Missed malaria diagnosis seen behind death of 22-year-old Tuschen man

Vishnu Singh Sr. and Bibi Singh

When 22-year-old Vishnu Singh of Tuschen, East Bank Essequibo developed a fever on October 5, his parents never realized that it would turn out to be malaria and lead to his death.

He had just returned from a trip to the mining town of Bartica, in the Essequibo River where he spent about five days, when he developed flu-like symptoms [fever and backache]. But yet, not even the doctors suspected that he had contracted the parasite.

The most hurtful part for his mother, Bibi Singh, a teacher and his father, Vishnu Singh (Sr.), a building contractor, is that despite visiting several places, including private and public health facilities, they only found out about the malaria when it was already too late.

Quacy Grant, Government Medical Officer with responsibility for malaria told Stabroek News that a key factor with malarial illness is to get the right diagnosis and treatment early.

He had learnt about Vishnu’s unfortunate situation and as a result, they want to work with the hospitals and private physicians on the coast so that the situation does not recur.

He pointed out that even though some people may have visited malaria endemic regions and have a fever, malaria is still not the first thing that the doctors think about.

“We would now be training physicians to use the rapid kits so that they would put malaria back on their agenda as a priority…,” Dr. Grant said.

He noted that despite having the symptoms, “malaria might be down on the list and that’s how cases are missed… So if a patient comes to you and say they were in Bartica, automatically you should think malaria.”

Dr. Horace Cox, Director (acting) of the Vector Control Unit (VCU), which is a part of the Public Health Ministry, said that at the malaria clinic, they would also “take it as an example to work with the doctors to educate them…”

He said: “There is the claim that malaria is not transmitted locally, along the coast, but we need to confirm by doing the necessary tests to see if they [coastal areas] have the anopheles mosquito.”

Desperately trying to find the right help, the parents took Vishnu to a different private hospital in Georgetown. He underwent a few tests and was eventually diagnosed with falciparum malaria.

According to information available on the internet, “falciparum is a protozoan parasite and one of the species of Plasmodium that cause malaria in humans.”

It is transmitted by the female Anopheles mosquito. This species causes the disease’s most dangerous form, malignant or falciparum malaria and has the highest complication rates and mortality.

Hope

With a diagnosis to work with finally, Vishnu’s parents thought there was hope but that hope turned to disappointment, anger and frustration and they felt that the health system had failed him. They also blamed the doctor for neglect.

When he was admitted, Bibi asked to see the doctor but he was only available two days later. He told her that Vishnu needed 25 units of AB blood – a rare type – and that his platelets were low.

Family members and friends immediately started making an appeal on social media for blood donors to come forward and got an overwhelming response.

But Bibi is saddened that even though so many donors came forward, only three units of the platelets were transfused.

Her son went from staying in the ward at the hospital to being placed in the Intensive Care Unit. All this time he was still fully conscious and even begged her to “take him out of the hospital because they would kill him there.”

Subsequently, the doctor told the parents that Vishnu had water in his lungs and “he pushed a hose [fat tube] down his throat. How he know my son had water there? He didn’t do any ultrasound or x-ray.”

She felt that the tube put him through further “ordeal and agony it caused his teeth to become spaced out in his mouth.” The doctor later told the parents that he had developed a breathing problem.

On October 12, the doctor said to them that they should “go and speak to him because you won’t be able to speak to him again.

By then he was “heavily sedated” and had stopped speaking. His parents wanted to move him, but “he was hooked up to the machine.”

Even though he showed no sign of improvement, the doctor kept giving the family hope up to October 14 that “he would be ok.”

To their horror, they received a call from the hospital around 2 am on October 15 that “they were not finding pulse.”

When they reached the hospital they were told that he had died and were devastated. Bibi said they have “accepted his death but we can’t get over what he passed through. I would not like another human being to go through that ordeal…”

They have tried to communicate with the doctor but the hospital contacted them on the day of his funeral to say that they would “call back and make a date to meet with him… we are still waiting.”

She said he had developed jaundice as well and when he started taking the saline, his “skin got clean.”

Elimination

Dr. Cox said he has noticed that as they look towards elimination of the disease and the numbers drop, doctors tend to keep malaria out of their minds.

He said “it might not be intentional but if the doctor … sees malaria every three years, that’s the last thing he’s thinking about.”

He said it was “discussed at different levels about how to keep medical practitioners on top it when you are about to eliminate something.”

There is also the call for doctors to use Vishnu’s case as an example and look out for the signs so that deaths can be prevented.

Recalling when Vishnu started feeling sick,” Bibi said she first took him to a private institution in Georgetown where he underwent some tests and they found out that his platelets were low.

The practitioner took him up to the ward and gave him saline. He was sent home the same day but his condition did not improve. They went a second time to the hospital and Vishnu was again treated and sent away.

They then went to a private clinic on the coast and the doctor gave him “two injections and strapped his back.” But he did not get any relief.

The frustrated parents said they took him to the Leonora Cottage Hospital after the fever continued and he was just given a Panadol and sent home.

He reached a stage where he was shivering and unable to walk and this time the parents decided to take him to the GPHC. They were asked to remain outside because “he was an adult” and he was given saline there as well and sent home the same day.

She said blood tests were also conducted at the GPHC but apparently none was done for malaria. The worried parents took him to a pharmacy in the area and there they were advised to rush him to the private institute where he was admitted and later died.

Services

Dr. Cox told this newspaper that the VCU offers services for diseases such as malaria, filaria and to a small extent, Chagas.

They also have clinics for zika, dengue and chikungunya and staff have been trained to conduct house to house inspection, treat drinking water or give advice about fogging.

According to him, some patients are taken to the medical outpatient unit, which is a part of the GPHC, but would not be classified as patients for accident and emergency.

While he does not have the details of Vishnu’s case, he said it is possible that he went to the outpatient area and got an injection.

He noted that once the patients visit the VCU “they are tested for malaria, whether or not they are symptomatic. This is based on if the person traveled to the interior locations…”

“One good thing is that 25 percent of the cases that are diagnosed with malaria are done centrally in Georgetown” and that he considers that to be “significant. Within one to one and a hour after testing, they get the results.”

In terms of mortality, he said “that’s secondary to malaria and the numbers are very small. Generally, mortality is not registered because we do not manage complicated malaria there.”

He explained that “there is simple non-complicated or complicated malaria” and believes that the fact that Vishnu “needed blood and his blood count was low, that’s complicated. If you have hypoglycemia – if your sugar level drops that’s [also] a complicated type.”

Dr. Cox explained that if patients are tested positive they receive treatment at the malaria clinic and is followed up after.

If weakness or vomiting persists, they are managed within the hospital setting after passing through the accident and emergency unit.

Miners

He said if the miners are “tested early but are not treated, it can lead to complications. Sometimes they go at a very severe stage and it’s difficult to treat and there is little that can be done to save them.”

He said too that when a patient is taken to a medical practitioner, he is diagnosed and treated or tested based on the information he provides.

Generally, the doctor is supposed to question the patient about whether he works in or visited the interior locations, where there is a high incidence of mosquito-borne diseases or whether he had malaria before if they had completed the treatment.

“Once the patients visit the malaria clinic they would be given the test… But at a normal clinic or an outpatient setting, malaria may not be the first thing that comes to the doctor’s mind – they may think about a wide range of things,” he said.

Prevention

Dr. Cox said that at the malaria clinic they focus a lot on prevention and have “rolled out a project for early detection, which is considered secondary prevention in regions one, seven, eight and 10 – the mining population.”

They have started a pilot project that is spearheaded by Dr. Grant, to teach the miners how to conduct the rapid tests, which gives the results in 20 minutes and how to give treatment.

He thinks it’s a “huge project because we are teaching lay-people medical skills; to test, diagnose and treat. And remember these are people without a base in medicine… so you have to work with them.”

He added: “We think that this is the best way to go because when people are working in the interior and for economic purposes and they get sick they do not [always] come out. They stay there and take whatever medication is available…”

He said that “over a period of time, even if they use the right medication, they do not use it in the right quantity and this is bad for Guyana because it leads to resistance. That is bad because there is a world drive towards the elimination of malaria.”

The project has already started in Region 8 and Dr. Cox said he is hoping to extend it to the other regions. The team would “go in from time to time to monitor and train the miners. We have to check on what drugs they have available and how they are using it.”

He pointed out that ‘the microscope is the main means of diagnosis but our aim is to use the rapid test throughout the country as it is much faster.” As such, they are working on it for the district hospitals and strengthening it as they go through.

Dr. Cox said it is very sad what Vishnu’s parents went through with the loss of their son because “malaria is a preventable and treatable disease. Therefore, for there to be a death, it is significant.”

The distraught Bibi said that “every time I went to see him I cried. Now I have to live day and night without my son. It is grieving us a lot. I wouldn’t like another human being to go through the ordeal that my son went through…”

 

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