My apologies to George Santayana.
Of course cantaloupes and salmonella are fresh on our minds, as the CDC reports a total of 178 persons infected with the outbreak strain of Salmonella Typhimurium have been reported from 21 states. 62 ill persons have been hospitalized and two deaths have been reported in Kentucky.
And, of course who could forget (we apparently did) the CDC’s report on one of the deadliest foodborne outbreaks in US history. Just last year a total of 147 persons infected with any of the five outbreak-associated subtypes of Listeria monocytogenes were reported from 28 states. 99% were hospitalized and Thirty-three outbreak-associated deaths were reported. Ten deaths not attributed to listeriosis occurred among persons who had been infected with an outbreak-associated subtype. Seven of the illnesses were related to a pregnancy; three were diagnosed in newborns and four were diagnosed in pregnant women. One miscarriage was reported.
Although not as large as our more recent failures to learn from history, cantaloupe related outbreaks have occurred in the past and have had just as personal results.
Viva Brand/Shipley Sales Cantaloupes 2001
An outbreak of Salmonella Poona occurred among persons who had eaten Viva brand cantaloupe imported from Mexico; the outbreak was first discovered in California. Cantaloupes were purchased whole and pre-cut. Shipley Sales, the US importer of the cantaloupes, could not provide proper Mexican documentation for inspection when requested by the U.S. Food and Drug Administration. The owners of the company were subsequently indicted for submitting false invoices and misrepresenting the facts to the federal government.
Florence Dodds was one of the victims. Ms. Dodds was a 78-year old woman with a history of rheumatoid arthritis with severe deformities of her hands, wrists and legs, osteoporosis, fracture of the spine and anxiety. Up until March 31, 2001, Ms. Dodds lived on her own at the San Jacinto Senior Apartments with the help of family and hired aides. Ms. Dodds finally reached the point where she felt she could no longer live alone.
On March 30, 2001, the arthritis in Ms. Dodds’ back flared up so severely that she was taken to Hemet Valley Medical Center. Ms. Dodds was admitted to the Cloverleaf Healthcare Center on April 3, 2001, directly from the hospital. Because of her complaints about the food served at Cloverleaf, Ms. Dodd’ brother and sister-in-law would bring her food and bottled water.
Ms. Dodd was doing quite well until April 7, 2001, when she began experiencing nausea, pain and weakness. Hemet Valley Ambulance was called to Cloverleaf nursing facility where the paramedics found Ms. Dodds supine on her bed and complaining of pain all over. She had been unable to keep any medication down, due to vomiting. She was taken to the Hemet Valley Medical Center ER for further evaluation and admitted to the hospital on April 8, 2001.
During her initial examination, she was found to be very weak, grossly dehydrated and hypotensive. Because of a drop in blood pressure and mental status, she was transferred to Intensive Care on a ventilator where she was intubated and started on pressers. She was given Hespan and started on dopamine to maintain her blood pressure. Her blood pressure remained low and she had shortness of breath. She wad diagnosed with gastrointestinal bleeding and was suffering from renal insufficiency, perhaps due to the gastrointestinal bleeding and hypovolemia. A central venous catheter line was placed into her right femoral vein.
Shortly thereafter, Ms. Dodds went into “code blue”. She was given Norcuron and, once the medication took effect, she began vomiting up large amounts of coffee-ground-like material. She was log-rolled onto her side, suctioned, and then had an endotracheal tube inserted. Her family was informed as to the seriousness of her illness and that she probably would not survive.
Her blood tests and cultures came back positive for Salmonella, which was consistent with a presentation of sepsis and shock. She eventually died on April 9, 2001, just two days after being admitted to the hospital. Ms. Dodds’ death certificate states that the cause of death was cardiorespiratory failure due to septic shock due to salmonella gastroenteritis. Dr. Mata, her primary doctor, believed that Ms. Dodds suffered a great deal during these last few days of her life due to her prior health condition.
Susie Cantaloupe Distributed by I. Kunik Company 2002
This multistate, Salmonella Poona, outbreak was one of three outbreaks that occurred between 2000 and 2002 involving imported, Mexican cantaloupe. Ten of the cases occurred in Canada. These outbreaks led to an import alert on cantaloupes from Mexico. The cantaloupe was purchased whole or eaten as part of a fruit salad or garnish. The I. Kunik Company of McAllen, Texas, who had purchased it from a Mexican producer, had distributed the cantaloupe.
Harold Elli was on of those victims. Mr. Elli was an 85-year-old widower who lived in Goldendale, Washington with his son Mike Elli. Prior to his hospitalization with a Salmonella infection in April of 2002, Mr. Elli led a remarkably active life for a person of his age. A machinist, carpenter and woodsman by trade, Mr. Elli still frequently did the repair work on Mike’s car and pick-up truck. Prior to the illness in April of this year, Mr. Elli’s only significant medical history was a fall in September of 2001, from which he had made a strong recovery. By April of 2001 Mr. Elli was again walking without a cane, and spending 20 minutes at a time, a few times a day on a treadmill that he had purchased to stay in shape. Mr. Elli’s father lived well into his 90s. As Harold puts it, “I figured I had a good seven or eight years left.” Unfortunately, the simple act of buying and eating a cantaloupe would change Mr. Elli’s outlook.
On April 15, 2002, Harold made a brief, twenty-minute journey to the Safeway store in The Dalles, Oregon, where he purchased a Susie brand cantaloupe. Upon returning home, Mr. Elli began eating the melon, slice by slice for two days. By the second day, Mr. Elli began to feel ill and weak. Obviously not suspecting that a fresh, ripe melon was causing his discomfort, Mr. Elli continued to finish the fruit, completely unaware that he was seriously jeopardizing his life. On April 17, 2002, Mr. Elli started vomiting and experiencing severe diarrhea, fatigue, and general aches and pains. Almost immediately following the onset of the vomiting and diarrhea, “Harold was having approximately twelve episodes a day.”
The symptoms continued to escalate, leading to Mike Elli taking his father to the Emergency Room of the Mid-Columbia Medical Center in The Dalles, Oregon, on April 20, 2002. By that time, Harold’s condition had become life threatening. His “profound dehydration secondary to diarrhea and vomiting” was so severe that his kidney function was greatly diminished. The diminished kidney function led to an additional diagnosis of prereneal azotemia, a dangerous excess of nitrogenous bodies in the blood. Additionally “secondary to the protracted vomiting” was Harold’s diagnosis of hypokalemia, a deficiency of potassium in the blood. See Emergency Room Notes, attached as Exhibit 3. Particularly alarming to the attending physician was Mr. Elli’s blood urea nitrogen (BUN) level. While normal levels of this metabolic by product in the liver are 7 to 10, Harold had a level of 88 when he arrived at the emergency room. Such BUN levels can indicate severe renal disease, congestive heart failure, gastrointestinal bleeding, starvation, or shock. Within a few days, Harold’s BUN level escalated even further, reaching 96. Upon his initial examination of Harold, the emergency room physician quickly established two I.V.s; one for saline hydration, and one to feed potassium into Harold’s depleted body. Mr. Elli was admitted to the hospital, where for the better part of two weeks, he lay unresponsive in his hospital bed.
Upon admission to the hospital, Mr. Elli continued to take IV fluids at a “fairly aggressive rate”, and “continued to exhibit green, slimy stool diarrhea” as well as having intermittent episodes of vomiting emesis which was similar to the feces. On April 22nd, Mr. Elli was having continuous diarrhea as he lay “sleeping” and a stool sample was sent to the lab for testing. Though not alert and “obtunded”, Mr. Elli was able to feel the discomfort, expressing the pain associated with “extremely red skin in the buttock and scrotal area.” Harold was also wheeled for X-Rays, and subsequently returned to his slumber.
April 23rd found Harold in much the same position, yet with escalating burning pain from the continuous diarrhea escalating. “The peri area continues to be red and inflamed. Small 1 cm area is beginning to be open. Transferred to 435 at 1500 due to the constant loose stools.” The next day, despite constant monitoring of Harold’s levels, his Potassium level escalated to 6.5 (from 2.5 at admission), provoking the nurse to page Harold’s doctor and suspend I.V. fluids until the doctor called in. That same day, following the page, Mr. Elli “was found positioned on R side, vomiting large amount of reddish, mucousy emesis in obvious distress; diarrhea stool also noted.” The skin around Harold’s anus was continuing to breakdown, causing escalating pain. Mr. Elli’s physician adjusted the IVs, gave orders regarding the presence of hypertension, and instructed the nurses to monitor Harold closely.
On April 25, the stool culture results were returned, revealing Salmonella. Mr. Elli’s physician summarizes the next few days:
The patient was started on a Cipro I.V. and the patient’s appetite totally failed and the patient was started on peripheral nutrition, PPN and given supplemental IV fluids. During this time, the patient did develop a cough and chest X-Ray revealed possible pneumonia. The patient was started on Zithromax orally to cover possible pneumonia. Patient did not respond immediately to the Cipro. The diarrhea continued for several days with patient not taking anything in orally.
By April 28th, Harold was noted as continuing to be “obtunded / asleep all day”, with the occasional “incoherent mumble”. He was taking virtually no food by mouth, thus his PPN / Lipids were providing what little nutrition he was getting. The following day, Harold rolled over onto his left side, accidentally disconnecting one of his I.V.s. This concerned the nurse, provoking her to note, “it might be that another means of delivering food to him will have to be arranged, he has poor veins, and it took seven attempts to find another I.V. site today.”
On May 1st, after 12 days of hospitalization, the pain and exhaustion became almost unbearable for Mr. Elli. As stated by a nurse, “Patient expressed feelings of not wanting to live anymore because he does not have a quality of life and can’t do what he likes to do. He states he is tired of not being well.” Harold was consequently started on yet another medication, the anti-depressant Zoloft. The next two days involved more pain and misery for Mr. Elli. On May 2nd, the nurse notified the doctor of “thrush-like tongue, yeast-like rash in peri area, and discharge from penis.” On May 3rd, while setting up for a “straight cath,” Harold became nauseated, vomited, and had multiple dry heaves. The next day brought “continuing extreme burning pain with urination.”
On the morning of May 6th, Mr. Elli vomited a bright red, mucous-like substance. Harold’s doctor was later notified of this while examining Harold for a surgical consult. During this examination, the doctor found several large bleeding sores on the inside of Harold’s lips and oral mucosa. The doctor ordered a GI scope that same day. Following this invasive procedure, Harold was found to have erosive esophagitis. Harold was started on Protonix and a Tagamet IV was established.
Finally, after 18 days in the hospital Harold Elli had improved, and it was felt that Harold could be discharged to a nursing home, where he could have his caloric counts etc. followed closely. Harold Elli was taken off the assisted feeding IV, the painful catheter was removed, and Harold was discharged on May 8, 2002. He was immediately transferred to the Evergreen Health and Rehabilitation Center.
Harold spent the next 20 days at Evergreen. Upon his arrival at Evergreen, he was given a physical evaluation. For the first week at Evergreen, Harold was able to do little more than to force him to eat. Working against Harold’s desire and efforts to eat was the continued presence of extremely painful red sores in his mouth, causing pain and preventing him from inserting his dentures. Additionally, as recently stated by Harold, “food just tasted funny; in fact it still does.” Harold was only able to eat Cream of Wheat Cereal, and the occasional peanut butter and jelly sandwich. In fact, as of the time of this correspondence, these items continue to be the two staples of Harold’s diet.
Unfortunately, despite making some minor progress with his caloric intake, Harold was forced to have a catheter reinstalled within his first week at Evergreen. Though the pain associated with this was nothing new to Harold, this occasion was particularly troubling for Mr. Elli. He became discouraged that his diligent efforts in regaining his health were not enough to prevent this step backward. The catheter remained for the next week.
After the first week, Harold began to show marked improvement. He had gained a few pounds and had slowly worked his way towards being able to walk the halls of Evergreen and visit with the other patients and nurses. Harold soon began physical therapy, involving gait training, step training and other therapeutic exercises. After two weeks at Evergreen, Harold had gained over six pounds and was feeling better. He was subsequently discharged on May 28, 2002.
Like he said: “Those who cannot remember the past are condemned to repeat it.”