Electrical burn or insect bite?

This is the story of a young woman who came to our clinic last week. She works as a housekeeping staff in a tertiary care hospital in the nearby town. She came with complaints of fever with severe body pains. There was no cough, no running nose, headaches. There were no symptoms to suggest that there was infection in any particular part of the body. It looked like an infection that is vague, usually referred to as an undifferentiated fever. There have been scattered rains in the area and dengue season is just about to begin. I started her on paracetamol to relieve her fever and body pains and asked her to drink plenty of water and fluids. That day, we had the physiotherapist's visit in the clinic and she went to consult him for a long standing neck and upper back pain. The physiotherapist had diagnosed a musculoskeletal problem in her upper back and advised her to undergo interferential therapy (IFT). He gave her the first sitting of the therapy and the lady felt immense relief. 

Ours is a simple rural clinic and the physiotherapist comes once a month. However, he has trained our nurse and auxiliary nurse midwife (ANM) on how to attach the interferential therapy leads and administer the therapy. He prescribes the therapy and the patients come to clinic on other days to get the therapy sessions from the nurse and ANM. For this young woman also the physiotherapist prescribed the therapy. She was supposed to come for 5 days to get the treatment done. 

Her visit to our clinic and the physiotherapy consultation was last Sunday. She came back on Tuesday to get the second sitting of the physiotherapy. I was in the clinic and the ANM came and told me she will administer the IFT. I asked her to go ahead. I was busy the rest of the day and the day passed by. Yesterday, the same young woman came back. She was visibly upset and angry and shouted at me, "I have 7 elder brothers. They all are extremely angry and would have come and destroyed your hospital and beaten you up. I have pacified them and made them understand and have come here to talk to you in a decent manner because I am also a staff working in a hospital." She was visibly shaking and tears were pouring out of her eyes. I stood up and guided her to a chair and asked her what happened.

"I came on Tuesday and your staff gave me 'current treatment' (IFT) for my back pain. See what has happened" she said this and opened her blouse and showed me her upper back. There was a dark black wound on the right upper back, just below the shoulder. As soon as she showed it to me, she broke down and started crying. "Do you know how painful this injury is? And all this is because of your staff. That day while giving me 'current treatment', I told her repeatedly that the tingling sensation on the spot is very high. I even shouted and cried. But she never listened to me. She kept on giving it and told me, "....it will be like that. dont worry....." The next day while taking bath I noticed this and got scared." She couldn't even complete her sentence and started sobbing. 

"I haven't eaten anything, I haven't slept, I haven't even got up from bed from last Wednesday. My brothers saw me like this and asked me what happened. I told them and immediately all seven of them got up and rushed to come and get justice for their sister. I pacified them and told them I will take care of it. I have come asking for justice. Tell me, is this right? Is this fair?"

My immediate reaction when I heard this was inner panic. Overall, my experience in the clinic has been peaceful and uneventful. But I have had past experience of violence in the clinic. Once I was hit by a drunk patient, who walked in while I was having lunch and demanded that I attend on his injury immediately. I have given refuge to a priest who was beaten up by a violent village mob in the village. So I am aware of the villagers' proclivity to violence. Therefore, my immediate inner reaction was panic. But I controlled the panic and continued a calm conversation. I addressed her health issue first. "Let me see the wound and examine it first. Please come to the examination couch." 

I took her to the examination couch and exposed the wound. It was a 2 cm by 2 cm circular punched out wound located on the skin over the right side of the back just below the shoulder. The floor of the wound was black and looked like a leathery scar. When I touched it, she winced with pain. There was no other scar anywhere else on her body. My first thought was that it could be an electrical burn by the IFT lead placed wrongly over the area. I immediately called my physiotherapist colleague to get this opinion on this. He said, "Yes, such a burn is possible either if the voltage applied is very high, or if the lead is placed wrongly without electrolyte gel, or if the voltage is increased despite the patient not being able to tolerate it." He advised to stop any further IFT and give topical cream to apply on the burn for it to heal. The young woman observed as I had this conversation and I relayed the conversation to her. 

We got back to the consultation table and I flipped open her notebook where I had documented her case history. This was a young woman who worked as a housekeeping staff in a tertiary care hospital. She travels a long distance daily from our village to the nearby town to work. She also has undifferentiated fever for more than a week. One of the differential diagnosis for an undifferentiated fever is scrub typhus. Scrub typhus is a type of fever transmitted by the bite of a mite (an insect) larva. The site where the mite larva bites becomes a leathery scar known as eschar. It struck me then that that burn could be an eschar. That wound could either be a IFT burn or it could be an eschar of scrub typhus. 

My immediate instinct was to tell her that she could be wrong about the IFT, and this wound could be an eschar. I could tell her that the eschar being in an inaccessible site, she wouldn't have noticed it. When her back pain started reducing, the irritation and pain due to the eschar would have started manifesting itself and so she must have noticed it. Firstly, I couldn't be certain that it is an eschar and not an IFT burn without knowing the exact sequence of when the wound appeared. Secondly, if I did explain about the eschar she would only think I am protecting my staff and myself by giving her a concocted story. She was angry, upset and emotionally fragile. Her entire family was agitated to see their little girl so sick. In her current mental state, there is no way she would believe my differential diagnosis. Moreover, I had already had the conversation with the physiotherapist and have reassured her that the burn would heal with some cream applications. 

I did what I thought was the best thing to do in that situation. "This wound is likely to be a burn due to the IFT. I sincerely apologise for causing the IFT burn, if it was that. We will do whatever we can to help that burn heal quickly." This seemed to calm her down and she said, "I am accepting your apology only because along with my 7 elder brothers, you are also my elder brother. You delivered my younger son and now he is 14 years old.  I am a young woman, so nothing will happen to me. But imagine if this had happened to an older person. Will their body be able to tolerate such injuries? Make sure this doesn't happen again to anyone."  She then got up and walked away. 

After clinic, as a quality control measure we gathered as a team in the clinic to discuss this incident. The ANM who had administered the IFT vouched that the lead was not placed in the area where the wound was located. We agreed that all further IFT lead placements will happen under supervision and photos of lead placement will be shot and shared with the physiotherapist before starting the IFT. It seems highly likely that the wound was an eschar. Maybe, at a later date when things are calmed down, I will talk to her to explain this thought process.