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

Hello friends 👋

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.

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Short Bio: Dr. Manjari Pophale grew up in India and attended medical school at Government Medical College, Miraj. She then moved to the U.S. for her pediatric residency at Children’s Hospital of Michigan in Detroit and is currently a Neonatology fellow at Vanderbilt. Her passion for global health comes from seeing how improved resources and training can save newborn lives. This experience has inspired her to improve neonatal care through education, knowing that even small changes can save lives.Her current research, in collaboration with Dr. Scott Guthrie, focuses on using video conferencing to teach the SALSA technique to resource-limited NICUs in Africa

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

Srirupa: Hello everyone, welcome to another episode of Rupa's Fellows Friday. I am very delighted to welcome our next guest, Dr. Manjari Pophale, 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 in Detroit and moved to Nashville to do her fellowship. I’m 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: I'm good, Rupa. Thank you so much for having me. This is such an honor and a delight.

Srirupa: 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 to talk about the amazing research that you’re doing at your level. So, let's start by talking a little bit about your project. I got a little abstract from you, and it seems like you’re doing a SALSA implementation project through video conferencing. Tell me a little bit more about that.

Manjari Pophale: My mentor is Dr. Guthrie, also at Vanderbilt, and we are trying to teach poor African NICUs surfactant administration through an LMA and show that we can improve their outcomes, like mortality and length of stay. That’s the basic aim of my project. The way we’re doing this is that Dr. Guthrie and I have made instructional videos, and we also offer on-demand video conferencing sessions. We just want to show that we can help places like these that don’t really have the capability for intubation or access to many resources.

Srirupa: That’s amazing. And tell me, are these NICUs level three NICUs? What is the capacity of these NICUs?

Manjari Pophale: These are actually really small NICUs. There are four hospitals that I'm currently working with. The first one is Sordo Christian Hospital in Ethiopia. That’s a slightly bigger hospital, and they have around 100 to 150 babies per year who end up needing surfactant. They learned the SALSA method in late 2022 and have already started doing it, which has shown a decrease in their mortality.

The second hospital is in Kenya, which is a bit smaller. Ghana is smaller than that, and then Malawi is a very small hospital with about 60 to 70 babies per year. The physicians there are not neonatologists, they’re either family medicine physicians or pediatricians. SALSA is such an easy technique that we want to show anybody can do it. It can be done in seven seconds, whereas intubation takes at least 45 seconds to a minute. It’s great for resource-limited settings to learn and use the technique. They don’t really have a classification like level two or level three, but they’re small NICUs trying their best to keep the babies alive.

Srirupa: Yeah, and that’s so interesting that you mentioned there’s no demarcation of level three or level four, which I think is very specific not just to certain centers but to many parts of the world. In the U.S., we have that demarcation, but it’s important to realize that the capacity, expertise, and competency for these procedures can vary widely. Remind me, which of these hospitals already know how to do SALSA or have some idea of what the SALSA method is?

Manjari Pophale: Just the hospital in Ethiopia does. They attended the Tiny Feet, Big Steps conference in Tanzania in 2022, where they saw Dr. Guthrie’s presentation, and they started implementing SALSA later that year. We’re modeling our entire project based on that site. They’re our pilot site, and the rest of the hospitals will follow suit. The other three hospitals haven’t started doing SALSA yet. Some of them don’t have surfactant or even CPAP. Fortunately, we have some donors who have graciously agreed to donate surfactant and CPAP to those centers. It just takes a while for everything to go through customs. I’ve already made the videos to teach surfactant administration through an LMA, and we have a toolkit that walks them through the procedure step by step.

Srirupa: That’s awesome. So, what stage of your project are you in? I see that you’re a second-year fellow, probably about six months into your second year. Tell me how this project started, where the idea came from, what stage you’re in now, and what you foresee your outcomes to be.

Manjari Pophale: When I started fellowship, I didn’t really know what I wanted to do. I was interested in a lot of topics but hadn’t made up my mind. During the first six months, I met with a lot of mentors and explored different ideas. Toward the end of my first year, I attended a Tennessee quality improvement conference where Dr. Guthrie was speaking. I fell in love with his work. It really spoke to me, and I decided this was something I wanted to pursue.

Dr. Guthrie already had connections in Ethiopia from when they started the SALSA project in 2022. It spread by word of mouth. Someone in Ethiopia knew a physician in Kenya, so those hospitals got involved. Then someone knew someone in Malawi, and Dr. Guthrie suggested we teach multiple centers at once through video conferencing. That’s how we came up with the idea. The fourth hospital, in Ghana, joined more recently. We also have interest from centers in the Philippines and Nepal. We already have the toolkit and training videos ready. These new centers aren’t part of my current study, but we’re helping them get started anyway.

As for progress, since these centers didn’t have CPAP machines or surfactant, we reached out to a pharmaceutical company and a CPAP manufacturer, pitched our project, and they generously agreed to donate supplies. The hospitals will receive their first batch of surfactant and CPAP machines in early March.

We’ve already collected baseline data on mortality over the past year. Once they get the surfactant, we can start collecting post-intervention data. That’s where we are right now.

Srirupa: Out of curiosity, what is the mortality like in general at these hospitals?

Manjari Pophale: For Ethiopia, where we have before-and-after data, before implementing the project, mortality was 13 out of 18 babies in the past year. After they started using SALSA, it dropped to 6 out of 18. So it decreased quite a bit, and they’re really happy about it.

Srirupa: That’s fantastic. I think we all know the magic that surfactant provides to neonates, especially our tiniest ones. It’s such substantial work to introduce this concept and a minimally invasive method in low-resource settings.

I always wonder, and this is something you might already be experiencing, whenever a change comes from a larger nation into a smaller country, the first reaction can often be, “Do we really need this?” Sometimes it’s met with hesitation, and sometimes with enthusiasm. What was your experience like? How did the people, both parents and medical personnel, respond to this intervention and the introduction of the SALSA method?

Manjari Pophale: I think the biggest question we got when we first started talking about this was to look at it from an evidence-based perspective. Once we shared that this was indeed an evidence-based practice and provided them with research papers, as well as data from hospitals that had seen improvements in Ethiopia, everyone got on board pretty quickly.

Another challenge was that there were no skilled proceduralists in these hospitals to administer surfactant. Some hospitals didn’t even have surfactant at all, and when they did, they had to call in an anesthesiologist who wasn’t always available. There were a lot of difficulties intubating these babies just to administer surfactant. So, everyone was really happy that there was another, faster way to do it. I think the idea spread so quickly by word of mouth that it didn’t take much convincing to get the physicians on board, especially because this is the only way to save their babies. Many of their patients currently pass away simply because they lack the capability to administer surfactant. So, everyone’s really excited, and we’re thrilled to finally start this in early March.

Srirupa: That’s fantastic. It seems like you’ve got your videos ready, and the toolkit as well. I’m curious, first, what was your experience making these videos? And second, could you share with us and the listeners what this toolkit entails? What kinds of things are included?

Manjari Pophale: We made the video in a simulation lab using a baby mannequin. To be honest, I’m very awkward in front of the camera! It was just me, Dr. Guthrie, and Mary Lee, one of our simulation nurses. I was so nervous and my voice was shaking. It was a small, home-style video that Dr. Guthrie shot himself, and he did a great job. At the end of this, I can share a QR code for the toolkit, it can be used in any setting, whether level two, three, or four.

In the video, we demonstrate how to administer surfactant using an LMA. We sent it to the physicians in the four hospitals, and they’ve really liked it. It’s about 15 minutes long, slightly longer than planned. We covered everything: the procedure, what’s needed, post-procedure care, and possible complications.

The toolkit includes everything. It starts with the evidence-based background, explaining why this is needed and how it’s helpful. Then it goes into protocols. We created both a CPAP protocol and a SALSA protocol, based on Dr. Roberts’ and Dr. Guthrie’s models. The CPAP protocol is based on the Vayu CPAP machines.

Because some sites may not have enough surfactant, we wanted to ensure the sickest babies received it first. The CPAP protocol explains how to enter the protocol, the criteria for giving surfactant, and uses a respiratory severity score. Typically, we use a score of 1.5 (PEEP × FiO₂), which corresponds to about 30% FiO₂. But in this project, we’re using a respiratory severity score of 3 to capture the sickest babies.

The protocol also explains how to exit CPAP, what clinical features to monitor, and includes the Silverman-Anderson score—an objective measure of respiratory distress—so that physicians and nurses alike can use it.

The SALSA protocol explains everything from indications to materials and step-by-step instructions for the procedure. The toolkit also links to the videos. Since this is an implementation research project, it also describes what we’re measuring: outcome, process, and structural measures, as well as complications to monitor. We designed it so that it can be adapted to any setting.

Srirupa: That’s awesome. It seems like you’ve put so much thought and hard work into creating this toolkit, and I’m sure it will be greatly appreciated by these centers. I’d also love for our listeners to see the video, because I’m sure you did a fantastic job. And I totally get being awkward in front of the camera! Kudos to you for putting this together; I’m sure it will make a real impact in these NICUs. I see that you’ve had a really meaningful experience getting involved in global health, and Dr. Guthrie has such a strong presence in that space.

I’d love to hear about your experience finding your mentor and building that mentor-mentee relationship. As you said, many of us come into fellowship not quite knowing what to do, and we each find our mentors in different ways. I think it would be helpful for listeners to hear how that relationship developed for you.

Manjari Pophale: Right. I want to start by saying that I’m so lucky I met Dr. Guthrie, he’s been with me every step of the way. I’m originally from India, where I went to medical school, and I’ve seen how just a bit of training and a few extra resources can save so many lives. I went into neonatology with the mindset that I’d eventually go back home and contribute to education there.

When I started fellowship, like you said, I didn’t have a clear picture of what I wanted to do. I was interested in neurodevelopment, nutrition, BPD, I liked everything! I spent most of my first year talking to different mentors who were doing great work. But after hearing Dr. Guthrie speak at a conference, I just knew his work resonated with me. I approached him afterward, and he was so welcoming. He told me to email him anytime so we could discuss my ideas, and that’s how all of this started. He’s been amazing. There have been times when I was preparing for a talk or a conference presentation and I’d email him at 9 p.m. asking for feedback on my slides. He’d reply by 9:50 p.m. with comments and suggestions. That kind of support means everything. At this point, it feels more like a friendship than a traditional mentor-mentee relationship. He even came to the simulation lab to shoot the video with me, it was a really fun experience despite my nerves. I’m so grateful for him and his constant feedback, whether it’s for research conferences or grant applications. It’s so important to find a mentor you enjoy working with, who enjoys working with you, and who provides honest, consistent feedback.

Srirupa: Yes I totally agree, golden words there. I think all of us as fellows need a lot of guidance and support during these years, and that relationship really shapes how we want to mentor others in the future. I often say this in my episodes: the mentor-mentee relationship should be strong and lasting. You never forget your fellowship mentor. They have such a profound impact on your career.

Well, that was fantastic, Manjari. It sounds like you’ve done amazing work, and I can’t wait to see your results and hear about your future presentations. I’m so excited about the impact your work will have. Congratulations on all the effort you’ve put in. One last question—and I ask this at the end of all my episodes—if you were to give one piece of advice to an incoming fellow interested in global health research, what would it be?

Manjari Pophale: The biggest advice I’d give is, first, pick a research project that you really love and something that doesn’t feel like just another task. This project has had a lot of logistical challenges, but I truly enjoy the work and the process of overcoming barriers. Love your project and enjoy what you’re doing.

Second, pick a good mentor. In global health, it’s especially important for your mentor to have existing global health connections. Honestly, if Dr. Guthrie didn’t have relationships in Ethiopia or Kenya, this project wouldn’t have been possible. It’s so important to choose a fellowship program that already has those relationships with international hospitals or to find a mentor who does. That’s the first critical step, because as a fellow, it’s hard to make those connections and get a project running within two years, especially since your first year is focused on boards and clinical training.

The third piece of advice is to be persistent and patient. Global health projects come with many logistical barriers. The IRB process takes time, and international coordination can be unpredictable. Sometimes things fall through. But stay persistent and remember that you’re doing meaningful work.

Srirupa: That’s amazing. You’ve touched on two really important pieces of advice that all fellows should take to heart: do what you love and find great mentors. These projects take patience and persistence, and loving your work makes all the difference.

Well, this was wonderful. Thank you so much for joining us today, Manjari. It was lovely having you and hearing about your experiences. We can’t wait to see the results of your incredible work once they’re published!

Manjari Pophale: Thank you so much, Rupa, for having me. This was so much fun and it was wonderful talking to you.