Dreaming about Equality
THE biggest disadvantage unborn children in KwaZulu Natal (KZN) face:
- The area has one of the highest incidences of HIV in the world
- Most mothers are uneducated and not empowered and so there is still a lot of mother to child transmission of HIV despite the free anti-retrovirals available to all pregnant women
So just managing to be HIV negative for a child in KZN is an amazing feat! But even if this does happen, it doesn’t mean that life will be easy for the child.
I have a story to illustrate. I will put all the disadvantages/inequalities in bold italics:
Last Thursday at 10h15 I was called to maternity ward because a child had arrived who was having trouble breathing. He had been born at around 06h30 in a car on the way to the local clinic. The mother had been in labour since around 20h00 the night before but had no transport to even get to her nearest clinic. Finally she found someone who could take her to the clinic in the morning, but the little boy couldn’t wait any longer and popped out covered in meconium, en route.
At the clinic the sister did what she could with the limited resources they had available and called the ambulance to take the mother and baby to the hospital. Because of the remote location of the clinic and the limited number of ambulance vehicles available, the child only arrived at the hospital almost 4 hours after he was born. By this time he was pale and was grunting.
Obviously I ran to see him as soon as I got the call and had him placed in an incubator on oxygen and IV fluids and started IV antibiotics for him and ordered a chest xray. He did improve markedly, but his oxygen saturation never rose above 90% and I was giving him all the oxygen I possibly could. He was breathing at a rate of about 90bpm; the upper limit for a newborn is 60bpm. So he was in trouble. He was also in one of the most remote hospitals in KZN. I am a very junior doctor as doctors go, but in this hospital I have comparatively excellent paediatric experience, which is ludicrous! If he was born just 3 hours south, he would have had a Paediatrician at his disposal! Which every sick child deserves.
Nontheless, I had to make a decision and I decided that he needed to be intubated and ventilated. But, of course, we can’t ventilate at our very rural hospital in KZN. The only ventilator we own is an Oxylog 1000, which is a mobile primitive ventilator kept in the disaster cupboard in our outpatients department and usually covered in dust. It’s only meant to be used short term in an adult waiting to be put onto a proper ventilator, it should never be used on a child.
So the first thing I needed to do was find an ICU bed for the little boy. I called the nearest referral hospital and they had no ventilators available, no surprise there, I was actually expecting it and would’ve been surprised if they had accepted the child. Next I called King Edward Hospital in Durban. After spending a long time trying to get hold of a doctor and then explaining the situation, I was told they would call me back. A little while later I got the call: No beds available. Onto the next hospital: Albert Luthuli, also in Durban, has some of the most high tech ICUs in South Africa, but also no beds!! I was practically begging, emphasising that this child was born to an HIV negative mother, he had a good birth weight (3,6 kg!) and he was neurologically intact, all factors that improved his prognosis and made him a good candidate for ventilation, because he wouldn’t be a waste of scarce resources. The doctor on the other end of the line said: I hear what you’re saying, but there’s nothing I can do. I don’t know what else to say to you, we have NO BEDS!
I put the phone down and allowed myself a minute to cry in frustration. Then I picked up the phone and called directory services to get the number for Greys Hospital in Pietermaritzburg. Their number is not even on our list of numbers because they’re not one of our referral hospitals and we usually never deal with them. I spent almost an hour on the phone with Greys. Spoke to two different doctors. I was told from the start: We don’t really have beds, but what do you have?
I sold that child to them like I was trying to sell ice to an Eskimo! And it paid off, they eventually said: Ok, we’ll take it.
The next thing I did was call the ambulance service and convinced them that we needed a plane to take the child to Pietermaritzburg as soon as possible. It would have been an almost 6 hour drive otherwise! Then I ran back to nursery and got the intubation process underway.
By 15h00 the child was intubated with a chest xray that wasn’t too pretty and a meticulously written referral letter. I didn’t want the accepting hospital to have anything to grouch about, I was just so grateful that they had accepted the child. I thought that I had overcome most obstacles and that the child would be in a better place (on Earth) in a few hours.
What I forgot to take into account was the things I can’t control. Not only is the hospital I work at one of the most remote in KZN, it’s also up quite high as far as altitude goes. So this means that if it should happen to be a cloudy day, the hospital and surrounding area is most likely covered in clouds.
This Thursday happened to be a cloudy day! So the plane had trouble landing of course. I had decided to play it safe and not attach the baby to the primitive ventilator and so was standing bagging it, with help from a colleague, watching the saturation monitor and adjusting pressure and frequency accordingly!! I had no idea what a workout my hands would have, we stood bagging that baby for almost 3hours!
When the paramedics eventually got there with their ventilator and enthusiasm, I once again made the mistake of thinking that eventually everything would be alright. I handed the child over and ran off and jumped in my car heading for a fabulous weekend in Durban. I was leaving two hours later than scheduled, but feeling happy.
Just under an hour later, while driving, I got a call: The plane can’t take off because of the clouds!!
How much more disadvantaged could this poor child get? Even the weather was against him! I was exasperated, I didn’t know what more to do. In fact there wasn’t really much that I could do: I was almost an hour away from the hospital and I couldn’t change the cloud pattern! The best thing I could think of was giving the paramedics the number for the doctor on call at the hospital that evening.
The child was brought back to the nursery and, for the first time ever, a baby was ventilated through the night in our hospital nursery. I’m not confident in the quality of the ventilation, but it was at least attempted. The next morning there was still trouble with taking off and to add to all of the problems, the battery for the paramedics’ incubator and saturation monitor had died!
This poor child eventually got to a hospital with the necessary resources: Paediatrician, ICU, proper ventilators and monitors, but to be quite honest I’m not sure what quality of life he’s going to have in the long run! Firstly, he had periods with less than optimal oxygen saturation and so the likelihood that he has some sort of brain damage is quite high. Secondly, he was ventilated in less than optimal conditions, so the likelihood of permanent lung damage is also quite high!
I just wonder how differently things would’ve turned out for him if he really did have equal oppurtunities for access to all the healthcare resources he has a right to! And I also can’t help questioning: Why? Is there a greater force at work? Is there a greater good that this poor child’s suffering is serving? Is there a reason or is it all just random?
