Wake Up

I thread the four-inch needles through the fibers of her extensor carpi radialis longus, trying to get maximum contact. I put another set into the bellies of her two other wrist extensors. She's seventeen and hasn't been able to use her right hand or foot since she had a stroke as a toddler. I asked her to come at least ten times. This is our eighth visit and she just showed me that she can move her pinky finger. I feel elated. I'm also kicking myself inside for not taking more video of her lack of movement in the beginning. I look up at Terry, "I should be about 15 more minutes."

There's a baby at the health post down the street who won't nurse. I don't know much else, but I've been asked to go over and see what I can do. I feel a little hesitant, as always, thinking that somebody else here would be able to do the job better than I can. I silently remind myself that this isn't the case: I am able to evaluate an infant. I am able to help a new mother nurse. I've done it before. I'll do it now. I am enough. There's that Brene Brown stuff again. I am enough.

I take a slow and deep breath into my belly as I sink more needles into the belly of this girl's tibialis anterior. Pawan grabs the electro-stimulation machine and we start connecting the six leads to her forearm and lower leg. I start with the first lead and I follow her eyes and head nod to recognize that she's feeling it. I press my extended wrist, palm up, into the air - a symbol that the two of us now know means, "Can I turn it up?"

She nods and I slowly increase the charge until her pinky finger starts jumping up and down on her lap. We do the same thing five more times and as I stand up to look at her, four fingers and two toes are popping up and down, five times per second. I smile and look at the clock; it took five more minutes than I expected. I ask Pawan to keep an eye on her while I run to the health post for the baby.

I find Tiffany outside with another patient. "Can you pull my patient's needles? I'm afraid I might be too long over there."

"Absolutely," Dr. T answers as she shows a Nepali woman how to do a shoulder exercise against the wall of the clinic. Her smile and demeanor are always so genuine and welcoming. I want to take her with me. She is a rock of calm when the chaos builds here. I wave and start out to the street.

I need a translator to talk to this mother and Ritesh and Terry are supposed to be meeting me. I don't see them anywhere. I walk through the fence and follow the path to the health post, past the "new" bright green birthing center and the dilapidated buildings that used to house the most frequented hospital in the area. For some reason, the government funding for the hospital was sent to the city of Hetauda, about an hour away. The Bhimpedi hospital was demoted to a rudimentary health post where staff and a resident doctor is able to spend about five minutes with each patient. Continuity of care can be difficult. We are still trying to build a relationship with the folks that manage this health post. There are a lot of politics involved as we try and understand how all of this works.

As I approach, I see that the gates to the post are closed but a number of women and children are gathered on a bench outside. I see a woman in the middle, holding a swaddled bundle on her lap. I assume this is the baby. It doesn't look like she's just given birth, but I can't ask her with Ritesh's help, so I go outside. I wait for a half-hour and my stomach is grumbling. I feel light-headed from working all day with no food. Finally, I see Tiffany coming from the clinic with Bibek and Pawan. They walk back to the group of women with me.

I ask the mother if she'd like our help to try and get the baby to nurse. "An ambulance is coming to take us to Chitwan Teaching Hospital. The baby is vomiting and won't eat."

My heart drops to hear that an ambulance has been called. Chitwan is many hours from this village. The mother reported these things to the resident doctor at the health post, a pediatrician, who immediately called for an ambulance. I asked again if I could look at the baby and she nodded.

I unwrapped the sleeping infant's feet as the women looking on shook their heads and tsk-tsk'ed me. Bibek translated that they were all worried the baby would get cold or windy. The mother told me that the baby girl was a day old and had nursed only one time, twelve hours ago. I scratched at her soft feet until she started to stir. "I need an ice cube," I smiled at Tiffany. She turned to go to the market and find a cold soda.

The baby wrinkled her forehead and looked as though she would cry. "Good!" I said, "We've got to wake this baby up." None of the women seemed at all happy about that, but a comfortably sleeping baby won't nurse. I took my laminated name tag off and began scratching at her feet. When Tiffany came back, we got a cold Mountain Dew on her toes and she began to look uncomfortable and whine. The mother squeezed a small amount of her nipple out of a too-tight shirt and tried to get the baby to latch. There was no way that this new infant could latch onto the misshapen form of breast. We took the party inside the birthing center.

As we walked in, I asked the mother about the vomiting, "Is she spitting up milk, or is she dry heaving and truly vomiting? This baby's reflexes are all fine. Everything is normal, she looks great. We've just got to get her to eat." The mother assured me that the baby was vomiting, she said it was right after the baby ate that she vomited up a small amount of milk.

I unwrapped the baby and laid her naked body on the bed. She hated it and started to scream. I asked the mother to pull her full breast out of her shirt and we got the baby to latch on. She suckled for a few seconds and fell back to sleep. The mother was producing so much milk, her shirt was soaked, the baby's hair was covered in milk, her cheek was wet with it.

"This baby is fine. She doesn't need to go to the hospital. She's just sleepy. You are fine. You have enough milk. There is no reason for an ambulance." I said this three times over the course of working with the group. "She is not vomiting. She just spit up because she has a new belly and you're making so much good milk."

I tried to reassure the mother. She looked exhausted, but worse, she looked defeated. I could see on her face and in the tears pooling at the edges of her eyes that she believed she failed this baby. One older woman cooed in the background, saying over and over in Nepali that the baby was so beautiful. Two women lurched over my back, trying to cover the baby with a blanket so that cold and wind didn't touch her body. Another kept saying that a vomiting baby needed to go to the hospital.

I put the baby in a football hold position and asked the mother to nurse her like that. "She's more likely to stay awake if you keep her naked and hold her up like this. If you can take your shirt off so that your skin is touching her skin, she's more likely to nurse." As I said this, the baby pooped. I said again to the group, "This baby is absolutely fine. You are absolutely fine. All of this is normal."

I looked to the group of eight women. I looked at this mother's five year old son. I didn't understand why there was so much fear and anxiety. I didn't understand why none of these mothers had been able to to help this woman nurse this baby over the last twenty-four hours. I was confused as to why the resident, who had studied pediatrics, had called an ambulance for a perfectly healthy child.

I was exhausted and hungry and I'd been fighting for patients all morning. The father walked into the room with the ambulance driver. I had no more fight left. I held the mother's hands. I finally realized that she spoke a fair amount of English. "You are so beautiful and you are doing a great job for this baby. You are so healthy, you are making so much milk. And, your baby is healthy and normal. She just latched on twice here and nursed. She has great reflexes and she's peeing and pooping. But, I see that you need to go to the hospital and I wish you safe travels on your journey and I wish you luck once you get there. I hope you find what you need."

We turned to go to lunch and walked past the modified Sumo "ambulance" on our way out. There was a wooden board inserted into the back of the vehicle where this mother would sit with her infant on the four hour ride, over gravel roads, on the way to the hospital. Tiffany shook her head as she talked about how dehydrated the infant would be when they got there. I felt badly that this mother was going to the hospital, but I'd held my hand out to her many times in the last thirty minutes and she'd not taken it. As the Nepali's say, "What to do?"

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