What you wanted to know about Dengue fever

What is Dengue fever (DF)? What are Dengue haemorrhagic fever and Dengue shock syndrome?

Dengue [pronounced Den' gee] infection is caused by a virus. There are 4 types of Dengue viruses,namely DENV 1, DENV 2, DENV 3, and DENV 4. It occurs commonly as dengue fever. Occasionally the patient suffering from dengue may develop bleeding. Common sites for bleeding are nose, gums or skin. Sometimes, the patient may have coffee ground vomiting or black stools. This indicates bleeding in gastro intestinal tracts and it is serious. The patient with dengue who has bleeding has dengue haemorrhagic fever (DHF ). Rarely the patient suffering from dengue may develop shock because of low blood pressure, then it is called dengue shock syndrome ( DSS). DHF and DSS are common in persons who had a previous infection with another type of Dengue virus.

How do one get infected with Dengue virus?

The Dengue viruses are transmitted to humans by the bite of an infected mosquito. The Aedes aegypti mosquito is the most important transmitter or vector of dengue viruses, although many of the recent outbreaks were transmitted by Aedes albopictus. It is estimated that there are over 100 million cases of dengue worldwide each year.

Aedes aegypti has a peculiar white spotted body and legs and is easy to recognize even by laymen. It breeds in clean water and has a flight range of only 100 – 200 metres.The mosquito gets the Dengue virus after biting a human being infected with dengue virus.

 When does dengue develop after getting the infection?

After the entry of the virus in the person, it multiplies in the lymph glands in the body. The symptoms develop when the virus has multiplied in sufficient numbers to cause the symptoms. This happens generally about 4-6 days ( average) after getting infected with the virus.

Can people suffer from dengue and not appear ill?

Yes. There are many people who are infected with the virus and do not suffer from any signs or symptoms of the disease. For every patient with symptoms and signs there may be 4-5 persons with no symptoms or with very mild symptoms.

When should I suspect Dengue?

Dengue should be suspected when you have sudden onset of fever WITHOUT cough,cold,pain on urination etc. The fever is high 103-105 degrees F or 39-40 degrees C. It is accompanied with severe headache (mostly in the forehead), pain behind the eyes, body aches and pains, rash on the skin and nausea or vomiting. The fever lasts for 5-7 days. In some patients, fever comes down on 3rd or 4th day but comes back. All the above symptoms and signs may not be present in the patient. The patient feels much discomfort after the illness.

How does Dengue fever differ from other type of fevers?

Fever is usually abrupt in onset and very high.There wont be any running nose,cough etc.Slowly rising fever peaking only in few days time is unlikely to be Dengue fever.The characteristics of dengue that make it different from other causes of fever are the pain behind the eyes, severe pains in the muscles, severe bone and joint pains, and skin rashes. These features make the diagnosis of suspected Dengue likely. Even though there is joint pains there wont be any joint swellings as in Chikungunya fever.The severe bone pains caused by DF is the reason why DF is also called break-bone fever.

Generally, younger children and those with their first dengue infection have a milder illness than older children and adults.

Dengue hemorrhagic fever is characterized by a fever that lasts from 2 to 7 days, with general signs and symptoms consistent with dengue fever. When the fever declines, symptoms including persistent vomiting, severe abdominal pain, and difficulty breathing, may develop. This marks the beginning of a 24- to 48-hour period when the smallest blood vessels (capillaries) become excessively permeable (“leaky”), allowing the fluid component to escape from the blood vessels into the peritoneum (causing ascites) and pleural cavity (leading to pleural effusions). This may lead to failure of the circulatory system and shock [lack of blood supply/oxygen to tissues], followed by death, if circulatory failure is not corrected. In addition, the patient with DHF has a low platelet count and hemorrhagic manifestations, tendency to bruise easily or other types of skin hemorrhages, bleeding nose or gums, and possibly internal bleeding.

How is the diagnosis of dengue is confirmed?

There are laboratory tests that provide direct or indirect evidence for dengue fever. These tests provide evidence for the occurrence of dengue infection. There are some additional tests that can help to identify the type of dengue infection. The tests for confirmation of Dengue should be done in reliable laboratories.

The method used for diagnosis varies depending on its availability,cost, speed of obtaining the result and reliability. It also very much depend on when during the course of the disease blood sample is taken.

Can dengue fever be treated at home?

Most patients with dengue fever can be treated at home. They should take rest, drink plenty of fluids that are available at home and eat nutritious diet. Whenever available, Oral Rehydration Salt/ORS (commonly used in treating diarrhoea) is preferable. Sufficient fluid intake is very important and becomes more important in case DF progresses into DHF or DSS where loss of body fluid / blood is the most salient feature.It is important to look for danger signs and contact the doctor as soon as any one or more of these are found.

What is the treatment?

Like most viral diseases dengue fever can subside on its own.Paracetamol is the main stay to reduce fever.Pain killers/anti inflammatory agents like Aspirin/Brufen should be avoided  since they can increase the risk of bleeding.. Antibiotics do not help. Doctors should be very careful when prescribing medicines. Any medicines that decrease platelets should be avoided.

 Symptomatic management is the main stay of treatment.

When should a patient suffering from Dengue go to the hospital or consult a doctor?

Generally the progress towards dengue haemorrhagic fever or dengue shock syndrome occur after 3-5 days of fever. At this time, fever has often come down. This may mislead many of us to believe that the patient is heading towards recovery. In fact, this is the most dangerous period that requires high vigilance from care-givers. The signs and symptoms that should be looked for are severe pain in the abdomen, persistent vomiting, bleeding from any site like, bleeding in the skin appearing as small red or purplish spots, nose bleed, bleeding from gums, passage of black stools like coal tar. Bring the patient to the hospital whenever the first two signs, namely, severe pain in the abdomen and persistent vomiting are detected. Usually it is too late if we wait until bleeding has occurred.

The most dangerous type of dengue is the dengue shock syndrome. It is recognized by signs like excessive thirst, pale and cold skin (due to very low blood pressure), restlessness and a feeling of weakness.

Can dengue fever become dangerous?

The infection can become dangerous since it may cause damage to the blood vessels. The damage may range from increased permeability of the blood vessels, causing leakage of blood fluid/plasma into various organs to completely broken blood vessels that causes bleeding.The symptoms and signs of dengue haemorrhagic fever and dengue shock syndrome are related to damage to the blood vessels and derangement in functioning in components of blood that help it to clot. Mortality in DSS is around 1-5%.

What should the doctors treating dengue do ?

Patients suspected to be suffering from dengue haemorrhagic fever or dengue shock syndrome should be admitted to a hospital without delay.

The progress of these patients should be monitored regularly at 1-2 hours interval.

Platelet counts and haematocrits should be monitored repeatedly to review the progress of patients.


If the haematocrit levels fall dangerously then a blood transfusion should be considered. A fall of more than 20 % as compared to previous levels may be an indication for transfusion.


If the haematocrit values rise the patient should be given fluids intravenously and the fluids carefully monitored to ensure that the patient does not get excess fluids. A rise of Hematocrit more than 20 % as compared to previous levels may be an indication for IV fluids. The doctor should decide based on best judgement of patient's condition.

What should the doctors treating dengue avoid?

Do not prescribe aspirin and brufen or any other medicine that reduces the platelets or increases the tendency to bleed.

Avoid giving too much IV fluids unless the patient is bleeding or the haematocrit level is rising progressively.

Avoid rushing into giving blood transfusion unless the haematocrit is falling dangerously.
Do not give platelet transfusion unless the platelet count is very low or unless there is bleeding.

Can you get dengue again after suffering from it once?

It is possible to get dengue more than once. Dengue can occur because of 4 different but related strains of dengue virus. If a person has suffered from one virus, there can be a repeat occurrence of dengue if a different strain is involved subsequently. Being affected by one strain offers no protection against the others. Recovery from infection by one provides lifelong immunity against that virus but confers only partial and transient protection against subsequent infection by the other three viruses. There is good evidence that sequential infection increases the risk of developing DHF because this partial immunity produces severe immune reaction in the body.

What is the Global incidence of dengue?

The incidence of dengue has grown dramatically around the world in recent decades. It is a disease of the tropical and sub-tropical regions Some 2.5 billion people – two fifths of the world's population – are now at risk from dengue. WHO currently estimates there may be 50 million dengue infections worldwide every year.The disease is now endemic in more than 100 countries Before 1970 only nine countries had experienced DHF epidemics, a number that had increased more than four-fold by 1995.

 Where does the mosquito that spreads dengue live?

What is the incidence and mortality of DHF?

An estimated 500 000 people with DHF require hospitalization each year, a very large proportion of whom are children and young adult. About 2.5% of those affected die.

Why there is an increasing incidence of severe Dengue infection World-wide?

Rapid and disorganised Urbanisation,poor solid waste management and lack of running water, leading to  storage of water in households etc are some of the factors that is causing an enormous increase in Dengue infections.

The highly domestic mosquito Aedes aegypti rests indoors, in closets and other dark places. Outside it rests where it is cool and shaded. The female mosquito lays her eggs in water containers in and around the homes, and other dwellings. These eggs will develop, become larvae, and further develop into adults in about 10 days.

How can the multiplication of mosquitoes be reduced?

Dengue mosquitoes breed in stored, exposed water collections. Favoured places for breeding are barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water coolers etc.

To prevent the mosquitoes from multiplying, drain out the water from desert coolers/window air coolers (when not in use), tanks, barrels, drums, buckets etc. Remove all objects containing water (e.g. plant saucers etc.) from the house. Collect and destroy discarded containers in which water collects e.g. bottles, plastic bags, tins, used tyres etc.
In case it is not possible to drain out various water collections or to fully cover them, use TEMEPHOS, an insecticide, ( brand name Abate) 1 part per million according to the local guidelines to prevent larvae from developing into adults.

How can I prevent mosquito bites to prevent dengue?

There is no way to tell if a mosquito is carrying the dengue virus. Therefore, people must protect themselves from all mosquito bites.

Dengue mosquitoes bite during the day time throughout the day. Highest biting intensity is about 2 hours after sunrise and before sunset.
Wear full sleeves clothes and long dresses to cover as much of your body as possible.

Use repellents- be careful in using them in young children and old people. Use mosquito coils and electric vapour mats during the daytime also to prevent dengue.

Use mosquito nets to protect children, old people and others who may rest during the day. The effectiveness of these nets can be improved by treating them with permethrin (pyrethroid insecticide). This bed-net is called Insecticide Treated Nets and are widely used in the prevention of malaria.

Is there any advice for the patient with dengue fever to prevent the spread of the disease to others?

The spread of dengue from a patient to others is possible. The patient should be protected from contact with the mosquito. This can be achieved by ensuring that the patient sleeps under a bed-net. Effective mosquito repellents are used where the patient is being provided care. This will prevent the mosquito from biting the patient and from getting infected and spreading it to others.

I am sure there will be many more questions about Dengue fever. Feel free to ask them in the comments column of this post.I will try my best to answer.

This post is dedicated to all those who tragically succumbed to Dengue infection and their families, especially to this young woman. blogger .

Links

http://www.who.int/mediacentre/factsheets/fs117/en/

http://www.cdc.gov/dengue/fAQFacts/index.html

http://www.searo.who.int/en/Section10/Section332/Section1026.htm#2

http://malayalidoc.blogspot.com/2010/08/tips-for-prevention-of-breeding-of.html

http://malayalidoc.blogspot.com/2009/07/feverish-rainy-season.html

http://malayalidoc.blogspot.com/2009/09/what-could-be-her-diagnosis-part-2.html

http://malayalidoc.blogspot.com/2008/11/non-medical-reasons-for-referring.html

 http://malayalidoc.blogspot.com/2008/12/non-medical-reason-for-referring.html

Tips for prevention of breeding of Aedes mosquito in your urban neighbourhood

Dengue fever is an acute febrile illness which can be life threatening.The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.So it is very important for us to know about these mosquitos and to learn how to prevent its breeding in our neighbourhood.

Dengue Virus Transmission


Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. The mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined.

Aedes aegypti goes through a complete metamorphosis with an egg, larvae, pupae, and adult stage. The adult life span can range from two weeks to a month depending on environmental conditions. The life cycle of Aedes aegypti can be completed within one-and-a-half to three weeks
 


After taking a blood meal, female Aedes aegypti mosquitos produce on average 100 to 200 eggs per batch. The females can produce up to five batches of eggs during a lifetime. The number of eggs is dependent on the size of the bloodmeal. Eggs are laid on damp surfaces in areas likely to temporarily flood, such as tree holes and man-made containers like barrels, drums, jars, pots, buckets, flower vases, plant saucers, tanks, discarded bottles, tins, tyres, water cooler, etc. and a lot more places where rain-water collects or is stored. The female Aedes aegypti lays her eggs separately unlike most species. Not all eggs are laid at once, but they can be spread out over hours or days, depending on the availability of suitable substrates. Eggs will most often be placed at varying distances above the water line. The female mosquito will not lay the entire clutch at a single site, but rather spread out the eggs over several sites.


The eggs of Aedes aegypti are smooth, long, ovoid shaped, and roughly one millimeter long. When first laid, eggs appear white but within minutes turn a shiny black. In warm climates eggs may develop in as little as two days, whereas in cooler temperate climates, development can take up to a week. Laid eggs can survive for very long periods in a dry state, often for more than a year. However, they hatch immediately once submerged in water. This makes the control of the mosquito very difficult.

Prevention of breeding of Aedes mosquito

Aedes mosquito lay their eggs in clear,clean water and not in contaminated water.As they fly only a few metres their breeding place is usually in our house itself.

Most common breediing places and tips to prevent breeding

Water storage tank/cistern ---should have mosquito proof lids
water coolers/collection pans in Fridge/ACs ------ water should be drained out periodically 

Drum   ------tight lids
Flower vase with water  [least in brass vase]----------change water frequently,use sand
Potted plants with saucers ------- change water frequently
Ornamental pool/fountain ---------water changed once a week
Roof gutter/sun shades------------check frequently for drain block
Animal water container----------- empty and clean periodically
Ant trap--------------------------use oil/salt
Used tyres-----------------------keep it under roof
Discarded large appliances-------bury or keep it under roof 
Discarded buckets,plastic cups,tin cans etc-----bury


Whenever piped water supply is inadequate and available only at restricted hours or at low pressure, the storage of water in varied types of containers is encouraged, thus leading to increased Aedes breeding.It is essential that potable water supplies be delivered in sufficient quantity, quality and consistency to reduce the necessity and use of water storage containers that serve as the most productive larval habitats.

Chemical and biological agents can also be used for prevention of breeding of Aedes mosquito.

from
Denguevirusnet
WHO

What could be her diagnosis? Part 2

She was 24 years old, mother of a 2-year-old child. She developed high-grade fever and was admitted in another small hospital nearby 4 days ago. She was discharged yesterday as she was apparently all right. Early this morning she developed tummy pain, vomiting and drowsiness and was admitted to my hospital.

She was really sick. Though drowsy she answered my questions. During her previous admission she only had fever and headache. No cough or breathlessness or loose stools. There were no joint pains too. Now from last night she is having vomiting, extreme tiredness and tummy pain.
On examination there was no fever. She seemed to have distension of her tummy more than that is expected of her 3 months of pregnancy. Her chest [lung] expansion was also less and the oxygenation low. Blood pressure was only 70/50 with almost no urine output for last 4 hours though her urinary bladder was catheterized.

By the time I saw her 3 pints of intravenous fluids had been transfused with no increase in blood pressure.

Is it a ruptured ectopic pregnancy?

A patient in early pregnancy coming with tummy pain and very low blood pressure should be considered as a ruptured ectopic unless proved otherwise.

I know the Gynaecologist must have ruled it out already before referring to me.

Yes she has by an ultra sonogram, which showed normal uterine pregnancy with a live foetus.


Ultra sonogram also showed moderate amount of free fluid in the peritoneal cavity and also in both sides of the chest inside the pleural space. That explains her abdominal distension and reduced lung expansion.

Now I looked at the lab results. Total WBC count is 3400 with 80% neutrophils while the Platelet count was 90 thousand. Both low. The Packed Cell Volume was 39% with a normal ESR. The liver enzyme SGPT [ALT] was high at 1050 with SGOT [AST] at 350. Rest of the lab values were normal. ECG was normal too.

What could be her diagnosis?

This was my post last week.

What did I do? I began to go thru the data again in my mind.




After 5 days of fever she developed shock. So an infection must be the cause.



Bacterial or Viral or Malaria?

Low WBC count usually rules out Bacterial infection. The pattern of fever and lack of history of travel to Malaria prone areas should rule it out. [Mercifully Kerala has almost zero cases of indigenous Malaria. All our Malarial fevers are imported from neighboring States].

So it must be a viral infection. Many viral infections cause low WBC count and low Platelet count. But only a few can cause Shock. In this rainy season such a viral infection producing shock can only be Dengue Shock Syndrome.

Any other clue that suggests Dengue infection?

Yes the moderate amount of free fluid in the peritoneal and pleural cavity. [Abdomen and chest]. This is classically seen in DSS due to increased capillary permeability causing plasma leak in to those spaces.



The low platelet count can cause bleeding if it falls below 20000.Then it is called Dengue Hemorrhagic fever.



The diagnosis is by detection of the virus by RT-PCR, which is very costly and the result may reach my place only after a week or by detection of antibody against the virus, which may become positive only after 7-10 days.

As the treatment is symptomatic with pumping in of large amount of fluids and if needed platelets and plasma, I did not send a blood sample for antibody detection at that time.

I started the treatment earnestly. Fortunately the relatives had confidence in my institution and me. Her urine output improved in a day and after about 3 days of pumping in of so many bottles of fluids and plasma her blood pressure started coming up.



Initially her PCV [packed cell volume] was high due to plasma leakage and blood concentration. Later it began to fall showing the treatment is effective. Rarely fall in PCV may also be due to bleeding. So a careful watch for bleeding is required.

I send the blood sample for diagnosis only on the 3rd day of admission. By that time she was shifted out of ICU. When the result came as positive for Dengue infection she was well in to the road of recovery.

When she was discharged on the 9 Th day of admission her Ultra sonogram showed a normal live foetus and no free fluid in the peritoneal and pleural cavities.


I have seen several patients with features of Dengue fever this season. All most all of them recovered without going in to shock as I pushed lot of intravenous fluids suspecting Dengue in all patients with high fever, headache, no joint pain, low WBC and low platelet.

There is a significant increase in Dengue fever cases this year in South India as evidenced by news reports. Large number of cases has also been reported from Sri Lanka.

I am hoping that all my patients with Dengue fever will recover fully like the patient in the story.

Feverish Rainy Season

The Monsoon is here.Though it really began pouring down only last week the Fever season started by early June. OPDs are overflowing and it is hard to get a hospital bed.
What kind of fevers are more commonly seen this year?
The usual influenza like upper respiratory tract infection is the commonest but the more serious fever this year is Dengue fever.Chikungunya fever is less common when compared to last year.
Dengue Fever[DF]
Dengue is a mosquito-borne infection that in recent decades has become a major international public health concern. Dengue is found in tropical and sub-tropical regions around the world, predominantly in urban and semi-urban areas.As per current estimates, availability of at least 100 countries are endemic for DF and about 40% of the world population (2.5 billion people) are at risk in tropics and sub-tropics. As per estimates, over 50 million infections with about 400,000 cases of DF are reported annually which is a leading cause of childhood mortality in several Asian countries.

Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses. Symptoms appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended.
Dengue hemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses increase survival of patients.
My Experience
When a patient presents with sudden appearance of high grade fever and headache without congested nose or cough my thoughts are about Dengue fever.If there is severe joint pain and swelling especially of small joints of hand I may consider Chikungunya as the first possibility.
I will then order a Complete Blood Count. A low total WBC count along with low Platelet count make my suspicion of Dengue fever stronger. Chikungunya fever may also have a low WBC count but the Platelets are usually not very low.
I admit the patient if the Platelet count is below 100000 or if the patient looks very sick. Maintaing hydration and blood pressure is most important. I had more than 20 patients with suspected Dengue fever since the beginning of June, but only one had the complication of Dengue hemorrhagic fever.There were no loss of life.

Diagnosis of Dengue fever is mainly by clinical features and not by laboratory methods.By the time the antibody levels rises and is detectable by blood tests the disease would have subsided.

Prevention of Dengue fever is mainly by reducing the mosquito breeding.Aedes breeds primarily in man-made containers like earthenware jars, metal drums and concrete cisterns used for domestic water storage, as well as discarded plastic food containers, used automobile tyres and other items that collect rainwater.
Vector control is implemented using environmental management and chemical methods. Proper solid waste disposal and improved water storage practices, including covering containers to prevent access by egg-laying female mosquitoes are among methods that are encouraged through community-based programmes.
The application of appropriate insecticides to larval habitats, particularly those that are useful in households, e.g. water storage vessels, prevents mosquito breeding for several weeks but must be re-applied periodically. Small, mosquito-eating fish and copepods (tiny crustaceans) have also been used with some success.
Fever season is always a challenge for an Internist like me. I love that challenge. Hope I can rise up to it.

Non medical reason for referring a patient-Part 2

You may recall my post few days ago on the above subject. Let me continue the story.
The patient a woman of 42 years was brought to my hospital next day morning. My physical examination and the blood results revealed that she is having Dengue fever with a decrease in Platelets, the cell that helps in clot formation when the blood vessel is injured. Apart from vomiting and mild fever she was doing well.
I reminded the relatives about what I told them the day before. I said to them that Dengue fever can be life threatening.
'Next few days are critical. Even if you take her elsewhere the management will be the same. Now you decide.If you like to stay I will try my best to make the patient all right'.
The decision was quick.'We have faith in you doctor'.
I was happy to see their faith in me.It is my experience that if you explain everything about the Patient's condition in simple terms looking in the eye the faith of the patient and the relatives increases.
With in 2 days of supportive therapy her Platelet count improved and she became asymptomatic. I discharged her from the hospital on the fourth day.The family was very happy and thankful.I saved them a lot of money and hardships.
Many patients are referred to a higher centre with out sufficient reasons.Nowadays doctors try to play it safe.
I took a calculated risk here.I admitted a patient to my small hospital with a probable life threatening illness who was referred to a big City Hospital by another Physician.The risk paid off and here we had a happy ending. That may not be the result in all cases.

Non-Medical reasons for referring a Patient-Part 1

You may think that if a patient is referred to a higher medical centre[with better facilities] from a smaller hospital it is purely due to medical reasons. Many a time it is not.
Today I was confronted with such a referral.

It was near the end of my working day. Four men came in to my consultation room wanting some advice regarding a patient admitted under another Physician in a small hospital nearby. She was diagnosed to have Dengue fever and had been referred to higher centre.

They had brought all the patients records.I went through the clinical notes and lab charts.She was not in a critical condition.But the doctor treating her had asked them to take her to Hi-tech hospital in the nearest City.
One of the men,whom I know before asked, 'Is there a hospital in this town which can manage such cases?'
'Yes, even the Hospital in which the patient is currently admitted may be able to take care of such cases. Dengue fever patients need constant monitoring,that is all.If there is a fall in blood pressure or bleeding they may need blood transfusions'.I said.
'Then why the referral?' He asked.
I asked them what the treating doctor told them about patient's condition.They revealed that the doctor had told them that the patient has a serious life threatening infection. The patient can be said to be out of danger only after 3-5 days.
'Would you have accepted death of the patient if it had happened in that hospital?'
I asked. 'If patient died there in spite of all the recommended treatment methods you would definitely would not accept it and will raise voices against the doctor and the hospital.You would have asked the doc why he did not refer the patient to better centre'.

[Most probably stones will be thrown and the doc manhandled, which is now the fashionable thing in Kerala.I did not say that aloud.Did not want to give them ideas]

'On the other hand if the patient died in the big hi-tech City hospital you will accept it as your fate and will be satisfied with yourself that you have done enough.That is the reason for the referral.So it will better for you to take the patient to the City',I concluded.

Their faces showed indecision.They went out of my room to discuss among themselves as I saw my last patient for the day.I thought they will not come back again.But they trooped in to my room once more. I did not expect what they asked.

'Can you treat the patient in your hospital?

I did not know what to say.My hospital was slightly better equipped than the hospital in which the patient is admitted currently.I wanted to take up the challenge.10 years ago I might have jumped at the opportunity. But age and bitter experiences have changed me a lot..[as explained in my earlier posts 30vs40 part 1]. I wanted time to decide.
'Let me see the patient and decide.Bring her to the hospital tomorrow morning'.I replied

Tomorrow they may or may not come.If they come I may take up the challenge.
To know what happened to that patient click here.