Case report: A patient with malaria at the emergency department

Highlights

• Language barriers may hinder the patients’ understanding of the importance of malaria prophylaxis.

• It is crucial that malaria is suspected in anyone who has returned from a malaria endemic area: it only takes one bite to contract malaria.

• Patients with suspected or proven malaria should be encouraged to seek early attention and to attend a hospital directly.

• A safety net including GP and ED staff ensuring the prompt arrival of patients with suspected malaria can be lifesaving.

Introduction

This case describes the delayed presentation of a patient with Plasmodium Falciparum (P. Falciparum) malaria to the emergency department (ED), and subsequent nursing care. It also discusses the apportion of responsibility for a patient to arrive promptly at the ED, as clinically required, after referral by a General Practitioner (GP). Furthermore, the case discusses the relevance of the patient-physician relationship for determining responsibilities.

A 62 year old lady presented to her GP with a two day history of fevers in the evening. The presentation to the GP occurred on July 13th, 12 days after she had returned to the Netherlands following a 5 day trip to Kinshasa, Democratic Republic of Congo. The patient denied any immunizations received before traveling.

The referral note from the GP provided the following information about the patient’s initial visit: ‘The patient is nauseous and has vomited once; her blood pressure is 117/62 mmHg, she has a pulse of 100 beats per minute (BPM), and an oxygen saturation of 99% on room air; her throat appears red’. Since the patient had no headache nor peaking fever, no further actions were undertaken by the GP at that time.

Five days later the patient contacted her GP again, now complaining of fever, headache, muscle ache, and fatigue. She had no chest pain or respiratory complaints. The GP visited the patient at home. Physical examination did not detect any abnormalities. The GP ordered lab tests including malaria blood smear and dengue rapid test.

Few hours later, the GP was called by the hospital microbiologist who told him that patients’ blood smear was positive for malaria caused by P. Falciparum. According to the microbiologist, eligibility for home treatment depended on her clinical signs and symptoms. The patient told the GP that she was feeling sick and tired, so the GP referred her to the hospital ED at 16.30 after he consulted the internal medicine specialist of the day shift. The GP sent a referral note to the ED by fax machine addressed to the consultant internal medicine.

Desk clerk Deanne (name used with permission), who had started her shift at 17.00, noticed at 18.00 that the patient still had not arrived at the ED. Deanne first called the patient at her home: no answer. To check whether the patient might have gone to another ED, Deanne called all EDs in the city and surrounding cities: the patient had not presented at another hospital. Then Deanne obtained the mobile phone number of the GP who had referred this patient: unfortunately, he was unreachable. Meanwhile, it was 22.00 and Deanne contacted the police to request that they pay a visit at the patients’ house. Nobody answered the doorbell. After a brief telephonic discussion between the policemen, Deanne, and the coordinating emergency nurse, it was decided to let the police force the door of the patients’ apartment. Policemen found the patient lying unresponsive in her bed. Upon arrival of the ambulance, 10 min later, the patient had regained consciousness. She was transported to the ED resuscitation room, arriving at 01.37 in the night.