Published online: October 25, 2017
“Doctor, please come immediately!” The voice of the nurse summoning him to the Anti-Rabies Clinic (ARC) indicated urgency, fear and exasperation. As he rushed to the ARC, Dr James felt an escalating sense of foreboding. The distress call from the usually calm and competent nurse in-charge of the ARC spelt serious trouble.
As he walked into the ARC minutes later, Dr James had to wade through a throng of hefty, uniformed personnel, uniformly glum. They were all heavily armed and Dr. James could sense he was being scrutinised by several eyes as he entered the clinic. Thoroughly unnerved, he felt his mouth go dry. The protagonist, apparently a General in the Army, was seated on a chair, his left hand heavily bandaged and in a sling. He was not in his uniform, yet from his demeanour and his entourage, Dr James could have counted the stars he wore. An equally (or perhaps more) intimidating woman, evidently his wife, stood next to him, agitated and impatient for attention.
Dr James tried hard to appear composed. The General winced in pain as his wife narrated the sequence of events that had happened in their home that morning.
“Our pet dog, a German Shepherd….” she began.
“That damned BEAST is YOUR pet, NOT MINE…..!” interrupted the General, obviously fuming.
“Well, he leaped to catch a ball I threw up in the air…” she continued unperturbed, “My husband suddenly came in his way and was accidently bitten on his hand…..”
“That is MY B@?!*#HOUSE and I can walk anywhere I want!” the General thundered.
She continued to ignore his outbursts and conveyed that the wound was rather deep and there was quite a bit of blood loss before it was sutured by doctors at the hospital they had rushed him to. They had now been referred to the ARC for the mandatory anti-rabies shots.
Dr James took a deep breath and took stock of the situation. He rolled his tongue over his lips to moisten them.
“Is your pet vaccinated against rabies?” he asked the General’s wife.
“No” she replied.
“Is he healthy? Have you noticed if he appears sick, more aggressive or has not been behaving like his usual self in the last few days?” Dr James solicited information to ascertain if the pet showed any clinical signs of rabies.
“No. He looks quite healthy to me.” replied the wife.
“Of course not! He is a SICK DOG!” the General retorted, gesticulating to make his displeasure obvious.
“Has your pet bitten anybody else in the last few days?” Dr James enquired.
“No.” She replied.
The General shifted uneasily in his chair, obviously annoyed and impatient to wrap up this visit.
Dr. James unwearyingly explained to the General that he would require five shots of the rabies vaccine spread over a month, beginning with the first dose now. More importantly, however, he would require the anti-rabies serum, a life-saving injection to be administered into his wounds immediately.
The General appeared traumatised even at the thought of receiving injections into his wounds. He had assumed that the most painful part of cleaning, suturing and bandaging the wound was over. The General became restless, his face flushed with anger.
Dr. James was prudent enough not to mention the serious lapse, on part of the earlier doctors, to have sutured the wounds before administration of the anti-rabies serum. It would mean grave consequences for everyone involved. Achieving haemostasis in the wounded arm would have been the priority of the doctors, he reasoned.
“What is the need for so many damned shots? Can’t you leave the cursed wound alone?” the General yelled.
“Since your pet has never been vaccinated for rabies, we need to assume he may be infected with rabies and can potentially transmit the infection to you through the bite. Once we acquire the disease, there is no cure for it. And so we have to be overcautious,” clarified the doctor.
“So the five doses of vaccine will help your immune system produce antibodies to fight the rabies virus. But it takes about a week to ten days for the vaccine to be effective” Dr. James explained patiently, “the virus that is deposited at the site of the bite, through the saliva of your pet, can infect you during this period and cause disease. We therefore infiltrate the wound with an anti-rabies serum, which has pre-formed antibodies. This helps inactivate the virus to a certain extent and protects you until the vaccine starts acting. It is called rabies immunoglobulin or RIG.”
“The RIG is safe to use, but because it is produced in horses, we need to do a small skin test before we proceed, to be sure you are not allergic to it”, he added.
“God save me!” shrieked the General, “I CANNOT take that doomed injection!”
Before Dr James could react, the General revealed that he had had a viper bite about a year ago, for which he had been administered the snake anti-venom (also produced in horses). He had developed a serious anaphylactic reaction to it which had almost killed him! He had been cautioned by the doctors about the use of any equine origin biological products in future.
“It’s a miracle I am alive and you want to give me that lethal injection AGAIN? I’d rather die of the bite of that vicious dog! ” the General shrieked.
Dr. James felt his blood gushing into his face. His ears felt hot. This was indeed a complicated case.
“Is there an alternative to the horse serum?” asked the General’s anxious wife.
“Yes. It is called Human RIG or HRIG and does not cause any allergic reactions, since it is not produced in horses, but is derived from human blood” Dr James answered, “but unfortunately it is not available in our country. We can try and import it from other countries, but it may take 2-3 weeks or more. We cannot delay giving the injection for so long.”
“What if he takes only the rabies vaccine then?” posed the wife who appeared quite concerned.
“Well, only if we can be sure that your pet is NOT rabid-in which case he does not require either the vaccine or the RIG. But unfortunately we cannot be completely sure just based on your pet’s symptoms and there is no other way to ascertain that”, he declared.
Dr James continued “Usually dogs which are rabid die of the disease within 10 days. So if your pet remains healthy beyond 10 days, we can be sure he is not rabid. But then, we cannot wait for 10 days to start the RIG-because if he does die of rabies, it may be too late to start the RIG-putting you at high risk.
“As of now, it looks unlikely that your pet might be rabid, but then it is my professional duty to explain all possibilities and the associated risks to you”, he said.
“Isn’t there a blood test or any other test which can confirm for sure if the BRUTE has Rabies or not?” the General asked.
“Well, err…” Dr James hesitated, “only a test on the brain can give us a reliable answer. But then it is not possible because the dog has to be euthanised to extract and test the brain.”
The General’s wife was visibly disturbed even at the suggestion.
“So shall we go ahead with just the vaccination?” she hastily enquired.
“Yes”, replied Dr James, “since we do not have any other choice.”
Dr James instructed the nurse to give the General the first dose of the vaccine and advised him to visit the ARC for the rest of his doses without fail.
He got up from his chair relieved to be done with all this. He could now go back to his regular out patient’s clinic and resume seeing his patients.
But the General was in no mood to be convinced so soon.
“Doctor, so do I have to spend 10 sleepless nights to know for sure that this dog does not have rabies?” he demanded to know. “It already feels like a ticking time-bomb strapped to my skull!” he howled.
“Yes. I understand your anxiety, but we do not have any other choice, sir”, Dr James said trying to pacify the General.
“Of course we have a better choice!” shouted the General. “Kill that DOG! Is HIS life more precious than MINE?”
The General’s wife shuddered at his outburst. Her face turned ashen. She abruptly rushed out of the clinic.
“Go get that BEAST now!” the General ordered.
Two of the guards left the clinic. They were back with a huge sack carrying the dog alive in less than 30 minutes.
Meanwhile, shocked at the unexpected turn of events, Dr. James had summoned the institute veterinarian, Dr Eric, who was obviously not at all pleased to be there.
The pet was released from the sack into a cage like enclosure. He was a strikingly good-looking, gregarious, young German Shepherd. As all of them stood outside the enclosure, Dr Eric and Dr James were engaged in a serious dialogue. The General and his entourage awaited their decision. The General’s wife was conspicuous by her absence.
Within a few moments of observing the dog, Dr Eric whispered to Dr James that it was highly unlikely that the dog was rabid and he could not agree to euthanise the beautiful creature.
As they continued to debate amongst themselves, the General turned impatient and demanded to know the cause for the delay. Dr James mentioned that Dr Eric was not convinced enough to proceed to euthanise the dog since he felt it was unlikely that the dog had rabies.
The General couldn’t take it anymore.
He pulled out a gun and forced it into Dr Eric’s hand. It was a large Israeli automatic pistol, the Desert Eagle.
“If you can’t, I will kill him”, he roared, his eyes bloodshot and his lips quivering.
Dr. James and Dr, Eric whispered to each other as sweat beads glistened on their foreheads. They did not have a choice or even much time to decide.
With trembling hands Dr Eric returned the gun to the General. He preferred to put the dog to sleep by injecting it with a lethal drug. It would at least allow a humane approach and death without much suffering.
Dr Eric informed the General that the entire procedure of euthanisation, followed by a necropsy to open the skull and extract the brain, and the laboratory testing to confirm or rule out rabies would take about 3-4 hours. Dr Eric and Dr James promised to inform the General about the report as soon as it was ready.
The General was extremely nervous when he received a call at his home about four hours later. He was elated to hear the laboratory report conveyed by Dr James. He did not have to take either the vaccines or the equine rabies immunoglobulin! However, to ensure protection from any such episodes in the future, Dr James advised him to just complete his vaccination schedule.
After all, the laboratory tests on the brain sample had revealed no evidence of rabies in the dog.
Post-script: Bruno, the gorgeous German Shepherd, continues to love his master – Eric – unconditionally, oblivious to the fact that he had got a new lease of life on an eventful day more than 10 years ago.
Note: Dr Eric was quite sure that the pet was not rabid. The possibility of the dog having rabies cannot be ruled out completely based just on the signs/symptoms. It was a risk he took. And of course to afford at least partial protection the General was advised to complete the vaccination schedule.
This story, based on an incident which happened several years ago (in a country which he doesn’t wish to identify), was kindly shared with me by Dr Henry Wilde, Professor of Medicine at the Chulalongkorn University at Bangkok, Thailand, in his endearing, inimitable style. Dr Wilde is a world renowned rabies expert recognised for his pioneering work in rabies postexposure prophylaxis.
*Corrected on November 5, 2017