She came with her father-in-law. Wasted and pale, she looked withdrawn, dejected, and lethargic. They were from a village in Kavrepalanchowk. Her husband was away for a labor job in a Gulf country. For the past several months, she was having fevers, poor appetite. As it became disabling, she came to our hospital and was admitted for evaluation. Her fevers persisted. The only clue to her disease was the finding of an enlarged spleen. But several diseases can cause enlarged spleen. Even after several days of hospital stay, multitudes of non-invasive and invasive tests, a cause could not be pinpointed. So our hospital team decided to discharge her from the hospital and have the results followed-up as outpatient.
As outpatient, she had several more visits and a battery of additional tests. Her fevers persisted. On this visit, they came with the results of all these tests. I went through each of these tests. They were essentially normal, one after another. I told them that these tests did not tell us what was making her febrile.
At this stage, her father-in-law entered the pleading mode. Help us, please. We have exhausted our money in quest for the cause of the fever. Almost 40,000 rupees have been spent so far. We have been staying in a hotel to have these tests done and fevers haven't budged. We can not afford to stay longer. What are we to do?
Fever is not an endocrinologist's forte. On top of that, one trained in North America. In these shores, where shit infuses drinking water, cattle and humans share abode, almost infinite souls share a crammed room breathing each other's exhaled air, flies cruise feces and foods, mosquitoes camp between man and animals, weirdest of the bugs can cause weirdest of the fevers. A specific diagnosis is a mammoth challenge. Furthermore, my patient is in desperate financial predicament. Any further testing would be adding salt to their sores. What am I to do?
Many of my patients who come with fever also have tight purses, limiting exhaustive investigations. In desperate attempt to deal with these fevers, I have developed my own way of looking at fevers. The way I see it is, what treatment are these fevers most likely to respond to. For this, I put them in broad categories. Are they, for example:
- Feces fever (caused by microorganisms found in feces)
- Viral fever
- TB
- Tarai fever (caused by several parasites)
- Non-infectious fever, etc.
Another big category I have invented is doxycycline fever. This pseudo-scientific category includes a whole bunch of fevers caused by atypical organisms that respond to an antibiotic called doxycycline.
After talking to the patient and examining her, I tentatively put this patient as having doxycycline fever. But as you may guess by my wobbly expertise on fevers, I can never be confident. What if this patient deteriorates? There is every likelihood that I will never see this patient, even if this patient is visiting my hospital everyday, just because of the way disorganization works here. Patients bounce back and forth between departments without someone taking up a responsibility. If she goes home, which she is highly likely to do because of financial issues, who knows what happens in some remote corner of Kavrepalanchowk? So I asked them if they have cell phones. Both the father-in-law and my patient had cell phones. I took their numbers and explained to them that I want to try a medication which she can take at home. I told them they have to come to the emergency room if fevers do not go away in 1 week. Otherwise, I will call them in 2 weeks. I put a diagnosis of ?Brucellosis on my chart and prescribed her doxycycline.
At 2 weeks, I called her. She sounded perked up, and rather overwhelmed that I called. She said she was doing very well. Fevers were gone, her appetite was up, she felt that she was back to her normal.
It was a big relief. Based on the results, this might sound like a wise decision but it is hardly that clear at the time of decision making. We call this empiric treatment. A treatment decision made based on hunches without hard evidences. Especially in academic setup, like the one I work at, this is frowned upon. Primarily because we see patients everyday who are indiscriminately put on many medications without compelling reasons. We emphasize to our students and trainees that there should be evidences and compelling reasons to make treatment decisions.
Yet, when you face social and financial constraints to do expensive investigations you will have to make decisions on empiric treatments based on your clinical judgement. It is a fine balance of how much to investigate and when to treat empirically. For short term illnesses like these febrile illnesses, I am getting much more inclined towards empiric treatments. It's hardly relevant to the patient if the fever was caused by Brucella or Leptospira or Mycoplasma. If the fever goes away and they can get along with their normal lives, structure of the cell membranes of these micro-organisms hardly disturbs their dreams.
As everything else in life, diseases do not always submit to clarity. This demands for an approach which is equally fuzzy. Perhaps this is when the realm of the art of medicine starts.
As outpatient, she had several more visits and a battery of additional tests. Her fevers persisted. On this visit, they came with the results of all these tests. I went through each of these tests. They were essentially normal, one after another. I told them that these tests did not tell us what was making her febrile.
At this stage, her father-in-law entered the pleading mode. Help us, please. We have exhausted our money in quest for the cause of the fever. Almost 40,000 rupees have been spent so far. We have been staying in a hotel to have these tests done and fevers haven't budged. We can not afford to stay longer. What are we to do?
Fever is not an endocrinologist's forte. On top of that, one trained in North America. In these shores, where shit infuses drinking water, cattle and humans share abode, almost infinite souls share a crammed room breathing each other's exhaled air, flies cruise feces and foods, mosquitoes camp between man and animals, weirdest of the bugs can cause weirdest of the fevers. A specific diagnosis is a mammoth challenge. Furthermore, my patient is in desperate financial predicament. Any further testing would be adding salt to their sores. What am I to do?
Many of my patients who come with fever also have tight purses, limiting exhaustive investigations. In desperate attempt to deal with these fevers, I have developed my own way of looking at fevers. The way I see it is, what treatment are these fevers most likely to respond to. For this, I put them in broad categories. Are they, for example:
- Feces fever (caused by microorganisms found in feces)
- Viral fever
- TB
- Tarai fever (caused by several parasites)
- Non-infectious fever, etc.
Another big category I have invented is doxycycline fever. This pseudo-scientific category includes a whole bunch of fevers caused by atypical organisms that respond to an antibiotic called doxycycline.
After talking to the patient and examining her, I tentatively put this patient as having doxycycline fever. But as you may guess by my wobbly expertise on fevers, I can never be confident. What if this patient deteriorates? There is every likelihood that I will never see this patient, even if this patient is visiting my hospital everyday, just because of the way disorganization works here. Patients bounce back and forth between departments without someone taking up a responsibility. If she goes home, which she is highly likely to do because of financial issues, who knows what happens in some remote corner of Kavrepalanchowk? So I asked them if they have cell phones. Both the father-in-law and my patient had cell phones. I took their numbers and explained to them that I want to try a medication which she can take at home. I told them they have to come to the emergency room if fevers do not go away in 1 week. Otherwise, I will call them in 2 weeks. I put a diagnosis of ?Brucellosis on my chart and prescribed her doxycycline.
At 2 weeks, I called her. She sounded perked up, and rather overwhelmed that I called. She said she was doing very well. Fevers were gone, her appetite was up, she felt that she was back to her normal.
It was a big relief. Based on the results, this might sound like a wise decision but it is hardly that clear at the time of decision making. We call this empiric treatment. A treatment decision made based on hunches without hard evidences. Especially in academic setup, like the one I work at, this is frowned upon. Primarily because we see patients everyday who are indiscriminately put on many medications without compelling reasons. We emphasize to our students and trainees that there should be evidences and compelling reasons to make treatment decisions.
Yet, when you face social and financial constraints to do expensive investigations you will have to make decisions on empiric treatments based on your clinical judgement. It is a fine balance of how much to investigate and when to treat empirically. For short term illnesses like these febrile illnesses, I am getting much more inclined towards empiric treatments. It's hardly relevant to the patient if the fever was caused by Brucella or Leptospira or Mycoplasma. If the fever goes away and they can get along with their normal lives, structure of the cell membranes of these micro-organisms hardly disturbs their dreams.
As everything else in life, diseases do not always submit to clarity. This demands for an approach which is equally fuzzy. Perhaps this is when the realm of the art of medicine starts.
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