knows it as well. Why should she emotionally attach to two babies whom, she feels, will have no chance?! Are we not just stretching the time of suffering for those little fellows? While they could stay next to their mother, in peace, and maybe make in? But otherwise just pass away an environment than might not be physically warmer, but would surely be emotionally warmer than that incubator?
We tried to discuss this with Tenaw, but it his he who will have to decide in the future and I don’t want to impose my ideas or temper his enthusiasm to change things (which he as an “insider” might be successful). But today - if they are still a live - I will bring up the subject again. Maybe we can install criteria to evaluate when to start more intensive treatment and when not.
And thanks to him, we had a chance to try out the incubator. That machine might help us to take good care of term babies which for other reason had a difficult start into this world. After resuscitation, our problem very often is that those babies are to cold. If we can use that incubator to prevent or treat this, it would be fantastic.
… one day later:
Today we discussed the possibilities of the twins (still alive and doing well considering the poor conditions). Their mother wanted to take them home. She has one daughter, 5 years old, whom she left at home (20 km from Motta). She decided she wanted to give preference to that girl who has more chances of survival. I think that in her situation this might be a wise decision. So we “unplugged” the babies and the family left. Being instable as they are, I think by now, in the evening, they might already have passed away. My only “condition” was that they would be loving and caring to the babies as long as they are alive. But if you see the mother while she was “kangarooing”, I think they have (had?) spent their last hours surrounded with some degree of love.
About the pictures: besides the work we also have a very busy social life: visiting neighbors for coffee ceremonies, cheering for the hospital’s soccer team, going to the market (I bought that skirt, because I like the colors. I did not know I’d look that “chubby” in it, but my colleagues here love it. They say I start looking like a real Ethiopian woman).
Dehna Deru! (Good Night!)
Tenaw is a health-officer. Health officers have more training and responsibilities than nurses, but less than MDs. The special thing about Tenaw is that he has been trained in emergency surgery. He can do emergency cesareans, bowel operations and other surgery. Furthermore he has a more thorough training in obstetrics and can do ultrasounds.
So we are very happy to have Tenaw. This means that we “ferenjis” will no longer be needed in the near future. And that was the plan in the first place.
Tenaw comes to our ward rounds in the morning, starts doing procedures, and helps finding solutions.
That is where the dilemmas begin. Obviously he is trained in Ethiopia and has another perspective than we ferenjis have. Very often that is most helpful and gives us insights in how things are, and why they are like this. He is very well aware how things should be done according to current evidence, and about how we handle things “in the developed countries”.
Only that the conditions and circumstances here are sometimes too different from the theory to apply that modern knowledge straight away. At least, that is our point of view as ferenjis.
On example are pre term babies.
Yesterday we had a twins being born after a pregnancy of surely not more that 32 weeks, probably less (the normal is 40 weeks). In our setting the mother would have come as soon as she had contractions. We would have given medication to stop labor. She would have gotten medication to ripen lungs and bowels. The babies would have gotten directly into an incubator, with oxygen, IV lines, monitoring of heartbeat, Oxygen in their blood, respiration and so on. The would have gotten special formula milk for preterm babies while the mother would have an electric pump to stimulate her breast and have some “real” milk for those little ones. (And I am sure and neonatal nurse reading this can think of 100 other things done specially for those early born babies!) They would be in hospital for several weeks.
When we arrived at the ward, the babies (1,3 an 1,5 kg) were 2 hours old, wrapped in old blankets, laying somewhere in the bed on a distance of their mother. They where grunting (a sign of unripe lungs, worsened by low temperature, lack of blood sugar etc).
Now here is the dilemma:
Usually here I would have the babies in skin to skin contact with the mother, and they would have to rink from mommy’s breast or being fed with a cup or a little syringe with mother’s milk and nothing else. If they would be strong enough, they would survive. Otherwise they would die. If they would survive the first days, it would still be very questionably if they would be alive one year from now, due to an underdeveloped immune system in combination with poor hygiene. – The survival of the strongest!
Tenaw is very eager and wants to improve things here. We found an old incubator in the storage room. The heating works more or less (the babies by then had a temperature of 33,5 degrees). There is no oxygen (and nobody bothered to get the oxygen concentrator from another ward, which anyway could only supply one of the babies). The babies have NG tubes going into their stomachs to feed them, as they are not sucking. They get normal formula milk, because there is no special mile for preterm babies. The mother can only express her milk by hand but does not seem to be eager to do so. I have seen her trying once. The babies still have breathing problems and first signs of NEC, condition that effects the unripe intestines when they are unable to digest the food, and which might kill them very soon.
In our countries they would be treated with IV antibiotics in an intensive care unit and would be fed through an IV line to keep the bowels empty.
And so I wonder if doing al this stuff, without proper equipment and without any specialized nurse or doctor, is the right thing. I do what I remember from my time at the neonatal unit in Assen and from midwifery school. But none of the midwives here has ever seen an incubator before. They have never inserted NG tubes or fed babies through them. Taking temperature regularly, preparing the meals and all those things are a lot of extra work on an already extremely busy day. While they probably realize that it is of no use. So they are not very interested. Which I can fully understand.
Maybe it sounds harsh, but I am sure these babies won’t survive, and I am sure the mother knows it as well. Why should she emotionally attach to two babies whom, she feels, will have no chance?! Are we not just stretching the time of suffering for those little fellows? While they could stay next to their mother, in peace, and maybe make in? But otherwise just pass away an environment than might not be physically warmer, but would surely be emotionally warmer than that incubator?
We tried to discuss this with Tenaw, but it his he who will have to decide in the future and I don’t want to impose my ideas or temper his enthusiasm to change things (which he as an “insider” might be successful). But today - if they are still a live - I will bring up the subject again. Maybe we can install criteria to evaluate when to start more intensive treatment and when not.
And thanks to him, we had a chance to try out the incubator. That machine might help us to take good care of term babies which for other reason had a difficult start into this world. After resuscitation, our problem very often is that those babies are to cold. If we can use that incubator to prevent or treat this, it would be fantastic.
… one day later:
Today we discussed the possibilities of the twins (still alive and doing well considering the poor conditions). Their mother wanted to take them home. She has one daughter, 5 years old, whom she left at home (20 km from Motta). She decided she wanted to give preference to that girl who has more chances of survival. I think that in her situation this might be a wise decision. So we “unplugged” the babies and the family left. Being instable as they are, I think by now, in the evening, they might already have passed away. My only “condition” was that they would be loving and caring to the babies as long as they are alive. But if you see the mother while she was “kangarooing”, I think they have (had?) spent their last hours surrounded with some degree of love.
About the pictures: besides the work we also have a very busy social life: visiting neighbors for coffee ceremonies, cheering for the hospital’s soccer team, going to the market (I bought that skirt, because I like the colors. I did not know I’d look that “chubby” in it, but my colleagues here love it. They say I start looking like a real Ethiopian woman).
Dehna Deru! (Good Night!)
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11 Februari 2013 - 21:52
Sadiye Demir:
He Anna, wat leuk om weer wat van je te horen ( lezen)!
hoop dat we nog van je mogen horen hoe het met die pre terme tweelingen is gegaan. :( :( :(
kom net van een vergadering (22.00 uur inmiddels) van koffie kan ik weer niet slapen je weet wel.:)
bedankt voor die mooie fotos, He Anna die jurkje wat je aan hebt staat wel heel anders dan die groene jurkje die je hebt gepast in Leiden :) LOL
wel Leuk om te zien!
veel groeten en heel veel liefs
Sadiye
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12 Februari 2013 - 13:07
Ineke Sturm:
Hoi Anna, Fijn om weer van je te horen. Wat is het toch een immens groot verschil met de geboortes van kinderen hier in Nederland en Europa en bij jou in Motta. Julia, de dochter van Thea en Tiemen, is thuis bevallen van haar tweede zoon. Alles goed met moeder en kind. Thea en Tiemen zijn trots op hun derde kleinkind. Hier in Boxmeer gaat alles z'n gangetje. Het is nog steeds koud en het vriest 's nachts. A.s. vrijdag komen Jaap en Anke mosselen eten! Groetjes en liefs van Phil en Ineke -
12 Februari 2013 - 16:20
Familie Grundmann:
Lieve Anna,
Wat maak je weer een ellende mee. Wat een groot verschil in cultuur. Ik vind het dapper dat je je zo staande kan houden. Goed blijven relativeren en let op jezelf (geestelijk en lichamelijk). Je rok is vast een goede Ethiopische stap geweest in zorgen voor jezelf! haha. Hier in Haarlem maken we ons op voor een week skieen over een paar dagen in Duitsland. Dat wordt genieten, zo anders dan jij op dit moment....Sterkte daar en blijf genieten en enrgie opslurpen dikke knuffel van ons allemaal de Grundjes. -
14 Februari 2013 - 15:20
Ria Bruijn:
Hey Anna,
Als ik jou verhalen lees heb ik gewoon heel veel respect voor jou! Echt knap hoe jij omgaat met dit grote avontuur. Door je verhalen heen kan ik me de (gezondheid)situaties in Ethiopië zo veel beter voorstellen.
Maar ik ben ook blij om te lezen dat je je gelukkig voelt (ondanks dat ik me kan voorstellen dat je je soms machteloos voelt ...)
Binnenkort (begin maart) komen er 4 studenten van de KHK (nu Thomas more) naar Mekelle om stage te lopen. vanaf 1 maart komen er ook twee docenten naar Mekelle.
Dus als je in de buurt bent, laat het weten he!
Anna, nog heel veel veilig avontuur gewenst!
Groetjes van alle collega's!
Ria -
19 Februari 2013 - 22:46
Herline Nina Ramon:
Hoi Anne,
We hebben elkaar helaas misgelopen toen je in Nederland was:-(! Nina groot lekker, kletst lekker veel net als mama. Zingt de hele dag kindliedjes hihihihihihi. Wat doe je veel daar zeg! Wij zijn trots op je! Knap hoor! En wat een leuke foto's allemaal!
We houden contact.
Herline Nina Ramon xxxx -
26 Februari 2013 - 12:39
Miekedebest:
Hallo Anna,
Weer een ervaring rijker, niet op de laatste plaats door andere denkwijze te honoreren! Wij gaan deze week vertrekken en hopen op wat voorjaarszon en warmte in Z.Spanje. Blijf je verbazen en ook genieten, succes met alles. Liefs, Toine en Mieke -
24 Maart 2013 - 01:33
Maarten:
Oef, beetje late reactie op je blog van vorige maand :-S.
Wat een dilemma inderdaad! Ik ben blij dat ik niet in je schoenen sta. In eerdere blogs heb je al verteld over leven en dood wat daar zo dicht bij elkaar zit. Misschien hangt het leven van een pasgeborene altijd wel aan zijden draadje, maar dat draadje is hier in NL/europa toch wel een stuk dikker dan in Motta. Je hebt mij in ieder geval weer met beide benen op de grond gezet. Afin, het is blijkbaar ook wel het cultuurverschil wat het moeilijk te behappen maakt... Knap dat je dit zo nuchter kan opschrijven; ik geloof dat je een goede vakvrouw bent :-) Heel fijn wel dat je toch nog een foto hebt van de lachende kangaroe-moeder (bah, wat een term) met haar 1-dags-babies.
Liefs,
Maarten.
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