"WAKE UP, HONEY. MOM FELL"
It was 2:30 a.m. and the words were coming from my wife Terry. Accustomed to composing myself at any hour, I found myself resistant to doing so now, probably because 1 was just getting used to being on vacation.
As a family physician, I never really leave work, even when I travel. I like that I don’t need technology and HMOs surrounding me to be useful, but I wouldn’t mind a few less intrusions at times, such as when I go with my family to the Caribbean. Later in the morning, I would have a conversation with Nora, a cheerful late-20s Winnipeg native. The inevitable topic of our professional lives would come up, which would lead to the tale of her gallstones, complete with recommendations from internists, surgeons, and herbalists. She did not have symptoms and she was therefore taking the herbal route. She would ask what I thought, and I would mention that one can take a bile acid by prescription that can help dissolve gallstones.
I don’t ever pretend to be an expert on herbs. Last year I sought out some helpful references about the ten most common herbs so that when one of my many patients who contribute to the multibillion-dollar herb industry asks me a question, 1 don’t look like a complete idiot, but that’s about as far as I get. Nora’s younger, taller, darker-haired, attractive companion Ronit would then ask me a few simple questions about her skin before I could close the impromptu breakfast-consultation session.
Two days earlier, my 16-month-old daughter Mia christened the interior of our near-new underpowered Daewoo rental car with the first of many vomiting eruptions. It took us 30 minutes and the entire bathroom paper towel supply of one local gas station to clean up that mess.
Now it was time for some night duty. Stumbling out of bed, I scooped a pair of shorts and a shirt off the floor, put them on, and pointed myself toward the fluorescent hall light, where I turned right into the adjoining room.
Muriel and Chuck, Terry’s mother and stepfather, had left their Florida home to accompany us on this vacation to the north coast of the Dominican Republic. They don’t enjoy travel in developing countries, but they adore their granddaughter and would do just about anything to spend time with her. Anything except, perhaps, volunteer to catch the stomach virus that had caused her such aggravation. Because we were traveling in a developing country, we had all thought that Mia might have ingested some local bacteria, but by this time, about 36 hours into her illness, 1 suspected that she had instead contracted an intestinal virus, perhaps from a fellow traveler during our flights to the Dominican.
Staphylococcus aureus, the common culprit in food poisoning from picnics when dairy products stay out a little too long, causes vomiting without diarrhea, which fit Mia’s illness well, but the symptoms tend not to last that long. The other usual suspects, E. coli, Campylobacter, Salmonella, Shigella, and Yersinia, cause diarrhea. Furthermore, none of the rest of us got sick when she did; she shared it with us later. This night was Muriel’s turn.
In my role as a family physician, it is not unusual for me to interrupt private moments. While making rounds at the hospital, I seem more often than not to stumble upon at least one telephone conversation, meal, bowel movement, or visit from a clergyman. So I am used to these awkward moments. But the prospect of walking in on my mother-in-law relieving herself gave me as much pause as it would have given anyone.
I entered Chuck and Muriel’s suite and noted the open doorway to the bedroom and bathroom. Rather than continue straight toward the door, I veered to the right and planted myself on the living room couch, deciding to wait for my wife to go ahead of me. Terry soothed our sick child for a few minutes before going in to get Muriel’s informed consent to have me see her. I prepared myself by getting a drink of water out of their kitchen refrigerator. After a couple of nervous cold gulps settled in my stomach, Terry summoned me. “You’d better go in. She’s holding a towel with a lot of blood on it.”
As I entered the bathroom, I noted several blighted drops of blood on the white floor to the left of me and about four feet directly in front of my mother-in-law. She sat upright on the commode, with her swollen nose emanating a dull blue-violet hue, more as though it were cold than injured, her eyes only partially open, her hands on her thighs, and her nightshirt hanging down over her knees almost halfway to her bare feet positioned next to each other flat on the floor. Her entire body trembled, and she was awake.
“I fell off the toilet and hit my nose on the floor,” she explained. She had gone to the bathroom already that night because of dry heaves, and now she had diarrhea.
“Can you breathe through your nose?” I asked and she nodded yes. It was obviously broken, but if a broken nose is not bleeding and the victim can breathe through it, the treatment is ice and reevaluation after the swelling goes down, usually about five days later. For now, I could ignore the plum in the center of her face.
Knowing that Muriel was prone to episodes of very low blood sugar (I had seen her have one before), I asked Chuck to go to the refrigerator to get the bottle of Pepsi that I remembered we had. Drinking proved to be difficult as Muriel’s level of consciousness waxed and waned, so Terry left to get her mother’s glucose tablets. Muriel chewed the hard tablets in bursts, much the way a dog chews a biscuit (I hope she doesn’t read this), rather than with the smoother rhythm she would have used if her state of alertness hadn’t been so unstable.
Her strength and lucidity returned enough to allow us, after 20 minutes, to help her off the commode and into bed. We began piecing together information to figure out what had brought this on. Chuck thought she had given herself too much insulin before dinner and he was probably right. Terry and I had left Mia with Chuck and Muriel at the hotel so we could go with other hotel guests, including our new friends from Winnipeg, to dine at an Indian restaurant nestled in the mountains above a small town just a few miles down the road from Cabarete. While we sat on mattresses in a tent and ate delicious food, our daughter was fussing and preventing Muriel from eating much of her room-service dinner. Muriel also wasn’t hungry. None of this would have mattered much except that Muriel’s blood sugar before dinner was high, a common sign of impending illness. Her doctor had given her a written “sliding scale” protocol to tell her how much insulin to give herself when her sugar reached certain levels, but she had misplaced the instructions. She had therefore guessed how much insulin to use, and she had decided on 12 units of regular insulin. Her blood-sugar level had measured in the low 200s, so this was a generous dose. Adding that to the fact that she did not eat a normal dinner made her vulnerable.
Even with all of that, though, she probably would have done all right except that she also took glyburide before dinner. Glyburide is a medication that causes the pancreas to secrete more insulin. Because she has adult-onset (Type II) diabetes, Muriel makes enough insulin, but her tissues resist its actions. There are four different classes of medications to help correct this relative-insulin deficiency if diet and exercise fail to do so. Several medicines help restore the body’s sensitivity to insulin, and Muriel would probably do better on one of these, as it would correct the abnormal physiology in her body and would not cause low blood sugar because she would not secrete extra insulin. The dose of injected insulin she gave herself before dinner probably lowered her blood sugar into the 60 to 70 range; the glyburide then finished the job of pushing her into real trouble.
We didn’t check her sugar until after we gave her glucose (we got it up into the 130s), but it was probably between 30 and 40. The lesson: she should not have taken her glyburide once she noticed that she didn’t have much of an appetite for supper, and she should have used more caution (a lower dose of insulin) when she discovered that she had lost her instructions. Variations in blood-sugar control are almost inevitable during vacations, but one has to err on the side of having higher sugars because these are not dangerous. Low sugars can cause serious neurological damage and even death.
To ensure her safety for the rest of the night, we gave Muriel some hard-boiled eggs, which one of the hotel workers was kind enough to fetch from the kitchen for us at 3:30 a.m., leftover cheese puffs, and some potato chips I bought from the hotel gift shop. The worker, a short Dominican fellow who looked to be about 45, came back with me from the gift shop into the room. He had an older relative with diabetes and believed this gave him the right to be our medical expert. “You should rub her feet,” he instructed in Spanish and began to demonstrate. Knowing that my mother-in-law was still alert enough to fear this level of courtesy, I repositioned myself between him and her toes and offered her more eggs and cheese puffs, i explained that what she really needed was food. A few minute, later, he left with the air of one who was not fully appreciated.
Muriel justified this sentiment the following morning. A Maine native who is therefore not accustomed to people of color, she blurted out the following soon after awakening "Was there a black man in my room last night?”
We made some simple adjustments in Muriel’s medications to prevent further hypoglycemic episodes, but the diarrheal illness weakened her for the rest of the trip. Terry’s bowels turned to water later that morning, by then it was obvious that our little wonder would be sharing her misery with all of us.
During the following morning’s conversation with Ronit, Nora, and their traveling companion Linda, I mentioned my family’s intestinal woes, and Linda volunteered to give us her loperamide, a generic Canadian version of the medicine known as Imodium in the United States, and I gratefully accepted, having left our own supply in the bathroom medicine cabinet back in California. The best over-the-counter drug for stopping the runs, loperamide works by slowing down the rampaging out-of-control contractions of our inflamed, swollen, and therefore irritable intestinal muscles, which send the food we eat careening down the winding coils from the stomach to the rectum too quickly to allow adequate food absorption and water resorption to occur. It fixes the mild cramping and brown watery diarrhea that the intestinal viruses cause, and in retrospect the relief it gave Terry was more than adequate compensation for my medical advice.
Loperamide is not the right drug to take for the more severe bacterial or parasitic intestinal diseases. These pathogens can invade the intestinal wall, causing bloody green stools (the green comes from the color of the white blood cells our body uses to fight infections), severe cramping and the sensation of having to have a bowel movement even when the rectum is empty, a symptom we call tenesmus. When this happens, it is not a good idea to slow down the bowels, as this promotes retention of the pathogen, when what you want is to get rid of it. Bismuth salicylate, better known as Pepto Bismol, is the best over-the-counter choice in this situation because the salicylate calms down the severe bowel inflammation and the bismuth has some antibiotic (germ-killing) capability. So having bismuth salicylate and loperamide in the travel bag is a pretty good armament against traveler’s diarrhea.
Chuck and I developed milder symptoms over the next couple of days. Mia didn’t stop vomiting until we returned to the mainland the following week. I’m thinking it would be a lot less work to spend the rest of our vacations in Idaho.