The Baby Died

Just back from the toughest morning report since I have been here, especially in contrast to the celebratory atmosphere as we gave some of the things we brought: protective eyewear – we need to bring these annually, scrubs - always welcome for the OR, miscellaneous alcohol wipes, gloves - non-sterile and sterile, etc. Dr. Sovelo was presented with a couple good 3M diagnostic stethoscopes for distribution. And all these things bringing kudos from our colleagues.

Those leaving had an opportunity to say thanks and goodbye.  I was pleased to offer appreciations to the staff for their good work and pointedly let them know they are role models for the nursing students.

Then we heard morning report.  First, a man died in the night.  He had complained of chest pain earlier and multiple other problems, including HIV at age 36, which was why he was admitted.  His death diagnosis was asystole.  It happens. 

Next, we heard what none of us wanted or expected to hear.  Our eight-month old patient, Adonis, with the severe malnutrition (marasmus) had died.  We all thought the baby looked slightly better after getting therapy started.  We learned some additional history too.  This was at least the third time the infant had been admitted to the hospital, the first two times at the Regional Hospital in Iringa.  Despite the efforts we made, he had a couple chances before he reached us. Did someone drop the ball at Iringa? This is information we cannot know.  It is tempting to climb the ladder of inference, but there are so many explanations!  Was this an unwanted baby?  Munchausen’s by proxy? Poor care at the Regional Hospital? Inadequate resources? Inadequate teaching? All of these things?

All I can say is I am deeply saddened at our failure to save this child, but perhaps it was inevitable. I know he would not have died in the US.

To make things worse, if they could be worse, Sovelo had a disaster too.  A woman with 2-3 previous C-sections and only two prenatal visits, presented in labor, an indication for emergency surgery.  The nurses noted fetal heart tones (FHT).  Unfortunately, at surgery, Sovelo found extensive adhesions (scarring) that made access to the uterus very difficult.  He delivered a macerated baby, indicating previous intrauterine fetal demise.  The baby was grossly deformed, with brain, meninges and heart malformations externally visible.

That tragedy was not enough.  The mother had severe bleeding. With heroic effort, Sovelo got that stopped, some blood transfused, the uterus removed, and the woman transferred to the Regional Hospital.

The case prompted a tirade from one of the nurses about patients who do not do what we say is best for them.  This happens at home too: competition between the medical professional principles of primacy of the patient, autonomy of the patient, and social justice, sometimes causing a clash that may be unresolvable.

The FHT disparity raises questions too.  Obviously, the baby had died before the FHT were recorded as present. What is the explanation? Shortcut? Lack of synchronization with maternal pulse? (This was kindly Sovelo’s explanation.) Again, it is difficult but essential not to climb the ladder of inference.  Handheld electronic Doppler Ultrasound fetoscopes may not be the perfect answer, however, they are durable, portable, reliable, quick and pretty inexpensive – under $100, I think.  Perhaps ILH should have one or two and each of the eight Lutheran Dispensaries should have one also.

We will debrief these cases this evening, perhaps mainly for reflection.  Now we have all seen such cases in our experience here.  Still I had a lot invested personally in the case of Adonis.