Normally I try to practice evidence based medicine, meaning that I try not to order unnecessary tests or prescribe unnecessary treatments. To do otherwise, more often than not, has just left me chasing down “false positives,” or unexpected results that mean nothing. I can’t think of many times that I have been truly surprised or changed a treatment by finding an abnormality on a test that I ordered just because the patient insisted. Nor do I really believe that all the antibiotics I’ve prescribed for sinus infections and otitis media really made much difference.
Recently, however, I lost a night’s sleep worrying about whether a treatment in which I became a participant might have done more harm than good. Here’s the scenario:
A young suburban couple was in the habit of feeding the raccoons that appeared on their deck most evenings. One night while hand-feeding the raccoons, all apparently healthy, one of them scratched the wife, causing a tiny 2 mm superficial scratch on the finger that drew almost no blood. Not much was thought of this until the next night when another (the same?) raccoon scratched the husband in similar fashion.
Upon mentioning these incidents to a few friends and family members and doing a bit of internet research, they presented themselves to the Emergency Department the next evening. The ER doc looked at the wounds, finding them nearly invisible, and consulted an Infectious Disease specialist, who suggested the couple come to his office the next morning to discuss the risks vs. benefits of anti-rabies treatment.
His partner saw the couple the next day, consulted with Public Health, and advised rabies immune globulin and anti-rabies vaccine. The couple returned to the hospital ER for their first dose of each medication. I was the doctor they saw.
I, too, found the couple’s wounds to be so miniscule that, were they my own, I would have done nothing and gone on with my life. However, others presumably smarter than me, recommended treatment. I discussed my concerns with the referring specialist, and was convinced when he astutely pointed out that if either patient were to get rabies, “we would all lose our homes.”
Rabies immune globulin must be injected as close to the site of injury as possible. In this case, that meant that a good portion of the total dose had to go at the base of the bitten fingers. Though the package insert contains no suggestions of potential damage from this recommendation, I was concerned that there could possibly be damage to the digital nerves, arteries or veins. Despite my qualms, I performed the injection, informing the couple that damage to a finger, though unreported, would be more acceptable than loss of life from rabies, though unlikely, or the inconvenience and discomfort of immunization, though considerable.
Fortunately, the couple did fine, but for 24 hours I did not. I couldn’t shake the feeling that if we were in a less litigious climate, I might have used my clinical acumen and the law of averages and managed this case differently. It was a disconcerting 24 hours.
The following is excerpted from the Washington State Department of Health “Rabies Fact Sheet”
What mammals carry rabies?
The primary reservoir of rabies in the northwest United States is bats. Between 5-10% of bats submitted for testing are found to be rabid… [but] less than 1% of healthy bats are infected… While rabid raccoons, skunks, foxes or coyotes have not been identified in Washington, the virus can be transmitted from bats to these mammals.
Has human rabies occurred recently in Washington?
There have been two cases of human rabies identified in Washington during the last 20 years. In 1995, a four year old child died of rabies four weeks after a bat was found in her bedroom and in 1997, a 64 year old man was diagnosed with rabies [also from a bat.]