A Difficult Dengue Death

 

I had just been wondering if I would lose my critical care skills while I\"m out here without the structure of western medicine, hospitals and resources.

As it turns out, patients get hypoxic, hypotensive, and unstable here, too! The difference is, things move much slower here and we don\"t have all the medications, equipment and algorithms for really sick patients.

I had started observing the clinic/hospital\"s departments one-by-one and saw the outpatient departments (OPD) last week. Then I figured out that the real emergencies seem to occur once the patients become inpatients. So my goal this week was to spend the days in Inpatient Department (IPD) and the Reproductive Health (RH) with the pre- and post-partum inpatients to learn from the midwives and RH medics about how they handle deliveries and OB complications.

I\"m still processing the case of a young adult who passed away last night, combing through it in my mind, wondering how it could have gone differently.

A young adult male presented with hypotension (70/40), hypoxia (77% on room air), tachycardia 125-140, and fever with profuse diaphoresis after 5 days of fever at home, coughing, one instance of coughing blood, 3 episodes of watery diarrhea, nausea without vomiting. He was previously a hale and hearty farm worker. 

It was my first day observing in the inpatient department, reviewing all the patient charts and examining, eyeballing or interviewing some of the patients. I got there early in the morning and there was no one sick. I wrote my phone number on the white board so they can all reach me with anything. When I went back in the early afternoon to check on everything again, a very helpful English-speaking nurse told me there were 2 new patients admitted. I spoke to one who was stable and was primarily there for borderline hypoglycemia and for depression with suicidal thoughts. I looked for the second new patient and was told "He is in the S-Room." I asked what is that, and was told "the Special Room..." which of course cleared everything up. Hahahaha.

Then one of the medics nonchalantly approached me and very calmly explained that they have a patient who seems sick with sepsis but they don\"t know the cause. He had been vaccinated for COVID already, rapid COVID test was negative today. "Could you please look at him?" she asked me. They had already given Rocephin and Flagyl and he had an IV dripping fluid at 420cc/hr.

They walked me to the "S-Room," which turned out to be the walled-off COVID Isolation Unit:

It was extremely humid in his room. Two fans were mounted on the walls but were not running. There were 4 beds but only one patient in the hard wood bed next to the door. He was a tall (for Southeast Asia), very dark-skinned male who was pouring sweat and looked awful. He had on a green plastic nasal cannula with humidified oxygen at 4L and his mother was at bedside in an orange longyi traditional skirt.  

The staff started adjusting things around and on the patient immediately but without gloves. I looked all over the isolation room. No gloves, no PPE, no equipment. I asked for gloves and got a blank stare. I said I\"d be back and went to another building to snag gloves from the lab results office. I brought some back for the others. 

The patient was able to speak to us and mental status was good, but he looked miserable. I examined him and he had epigastric tenderness but no distention, rash or petechiae, lymphadenopathy, edema, jaundice, scleral icterus, joint pain/swelling, meningismus or abnormal lung sounds. GU exam was fine. He just said his leg muscles ached, and his mom said he had watery diarrhea. No further bleeding from any source after the episode of blood in his cough.

I turned to the medic and said my first thought was Dengue Fever or Chikungunya. Also always possible it can be malaria in these here parts, but he\"d already had a negative blood smear in the afternoon. I asked if he worked outdoors or with animals. I think something got lost in translation because the interpreter said no, the patient did not work outdoors. This was later corrected.

I rechecked his vitals. Horrendous. We took the blood pressure manually, and when the sphygmomanometer crept below 90 then below 80 and I didn\"t hear any thumping, I thought my stethoscope was broken. (Which it sort of is - the tube cracked in half while I was working in Maine so I taped it back together. Then my replacement steth got lost in the mail, so here I am with my half-ass stethoscope). But then came the rapid thump, thump, thump of his systolic pressure rolling in right at 60 and disappearing at about 30. 

His blood pressure had not improved from the initial 70/40, his heart rate was 129, and his oxygen saturation was 80-85% with the nasal cannula on. The only good news was his fever had gone down from 100.8 to 99.8

Well, crap, I thought. Maybe it is COVID. He\"s so hypoxic even though he looks more uncomfortable from the sweating than from trouble breathing. I asked if they could also get a COVID PCR to be sure the rapid test wasn\"t a false negative. They said they could - tomorrow. It was too late for labs today. 

I also asked about TB. We don\"t have an Xray machine on site, so that was a no. And they said he had to wait 1 week for the AFB test. 

But my hunch was still a mosquito-borne illness. They had done a CBC showing normal WBC, Hgb 9.2, but had lymphopenia and platelets 39. I was leaning toward dengue. But still wondering about COVID, esp the delta variant. 

We have an amazing physician consultant who is also an expert infectious disease specialist. I sent him a message about the most likely endemic diseases here on the border. He was concerned about malaria and possibly dengue shock. He also mentioned melioidosis, which honestly I have to look up, and leptospirosis as well as (rarely) typhoid. 

I asked the staff if they could please place a second IV for more IV fluids. They asked me if the patient needed it. I said yes, he needs fluids faster. I asked if we could pressure bag the fluids, too, and they said it was only set to drip at 1/2 L/hour but they could just let it run. I said, "Yes! Please. Run it as fast as it will go." 

Then we re-checked his oxygen level. 

I\"m Chinese and we have a saying that means something is so bad, you don\"t know whether to laugh or cry. Ku Xiao Bu De. The finger oximeter was now reading at 78%. I asked if that was real. The nurse went to go change the battery just in case. But then with new battery, the oxygen was even lower at 75%. Total Ku Xiao Bu De.

I asked them to please turn the oxygen up. They asked me if he needed the oxygen increased. I replied that if 75% was his real sat, he needs more oxygen. We had to go through the same conversation about 3 times, to the point that I was not sure if oxygen was at a premium and we had to use it sparingly or something. Finally the medic in charge came in and asked if I wanted a mask. I still am not sure what resources we have here, and I was ecstatic that we have breathing masks. She ran back to the inpatient unit and brought back a simple face mask. I asked if there was one with a bag (non-rebreather), expecting her to say no. She said we have it! After about 10 minutes, we got a non-rebreather on this guy and minute-by-minute his oxygen crept back up to 91%

With the double IV\"s and IV fluid, his BP started to trend upwards. He sat up in the bed and was still speaking to us. When he sat up, we saw a puddle of watery diarrhea that had leaked out of his hospital diaper, all over the wooden bed and dripped through the bed slats onto the floor. His mother used a spare longyi to wipe off his back and bed. There were diarrhea tracks all over the floor from where she had been cleaning up after him all afternoon. 

Unfortunately, the mother had already been given the option to transfer her son to the bigger Thai hospital in town but she declined. She wanted him to stay at our site and see how he does. I asked the nurse and medic if we could tell the mother again that we don\"t have many more resources we can use if his oxygen drops again or his blood pressure doesn\"t improve. We also cannot run many lab tests to investigate the cause of illness or check his metabolic panel or kidney function. I had asked if they can test for dengue and they said nope, only the bigger hospital can. The staff said they had told her and she understood. 

The issue is that our clinic specializes in serving the Burmese migrant population. Some Burmese migrant folks have the special Thai migrant worker health plan and can go to Thai hospital. However, they still prefer us because of language barriers there. Our staff all speaks Burmese (except me and one Korean staff member ). Plus, if they go to the Thai hospital, they must pay a minimum of 10,000 baht and possibly higher. For perspective, a Burmese migrant worker maybe makes 250-300 baht per day. A hospital bill can put them in debt for a long, long time. Also for perspective, 10,000 Thai baht is approx 300 USD.

I had already gone in person to the pharmacist to check what pressors and other medications we had at our disposal in case things went south. She told me it\"s Adrenalin or IV fluids. That\"s it. So I reiterated to the staff that Adrenalin was next. They said ok. 

It was already 5:30 and sunset is around 6:30

I have a bicycle for transportation and the route home lacks lighting on the roads. The patient was looking better so I got the contact info for the night shift team and pedaled home. 

After 2 hours I had made it home, bought eggs off a street vendor, boiled and eaten them. And then I asked the staff how was the patient. They told me his oxygen was 78% again and his blood pressure was 85/40 after 5L IVF. HR was still in the 120\"s, RR 56!  

I said we need to start the Epi now. No reply from any of the staff. They instead suggested a blood transfusion. I was confused. They explained that the Hgb was 9.2 and platelets were 39, so they wanted to give a unit of whole blood. I was scouring UpToDate to see if there was something new about mosquito-borne illnesses or COVID that I hadn\"t heard of. He wasn\"t overtly bleeding from anywhere but Dengue can be hemorrhagic so a blood transfusion might be reasonable.  

But regardless, I kept saying Adrenalin. And if that didn\"t work, try a dose of steroids in case of sepsis adrenal insufficiency. They said they only have 1mg ampules of Epi. So I gave step-by-step instructions on preparing and administering a dirty Epi drip. I asked how can I come to the clinic to help because I don\"t have transportation at night. No one could answer this. I wanted to get to the clinic and I could do the Epi infusion for them. 

I also urged them to counsel the mother again that the patient needed a higher level of care. The reply was that they had already tried multiple times and she refused. I asked them to please try one more time and tell them that I am very concerned that her son will DIE tonight and he really needs to go. 

After an hour of me urging them again to get the Adrenalin started, one of the head medics at last told me they were sorry but they had never given an Epi infusion. Now it all made sense! I made the mistake of assuming there was a universal algorithm for sepsis and that pressors go without saying in a persistently hypotensive patient after fluids have failed. I also made the mistake of assuming that if I could teach them how to prepare the Epi infusion, they would feel comfortable doing it. This was my misstep in cross-cultural communication. 

However, at that point, the head medic told me the mother had finally consented for the patient to transfer to the Thai hospital. 

Now, in western medicine, a patient needs to be stable for transfer. This was not going to happen here. We had no equipment to improve the oxygen more than we already had. I still wanted the Epi drip started and the medic assured me there would be Epi in the ambulance, too. However, about 30 minutes later, the medic asked me, "Do you think we should start Adrenalin?" Wait, what? It has never been started? YES. Yes, PLEASE start it. The head medic asked me again for the step-by-step instructions on preparing the Epi infusion.

However, at that moment she was notified that the patient had already been loaded into the truck for transfer. So the Epi ship had sailed...

I was both relieved that the patient was finally going somewhere he could get the resources he needed to survive but also perplexed by the communication and sociocultural gaps I had discovered during this case. 

Then in the morning I asked the medic how we can find out from the other hospital how is the patient doing. She told me, "They already told me he expired last night."

Oh my god. A 23 year-old dead from septic shock. His poor mother. 

Would he have died anyways? I don\"t know. Dengue septic shock is severe and can be fatal. But he was young and healthy. We didn\"t get to try the pressors. We didn\"t get to try steroids. We didn\"t try everything we can. 

This hurts my heart, and I spent all day ruminating on what to do next time.

Demand hourly updates?

Stay at the clinic site 24/7? 

Organize a plan and schedule for who can help me transport to our site for nighttime crises?

Offer to teach a training class on sepsis, pressors, airway? 

Start a new protocol where the isolation room(s) must be monitored by a staff person at all times (there is no one near the isolation area regularly. Someone goes over there to check vitals every 2 hours). 

Suggest a staff position who strictly monitors the patients for signs of decompensation and critical illness?

Talk to pharmacy about preparing infusions?

Find out how to help the patient\"s mother pay (I later found this out) her 40,000 baht hospital bill for her son\"s few hours at the other hospital where he promptly died?

Start an endowment fund specifically for these critical cases when money is the main issue and the difference between life and death?

Eat my feelings? (I did destroy an entire bag of caramel popcorn while mulling over these things)

I don’t sleep the entire night because I was so upset.

Big sighs to end an interesting but tough day.

https://www.news18.com/photogallery/india/how-does-dengue-fever-spread-know-biting-facts-ways-to-protect-yourself-in-pics-4165397.html

Yacoub, S., Wertheim, H., Simmons, C. et al. Cardiovascular manifestations of the emerging dengue pandemic. Nat Rev Cardiol 11, 335–345 (2014). https://doi.org/10.1038/nrcardio.2014.40

A description of Dengue Shock Syndrome:
"Dengue Shock Syndrome (DSS) is defined as hypotension, narrow pulse pressure (20 mm Hg), or frank shock in any case patient whose illness meets the criteria for Dengue Hemorrhagic Fever (DHF)."

"A relatively mild first phase with an abrupt onset of fever, malaise, vomiting, headache, anorexia, and cough may be followed after 2 to 5 days by rapid deterioration and physical collapse. In Thailand, the median day of admission to the hospital after the onset of fever is day 4. In this second phase, the patient usually has cold and clammy extremities, a warm trunk, a flushed face, and diaphoresis. Patients are restless and irritable and complain of midepigastric pain. Frequently, scattered petechiae appear on the forehead and extremities, spontaneous ecchymoses may develop, and easy bruisability and bleeding at sites of venipuncture are common findings. Circumoral and peripheral cyanosis may occur. Respirations are rapid and often labored. The pulse is weak, rapid, and thready, and the heart sounds are faint. The pulse pressure frequently is narrow (≤20 mm Hg); systolic and diastolic pressure may be low or unobtainable." - Theodore F. Tsai, in Feigin and Cherry\"s Textbook of Pediatric Infectious Diseases (Sixth Edition), 2009 from the CDC Health Information for International Travel 2010, 2009