Category International Activities

TEACHING TEAM
Jennifer Norgaard RNC-NIC, MSN (Lead Instructor)
Leslie Williams (Support Instructor)
Beth Case (Support Instructor)

Children’s Hospital Central California
NICU
9300 Valley Children’s Place
Madera, California

Leslie Williams teaching S.T.A.B.L.E.

ABOUT THIS MISSION TRIP
This educational mission was supported in part by two groups, FOPH (Friends of Patan Hospital), and ANMF (American Nepal Medical Foundation). Patan Hospital, the focus of our efforts, located in the city of Patan in the Kathmandu valley is known for its compassionate care and high values. Patan, which began as a small missionary hospital has emerged as a busy acute care city hospital providing primary care as well as specialty services both to the local people as well as to patients coming from diverse geographic areas within Nepal.

In the summer of 2009 we were joined by team members from across the United States for an adventure of a lifetime. Our mission was to fulfill a nearly three year project designed to train staff and provide on-going clinical support for the opening of one of the first neonatal and pediatric intensive care units in the country of Nepal.

1st baby admitted to the NICU at Patan Hospital

A country of nearly 30 million, Nepal is bordered to the north by China and to the south by India. The country struggles with an infant mortality rate of 62 per 1000 live births compared to the United States rate of 6.3 per 1000 live births, with a life expectancy at birth rated in the lowest quartile comparatively throughout the world.

The plan to establish a PICU and a NICU started in the summer of 2006 when a generous donor decided to build a maternity wing with space for the units next to the existing Patan Hospital in Kathmandu, Nepal. Patan Hospital is a 500 bed charity hospital, with 50 pediatric beds and 300 pediatric admissions per month.

Infant receiving oxygen in “head box” in newborn nursery

Preparation work for the trip included the development of training curriculum along with the procurement of supplies and learning manuals to leave with our new friends. We arrived with suitcases filled with donated baby clothes from staff in the NICU at Children’s Hospital Central California. Our curriculum, focusing on the care of critically ill newborns, was developed for a group of approximately 35 nurses and physicians working at the hospital. This curriculum included didactic lectures along with daily hands on scenario based exercises that allowed the participants the opportunity to practice and apply skills as they were learned. We started the curriculum with two days of NRP followed by two days of S.T.A.B.L.E. training. Subsequent lectures included topics such as mechanical ventilation, basic oxygen therapy, physical assessment, and basic skills labs.

Jennifer Norgaard with first Intubated Patient in the NICU

The 6 bed pediatric and 6 bed neonatal units were newly built and furnished with much of the latest available technology including infant incubators, warming tables, IV infusion pumps and state of the art ventilators and a blood gas machine. The technology enhancements contributed greatly to the success of the intensive care units, however, much is still needed to continue and sustain the efforts of the team. After nearly three weeks of training, the NICU admitted its first patient in early July, 2009.

How do you envision The S.T.A.B.L.E. Program will help the health care providers you taught?

S.T.A.B.L.E served as foundational content for the entire NICU curriculum. Both physician and nursing attendees were able to gain core competencies in the stabilization and care of ill newborns. These competencies were demonstrated as the NICU admitted it’s first patient and the principles were applied and reinforced. Learner manuals (provided by the S.T.A.B.L.E program) were left with the hospital as they sought to continue the program for future caregivers. Teams from the US are planning return visits in March and November of 2010 to reinforce learning and skills taught in 2009.

Teachers and Students together

Materials donated by The S.T.A.B.L.E. Program: 10 Learner Manuals

MaryJane McGregor teaching in Kiribati

April 25th –May 3rd, 2004 Lead Instructor M.J. McGregor, BSN, RN and Support Instructors, Weatherford Clayton, MD, Douglas Coombs, MD and Gordon Lassen, RT presented the S.T.A.B.L.E. Learner Program on the Island of Tarawa in the Republic of Kiribati. (Pronounced Kir-ree-bas). The Republic of Kiribati is an island group in the Western Pacific Ocean, consisting of an archipelago of some 33 low-lying coral atolls surrounded by extensive reefs with a total land area of 800 square kilometers.

The trip to Kiribati was sponsored by the Humanitarian Services Department of the Church of Jesus Christ of Latter-day-Saints (LDS), which brings S.T.A.B.L.E. and Neonatal Resuscitation (NRP) training to physicians and nurses in remote areas of the world.

Graduating class

A group of 59 physicians, midwives, nurses and nursing students enjoyed 2 days of NRP training and 2 days of S.T.A.B.L.E. training. Both programs were very well received. The group was very eager to learn and excited about the information presented. Many of the concepts were very new to the majority of the group, but they were grateful for the information and eager to begin using their new skills and information in the nursing school curriculum and in their practices.

The classes were held in an LDS church facility. The building was beautiful with a gorgeous view of the ocean right out of the classroom window.
There are some challenges, however, in teaching in these remote areas. First, many of the supplies that were shipped in advance did not arrive. The S.T.A.B.L.E. manuals were in the boxes that did not arrive. However we learned this before leaving the U.S., and we were able to take 40 Learner books with us. We did have some instructor books as well, so almost everyone ended up with a book.

Second, we really did not know the training or capabilities of the staff attending the class or any information about equipment that was available to the staff in the hospitals and clinics. It would have been helpful to know these things in advance so that we could tailor the course for them and their abilities.

Students taking post test

We originally were planning an instructor course as well as a learner course, but we soon realized that no one was qualified to be a lead instructor. None of the doctors had any high-risk neonatal training. We therefore did not teach the instructor part of the course. There were however, some attendees capable of teaching certain sections of the class, so some will be registered as support instructors. However, they will not be submitting rosters since they have no lead instructor on the island.

The situation in Kiribati is interesting. They have no way to transport sick babies from the outer islands to Tarawa where the hospital is located except by small boats. On the outer islands, they have some small clinics, but most babies are delivered in their homes or huts. If the patients do survive long enough to get to the hospital in Tarawa, there is no way to transport them to a larger hospital with more neonatal services except on a commercial flight that flies once or twice a week to and from Fiji. Therefore, the mortality rate in Kiribati is quite high, about 51/1000 births compared to the US which is 7/1000 births.

Babies born in the hospital at Tarawa do have the advantage of one working isolette. They can provide IV therapy and do blood gases. They also have one O2 saturation monitor that works part of the time.

I was very impressed with the dedication and excitement of the people of Kiribati. Even though they lack much of the training and equipment that we take for granted, they want desperately to improve the care that they give to newborns. Their dedication is inspiring under very difficult circumstances. I have no doubt that as they implement the information and skills they learned and practiced in NRP and S.T.A.B.L.E. they will improve the outcomes for the children of Kiribati.

More photos from Kiribati:

                                      Norma Brown teaching in Honduras

Two S.T.A.B.L.E. Lead instructors, Norma Brown (Nevada) and Ramona Wilder (Utah) traveled to Honduras in March 2004 to implement the S.T.A.B.L.E. Program (Learner and Instructor courses) in two locations (Tegucigalpa & San Pedro Sula). Norma Brown submitted the following trip report upon her return. We are very grateful for the expansion of the S.T.A.B.L.E. Program to so many healthcare providers in the many countries who feel they benefit from this increased knowledge and systematic approach to caring for sick infants.

In March, Ramona Wilder and I had the great opportunity to bring the S.T.A.B.L.E. Program to physicians and nurses in Honduras. The program was very well received and both physicians and nurses were very excited about the possibilities of implementing this program in Honduras. This was such a rewarding and wonderful experience for us.

The trip to Tegucigalpa & San Pedro Sula, Honduras, was sponsored by the LDS Church Humanitarian Services, to bring both the Neonatal Resuscitation Program (NRP) and S.T.A.B.L.E. Learner Program instruction and training to physicians and nurses.

• In Tegucigalpa, there were 57 participants in the S.T.A.B.L.E. Learner Course and nine participants in the S.T.A.B.L.E. Instructor Course. There were 17 physicians and 40 nurses and other healthcare providers in attendance. We held both courses at the LDS Conference Center in Tegucigalpa. Two physicians registered as Lead instructors and seven physicians registered as Support instructors.
• In San Pedro Sula, there were 33 S.T.A.B.L.E. Learner Course Participants and seven S.T.A.B.L.E. Instructor Course participants. There were 23 physicians and 9 nurses in attendance. Both Learner and Instructor courses were held at the Hospital Mario Catarino Rivas Conference Center, in San Pedro Sula. Four physicians registered as Lead instructors and three physicians registered as Support instructors.

The NICU Unit in San Pedro Sula, Honduras

The biggest challenge we faced on this trip was trying to teach the S.T.A.B.L.E. Learner and Instructor course without manuals! Unfortunately, the books had arrived in Honduras, but customs would not release them in time for the course. We did have the Spanish version slide presentation to guide the course; however, it was still difficult to present the material and explain the charts and graphs without the books. Nevertheless, the enthusiasm and interest expressed by the participants, particularly in Tegucigalpa, was great.

In discussion with the groups, participants identified several issues concerning their situation in Honduras.

First, Emergency Medical System and Ambulance Services essentially provide transportation from one place to another, but no one is available to monitor or provide care to the patient during transport. There are no trained personnel who are available for transport of patients. This, of course, poses a great problem for transport of an infant. Second, small hospitals in rural areas do not have trained personnel or equipment necessary to stabilize ill newborns.

The group of new S.T.A.B.L.E. Instructors were already planning a proposal to submit to the city government for funding to provide S.T.A.B.L.E. Program instruction and training to Ambulance personnel in the city and in rural areas. This would raise awareness of the importance of monitoring the infant during transport and at the very least, keeping the infant warm. In addition, there was much interest in taking the S.T.A.B.L.E. Program to physicians in rural areas to instruct them on neonatal stabilization and transport.

The NICU Unit in San Pedro Sula, Honduras

All in all, I must give tremendous credit to these groups of physicians and nurses, who despite the lack of resources and personnel take wonderful care of sick neonates. Their dedication and commitment are unsurpassed. I wish them great success in their endeavors to implement the S.T.A.B.L.E. Program in Honduras.

TEACHING TEAM
Jill Bauer, BSN, RN, Neonatal Outreach Nurse, S.T.A.B.L.E. Lead Instructor
Stephanie Damlo, BSN, RN
April Weston, RN

Children’s Hospitals and Clinics of Minnesota
Minneapolis, MN

April and Stephanie demonstrate how to respond to apnea and bradycardia spells with hands-on skill practice.

ABOUT THIS MISSION TRIP
In March 2010, several nurses from Children’s Hospitals and Clinics of Minnesota in St. Paul and Minneapolis campuses traveled to Guatemala on behalf of the Baby’s Breathe Project, located in Minneapolis, Minnesota; and the Children’s Hospitals and Clinics of Minnesota. Baby’s Breathe Project is the non-profit start up of two NICU nurses, Meg Dornfeld and Terri Tjaden, from Children’s Hospitals and Clinics of Minnesota. While vacationing in Guatemala several years ago, they decided to reach out to a hospital to see if they could do anything to progress the education and care of neonates while they were in the country. They contacted a Neonatologist from Roosevelt Hospital in Guatemala City and that relationship began the efforts to improve the education of nurses and outcomes of infants in that region, which is now three years in the making. Our S.T.A.B.L.E. Instructor teaching team has taught the S.T.A.B.L.E. Program for the past two years in Guatemala, which has been extremely well-received and popular!

Guatemala City sits in the central region of Guatemala. The climate is very tropical, warm and humid. Our teaching began at Roosevelt Hospital, the tertiary NICU of that area which cares for approximately 85 NICU patients per day. The lowest gestational age that they care for is 28 weeks. Equipment in the unit includes ventilators, oscillators, isolettes, CPAP machines, IV pumps, UV/UA lines, etc. However, shortages of equipment, in relation to the numbers of babies, often limits which infants can be monitored and supported with the equipment. Usually 1 or 2 neonatologists staff the unit along with several nurses. Medical students also provide a very vital role in caring for patients in the NICU. In addition to these caregivers, there are also designated lactation consultants which provide important education and assistance to mothers. Kangaroo care is highly encouraged as well, with both mothers and staff participating.

A tiny infant in the NICU at Roosevelt Hospital.

One of the rooms in the NICU at Roosevelt Hospital.

The nurses love and appreciate the education very much, as options for advancing knowledge are limited. They also enjoy doing simulations which allow them to participate in actual hands-on activities, incorporating the principles taught in the classroom. After one class was completed, a physician told us that some of the nurses were enthusiastically practicing interpretation of blood gases on patients in the NICU and incorporating principles of infection prevention. The course had sparked a curiosity and enthusiasm in them that he was very exciting to see!

In 2009, we had approximately 100 nurses and 10 medical students or residents from 2 hospitals attend the S.T.A.B.L.E. Course. In 2010, we had 190 nurses and approximately 15 medical students/MDs from 26 hospitals in attendance.

The Guatemalan nurses really enjoyed being able to practice hands-on skills with April.

Jill teaching a small group of nurses how to calculate lab results. A medical student assisted with interpretation.

Shown below are some of the comments made by students who attended the S.T.A.B.L.E. course.

“In 17 years of seeking education in Guatemala, you taught me more in 2 days than I have learned in all these years! Thank you so much! Please come back again.”

“The training was excellent, the practice was very good. I learned very elementary and basic things that if you act immediately, can save the life of patients. If possible, we would like these skills more frequently. Thank you very much, I learned alot.”

“Thank you for the course, it was very good. I hope that it will continue and we wait for you next year”

“Thank you for all of the knowledge, we hope to see you again. Thank you, thank you to all.”

“Thank you for expanding my knowledge and taking into account these activities which helped my professional competency. God bless.”

After learning the S.T.A.B.L.E. Program, 2 nurses returned the next morning with a thank you gift to express their gratitude.

Guatemala is in great need of resources for education that are written or recorded in Spanish. They also have a need for items such as Ambu bags, oximeters and cardiac monitors along with any and all types of NICU supplies (tape, duoderm, breast pumping equipment, stethoscopes, blood pressure machines, etc.)

For additional information on how you can help, you may contact the Instructor directly though this link. Contact the Instructor

MATERIALS DONATED FROM THE S.T.A.B.L.E. PROGRAM: 5 Spanish CD-ROM Slide Programs that were given to key educators/physicians in the hospitals who attended in Guatemala City.

1 Cardiac Student Handbook, which was given to a local pediatrician who desires to become a pediatric cardiologist.

Skill practice drawing from a simulated umbilical line.

200 nurses from 26 Guatemalan hospitals showed up at a hotel in Guatemala City where we presented the S.T.A.B.L.E. Program and other infant care teaching.

Guatemalan nurses practice hands on skill of bagging an infant.

Nursery where infants with neurologic issues are managed.

NICU at Roosevelt Hospital where they care for about 85 infants each day.

A Beautiful Guatemalan baby in the NICU.

After helping one of the mothers on the OB unit whose baby was in the NICU, she named her baby after me! A very touching moment! Meet little baby Jill!!!

Cynthia Jensen RN, MSN, CNS, CCRN
S.T.A.B.L.E. Lead Instructor and Neonatal Outreach Educator UCSF Children’s Hospital
Jennifer Parson RN, BSN UCSF Children’s Hospital
David Wanderman MD Department of Pediatrics UCSF Children’s Hospital
Andrea Marmor MD Department of Pediatrics San Francisco General Hospital

Jennifer Parsons teaching how to bag-mask ventilate to one of the physicians

The International Pediatric Outreach Project (IPOP) was founded in 2002 by two pediatricians, Dr. Theodore Ruel and Dr. Sadath Sayeed, with the broad aim of improving the health of children in developing countries through direct and lasting collegial relationships with local health providers. The strategy of IPOP is to assist these providers in addressing what they consider the most pressing problems of child health in their communities through education, research and material support.

Reviewing principles of post-resuscitation stabilization with a bedside nurse

Armed with a generous donation of books and supplies from the S.T.A.B.L.E. program, our team from San Francisco travelled to Heal Africa Hospital in Goma, Democratic Republic of Congo (DRC) to provide a week of medical and nursing education with a focus on neonatal resuscitation and stabilization. Approximately 50 students attended the first class and by weeks end we had upwards of 150 participants from Goma and neighboring communities. We were unable to cover the entire S.T.A.B.L.E. learner course for a multitude of reasons (rain, time constraints, availability of translators) but we were able to provide parts of the curriculum and look forward to returning to Congo so we can continue to reinforce what we have taught and also expand on those concepts.

Blood pressure lecture

The Democratic Republic of Congo is a country that has endured more than its share of strife. War, poverty, disease, gender violence and internal displacement of citizens fleeing conflict are some of the issues that the Congolese deal with on a daily basis. In 2002, the volcanic eruption of Mount Nyiragongo covered Goma with lava making the roads impassable and the soil unusable. Shortly after we left, a plane crashed in a highly populated area in Goma, killing passengers and local residents. 93 people were admitted to Heal Africa Hospital overwhelming the staff and depleting the entire supply of Tetanus vaccine and saline. Even in the face of this crisis, the Heal Africa staff rallied to aid crash victims. Their strength and resilience is amazing and inspiring.

Cynthia Jensen and children at Heal Africa Hospital

One member of our team, Jennifer Parson RN, stayed in Congo for 10 weeks to help create an intensive care nursery at Heal Africa Hospital. Jennifer has done an amazing job starting with an empty room that is now a growing unit. She has been training a core group of nurses to care for this special population. IPOP will continue to mentor and support our colleagues with the shared goal of improving outcomes for mothers and babies in Congo.

Heal Africa MDs and mannequin

Materials donated by The S.T.A.B.L.E. Program:

• 20 Learner Manuals
• 20 CD-ROM Slide Programs
• 20 Bedside Quick Reference Cards
• 20 Physical Exam and Gestational Age Assessment CD-ROMs
• 2 Cardiac Module CD-ROM Slide Programs
• 4 Cardiac Module Handbooks

First patient admitted to the NICU

Babies with their Mom�s in the NICU

Physicians rounding in the NICU