Out on a Limb - Troubles Abroad

This is our second in a series of 3 posts entitled "Out on a Limb."  We are looking at the practice of Emergency Medicine in environments very different than the Emergency Department. Each post is accompanied by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (July 15), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during our Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

You are an EM resident from the US working in a rural South African hospital as part of a global health elective.  The political climate is such that a prolonged government strike is leading to severe staffing and resource shortage.  There are no disposable gloves and many procedures are performed barehanded.  One day during rounds in the Labor Ward, the Chair of the department asks you to draw blood from an HIV-positive woman in labor as the team is presenting the patient in her room.  The only remaining gloves in the hospital are a few pairs of sterile gloves reserved for emergency cesarean deliveries.  There are high rates of HIV-exposure and many staff members are currently on post-exposure prophylaxis.

Q1 - How do you respond to this request? What are your options? What are the pros/cons of possible responses?

An HIV-positive mother whose baby you delivered and who is in your research study returns for a 3 month follow-up visit with her child. She has walked ten miles bare-footed to come to the clinic.  The child at 3 months of age is the size of a 1 month old infant.  He is emaciated and limp like a rag doll with sunken eyes but appears to be awake and appropriately oriented as far as you can tell.  You notice that the mother is feeding him a black solution from a bottle.  Upon further questioning the mother states that she is not able to breastfeed and cannot afford formula (formula costs <$1 per day) so she has only been feeding her child black tea.

Q2 - What options do you have for helping this child?  

Admission to the hospital requires advance cash payment.  You happen to have an extra $200 from your traveling stipend.

Q3 - Do you try to admit the child to the hospital? How do you decide whom to help and whom not to help?

Your research study looks at the growth and development of HIV-exposed infants.  Both the mother and child were already enrolled during labor and time of delivery, which involved obtaining detailed questionnaires, maternal blood, and umbilical cord blood.  They were offered a free 3-month follow-up visit to assess growth and development of the child and were also offered a 2kg bag of mielie meal as compensation.

Q4 - From a research standpoint how do you address the mother and baby since they are both in your study?  Do you do nothing, since intervening would change the outcome of the particular variable you are studying (childhood growth and development)?  What are the ethical ramifications of including them in your study? 

Q5 - Is the compensation that was provided excessive and/or do you think it unduly influenced the patient to return?

We're looking forward to seeing your thoughts on this case! When responding please indicate the question you are responding to with Q1, Q2, etc.