Lost in Translation

I've been looking forward to last night for months....and it certainly lived up to expectations...I came home on an enormous high with a giant smile plastered across my face. Trudy said 'So tonight went well then? How was Joseph? Where did you go for drinks then?' I had been excitedly jabbering about seeing Joseph since she moved to mine for a few days. I realised then how easy it was to get things lost in translation.....my date had been a fantastic rollercoaster of emotions and the euphoria I felt......was shared (sadly!) with a few hundred other rapturous souls who had also been with me watching Lee Mead (swoon) perform in Joseph at the Adelphi. God he's good. I've still got a huge smile and a warm fuzzy feeling even now which it has to be said compares extremely favourably against most of the dates I've ever been on, but dosen't quite compare against Hugh Jackman in Oklahoma in 2002. Don't panic Hugh, you are still No.1 in my affections for 'Men who are gorgeous but can't have as they're too famous/married/made-up(Viggo Mortenssen is No.2)' as I had a smile for at least a week after sitting in the second row from the front in very close proximity to his gorgeous half naked and beautiful singingness. Ahhhh. Lee Mead is tied at No.2 with Viggo. The guy selling programs at the theatre was so funny...I had the choice of normal program or a full colour show souvenir featuring ' a free poster of Lee in a loincloth' said in a very camp manner - be still my beating heart! I restrained myself - just.

Hydatid disease.

Dr Gregory House would have liked this case, a mysterious cause of paraplegia. Irreversible unfortunately.

I'm getting under your skin......

Sea Urchins....so pretty but oh-so-painful if you accidentally tread on one. Not only does it discharge poison sacs into your skin but the tips of its spines often break off and become embedded there. You can try urinating on the wound (surfers swear by this approach but you JUST never know whether these guys are yanking your chain) or dowsing it in lemon juice, but sadly little works. The spines just have to stay there till the body resorbs them or expels them or fibroses around them, and they HURT. SO.....now I need a burqua, shower hat and armour coated flipflops with verruca socks to avoid the nasties!!

Is Lithuania tropical?

So there we are...sitting in an emergency clinic in the Hospital for Tropical Diseases and this European lady comes in with some nasty looking itchy blisters that had been popping up over two weeks. 'Where have you been?' we asked expecting some wonderous location...'Lithuania - my home country' was the reply. She had been wondering around a meadow with large plants in it and had thankfully taken a picture of them. Hurrah! Alan Titchmarsh would be so proud of me as I identified the Giant Hogweed (Bearclaw in Dutch) straight away. Nasty plant. Burns and blisters are due to pollen and stuff and can keep appearing for many months after exposure.....keep away...you have been warned!!

Himalayan Mountain Salt

And then there are the just plain wierdys......such as a 50 year old permatanned eco warrior who had come to clinic on a D-day with the usual going up to 15 times daily and had been for the last few days after eating a dodgy sausage at a Bulgarian Beinsa Duno Dance festival. Only he hadn't pee'd for over 24 hours. This was a bit concerning, but immenant renal damage wasn't going to bother him if it meant having to infuse the wrong sort of salt (as normal saline) into his body. 'Poison' he said 'I won't put that into my body...the only salt I will use is Himalayan Rock salt...its pure you know.....I'll drink some of that in water mixed with honey if you insist but nothing else...no, absolutely not!.' Okay then......

'Himalayan crystal salt is pristine and natural. It consists of the most perfect geometric structure possible in rock crystals, the result of millions of years of compression under the Earth’s surface. Its has precise mesh with our body's inner workings because Himalayan crystal salt contains an almost identical set of elements to those found inside the human body, 84 of the possible 92 trace minerals, in the same proportion as naturally exists in our blood'

I've got chills! they're multiplying....

'Break-bone fever'

What a fantastically descriptive term for Dengue fever. We've had a few cases of this recently from Thailand and Indonesia and thats exactly how the poor erstwhile holiday makers described their symptoms....terrible fevers, myalgia, aching joints and intolerable malaise. One poor 2nd year medical student was so incapacitated by it that he went all vasovagal and fainted on his Dad in an Underground train. Worst case of green around the gills we've seen so far, especially when he was told he had to be admitted and had an armful of blood taken and an IV put up.... Some are more stoical...like the Bostonian hedge Fund analyst who had come straight from work with symptoms that would have flattened most people and was aghast when told that she needed to stay in hospital overnight on account of the subprime market doing a nose dive and that she needed to be there to monitor the situation! She was so funny - she had literally taken every precaution against biting bugs she could think of (sprays, creams, electronic plug things, bednets, long trousers - not a burqua mind!) and still got the lurgy....all taken with great humour - atta girl! So far no one has had the haemorrhagic version (thankfully) which happens when you get more than one strain of Dengue at once.

Oh yes, and as you can see Dengue is an epidemic in Central America as if I didn't have enough flies to worry about!

Typhoid is on the up if clinic diagnoses are anything to go by. It can be really nasty too....within 4 weeks 20% are dead from multiorgan failure and/or massive GI haemorrhage if untreated. Mostly it seems to be folks back from visiting India. So......if any of you guys are out in India and you start getting terrible but remitting fevers, constipation rather than the squits, no energy to do anything and a bad headache then you might have it...especially if you develop 'rose spots' the next week when the fevers don't subside and you feel even worse. Oh, and you have super infectious poo and can give it to everyone else! Typhoid Mary did this very effectively in the 1900's and killed loads of people - she had to be bunged in the clink to stop the epidemic.

As far as causes of fever go it has to said that Malaria has not been high on the list of eventual diagnoses in the emergency clinic. We've only had two vivax cases which is a bit disappointing! The last chap had come back to clinic after 6 months of no symptoms with a re-emergence of fevers that he had developed after travelling through Thailand, Vietnam, Cambodia and India (where he had to be hospitalised due to a temp of 104 degrees and lost most of his platelets) but had had a negative malaria blood film on his return in March. He was given a bollocking by the SHO who then had to then turn the other cheek when P. vivax parasites were found again this time..... Apparently the Indians had recommended 6 months of chloroquine to clear it but the drugs made his liver and one testicle (!) so painful he stopped it. After the obligatory G6PD test we gave him some primaquine and so hopefully he's cured now.

The advice for malarial prophylaxis has undergone a bit of a revolution recently. The boss of the Travel Clinic Dr Behrens has just published a paper in ...yes you've guessed it...'Malaria'...that rubbishes the idea of taking prophylaxis in predominently P.vivax regions (ie. most of India and Central America) as it's not common, fatal, the drugs are unpleasant and possibly even not very effective at protecting against it (compared to P. falciparum). Excellent. Better go somewhere where I can use up my Mefloquine next year then!

D-day

Snowbelle has taken to sleeping in my rucksack...maybe in a vain attempt to stop me leaving the country (or to come with me - ah...if only...do they eat cats in Belize?). Unbeknown to her I have obtained a secret weapon to foil her cunning plan....a suitcase!

Everybody at the walk-in clinic is lovely. The nurses and assistants are amazing and have seen it all before so guess the diagnosis even before you've seen the patient - which is slightly unnerving. But they always keep lots of biscuits in the cupboard which are essential cures for Trudy and my hunger pangs which seem to hit earlier and earlier each day...despite the worms and poo, so we forgive them being way cleverer than us! And then there's Richard our SHO. You can just tell he's going to be a great Haematologist when he 'grows up' - he's got that palliative care kind of an approach to patients with a nice kind voice- kind of the opposite to my rather direct questioning style. We operate a kind of 'good cop - bad cop' clerking technique - but it works...although it occasionally wierds the odd one out if they're on their own.
And he keeps chickens!

Back to D-day....which happens seemingly every other day. It comprises of large numbers of patients all suffering with the same complaint. Diarrhoea. (sigh). Make you happy to see the worms - no really... even though the worms are commonly the course of the squits they are the only light at the end of the tunnel......could there be one...could there?!

Of course there are clues to the cause of all the trouble...in theory. We've had several cases of Giardia none of whom had sulphurous burps or fishy offensive watery stools. Periodic cramping abdominal pain and bilious vomiting seems to point to tapeworm overcrowding...but could also be strongyloides. There are the 'diarrhoea asscoiated with fever' patients who are way more complicated and a bit scarey and finally those who have had something nasty, had it treated but whose guts are still suffering post traumatic stress disorder and still not got with the program. They are hard to treat (and go a bit mad - they carry detailed poo diaries with them), so we send them to the clever Gastro doctors!!


D-days are bad. Luckily my cat is very cute!

The worm has turned...

There are days at this clinic when I am convinced that the whole of London is harbouring unwanted guests. Bot fly larvae, surprise mycobacteria caught 20 years earlier that pop up out of the blue and suddenly paralyse you, hook worm larvae that mistook your foot for a dog's, burrowed under your skin and consigned themselves to travelling under your skin for the rest of their lives to find a way out, and then then are the worms.

Do you remember the song you used to sing as a child?

"Nobody loves me, everybody hates me I'm going to go and eat worms...long thin slimy ones, short fat chewy worms. etc etc"

Well the worm has turned (TV reference there...go on guess....) and the worms are invading us like an episode of Star Trek only its very much on their own terms. I could even be convinced that invasion of the brain in cystercosis was a attempt to mind control us....(Oh God I watch too much House)

Trudy and I have had our eyes truly opened to the apparent world domination of these creatures. They have been coughed up in front of us (Ascaris - round worms), pulled out of bottoms and presented to us (Taenia - tapeworm), shown on radiological scans (Strongyloides - that one's for you Rob), swum across eyes to wave to us (Loa Loa) - (bleugh....sorry need to concentrate again), grown in the spinal canal of one poor British chap and destroyed the spinal cord and column making him paraplegic (hydatid disease) and traced the words 'help us... we're lost' on the back of a rather attractive gap year student (Cutaneous Larva Migrans - OK not strictly a worm at that stage but it grows into one usually!)
How do you escape an enemy that can invade with your food, be carried and inoculated by insects (day and night...damn! looks like the burqua is here to stay), contaminate the water and food if someone has not washed their hands, and attack you whilst you're cooling off in some fresh water in the middle of a blisteringly hot country? OK you don't - you hit them where it hurts and kill them with DRUGS.....if you know they are there.......which you often don't.

Till you cough one up. (Retch)




PS. It was the Two Ronnies !

Bit Bot

You remember how I was making a big deal about the not wanting to be bitten thing? Well we've had a number of good reasons turns up at the walk-in clinic over the last few days. People with larvae IN THEIR HEADS. Yes, wriggling and generally being really painful and disgusting. The nasty in question is a bot fly larva - dosen't he look friendly?

The worst case was of a university student who had been in Guatemala for three weeks (yes, Guatemala completely surrounds Belize so this is another cause for paranoia!) and came back through customs but neglected to declare that she was carrying SEVEN bot fly larvae in her head. Ah, but she wasn't bitten by a bot fly....oh no...the bot fly gets something else to do all the dirty work. It catches a mosquito or another blood sucking fly in mid air, transfers fertilised eggs onto its victims abdomen, then flies off happy in the knowledge that when the fly lands the eggs will be transferred, hatch and the larvae will burrow under the skin of the new host......clever! These larvae then grow and feed on the blood and skin of the host, and breathe by sticking their tail ends out of an air hole. Luckily this proves to be their undoing as the cure is to cover the air hole with Vaseline for 30 minutes or until the wriggling and thrashing stops and then squeeze the large inflamed 'zit' like lump and force the damn thing out. there is a catch though as it has three rows (or more) or backwards facing spines that try to stop this happening....

So its a burqua minus one hole at the bum plus a plastic showercap for me......

Unleash the leish.....

Uh oh.....

I've found the first really nasty thing I'm likely to get out in Belize. Now you know how medical students are...they meet a disease for the first time and then start displaying symptoms of it - a kind of medical hypochondria...well this time it could be serious.

We've had a few patients with Leishmaniasis in clinic. One chap - a young kid from Ethiopia has intrigued the experts for months to whether he has a normal cutaneous variant of the disease or a more complicated 'Post kala azar' picture. He doesn't care. All he knows is that the end of his nose has been eaten away and he has something terrible happening all around his mouth that might be signalling that the same might happen there too. Then there was the soldier who had been based in Belize who came back with a large ulcerated and very painful area on his forearm (you can't help but think he got off lightly compared to the boy), and then the beautiful Afghani girl from Pakistan with a giant carbuncle on the end of her nose that just started off with a pink pimple but on biopsy is chock full of Leishmania amastigotes despite weeks of intralesional (yes into the bump) of toxic painful stibogluconate.

And the reason I'm worried? It's carried by sandflies. And I'm very tasty to sandflies (if Fiji was anything to go by), and mosquitoes and most other biting things. Interestingly (well I think so) mothers in the middle east have come up with a way to immunise their children without the need for a western vaccine (which still dosen't exist). They hold the buttocks of their child near a sandfly nest and get them bitten early on in a non-cosmetically dodge place and then the kids are immune for life. I reckon a burqua would do.....with a hole cut in it at buttock level...what d'ya think?

Now if you think I'm overexaggerating and just being a bit of a drama queen about the facial disfigurement then scroll down......this guy didn't get the buttock treatment as he lived in Peru.

Bug Central

I finally made a decision on the hat...SPF50 and flat packable - sold! Also sold was a very big mosquito net and a double silk sheet thing...all anti bug measures that will hopefully make Belize nights a nibble free zone.....all the more important given what I find out in the coming weeks!

Isn't it funny how just when you are starting to really enjoy your holiday, something happens - oh yes, I had to go back to work. One day I was on a beach in SaltDean near Brighton basking on heated stones gazing inbetween a teenaged wizards adventures and azure skies and swimming in chilled waters and the next I was rudely awoken at 6am for a trip across town to Bug Central.


The first obstacle was how to actually get to The Hospital for Tropical Diseases....underground? overground? .... I chose Wombling free courtesy of a train to Bedford from London Bridge which dropped me at Kings Cross...easy walk from there I thought...its funny how much longer walking is than driving.....30 minutes of route marching got me there...just... with a couple of double backs to find a shabby looking building which houses the clinic around the corner from what seems like the biggest campus in Britain. Everywhere you look is UCL university buildings or hospital...seriously...for 6 blocks in each direction...and more! After finding that my contact had retired and elective partner metamorphosed from a German male to a Dutch beauty named Trudy and been subjected to the usual form filling and traipsing around getting photo ID we were ushered into our first clinic - Leprosy (and rather alot of Leishmaniasis) with the phenomenal Professor Diana Lockwood (complete with cute but huge dangly dragonfly earrings) and the research Dermatology registrar with the best hairdo in the hospital; Stephen Walker. Serious 'fro man!

Leprosy is a seriously terrible disease. Over the next few weeks I saw people with small patches of anaesthetis hypopigmented skin and little else to leprosy technicians from Afghanistan who had caught the disease from their patients and now could not use their hands, to a man with clawed hands and neuropathic damaged feet with bits of toes missing. You can catch it and kill the bacteria fairly easily but the problem is that the tissue that it likes - the Schwann cells that insulate nerves still continue dying and its that which causes the nightmare for the patients. Sometimes its just single nerves or muscles weakness if you're lucky and you've got the tuberculoid form, however if you've got the lepromatous form - it's glove and stocking time and you can't feel anything so you damage everything.


A slightly wierd thing to look for on your travels are people with the outer third of their eyebrows missing...the leprosy does that too....