The blog begins a month and a half and several thousand miles before its destination.
Amazonia is relatively flat (as long as you forget Werner Herzog's Fitzcarraldo) but offers much more
manageable hazards, many of which are medical or entomological. The former are managed by
inoculation and the latter by knowledge. It's not a coincidental destination..
Once upon a time the would-be traveller could call the Foreign Office and be advised of what precautions should be taken on the medical front but now you traverse a cliff of links and conclude by signing up for some kind of on-line consultation with a private health care company who, within 3 days, repeat the exercise by telephone. As a result the traveller, in a most un-Livingstone manner found himself at a major dispensary in the city.
Seated in a consulting room with the charming young pharmacist the procedures (one Hep A injection one Yellow Fever jab and the purchase of sufficient antimalerials) should have been straightforward. Twenty minutes later and benefitting from some unsolicited but welcomed advice Mina had logged onto the system and located the record of the telephone consultation.
"Ah, yellow fever vaccination and Hepatitis A," she said from behind her khimar. She reached for the refrigerator and extracted a small box. Without pause she raided a box labelled "for insulin only" and produced a needle better suited to darning a giant's socks or knitting a jumper. The box on the desk was clearly labelled as Yellow Fever and this triggered a distant memory which included the word subcutaneous. Now there are those who have called the would-be vacinee "thick skinned" but this doesn't qualify him for a 50mm needle to deliver a subcutaneous dose.
"Is there not a syringe and needle in the pack?" The size of the pack indicated that this would be the case - either that or the volume of vaccine was prodigious.
The pack was opened and Mina discovered the requisite equipment including the appropriate 12mm needle and a dedicated syringe.
"Where would you like the injection?"
"My left arm please."
The sleeve rolling caused some alarm with a proto-disagreement about how high it should be rolled. The awful fear that shirt removal might be required.
"Do you have any problems with injections?"
"Not so far."
"Do you understand the risks?"
"Yes, thank you."
"At your age the risk of a FLA-VIR reaction is considerably increased."
"Are you about to tell me about the 90% mortality rate?"
"We don't have to say that but," she glanced at the screen," it's true."
"Thank you."
Mina then proceeded to list the adverse reactions that 10, 20 and 30% of recipients experience and very few seemed pleasant. Impotence is of little consequence at this time of life but severe, flu-like symptoms for 5-10 days were not on the wish list.
"Relax your arm - it makes it easier for me."
A naturally helpful chap feels obliged to assist but this is difficult when the shirt sleeve, grasped by the right hand is forming a tourniquet around the left arm. The shirt sleeve was released and both arms relaxed.
"Oh."
"Sorry."
"Please could you hold your sleeve again."
"Of course but my arm might not be so relaxed."
The training had not allowed for deviation from the script. Neither had it differentiated between subcutaneous, intramuscular and intravenous when relaxing might matter for the latter two, it would make scant difference with the former except in the most anorexic of arms.
Sleeve held, skin pinched and attenuated live vaccine delivered it was time for Hep A and the repeat of a familiar routine.
"Please roll up your right sleeve."
"Please can we stick to the same arm."
"It's not usual - what if you react to both?"
Once upon a time the would-be traveller could call the Foreign Office and be advised of what precautions should be taken on the medical front but now you traverse a cliff of links and conclude by signing up for some kind of on-line consultation with a private health care company who, within 3 days, repeat the exercise by telephone. As a result the traveller, in a most un-Livingstone manner found himself at a major dispensary in the city.
Seated in a consulting room with the charming young pharmacist the procedures (one Hep A injection one Yellow Fever jab and the purchase of sufficient antimalerials) should have been straightforward. Twenty minutes later and benefitting from some unsolicited but welcomed advice Mina had logged onto the system and located the record of the telephone consultation.
"Ah, yellow fever vaccination and Hepatitis A," she said from behind her khimar. She reached for the refrigerator and extracted a small box. Without pause she raided a box labelled "for insulin only" and produced a needle better suited to darning a giant's socks or knitting a jumper. The box on the desk was clearly labelled as Yellow Fever and this triggered a distant memory which included the word subcutaneous. Now there are those who have called the would-be vacinee "thick skinned" but this doesn't qualify him for a 50mm needle to deliver a subcutaneous dose.
"Is there not a syringe and needle in the pack?" The size of the pack indicated that this would be the case - either that or the volume of vaccine was prodigious.
The pack was opened and Mina discovered the requisite equipment including the appropriate 12mm needle and a dedicated syringe.
"Where would you like the injection?"
"My left arm please."
The sleeve rolling caused some alarm with a proto-disagreement about how high it should be rolled. The awful fear that shirt removal might be required.
"Do you have any problems with injections?"
"Not so far."
"Do you understand the risks?"
"Yes, thank you."
"At your age the risk of a FLA-VIR reaction is considerably increased."
"Are you about to tell me about the 90% mortality rate?"
"We don't have to say that but," she glanced at the screen," it's true."
"Thank you."
Mina then proceeded to list the adverse reactions that 10, 20 and 30% of recipients experience and very few seemed pleasant. Impotence is of little consequence at this time of life but severe, flu-like symptoms for 5-10 days were not on the wish list.
"Relax your arm - it makes it easier for me."
A naturally helpful chap feels obliged to assist but this is difficult when the shirt sleeve, grasped by the right hand is forming a tourniquet around the left arm. The shirt sleeve was released and both arms relaxed.
"Oh."
"Sorry."
"Please could you hold your sleeve again."
"Of course but my arm might not be so relaxed."
The training had not allowed for deviation from the script. Neither had it differentiated between subcutaneous, intramuscular and intravenous when relaxing might matter for the latter two, it would make scant difference with the former except in the most anorexic of arms.
Sleeve held, skin pinched and attenuated live vaccine delivered it was time for Hep A and the repeat of a familiar routine.
"Please roll up your right sleeve."
"Please can we stick to the same arm."
"It's not usual - what if you react to both?"
"Then using both arms will result in being armless - at least this way the odds are that if an arm reacts
my dominant arm will remain active."
She reached for the diabetic syringes and needles once more.
"Methinks you'll once more find a syringe and needle in the pack."
Shuffling and opening of an over-chilled box.
"Oh yes."
Hep A is intramuscular and does, indeed, benefit from relaxed muscles but this was going to be difficult to contrive.
"If you don't want this in your right arm you could have it in your thigh or buttock."
It is odd that risks to the deltoid muscle pale into insignificance against the levels of exposure being proposed.
"No, really, it's fine in the left arm with the Yellow Fever."
"If you're sure."
There are so many ways of being sarcastic, at best, and patronising at worst but Mina was charming, well meaning, hopeless and deserved neither.
"Yes, I'm sure, thank you."
How strange to be thanking the torturer, especially one so inexperienced but there was the compensation that nothing intravenous was proposed and so no anxious watching for the assassin's air bubble.
The injection over, it was time for the paperwork.
"Just need to complete the Yellow Fever Carte Internationale for you. Please call for me if you start to feel unwell - any restriction of the throat, swelling or shortness of breath."
The irony was lost like a stifled cry for help through a restricted throat across a busy shop.
Time passes slowly when you are waiting for paperwork or anaphylaxis. There was some reading matter - the advice leaflet that had been discarded, not passed to the innoculee.
"Headache, myalgia and low-grade fever. These are common - they can occur in 10-30% of those vaccinated . . . encephalitis and, of course: neurotropic disease (YEL-AND) that starts with a fever and headache and then progresses to include one or more of confusion, focal neurological deficits, coma and Guillain-Barré syndrome." Failing this it seems that there is viscerotropic disease (YEL-AVD) "which progresses to hepatitis and multi-organ failure, like wild-type yellow fever. It also has similarly high fatality rates." Perhaps a light novel would have been a sensible thing to have taken to the appointment.
Mina returned empty-handed - no Carte Internationale.
"I'm sorry but my handwriting was too big for the card but that won't effect the immunisation of course."
"The card is rather important. They will not allow me to enter Barbados without it as my passport will show a recent visit to Brazil."
"Ah. Well I could ask my colleague to fill in the details but she isn't registered or trained in Yellow Fever vaccination."
"Maybe she could fill in the details and you could sign it?"
"That's a good idea. Wait here and remember to call if you . . . "
". . . feel constriction in the throat, breathless, nauseous or dizzy?"
"Are you a medical man?" she asked nervously.
"No, it's just that age hasn't seen off my short term memory yet. I'll be fine: if anaphylaxis was going to happen it would have set in by now."
"Really?"
"Yes, it's fairly immediate in most cases."
"I'll be back soon with your card."
"Thank you."
It was only 15 minutes, and with nothing else to do this was of no consequence, before Mina returned with a meticulously completed Carte Internationale. The handwriting was precise and tiny, carefully poised on the lines and, where necessary neatly centred in the boxes. Below it was a Jackson Pollock of a signature.
"Please come around to the counter to pay," asked Mina.
With a broad gesture towards the computer screen, "please can we resolve the malarial chemoprophylaxis first?"
She reached for the diabetic syringes and needles once more.
"Methinks you'll once more find a syringe and needle in the pack."
Shuffling and opening of an over-chilled box.
"Oh yes."
Hep A is intramuscular and does, indeed, benefit from relaxed muscles but this was going to be difficult to contrive.
"If you don't want this in your right arm you could have it in your thigh or buttock."
It is odd that risks to the deltoid muscle pale into insignificance against the levels of exposure being proposed.
"No, really, it's fine in the left arm with the Yellow Fever."
"If you're sure."
There are so many ways of being sarcastic, at best, and patronising at worst but Mina was charming, well meaning, hopeless and deserved neither.
"Yes, I'm sure, thank you."
How strange to be thanking the torturer, especially one so inexperienced but there was the compensation that nothing intravenous was proposed and so no anxious watching for the assassin's air bubble.
The injection over, it was time for the paperwork.
"Just need to complete the Yellow Fever Carte Internationale for you. Please call for me if you start to feel unwell - any restriction of the throat, swelling or shortness of breath."
The irony was lost like a stifled cry for help through a restricted throat across a busy shop.
Time passes slowly when you are waiting for paperwork or anaphylaxis. There was some reading matter - the advice leaflet that had been discarded, not passed to the innoculee.
"Headache, myalgia and low-grade fever. These are common - they can occur in 10-30% of those vaccinated . . . encephalitis and, of course: neurotropic disease (YEL-AND) that starts with a fever and headache and then progresses to include one or more of confusion, focal neurological deficits, coma and Guillain-Barré syndrome." Failing this it seems that there is viscerotropic disease (YEL-AVD) "which progresses to hepatitis and multi-organ failure, like wild-type yellow fever. It also has similarly high fatality rates." Perhaps a light novel would have been a sensible thing to have taken to the appointment.
Mina returned empty-handed - no Carte Internationale.
"I'm sorry but my handwriting was too big for the card but that won't effect the immunisation of course."
"The card is rather important. They will not allow me to enter Barbados without it as my passport will show a recent visit to Brazil."
"Ah. Well I could ask my colleague to fill in the details but she isn't registered or trained in Yellow Fever vaccination."
"Maybe she could fill in the details and you could sign it?"
"That's a good idea. Wait here and remember to call if you . . . "
". . . feel constriction in the throat, breathless, nauseous or dizzy?"
"Are you a medical man?" she asked nervously.
"No, it's just that age hasn't seen off my short term memory yet. I'll be fine: if anaphylaxis was going to happen it would have set in by now."
"Really?"
"Yes, it's fairly immediate in most cases."
"I'll be back soon with your card."
"Thank you."
It was only 15 minutes, and with nothing else to do this was of no consequence, before Mina returned with a meticulously completed Carte Internationale. The handwriting was precise and tiny, carefully poised on the lines and, where necessary neatly centred in the boxes. Below it was a Jackson Pollock of a signature.
"Please come around to the counter to pay," asked Mina.
With a broad gesture towards the computer screen, "please can we resolve the malarial chemoprophylaxis first?"
"Oh yes, sorry. How many days will you be in an malaria zone?"
"About 12."
"Well we can offer you mefloquine or chloroquine."
"Sorry but the first is incompatible with my other medication and Brazil is chloroquine resistant." "Pardon. Are you sure you're not medical?"
"Absolutely. Do you have Malarone?"
"Yes, but it's very expensive."
"Not if it works and, for me, the cheaper options won't."
"Well if you're sure, how many days will you be in an affected area?"
"Twelve to fourteen."
"Then you will need ......" there was a pause while Mina attempted to log back onto the computer. "Sorry, this won't take a minute."
How right she was: at least 2 or 3 minutes were required to discover that the answer would be 23. "You will need 23 tablets. You start taking them two days before entering an endemic area and continue for 7 days after you leave."
"That's fine, thank you."
"I'll just go and collect a few other bits and pieces from the shelves and see you at the till with my Malarone."
"It will take five minutes."
"That's fine, thank you."
Close to the pharmacy there was a stand of travel accessories and medicines. Now there is something terrifically ironic about an entomologist searching those shelves for a chemical to repel the objects of his affection.
There is only one really dependable insect repellent, namely diethyl-meta-toluamine or DEET to its friends. (There is another but it has a narrower spectrum and shorter active period). Why then does an apparently reputable pharmacy sell mumbo jumbo next to the real thing? Anyone going to a malaria region wearing nothing but their organic sandals, recycled cotton clothes and a smearing of bog myrtle can look forward to asking themselves the question, "Are these the symptoms of malaria?" The acronymic advice for preventing malaria is ABCD: Awareness, Bite prevention, Check and Diagnosis. Water that has been bottled on a ley line or in the middle of a crop circle will not inhibit a female mosquito. It might make you think that Scottish midges are less bothersome but it will not actually protect you from mosquito bites.
The 50% DEET was tucked between Jungle Juice and Mozzie Magic. Having selected an appropriate size it was time to settle the account. Mina was waiting at the pharmacy charge point.
Mina was waiting there and apologised for the size of the bill.
"You are welcome to stay in the consulting room until you are sure that there is no reaction."
"That's very kind but I'll make my way home now, thank you."
PIN number entered and payment made it was time to take the first prepared steps towards Amazonia - strange that they should be out onto the pavement of the bustling city.
"About 12."
"Well we can offer you mefloquine or chloroquine."
"Sorry but the first is incompatible with my other medication and Brazil is chloroquine resistant." "Pardon. Are you sure you're not medical?"
"Absolutely. Do you have Malarone?"
"Yes, but it's very expensive."
"Not if it works and, for me, the cheaper options won't."
"Well if you're sure, how many days will you be in an affected area?"
"Twelve to fourteen."
"Then you will need ......" there was a pause while Mina attempted to log back onto the computer. "Sorry, this won't take a minute."
How right she was: at least 2 or 3 minutes were required to discover that the answer would be 23. "You will need 23 tablets. You start taking them two days before entering an endemic area and continue for 7 days after you leave."
"That's fine, thank you."
"I'll just go and collect a few other bits and pieces from the shelves and see you at the till with my Malarone."
"It will take five minutes."
"That's fine, thank you."
Close to the pharmacy there was a stand of travel accessories and medicines. Now there is something terrifically ironic about an entomologist searching those shelves for a chemical to repel the objects of his affection.
There is only one really dependable insect repellent, namely diethyl-meta-toluamine or DEET to its friends. (There is another but it has a narrower spectrum and shorter active period). Why then does an apparently reputable pharmacy sell mumbo jumbo next to the real thing? Anyone going to a malaria region wearing nothing but their organic sandals, recycled cotton clothes and a smearing of bog myrtle can look forward to asking themselves the question, "Are these the symptoms of malaria?" The acronymic advice for preventing malaria is ABCD: Awareness, Bite prevention, Check and Diagnosis. Water that has been bottled on a ley line or in the middle of a crop circle will not inhibit a female mosquito. It might make you think that Scottish midges are less bothersome but it will not actually protect you from mosquito bites.
The 50% DEET was tucked between Jungle Juice and Mozzie Magic. Having selected an appropriate size it was time to settle the account. Mina was waiting at the pharmacy charge point.
Mina was waiting there and apologised for the size of the bill.
"You are welcome to stay in the consulting room until you are sure that there is no reaction."
"That's very kind but I'll make my way home now, thank you."
PIN number entered and payment made it was time to take the first prepared steps towards Amazonia - strange that they should be out onto the pavement of the bustling city.
No comments:
Post a Comment