Many questions after woman dies in spite of anti-rabies vaccine

I am a doctor, a graduate from the University of Colombo who has been working overseas for the past 10 years.

Whenever I visit Sri Lanka there are several friends and relatives who ask me for medical advice. I would like to mention two patients whom I came across, both of them close to me, one being my father-in-law and other a person who has been living with my in-laws for nearly a year.

This lady was diagnosed with advanced breast cancer. We will call her Sriya, which is not her real name. Her disease also involving her hip caused a fracture. Sriya was treated at the Cancer Hospital Maharagama. I noticed that she was in severe pain due to her hip fracture, thus inquired what pain killers she was taking. To my shock I found out that she was only prescribed panadeine ( combination of paracetamol and codeine) and diclofenac. From experience I know these medications are not strong enough to manage her pain. She was never prescribed stronger pain killers despite having a terminal condition.

In a desperate attempt I tried to purchase stronger pain medications from a local pharmacy but was told by the pharmacist with a surprised face that he has never heard about it. Further inquiries revealed that tramadol is available via State Pharmaceutical Corporation outlets with a prescription from a consultant. Even then only two weeks supply can be dispensed. Sriya went on to suffer till the last days of her life and was finally prescribed oral morphine via the Cancer Hospital.

My father-in-law who had several advanced medical problems, towards his last days developed blockages in his leg vessels and was deemed inoperable. He too went on to suffer till his death with only 50mg of tramadol per day to alleviate pain while parts of his leg fell off.

Confused and traumatised about the whole situation I asked my doctor colleagues working in Sri Lanka about the policy on pain management and end of life care. What I gathered is depressing. As a doctor treating cancer patients I have been exposed to many patients who are dying of their cancers. End of life care or palliative care is a separate speciality in many developed countries with medical practitioners sub specialised in the area. We do not have such a sub speciality in Sri Lanka, but at least basic knowledge about pain and symptom management is know-how for any doctor.

In terminal medical conditions which are by no means limited to cancers, we ultimately come to an end point where we cannot do anything medically to prolong life. The situation is easy to explain with cancer patients due to the nihilistic attitude towards cancer patients in the country, yet think about a patient suffering from extensive lung damage due to smoking or a patient having heart attacks where nothing more can be done due to extensiveness of disease or other medical problems. In my father-in-law’s situation it was blocked arteries in his legs which could not be corrected due to multiple other intervening medical problems.

In my experience when I come across such patients I explain to them that further medical intervention is not going to prolong their life. Most of these patients, if being treated properly know their condition is going to take their life one day. The inevitable next question from my patient is ‘doctor am I going to suffer?’

The answer should not be difficult. Why should anyone suffer if it can be avoided?

Reading this article, we all think that it’s not going to happen to us.

The bad news is we all have to go some day and with the mod- ern medical interventions it is more likely that we will end up facing this dilemma. In order to address this, it is important to get the attention of educators, and policy makers. The current almost non-existence of potentially addictive drugs for medicinal uses is shocking. We have to restrict access and closely monitor use of these drugs, yet does that mean we have to suffer a painful death?A patient who is facing this question is very likely to be you some day.

These are things that I feel needs to be addressed in a very broad sense.

Proper management of terminally ill patients has to be taught at medical schools.

Current medical professionals have to be educated about proper management of terminally ill patients.

Medications to manage pain and other symptoms should be more accessible to doctors.

Wider discussion is needed to change the thought process of the general public. ‘When that day finally comes, do you want to leave this life in peace, at home, surrounded by your loved ones or do you want to be in agonizing pain, in a busy hospital bed? Dr. Mihitha Ariyapperuma

Western Australia

The number of people affected by stray dogs seems to increase day-by-day throughout the country. Among such incidents, the death of a resident of Alvai, Jaffna, on December 10 who had been afflicted by rabies, has created panic among the citizens of Jaffna.

This lady was severely bitten by a stray dog while returning home after visiting one of her relatives nearby, a month before. She was rushed to the Point Pedro base hospital and got herself administered with the Anti-Rabies vaccination. Her wounds were cured and she had been moving about till the beginning of December, 2016. But suddenly, she was stricken by an unidentified fever and was admitted to the Jaffna Teaching Hospital where she died in the morning hours of December 10.

The unanswered question among the public is why she died, even after she had received the Anti-Rabies vaccination? The hospital authorities have labelled the death as ‘one in a billion cases’. But the family members, relatives and the citizens of the region sadly question, ‘Why did she become that one in a billion case?’

Their desire is that such an unfortunate incident should not happen to another citizen of this country in future. The unwritten plea is that the hospital authorities should forward a report on this matter clarifying the reason behind the death. It is certain that such an explanation would reduce the phobia towards stray dogs and lack of confidence in the Anti-Rabies vaccination that has emerged among the citizens of Jaffna Peninsula just after this death of an innocent civilian. S.Varahan Jaffna

APPRECIATIONS