BE WARNED: THIS BLOG CONTAINS A REAL PATIENT HISTORY OFFERED FOR ADVICE AND SUGGESTIONS, WITH THE EXPRESS CONSENT OF THE PATIENT. THE DETAILS AND PICTURES OF THIS CASE, A PARASITE CASE, MAY BE GRUESOME.
Today during a scorching sunny afternoon, Christmas came the Southern Wind–here’s how:
When we first left Miami for Haiti, we left behind 5 pallets of additional medication and supplies that we could not fit onboard. We planned to return to Miami and pick them up after finishing in Haiti, and then continuing on to Central America.
From Haiti, we connected with Clinica Esperanza and Barefoot Cay Marina in Roatan, so
we came directly here instead of going back to Miami. We saved a lot of fuel and time but it meant we had to ship our pallets here to Roatan. Fortunately, Gary and Donna Evans arranged for Roatan Rotary Club to sponsor the shipping by providing part of Rotary’s yearly donated shipping allotment from Hyde Shipping here on the island. We also had to coordinate someone willing to drive a truck from the warehouse in Miami that was kind enough to hold our supplies to the Hyde Shipping warehouse in Miami…all the while seeing patients, planning our Haiti mission, fueling, securing the boat for sea, coordinating our 40-foot container from Direct Relief International for the island clinics and for Haiti. It has been BUSY.
However, health care is always our primary mandate, and when we are in danger of being overwhelmed by everything we have to do, we ask for help. Especially any clinicians reading this, this patient has suffered significant symptoms for months and has given permission to post his case for review by any of our medical followers.
Please post comments or questions for more details about the case directly on this page where we can all see them and brainstorm together. All posts are visible only after review and approval by Floating Doctors to protect patient dignity and confidentiality.
Patient: 27 year-old Caucasian male; 6’2”, 180lbs
*No prior medical history of note, no medications, no allergies
- Cardio : BP: 125/85, HR 74 (regular)
- Respiratory: Lungs clear, good air entry across both fields, no creps/wheezes
- GIT: Abdo soft and non-tender, non-distended
The patient had spent 7 months in Honduras working as a volunteer co-pilot on a non-profit emergency helicopter service, with frequent trips to the mainland while transporting patients.
3 months ago, a few weeks before his return to the US, he had complained of occasional vague stomach cramps (sometimes acute) and diarrhea. The night before returning to the US, he took a single dose of albendazole and subsequently had what he referred to as an episode of extreme cramping and “explosive worm diarrhea.” The worms he described were 6-8 inches long and very mucous-like. He continued taking a daily dose of 400mg of albendazole for the next few days, but continued to pass similar worms. He went on a strict fruit diet, eliminated fats and although the symptoms seemed to lessen he still passed stringy worm-like strands, some longer than 12” (in the initial days of treatment). After several days, he went to his local doctor and subsequently sent this email:
“I went to the doc yesterday and got a scrip for Flagyl. I never saw the doctor but the nurse
talked to the doc and he prescribed it. I’ve been on it for, now, two days. I’m coughing up some terrible stuff. One time (within the last week), while in the shower I blew my nose in my hands. In the mucus there appeared to be a worm about 1/2 inch long. It was either a worm or the most congealed mucus I’ve ever seen. Figuring I was exhibiting symptoms of hypochondria, I chalked it up as my mind playing tricks on me. Today, about a week later, after taking the Flagyl for two days, I’m coughing up some horrible stuff, which looks similar, but not exactly the same, as the worms in my stool. It’s stringy, if stretched out about 6-8 inches long. From what I’ve ever seen, mucus isn’t generally this stringy with elastic properties. When running the sink full of water, swirling one around rinsing it off, and then picking it out of the water with my finger, it’ll run over my finger like a spaghetti noodle would. It doesn’t look like a spaghetti noodle, (much smaller in diameter) but acts in a similar fashion when running one over your finger.”
He augmented his treatment with Pyrantel Pamoate equine anthelmintic, taking the same dose as for a 250-lb pony (900mg) daily for three days off 4 days, then repeating, and was also prescribed mebendazole 100mg twice daily for three days, then 4 days off, then repeating the regimen for a month along with the flagyl (metronidazole). He also ate enormous amounts of fruit and had a colonic irrigation (though he saw no worms come out during the evacuation, only the next day), and is taking 15,000mg of garlic daily.
He has not had blood work or an ova and parasites study (stool sample). He has been advised to collect one of the worms and bring it to his hospital or GP for parasitology, and to have a full blood count with differential to look for raised eosinophils. Results will be posted as soon as available.
The ‘worms’ pictured do not look at all typical. Could they be some kind of mucous shedding of the intestine post infection or from the treatments he has given himself…even the garlic? If so, what about the episodes of coughing and similar, smaller mucous strings from his nose? He has tried most of the heavy-hitters for parasites…even horse worming medication (not on my advice!).
Does anyone recognize these as worms or other pathology, or have suggestions for further treatment or investigations? The patient has no medical insurance so cost will be a factor in patient ability to comply with investigations. Taking the worm to a doctor so it can be sent to a specialist and analyzed if necessary is definitely the next step, but any advice or ideas would be appreciated.
Our 40-foot container from Direct Relief is supposed to be cleared through customs Thursday!
Then we can distribute everything, load the boat and depart at the first weather window to Jamaica for fuel and back to Haiti!
All Photos (Except The 3 Worm Pics) Courtesy of Dan Chomistek
Yesterday we returned from our first vacation in almost two years…the first time we have been truly out of contact (although we did have Sky’s blackberry) and doing something that was just for us.
Sky, Noah, me, and Dan from ‘Satisfaction Plus’ (our neighbor and erstwhile Floating Doctors cameraman), took the ferry from Roatan to La Ceiba on the mainland. We planned to go to Copan, about 400km inland up in the mountains and site of the famous Mayan ruins.
Oh, man…I don’t even know what to say. If you grew up watching Indiana Jones, and ever fantasized about
exotic ruins from ancient civilizations hidden in the dense jungle, then Copan is exactly as advertised. Skulls, grinning jaws, imposing birds and leering faces carved everywhere…tunnels dug by archeologists showing the temples buried beneath the pyramids…dead kings looking down onto the stone altar where human sacrifice was carried out, and the court where slaves played deadly ball games in which the losers were sacrificed at the end. We sat in the king’s seat at the top of the pyramid and strolled through the ‘Mayan Discotheque’ where the royal family and nobles of the court celebrated.
It was everything you ever imagined…totally and completely AWESOME.
The town of Copan was a beautiful little mountain town set in the geologically tortured hills along the Honduran/Guatemalan border…cobbled streets, red tile roofs. It was cool, without mosquitoes, and REALLY inexpensive. We were only there for two full days, but I could’ve stayed for a couple of weeks. Everywhere you walk in the jungle, mounds of collapsed jungle-covered rubble betray the site of yet another Mayan ruin not yet investigated (they have only found 5 of the tombs of the 16 Mayan kings of Copan).
On our second day, we drove 30 km down a really bad road (torn to pieces after the rainy season, took us an
hour and a half in a big pickup truck) through the narrow valleys of the mountains. We stopped at the Luna Jaguar thermal hot springs…I don’t know if I’ll ever be able to go in another hot spring without sneering in contempt…the most amazing hot springs ever.
A dozen or so rock pools on a steep, jungle covered hillside along a narrow fault through the mountains…boiling, sulfurous water at 176 degrees pouring from the rocks and into the rock pools and sending clouds of steam up through the jungle canopy. We lingered among the pools for hours, until after nightfall when candles were set out, then finally we tore ourselves away and drove back through the jungle night to Copan; leaving in the morning for San Pedro Sula to pick up Holly at the airport.
Holly is our new volunteer and is a Tropical Medicine and Emergency Room Medicine specialist from Liverpool. Holly will be onboard three months, and her timing could not be better since we are headed to Haiti. We got back last night and worked on the boat all day today; Ed is coming back tomorrow, Captain Randy is just back, and we have TONS of preparations to make before leaving.
The cholera epidemic in Haiti continues to kill…we have several other doctors and nurses meeting us in Haiti, and others continue to contact us
to see about coming. This is turning into a big collaboration between us, Partners in Health, the Cap Haitian Health Network, SIFAT (water purification systems), Direct Relief International—I’m excited to go back.
When we left for Haiti the first time, the essential systems on the boat were done but we have continued to modify and rebuild ‘Southern Wind’ a little at a time ever since we first left the dock, and this time we will be even more well-equipped than our first trip. We will be working along an area of over thirty miles of coastline, so we will have to be mobile and adaptable…and that’s what we designed our project to do. This time we may well have our team split up and working in several locations at once, so this is going to be a real challenge.
Plus, we also have a lot of patients still to see here on Roatan while we prepare for Haiti…going to be a CRAZY couple of weeks, but the countdown to Haiti starts today!
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All Pics For This Blog Courtesy Of Dan Chomistek
Medicine in developing nations is, most people would probably agree, substantially different from medicine in developed countries. Still, there are many aspects of the health care experience that seem to be universal, shared by ‘have’s and ‘have-nots’ alike. For example, the prospect of surgery under general anesthesia is daunting whether you are having it at the world’s most advanced hospital or in a temporary medical mission surgical tent.
And of course, men, women and children of all ages all hate getting injections (except for little old ladies, who—in every country I have ever worked in—take injections and other potentially uncomfortable procedures pretty much in stride). This week marks the end of our management of one particular patient whose experience made me think about the parallels in health care experience that are shared by patients worldwide.
One day a few weeks ago we had returned to the boat after a long day in clinic, and a 43 year-old
guy walked up to the boat asking if we were the medical doctors and could he consult with us. We invited him aboard, and I immediately noticed he was taking small, tentative, shuffling steps and was bent forward slightly from the waist, pressing his right hand over his bladder. He told us that 9 months ago, after several months of severe pain, blood in his urine, and repeated urinary tract infections, he had saved up for an ultrasound and they had found a great big 3 cm stone in his bladder.
At this stone’s size, open surgical removal is the indicated treatment, but he could not afford the 60,000 Limpira (about $3,300) charged by the private surgeon he saw, but the surgeon said he would make him a deal—he would do the surgery for 45,000 Lempira if the patient arranged for the surgeon to do it at the public hospital, thereby not using any of his own equipment and resources.
The patient DID arrange permission from the hospital to have the private surgeon operate there, but fortunately the patient came to see us (he had no choice, as 45,000 Lempira might as well have been 450,000; he had not worked for weeks and weeks because of his crippling pain).
I visited the public hospital to speak to the chief of surgery there, Dr. Indira Sanchez. She is a fabulous surgeon; the first night I dropped in to help in the hospital I assisted her doing an open abdominal surgery on a gunshot victim, closing perforations in the colon and removing and directly re-attaching a perforated piece of small intestine (total number of personnel involved in the entire surgery, including me? Only five people; patient did fine). She has great hands for surgery—sure, experienced, and capable. I presented the patient’s case to her, she consulted with him, and booked him for surgery only a few days later.
She gave him the orders for his pre-op blood work and chest x-ray (which he had to get at the private hospital because the public
hospital x-ray was not working), and he went straight out and got the tests all done, which we microfinanced. Then he came back to present his test results to one of Dr. Indira’s team, the doctor sent the patient back to Dr. Indira with his endorsement that he was ready for surgery (which we also financed), and two days later the patient had the stone removed in about 30 minutes under general anesthesia.
He recovered well, and is no longer in agonizing pain all day every day. In a few more days he can go back to work, after over 9 months of debilitating pain.
Pre-op blood tests and x-ray: $80
Open surgery for bladder stone removal: $20
Price for living without pain? Pretty hard to quantify, but it seemed pretty important to the patient!
The whole thing got me thinking about the complexity of health care, and how daunting it can be for a patient to try and navigate
their way through the system—DEFINITELY an experience shared by patients in the developing and developed world. Almost anyone who has ever had to use their health service, especially for something major, can appreciate the confusing nature of going from specialist to specialist, office to office, exam to exam, wondering when the whole process will finally be over.
This case was a classic example of one of the main roles now played by General Practice and Family Practice physicians—that of a guide to navigating the maze of specialists and tests and procedures available in an ever-increasingly complex health care system. As Medicine gets more and more specialized, it will become more bewildering for patients—especially for patients who do not have a wide base of health knowledge—to find their own way through it.
The patient gave us permission to document his whole experience; soon we will put out another short video focusing on his experience with a health care system. I think that people in any nation at any socioeconomic level will resonate some part of his experience with their own history of interactions with health care. Some aspects of being a patient appear to be universal…watch and decide.
In this case, the patient was unaware of how to try and arrange a public hospital surgery and our representation (based on the good working relationships we have developed with many clinicians here on Roatan) was key to the surgery being performed.. Although we assisted the surgery and post-op care, our main role here was simply to take a patient and help guide him through the whole process, making an overwhelming prospect (especially for someone acutely sick!) a smooth series of events resulting in the patient regaining his health.
The other primary role of the GP or Family doctor is to try and help keep their patients well enough that they never have to go to the hospital!
A real highlight of the whole experience for me is that it all happened when my mom and
Grandmother and cousin Ishan and his wife Maria were here visiting us in Roatan. These were the people who have been there from the very, very, very beginning, when Floating Doctors was a wild dream keeping me sane during months of freezing, dreary weather in Ireland, to the year of frantic planning and fund raising, to the year of rebuilding the boat, to Haiti and thence to the shores of Honduras.
Our families have been so supportive…without them this never would have been possible. I was very proud to finally be able to show them what all their encouragement and support made possible; it meant the world to me that they came all the way to Honduras to see us. Love to all of you–fair winds and a fast return.
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All Patient Photos Used With Patients’ Consent
On Friday we painted a school in Jonesville, one of the original pirate settlements on Roatan. Last week we visited the school to drop off worming medications for the 54 students there, and while we were there we noticed that the school was in dire need of painting. We spoke to Norma, the lady who runs the school, and offered to come back and paint it. We rounded up some help, got 10 gallons of paint from our friend Joseph’s foundation Intensive Heart Ventures, bought some primer and some brushes and rollers and headed back to paint the school the following week. It was perfect–Norma got the students to clear out the building, their session ended for the season, and we arrived at an empty building ready to prep and paint.
We had Pat and Randy with us (two cruising sailors from SV Homeward Bound who have been
helping us with our clinic), Larry (a longtime expat living in the neighborhood of the school), and four kids from French Harbor that have begun having around the boat. I love having them around; they remind me of Bichal and Yvenson and Jonas and our other young Haitian friends. Noah is always the one the kids gravitate to the most–as he is the most ferocious-looking, the young kids naturally hero-worship him wherever we go, so it is usually Noah that takes charge of the kids when they are working with us. Noah has a knack for connecting with the most at-risk kids, getting enormous influence with them right away and creating opportunities to provide them with tools and new ideas.
Meanwhile, I can’t help trying to fill their heads with all kinds of random knowledge (being a teacher dies hard, and when I have them fishing out in the skiff I have a captive audience for the concepts of biology and ecology I’m constantly spouting to them). Sometimes stuff makes it through their burgeoning hormones and days later I overhear one of them telling another to throw a small fish back so it can grow bigger and have babies so when they catch it later it will be bigger, and there will be more of them. For me, those are great moments.
Friday, when we painted the school, was a great moment for me for another reason. As the chipped and faded
colors were covered by smooth new paint, I looked at the group that had assembled on a small peninsula on an island off the north coast of Honduras…a cruising couple, kids from a neighboring community, an expat, the local teacher, and us. So many people that might never have all been drawn together, all working together to do something for some kids they will probably never meet.
That is one of my favorite aspects of our project…the connections created between people, and so many people doing what they can. The school got emptied and cleaned out by the students, and we repainted the whole school, inside and out in less than 5 hours with some touching up a few days later (ran out of paint and a few folks went back with new paint to finish up the last spots).
I love that the same way our whole project was accomplished was the way the school got painted; the school was like a microcosm for our whole project: a lot of people from all walks of life all did a little (some did a LOT more than a little) and got it done.
And continue to do so…thanks to everyone who helped us from day one to painting the school last Friday!
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All patient photos and cases used with patients’ consent
Man, sometimes a week brings a flood of minor upper respiratory tract infections, fungus, and the usual small town clinic maladies…and some weeks, the dam opens and all kinds of situations arrive on the doorstep. We did a lot of small surgeries, mostly taking off cysts and dealing with minor wounds, and did loads of ultrasounds (lots of ovarian cysts, some gallstones and bladder stones); but we also had a few more unusual cases come in.
First, there was Missty (yes, that is how it is spelled). She lives on a sailboat with her mom and dad, and climbs all over the place like a wild child. She is the cutest little girl ever—she came in a week after getting her knee stitched up at the hospital; she sliced it about 4 inches across the front on a piece of sharp metal and then tore ALL her stitches jumping down onto her boat/home and landing in a deep knee bend. Then it started to get infected, so it was a green mess when I took off the bandage.
Tough as nails, she let me take out the stitches and debride the wound, then I steri stripped it together and rebandaged it and sent her home with some antibiotics and dressing changes… “No more running around like crazy on the boat for one more week!”
Then a guy came in unable to swallow or drink, and unable to lower his chin because his tonsils were so badly inflamed they were like tennis balls, with another tennis ball sized abscess in his
cheek. He was really dehydrated, so we gave him IV fluids and pumped him full of antibiotics. The next day he was marginally better, so we kept him on the antibiotics and after a few days he could swallow and take liquids. Only his cheek abscess remains, and it is shrinking rapidly.
We had a baby come in with a mysterious rash (see the photos below for the case details)…we did two surgical house calls for minor procedures at a shop run by two ladies in French Harbor. One of the ladies, from whom I removed a ganglion cyst, was in a hurry to get home so she could make dinner for her husband. I told her he should do it for her while her wrist has just had surgery, and she and her friend agreed…and both laughed at what a delightful fantasy it was, and how impossible. Still tough to have two X chromosomes around these parts.
Still, our clinic is seeing lots of patients. It was great to have Megan with us. She set up two of the clinic rooms for acupuncture and treated patients two at a time every day our clinic was open, and was always running all over the island after hours giving treatments in the community. Being able to combine acupuncture with western medicine was great—in the community we serve, there is a lot of stress and post-traumatic stress from abuse or violence, and mental health issues are somewhat of a taboo. These issues are often compounded with some form of chronic pain, usually in the knees or back or feet after years of hard living.
When patients I had treated medically and then referred to Megan came back for follow up, they raved about how much they felt the treatments helped, and I have seen acupuncture be effective way too many times for me to doubt that is has efficacy in a number of situations. I’m not sure I understand why it actually works, but although I would really like to know for my own interest, ultimately I don’t care—I really only care that it works! My dad always says that despite their frequent disagreements, there is one way doctors and lawyers are always in agreement: ‘Ultimately, both are only interested in results!’ Especially doing this kind of remote medicine, a doctor has to be ready to use any tool in the toolbox that can help, and I felt that of lot of patients got a good result from their treatments. A lot of them burst out crying after or during their treatments and shared all kinds of horrific personal tragedies with Megan…it turned out that often they were crying about it for the first time, even horrible experiences years ago.
I also think the patients were really, really receptive to the concept, too. Certainly, against the blend of bush medicine, Obia, and traditional home remedies in common use,
acupuncture probably didn’t seem too out of place, and there was also an element of the ‘well, the doctor has suggested this, it must be a good idea’ kind of thinking I often saw among older patients in Ireland and most patients in the developing world. Although in this case that attitude it made it easier to get patients to accept acupuncture treatment, that same outlook can sometimes put patients at risk of medical error. One way to bring people into more active participation in their health knowledge (i.e., questioning the doctor), is by empowering them with knowledge about their own health, and we spend a lot of time in consults drawing diagrams and explaining people’s physiology to them.
Sometimes, however, one of us becomes a patient…last night, walking barefoot on the deck, the side of my foot kicked the slivered edge of a cut pine board, and a giant splinter wedged itself into the bottom of my foot. It was wedged in deep and barbed like an arrow, but after I anesthetized it Noah and Sky got a scalpal and some forceps and pulled it out. Man, it sure is sore today…going to go soak it in salt water before showering tonight.
That’s when you know you have an awesome sister…an awesome sister is one who will hold the light for you when you have to inject yourself on the bottom of your foot, which is pretty much exactly like you imagine. So much is happening all at once—we just found out there is a possibility we will be going back to Haiti to help with the cholera outbreak, we are investigating ways to keep the Oakridge clinic operating on a permanent basis, we are coordinating containers of medical supplies and gear from California and Florida to Honduras, and in our spare time continuing to improve and strengthen Southern Wind.
With this much on our plates, I sleep a lot better knowing Sky and our crew are facing this with me.
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All patient photos used with patients’ express consent.
Last week we managed to get a weather window permitting us to visit Isla Guanaja, about 30 miles east of Roatan. This island, which was heavily damaged by Hurricane Mitch, has only one small Centro de Salud public clinic, and only one doctor for the 10,000+ people living on the island. We plan to visit again on our way south towards Panama and drop off a shipment of medical supplies, so this was our chance to visit and see what the particular needs of the community are and what the clinic could really use.
We left from Oakridge at dawn, around the corner from our little clinic there. We were fortunate to hitch a ride with Captain Larry from East End Divers; when we come back here in our ship we will have already been over the ground once with Captain Larry. Now we know where the safe approaches are, where the anchorages are, and how the winds and currents normally run. As it happens, Captain Ed talked to the mayor of Bonacca Cay (the largest settlement on Guanaja) while we were there and managed to get us secure dockage when we return, so it was a very helpful trip!
There is no better way to understand the needs and capabilities of a clinic than to roll up your sleeves and get to work in it, and since we had contacted the
Centro de Salud in Guanaja to let them know we were coming, we had a long list of patients waiting when we got there. On islands, sometimes particular genetic conditions become very prevalent in the population, and we saw a lot of diabetes and high blood pressure–perhaps not surprisingly, we also saw way more obesity on Guanaja than on Roatan.
Whenever I have patients with high blood pressure, I treat with advice on how to lower blood pressure combined with medication to control their blood pressure. Sometimes I see patients on expensive brands of blood pressure pills that they can only get on the mainland (if at all) or can’t afford, so they end up with their blood pressure intermittently controlled and rebounding. The Centros de Salud nearly always have some basic blood pressure medication, so I always try and change people onto medication that they have access to or can afford rather than some of the things private doctors put people on when they can afford to go to one.
Our volunteer acupuncturist Megan did 24 acupuncture treatments, mostly for chronic pain, insomnia, neck pain, and anxiety. The patients really took to it; several came for a second treatment on our second day on Guanaja. Noah saw a lot of adults and kids with poorly healed fractures and soft tissue injuries, and spent time with them teaching exercises to improve their flexibility, support weakened joints and regain strength and flexibility. With our ultrasound, we drew a lot of pregnant women and we ended up distributing over 6,000 vitamins.
As well as diseases, bumps and scrapes that are common to both the developing world and developing nations, we did a house call on a 24 year-old man who weighed 450 lbs and had a huge, painless swelling of his lower right leg developing over the last couple of years. After examining it and talking to him, I am pretty sure he has filarial elephantiasis, sometimes mistakenly called ‘Elephantitis.’
Elephantiasis refers to huge amounts of lymphatic fluid (the clear stuff that makes your organs all wet and shiny looking and that seeps out of your skin
when you get a bad graze) getting trapped in some part of the body, very often the legs or genitalia. If the lymph glands in your body (little balls of immune tissue that your lymphatic fluid seeps through to be filtered) get clogged, the drainage of lymphatic fluid from that part of the body can be blocked and enormous swellings can occur.
Over 120 million people in 80 countries suffer from elephantiasis, primarily in the tropics and with a very high incidence in parts of Africa. There appear to be two kinds of elephantiasis;
one caused by persistent barefoot contact with irritant volcanic soils (particularly in east Africa), and another caused by the parasitic filarial worms like Wucheria bancrofti. Transmitted as larvae in the saliva of mosquitoes, Wucheria nestles in lymphatic glands and blockage of lymphatic flow occurs.
The swelling is painless (though physically and socially debilitating), but crusting and thickening of the skin (probably in part to the victim’s own immune response to the parasite) can result in secondary infections, and the stretching of the skin can cause itching. Rigorous moisturizing, cleaning, washing and drying of affected area is helpful for avoiding secondary infections and other complications, and the worms can be treated with Diethylcarbamazine, Ivermectin, Metrifonate, Suramin, Mebendazole and Levamisole, but most of these are most effective against larval worms and do not get all the adult worms.
Doxycycline over 8 weeks has shown great success at eliminating both larval and adult forms of the worm (possibly by killing the symbiotic bacteria in the worms), but that creates its own special problems. When the worms have been killed, their dead bodies nestled in the lymphatic glands can cause a massive anaphylactic reaction–you could break out in a rash, your blood pressure could collapse, and your throat and airways could swell shut. These symptoms can be treated with antihistamines and steroids, but if the reaction is severe, a patient might have to be intubated.
With the patient we saw on Guanaja, this could be a real problem. Because of his weight, his neck already has a lot of compression on it (and a tracheotomy would sure be hard, as would
IV access) so intubating if his throat started to swell to that level of danger could be a real nightmare. I am going to inquire about whether the initial dose can be done in the hospital on the mainland with an anesthesiologist present–maybe not necessary (prophylactic steroids, antihistamines, and IV access and nebulizer beforehand might be enough) but I don’t think the risk is worth it. I’d rather he was inconvenienced by a long trip to the mainland to have his first doses in hospital only to have nothing bad happen, than to have him risk it at home and be inconvenienced by his own funeral.
If any doctors reading this have more experience treating elephantiasis with doxycycline, please contact me if you have any advice or suggestions. I plan on seeking many expert opinions in my search to find a solution for this young man. Even if the worms are safely eliminated, the swelling may be difficult to get rid of (though massage and compression bandaging can help), but I really want to find a way to get this guy treated.
This is the problem with remote paradises, especially very, very poor ones. The sunrises are beautiful, like this one on our way to Guanaja…but sometimes care for a problem that can be taken care of with some basic treatment is an impossibly long way off. By the time we come back to Guanaja on our way south I want to have a solution for this guy.
Please click on one of the thumbnails below to view a slideshow of pics from our trip to Guanaja
All pictures of patients used with patients’ consent
As we were closing up shop after a busy clinic day in Oakridge, we got a call from the Roatan Zoo—one of the new keepers had been badly mauled by one of the monkeys while cleaning the enclosure. Oh man…after a late night working on the computer and a CRAZY day in clinic I was looking forward to lying down for a while, but when the call comes for help, you have to help–so we grabbed our minor surgery bag and some antibiotics and headed over.
Apparently, the victim had been employed there about two months, and was working (as usual) with the main keeper, who had been with the zoo
for 5 years. They had been in the cages together many times before, and had no problems, but this time the head keeper stepped out to grab some additional cleaning supplies and one of the monkeys decided to challenge the new guy.
While with the head keeper, he had been safe—the head keeper’s place in the monkey society was well established (as boss), so the new keeper got a free pass. But when he was left on his own, one of the males just went for him. He was knocked to the ground and savaged, bitten and clawed all over his legs and his arms and hands; the monkey actually went for his face—all the wounds on his arms and hands are classic defensive wounds. Fortunately the head keeper heard the commotion, ran back and pulled the monkey off (the monkey immediately submitted to the head keeper).
The male in question had been horribly abused in its previous home; it had come to the zoo nearly dead…now it is in fine form; I guess it feels strong enough to challenge newcomers in its little kingdom. Everyone always looks at monkeys and goes ‘Awwww….how cute.” And it is true, with their little human faces and adorable antics, they are pretty fun—but they are also wild animals with motivations all their own, and with lots of strength, agility, speed and teeth and claws!
When we got there, the poor guy was a little shocky, covered in blood, dried monkey saliva, and dirt and debris from the bottom of the monkey enclosure. He was so filthy and crusted that we couldn’t even see where the wounds were. Pretty bad scenario from an infection point of view; monkeys have fangs that can bite pretty deep and inoculate your tissues with their raw sewage-like saliva (pretty similar to human saliva, probably).
I immediately gave him an injection of ceftriaxone and an injection for pain. We used a garden hose (the water at this resort/zoo is filtered and potable) to soak off the filth and dried blood as it would have taken more gauze than we had with us, and been more painful. The hose helped gently soak open the dirty scabs over the wounds, and let them bleed out a little to help clean them. Finally we could see the wounds—lots of them, probably around 40 bites and claw marks. If he hadn’t been wearing jeans, I think he would have lost half the skin on his legs, and if he hadn’t had his arms up in front of his face things would have been a whole lot worse.
After disinfecting and irrigating all the wounds, we salved them with antibiotic ointment, dressed them, and gave him oral antibiotics and painkillers, and fresh bandages for his family to change for him if he got wet. We also started him on acyclovir, an antiviral given as prophylaxis for monkey bites. The next day, all his wounds were clean and dry except for his right hand and left forearm, which were very swollen (and pus was expressed from the hand). We added a second, stronger antibiotic and got him to start bathing his wounds in hot soapy water a few times a day.
It worked—his swelling went down and his wounds are healing nicely. Never a dull moment practicing medicine in the tropics, but most of all I liked that we were able to bring care to his home. The house call is still my favorite consult.
When I was a kid I watched my dad do house calls in Los Angeles…practicing Alaskan small-town doctor medicine in a big city. In my folks’ house, as long as I can remember, there is an old print of a painting of a doctor, circa 1830ish, on horseback with a lantern and black medical bag in the dead of night, riding slowly through a driving rainstorm. There’s no adrenaline rush about the figure; the doctor is not flying down the road, coat trailing behind and sparks flashing from the horse’s shoes on the cobbles.
Instead, the doctor looks cold and wet—can barely see his face behind his upturned collar, peering head through the dimly lit night. He has the air of one doing a job that he is doing because he has no choice, because it is who he is. It would never occur to him that someone else should be the one to go out in the night and go help a sick patient. He goes, and gets cold and wet and more tired (he must be a critical care doctor), because to him, that is what a doctor does. It isn’t even a sacrifice, just a part of his core being. I always felt like that picture captured some of the essence of what being a doctor means to me.
All photos of patients are depicted with consent of the patients.
Wow, what a ride…a few days ago, Hurricane Richard passed almost directly over our position here on Roatan. For several days, we watched it approach, slowing down and gathering strength as it hesitated out in the Atlantic, almost as if it were undecided about whether to move northwest, as most hurricanes do, or to move directly west and sweep over the Isla de Bahia in Roatan. Naturally, we began to take elaborate pre-hurricane precautions, hoping that they would not be necessary.
We cleared all of our gear off the decks and lashed all the big stuff down tight, covered our bridge windows to protect them from flying debris, charged our batteries and filled our water, stocked up on food, added about a dozen dock lines and more fenders, and prepared to ride it out. These are the moments that are a true exercise in letting go; when you have taken all the precautions you can, and done everything you could–then whatever happens is beyond your control. The sea can be a very scary and intimidating place when you try to maintain the illusion of control on the water.
From the bridge, we waited, and tracked the storm on satellite imagery. As it came nearer to our position on the screen, the air felt heavier and heavier as the pressure dropped, and all of us–including Tweek and Giles, our ship’s dog and cat–started feeling restless and agitated…I guess it is true what they say, the waiting MAY not be the worst part, but it is surely no picnic!
First, the weather turned dead calm and still, the only change being the plummeting barometer…then came the rain, and then more rain, and then a LOT more rain…and then the wind. At first the wind wasn’t too bad, blowing at around 30-45 mph for the evening, but as 3:00 AM rolled around the wind began to pick up sharply, whipping the trees around us and surging the already full-moon high tide up over the concrete dock. Thank goodness we had had a chance to adjust and tune all our dock lines while the wind was still blowing only 30, since by the time the wind hit 79 mph it was difficult to move around safely outside.
The boat rocked and heaved amid the spiderweb of dock lines holding her out in the middle of the basin–one line snapped, but Captain Ed and Noah managed to get a replacement line around another cleat in time to keep us from being
pushed forward onto the seawall 8 feet dead ahead. As dawn brightened, the wind began to die down to gale force, and eventually petered out amidst a series of heavy showers into a preternatural stillness, and the first tiny patches of blue sky we had seen for days finally peeking out in the eastern sky.
Then all hands checked the lines one more time and turned in for some well-earned sleep–back at it in the clinics tomorrow! What did Graham Greene say about the sea.. “The ocean is an animal, passive and ominous in a cage, waiting to show what it can do.” The power of the Hurricane, this ‘little’ category one hurricane, gave us a brief glimpse at the forces that lie in wait under the deceptively calm waters and blue skies of the tropics.
The price of having even a chance of survival on the sea is eternal vigilance…when situations turn bad, they tend to do so quickly. Better to prepare thoroughly every single time than be caught out the ONE TIME you fail to take every possible precaution.
Live to sail another day!
Cayos Cochinos, Honduras
Today we voyaged to the Cayos Cochinos island group to do a mobile medical clinic among the Garifuna people living on theses scattered, isolated cays. About 150 people, mostly children, live on the Cayos with little or no access to health care except on the mainland–and for most of the inhabitants, making a bare subsistence living fishing and on the few adventure tourists who visit the Cayos, the 14-mile journey to the mainland might as well be a thousand miles away.
We were joined by volunteers from Clinica Esperanza and the Roatan Rotary Club. A dawn departure with beautiful weather for a crossing saw us
reaching the Cayos Cochinos around mid morning. Because the normally east trade winds were reversed, blowing from the Northwest, there was no place we could anchor in shelter, and Southern Wind had to stand off the island while our team went ashore for the clinic.
The local officials were kind enough to use their panga to run us to shore, and we set up on the beach and began to see patients. We saw adults and children, men and women, all suffering the diseases of poverty that we see everywhere there are people living at the subsistence level such as worms, skin diseases and fungus, poorly healed wounds, poor nutrition, anemia, malaria…and we also saw a lot of ear infections since the islanders spend a lot of time diving for food.
It is heartbreaking to see people living their lives with so little support from anywhere, and yet they laugh and smile, and the children play, and when they get sick, they either get better or they don’t, so it was a wonderful experience to bring care directly to their homes. We distributed over 6,000 vitamins, and treated almost all the residents of one of the cays for parasites, and managed to get some health education to the moms on the island. They have little or no access to health knowledge, and we always look for any opportunity to provide health knowledge that can help our patients get better and stay healthier.
Bad weather and a broken mooring line in the middle of the night forced our early return to Roatan, but we will be going back to the Cayos soon to do follow-up on the patients we saw, and to visit the families living on the other cays as well. Our goal is to provide care for every man, woman and child living on the Cayos!
Here in Honduras, as it was in Haiti, on any given day my crew are usually spread out at several locations, and when I find out later the details of what they have been doing, I am always astonished. Today we recognize the awesomeness of the work done by nurse and instructor Sirin Petch. By the time we had been here about a week, we learned that the single fire station on Roatan had not been given much formal training, and Sirin agreed to work with Maddie to provide training in emergency response. Nearly every day for almost two months, Sirin worked with the firecrews to provide training in airway management, scene assessment, lifting and immobilization, choking, and other techniques necessary for EMS response. Some of them had joined the department when they were 14, but few had been able to get formal training. The firemen are paid very little (they have to buy oxygen for the ambulance out of their own money), and they work hard.
Sirin first asked the Firemen what they would be most interested in learning, and looked at the resources that were available and would be the most useful instruction for work here in Roatan, and then provided training. Maddie was instrumental in helping communication, plus she is a naturally gifted teacher, and later they were joined by Zach, one of the pilots on the emergency helicopter, and Yolanda, a paramedic from Montana volunteering for a couple of months on the helicopter.
Sirin and her team trained the fire crews, went on night calls with them, and even after Yolanda and Maddie had gone home, Sirin continued with the firemen. Near the end of Sirin’s time with us (for now?), an incident occurred that says a lot about the relationship Sirin created with the Bomberos. I got a phone call to transport a patient on the helicopter to the mainland, so I made my way to the landing field, prepped the gear in the helicopter and waited for the Fire Department ambulance to bring a patient with suspected barbituate overdose. The ambulance arrived, the doors were kicked open, and out jumps Sirin and the firemen, who hand off the patient to me on the helicopter.
On the way back to the station, Sirin and the firemen got a call for a woman in full arrest. Sirens blazing, they arrived at a house surrounded by wailing family members. A larger woman in her 40s had a full arrest, in a house at the top of a 30-foot embankment. Using the techniques Sirin had taught, they put her on an immobilization board, inserted an airway, maneuvered her down the hill to the ambulance and raced to the hospital. They worked hard to resuscitate the woman, both in the ambulance and the hospital, but eventually had to call time of death. Sirin helped arrange the body and deal with the distraught family thronging the hospital corridor, then she and the Bomberos headed back to the Fire Station, only to be diverted to a brush fire. They gave Sirin a brush jacket and sped off to a banana plantation, arriving as it burned itself out. Scrambling up the smoking, scorched earth, they made sure the fire was completely extinguished, then returned to base.
Beyond the skills and training that she made available to the firemen, I believe that Sirin gave them something much more valuable. They looked at what Sirin knew, and her professionalism, and saw its value. She earned their respect (not always easy for female professionals in Latin America) and their friendship, and helped inspire them and motivate them to want more training and to seek it out. They have asked Sirin to send EMS instruction books and have increased their physical training (Noah has worked with them in the gym and done lifting and transferring instruction with them, and a few days ago I boxed with another).
I am very, very proud of the work at the Fire station, and very proud to have seen Sirin rise to such a challenge. Long after we are gone, I hope the knowledge and professional pride she left behind will continue to grow and help people.
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