Indecisiveness...

One of my biggest frustrations this week has been my own indecisiveness when it comes to referring patients. I feel like there are times when I am just not sure if I am judging the situation correctly. Having said this I can already tell you that many of these children would be admitted in the West but have to be treated as outpatients here because of lack of bed space at the free NGO and the other option (government hospital) being unaffordable and of lesser quality. So, I suppose when you really think about it, my indecisiveness can be attributed to the poor healthcare infrastructure here, rather than to myself. Sounds like an easy cop out. Let me give you an example.

Hawa has come to my clinic since the age of 5 months. She is now 2 years and 10 months and came in on Tuesday with a 2 day history of fever, swollen feet and convulsions. She didn’t look great and her lab work showed she had malaria and a hemoglobin of 5.7. This is when the decision making comes in; try to refer her for admission or see if she takes her antimalarial medication fine and send her home. The decision was simple; I already knew there was no space at the NGO hospital, so I would try outpatient treatment seeing as the child was stable. She took her antimalarials fine so I told her to come back the next day. 24 hours later she showed up at the clinic looking worse; even puffier, breathing at 60 per minute, on and off nasal flaring. Her hemoglobin had dropped to 4.0 g/dL; time to refer. Praise God there was a bed available at the NGO hospital. I sent her off in a chartered taxi for a 25-30 minute journey. Two days later I went to the NGO hospital and heard that Hawa had been transfused, improved greatly and was discharged early on Friday; a good ending.

So, the dilemma of course is that you just don’t know if the children will survive till the next morning. Fortunately, although Hawa was doing worse on Wednesday, she was still alive and could be referred. But, she could also have died that night. And I would have felt terrible for not referring her on day 1. Then again, my only option of referring was to the government-run hospital. And sometimes the treatment can be questionable and it’s expensive. Again, the never-ending financial burden; money to see the doctor, to buy a notebook for medical notes, for medication, for a blood transfusion etc. Also many people don't like going there 'because so many children die' (in my opinion because many of them go there so late).

The hardest for me is when I decide to treat as an outpatient and see the kids back the next day and then they don’t show up. Did they get worse and go to a hospital overnight, did they get better and not see need for follow-up, did the parents get distracted or worse case scenario: did they die? If they don’t show up I feel like I have misjudged the situation and it's always hard to trace what happened. Bottom line, I'm faced with tough decisions every day and I don’t like this indecisive feeling. All I can do is pray for wisdom and trust these kids into His hands.