Too late

One of the most difficult things in medicine is accepting that there was nothing more that could have been done.

One case that affected me quite badly was that of a young pregnant woman with TB .

When she came in she was already 7 months pregnant and had been on TB treatment for a few months. She was in a bad way. She was wasted and malnourished, had oral candidiasis and was short of breath. She tested HIV negative on rapid test. I didn't believe the results so I sent stat blood to the lab for an Elisa. It also came back negative.

In the meanwhile, she'd had a chest x-ray which should extensive infiltrates and lung damage - she barely had any normal lung left.

I made a tentative diagnosis of multi-drug resistant TB.

The baby was also not doing so well. There was very little amniotic fluid and although there was a heartbeat on ultrasound, there were no foetal movements.

The patient also complained of abdominal cramps and on abdominal exam she did seem to be having some mild contractions. On vaginal exam her cervix was very posterior and very difficult to assess.

I sent her to the state hospital with a diagnosis of probable multi-drug resistant TB, oligohydramnious and possible early labour.

She was reluctant to be admitted but her mother seemed to understand the gravity of the situation and talked her into it.

Next day, on enquiring after her at the state hospital, it seemed there was no record of her being in either the gynae or obstetric wards (the baby was viable, but the state hospital did not have adequate staff or resources so whether the baby was considered viable by them probably depended on whether they had a neonatal ICU bed. Nevertheless, she was apparently in neither ward.)

I remember thinking that she might have absconded, considering how reluctant she had been to be admitted. More likely though was that she was in fact in the ward but the hospital staff were just too lazy to look and claimed they had no patient by that name (very, very common in South Africa. In fact, if you enquire after a patient, it's the exception rather than the rule that anybody bothers to make any effort to help you).

About two months later, I saw her mother again on an unrelated issue. She told me that her daughter had been admitted to the hospital. She said that the baby had died in utero and that her daughter had then died a few days later.

I was devastated.

She had essentially died from a curable disease.

What had happened up to the point that she'd presented to me was uncertain. Whether the system had failed her, or she had been non-compliant, I don't know, but from the time that I saw her, it was already too late it seems.