1st Dengue Death for 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.