Swallow study results!

Miss Tara completed her swallow study yesterday and passed, so no G-tube or Nissen fundiplication surgery. As if I had any doubt! As expected she has been aspirating milk this entire time, because the barium swallow did show "penetration." It is not severe, so they are able to thicken her formula to a nectar consistency with 1 tsp rice cereal per 1 ounce of formula.

I'm so happy to finally have an answer to the questions of what has been going wrong this entire time that kept putting her back in the hospital, and to confirm that it is what we thought it was. I'm still frustrated this couldn't have been identified earlier in India, but even if I'd been more sure it was the issue and pushed harder I'd be willing to bet they still wouldn't have given us the swallow study I kept asking for.  It sucks when you don't have the power that you do here. It is hard not to beat myself up, because I wonder if I should have just thickened it with the rice cereal I brought for that purpose on my own and realized the doctors were wrong. It just seems so much more obvious  now that was the problem all along, but then again hindsight is 20/20.

I'm also more certain with each passing day that she was always a little tachypneic and they didn't see the respiratory rate as so much of a problem as they do here. I've been watching old videos of my babies and counting their breathing by studying their chest and necks, and the rate is often 20 breaths above what is considered normal despite high oxygenation levels. They shouldn't have to work that hard to get there, and perhaps that was why she always slept so much...she was exhausted. When this is all over I plan to write a long email to Dr. Kothiala explaining Tara's complications since discharge and recommending that they take a harder line on respiration rates and recognition of feeding issues. Dr. Kothiala I know will listen, but trying to say something to Sir Ganga Ram I know would be futile.

She has had two bottle feeds today, one of which I was able to give her! She did great but they are giving her a 10 minute time limit because she tires out due to her respiratory status and that can affect her ability to regulate swallowing and sucking and breathing. She can finish 1/2-3/4 of the bottle in that time before they give the rest via her NG tube, and from what I can tell so far it helps her not to gulp like she was before. They will keep with the bottle feeding and see how it goes, and if there are no signs of aspirations she will get to feed more and for longer periods of time. As an added bonus the nectar consistency flows at a perfect rate through a standard flow nipple...which we have a ton of and is the same type my son uses. So no worries now about buying more nipples and getting them mixed up with each other by accident!

Everyone is still non-committal on discharge, but I'm starting to think that it is unlikely she'll be home by Friday but maybe over the weekend. I have to have the prescriptions in hand before I can take her and I'm sure they'll be impossible to fill Thanksgiving day and hard to fill the day before. They have to do some exit counseling stuff, and possibly a car seat study. I also need to carve out time to talk to the social worker about filling out Early Childhood Intervention paperwork to get them in the program for developmental therapies. Plus the home health folks have to do a home visit to train us in the breathing treatments, and that scheduling could be a factor.

But after I've had a few hours of sleep it doesn't seem so bad. I'm just happy to have her home soon. Also someone awesome at work took the bullet and took my overtime mandate Thanksgiving Day, so that extra pressure is off! But the biggest reason I have a smile on my face is NEKKID BAYBEE!!! I walked into a sponge bath scene tonight and was thrilled to snap a few photos that she will hate me for later. She is 7lbs and 13oz now, and working an excellent little muffin top.

Vivek is doing well and his daily colic episodes at 1:45 am are beter some days than others. His feeding habits have shifted but my pediatrician's nurse line tells me not to worry and every month I will notice feeding changes. He will totally refuse a bottle now if he is really sleepy, and at least once a day seems to prefer a four hour nap before his bottle. He mostly makes up for it at other feedings.

 


















Interesting news in India below. As developed as India is, it just goes to show how backwards things still are there. Every day now I have such a deeper appreciation for the sense of justice and belief in civil rights that is part of American culture, thanks to the protections of our legal system and the Bill of Rights. It ain't perfect, but it is a far cry from getting arrested for liking something political on Facebook!

http://newsfeed.time.com/2012/11/19/indian-woman-arrested-over-facebook-like/

In India, the world’s largest democracy, civil rights are running up against the world of social media. On Monday police in Palghar, some 100 km north of Mumbai, arrested 21-year-old Shaheen Dhada for criticizing a traffic shutdown in a Facebook status update, the Mumbai Mirror reported. Another woman was arrested for merely “liking” that status update. Both women expressed their discontent with Mumbai being shut down for the funeral of leading Hindu nationalist Bal Thackeray, who passed away on Saturday at the age of 86 — an event that brought India’s financial hub and most populous city to a virtual standstill. The two women questioned whether the bandh, or shutdown, was necessary. Dhada quickly deleted the comment from her Facebook page and apologized for it. But that didn’t stop a mob of about 2,000 Thackeray supporters from ransacking her uncle’s orthopedic clinic in Palghar, according to the Mirror. Thackeray, founder of the extreme right-wing Shiv Sena party, has been widely criticized for inciting religious hatred and violence.

In America when even small things go wrong, you have a power here to do something about it that you don't have in India. It's not just because of the law, but because of the cultural belief system in justice that stems from it. My co-workers told me that they were surprised to read about stuff in my blog and told me "The Emily I know would have throttled the nurse for doing that!" But I didn't because I knew it wouldn't do any good or change anything for that individual, and trying to go up the chain would have even less effect. I used to think mostly negatively about our liability obsessed culture, which bears the fruit of too many frivolous lawsuits. But I took a lot of positives for granted. I appreciate more now that people do the right thing in America more often than they would otherwise because they are afraid of legal consequences that don't exist elsewhere. But I also now think our laws contribute to a culture that believes in integrity and makes us people who make better choices as individuals and a society, even when adverse legal consequences are not really practical to the situation.

I am thankful that this extended trip out of my country gave me a deeper love for my homeland, and a renewed dedication to my chosen field of law enforcement.

Day 42: Discharge day!!!

This day has been absolutely overwhelming!  I cannot believe they are actually at the hotel and mine to take care of. I'm feeling outnumbered even though at the moment there are 3 of us (including the professional nanny) and two of them. My mind has been racing all day trying to stay on top of what to do next. I'm sure if I was at home with all my stuff and perfect setup and devices and gadgets and phone and resources and nurse line AND HUSBAND I would be much more relaxed.

The hotel staff was nice enough to have four dudes help carry our stuff to our new room this morning so I got it set up to my liking. It isn't home, but it will do for 6 days.

I'd seen others discharged so I knew it would take a while. First you talk with Dr. Kothiala and get basic discharge instructions, and since I have been around here for a while they mostly consisted of what meds and supplements to administer and when. She also wrote me a prescription to fill in case I needed it for a few things. Figuring out when to give what dosages of the calcium, iron, folic acid, multivitamin, and domperidone drops took some doing but I wrote it on some hotel stationary and coordinated it with certain feedings to make it part of the routine. We have to go to the retinal surgeon for follow up tomorrow and I'll fill those prescriptions. Thursday we have to pack for the friend of Vinnie's cousin Manu who is picking up less essential luggage and shipping it to Delhi for us so we can fly light. Then back to Dr. Kothiala on Friday for follow up and to get two letters for permission to fly in case Tara is under 2kgs and a letter to their new pediatrician/neonatologist in Delhi "introducing" them as well as copies of all her medical records for the both of them.

After seeing the doctor, I had to go upstairs and pay surprise medication fees, then some more lab fees downstairs. I ran to the hotel with all their stuff and supplies and the two wooden risers they loaned us so that they can sleep with their heads elevated. We'll return the latter before we leave. Then back to the NICU after I secured a tuk-tuk to take us for the very short drive to Rama. Then we went in to see Dr. Kothiala for one last checkup before we left. She was tickled at the lovely "graduation" outfits I had for both of them. I bought them special at a store that sells doll clothes! She thought it was so cute she took a picture.

Then the short walk to the tuk-tuk with precious cargo. Mom had us stop at the Ganesh mandir in front of Rama just outside the elevator and offer blessings before we walked in.

Once inside the room I laid them down and tried to warm them up because I can't seem to figure out how to make the AC not blow so darn cold. Priyanka figured it out later for me. I changed them out of their NICU outfits into a little monkey outfit to make Mom happy and a pink ensemble for the little lady. They looked adorable and I was thrilled to have them out of their boring Indian tie on outfits they have worn every day up until now.  I promised Vivek to never dress him in pink again. I didn't do a very good job dressing them but I know it will get easier. I hate to admit my hands were shaking a bit because all the nerves were settling in. The silence of no beeping is shocking to the system. They seem to have adjusted better than me.

My little monkey man



Tara loves her new girly clothes




Tara trying to leave and go back to NICU

So none of my nightmares came true where I couldn't make a bottle. We got them right back on the NICU feeding schedule, and until they are bigger we'll stick with 2 hr feedings. I'm so glad my brother gave me those small bottles because I could bring so many that I don't spend half my day washing and sterilizing. I have changed Mr. Vivek two times already today, once because I didn't catch his pee mid diaper change...again. The other one was due to a diaper leak.

The silence between feedings is deafening. I keep thinking I should be doing something. I can't fathom sleeping but I know at some point I'll have to. So far the apnea alarms work great, and I've had a few false alarms but learned how to attach them to the diaper better. I know it is the only way I'll be able to sleep.

So many thoughts race through my head and my confidence is like a roller coaster. But I look at them and bond in a way I haven't been able to before. They are really mine. I keep repeating that but it still seems so impossible that the dream is alive and happening right now.

It is now 11pm and I'm going to try to sleep. Tara just had the oddest feed I've seen so far, and just about spit all the milk across the room. I've never seen her refuse to suck like that. She was NOT having it but we managed to get some down her. I've also never realized up until now how much these little ones toot. It turns out with all the beeping monitors and alarms in the NICU I couldn't hear it before. So I'll sleep now. In theory...

Day 41: Last day in NICU!!!

So exciting! It was our babies last day in NICU, and I still found it hard to believe that they are actually handing these babies over to me tomorrow in spite of the several day countdown to that moment. Feeding them is much easier, and Mom has bottle feeding down for both babies just fine. Master Vik has made a colossal weight jump and is just under 2kg by a hair!!! He's got some super chubby cheeks to show for it too...



Those cheeks make me want to kiss and pinch them!

Our nanny Priyanka did not show at 11am as planned, but it turned out to be Dr. Hitesh's mistake who had told her to be at his office at 10am. She was not just prompt, but she had been waiting there since 9am! She stuck around and did a bang up job at the 1pm feeding, then went home and came back for the 5pm. Mom and I decided she deserves to be paid for today because she put in so much extra time. She has been a nanny too many times to name, and has 3 children of her own. Mom asked her and it turns out her husband left her and so she pays $50,000 rupees per year for boarding school for all of them and she works like a dog to pay for it. She makes a lot doing nanny gigs, so she gives that her all. I could tell from the way she handled them that she knows what she is doing, so I may be able to sleep while she cares for them after all.

Tara wondering what life outside of the NICU will be like

It will be rough because until they are both 2kgs we are keeping them on a 2hr feeding schedule, but afterwards will gradually switch them to 3. They also have 5 different oral suspension drops to administer each day so I'll have to take notes and schedule those. I just set my iphone clock to the feeding times.

I've worked my way down all the prep lists, and just finished sterilizing all my silicone nipples so that we will only have to sterilize anything once a day because everything is now pre sterilized. I have enough of the small bottles that my brother supplied me with that we could go two days if we really had to. 


Tomorrow morning we pack up and move to the big room with the extra twin bed and small floor level framed mattress that serves as a giant crib. Dr. Kothiala will loan us some of the plexiglass risers she uses to keep the babies elevated, which we can return before we leave. I've also gotten back my 6 preemie hats that had gotten mixed in with the rest of the baby hats somehow.  I've redone my budget and solved some problems and once we get our new room setup done we'll be ready to go!!! I discussed tomorrow's transition with both babies as you can see, to a mixed reaction.

P.S. As an interesting side note to those who visit the NICU in the future, if you are wondering why there are no suctioning machines, it is because they use manual power! They have a device with a vial in the center to catch the liquid and one tube goes down baby and the other goes right into the nurses mouth! It works just as well, and perhaps even better because you can instantly adjust as needed.



Day 34: Fit to be tied

 



















So as you can see, she has once again caught up and they are both 3lbs 11 oz. I'm betting by Friday they finally reach the 4 lb landmark, which will be about double Tara's size from when she was born!

News from the USA is that my husband is fine and will be discharged today around 10am. Thank goodness! He apparently felt well enough to post on my Facebook page that he is alright and appreciates everyone's concern. I miss him so much anyway, but now I'm missing him so much my heart's about to explode.

I solved a few problems to either buy time until Vinnie gets here or avoid him coming. The first is we made some corrections to the contract so that Vinnie will not need to come to Anand to re-sign it. The second is that Dr. Hitesh said it isn't essential that Vinnie come at all to the Delhi embassy from what he knows, but I'm waiting on an embassy email to confirm that. The last problem was getting more formula, because Vinnie was going to bring 6 extra cans of Similac Neosure. I asked if Hitesh's friend Uday still had the cans of formula my friend Michelle left, but he had already given them away to another family like mine. However I asked Dr. Kothiala and she said that by the time I'll be running out of preemie formula that they will need to switch to regular fomula anyway. She assured me the Indian fomula Farex is good, so for maybe two weeks we'll have to use it if Vinnie can't come, which is no big deal. If he does come I'll have him bring Earth's Best formula, which is my formula of choice anyway.

Mom and I met with Dr. Kothiala today and discussed discharge. She didn't want to say much until she saw the results of their blood test and saw how their hemoglobin levels were. I did not get to hear the results today, but will ask tomorrow. She did say the both of us have to be comfortable with bottle feeding, so while I am (with a monitor attached for right now), Mom still has a ways to go in getting confident and having Vivek finish a bottle. She suggested I feed Tara exclusively since she is more difficult. I've gotten pretty good so that is no problem. She assured us that in two weeks we will see a big difference in their sucking/swalllowing/breathing coordination...which was good to hear. She said 1-2 weeks until discharge, we'll have to wait and see. I'm having a harder time leaving them and missing them more. It seems like all I can think about is how much I want to bring them home as time goes on. She did not suggest traveling before 2 weeks.

I finally told Master Vik about the terrible news of his Daddy's hospitalization.

Vivek was initially distressed, but I patted his belly and calmed him down. He said he looks forward to meeting his Daddy and promises not to pee or urp on him for at least one day.

Day 27-29: Bouncing back

So I've taken a few days off from blogging, mostly to have some time to deal with the news that my Mom is not coming. I'm feeling more upbeat today and feel like writing again. I tried to go to The Chocolate Room for the first time to drown my sorrows in chocolate, but it was closed for 2 days so it wasn't meant to be. So today I went to the Jungle instead, though the tuk tuk drivers seem to know it by "Hungry" that is on the sign. I drowned my sorrows in chicken tikka and kachumber salad and got a slice of a delicious bluberry cheesecake from the bakery outside. Yum! I found out that if you have your driver wait for a return trip (which you should if you are going to the Jungle or as far as) it is 150 rupees, and in the conversation to establish that they keep asking me "1 horse or 2 horse?" I have no idea what horses have to do with it, but somehow he wound up waiting for me. For the first time since I've been here, I think I ate too much.



Vivek raising the roof when he heard Dadima was coming

  

Tara smiling resting up for Dadima

But now it is only 2 days until my mother-in-law gets here! Getting the room cleaned up and prepped for company as well as babies eventually. It has been pretty lonely here except for little chats with my NICU buddy Petra and her mother. There are two new couples here that speak English, but I haven't said hello yet. But the staff at the buffet breakfast automatically make me the same breakfast every morning without me having to order since I'm “Norm” around here. Someone else named Amy emailed me and got here a few days ago for an attempt, so I emailed back and maybe we can get together for lunch.


Vivek's Dr. Evil impression



Sleepy girl



A little bit of news for Tara...her hemoglobin got low, as did Vivek's but not quite as low. It was just slightly above the normal range, so they gave them iron drops/ iodine to help their systems catch up and their bone marrow naturally produce more hemoglobin. So if you come in and find a substance that looks like brown blood leaking out of the side of your babies mouths, don't panic! It's iodine in an oral suspension they drop into their mouths. The only reasons I didn't panic are that everything in the NICU that has scared me turned out to be something I was just ignorant or inexperienced about, and it was just too brown for blood and looked more like betadyne. Hemoglobin level decline is common in preemies, and all babies actually. Dr. Kothiala explained this method avoids blood transfusions, and that all babies are born with fetal hemoglobin and it takes over a year for the body to produce “adult” hemoglobin.

Tara also had a stuffed up nose and it was making her have more difficulty breathing and feeding. They cleared it and she felt much better. I asked Dr. Kothiala how I will know to do that when I have them, and she said you can see the crust on the nose and it is pretty obvious when feeding them. I have two suction bulbs ready to go!

Yesterday I fed Princess Tara and Master Vivek, and both went better. Today as well, but I let Suvarna finish one of Tara's feeds where she wouldn't suck at all. Tara is still pretty difficult and wants to sleep and brady and desat, but she just needs time to get better. I'm not as determined to overcome the hurdle of me feeding her and being as good as the nurses, and instead focusing now on letting her overcome the hurdle and become better at it. I let the nurses feed her or finish a feed I start happily, and I'll just feed Vivek or hold them like only a Mommy can do.

The most exciting news is that Vivek is 1500 grams!!! This is a huge milestone according to all the doctor's and nurses, though I'm not entirely sure why. Tara is just under but still gaining at an appropriate rate.

I've started having nightmares again, and this time it is about having them home and being inept. No surprises there...just a continuation of the dreams I had before. The first one the babies were cleared to be discharged, and so the nurses took them out of the isolettes and put them in a box and stuck them on a shelf to make room for more babies! I came in and was panicked and didn't know what to do with them.

The second dream I kept sleeping through them crying and when they needed to eat, and I would wake up and one would be missing. In every dream I find it exceedingly difficult to make a bottle full of formula, but in the very last one I succeeded in about 20 minutes after having to rummage through a box of dozens of plastic containers that were very, very similar to the bottles but slightly different and wouldn't work.

Ramdom complaint: the glass on my iphone cracked. Fortunately it is a long one across and barely noticable, and should remain stable until I return to the states to fix it.

Only other thing worth mentioning was an interesting side conversation I had with Dr. Kothiala, where she explained the technique behind the saree I was wearing. I had considered it one of my more plain ones and probably my least favorite until I found out how much work goes into it. She told me how in the small villages they take the silk and use small beans (dal) and put it in the fabric, then tie a small string around it making the bean wrapped in the fabric with a tight tie behind it. Then they dye it and it makes a small white square where the string is, since the fabric is originally white. They repeat the process depending on how many layers of color and what color squares they want. It has to be complicated and tedious work! Below is a pic of the process, where when the fabric is stretched the strings will snap and fall off along with the tiny beans. Then you see the end result.

Day 25: Love hurts

Today was one of those days I wish I wasn't alone here.

It started off on a positive note changing rooms. The air conditioner hardly worked in my original room, the faucet was wierd, and the room setup wasn't optimal. My new room is the same size, but it is set up slightly different in a really good way that works so much better for me. It is also cleaner and has a great faucet though the bathroom is smaller. The AC blows ice cold and no sediment is coming out of it. It's amazing how refreshing and engergizing this small change of scenery is. Now if I can just stop freaking out the new resident of 308 and stop trying to open their door out of habit.

The problem was that Tara had a rough feed early this afternoon and it really shook me up. All the bottle feeds I have done turned out to be when they were hungry and semi-alert. But Tara was not any of those things. She wouldn't open her mouth, blocked the bottle with her tongue, and was determined to sleep. She didn't want to suck, and would barely swallow what she had in her mouth or would start to gag on it. I had no idea bottle feeding could be so difficult and require such subtle skill, but now I have a taste of the bottle feeding difficulties I've read about. I'm frustrated with myself that I seem inept when it comes to detecting her getting cyanotic, because something about their skin coloring being darker must make it harder for me to see when paleness or duskiness occurs. I'll try to focus on the palms of the hands or lips, but it causes me a lot of anxiety. She dipped the lowest I've ever seen her and the nurse grabbed her out of my arms and gave her some painful stimulation until she cried. I know it was good for me to see and learn, but it broke my heart. I felt like an idiot that she got down that low and I didn't realize and stop it. I thought it was a faulty monitor at first because it had just malfunctioned and had to be reattached a few moments before then. I have to be decisive during feedings about when to take breaks and burp them to keep them alert or give them rest, when to turn or tap the bottle, when to back off a bit. I need a third arm to stimulate her while the others hold her and the bottle. Sigh. Sandia assured me this is something that should not be happening around the time of discharge when I asked, because there is no way at this stage I could feed her without guidance from the nurses.

I took a late lunch break after that since I'd gotten a late start with the room switch and ordered lunch from room service, and was determined to get back in the saddle later today and bottlefeed at least one of them again. They have two weeks to improve their weight and bottle feeding skills, but I think it is still possible. I'm keeping the mantra in my head of "The most important thing to remember about the NICU is that it will end." I let Sandia handle the rest of Tara's feedings for the day, and they were equally as difficult it appeared.

Vivek was also a sleepyhead though and I applied some of my knowledge with him and felt I did a better job feeding him. Then as soon as the feed is over he wakes right up, as did she, and is being alert and adorable when he should be asleep.

I tried kangaroo care with Tara after, and then she went and desatted and bradyed pretty hard into 60%/70bpm. This time I didn't hesitate and stimulated her hard and flicked her foot hard enough to hurt until she cried loudly twice, and she went right back into the upper 90's and stayed there. Sometimes you have to hurt the ones you love. 

The most important thing to remember about the NICU, is that it will eventually be over. I ordered Domino's pizza to end the night and remember as Scarlett O'Hara said..."tomorrow is another day."



Vivek foreground Tara background



Day 23: The Comeback Kid

I am over the moon today! I feel like I'm walking 10 feet above the ground. It was a spectacular day. I though maybe next week bottle feeding would start, but they started today. Vivek decided to start off the morning showing up his sister since he was upset about yesterday.

I've decided to nickname my son Hoover for the week! He bottle fed like a pro with no desats at all and stayed at almost 100% the entire time when I witnessed the nurse feeding him! Pretty amazing. He was sucking and breathing and swallowing like the little multitasker he was born to be. I was stunned and so happy I was trying not to cry. I thought it would take weeks, and I've read how there can be considerable difficultly overcoming this particular hurdle. I got to feed him myself for the first time later that night, and he did desat at the end but that probably had more to do with my ineptitude than anything else. It won't go perfectly of course, but it is a surprisingly strong start.

Words cannot describe the joy I got from feeding my tiny boy and watching him suck away, or the overwhelming sense of triumph when I got my first burp out of him. I was pleased that earlier in the day I hadn't realized his feeding had come late and my instincts that he was hungry and frustrated were right, because I'd been operating on the assumption he had just been fed but he was acting more than just hungry. It's easy to worry so much that you won't be able to sense what's going on with your babies, but every day I trust myself more.

But the kicker was earlier in the afternoon the nurse said she though Tara would need more time and wasn't quite ready to bottlefeed. She thought she would take longer. Tara must have heard that because that evening not only did she bottle feed perfectly while I fed Vivek, but I heard the nurse yell out "first prize!" and hold up her empty bottle while Vivek still had half left! The best part was after she finished the bottle and they took it out of her mouth, she was still sucking away like it was still there. It was so incredibly cute I almost overdosed on adorable, but unfortunately my camera was in the other room.


Tara exhausted from the "bottle races"

When I hold them now I'm so much more relaxed and the alarm of any desat surprises me rather that being something I expect. They typically do a very slight de-sat now and pull themselves right out,  and if any stimulation occurs it is early in the game and mild on my part and maybe not even necessary. My only worry right now is that Vivek is so alert and moving that I worry he is not sleeping enough like his sister.

I went out to lunch to celebrate at Decent Restaurant for some more bartha. It was a yummy meal, but ended on a humorous note. I ordered a mango milkshake as a little dessert treat to celebrate the morning events, and ordered it while I had them box up my leftover bartha. I waited. Then I waited some more. How long does it take to make a milkshake? Finally I called over the waiter, and it turns out they had put my milkshake in a baggie with the leftovers. Language barrier 1, Emily 0.

On the way back I did witness something disturbing. One of the stray street dogs was trapped in between the security grates of one of the businesses, and I got the sense that it was done on purpose because it was acting aggressive. Then a man came out and began beating it with a bamboo stick. It was upsetting, but I didn't stick around to see how far it went.

Tonight the family members arrived for the baby that had been on the ventilator next to my son, but is now graduated to a CPAP though he is having some seizures. The mother speaks perfect English and sounds American though she appears to be and speak Japanese. She was full of questions for me because she could tell I was the veteran around the place, so I answered as much as I could. Unfortunately her baby is full term and a lot of my recent knowledge base relates to prematurity specifically. I invited her out to lunch tomorrow after the 11am visitation, and hopefully I can help in some way. She is staying at Madhuban, so I may follow them back to their hotel so I can try the food there because it is probably the best in town.

I got my hubby's paperwork printed out for FMLA, and I'll have Dr. Kothiala sign it tomorrow since she is easier to hunt down than Dr. Patel by far! I did speak with Dr. Kothiala today for the first time about general time frame for discharge. She asked me "how soon do you want to be caregiver?" I was confused by the question, but maybe some folks are more timid than I am and want their babies to be bigger and a little more developed or feeding more than 2 hrs apart before they take them home from the NICU. I told her that while we would have apnea monitors being brought on the 7th with my mother in law, that I wanted to take them home when she felt it was safe and the risk of apnea and bradycardias have reasonably passed. However, the sooner that happens the happier I am. She said two weeks at the earliest, so around the 13-14th of September. That means about two weeks and my husband and mother will be here!!! My husband has a fire lit under him and he is rushing around getting everything done on his to do list. Between getting the car seats installed, getting extra apnea alarm batteries, adjusting the stroller to the car seats, contacting the DNA lab, buying formula, getting proof of residency documents, and packing....he has his work cut out for him!

Day 21:Company's coming!

I'm getting so excited because travel reservations have been made for my mother in law to arrive in Anand on Sept 7th!!!! I can't wait...just have to hold on until then.

Today started by my spectacular timing. I had a slow morning and slept in and arrived late, but fortunately it was right when the eye doctor was there examining my babies. He came in just to examine the both of them to establish their risk for ROP, or retinopathy of prematurity. It is an eye disease that affects almost exclusively preterm babies, though they eventually realized the risk ran higher in developed nations where more oxygen support was provided to preemies and changed protocols. In simple terms, full term babies are born with all the blood vessels they need in their eyes, but with preemies once they are born that growth can sometimes proceed abnormally. If you don't examine babies to see if the growth of vessels is abnormal, then it can affect vision and unchecked can cause blindness. Like a weed growing on a well groomed lawn, it must be stopped before it can take over. So the way to fix it is a procedure with a green laser that will cut off the blood flow to any abnormal vessel.

It has five stages, and my son almost perfect and only at stage 1. My daughter's right eye is stage 2, but her left is stage 1. She was at more risk because of her lower birthweight. He is going to return in 15 days to doublecheck their eyes, and if the growth hasn't arrested on his own we'll look into the laser procedure to make sure their vision will not be affected. I saw him take out tiny silver prongs that I knew were for keeping the eyelids open while he examined them, so as soon as he pulled out that with dilation drops and a bright light I decided to wait in the other room of the NICU. That way I wouldn't make a blubbering fool out of myself when they struggled and cried while the two other nurses held them still.

Another sign of progress today: they were taken off caffeine! This is standard for all preemies to decrease apnea, and now that it is removed I'm bracing myself to witness them desatting or having more apnea alarms. There is a chance they may not react, but we'll just have to see. If it has a strong affect, then they can continue it into week 34. But taking that step is a sign of progress, so it's exciting.

I decided to keep myself focused on the light at the end of the tunnel by buying the two baby carriers and the two baby beds I will need for them at Seven Eleven. I placed them by the door to remind me everytime I come and go that they will be filled with babies soon. The beds have mosquito nets that you can use if you want to or put underneath, along with little head pads. The carriers are rather cheap and simple but too deep for preemies according to Dr. Kothiala, so use the little head pads from the cribs and possibly other padding to raise the depth of the carriers to help make sure the babies heads don't roll foward. They have detachable plastic backs that keep them from rocking back and forth when you set them down. The carriers are just over 1100 rupees, and the baby beds are more reasonable at 395 rupees.

I couldn't bring myself to eat my leftovers from Flavours Restaurant yesterday, so I feel guilty for being wasteful but it just wasn't what I hoped it would be when I ordered it. Tonight I tried "Decent Restaurant" and promised myself I would figure out how to order soemething I really liked. I actually found bartha, though for some reason they put corn in it too. It was pretty decent. (Sorry..it was obvious but I had to.) It has a nice view of the traffic from the picture windows on the second floor, and I saw a carriage being led by two white horses appear out of nowhere. Tomorrow I'll see if Dawat has baingan bartha (without corn) and see who makes the best in town.

Hitesh didn't seem to be in at Dr. Patel's, and so I didn't pursue getting printouts and signatures on my husband's FMLA paperwork today. However the hotel will print out the pages for me, so I may just have them do it for me and try to get them signed tomorrow. Scanning is another hurdle entirely to email back, but maybe Dr. Patel's office can help.

Here's hoping tomorrow is a more productive day and I don't sleep through bath time or have two short visits like I did today. I don't think either one of my babies got held for more than 45 minutes today, so tomorrow lots of cuddles are in store to make up for it. But they don't seem to be suffering for lack of cuddling, because today she is 1335 grams and he is 1345. That means they are both over 2lbs and 15 oz, so by tomorrow there is a chance they could both hit 3lbs!

Day 17-19: One month old!

I haven't posted in a while because Day 18 I had a splitting migraine and couldn't leave the hotel. Day 17 was typical, but ended on a sad note for me because my friend Lakshmi and her husband left to go home with their twins. I'm happy for them, but it will be that much lonelier here...though I did get an awesome hour cuddling their son while he slept on me. They very generously gave me their steam sanitizer so that I have a second one for bottles and nipples, as well as a kettle for sterilizing water for formula, baby clothes they bought locally, clothesline, hand sanitizer, and a few containers! I am also waiting to find out if their surrogate Divya's husband agrees for me to purchase her milk for at least another week. It is better for the babies to continue some breastmilk, and will help me not run out of formula too soon. As it is I'm realizing I may have to have my husband buy some more and bring it in my mother's suitcase. Thank goodness I got a pile of coupons from someone in the Mothers of Multiples Club back at home.

It was an awful day stuck in the hotel in bed, and I hope it is the last day in a very, very long time I go without seeing my children. But today I scored some Paracetamol, which may or may not be like Tylenol but makes the pain to go away sufficiently enough. I had a nice morning holding the babies, though I had to wait in the hall for the first time since they brought in a new baby who was more critical and on a ventilator. Dr. Kothiala and another doctor and several nurses have been giving that baby lots of attention and care, and they set up a chair by the bedside.

Today I decided to take a trip in a tuk-tuk out to the Jungle Restaurant, which is like an Indian version of the Rainforest Cafe. I've been there once before, and it has CHICKEN!!! I ordered far too much so that I could bring leftovers back to the hotel. It tasted fantastic, and I guess since I've been here two and a half weeks and it's the babies 1 month birthday that I should celebrate by taking a day long escape from vegetarianism. I even had a pina colada mocktail (Gujarat is a dry state unless you get an expensive personal permit) Between the chicken and talking to both my in-laws and my husband yesterday I'm feeling much better.

Two random things I noticed today. The tiny numbers off to the right of the pulse ox monitor appears to be the blood pressure, which I'd wondered about since I'd never seen one taken manually. I also noticed that they laundered and replaced the curtains, so truly no surface goes uncleaned around there. I might also mention that I've confirmed Sandia speaks pretty good English, and is an excellent nurse. I also like Anju a lot, who is a plus size gal like me and is super assertive and careful nurse who speaks a few essential words of English.
Yesterday they were officially tied! Tara had caught up with Vivek and they are both 1250 grams, or 2lbs 13oz.  However Vivek was having none of it and shot up today right after his feeding to 1305 grams, or 2lbs 14 oz. C'mon 3lbs!!! She gained 10 grams today and is looking at the 14oz mark but not quite there. 


Tara showing off her hiney during evening weigh in





But as I've been told, expect two steps forward one step back. Vivek tends to have a tiny bit of urp now, which he never did before when he was on straight breastmilk. It isn't an all out vomit, but I notice it. He also desats more but pulls himself out. He never used to de-sat hardly at all. She was having an awesome few days, but after putting him back in the crib early from kangaroo care due to a de-sat, we repositioned her to cradle hold then shoulder hold because of several. None were really bad bradys, but still frustrating. I guess their little bodies can't do everything at once when they are growing so much.  But again, must keep perspective. My babies may be the smallest, but judging by other babies needs for IV's or oxygen support alone they are doing among the best. It's just hard not to want so badly to see everything only getting better all the time I guess.

Regardless of any apparent setbacks, my mind keeps drifting to the day they are discharged and my husband and mother are here. It is so hard to wait, but when I start to calculate how many days of diapers and formula I have left and how many days until they reach 1800-2000 grams for possible discharge until then I get overwhelmed trying to predict the future. When it happens it happens and I'm once again not in control here.

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.

Day 11/12: Monkeys belong on the stairs...not NICU

So yesterday was an interesting day. Either the tuna came back to haunt me or I have gastritis from eating so much spicy food. I'd rather eat spicy food than go on a daily long quest to the few places that serve a precious few non-spicy western selections. But more days than not it seems I pay the piper for that decision. I love Indian food so much more in the US where it is a special once in a while departure from usual fare that I look forward to and enjoy. Anyway, I'll stop complaining about the food again. I'm cooking oatmeal with peanut butter in my room for a momentary reprieve.

So last night I walked back to my hotel from the NICU in shock thinking over and over again "Holy crap I yelled at a NICU nurse Holy crap I yelled at a NICU nurse...."

Let me start by mentioning about a week ago during an evening visit a nurse that I got a negative vibe off of appeared to be teasing the male nurse (?) that I only see on occasion. I am only deducing the conversation from intonation and body language, but it appeared she was giving him a hard time and took it to far. He punched her in the shoulder. It looked like it was hard and he looked genuinely angry. She looked a bit contrite and everyone settled down after that. It bothered me a lot, and I pondered all the next day whether to say something to Dr. Kothiala about it. Don't get me wrong, I understand that the culture here is a few 100 years behind in women's rights and the way women are treated here is unacceptable...but I don't expect to change the culture. My problem is that I expect them to behave professionally in a NICU. I understand stressfull jobs with long periods of downtime, and the need to goof off a bit. I honestly don't mind as long as you do your job. But getting physical is inappropriate. However since it happened once and they immediately gained some sense of decorum I decided to let it go rather than make enemies of the nurses on the shift that will get the least supervision from myself or Dr. Kothiala or Suvarna, who I respect as a leader in the NICU even if officially she may not be supervisory.

Last night the male nurse was there, but two female nurses were goofing off and got into a playful shoving match. Right next to my daughter's isollette.

I'll let that sink in for a moment.

I didn't think or ponder, I just reacted. One nurse seemed to lose balance on one foot and almost bumped my daughter's isolette and had it continued she could possibly have fallen into it. I yelled, and the only way I seem to know how to yell anymore  is in my deep-voiced police 'command and control' voice. I sounded seriously pissed, and I physically grabbed the nurse that was closest to my daughter's isollette on the shoulder and pushed her back towards the other nurse. I yelled out "NAHEEN! RUKO!" That means "NO! STOP!" in Hindi, which I'm not sure if they understood, but they certainly got the gist of it from the sound of my voice and the look on my face. They instantly retreated back to the other room and settled down, and while they still seemed to be joking around for a while after that while I said good night to my babies, they seemed contrite and I got a bowed head or two as I left.

I didn't speak to Dr. Kothiala about it because hopefully I made my point, but three strikes and you're out. I did mention it to Suvarna this afternoon because I trust her and she understands the politics there. She agreed I was in the right and their behavior was inappropriate.

Before this whole fiasco though, I had been called into Dr. Kothiala's office. I was very suprised because it was 8pm and she was still there. I was scared to death that it was about a problem with either baby, which I guess is the instant fear for anyone in my situation. Fortunately, it was only mildly bad news. She explained to me that the 2nd surrogate wanted to go home in a week. Now that Manju is also gone, from the sound of it there were a shortage of extra surrogates to provide breast milk. Dr. Kothiala said that she felt the best thing was to start my babies on formula sooner than planned, and for next week she will do formula for every other feeding and see how they tolerate it. She originally planned a formula switchover in two weeks, but now we are doing half starting tomorrow and full the week after ( a week early).

I am still concerned this could raise the risk for NEC, but it will allow my babies to grow much faster and begin learning to coordinate the skills of coordinating sucking, swallowing, and breathing that they will need to be discharged. Hopefully once we give breastfeeding a try I can produce more milk and hopefully help them along a bit. And that is another exciting note: I brought my own milk for my babies today to be added to their feed! Okay...so it is only a teeny tiny bit barely enough to wet each of their mouths with, but it's mine. I'm proud of the effort I've made and will keep at it in the hopes that I can produce more. I'm trying to force feed myself more despite my upset stomach in the hope that my reduced food intake and weight loss due to the diet changes here are a part of the problem.

Speaking of growth, Vivek is now officially over his birthweight at 1140 grams, or 2lbs 8oz. He was born at 1125. She is now at 1090, or 2lbs 6oz.  She was born at 920.

This morning was exciting for other reasons. I missed all the bathtime photo ops and didn't have any non-sleeping/covered up shots, but I have a good excuse. Monkeys.

 

 Okay, so they weren't blocking my particular stairwell...but still...MONKEYS!! I did a double take walking to the NICU when I looked up across the street to see what the dogs were making a fuss about. I was shocked to see an entire troop of at least 20 monkeys, including some babies and an obvious alpha leader who was large and perched at the highest point keeping lookout. I've seen a monkey or two in Delhi, but none in Anand and certainly never an entire troop of them! The locals seem to consider them a nuisance that are bad for business, and I'm curious if the one up top left in the first shot with the banana was given it or stole it.  I'm sure the white lady with the camera in the street with a big stupid grin on her face wearing a saree was of more interest to the locals. I also took a cool video that has the monkeys and then police and motorcycles and tuk tuks and possibly cows or some type of water buffalo I hadn't seen before moving through the street. An interesting slice of life just outside my hotel front doors.

Now if I can just see an elephant before I leave India I'll be satisfied.