It was a Saturday night during festival season and we were the only Emergency Department in town. When I walked in we were completely full, with three-fourths of the patients waiting for a bed in the wards. There were only two nurses and two physicians. At 4 AM, the triage nurse left her post. With no one guarding the waiting room, checking vital signs, and explaining the process, we were bombarded.
The hospital and outlying health centers were full, and we were the final stop. Patients, each accompanied by at least three family members, stormed the ED hall, demanding to be seen. We were forced to use benches and makeshift wheelchairs to evaluate a range of complaints – an open boxers fracture, abdominal pain, febrile illness, chest pain, car accidents. This is an all too familiar scene, but this time it was different. The entire emergency department was already jam-packed with men and women, young and old, Indian and Fijian, each one in seemingly a different stage of an identical illness.
I have just returned from a global health elective in Fiji, where I worked as a physician in the Accident & Emergency (A&E) Department of the capital’s Colonial War Memorial (CWM) Hospital. My time there coincided with an unprecedented dengue outbreak, and the health care system was quickly overwhelmed. The situation required an improvised “Dengue Contingency Plan.”
As critical saturation was reached at CWM, the physicians and hospital administrators were challenged with implementing a literature-based strategy to help direct management of dengue patients. Though there is no approved vaccine and treatment is largely supportive, organizations such as the W.H.O. and the Sri Lankan Ministry of Health have published guidelines on patient monitoring and admission criteria. A literature review revealed clinical predictors of poor outcomes. Nearly all of the patients we saw in the ED met admission criteria based on clinical status, lab values, and expected course. Keeping all of these patients in the hospital, however, would saturate the hospital’s ability to care for the ill and functionally shut it down. As is often the case back home, clinical guidelines cannot always be applied to individual patients. Policies adopted from foreign countries with their unique pathologies, resources, and practice patters may not adequately address local problems.
While the recent arc of global health has concentrated on non-communicable disease, emerging tropical diseases continue to surprise us back home. I imagine most of these diseases will be misdiagnosed in the early stages.
I work in a hospital with a large immigrant population near an international airport, where every headache could be neurocysticercosis, every pneumonia could be tuberculosis, and every biliary colic could be amoebic liver abscess. Last year alone, southern Texas saw dozens of confirmed dengue cases. I wonder how many of these were initially diagnosed with acute viral illness or aseptic meningitis after lumbar puncture. Identifying emerging threats requires a high index of suspicion, yet physicians may have filed away diseases learned in medical school as pathologies we never thought were going to happen in our backyard.