Medic Field Notes

Medic field notes: (London 1852)

Carla Rasich is a 32 year-old lower class woman living in a one-room tenement on Berwick Street in the Soho area of London. She presented with extreme diarrhea, sharp muscular cramps, vomiting and fever. Thirty-six hours after presenting with symptoms she died of apparent dehydration and shock.

Carla resided in this tenement with both her family and another family. Conditions in this section of the city were appalling with dirty water as a result of poor drainage. A single water pump serviced the entire street. In the tenement, water was used sparingly for food preparation as in her illness, Carla had been unable to go to the water pump as frequently to refresh the water for the tenement residents. Carla was responsible for the care and wellbeing of many in the tenement, worked out of the home and was still involved in household duties.

Many other people in neighboring tenements complain of the same symptoms. With the occurrence of illness both within this tenement and along the street, it is likely that this is yet another person to succumb to the current outbreak of Cholera

Teacher Background- Cholera

In the 1800’s England was devastated by cholera outbreaks as were countries across the globe. During the height of the 3rd pandemic it is thought that 1000 people a day died in England. The website http://www.ph.ucls.edu/epi/snow does an excellent job of describing the path that cholera took across the globe. At the time of the case study students have, the general consensus was the cholera was transmitted via a miasma in the atmosphere. Dr. John Snow theorized that cholera was actually transmitted by contaminated water. He used data from the London outbreaks to establish that something in the water was actually the root of the illness. Snow used mapping to identify the source. Unfortunately he was unable to convince the health authorities and it was only much later that his explanation was accepted.

Medic field notes: (Papua New Guinea 1954)

Konio was a 28 year-old mother of three children and a member of the Fore tribe of Papua New Guinea. She was a good mother, but approximately a year ago started exhibiting erratic behavior, including speech slurring, tremors and fell down more and more frequently. Over time, she became unable to physically support herself and eventually also became unable to support her family. During her convalescence, she was unable to bring water from the nearby spring, and neighbors had to help out by offering food from their own stores. The local kitchen offered to increase their food preparation to help out the family. She was observed to have abrupt outbursts of laughter and periods of debilitating sadness and lethargy. Eventually, near the end of her life she was unable to even sit up or take care of herself. Some attributed her death to a mania following the death of her well-liked uncle, as other family members have shown similar effects since his death; others to evil spirits or village sorcerers. A dark and withdrawn neighbor was killed to try to alleviate the disease in this well- liked family. Symptoms are those of the disease known as Laughing Disease, which is only really seen among the Fore tribe of Papua New Guinea. This disease seems to particularly affect the women and children of this Tribe. The official name of Laughing Disease is Kuru Disease. Teacher Background- Kuru

Kuru was rampant among the South Fore tribe for several decades. The Fore participated in ritual acts of cannibalism when members of the tribe died. This behavior was the source of the disease. Kuru is a prion disease, one of five known transmissible spongiform encephalopathies in humans, like Mad Cow disease. When a family member died, the female kin prepared the body, feeding bits of the brains to the children and elderly. It is also suspected that Kuru may have been transmitted through the wounds in the skin. It is the higher rate of disease among women, children and the elderly that was the vital clue to figure out the route of entry into the body. Before recognition that laughing disease was transmitted via the cannibalistic ritual there were a variety of hypotheses as to the transmission of the disease. It was thought that it might be genetic in origin or that it might be a slow virus. The nature of the disease remained a mystery until 1982 when prions were described. Prions are still being researched. The disease has all but disappeared with the ending of ritual cannibalism in New Guinea among the Fore.

Kuru means trembling in the language of the Fore. A general source of information on prion diseases can be found at http://news.bbc.co.uk/2/hi/health/medical_notes/355601.stm

Medic field notes: (New York, 1989)

Anthony Johnson is a 26 year-old man living on the Upper East Side in New York City. Six months ago he visited a clinic with a persistent cough, pain in his chest and was also experiencing a low grade fever and night sweats. He has a high powered job and had just finished an important project that had him working around the clock with little time for sleep or proper meals. He complained that he felt tired all the time (even since the project had ended) and that he had dropped 10 pounds. He wouldn’t have come to the clinic, but one evening he found himself coughing up blood. After a skin test he was diagnosed with tuberculosis and given rifampin to take over a six-month period. At the end of the six months, the clinic made a house call since he had missed his previous two appointments. He complained of similar symptoms, but said that he was taking some of the medicine that he had left over and that he was not worried, since taking the medicine had done such a good job in the first two weeks after diagnosis.

Teacher background- Tuberculosis

Tuberculosis is caused by Mycobacterium tuberculosis and is passed through the air from person to person by coughing or sneezing when it infects the lungs. TB can also affect the kidney, spine and brain and can be fatal. Not everyone who becomes infected with TB becomes sick, however. A latent infection will show no symptoms, be non-infectious, and may never affect the person unless the bacterial growth gets the upper hand through a lowered immune system. Medicines were found to control TB, but in the 1970’s and 1980’s TB control was neglected, leading to an outbreak between 1985 and 1992. TB has since been better controlled, but there were still 14,000 cases in 2003 in the US alone. When breathed in, the bacteria end up in the lungs and begin to multiply. They can move through the blood to other areas of the body. If the infection is active and in the lungs, the person afflicted can spread it to people they spend time with everyday through coughing and sneezing. It can only be passed through the air, not through handshakes or food-sharing, as the bacteria are within the lungs. In hospitals, air vent systems must be taken into consideration to prevent the spread of the disease. When active, the multiplying bacteria can attack and destroy tissue. Again, a latent infection can become active if the immune system is compromised in any way. The very young, the elderly, and the already sick have compromised immune systems that are more prone to active infection. The symptoms include: a cough (3 weeks or longer), chest pain, coughing up blood or sputum, weakness or fatigue, weight loss, no appetite, chills, fever and night sweats. TB die slowly, and it takes six months (!) for medicine to fully kill the bacterial population. Patients may feel well after only a few weeks of treatment, but TB is still active and if medicine is discontinued can begin to multiply again and those drug resistant strains will have been selected. http://www.cdc.gov/nchstp/tb/faqs/qa.htm

Medic field notes: (Chicago 2005)

Frieda Frylaard is a plump 22 year-old woman from Chicago. She visited the office last week complaining of blurry eyesight, and recognition that papercuts she had gotten while working as a human resource director for a large Communications Corporation were taking a long time to heal and hindering her work. Upon taking a full history, she was found to also be suffering from itchy skin and after being excused three times (once to get water and twice to urinate) offered that she felt continually thirsty and seemed to always be needing to take a bathroom break. In fact, she has had to up her water order from the local bottled Water Company. In the course of her workday, she has little time to take away from her tasks and often eats at her desk. She usually takes a hasty breakfast from a local bagel shop and eats this meal both on the way to work and finishes at her desk. Since she works late, she sometimes meets with friends for dinner at local restaurants to wind down. She has frequent contact with her family, as they all gather on Sundays for a big meal, and some of these relatives have complained of similar symptoms. At home, she lives with a 3-year old cat, with whom she spends the remainder of her free time.

Teacher Background- Type II Diabetes

Diabetes is an increase in the glucose level in the blood resulting from an inability to regulate it. Type I Diabetes (or childhood diabetes) is the gradual non-functioning of beta cells in the pancreas. Beta cells make insulin, and insulin is responsible for the processing of glucose in the blood for energy that will be used by cells. Type I Diabetics must take insulin to manage their glucose levels. Type II diabetes has its onset later in life, where cells in the muscles, liver, and fat do not use insulin properly. No matter how much insulin the body makes, it is not enough to deal with the glucose levels in the blood and the glucose levels are often high. Over the years, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. Type II Diabetes can be prevented or at least delayed by keeping blood glucose levels normal. This can be done by limiting the intake of sugars or by using up excess sugars through exercise. Recently, rates among juveniles are rising as a result of dietary and obesity shifts within the general population. There are certain populations that appear to be more susceptible to Type II Diabetes, and members of the same family are often affected (strong genetic component); but insulin resistance is affected significantly by weight and diet. http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/