Her bark's worse than her bite....

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.

WPW - part 4

So its been a while since I last blogged & it wasn't because I didn't have anything to say, in fact quite the opposite. But my silence has been broken by part 4 of the patient with WPW syndrome saga. If you remember M was the 17 year old girl that the ICU staff at my hospital nearly sent home to die. I won't go through all the details again as it still makes me angry but the outcome was a failed Ablation (burning of the accessory pathway causing the tachyarrhythmia) but the promise of a repeat try in February when a group of American Cardiologists would be visiting.

So its February now & after ensuring that the Flecainide we had bought from donated funds had been stopped (can't do an ablation if the patient is on anti-arrhythmics) and confirming the date of admission & procedure we booked a bus to take M & her Mum down for a second attempt.

I am an idiot - people who know me will know this to be true. I emailed Dr C - the Cambodian Cardiologist -  the week before confirming the date & asking for written confirmation that she would not need to pay for the procedure again which I got BUT I did not re-confirm the day before. More fool me.

I was feeling proud that we had successfully got them on the bus & given sufficient funds to the health equity fund (HEF) to pay for her user fee & additional fees. I assumed that it would all go smoothly if I wasn't there as a walking dollar sign & just let the HEF advocate for the patient. We all know what assumption is the mother of!

L - my VA - has spent a lot of time on the phone with M's mum. Without their good communication nothing good would have ever happened. The Mum told Liong to tell me not to worry -  they would be fine. Easier said than done.

HEF met them off the bus & paid for a tuk tuk to the hospital, then it all went pear shaped. The hospital sent them away until Friday - no explanation. Luckily they have a relative who lives in Phnom Penh. I rang the Cambodian Cardiologist Dr C - no answer, I texted Dr C - no reply & emailed - still waiting now for a response. Eventually with some investigation & after they had met with Dr C the following day it became clear the Americans were coming a week later - always nice to have good communication & all the information.

They were sent away & told to come back in 2 days. HEF gave them the standard rate to live an a day R5000, that $1.25. M's Mum told L that the staff were rude & mean to her but when she felt scared & sad she just thought about me because she knew I was a doctor that actually cared. This still upsets me to think about it.

She finally was successful in getting an admission to hospital & was seen & operated on the following Monday. By chance I happened to be in PNH that week so could go & visit her. One look at the monitor revealed the second ablation had not been successful. M's Mum was hugging me & so pleased to see me - I just wanted to cry.

It turned out from what I could gather via translation from Liong on the phone & Rady who came with me to visit her, that the Cardiologists had tried to ablate but the accessory pathway was too close to her AV node & there was concern that if they ablated it they would put her into complete heart block. Pacemaker care is not so good here. This was mildly disappointing. Cambodia has prepared me well for disappointment but this one really stung.

She was then inexplicably kept in for the next 3 days, this was clearly not due to clinical need but more financially related. This greed & corruption actually went in M's favour in the end.

I was in PNH for a conference which by coincidence was where the Cardiologists from the states were staying. I tried to get their contact details by asking at reception & emailing Dr C - no luck. But one morning I had lost my phone & was rushing back to my guest house to find it when I literally bumped into them. It was the stethoscope around his neck & the clipboard with a list titled (in big bold letters) 'PATIENTS FOR ABLATION" that gave it away.

I explained who I was & we discussed M's case. No one had told the american cardiologist Dr Ch about how ill she had been previously or how poor she was. They had thought she could buy a years supply of Flecainide & they would come back next year with different equipment. When I explained she couldn't afford that & we had used all the money raised so far on the first & second failed ablations & the 3 months of medication, they offered to provide the medication for free.

They couldn't believe she was still an inpatient - there was no clinical reason but obviously the reason she was still in hospital was not clinical. But seeing me had then prompted Dr Ch to check on her - and he found her in SVT at a rate of 180/minute. It would seem that even in the cardiac ward of the biggest hospital in Cambodia staff don't recognise or more likely don't care about life threatening conditions in patients if they are poor. No money, no life.

It was lucky that I lost my phone, it was serendipitous that I bumped into Dr Ch in the hotel lobby & it is heaven sent that Dr Ch on seeing her clinical condition took her back for a third attempt at ablation.

He called me afterwards to let me know that after 5 hours he was pretty certain that he had damaged enough of the pathway to prevent further life threatening arrhythmia. He was so confident that he was happy for her to go home without medication & if she does develop further SVT it can be controlled with cheap & easily available B-blockers.

M looked well when I went to see her that evening, her Mum was relieved & was keen to get out of PNH & back home.

Janice, Elaine, Joan, Ruth, Hannah, Liong, Dr Ch & HEF - thank you for giving me the best 40th Birthday Present.

M - you just need to stay in sinus rhythm - please!