Neonatal
Resuscitation Training
Jill King
is a Paediatric doctor from Scotland, placed by Voluntary Services Oversees
(VSO) to share her medical skills at the Bamenda Regional Hospital in the North
West Region of Cameroon. Jill’s Paediatric
training program made it possible for her to take a year away from her position
as a Paediatric Registrar at the Royal Aberdeen Children’s Hospital to volunteer
in Bamenda on a Royal College of Paediatrics and Child Health (RCPCH)
Fellowship post.
Bamenda
Regional Hospital is situated on a small hill overlooking the city, with expansive
views to the large, volcanic mountains beyond.
A series of single story buildings, the majority built in the 1950s, are
spread out across the green-field site, with covered walkways cutting through
the manicured grounds to link the wards and provide protection from the rains.
The wards are simple, containing only basic equipment, metal beds, crumbling
paintwork and mold growing on the damp walls and leaking roof.
In the
children’s ward children line up to receive their treatment from the nurses,
the crying mounting as they see the child in front of them receive their
treatment and anticipate their own.
There are no toys, or thoughts of distraction for painful procedures. The patients provide their own food and bed
linen, and the parents or carers sleep on the floor underneath their child’s
bed. Privacy is a luxury that is not
available to most.
Jill works
predominantly in the Nursery where her day is consumed by the simplest of tasks;
keeping her tiny patients warm, hydrated and trying to fight off infection. On
a typical day, Jill will consult and treat patients with anything from the
common cold, to serious infections such as pneumonia, meningitis or malaria. Despite the many challenges, Jill is enthusiastic
about her experience and really believes there is potential for things to
change. She soon realized a lot of the
things that are done badly are done so because the staff have never been taught
any other way. There was one particular
skill set Jill noticed the medical staff were lacking – a simple thing that if
learned could make a dramatic difference to a child’s life - how to properly
resuscitate a newborn baby.
Jill
decided to focus her efforts on developing and equipping resuscitation stations
and training nurses and doctors on how to effectively revive a newborn baby because
she had noticed a major issue in the hospital: infants were too often dying
from birth asphyxia.
There was
one particular day when Jill realized the main purpose of her placement. While Jill was doing the morning ward round
in the Nursery a nurse from labour ward walked slowly into the nursery carrying
a bundle, casually chatting with the nurse in the nursery as she came to put
the bundle on the treatment table. Jill
stopped what she was doing to go over and check the baby was okay. Inside the bundle of cold, wet towels was a
small preterm baby who was very blue and not breathing. Jill immediately started to resuscitate the
baby only to be told “Doc you need to wait until the family bring gloves” to
which another mother promptly handed over a pair of gloves, and then she was handed
an oxygen mask from the nurse in the nursery – a completely useless piece of
equipment if a baby is not breathing.
That same evening, on her final check on the Nursery before she left for
the day, Jill arrived to find a nurse doing chest compressions on an older
preterm baby who she had found in an incubator not breathing – an entirely
pointless exercise if you do not also breathe for the baby. Jill had seen too many babies die this way
during her short time at the hospital and decided this was a priority issues. Nurses
needed to learn how to resuscitate a baby.
Jill decided
to look at the hospital’s mortality statistics.
In 2011, the under 1year mortality was 9.5%, with 28% of those deaths
resulting from birth asphyxia. Jill
discussed the issue with the nurses who explained they had never had any
training on how to resuscitate a baby but were keen to learn.
In the
Nursery, where approximately 70 newborns and infants are admitted each month and
one nurse cares for between 30 to 40 infants at any onetime; where equipment
for monitoring children’s vital signs is non-existent; where a single oxygen
tank must be split between multiple ailing infants; and where broken incubators
have been fitted with electric bulbs to provide warmth on surprisingly cold
Bamenda evenings, Jill went to work developing resuscitation stations and
training workshops.
The
project was threefold. First she ensured the resuscitation stations were equipped
with the necessary tools, including step-by-step instructional posters,
ambu-bags with appropriately sized masks, oxygen tubing, oxygen face masks,
naso-gastric tubes, syringes, gloves, suction catheters, a stethoscope and hats
that Jill knitted herself to keep the preterm babies warm.
Next
she held hands-on workshops where 15 nurses learned how to recognize a baby who
needs resuscitation, how to manage a baby’s airway, how to provide bag-valve-mask
ventilation, how to do chest compressions, how to manage when alone or with two
people, and how to preempt and prepare for
babies that may need resuscitation . In teams they practiced their
acquired knowledge by going through scenarios and working with manikins. Finally,
Jill developed a manual and refresher course to ensure the nurses would feel
confident in their abilities when she left and so they would have the workshop
components at their disposal for training new staff.
The
training was so well received that she will be taking her course to a
neighbouring hospital, Banso Baptist Hospital, where nurses from 8 affiliated
rural health centers will also attend. Before Jill leaves in a month, over 60
nurses, midwives and doctors will have completed the training.
The results
of the training were immediate and dramatic. Fewer newborns and infants were dying
or suffering from the consequences of asphyxiation. The nurses and midwives
were enthusiastic about their new knowledge and even tried to train those who
had been unable to attend. The medical staff were bombarding her with questions
and not just related to resuscitation. The staff were thirsty for knowledge which
to Jill was a noticeable change in people’s attitudes. In a culture where medical staff are expected
to have all the answers and where asking for help is seen as a sign of
weakness, this attitudinal shift was hugely significant. For the first time,
the medical staff felt they could ask questions and ask for help. “One of the
most frustrating parts of my placement was that no one would ask for help,”
Jill shared. “Sometimes I would just be checking in on the ward and I would
find out there had been a death that could have been prevented if someone had
just asked for help.”
Jill was
encouraged when she saw the medical staff’s attitudes changing. However, after a few months she started to
see the number of babies admitted with birth asphyxia creeping up again.
Somewhat discouraged, Jill investigated and found a large number of the nurses
in labour ward had been moved to other areas and there were new staff in their
place. This is a common problem in government hospitals in Cameroon, where staff
are frequently moved without any warning.
Despite
the setback of having to encourage and train new nurses, a powerful moment for
the Paediatrician from Scotland was when she saw history repeat itself – kind of…
Jill went in one morning and found a
nursing student at her door, “Doc they need you in the nursery!” she recalled.
She rushed to the Nursery to find two nurses who had completed the training
effectively resuscitating a newborn that had been brought in from Labour Ward.
The nurses were at a resuscitation station. They were working together to
provide effective resuscitation and “by the time I arrived, the baby had a good
heart rate and gradually started breathing on its own. They were doing so well. They were using the
skills perfectly while working as a team. And they were successful. They didn’t
need me anymore.”
The Pediatrician from Scotland shared her skills, not only
changing the lives of nurses who are more capable and confident in their jobs
as a result but she was able to see the infants, mothers and families that will
forever be grateful that their child’s life was saved by a professional
Cameroonian medical team.
Jill is currently helping the hospital collect
more thorough statistics on the causes of neonatal mortality. She is also
looking to work with VSO to expand the training to other health centers in the
area. She has fostered a partnership
with Maternal and Childhealth Advocacy International (MCAI) to help provide the
necessary resuscitation equipment.
Although Jill will be leaving Cameroon in a month, she is eager to
see a train the trainer program be implemented so the Regional Hospital medical
team can share their acquired knowledge with surrounding rural health centers
where knowledge, skills and equipment are even more limited.
