costly mistakes

Monday

I meet Emmanuel for the first time, he is lying weakly in his mother’s arms. He is one and a half years old, and was admitted to Bugando three weeks ago for severe malnutrition. Since being admitted, Emmanuel hasn’t gained any weight.  Part of the reason is because the hospital has run out of milk formula therapy and Plumpy Nut (a ready to use therapeutic food to treat malnutrition). 

Today, he weighs even less than when he first arrived.  The medical team (1 resident, 1 intern and medical students) and I discuss his case and make adjustments to his care.

Tuesday

Emmanuel looks a little better than yesterday, and for the first time since admission, his weight has not dropped.  The medical team and I review his chart again and make updates for his care.  

Wednesday

My schedule has me going to Magu District Hospital to mentor at their HIV clinic, so I do not see Emmanuel at all. The intern was also away, so only the resident was around to see Emmanuel. 

Thursday

In the morning, the resident is called to proctor a medical student exam, so it is only the intern and me for morning rounds. We visit Emmanuel first, since we learn that his condition has changed for the worse. We enter his room and find him on oxygen and breathing rapidly. His lungs sound coarse on both sides.  He doesn’t respond to touch or pinch, his fingers and toes are clammy, and mom says he hasn’t urinated for 12 hours.  The intern and I quickly flip through his chart to read yesterday’s notes. The resident gave Emmanuel IV fluids, because she thought Emmanuel was dehydrated. Emmanuel then developed respiratory problems, so the resident started antibiotics and gave him oxygen for concern of pneumonia.    

After further assessing Emmanuel, the intern and I think he is in shock, so we give him a bolus (a certain amount of fluid given in a short period of time) and call the ICU to check if any beds are free.  The ICU is full, and when we return to see how Emmanuel is responding to the bolus, we discover that he has died.  

I’m distressed and puzzled about how quickly things had turned for the worse within 24 hours.  After counseling the mother, the intern and I sit down to review Emmanuel’s medical chart. We discover a page of notes that we had not seen earlier, and realize too late, what had happened to our little patient. 

What Happened

While we were away on Wednesday, the resident, thinking Emmanuel was dehydrated, gave him an extremely large bolus (30ml/kg) before giving fluids. The fluids given were also of an extremely large quantity (70ml/hr x 5 hrs) for a child weighing only 5 kg.   

Malnourished children have weak hearts and can quickly develop heart failure when given too much fluid. To treat dehydration in malnourished children, it is recommended to rehydrate with oral fluids only. IV fluids are reserved only when they are in shock. Emmanuel had been given more fluid than his heart could handle. The respiratory problems he developed were not from pneumonia, but from his heart not being able to pump the extra fluid.

I was angry at the resident’s poor management of Emmanuel, frustrated at the lack of communication between the day-to-day medical teams, but also upset at myself for not having been more astute and missing that page of notes in the chart.  

As frustrated as I am now, I know the best thing we can do is to learn from the mistakes made in Emmanuel’s case.  I will be presenting the story at a Morbidity & Mortality Conference next week, hoping that it will help improve care at Bugando. 

Please pray that God would give me the strength and wisdom to care for the children here well, and also the ability to teach the future physicians of Tanzania effectively.