1st Dengue Death for 2008 ?

Monday, January 28, 2008

A 7 year old girl, native to HDh. Hanimaadhoo, living in Male' has passed away within a few hours of arriving at IGMH Emergency Room (ER) from what is believed to be Dengue Hemorrhagic Fever with Shock.

A family member, who wish to remain anonymous, was contacted by our team on 27th January for details of what had happened. Our informer was clearly unhappy with what had transpired at IGMH and at home in the lead up to the child's death.

According to our informer 7 year old Ifaasha was first taken to IGMH ER on 25th of January because of fever for two days and severe vomiting with a very severe abdominal pain. Unfortunately, Ifaasha was taken to the hospital by a relative who did not know the details of her illness. Our informer suspects that this probably was one reason for the sad end to the story. In the ER, Ifaasha was seen by a junior doctor and given an injection for vomiting and sent home on Panadol doses for fever. Our informer reports that not much attention was given to Ifaasha's history and that she was rushed out of the ER and sent home without a full examination or investigations.

We were able to talk to 2 doctors, who also spoke to us on the condition of anonymity, from IGMH ER who gave a different version of events. According to the doctors, Ifaasha was brought to the ER by a distant relative who gave a history of fever for less than one day and abdominal pain. At examination, they report that, Ifaasha had no abdominal pain and the fever was mild. The rest of the examination was normal according to the doctors. This was the reason, they claim, that Ifaasha was sent home without any investigations. MMW notes why history was not taken from Ifaasha herself. She was big and mature enough to give a full history herself. The doctors reported to us that Ifaasha went home well on the 25th january and that the family was advised to bring the child back if there were any other problems.

Our informer reports to us that since returning home, Ifaasha continued to complain of severe abdominal pain. He also reported that after a few hours of returning home the vomiting had become worse and Ifaasha was unusually weak and sleepy. The parents however, did not worry much as they were assured by the ER doctors that what Ifaasha was having was Gastritis (gas- vaige undhagoo).

On the 26th January, less than 24 hours of the first visit to ER, Ifaasha fainted at home and looked really sick. Her mother, now concerned for Ifaasha's life rushed her to IGMH ER. When they arrived in ER for the second time, our informer reports that, Ifaasha was conscious but clearly very weak. She was made to lie in a bed and a junior doctor examined her while a nurse checked her blood pressure. Our informer reports to us that, his impression was that Ifaasha was too pale; "death pale" he had said.The ER doctors and the nurses then quickly swarmed around her and got an IV going. One of the doctors talked to the mother and said that they were unable to get Ifaasha's blood pressure and that they felt that Ifaasha was bleeding somewhere within her abdomen.

The ER doctors reported to us that Ifaasha was received in ER on 26th in shock with no recordable BP and was extremely pale. They suspected internal hemorrhage and tried to get urgent blood for transfusion.

In about 20 minutes of arrival in ER, Ifaasha was reportedly seen by a Pediatrician [Dr Sunil] and advised to be transferred to ICU for management of suspected Dengue Hemorrhagic Fever with Shock and hemorrhage.

Our informer reports that when transferred to ICU, Ifaasha was almost dying. He had himself lost all hope.

Within a couple of hours of Ifaasha being transferred to ICU she died from bleeding into her lungs and intestines. She had blood coming out of her mouth, when our informer last saw Ifaasha alive.

The ER doctors reported that Ifaasha may have been saved if they had blood available for immediate transfusion, blood bank was out of stock of O- blood. They also said that the history given to them on the second visit; fever for more than 4 days, had not matched with the first history given on 25th. This was the reason why investigations were not done on first visit, and diagnosis missed.

We were told by family members that that they accept the efforts of the doctors on the 26th of January, as they did everything they could to save Ifaasha. They were however, very bitter about the way Ifaasha was managed on the 1st visit. They felt that, a proper examination and investigations could have save Ifaasha.

One nurse from ICU reported to us that even at the time of death, no reports were available to confirm what Ifaasha had died from. The lab had taken too long to give the results. She told us that the reports, although not 100% diagnostic, were highly suggestive of Dengue Hemorrhagic Fever with internal bleeding.

Could this death have been avoided? Has the hospital started an internal evaluation into how the case was handled? Has the family been given a good enough explanation of what had occurred? When would IGMH administration consider setting up a mechanism to evaluate mortalities and major morbidities promptly, even if a complaint is not lodged? [Dr Solih repeatedly disconnected our call and as usual Dr Yasir is unavailable for comment].

Was this really the 1st Dengue death for the year?

Update:

1. Our informer reports that the family are considering sending a letter to IGMH and MoH to complain against the way the case was handled.

2. Over heard by an IGMH staff: The case is being discussed by the Department of Pediatrics and ER to see if case could have been handled differently. Initiative taken by Dr Zumra, not by hospital administration. The process is not likely to yield a report.

3. The lab reports were not delayed in the lab? Our sources at the hospital confirm that the samples were sent to the lab late, reports were generated as urgent, delay in collecting reports by ICU to blame for delayed availability of reports to treating doctor. MMW: with the new database system at IGMH, is it still not possible to view lab reports from ICU and other intensive care areas? When will this happen? Would having the reports available change the treatment?

4. Reports: we showed the report values to our team: thrombocytopenia, severe anemia, elevated liver leaked enzymes are all suggestive of DHF; and based on the clinical course: DHF with Shock and Hemorrhage are plausible diagnoses.

5. Case reported to DPH, officially, as a case of Dengue. DPH sources confirm that if proven (an internal review at IGMH is expected) this would indeed be the first Dengue death for the year. Our DPH source also reports that there is a small but significant increase in the number of cases of Dengue being reported in the past 1 month.


38 comments:

Anonymous said...

What is the protocol of the hospiatl in doing "further" investigations?

Is it one day .. two day .. or severe unmanageable fever?

Anonymous said...

Given that DHF is common , each and every case of fever in a child should have been suspected of having that. I think this is a case, where the first doctor who saw the child is at fault here.

Anonymous said...

Watch this space for updates? Are you hiding something from us?

Medical Investigator said...

We are continuing to investigate the case and feel that there is more to the story.

We are hoping to get some details of the tests as well.

Anonymous said...

hmmm anonymous..as usual looking for someone to blame...simple fever for three or more days is what usually warrants an investigation except if at time of presentation there are other features suggestive of other things... clearly history is very important.. it is always gfood for someone who knows abt patient condition to go when taking to hospital.. more so in case of children.... am sorry for the family's loss... and the reason for 3 days is even if u do before that the tests wouldnt be of much help

Anonymous said...

and as u say it wont be possible to test every single fever case as dengue... then u will complain the queue at lab is too long.. the queue for showing to doc too long.. too long to wait

ER nurse said...

This report is less biased, quite factual. This is better. Give both sides of the story.

But both side of the story only possible when both sides speak to you, right? Even now official IGMH people are not talking to you guys.

Sad about what happened. Medical report necessary.

ER nurse said...

This report is less biased, quite factual. This is better. Give both sides of the story.

But both side of the story only possible when both sides speak to you, right? Even now official IGMH people are not talking to you guys.

Sad about what happened. Medical report necessary.

findhana said...

Sad.

I was told by a doc few days ago that they hadn't had a child die of Dengue at IGMH for almost 2 years.......and now .....

DeJoker said...

Visible improvement in reporting!

Kudos to the MMW team.

Can you elaborate for the public the conditions where upon the patient would have been sent home, without any intervention besides Paracetmol..and why it is that NSAIDs such aspirin are dangerous in dendue..
also the complication rate in dengue- ie DHS...also the management modalities, which go little beyond monitoring platelet levels and maintaining Normotension!..esp given that dengue is a viral infliction, no specific drugs are available for this..

which is why prevention cannot be overemphasized; Aedes aegypti are DAY-TIME mosquiotoes which frequent house plants and stagnant water sources etc

I think it would be good if MMW could also provide these info for the public

keep it up

Medical Investigator said...

Dejoker,

It is beyond the scope of MMW to discuss the kind of explicit medical details and management options that you have referred to.

As you'd be well aware, from our profile, we are mainly non-medical people. We do receive medical advise from a small panel of doctors on certain issues, but we'll have to get a bigger commitment from them to do what you have asked us to. We will certainly pose that question to them.

We do not have any relation to his site, he has even publicly refused to join our discussions, but we' recommend that you visit a site like http://niyaf.blogspot.com/ to ask for that kind of information.

DeJoker said...

Appreciate it if you would try...

because i have a feeling people will listen if it comes from you guyz...coz if a doc says there is no specific treatment for dengue, then the family packs their bags n leaves to lanka; only to be prescribed ASPIRIN by the doc in lanka(absolutely contraindicated in dengue)..
the patient by this time has attained convalescence since dengue is self-limiting- gives all the credit to the doc in lanka, and blasts the doc in Male'..

this happnd to an aunt of mine...

thanx ne way

Anonymous said...

ure very right dejoker...and sadly the lanka doctor doesnt even get punished for that..lot of docs in india and lanka have done that in the past but our pple dont take that fact into account.. if not for the current treatment and management by the maldivian docs there would be deaths by dengue every week.everyday igmh is at a loss for beds for patients with this disease but fortunately these patients survive..it is sad that this incident had to end like this.shows the public how important the history given by the relative is...cos this disease changes its ourse by hours..and the action that needs to be taken only depends on the history given...my condolence to the family

reporeter said...

Fyi,

There is a second child with Dengi in IGMH ICU in a critical condition.

Maldiveshealth said...

I will go with the doctors on this case. It is very difficult to diagnose DHF if a solid history is not given. And i think there lies a responsibility of parents to take care of their little loved ones too. The questions raised at the end of this reporting is very valid.

When will a system come in to place where lab reports can be viewed from a computer rather than physically going there and getting it?

Anonymous said...

It is important to keep it simple in laymens terms and not use too much medical jargons as the public will not be able to understand what you are talking about. If needed things can be relayed in simpler terms here.

Anonymous said...

MMW, while I appreciate your good intentions, I do wonder if your so called sources report all these patient information with the consent of patients or their family. If not, they are doing a great disservice and they are no better than the people they accuse of wrongdoing.

Breach of confidentiality should not be seen as a trivial issue. One might argue that in the current Maldivian context the means justify the end. I would strongly disagree with that. I say this not because I want doctors to use confidentiality as a pretext to cover their mistakes. Admission of mistakes and disclosing them to the patients will gain more trust, in the long run ( a tall order to ask).

If our system is to improve, ethics need to be taken seriously. All it requires is a change in attitude and behaviour on the part of healthcare workers, not expenditure of millions of dollars.

One of the reasons for the lack of trust in our healthcare is perhaps failure to take seemingly 'trivial' things seriously. The failure to take a direct history from the patient in this particular case is a good example.

It should not take discussions in the public domain for the powers that be, to take appropriate meaures at improving the quality of care. It should be done beacuse it is the right thing to do and every resident in the country -rich or poor- stand to benefit from them.

Perhaps as starters, CME programs and clinical audit will go a long way. That is by no means to find who is at fault. After all, who on earth practices perfect medicine and knows everything?

mi said...

Where names of patients are mentioned, we have permission of the relatives of the child to do so. In this case we have permission from the immediate family!

"I say this not because I want doctors to use confidentiality as a pretext to cover their mistakes. Admission of mistakes and disclosing them to the patients will gain more trust, in the long run ( a tall order to ask)."

Anonymous said...

some asked for proof for the previous article "life saving surgery?" and here it is....

http://www.jazeera.com.mv/posts/view/8100

siadh said...

MMW is quick, and its reliability is being documented in mainstream media.

Haveeru has finally written a bit about the Dengue case.
http://haveeru.com.mv/?page=details&id=63544

Anonymous said...

noohehga ehcheh jeheema ekani dho sahha vanee.

Anonymous said...

its been told that blood bank had 5 pints of B+ blood (pt's blood grp) but unfortunately when cross-match was done none of them was campatible with the pts blood. one of the ER nurses volunteered but her blood was also not compatible. a discussion was held among the paeds drs and ER drs as to the diagnosis and now a pre-existing autoimmune blood disease is being suspected as to the deterioration of the patient's condition and ultimate death

doc oc said...

Just because multiple cross-matches (five or six in total) came incompatible we should not jump to a conclusion of autoimmune disorders!

The child was in DIC a condition in which cross-matching maybe difficult.

If O-ve blood was available, it could have been transfused without prior cross-matching.

It is easy to blame "a natural fault", but there isn't any significant evidence to justify jumping to that conclusion.

xenon said...

quality of reporting is definitely improving... keep it up..
However if the reason why docs dont investigate a case of fever of a day or two was mentioned, it could have been better..
it is bcos within a day or two the investigations usually will be normal...
thanx

Anonymous said...

its not mentioned that the diagnosis was concluded to be autoimmune...the statement was "being suspected"

Anonymous said...

hi... am a memeber of that community whom you all love to hate... just a few things that goes thru my mind.. did anyone ever stop to think that we also do have a conscience...dont you think we also feel happy when our patient gets well.. its the most wonderful feeling to be able to heal someone.. to meet that person on the road and to see a smile n to hear that he is doing great..even if you think about money dont u think we will be better off treating our patients with kindness and care so they get well and will keep coming back to us... so are we so stupid not to realize above..i have been lucky that no one has ever abused me in the few years that i worked in maldives ..another thing is most of you say about the good service given in neighbouring countries...let me tell you i have accompanied patients as well as had the opportunity to personally receive the so called health care.. i would definitely prefer maldives..have seen the way they play with the minds of poor people..the patient was stable walking on his own and in hospital normal ward for 1 week prior to india.. went for an investigation that was unfortunartely not available and they immediately admitted to ICU despite patients protests..ofcourse the "maldivian helping agent " was there... i ve seen people waiting whole day without complaining to see the doc.. they dont shout abuse when they finally see the doctor coming into clinic cos he had to go and attend an emergency in the hospital.. they dont assume he went to tea.. most of my colleagues dont take more than fifteen minutes for a break during the six or seven hr work shift.. i wonder how many of the people working in government and private providing service to public can say so abt themselves.. most of the maldivian doctors are trained in nearby countries because of resources that our country has.. medical education is expensive even there.. doesnt mean that they are less qualified as can be seen by anyone who wishes to find out how many maldivian docs sit the US or UK licensing exams and what proportion do extermely well..yes they are all moving abroad..how do they suddenly become so good that they get accepted in US/UK but not in our Maldives.. we do care abt the people we treat.. some of the best brains in the country opt for medical education not cos of money.. there are better things to do for that... less work and more money faster. we do it because we care and want to help people.. but if at the end of six or seven yrs of hard work studying six to seven hrs per day sacrificing the best days of our lives to come to this i dont feel a lot of maldivin would be opting for it in future.. yes i do tell younger generation to think very carefully before they decide to become a doctor.. to make sure there isnt anything else they are remotely interested in.. if so choose that and dont become a doc

Anonymous said...

bingo..well said "dr anonymous"...its time people realised its not the doctors that need to to be punished..its the system...im sure you, like ,must be working abroad due to the negative effect of our own people against us..

Golha Aseel said...

I don't hate Maldivian or Foreign doctors! I like and respect doctors. But I really despise some specific people for what they do, how they treat us and their corruption.

I hate one Dr Fathmath fucking Ali Didi, another Dr Mohamed Firdous arsehole, and yet another Shithead solih...........Not because they are doctors, but because of things they have done.

Anonymous said...

"i ve seen people waiting whole day without complaining to see the doc.."

That is because in the end they leave the hospital satisfied despite of the treatment given.

This just shows the mentality of those who are in these committees. How can things be right if it is like this?

Anonymous said...

u want doctors to work lik robots...wait a couple of decades then

Anonymous said...

working in igmh does not actually gives me time to read all this stuff you guys have been writin but i just read some and thought id like to comment...
we work everyday for about 7-10 hours there takin a break for 10-15 mins only becos our stomachs start to growl and our mouths complain of dire thirst...we dont do the normal 7.30am to2.30pm jobs where women gossip and surf the internet most of time and men go out to fetch their wives and kids from work and school..
unfortunately working our ass off and tryin to understand the complex management, running between wards,answering the pager the minute it starts beeping and not to mention the long queue of patients that we take pleasure in seeing...its really rewarding to see that people actually only DISGUST us...REALLY WONDERFUL WORK guys
i am writing here cos i want the health system to improve..if you think you can abuse doctors with those words and tell them to work like robots i think you seriously need to look into what i just said about what doctors esp the maldivian doctors do for the patients in the hospital...
i think they deserve credit and if people like you keep writin all bad stuff..theres never going to be room for improvement

Medical Investigator said...

Last anonymous,

Please get off that high horse. Don't equate your profession to others. Your responsibility is greater simply because of your profession. If you need to change your working condition; we can help you demand for the changes you deserve. BUT don't use it as an excuse!

We do not enjoy the kind of maltreatment that is described in this blog, we detest it. That is why we want to bring it to the attention of the masses. We DO want things to improve, but we are sick and tired of waiting for it to happen, we want to inform the public so that they may pressure the authorities to get off their butts and act.

We do acknowledge that a large number of doctors including Maldivians do a lot of good work, are genuinely dedicated and caring. We are not running a smear campaign on the entire medical profession. We write on specific events and specific acts by individuals and group of individuals.

If you dare, being truthful to yourself and your profession, say that the stories are fabrications or false. We assure you and swear that they are the truth. If you don't know that said events have taken place in your institute; then you are being selectively blind to other peoples plights.

People are allowed to voice their comments here to make sure everyone, yes even the accused, gets an opportunity to defend themselves. You, like other are encouraged to comment and have your say.

chef said...

Last anony,
who told you to become a doc and who told u to work that long. If the kitchen feels like to be too hot for you why not get out of it.

Anonymous said...

well...for the last chef..i dont think thats the point the last anony made..not the pots and pans,,maybe the picture is different for them and we do need to give some credit for them

Anonymous said...

thanx the last anony..really.i'm not a doc but i hav seen how they work.how they care..n how they get tensed if hteir pts are sick..they work so hard..only they can understand..so i take the pride in thanking all the doctors who r doing their job well..keep it up.
there r bits n places where u've given a wrong story to the public, MMW. But i think this was one of the most readable articles. u've mentioned doctors being sorry for what happened to ifaasha..mostly this is the vision shown by u "all deaths, negligences are deliberate". y wud any one want to purposefully harm any one..cummon u guys, i dont think u believe that doctors, nurses n igmh staff they r certified to harm others..then. do one thing, advocate ppl not to get NEAR igmh..they'll get killed by anyone reporting as igmh staff. U r so biased..its really a sad thing to know this we maldivians are turning against each other...
we r soon going to lose our independency this way guys...wake up, support us so that we can join-handedly try to bring good to our families, children, community n our country.

Anonymous said...

if a person is destined to die he/she will die no matter what

Anonymous said...

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