#010 - Teaching Life-Saving Care Across Borders: Dr. Manjari Pophale’s SALSA Project

In this episode, Dr. Manjari Pophale discusses her innovative global health project focused on implementing surfactant administration techniques in resource-limited NICUs across Africa. She shares insights into the project's development, the importance of mentorship, and the positive impact of the SALSA method on neonatal outcomes. The conversation highlights the challenges and successes of global health initiatives, emphasizing the need for effective training and community engagement.

Transcript

Srirupa (00:01.146)
Hello everyone, welcome to another episode of Rupa's Fellows Friday. I am very delighted to welcome our next guest, Dr. Manjari Pofle, who is from Vanderbilt University. She's currently a second year neonatology fellow at Vandy. She did her residency at the Children's Hospital of Michigan, Detroit and moved to Nashville to do her fellowship and very excited to talk a little bit more about

the amazing global health projects that Manjari has been doing. Welcome to the episode, Manjari, how are you doing today?

Manjari Pophale (00:36.846)
I'm good Rupa. Thank you so much for having me. This is such an honor and delight.

Srirupa (00:40.506)
Yeah, of course. And I'm so glad that a lot of fellows are reaching out to me because I want to make this platform just for you all fellows to talk about the amazing, amazing research that you're doing at your level. So let's start by talking a little bit about your project. And I got a little abstract from you, and it seems like you're doing a salsa implementation project through video conferencing. So tell me a little bit more about that.

Manjari Pophale (01:10.072)
So what we're trying to do, my mentor is Dr. Guthrie. He also works at Vanderbilt. So we are trying to teach poor African NICUs, surfactant administration through an LMA, and show that we can improve their outcomes, like their mortality, decrease their length of stay. So that is the basic aim of my project. The way we're trying to do this is,

that I and Dr. Guthrie have made videos and we also have like on-demand video conferencing like sessions. Yeah and we just want to show that we can help places like these that don't really have the capability of like intubating or don't have like a lot of resources.

Srirupa (02:01.88)
that's amazing. And tell me, are these NICUs level three NICUs? Like what is the capacity of these NICUs?

Manjari Pophale (02:10.413)
So these are actually really, really small NICUs. There are four hospitals that I'm currently working at. The first one is Sordo Christian Hospital in Ethiopia. That is a little bit of a bigger hospital and they have around 100 to 150 babies per year that end up needing surfactant. They have actually learned the salsa method in late 2022 and they have already started doing it and

it has shown that their mortality has actually decreased. The second hospital we have is in Kenya and that is a little bit of a smaller hospital. Ghana is smaller than that and then Malawi is also like a very small hospital with 60 to 70 babies per year. The physicians there are not neonatologists. They are either family medicine physicians or pediatricians.

Salsa is such an easy technique. We just want to show that anybody can do it. Like it can be done in seven seconds versus intubating takes at least 45 seconds to a minute. So it will be nice for resource limited settings to learn the technique and be able to do it. So they don't really have like a classification of like level two or level three.

Srirupa (03:35.396)
Yeah, no, and.

Manjari Pophale (03:39.842)
but they're really small nicus who are just trying to do their best and keep the babies alive.

Srirupa (03:46.456)
Yeah, and that's so interesting that you mentioned that there's no demarcation of level three and level four, which I think is very specific to a lot of centers around the country, but around the world. But specifically in the US, we have that demarcation. And it's important to kind of realize that the capacity and expertise and competency for these procedures might be pretty variable in these centers. Han, remind me, all of these hospitals you said already

Manjari Pophale (04:08.269)
Right.

Srirupa (04:15.763)
know how to do salsa or like have some idea of what salsa method would be.

Manjari Pophale (04:21.966)
Just the hospital in Ethiopia does. They attended the Tiny Feed Big Steps conference in Tanzania in 2022 and they saw Dr. Guthrie's presentation and they started implementing Salsa in late 2022. So we're modeling our whole project based on that site. So they're like our pilot site and the rest of the hospitals are just going to follow suit.

Srirupa (04:25.976)
Gotcha.

Manjari Pophale (04:50.444)
The other three hospitals have actually not started doing salsa in their centers. Some of these hospitals don't even have surfactant. Some of the hospitals don't have CPAP. So we have some donors that have graciously, they're willing to donate surfactant and CPAP to the three centers. So that's what we're working on. It just takes a lot of time for

everything to go through customs. So that's where we are at. I've already made the videos to teach the hospitals, a factored administration through an LMA. So all of that is available. And then we have a toolkit available that will help them implement this whole procedure step by step.

Srirupa (05:39.416)
Yeah, that's awesome. So what stage of your project are you on? I see that you're a second year and you're probably six months plus into your second year, I would say. So tell me a little bit about how this project started, where this idea came about, and what stage of your project are you on, and what do you foresee as what your outcomes would look like, and what stage of your project are you at right now?

Manjari Pophale (06:04.684)
Right, I actually in my first year, I came into fellowship kind of not knowing what I wanted to do. I was interested in a lot of different topics, but I still hadn't made up my mind. So the first six months of my fellowship, I was meeting with a lot of mentors, talking with a lot of mentors. And then towards the end of my first year, I ended up attending

a Tennessee quality improvement conference where Dr. Guthrie was speaking and I just fell in love with his work and it just spoke to me and I decided that, this is something that I really want to do. So Dr. Guthrie already had connections with Ethiopia as they had gotten in touch with him to kind of start the Salsa project in 2022 and then

It just spread by word of mouth. So somebody at Ethiopia knew a physician in Kenya. So the two hospitals got involved. And then someone knew someone in Malawi. And then Dr. Guthrie was like, since this is spreading so rapidly, why don't we just do this through video conferencing? And that's how we came up with the idea of just teaching three centers at once through video conferencing.

And then the fourth hospital in Ghana joined pretty recently. So now we have four centers. We also have interest from a center in Philippines and a center in Nepal. We still have the toolkit ready, and then we have the videos ready, but they're just not a part of my study. But we're trying to get them included just so that they can start doing this. Where I'm at in my project is...

So these centers didn't have like CPAP machines or surfactants. So we got in touch with a pharmaceutical company and then a company that makes CPAP and pitched our project to them and they very generously have decided to donate resources to the hospitals. So right now they will be getting their first batch of surfactant and CPAP machines in early March. And then.

Manjari Pophale (08:27.424)
We have already finished the baseline data collection about what their mortality has been over the last year. So once they get their surfactant, we can start collecting data going forward. So that's where I'm at.

Srirupa (08:42.682)
That's curious. And out of curiosity, what is the mortality like in general in these hospitals?

Manjari Pophale (08:48.63)
Yeah, so I'm just going to talk about Ethiopia first because we kind of have their before and after data. So before they started implementing this project, their mortality was 13 out of 18 babies in like the past year. And after they started implementing the salsa in their units, their mortality was

6 out of 18. So like it decreased by quite a bit and they're really really happy about it.

Srirupa (09:27.466)
That's fantastic. think we all know the magic that surfactant provides to these neonates, especially our little tiny ones. And I think it's such a substantial work that you're involved in to actually introduce this concept and this minimally invasive method to all of these low resource settings, which is amazing. And I always wonder, and this is just something that you probably are going to experience or maybe are experiencing.

Manjari Pophale (09:44.782)
Mm-hmm.

Srirupa (09:54.138)
But whenever there's a change that's coming from a big nation into a smaller country, the first reaction almost becomes, do we really need it? That's always sometimes the case. And in some situations, it's welcome with a lot of positivity. But I'm curious to know, what was your experience? And how did the people, which include parents and the medical personnel, what was their response to this?

Manjari Pophale (10:19.79)
Thank you.

Srirupa (10:22.348)
intervention and this introduction of SALSA method.

Manjari Pophale (10:27.022)
think the biggest question that when we first started talking about this, what we got was more of like, let's start by looking at this as evidence-based. And then when we kind of spoke about how this was like an evidence-based practice and gave them like a lot of papers and the other hospitals had seen like how

how much this helped in Ethiopia. think everybody got on board pretty quickly. The other thing I also wanted to add was that there's no skilled proceduralist in the hospitals to actually administer surfactant and some of the hospitals don't even have surfactant. So they had to call like an anesthesist that was not in house. And there was a lot of trouble incubating like these babies.

to even give surfactant if they had surfactant. So I think everybody was really happy that there was another way to very quickly administer surfactant. And I think it just spread so quickly by word of mouth that it didn't take a lot of convincing to get the physicians on board. Also, because this is the only way to save their babies.

And now a lot of their patients end up passing away just because they don't have the capability to administer surfactants. So everybody's pretty excited and we're very excited to finally get this started in early March.

Srirupa (12:09.816)
Yeah, no, that's fantastic. And it seems like you're getting all of your videos ready, and you've gotten them ready, and the toolkit ready. I'm curious to know, one, what was your experience, or how was your experience in making these videos? And two, could you share with us and the listeners what this toolkit entails? Like, what are the things that are included in this toolkit?

Manjari Pophale (12:34.294)
Yes, so we made the video at a simulation lab. So we had a baby, a model baby. And to be very honest, I am very awkward in front of the camera and Dr. Guthrie, it was just me and Dr. Guthrie and Mary Lee, who's one of our sim nurses. I was so nervous and so awkward. And I can put up the QR code at the end of this if.

someone wants to take a look at the toolkit because that can be utilized in any setting, whether it's like a level four, level three or level two. But you can like see my nervousness and my voice is like shaking. So yeah, it was a very like small, kind of like a home based video that Dr. Gutsy was shooting. He did a great job. And then we had like this model baby where we showed how to administer surfactant.

using an LMA.

We sent it to the physicians in the four hospitals and they've actually really liked it. It's a 15 minute video. It's a little bit longer than we wanted it to be. But we've kind of spoken about everything, about the procedure, what they need, and then what to do after the procedure and what to look out for, complications. The toolkit has everything. So it starts by like,

talking about the evidence-based medicine of it. It starts by listing out why this is needed and how this will be helpful. And then it goes to the protocols. So we also made a CPAP protocol and then a SALSA protocol, which is based on Dr. Roberts and Dr. Guthrie's protocol. But the CPAP protocol is based on the YU CPAP machines.

Manjari Pophale (14:35.764)
the sites are not going to be having enough surfactant, we wanted to make sure that the sickest babies got surfactant first. So the CPAP protocol kind of states how to enter the CPAP protocol and then what is the criteria for actually giving surfactant. So here we use like a respiratory severity score of like 1.5.

that is P into FIO2, which is like, if you use an FIO2 of around 30%, that comes to around 1.5. But the way we have made the CPAP protocol, we're using a respiratory severity score of three so that we can capture the sickest babies. And the surfactant goes to the sickest babies just because they're so limited in resources. So we have...

that CPAP protocol and then how to exit out of the protocol. So just kind of listing what are the clinical features you're looking at. And we're using the Silverman Anderson score, which is, it's kind of like an objective score for respiratory distress so that anybody should be able to do it. Physicians, nursing, so all of that is listed. And then the SALSA protocol just.

says what I've said in the video, which is everything that you're going to need, who is this indicated for, and then how do you do the procedure. The toolkit also has the links to the videos. And then this is more of an implementation research project. So the toolkit also

mentions what we're going to measure, like what our outcome measures are, what our process measures are, what complications to look out for, what our structure measures are, so just like all of it. And the way we made it is so that we can use this in any setting.

Srirupa (16:46.414)
That's awesome. It seems like you've had a lot of thought and hard work behind creating the toolkit, which I think will be very well appreciated by lot of these centers. And I would love for our listeners to also maybe look at the video, because I'm sure you did a fantastic job. And I think that all of us are a little awkward in front of our cameras, so I totally understand that. But I think that kudos to you and your efforts in trying to get the video out.

Manjari Pophale (17:02.382)
Mm-hmm.

Srirupa (17:14.788)
which has probably going to have a lot of impact on the things that are happening in these NICUs. Tell me, I see that you've had a very beautiful experience with getting involved in global health and Dr. Guthrie has such a massive presence in the global health world. And I would love to hear your experience and one finding your mentor and your mentor relationship and how that's going on. Because I do think that as Neo Fellows, you're absolutely right.

Manjari Pophale (17:33.582)
you

Srirupa (17:44.856)
majority of us come in not knowing what to do. And majority of us, you know, have different ways to reach our mentor, like ultimately get to our mentor. And I think that's very helpful for listeners to like get everyone's experience on how that mentor-mentee relationship eventually develop.

Manjari Pophale (17:54.99)
I'm sorry.

Manjari Pophale (18:05.378)
Right, I want to start by saying that I'm so lucky I met Dr. Guthrie and how he's been with me every step of the way. I am originally from India, that's where I did med school and I kind of have seen how just by like increasing a little bit of training, increasing some resources that so many lives can be saved.

I got into neonatology also with the mindset that I want to go back home and do some education at some point in my life. So when I started first year, like you said, I didn't have a very clear picture of what I wanted to do. I was interested in a lot of topics. I liked neurodevelopment, I liked nutrition.

like BPD and I was just like, I am not sure what I actually want to do. So like I was saying, I spent a lot of first year talking to a lot of people who did some great work, but I finally fell in love with Dr. Guthrie's work after I heard him speaking at one of the conferences. So I approached him and he was really welcoming. He said, know, email me anytime and

We can talk more about the ideas that you have. And I did. And that's how all of this was born.

Like I was saying, he has been great. Like there have been times that I was preparing for a talk or was going to go to a conference to just like showcase the work that I've been doing. And I would email him at like 9 PM and say, Hey, Dr. Katwi, how do you think my slides look? And you know, he'll send me a reply back at like 9.50. Like, oh, these are, this is the feedback, you know, just change it and send it to me. So like, he has been great.

Manjari Pophale (20:09.902)
And I think that is really, really important to have that kind of a mentor-mentee relationship. I think it's more of like a friend relationship at this point. He came to the SimLab and we shot the video together. It was just like a fun experience, even though I was very nervous. But I'm very thankful to him and I'm very lucky at his constant feedback that he gives me when I apply to.

like the fellow research conferences or I apply to some other grants and...

think it's really important to find a mentor that you like working with and also likes working with you and is very open and gives you constant feedback.

Srirupa (20:56.952)
Yeah, no, I totally agree. Golden words over there. think that we all, neophilos, require a lot of handholding and a lot of support as we go through our fellowship. And it sets a very solid foundation on how we want to view ourselves as mentors in the future for another mentee as well. And so I strongly, and I say this in most of my episodes, that it's so important that that relationship

Manjari Pophale (21:05.08)
Mm-hmm.

Manjari Pophale (21:14.254)
Right.

Srirupa (21:22.794)
is solid and is something that I think persists for life. You like you can never forget your mentor in your fellowship and you always have to have that relationship sort of flourished during those three years and have such an impact over your course of your career. Well, that was fantastic and Manjari, it seems that you've done like amazing work and I can't wait to, I'm excited, as excited as you are.

Manjari Pophale (21:35.214)
Bye.

Srirupa (21:48.41)
probably a bit more to understand your results. And I can't wait for you to present your results, hopefully in the future soon. But I'm pretty excited about the work that you're doing and the impact it's going to have. So congratulations on all of the effort that you put in. One last question, and I ask this at the end of all of my episodes. If you were to give a piece of advice to any incoming fellow who's interested in global health research, what would that be?

Manjari Pophale (22:03.544)
Thank you.

Manjari Pophale (22:17.932)
I think the biggest advice that I would give is the first thing I would say is pick a research project that you really really like and does not feel like you're just doing another additional thing.

This project has had a lot of logistical challenges, but I really enjoy the work that I'm doing and I really enjoy all of like getting over all of the little barriers. So I think that is like the first piece of advice. Like love your research project and like actually enjoy your research project.

And then the second thing is pick a good mentor. I think what is very important in global health is for your mentor or someone to have existing global health connections. Because to be very honest, if Dr. Guthrie did not have the connections in Ethiopia or Kenya, then this project would not have taken place. So think it's so important to.

either go to a fellowship program that already has existing relationships with other hospitals and international sites, or pick a center that has, I think that is the first step that is very important because as a fellow, it's really hard to one, make these connections and two, like get a project like up and running in like your two years of fellowship, essentially, because your first year is like you're

doing boards and you're trying to become a good neonatologist. And then the third thing is that if you're doing a global health project, like there's going to be so many logistical barriers. The IRB process takes a lot of time. Sometimes the international sites, like it doesn't work out. Just be persistent and be patient. And in the end, you know, you're doing great work.

Srirupa (24:27.576)
that's amazing. And I think you've touched on two very important pieces of advice that you need to take forward. I think as fellows, we all need to listen to what your heart wants. And that is what we need to go on with because these projects can require a lot of hard work and patience.

doing what you love is very important. of course, mentors are the key for this whole thing. Well, this was amazing. And thank you so much for joining us today, Manjari. It was lovely having you and having you share all of your experiences. none of us can wait to hear the results and amazing work that are going to be published hopefully soon.

Manjari Pophale (24:49.411)
Yes.

Manjari Pophale (25:07.16)
Yeah, thank you so much Rupa for having me. This was so much fun. It was so nice talking to you.

Srirupa (25:11.482)
Yeah, amazing. Thank you.

Manjari Pophale (25:16.206)
Thanks.