Monday, July 20, 2015

Dengue in Tassie

Exactly a year ago today, I was admitted to the Royal Hobart Hospital via the Emergency Department for PUO (aka pyrexia of unknown origin) (aka a fever). The origin of the P (aka pyrexia) (aka fever) was later discovered to be dengue. It was pretty interesting being a patient instead of a med student in the hospital, and it was an experience I wanted to remember, so I was determined to get everything down on paper...or rather, on screen. I spent four days post-discharge typing out everything that had happened, but never got around to finishing it since I was constantly tired and had uni to catch up on and was lazy. I got down the entire hospital stay, anyway, which was the most important part.


The following 5.5k words (I know) are the edited, final product of everything I got down. The final four paragraphs were written today, but they were written in the context of last year to ensure that everything flowed. I then conclude with a few remarks for today, as, funnily enough, this whole experience turned out to be pretty relevant to third year. So, without further ado I present to you (as I'd so creatively titled the draft a year ago) : Dengue in Tassie!







I feel like before I begin, I should explain the term 'incubation period' for those who don't know it. Hopefully this doesn't sound patronising or anything, it's just that it's something I've had to explain over and over again to people I've told, so it would be good just to get it out of the way first. So! According to the Merriam-Webster online dictionary, an incubation period is "the period between the infection of an individual by a pathogen and the manifestation of the illness or disease it causes". In the case of dengue, it would be the space of time between being bitten by an Aedes mosquito and when you first start exhibiting symptoms, anywhere from four to ten days. And I got back to Tassie on the 10th of July, after spending winter break in Malaysia where there had been a dengue outbreak.


Now we can begin!


It all started on the 18th of July, with Vincent asking me why my face was so red after OCF. It was strange because I hadn't been feeling particularly embarrassed or emotional or anything. I shrugged it off, but later that night the awful headache and wooziness came on, and I finally figured out that, hey, I actually had a fever. I dragged myself to bed, thinking that I was coming down with one of those winter viruses. The entire night, I alternated between uncomfortably warm and really freaking cold, complete with uncontrollable shaking. I realised in retrospect that those were rigors and an indicator that something was seriously wrong, but I was way too out of it to think of that at the time. 


The thing about viral infections is that some of the time you feel like death, and some of the time you feel sort of okay. I was somewhere in between the two when I got up early the next morning to welcome one of my housemates home. After some breakfast and Panadol, I dragged myself back to bed again. I woke up hours later feeling pretty alright. But then the switch flipped, and I spent the day like the night before, except worse: bright red and burning one moment, freezing and shaking like crazy the next. By evening, I literally could not leave my bed and, to my embarrassment, had to ask Dhanushia to help me get water from the kitchen, a simple task that I was now unable to carry out. At night, the vomiting started, which made things worse -- I was still burning hot, but now couldn't keep fluids down. It wasn't even normal puking, either, more like my stomach going "Excuse me while my tri-directional muscles contract to projectile vomit every last thing in me".


I was pretty out of it at this point so I don't actually know who was doing what, but what I do know is that my housemates were absolute angels. Hui Ning in particular was coming in every few hours to sponge my burning face with a cold towel, which felt amazing. I could hear someone (Shi Hui?) dealing with my pukey bucket as well, bringing it back well-washed every time. Every time I think about that night I'm just so overwhelmed with gratitude. They're just amazing, amazing people and I wish I could pay them back somehow!


The next morning, I was still feeling pretty worse for wear, but managed to keep some porridge and water down. I'm usually the kind who puts off going to the doctor for as long as they can, but by this point, I was on the Collins St GP website to see if they were open on Sundays (they aren't). So I did the next best thing: typing out my list and order of symptoms, I Facebook messaged JLoh, one of my fifth year friends, asking him whether I should bother trying to get a doctor's appointment or if this was something that would resolve on its own. About ten minutes later, he called to say he was on his way to my house, and he showed up five minutes later, bag and stethoscope in hand.


After an overall and abdominal examination (he'd had trouble finding my radial pulse during the former and had seemed pretty worried about that), I asked, "So, uh, should I go to the doctor?"


"No," he replied, "you should go to the hospital. Now."


He and Hui Ning brought me to the DEM and I was seen and admitted in what Hui Ning said was record time (probably because 'query: dengue'). The intern who saw me had been my Path tutor in first year, but I don't think she remembered me. After trying and failing to get a cannula in twice (during which time I probably crushed all the fingers on poor Hui Ning's left hand), she got a more senior doctor to do it and they finally got one in in my cubital fossa. I have really small veins and had been ridiculously dehydrated, so it was difficult, to say the least. I didn't envy her, but all the same, I was in agony and also tears. They put me on 1L of Hartmann's stat, and it was amazing how much better I felt after half an hour. (Fun fact: 1L/hour is the fastest the drip can go!)


Steven and Yuen Peng had come in to wait with Hui Ning and me in the waiting room (JLoh left) and they saw me again later on my glorified gurney in the DEM. Coincidentally, I was put under the care of Steven's Gen Med team, so I assumed I would be in good hands. Corinne, Nish, and Calvin came to see me after church, and prayed for me. Yuen Peng prayed for me too, and so had Hui Ning, earlier on during the nightmarish cannulation. I honestly cannot thank God enough for surrounding me with such good people. Anyway, a while after everyone left, the nurse brought me a sandwich and some apple juice as I'd missed out on the dinner rounds. By this point I would've been happy with plain bread, so I ate, drank, and slept.


Sometime later that night I was wheeled to the paeds section of the DEM and had to spend the night there as there wasn't any room anywhere else (an 80-year-old man had been transferred there too). Almost zero sleep was had as crying babies were aplenty. I couldn't even be grumpy about it, because here were these sick kids, crying, not understanding what was going on with them. In fact, I couldn't even be grumpy about anything at all, because when you overhear that a ten-year-old kid was being transferred to the onco ward and a fourteen-year-old was threatening to kill himself, really, what did I have to be grumpy about?


But that was what sucked about being a young adult in the paeds section: the kids got way more attention because they were kids, the 80-year-old man got more attention because he was an 80-year-old man, and then there was me, seemingly forgotten behind the curtain. I mean, they'd left both my bottle of water and the call bell out of my reach, which was enough to make me want to weep. In the wee hours of the morning, I slowly made my way to the toilet to discover that my period had come ridiculously early, so it felt like my entire body was rebelling against me. Throughout the night, I asked for blankets twice because it was so darn cold. The next morning, I had to listen to a nurse cooing to the boy in the room (room!) beside my little curtained alcove about what he wanted for breakfast a good 45 minutes before I was brought mine. Also, they needed more blood from me for more blood tests. So it turns out I did have a lot to be grumpy about, it's just I couldn't be, really. 


I perked up quite a bit over breakfast and the stuff that I'd asked Jac to bring over for me: glasses so I could stop being half-blind, iPod, chargers. The nurse told me that I'd spiked a fever overnight, so it looked like I wasn't going to be discharged that morning, as previously thought. I could see in her eyes that she saw that little bit of me die inside, and tried to hitch my lips up into a smile again -- it wasn't her fault! Steven and his team of furiously-writing interns came in to see me, and what the nurse told me was confirmed: I'd be kept in because of my fever, until the dengue results came back either later that day or tomorrow. (Here I must interject with a retrospective 'HA!' -- my blood had to be sent to Melbourne for the dengue serology, and the results weren't back till after I'd left the hospital.)


They'd stopped the drip overnight, and I was finally feeling not-dizzy enough for my first shower in days, which perked me up again after that little downer. I had been able to get disposable underwear and a fresh gown and towel, which was fortunate. I walked back to my bed with a new spring in my step, only to be told that I was being transferred to the APU as there was finally a bed available. I can't say I was very sorry to be leaving the paeds DEM at all, but I would miss the morning nurse, who was my favourite.


Due to the transfer, I had missed lunch, but it was okay because Yuen Peng brought over some porridge she had made. I'm not a picky eater, and the hospital food really wasn't that bad, but Yuen Peng's porridge trumps hospital food any day. A few people came in to see me in the APU that day: Yuen Peng, Hui Ning, Dhanushia, Nish, Daniel, and Steph Poh (she's doing Pharmacy and happened to be doing her placement at the Royal when she spotted my name on the wards admissions or something). Yuen Peng was saying how I must've been the most popular person in my room of four patients, and she was probably right.


I don't know what it was about the APU, but everyone there was old. When I first got into 3B (Room 3, Bed B), there were two women already there: a 90-year-old and a 96-year-old. The 90-year-old was the kind of old lady who wouldn't stop talking and managed to turn every conversation around so that she only ever talked about herself. The 96-year-old seemed like your typical, sweet, little old lady. At one point in a conversation, she recited a poem about old age and memory loss. She recited it beautifully in a sure, reedy voice, though whether from memory or not I cannot say as my curtains had been drawn. (Is it more heartbreaking if she committed it to memory or if she carried it around on a slip of paper wherever she went?) Anyway, the turnover rate in the APU is pretty high, so my roommates came and went. It was a little bit depressing, just staying where I was -- APU stands for 'Assessment and Planning Unit', and since the doctors were still assessing and planning (ie they didn't know what it was I had), there I stayed.


Many visitors during the day meant that not much rest had been had. By nighttime, I was absolutely exhausted. While noise levels were thankfully much lower than those of the paeds DEM, it was hard to sleep because, well...old people. There was a lot of snoring and farting and middle-of-the-night painkiller administration, and I lay there, exhausted but wide awake, wishing more than ever that I was in my own bed in my own room.


I finally dropped off to sleep, but it wasn't long before a nurse came in to take my vitals. She commented that my blood pressure was low, and I explained to her -- like I had to all the others -- that it was always low and the systolic reading never went above 100mmHg. She relaxed, but got all worried again when she took my temperature -- I think she said it was approaching 39 degrees. Taking away my blankets, she left me with a damp paper towel on my forehead and bustled off. It didn't look like any paracetamol was forthcoming, so I went back to sleep.


A few hours later, I awoke to realise that I'd leaked onto the bed (in my defence, the pads they had given me were weird!). A nurse had been assisting the 96-year-old across from me, so I called her over rather shamefacedly and showed her what had happened. After checking that I didn't need a fresh gown -- I'd miraculously avoided staining it -- she left and returned pretty quickly with fresh sheets, 'knickers', and some proper pads. I got off the bed so she could change the sheets, and headed to the bathroom, clutching a pad and a fresh pair of disposable underwear.


I never made it to the bathroom. There was a sink right beside the door, and that was as far as I got because I suddenly became incredibly dizzy and nauseous. I grabbed hold of the sink, grateful for its double role as something to help steady myself and something to puke in should the need arise. The nurse walked by, telling me that my bed was ready for me, and I told her that I was feeling nauseous. That was when I started hyperventilating.


The nurse helped me back to my bed and I was crying at this point because What is happening to me why do I feel like this why is my mouth making weird sounds what's going on make it stop. She asked if I was having trouble breathing and kept asking me to tell her what I was feeling. I kind of had to step outside myself and take note of my breathing before I realised that I was actually hyperventilating, something I hadn't done or seen before; each new breath came before I was quite finished with the last, and each inspiration was a desperate, deep gulp of air. I knew I needed to stop.


"Are you having any trouble breathing at all? Tell me what you're feeling."


"I think I need to breathe slower," I choked out.


She made me breathe along with her, and when my breathing began to slow, she left me with a nausea bag for company (it looked a bit like an expanded N95 mask). As my breathing returned to normal, my worries took on a different route: I still really needed to go to the toilet, and now there was no one around to help me. I reached for the call bell and gave it a press.


A few minutes later, someone I'd never seen before came to my bed. She introduced herself as the overnight doctor and began to take a history from me again; she also conducted an abdominal examination. She left once she was done, and a nurse came to check my BP again -- the systolic was 102mmHg, which is pretty high for me. Hui Ning later told me she thought that the hyperventilation had been a compensatory mechanism to boost my super low blood pressure that caused the dizziness and nausea when I'd stood and begun to walk. It'd done the job, I guess!


I was then wheeled to the toilet in a wheelchair, did my thing, and a nurse helped me slowly walk back to bed. By this time, we were having breakfast trays brought to our beds. Waiting for me alongside my breakfast was the overnight doctor, who was wanting to take more blood to do bacterial and fungal blood cultures. After breakfast, I got some paracetamol for my fever.


Dr. Gary and the same team of interns as the morning before came by on their rounds. I told them I wasn't doing so well, and they nodded; I assumed they'd been informed of my little episode as well as the fever I'd spiked overnight. Dr. Gary said he would be ordering tests for EBV, CMV, parvovirus, and HIV. He mentioned HIV so tentatively, and actually seemed to be asking my permission first, which seemed strange to me. The dengue results, I was told, still weren't back and weren't likely to be 'for a few weeks', but the malaria screen had come back and it was negative. After Dr. Gary answered my questions, they stood around and discussed what other tests might be carried out or what medications might be given. "Prophylactic Clexane?" suggested the intern from India (I knew he was from India because he'd told me so while examining me in the DEM the night before). Dr. Gary agreed, and all the interns started furiously scribbling on their clipboards again. After that, they left, and I went to sleep.


I was determined to get a whole lot of rest and spend the day sleeping, and I think I did a rather good job. You'd have thought that, having spent the entire day just sleeping, I wouldn't have had a very interesting one, but that's the furthest thing from the truth; stuff kept happening, I was just asleep when they did. I was asleep when roommates were transferred elsewhere or discharged. I was asleep when the blood nurse came to get blood for the tests Dr. Gary had just ordered ("Again?!" I exclaimed, when she joked she was there for my blood). I was asleep when a male nurse came in to get respiratory swabs (nares and throat) from me to test for respiratory viruses. I was half-asleep when the same nurse came in to give me the prophylactic Clexane that had been suggested earlier; it turned out to be enoxaparin, a low molecular weight heparin used to prevent clots since it didn't look like I was going to be moving around very much. It was in the form of a subcutaneous injection, and so my newly-sore stomach and I cursed the nameless intern from India.


I was asleep when the same nurse came in to tell me I was being transferred into a single room to be isolated (since, as they hadn't figured out what was wrong with me, I might be contagious). I was also asleep when they transferred me back to 3B a mere few hours later. Chris and Sandeep came to see me, but I was -- as you might have guessed -- asleep. I got a whole lot of rest that day. Good job, self!


Being in isolation was weird. It was great because, there being no one else there, it was the most peaceful place I'd been in, hands down, and I was far too tired to feel lonely. Also, I had my own toilet (which didn't mean much since I still needed help getting to it). However, there were windows but no curtains, so there was zero privacy. But it was okay, because all I really wanted to do was sleep. After popping a pill for nausea, I was able to make it to the toilet alone. There, I discovered a rash on my thighs and showed the nurse, who went off to notify the doctor; people had been asking me over and over again if I'd had a rash anywhere, and finally there was something I could tell them. Hui Ning stood in the doorway (you had to gown up and wear a mask if you wanted to enter) and chatted with me as I had my lunch, and then I, well, went to sleep. I only woke up again when I was being transferred back to 3B.


Even though I was out of isolation, people still had to gown up and wear a mask if they wanted to get past my curtain. Someone from ID (Infectious Diseases) came in to get yet another history from and perform yet another examination on me, and she had to gown up and wear a mask. She didn't seem too pleased with her check for hepatomegaly, which made me uneasy. This whole gowning up plus mask thing was unnecessary, said Dhanushia, who'd come to see me, as my respiratory viruses swabs had come back negative. This meant that I wasn't contagious, but as they hadn't taken down the sign on my curtain, all visitors had to either gown up or talk to me from outside the border of the curtain. This was what Dhanushia was doing; it was also what Sandeep and Hui Ning opted to do when they came to see me later. After everyone left and after I'd had my fill of the Internet (thank God for 3G and data plans!), I decided there was nothing else to do but get ready for bed.


On my way back from the toilet, I was stopped by an apologetic nurse. One of my new roommates only spoke Chinese, and she was wondering if I spoke any Chinese at all as she wanted to tell her not to drink the water that came from the tap. "I can say it in Mandarin," I said quite happily (finally, some use for my rudimentary Mandarin!), but she said thought the lady only spoke Cantonese. We figured I'd give it a shot in Mandarin anyway, but my "Aunty, ni ke yi jiang hua yu ma?" was met with a blank stare and subsequently ignored. The nurse seemed finally managed to get the message across by herself in English and apologised to me again for having had to ask for my help.


The patient in the bed next to mine that night was this really old lady who used to be a nurse at the Royal. She was pretty much deaf because she hadn't brought her hearing aid with her, so there was basically zero privacy when the doctors or nurses came to talk to -- or, rather, 'yell to' -- her. (It was the same with every old person in my room, but it was especially bad with her.) She was unable to get up to use the toilet and seemed to be getting incontinent, wetting the bed once. I could smell it from my bed and wrinkled my nose as she croak-yelled her profuse apologies to the nurse. Just as I was marvelling at the nurse's patience and wondering how they dealt with this stuff every day, the nurse said (yelled) something that really struck me: "It's okay. One day this'll be me."


Obviously, this scenario was far more pertinent to the nurse as the old lady had also been a nurse in the very same hospital. If you think about it, though, that's more or less how we're all going to end up, if we're lucky enough to survive that long. Why the disgust? Why the embarrassment? It's only human, and ageing is no fault of ours. Still, that hospital stay gave me a newfound respect for nurses -- good nurses -- because of all the things they go through, seemingly so cheerfully. I'd encountered some really excellent nurses while I was there, and I'm grateful to them for giving me much to think about and for making my stay there that much more bearable.


Later, I was lying in bed unable to sleep (due to having slept all day) when it hit me: 'Mm oi yum'. 'Don't drink' in Cantonese. D'oh! I later learned that the lady was originally from Hong Kong and had been in Australia for 40 years. This kind of really blew my mind, because how do you not pick up basic conversational English in that amount of time? I still don't quite understand it. Oh well.


It had been an eventful day, and the next was to start out pretty eventfully as well.


Early, early in the morning, a nurse came to take my vitals to fill in the ADDS chart at the foot of my bed. ADDS stands for 'Adult Deterioration Detection System'. The chart has a few components to it (heart rate, blood pressure, breathing rate, oxygen sats, etc) which are scored and then added together to give you an ADDS score. Low is good. The higher it gets, there are different procedures the nurses have to carry out, ranging from watching and waiting to placing a MET (medical emergency team) call. However, if any one of those components is in the danger zone as indicated on the chart, the nurse is meant to place a MET call right away.


I mentioned earlier in this post that I have naturally low blood pressure, the systolic reading of which pretty much never went above 100mmHg. You can probably guess where this is going.


Well, the nurse took my temperature like normal and clipped the oxygen sats clip onto my finger like normal and wrapped the blood pressure cuff around my arm like normal. What was not normal, however, was my blood pressure. I wasn't able to see the screen since it was turned to face him, but the nurse was frowning at it very hard. I told him like I had the other nurse that my blood pressure was usually low, and he replied that this was really low. He decided to try again. Again, I wasn't able to see the screen, but I did see the expression on his face, which did not look promising. He began to chuckle nervously, saying that if it didn't go up above 90mmHg he would have to place a MET call, which he was obviously very reluctant to do. He adjusted the bed such that my legs were positioned higher than my head (in the hopes of sending more blood back to my heart or something, I guess), and left me like that for a while as he bustled off to do other things.


Having sensed the nurse's reluctance, I decided that I did not want to have to have him place a MET call. I cast my mind about for something stressful or scary to think about in an attempt to raise my blood pressure. As I was thinking, my eyes fell on my cannula, and they lit up instantly; cannulation had been both stressful and scary -- perfect! The next few minutes was spent psyching myself out by thinking over and over that if I didn't get my blood pressure up, they were going to have to put in a new cannula. And how awful would that be, how much had putting this one in hurt? Surely they would miss and try multiple times again, and this time Hui Ning wouldn't be there to hold my hand/allow me to crush every bone in her fingers. All this probably sounds a bit silly, but it (or maybe the change of positioning, or both) worked! After the nurse had breathed a long sigh of relief, scribbled down the reading in the ADDS chart, and left, I swivelled the screen around so I could see it: my blood pressure was 92/67mmHg, oxygen sats were 99%, and heart rate was 112 beats per minute. That last bit might've been because I was sick or a testament to how much I'd freaked myself out with the cannula thing -- normally, my heart rate is around 65 beats per minute.


A few hours later, the usual group of interns plus a few I'd never seen before came to see me. I was still halfway through my breakfast and surprised to see them there so early, without Steven or Dr. Gary. They kind of just hovered at the border of the curtain, staring at me, and so I stared back at them, torn between amusement and feeling like an animal at the zoo. "No one likes gowning up," one of them finally said apologetically, gesturing to the isolation card still hanging from the curtain rail. In the end, the intern from India bit the bullet and took one for the team, gowning up to examine me and have a look at the rash I'd reported yesterday. They left then, and I continued with my breakfast, appetite somewhat diminished after the uncomfortable abdominal palpation (not that he'd been rough, it's just that abdominal palpation is never pleasant).


A nurse came with another dose of Clexane, and I warded her off with "If I've been moving around and stuff, do I really need that?". She agreed to put it aside till I asked my doctor if I still needed it. As it turned out, I didn't! An intern came to my bed a little later and said that Dr. Gary was happy to let me go as the fever hadn't been back over the past 24 hours. Knowing that it would be some hours before I actually got to leave, I forced myself to contain my excitement and be patient, taking my time to pack my belongings. The blood nurse came to get blood samples from everyone in the room; I thought this odd since I was being discharged, but went along with it anyway. Another nurse came to remove my cannula, which I was delighted about as I hadn't been able to bend my left arm in three days! I tried to as soon as she left, but blood spurted out of the open hole, so I stopped. I tried again a little later on and found that I couldn't bend it beyond 90 degrees, which was a little unnerving. It made me wonder how long muscles took to atrophy. I mean, it wasn't like I had killer biceps to begin with.


Yuen Peng and Olive came over and walked me home, helping me carry my belongings and new meds (paracetamol for fever and metoclopramide for nausea). What would've normally been a three-minute brisk walk turned into a long, arduous trek on account of my being ridiculously weak; I was glad to be able to stop for a bit at the traffic lights right outside the hospital. Getting to my room took a while as it involves going up three flights of stairs, but I made it eventually. After my first shower using non-hospital soap in days, I very happily sank into my own bed and slept.


I awoke hours later to an SMS from Dr. Gary. The blood test results from that morning had come back, and both my platelet and neutrophils counts were low (low platelets meant I was at risk of spontaneous bleeding, and low neutrophils meant my immune system wouldn't be able to deal with viruses and bacteria and stuff as efficiently as it normally would). If this persisted, I would need to go back to the hospital. My heart sank, down past my toes, down the three flights of stairs I'd laboured so hard to climb. Also in his message, he told me to go to Pathology South at the Wellington Center in a couple days to get more blood taken; hopefully, my platelet and neutrophils counts would've gone up by then and I wouldn't have to be warded again.


I obediently did as I was told, and Jac was kind enough to come with in case I collapsed or started spontaneously haemorrhaging or something. Fortunately, the counts did go up, so I was spared from having to go back to the hospital. The dengue serology results from Melbourne came back, with the presence of NS1 antigens confirming the diagnosis of dengue; I'll never know which strain, though, since they don't do those tests in Australia. Days after my discharge, I received a call from the Australian Department of Health. Dengue is a nationally notifiable disease, so they wanted more details about my case, which I was very well-versed at regurgitating by this point. Despite having been discharged in the middle of the week, I ended up missing an entire week of uni on account of feeling really, really tired all the time (the first time I was able to make it up all three flights of stairs to my room without stopping, I did a little mental jig -- mental because I lacked the energy to do a physical one). It took two weeks for the constant fatigue to begin to slowly wane. What is it with viruses and causing extreme tiredness? Such an inconvenience.


Dengue is horrible and I wouldn't wish it on anyone. There were definitely some low points in the hospital, especially when nobody knew what it was I had and they took more and more blood to do more and more tests when my condition deteriorated. Nevertheless, this was an experience from which I learned many things -- most importantly, what it's like to be on the other side of the hospital bed. Not to sound all reflective piece-y and stuff, but I hope this new knowledge will help make me a better medical student and doctor in the future. If nothing else, at least I know I'll have my travel history down pat!


--


Not to brag or anything, but we had to take a travel history from a patient for our DOCS/mock OSCE in the Medicine rotation this year, and I absolutely nailed it. Also, we started off Sem 2 with a series of lectures on global health, including lectures on dengue, which I grinned throughout. Questions on dengue are bound to come out at the end of the year as well, so I'm looking forward to (hopefully) actually definitely knowing the answers to things. It really was a blessing in some ways, this experience. It was awful, but I'm thankful.


This has been a ridiculously long post and took like five days to write and edit. If you've made it through all the way, thanks very much for reading!



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