Ebola Grand Rounds Handout with more information

Ebola: A Personal Perspective as a Short-term Clinician in Sierra Leone, West Africa

Vijay Aswani, MD, PhD, FACP

Grand Rounds: May 29, 2015

Notes and Handout

Link to Video of the presentation:
http://mediasite.mfldclin.edu/Mediasite/Catalog/Full/ccabc617b83848c8b0ceff43bf7e695d21/a719557fcd4e44459162ec5e59c5646f14/ccabc617b83848c8b0ceff43bf7e695d21

1.      Personal account of the discovery of Ebola by Peter Piot can be found at:

http://news.sciencemag.org/africa/2014/08/part-one-virologists-tale-africas-first-encounter-ebola

2.      Link to original paper describing 1976 Ebola outbreak: Report of an International Commission (1978). Ebola haemorrhagic fever in Zaire, 1976. Bull World Health Organ. 1978; 56(2): 271–293.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2395567/pdf/bullwho00439-0113.pdf

3.      Article from NEJM about Ebola Virus Disease among Children in West Africa.

http://www.nejm.org/doi/full/10.1056/NEJMc1415318

 

4. Ebola Virus Disease Case Definitions (Source: WHO)

(http://www.who.int/csr/resources/publications/ebola/ebola-case-definition-contact-en.pdf)

SUSPECTED CASE:
Any person, alive or dead, suffering or having suffered from a sudden onset of high fever and having
had contact with:
- a suspected, probable or confirmed Ebola case;
- a dead or sick animal (for Ebola)
OR
any person with sudden onset of high fever and at least three of the following symptoms:
• headaches • vomiting
• anorexia / loss of appetite • diarrhea
• lethargy • stomach pain
• aching muscles or joints • difficulty swallowing
• breathing difficulties • hiccup
OR
any person with inexplicable bleeding
OR
any sudden, inexplicable death.

Ebola case contacts:
Any person having been exposed to a suspect, probable or confirmed case of Ebola in at least one of the following ways:
· has slept in the same household with a case
· has had direct physical contact with the case (alive or dead) during the illness
· has had direct physical contact with the (dead) case at the funeral
· has touched his/her blood or body fluids during the illness
· has touched his/her clothes or linens
· has been breastfed by the patient (baby)

Contacts of dead or sick animals:
Any person having been exposure to a sick or dead animal in at least one of the following ways:
· has had direct physical contact with the animal
· has had direct contact with the animal’s blood or body fluids
· has carved up the animal
· has eaten raw bush-meat

Laboratory contacts:
· has had direct contact with specimens collected from suspected Ebola patients
· has had direct contact with specimens collected from suspected Ebola animal cases

Ebola Sierra Leone Experience Grand Rounds

Ebola Experience in Sierra Leone Grand Rounds, May 2015 Marshfield Clinic from Vijay Aswani

To view the presentation, you may need to click the link above

January 17, 2015

It is Saturday and I am writing this from New York’s JFK airport. It is 6 pm and my flight to Brussels boards at 6:43 pm. I have not written for a few days. Here is what has happened since I last wrote.

Tuesday morning Amy and me left Phoebe to school. We went to Walmart and I bought a new strap for my watch and a new duffle bag – I found the one we had bought at Cabella’s too big. I was more satisfied with this one.

I finished packing and we drove to CWA. Amy sat with me for a few minutes outside security. She told me she was proud that I was pursuing something I believed in, that was a worthy cause (or something like that). Because we have not been getting along very well, our parting was a little cold.

My flight to Boston was relatively uneventful. I decided to be brave and take the T, rather than a cab, to save money. It went quite well and I did not get lost. I got to the Holiday Inn by about 9 pm and settled into my room for the night.

The next few days were pretty much the same.I walked down to Commonwealth street where on the 3^rd floor of building 888 were the offices of PIH. The staff were extremely polite, friendly and very young. We met every day there.

Our group – the January 12 cohort – consisted on 19 people, 6 going to Liberia and 13 to Sierra Leone. To my count, there were 5 doctors – Guy, Marcus, Jessica, Molly, Emily, Rick and Katie. Rick and Jessica were going to Liberia and the rest of us to Sierra Leone. I noted that several of us had international experience, some having spent a year or more in another country as part of the Peace Core or some other medical work.

Here we are on the last day of our training…

The office training was delivered as a mix of PowerPoints, Skype interviews and some audio. It was practical and pertinent. While most of the group socialized in the evening, I chose to spend the time in my room. I did find a nice Indian restaurant, Rani’s Bistro where I ate most of my dinners.

So here are few thoughts…

A nice young man named John gave us a talk on the mission of PIH. It was filled with heady stuff about healthcare being a basic human right, working with governments to strengthen their country’s healthcare system being the key to longterm success and such. While I agree in principle, my past experience with government corruption, the transient nature of most people in power and their promises and commitment often being overwritten by the next to assume power makes me a little cynical. Yes, healthcare is a basic human right… like food, clothing, housing, education, and the right to dignity, happiness, ability to achieve one’s potential unhindered by lack of opportunity, blah , blah. So what? How do you make this real?

Here I sit at an airport going to Africa to work in Sierra Leone with Ebola for 5 weeks. I wonder about how much good I can do, and how does this fit in the grand scheme of things. I guess I am one of an army of short term workers, taking some time out of my life to contribute manpower hours to care for those suffering from Ebola, to contribute to the process of controlling this epidemic. After this, I return to my existence as a small country doctor, treating the about 1500 people who visit me regularly for their healthcare. Is it worth it? Should it be left to the professional ‘world-changers’ – doctors who do global health as a career?

I feel like I can certainly learn protocols and read and assimilate and be ‘boots on the ground’ for 6 weeks. Hopefully, my mite, along with that of other cohorts strung in time make for some continuity that makes a difference. Meanwhile, my life is on hold – my practice, CF patients, Peds Board preparation, family, all cease for a few weeks. Am I being selfish, seeking the direct fulfillment of doing something while others share in the price of what I do? Is this the right way to do this?

I certainly want to help – to work in a third world setting with intelligence, creativity and energy. However, I am a little cynical about effecting global change. Meanwhile, how do I support my immediate and extended family financially? Am I letting my CF patients and other patients in Marshfield, WI down doing this while leaving them to the mercies of whoever can help them there? Are there lives, because they are not the focus of the world and do not have a ‘glamorous’ eye catching disease or make a photo-op moment, worth any less? Yet, am I content to serve them in obscurity, putting in decades until I am old and must retire, as many of the older docs in the community of Marshfield have done?

In the end, only God can give perspective, direction or meaning to any of this. The ‘machine’ is too large for one part to behold how and where it turns and what it produces.

January 18, 2015

It is Sunday. The day began in the plane. Because of time changes, most of the day is spent in the plane, going from New York to Brussels, Brussel to Freetown, via Dakar, Senegal, Conakry, Guinea on our Brussels airlines flight. Sitting next to me was a young man, Sam, who was from Wales. He was going over as part of the British Red Cross to work in Konama. There were a number of ex-pats in the plane, all going to Freetown as part of an Ebola response from one or the other organization.

We arrived at the airport in the evening. It was dark. From the airport, we were driven by bus to a ferry stop (here is picture taken athe ferry stop that showed us our first public sign (outside the airport) regarding Ebola; we would see numerous signs everywhere.



 and took a Sea Coach ferry for about 30 minutes in the pitch dark. On the other wide, we got into a bus and drove to King’s road, where PIH had an apartment building. I got to share an apartment on the 4^th floor with a Sierra Leonian, Edward Vandy (an RN from the UK who had been working with GOAL and was now returning to work with PIH), and two nurses, Kim and JoAnne. The apartment had 3 rooms, a hall, kitchen and 2 bathrooms. The men got one half (with 2 rooms) and the women shared a room with bunk beds. The apartment was surprisingly comfortable, with a television, air conditioning in the rooms and spotty internet. After settling in for the night and calling Amy, I went to bed at 12:30 am. Here is a view from our apartment…

DAY T-1 January 12, 2015

Today is Monday. We all got up and took Phoebe to school. I don’t think I have ever done this, since I usually work and Amy drops Phoebe off. Amy and we went to breakfast at Perkins and I left her home. I went to the Clinic to get some Peds Boards review files from Sarah. I stopped by Walmart to get my old watch battery replaced and the strap fixed. I reason that it is not wise to take the expensive Raymond Weil I got for my 50^th birthday to Africa. Instead I pulled out the abut $ 30 Lorus and tried to buy a strap and battery for it. The strap costs $ 14 and for about $ 20 I can get a new watch! Times have sure changed. I came home and began to pack.

DAY T-2 January 11, 2015

Today is Sunday. Our family got up and went to church. While Amy had originally said she would not sit in the service with me, she changed her mind and did. I kept tight-lipped about my travel plans. I reasoned that it would alarm and inspire fear in some of our congregation if they knew where I was going and that I intended to come back to them. Dave Heegeman knew however, and he prayed with me after the service.
We went to Perkins for lunch and went to see Night at the Museum Part 3. It was a fun movie and we exited the theater in a good mood. We came home. I worked on backing up my data while Amy and Phoebe practiced piano and violin. After dinner, Phoebe was put to bed and Amy and me watched ‘The Good Lie’, a movie about the lost children of Sudan. Went to bed.

DAY T-3 January 10, 2015

Amy and me are not getting along. She woke up to go to counseling with Dr. Benson.  I went to the clinic to try to back up my files. We met at home at noon to go and pick up Phoebe. After going to the Mall to try to find her remote control helicopter (Amy and me had sort of promised Phoebe she could use money she got from her grandma to buy this), I left them and home. I called my mother and brother. It felt odd not being to tell them about Africa, while I have resigned my job and am shopping and packing for this. But, how would it help them? They would be tortured thinking about the risks I am taking on the job front, traveling to Africa and working with Ebola. I reasoned, they are better off knowing when I am back, if that is possible. Phoebe and Amy stayed at home, while I went to Walmart, Office Max and Fleet Farm looking for things I needed – adaptors, shoes, etc. I came home and we ate dinner. We watched the Night at the Museum 2, as Amy and Phoebe had not seen it before and were keen to see the third part in the theater tomorrow. After Phoebe went to bed, Amy and me talked some. Her initial anger and wanting a divorce has calmed down some.

Day T-4 January 9, 2015

DAY T-4 January 9, 2015

Today I resigned from my job at the Marshfield Clinic. It felt sad taking off my badge and leaving my pager on the desk. Due to HIPPA requirements, since I am not an employee, I cannot access the Clinic’s email system or read notes, look at labs or anything. I am cut off completely.

It felt odd and scary to walk away and know that I am no an employee of the Marshfield Clinic. I am unemployed. I can no longer expect a salary. What have I done? What am I doing? I backed up all my research and files on a portable hard drive, because since I resigned, IS may wipe out all my records.

It was a harrowing day as I had still not received an itinerary or confirmed ticket. Finally, after several emails and one phone call, I received it at 8 pm at night. I am flying to Boston on Tuesday, January 13, 2015 at 2 pm.

It is going to be interesting trying to record this on an iPad.

Camp Angel, Summer 2014

It's summer again. Among other things, that means... Camp Angel! The camp this year was held from Friday, July 11 to Sunday, July 13, 2014. Here's what we did:

 

The Campers were divided into 4 groups:

Foxes (3 counselors and 8 campers -- girls, ages 10 to 12), that lived in the Treehouse

Wolves (2 counselors with 7 campers -- boys ages 10 to 12), that lived in the Tower

Bears (2 counselors and 9 campers -- boys ages 8 and 8), that lived in the Fort

Bunnies (2 counselors, 2 junior counselors and 8 campers -- girls ages 7 to 9), that lived in the Covered wagons.

 

So, if you're wondering what the 'special visit' was on the schedule of the first day at camp, it was... a visit from the local Harley-Davidson riders club. They bought cool biker bandanas for us all too.

 

My daughter, Bunnie friend and a biker

Camp Angel is a wonderful opportunity to have kids between the ages of 8 and 12 (well, some older and younger ones sneak in) to get away from cancer in their families and have fun. Although there are no formal or oganized events where kids talk about cancer, you catch snatches of conversation between kids. They realize that they are not alone.

campers, counselors and some of the bikers

My duaghter, our camp photographer and me in front of a bike

The campers had fun around the fireplace and sleeping cool camp sites.

 

The towers, where the Wolves stayed

The covered wagons, where th Bunnies stayed

  

Bunnies and bears waiting for their turn on the pirate ship

 

First group of campers getting into dock

  

Bunnies making bunny ears!

 

coloring shirts on the pirate ship



Captain Steve makes the BEST pirate drawings for your T-shirt, AARRR!

Phoebe drives us onward to find treasures... or unsuspecting ships to attack!

Can we get the swim tests over with so we can jump in?

Getting ready for tubing on the lake!

Hey! Wait, that's not where your slug goes! It's your bait for the fish....

 

Who says bunnies can't fish?

Yay! I got another one!

We're all ready to party! Where's DJ Dan?

Let's go to the Y-M-C-A! Yeah!

Do the macarena!

Note to self: do not compete in a limbo competition with 8 year olds, you won't win!

Camp Angel is loads of fun. More importantly, it is a great example of how to turn tragedy into a blessing to others. In 1995, after losing her husband to cancer, Lolly Rose noticed that children were often sidelined when a loved one of theirs got cancer. It broke her heart. She founded these camps for children touched by cancer in a loved one to be able to come up for a weekend in summer and winter. She took her personal loss and transformed it into an outpouring of love and support for other families touched by cancer. The camps are free to the campers and their families. For more information, go to http://angelonmyshoulder.org/

In memory of a young cystic fibrosis patient...

My heart is heavy with grief. A young man with cystic fibrosis died in the intensive care unit today. I have taken care of this young man as a patient for about 5 years. During that time, he has had several close calls and has spent a fair amount of time in the hospital. I last took care of him during a 33-day hospital stay in which I rounded on him every day. We would sit and watch WWF raw on tv (his favorite show). We talked about how when he got out, we would go to Madison to see an actual wrestling match -- the one they televised and that we watched. I promised to go. That is a promise I can never keep. I had sat by his side when his marriage fell apart and he wept bitterly. I had reassured him when he thought he would die and together, we fought until he lived to fight another day. He trusted me with his life. I felt that I gave him good care. This last time around however, he came to the ER when I was out at a children's camp. He was admitted directly to the ICU and sent off to a university hospital the following day. Within 2 days of getting there, the team decided that continuing agressive care was futile and with the patient's decision to give up, support was withdrawn. He died within the hour of withdrawal of support. I do not doubt that the doctors there gave him excellent care. I do not doubt that the decision was made competently. I do believe however, that they did not him like I did. One of them told me over the phone that he had no 'quality of life'. I told him how this young man had celebrated the 4th of July with his family and ate a barbeque. I mentioned how he joked and laughed and enjoyed wrestling on tv. He was surprised. In the end though, my patient, my friend, died. I feel the loss. His death reminds us that CF is an ugly disease that steals away the youth, vigor and ultimately the life of these young people. It leaves behind weeping parents, spouses and sometimes children. I take care of adults with cystic fibrosis. Some days between waiting for one patient to receive a lung transplant and the always untimely death of another patient, I almost want to walk away from this work ... almost. But I will not. I will fight it on every front with the anger born of loss. I will aggressively fight for the lives of my young patients and purchase every breath and every day from this relentless disease. What else can I do?

Doctor, I made you a comic...

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Makayla Schwantes is a wonderful 7 year old girl who made me a comic. I think she is a wonderfully creative and intelligent little girl. Thank you Makayla! (Thank you to her parents for letting me share this).





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"I miss her something terrible."

A daughter brought in an 85 year old man for an office visit. He and his wife lived on their own. The elderly couple had resisted every effort on the part of family to move out of their house into an apartment in a senior center or in an assisted living facility. Together, the frail couple helped each other with their medicines, activities of daily living and went everywhere together. His wife had crippling arthritis and was in constant pain. Finally, after 2 months in hospice, she died.

Here was the husband in my office, bereft, tearful and lost. He had lost his wife of 64 years. That is more years than I have lived.

"We went everywhere together, doc" he told me.

He looked up to me with tears in his eyes, his voice cracking as he said almost in a whisper, "I miss her something terrible."

There is no medicine, no pill, indeed, no answer to grief.

It's the highlight of my year!"

This 51 year old construction worker came in for his annual physical. His hands were rough and grease-stained. He was large, muscular and plain of speech and dress. While I did his physical exam, we talked. I asked him how his kids were. His face lit up when he told me this story about his 16 year old daughter:

"You know what the highlight of my year is, doc?" he asked me.

"No, what is it?" I replied, thinking he would tell me about his annual fishing or hunting trip, or a vacation.

" Every year, my daughter's dance class puts up a production of the Nutcracker. The opening scene has some adults dancing the waltz at a party. I always participate so that I can be on stage with my daughter. She usually plays one of the wind-up dolls later in the play."

"You dance?" I asked, as I looked into his ears with the otoscope.

He laughed. "Not very well. But I wouldn't miss it for anything."

"This year, they are going to let the actors, including my daughter play more than one role and I get to do the waltz with my daughter in the opening scene. Imagine! I will be able to dance with my daughter this year!"

His face beamed.

"The high point of my life is spending time with my kids and the Nutcracker dance with my daughter is the highlight of my year."

I love listening to my patients' stories and my heart was warmed and touched by this seemingly rough, macho construction worker's tender spot.

"She's worth it!"

I was seeing an 83 year old male for follow up of recent health problems. I asked him how things were going. He pointed out that he was a little tired. His wife (81 years old) was formally diagnosed with dementia. She had had a recent hospitalization for an acute illness and had been discharged to a nursing home. At this time, my patiet's eyes flashed as he told me, "I didn't like the place! They had her walking with a walker." I got her home and in 3 days, she was walking on her own."

He told me that now she was home, he had to watch her carefully -- in case she turned on the stove, or left a tap running. He did all the cooking, cleaning and helped her get dressed. Concerned about his health, I explained as sensitively as I could that there were options: he could have home health come and assist him ("I won't have strangers coming into my home to care for my wife!"), he could place her in a nursing home or assisted living facility where he could visit her often ("I will never do that!"). In the end, somewhat exasperated, I told him that I was concerned about his failing health and strength. In the process of sizing up the task of his caring for his wife full-time, I explained that it was a lot of work for one 83 year old man to do. He fixed his gaze on me and simple said:

"She's worth it!"

Changes

I was returning from the country of Panama where I had gone to attend my nephew's graduation from law school. As I was going through immigration upon entering the United States, the immigration officer and me had the following conversation:

"What do you do?" asked the immigration officer.

"I'm a physician." he answered.

He continued to look through my passport and at his computer screen.

"You know" he said, "I used to go to my doctor and have enough time to tell him about what was wrong and things I wanted to discuss regarding my health. The last time I went, I waited about 3 hours for my appointment and it felt like it was all over in 15 seconds. He didn't have time to talk to me! He had to rush because he was only given so much time per patient. He did not want to listen to my questions. He asked me to make another appointment for those.

"I went to the Cleveland Clinic and felt like the doctor there took his time with me."

Healthcare is changing. Some clinics stay afloat by using a 'production' model -- physician's salaries are based on how many patients they see -- the more they see, the more they get paid. Other clinics pay their physicians a fixed salary, regardless of the volume of patients they see. In the latter model, there must be some honor system that physicians will not be lazy and skip out on seeing patients. They do get to take the amount of time they feel necessary to meet their patient's needs.

I believe in addressing my patients' needs. So I run late. Oh well.

What is the answer?

QR Code link to References to Poster

Welcome to the link for my poster at the ASM 2014 Meeting.

I can be reached for more information at aswani.vijay@marshfieldclinic.org. 

References to Poster presented at ASM 2014

1. Abedon ST1, Thomas-Abedon C, Thomas A, Mazure H. Bacteriophage prehistory: Is or is not Hankin, 1896, a phage reference? Bacteriophage. 2011 May;1(3):174-178.
2. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 55, 64
3. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 64
4. Raettig, H. 1958. Bakteriophagie 1917 bis 1956, Teil I and II, Gustav Fischer Verlag Stuttgart
5. Raettig H. 1967. Bakteriophagie 1957 – 1965. , Gustav Fischer Verlag Stuttgart.
6. Brussow H. Phage Therapy: Quo Vadis? Clinical Infectious Diseases 2014; 58(4): 535-536
7. Hankin ME. Les microbes des riviíres de l'Inde. Ann Inst Pasteur (Paris) 1896;10:175–176.
8. Twort FW. An investigation on the nature of ultramicroscopic viruses. Lancet. 1915;2:1241–1243
9. d'Hérelle F. Sur un microbe invisible antagoniste des bacilles dysentériques. C R Acad Sci Ser D. 1917;165:373–375.
10. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 82-96
11. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 114
12. Chanishvili, N. A Literature Review of the Practical Application of Bacteriophage Research.Nova Biomedical Books, NY.2012. Preface.
13. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 125-144
14. Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 158

[15] Abedon, ST, Kuhl, SJ, Blasdel, BG, Kutter, EM. Phage Treatment of Human Infections. Bacteriophage 1:2, 66-85. 2011

[16] Summers, C. 1999 Felix d’Herelle and the Origins of Molecular Biology. Yale University Press. Page 206

[17] Ruska H. Über die Sichtbarmachung der bakteriophagen Lyse im Übermikroskop. Naturwissenschaften. 1940;28:45–6. Ruska H. Über die Sichtbarmachung der bakteriophagen Lyse im Übermikroskop. Naturwissenschaften. 1940;28:45–6.

[18] Pfankuch E, Kausche GA. Isolierung und übermikroskopische Abbildung eines Bakteriophagen. Naturwissenschaften. 1940;28:46.

[19] 14

[20] Sanger, F.; Air, G. M.; Barrell, B. G.; Brown, N. L.; Coulson, A. R.; Fiddes, J. C.; Hutchison, C. A.; Slocombe, P. M.; Smith, M. (1977). "Nucleotide sequence of bacteriophage ΦX174 DNA". Nature 265 (5596): 687–95.

[21] Thiel K. 2004. Old dogma, new tricks—21st Century phage therapy Nature Biotechnology 22(1): 31-36. See Table 1 on page 35.

[22] Smith, Hamilton O.; Hutchison, Clyde A.; Pfannkoch, Cynthia; Venter, J. Craig (2003). "Generating a Synthetic Genome by Whole Genome Assembly: ΦX174 Bacteriophage from Synthetic Oligonucleotides". Proceedings of the National Academy of Sciences 100 (26): 15440–5.

[23] Bruttin A, Brüssow H. Human volunteers receiving Escherichia coli phage T4 orally: a safety test of phage therapy. Antimicrob Agents Chemother. 2005;49:2874–2878.

[24] Davison, WC. 1922T he bacteriolysaant Therapy of Bacillary Dysentery in Children. American Journal of Diseases of Children 23:531-534.

[25] Spence RC, McKinley EB. 1924. The Therapeutic Value of the Bacteriophage in Treatment of Bacillary Dysentery. Southern Medical Journal 17 (8): 563-571

[26] Larkum, NW. 1929. Bacteriophage From a Public Health Standpoint. American Journal of Public Health 19: 31-36

[27] Schultz, EW. 1932. Bacteriophage: possible therapeutic aid in dental infections. Journal of Dental Research 12: 295-310.

[28] Straub, ME and Applebaum M. 1933. Studies on commercial bacteriophage products. JAMA 100: 110-113

[29] Eaton MD and Bayne-Jones S. 1934  Bacteriophage therapy: review of the principles and results of the use of bacteriophage in the treatment of infections. JAMA. 103(23):1769-1776.

[30] Eaton MD and Bayne-Jones S. 1934  Bacteriophage therapy: review of the principles and results of the use of bacteriophage in the treatment of infections. JAMA103(24):1847-1853.

[31] Eaton MD and Bayne-Jones S. 1934. Bacteriophage therapy: review of the principles and results of the use of bacteriophage in the treatment of infections. JAMA. 103(25):1934-1939.

[32] Krueger AP and Scribner EJ. 1941. The Bacteriophage: Its Nature and its Therapeutic Use. JAMA 116 (19): 2160-2167.

[33] Krueger AP and Scribner EJ. 1941. The Bacteriophage: Its Nature and its Therapeutic Use. JAMA 116 (20): 2269-2277.

[34] Kutter, E., and A. Sulakvelidze. 2005. Bacteriophages: biology and applications. CRC Press, Inc., Boca Raton, Fla. Page 396.

[35] Kutter, E., and A. Sulakvelidze. 2005. Bacteriophages: biology and applications. CRC Press, Inc., Boca Raton, Fla. Page 398.

[36] Rhoads DD, Wolcott RD, Kuskowski MA, Wolcott BM, Ward LS, Sulakvelidze A. Bacteriophage therapy of venous leg ulcers in humans: results of a phase I safety trial. J Wound Care. 2009;18:237–243

Father's Day

It was Father's Day last Sunday. My wife and daughter decided to take me to breakfast to my favorite restaurant. While we sat at the table, I saw a family sitting some distance away from us. They did not see us. At the table were a mom, her oldest son and her 2 daughters. There was no man at the table. I recognized them from clinic. The children had missed their well child visits, although I did not know why. Seeing them on Father's day was poignant. There is a story there.

A year or so ago, it was a Friday afternoon and I was going in to an examining room to see the last patients for the day. It was a well child for 3 siblings. We were runny behind and I was tired. I was scheduled to fly out of the country the next day to visit my family in Panama.

As the clinic visit unfolded, it became clear that their dad was physically abusing the children. He hated the oldest one, since he was a step-son. He had no patience with the younger ones. They were traumatized. After investigation, the father was removed from the home and mandated to go to anger management. When I saw the children in a follow up visit, the youngest one said to me:

"I miss my daddy! It's my fault he had to go away. I broke something and I made him angry. It was my fault!"

It broke my heart.

That was the family sitting at the table in the restaurant... without the dad. I did that.

Pediatricians are mandatory reporters of child abuse.

Aswani Salvador

I should start by saying that I have the parents' permission to write this entry, because I shall be divulging some identifying information.

I have a wonderful family in my practice. I see both the parents and kids (one of the fun things that comes from being a Med-Peds doc). Recently, the family was blessed by the addition of twin boys. I was excitededly looking forward to doing their newborn exams.

As it turned out, my schedule was packed, and their first exam in the Med-Peds department was to be done by my colleague, who had openings in her schedule. When they checked in, one of the girls at the appointment desk came up to me with a big smile on her face and asked me if I knew about this. I thought she was asking about whether I knew that one of my families had had twins. I smiled back and said, "Oh yes! I can't wait to meet them!"

She shook her head to indicate that that was not what she meant and smiled and showed me their appointment. They had named one of the baby boys Aswani Salvador! Aswani is my last name and we had chatted in the past about my mission trips to El Salvador. Dad had mentioned at one point in the pregnancy that he would like to name one of his children after me. I had thought he was kidding. Guess not.

It was a bit ironic that even Aswani could not get in to see Aswani -- the practice is that busy!

I did get to meet the twins eventually and was somewhat embarrassed to be holding Aswani.

I hope that Aswani doesn't get flak for his name growing up. :-)

Listening to her heart

My mom visited me here recently. While here,she developed a slight cough and congestion. In order to determine if she might be cooking a pneumonia, I decided to listen to her heart and lungs -- something I do for my patients.

I have listened to thousands (if not tens of thousands) of hearts and lungs by now. Just like other physicians who do this, I am listening for certain sounds, characterizing what I hear into abnormal and normal and building a differential diagnosis based on what I hear. Listening to a heart or to lung sounds is not the same as listening to a song in iTunes or on your phone or music player. One usually isn't appreciating some asthetic.

All this said, when I put my stethoscope on my mother's chest and heard her heart, I had a strange feeling. It occurred to me that when I was in her womb for 9 months (I was born full term), I heard that sound day and night. I was drawn by the experience to reflect on how my relationship to that sound has changed. As a fetus, I simply heard it. I wonder if fetuses derive comfort from hearing that heart sound as some have suggested. Here I was now listening with a physician's ear. I probably heard the sound of my mother's breathing both inside her womb and thereafter as she held me. Now I was listening for subtle changes in her breath sounds to determine if she had fluid in her lungs, an asthmatic's wheeze or something else.

It was a bit surreal.

El Salvador Mission Trip 2013

Before the trip….

I was praying for doctors and nurses. We had only 2 doctors – Yakub Elias and myself. We had only one RN I knew of, on the team. We had a few ER techs and nursing students, CNAs.

Day 1 in El Salvador – January 20, 2013

We arrived safely. On board the plane ride to El Salvador from Chicago, one of our team members passed out. She became cold and clammy. It was touch and go for a bit. However, she held on. It was probably a combination of being awake, on her feet and exhausted. She did okay.

Chatting with Richard Pickrell -- our worship pastor at the airport in Chicago on the way

We went through customs without a hitch. However, we were told the bad news: the customs officer would keep our medicine bags. Apparently, the processing of documents that would allow us to bring the medications into the country was not complete. The medications were therefore to be left there until the paperwork could be completed. Since we arrived on a Sunday, nothing could be done that day.

The Castillo del Rey bus that took us around El Salvador

Happy to be back in El Salvador -- loading up luggage from the airport

a 'tower' of medicines ready for clinic the next morning

at the airport at San Salvador, waiting for our ride

In the evening, we sat and counted out tablets and poured liquid medications (we had sent an order of medications that was delivered from Europe to King’s Castle and this was what we had to work with). We wondered if it would be enough. I discovered that 2 nurses that had come with a team before us had stayed behind to work with us. One of them – Mary flushed ears all day and the deaf could hear after she was done!

Day 2 – January 21, 2013 – First day of work

After a 2.5 hour drive to Miraflores, El Salvador (picture), we set up clinic in the church. We saw 158 people there. A mother brought in a toddler with a fever of 104. We were able to treat this child with an antibiotic and brought her temperature down to normal.

She was playful when she left. We saw 10 dental patients and gave out 45 pairs of eyeglasses.

Day 3 – January 22, 2013 – Second day of work

We worked out of the gym in Lago Coatepeque that day. I was nervous because we were already low on medicines (not having what we had brought down from the States yet). We saw 182 patients this day. I gave a walker to an 103 year old male (picture) who took off.

103 year old man with his new walker

We saw a 44 year old female with a piece of sewing needle stuck in her hand for 7 months. Dr. Elias removed it. My last patient of the day was a 12 year old female that had been sexually abused for 4 months. Mom wanted a pregnancy test. She was not pregnant but did have symptoms consistent with a sexually transmitted disease. We treated her and she received counseling. Yakub’s last patient was a 4 year old boy with seizure-like spells. He too had been abused when he was younger. He was on 3 different classes of medications for seizures but his EEG was negative. We prayed for him. We saw 15 dental patients and gave out 76 pairs of eye glasses.

Planning the day with Tammy, one of the local missionary nurses from Castillo del Rey

Our dentist, Andrea McNeely, assisted by Richard Pickrell

Our meds arrived! Our whole team worked hard to count them up and have them ready for the next day. It was great team work!

Day 4 – January 23, 2013 – Third day of work

We worked out of the gym again. We saw 191 people that day. One of them was an 11 month old boy that was severely dehydrated with a high fever, diarrhea and a rash. We were able to get an IV started and treated him with fluids. We saw 14 dental patients and gave out 78 pairs of eye glasses.

I LOVE working in medical missions!

Guadalupe is a small town we passed on the way

Day 5 – January 24, 2013 – Fourth day of work

We got in the bus and drove about 2 hours to San Juan Miraflores Abajo, in the same municipality as Miraflores. We saw 143 patients. Patients here asked about diabetes, cholesterol and weight. One patient wanted to know if the vitamins I was giving her would make her fat. Several patients had blood sugars in the 500s. Dr. Yakub sort of yelled at one woman to be more careful with her diet and she recommitted her life to the Lord in counseling after that. Another complained that her son would not eat regular food, but would eat pizza and burgers just fine. We saw 12 dental patients here and gave out 59 pairs of eye glasses.

Examining the eyes of a young man

Hands - a little girl's hand in mine

A cheloid on the ear of a teenager, came from wearing an earring on her pinna

a skin rash on a middle-aged man -- I suspect ichthyosis

the rash was on both the upper and lower extremities

A close up of the rash on the lower extremity

Day 6 – January 25, 2013 – Last day of work

the portable dental suction unit our dentist uses

Our dentist had all her instruments set out daily for the work ahead

Hands - our dentist holding some of the infected teeth she extracted.

We drove to Nueva Esperanza (about an hour away). We saw 266 patients here. There were a lot of young mothers – 13 through 18. Dangerous place: girls are lifted out of the classrooms by gangs and no one does anything. We treated one 4 month old baby with a severe staphylococcus infection. We saw 19 dental patients and gave out 88 pairs of eye glasses.

Why do we give out glasses? (Picture 1 of eye) – because sun damage causes pinguecula that progresses to (picture 2 of eye) pterygium, that causes blindness. Only surgery can remove this growth once it forms.

pinguecola -- spreading from the medial canthus towards the pupil

Pterygium -- the growth now covers the pupil in this older woman

All told, we saw 940 medical patients, gave out 346 pairs of eye glasses and treated 70 dental patients. With only 2 doctors and not having our US meds for 2 of the 5 days, we still saw more patients than we have in each of the past 3 years. The LORD knew how to space us out with our meds and he gave us grace to serve. In the end, we had enough doctors, 4 awesome nurses who did excellent work and many, many helpers in the medical work. Everyone pitched in to count meds and load the buses each day.

from left to right: Drs Yakub Elias, Vijay Aswani and Boris Magana

Nail disorder in an older woman

assymmetric enlargement of right lobe of thyroid

Vitiligo patch on knee of a teenage boy

vitiligo patch on the back of neck of the same teenage boy

I suspect Buerger disease in this unfortunate lady, who has had bilateral above the knee amputations due to poor circulation and now has decreased circulation in her fingers.

Listening to the lungs of a man complaining of cough

Dr. Elias checking ocular movement and cranial nerves in a young lady

100 people who came to the medical work accepted Christ.

On the last day, I was discussing why so many people in the sites where we saw patients get intestinal parasites. We were discussing how we might improve sanitation and drinking water. One of the missionaries that was there this year holds a Masters in Environmental Engineering from Johns Hopkins and was with Engineers without Borders. He is going to work on setting up an appropriate technology solution.

We plan to work on educational materiel to teach basic hygiene, sanitation.

Oscar.

Last year, at Nueva Esperanza, I got to see a paraplegic who had the worst pressure sores I had ever seen (picture of buttock sore). Working under less than sterile and optimal conditions, with Terry Martin as a nurse to assist, I debrided his wounds. He told me they healed and closed us on their own (picture of healed sores).

Sacral and buttock ulcers before debridement last year

This year, most of the ulcers have healed up well!

We gave him a wheelchair cushion and a mattress.

This is a picture of the mattress we got Oscar. His little nephew stands nearby

Oscar with his mom, a nephew and a niece in his house.

This time, I was able to go to his house and see where he lived. Here are the pictures. For someone in a wheelchair, he lives in a dirt floor house with boulders in the driveway.

the floor of Oscar's house

Oscar lives in poverty, the only breadwinner in his home being his sister. She works in a Fruit of the Loom factory in El Salvador making mens underwear (check the labels on yours, if you wear FotL).

The dirt flooor of Oscar's home is readily visible in this picture

and in this one

This is Oscar's driveway that turns to mud in the rains.

During rains, it turns to mud. He is unable to leave his room to go to his sister’s room next door because of a step-down into her room. We would like to put a floor in his house, level his driveway and put cement over it. This will cost $ 1200. We have someone reliable who is presently there and can help.

Update on the Clinic

The clinic is coming along nicely and God willing, should become operational before the year is out. We need money or airconditioning, electricity and supplies within the building. Here are some pictures.

Outside the clinic... I swear the wind was blowing through my shirt... I am not that fat!

The inside of the clinic near the receiving entrance. The floor has been laid down and there are now windows and doors in place

Our dentist with Dr. Boris in a proposed work area.