Urgent! Assistance Required

[BuddhistDruid]

To all TV members with connections in to Thai hospitals, especially Thai government hospitals, I am in urgent need of assistance.

I have 2 premature twins that may come at any time. Mother was admitted to Thammasat in Pathumthani, 28 weeks pregnant and 4cm dilated, but they have no space in their NICU. They are currently doing everything they can to stall as long as possible. They tell me they contacted over 30 hospitals trying to find anyone who is able to take the case, but everyone is full.

They recommend I try a private hospital, but I do not have the financial means for that. Even at only 10,000 baht per bed per day, that is 600k per month, and the likely stay is at least 3 months. I will be stretching my finances to the breaking point to afford 30k per month.

If anyone knows of a government hospital that can take this case you just might save 2 small lives. I have no way of knowing whether they are really doing everything they can in this instance, or simply feel that telling a farang to go to a private hospital is easier for them.

What I do know is that my children are likely to die if I can not find affordable care.

Thank you for any help you can offer. You can respond to this thread or via PM.

[Sheryl]

I don't think anyone here has a particular connection to a Thai govt hospital...and even if they did, not much they could do, especially as the delivery has not yet occurred and we cannot say exactly when it will. For obvious reasons, space in a NICU is not something one can predict much in advance.

Lacking insurance or money, your best bet is simply to stand fast and tell them you cannot afford a private hospital. When the time comes, the hospital will simply have to either make room in the NICU or transfer you somewhere else.

Hopefully they will be able to prevent labor for a while. At such early gestation every passing day helps.

Good luck

[BuddhistDruid]

Does anyone know where I can get a list and contact information for all government hospitals throughout Thailand?

We have located 37 government hospitals and there is not a single NICU bed available in any of them. We've checked as far south as Rayong and as far north as Saraburi.

I am desperate to save my children. Any help is appreciated.

[Sheryl]

I have not been able to locate a list, but I do know that there are 5 teaching hospitals in Bangkok plus 26 general hospitals (not all of which will have NICUs). If you have checked with 37 hospitals already it is very unlikely any government hospitals in the Bangkok area have been missed.

I would suggest contacting the Prince of Songkhla Hospital, although it would mean a flight, it has excellent pediatric services, and is far enough from Bkk not to have been affected by the current crises. Part of your trouble may be due to Chula Hosp having transferred patients elsewhere.

Should also look into the Queen Sirikit Naval Hospital in Sattahip if you haven't already done so.

Lastly, suggest contacting some of the not-for-profit private hospitals as they often cost only slighlty more than govt facilities. These are:

Saint Louis Hosp http://www.saintlouis.or.th/clinic/clinic_....php?dept_id=28

Camellian Hospital http://www.camillian.org/Home.html

Bangkok Adventists (Mission Hospital) http://www.mission-hospital.org/new_mission/index_en.php

Bangkok Christian is another but due to its location (Silom near aladaeng) may not be feasible at present.

Note that these will not all necessarily have NICUs, you'll have to ask

Good luck

-

[BuddhistDruid]

I have not been able to locate a list, but I do know that there are 5 teaching hospitals in Bangkok plus 26 general hospitals (not all of which will have NICUs). If you have checked with 37 hospitals already it is very unlikely any government hospitals in the Bangkok area have been missed.

I would suggest contacting the Prince of Songkhla Hospital, although it would mean a flight, it has excellent pediatric services, and is far enough from Bkk not to have been affected by the current crises. Part of your trouble may be due to Chula Hosp having transferred patients elsewhere.

Should also look into the Queen Sirikit Naval Hospital in Sattahip if you haven't already done so.

Lastly, suggest contacting some of the not-for-profit private hospitals as they often cost only slighlty more than govt facilities. These are:

Saint Louis Hosp http://www.saintlouis.or.th/clinic/clinic_....php?dept_id=28

Camellian Hospital http://www.camillian.org/Home.html

Bangkok Adventists (Mission Hospital) http://www.mission-hospital.org/new_mission/index_en.php

Bangkok Christian is another but due to its location (Silom near aladaeng) may not be feasible at present.

Note that these will not all necessarily have NICUs, you'll have to ask

Good luck

-

Thanks Sheryl. I know you are trying to help. Unfortunately, nobody else is. Thammasat does not even want to consider Hat Yai. They consider the trip to be too dangerous in her condition.

I called all 4 of the hospitals you mentioned. Camillian will not even answer their phone. Just rings forever.

Bangkok Adventists answers their phone, and after telling them your inquiry, puts the phone down and nobody comes back to talk to you until after 20 minutes you finally give up. Twice.

Saint Louis does answer the phone, but spent the entire time telling me how expensive they were and this was not the right hospital for me. Minimum 200,000 baht per month per child, and that was just for care. They had no idea of the charges for the NICU, but advised me to look somewhere else.

Bangkok Christian looked promising, until I realized their website can at best be described as false advertising. They would be guilty of a crime anywhere in the West. The website says 2400 baht per day for NICU which is possibly something I could work with given some flexibility and payment plans. When you call them this figure inexplicably jumps to 15,000 per day. Might as well just charge 1 million at this price.

So for anyone else having similar problems, these hospitals are not slightly more than government hospitals, unless you consider a factor of 12 slight.

Unfortunately, I am realizing that my children may die due to lack of concern by the Thai medical community. This is truly a country with no feeling for its citizens.

Every promising lead I've tracked down at an upcountry government hospitals (Ratchaburi even told me they had space), after Thammasat calls and talks with them the answer always comes back "dem".

The ghouls are apparently intent on killing my children, and nothing in this world will make them care. I have never seen a hospital with less concern for its patients. I am not joking. The poor girl was on saline drip only for 24 hours. She was starving by the time the restriction ended at around 7 pm. She asked for food. The nurses just responded "ahan mot".

No, "we'll call your relatives to bring you food", no "we'll try and work something out", just a totally indifferent attitude to her suffering. The medical community here are truly sickening people with no redeeming moral values.

[Sheryl]

Remember that you and your wife habve an absolute right, as pateints, to change hospitals.

Have you looked into Queen Sirikit?

With regard to Camellian and Adventists you might do best to go in person.

Suggest you not lead with stressing how little you can afford, that will put any place off (even a govt hospital). Odds are no matter where you go, you will end up with a bill you cannot pay all of. Best you can do is minimize that to extent possible by selecting a less costly but still adequate hospital and one more likely to be amenable to working out a payment plan. It is not uncommon for hospitals to face the situation of a patient who can't pay and such plans (i.e. payment in monthly installments) can be worked out. However the time to negotiate that is not in advance, at which point, pre-warned that they might take a loss, the hospital will generally try to avoid admitting the patient. This may be part of the problem you are having with the opther govt hospitals.

And what is the situation with yiour wife now, e.g. is she having contractions? Still dilated?

And does your wife have a universal health care card? Because if not, even costs in a govt hosopital are going to be pretty high. Certainly much, much more than the 30,000 baht a month you indicate is all you can afford.

[neverdie]

Contact Information:

Vejthani Hospital

+66 02 734 0000 Location:

1 Ladprao Road 111, Klong-Chan Bangkapi

Bangkok, Thailand 10240

Sorry, I don't know about cost, just googling hospitals with NICU. The few public hospitals that I do know in my area don't mention NICU.

Edited May 17, 2010 by neverdie

[Sheryl]

Vejthani is a private for profit hospital. There is a TV member who had premature triplets there, believe the final bill was around 10 million baht and that he was able to work out a payment plan. I have PM'd him for more info on that.

[BuddhistDruid]

Remember that you and your wife habve an absolute right, as pateints, to change hospitals.

Have you looked into Queen Sirikit?

With regard to Camellian and Adventists you might do best to go in person.

Suggest you not lead with stressing how little you can afford, that will put any place off (even a govt hospital). Odds are no matter where you go, you will end up with a bill you cannot pay all of. Best you can do is minimize that to extent possible by selecting a less costly but still adequate hospital and one more likely to be amenable to working out a payment plan. It is not uncommon for hospitals to face the situation of a patient who can't pay and such plans (i.e. payment in monthly installments) can be worked out. However the time to negotiate that is not in advance, at which point, pre-warned that they might take a loss, the hospital will generally try to avoid admitting the patient. This may be part of the problem you are having with the opther govt hospitals.

And what is the situation with yiour wife now, e.g. is she having contractions? Still dilated?

And does your wife have a universal health care card? Because if not, even costs in a govt hosopital are going to be pretty high. Certainly much, much more than the 30,000 baht a month you indicate is all you can afford.

Thank you Sheryl for your kind help. Please understand I have barely slept in 3 days and I am emotionally exhausted. If I am not presenting myself well, I just hope you can understand that it is from stress and not necessarily because of intent. I hope I have not offended you.

Of course I haven't discussed my financial situation with anyone when contacting them. But I think they infer it when I start asking questions about how much different things cost. They aren't stupid. They know how expensive this is, and if you have to ask, it means you can't afford it. It isn't that I am unwilling to do whatever is necessary, but it is a serious problem that I can not just overlook.

The twins will have a gold card about 15 days after they are born, so there are no problem at a government hospital. NICU charges in a government hospital are about 1200 baht per day per bed which is still something I can swing even if I had to pay cash, although I might be a little slow on payments if it goes the full 3 months.

But the simple fact is, there are not 2 NICU beds at any government hospital within 3 hours of Bangkok, and the hospital will not consider longer distances due to risk.

As Sheryl said earlier, the default in this case is the hospital will do nothing until the twins are born, at which point it is an emergency. In that case, the hospital will send them wherever is necessary, but there will be delays getting administrative approval, and such approval can not start before the emergency actually arises. If the only available bed is a private hospital, then that is where they go. The government hospital will be responsible to the private hospital, and they will try and collect from me. Obviously, given my resources, they will be on the hook for a large bill. They don't want that.

It has further been implied there is a risk for deaths to occur during these administrative delays, and that if I want to protect my children the birth should occur at the hospital where the beds are located. That gives my children the best chance of survival. The only way that can happen today is by moving to a private hospital now.

I accept this is simply the way it is. This is Thailand. If you can not pay, then you receive lower quality care. I just don't want my children to die for something as foolish as the inability to move a group of tokens from one balance sheet to another.

(I have been told by a friend that what is happening is that every hospital understands the situation right now. Thammasat requires a legal statement of responsibility from the new hospital when transferring the patient. Nobody wants the responsibility of having to pay the private hospital in the event of a shortage of beds, and they all know there are not enough government beds to go around, so nobody will accept the transfer. Thus the full court press for me to voluntarily move to a private hospital and solve their problem for them. I'm just not interested in playing their games with the lives of my children at stake.)

At this point I need to find a private hospital in Bangkok with a reasonably priced NICU. If there was something that was 5000 baht per bed per day I might be able to swing that over a period of time. Even 10,000 baht per day and I might be able to make a serious dent over time and get them to forgive the rest. Over 10k and the numbers just become astronomical. At 10k per bed per day for 3 months, that is already 1.8 million baht. I've never owned an asset in my life that expensive.

If there are any TV members visiting hospitals in the near future, could you please ask them how much they would charge per day for a premature infant to stay in NICU? I can't possibly find them all myself, and the larger more well known ones are unlikely to fit my criteria. I suspect the solution, if it exists, will be at a small, private Thai hospital off the beaten path. Some of you in the social security system use those.

I don't want to be a problem for anyone. I just want to save my children. There are lives at stake here. At the moment the mother is still dilated between 3-4 cm but stable. She is confined to bed. Nobody knows how long this situation will last.

Finding such a place may be a longshot, but I have to exhaust every possible resource. I am thankful there is a forum where I can even make such a plea.

[Sheryl]

Rates are not constant or uniform, it depends on the babies' condition, whether on a respirator etc. The bed charge is the least of it. I suspect the actual Govt hospital cost will be great deal more than the 1200 Baht you mention. That's just the bed + nursing care, respirator, medications etc etc will all be in addition.

A TV member who had premature triplets at Vejthani Hospital reports that the total (treatments, vent, meds, NICU bed etc) it was 50,000 baht/day initially dropping to 20,000 as their condition improved. Vejthani is not the least expensive private hospital but it is far from the most expensive.

For the acute initial period while requiring ventilator assistance I do not think you will find any private hospital where it is not above 10,000 baht/day.

I think you have correctly sussed out the dynamics at play here i.e. the hospital is trying to avoid being liable for private hospital bill by "persuading" you to voluntarily move to a private hospital at your own expense.

Aside from transfer to another hospital there is another scenario that often unfolds when there is urgent need for a NICU spot: the condition of the infants in the NICU is reviewed and the most stable ones, if any, are moved out to make room for the incoming. This is done all the time, both in NICUs and adult ICUs.

As your wife is not having contractions yet there is no telling at this point when she will deliver, thus even if there were space in the NICU now there's now guarantee that there would still be space when the time comes.

There is an ombudsman type number to call with problems relating to the Thai universal health scheme, they may be able to run interference for you at the hospital where you are or inform you of private hospitals that accept reimbursement under the government scheme (altho I'm not sure any will do so for NICU care). The number is as follows however need to be a Thai speaker. If possible have your wife, as the patient and a Thai, make the call herself:

dial 1330

Could also try the National Health Security Office (who may also be able to advise which hospitals in Bkk area will accept reimbursement under the scheme. http://www.nhso.go.th/eng/index_main.jsp#

National Health Security Office (NHSO)

The Government Complex Commemorating His Majesty the King's 80th Birthday Anniversary 5th December, B.E.2550 (2007)

120 Moo 3 Chaengwattana Road, Lak Si District, Bangkok 10210

Tel : 66 2 141 4000

Fax : 66 2 143 9730

I believe they are the ones responsible for such things as billing/fee collection arrangements and they also have the mandate to ensure quality of care, so a chat with them but be in order. Likely to take a while to get through the the right person/dept. Try the 1330 number first.

[BuddhistDruid]

This is an update.

I would like to thank everyone who has tried to help me. This has been a difficult time for me and I may have not been as patient or polite with people as I should have. It has been an experience for me that while it is easy to be rational and objective when something is a theoretical problem, once the lives of people you love become threatened it seems these areas of your brain simply shut down. I suppose medical professionals receive alot of practice at this and are able to maintain a detached perspective. I haven't done so well this time.

I have learned alot about how the system works in Thai government hospitals. I am going to relate my experiences so that if anyone searches in the future they may find this information helpful.

For now, the situation is that mother of the twins has been diagnosed with HELLP. Her blood pressure is currently 140/90 and rising. She is having kidney problems. They are keeping her in the general delivery ward under continuous observation and confined to bed. They will not allow her to move to a private room because they can not easily monitor her there. I can not see her any more. I can only call on the phone and deliver food to the nursing station.

They can not give me an estimate of how many days she has left. Essentially, the toxins are increasing by the hour and the only way to stop it is to remove the placenta. This means delivering the babies. They are currently 1.2kg and 1.4kg. This is in the weight class where there is a high probability of survival, but also have a high probability of life long complications and conditions from the premature delivery, including learning disabilities and neuromuscular disorders. That said, accounts of Isaac Newton's birth imply he was in a similar weight class, and he seemed to do OK. Of course, this could also explain some of his extreme personality quirks, reclusiveness and paranoia, which studies show are common symptoms of people who are born premature.

I am very scared for my children. Even if they avoid physical problems, they will likely require extensive therapy during their formative years for attention deficit disorder and learning problems. I have no idea where in Thailand such therapy will be available. Any advice on this is appreciated.

I had about a 2 hour conversation with the wife of a friend of a friend. She was an OB nurse at a government hospital here in Thailand for many years, and explained to me what is likely going on. The fact is, there are limited resources for this problem, and in the government hospitals you can not reserve beds even if you suspect a crisis is coming. If resource usage is light, hospitals will generally try and be helpful. If a hospital had an excess of NICU beds they would likely accept the patient. In the current situation, NICU beds are nearly at capacity. There may be hospitals that currently have 2 open beds, there are certainly some that have 1, but they will not say that. This is because the beds are allocated only on an emergency basis. If a hospital accepts the transfer, and then an emergency comes up before ours, they will have to make their beds available. That will leave them stuck with this problem case, which could be very expensive.

Essentially, if the babies need to be delivered and there are no local resources, a chain of events is set in motion which makes life extremely difficult for the hospital and medical personnel. Because these are twins, the problem is doubled. This can only start once an emergency is declared. In order to move a premature infant, a special ambulance is required with special equipment. It requires a minimum of 6 people in the ambulance, including 2 doctors. There are a minimum of 4 trained specialists required to move the infant from the delivery ward to the ambulance at each hospital. That means logistically coordinating at least 14 specialists including 2 doctors. Since these are twins, that means 28 people and 4 doctors. This all has to be done within an hour or so of the emergency being declared. Nobody wants that headache.

It gets worse. In the event they can not find resources at another government hospital, they have to send the children to a private hospital until a bed opens up. That means, they have to do this entire procedure twice, and they have to pay a huge bill to the private hospital. Since the children are going to be using gold cards, they then have to try and recover the money from the government, which is not an easy task.

My friend's wife suggested that the nursing staff is well aware of how difficult this is, and there is probably a culture at the hospital of trying to get people they feel may have means to remove this headache from them. The doctors I have talked to, by contrast, have all told me not to worry about this and that the hospital would take care of everything. She was also not surprised by this either, as the doctors who are doing the delivery will not be involved nor have any responsibility for the move or the NICU care. I've been in Thailand long enough that conflicting positions like this immediately set off alarm bells for me, and I assume nobody knows what they are talking about. I guess what I've learned this isn't always the case. Sometimes it means they just aren't telling the same convenient lie.

I asked her if she understood how much stress and confusion this creates for the parents and she said yes, that the nurses knew on some level, but the suggested course of action does have the advantage of being safer for everyone involved, as moving an infant is a risky procedure. Most Thai parents would simply accept the nurse's word and pay for a private hospital if they had the means, or else would simply accept the situation for what it was if they did not. Only farangs and troublemakers would do something stupid like trying to understand the truth and the details behind the information they were receiving. (Yes, she was joking, but only somewhat.)

So, the short answer is, that a private hospital who can reserve a bed is the safest way to go. However, the expense is huge. While I do not have an idea of the level of danger in moving a premature infant, the fact that my friend's wife had never experienced a infant die during transit from one hospital to another during the entire time she was working leads me to believe that there is a risk, but it is a manageable risk. The question becomes is it worth all the money to avoid this risk?

I'm already likely staring at large bills for extensive therapy. If I were to go far into debt today in order to reduce the risks at birth, I may not have the resources to pay for the risks after birth. Which one is more important for the children? The risk of having to move them after birth, or the risk I can not pay for therapy which may help them lead a more normal life?

The hospital today told me that the violence in Bangkok has severely impacted their ability to find beds locally. The closing of Chulalongkorn and Ratchewiti has created a crisis. They will likely have no choice but to send the children to a hospital in the provinces. They are still going to try and find a place to transfer the mother before the birth. They don't know which hospital, but the head doctor promised me they will find a solution and not to worry.

Guess what? I still worry.

For now, I have decided to leave her at Thammasat. It may not be the best hospital, but the nurses and I have built up some kind of an understanding. I now think I understand why they tried so hard to get me to go elsewhere. I am confident they will be professional though when the time comes. There is no perfect solution to this problem. There are just degrees of risk, and hope. I only hope that in the future I can accept that my decision is the best one I could have made under the circumstances, and I hope that my children are born healthy with no lasting complications.

If anyone knows an institute here in Thailand who can help me evaluate my children after they come home from the hospital for possible developmental disorders, please let me know.

[bina]

and the health of the mother? with aniamls the mother is usually induced /or c section to save the mother, try for offspring a second time... when waiting too long, the chance of losing both mother and offspring rises;... not being judgmental here, but curious as to what would be best for the mother?

and from what i read about micropreemies... and from the little info we've seen here on the forum about followup /therapy for LD /handicapped children... thailand might not be the best choice... u arent just talking about therapy but also phsical health problems that may need intervention later...

the thing is, is that u are trying to get too much info for an outcome that is not very certain (all the ifs involved). do try to get info if u havent already from the link sheryl gave u for a forum member that went thru/is going thru for his preemies...

there is something to be said for excepting the situation for what it is like your nurse friend says many poor thais would do. there are too many parameters for u to try to control and o matter what the outcome, u may feel guilty for 'not trying hard enough' when in actuality, u are doing your best as u see it/can deal with it now. not easy either way...

perhaps getting info from your home country might help? or financial help from relatives/friends in your home country/charity (there are charities for helping families that are in treatment for having preemis and micro preemie in some countries from pre birtht through the end results both good and bad...

i wish u luck

bina

israel

[Sheryl]

Bina is right. Don't drive yourself crazy worrying now about possible needs years down the line. There are too many different variables and unknowns...and much more immediate problems.

Your wife's condition is quite serious. She cannot be moved anywhere far away and under the current conditions in Bangkok is probably best staying where she is.

I won't tell you to relax as that is obviously impossible. But do try to focus on being there, enotionally, for your wife and keeoping her spirits up. That is soemthing only you, her husband can do. Let the doctors and nurses take care of the medical aspect and focus more on that, is the best advice I can offer you. From what you have described it does sound like they are on top of it and doing all that they can.

And try not to drive yourself crazy with worrying about the mechanics of getting the babies, once delivered, into an NICU. The hospital will, one way or another, take care of that and worrying about it is not going to help anythinmg, just increase your tension at a time when you need to be strong for your wife.

Good luck and keep us posted

[BuddhistDruid]

This is an update on this case.

Everything is holding steady for now. The babies are currently at 30 wks +4 days. The girl has been on a growth spurt, and is now actually heavier than her brother at 1.6 kg. The boy is at 1.5 kg.

The mother's blood pressure is still stable at around 140/90, and no symptoms of HELLP. She has severe preeclampsia due to extreme proteinuria counts greater than 5000 in 24 hours. She is still confined to bed in the hospital. She is still dilated to almost 4 cm. No other complications have arisen.

My problem now is they have been giving her terbutaline (Bricanyl) on a continuous IV drip for almost 12 days. I am extremely worried about this course of treatment.

Accoriding to the following December 2009 paper in the American Journal of Obstetrics and Gynecology, this course of treatment is not effective for controlling premature delivery beyond 72 hours and places the children at significantly increased risk of autism.

http://www.ajog.org/article/S0002-9378(09)00776-5/abstract

Now the question becomes, what do I do about it? I have already had one run in with an extremely rude doctor at this hospital who chastised me in front of all her students for asking questions and "interrupting" their precious work. (Who are you? Are you a doctor?) My question was a very polite inquiry as to the results of the blood test taken that morning. As much as I wanted to abuse her and slap her silly in front everyone (she was extremely rude and definitely deserved it), I bit my tounge and walked away for the sake of my family.

Now I want to go in and seriously question a treatment option. Not just question either. I want to tell the doctor I believe she is wrong. I feel in my heart I have to do it, but I am afraid of the consequences of this. These are my children though. How can I NOT do this?

My real dillemma is I have only this one paper to go on. I have not been able to find anything else in the scientific literature to give a more complete perspective.

Does anyone have any advice for me? I can't even close my eyes without vividly seeing the damage that terbutaline drip is doing to my unborn children. Is this paper realy correct that it does not help to control premature delivery after 72 hours?

This is agonizing....

Any advice on either my interpretations or the proper way to address this problem with the hospital staff is appreciated.

[BuddhistDruid]

As a follow up to this question, the paper above makes a rather bold statement that prolonged use of terbutaline is not effective in preventing preterm delivery beyond 72 hours. A little more research has led me to the belief that this conclusion is not nearly so obvious. There does appear to be contradictory evidence as to its efficacy in maintenance tocolytic therapy. It would not be fair to take an absolute stance one way or the other.

There appears to be an option of using nifedipine (Procardia) instead of terbutaline in this case. Does anyone know why they might prefer one over the other? Nifedipine seems to be less controversial from a long term neurological development perspective.

I do apologize if this is getting rather technical, but when doctors fail to share basic information with you there is little choice but to do your own research. I am just trying to do the best I can for my children. I don't know any other way.

[Robby nz]

I have been uaing the Army hospital Phramongkutklao in BKK .http://www.pmk.ac.th/ give them a try.

Good luck

[Sheryl]

Glad to hear the update, was wondering how things were going.

As you probably know, it is a huge plus to have gotten from 28 to 30 weeks and greatly increases the odds of a successful birth. They are already at a point where >90% of infants survive. They still have about a 50% risk of significant complications if born now but that risk drops every day; below 40% by 31 weeks, below 30% by 32 weeks (i.e. more than 2/3 of infants biorn at that point will not have serious complications), and by 34 weeks you are pretty well out of the woods. Note that when I say serious complications, this means things like respiratory distress syndrome but it does not mean certain long term damage by any means.

It is also very good that your wife's blood pressure is holding as it is in the range of pre-eclampsia, were it to worsen they might have to deliver her which of course is undesirable for the babies. As long as they can keep it from going beyond the present range she should be OK to continue the pregnancy. Due to the dilatation she will have to remain on bed rest, which must be quite boring and stressful for her, so do provide all the moral support you can.

Regarding your question, tocolytic agents (drugs to reduce uterine contractions) are used when contractions are present (these may be so mild that the woman does not feel them, but they can be measured with instruments) at a certain frequency. Presumably this is the case with your wife. The best management of preterm labor is a matter of some uncertainty and debate, in no small part because of the tremendous ethical and medico legal barriers to conducting the type of random trials that are the "gold standard" of proof.

It is generally agreed that between 24 and 33 weeks gestation the benefits of tocolytic therapy outweigh the risks. By 34 weeks the risk of death or permanent disability is minimal with proper neonatal care and at that point it is considered best to allow labor to progress.

It is true that in the West, terbutaline has largely been replaced as first line treatmentby other drugs e.g. magnesium sulfate (MgSO4), indomethacin, or nifedipine; there are pros and cons to which if these 3 to use The reason for the shift away from terbutaline and related drugs is a higher incidence of maternal and fetal side effects, which does not, of course, mean that serious maternal or fetal side effects occurred in all or even most cases, just that they occurred in a larger minority of cases than seems to be the case with these other agents. However tyerbutaline is still recommended in cases where these other drugs either failed to work or were contraindicated. In either such circumstance its use would be justifiable. You will note that the article you cite specifically states that the risks of using it are less than the risks of no treatment.

Also note that the association between exposure to terbutaline in utero with autism and other developmental disorders is by no means clear or proven. Some studies found no effect at all, others showed only a correlation, which is not in itself proof of causation. In addition, in many of the cases studied terbutaline was taken for asthma in the mother, which introduces a whole other set of potential confounders.

And, even if in fact there is causation, it is one of increased frequency of something that still affects only a minority. (I have noticed your penchant for treating worst case scenarios as if they were likelihoods!)

I don't see where in the article it says that use beyond 72 hours is ineffective. It cites studies that indicate that "maintenance" therapy is ineffective but there is no clear rule that over 72 hours = maintenance therapy nor any clear point at which that line is crossed. We also don't know for sure that the therapy has been nonstop for 12 days or whether it has been stopped and then resumed due to renewed contractions. At least I don't, and it doesn't sound like the level of information you are able to get would ensure that you would, either.

Which brings us to the fundamental problem, which is not that your wife's treatment is necessarily wrong but that you do not receive adequate information from the doctors let alone involvement in decisions. This is, unfortunately, typical in Thai hospitals, especially government hospitals. It is possible that you have landed in a place where the team is unusually bad in that regard and that you might end up with a slightly better situation if you transferred elsewhere but no guarantee of that and hard to ascertain in advance.

The only tip I can offer is that it is always better to ask questions of the attending physician rather than the interns and residents and especially not to question the interns or residents when they are on rounds. The reason for this is that the less senior doctors know less and worry more about having that fact revealed, especially before others. (The Thai "loss of face" thing). Senior doctors confident of their own expertise and with already established reputations are less touchy. However, they are also much harder to get hold of and have little time to spend. If you can, find out from the nurses when the attending is likely to come by and ask them to help you get a few minutes with him or her. You will need to wait, possibly a long time, but are much more likely to get a meaningful reply. One of the problems you may have with the rest of the team is that they themselves may not know why the attending has decided on a particular course of action. The logical option of just saying so and referring you to that person doesn't fly here because doctors believe that they are supposed to appear omnipotent to patients/families and therefore to ever say "I don't know, ask so-and-so" would be a loss of face.

For simple factual information (what meds being given, what tests done, test results) the nurses are often the best source but you have probably figured this out by now. If you have not already, start assiduously cultivating their favor (smiles, pleasant chit chat, show concern for them/how hard they work, notice if one has been on duty for more than the usual number of hours or many days in a row, and without making a nuisance of yourself, appeal to their pity. And plead forgiveness for any mistakes with the "I'm just a farang, I don't know the system"). Etc.)

Basically you need to decide to either transfer your wife elsewhere in the hopes of getting physicians more amenable to answering questions (understanding that, as you are constrained to government hospitals, you can't guarantee that outcome) OR learn to live with the system and stop torturing yourself with trying to second-guess what they are doing without benefit of knowledge of the reasons behind the various treatment choices and probably without knowledge of many of the clinical findings which prompted them.

It is just not the custom here to tell patients/family the kind of medical detail routinely shared in the West. Doctors who have trained in the West have learned to do that and usually will, at least with Western patients/relatives, but in a government teaching hospital the only doctors that applies to (if any), will be senior faculty/attendings while the bulk of the care is delivered by interns and residents who are not remotely exposed to that style of working plus are still earning their stripes within the Thai medical establishment and thus especially touchy about "face". In addition, I should add that workload/time constraints in government hospitals mitigate against providing much in the way of communication or reassurance to family members.

Do keep in mind that these shortcomings have not prevented these practitioners from successfully prolonging the pregnancy by 2 critical weeks so far nor from keeping your wife stable despite some potentially serious maternal complications. The situation and prognosis is vastly better now than it was at admission.

I am going to be driving through Patumthani on route to Bkk next Thursday, if you feel it would be useful for me to try to visit her (or just have a cup of coffee with you) I'm glad to do so, just send me a PM with your phone no etc

[Sheryl]

P.S.

Please remmebr that, while right now there is very little you can do other than provide emotional support to your wife, and this lack of action is driving you crazy, you will soon face the huge task of caring for two newborns. More work than you can remotely imagine.

You need to go into that as rested and calm as you can, not start out on it with your nerves frazzled. So please, try to take it easier. Change hospitals or not, up to you and your wife, but in either case, accept the fact that at this particular juncture your role is limited, frustrating though that may be.

Your wife likewise needs to minimize her stress. You can't help support someone else emotionally if you yourself are full of anxiety.

You wife's feelings about the hospital and staff should be given considerable weight in the decision as to whether or not to transfer elsewhere.

[BuddhistDruid]

This is an update to this thread.

My twins were born this morning, June 7th, 8 weeks premature at 1.97kg and 1.53kg via cesarean. Their apgar scores were 8 and 9 at 1 minute, and 10 and 10 at 5 minutes. They appear to be strong and healthy, albeit very small. They are both on CPAP (continuous positive airway pressure) at the moment, and both are crying and restless. (That's a good thing by the way. Shows their lungs have enough surfactant.)  The boy (1.97kg) is opening his eyes for short periods. Neither child is currently showing symptoms of PDA or other complications, although the girl (1.53kg) is not showing a satisfactory sucking reflex.  The mother is currently in ICU recovering from severe preeclampsia. She is on magnesium sulfate, her blood pressure is currently 147/106 and she is having intermittent blurred vision.  The babies are both in the NICU on open beds with an overhead heater.

A bit of history. On Friday, June 4, the mother was discharged from Thammasat. I was surprised at the decision, but since nobody was happy with the hospital we did not question the decision by the doctors. Only 36 hours later the mother's water broke and she was 5 cm dilated. We took her back to a hospital, but this time to Chulangkorn, as there were no bullets flying around the area any more.  They did make a comment that our checking in caused them difficulty because there was an other emergency case requiring an NICU bed that they were now going to have to refuse as we got there first, but they never made us feel bad about this. They were suspicious of why we were previously at Thammasat but now coming to see them. They asked several times if the doctor at Thammasat told us to do this. I admit it probably looked suspicious from their perspective, but the truth is the decision to go to Chula was entirely our own, and there was no collusion or even discussion about this between us and the staff at Thammasat.

For anyone who may find themselves in similar circumstances, I would like to tell you that the correct selection of a government hospital is like night and day. You may not have a choice of hospital in a non life threatening procedure if you are on the government gold card scheme, but during an emergency you can go anywhere necessary, and the hospital you choose can make all the difference. While there are always exceptions and it is not fair to generalize, I am going to do it anyway. The staff at Thammasat are rude and lazy. They will not speak with you or answer your questions. When asked a valid question they generally make up a story that turns out to be false because they are too lazy or possibly too ignorant to explain the truth.

By contrast, the staff at Chulangkorn is completely different. They are patient and helpful. I found them willing to spend as much time with me as necessary to explain the situation. Even with my less than perfect Thai, I never felt they were annoyed when I expressed that I did not understand. The nurses never once made me feel like I was an imposition as they did constantly at Thammasat. They never asked me to go somewhere else. Again, it is unfair to make blanket generalizations, but the culture at Chulalongkorn is shockingly different than the culture at Thammasat.  This is not only a farang impression. No less than 3 very Thai family members expressed exactly the same sentiment.   Everyone is universally happy with Chulalongkorn. Everyone was extremely displeased with Thammasat. 

I am now left with having to fight the accounting staff at Thammasat. When we first checked in, they refused to accept the gold card, even though the situation was considered an emergency. (The gold card is from Surin province.) They fabricated a story about why we had to pay cash. Eventually, after a little over a week and consulting with an attorney about the rules for the government sponsored health care plan, I succeeded in getting them to accept the gold card after I refused to pay any more bills in cash and told them if it was an emergency here was the card, and if it wasn't to discharge the patient and accept responsibility for anything that happens. Obviously they accepted the card at that point. In a perfect world I would have done this on the first night, but I needed to learn the rules first before I could fight them with conviction, and that took some time. (Besides of which it was late on a Saturday night and the people saying  "no" probably would not have had the authority to say  "yes".)

Unfortunately, they are refusing to refund the money on the two bills I did pay (almost 40,000 baht). No reason for this. They simply say "mai dai."  My position is since they have already admitted this was an emergency (they would not have legally been able to accept the gold card later if it wasn't), then it was inappropriate for them to demand cash settlement when we first checked in and tried to use the government health care plan.  They need to back out those transactions and bill the government. Again, I suspect they are too lazy to do this. I do not believe this is a real problem. The fact that I am a farang does not give them the right to make their own rules when it suits them.

I paid for the bills with my Visa card. My next step is to try and talk with an administrator at the hospital and tell him if he does not refund my money I am going to try and institute a chargeback with Visa.  My contention is I signed those credit card slips under duress. I did not believe them when they said they could not accept the gold card, however they were simulateously telling me that the lives of my family were at stake if I did not sign. Who would have done anything different? If someone held a gun to your wife's head and said "I may kill her if you do not sign this contract", is that transaction really considered valid?

The whole thing seems fraudulent to me.  I am not sure the best way to address this problem, but I have learned that there are good and bad hospitals in Thailand. The statistics they report on survival and recovery may be similar, but their attitudes can make all the difference about how you perceive your injury or illness. A poor hospital is just not something you want to experience if a good hospital can be obtained at a similar price.

Anyone with suggestions on how to handle the Thammasat problem please let me know. To anyone who finds this thread while researching Thai government hospitals, my only advice is to be extremely careful about where you go. Be dilligent when checking their reputation. They are not all created equal. Statistically, they seem to provide similar levels of care, but if you are concerned about the psychological health of the patient and the family, do not go anywhere that does not come highly recommended by someone you trust.

To anyone curious about the trials and tribulations of having a premature baby on a budget, send me a PM. I will try and help you as much as I can. I bought a great book on Amazon called "The Essential Guide for Premature Babies." Highly recommended. Only about 900 baht shipped and got here in only 10 days despite using the cheapest shipping option. Helped me immensely in communicating with the doctors today. Much easier to ask something like "ben RDA rue blau" than trying to understand 5 minutes of Thai euphamisms for various conditions. They will also start using medical terms that you can understand (or at least look up) when they see you have some knowledge, vs. layman's language which will likely just confuse you.

Thank you to everyone who made helpful suggestions during my ordeal. This is just the beginning of the journey for me and my children. While it has not been entirely pleasant so far, and my reactions have not always been ideal, the fact that my babies are apparently healthy and receiving care at Chulalongkorn makes me realize I could not have asked for a better result even if it had all been planned this way.

[Sheryl]

Congratulations on the birth of your children!

Your wife's condition should improve rapidly now that she has delivered.

Re the bill dispute with Thammasart, no harm in trying a chargeback through Visa but I'd be very surprised if it works as (1) the hospital is not like a usual Visa vendor and (2) the reason for refusing the payment is different than the usual Visa story and will be hard for them to assess.

The NHSO is the place for handling this, see post #10. However it may need to be contacted by your wife, as she is the gold card holder. And will certainly need a Thai speaker. Will probably work best to go there in person rather than by phone and then just apply "patient persistence i.e. settle in and show no inclination to leave the office until the matter has been resolved.

Good luck