After a brief trip back to the US to see my brother graduate from law school and my cousin get married, (both wonderful events), I returned to Botswana to start my last week on the inpatient wards (June 6-10)!
(Just to back up for a minute for those who don't know. I have moved back to Gaborone, the capital, permanently. Our program is being downsized to begin the transition to more local control. We started the year with 9 PAC (Pediatric AIDS Corps) doctors and 3 are leaving us. So it was decided that there could no longer be 2 people in Serowe all the time. Also we had already accomplished much of the basic training and now need to focus on teaching local providers to manage challenging patients (or those who are not doing well on standard therapy). So we have started "challenge clinics" and will be traveling to the area twice a month to see patients who are failing. We are also going to be pulling out of the inpatient wards as there is now a pediatric residency program and several new pediatricians who are going to cover our team. Hence I have completed my last week on the wards. From now on I will be working in our clinic, doing outreach, trainings, etc)
So the week began with being on call on Sunday (June 6) when I met Thabang a 3 month old male who was previously healthy, but had developed vomiting and diarrhea 3 days prior to admission - he was admitted on Friday. His paternal grandmother took him to a traditional medicine doctor who gave him several teaspoons of a liquid that was greenish in color. About three hours later he began to breath very very fast and was very tired so his mother brought him to the hospital. He was found to have severe metabolic acidosis, renal failure, liver dysfunction, and was very sick. As part of the work-up a lumbar puncture was done on Friday night as he had a fever and was very ill appearing and the doctors needed to rule out meningitis. He was given a lot of fluids, antibiotics, oxygen. etc. When I arrived on Sunday he was still the sickest patient in the wards. I did a lot of counseling of the mother to explain that he had a very poor prognosis. All of the doctors involved in his care over the weekend felt that the most likely cause of his condition was the traditional medicine ingestion. The traditional medicines have multiple different herbs and other medicines mixed together and most of the traditional medicine doctors are used to treating adults. We have seen numerous cases of children who have developed renal failure following traditional medicine ingestion. Unfortunately there is no way to be exactly sure as we do not have any way of testing for them in the blood. We also do not have dialysis which could potentially clear the toxins from the system. So the only treatment we can offer is supportive care and fluids to reverse the dehydration and metabolic acidosis. Thabang's mother seemed to understand the severity of the situation and also to understand what had caused it. The baby was still breathing very fast in an effort to get rid of the carbon dioxide (CO2) in his body, but I was worried that he would get tired.
On Monday morning he was in fact getting tired. He was now breathing very shallowly and his blood gases showed that he was not blowing off CO2 as well as he had been before. He needed to be intubated to have any chance of living through the day. We had another family meeting this time with the mother and the paternal grandmother. The paternal grandmother was furious. She was convinced that the lumbar puncture that had been done on Friday night was the cause of his illness. She said that she had a family member who had died after a lumbar puncture. For over one hour I tried to explain the risks of lumbar puncture (which absolutely can not cause renal failure or liver dysfunction) and why we had done the lumbar puncture. She spent most of the time yelling at us in Setswana which was translated to me. Eventually I could see that we would get no where and told her that I understood how she felt about the lumbar puncture and I was sorry that she felt she had not been consulted (after all the mother is the one who has the right to give consent) but that I could reassure her that it had not contributed to his decline and that what we needed to do now was focus on Thabang and trying to make him better. She eventually agreed to disagree. I then spent 6 hours trying to get a doctor from the ICU to come and evaluate Thabang and see if he they might be able to take him in the ICU. Eventually they agreed, though so much time had passed that we almost lost him in the transport. He was admitted to the ICU on Monday night and intubated, but despite our best efforts he passed away late Tuesday night.
On Wednesday morning I arrived to find Thabang's mother and both of his grandmothers waiting for me. They wanted to discuss what had happened. I sat down with them again and explained what I knew with the help of a nurse who translated whatever was not understood. But both grandmothers remained focused on the lumbar puncture. Now they were most concerned with the fact that the intern on call had obtained consent from the mother without involving either of them. The mother is 22, very smart, and has full legal right to consent for her baby, but the grandmothers felt that they should have been consulted. Unfortunately there is no formal consent process here for things like lumbar punctures, everything is verbal. After over 2 hours of discussion, I think the grandmothers still believe that the lumbar puncture is in some way responsible for the baby's death. I assured them that we will work on better ways to document consent, but unfortunately it is not really practical to convene a full family meeting every time any sort of procedure needs to be done. I felt very frustrated. After working so hard to do everything possible for the baby, the family believed that we were the ones who had caused the death. It is one of the many examples of the challenges of combining western medicine with traditional beliefs and stressed to me again the importance of good communication (and documentation of that discussion) from the very beginning.
On a happy note, Chuma (the 9mth old I wrote about in the last post) was started on antiretrovirals (I paid for the first month's supply) and finally began to improve. He was discharged from the hospital after a month stay and will be getting medicines from a non-citizen clinic and from Zimbabwe (when he is able to return).
