Rabies and the miracle of ‘Starfish’ palliative care

I was back in Manila, headed towards San Lazaro hospital, a veritable mecca for Infectious Diseases in the Philippines.

 

Stepping down onto the platform of the LRT (Light Rail Transit) into a throng of people, the thick humid air  descended on me immediately.  The steam bath was oppressive.  I pushed through the crowds, cringing as the train screeched away.

 

I worked my way through the turnstiles, passing a gaggle of beggars dressed in rags with dirty, tousseled hair.  Mostly young children, four, five years old.  What a future…  Motorcycles sputtered by like annoying kazoos.  Sometimes 4 or more people were seen variously packed onto these bikes.  How they ever didn’t fall off, I wasn’t sure.

 

Hulking shiny metal jeepneys, brightly hand painted, revved up and down the roads.  Filthy soot belching from their exhaust pipes.  Most of the female passengers held handkerchiefs to their faces to limit the particulate inhalations.  Ten, twenty, maybe even more passengers were crammed into the back.  Hundreds of children in school uniforms, everywhere, walking linked together at the arm.

 

I looked up at crowded houses and shops, laundry-lines criss-crossing the skies.  Webs of hundreds of wires interconnecting everything – it was an electricians worst nightmare.

 

This was my new home for the next month, and I just loved it.  Despite the outward appearances of an over urbanized mega-metropolis, the human heartbeat of Manila was palpable all around….

My first patient with rabies

I will always remember Joey, the first patient
I ever saw with rabies.

I was a medical resident on a rotation at San Lazaro Hospital, in the heart of Manila, 10,000 miles from home.

Joey was a small boy, not more than 5 years old. Two months ago, he suffered a dog bite on his leg from the neighbor’s puppy. It was just a small nip in the skin, with only a few drops of blood produced. The puppy seemed alright, but it died a few days later – seemingly a victim of the stifling Manila heat. The parents struggled to make ends meet for their family of 5, it would be too much to take Joey to see a doctor – instead they would visit a local faith healer.

After some incantations and a procedure where a black porous stone was affixed to the wound (tandok), the family felt reassured rabies would not strike. The family had heard of rabies, but trusted the faith healer, as he proclaimed to have saved many lives from that cursed illness.

When Joey started to get sick 7 weeks later, the parents thought it was just a cold. He didn’t have much appetite and had some headache. A few days later he had some fever and felt tired. Then, he started to complain about itching on the leg where he had been bitten before. That night, he didn’t eat any dinner. His older sister thought he should at least try to drink something, so she brought him a glass of water. Joey suddenly shrieked and held his hand to his mouth when he saw the water, trying to get away from the threat in front of him. Terrified, the mother realized her son had rabies!

Hoping for a miracle…

Sheila was just a 7 year old kid.

I met her at San Lazaro Hospital, the Infectious Diseases and Tropical Medicine referral center for the Philippines. I had just arrived there to observe the practice of Infectious Diseases that are rare but important in the States – tetanus, bacterial meningitis, measles….

Sheila had come in for treatment, after experiencing difficulty swallowing at home. She was from Bulacan, a province in the southern part of Luzon.

Nine weeks earlier, she had been attacked by a dog. The dog had bit her on the right arm, and died a week later. Her mother had taken her to a local ‘herbalario’ because of the fear of rabies.

A herbalario is a practioner of ‘folk medicine’ and uses various herbs, incantations and concoctions to try and effect a cure. Although not formally trained in medicine, they are respected in their communities. Their rituals have a certain credibility, born out of an ingrained belief in the supernatural. Certainly, for some diseases, such as ‘coughs and colds’, a mentholated poltice or other vile remedy might actually work or ameliorate symptoms. Not for rabies though, which mandates appropriate medical treatment to prevent disease.

Rabies is 100% fatal, and any miscalculation can prove deadly.

Unfortunately, Sheila was showing the physical sign of hydrophobia. When she drank water from a cup, she recoiled with spasms of choking and reported chest pain. When I saw for myself this reaction, my heart sank because I knew she would die.