Tuesday, August 21, 2012

Review of Dr. Kothiala's NICU

I posted what is below in the Dr. Patels surrogacy forum, but decided to repost it here. I started as one paragraph, then grew into a small novel. I didn't realize I had so much to say, but hopefully this encompasses a lot of info that someone who winds up in this boat can use in the future.

I would like to leave some detailed comments about Dr. Kothiala's NICU based on my experience. So far I have been here 2 weeks, and will easily do another month in the NICU. My twins boy and girl were born at 27 weeks and are doing quite well. My comments are mostly positive, some negative. I have not seen or experienced anything that would cause me to not recommend her NICU to others. However, the fact that my babies are doing well allows me to be more relaxed and not have as much reason to question. Others have had babies who were less stable with more severe problems, and had more to second guess and may have found more differences with advanced protocols in more developed countries. My babies are also not on any medications other than vitamin drops and the standard caffeine to stimulate respiration, so I don't have reason to question medication management. I have heard that Dr. Kothiala was amenable to medication modification when a reasonable arguement was presented. I find Dr. Kothiala to be a very approachable and kind workaholic, who is here at 8am and often 8pm and told me she has nothing else she does. Her husband Ajay Kothiala is a co-founding doctor here, and they run this hospital together with supporting physicians. She is experienced and has gray hair, and she trained Dr. Biren. She is proud of the fact that she was one of the first to do a particular type of surfactant therapy that is now becoming more standard.

I spend anywhere from 4-6 hours a day in the NICU visiting and doing kangaroo care with my two babies, who were stable enough for me to do it with on the first day I arrived. Unlike folks with bigger babies who are bottle/breast feeding and not doing kangaroo care who are told when to come and go typically around feeding time, I come and go as I please and spend hours here. They never know when I'm going to pop in and I've been here from 8am anytime until 9pm. They know I will be a fixture here for a while, so it seems the rules don't apply as much to me regarding visitation.

Regarding hygeine and cleanliness, a lot has been said about Dr. Patel and Dr. Kothiala's facilities. My own doctor in the states has said that what is probably best and reasonable is a halfway point between how things are here and how things are there, because he believes the US goes overboard. I tend to agree, though the NICU is a special circumstance. It seems that a lot of folks have an impression about things being dirty, but sometimes that opinion is superficial. I've paid close attention to hygeine and sanitation in the NICU because of what I've heard and because it is so important. There isn't a new coat of paint on the walls and the equipment looks older or mismatched or has a stain, but from what I've seen I would eat off of it more readily than I would the dishes at my hotel. I think that you need to look beyond the surface to form a reasoned opinion on this matter.

First off, there is a woman 24-7 who is not a nurse and her sole job is cleaning. She is easy to recognize because she never wears a gown and never touches a baby. She stays busy doing all the laundry, sanitizing all the pump parts and bottles and all equipment, washing down all surfaces, and hand mopping the floors several times a day. She is thorough, and gets the hard to reach spots including the tops over your head where you can't see the dust. She changes all the bedding and clothes and blankets every morning when the babies are bathed from head to toe around 8:45. The babies get a fresh orogastric gavage tube for feeding every morning. They do disinfect by wiping down all parts of the isollette, though they don't wipe down unoccupied ones as much.

You leave your shoes at the door, because like anyone who has been to dusty Anand knows, there is good reason why the feet are considered dirty. THey have shared plastic flip flops that are cleaned daily you can use, but I always choose to go barefoot. I did get in trouble once during kangaroo care and Dr. Kothiala scolded me because my legs were crossed and my hand was inches away from touching my foot.

They do use shared sterilized gowns and hats, though on occasion I will see a nurse without one touch the baby with hands only. The visitors use them too if they are touching and definitely if holding a baby, unless you are doing kangaroo care. A study in the US showed that gowns do not significantly reduce the spread of infection, but that study was in the US and India could be different.

You are told to wash your hands and then use a sanitizer in a pump located in several convenient places.
They re-sanitize before touching a different baby, if 10-15 min elapse between handling, or they handle equipment between touching babies. I have seen the cleaning gal cough once without covering her mouth, but then again I sneezed on my son's head in kangaroo care cause it caught me off guard and I didn't have a close hand free.

They are careful about illness. I don't have allergies at home, but perhaps in reaction to the pollution and dust, here I do. I also get a cough the first few days until my throat adjusts to all the fans blowing to keep things cool. I was questioned several times by nurses and two doctors, and had to repeatedly assure them I was fine for them to let me stay in NICU. They do have fans blowing in the NICU on occasion to keep things cool, but no AC. I haven't been more that slightly hot and sweaty, but the weather is warming up so the jury is still out on that comfort point.

Regarding visitors, I'm not sure what people have an issue with. All I've seen are parents and for shorter periods of time grandparents allowed in. The rest are all staff, or surrogates dropping off breastmilk handing it off to staff. Non-NICU employees open the door and stand in the doorway to deliver their message and equipment. Any others, including children, have been allowed to look in a window that usually they leave the drapes closed on. My friend Lakshmi and her husband were allowed in, but they mentioned my name specifically and that I requested a photo of my babies because I was going nuts because it was a week before I could travel. Plus they were having twins in a few days and would be in the NICU and deserved a tour. It does get crowded around afternoon feeding time, but it is usually all the parents coming in to practice their bottle feeding skills to prep for discharge.

They have the cleaning gal do all the sterilization. The surrogates turn in the entire breast pump when they bring their milk, so all sterilization is controlled there. They use hand pumps that are sterilized with each use, though I've seen a double electric pump on a shelf. Since I am inducing lactation, I was questioned extensively about medications and sterilization by the nurse Suvarna. She corrected me on one of the steps of my sterilization procedures at my hotel, and only with much convincing did she agree to let me sterilize at the hotel instead of bringing everything there every few hours to sterilize.

The NICU is small, but I see that as an advantage to care level because it is harder to miss stuff going on with the babies and less to keep sterile. There is always someone walking by the isollettes for something, so they rely on eyes and not as much on alarms and machines. I wish it didn't get so crowded during 11am feeding time when we had four sets of twins in there and were filled to capacity with 12 babies, but you can't have everything.

I don't like that you have to walk through a crowded waiting room and past the ICU and hospital rooms to get to the end of the hall where the NICU is located. I also don't like that there isn't a fancy air purification system that is probably not feasible in this part of the world. Instead they do have two windows that they tend to open to outside air in good weather. I've only seen one fly and one ant in two weeks, but one night after the rains they did pull out a bug zapper and I heard it go off a few times.

Speaking of rain, during the end of the rainy season the power did go off twice in an hour. There was no reaction, because everything important was on an uninterruptible power system. They did get up to reset machines when the power came back on though.

I don't like how loud the nurses are when they talk, but I did read something today about how the noise in the womb is the decibel of a vaccuum cleaner. This is supposedly why babies like hair dryers and car rides and vaccuum noises. The babies seem to sleep through it okay, but it still bothers me. The beeps are easier to tune out after a while than the voices.

The nurses do not behave with as much decorum and professionalism as I would like, but they are more relaxed around me because I'm always there and try to be a fly on the wall and stay out of their way. They still do their jobs, but they do gossip and tease and joke (I can tell by the voice tone and body language) when there isn't something to do. 50-75% of the time though there is something to do so someone is usually walking around to notice anything wrong with the babies. The nurses tend to hang out at the juncture where the two small rooms adjoin near the main phone line, and it does give them a better view of all the babies.

I have had two incidents with them goofing off that bothered me, but I handled it myself and it was rectified without me having to say something to Dr. Kothiala. I've been told some folks offer bribes and not just tips at the end that may help this some, but for now I've elected not to offer money until discharge. This seems standard, but may get them in trouble also...not too sure on that topic.

They do seem to change diapers frequently based on the babies cues and at certain times, and they often check the diapers when doing routine care since the littler preemies can't cry to signal discomfort as much. They always reposition the babies when they get discombobulated enough in the crib to mash their faces against the side or get something covering the mouth or nose, even though the monitors may still be stable.
Monitoring. A lot to say on this topic. First of all the babies will have monitors attached by two cords to measure three things. The first cord to the foot (wrapped around) is the pulse-ox monitor that measures pulse per minute and the oxygenation by percentage. Normal is 80-100%, but you really want to stay in the 90's and it alarms at 85% after a few seconds. The pulse should be (from my observations on my babies only) 110-145 or so. The constant beeping you hear is the heart rate, and the tone goes high for high heart rate and deepens for low heart rate. After a few days I subconsciously became aware of the beeping tone and would hear it deepen only to look over seconds before it alarms. This is one reason the nurses don't jump at alarms, because they were expecting it. More on that in a minute.

The second blue cord goes from the lower left of their chest (taped on) to an apnea monitor that sounds an alarm if they stop breathing for a certain period of time.

I think what will send the nurses running is a "trifecta" where the apnea monitor goes off along with the pulse-ox monitor signifying low oxygenation as well as bradycardia tones(low heart rate). A local baby that was born unhealthy and on a ventilator did die while was at NICU, and they ran to the other room even though I heard no alarms, so something else was noticed or I was in my own world.

It's hard to say how well they monitor and react to the monitor alarms, and some nurses differ slightly. Keep in mind my opinion is on my babies who aren't that bad off, and I haven't had any babies with more severe dips than mine to observe.

Everyone monitors them if they are a nurse, but sometimes it is the closer person or a nurse who is more of the leader who checks it first. I can tell they respond faster to an apnea alarm.

I think for my baby girl who "de-sats" to the 70th percentile 2-4 times per hour after feeding due to reflux issues, they base part of their reaction on knowing her pattern. She typically pulls herself out of it without stimulation by the nurses, so I think they wait a bit to see if the alarm goes off by itself. However they do listen for the low tone of a bradycardia pulse with it. If it keeps going off and on they come and check her positioning to make sure her airway is good and make sure the monitor is on her foot solidly. They also look to see if the baby is cyanotic (blue) or moving and making noise. Motion will cause it to dip a bit or false alarm, and the foot monitors do come loose. I realized that babies who are Indian like mine (egg donor) are harder to tell when they get cyanotic, so they check the palms and bottoms of the feet where they are paler to check coloration.

Regarding monitoring and prompt responses to alarms, it is hard to judge fairly as a parent. At first I thought they were too slow and too quick to assume it was the foot monitor acting up. But in truth I don't think I'd be satisfied unless someone were sitting in a chair watching it 24-7. Keep in mind that my brother ironically had twins 5 months ago born at 28 weeks and prepped me extensively for the NICU experience, although his was in a US NICU. So when my baby girl desats into the 70's I am tense. But the first two times it happened, I was freaking out inside trying to appear calm. I knew it was 100% normal for her stage of development but it scared the ever living crap out of me. When she bradied (bradycardia-heart slowing down) to the 50's along with desatting the first few times I cried. Seeing her needing to be stimulated out of it the first two times was excruciating. I work for law enforcement where you are used to being tough and you never cry, and I 100% expected this to happen but none of that made it any easier to take. 

One clear difference from my brother's US experience to mine is that here they don't chart all the A's and B's (apneas and bradycardias). I asked Dr. Kothiala and she said only if it is pretty bad do they chart it. Overall charting is morw minimal here, and because they are smaller with a low number of staff compared to a large US NICU, they rely on verbal communication and passing on general observations. That is one way in which small size may be an advantage. I also think that with fancier newer machines in the US that they probably take closer recordings, and it records and probably prints out all the readings for the chart.

My brother's babies did seem to have a temperature monitor attached to them as well as an automatic blood pressure cuff I think. They do chart a BP at regular intervals on the chart, but do it manually here. They maintain temp here by using the warmers that are adjustable, and there is a temp sensor located close to the baby but not on the actual baby so it is harder to tell. They keep them clothed with hats and blankets over them, though the babies with jaundice under bili-lights have no shirts or blankets so their skin can recieve the healing light. When I changed my daughter's diaper I was given a 2 min time limit so she didn't get cold and watched closely. They occasionally touch the extremities to see if they feel cold. One of the reasons they don't swaddle them here or allow for clothing beyond the accessible tank shirts is so they can monitor skin tone and access babies better more quickly, per Dr. Kothiala.

Regarding brain bleeds, which are a risk with preemies, they do not have an MRI machine. I would be surprised if they had one anywhere in the city and I imagine you'd have to go to Ahmedabad or Mumbai. However they did a scan after my babies were born (CT?) that she showed me that was clear. She said they rescan after four weeks, or sooner if there are signs of a bleed.

Dr.  Kothiala takes a minimally invasive approach, so she avoids IV's unless they are absolutely necessary and prefers oral suspensions whenever possible to deliver meds. She does routine blood testing, but not daily or more than necessary.

THey are on a 2 hour feeding schedule starting at 7am, though once babies are discharged it is more adjustable. In NICU they are trying to get them to put on weight to be discharged, so the schedule is more rigorous. I've never seen them feed later than 15 min behind schedule. It is funny because there is no alarm signaling them it is feeding time because they are so used to it and the babies let them know because they get fussy and restless. My son starts smacking his tiny lips and sucking on air a full 30 min before feeding time!
Regarding oxygen support, my general impression is that they are less likely to use it than in the states. I'm not certain of that, but one other person has echoed that sentiment. It seems the philosophy is to help them develop strong lungs and breathing skills, even though it may result in more alarming. My babies were on CPAP then oxygen by nasal cannula only 3 days. I've seen bigger babies here on cannula longer, and there are sterilized containers of sterile water keeping it humid. They use the ventilator if absolutely necessary, but Dr. Kothiala is well aware it can be problematic and damaging if prolonged.

My last comment is on the chairs. They only have those awful stackable plastic lawn chairs that are so popular here, some without arms some with.  I'm convinced the person who invented them was an expert at torture and interrogation and designed them specifically to systematically cut off your circulation in key areas. Sometimes after holding my baby motionless for an hour and a half my hand will be swollen and I lose sensation in my feet. I saw a picture of my brother in the NICU doing kangaroo care and he was in a plush chair with a slight recline with a head rest AND a foot rest. I was seething with jealousy. Much easier to stay motionless for 2 hours in one of those puppies. Right now those chairs are the bane of my existence and the #1 reason I don't spend more time in the NICU than I do already.

Anyhoo, I hope this review of my overall experience so far is helpful to someone. I'm a person who likes to be in control and when I have no idea what to expect I get pretty anxious, so hopefully this prepares someone a little better than I was. I hope that very few of you wind up in this exclusive club of NICU vets, though many of you with twins will be in the "sub-club" with your giant short-timer babies who are gone after a week. (If I sound jealous, it's cause I am!) Email me if you have any questions and I'll answer what I can, and I appreciate any feedback or correction if your experience was different than mine.

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