Tony's Story

February of last year, a boy came into this world, uneventfully actually, to a family of 2 older brothers and sisters. Although he didn’t know it yet, he has been born into the 3^rd poorest country of the world - Malawi. His young parents owned a small plot of land on which they farmed maize, earning them enough to get by.

Shortly after his birth, his mum became more and more unwell, and was diagnosed with HIV. She attended a group session to learn about antiretrovirals and was given an appointment to come in to start these. Unfortunately, she died before this day came. Tony was by now 2 months old, and left with no wife Tony’s father felt unable to cope and sent the children to live with their grandmother, sold the farm and left for the city to make some money. Tony never saw his father again, and his grandmother never received any support for looking after the children.

She cared for the children as best she could, but finding money for food, clothes and healthcare - the basic needs of a child was difficult, and they often went short. Tony, was especially vulnerable due to the fact that he needed formula milk, expensive to buy and hard to prepare. By 10 months old he weighed 5 kg – a weight at which it is possible to be born at.

The week after Christmas, he developed diarrhoea and vomiting, and a rash on his groin which gradually spread over his whole body, sparing his face. After waiting a few days to see if he would recover, his grandmother eventually took him to see a traditional medicinalist, the cheapest ‘consultation’ around. He was prescribed a white paste which his grandmother dutifully painted on his whole body day and night… soon his skin broke out into a red raw rash, and opportunistic fungal and bacterial organisms likely took hold. His condition worsened and worsened until he stopped eating and crying, and she then took him to the nearest health centre who referred them to Kamuzu Central Hospital with a large paediatric department.

At the clinic, in his condition, an IV line should have been set up and at a minimum some fluids and antibiotics started before being admitted. Instead he was sent to the ward and started on oxygen, and left, presumably to be seen later. This is where I came in. I was in the treatment room, inserting various IV line for kids in the ward, and being lunchtime, I appeared to be the only ‘member of staff’ around. This baby caught my eye, as it appeared not to be breathing ( I had resuscitated one the day before, so my eyes were possibly more adept to checking!). I went to the patient and indeed it was having apnoeic episodes (episodes of not breathing). Knowing the baby needs help to breathe, I quickly make a decision whether to start on my own or go and find help…the second was more sensible as I am really not qualified to resuscitate a horrendously malnourished, dehydrated, for child so I ran to all the wards but could not find a soul. I then ran back and bag and masked the baby, gladly noticing that the heart rate picked up beautifully when he was ventilated – a good sign. After about a minute, maybe too, I again left the baby and went to the secretary to call someone at which point I found a senior consultant who was not at all pleased at my dragging her to see the baby. She assisted me in getting IV access whilst still ventilating the child and told me to run some fluids and see if the baby picks up. She told me it was very poor prognosis and left.

By this time, an intern (fresh out of medical school) was also helping me, and after about 20 minutes of resuscitation, we began asking ourselves what are we doing for the child besides fluids? So we eventually did what we should have done at the beginning and checked the blood glucose, discovering it was hypoglycaemic. I have always been told giving glucose in hypoglycaemia is a very satisfactory thing, and indeed it was, the baby came round and was breathing spontaneously with a good heart rate.

It was now safer to leave the child for short spaces of time so I went to find one of the Baylor Doctors. Baylor is an institution linked to a medical school in the U.S which is here to treat HIV infected children. They have access to more advanced resources than the hospital, and the children seem to get a very high standard of care. It does however create a situation where the HIV infected children are receiving better care and surviving very serious HIV related diseases, whilst non infected kids die of malaria or diarrhoea which could sometimes be caused by a lack of staff or resources.

Dr Gordon came to my assistance and reviewed the child, and we developed a management plan, and started the child on expensive antifungal and antibacterial creams, as well as systemic therapy not usually available on the ward. Luckily there was a bed on the high dependency unit and after a lot of persuasion whilst trying not to get angry/upset, the nurses eventually accepted him in and it was time for me to go home.

The next morning, I was told that Tony had passed away a few hours after I left. Every death I have witnessed so far has affected me in some way, and I hope I will always be that way, but some seem to get you more than others, the previous day I had performed CPR on a 5 day old baby, and yes it was hard, but Tony got me in a different way. Maybe because of the state he arrived in, maybe because I was able to get more of a background story from the grandmother, or maybe just that he was obviously a pure fighter..having got so far with so much against him. This boy made me think what if?

What if… I had not been first on the scene?
What if… the consultant had not been so busy and frustrated with her work?
What if… there had been more staff in HDU to actually monitor the child during the night?
What if… the person who had admitted him had managed him properly from the start?
What if… his grandmother had taken him to the central hospital in the first place?
What if… his tiny body had not been covered in some unknown white paste?
What if… he had been given a good nutritional diet from the start?
What if…his mum had been diagnosed before pregnancy?

What if…he had not been born in Malawi?

*names have been changed to respect confidentiality.

*some (unimportant) parts of this story have been made up.