Monday, February 2, 2009

Neonatal Resuscitation Training Project

January got 2009 got off to a very busy start. To save some time and keep the blog going, I'm posting a report that was prepared for the 8 days we were on the road last month. Not sure how close to the actual report this attempt will turn out, but I'll give it a try. If any bloggers out there know how to upload a Word document and post it intact, let me know. I'm still doing copy/paste.
A team of volunteer doctors came to India as part of a Latter-day Saint Charities project to train trainers in neonatal resuscitation. You will see references to the 'First Golden Minute', the name IAP has chosen for its NR project. The name refers to the first minute of life for a newborn when asphyxia is a fairly common problem and is the source of many infant deaths or results in brain damage. Getting birth attendants trained in ventilation procedures is a proven way to reduce the infant mortality rate. Unfortunately, India has states that are among the world leaders in infant mortality. This was a very significant event as we now have an organization, Indian Academy of Pediatrics, that appears to have the leadership and vision to really do something about it. Their First Golden Minute project was launched with the support of LDSC and with the American Academy of Pediatrics (AAP) joining in the Bangalore event. Working on this project was frustrating at times, but in the end, it proved to be very rewarding to realize we played an important part in its success. The project report follows:
GANDHIDHAM, GUJARAT – January 17th and 18th NR Training

The logistics for the NRT events proved to be interesting undertaking. Dr Robert Clark, Dr Richard Bell, Dr Donna Dizon-Townson, and Dr Jack Christensen were the assigned members of the LDSC medical team. Dr Christensen received word at the airport just prior to departing to come to India that his father was failing fast. He returned home to be with his father. The needed materials that Dr Christensen was to bring had to be replaced on the fly during the events.

Dr Walter Townson, traveling with his wife, Donna, was certified in NRT and did an outstanding job by stepping in to help in Gandhidham. He could not stay for Bangalore due to prior commitments. Drs Clark and Bell flew into Mumbai from the states on Thursday evening. The Townsons had arrived a week early and were touring in northern India. They flew into Mumbai Friday morning from Jaipur and the Tanners flew into Mumbai from Delhi Friday morning. Everyone connected in the Mumbai airport and flew together to Bhuj on the same flight.

From the Bhuj airport, the team travelled in cars to Gandhidham and stayed at the IFFCO guest house. IFFCO is the Indian Farmers Fertilizer Cooperative and has a company residential township with a guest house in Gandhidham. It was a very clean and green area. One sign read, “Want free oxygen? Plant a tree.” IAP paid for all of the LDSC team’s ground transportation to, from, and in Gandhidham, and their accommodations and meals during their stay.

The local Rotary Club provided their hall for the neonatal resuscitation training event. It was well suited to the purpose with a stage, ample seating, and plenty of room on the periphery to set up practice stations on long tables that they provided. Attendance exceeded pre-registration and the planned number to be trained by more than 25%. There were 8 practice stations, 4 manned by LDSC doctors and 4 manned by IAP trainers, one each per table so the IAP doctor/trainers could also benefit from the LDSC doctor. The Gujarat state government sent 40 of their medical officers to receive the training and fully supported the event.


On Saturday, while 52 doctors were being trained downstairs, around 30 paramedic personnel, similar to LPNs in the states, received basic resuscitation training at 3 stations manned by Indian instructors in an upstairs location. The LDSC team rotated providing oversight and coaching at the 3 upstairs stations during breaks in the training downstairs.

At the conclusion of the event, the Gujarat State Superintendent of Nurses told Elder and Sister Tanner that she wanted bags and masks in the hands of all birth attendant nurses and wanted them trained in their use. She was sold on the NR program and seemed very motivated to make it happen. It was great to see someone in a government position that caught the vision of what LDSC was attempting to accomplish.

Dr Jagdish Chandra, an IAP executive and one of the national coordinators for the IAP Golden Minute program (NRP), came from Hyderabad to attend the 2 day event in Gandhidham. He is a certified NR trainer, but he made the comment that he came to observe and learn from the teaching techniques used by the LDSC doctors. He provided critical assistance in arranging supplies in Bangalore to make up for the advanced kits that did not make it from the US.




















A press conference was held right after the Saturday training and reporters attended from as far away as Ahmedabad, 200+ Km.

The local Gandhidham papers carried stories of the NR training event in Gujarati and at least one had a picture of Drs Clark and Bell. Elder Tanner was told that all of the Gujariti language papers had mention of LDSC. The best report of the event for LDSC recognition was the following in an Ahmedabad English language paper. The acronym may be short a letter, but the name is correct.


Saturday evening, a dinner was held for the IAP leaders and spouses and the LDSC team. The Gandhidham Rotary president, Vijay Hariyani, secretary, Mulraj Thacker, and a board member, Raghuvir Goyal all came to meet Elder and Sister Tanner and stayed for dinner. Earlier in the day, Elder Tanner had talked with a gentleman who was retired from the Indian Air Force and a Rotarian. He had come to the hall to see what was going on at the training. That visit ultimately led to the local Rotary president coming to the dinner and seeking out Elder Tanner. Elder and Sister Tanner had a delightful time at dinner with the three gentlemen as the five sat together. Elder Tanner jokingly referred to the board member, Raghuvir, as ‘spicy man’ because he added lots of additional spicy condiments to his soup and other dishes. There were many laughs about ‘spicy man’ during the rest of the meal. Afterwards, the Rotarians insisted on taking Elder and Sister Tanner back to the IFFCO guest house. While saying goodbyes with hugs, etc., Mulraj made the comment that Raghuvir wasn’t Spidy Man, he was spicy man. Everyone had another really good laugh over that one. It is amazing sometimes how close you can feel to people in such a short time.

A training session was held on Sunday in order to accommodate the only time available for the doctors that had traveled in for the event. Afterwards, the LDSC doctors left to fulfill another obligation while Elder and Sister Tanner took care of the training gear. It was a challenge gathering and sorting materials and putting things back together. Over an hour later, the basic kits, the manikins, and the bag and mask kits were together and then everything left was put in the large bags to take back to the hotel. Dr Naveen Thacker had waited while Elder and Sister Tanner cleaned up and once they were finished, six Baby Anne manikins and 10 basic training kits were presented to him for IAP use. Four more Baby Annes were delivered later that did not make it to Gandhidham in time for the training event. Fortunately, Dr Clark had 5 advanced manikins with him for Bangalore that had to be carried from the US and everything worked out just fine.

When the LDSC team was all together again later at the hotel, the contents of the large bags were dumped on the bed and everyone had a good time sorting things out and putting as many of the advanced kits back together as possible. Once that task was finished, things were as ready for Bangalore as they could be without additional supplies.

Sunday evening after dinner at the guest house, the LDSC team met in Dr Clark’s room for a sacrament meeting. It is reasonably certain that it was the first time the sacrament had been administered in the Indian state of Gujarat, definitely the first time in Gandhidham. After the sacrament was administered, all bore their testimony. It was a spiritual and tender time in a hotel room for the six team members and a fitting end to a very busy Sunday.

Monday morning, before leaving the guest house, Dr Thacker took everyone back into the dinning hall where the LDSC team was individually introduced to Ashok Bhatt, Speaker of the Gujarat Legislative Assembly and to an Assembly woman (name was lost). The Assembly woman is a doctor by profession and was aware of the NR training that had taken place. Both expressed support for the IAP program and thanked LDSC for its participation.

Summary

• Over 100 doctors received IAP certification as neonatal resuscitation trainers.
• All of the doctors benefitted from conducting practice teaching sessions and received coaching on positive teaching without intimidation.
• More than 10 IAP doctors specifically attended to observe and learn the administrative, logistical, and teaching aspects of conducting neonatal resuscitation training. This will strengthen the IAP First Golden Minute project.
• Training down to the non-MD birth attendant level was emphasized along with the goal of having at least one person trained in NR present at every birth in India.
• Several Gujarat state officials caught the vision of the IAP NR program and left the event committed to support it.
• The objective of successfully conducting a pilot IAP First Golden Minute training event in Gandhidham was met.
• 10 Baby Anne manikins and 10 basic training kits were delivered to IAP.

The LDSC team visited the Bhuj district hospital on the way to the airport and met briefly with Dr Suryakant Bheda, Chief District Medical Officer and Director of the hospital. A tour of the Pediatric and Neonatal wards was provided. The LDSC team left Bhuj and flew to Mumbai. Drs Clark and Bell then flew from Mumbai to Delhi for a meeting Tuesday morning with UNICEF, NNF, and IAP officers. The meeting was also attended by 2 representatives from the American Academy of Pediatricians (AAP). The IAP First Golden Minute program has apparently ruffled some feathers at NNF, an organization that views neonatal resuscitation (NR) as their program, but it appears it may be as much a face saving issue as a turf issue. It was a good thing that LDSC was represented at the meeting. Dr Donna Townson and Elder and Sister Tanner went on to Bangalore and Dr Walter Townson stayed in Mumbai to catch his flight home that evening.


BANGALORE, KARNATAKA – January 21st and 22nd NR Training

The neonatal resuscitation (NR) training was the launch event for the IAP First Golden Minute Project, a national program in scope with an objective of training 250,000 skilled birth attendants in 5 years. The First Golden Minute training was scheduled for the 2 days prior to the Pedicon 2009 conference in Bangalore which would draw over 7,000 attendees. This training event was targeted specifically to State level trainers and IAP officers from all over India who will play key leadership roles in the FGM project rollout. Two LDSC doctors were invited to participate in the Pedicon 2009 conference. Dr Clark addressed a plenary session on Saturday and Dr Bell was a panel member in a Friday panel discussion.

The NR training venue, the Nursing School’s auditorium at St Philaminas hospital, was excellent. The lecture space was partitioned off and immediately adjacent to the practice area which was large. It facilitated a very efficient transition from lecture to practice sessions and back. There were several adjacent classrooms available for training faculty meetings and participant testing.

Tuesday morning, Dr Townson and Sister and Elder Tanner took a break and went to Mysore to visit the Palace. After spending 3 hours down and 3 hours back in a car with 2 hours to sightsee, that decision might be different next time, but it turned out to be a good break. An hour after returning, they met Elder and Sister Fairbanks at the hospital who brought the equipment that had been shipped to Bangalore in advance.

The group met with Dr Ranjan Pejawar and Dr Archana Bilagi who practice at St Philaminas and were in charge of the event. They were both great people to work with. All of the supplies had been delivered that were required to prepare the additional advanced training kits. Dr Chandra, who attended in Gandhidham and offered to assist the team, came through for LDSC. He also brought five intubation heads from Hyderabad the next day to complete the training equipment needs.

Seven tables were set up on the floor and 3 more on the stage, each with ample room around it to accommodate the personnel involved. The ends of each table were set up for a total of 20 training stations. The 20 stations were not equipped exactly as originally planned due to several logistical problems, but LDSC managed to cover 15 stations and using Laerdal’s new NeoNatalie manikins and 5 intubation heads that came from Hyderabad, it all worked out.

The LDSC team was down to 3 doctors in Bangalore, but the shortfall was made up by six AAP doctor/trainers from the states and eleven IAP doctors/trainers.

The next hour and a half was spent organizing and setting up the practice stations while Dr Archana put several interns to work assembling the advanced training kits. We left the hall knowing everything was in place for Wednesday’s session except for the 5 manikins that would come from Laerdal and the 5 heads coming from Hyderabad.

Tore Laerdal, CEO of a Norwegian company that makes all types of manikins and simulators used in medical personnel training, was in Bangalore to attend the training. He brought 14 manikins with him. The manikins were a new type, NeoNatalie, being developed to go with the AAP’s Helping Babies Breath (HBB) program that should be launched sometime this year. Mr Laerdal approached Elder Tanner in the hall before things began early Wednesday morning and politely inquired why only 5 of his manikins were being used. Once it was explained that intubation capabilities were needed at each station and the number of intubation heads was limited, he understood. The 11 advanced manikins all had intubation capability, the new NeoNatalie manikin did not.

While the early lectures were going on, Elder Tanner spent time evaluating the new Laerdal NeoNatalie manikin. With its new features, it is actually a low level, manually controlled simulator. The instructor has the ability to control the heart rate and the breathing so the student has to evaluate the baby, not be told what the situation is as occurs with the current manikins, both basic and advanced. It has positive audio feedback during chest compressions. The new manikin is collapsible and is either water or air filled or a combination of both. If water is used, the weight and feel of the manikin is close to that of a real baby. Elder Tanner noticed that the manikin on station #1 appeared to be leaking and it was replaced. Later, when Elder Tanner attempted to demonstrate the breathing rate feature, it would not work. An inspection led to the discovery of a crimping situation where the external tubing was connected to the internal tube. The internal tube was stiff and seated to a metal connector. The external tube was very pliable and depending on how the baby was packed, handled, etc., the external tube could crimp at the edge of the metal connector blocking air flow. This condition, to varying degrees, was found on 4 of the 5 manikins in use.


During the morning lecture session, Tore Laerdal approached Dr Clark about LDSC supporting a proposal he wanted to make to IAP. Dr Clark in turn talked to Elder Tanner who expressed concern with the new manikin’s reliability given the 2 observations that morning. It was agreed that Elder Tanner would talk to Tore Laerdal. When Elder Tanner approached Mr Laerdal, he was very interested in what was shared and spent time with the elder reviewing the design of the manikin. He agreed that there was a design problem and took notes and pictures of the tubing and connection point. He also followed up on the suspected leak and reported back that the problem was the fill tube valve which had not been properly closed. The manikin itself did not leak.

Mr Laerdal explained that the new manikin was less expensive than the Baby Annes that LDSC had agreed to purchase for IAP. If the NeoNatalie manikin was purchased instead, the number of manikins could potentially increase from around 200 to 300. If that were done, then Laerdal, Inc. would gift the same number purchased increasing the total to IAP to 600. He also committed to an immediate 1 for 1 replacement of any manikin that leaked or had any other defect. In return, he wanted IAP to provide feedback on their use of the manikins in training. Training suitability, reliability, and any other observations on the manikins use they could share. In essence, he was looking for a field trial for the next engineering version that would be ready sometime in March. It was agreed to pull a meeting together with Mr Laerdal, IAP, Drs Clark, Bell, and Elder Tanner.

The meeting occurred during lunch. After emphasizing that the decision was IAP’s and LDSC would support their decision, Elder Tanner gave a soft endorsement of the manikin and its benefits based on the limited experience at the training. IAP said they would take the offer under advisement and present it to their officer group for a decision. Mr Laerdal will prepare an MOU outlining his offer and expectations for both parties.

The certificate below was presented to all training faculty who taught at the event. All LDSC team members were considered faculty. 92 attendees who successfully completed the NRP training and the associated testing received a similar certificate that included the LDSC logo and program sponsor reference.










During one of the first day lecture sessions, Dr Bell was given time to respond to many inquiries from attendees about who or what LDSC was. He explained the role of the LDSC organization and how it was related to the Church of Jesus Christ of Latter-day Saints. Given the audience and the high profile of many in attendance, that 5 minute talk by a stake president was golden.












Thursday evening was the opening session of Pedicon 2009 and the new IAP president, Panna Choudhury, addressed the conference. He spent considerable time on the First Golden Minute Project and the role and support of LDSC for that IAP project. Drs Clark and Bell were in attendance and reported on the incoming president’s address.




Top - AAP, IAP, and LDSC Faculty
Bottom - Faculty, IAP Officers & Trainers, Hospital Personnel

Summary

• 92 doctors key to the IAP First Golden Minute project were trained in NR techniques as well as administrative and teaching aspects of an NR program and received certification. These men and women will constitute the core national leadership and state training resource for the IAP First Golden Minute (FGM) project.
• At least 10 more doctors received certificates of participation, but did not qualify for certification.
• LDSC received significant recognition for its role in NR training and support. Its association with the Church of Jesus Christ of Latter-day Saints was clearly presented to all in attendance. That association was followed up on multiple times by LDSC team members in individual conversations with attendees.
• LDSC received recognition regarding the FGM project in the incoming president’s address at the opening session of Pedicon 2009.
• Contacts and requests for NR training were made with officers of additional medical associations. These may provide opportunities for IAP to prepare and instruct without LDSC participation.
• NNF was recognized and an NNF officer given an award during the training. IAP is apparently working hard to improve relations with NNF regarding NR training.
• 5 advanced manikins and 5 complete advanced training kits were delivered to IAP for use in their training program.



Some of the Bangalore NR logistics team.
L-R Dr Bhala, Elder and Sister Tanner, Dr Archana, Sister and Elder Fairbanks.







To Conclude, Three Noteworthy Observations:

1. At both training locations, but especially Bangalore, multiple IAP trainers mentioned that though they had been NRP instructors for many years, the techniques of teaching employed by the LDSC staff were well worth emulating. They were all very positive about the LDSC training approach, even when compared to the approach used by some of the AAP faculty.

2. Comments from Dr Richard Bell, an LDSC team member. “…I have been doing this for about 17 years now and I have never seen the Church get better press or better acknowledgement in the past…it was absolutely remarkable to me how visible the Church was in this entire process at both training sites…Rob and I both discussed what a remarkable thing it was to have this degree of visibility for the Church. As each of us was introduced for the IAP Pedicon [2009] meeting presentation, we were both introduced as representing LDSC.”

Note: The introduction mentioned was in front of 7,000 doctors and medical professionals and the usual cadre of press and media personnel for a large, national level event.

3. The following is an unedited email received from Dr. Vyas from the Gandhidham training in which he forwarded photos and comments to Dr Clark. Note especially the comment about his discussion with the District Health Officer:

Dear Dr Robert Clark


greetings it was wonderful experience with you and your NRP team at Gandghidgam. we learnt as well shared the experiencee very much. I am really hopeful for health workers attitude, skill and enthsiasm during training. With your constant support and guidance we can make each and every delivary in periphery with traned NRP persons avalability. I discuss with my district health officer aftewr arrival here, he is already agree for purchase equipment as well training for their health workersI am sending few memories of the workshopthanks with regards


Dr Bhaddresh Vyas
Professor and head of Pediatric Department
M P Shah Medical colleger jamnagarindia




























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