Terrain Acra Port au Prince

HAITI
Today is Day 3 of my visit here.
The first thing you notice when you arrive here is how hot it is! I have never sweat so much in my life, not even in Africa.
After a slight wrinkle at the airport on Sunday I made my way to the “group house” that is shared with 5 other people. It is actually a beautiful house in a ‘safe’, gated community. I sleep in a tent on the ‘balcony’ which fortunately is inside. Fortunate because this is the rainy season. It rains every afternoon, sometimes it is a thunderstorm with a deluge and sometimes it is lighter.
On the drive from the airport there were obvious piles of rubble and destruction and a fair amount of traffic.
I met my house mates and forced myself to stay awake until after we went out to dinner, getting to the restaurant took 40 minutes. The traffic in Port au Prince is really bad and I was to discover just how bad the following day. A large part of my time is spent sitting in traffic, after a stop at the main office and a security and camp briefing I finally got to the “Tent city” where I will be practicing for 2 weeks. It is called Terrain Acra.
Terrain Acra has to be seen to be believed, it is a community of 28,000 people displaced by the earthquake all living under pieces of plastic sheets. There is no running water or electricity, the temperature outside is between 97 and 103 degrees, this is magnified by the plastic sheeting and lack of air circulation. Children, goats and pigs rummage freely in trash piles that are everywhere. What is it about pigs that makes them smell so bad?
Terrain is a squatter settlement on the waste dump of a factory owned by 3 brothers with the last name Acra (I understand they are of Lebanese origin). The brothers have agreed to allow these people to stay on the land until January 11 2011 at which time they want their land back. The police have agreed to forcefully remove the people at that time.
The ‘clinic’ is a large tent donated by Unicef, it has been divided up into 5 examination cubicles and a table which represents the pharmacy. I was only there for a few hours on my first day and then I was told to return to the office. Once there no one seemed to know what I was there for so I guess I should have gone in the ‘mobile clinic’. In the office I was given a disc on key by the data entry guy. I tried to open it later on my own computer. There was nothing on it but viruses, my computer went crazy!
DAY TWO
My second day began with a quick breakfast and then the long car ride to the camp, on the way in, I could tell my stomach was starting to rebel. I had the dreaded thought that I might have to use one of the latrines (a hole in the ground which is used as a toilet). Try as I might I couldnt ignore it and the cramps got worse. Just in time to start the daily meeting ! Great, why didn’t it start before I left the house so I could take something? I checked in at the pharmacy table, No, they didn’t have any diarrhea medicines! I decided I had no choice but to bite the bullet and go to the latrine.
The latrines stand proudly with their graffiti covered plastic flapping whenever there is a suspicion of a breeze. I am not too proud and I do need to hurry up before I run out of options, I thought. Let me check them out.
I went back and got some gloves, I didn’t like the idea of toughing the plastic not even for the second it would take me to get into position. OK, now I’m ready! I picked up the plastic and the smell was overwhelming, I reeled back and rethought my strategy, Nah! I can wait!
Unfortunately my stomach had other ideas. The cramping got worse, I was dodging in and out of the meeting trying to look very busy without doubling over. I thought perhaps I could wear a mask and that might make it tolerable (“does anyone have a hazmat suit, I’m going in!”) but I couldn’t find one. Finally on my third attempt I stepped inside the latrine and held my breath. It sounded like everyone in there had similar problems! I tried to hold the plastic ‘cover’ with one gloved hand a failed attempt at some modesty and prayed it would soon be over. Added to this was the fact that the latrine temperature is a good 10 degrees hotter than the outside. Now, you can understand why in 3minutes you lose almost a litre of sweat and exit with near syncope (that means fainting). I recalled one of my colleagues had mentioned he was about to pass out the day before doing the same thing. I returned to the clinic tent sweating buckets and seriously nauseous just in time to hear the medical director announce “I would like to introduce Dr Tuakli, our new visiting doctor!” Showtime!
So why do I tell this graphic tale you wonder? Because it really brings home how these people are living on a day to day basis with zero options, it’s a wonder a massive epidemic of cholera or dysentery hasn’t wiped the whole camp out or that people don’t become despondent in the face of such living conditions. Compared to this the rest of the day was less traumatic. I saw patients in the clinic including an 82 year old resident of the camp and several children. There was some mention of me organizing the women and child care system for the camp , we’ll see how that pans out. I guess every little bit helps and I am glad to make my contribution.
Around 3pm I went with the medical administrator to a ‘cluster meeting’. This is where all the organizations that have health programs helping out in the various camps get together and decide on strategy. There are Aid organizations from all over the world mostly Europe and the US. They decided with the WHO to call on the Haitian government to stop forceful removal of squatters in camps. By the time I spoke to my husband on skype my voice was gone and I was wiped out, I thought it was just dehydration and a stomach virus, but No, this morning I woke up with a full blown cold.
DAY THREE
I have spent the day with a nose dripping like a faucet but in addition to that I worked in the clinic in the morning. I am discovering creative talents I did not know I possessed. Yesterday a lady brought a child in with a fever of 40 degrees centrigrade (normal is 36) and said the baby had begun to have seizures, requests for Tylenol were not working and after insisting I was told there was none in drops. The child had already been stripped and sponged but was still hot (big surprise in that tent!). Brain wave! I asked for a tablet then crushed the end with my otoscope and poured the powder into the child’s mouth. He didn’t like that and started to whine, next I grabbed my water bottle and dripped some water into his mouth, Voila! All washed down.
Today, a lady came in with a child with Hydrocephalus (a big head from too much water on the brain) the child is 15 months old and has a fresh scar on the head where some surgery has been done to relieve the pressure in the brain. A sad case, the child cant walk or talk, legs are paralyzed. Apparently the doctor she saw had given her a prescription for Amoxicillin liquid, which was not available so she was told to go and buy the prescription elsewhere. The child’s caretaker came to me and asked me to help. She said the child’s mother had died and she had no money. I spoke with the doctor, “well she can come back tomorrow and she can see if we have some then” she said. Ahh, I don’t think so! I went to the pharmacy and told them to take an adult pill and have them crush half of it three times a day.
I have treated four staff people so far!
A middle aged lady came in with a 3 day old baby, apparently it had been delivered ‘at home’ in a tent, the mother was not there. Unfortunately, this opportunity to intervene was missed, the clinic staff cleaned the umbilicus and sent the baby ‘home’.
This plus several other issues prompted me to send a long email to the program director. I’m not sure how popular I am going to be after this!
My mind is racing with ideas of things we can do to help the community at Terrain Acra .
I will keep you posted!

Headed for Haiti, Emotions!

Its 5 AM!

And so begins my self-inflicted adventure to Port au Prince in Haiti. I said goodbye to my worried husband around 7.15 am at BWI and boarded the flight to San Juan. I was very worried that my bags would be too heavy but we were able to include all the prenatal and kiddie vitamin bottles I had brought with me plus a 5 pound bag of candy for the kids.

What are my emotions? I am not sure, after having so many people,including my dear husband, tell me not to go, then the security advisories and disclaimers from the American Refugee Committee (ARC) the group I am going to work with,I feel mre anxious than I usually am when I leave for a volunteer trip. The positives include the possibility of perhaps making a difference to someone in Haiti and also the chance that I may actually get more rest there!

Apart from only getting 3 hours of sleep last night and getting up with a sore back, the past few weeks are starting to take their toll. In addition to organizing a women’s seminar and having to evict a tenant from a rental property, I have had to work through my son’s “senior pranks” and graduation plus get my practice ready to do without me for two weeks and prepare for Haiti, all the while reassuring everyone that I will be coming back alive! In retrospect its been a tough year so far – a sentiment I am sure that is shared by everyone in Haiti! That thought rapidly puts everything in perspective doesn’t it?

I am hopeful that I can maintain my enthusiasm but am a little scared of being overwhelmed by the squalor and misery. My other fears are another earthquake or hurricane making orderly functioning impossible, plus I am claustrophobic so I will not be one of those surviving for days under the rubble- and then there's security.
Clues to the security situation have been provided by ARC: a casual mention that I will be picked up from the airport by an armed guard and their repeated requests that I fill out a “proof of life” form. “What is that?” I finally asked. “Just a form that lists answers to questions only you would know in case you get abducted” Aaah, yes of course!

I am anticipating up to 12 hour work days and I wonder if arriving exhausted is really doing a disservice to my potential Haitian patients.

Enough about you, what’s going on in Haiti you ask. Well I don’t know yet, I’m on a little plane on the way there from Puerto Rico. The captain says it is 33 degrees centigrade at the moment – what is that?

I will write about my initial impression and emotions shortly. Meanwhile where are my tissues……..just in case!

Shout out to sponsors!

I wanted to acknowledge those who sponsored our seminar:
Northern Pharmacy with a special shout out to April!
Vien clinics of America
Spectracell

Happy 90th birthday Ms. B! News about our great seminar!

Here is a picture of me with a patient of mine who turned 90 this month. Doesnt she look great!Happy birthday.

Last weekend I held an anti-aging and hormone replacement seminar entitled: looking good and feeling good after 40! It was great and very inspiring for me personally to see women so receptive to receiving new information.
The seminar opened with Claudia Salomon a renowned Nia (and Zumba) teacher helping us claim the space that we were in. What I thought was going to be a mild stretching exercise had me breathless when called upon to speak even though we performed the movements right where we stood. After lunch she gave us another 7 minute workout and for those who wished she did a full class at the end. So invigorating and energizing, after Claudia the excitement was palpable, the room was electrified.
The first discussion was about Bio identical Hormone replacement and evaluating what hormones need to be replaced. Over 40, the most important hormones to get in harmony are: Estrogen, Progesterone, Cortisol, Thyroid and Insulin. Many people were surprised to discover that all steroid hormones are derived from cholesterol and there is such a thing as a too low cholesterol.
We also talked a lot about women's sexual dysfunction, how to manage it, how hormone replacement can help and what Herbs maybe useful. Its interesting that "erectile dysfunction" is all over the airwaves now and is considered a socially acceptable topic of conversation but more women than men suffer from sexual dysfunction yet no one feels comfortable talking about it.
Wow! No one knows unless they ask. "Is this normal?"
Dr Kanter followed with a very concise presentation on body contouring with plastic surgery. He got rave reviews from all the participants. He covered the body from head to toe and kept the audience spell bound with his before and after photos.
After lunch Claudia's routine helped with digestion and then we were back to talk about Anti-aging and Telomeres.
Three scientists were given the Nobel Prize for medicine last year for their work in this amazing field. Its implications are profound for understanding the aging process.
(Call our office if you would like to get your telomere length measured).
I was able to discuss a full and comprehensive Anti-aging workup such as the one we perform, in great detail. A very important component being neurological testing.
Dr Comeau a local physician talked about Botox and Fillers and then did a demonstration on my office manager Cindy. Once again everyone was riveted with attention.
There wasnt a dull moment!
It helps to be a woman over 40 and with the number of women I see in my practice I know what subjects are of interest to Baby Boomers. It is my goal to keep bringing you seminars
that are relevant, interesting and exciting with the end result of bringing life to your years!
We shall be holding another seminar in early fall, if you would like to be notified of our events please call our office at 410 992 0011 and give us your email address or send it through the contact page of the website.

Next week I will be blogging from Haiti !

Vitamin D the under represented vitamin

I first got interested in Vitamin D a few years ago when a professor of Dermatology at a high profile institution in the North East got kicked out of his job for recommending that people get more sunlight. I was a little curious as to what sparked such controversy as clearly, an Ivy League dermatologist would be unlikely to put his job on the line over a vitamin!

After that I started receiving emails from the 'Vitamin D Research Council' an organization apparently funded by a doctor who believed so much in the importance of vitamin D that he put his career and a fair amount of his own money into proving the point.

Initially I was a little skeptical of the apparently far reaching consequences of Vitamin D deficiency: from possible association with Autism and ADHD to an increase in Cancer and infections. Then my skepticism turned to concern, the more I read and the more I checked my patients' vitamin D levels. Almost 90% of my patients were vitamin D deficient and at least 50% severely so. As a result, I have been checking Vitamin D levels routinely in all patients presenting for an annual physical exam for at least 2 years.

Most patients are not aware that they are deficient and have no symptoms but sometimes people are markedly symptomatic. Fairly often I find that Vitamin B12 deficiency and Vitamin D deficiency go hand in hand.
Such was the case with a patient of mine who came in to my office complaining that she thought she was developing Alzheimer's. She was very distressed and told me a story of constantly forgetting things and her anxiety about this. She became emotional when she explained how she did not want her children to find out. I suggested she see a neurologist and get some labwork done while she was waiting for that appointment.
Apparently she was so demotivated and forgetful she didn't get the labs done, continued with the neurologist who told her she didn't have Alzheimer's but she could try some medicine if she wanted, in case it helped. She declined.
She came back to see me 3 months later more tearful and agitated than before, she could hardly get out of bed in the morning because she was so tired. Her legs hurt and everything was a struggle. This time she got her labwork done and both her Vitamin B12 and Vitamin D level were extremely low.
With replacement she is fine, two weeks later she was back working the garden she loves and now she laughs when I remind her that she was convinced she had Alzheimer's.

Most cases are not as dramatic but is Vitamin D deficiency another one of those 'silent killers'?
Andrew Weil recently wrote an article stating that he is raising his recommendation for Vitamin D to 2000 daily (something most of my patients are already doing) because of a recent study out of the University of San Diego California which suggested that raising vitamin D levels could prevent one-half the cases of Breast cancer and two-thirds the cases of Colon cancer.
Hello this is HUGE!! As Dr Weil points out: a 50 percent reduction in Breast cancer would have saved the lives of more than 20,000 American women in 2009.

Vitamin D is thought to affect the immune system, it controls the utilization of calcium by the bones and so is important for bone strength, lack of it contributes to fatigue, it helps seniors retain their balance. It is important for cardiovascular health, in Diabetes, Psychosis and every month a new article comes out with different attributes.

In short, we need it! You can get it through fortified foods like milk and cereals but the main way is either supplementation or the sun. The latter recommendation being what cost my dermatology colleague his job because he suggested patients go out in the sun for half an hour a day without sunscreen.

Bottom line vitamin D is beginning to be recognized as a critical vitamin, if you have not had yours checked, do it now and take the necessary steps to keep it above a level of 32 (ideally closer to your age).

As always wishing you good health

Dr Tuakli

Latest mammogram recommendations

I have been asked by some patients what my thoughts are regarding the new mammogram recommendations. Quite frankly they don't make sense to me and will not change my current management of patients at all. Why?

Well first of all they are exactly what they claim to be "guidelines", I can choose to follow them or not. In this case I would rather not.

Mammograms are problematic from the standpoint of radiation however I have seen MANY patients diagnosed with Breast Cancer as a result of them. One of the most concerning trends has been the discovery of breast cancer in younger and younger women, the idea that they would not be diagnosed because they would delay their mammograms to the age of 50 is scary.



The bottom line is, as with most things in medicine, tailor the recommendation to the patient. It is important to have an on going relationship with a physician who knows you and who will make recommendations based on his or her knowledge of you and your particular situation, not based on guidelines. For example prolonged use of certain contraceptives, family history, breast exam findings are all things that would change how often and when a particular patient should get a mammogram.

Remember guidelines come and go, they are not set in stone and neither is your wellness. It should be a dynamic process arrived at by rational thinking and on going education.

When insurance companies finally start paying for thermograms we will have alternatives that don't involve radiation that may be more appropriate for some patients.

Until then for most people mammograms are the best they can afford ......
If you are at high risk remember to avoid caffeine, take indole-3, do regular self breast exams, do not take Provera and follow your doctors screening schedule.



Wishing you a healthful 2010

Dr Tuakli

Is the fedex man delivering more than just packages?

There is a story that is told in medical history about a milk delivery maid who was dubbed 'Typhoid Mary' because she single handed contributed to the biggest typhoid epidemic in England. An interesting story often told to very green medical students as an introduction to the term "carrier".

A patient of mine came in recently with the Swine Flu H1N1) he was very sick and was still wearing his Fedex uniform. I advised him that the type of work he was doing and his exposure to the elements would only make him sicker, needless to say I put him out of work for a week.

As I looked at this poor person with bloodshot eyes, sweating and coughing up a storm, I had cause to rethink our (the Health Establishment's) definition of 'High Risk' patients i.e those who are eligible to recieve the H1N1 vaccine. Surely the delivery man innocently delivering packages from one establishment to the next and potentially picking up infection at one and depositing it at the next, is at high risk. Not only that, he (or she) presents a risk to the community at large as he proffers his pen with a grin and the instruction to 'sign your name!' before darting off to the next densely populated building.

In my office we have been lucky enough to have had the H1N1 shot throughout the 'shortage' and we have religiously followed the Health departments instructions to limit its use to high risk individuals; children ages 6 months to 24 years, healthcare workers and pregnant women. As of this week I have opened it up to many more people that I consider high risk such as teachers and metro workers.
I have been struggling with the idea from the beginning that students need to be vaccinated but not those who teach them. Maybe I am more sypathetic because my husband is a professor or just because I have NEVER seen my 17 year old son as sick as he was with the Swine Flu. He rarely gets sick but this bug made him as sick as a dog! (He came down with it 3 days before I recieved my supply of vaccines ...........).

Anyway to cut a long story short, come on and get your H1N1 vaccine, lets curb this epidemic. It takes 2 weeks to develop a good immunity so hurry in, next week is Thanksgiving and yes, if you drive a UPS truck ................ you are welcome too!