Occasionally one can gain an interesting piece of information from the hospital's daily morning meeting. One such occasion happened recently when it was announced that there was a patient with Rabies in the hospital. I was a little surprised to discover that said patient wasn't on ICU Medicine as one would expect a patient with a life threatening neurological infectious disease. She was in fact on the general medical ward - a 23 year old woman.
None of the staff would go anywhere near her as they were terrified of catching Rabies. So we (L, R & J) went to investigate. The patient had presented after having a seizure & was now left with a facial droop, she had a headache & was afebrile & other wise in good spirits.
When were you bitten by a dog? I inquired
One year ago - was her response.
And how is the dog? Was it ill? Has it since died? - J mused
Alive & well - her & her husband merrily replied.
You don't have to have a diploma in tropical medicine & hygiene to realize that this woman did not have rabies.
Unfortunately persuading the staff that this was the case proved to be challenging.
The nurses would not entertain the idea that this wasn't Rabies - despite a long conversation about incubation periods, transmission & clinical signs. Realizing that I was on a hiding to nowhere I changed tactics & suggested even if she did have Rabies (which she didn't!) the staff couldn't catch it by taking her blood pressure.
A new doctor had diagnosed her with rabies because when she was post seizure she had been reluctant to drink water - that and the history of being bitten by a perfectly well dog ONE year ago obviously made the diagnosis obvious. The nursing staff refused to listen to my clinical reasoning - probably as they were unfamiliar with it as a concept.
As the new doctor is never actually at the hospital & I don't know where his private clinic is, I was unable to challenge his diagnosis. I then went away to the border hospital for a week.
On returning the 'Rabies patient' had been transferred to ICU after having further seizures & being in a coma for 4 days. When I found her she was happy to see me (clearly she was no longer in a coma) & was puzzled as to why I'd bother to come to examine her & talk to her. The staff continued to treat her like a leper & would go no where near her. Particularly harsh for when she was in a coma & therefore by definition required high care nursing. She now had a dense left hemiparesis, slurred speech, couldn't walk or swallow properly & her facial droop was worse. She was afebrile & lucid.
I tried to suggest to the duty doctor that perhaps a CT scan would be useful in this woman. He assured me her physical signs were all old & there was nothing new. He could see no value in repeating blood tests or doing a CT scan.
I went to the poor patient fund to see if they would support a transfer to Phnom Penh to the neurology centre if the scan showed a bleed or space occupying lesion. I was prepared to pay the $100 for the CT myself from funds left over from the WPW fund. Then depending on the findings of the CT we could plan her further management.
I went back to say this - the doctor, after the patient had been in hospital for 3 weeks at this point, had discharged her home as a hopeless case.
Words fail me.
The best bit of this whole story is 8 staff insisted on getting Rabies vaccines - $80 a shot - that the hospital had to paid for. The director went ballistic. At a morning meeting I missed he apparently told all the staff they were idiots. The patient didn't even have Rabies. Dr Esther had told them all it wasn't Rabies - why don't they listen to her? That money spent on them should be spent on patient care.
This was pleasing to hear. I perhaps would have said exactly the same to them as the hospital director, given half a chance, but maybe I would have added - AND THE DOG IS STILL ALIVE YOU FOOLS!
If a young woman's life wasn't in the balance I'd even find this whole episode funny. In fact I do find it funny because the other option is blinding rage.
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