UNFAIR

Earlier this week I was asked to consult on a patient on the pediatric inpatient ward in Serowe.  I was told that the patient was a 14 year old with heart failure.  As I walked to the ward with my fellow PAC doctor (Steph) we wondered allowed what we would be able to offer the patient given our limited experience managing heart failure (after all it is not a common problem in children and not one that general pediatricians routinely manage.)  When I started looking through the chart I began to think that the story sounded all too familiar.  The patient (we'll call him Tefo) had just been diagnosed with HIV at the late age of 14, he was an orphan, and had just been started on antiretrovirals (ARVs) despite a high CD4 count.  Steph wondered why he had been started on treatment. (In Botswana, when a patient has a CD4 count >250 there has to be another reason for starting ARVs - like an opportunistic infection or failure to grow, etc.)  And then all of the pieces fell together, Tefo was the same child I had seen just 2 months earlier with his aunt in one of the local clinics (see last blog about disclosure).  I had started him on ARVs because at 14 he was the height and weight of an eight year old.  As soon as I saw him I knew it was him.  He had been admitted to the hospital for chest pains and shortness of breath about 1 week earlier and it was discovered that he had an aortic aneurysm and severe aortic regurgitation.  By the time we saw him he was stable and was actually walking around the ward.   However, his heart sounded nothing like it had just 2 mths earlier, which means that his heart problems were acute.  It is possible that the aneurysm has been there for some time, but has suddenly grown larger causing him to be symptomatic.  We are still unsure what caused an aneurysm in the first place, could it be congenital?  Could he have Marfan's syndrome?  What would Marfan's Syndrome look like in a child who is so stunted (given that people with Marfan's are usually very tall)?  We don't have genetic testing available here and the bottom line is that he needs to go to South Africa for heart surgery, since we don't do heart surgery here either.  The adult cardiologist who visits Serowe a few times a month, and had been the one to perform the echo and diagnosis the aneurysm, is working on getting an MRI to better visualize the aneurysm and transfer him to South Africa.  There was really nothing more that we could suggest, but I was just struck by the unbelievable unfairness of it all.  It is not enough that Tefo is an orphan (though he has a loving aunt, she also has her own children), he also had to be diagnosed with HIV, and then he has to have heart surgery as well.  And yet there he was smiling at us as we asked him to do all sorts of crazy things in our quest to see if he might meet clinical criteria for Marfan's.  His strength gave me hope that he will make it through all of these challenges despite the hand that he was dealt in life.

There have been changes in the grants that we have gotten and in the requests for our time from the Ministry of Health; so I will now be spending about half of my time in Gabarone and half or so in Serowe.  It will be a good chance for us to see how much the medical officers we have mentored have learned and it will be an opportunity for me to become involved with some other projects which will be interesting.  It also means more consistent access to internet so I will try to update the blog more often ;)

I have had some time to knit recently and since this blog has no pictures, here are two of my recently completed baby sweaters (since many people I know are having babies and they are fun and cute to knit).  Thanks Mom for blocking and sewing the buttons on the first one ;) They are both the same pattern (the sideways sock yarn baby sweater), which is my new favorite baby sweater pattern (for now). It is excellent because there are really no seams so when you are done you are done! This is great since my least favorite part of knitting is sewing it together at the end.