During the past few months, the LFHC team has faced an extraordinary challenge: caring for two of the smallest infants ever admitted to the Neonatal Unit.
The first, Airnoy Larnoy arrived at LFHC on Feb. 12 after spending three days at a district hospital. She weighed a mere 28 ounces (800 grams) at birth and was much smaller than our average neonatal patient.
Our nurses and doctors were concerned about the infant’s ability to survive, but they were not discouraged. Over the next several weeks, they worked diligently to care for her. They administered IV antibiotics, IV fluids, multiple medications, phototherapy, a nasogastric tube to help her feed and a blood transfusion. The clinical staff became optimistic as she responded to the intensive care and started to grow.
Airnoy Larnoy was discharged weighing more than four pounds (just over 2 kg). It was an exciting day for the staff, which deftly handled a very challenging case and saved the life of another tiny patient.
Not to be outdone, a second tiny infant, Airnoy Vahn, arrived on March 7, weighing only 21 ounces (600 grams). Born at home, he and his parents travelled for two hours to reach LFHC. The team at LFHC immediately applied life-support measures. Much like Airnoy Larnoy, Airnoy Vahn required a lot of specialized support, but showed steady progress over the course of his stay, which lasted nearly 12 weeks. By the end of May, he was discharged, weighing 3.3 pounds (1.95 kg), and secured his place as the smallest Neonatal Unit patient to be successfully discharged from the Neonatal Unit to date, as well as a huge victory for LFHC.
During their long stays, the families got to know and support each other. Both mothers lovingly cared for their infants and worked with the doctors and nurses to tend to the needs of these tiny patients.
These two success stories are a testament to the achievements of the Neonatal Unit and enhance the reputation that the hospital has earned in the surrounding communities.
The first 28 days of life represents the most vulnerable time for a child’s survival and accounts for approximately 46% of all deaths of children under the age of five, according to the World Health Organization. This is especially true for infants born prematurely, which is the leading cause of death in this age group.
The LFHC Neonatal Unit opened in 2016 with the goal of providing specialized care to our smallest patients. Given the increasing number of babies who needed specialized care, this unit was expanded in 2018. There are now nurses dedicated to the Neonatal Unit and assuming leadership roles. Nurses working in the unit have completed additional training courses and received mentorship from expat volunteers with expertise in this field to ensure that they have the skills necessary to care for premature patients. Several neonatal physicians have also volunteered in past years to help develop the unit.
The hospital’s vegetable garden project started six months ago with the goal of providing food assistance to select patients and their families.
Some families travel long distances to bring their sick or injured children to LFHC. If their children require extended hospitalization, these families remain at the hospital, but simply cannot afford to cover food costs. Our Outreach Team assesses families to determine whether they need food assistance. Administrative Assistant Phonesavanh Phongsavath (Norm) and the nutrition team then coordinate the daily food supply for families who qualify.
Prior to the vegetable garden project, the hospital bought vegetables at the local market. However, the hospital’s garden has grown more than 880 pounds (400 kg) of vegetables since February – produce that has provided meals for many patients, families and caretakers. Rows of morning glory, onions, corn, eggplant, chilis, cabbage, green beans and lettuce now grow in our garden.
Any surplus produced is offered to families to bring home when their child is discharged. Hospital nutritionist Bounmark Phoumesy (Toun) noted that the project not only helps families and patients during a hospital stay, but also teaches families about including various vegetables in their meals at home.
The LFHC garden would not be as beautiful and productive without the support of gardener Semany Phongsavath (Aye), who is in charge of preparing the soil, watering and taking care of the vegetables. Many thanks to Mr. Aye.
World Blood Donor Day is observed on 14 June every year to raise awareness about the global need for safe blood and to thank blood donors. Our hospital uses donated blood for surgeries and to treat children with anemia and thalassemia.
There is always a need for blood donations in Luang Prabang. The LFHC laboratory and external relations team work closely with the Luang Prabang Blood Center throughout the year to assess the blood supply and to encourage the local community and visitors to become blood donors.
Donated blood is critically important to our Thalassemia Clinic, which currently cares for 325 patients. Patients come to the clinic on Wednesdays and Thursdays for their appointments and are examined by a doctor who orders laboratory tests and, if needed, a blood transfusion. Thalassemia is an inherited blood condition that causes abnormal hemoglobin and if these patients do not get blood transfusions, they can have difficulty doing normal activities and suffer serious health consequences.
Thalassemia is quite prevalent in northern Laos. A proper diagnosis and management of the disorder enables patients to feel stronger and perform normal activities. An example of this is the case of 12-year old Vathtana who first came to LFHC in 2018 when his parents noticed that he always seemed pale and tired. He had required occasional blood transfusions prior to that time, but his parents never understood why or received a diagnosis. The doctors at LFHC took a thorough history, performed a physical exam and obtained blood tests. They suspected thalassemia and requested additional testing. Then test results finally came back, a diagnosis of beta thalassemia was confirmed.
Vathtana has since returned to our Thalassemia Clinic every 3 weeks to receive blood transfusions and medications. Thanks to these transfusions and appropriate care, he has been able to feel better.
National Lockdown Lifted: LFHC Update
The Lao national lockdown in response to the COVID-19 pandemic was lifted in early May which allowed all LFHC staff members to return to work. The caseload began to increase as families were once again able to leave their homes and bring their children to LFHC.
The high level of compassionate medical care was never compromised during the lockdown. Lao doctors and nurses demonstrated outstanding leadership during the absence of the ex-pat volunteers who typically supervise and mentor them. The hospital’s medical director and medical education director provided guidance and support to the Lao staff and worked rotations to ensure that one of them would be on call throughout the day and night.
The Lao nurse shift leaders assumed the duties of confirming dosages of medicine administered to patients — a responsibility formerly handled by volunteer nurses.
The hospital’s Development Clinic and Thalassemia Clinic were again conducting weekly sessions and classrooms were reopened for medical instruction and English language training.
Bone Marrow Procedure Helps Save Baby’s Life
A 15-month-old girl recently brought to LFHC exhibited symptoms that appeared to indicate that she was suffering from sepsis, a bacterial infection that overwhelms the body and can be fatal. However, the child failed to improve after being treated with antibiotics.
Her condition had troubled our doctors from the outset. Her blood cell counts were low, her liver and spleen were enlarged and she had developed a rash that rapidly spread over her face and body. Doctors quickly doubted that sepsis was the problem.
A blood triglyceride test prompted doctors to consider that the baby had a life-threatening blood disease called hemophagocytic lymphohistiocytosis (HLH). To confirm the diagnosis a bone marrow sample was needed.
Fortunately, Dr. Dorkeo Boupao had recently completed her pediatric residency in Vientiane, where she learned to perform blood marrow aspirations. She performed the aspiration and our laboratory staff prepared the bone marrow slides. The diagnosis was confirmed.
The child was taken to Children’s Hospital, Vientiane, which is the only facility offering HLH treatment. The diagnosis by our LFHC team expedited treatment for this little patient who continues to recover.
Hospital Salutes Nursing Staff During Lockdown
LFHC celebrated the International Nurses Day on May 12 and acknowledged the essential work of the entire nursing team at the hospital. Our nurses provide support and compassionate care to our patients and prove their commitment to their patients by continuing their medical training — even in challenging times.
The national lockdown in response to the pandemic challenged LFHC to find educational alternatives to classroom instruction. Khamxai Xongyikhangsuthor, Lao nurse educator at LFHC, coordinated and delivered the nursing curricula during the lockdown and provided orientation to the new members of this team.
During this month, Khamxai assisted in delivering 72 hours of clinical bedside education to nurses working on their shifts. Education focused on nursing assessments and interventions based on patient diagnosis, improved communication among team members, PALS (Pediatric Advanced Life Support) resuscitation and blood gas interpretation.
Outreach Team Takes Family on Life-Saving Trip
During Lao’s national COVID-19 lockdown, transportation and movement in the country was restricted among and inside the provinces. As a measure to protect the communities we serve and our staff, the LFHC Outreach Team limited their visits to villages and to patients’ homes during April and a few days in May. Nonetheless, the team continued to provide much needed assistance to critical cases inside and outside the hospital.
In one particular case, our Outreach Team performed an extraordinary life-saving task: transporting a child to Vientiane for a critically needed surgery.
The child, 11-month-old Chik Chot, was referred by our doctors to Vientiane in March because he needed a nephrectomy, the removal of a kidney. He returned to LFHC in early April, but developed post-operative complications.
Under normal circumstances, patients travel by bus to Vientiane. However, travel restrictions had already begun, so the Outreach Team decided to use an LFHC vehicle to safely take Chik Chot and his parents to Vientiane. Chik Chot was treated by a surgeon there and brought back to Luang Prabang by the Outreach Team. He was recently discharged and is recovering nicely.
WHO Trains Staff in Coronavirus Response
Although Lao PDR has reported only 19 confirmed cases of the coronavirus since announcing its first case on March 24, representatives of the World Health Organization recently travelled in the country to ensure that healthcare workers are prepared for a possible new outbreak.
Three LFHC nurses and two doctors participated in the training and they have been disseminating the information to the rest of the staff. The training focused on triaging, treatment, isolation ward management and staff wellbeing.
For two days, the Luang Prabang Provincial Health Department and WHO representatives conducted the special training for healthcare providers from the provincial and district hospitals, as well as for community health workers. The Lao Ministry of Health collaborated with WHO in the training sessions.
When 15-month-old Noy* arrived at LFHC, doctors thought she was another case of sepsis, a bacterial infection that overwhelms the body. Sepsis is a potentially dangerous condition, killing an estimated 2.9 million children under five years of age globally in 2017 alone1.
Our doctors are able to recognize and treat sepsis promptly, relying on basic blood tests in the absence of more expensive microbiology tests which doctors in well-resourced settings use to identify bacteria. Most sepsis patients start to recover within a couple of days.
However Noy did not get better. The doctors changed her antibiotics and looked for more unusual infections, all to no avail. And her case had some unusual features that had troubled doctors from the outset. Her blood cell counts were low, her liver and spleen were enlarged, and a few days into the admission she developed a rash which rapidly spread over her face and body. A blood triglyceride test raised doctors’ suspicions that perhaps she didn’t have an infection at all, but a life-threatening hematological disease called hemophagocytic lymphohistiocytosis (HLH).
To confirm the diagnosis, a sample of her bone marrow was needed. In the past, this had been a procedure referred to Children’s Hospital, Vientiane, which is the only facility offering chemotherapy (the treatment for HLH) in Laos. However, on the verge of a national lockdown and fear of COVID-19, travel to Vientiane was already extremely difficult.
Dr. Dorkeo Boupao had returned to LFHC recently having completed her pediatric residency in Vientiane, where she learned to perform bone marrow aspirations. After discussions with the parents, who are always an integral part of the patient care team at LFHC, the team decided to do the bone marrow aspiration here at LFHC.
This case is truly a story of Lao leadership and teamwork. Dr. Dorkeo and Laboratory Leader Anousine Phonedala worked together to plan and prepare for the procedure. Dr. Dorkeo obtained the samples and Anousine and his team prepared the slides. Our doctors examined the slides and found the typical appearance of HLH.
The nurses assisted with the sedation for the procedure, and helped support and advocate for the parents throughout the child’s nine-day hospitalization. The parents were amazingly patient and brave as they maintained a vigil by her bedside, helping to care for her as they watched their usually beautiful child become almost unrecognizable as the rash crept over her face and body.
With the diagnosis confirmed, it was much easier for the parents to commit to spending the time and money needed for treatment in Vientiane. The Children’s Hospital, Vientiane used LFHC’s slides so that she was able to start treatment without delay after arriving in Vientiane. She still has a long road ahead of her, but days after starting chemotherapy, she was rash- and fever-free.
Although LFHC cannot yet treat such cases, being able to perform the diagnostic procedure at LFHC makes a huge difference for patients and their families. Sending patients to Vientiane for this procedure incurs great cost for the family and there’s no guarantee that the subsequent treatment will cure the patient. In this case, the family was given accurate information about prognosis and treatment cost to aid their decision-making and give them peace of mind that the expensive treatment was justified. The journey is long and arduous, especially with a sick child, and in the future, we hope that we can save some children and their parents from going through this unnecessarily.
We are extremely proud of our Lao team, who didn’t stop thinking and caring about their patient, and displayed an ability to learn, innovate and develop their service, even in the midst of a historic pandemic and its attendant restrictions. They were excited to learn about this rare condition and to see that the quality of care that they provide to their patients continues to improve. In the future, we hope to have more LFHC doctors trained in the procedure and in reading the slides so that we can expand the repertoire of diseases that we can diagnose locally.
* The name of the patient has been changed to protect confidentiality.
- Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Rudd K.E. et al. Lancet 2020; 395: 200-11
Attempting to prevent the spread of COVID-19, Laos followed lockdown restrictions during April and it wasn’t until May 4 that some of those restrictions were eased, allowing some activities to resume at LFHC and Luang Prabang. It has been more than one month since a new case of COVID-19 has been confirmed in Laos and the majority of the 19 existing cases have recovered.
LFHC kept its commitment to provide health care to the community of northern Laos during the lockdown. We made sure our team as well as all the supplies and equipment were always ready for our patients. However, to follow the government’s lockdown restrictions and to protect our team, patients and their families, we implemented such precautions as suspending weekly clinics, classroom teaching and normal homecare schedules.
Compassionate care has always been a priority at LFHC. Patients who needed urgent care were always received and treated at the hospital. Our Outreach Team visited critical patients with a special permit from the health department and the LFHC staff ensured that patients and families at the hospital were cared for and supported. During the travel restrictions, LFHC offered food to any family with a hospitalized child and we made room in the Thalassemia Clinic for the parents of babies in the Neonatal Unit (The Thalassemia Clinic was suspended, but its patients could receive treatment in the Outpatient Department). During the lockdown, our team noticed a reduction in the number of families who expressed a need to return home with their children earlier than medically advised.
In the absence of foreign volunteer clinical supervision (volunteer doctors and nurses returned to their home countries at the outset of the pandemic), the Laotian clinical team demonstrated outstanding leadership. The presence of local doctors had been increased at night to ensure better supervision of emergency cases during the few hours they are working without direct supervision from our medical education director and medical director (they both rotated shifts to provide 24-hour on-call support). The nurses’ shifts became independent and their shift leaders stepped up at confirming dosages of medicine administrated to our patients, a responsibility formerly handled by nurse volunteers.
The end of the national lockdown in early May allowed all hospital staff to return to work and it has been wonderful to have all the team back! Development and Thalassemia clinics once again began weekly sessions, classrooms reopened for medical education and English language lessons resumed.
Our caseload has begun to grow and we expect the patient attendance rate to come back to its formerly high level.
Charity Navigator, an independent watchdog of U.S.-based charities, has given its highest rating to Friends Without A Border.
Charity Navigator awarded Friends a 4-star rating for “demonstrating strong financial health and commitment to accountability and transparency.” Four stars is the highest rating a nonprofit can achieve.
This is the fifth consecutive year that Friends has attained the 4-star rating.
“Only 15% of the charities we evaluate have received at least 5 consecutive 4-star evaluations, indicating that Friends Without A Border exceeds industry standards and outperforms most other charities in America,” wrote Charity Navigator President and CEO Michael Thatcher in a May 1 letter to Board of Directors Chairman Steven Williamson.
“This exceptional designation from Charity Navigator sets Friends Without A Border apart from its peers and demonstrates to the public its trustworthiness.”
The national lockdown imposed by Lao PDR in response to the pandemic has affected operations at LFHC, but it hasn’t quashed its role as a teaching hospital.
Staff members are not allowed to travel to the hospital for education programs or to enter classrooms. However, administrators have selected topics and learning activities that are appropriate for distance-learning.
During the lockdown, each doctor still receives two full days of teaching per month — one focusing on evidence-based medicine and the other using interactive case studies to revise a previously taught module from the LFHC Child Health Foundation course (infectious diseases).
For the evidence-based medicine piece, we created a virtual journal club. Each doctor was given a published research article to read, accompanied by a reading guide which has exercises and discussion questions throughout, as well as explanations of key points in the article.
As with our in-hospital teaching, we employed a “training of trainers” approach, with each facilitating senior Lao doctor given a teaching guide containing answers to the questions and discussion points. The ability to critically appraise evidence and apply it to their practice is a vital skill that we need to build in our medical team to ensure high quality, evidence-based practice for the long-term, under Lao leadership.
The doctors used the Facebook video chat function for group discussions and two doctors were even able to join from quarantine in the isolation ward (both subsequently tested negative). They had to use their own devices and those with poor Internet connections or having to use their phones to look things up and read found that difficult. However the feedback was overwhelmingly positive.
This was the first time that most of the Lao doctors had read a paper by themselves and they have asked for more reading guides to help them read articles. Published research uses dense language and is at a reading level that is usually far above all of our staff. The combination of the reading guide and using a Lao teacher appeared to adequately overcome the language barrier. Thus this method can help to strengthen independent learning in the future.
All the doctors appreciated the opportunity to learn about research that was done in Laos and identified appropriate changes to personal practice as a result of reading this paper. The sessions also allowed the doctors to practice using appropriate online resources to find answers to medical questions – an essential skill for all clinicians.
The teaching days in the hospital have allowed our doctors to interact with each other away from the stressful clinical environment and play an important role in team bonding and self-care. In a new, socially-distanced world, we have found these distance-learning methods and tools to be useful in allowing medical education to continue and our team to stay connected.