Debrief

You be my psychologist, because I basically work in a war zone 60 hours a week and I don't sound these things out enough. Some things have hung around in my head for the last little while.





I saw a 7 week baby on Friday morning, who was referred in because of respiratory distress. According to the mom she started breathing fast the previous afternoon... no coughing, no fevers, no issues feeding. The baby was beautiful... and blue. Her oxygen saturation in room air was low 70%...(this is baaaaaad.) A bronchodilator didn't do much, a 100% oxygen got her sats into the high 80's. An x-ray a big fat heart! Blood gas shows a pC02 of 7.3 and a lactate of 10! Prognosis is worsening.
Within 3 hours she was reviewed by an ICU doctor and a cardiologist who with a 10 minute echocardiogram diagnosed this little nunu with TAPVD - total anomalous pulmonary venous drainage...basically, the pulmonary veins don't connect with the heart, so the heart pumps blood to her lungs but then it dead ends...the only thing that's kept her alive for 7 weeks is an ASD (atrial septal defect) which allows some mixing of the pulmonary and systemic circulation.
And I watched a mom watch us make a diagnosis on her child. And I watched her get told that her 7 week old baby girl, who seemed perfectly well on Wednesday, needs emergency open heart surgery if she wants a shot at life.

On my rounds this morning I had to see a 3 year old little boy who weighs 8kg. He managed to escape getting his mom's HIV but unfortunately not her TB last year or her poverty. He's had an admission for severe malnutrition once before in his 3 short years. Now he's back...with a round puffy kwashi face and a stick thin marasmic body, the skin on his tummy is loose like and old man's. His electrolytes are in the floor, he's temperature is through the roof, his chest X-ray is a disaster and he won't eat - dying of starvation in the shadow of Table Mountain.
His mother sits next to him with a sad, bewildered look on her face. She doesn't speak a word of english. She doesn't look super healthy herself. I know she doesn't realise that he's so sick he probably won't pull through and I wonder how did they get to this point - twice. It's easy to blame.
But when I take him through to the procedure room to do more bloods I watch her put her face close up to his and comfort him with words I don't understand and soothing smiles... and a little voice whispers in me..."she's doing the best she can."

Upstairs in B1 high care is the loveliest little kid. Mich lived in B1 from February to May getting TPN (total parenteral nutrition) - which is food in a drip - but hectic R1000 a bag, too corrosive for small little arm veins, has to be run through a central line (sited directly into one of the big vessels in your chest or abdomen) stuff.
It also meant she could have absolutely zero food orally because a combination of her HIV and a couple of nasty stomach bugs have wrecked her intestines so badly that not only does she absorb nothing but eating something actually just damages her gut even more. Imagine being 5 years old and not being allowed to eat a thing!

She made it home for a few weeks, getting by with a lactose free diet...picked up a stomach bug and is back at square 1. Weighing in at 12kg's she is a scrap of the little sunshine kid she really is. She is lying propped up by a few pillows, shuffling through songs on one of the nurses cell phones. Realistically I'm not sure she's got more than a year of life in her body, though her little soul has fight for a few more. She starts listening to a Celine Dion song "Goodbye's the Saddest word"... and that was the end of me. I had to leave.