International Medicine Center (IMC)
Doctor at a Distance
We were closing up for the week on Friday when the call came in at 3:34PM that would change the weekend. An official of a U.S-based energy company with operations in Angola, Africa was in trouble, dire trouble. He had been calling hospitals and medical facilities throughout Houston all day, with no way to engage the expertise needed as a life was about to end in a seaside hospital in Cancun, Mexico.
Apparently, a 31yr-old woman, who was an employee of the company, had traveled to Cancun for holidays. She had developed malaria and was comatose and on a ventilator in the intensive care unit. She had cerebral (brain) malaria, almost certainly originating in Angola. She had been hospitalized 2 days and the physicians were only familiar with the more benign malaria in Mexico. Their antimalarial medications were only oral/and unreliably absorbed from the GI tract of someone so ill, and likely ineffective against Angolan falciparum malaria, the diagnosis by blood smear. Dr. Rensimer told the company official that the situation was grave and time was of the essence. IMC would do what it could, but it was very uncertain what could be achieved on a Friday evening as the medical system went after-hours like everything else. The official was grateful that anyone would even try to help.
Dr. Rensimer immediately talked with Dr. Rojas at the Cancun hospital.
First-off, he reviewed the hospital pharmacy’s anti-infective medication formulary. They had oral doxycycline and intravenous clindamycin. Dr. Rensimer told Dr. Rojas to start those immediately, as those were acceptable 2nd-line drugs for African falciparum malaria. He also discussed exchange transfusions (draining off the patient’s infected blood, to be replaced by stored, clean blood), should the patient’s parasite blood levels (parasitemia) be extreme. There was no time for hesitation or error. This patient was at risk to die at any minute; almost certainly she would not make it through the weekend. Dr. Rojas was told we would come up with an action plan and call him back shortly.
Dr. Rensimer turned to IMC’s in-house staff, pharmacist Matt Parris, R.Ph., and Ruth Gochenour, RN. Ruth was to immediately contact company officials to see if someone were available to transport medications to Cancun that night. Matt was to see if he could collect a one-week supply of quinidine gluconate (IV) and doxycycline (IV), with instructions written in English and Spanish for their preparation and administration IV. Quinidine gluconate was the medicine of choice and extremely hard to locate (currently only available directly from the Centers for Disease Control in Atlanta, GA).
Within 45 minutes, the needed medications were found at several sites throughout Harris County. Provision was made for their immediate delivery to IMC and kits for medicine transport were made, including documents for airline and immigration officials to explain the urgent medical necessity. An official from the company arrived and headed to the airport for the 8PM flight to Cancun after IMC gave him the critical medicines.
By 6:55PM, Dr. Rensimer called Rojas to inform him of the medications that were on their way. He discussed all the details on safe preparation and administration, as well as the essential issues in stabilizing the patient in order to buy time for the en route medicines to work. Her projected mortality rate was in excess of 90%.
On Saturday, at 11:13AM, Dr. Rensimer called Dr. Rojas. The medications had been started the night before at 11:30PM, 8 hours after IMC first contact and in another country. Dr. Rojas felt the patient had improved somewhat, yet she was on a ventilator and IV medications (dobutamine and dopamine) to support her shocky blood pressure. She had infiltrates in her lungs suggesting pulmonary edema. Her platelet count was 40,000 (normal 150,000), suggesting the severe coagulation disorder associated with fatal malaria. Her parasitemia level (blood concentration of parasites) was greater than 15% of her red blood cells (over 5% is considered severe, often fatal). Dr. Rojas was to monitor this value every 6 hrs. If it or the patient should worsen, he should perform exchange transfusions.
Dr. Rensimer talked with Dr. Gomez (covering physician) at 7:45PM, Saturday. The patient appeared to be improving clinically, emerging from her coma for the first time by spontaneously opening her eyes. Her platelet count had stopped declining, settling at 50, 000.
At 7:55PM, Dr. Rensimer updated the status with the company official. Her parents were on their way to her from her home in Lisbon, Portugal.
On Sunday, 12:04PM, Dr. Rensimer called Dr. Gomez. The patient had been awake since 4AM.She was still on the ventilator, but seemed to understand conversation. Her blood pressure was rising toward normal and support medications were being tapered. Her chest X-ray had improved.
On Monday, 9:45AM, Dr. Rensimer discussed the case with Dr. Larios (Internal Medicine, Cancun). The patient’s heart rate had dropped to 40/minute and her electrocardiogram showed acute conduction defects. Dr. Rensimer told him to immediately stop the IV quinidine gluconate which can have fatal effects on cardiac conduction. The malaria disease was responding, but there was now a clear risk of killing the patient with a medicine the local doctors had never used. As so often happens in complex, high-risk cases, just as improvement of the main presenting problems occurs, ironically, a complication threatens to kill the patient on the way to recovery, sometimes related to the life-saving treatment. Physicians working at this level of medicine must be vigilant about this precarious prospect. You don’t rest, intellectually, until the game is over.
Dr. Rensimer talked with Dr. Rojas at 6:35PM. The patient’s brady (slow) arrhythmias were responding to atropine IV, as the quinidine slowly made its way out of her cardiac conduction system and body. The malaria would need to be monitored every few hours for relapse and exchange transfusion would be done with any backsliding.
On Tuesday, 6:15PM, Dr. Larios told Ruth Gochenour, RN, that the patient’s parasite level had decreased to 5% and her platelet count had increased to normal, 150,000. Her chest X-ray had cleared and she was off the ventilator. 4 days after IMC started case management, it appeared the patient would survive substantially intact.
On Thursday, 5:45PM, Dr. Rensimer talked with Dr. Larios. The patient was doing excellently, off the ventilator, alert and intelligent, with full body movement and no apparent neurological damage, despite having been in deep coma for days with marginal blood pressure. There were no more cardiac arrhythmias. Her blood smears still showed 7% parasitemia, but mostly inactive (killed) forms.
Nine days later, the patient returned to Lisbon with her parents, totally recovered. No one at IMC ever met or talked with the patient.
CONCLUSION: This case report is intended to show the power of information, expertise, and communication. A life was saved because of timely, deliberate, and purposeful action and coordination and follow-up of the highest level of care. This is medicine at its best and it is only one of many IMC stories.