COTW: Decision-Making

A few weeks ago, we admitted a 3-month old child, reportedly previously healthy as well as previously unimmunized. After getting the story of the illness and examining the child, the most likely diagnosis was Pertussis, or Whooping Cough. She was put on oxygen and started on antibiotics.

A couple days later, she began to get worse with her breathing, and it became evident that if she was going to survive, she would need to be put on the ventilator to assist her breathing. Having no other option, we did this, with the help of our visiting Respiratory Therapist from Canada.

The next few days were extremely touch-and-go, but she persevered. We knew that Pertussis can take a while to resolve, and so weren't surprised that she didn't seem to be able to yet come off of the ventilator.

We decided to get a chest x-ray. This was her first chest x-ray, which may surprise you, but we go to great lengths to preserve cost for our patients (and that's another conversation). Here is our xray.

The most obvious thing about this xray is that the heart (the white part in the center and to the right) is huge, at least twice the size that it should be. The most careful observer (with a higher resolution image) might also notice that the ribs and spine have multiple anomalies, likely from birth, including hemivertebrae and fused ribs. Putting this all together, what we see is that she is extremely likely to have been born with a heart malformation. Thus, she may have Pertussis, before even before that (and thus, after it as well), she would not be healthy, but rather has a condition that has likely no recourse to fix here in rural Kenya.

So, now what do we do? We could keep her ventilated, try to improve her heart with medicines, and hopefully get her off the machine, but even if she managed to get discharged home, her days are extremely limited.

In the meantime, her family is accumulating a big hospital bill, which means food and school fees for the other children at home may have to go unsupplied. This issue of cost is marked here. In the US, it's frustrating that we spend 15% of GDP on health care, but no one is missing out on life necessities because of a hospital bill. And keeping her here means that 1 of 2 ventilators is occupied, and 1 of 6 ICU beds is occupied, and terribly sick patients are showing up all the time.

Our training didn't teach us how to answer this question. And, in this scenario and culture, discussing the options with the family in order to let them make their own decision is not an adequate solution for a number of reasons.

We face these questions very often, ones that matter intensely for patients and families, and for which we aren't certain of the right answer, and no one can supply us the right answer.

Pray that we would have wisdom.