Stefan Johansson

As you probably know, 99nicu is a project run with enthusiasm and for the good cause. For almost 10 years However, we feel that we need to re-vitalize the 99nicu community, and our strategy is to involve more people in the Team behind 99nicu.org. We search for people that would like to act as "moderators", and people that are willing to start up a 99nicu Pharmacopedia, like a dictionary of short but informative posts of commonly used medications in the NICU. Do you want to get involved as a 99nicu moderator, i.e. work a bit behind the scenes and participate in site moderation and development? Do you want to get involved in planning and setting up of Pharmacopedia? Click on the post below to read more about the principal idea, (but note that you need to be logged-in to read this topic as it is posted in the Lounge, a members-only forum) Interested?! Then I look forward to an email on stefan.johansson@99nicu.org

In our Interview series, we are grateful to present Ruth Davidge, South Africa, a strong and passionate advocate for neonatal nursing! Among achievements, she was the founding president of the Neonatal Nurses Association of Southern Africa (NNASA). Today, Ruth Davidge is the responsible coordinator for improving quality of neonatal care in a province where 200.000 infants are born every year. * * * * * * * * * * * * * * * * * * * * * * * * How would you introduce yourself and where do you currently work? My name is Ruth Davidge. I am a passionate neonatal nurse and Christian. I am unmarried but am a devoted aunt to my nephew and niece of 5 and 3 and 'mother' to a darling dog who keeps me sane. I could not do what I do without the loving support of my family and the strength, love and wisdom given me. I live and work in Kwa -Zulu Natal on the east coast of South Africa. It is a very diverse province with spectacular scenery, bush veld, mountains and 100s of kilometers of pristine coast line. Our population is mainly rural but we also have some big metropolitan centers. Kwa -Zulu Natal is the epicenter of the HIV pandemic with an incidence of 39/1000. This has a huge impact on the health of our population and demands for health care. However with much hard work and the availability of antiretrovirals we have dropped our mother to child transmission rate to less than 1%. Approximately 200 000 babies are born in the province annually. Combined births in Kw-Zulu Natal and Gauteng (another province with Johannesburg as its capital) account for approximately 42% of all the births in South Africa. The province is working hard to reduce neonatal mortality which is currently less than the national average with a neonatal mortality rate of approximately 12/1000. However there is great inequality. Durban (our largest city) has the lowest under-5-mortality in the country but some districts in the province have mortality rates 4-5 times greater! We have some state of the art NICUs and yet some hospitals cannot provide blended oxygen or guarantee that the baby will be seen by a doctor every day. How did your professional career lead you to this spot? I started nursing neonates in 1994 and received 6 months training in 1996. I was the unit manager of a busy tertiary referral hospital for 10 years, the founding president of the Neonatal Nurses Association of Southern Africa (NNASA) and a board member of the Council of International Neonatal Nurses (COINN) before commencing my current role. I am now the provincial neonatal coordinator for Kwa -Zulu Natal - responsible for improving standards of neonatal care in all the public hospitals in the province. I have been fortunate to work in a hospital renowned for the quality of its nurses and standards of care and have learnt from the visionary leadership of 2 special doctors. My current supervisor and head of paediatrics in the province has always passionately believed that's hospitals and those that work in them have a responsibility not just to their patients but to the whole population they represent. He has doggedly persisted in striving to ensure all our population has equal access to quality care. A friend and colleague is a neonatologist who has taught me the true meaning of dedicated servant leadership, excellence in neonatal care and passion (compassion) for the vulnerable babies and families we serve. I believe the solid grounding I received during my early years and the exposure both nationally and internationally to other passionate skilled professionals has bought me to where I am today. I think NNASAs core values of Care, Passion and Excellence really sum up what I believe are critical for every nurse. What do you typically do during a working week? I really enjoy the variety of my work. 2 days of the week I'm in the office trying to catch up with emails, writing reports, compiling and updating guidelines and developing standardised records and quality improvement / monitoring and evaluation assessment tools amongst other things. (We are about to launch a new set of neonatal records for use in all our neonatal units in the province and have just completed a detailed baseline assessment/ accreditation of each hospital's neonatal service) When not in the office I travel to each hospital in order to support and encourage their efforts at improving neonatal care. I teach the nurses and doctors and meet with management to ensure they are aware of the required norms, standards and systems for neonatal care. This allows me to keep my skills up clinically ( I think I would shrivel up and die if I didn't spend some time actually caring for babies!), to gain insight into the challenges experienced at the coal face and ensure staff feel motivated and supported in the work they are doing. I also conduct workshops on Helping Babies Breath, KMC etc and run short (2 week) basic neonatal training courses. What are the challenges? Working in a middle income country, lack of resources is always one of the biggest challenges. This includes personnel, equipment and consumables. There is such a feeling of frustration when you are aware of the money that is available nationally that just disappears before it gets to the front lines. Corruption, politics, favouritism and complicated dysfunctional systems make for a very challenging and frustrating work environment. The lack of neonatal nurse training in South Africa and many other countries around the world poses huge challenges to the delivery of quality neonatal care. There are very few trained neonatal nurses in South Africa. (Our nursing Council stopped neonatal training a number of years ago believing that there was insufficient unique knowledge/ skills required in neonatal nursing that couldn't be taught during post basic midwifery or paediatric training) This has resulted in either general nurses or midwives caring for sick and small babies. They have no extra training for this and cannot learn from experienced colleagues/ leaders (as was my experience) as these are now few and far between. They therefore feel nervous, inadequate and ill equipped for the work they are doing resulting in large absenteeism and rapid turnover of staff. It concerns me that in global planning neonatal nurses are seldom mentioned. Midwives are necessarily advocated for but there is little understanding of the need for specialised nurses to care for sick and small babies at all levels. There is an idea that neonatal nurses are only relevant in first world intensive care or academic centers and yet from my experience when rolling out even basic neonatal programmes at low levels, an experienced neonatal nurse can have far more impact and influence than other nurses/ doctors. I am also personally challenged in that I don't have a gift for languages (we have 11 official languages) and I don't speak the first language of most of my colleagues and patients. This can sometimes make communication slow and difficult. However people are usually patient with me and we laugh together at my poor pronunciation. I feel sad when I see colleagues, who through lack of training, support and exemplary leadership, have become lazy, dispirited and hopeless - mainly driven by a desire to earn more or achieve greater status rather than a passion for their patients. This makes it very difficult to introduce new ideas, skills or programmes as they lack motivation to implement them and don't believe they are sustainable. However I am encouraged by the joy, excitement and interest with which my visits are usually received. Frequently I am met with colleagues who are trying to give of their best despite challenging circumstances and who are craving knowledge, support, advice and encouragement. What are the greatest potentials you see unmet in neonatal care? Specifically trained and allocated nurses ( allocated just to neonates) acting as skilled advocates for and deliverers of improved quality care More accessible research/ evidence based care - nurses have very limited access to academic journals and lack training and insight in how to interpret research findings. I have been recommending Keith Barrington's blog to many nurses who are trying to develop themselves further. Access and support to attend conferences to stimulate and excite nurses in their field Understanding the critical role stress plays on the neonate and the God given gift of the mother to counteract this. Kangaroo mother care and developmental/ family centred care should be core to the care of neonates at all levels and settings and is often missing where focus is placed only on survival. Excellent, passionate clinical leadership. Both doctors and nurses need to have strong mentoring by a leader that is present and committed to teaching by example. As nursing leaders have been forced to become administrative leaders (removed from clinical supervision and teaching by paper work and meetings) clinical leadership, teaching and oversight have suffered. For newly graduated colleagues around the world - what would be your best advice for their future professional development? Don't loose your passion in the face of disillusionment and challenges - your patients are depending on you to be their advocate and skilled provider when others have given up. Don't follow bad examples- if people around you are lazy and uncaring try not to join them Look for and seize every opportunity to develop yourself- don't wait for it to be offered you on a silver platter. Look for and learn from colleagues who put their patients first, don't think themselves too special to change a nappy (diaper), who treat you with respect and value excellence in care above their own careers. At whatever level you are practicing remember that you are a nurse first and foremost which means that care, compassion, healing hands and time spent nurturing your patient and their family are just as important as administering the correct medication, skilfully adjusting the ventilator or gaining yet another academic qualification. What are your own future plans? To live a life with a higher meaning. To continue to strive for excellence in all that I do. To continue to try and make a difference for the neonates and families, colleagues and friends with whom I interact. To share passion, joy and hope. ************************************** "Photo taken a small district hospital during one of my outreach visits. It had recently been renovated and we were discussing appropriate admission and discharge criteria to ensure the unit didnt become overcrowded." "A small district hospital. In the picture are the doctor and nurses working in the unit. We are discussing a guideline in the standardized guideline book developed in the province." "The view of my old unit. It no longer exists now as the hospital has a newly built neonatal unit and the old unit has been converted to house a high care KMC unit-the first in our province (offering nasal CPAP in 24hr KMC), on call rooms, a donor milk bank and seminar room." "Me in my younger years as a unit manager." "Photo taken in winter at Njasuti in the Drakensberg Mountains. They are a world heritage site famous for their scenic beauty and the San Rock Art found in isolated caves. Archaeologists believe that the San are descendants of the original Homo sapiens and that modern Khoe-San have the oldest gene pattern dating back 80 000 years. All other peoples on earth descend from this gene type." "View of our beautiful Kwa- Zulu Natal coastline which can be very wild and isolated in places or packed with tourists and development in other places. We are proud to have a number of Blue Flag beaches." "Me standing next to the Red Cross Air Mercy Service airplane thats flies me and other outreach doctors to outlying hospitals that would otherwise take hours to reach. The purpose of these outreach visits is to try and increase capacity at these small hospitals and also to bring expert consultant care to patients that might otherwise not be able to access this. The airstrips we land on are often owned and maintained by farmers and may only consist of a mown grass strip in a field. The Redcross are paid by the KZN Dept of Health for this service."

Ethical questions are common in neonatal care. Dominic Wilkinson is not only a consultant neonatologist, he is also an ethicist who has written a fantastic book. The title "Death or Disability" catches questions we and parents commonly ask. I can recommend this book to everyone. It should be available in the staff book shelf in every NICU. Leaning against examples of situations and practises over the last 2000 years, Wilkinson dissects ethical questions related to clinical care and decision-making. First, he focuses on the question of the “best interest”. I was especially caught by the chapter on competing interests, when decisions in the NICU may be complicated by imbalances between what may be considered to be in the best for the infant, in the best for the parents, and even in the best for other infants and families when resources are constrained. Then Wilkinson continues with addressing our difficulties to make predictions of later outcomes and how that uncertainty may impact our treatment decision, and the interests of the infant and parents. You can read the full review on our review section, here!

We are launching a new Series - interviews with interesting people within the big world-wide neonatal community. Our goal is to publish one interview per month. First out is Mats Blennow, Stockholm, Sweden, senior consultant neonatologist at the Karolinska University Hospital and professor in neonatal neurosciences at the Karolinska Institutet. Furthermore, he was also a president for the European Society for Neonatology (2008-2014). Mats Blennow took a break from the level-3 NICU life in Stockholm to do something extraordinary... * * * * * * * * * * * * * * * * * * * * * * * * Where are you working now? I am working in Irbid, a city in the north of Jordan approximately 25 km from the Syrian border. I work here in a project run by Medecins sans Frontieres (MSF- Doctors without Borders). This is, for MSF, a unique setting as Jordan, a middle-income country, is considered safe and developed. This in contrast to the usual MSF projects dealing with situations in war, natural and man-made disasters. The MSF rationale for this project is that the Syrian refugees here do not have free access to the Jordanian health care. In my project we provide maternal and neonatal health care for the approximately 130,000 syrian refugees living in the Irbid Governate. We run a highly efficient maternity unit, annually providing antenatal, maternity and neonatal care for 3,500 pregnant women and their offspring. The project is housed in a private hospital, where MSF rents 2 floors. I work as a pediatric/neonatal expat in the small neonatal unit. Recently, in matter of fact this week, we have expanded the unit from 10 to 16 cots/incubators. I would describe this as a level 2 unit, for example we do not provide ventilator care or long-term TPN. Our admission criteria include babies from 32 weeks gestation. Very preterm infants are referred to other local private or Ministry of Health facilities, and then MSF covers the costs of care also there. Why did you choose to go on this mission to Jordania? Since many years I have wanted to broaden my views on paediatrics and neonatology to other settings than working in a tertiary NICU in a high-income country, preferably by working for some NGO. The reputation of MSF is highly respected by everyone. For example, in a survey in Sweden, more than 50% of the responders expressed high confidence in the work MSF provide in more than 70 countries. The MSF charter stating the organisation is to provide medical help irrespective of race, religion, creed, or political convictions and doing this observing neutrality, impartiality and independence is to me fundamental. The fact that my current mission is in Jordan is primarily not from my own choosing. Signing up to work for MSF, I had full confidence that the organisation would send me on an important mission. What is it like to work there? What are the largest similarities and differences compared to the NICU you normally work at in Sweden? The work has many similarities, but also differences, to the work I usually do in Stockholm. The national staff is well educated with very good theoretical and practical knowledge. Nurses and doctors work together, although the emphasis on teamwork is not as strong as in Europe. The organisation of health care is not as developed as back home, and a lot of attention needs to be given to organise for referrals to tertiary units, to follow-up clinics and for more advanced tests and examinations. For example, when I first arrived here we did not have access to blood cultures. Due to this, many infants with only risk factors for early onset infections were given full courses of antibiotics despite no clinical signs of infection. Consequently, this resulted in prolonged stays in the neonatal unit and mother-child separations as many families live far from Irbid and have several children at home needing attention. Another difference is the access to respiratory support. My primary task was to start CPAP care in the project, which was successfully started after 2 weeks. Before that, infants with any respiratory distress were given nasal cannula oxygen with FiO2 of 1.0 and rather high flow rates. Perhaps the biggest difference however was the nursing care of the infants. I was lucky to be able to recruit a neonatal nurse expat, and together we worked hard to implement as many elements of developmental care as possible, including reducing ambient noise, covering incubators, nesting and supporting the infants position, and clustering of blood sampling. We also managed to expand the area of the neonatal unit with 2 additional rooms allowing mothers to remain with their babies 24/7 in the unit. What expertise have you brought to Jordania and what experience can you bring back to Stockholm? Medically, my most important contribution has been to update the protocols on non-invasive ventilator care. This includes implementing nCPAP treatment, but also t-piece ventilation for resuscitation, guidelines for treatment of apneas, use of fractionised oxygen and emergency surfactant treatment before referral of very preterm infants with RDS unintentionally delivered at the MSF hospital. I have also trained the staff after updating many other protocols, such as those for infants at risk of septicaemia and the use of a Neonatal Early Warning Signs (NEWS) protocol in the maternity. To bring back home is the knowledge of good care being given also in this resource limited setting, problem solving in an environment that doesn´t have all the expertise available just around the corner. The basic principle to always have a humanitarian approach to everything we do in medicine. Working with the dedicated MSF-expats from all over the globe is extremely rewarding. In my project we had expats from France, Scandinavia, Canada, Liberia, Sudan, Lebanon and Australia. Personally, I think I will after my mission come out as a better and more humble person J. What is your advice to those wanting to go on a similar mission? Take a good course preparing for NGO work. It was invaluable for me to take an 8-week course in Humanitarian Health Assistance and 1 week of Preparation Primary Departure (PPD) before leaving. There is also an abundance of information to be found on the webpages of UNHCR, WHO, MSF and other NGOs. There it is possible to, once the destination is decided, to get detailed information about the country, project and security issues. Most important is to keep an open mind to new cultures and experiences, to have a great respect for the knowledge and integrity of everyone you meet; patients, locals and colleagues. ISH - the hospital where the delivery unit and NICU is located. The NICU environment at ISH The first infant recieving nCPAP in the MSF NICU. Umm Qais - a popular area to visit in norther Jordan - an old town with a history going back >2000 years. From this site it is possible to view (from the left): Israel, Lake Genesaret/Tiberia, Palestine (in the valley), the southern parts of the Golan mountains, and distantly Lebanon and Syria.

The topic for this journal club on 12 January was outcomes of infants with Apgar score of zero at 10 min. Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up. The paper was accompanied by an interesting editorial. Both articles are available as Editor's Choices at the ADC web site: http://fn.bmj.com/content/100/6/F492.full http://fn.bmj.com/content/100/6/F476.full ADC also produced a podcast that you can listen to here: https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat Here comes the transcript of the JC! ----------------------------------------------------------------------------- Stefan Johansson Hi everyone and welcome to the 2nd 99nicu JC! The topic this time is outcomes of infants with Apgar score of zero at 10 min. Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up. You find the original article and the and the editorial: http://fn.bmj.com/content/100/6/F476.full What was your general impressions reading the article and editorial? Fcardona It was definitely an eye-opener for me. I mostly considered APGAR of 10 as sure predictor of death or terrible outcome Jonathan Davis My overall impression that is that this is an important topic area and one that is currently under justifiable scrutiny. I too was surprised at the survival potential Stefan Johansson What is your current (or previous) guidelines about resusc when the Apgar is /was zero at 10 minutes? amirmasoud2012 The decision is difficult Jonathan Davis In Bristol where I currently work we don't have a specific guideline Fcardona neither do we here in vienna have a guideline Stefan Johansson The Swe guidelines has been to continue resusc until 15 min if there is asystole Jonathan Davis it is generally accepted that one would stop resuscitation once a consultant has at least been present dracunculus In Ulm where I currently work we dont have a guideline, but I think nobody would stop resuscitation here after 10 minutes Stefan Johansson I have felt discomforted about this (as the international guidelines are evaluation at 10 min). Have had cases with apgar0 at 10' who started going at >14 minutes... and outcomes were quite bad (severe CP) Jonathan Davis if out of hours that should be at max 20 minutes Stefan Johansson Do you generally use chest electrodes to monitor heart beats? Jonathan Davis I agree Stefan the push for longer resus is definitely one that shouldn't be made with haste amirmasoud2012 Several issues must be considered rate Population growth of the country The development level of the country Religious beliefs communities The ability of parents The health system support If the above condition is better we continue to resuscitation. In our country under the above conditions there and I 'd rather stop after ten minutes of resuscitation Stefan Johansson @Amir - valid points, the context matters Jonathan Davis I certain agree that all the above must be taken consideration... the evidence base of survival and with or without disability is also important Dracunculus We are starting to use ECG electrodes. Stefan Johansson One thing about the case series in ADC - how certain where the authors that apgar was really zero? It does not say how heart beats were monitored. Could the babies be Apgar=1 at 10 min? Jonathan Davis That is the flaw in these papers, the apgar is a subjective measure who listened... and for how long and how practised where they fcardona I agree stefan, it is unclear how objective heart rate was assessed Jonathan Davis ECG is the new european rests council guidance fcardona? Stefan Johansson Thanks for support I just think there is some problem with the internal validity of this report After the JC I can recommend this blog post by MichaelN (All Things Neonatal) ; http://99nicu.org/blogs/entry/169-apgar-score-of-0-at-10-minutes-why-the-new-nrp-recommendations-missed-the-mark/ How do you handle the contact with parents in a situation like this? Do you give a "trial of life" on mechanical ventilation etc and discuss options thereafter? (In Sweden, we generally (I think) do not listen enough to the voices of the parents) Jonathan Davis If heart rate was achieved, a trial of life is appropraite early measures of brain injury are difficult and poorly predictive fcardona yes, jonathan - ecg is suggested for use during neonatal resuscitation in the 2015 guidelines Jonathan Davis parents wishes extremely important and the context as above essential fcardona i agree about parents wishes Jonathan Davis I had a recent case of no heart rate at 10, baby extremely unwell. Trial of life with EEG and discussion with parents at the bedside additional colleague opinion sought also for second brain Stefan Johansson This is just an impression but in the "pre-cooling days" (when I was fulltime at a level3 unit) I think babies were more often given palliative care if the asphyxia was very severe. Now we are more active, start cooling shortly after birth (usually within 2-3 hours), and then there is a rolling stone of activity. @Jonathan - good point about intercollegial support and discussion Jonathan Davis Very true re activity. Early marker of severity of asphyxia can often mislead and none are perfect... some work done by the Brain group in cork... will look for link on early predictors from umbilical cord samples Stefan Johansson One problem is the lack of models that can predict bad outcomes with good precision. How could we do better? Jonathan Davis https://clinicaltrials.gov/ct2/show/NCT02019147 fcardona I agree, do we know anything about the EEG and MRI in the survivors of this study? Stefan Johansson @Francesco - I cannot find this info in the paper only that "All eight deaths were because of withdrawal of life support in view of severe encephalopathy on clinical exam- ination, electrocortical inactivity on electroencephalogram (EEG) and extensive damage to the brain on MRI” Jonathan Davis the group in cork appear to be collaborating with the Karolinska Institutet Stefan Johansson @Jonathan - I see that. The current head of the Karolinska Neo Dep (Boubou Hallberg) is a co-investigator fcardona in the study: i am still concerned about selection bias in the study. what is the denominator of the study population? Stefan Johansson @Francesco - you mean, where is the epidemiologist fcardona I guess Jonathan Davis I think the study represents a pragmatic interrogation of the data that is routinely collected and submitted to the ANZNN fcardona and how many cases with apgar 10 of zero were not included because they didnt make it into the database Jonathan Davis I think we are back to the antithesis of the 'were they sure it was zero' argument where there miscounted apgars? Stefan Johansson Valid point, if we are to study outcomes, we need to know about the population base. If you look into the blog post I linked to above, I non-secretely display one of my fancy research ideas... Jonathan Davis The population as far as I can tell is all babies who were admitted to KEMH and PMH in WA.. Interesting that APGAR is now being used or certainly reported as a predictor. In my training the APGAR score was always derided as an unreliable subjective measures I need to confess that I will soon be a consultant in the unit that authored the paper in Australia. I haven't had anything to do with the paper however... nor any other particular bias Stefan Johansson @Jonathan - But in 2001 even NEJM had an article about that Apgar was not entierly wrong @Jon - are you moving to Australia?! Jonathan Davis The first question.... Yes I have come to the conclusion that my mentors had an anti APGAR bias... a subjective measure but potentially a useful one.. experienced hand quiet useful.. the second question.. yes starting hopefully next month... fellowship in oz previously and now appointed in Perth.. Stefan Johansson This is off-topic... but Perth sounds great! Jonathan Davis yes... sorry.. needed to disclose that fact Stefan Johansson @Jonathan - no worries! @all: what can we learn from the paper and editorial? I think one important thing raised in the editorial is that "Clinicians must be guided primarily by the best interests of the infant." Jonathan Davis I think personally we can learn that perhaps 10 minutes may not be long enough... the resuscitation needs to be effective and all reversible causes need to be excluded Also the suppose to me was that the outcomes are still not great but they are better then I expected and that needs to influence what we discuss with parents. Stefan Johansson another important message it seems, is that noone with Apgar=0 at 20 min did survive +1 on that last comment Jonathan Davis I will have to duck out of the conversation at this stage... but although involved in the podcast... the discussion with Ben Stenson and Dominic Wilkinson makes interesting listening... expands on the editorial a little.. Stefan Johansson And here is the link to the podcast: https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat Jonathan Davis thanks for the great discussion.. I tweeted along the way!! Stefan Johansson I will also need to leave now. Any final thoughts ? amirmasoud2012 thanks Stefan Johansson Thanks all for a another great experience! Meet you next time!