SECOND OPINION | Foodborne Illness | APT | Full Episode


SECOND OPINION
EPISODE #904 FOODBORNE ILLNESS Announcer: MAJOR FUNDING
FOR “SECOND OPINION” IS PROVIDED BY THE BlueCross
AND BlueShield ASSOCIATION, AN ASSOCIATION OF INDEPENDENT, LOCALLY OPERATED,
AND COMMUNITY-BASED BLUE CROSS AND BLUE SHIELD COMPANIES.
FOR MORE THAN 80 YEARS, BLUE CROSS AND BLUE SHIELD COMPANIES
HAVE OFFERED HEALTH CARE COVERAGE IN EVERY ZIP CODE
ACROSS THE COUNTRY AND SUPPORTED PROGRAMS
THAT IMPROVE THE HEALTH AND WELLNESS
OF INDIVIDUAL MEMBERS AND THEIR COMMUNITIES.
THE BlueCross AND BlueShield ASSOCIATION’S MISSION IS
TO MAKE AFFORDABLE HEALTH CARE AVAILABLE TO ALL AMERICANS.
NEWS ABOUT OUR INNOVATIONS IS ONLINE AT BCBS.COM AND ON TWITTER
@BCBSAssociation. “SECOND OPINION” IS PRODUCED
IN ASSOCIATION WITH THE UNIVERSITY OF ROCHESTER MEDICAL CENTER,
ROCHESTER, NEW YORK. Salgo: WELCOME TO “SECOND OPINION,”
WHERE YOU GET TO SEE, FIRSTHAND, HOW SOME OF THE
COUNTRY’S LEADING HEALTH CARE PROFESSIONALS TACKLE HEALTH
ISSUES IMPORTANT TO YOU. I’M YOUR HOST, DR. PETER SALGO,
AND TODAY I’M HAPPY TO WELCOME FOOD SAFETY SPECIALIST
FROM NORTH CAROLINA STATE UNIVERSITY,
DR. BENJAMIN CHAPMAN. OUR “SECOND OPINION”
PRIMARY CARE PHYSICIAN, DR. LOU PAPA.
DR. MICHAEL APOSTOLAKOS FROM THE UNIVERSITY OF ROCHESTER
MEDICAL CENTER. DR. BARBARA MAHON FROM
THE CENTERS FOR DISEASE CONTROL AND PREVENTION.
AND ELIZABETH ARMSTRONG, WHO’S HERE TODAY TO SHARE HER PERSONAL
STORY — A STORY THAT OUR PANELISTS, ALONG WITH YOU AT
HOME, WILL BE HEARING FOR THE FIRST TIME.
THANK YOU SO MUCH FOR JOINING US, ELIZABETH.
NOW, I KNOW THIS IS NOT AN EASY STORY TO TELL, BUT TAKE US BACK
IN TIME JUST A LITTLE BIT. YOU’RE A MOTHER OF TWO.
LET’S GO BACK TO 2006, WHEN THIS ALL BEGINS.
HOW OLD WERE YOUR CHILDREN BACK THEN? Armstrong: 4 AND 2. Salgo: AND THEY WERE HEALTHY
AT THE TIME? Armstrong: THEY WERE PERFECTLY HEALTHY
LITTLE GIRLS. Salgo: AND WHAT KIND OF DIET
WERE THEY EATING? Armstrong: WE TRIED TO EAT VERY HEALTHY.
TRIED TO HAVE VERY LITTLE SUGAR, MOSTLY FRESH FRUITS
AND VEGETABLES. WE MADE A CONCERTED EFFORT
TO FEED THEM WELL. Salgo: BUT THEN SOMETHING
HAPPENED. WHAT HAPPENED? Armstrong: IT WAS SUNDAY DINNER, AND WE
MADE A FRESH SPINACH SALAD. NOT UNUSUAL — MY KIDS LIKED
SALAD, AND THEY ACTUALLY LIKED THE BABY SPINACH THAT I PUT IN
THE SALAD. Salgo: OKAY, NOW, BABY SPINACH,
THAT’S THE STUFF THAT COMES IN THE BAGS SOMETIMES? Armstrong: YES, I BOUGHT THE BAGGED,
PREWASHED, READY-TO-EAT SPINACH. Salgo:>>WHAT HAPPENED NEXT? Armstrong: ABOUT FOUR OR FIVE DAYS
LATER, MY OLDEST DAUGHTER, WHO WAS 4, STARTED HAVING A LOT OF
DIARRHEA. AND THAT LASTED FOR TWO OR THREE
DAYS, AND THAT’S WHEN WE WENT AND SAW HER PEDIATRICIAN TO FIND
OUT IF MAYBE SHE HAD A BUG. AND THE DOCTOR SAID THAT SHE
LOOKED FINE, IT WAS PROBABLY JUST VIRAL, JUST KEEP HER
HYDRATED. BUT SHE WANTED ME TO LET HER
KNOW IF I FOUND ANY BLOOD IN HER STOOL. Salgo: WHAT HAPPENED NEXT? Armstrong: ABOUT TWO OR THREE DAYS LATER,
SHE STARTED TO GET BETTER, SO WE THOUGHT WE WERE OUT OF THE
WOODS. BUT THEN OUR YOUNGEST DAUGHTER,
WHO WAS 2, STARTED EXHIBITING THE SAME SYMPTOMS. Salgo: THEN WHAT?
YOU TOLD THE DOCTOR? Armstrong: UM, WELL, WE KEPT AN EYE
ON HER. WE THOUGHT IT WAS JUST THE SAME
VIRUS THAT THE OLDER SISTER HAD. HER BEING 2 AND SHE WAS STILL IN
DIAPERS, WE WERE ABLE TO KEEP A BETTER EYE ON WHAT WAS GOING ON,
AND A COUPLE OF DAYS IN, WE DISCOVERED BLOOD IN HER STOOL. Salgo: ALL RIGHT, SO THIS IS WHAT
THE DOCTOR WARNED YOU ABOUT. AND YOU CALLED THE DOCTOR
AND SAID…? Armstrong: “WE FOUND BLOOD IN HER
DIAPER, AND SHOULD WE BE ALARMED?”
AND SHE JUST SAID TO BRING HER IN, JUST TO TAKE A LOOK AT HER. Salgo: AND SHE TOOK A LOOK AT HER? Armstrong: SHE TOOK A LOOK AT HER.
THE DIAPER WENT BACK TO THE LAB, WHERE THEY TOLD HER — THEY
TESTED IT AND FOUND OUT IT WAS BLOOD.
BUT THE DOCTOR WASN’T CONCERNED, AND SHE SAID THAT SHE THOUGHT MY
DAUGHTER MIGHT BE A LITTLE DEHYDRATED.
SO THAT’S WHAT SHE WAS WORRIED ABOUT, AND SO SHE SENT US TO THE
HOSPITAL JUST TO GET AN I.V. TREATMENT. Salgo: ALL RIGHT. LOU, YOU’VE
HEARD THIS STORY. BLOOD IN THE STOOL.
WHAT’S WRONG WITH ELIZABETH’S KIDS? Papa: WELL, I MEAN, ONE OF THE
THINGS YOU THINK ABOUT WHEN YOU HAVE DIARRHEA IS, IT’S USUALLY
AN INFECTIOUS CAUSE, ESPECIALLY AMONG SIBLINGS.
SO THAT SEEMED PRETTY REASONABLE, BUT THE BLOOD IN THE
STOOL RAISES A LITTLE BIT MORE CONCERN — THAT’S NOT SOMETHING
YOU EXPECT TO SEE, ESPECIALLY IF, ON EXAMINATION, THERE’S NO
OBVIOUS CAUSE FROM IT, LIKE, WITH THE DIARRHEA, THE BACKSIDE
KIND OF GETS RAW, AND SOME PEOPLE GET SPLITTING OF THE SKIN
AND BLEEDING FROM THE SKIN ITSELF. Salgo: SO, BASICALLY, YOU’RE LOOKING
AT THE COMMON STUFF FIRST. Papa: RIGHT. Salgo: BUT HER PEDIATRICIAN SAID,
“WATCH OUT FOR BLOOD.” Papa: RIGHT. Salgo: AND SHE FOUND BLOOD.
OKAY, SO, DOES THAT CONCERN YOU AT ALL? Papa: IT DOES, BECAUSE THERE ARE
SOME PATHOGENS THAT CAN CAUSE BLOODY DIARRHEA, A NUMBER OF
DIFFERENT PATHOGENS, THAT CAN BE INFECTIOUS IN THE COMMUNITY OR
INFECTIOUS FOODBORNE ILLNESSES THAT CAN BE VERY SERIOUS. Salgo: OKAY, WHAT’S GOING THROUGH
YOUR MIND? Papa: WELL, ONE OF THE THINGS I
WORRY ABOUT IS, IF IT’S ONE OF THESE CONDITIONS THAT CAUSES
BLOODY DIARRHEA, THAT THE PEOPLE, INDIVIDUALS, ESPECIALLY
SMALL CHILDREN AND THE ELDERLY, CAN GET SICK VERY QUICKLY
AND CAN CAUSE SERIOUS ORGAN COMPLICATIONS, SO THEY HAVE TO
BE WATCHED CLOSELY. Salgo: SO YOU’RE IN THE
PEDIATRICIAN’S OFFICE, THEY WANT TO TAKE HER
TO THE HOSPITAL? Armstrong: MM-HMM. Salgo: AND THEY WANT TO GIVE HER
SOME FLUID. HOW ARE YOU DOING,
AT THIS POINT? Armstrong: A LITTLE CONCERNED.
MY BIGGEST CONCERN WAS, MY NORMAL, HEALTHY, RAMBUNCTIOUS
2-YEAR-OLD WAS JUST VERY LETHARGIC, AND SO WE WERE
HAVING TO CARRY HER AROUND, AND THAT WAS JUST UNUSUAL.
SO IT’S A LITTLE DISCONCERTING TO KNOW THAT YOU HAVE TO GO TO
THE HOSPITAL TO GET AN I.V. Salgo: OKAY, SO SHE GOES
TO THE HOSPITAL. THEY PUT AN I.V. IN.
I’M GUESSING THEY ALSO WANTED TO CHECK HER URINE OUTPUT.
DID THEY PUT A CATHETER IN? Armstrong: MM-HMM, AND SHE WAS NOT
ACTING LIKE HERSELF, AND — SHE STARTED ACTING MORE AND
MORE DIFFERENT, THE LONGER WE WERE IN THE HOSPITAL. Salgo: OKAY.
PANEL, WHAT’S GOING ON WITH — IT’S ASHLEY, RIGHT,
YOUR LITTLE DAUGHTER? Armstrong: ASHLEY. Salgo: WHAT’S GOING ON WITH ASHLEY?
ANYBODY HAVE AN IDEA? Apostolakos: WELL, WHAT I WORRY ABOUT IN
CHILDREN ESPECIALLY IS, THEY HAVE LESS FLUID VOLUME TO LOSE,
SO THEY GET SYMPTOMATIC MUCH EARLIER WITH FLUID LOSS
THAN AN ADULT. AND THE BLOOD —
IN AN ADULT, THERE’S A LOT OF DIFFERENT INFLAMMATORY AND OTHER
DISEASES, BUT BLOOD IN THE STOOL OF A CHILD, I’D BE THINKING
VERY HIGH OF INFECTION. AND WITH THE MENTAL STATUS
CHANGES, IT SUGGESTS TO ME EITHER SHE’S REALLY SICK FROM
THE INFECTION OR DEHYDRATED AND NOT GETTING ENOUGH BLOOD FLOW
TO THE BRAIN. Mahon: AS A PUBLIC HEALTH
PERSON, I’M JUST HOPING THAT A STOOL CULTURE IS
ABOUT TO BE DONE TO FIND OUT WHAT THE PATHOGEN IS, ‘CAUSE I’D
BE VERY CONCERNED THAT THIS IS AN INFECTIOUS CAUSE, AND THAT A
STOOL CULTURE WOULD BE NEEDED TO GET THE DIAGNOSIS. Salgo: ALL RIGHT, SO THEY
START HER ON AN I.V. AND THE HOPE WAS THAT IF SHE’S
JUST DEHYDRATED, SOME OF THIS MENTAL STATUS CHANGE IS BECAUSE
HER BLOOD PRESSURE MIGHT BE LOW, SHE NEEDS TO RE-EXPAND A BIT.
DID SHE GET BETTER? Armstrong: NO, SHE GOT MUCH, MUCH WORSE.
Salgo: OH. TELL ME ABOUT THAT. Armstrong: WELL, AS A 2-YEAR-OLD IN A
HOSPITAL BED, THEY’RE IN A CRIB, AND SO THAT SHE WOULDN’T FALL
OUT AND HURT HERSELF, THE BARS WERE UP.
AND MY SWEET LITTLE 2-YEAR-OLD IS GRABBING THE BARS OF THE
CAGES, AND JUST NOT HERSELF, SCREAMING, VERY AGITATED,
WOULDN’T LET US COME NEAR HER OR COMFORT HER.
DIDN’T EVEN WANT US TO LOOK AT HER.
AND SHE’S STARTING TO VOMIT, AND THE VOMIT IS GETTING DARKER AND
DARKER. Salgo: SO YOU’VE GOT DARK — IS IT BLACK-COLORED? Armstrong: IT EVENTUALLY GOT BLACK. Salgo: ALL RIGHT, DOES THAT TIP
ANYBODY TO ANY DIAGNOSIS YOU WANT TO EXPLORE? Papa: IT SUGGESTS TO ME THAT THAT’S
BLOOD THAT’S COMING UP NOW, DIGESTED BLOOD THAT SHE’S
VOMITING UP, THAT THE BLEEDING IS BECOMING MORE EXTENSIVE. Salgo: OKAY, SO WE HAVE
A 2-YEAR-OLD CHILD WITH BLOODY DIARRHEA IN THE
HOSPITAL WITH A CATHETER, WITH A MENTAL STATUS CHANGE,
AND NOW DARK VOMITUS. WHAT’S GOING ON?
ANYBODY HAVE AN IDEA? Apostolakos: WELL, I’M CONCERNED —
THERE ARE CERTAIN BACTERIA THAT RELEASE TOXINS,
SHIGA TOXIN, ESPECIALLY, IN CHILDREN, THAT CAN LEAD TO
PROFOUND SYSTEMIC EFFECTS, TOTAL-BODY EFFECTS, WITH
PLATELET COUNTS DROPPING, BLOOD CELLS HEMOLYZING,
CHILDREN GETTING QUITE SICK, AND BLEEDING. Salgo: ALL RIGHT, LET ME
TRANSLATE A LITTLE BIT. YOU’RE WORRIED ABOUT A TOXIN.
NOW, SOME BACTERIA MAKE YOU SICK BECAUSE THEY GET IN THE BLOOD,
AND THE BACTERIA THEMSELVES DO BAD THINGS.
SOME BACTERIA CAN MAKE YOU SICK BECAUSE THEY EXCRETE, IF YOU
WILL, A POISON, A TOXIN. Apostolakos: CORRECT. Salgo: AND SOME OF THESE TOXINS CAN
BE REALLY DANGEROUS. Apostolakos: CORRECT. Salgo: AND DO THINGS LIKE TRASH THE
ELEMENTS OF YOUR BLOOD THAT ALLOW YOU TO CLOT, LIKE YOUR
PLATELETS, AND MAKE THEM GO AWAY.
THEY CAN TRASH YOUR RED BLOOD CELLS, SO YOU CAN’T MOVE ENOUGH
OXYGEN AROUND THE BODY TO SUSTAIN LIFE.
THIS IS A BAD SITUATION. WHAT HAPPENED NEXT? Armstrong: I GOT A CALL FROM OUR
PEDIATRICIAN, WHO TOLD ME SHE WAS GOING INTO RENAL FAILURE
AND THEY NEEDED TO LIFELINE HER DOWN TO THE CHILDREN’S HOSPITAL. Salgo: WHAT WAS THAT LIKE?
SHE WENT IN AN AMBULANCE? TELL ME ABOUT THAT. Armstrong: SHE DID.
THEY WHEELED IN THE AMBULANCE, AND THEY STRAPPED MY LITTLE TINY
2-YEAR-OLD TO THIS BIG GURNEY. AND WE ASKED IF WE COULD COME IN
THE AMBULANCE, BUT THEY EXPLAINED THAT THERE’S JUST TOO
MANY DOCTORS AND TOO MANY MACHINES IN THERE TO KEEP HER
ALIVE FOR US TO COME IN THE AMBULANCE WITH HER.
AND SO WE HAD TO FOLLOW THE AMBULANCE DOWN TO THE HOSPITAL. Salgo: OH, MY GOSH.
WHAT DID THAT FEEL LIKE? Armstrong; WORDS DON’T REALLY DO IT
JUSTICE. I MEAN, YOU’RE JUST,
YOU’RE TERRIFIED. Salgo: WHEN DID YOU FIND OUT WHAT
WAS WRONG WITH ASHLEY? AND WHAT DID THEY TELL YOU? Armstrong: WHEN WE GOT TO THE EMERGENCY
ROOM AT THE CHILDREN’S HOSPITAL, THE RECEIVING PHYSICIAN TOLD US
THAT SHE HAD HEMOLYTIC UREMIC SYNDROME, AND THE MOST COMMON
CAUSE OF THAT IS E. COLI. Salgo: OKAY. WHAT’S E. COLI? Apostolakos: E. COLI IS A BACTERIA THAT A
LOT OF US HAVE IN OUR GASTROINTESTINAL TRACT, BUT
THERE ARE CERTAIN STRAINS THAT ARE PATHOGENIC AND CAUSE
DISEASE, AND SOME OF THEM MORE SERIOUS THAN OTHERS. Salgo: HOW BAD CAN
E. COLI BE? Mahon: WELL, IT CAN BE
VERY BAD. ONE OF THE WORST IS THE
SHIGA TOXIN-PRODUCING E. COLIS. Salgo: SHIGA TOXIN IS
A POISON, A TOXIN THAT SOME E. COLI CHURN OUT. Mahon: MM-HMM. THE SHIGA
TOXIN-PRODUCING E. COLI, THE BAD ONES, CAN CAUSE SEVERE KIDNEY
FAILURE, THE HEMOLYTIC UREMIC SYNDROME, AND DEATH.
AND THE YOUNGER THE CHILD IS, THE MORE LIKELY THEY ARE TO GET
HEMOLYTIC UREMIC SYNDROME IF THEY HAVE IT. Salgo: BUT THIS IS A 2-YEAR-OLD
GIRL, A 2-YEAR-OLD GIRL, WHO HAD A MEAL OF SEVERAL DAYS BEFORE,
WASHED RAW VEGETABLES. SPINACH, RIGHT?
AND SUDDENLY, WITHIN HOURS, IT SEEMS, SHE’S AT DEATH’S DOOR.
HOW DOES THIS HAPPEN? Papa: WELL, INFECTIOUS AGENTS HAVE
A BILLION-YEAR HEAD START ON US, SO THEY’VE BEEN AROUND A LONG
TIME, AND OUR SOCIETY IS MASS-PRODUCING FOOD, SO THERE’S
A LOT MORE HANDS THAT ARE COMING IN CONTACT WITH THAT FOOD.
SO THERE’S A GREATER CHANCE FOR SPREADING FOODBORNE DISEASE.
AND THEY USUALLY COME ON PRETTY QUICKLY, AND A LOT OF PEOPLE GET
SICK — THEY GET DIARRHEA — AND THEY GET BETTER.
THE VAST MAJORITY. YOU KNOW, IT HAPPENS
TO ALL OF US. Salgo: THAT’S WHAT HAPPENED TO YOUR
4-YEAR-OLD DAUGHTER. Armstrong: MM-HMM. Salgo: RIGHT?
AND IT WAS LIKE, WHAT, THE 4-YEAR-OLD DAUGHTER GOT SICK HOW
MANY DAYS AFTER EATING? Armstrong: ABOUT FOUR OR FIVE. Salgo: AND THEN YOUR LITTLE
2-YEAR-OLD SEVERAL DAYS THERE– IT’S A LONG TIME OUT.
WHAT’S GOING ON THERE? Mahon: WELL, DIFFERENT
SORTS OF BACTERIA HAVE INCUBATION PERIODS — THE TIME
BETWEEN THE TIME WHEN YOU EAT IT AND THE TIME WHEN YOU GET
SICK — OF DIFFERENT LENGTHS. SO, FOR SOME OF THE SORT OF
WHAT WE CLASSICALLY THINK OF AS FOOD POISONING, YOU EAT THE BAD
STUFF, AND YOU’RE VOMITING TWO OR THREE HOURS LATER — THAT’S
JUST A TOXIN, SHORT-ACTING TOXIN, VERY SHORT INCUBATION
PERIOD. BUT IN A SITUATION LIKE
E. COLI, THERE’S A WHOLE SERIES OF EVENTS THAT ARE GOING ON
INSIDE THE PERSON, WHERE, YOU KNOW, THE PATHOGEN GROWS,
IT ATTACHES TO THE INTESTINES, IT MAKES THE TOXIN, THE TOXIN
ENTERS THE BLOODSTREAM, IT TAKES TIME FOR IT TO ACT.
SO YOU CAN SEE INCUBATION PERIODS THAT ARE A LOT LONGER
THAN JUST A FEW HOURS. Salgo: WE HAVE A QUESTION
FROM TWITTER. KRISTEN, I BELIEVE, ASKS US,
WHY WAS IT THAT THE TWO CHILDREN GOT SICK, BUT YOU
DIDN’T GET SICK, AND YOUR HUSBAND DIDN’T GET SICK?
YOU ALL ATE THE SAME FOOD. I’M ASSUMING YOU ATE A LITTLE
BIT MORE THAN THE KIDS DID. HOW DO YOU EXPLAIN THAT?
GOOD QUESTION. Papa: I THINK IT WOULD BE NICE TO
UNDERSTAND THAT. THAT’S TRUE WITH MOST INFECTIOUS
AGENTS. WHY WOULD SOMEBODY GET
PNEUMONIA IN THE HOUSEHOLD, GET A SINUS INFECTION, RESPIRATORY
TRACT INFECTION, AND OTHERS DON’T?
YOUNG CHILDREN, OLDER FOLKS ARE MORE SUSCEPTIBLE FOR GETTING AN
INFECTION. Salgo: E. COLI — SPINACH
BOUGHT IN THE SUPERMARKET SHOULD BE SAFE, BUT WE’VE HEARD OVER
AND OVER ON THE NEWS, RIGHT, ABOUT FOODBORNE ILLNESSES, AND
E. COLI IS ALWAYS IN THIS MIX. Chapman: YEAH, E. COLI DEFINITELY
POPS UP A LOT OF THE TIME. IT’S THE ONE THAT I THINK
CREATES SOME VERY TRAGIC SITUATIONS, AS ELIZABETH SHARED.
WE SEE 48 MILLION CASES OF FOODBORNE ILLNESS EVERY YEAR
IN THE U.S. E. COLI MAKES UP A SUBSECTION
OF THAT GROUP, AND WHEN IT COMES TO FRESH FRUITS AND VEGETABLES,
IT’S NOT A SURPRISE THAT WE SEE CONTAMINATION.
IT’S NOT SO MUCH THAT THESE THINGS AREN’T SAFE, IT’S JUST
THE FACT THAT THEY’VE — THEY’RE RAW, THERE ISN’T A COOK STEP OR
A KILL STEP FOR THESE PRODUCTS, MAKES IT SO ANYTHING THAT’S COME
IN CONTACT WITH THEM COULD CONTAMINATE THEM.
IT PUTS A LOT OF ONUS OF THIS BACK ONTO THE PRODUCERS THAT
PRODUCE THIS FOOD TO MAKE SURE THAT THEY’RE DOING WHAT THEY CAN
TO MAKE SURE THERE ISN’T CONTAMINATION BEING ADDED TO IT,
BECAUSE THERE ISN’T ANYTHING THAT ELIZABETH COULD HAVE DONE
IN HER KITCHEN. I MEAN, YOU MENTIONED THAT IT
WAS A WASHED PRODUCT, AND IN FACT, OUR RECOMMENDATIONS ON
LOOKING AT FOODBORNE ILLNESS WOULD SAY, DON’T WASH THAT
AGAIN, ‘CAUSE YOU’RE AT A GREATER RISK OF CONTAMINATING IT
WITH SOMETHING THAT’S IN YOUR KITCHEN THAT’S ATTACHED TO THAT
LEAFY GREEN, AND YOU REALLY CAN’T DO ANYTHING ABOUT IT. Salgo: SO, WHAT DO YOU DO?
YOU’RE AT THE RECEIVING HOSPITAL, IN COMES LITTLE
ASHLEY, RIGHT, AND THEY’RE TELLING YOU, “MENTAL STATUS
CHANGE,” AND YOU MUST BE THINKING, “HEMOLYTIC UREMIC
SYNDROME.” Apostolakos: ABSOLUTELY. Salgo: WHAT DO YOU DO FOR IT? Apostolakos: WELL, THE BEST TREATMENT
WE HAVE IS PLASMAPHERESIS, WHERE IT’S SIMILAR TO DIALYSIS
BUT YOU EXCHANGE, FOR LACK OF A BETTER TERM, THE PLASMA OR BAD
HUMORS FOR NORMAL, FRESH-FROZEN PLASMA, WHICH IS
ESSENTIALLY THE SERUM, THE NON-RED CELLS IN HER BLOOD.
AND THAT HAS REALLY CHANGED THE COURSE OF THIS DISEASE. Salgo: WHAT DID THEY TELL YOU
WHEN ASHLEY GOT TO THE HOSPITAL? Armstrong: THE RECEIVING DOCTOR WAS
ACTUALLY A SPECIALIST IN HUS. AND HE SAID — WELL, THEY SAID,
THE PROBLEM WITH HUS IS YOU JUST ESSENTIALLY MANAGE SYMPTOMS.
THERE’S NO CURE FOR IT. AND SO THE ONLY THING THEY CAN
DO IS TRY AND KEEP HER ALIVE AND MANAGE THE SYMPTOMS.
AND HE SAID FOR HER, BECAUSE HER KIDNEYS HAD SHUT DOWN, THAT SHE
NEEDED PERITONEAL DIALYSIS. Salgo: I WANT TO PAUSE
FOR A MINUTE. I WANT TO SUM UP WHERE WE ARE,
AND THEN WE’LL KEEP GOING. E. COLI.
A DANGEROUS FOODBORNE PATHOGEN THAT CAN CAUSE SEVERE ILLNESS
AND EVEN DEATH. IF YOU ARE SICK AND YOU SUSPECT
A SERIOUS FOODBORNE ILLNESS, OF WHICH E. COLI IS ONLY ONE,
SEEK MEDICAL CARE RIGHT AWAY, BECAUSE DELAY CAN BE LETHAL.
SO, WE’RE TALKING WITH ELIZABETH AND YOU’RE SHARING YOUR STORY
ABOUT YOUR DAUGHTER, WHO BECAME DEATHLY ILL BECAUSE OF E. COLI.
WHILE YOU WERE IN THE HOSPITAL AND E. COLI WAS NOW RISING TO
THE SURFACE AS THE CAUSE OF ALL THIS TROUBLE,
WAS THE HEALTH DEPARTMENT INVOLVED? Armstrong: YEAH. WHEN THEY PUT US IN THE PICU,
THEY KIND OF QUARANTINED US, BUT I THINK IT WAS A FEW DAYS
LATER WHEN WE GOT A CALL FROM THE HEALTH DEPARTMENT. Salgo: AND WHAT DID THEY
ASK YOU? Armstrong: THEY JUST RAN THROUGH THEIR
LITANY OF QUESTIONS ON, “WHAT DID YOU EAT IN THE PAST,
YOU KNOW, WEEK OR TWO?” Salgo: DID THE CDC COME? Armstrong: NO. Salgo: WHEN DO THEY GET INVOLVED? Mahon: WELL, A LOT WAS GOING ON
BEHIND THE SCENES, I THINK, THAT ELIZABETH AND HER FAMILY
PROBABLY DIDN’T SEE AT THE TIME. SO, THE WAY WE DO SURVEILLANCE
FOR FOODBORNE OUTBREAKS IS BY GETTING REPORTS IN FROM DOCTORS
AND FROM LABORATORIES THAT HAVE TAKEN CARE OF PATIENTS THAT HAVE
DIAGNOSED THESE INFECTIONS. THEY REPORT THEM TO
THE HEALTH DEPARTMENT. FOR E. COLI, FOR SALMONELLA,
THEY ALSO SEND THE ACTUAL BACTERIA THAT WAS ISOLATED FOR
THE PATIENT TO THE HEALTH DEPARTMENT, AND THE STATE PUBLIC
HEALTH LABORATORY DOES SUBTYPING ON IT. Salgo: DID THE HEALTH DEPARTMENT
EVER COME TO YOU, DID THE CDC EVER COME TO YOU AND TELL YOU,
“THIS IS PART OF AN OUTBREAK,” THAT “WE’VE SEEN OTHER CASES”? Armstrong: NO, BUT WHEN YOU’RE IN
THE PICU, THERE’S NOTHING MUCH TO DO BUT WATCH TV, AND THAT’S
WHEN THE NEWS WAS BREAKING THAT THERE WAS AN E. COLI OUTBREAK IN
SPINACH. Salgo: SO YOU SAW IT ON TELEVISION? Armstrong: MM-HMM. Salgo: SHOULDN’T SOMEONE HAVE TALKED
TO HER? Mahon: WELL, WHEN THEY TALKED TO HER
AND FOUND OUT WHAT HER CHILD HAD EATEN, THAT WAS GATHERING THE
INFORMATION THAT WAS NEEDED TO DETERMINE WHAT THE CAUSE OF
THE OUTBREAK WAS, SO THAT THEY COULD INTERVENE TO STOP IT. Papa: AND I THINK THE PUBLIC
HEALTH OFFICIALS’ ROLES IS, THEY’RE NOT REALLY INVOLVED IN
HER CARE. IN TERMS OF WHAT CAUSED IT AND
WHAT THE TREATMENT PLAN, THAT’S PART OF HER CARE TEAM.
HER CHILD HAS BEEN EXPOSED. WE NEED TO GET THE WORD OUT SO
THE REST OF THE COMMUNITY KNOWS THAT THERE’S THIS OUTBREAK AND
THEY NEED TO AVOID THE POSSIBLE EXPOSING AGENT. Salgo: I UNDERSTAND
THAT, PRIOR TO YOUR DAUGHTER’S GETTING SICK, SOME OTHER
CHILDREN HAD GOTTEN SICK FROM SPINACH PURCHASED IN
THE GROCERY STORE AND THAT THERE WAS A HIGH
SUSPICION, IF NOT CERTAINTY, THAT THIS SPINACH WAS THE CAUSE
OF THE E. COLI. IS THAT TRUE, IN YOUR MIND? Armstrong: AS WE GOT FURTHER AND FURTHER
ALONG IN HER ILLNESS, AND MORE AND MORE RESEARCH WAS DONE,
YEAH, BY THE DATE THAT WE HAD BOUGHT THE SPINACH, THERE WERE
ALREADY CASES — YOU KNOW, WEEKS PRIOR.
SO, IF THE SPINACH WOULD HAVE BEEN PULLED BACK THEN, IF IT
WOULD HAVE BEEN IDENTIFIED AS AN OUTBREAK AND THE FDA WOULD
HAVE BEEN ALLOWED TO FORCE A RECALL BACK THEN,
THEN THE BAGGED SPINACH WOULD NOT HAVE BEEN ON THE SHELF
BY THE TIME WE BOUGHT IT. Salgo: CAN THE FDA FORCE A RECALL? Chapman: YES. Salgo: THEY CAN? Chapman: YEAH, THEY CAN,
AND BACK IN 2006 WHEN THIS HAPPENED, THEY DIDN’T HAVE THAT
LEGISLATIVE AUTHORITY TO DO THAT.
THAT’S PART OF MORE UPDATED RULES THAT PASSED SINCE THEN.
BUT WHAT THE FDA WAS ABLE TO DO AND HOW THAT INFORMATION GOT OUT
WAS THEY WERE ABLE TO PUT A HEALTH ADVISORY OUT,
WHICH IS — IT SOUNDS LIKE SEMANTICS BETWEEN
A RECALL AND A HEALTH ADVISORY, BUT WHEN PUBLIC HEALTH OFFICIALS
SAY, “DON’T EAT SPINACH FROM THIS PRODUCER OR THIS COMPANY,”
IT HAS A SIMILAR EFFECT ON THAT PRODUCT. Salgo: BUT IT PUTS THE ONUS
DIFFERENTLY, RIGHT? A RECALL PUTS THE ONUS ON
THE STORE. OR, IF YOU WILL, THE PRODUCER,
RIGHT? Chapman: RIGHT, BUT I THINK ONE THING
WE NEED TO POINT OUT HERE IS THAT, OFTEN WHEN THOSE HEALTH
ADVISORIES HAPPEN, THOSE STORES GO AHEAD AND RECALL THAT PRODUCT
THEMSELVES. Mahon: WITH THIS OUTBREAK, WHAT I
UNDERSTAND HAPPENED — I WASN’T THERE AT THE TIME —
WAS THAT, IN THE MORNING, THE REALIZATION HAPPENED
WITH THE PUBLIC HEALTH AGENCIES, CDC,
AND SEVERAL STATES THAT WERE INVOLVED, THAT IT LOOKED VERY
MUCH LIKE IT WAS SPINACH. AND THAT AFTERNOON, FDA MADE
AN ANNOUNCEMENT TO THE NATION THAT PEOPLE SHOULDN’T EAT
BAGGED SPINACH AT ALL. AND AT THAT POINT,
THE INFORMATION ABOUT WHAT BRAND, WHAT LOT, THAT WASN’T
AVAILABLE, SO THE ANNOUNCEMENT WENT OUT, “JUST DON’T EAT
BAGGED SPINACH.” Salgo: FROM YOUR PERSPECTIVE,
THOUGH, AND I THINK WE CAN UNDERSTAND WHERE YOU’RE COMING
FROM, YOUR DAUGHTER’S IN THE HOSPITAL, DEATHLY ILL,
LITERALLY LIFE AND DEATH, AND THE BAGGED SPINACH IS STILL
OUT THERE IN THE SUPERMARKET. Armstrong: YEAH. A FEW DAYS AFTER WE HAD
GOTTEN INTO THE PICU IS WHEN THE ANNOUNCEMENT WAS MADE BY
THE FDA AND THE SPINACH WAS RECALLED OFF THE SHELVES. Mahon: ONE OF THE DELAYS THAT PUBLIC
HEALTH DOESN’T HAVE A LOT OF CONTROL OVER
IS THE DELAY FROM, THE PERSON GETS SICK AND GOES TO THE DOCTOR
AND THAT STOOL SPECIMEN IS OBTAINED, AND IT TAKES A COUPLE
OF DAYS IN THE LABORATORY FOR THAT BACTERIA TO GROW. Salgo: THAT’S JUST BASIC
SCIENCE. Mahon: IT HAS TO BE SENT TO THE
STATE LABORATORY. THAT COULD BE ANOTHER DAY.
THE STATE LABORATORY HAS TO SUBTYPE IT.
THAT COULD BE ANOTHER SEVERAL DAYS.
AND THEN THAT INFORMATION IS SENT TO THIS NATIONAL
REPOSITORY, WHERE THE INFORMATION CAN BE COMPARED.
SO, YOU PUT ALL THAT TOGETHER, IT COULD BE EASILY A COUPLE
OF WEEKS. Salgo: YOU SAID SOMETHING
INTERESTING, AND I WANT TO REVISIT THIS.
THIS WAS, WHAT, TRIPLE-WASHED SPINACH?
THREE TIMES. IN A SEALED PLASTIC BAG.
NOW, IS THERE ANYTHING ELIZABETH COULD HAVE DONE
TO MAKE THIS ANY SAFER? SHOULD SHE HAVE WASHED IT?
AND I THINK I HEARD YOU SAY NO. IT WAS MORE DANGEROUS TO
WASH IT, PERHAPS, THAN NOT. Chapman: RIGHT, YEAH.
IN FACT, THAT’S THE SITUATION WITH THIS PRODUCT.
THE BACTERIA IN THE FIELD OR IN THE PROCESSING PLANT ATTACHES SO
WELL TO THAT ROUGH PART OF THE LEAFY GREEN LEAF OR IN
THE STOMATA, THAT THERE’S NOTHING THAT ELIZABETH COULD
HAVE DONE TO REDUCE RISK IN HER HOME.
IT REALLY COMES DOWN TO, WHAT THOSE GROWING PRACTICES WERE AND
WHAT THE PRODUCTION PRACTICES WERE.
WHAT WE DO KNOW IS THAT, IT’S PRETTY UNLIKELY THAT ANYBODY
COULD HAVE WASHED IT FURTHER. WHETHER IT’S INSIDE THE PLANT OR
REALLY ATTACHED HARD ON THE OUTSIDE OF THE PLANT, AT THIS
POINT WE’LL NEVER KNOW BECAUSE WE CAN’T GO BACK TO SEE THOSE
INDIVIDUALS, BUT THAT’S POSSIBLE.
IT’S ENTIRELY POSSIBLE THAT LEAFY GREENS CAN INTERNALIZE
E. COLI 0157:H7. Salgo: AND IN THIS PARTICULAR CASE,
THE E. COLI WAS TRACED ALL THE WAY BACK TO A FIELD WHICH
HAD BEEN USED FOR ANGUS CATTLE AND CONTAMINATED BY
THE CATTLE FECES. IS THAT WHAT I UNDERSTAND? Mahon: THERE WAS A FIELD
THAT HAD, AS YOU SAID, BEEN USED FOR CATTLE PREVIOUSLY.
THERE WERE CATTLE IN A FIELD NEARBY.
THE SAME STRAIN OF E. COLI WAS ACTUALLY ISOLATED FROM WILD PIGS
THAT WERE IN THAT AREA. I DON’T THINK WE KNOW EXACTLY
WHAT THE SOURCE WAS, BUT CERTAINLY THERE WERE PLENTY OF
OPPORTUNITIES IN THAT AREA FOR STUFF THAT WAS GROWING THERE TO
GET CONTAMINATED. Salgo: NOW, I DON’T WANT TO LEAVE
OUR VIEWERS WITH THE IMPRESSION THAT, “AH, DON’T BOTHER WASHING.
IT CAN’T COME OFF ANY MORE.” IN FACT, THERE ARE THINGS YOU DO
IN YOUR KITCHEN EVERY DAY, RIGHT, WHICH CAN PROTECT YOU IN
A VERY REAL SENSE FROM CONTAMINATED FOOD.
WHAT WOULD YOU SUGGEST? WHAT DO YOU TELL FOLKS WHO ASK
YOU ABOUT THAT? Papa: WELL, IT’S LIKE ANY
FOOD HANDLING, THAT, YOU KNOW, YOU USE CLEAN SURFACES,
YOU USE CLEAN HANDS. YOU KEEP YOUR MEAT AND YOUR
VEGETABLES SEPARATED. THOSE ARE ALL VERY IMPORTANT. Apostolakos: WASH YOUR HANDS. Salgo:
WASH YOUR HANDS. Apostolakos: WASH YOUR HANDS
OVER AND OVER AGAIN. IT’S IMPORTANT IN THE HOSPITAL.
IT’S IMPORTANT AT HOME. IT’S IMPORTANT WHEN YOU’RE
HANDLING FOOD. Mahon: THANK YOU. AND ESPECIALLY
AFTER TOUCHING ANY RAW MEAT. OR ANY RAW FOOD OF ANIMAL
ORIGIN. AND THE OTHER THING THAT’S ONE
OF MY PERSONAL FAVORITES IS TO KEEP FOODS THAT ARE SUPPOSED TO
BE REFRIGERATED, REFRIGERATED AT THE RIGHT TEMPERATURE.
A LOT OF PEOPLE’S REFRIGERATORS AREN’T AS COLD AS THEY SHOULD BE
AND A LOT OF PEOPLE LEAVE STUFF OUT, AND BACTERIA LOVE
WARMER TEMPERATURES. Salgo: THIS BEGS THE QUESTION, WHAT
TEMPERATURE SHOULD YOUR REFRIGERATOR BE AT? Chapman: YOU WANT TO KEEP THAT FRIDGE
AT 41 OR BELOW, REALLY, AND THAT’S GOING TO CURB THE GROWTH
OF MOST OF THOSE PATHOGENS. AND ONE OTHER THING THAT I’D
ADD IS, IF WE ARE COOKING FOODS OF ANIMAL ORIGIN, THAT YOU COOK
THEM TO A TEMPERATURE WHERE YOU’RE GOING TO KILL ANY OF
THOSE PATHOGENS IN THERE. AND THE BEST TOOL THAT I HAVE IN
MY HOME IS A MEAT THERMOMETER. I USE A DIGITAL MEAT THERMOMETER
FOR EVERYTHING SO I KNOW THAT I’M REDUCING RISK FOR MY FAMILY. Salgo: WHAT HAPPENED TO
ASHLEY? SHE’S GETTING DIALYSIS.
WHAT HAPPENED TO HER OVER THE NEXT FEW DAYS AND WEEKS? Armstrong: WE FOUND OUT THAT HER BRAIN HAD
SWELLED, AND THAT WAS WHAT WAS CAUSING SOME OF THE
BEHAVIOR PROBLEMS. SHE DEVELOPED PANCREATITIS. Salgo: OH, MY GOSH.
THE PANCREAS IS AN ORGAN IN YOUR ABDOMEN THAT DEALS WITH A LOT OF
FUNCTIONS, INCLUDING A LOT OF ENDOCRINE FUNCTIONS
LIKE INSULIN. THAT’S A NASTY COMPLICATION. Armstrong: YEAH. LUCKILY, AFTER SEVERAL
DAYS, THAT STARTED TO HEAL ITSELF.
THAT WAS FINE. WHAT THE DOCTORS WERE MOST
CONCERNED ABOUT WAS, SHE HAD NO URINE OUTPUT FOR WEEKS.
WE WERE ON 24-HOUR DIALYSIS FOR…
WELL, THE WHOLE TIME WE WERE IN THE PICU, SO SIX, SEVEN WEEKS?
AND THEN… ONCE HER LEVELS STARTED TO
BECOME A LITTLE BIT MORE NORMAL, WE WENT TO THE MANUAL DIALYSIS
EXCHANGES. AND WE WERE TRAINED ON HOW TO DO
THAT SO THAT WE COULD BRING HER HOME. Salgo: WE’VE HAD A LOT OF
INFORMATION OVER HERE, SO I WANT TO STOP AND SORT OF SUMMARIZE
WHAT’S GOING ON. WHILE FOODBORNE ILLNESS CANNOT
ALWAYS BE PREVENTED, IT’S ALWAYS A GOOD IDEA TO USE FOOD SAFETY
PRECAUTIONS, THE SIMPLE STUFF IN YOUR KITCHEN,
AND THESE INCLUDE THOROUGHLY WASHING FRUITS AND VEGETABLES,
COOKING FOODS AT THE RECOMMENDED TEMPERATURE.
IT DOES WORK, IT DOES WORK. EVEN IF SOMETIMES IT WON’T HELP,
IT’S GOING TO PREVENT THE VAST MAJORITY OF FOODBORNE ILLNESSES.
IS THAT FAIR? Mahon: WELL, IT PREVENTS THE VAST
MAJORITY THAT THE CONSUMER CAN PREVENT. Salgo: WELL, YOU’RE SIX YEARS OUT.
HOW IS ASHLEY DOING? Armstrong: SHE’S STABLE.
SHE HAS PERMANENT KIDNEY DAMAGE AS A RESULT OF THE E. COLI.
HER KIDNEYS ARE FUNCTIONING WELL ENOUGH THAT SHE DOESN’T HAVE TO
BE ON DIALYSIS, BUT THEY’RE FAR FROM NORMAL.
HER NEPHROLOGIST ESTIMATES THAT THEY’RE WORKING ABOUT 10%
TO 15%. Salgo: AFTER ALL OF THIS, WITH
EVERYTHING WE’VE HEARD, WITH ALL THE DISRUPTION THAT IT
CAUSED — IT ALMOST KILLED ONE OF YOUR DAUGHTERS —
ARE YOU ANGRY ABOUT ANY OF THIS? Armstrong: I WOULDN’T SAY I’M ANGRY, BUT
I WAS DEFINITELY NAIVE BEFORE. I ASSUMED THAT OUR FOOD WAS SAFE
AND I ASSUMED THAT IF IT WAS, ESPECIALLY, BEING SOLD IN
A GROCERY STORE, THAT STEPS HAD BEEN TAKEN TO MAKE SURE THAT
IT WAS SAFE. AND I REALIZED THAT THAT’S
NOT TRUE AND THAT WE ALL AS CONSUMERS HAVE TO BE OUR OWN
BEST ADVOCATES. AND SO, WE MAKE SURE THAT WE
GROW A LOT OF OUR FRESH FRUITS AND VEGETABLES AT HOME SO THAT
WE CAN KIND OF AT LEAST HAVE A SEMBLANCE OF CONTROL.
AND THEN WE DO A LOT AS A FAMILY TO ADVOCATE FOR BETTER
FOOD SAFETY PRACTICES. Salgo: I WISH YOU AND, ASHLEY, YOUR
ENTIRE FAMILY ALL THE BEST. THANK YOU SO MUCH FOR
JOINING US. IT WAS A TERRIFYING STORY AND
THANK YOU FOR SHARING IT. WELL, UNFORTUNATELY, WE ARE OUT
OF TIME, BUT I HOPE THAT YOU CONTINUE THE CONVERSATION ON
OUR WEB SITE. THERE, YOU ARE GOING TO FIND
THE ENTIRE VIDEO OF THIS SHOW AS WELL AS THE TRANSCRIPT
AND LINKS TO RESOURCES. THE ADDRESS IS
SecondOpinion-tv.org. THANKS FOR WATCHING.
I WANT TO THANK ALL OF YOU FOR BEING HERE.
THANK YOU ESPECIALLY FOR SHARING YOUR STORY.
I’M DR. PETER SALGO, AND I’LL SEE YOU NEXT TIME
FOR ANOTHER “SECOND OPINION.” Announcer: MAJOR FUNDING
FOR “SECOND OPINION” IS PROVIDED BY THE BlueCross
AND BlueShield ASSOCIATION, AN ASSOCIATION OF INDEPENDENT, LOCALLY OPERATED,
AND COMMUNITY-BASED BLUE CROSS AND BLUE SHIELD COMPANIES.
FOR MORE THAN 80 YEARS, BLUE CROSS AND BLUE SHIELD COMPANIES
HAVE OFFERED HEALTH CARE COVERAGE IN EVERY ZIP CODE
ACROSS THE COUNTRY AND SUPPORTED PROGRAMS
THAT IMPROVE THE HEALTH AND WELLNESS
OF INDIVIDUAL MEMBERS AND THEIR COMMUNITIES.
THE BlueCross AND BlueShield ASSOCIATION’S MISSION IS
TO MAKE AFFORDABLE HEALTH CARE AVAILABLE TO ALL AMERICANS.
NEWS ABOUT OUR INNOVATIONS IS ONLINE AT BCBS.COM AND ON TWITTER
@BCBSAssociation. “SECOND OPINION” IS PRODUCED
IN ASSOCIATION WITH THE UNIVERSITY OF ROCHESTER MEDICAL CENTER,
ROCHESTER, NEW YORK. -END-

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