Episode I: The DENGUE Menace

9:10 AM

In a Galaxy far far away called Malaysia, the force of the DENGUE remain strong. Despite all the pamphlets and ads on DENGUE fever we are still galaxies away from nailing the Dengue outbreak. Recently the honorable health minister, Dato' Dr. Subramaniam released a rather surprising press statement;

"99% of cases of Dengue were missed on the first visit at general practitioners."


No one is really sure how the statistics were gathered, but it doesn't put GPs in a good light. It might also cause some loss of confidence of the public towards the GPs. Personally, I think this is typical Malaysian mentality (not confined to Ministry of Health or the Government service) to BLAME others first. However, I do agree with Dr Raj Kumar Maharajah's Letter to Malaysiakini:


The one to blame is the mosquito! You can't just TREAT, TREAT, TREAT.....let's move on to PREVENT, PREVENT, PREVENT!



DOCTORS, FOCUS!

I am a regular MO at a small Klinik Kesihatan. But I believe there are specialists in all sorts of areas reading my blog. I know for sure that there are emergency physicians, surgeons and physicians (internal medicine) among the almost 10,000 readers. Let's try and come together and find a proper solution for this problem. Let's use this blog as an avenue for discussion. Very difficult right to make proper meeting....plus nowadays budget cut, no makan makan for meetings! If you are in the proper field, kindly provide some JEDI FORCE information in the comment section. Come, come. Lai, lai. Sila tambah nasi!



What are the common problems faced:

1. Early detection

The NS1 kit to detect Dengue antigen seems promising and is a helpful tool. But the cost factor (RM 80) and the limited supply of these test kits is limiting its use. Some clinics run out of the kits within days of getting a new stock. In the good old days, results for Dengue serology could take weeks! Furthermore, instead of relying on clinical suspicion, doctors are expected to notify the case only AFTER getting it confirmed by an NS1 test.

Here's the equation:

No money      =     no test        =   no notify  =  boss marah why lambat detect
Got money     =  out of stock   =  no notify   = boss marah why lambat detect

Clinical suspicion  =  notify without confirm = why you notify without confirm? We got banyak kerja tau?!

So, how?

2. Admission criteria

I'm sure a lot of my colleagues in primary care will go through the same problem.

Day 3 fever, BP: 95/60, PR: 110
Platelet: 125, Hematocrit: 48%
Has abdominal pains, nausea and giddiness.
NS 1 out of stock.

Most would think that it looks bad. "Better be safe than sorry" we all say. When the patient is referred to the hospital, the next day the same patient will come to repeat and monitor full blood count. Then, when the doctor refers again due to deteriorating blood results, the patient will be discharged and the cycle repeats itself. Patients will complain for being treated like a ball so often and later on will be put off from going to the hospital and just absconds.

Any other problems? At least these are problems I can think of at 12 am! Do top up in the comments section. If you are malu, just email me or message me on Facebook.

REVISION

A bit of a revision. I managed to go to a Dengue update a while back and it proved to be very beneficial for me. However, was so - so only. Maybe because it was on a weekend. But I encourage my fellow colleagues to attend updates and workshops on Dengue.

1. Dengue is a VERY DYNAMIC disease.

We have to look at the disease process in terms of HOURS not days. An infected person can appear perfectly normal in the morning and end up in the ICU at night.

2. Platelet is NOT EVERYTHING

To just look at platelets will put you in the same position as Loktors. Look at the hematocrit. Look at the trends. Look at the patient as a whole. What are the red flags you need to look for?

i. CCTV-R (colour - capillary refill - temperature - volume - rate)
This is the magic touch. You can assess all these by holding the patient's hands. Does it appear pale? Is the CRT more than 2 seconds? Are the peripheries cold and clammy? How's the pulse volume and rate?
If you don't know how to assess all these, you shouldn't have graduated from medical school!

Image from Healthplansinc.com

ii. Abdominal pain severe enough to be the chief complaint.
An example is when a person complaints of severe abdominal pain. Only after assessment did you note that the person is having a high grade fever.....before you diagnose it as perforated appendix, think again; CAN IT BE DENGUE?

iii. Severe vomiting.
It is considered as severe when there is at least 3 episodes of vomiting on the same day.

iv. Activity
If the patient says he is too tired to even walk to the toilet and has been in bed all day; you might just have a haemodynamically unstable patient....a walking time bomb!

v. Urine output
No need to insert a CBD yet! Just ask when was the last time the patient passed urine. If it is more than SIX hours and concentrated, be extra careful.

3. Whatever you give, DO NOT GIVE NSAIDS!
Just don't!

Some of these information may need to be updated. I appeal to you to share this among your colleagues. If you know someone who specializes in this area please ask him to top up our knowledge via this platform. Some may rubbish my blog but at least I made an effort (Surprisingly, when I conducted an interview for a foreign university and highlighted my passion in blogging, they considered it as a plus point!). Sudah sudah la tuduh orang lain salah. (Tuduh NYAMUK takpe!) It's getting tiring. Let's together come up with a solution.

I will post another entry for the public as the contents in this entry is more suited for medical professional.

May the FORCE be with you!

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7 comments

  1. Not a physician (trained to be a lab rat) but am appreciative of this refresher.

    ReplyDelete
  2. Not a physician (trained to be a lab rat) but am appreciative of this refresher.

    ReplyDelete
    Replies
    1. Everyone can benefit from this :)

      Delete
    2. Everyone can benefit from this :)

      Delete
  3. Salam, hye. Not an expert, an mo in kk, just to state a few points that may differ in other states.

    In negeri sembilan, we are still allowed to notify suspected cases.

    Ns1ag will be positive if the viral load still high, different patients will have different time frame and different load. I have seen lots of false negative result, and will still treat as dengue despite the ns1Ag turn out to be negative. Like u said, treat the patient first, then the result

    ReplyDelete
    Replies
    1. Yep. If I'm not mistaken there was a mortality case whereby NS1 on 1st day of fever was negative. Then after a few days patient had plasma leakage & subsequently died.
      As my lecturers always say, treat the patient not the investigations

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  4. Rainy season has more possibilities of getting infected with various diseases like dengue, chikungunya, malaria etc. Once should take more precautions during this season. Every country has similar issue for this diseases and everyone is affected by this. Find more on symptoms of dengue

    ReplyDelete

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