A new angel

Today was one of those days you just know is out there but dread. I was past due for this....a child died in my care. We, two dermatology residents and I, were in Lobatse today. They had given a great talk about the latest ideas regarding care for a perfectly miserable spectrum of skin diseases characterized by anything from rash to blistered lips to burn-like wounds across the entire surface area of the body. It's called TEN (toxic epidermal necrolysis) for short and is a true bitch.

It is quite prevalent in HIV prone areas because one of the anti-retrovirals used early in the care of HIV is frequently associated with it. It's interesting in that the care for TEN in western countries involves intense intensive care with a mortality rate of 50-70%. I've cared for it in remote Sudan with a perfectly lousy outcome as well. In South Africa they are as diligent but use less invasive techniques and have a rate of generally <10%.

In the middle of the talk a nurse came into the room and asked for Roger, a good friend of mine and excellent doc. We casually finished the discussion and went out to see if the residents could shadow him in the A&E (the emergency area; "Accident and Emergency"). I walked into the room and found him bagging (breathing for) a 3mo old boy.

Apparently the child had gastroenteritis for three days and had visited a "traditional healer" at least once. He was brought by his parents and grandparents who were arguing about whether to let us treat him. By now he was obviously dry and in shock. When the powers that be relented or won, depending on one's point of view, Roger got busy. He had started an IV in the external jugular (the guy can canulate a capillary!) but didn't have normal saline, the mask didn't fit, the 02 wasn't reliable and the tubing the wrong size. In short it was like a lot of pediatric codes in western hospitals that haven't had one in a while.

So I got in the middle of the flail and started to rehydrate, establish and airway, decompress the stomach, and initiate CPR. Now if a three month old's heart stops it has to be from electrolyte abnormality, profound sepsis and shock, or.....well that's about it if it was previously working fine. So we suspected the traditional remedy but who knows. He was terribly ill and appeared to be caught in a power struggle that relented too late. For that matter it could have been a clean kill from traditional medication. We'll never know and that is so damn maddening. Nothing to learn about the cause of death, just an opportunity to review pediatric resuscitation in a secondary hospital. Maybe that can be his legacy. God I feel empty..