Undiagnosed Human Rabies Deaths?

[Skeptic Ginger]

Lets figure out exactly how many cases of encephalitis from an undiagnosed cause end up being donors before we mention numbers like a couple million.

I was referring to all donor candidates, not all candidates with encephalitis.

We don't know that this patient had an undiagnosed cause of encephalitis. A wrong diagnosis, probably, but not an undiagnosed cause.

I doubt very many, if any, patients with undiagnosed encephalitis are candidates for organ donation. In the first example the patient was diagnosed with a subdural hematoma. And in the current case we only know what the newspaper said and that the CDC did say encephalitis in the preliminary summary of the incident.

I find it very difficult to believe any patient with an unknown cause of death where a pathogen is even remotely suspected is going to be an organ donor candidate.

So in your scenario, if you are only talking about patients with an unknown cause of encephalitis, I don't believe they would be a viable donor candidate. AFAIK, the donor candidate would have had a non-infectious cause diagnosed so there would be no reason for a rabies screen. And head injury (including hematoma) is going to be the cause of death of a large proportion of organ donors.

There's more to this story than we have here.

 

[Robin1]

I was referring to all donor candidates, not all candidates with encephalitis.

We don't know that this patient had an undiagnosed cause of encephalitis. A wrong diagnosis, probably, but not an undiagnosed cause.

I doubt very many, if any, patients with undiagnosed encephalitis are candidates for organ donation. In the first example the patient was diagnosed with a subdural hematoma. And in the current case we only know what the newspaper said and that the CDC did say encephalitis in the preliminary summary of the incident.

I find it very difficult to believe any patient with an unknown cause of death where a pathogen is even remotely suspected is going to be an organ donor candidate.

So in your scenario, if you are only talking about patients with an unknown cause of encephalitis, I don't believe they would be a viable donor candidate. AFAIK, the donor candidate would have had a non-infectious cause diagnosed so there would be no reason for a rabies screen. And head injury (including hematoma) is going to be the cause of death of a large proportion of organ donors.

There's more to this story than we have here.

May be more to the story... but so far the story is most definitely that the donor was indeed diagnosed with encephalitis of unknown origin. And that is huge! We'll see if it changes.

 

[Skeptic Ginger]

May be more to the story... but so far the story is most definitely that the donor was indeed diagnosed with encephalitis of unknown origin. And that is huge! We'll see if it changes.

How do you know "unknown origin" was the final diagnosis?

 

[Robin1]

How do you know "unknown origin" was the final diagnosis?

Final schminal....doesn't matter. If donor was still suspected of having encephalitis of unknown origin at the time of death his organs should not have been donated. Or they could have proceeded with the organ donations using the procedures I suggested in a previous post. There's a lot to be said for plain old common sense.

 

[Skeptic Ginger]

Final schminal....doesn't matter. If donor was still suspected of having encephalitis of unknown origin at the time of death his organs should not have been donated. Or they could have proceeded with the organ donations using the procedures I suggested in a previous post. There's a lot to be said for plain old common sense.

How do you know 'unknown origin' was the diagnosis at the time of death?

I think you have a misunderstanding of the organ donor system. It's not that careless or sloppy.

 

[Robin1]

How do you know 'unknown origin' was the diagnosis at the time of death?

I think you have a misunderstanding of the organ donor system. It's not that careless or sloppy.

I think the organ recipient who died needlessly of rabies would beg to differ. And the 3 other organ recipients currently on anti-rabies shots. And the hundreds of people who are currently being assessed for possible need of anti-rabies shots etc.

 

[Skeptic Ginger]

I think the organ recipient who died needlessly of rabies would beg to differ. And the 3 other organ recipients currently on anti-rabies shots. And the hundreds of people who are currently being assessed for possible need of anti-rabies shots etc.

You didn't answer the question, how do you know 'unknown origin' was the diagnosis at the time of death?

And what hundreds of persons would that be? Surely there weren't hundreds recipients of this person's organs.

 

[Robin1]

You didn't answer the question, how do you know 'unknown origin' was the diagnosis at the time of death?

And what hundreds of persons would that be? Surely there weren't hundreds recipients of this person's organs.

I did answer the question....remember "final schminal?"...I mean who could forget that ridiculous quote?! : )
Doesn't matter, if by final diagnosis you mean "cause of death" on death certificate. My Dad most certainly had herpes encephalitis which definitely caused his death( would not have died without it causing other health issues) but on death certificate it only lists herpes encephalitis as a contributing factor in his death. If donor was suspected AT ALL at time of death as having encephalitis of unknown origin, organs should not have been donated ( certainly not without anti-rabies shots). Actual final diagnosis or cause of death could be different for donor ( as with my Dad) but would not change the fact that encephalitis of unknown origin was diagnosed and present in his body and should have set off alarms to doctors in terms of his being an organ donor. Unless of course the story changes.

 

[sol]

betcha? well... im convinced.

 

[Robin1]

betcha? well... im convinced.

Asked my hubby to read my new thread post before I submitted it. He told me "betcha" was so annoying I should take it out. I didn't listen to his advice . Should I have? You betcha!

 

[Skeptic Ginger]

I'll say it once more, Robin, we don't yet know what the final diagnosis was. I do know the organ donor system is not a sloppy system.

 

[Estellea]

Robin, I think it's easy to play Monday morning quarterback in such cases but the reality is, is that the risk of a subclinical rabies infection upon an organ donors death and the time difference between testing and organ viability pale in comparison to the potential benefit to numerous organ recipients.

I believe that this case may cause a revision in donor organ testing but what will most likely happen is that the organs will be transplanted with test results pending and then prophylaxis administered with definitive results.

Este

 

[Skeptic Ginger]

An unrelated but definitely analogous example:

A few years ago a teen here died of an anaphylaxis reaction. There was a delay calling 911 and her own epi was expired. The EMS response here is to send the aid unit with basic EMTs and the Medics are a minute or two behind in another unit. At the time, EMTs were not trained or certified to give any meds, including epinephrine.

Despite the extra minute or two it took the Medics to get there and administer the epi, it was probably the delay calling 911 that was most responsible for the death.

Nonetheless the grieving parents campaigned for having epinephrine on all aid units in the county. And given the emotional reaction to the death, they got policy changed.

So what you say?

Well, every single EMS engine has to carry what started out as a $30 epi-pen but which is now $100 epi-pen, and the meds have to be replaced about once a year. Every firefighter had to be trained and certified as able to give the injection. The training and certification need to be renewed every year or so, not sure of the exact term. All that costs money. Every single fire fighter has to practice wasting one epi-pen per employee.

Then there's the disposal of all that epi which is a drug that can't be put in the landfills. It ends up in drinking water. Of course, errors have been made with that disposal. No one knew there were disposal regulations so every firefighter practiced using the epi-pens on an orange, that were then put in the general waste stream. If that has been corrected, there's the additional disposal cost for the county.

Literally, millions have been spent now and continue to be spent. While I think the EMTs have maybe used the epi-pens a couple times, not a single case involved such a close call as the girl's. IOW, not one life has been saved.


Emotions are not a good basis to make medical resource decisions.

 

[platon20]

I side with Ginger on this....

There are about 100 causes of encephalitis and I figure that rabies ranks about #91 on the most likely causes of encephalitis.

Seriously, if you asked a neurologist for a differential diagnosis on encephalitis, rabies would be very, very low on the list. They'd rule out at least 20 others before even considering that as a possible diagnosis.

Now, certainly if there was a KNOWN bite exposure then I think it would be reasonable to expect the docs to do a little more testing before the transplant. But since the vast majority of causes of encephalitis would not transfer to the organ recipient it is UNREASONABLE to block organ transplants until there is a quick/rapid test available for rabies (which there is not).

If someone is dying from liver failure and their death is IMMINENT I think 100% of them would take the chance on a 1 in a million shot from dying of rabies s/p transplant.

 

[platon20]

An unrelated but definitely analogous example:

A few years ago a teen here died of an anaphylaxis reaction. There was a delay calling 911 and her own epi was expired. The EMS response here is to send the aid unit with basic EMTs and the Medics are a minute or two behind in another unit. At the time, EMTs were not trained or certified to give any meds, including epinephrine.

Despite the extra minute or two it took the Medics to get there and administer the epi, it was probably the delay calling 911 that was most responsible for the death.

Nonetheless the grieving parents campaigned for having epinephrine on all aid units in the county. And given the emotional reaction to the death, they got policy changed.

So what you say?

Well, every single EMS engine has to carry what started out as a $30 epi-pen but which is now $100 epi-pen, and the meds have to be replaced about once a year. Every firefighter had to be trained and certified as able to give the injection. The training and certification need to be renewed every year or so, not sure of the exact term. All that costs money. Every single fire fighter has to practice wasting one epi-pen per employee.

Then there's the disposal of all that epi which is a drug that can't be put in the landfills. It ends up in drinking water. Of course, errors have been made with that disposal. No one knew there were disposal regulations so every firefighter practiced using the epi-pens on an orange, that were then put in the general waste stream. If that has been corrected, there's the additional disposal cost for the county.

Literally, millions have been spent now and continue to be spent. While I think the EMTs have maybe used the epi-pens a couple times, not a single case involved such a close call as the girl's. IOW, not one life has been saved.


Emotions are not a good basis to make medical resource decisions.

Good story. I hope they at least attempted to administer the expired epinephrine. Unless it was kept in a hot car for a year, I bet it would still have some biologic effect. Certainly would NOT have hurt her to try it.

I always tell people that if you are even THINKING about giving epinephrine you should just go ahead and do it.

 

[Skeptic Ginger]

Good story. I hope they at least attempted to administer the expired epinephrine. Unless it was kept in a hot car for a year, I bet it would still have some biologic effect. Certainly would NOT have hurt her to try it.

I always tell people that if you are even THINKING about giving epinephrine you should just go ahead and do it.

I don't know if they gave her the expired epi. I know the delay calling 911 contributed to the death. It was really tragic, she was 12.

Here's a news clipping, and another news report. Neither one says but I think the papers were sensitive to not making it sound like it was the parent's fault at all.

PBS presented the case poorly, without commenting on the cost that change in the law was going to cause.

LEE HOCHBERG: Paramedics showed up eight minutes after the first EMT had arrived, but the girl's heart had stopped. Her family believes those eight minutes cost her life. Mercer Island fire commander Al Provost says his EMT's were hampered by the law.

AL PROVOST: We're not giving the best care we can give to these individuals that need it in a true emergency.

DR. JOHN BRENNAN: It is unconscionable that a patient died when we have the technology and the medicines to take care of those kind of patients.

LEE HOCHBERG: Emergency physician Brennan says EMT's should be trained and allowed to give several medicines, like epinephrine for life-threatening allergies, inhalers for asthma, nitroglycerin for heart conditions.

Our Medics do have a longer response time, and EMTs and Medics are often sent at the same time. In this case, Mercer Island has their own firefighters and they use Medics from Bellevue. The medics are still only 6 miles away (give or take a couple more miles from one end of the island to the other), stationed at Overlake Hospital. The EMTs can do CPR which is usually enough until the Medics arrive only a few minutes later. It's a very good way to allocate resources. King County has one of the finest EMS systems in the world.

The article also conflates the use of AEDs with every engine carrying epi-pens. The costs are like night and day.


Oh look, a Google search turns up my 2009 forum comments. Prometheus had a good point, the law should have required the parents have the epi, not the EMTs.

This was a blog comment by the wife of one of the Mercer Island EMTs. She may have had correct information.

The mother was asked if she had an "Epi-Pen". This is a device that can automatically inject a dose of epinephrine that can relieve the symptoms of a life threatening allergic reaction. The are available by prescription - not over the counter. She had one. It malfunctioned.

My information was also from the fire fighters telling me what happened. (I do work for the Bellevue FD.)


People hear, "all we need is for EMTs to carry epi-pens". It sounds so simple. But they don't have a clue what that actually costs.

 

[Robin1]

I side with Ginger on this....

There are about 100 causes of encephalitis and I figure that rabies ranks about #91 on the most likely causes of encephalitis.

Seriously, if you asked a neurologist for a differential diagnosis on encephalitis, rabies would be very, very low on the list. They'd rule out at least 20 others before even considering that as a possible diagnosis.

Now, certainly if there was a KNOWN bite exposure then I think it would be reasonable to expect the docs to do a little more testing before the transplant. But since the vast majority of causes of encephalitis would not transfer to the organ recipient it is UNREASONABLE to block organ transplants until there is a quick/rapid test available for rabies (which there is not).

If someone is dying from liver failure and their death is IMMINENT I think 100% of them would take the chance on a 1 in a million shot from dying of rabies s/p transplant.

The whole point of my blog (written last year) was that perhaps rabies is not as rare in humans as it is being portrayed...perhaps doctors are incorrectly diagnosing it as something totally different. And remember, I have personal experience with having encephalitis in general being missed. Or they get close to a correct diagnosis but then just label it encephalitis of unknown origin. Or they mistake it for a different type of encephalitis. Close, but no cigar. This whole case of the donor having undiagnosed rabies totally proves my point! And if that donor had never signed up to be an organ donor his true cause of death...rabies...would never ever have been discovered!
Yes, organs are precious and time is of the essence. Easy solution... If donor is suspected of having encephalitis and the origin is unclear...you still immediately use the organs. BUT, anti-rabies shots should also immediately be given to organ recipients while other tissue from donor is sent out to be tested for possible rabies. If test comes out negative for rabies the anti-rabies shots are then stopped. A no-brainer.

 

[Capsid]

BUT, anti-rabies vaccine should also immediately be given to organ recipients while other tissue from donor is sent out to be tested for possible rabies. A no-brainer.

How well would a rabies vaccine work in an organ recipient on immunosuppressive drugs? It may be better to give rabies immunoglobulin in such cases.

 

[Robin1]

How well would a rabies vaccine work in an organ recipient on immunosuppressive drugs? It may be better to give rabies immunoglobulin in such cases.

Yes, sorry I corrected it to anti-rabies shots earlier. In terms of how well it would work, I would guess trying it is better than doing nothing.

 

[Estellea]

Yes, organs are precious and time is of the essence. Easy solution... If donor is suspected of having encephalitis and the origin is unclear...you still immediately use the organs. BUT, anti-rabies shots should also immediately be given to organ recipients while other tissue from donor is sent out to be tested for possible rabies. If test comes out negative for rabies the anti-rabies shots are then stopped. A no-brainer.

It's neither an easy nor good solution to administer biological products without a clear indication to do so. There is enough of a time lag between testing time and symptomology to get a rabies diagnosis.

Este