Hotel Tropicana, Part I
For the last year I've stayed largely outside the world of clinical medicine and delved mostly into the realm of public health. Intuitively those don't seem like very different things, but they can be almost two entirely separate bodies of knowledge - as evidence by ability to expound at great length on the relative merits of various insecticide-treated bed net distribution schemes while I have totally forgotten all things clinical, such as which valve lesions cause which heart murmur. Late last fall, one of the infectious disease lecturers mentioned that just up Gower Street - only a few minutes' walk from LSHTM - is the old Hospital for Tropical Disease (HTD). I enquired as to whether the facility ever takes foreign medical students on rotation, and after some rapid maneuvering to get paperwork together, I signed up for the only spot that was available before the late fall - which happened to coincide with the three-week block I was due to study for the cumulative June exams. But I was very interested in doing the rotation, so I took the less-than-ideal dates and now here I am.
Because of the tendency for patients to come back from glorious tropical travels only to land in an HTD bed, the ward consultant this month (what in the US we would call the attending physician) politely but aptly refers to the eighth floor ward as "Hotel Tropicana." This particular consultant is a slightly wild-eyed Irishman whose lectures (both on the medical ward and in the CID course last fall where I first encountered him) are marked by an equal mixture of noir humor and photos of tropical skin disorders that inevitably turn out to be polaroids he took of his own arms and legs during his years in equatorial Africa. I've now heard his lectures on worms and other sundry parasites so many times that I can recount the original stories from the photos included in his standard Power Point presentation - the bucket-filling tapeworm that some poor gentleman spent most of a day winding out of his rectum while his very pregnant wife edged into labor; the migrating loa loa worm snaking across a patient's anterior eyeball while a very self-amused trainee doctor proclaimed that "the worm just came out to say hello-hello-a!"; and, more sobering, the newspaper headline from only a couple of years back that announced that Britain was trying to sell Tanzania a $23 million air defense system in a time when the Tanzanian government was spending about a dozen dollars per capita per year on health care.
The HTD itself is located on the eighth floor of a gleaming and spanking new building that is so close to my studio in Euston that if I lean far enough out the window, I can stare into the windows of the eighth floor where I see patients during the day. And from that floor, the rooms with southward-facing windows get an excellent view of London - with the cross-shaped and gable-roofed Cruciform Building (which houses the University College London medical school) in the foreground, and the London Eye (the enormous Ferris wheel that sits alongside the Thames) off in the distance, London looks like a carnival, even perhaps through the jaded eyes of the patients who are temporarily incarcerated on the hospital floors. The attached outpatient clinic is located a few blocks down the street toward the school. By the end of the month, I will have spent two weeks at each site, minus the two mornings in the last week that I will be obligated to make an appearance at school to sit through two three-hour exam sessions.
Two weeks ago now I started over on the hospital side, where a daily patient census sees more tropical diseases than a year back in Oregon. Most of these folks are travelers of some sort. Many are British nationals returning from vacations or work trips abroad; some are on their way home to other parts of Europe but get dragged off a flight into Heathrow barely conscious and hauled into the HTD for a few days of resuscitation before they are able to continue on home. Because most staff at LSHTM have international aspects of their jobs, there also seems to be a sporadic supply of lecturers and researchers floating through the ward who have picked up all manner of fever in the tropics; when one does show up, there is an uncomfortable shuffle to find a medical team who is staffed entirely by consultants and trainee doctors who aren't actually close personal friends of the unfortunate victim. Since there are three teams on the ward (tropical medicine, general ID, and HIV care), usually one or another fits the requirements - but not before most everyone on the ward has heard the intimate details of the patient's last dozen bloody bowel movements and other such unsavory personal details.
The remaining patients are largely native to Africa, Asia, or other exotic locales who have resident status in Britain. Some bring simmering infections with them on their immigration, which show up years later as, for example, the temporary seizures caused by a dying tapeworm cyst that has lodged itself in the patient's brain a decade or so earlier. Others return from short visits back home with some more acute condition; it was sadly pointed out during a lecture last fall that many of the ex-patriate Africans are admitted to the HTD after visiting home for the funeral of a close relative - and almost always, those funerals are AIDS deaths. A preventable disease, a treatable (though not yet curable) disease, and AIDS is still the leading killer of adults in most African nations.
But usually those returning to Britain are plagued with uncomfortable but far less serious infections - malaria at the top of the list, a whole host of enteric pathogens below that, and then some of the more obscure germs like a bacterial infection called brucellosis that one might acquire if one were to drink, for example, unpasteurized camel milk. Malaria is a very different disease for locals versus travelers in endemic regions; people who live with it all the time tend to carry a low level of parasites throughout the year, and if it doesn't kill them in childhood, they are virtually immune to getting ill from the bug as adults, as long as they are continually exposed. Immunity fades fast once they move to a temperate malaria-free zone like Britain, but most don't think of it as an adult disease and don't take prophylactic drugs when they go. There are several legendary horror stories about this phenomenon - people coming back to London so sick they can't think straight any more, but no one thinks to consider malaria until they turn up on an autopsy table. For this reason, just about anyone who walks through the door of the HTD with a fever automatically gets a blood smear to check for the parasites.
Aside from malaria, perhaps the most interesting cases to turn up harbor a vicious little disease called leishmaniasis. A few months back this parasite was making the news because it's endemic to Iraq and passed by biting sand flies - and more than a few Americans and Brits have returned from the various incarnations of the Gulf War with a teeming mass of these creatures carving out non-healing ulcerous wounds on arms and legs and various other exposed body parts. Most cases of leishmaniasis seen in London are not from the Middle East but from Central America - particularly Belize, by default of the fact that Belize is an ex British colony and thus a popular destination for British tourists. Some forms of the disease hit the gut, and that can be fatal. But one of the sorts found in Belize can have a less fatal yet almost equally unpleasant effect: some subtypes of the parasite stay in the skin, but some head for mucous membranes, where they invade and cause serious disfigurement of both the soft and bony structures, particular around the face. With one particularly unfortunate gentleman that we admitted this week, it was not yet clear whether the enormously inflamed lesion located on the tip of his nose was invading into the bone or not, but in any case he'll be coming into the hospital for a month of daily infusions of a ghastly antimony-based drug that almost universally causes heart arrhythmias and pancreatic damage - probably with a referral to plastic surgery on his way out the door.
In any case, the ward is never boring. Next week, onto the clinical side...
Because of the tendency for patients to come back from glorious tropical travels only to land in an HTD bed, the ward consultant this month (what in the US we would call the attending physician) politely but aptly refers to the eighth floor ward as "Hotel Tropicana." This particular consultant is a slightly wild-eyed Irishman whose lectures (both on the medical ward and in the CID course last fall where I first encountered him) are marked by an equal mixture of noir humor and photos of tropical skin disorders that inevitably turn out to be polaroids he took of his own arms and legs during his years in equatorial Africa. I've now heard his lectures on worms and other sundry parasites so many times that I can recount the original stories from the photos included in his standard Power Point presentation - the bucket-filling tapeworm that some poor gentleman spent most of a day winding out of his rectum while his very pregnant wife edged into labor; the migrating loa loa worm snaking across a patient's anterior eyeball while a very self-amused trainee doctor proclaimed that "the worm just came out to say hello-hello-a!"; and, more sobering, the newspaper headline from only a couple of years back that announced that Britain was trying to sell Tanzania a $23 million air defense system in a time when the Tanzanian government was spending about a dozen dollars per capita per year on health care.
The HTD itself is located on the eighth floor of a gleaming and spanking new building that is so close to my studio in Euston that if I lean far enough out the window, I can stare into the windows of the eighth floor where I see patients during the day. And from that floor, the rooms with southward-facing windows get an excellent view of London - with the cross-shaped and gable-roofed Cruciform Building (which houses the University College London medical school) in the foreground, and the London Eye (the enormous Ferris wheel that sits alongside the Thames) off in the distance, London looks like a carnival, even perhaps through the jaded eyes of the patients who are temporarily incarcerated on the hospital floors. The attached outpatient clinic is located a few blocks down the street toward the school. By the end of the month, I will have spent two weeks at each site, minus the two mornings in the last week that I will be obligated to make an appearance at school to sit through two three-hour exam sessions.
Two weeks ago now I started over on the hospital side, where a daily patient census sees more tropical diseases than a year back in Oregon. Most of these folks are travelers of some sort. Many are British nationals returning from vacations or work trips abroad; some are on their way home to other parts of Europe but get dragged off a flight into Heathrow barely conscious and hauled into the HTD for a few days of resuscitation before they are able to continue on home. Because most staff at LSHTM have international aspects of their jobs, there also seems to be a sporadic supply of lecturers and researchers floating through the ward who have picked up all manner of fever in the tropics; when one does show up, there is an uncomfortable shuffle to find a medical team who is staffed entirely by consultants and trainee doctors who aren't actually close personal friends of the unfortunate victim. Since there are three teams on the ward (tropical medicine, general ID, and HIV care), usually one or another fits the requirements - but not before most everyone on the ward has heard the intimate details of the patient's last dozen bloody bowel movements and other such unsavory personal details.
The remaining patients are largely native to Africa, Asia, or other exotic locales who have resident status in Britain. Some bring simmering infections with them on their immigration, which show up years later as, for example, the temporary seizures caused by a dying tapeworm cyst that has lodged itself in the patient's brain a decade or so earlier. Others return from short visits back home with some more acute condition; it was sadly pointed out during a lecture last fall that many of the ex-patriate Africans are admitted to the HTD after visiting home for the funeral of a close relative - and almost always, those funerals are AIDS deaths. A preventable disease, a treatable (though not yet curable) disease, and AIDS is still the leading killer of adults in most African nations.
But usually those returning to Britain are plagued with uncomfortable but far less serious infections - malaria at the top of the list, a whole host of enteric pathogens below that, and then some of the more obscure germs like a bacterial infection called brucellosis that one might acquire if one were to drink, for example, unpasteurized camel milk. Malaria is a very different disease for locals versus travelers in endemic regions; people who live with it all the time tend to carry a low level of parasites throughout the year, and if it doesn't kill them in childhood, they are virtually immune to getting ill from the bug as adults, as long as they are continually exposed. Immunity fades fast once they move to a temperate malaria-free zone like Britain, but most don't think of it as an adult disease and don't take prophylactic drugs when they go. There are several legendary horror stories about this phenomenon - people coming back to London so sick they can't think straight any more, but no one thinks to consider malaria until they turn up on an autopsy table. For this reason, just about anyone who walks through the door of the HTD with a fever automatically gets a blood smear to check for the parasites.
Aside from malaria, perhaps the most interesting cases to turn up harbor a vicious little disease called leishmaniasis. A few months back this parasite was making the news because it's endemic to Iraq and passed by biting sand flies - and more than a few Americans and Brits have returned from the various incarnations of the Gulf War with a teeming mass of these creatures carving out non-healing ulcerous wounds on arms and legs and various other exposed body parts. Most cases of leishmaniasis seen in London are not from the Middle East but from Central America - particularly Belize, by default of the fact that Belize is an ex British colony and thus a popular destination for British tourists. Some forms of the disease hit the gut, and that can be fatal. But one of the sorts found in Belize can have a less fatal yet almost equally unpleasant effect: some subtypes of the parasite stay in the skin, but some head for mucous membranes, where they invade and cause serious disfigurement of both the soft and bony structures, particular around the face. With one particularly unfortunate gentleman that we admitted this week, it was not yet clear whether the enormously inflamed lesion located on the tip of his nose was invading into the bone or not, but in any case he'll be coming into the hospital for a month of daily infusions of a ghastly antimony-based drug that almost universally causes heart arrhythmias and pancreatic damage - probably with a referral to plastic surgery on his way out the door.
In any case, the ward is never boring. Next week, onto the clinical side...
posted by skylanda at 12:52 PM
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