Expedition Medicine: July 5th round-up

Posted on July 5, 2009 by Adventure Doc

I am very excited to say that I am a now a resident of Arizona!  I have survived the move from Chicago and am now back home in Tucson.  I have also been spending a lot of time on running, biking and exercise.  Obviously, sunburn and staying hydrated are two of the top things on my mind.

There are a lot of exciting things coming up in the next month and I wanted to share a bit of what has been occupying my time on the web, lately.

Global Health Workshop and Courses

The University of Arizona School of Public Health is about to begin their annual Global Health program.  I am especially excited to participate in this and hope all goes well!  Those looking to get a background in this subject should seriously take a look at their courses.

Expedition Medicine Textbook

Since I have finished residency, I have a bit more time to read before I start my new job in August.  One of the books that I have really been enjoying is “Expedition Medicine” by Drs. Bledsoe, Manyak and Townes.  I believe this book to be one of the premiere sources on expedition and remote medicine.  The contributing authors are exceptional and cover a wide range of topics, all required by expedition doctors.  I cannot say enough good things about this book and am totally enjoying reading it in great detail. 

Changes with AdventureHealthClinic and my websites 

I have assembled a very cool team to begin making some large changes to the websites I currently work-on.  Both www.adventuredoc.org and www.adventurehealthclinic.com will be undergoing some big changes in the upcoming months.  Look for a lot more information, more services and resources for travelers and a lot of practical knowledge about expedition, travel and remote medicine.

World Nomads

I am very happy that WorldNomads.com has again published some of my articles on travel illnesses and immunizations related to Costa Rica.  Check-it-out over at their Travel Safety Hub.  I am very lucky to have such cool friends at this great organization.

Wilderness Medical Society Conference

The WMS conference in Snowmass, Colorado is coming up quickly (July 24-29) and it should be a great event!  Visit their site here  to learn more about this wonderful organization and this conference.  Those looking to learn more about topics in wilderness medicine will not find a better conference.

Filed under: Conferences and Coursework, Global Health, Websites | Tagged: , | 2 Comments »

Specialized Generalists and Remote Medicine

Posted on June 20, 2009 by Adventure Doc

RemoteI have been a bit absent from writing on the blog lately due to gathering up paperwork, evaluations and the like.  This is because yesterday was my last day of being a resident doctor!  I am done with my official training and very happy to write that!

Specialized Generalist

Being a life-long learner is something that is aspire to.  This means to me that one does not stop their learning and educational process, just because they are not in a formal training setting or classroom.  I realize that my formal training is complete but that the field of medicine I have chosen requires continuous learning, review and scholarship.   I am very fond of the term “specialized generalist” and like to consider myself within this scope of medicine.  I am not going to be the best physician in any specific area.  I will never be a premire cardiologist, vascular surgeon or infectious disease expert.  Being a physician trying to specialize in general medicine requires a very unique skill set and knowledge base, drawing on all disciplines of medicine.  The scope of practice is just that…general.

Taking care of persons in remote areas of the world, often in resource poor conditions requires a very broad and general knowledge of all medical conditions.  The joke I always say is that I will be considered the worst doctor, by all the specialists.  I am not an expert at the conditions I will be required to treat.  My conversations with friends in their respective medical specialities often illustrate to me just how little I do know.  I frequently make use of their vast knowledge in their respective areas and try to learn from them as much as possible.  A generalist must never get compliant in their knowledge, as it will never be enough.

Through my residency years I have tried to gather my procedural skills and knowledge base around this type of practice.  I am not a general surgeon but have performed my share of surgeries to remove an inflammed appendix.  This is a basic surgical skill and easy for my surgery friends.  For me, as the only physician in the area, it will be harrowing but I have gotten exposure to do this procedure.  The same can be said about both vaginal and Cesarean childbirth.  I am by no means an OB/GYN doctor.  However, I have completed a decent number of both vaginal and surgical childbirths.  Should there be a patient with this need and no other physicians around, I will be the one called to perform this procedure and ensure safety of both mom and baby.  By no means can I consider myself a pediatrician but I am versed in treatment of newborns and children.  The reason that I am called upon to perform this type of care is by a fact of location and lack of access to specialized physicians. 

Remote and Expedition Medicine

Explorer in ActionLooking after the health of those who are far from medical care is my passion.  Frequently, there are no other doctors within hours of air-travel, let alone hospitals to treat them.  I have an obvious interest in caring for adventurers who enjoy travel to these remote locations.  Travel and Expedition medicine draw a great deal of their procedural skills from Rural Generalist physicians.  These rural generalists are the docs who are required to be the “only doctor” for their area, attempting to fulfill all the medical needs of their patients.  Adults, children, surgical, medical and mental health needs are merely the beginning.  One of my favorite quotes about this type of medical speciality is “The rural doctor is one who is chewing more than can be bitten off”.  To me, that exemplifies the profession!  A remote medical doctor must be comfortable working outside their comfort zone, working in a resource poor environment and continually learning in all areas of medicine.

Residency Training

A resource poor area does not have access to many of the modern medical instruments such as CT scan, MRI and 24 hour specialist consultations.  Physical exam skills, experience and telemedicine consultations are required in such areas.  Knowing this, I choose to train at a VERY large hospital in Chicago.  My training was at a facility with all these conveniences.  For me, the decision to train there was a tough one.  I did have the opportunity to learn from all of these specialists.  I was taught surgical skills from exceptional surgeons and had access to a large number of cases.  The same with pregnancy and childbirths.  What I did get access to was a large volume of cases under the supervision of world-class specialists. 

From the beginning of my training I informed my teachers that I planned to work in these remote and resource poor areas.  Fortunately, they were very supportive and attempted to impart to me their skills and what I needed to know for this unusual practice location.  I received extra attention in the fields of surgery, anaesthesia and critical care of both adults and children.  Often times, I was literally taught what to do when things go horribly wrong, how to stabilize the patient and the basics to get the job done.  This was then augmented with extra time devoted to “hands on skill”.  Most of my fellow residents in their respective specialities were all to eager to give up the “basic cases” of appendectomy, primary c-section, epidural anaesthesia and trauma management.  This was because, for them, these cases had all become routine and quite basic to them.  For me, this was perhaps my only opportunity to deal with such procedures under the private tutelage of my expert instructors. 

Future Plans

thailand roadI am very close to moving from Chicago to Southern Arizona.  I have plans to work in a rural, single physician coverage emergency room and do some locum tenens (temporary) work at various locations through the US.  All these locums positions will be in remote ares and often resource poor.  I also plan to do a healthy amount of international work, serving as both an expedition doctor and humanitarian responder.  There is also going to be my own travel medicine clinic opening soon, as well!

Writing about medicine is another passion of mine and I plan to continue this.  In fact, I am preparing to make some dramatic upgrades to my website and blog in the upcoming months.  Changes will include publishing much more information on travel and expedition medicine through a book I have written and plan to publish for free on this website.  I am currently working to design the new site and make it much more “user friendly” and allow for visitors to easily find the information they are searching for.  I plan to continue blogging about news related to keeping travelers and adventurers healthy.  The new site will also include some new forms of media, in addition to standard text.   I hope that all visitors to my site check back-in over the next few months and enjoy the changes as they are completed!

Thanks to everyone who reads my site, leaves positive comments, those who have published my writing on other websites and most importantly:  Thanks to all my wonderful instructors who were so patient with me and helped increase my fund of knowledge.  I hope it goes to good use!

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Artemisinin resistant malaria in Cambodia: counterfeit drugs to blame?

Posted on June 8, 2009 by Adventure Doc

Artemisia abrotanumArtemisinin is considered the best weapon the world has in the war against severe malaria.  This humble, plant derived medicine comes from the quinghasou (sweet wormwood) plant and has been used for centuries to combat malaria.  Unfortunately, it is becoming less and less effective.

Pro-Med reports an interesting and scary case of a teacher in the Battambang province in Cambodia who has been treated with artemisinin and is still showing malaria parasites in his blood.  Unfortunately, this patient is not the only one showing resistance.  Typically, malaria parasites are killed in 2-3 days when using artemisinin.  The patients in question are participating in a US Armed Forces Research program and the researchers report that approximately 1/3 to half of the 90 patients involved in the trials are still positive for malaria parasites, days after being treated with artemisinin.

Southeast Asia, particurlarly on the Cambodia and Thailand border regions, has long been know as a “front-line” battle against drug resistant malaria.  Drug resistant malaria strains are known to occur here and several of those strains have originated in this specific area.  Many factors contribute to a resistance of a parasite or bacteria to a certain medicine.  Why this specific area produces so much resistance is being questioned.

Drug resistance: Why?

Many theories exist as to why this geographic region produces so many resistant strains.  Some of the top ideas focus on the counterfeit drug trade in South East Asia and lack of proper medical supervision when taking anti-malarials.  All pharmacies should be licensed and approved to dispense accurately labeled medicine.  However, many pharmacies operate without licenses and dispense anti-malarial medicine with little or no actual medicine.  These “market stands” often appear in road-side markets between clothing retailers and food stands.  Often, they offer a better price than reputable pharmacies and are frequently used by travelers and locals, alike. 

The concern with receiving anti-malarials with little actual medicine is that the tablets contain just enough active ingredient to allow the parasite to develop resistance, without actually killing them.  In addition, using mono-therapy with artemisinin alone is very risky and may further contribute to this resistance problem. 

Advice for the traveler:

Travelers to this area of the world need to be informed of not only the possibility of artemisinin resistant malaria but also the counterfeit drug trade.  Reputable pharmacies should only be used and the traveler should inquire if they have a proper license.  Trying to save a few bucks on discount malaria medication is just plain crazy and similar to buying a discount helmet.  When I bought a motorcycle helmet, I was asked if I had a $20 head of a $200 head.  Somethings are not ment to be scrimped on.

Adventurers in the area who suspect they have malaria (fever, chills) should also seek qualified medical treatment and not attempt to self-treat unless this specific option was previously discussed with their travel doc.

Artemisia

Artemisia plants encompass about 200-400 different species and only a few species contain effective quantities of medicine to fight malaria.  A few other sues of Artemesia species include making the popular drink Absinthe and the cooking herb Tarragon.

Filed under: Global Health, Journal Club, Outbreaks and Updates, Travel Health, Tropical Medicine | Tagged: , , | Leave a Comment »

Travel Medicine Business

Posted on May 27, 2009 by Adventure Doc

TCAAs I am nearing the end of my residency and getting a chance to see what exists outside the world of training, I am finding myself looking more and more at different ways to practice medicine.  Obviously, travel medicine is a great passion of mine and I plan to eventually open my own clinic.
 
I may be good at helping travelers decide which vaccines they might need, discussing safe and healthy travel and diagnosing travel related ailments, but that is only part of the equation.  How do I open my own clinic?  Where do I get travel medicine clients?  How should I advertise?  Fortunately, I have met some very knowledgeable people who help do exactly this! 
 
I have been fortunate enough to meet many great people involved with travel and expedition medicine and wanted to share some information about some new friends.  The doctors I have met at Travel Clinics of America (TCA) are like-minded practitioners of travel health and offer a service that increases travel medicine clients.  In fact, they not only offer great advice, they even help bring in new clients to an existing practice.
 
The TCA service also seems to be “minimally invasive” to a practice pocket-book, as well.  Through taking a small percentage of profits from only the clients that are involved with travel medicine, they will not interrupt the money generated from an existing practice such as a primary care or urgent care business.  Thus, using the service from Travel Clinics of America will only generate additional revenue.  Plus, the existing practice gets to offer travel health services to their patients!
 
For physicians that have not yet had the opportunity to study travel medicine, TCA even offers to educate physicians!  Educational modules are available and cover the basics that travel medicine practitioners need to know.  Obviously staying abreast of global health and disease spread is a key component and their blog is taking steps to help both travelers and practitioners keep up-to-date with this very dynamic field. 
 
This type of a post may be a little different than my usual writing but my goal with this is to help other health care practitioners become involved in a field of medicine that I dearly love.  Additionally, more travel providers means healthier travelers, overall.  That is one of the goals of my life and one of the goals of the Travel Clinics of America.
 
For healthcare providers looking to learn more about either starting a travel clinic of their own or incorporating travel medicine into their existing practice, I think a stop by their website would be time well spent.

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Forest Fires and Outdoor Athletes

Posted on May 23, 2009 by Adventure Doc

Wildland fireSummer is a perfect opportunity to spend more time in the forests and outdoors pursuing your favorite activities.  Unfortunately, the warmer climates and increased activity outdoors increases risks for wildfires.  Hikers, bikers, climbers and all athletes who get their adrenaline fix off paved roads needs to know a bit about wildfires and how to avoid them, protect themselves and fire safety in wildfire situations.

I was lucky enough to spend a summer as a wildland firefighter and found it to be one of the coolest and most challenging jobs I have ever had.  The science and study of wildfires is a very complex matter and most of the elite wildland firefighters I met always referred to themselves as “students of wildfire science” because they were always trying to learn more about this very large and always evolving discipline.  A few basics about wildland fires will be discussed here, as well as some links and information on where to learn more.

Perhaps the most important things that should be learned from experienced wildland firefighters are the basics.  To me, the basics include the “10 standard wildland firefighting orders” and the “18 watch-out situations”.  These are memorized and drilled into the heads of all new wildland firefighters simply because they save lives.

Watchout Situations:

  • Fire not scouted or sized up
  • In country not seen in daylight
  • Safety zones and escape routes not identified
  • Unfamiliar with weather and local factors influencing fire behavior
  • Uninformed on strategy, tactics and hazards
  • Instructions and assignments not clear
  • No communication link with crew members or supervisors
  • Constructing fireline without a safe anchor point
  • Building fireline downhill with fire below
  • Attempting frontal assault on fire
  • Unburned fuel between you and the fire
  • Cannot see the main fire, not in communication with anyone who can see main fire
  • Weather is getting hotter and drier
  • Wind increases and/or changes direction
  • Getting frequent spot fires across line
  • Terrain and fuels make escape to safe zones difficult
  • Taking a nap near the fireline

Fire Orders:

  • Fight fire aggressively but provide  for safety first
  • Initiate all action based on current and expected fire behavior
  • Recognize current weather conditions and obtain forecasts
  • Ensure instructions are given and understood
  • Obtain current fire information and status
  • Remain in communication with crews, supervisors and adjoining forces
  • Determine safety zones and escape routes
  • Establish lookouts in hazardous situations
  • Remain in control at all times
  • Stay alert, keep calm think clearly and act decisively

These orders and plans are the basics that are designed to keep those with training safe and alive when fighting wildland fires.  For the recreational outdoor person who encounters a fire in the wild, seeking safety should be the number one priority.  Once safe, contact should be made with the local fire department to inform them of the following information on the fire:

Incident Type: vegetation fire, vehicle accident, hazardous material involved, etc

Incident Status: fire behavior such as smouldering, running, creeping, etc

Location:be as exact as possible using landmarks, or latitude/longitude if possible

Incident size: rate of spread and potential for growth

Fuel type: trees, ground cover, trash

Wind speed and direction

Slope steepness and direction slopes face

Best access points: nearby roads the firefighters may use to gain entry

Special hazards and concerns

Cause:if known such as campfire, vehicle accident, lightening strike, etc

Values threatened:  houses and property involved

Weather:  raining, temperature, etc

Resources at scene:  who else is there

Perhaps the best advice for a non-trained person who is confronted with a wildland fire is to simply get out of the area.  Fire behavior is to move up-hill and caution should be used when walking on ridges or slopes with fire burning below.  Fire has a tendency to move up-hill at a frightening speed and the best bet is to not be in that position.  Smoke inhalation can be a problem and a simple bandanna tied around the face can help reduce inhalation of smoke particles and flying debris.  Eye protection should also be used, if available. 

When leaving the area of a fire, ensure that you are not moving into more danger and sometimes the most direct route to safety may be blocked.  Ensure that all of your party remains together and within eyesight of each other, keeping good communication along the way.  Take care of each other and move at the pace of the slowest member.  Remember that material items such as tents and campsite gear can be replaced. 

For more info:

http://www.fs.fed.us/fire/safety/index.html

http://www.smokeybear.com/

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H1N1 and travel: it takes a whole village to raise a virus

Posted on May 12, 2009 by Adventure Doc

GlobeThe recent events of the H1N1 influenza virus and its simultaneous grip of the media and public attention as well as rapid spread may have been the best thing that could happen to travel health.  Further, I hope the virus has shown that international borders and cultural differences were not factors in this illness and its transmission.

Following the Virus

The real-time updates, global tracking maps, use of twitter and other social media sites and various other media sources served to rapidly spread the information about H1N1, even if the information was not always accurate.  Fortunately, use of social media and ease of communication allows for information to travel around the world at a rapid rate.  Almost as fast as the virus did.  I personally found the use of these social media sites very useful for receiving and sending information and am glad to see medical and public health professionals making use of these services.

Everybody at risk

As people watched the number of suspected and confirmed cases pop-up on maps, along with infection rates and death tolls on the nightly news, they were united with others around the world who shared similar concern.  Most viruses do not care about religion, race or social standing, they just infect.  This was truly a “global uniter” of fear and risk of illness.

Traveler’s role

Travelers have long know that they are capable of acting as the perfect vehicles to spread things around the globe.  Travelers can spread cheer, wisdom, passion and illness.  As seen by the rapid spread of the virus, airlines were a major factor in global disease spread.  The intense media attention and global effect of the recent H1N1 virus should have shown that all people of the world are interconnected, especially by international travelers.  Exaclty like the “six-degrees of seperation” game, epidemiology is showing the world is frighteningly small and closely linked.  Travelers need to realize their position in the global health chain and the responsibility of international travel, especially when it comes disease spread.

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Personal Note!

Posted on May 6, 2009 by Adventure Doc

Beer :)Finally a post about something other than H1N1 influenza, outbreaks of diseases and things that can hurt travelers.

I am very relieved that I passed my last medical board examination.  I am done.  Residency ends in 6 weeks and a team is already being assembled to help complete some “upgrades” on the website.  Lots of excitement!

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Pandemics and Influenza: Swine Flu H1N1 next?

Posted on April 29, 2009 by Adventure Doc

Nurses in 1918 Flu outbreakToday 4/29/2009 the World Health organization upgraded the “pandemic level” to a level 5 out of 6.  This is the last step before officially declaring a pandemic.  Humans have already dealt with several pandemics in the 20th century and what exactly is a pandemic?

Pandemic

The term “pandemic” comes from Greek with PAN meaning “all” and DEMOS meaning “people”. Actually it was the Greek physician Hippocrates first described influenza in 412 BC.   A pandemic is basically a new, infectious disease that spreads between humans on a large scale.  Currently the WHO uses a scale of 1-6 to rank an infectious disease and its ability for causing a pandemic. 

  • Phase Four:  Human to human spread possible
  • Phase Five: Human to human spread of the virus in at least two countries in one region of the globe
  • Phase Six: Global Pandemic with widespread outbreaks

So looking at the previous few days of the H1N1 influenza virus (swine flu) we cannot be surprised that this is moving towards a “pandemic” and it actually appears that we are already at the pandemic point.  There is currently spread between humans, it has infected people in multiple countries in the same geographic region and it has crossed continents.

 

Come back later, please?Famous Previous and Current Pandemics

The Black Deathof Europe, Plague caused by the bacteria Yersenia Pestis started in the 1300’s and killed 20-30 million Europeans over 6 years

First cholera pandemic at the Indian Sub-continent 1816-1826 killed greater than 10 million and many records indicate a higher toll, all caused by a humble bacteria

Spanish Flu was first noted in March of 1918 in Kansas and had spread to all continents by October.  Estimates of 2.5-5% of the total global population was infected and killed 50 million people in six months

Asian Flu in 1957-1958 killed 2 million globally and about 70,000 in the United States alone

HIV  is an active pandemic that has spread from one continent to another, is infectious and its death toll may reach 100 million in Africa alone, by 2025

Smallpox  is a virus that had a death toll of 500 million in the 20th century alone, until it was eradicated, in an amazing global effort, 1n 1979

Clearly, the term pandemic does not mean the end of the world.  Humans have suffered through and still grapple with pandemics, on a daily basis.  Taking proper personal safety measures such as handwashing, using condoms, covering your cough, not sharing needles and disposing of your dirty tissues properly are what help stop disease spread.

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Travel Health and Swine Flu

Posted on April 28, 2009 by Adventure Doc

PillsThe H1N1 virus continues to circle the globe and infect new areas thanks to the “person to person” spread.  Clearly, this influenza outbreak will have long-reaching impact on travelers.  A few things that may help travelers make informed decisions:

  • The Center for Disease Control (CDC) has advised all non-essential travel to Mexico be postponed
  • The World Health Organization has not advised closing international borders or suspending trade

The CDC has advised the following persons to use antiviral medication such as Zanamivir (Relenza) or Oseltamivir (Tamiflu):

  • Household close contacts who are at high-risk for complications of influenza (e.g., persons with certain chronic medical conditions, persons 65 or older, children younger than 5 years old, and pregnant women) of a confirmed, probable or suspected case.
  • School children who are at high-risk for complications of influenza (children with certain chronic medical conditions) who had close contact (face-to-face) with a confirmed, probable, or suspected case.
  • Travelers to Mexico who are at high-risk for complications of influenza (e.g., persons with certain chronic medical conditions, persons 65 or older, children younger than 5 years old, and pregnant women. 
  • Health care workers or public health workers who were not using appropriate personal protective equipment during close contact with an ill confirmed, probable, or suspect case of swine influenza A (H1N1) virus infection during the case’s infectious period.

The following persons are instructed to consider using antiviral post-exposure treatment:

  • Any health care worker who is at high-risk for complications of influenza (e.g., persons with certain chronic medical conditions, persons 65 or older, children younger than 5 years old, and pregnant women) who is working in an area of the healthcare facility that contains patients with confirmed swine influenza A (H1N1) cases, or who is caring for patients with any acute febrile respiratory illness.
  • Non-high risk persons who are travelers to Mexico, first responders, or border workers who are working in areas with confirmed cases of swine influenza A (H1N1) virus infection.

air-purifying_respiratorUse of N-95 respirator masks may also decrease flu transmission, although they require proper fitting to ensure adequate face to mask seal.  Simple surgical masks likely offer little protection.  A 2007 statement from the CDC discussed little evidence that using such masks decreased influenza transmission.

One important point is the reserve supply of these anti-viral drugs and availability.  These medications are prescription only and advice should be sought from a physician before use.  Second, the manufacturers of these medicines are releasing stockpiles to help cope with increasing demand and obviously, areas with known outbreaks and those with confirmed infections receive priority.

Google Maps has created a real-time mapping of the virus spread, according to WHO data

CDC Guidelines for use of antivirals for H1N1:

http://www.cdc.gov/swineflu/recommendations.htm

Filed under: Outbreaks and Updates, Travel Health | Tagged: , , , | 1 Comment »

Swine Flu in USA, Mexico and many more? 4/27/09

Posted on April 27, 2009 by Adventure Doc

Swine Flu is gathering more frequent flier miles than I will ever hope too.  By getting a free-ride in the respiratory systems of paying passengers, swine flu (H1N1) has been able to spread to more and more places.  As of April 27th 2009:

  • Mexico- 19 of 32 states in Mexico have clinical cases and 18 confirmed cases as of 4/26/09.  Thus far, there are 68 estimated fatalities
  • USA-  20 cases in America (8 New York, 7 California, 2 Texas, 2 Kansas, 1 Ohio) located in 5 of 50 states.  There have been no known fatalities in America as of 4/26/09.
  • Canada-  Nova Scotia has confirmed 4 cases of H1N1 (Swine flu) and British Columbia has 2 cases

Many other countries such as New Zealand, Spain, France and Israel have suspected cases that are awaiting testing and confirmation of H1N1.  These suspect cases are all in travelers who have returned from Mexico. 

Countries around the world are increasing surveillance at airports to detect ill travelers and some are beginning to quarantine travelersas they get off planes (Hong Kong, Russia, Japan).

Hong Kong and South Korea have advised their citizens to avoid travel to Mexico, while Italy Poland and Venezuela have issued advice to avoid travel to Mexico and USA.  The WHO (World Health Organization) has made no specific advise to avoid travel plans or stop trade/business.  There is rumor of a US State Department Warning  advising all non-essential travel to Mexico be posponed.  This warning has not yet been issued and is likely set for release on Monday 4/27/09.

The reported cases in New York and Canada are encouraging in the fact that none of the infected have died, but merely suffered a “bout of the flu” and are appearing to recover without problems.  Any person know to have traveled to an area with confirmed outbreak of H1N1 and meeting the case definition of an influenza-like illness is considered a suspect case pending laboratory confirmation.

For More Info:

A well summarized article from Pro-Med Mail, detailing events around the world related to Swine Flu

http://www.promedmail.org/pls/otn/f?p=2400:1001:6762198105018576::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1010,77215

Check out Google Maps: http://maps.google.com/maps/ms?ie=UTF8&hl=en&t=p&msa=0&msid=106484775090296685271.0004681a37b713f6b5950&ll=32.639375,-110.390625&spn=15.738151,25.488281&z=5 for a realtime map of the world showing confirmed cases in purple, suspect cases in pink and deaths do not have a black dot.

Filed under: Outbreaks and Updates, Travel Health | Tagged: , , , | 1 Comment »

Why Swine flu is called “Swine Flu”

Posted on April 26, 2009 by Adventure Doc

Still more problems as Swine flu seems to be spread to new areas.  A very nice post from Pro-med mail  looks at why Swine Flu takes this name. 

In 1918-1919 the Spanish Flu caused significant death and morbidity in both human and swine populations, although it is likely to have originated from birds.  “Swine Flu” is bascially any virus that circulates through pig populations, such as H3N2, H1N2 or the present H1N1.  The terms H and N stand for haemagluttin and neuraminidase, which are unique ways influenza viruses infect humans.

This particular strain of H1N1 influenza nicknamed Swine Flu is able to be transferred between persons, without swine contact.  Further, there is a lack of evidence showing the initial jump from swine populations to humans.  H1N1 also carries a component of bird flu, as well.  Thus, simply calling it swine flu is inaccurate.

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Swine Flu Outbreak in USA and Mexico 4/25/2009

Posted on April 26, 2009 by Adventure Doc

Pig problems?For those who have been hearing about this on media sources such as CNN, I thought this might be of interest.  An outbreak of Swine Flu (H1N1) has been reported in several states of Mexico including Mexico City.  The outbreaks in Mexico appear to be carrying a case fatality rate of around 7% with 68 deaths and approx. 1,000 cases reported.  The cases reported in the USA were in San Diego and Texas, with no fatalities yet reported in America.  The strains of the viruses isolated thus far has proved to be similiar, both from America and Mexico.

Here are some decent links:

World Health Organization Influenza Outbreak in USA and Mexico  http://www.who.int/csr/don/2009_04_24/en/index.html

CDC Travel health Precaution for Mexico  http://wwwn.cdc.gov/travel/contentSwineFluMexico.aspx

 

There is no advice to postpone travel to Mexico and travelers should exercise “common sense” travel precautions such as frequent handwashing, avoidance of those with cough, sneeze or sniffles and low threshold for seeking medical care if fever and flu-like illness occurs.  Swine Flu appears to be sensitive to anti-virals such as Oseltamivir (tamiflu) and Zanamivir (relenza).  These medications are advised for treatment of swine-flu and should be started within the first day or two of symptoms.

Very interesting and scary stuff!  More to come…

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Heat Illness: Prevention and Treatment

Posted on April 20, 2009 by Adventure Doc

MirageAs the warm months of summer begin to draw closer and closer, getting outside and adventuring becomes a bit easier.  I personally love long runs in the hot part of the day and consider this my favorite time of year.  Physical exertion in a hot environment carries with it special risks and requires some knowledge about heat related illnesses and basic prevention.

Acclimatization to Heat

This is often a luxury adventurers do not have, especially when a traveler arrives to a new area and begins physical activity in a new and hot environment.  Typically, 8-10 days are required for a person to acclimatize to a hotter environment and daily exercise in the new environment can help the process.  Exercise for 30 minutes to 1 hour per day is generally sufficient.  As the body begins to acclimatize to the heat, it begins to sweat at a lower temperature, helping cool the body earlier.  Care should be taken to ensure adequate hydration, with oral water and sports drinks containing both sugar, salt and potassium.

The basic categories of heat illnesses can be divided up based on core body temperature and physical findings of the effected person.

Heat Exhaustion

  • Body temperature less than 39 C (102.2 F)
  • Presence of sweating
  • Increased heart rate (>100 beats per minute)
  • Normal mental status and awareness
  • Flu-like symptoms may be present such as malaise/fatigue, vomiting and weakness

Treatment of Heat Exhaustion centers around stopping physical exertion and getting the person into a cool and shaded environment.  Ensure adequate oral rehydration occurs and remove all restrictive and tight fitting clothing.  Ice packs may be placed on chest, arm pits and groin as these areas have blood vessels that run close to the surface and help facilitate cooling.  Wrap ice packs in towels to avoid skin damage from prolonged contact.  Lastly, spraying cool water on the patient and fanning them will help to reduce their body temperature quite rapidly as well.

Heat Stroke (True medical emergency)

  • Body temperature above 40.5 C (105 F)
  • Presence of sweating, severe cases may have absence of sweating
  • Increased heart rate (>100 beats per minute)
  • Changes in mental status (confusion, disorientation)
  • Difficulty walking
  • Low blood pressure

This condition is a true emergency and requires prompt medical care as this condition can be fatal.  Heat stroke occurs after the person passes through the first stage of heat exhaustion and does not receive proper treatment or continues to exert themselves in the heat.  Most experts agree that heat stroke can be diagnosed when changes in metal status occur in a patient with heat exhaustion.  Treatment centers around rapid re-cooling of the patient and the faster this occurs, the better the prognosis.  Icepacks (wrapped in towels) should be placed on groin, axillae and neck.  Spraying with cool water and fanning the victim is most effective in rapidly cooling the patient.  Intravenous fluids should be given and often require copious amounts to correct deficits.  Ensure their airway is protected if their mental status deteriorates or if vomiting occurs.  Seizures and shivering can be treated with benzodiazepines and oxygen should be given.  This person requires prompt transfer to a medical center and close monitoring.  Aggressive cooling should continue until core temperature drops to 38 C (100.4 F).

 

Tucson, ArizonaHeat Cramps

I think of heat cramps as a sign of dehydration and muscle fatigue in a hot environment.  Mild heat cramps can be treated by adequately rehydrating the person, generally with a commercial sports drink.  The key electrolytes are sodium and potassium, generally found in adequate concentration in products such as Gatorade.  I prefer to mix one half cup water with one half cup of electrolyte drink, due to increased osmolality of the sports drink.  Also, the sugars found in sports drinks help speed water into the bloodstream from the stomach.

 

Hyponatremia (low salt)

This is one of my favorite topics and frequently discussed in ultra-distance athletic events.  True hyponatremia occurs when the measurement of sodium in the blood drops below 130mEq/liter.  A frequent scenario that causes this is a person drinking large amounts of plain water to replace sweat losses which are high in sodium.  The person basically loses large amounts of sodium through sweat and water loss and replaces it with a low sodium concentration fluid, like plain water.  Difficulty can occur in differentiating heat stroke from hyponatremia and measurement of core body temperature can help with diagnosis.  Hyponatremia generally occurs in a setting of a normal core body temperature.  Treatment centers around providing intravenous re-hydration with normal saline fluid.  If the patient can take oral fluids, use a full-strength (non-diluted) sports drink for fluid replacement.  Prevention fo this can be accomplished by not only drinking adequate amounts of water but also regularly drinking a sports drink, before, during and after exercise.

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Loa Loa: The “African Eye Worm”

Posted on April 14, 2009 by Adventure Doc
Loa Loa migrating through eye

Loa Loa migrating through eye

Nicknamed “the African eye worm”, Loa loa is one of those tropical parasites that myths and legends are made of.  A medically important parasite from Africa, this is commonly a disease of local people but can effect travelers and adventurers in the endemic areas.

 Basics:

Also known as “African Eye Worm”. Filarial worms migrate through all tissues of the body. Transient swellings and itching are most common symptoms and can take years to appear.

 

Location:

African rainforests and especially Central Africa

 

Transmission/ Incubation:

Transmitted by the bite of an infected Deer Fly (Chrysops species)

Prevention:

Standard flying insect precautions, vector control, 300 mg once per week DEC (diethylcarbamazine) for high risk persons

 

Diagnosis:

Demonstration of microfilariae in daytime drawn blood smear

 

Treatment:

Diethylcarbamazine (DEC) 5-10 mg/kg three times per day for 3-4 weeks generally kills larvae and eliminates adult worms. Treat possible histamine/allergic based reactions with antihistamines/steroids. Albendazole and ivermectin may have a slower kill of larvae, causing a less severe treatment reaction.

 

Chrysops fly

Chrysops fly

This parasite is very similiar to the other nematodes including W. bancrofti.  however, this worm likes to move through tissues, without setting up a real permanent residency.  Soem trouble with this infection can occur when treatment begins.  Use of medications often used to treat other parasitic infections, found in the same geographic area, can cause bad reactions.  Caution should be used with ivermectine (treatment for onchocerciasis) as encephalitis/brain swelling can occur.  Common treatment reactions with DEC can involve histamine and typically respond well to antihistamines and/or steroids.

 

distribution of common parasitic infection

distribution of common parasitic infection

 

 

 

 

 

 

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New vaccine for Japanese encephalitis approved in USA

Posted on April 1, 2009 by Adventure Doc

Distribution of Japanese encephalitisJapanese encephalitis (JE) is a viral disease spread by mosquitoes (Culex) and found primarily in rural areas of Southeast Asia, although reports have been scattered all over Asia.  This infection has an affinity for the brain and spinal cord tissues as is know to causes meningitis like symptoms including headache, neck stiffness, fever and malaise.  A majority of these infections are asymptomatic although JE carries a 0.3-60% case fatality rate.  Infants are a particularly vulnerable population and often hardest hit.  Pigs and birds are a key reservoir of the illness, making visitors to rural farming areas at particular risk.  30,000 to 50,000 people are affected each year with 10,000 too 15,000 deaths.

The Vaccines:  

Japanese encephalitis is a vaccine preventable disease.  A vaccine is licensed in the USA, under the name JE-VAX  but has been difficult to obtain due to shortages and decreased production.   However, a new vaccine against Japanese encephalitis was approved by the FDA  March 31, 2009, called IXIARO and manufactured in the UK.  This will be the only vaccine against Japanese Encephalitis in the USA.  Research showed that only two doses of the newer generation vaccine were needed to provide adequate protection versus three does with JE-VAX.  A copy of the InterCell (manufacturer) press release can be read here. 

Who Needs It?

Most travelers to Asia do not require the JE vaccine.  This illness is not considered a risk for short-term travelers to urban areas and developed resort areas.  Those traveling to remote/rural areas (especially farming communities) during the rain season are the adventurers who should receive this vaccine.  Also, travel to an area with a previous outbreak of JE should prompt discussion about being vaccinated with your expedition/travel doctor.  Estimated risk of travelers to rural areas during transmission season is about 1 in 5,000 per day.

As with any mosquito-borne illness, preventing mosquito bites is a key step and should be done by all, regardless of being vaccinated.  Long sleeves and pants, avoiding peak biting times (dawn/dusk) and use of insect repellents are critical.  Bed nets are also another key ingredient for travelers sleeping in open areas.

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Chloroquine, Azithromycin and arrhythmia?

Posted on March 30, 2009 by Adventure Doc

EKGTravel medicine frequently uses medicines that are taken under special circumstances and for short periods of time, like a trip.  Many travelers carry an antidiarrheal antibiotic on their trip and a common choice is azithromycin.  This can potentially be a problem when they are also traveling in a malaria area and using chloroquine for prevention.  Two very commonly used medicines chloroquine (antimalarial) and azithromycin(macrolide antibiotic used for respiratory infections and diarrhea) both have wonderful safety profiles, individually.  However when taken together, there is discussion of the chance of a heart arrhythmia, specifically prolonging the QT interval.  In fact, my software I use for prescribing cites this as a combination to avoid. 

There are severalimportant articles that can be used to look at this problem and evaluate the risks.  One very good paper looks at medications that prolong this QT interval:

These authors list azithromycin as a “very improbable” medication, although other macrolides are listed as higher risk.  Chloroquine is listed as an “Unknown” medication, with respect to prolongation of QT interval.  This article was based on expert opinions.

This study looked directly at this problem, in animal models.  Their research showed no increase in arrhythmia risk. 

A wonderful article that is actually helping to look at using this drug combination to treat resistant forms of malaria.  More about this combination and treating malaria here.  Their study did show an increase in the QT interval in both groups of those who received chloroquine alone and those who received the combination of chloroquine and azithromycin.  This QT interval increase was maximum on day number three and returned to baseline by the end of the study.

Most of the information I am finding looks reassuring for safely using this combination, in healthy individuals.  Those with a history of arrhythmia should use this combination with caution and discuss this problem with their doctor, before they take these two medicines within a close amount of time.

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Wilderness and Expedition Medicine Round-up: 3/24/09

Posted on March 24, 2009 by Adventure Doc
Image: Inju

Image: Inju

With just a few more days remaining in a very tough month of work for me, I am excited to get back to writing more.  I thought a good way would be to re-cap the last few weeks of what I have been reading on the web:

HELMETS and OUTDOOR SPORTS INJURY PREVENTION:

Obviously, the recent high-profile case of head injury while skiing has generated a flurry of attention.  There are numerous articles and information to support wearing a helmet as an important method of injury prevention during outdoor sports.

DISEASE OUTBREAKS and UPDATES:

  • Meningococcal disease in Nigeria continues to rise with over 5000 new cases reported since January 1st, 2009, and a fatality rate of just over 6%.  The sero-type of Nisseria implicated is group A and is preventable with a vaccination.
  • Malaria Atlas Project showcases their work on mapping locations of endemic Plasmodium Falciparum and a great article in PLoS (Public Library of Science) discusses the research
  • A bit older now, but MMWR (Morbidity and Mortality Weekly Report) from the CDC featured a very interesting article in the December 19, 2008 edition looking at Histoplasmosis in travelers from the US who participated in a church renovation in El Salvador

ASSORTED INFO:

  • Guidelines for Field Triage of Injured Patients was published by the MMWR (CDC) in the January 23, 2009 edition and features a wealth of information building on their previously published work in 1999
  • The Gorgas Courses in Clinical Tropical Medicine have been sending out their “Case of the Week” and I have been enjoying them immensely.  Their tropical medicine program is one of the best in the world and anyone looking to further their clinical tropical medicine knowledge should look into this program.  I hope to attend one day, as well.

TRAVEL SITES:

  • I am very happy for the team at IndieTravelPodcast.com for their Lonely Planet nomination and am always finding new and cool stuff on their site
  • TravelofftheRadar.com is another site that is very well done, featuring loads of info on adventure travel including some great pictures
  • A new web and print magazine about adventure travel, sports and environmentalism over at WendMag.com is also a wonderful site

Filed under: Journal Club, Outbreaks and Updates, Travel Health, Tropical Medicine, Websites, Wilderness | Tagged: , | Leave a Comment »

Help out Indie Travel Podcast win a deserved award!

Posted on March 17, 2009 by Adventure Doc

I got an email from a friend with a request for help on his really awesome travel podcast website and I wanted to pass this along to anybody who might read this blog:

 
“The Lonely Planet travel blog awards is on, and our site, Indie Travel Podcast, is in the final five. Obviously, Lonely Planet is a huge name in travel and winning this would mean a lot to us.
 
We have until Friday to get 140+ votes for second place or 250+ votes for first place.
 
No registration, etc is needed. Just open this page, scroll down until you find “best podcast”, click the button beside “indie travel podcast” and click vote.
 
http://lplabs.com/2009/02/25/voting-open-for-the-2009-travel-blogger-awards/

The competition is based on 50% public vote; 50% judges’ choice. Even in 3rd place we have a reasonable chance of winning. If we can make second, it would really help.
 
We need 140 votes in three days: can you help with one vote?
 
Would you consider emailing your friends/office too? Like I said, we need to find 140+ extra votes by Friday.
 
Thanks in advance,
Craig

–
Craig is the author of Travelling Europe — http://indietravelguides.com

Email: craig@mars-hill.co.nz
Twitter: http://twitter.com/craig_martin
Skype: mars-hill
IM: spamandspamandspam@gmail.com

Homepage – http://craig.mars-hill.co.nz
Podcast – http://indietravelpodcast.com
Other – http://indietravelguides.com | http://eurailstories.com | http://traveltalks.tv “

Give him and his very cool/informative site a little love and vote!

Filed under: Rants, Websites | 1 Comment »

Murray Valley Virus in Australia

Posted on March 15, 2009 by Adventure Doc

Western AustraliaAs usual, Pro-Med mail has some of the best updates on disease spread.  The northern part of Western Australia has been subject of a warning from the Department of Health on increased transmission risk of the mosquito borne virus known as Murray Valley Encephalitis Virus.  Transmitted by the bite of an infected mosquito, the virus is known to damage the brain, spinal cord and meninges (encephalitis).

Heavy rains in the areas of Kimberly and Pilbara have contributed to an increase in mosquitoes and widespread biting.  The University of Western Australia Dept. of Epidemiology has also reported cases of Ross River and Bramah Forest virus in the area, as well.  There are no recommendations for travelers to avoid the area but mosquito bite preventionis highly suggested.  Warnings are specific for travelers and new comers to the area, who are most likely to be effected.  Children are also considered at high risk.  Those camping or sleeping near rivers or swamps in the area should have adequate preparation for mosquito bite prevention. 

Symptoms of the viruses include fever, headache, malaise/fatigue, stiff neck, nausea and dizziness.  If left untreated, the person may loose consciousness and suffer from seizures.  Death or permanent brain damage are possible.

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Hookworms and why to wear your shoes!

Posted on March 10, 2009 by Adventure Doc

Image: berbercarpetTropical climates are hot and sweaty.  A hot and sweaty environment, for me, usually means sandals or no shoes at all.  Aside from cuts and scrapes to delicate feet used to being protected by shoes, there are infections that can be acquired from going barefooted on your travels. 

Hookworm is a slang term used to describe a pair of intestinal parasites called Ancylostoma duodenale and Necator Americanus.  These parasites belong to the phylum Nematoda and are commonly found in the victim (or host) intestinal tract.  Evidence of the parasites can be found in literature as far back as ancient Egypt.  It was the ancient Egyptians who made a connection between anemia, a very common symptom, and the parasite. 

Hookworm under microscopy

Basics:
Helminthitic infection of the intestines that frequently causes iron deficient anemia secondary to blood loss. Two species exist: Ancylostoma Duodenale and Necator Americanus. Acquired by direct contact with infected soil, usually walking barefoot. Characteristic “ground itch” is common at site of penetration. The life cycle is simple:  penetration of skin to blood stream, migration through the lungs, coughed up in phlegm and swallowed to stomach where they make their final home.  Eggs from the worms are passed into the soil through improper disposal of feces.  In the soil, the eggs mature into a form that can directly penetrate the human skin.

Location:
Tropical countries in areas with moist soil and poor hygiene in respect to fecal waste management. Both species are found in Africa, Asia, South Pacific and South America.  Americanus is most common in South/Central America. 

Transmission/ Incubation:
Transmitted via contact with infected soil containing 3rd stage larvae. Larvae directly penetrate skin. Most commonly acquired through human waste but some other species can transmit via cat/animal feces. Incubation can take weeks to months, as the parasites develop. Larger burdens of infection present quicker.

Hookworm egg under 400x microscope, in fecal smear

Hookworm egg under 400x microscope, in fecal smear

Prevention:
Use of shoes when walking, sanitary disposal of feces

Diagnosis:
Isolation of eggs in a fecal smear

Treatment:
Albendazole or Mebendazole. Studies done to show benefits of treatment based on number of eggs per gram of feces.

 Overall, this parasitic infection is a major health concern in developing nations causing anemia, pregnancy complications and malnourishment, espcially in growing children.  Fortunately, the infection typically responds well to medicine and elimination is possible provided there is adequate acces to healthcare.

For other trop med geeks (like me), you can visit the CDC DpDX website for some great pics on how to tell the difference between the two species.  Necator has cutting plates on the mouth while Ancylostoma has teeth, when viewed unuder a microscope.

Filed under: Global Health, Travel Health, Tropical Medicine | Tagged: , , | 2 Comments »

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