#300 - 🌍 Neonatal Care in Trinidad & Tobago: Challenges & Triumphs (ft. Dr. Marlon Timothy)

Hello friends 👋

In this episode, Dr. Marlon Timothy shares his journey as a neonatologist, discussing his experiences in Trinidad and Tobago and the evolution of neonatal care. He highlights the challenges faced upon returning from training in Toronto, the establishment of neonatal units, and the implementation of therapeutic hypothermia. Dr. Timothy emphasizes the importance of training and collaboration in improving neonatal outcomes and shares insights into the ongoing efforts to enhance maternal and neonatal health in Trinidad and Tobago. In this conversation, Dr. Marlon Timothy discusses various innovative interventions in neonatal care, the importance of funding and government support, the training and development of neonatologists, the role of research and data in improving care, and the challenges of maintaining work-life balance in a demanding field. He emphasizes the need for global collaboration to enhance neonatal outcomes and shares insights from his experiences in Trinidad and Tobago.

Link to episode on Youtube: https://youtu.be/jUyLLaYLFHY

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Short bio : Dr Marlon Timothy graduated from The University of the West Indies in 2003 with his MBBS and then completed the Doctor of Medicine (DM) in Paediatrics in 2009. In August 2010 he started as a consultant Paediatrician at the Sangre Grande Hospital where he still practices today. In 2012, he was accepted to join the prestigious Perinatal and Neonatal Medicine Program at the University of Toronto and was awarded a scholarship by the Ministry of Health to pursue this field of study. During that time, Dr Timothy worked at the three largest Neonatal ICU’s in Toronto, The Hospital for Sick Children (SickKids), Mt Sinai Hospital and the Sunnybrook Health Sciences Centre where he excelled and graduated in 2014 as the Fellow of the Year. On his return to Trinidad in June 2014, he was appointed by the Minister of Health to form and Chair, the National Neonatal Committee.

Contact: LinkedIn- (6) Marlon Timothy | LinkedIn

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The transcript of today's episode can be found below 👇

Shelly-Ann Dakarai (00:01)

Hello there, friends. Welcome back to another episode of the Global Needed a Podcast. We're happy to have you join us today. Bozu, how are you doing today?

Mbozu Sipalo (00:10)

I'm really good. I'm glad it's springing in London. So it's a good time to be outside. How are you guys doing?

Shelly-Ann Dakarai (00:18)

Good, good. I'm enjoying that it's getting warm again. Yes, great. So we are excited to bring you yet another interview today. And today we are honored to have our guest, Dr. Marlon Timothy. He is a distinguished neonatologist and a passionate advocate for neonatal care. With over two decades in pediatrics and neonatal care, Dr. Timothy trained at the University of Toronto's Hospital for Sick Kids, where he was named fellow of the year.

Since 2015, he has served as the chair of the National Neonatal Committee, leading groundbreaking initiatives like the nationwide implementation of therapy hypothermia. In 2022, his pioneering approach to neonatal interventions earned him the Innovation in Healthcare Award and the title of Physician of the Year. His innovative work is some of what we'll explore here today, and we're very excited to have him. Beyond medicine, he and his wife, a fertility specialist, are proud parents to two daughters.

Dr. Timothy, welcome to the podcast.

Dr Marlon Timothy (01:20)

Thank very much for having me, it's really a pleasure to be here.

Shelly-Ann Dakarai (01:24)

All right, so before we get into all the neonatal stuff, we always like to kind of talk a little bit about where people are joining us from. So can you tell us a little bit about Trinidad and Tobago, where it's locating and a little bit of country fact.

Dr Marlon Timothy (01:36)

Absolutely.

So Trinidad and Tobago is a twin island republic in the southern hemisphere, southern part of the Caribbean. We have beautiful, beautiful weather all year round. So if you are cold in London now, I'm sorry for you. And we just celebrated, again, a mega carnival. We have one of the best carnivals in the world. They actually describe it as the greatest show on Earth. We're a small population, 1.4 million across

islands.

and we are very close to Venezuela but English is still our primary language. We were once colonized by almost everyone, French, Dutch, Spanish and then eventually the English and so English is our primary language here. And yeah it's just beautiful, we have the best food, have the best weather, we the best beaches, don't let anybody fool you otherwise and we have the best carnival in the world. So that's where I'm coming from, a really sunshiny state.

Mbozu Sipalo (02:33)

Thank you.

Well, I think I'm sold. I think I'll put that next on my destination list, Trinidad and Tobago. So yeah, and obviously everyone wanted a piece of it. That history says a lot about why it is beautiful and why you're so biased. I'll call you biased as well.

Dr Marlon Timothy (02:56)

Yeah, it's

Shelly-Ann Dakarai (02:56)

You

Dr Marlon Timothy (02:58)

not, no, we're

like the melting pot of the Caribbean because we have, you know, everyone here. So our motto is, part of our anthem is, every creed and race finds an equal place, you know, and we really embody that here in Trinidad and Tobago.

Shelly-Ann Dakarai (03:01)

Yeah.

Mbozu Sipalo (03:15)

Sounds really fun. And I hope our listeners will be inspired to visit your beautiful island and yeah, get inspired with the beautiful weather that I cannot relate to at this moment in time. yeah, thank you so much. Thank you so much for sharing that really well-rounded account of what your country has to offer. We know that you're a pediatrician with a few years of experience that you

Shelly-Ann Dakarai (03:26)

You

Dr Marlon Timothy (03:27)

I'm inviting everyone to come.

Mbozu Sipalo (03:44)

did before pursuing your neonatal fellowship. Could you please tell us what prompted you to do neonatology?

Dr Marlon Timothy (03:52)

You know, there is something unique about neonatology and that it's the BBs have no voice and if I really have to you know think what really drew me to it, was the fact that

You have a human who requires care, but they can't tell you what's wrong. And you have to be skilled enough to know how to figure out what's wrong with them, how to manage them, how to treat them. And, you know, I think that is what just drew me deeper and deeper in. You know, I also said my mom made a deal with God for me to become a neonatologist.

backstory when I was born, Easter Sunday 1978, she said I was not doing well. She said I was not breathing properly. I was maybe some meconium. sounded like, know, just given the history and how she said it. And she said, you know, I was I was basically told she was basically told that I would not survive.

And so she said she took me outside. She was there in the sun with me and walking around the nursing home with me. And, eventually started like, you know, breathing and, you know, my respiratory distress settled. And, you know, I said, you know, that's probably a deal that you made with with God. And so it felt like I've been always pushed in that direction. So after I did my pediatric training, I was like, what's next? And then I decided, you know what?

to do neonatology as a specialty and so I applied to the Hospital for Sick Kids program in University of Toronto. They accepted me and I got a government scholarship from Trinidad and Tobago to pursue that study and I made the best of it and the rest is history.

Shelly-Ann Dakarai (05:54)

Thanks for sharing your story. Very inspiring. And it's always interesting to find out what led each of us to care about the neonates. So thank you for being vulnerable and sharing that backstory. So you went from Trinidad, you went to Toronto, did your fellowship, and then you returned home. What was that transition like when you returned? How was the care different in Trinidad at that time versus what you were able to provide back in Toronto?

Dr Marlon Timothy (06:24)

world's apart so

You know, coming home from Toronto where you not only have the best available equipment, you also have all of the personnel. So, for example, in our setting, we don't have respiratory therapists. don't have pharmacists doing rounds. We don't have dietitians that are so specifically neonatal trained, etc. And so, you know, it was really difficult coming back to a setting where you have to do all of that work.

to be the advocate, you have to be the respiratory therapist, you have to be the neonatologist. And at that time when I came back, I came back two weeks early.

than the earlier than scheduled. And I was trying to hide out because I really wanted a little vacation, right? I was scheduled to work in two weeks time. But at the time, Trinidad and Tepeguachi had a crisis that was making national news where an unfortunate incident took place in one of the hospitals and a neonate had a massive brain injury and passed away. And it was all over the newspapers. There was a report commissioned by the government

at the time to look into that death. And the day after I arrived, they were reading that report in Parliament. And I'm hiding away, finally got my barbecue chicken, you know, from being away from home for so long. And I'm just about to have my lunch and I get a call and said, could you come to Parliament now, please? And I was just like, for what? And they're like, oh, this report, it's problematic.

We need help with it. We need some guidelines and we know you've just come back. I was just like, oh my goodness. And I've been working tirelessly ever since. I didn't even get my two weeks off that time. I just straight went into Parliament, met the Minister of Health and some other physicians. And yeah, we took off running thereafter. So it was a big transition coming back, you know, even going back to the hospital that I

actually came from Sandy Grandy Hospital. It wasn't a neonatal unit at the time that I was sent for training. And so, and that incident happened in another hospital. And so it was me really going back to work to start planning that new unit and planning the training. And then I got hoist into the national picture of can you fix our national picture for us?

And that's, you know, it was a lot. It was a lot to take in at the time. But I think my biggest thing coming back was that I was trying to show them that we did not need a lot of money initially to fix our care. We just needed to change some of our practices, you know, and so, you know, really, you know, interventions that were more cost effective and things like we didn't have caffeine citrate at the time when I

came

back, you know, and so had to advocate for that. you know, to be honest, you know, the support that I received coming back was amazing in terms of from the Ministry of Health, the Minister of Health, from all the administrators at my hospital and, you know, throughout the country, really. You know, so I was well received coming back. So I did not have a lot of opposition, if you want to call it that, or didn't have too much red tape to battle.

because I could show, you know, immediately the effect of if we introduced this simple thing, it will have this great effect. And I think that really helped, you know, gather support and, you know, people really rallied with me. So even though the differences were kind of huge coming back.

The support was there and the willingness was there. And so that really did not make the journey feel as burdensome. know, there was not a lot of fighting or fight down per se. So it was really good.

Mbozu Sipalo (10:36)

Thank you for sharing that background of like how it was for you when you just transitioned into neonatal care. think I have like two questions linked to what you shared. The first one was, could you give us a like a landscape, a neonatal landscape of Chinita and Tabaco so we get an understanding of what you found when you returned home? And then the second one was

Link, you sort of hinted on it when you were speaking, but just like how neonatal care has evolved since you joined and you tried to like fix a few of the things that you could. Yeah.

Dr Marlon Timothy (11:18)

Okay, so you know when I when I would have returned I would have been now the only neonatologist in the public sector for the entire country. Prior to that our last neonatologist I think would have retired or resigned in about 2010 or thereabouts. Not sure of 100 % of today's but at the time

there were three neonatal units in the country. So one at the Port of Spain General Hospital, one at the San Fernando General Hospital and one at the Mount Hope Hospital. So three of the major hospitals had neonatal units. Tobago did not really have an established neonatal unit. San De Grande did not have one as well. So these were other public hospitals. So there were three major hospitals that had units. They were led by

consultant pediatricians who were, you know, charged to take over these units when, you know, there were resignations or retirement. you know, neonatology was not really seen as popular back then.

And it really was, you know, people, when they were assigned to neonatal units, I was later told, they would cry. They would think, wow, why, why am I being punished? You know, why? What did I do to be sent to the the NICU? You know, it's it's so it was seen as really punishment. And when I came back, you know, there was there were so many things I was so fortunate to learn.

in my fellowship and one of the things I think that made one of the biggest differences was therapeutic hypothermia. Because when I was in Canada in 2012, it was now coming in and it was an opt-in. So, you know, we would sit and explain to parents at that time, you know, this is what we think a baby has HIE. You know, we think that this therapeutic hypothermia would help us prevent injury, etc.

And I watched that go from, you know, opting in to now becoming the standard of care by 2013, where we no longer asked parents to allow us to do a therapeutic hypothermia. It was the standard of care. And so coming back to Trinidad, you know, that was something I really quickly implemented. And then other simple things like antibiotic stewardship, you know, us doing the right antibiotics for the right

duration of time.

caffeine citrate, you know, just having that because we were using aminolpherine at the time, you know, and it had its tremendous slew of side effects. So, you know, these simple quick wins. And then, of course, none of the neonatal units at that time, we didn't speak to each other. We all kind of, you know, operated in our silos. did not, you know, it almost felt territorial. following my return, the Minister of Health at that time,

asked me to, you know, see if I could join the heads together. So at this time I was not the head of a unit yet, because again, I'm at a hospital that does not have a unit. So, you know, I'm kind of like a good referee, so to speak. you know, so I, you know, we brought all the heads together and, you know, we had fantastic discussions and we had fantastic ideas for implementation. And so we went about doing that. And through that, we actually formed the National Neonatal Committee of

Trinidad and Tobago. that has been in evolution ever since, but we've been functioning ever since with all the heads of the NICUs in addition to community pediatrics and nursing, et cetera. So we've continued expanding that committee. And that has really made lots of strides. as each government changed during that time.

And then they introduced the directorate of women's health under which neonatal medicine fell. And working with the director, who is still the director, Dr. Surya Singh, we've been able to really implement so many things on a national level that has allowed us to really smoothen out and equal a lot of the playing fields down between the level 3s, introduce level 2 services at San De Grandi and at Tobago.

and we're just about to launch another level 2 at one of the most southern hospitals in Point 14 and then you know I was able to actually even open a private neonatal ICU which was something that a lot of private sector hospitals were asking for as well so during that time we've now opened well it'll be four NICUs in the next couple of months.

Shelly-Ann Dakarai (16:26)

Wow, that's pretty impressive. So I want to kind of camp here because I feel like there's so much here to explore on opening the NICUs and all that goes into that. So when you came back, so were the three NICUs that were in those hospitals, did they have, and they were managed by pediatricians, were they doing mechanical ventilation at that point? What type of care was being done? Okay.

Dr Marlon Timothy (16:51)

Yeah, so definitely we were doing ventilation, mechanical ventilation at that time. Prior to my departure in 2012, around 2005, we had a neonatologist that would have trained in the US come back to train at Dr. Gary Youll. And Dr. Youll was stationed at the Mount Hope Hospital. During that time, he was really instrumental in getting surface

getting high frequency oscillation and getting us new mechanical ventilators. And I was actually training there at the time. And I think that also helped pique my interest in neonatal medicine. He was very meticulous, but he was always accommodating with his teaching. And I really felt, gosh, this is amazing. I'm loving this surfactant. I'm loving high frequency oscillation. These things are fascinating when you

see

a baby in trouble and you see you hook them up and you see them go from saturating 60 % to 100 % and you know and they're comfortable and they get stable and then they go home. I mean you just you know it kind of thrills you. So you know there was mechanical ventilation

in use, was surfactant in use. And of course we've modified how we do things because again, looking to be cost effective and understanding lung ventilation and critical opening pressures and stuff of that, all of that. Now we do things a bit differently, but it was truly fascinating still, even at that time. So when I came back, those things were still in use. We did have surfactant, we did have mechanical ventilation going on, we did

have central lines already in place. Some units did not, to be honest, so not everybody were using central lines appropriately. Some units, know, sometimes they would do some ad hocs, you know, and you had to be like, well, you appreciate the try, but you know, we're going to stop that now. Because, you know, again, our first, you know, tenant is to do no harm, you know, and in some of the situations we would have done harm.

So we, you know, I kind of stopped some practices and then introduced others. And I think that was a good balance of, you know, getting people to understand, you know, this is no longer there. And it wasn't just me saying it was also showing them the evidence. You know, I would not just come and be like, oh, I'm trained. You know, I don't do this anymore. No, I'd be out. Go to the Cochrane Library. I would show them the papers that showed them the research on, you know, what we were introducing or what we

were taking out of practice. And I think, you know, using the evidence and showing people the evidence was, you know, the best way of getting them to really be on board. But, you know, the changes I was making.

Shelly-Ann Dakarai (19:53)

And you talked a little bit about the starting of the level two at Sangre Grande. And so a lot of places are not, they don't even have that level two type care. They have basic newborn care. Trinidad was fortunate. They already had some level three care, but trying to now decentralize and have more community type level twos. What did it take to start that in that hospital? Not having had a unit at all to then building it to the point where now it's a, where it's a level two.

Dr Marlon Timothy (20:24)

Well, Sanne Grande, first of all, is in the eastern part of the country. So it's a bit far. And let's say it's about maybe 40 kilometres, 30 to 40 kilometres from the nearest hospital, which would be Mount Hope. So, you know, we were becoming pretty versed in transportation of the Neonate because of course that is what was happening. So there was an established obstetric unit and they were doing great work, but there was no support for that unit. So, you know,

the medical director at the time was actually Dr. Sirdrasinghe who is the director of women's health now. And so he kind of had this vision and this plan for me going to train obstetric services, increasing and coming back and creating this NICU.

And so, you know, we had a plan. And so coming back, you know, I was heavily involved in, looking at it was a small space, just about four beds and designated level two, because, you didn't want to create a concrete for bed level three. So, you know, we sat out even looking at the construction and how we would, you know, which rooms we put where, what space, how it would link to the existing ward, what ventilators we would order.

We went through everything. And I must say the team there at Sandy Grand Yacht was fantastic. Again, everybody was very, very much on board with having and this NICU. So it was something that, again, everybody was for. everybody was working toward that goal. And so it was really seamless. And I remember before we even had gotten the ventilators,

that we had not commissioned a space yet, but we had space. We had a baby that was born in distress. And I said, guys, sorry, I'm not transporting this one today. I'm going to show you how these ventilators work. And, you know, just a few hours of CPAP. And again, the nursing team, the staff, they were just like amazed that, you know, this baby who is in like so much distress just after delivery was now comfortable.

and able to be managed in Sandingham without us having to make this hour and a half long trek to the next hospital up and down in this bumpy ambulance. know, was it's really it was really harrowing these transportation runs, especially if it was an intubated and ventilated patient. Again, we did not have a mechanical ventilator on our transport incubator at the time. So it was like handbagging this baby, you

no peep, you know, going down, you have no blended gases, it's 100 % oxygen, you know, like, so it was really, it was really needed to not be, not keep rushing with babies to the central bigger hospitals. And it was really needed to have a unit where you can stay and manage your patients, stabilize them, not separate mothers and babies, you know, and have that, because Sanjeev Gandhi's

is considered a community hospital. I tell people not community, family, because it was really, it's so tight knit. It's a lovely community. Everybody knows everybody, but the level of service and care there is like exceptional, you know, and, and the burgesses of that area, really, really humble people, you know, you know, sometimes after deliveries, they'll come back and be like, you know, doc, brought some plantains for you. I brought some, you know, cook

that's for you, you know, that's really, really nice people and you know, they really deserve to have that neonatal unit there as well. So, you know, it was a lot of things that came together really nicely for that whole thing to come to pass.

Shelly-Ann Dakarai (24:27)

So it sounds like there was a lot of support from the beginning and continued support from the administrative front on the importance of women and child, and in this case specifically neonatal health care. And so that's one of the things that is commendable in this story because we've talked to other guests who've had varying levels of challenges when it comes to the administration. So I wonder,

how that affects nursing care. Because a lot of times we hear the nurse, it takes a while for a nurse to get comfortable with taking care of babies, let alone sick babies. And in some situations, there is no room for growth in that area and nurses often get moved. And so I wonder, because you already had such supportive administration, how is the nursing care there? Are nurses specifically trained in neonatal care?

Are they moved often? Tell us a little bit about that.

Dr Marlon Timothy (25:29)

Yes, so the nursing care, again, because we had a plan and again, because it was in a national, you know, consciousness. So neonatal nursing programs were created and were being conducted by the Ministry of Health and different stakeholders to increase the level of competence of our nurses coming into neonatal units. And so as we even when I came back and we

like let's say introducing therapeutic hypothermia, you know, we would teach a lot. would teach a lot and, you know, really sit with nursing once the administration understood that, like I said, I got green lights almost in every sector. And so, you know, I had nursing classes, I did lectures to midwives. You know, I was really, I was really a busy body at the time, of course, didn't have kids at the time.

So, you know, I would really do as much teaching as I can and even do as much hand holding as I can. Because I remember when we had our first case of therapeutic hypothermia, you know, it was I was I was so blown away by the response of the nursing staff. It was so interesting. They were engaged, you know, they were keeping up to make sure that the temperature stayed within target range. Like I was so.

like proud to see them you know rise to the challenge of something so new and they've kept on doing that they've kept on learning even now we are trying to do a twinning program

with Sunnybrook Health Sciences Centre in Toronto to again send some nurses so that they can get some additional exposure to higher order level 3s and again keeping that thrust of education and training going because again those partnerships mean I think a lot where we can have that exchange of personnel and expertise and really keep a training initiative.

going. So I think, you know, the response from the nursing team again was phenomenal. And again, because the administration saw the benefit of, you know, when I'd return, I would need the nursing support. And so the nursing programs were ongoing all the while.

Mbozu Sipalo (28:00)

All right. Thanks for sharing that background of therapeutic hypothermia. I would like to unpack that further. I know that for LMIC context, that therapy has sort of contradictory or it's still under debate whether it's something that we should invest in. So my question is, how did you do it? Number one, how did you like scale it up? And number two,

You mentioned at the beginning that it was simple to do, think, or you sort of used this word that was like, wait, is it simple? So I love just more insight on that. Like really, how was it, like how did you get it done? yeah, like just any insights on it being like the therapy still being there in your setting.

Dr Marlon Timothy (28:54)

Yeah, so I think the approach to therapeutic hypothermia was twofold, right? One, the first part was to eliminate HIE. And so we focused a lot on obstetric training, midwifery training as well. So it wasn't just a matter of, we just have this thing that we can treat these babies with now. We still looked at how can we improve our monitoring interpartum? How can we improve our interventions that will then prevent babies from

having HIE. So we set off on that arm and we let that arm take course with training and so on. And then, yeah, you're right. So there are studies out there that show that in low to middle income countries, therapeutic hypotermia has not been shown to be beneficial. And I would argue completely to the contrary. In fact, I'm hoping to put out a publication soon. I want to call it Chillin in the Caribbean, where

You know, we show that, you know, it has been of immense value. You know, I remember that same first patient that we would have called.

Those parents up till now, wherever they see me, they stomp and they show me their kid and they say, listen, this is her and she's perfect. There's nothing wrong with her. She knows her ABC. She knows this. She knows that she's doing so well and they cannot stop thanking us. know, and when you have and that story is repeated multiple times.

because I think we had a great protocol. I took from training a lot of the protocols that we were using at the time. So I had the protocol from Mount Sinai in Toronto and I modified it to our setting. again, because the staff, think we all had the same drive to see better outcomes. And I think with that, everybody was invested from the get-go.

Once we and again, teaching that protocol, having them understand why we're doing what we're doing. And again, so I had this PowerPoint that I knew by heart because I was teaching this thing everywhere, everywhere. And so I think, you know, people started to buy in.

And once they bought in, and we were able to help them get some of the consumables, make sure they had the proper central lines, the UV and the UA lines, et cetera. And, you know, really start. I wrote. So I wrote a local protocol. I was really point form, really easy guidelines to follow. And then, of course, I told people, if you have difficulty, please call me. And so, you know, I made myself available. And, you know, that's why I say, you know, looking back on it now, I can't.

Remember it being difficult. You know, I just remember people being so eager to see improvement that, you know, it really went without major difficulty. you know, some, some of the cases, of course, you know, way past the Asana at stage three, where they would benefit. But, you know, those that did, the outcomes were amazing. And again, you know, the response of the staff to those situations was

phenomenal. They were exceptional in rising to that new challenge. So to a therapeutic hypothermia is just one of those things that, know, and we've been using it less and less, you know, and why we're using it less and less is again, because remember I said we focused on the other arm of HIE. And so through the Directorate of Women's Health and Pan-American Health Organization and other agencies, you know, we've had

significant training, postpartum hemorrhaging. There's so many training programs and again we've looked at you know what was our root cause of all of our HIE cases and we got better CTG monitors, had more midwifery training etc and so now

Again, knock on wood, we're not doing therapeutic hypothermia as much. And I'm happy for that because again, we looked at the root cause and we tried to fix that. Even though we introduced the therapy for treating the babies, we tried to eliminate even having to get there. And so, you know, that two-pronged approach now pays benefits.

Shelly-Ann Dakarai (33:35)

Were there any other interventions that the National Neonatal Committee rolled out other than HIE? Are there other ones that you'd like to share about?

Dr Marlon Timothy (33:46)

So I wrote so many protocols, I can't even remember them all. Because when I came back, was just on a mission. My mission was to have us standardize what we did, even surfactant delivery, how we were doing that. So again, surfactants is very costly. And the administration of it, I thought, wow, this does not make sense.

You know, we are taking it to the delivery room before we even and we're not using peep. You know, so we're giving it in a closed lung. You know, so again, teaching and training and you know, had people. I stopped it completely. I said, no, no more surfactants in the delivery room because we don't have peep in the delivery room.

let the baby come into the unit, let's do some inflation. Yeah. And after we inflate and we adjust and we look at parameters, you know, then we can say, okay, yes, this one qualifies for surfactant before it was, no, you're 28 weeks. get surfactant, you know, regardless. and we've shown time and time again where 28 because they, they come to you. We set them up on the appropriate ventilation and their oxygen requirements is, is there at 21 % satting a hundred percent in your

like, no, he's good. You know, so even how we administrative fact and, you know, need it more cost effective, you know, was something that again, we rolled across the entire country. Protocols for group B strep intervention was again, something that we rolled across the entire country. A lot of our obstetricians are UK trained. And so the UK is not big on GBS screening, but I looked at, again, our local data.

And, you know, there were studies done by microbiologists in our setting that showed that we had a high carriage rate, you know, and unfortunately I had seen GBS meningitis and GBS sepsis and even some babies that passed away from GBS sepsis. And so, you know, that universal screening for GBS is something that we again kind of pushed forward and our management for seeing, you know, so there are so many like interventions that, you know, we've we've put

in place. know, I think again, caffeine citrate was one of the simplest ones. And having the Minister of Health again buy in. I remember when I first met him at a conference just after the election, and I introduced myself and said, Hi, I'm Marlon Timothy. He said, Ah, they gave me your name separately. I said I had to speak to you, you know, and and then he held that promise. he, you know, we were called to a meeting and he asked me, what do you need? said, caffeine citrate.

If you give me nothing else, let me start caffeine citrate. And within a couple of months, we had caffeine citrate. And that made a huge difference in how long we'd keep babies on the unit who were ready for discharge. But we had to wait on the aminolphthalein to see if there would be recurrence of apnea and so on. And that made a huge difference. We could take out IV accesses earlier, less risk of hospital-acquired infection.

benefits just kept going on and on just by again simple cost-effective interventions.

Mbozu Sipalo (37:12)

I have a question. think you've sort of hinted on this that you have good buy-in from the Ministry of Health, but I'm still wondering on, you've mentioned so many interventions, so many things that you were shooting like to improve the neonatal care. Question around the funding, like is it all funded by your government or do you have other funders involved? And also like,

you mentioned that you wrote a lot of protocols. Was that all through the government or you also had like private donor funding or external donor funding? Just tell us about the funding landscape as you were trying to improve the neonatal care.

Dr Marlon Timothy (38:00)

So our healthcare system in China, to be honest, is 100 % free. And all of the interventions we were able to achieve are 100 % government funded.

So we were, and again, in a fortunate position where health was now being pushed to the forefront of the national consciousness. And so again, that has been one of the thrusts of the Minister of Health and the entire Ministry of Health team. So it was not that difficult. And I said, I came back maybe at the perfect time. And being back

that time, they said there was very little opposition to seeing improvement. Part of our developmental plan for the country, which was freely available at the Ministry of Public Administration, they always put out a list of

specialists and personnel that are required to keep building the country and keep going forward. And neonatologists have been on the list for years and years and years and years. And so, you know, even to go to Toronto, you know, the government 100 % funded my education and my living expenses there.

And, you know, so that was really, I think, a major advantage being back at a time where the money was there. Because Trinidad and Tobago is a...

hydrocarbons and oil and gas producer. And so, you know, we do suffer with fluctuations in market price, of course, but at that time, I think, you know, we had a really good market price for our hydrocarbon products. And so the money was there to really invest in improving maternal and neonatal health. And that's exactly what they do.

Shelly-Ann Dakarai (40:06)

Before I move into research, because you seem to have a passion for looking at what's, what is known and then looking at your local evidence and then coming up with an appropriate plan. And so I kind of want to touch on that. But before that, you mentioned about, you know, neonatologists being on their list. so when the opportunity came to send you, they were very on board with that because that's one of the, one of the needs. How many neonatologists now would you say Trinidad and Tobago has? Is it still?

Just you in the public sector or are there more?

Dr Marlon Timothy (40:39)

So right now, so I'll give you two counts. There are two of us now in the public sector. However, since my return, we have trained, there will be a third one actually later this year. But since my return and really taking that...

Shelly-Ann Dakarai (40:42)

You

Dr Marlon Timothy (41:00)

that stigma off of it, so to speak. We've sent many more persons for training. Some did not return. So I still count them as my neonatologists. But, you know, so I think I'm up to like six or eight neonatologists now that have been trained. I currently have one in the University of Calgary. One is about to go to University of British Columbia.

Shelly-Ann Dakarai (41:13)

you

Dr Marlon Timothy (41:31)

One is coming back from University of Toronto, so that'll be our third one for this year. We have two who stayed in Toronto, and if you're listening to this podcast, please come home. And, you know, there's Darren Bodkin who worked with me. He was on the podcast a couple of years ago, I think.

He was he's also from Polispey and General Hospital as well. So he's now in the US doing neonatology. And a fun fact about Darren, he once left NICU, he said, no, I'm going to do adult ICU. And I said, OK, sure. And I let him go. And he came back and he's like, after about two months, he's like, can I please come back in? And I'm like, sure. And so, know, so, you know, I think and we have three more interviewing next week for fellowship positions.

Shelly-Ann Dakarai (42:13)

you

You

Dr Marlon Timothy (42:28)

So these are not funded posts by our government anymore. What I think I was able to achieve is take us from a position of needing government funding to go for these scholarships. And I've made us internationally competitive. Because now when I went, my god, I was quiet. I did not speak a lot.

because I was just assimilating so much. I'm like, my God, this is so different. This is so different. This is so different. I don't know what to do for this. You know, and so I kind of just was in my absorptive phase. When I came back, that information could not stay within me. I had to share that. And I shared and shared and as I I had these power points that I knew by heart and I was doing everywhere. I was going everywhere and teaching. And so we went from needing funding from our government to then becoming competitive.

internationally and I would dare say sometimes I think our candidates are now getting the first calls, know, where fellowship results, well, interview results are coming out and I'm being woken up at 6 a.m. Doc, I got in, you know, and, you know, so I think, you know, that is one of the things I'm most proud of, you know, having, you know, shared what I learned and then, you know, encouraging others to go and get that experience.

and come back and come back and I emphasize on and come back because you know we still do have a lot of the units without neonatologists running it so even though we have the National Committee you know it would still be nice to have a neonatologist at every institution because at one point in time I was covering three institutions you know you're making sure that you know we're covered and you know babies didn't get into too much trouble etc but we need people to come back.

Shelly-Ann Dakarai (43:54)

You

Dr Marlon Timothy (44:20)

from what they've learned and come and share and that's how we're to improve. I think I've done a good share of it. Now it's my time to go into the administrative arm of things and really help create different channels of opportunities. like partnering with other countries and trying to get other Caribbean islands involved, creating our own Caribbean

database, you know, these are the kind of things that I want to do now, which would again make research amongst our Caribbean population so much easier. And so, you know, I really need our young clinicians who are getting the opportunity to actually come back once they've had that opportunity and, you know, give back to the country, you know, because it's a beautiful country like Trinidad and Tobago is this is an amazing country, great quality of life and our health care sector is really

Shelly-Ann Dakarai (45:06)

Okay.

Dr Marlon Timothy (45:20)

developing and we're marrying technology with personnel and we're getting some fantastic results.

Shelly-Ann Dakarai (45:28)

Yeah. So I think, you know, without mentioning it, I think you've shown that pediatricians, which are the majority of the workforce when it comes to neonatal care in most of the world, have an important role to play because as there aren't enough neonatologists, like for example, in some of the countries, like in the US, the neonatologist is the one at the bedside doing most of the things, but in other places, whether you don't have that many, the neonatologist is tasked with training the pediatricians or the house officers to therefore

be able to take care of the neonates. And so I think for those who are listening, who may have a lot of pediatricians, but no neonatologist, there is still room for growth. There's still so much you can do despite not having that term, you know, neonatologist there. So that's pretty remarkable and thank you for sharing that. And that brought us up to talking a little bit about research because you're talking about data and getting, you know, together as a region.

You've done some work as it relates to transcutaneous bilirubin monitoring. Could you tell us a little bit about that? I think it was probably the first study to look at a heterogeneous population of patients. Tell us a little bit about why you felt it was important to do that and what the results were.

Dr Marlon Timothy (46:44)

Sure. So again, as technology evolves, we're trying to adapt and we want to make sure that it's working for our population. At that point where I'm not accepting carte blanche that...

this we're ruling out this globally and everybody should adopt it. It's no it's it's OK. You're ruling out globally. Let me see if it works for my people. Let me see if it works in my region because, there are so many major differences in how babies respond. So I'd give an example in Canada, for example, lots of BPD, lots of BPD because of the early gestational ages, steroid use, etc.

And

we are completely the opposite our babies there's a okay paper came out Saying that you know inhale steroids does not work for BPD. All right, do not use Like okay Different in our population completely different we got one to two weeks of steroid inhaled and we're off all support, you know, so again, you know, we are seeing major differences in how those northern European and

American research papers translate into our Caribbean population. And so when transcutaneous bilirubinometers came out, I was curious because again, they were having difficulty using it on darker skinned. And so one of the first ones that came out, I think was a Draeger GM 103 that touted that it would be great in all skin tones. And everybody was like, OK, yeah.

let's go ahead and use it and other countries adopted it wholesale. I was like, not so fast. I need to see how does it correlate with our laboratory values and even our photospect values because we're still using a photospectrometer to do some of the bilirubin results. And so I decided to do a prospective study with my team in Sandy Grandy using the unit. And only after satisfying that need,

of seeing that there was a correlation and we created a correlation equation between the transcutaneous and the serum value, then we felt comfortable that it fell within an acceptable range and we created parameters whereby if it fell within a particular transcutaneous range, we would then still do a serum, et cetera. And so it was exciting to do, it was exciting to see that correlation come to life.

and you know it's one of our proud moments.

Mbozu Sipalo (49:46)

Thank you for sharing that and just giving us like the global perspective of all the work that you've been doing. The thing that I find very fascinating is just the buy-in from the government and the fact that they were on board on basically almost everything that you set out to do. That's not very common, I think, in certain settings. So yeah, really appreciate you giving us that insight and giving us hope.

for different settings that when the government is on board, things do move and you don't necessarily need to rely on outside funding. So thank you for that. You sort of touched on this a bit that your career has evolved with your personal life and just clear us around that. Like, obviously you had more time then versus now. How are you managing your work life balance now as someone who is married with kids?

And what advice do you think do you have for people who go through that transition?

Dr Marlon Timothy (50:52)

So I think having the right partners is definitely the start, yeah? Because at the time, I would leave home almost like 4 a.m. and not return until some ridiculous hour.

you know, in the night, you really have to have an understanding partner. So, you know, when I started, you know, working everywhere and even flying across the Tobago every couple of every like every month, you know, it was initially, you know, very hard, very tiring. And, you know, again, the government, you know, did help ease my my my transition and transportation even. So they helped give me certain accesses that would help me move

around the country even quicker and so was very grateful for that. know the energy that had then you know I think was you know it was so much I would do work all day if I get home early I'd go paint some house some rooms in the house you know I had I just it was just brimming with energy now if you asked me to do that it would be like no I'm okay I'm not I'm not doing anything I just want to sleep you know.

And so it is in that early phase when you come back, I think I had a goal. had a goal to see. As a kind of autonomous unit, I didn't want to have to be there 24 7, 365. I wanted to be able to train persons so that, you know, there would come a point where they would call me and say, hey, this is what happened and this is what we did.

and not this is a we need you to do and tell us what to do for this. I didn't want to have that. And so even during fellowship, I actually traveled to University of Cambridge and did cranial ultrasoundography programs there and went back and did my elective in cranial ultrasound and with the radiology department at Sunnybrook.

And when I came back, was teaching them how to do Crayonelgesons. I was teaching them how to do echoes. actually took a group of us and I said, OK, let's go in New York. And we went to Echo program in New York and came back. So, you know, constantly been, you know, taking people with me along the journey of education and training, because I didn't want to be the one running out at midnight to go rescue a baby. That's too late. You know, the people who are there who are manning the floor.

need to know how to do exactly what they need to do at that time for that patient. And so, know, I really focused on training the individuals there. And then as the kids came in and, you know, the kids came along, you know, I started to see that self-autonomous NICU. I started to be able to, you know, do the daycare drop off and then go to work, you know. We introduced

our handover, morning handover process, you know, which we've digitalized. And so I'm able now to see the entire unit on my spreadsheets, from my phone, on my, you know, when I'm having my morning coffee, I can go through all the patients, you know, so I can do all of these things, you know, just, you know, I had to drop off a hat now. And again, so I could say, hey, you know, this is the plan going forward for today, for the unit. I'll be in at nine.

when I drop off the kids, you know? And so it's again, and then having trained so many persons under me, you know, by the time I get in, they're like, doc, everything's done. You know, like, well, you know, I could go to the beach then. I mean, I wish, but it's kind of far. you know, so that's why, you know, now I'm more doing a lot of administrative things. One of the things I'm working on now.

is trying to get inhaled nitric oxide to the unit. Because again, we've looked at our data, we've looked at our term mortality, and our term babies are mostly dying from PPHN. In our setting, we are using different medications. We don't have Milbrenon as yet applied for it. We're using vasopressing, we're using sildenafil, and we don't have IVs, so there's PO sildenafil as well.

And you know, we're seeing the wild fluctuation in outcomes. And we say, you know what, we need the gold standard. And so right now we're negotiating with a couple of companies to bring the inhale nitric oxide systems to Trinidad and Tobago so that we could provide a gold standard where, you know, we can again improve our outcomes. So, you know, it's really, it's really, you know, challenging initially because it was

the four o'clock, the out how will the and then you train people and then you're like, OK, less and less and less and less. And now you're we're at a point where as more new unitologists come back trained, I can now focus on, you know, looking at the bigger national picture. And what do we need? How do you create centers of excellence at this particular institution, at this particular institution and that particular institution? Do how many more level twos do we need? You know, how do we improve?

our community resuscitation you know all of these things are because we still do have quite a lot of people who live in far-off communities and they do have unfortunate incidents where you know they have a preterm birth out in the community you know I want us all to be able to provide a level a particular standard of care no matter where this baby is born so that we can give our children the best chance yeah so so it's been it's been challenging so to those who are

coming up I say you know sleep a lot now but it's not as difficult now I think you know the systems that we have in place now and we've been getting our electronic medical records in place now I think it's much easier now to transition you know back from UK or US or Canada back into Trinidad and I think now you know what I would like to see because even though I've done some research

It is still, I think on the lower end, I would love to do more. But again, because I'm so involved, I could not do as much research as I wanted to. So now I think we're at the point where we need to one, create even our own training program, because there's so many of us coming back now. We could create our own training program. We can do significant, robust research. And again, looking at the differences between some countries and ours and whether or not those things actually, you

who will true for us. So like the hypothermia has been fantastic for us, inhaled steroids fantastic for us. We don't have other drugs like indomesticine for IVH prevention. We've been trying acetaminophen, you know, that has worked tremendously for us, you know, so, you know, we want to be able to now put some robust research to some of the things that we've been doing and really show the evidence out there, you know, and I love that.

where small

settings like ours, because, you again, the low middle income country setting is a is still a huge part of our global landscape. You know, and they may not have the facilities to do the research. They may not have the facilities and the ability to, you know, have the higher end medications, but they might be able to get acetaminophen, you know, which would prevent, you know, IVH and, you know, PDE closure and all of these things. And so it will really

be good to have research at this level that can be shared on a global level.

Shelly-Ann Dakarai (59:09)

Thank you so much for this discussion. We have learned a lot. We've been inspired. We've learned about Trinidad. And, you know, I always leave these interviews excited about the next step, you know, what more can I do? Because it's just, again, so inspiring to see what various countries and regions are able to do to improve care. Because at the end of the day, that's all we want is we want to make the lives of our babies better.

and by sharing our stories and what works for us and what doesn't, can go further, faster together. And so we're getting to the end of the discussion. And again, thank you so much for such a rich conversation. You've given us a lot of advice so far, but I just wanted to see if there's any closing comment that you wanna share. Somebody who is in a low and middle income context, they're trying to improve needing a care.

They may or may not have support from the administration. Any words of encouragement or advice for that provider?

Dr Marlon Timothy (1:00:14)

Yes, so, you know, one of the things that I value in, you know, low to middle income countries is that we're a global community. And I think in being a global community, I think there is a huge opportunity to share.

Let me share our experiences with each other. We were able to now close a lot of gaps that would traditionally seem insurmountable. know, I did at one point in time interview to become a consultant in the UK when I was like, OK, Trinidad, I've done enough. I'm leaving. And but in that interview, I shared with them, they said, what are your plans for, you know, neonatal medicine and blah, blah?

And I said, listen, I want to introduce a program called Adopt a NICU. And he said, elaborate. And I said, first world countries have a lot of wealth and a lot of expertise and a lot of equipment and so on.

low to middle income countries, we are on the tail end of receiving a lot of what we need. But if a first world country adopts a particular NICU from a low to middle income country and there's sharing of technology, teaching, data, even what they consider old equipment in that first world setting would be perfectly fine.

in another country, you know, as long as we have manufacturer guarantees for parts and so on. You know, and so I was like, let's try that approach of maybe having an adoption process where, you know, like, let's say I trained at SickKids and I'm going back home, SickKids says, hey, we're going to adopt your NICU. So, you know, if you need respiratory therapists, come and do.

courses, if you need us to come and do lectures, well, however we can help, let's help. Because, you know, we have a sustainable developmental goal of trying to reduce global near-neutral mortality. But we have some countries that are at the minutiae of trying to make 21 and 22-weekers survive, and other countries are struggling with 32-weekers and 30-weekers. You know, let's get everybody on that same page. So let's start all making sure that all 32-weekers across

across the globe survive. Let's make sure all 31 week has survived. 30 week is 29. As we do that, then we'll see global neonatal mortality drop. Until we start looking at it from that global perspective, and sharing. So what's happening in the world right now is everybody's want to go back into silos. We can't do that for health. You can't do that for health care. We have to share with each other. So anyone who is in this particular situation, if they

You must have buy-in. You must have buy-in from your medical chief, your local representative, your minister, your ministry. Once you have that buy-in and can show the evidence for...

your interventions, I don't think anybody is going to block you from trying to see better for your population. know, so it is, you really need a supportive team. You know, it's a difficult journey by yourself. you must have advocates. I've had people advocating for me, even when I didn't know they were advocating for me, you know, and that still happens up till today, you know, where if there's something I want and

even though the minister and I are good. And I was like, he might not want me to have this or he might not approve this. There's somebody else whispering in his ear, hey, you know what, we need this, you know, and so you must have that network of advocacy that would really help you push, you know, your your your goals and directives for neonatal and maternal care, because, you know, they go hand in hand, you know, so get the obstetricians involved, you know, every because I really think it's it's a real

team responsibility, neonatal medicine. So we really need to get that advocacy going. And I think once you do that, and again, if you get in difficulty, call me. We'll help. But I think it's really important to have that advocacy and have that team that really stands by you and help push your agenda.

Mbozu Sipalo (1:04:44)

you

I just want to say I loved that you said about the global community, like as LMICs, because we're innately very social even, and we have that community mindset. And we need that to be reflected in how we do our health and how we want to improve our outcomes. The silo thing is definitely evident in many.

Shelly-Ann Dakarai (1:04:58)

And I'm, yeah.

Yes.

Mbozu Sipalo (1:05:22)

spaces. yeah, and that's the ethos and the heart of the Global in your NATO podcast to connect to share. And I really do appreciate that insight that you shared. So we're about to conclude. And I know sorry, Shelley and I sort of jumped again. But yeah.

Shelly-Ann Dakarai (1:05:38)

No, this is great. When the conversation

is great, you have no choice. Keep going.

Mbozu Sipalo (1:05:44)

Yeah, we usually just end the talk to ask how people can connect with you. So yeah, how would you like listeners and people who've been inspired to connect with you?

Dr Marlon Timothy (1:05:57)

So I must confess, I'm a bit of a social media dinosaur. So I do have a LinkedIn page. I think it's Dr. Marlon Timothy. I do have an Instagram page, think, under the same name, Dr. Marlon Timothy. And so those are two of my socials where people can connect. They can also, I think, if they go through the Ministry of Health in Trinidad and Tobago,

again, looking for even if it's global cooperation or just wanting to have that chat. know, the Ministry of Health is also a good contact point in Trinidad and Tobago for us to have conversation, do tours, you know, see how we can help because, you know, it's really important, I think, for us, as I said, to really help each other, you know, and, you know, in doing so, I think that's how we really going to improve our global picture and not just everybody.

looking after themselves.

Shelly-Ann Dakarai (1:07:02)

Well, thank you, Dr. Timothy. Such a pleasure. And to our listeners out there, we will see you next month with another episode of the Global Neonatal Podcast. Thanks. Bye.

Dr Marlon Timothy (1:07:16)

Thank you very much.