Regrets
I was shaken today by the unexpected death of J, one of our HIV-infected children. A week ago he was doing fairly well and, having started on anti-HIV drugs, we had every reason to expect he would do fine. Friday, his mother brought him back saying he was having diarrhea and not eating or drinking. We decided to admit him “as a precaution, just for a couple of days.” He did respond well, but then had a serious setback Sunday night, going into shock after having an increase in his diarrhea. I’ve heard the “adult” doctors talking about how often their adult HIV patients come in with diarrhea and shock and cannot be resuscitated, but I haven’t seen it in children.
We resuscitated him with fluid, adding hydrocortisone, and yesterday he seemed to be doing well, though still weak. A lab result yesterday showed his serum potassium level to be quite high, so we rechecked it as our labs are often not too reliable. The repeat level was even higher, seemingly impossibly high, but an EKG showed none of the changes one would expect to see with high potassium levels, and there seemed to be no reason he would have such levels (diarrhea usually causing the opposite) so I didn’t worry about it.
Then this morning I went to morning report and learned that he had just died suddenly, shortly before. We’ll never know the reason. Perhaps it was the potassium after all, which could fit the sudden death. Or perhaps he had been fading during the night and that wasn’t recognized. Perhaps it was something unavoidable, but I feel I probably should have done more, and might have seen him safely home.
We went on to have two more deaths today, both of newborn, premature babies who had had difficult deliveries. Both arrived ill and, despite what we could do, died within 24 hours. Their families and J’s both suffered a great loss, but I do not feel burdened by the babies’ deaths as I do over J’s, as I don’t think there was anything else we could have done, the outcome (medically speaking) being determined at birth.
Two other patients in our ICU have suffered severe brain damage from meningitis or encephalitis. Both are still unconscious several days after starting treatment, and there really isn’t any hope for a quick or complete recovery for either one. I decided to start anti-tuberculosis treatment on one today, on the quite unlikely possibility that TB meningitis is the infectious cause. It’s an outside chance, and I had to consider whether the nine months of treatment was reasonable or a waste of resources. It’s very sad to see kids like this suffer such severe brain damage, and I wonder how the families are going to cope.
I did see Grace and her parents yesterday, though. A year ago, she too was one of those severely disabled children after a bout of some neurologic infection, but month by month she is progressing. She still doesn’t talk, but she looks more like she understands things that are happening, recognizes people, and is almost walking again. Encouraging!
Coming soon … a wedding in the works; a new foster baby; update on the pediatric HIV/AIDS program