Can You Correctly Care For These Three Patients?

April 14th, 2023 by Nicholas Comninellis
Posted in Low-Resource Healthcare Pearls|

Test Your Skills


Low-resource, cross-cultural healthcare will test your skills to the extreme. Begin by eliminating the options of comprehensive laboratory testing, advanced imaging, or even specialty consultations. Would you be able to care for these three patients correctly?


1. You are volunteering at a safety net clinic in Oklahoma City and seeing Erasto – a sixteen-year-old refugee newly arrived from Somalia. He has cough, weight loss, poor appetite and vague but increasing abdominal pain. On questioning you learn that in his Somali home safe drinking water is a luxury and sanitation is in disarray. On exam Erasto has an oral temperature of 38.8, respirations of 30, and capillary refill time of 5 seconds. His abdomen is tense and diffusely tender. You are considering the possibility of typhoid fever. Which ONE of the following statements about typhoid fever is TRUE?


A. Salmonella typhi is transmitted by ingestion of contaminated food or water.

B. Typhoid fever almost always causes diarrhea.

C. Typhoid fever commonly presents as an acute illness.

D. Typhoid vaccination is quite effective.

E. Typhoid fever can be readily differentiated on clinical examination from other infectious diseases, such as mononucleosis and infectious hepatitis.


Carefully consider before selecting your answer. The correct response is A. Although typhoid fever does not frequently cause diarrhea, it shares many of the risk factors associated with diarrheal diseases and is usually transmitted by fecal-oral ingestion of contaminated food or water. Typhoid should be considered in persons with non-acute, persistent, unexplained fever and GI symptoms, especially diarrhea and abdominal pain. Diagnosis is often challenging. The differential diagnosis includes malaria, infectious hepatitis, enteric fever syndrome (due to Yersinia enterocolitica, Y. pseudotuberculosis, or Campylobacter), atypical pneumonia, mononucleosis, bacterial endocarditis, tuberculosis, and brucellosis. Common complications include intestinal hemorrhage and perforation, with osteomyelitis and endocarditis occurring less commonly. Typhoid vaccination is available, but it is of marginal effectiveness.


2. You are in the Middle Eastern nation of Jordan caring for Anas, a 2-year-old child whose family just escaped the bloodshed in Syria. Anas is alert, temperature is 38 degrees C, respirations are 30 per minute, pulse is 90 bpm, and blood pressure is unobtainable. He has extreme muscle wasting throughout, reddish hair discoloration, and loss of adipose tissue with no peripheral edema. Your first priority in managing this child with acute protein-energy malnutrition (PEM) is which ONE of the following:


A  Treatment of coexisting medical illnesses

B  Provision of high-concentration protein supplement

C  Administration of micronutrient supplements

D  Immediate refeeding

E  Correction of hydration and acid-base alterations


The appropriate answer to this question may not be the most intuitive. The correct answer is E. The management of acute protein-energy malnutrition (PEM) can be separated into two stages. The first stage is stabilization: to immediately correct hydration and acid-base alterations. The second stage is refeeding. This can begin as soon as medical problems are reasonably stable and rehydration is complete. It may be necessary to begin initial refeeding slowly in persons who have advanced PEM or kwashiorkor because of damage to the intestinal mucosa. During the period of renutrition, micronutrient supplements and attention to any coexisting medical illnesses may also be indicated.


3. You are in Cambodia, South America, seeing Solyna, a twenty-one-year-old lady, who suddenly developed fever, vomiting, severe headache, and pain on moving her eyes. On physical examination you note that Solyna is lethargic, has generalized lymph node enlargement and a slow heart rate relative to her fever of 39 degrees. Your initial differential diagnosis is broad: influenza, dengue, typhoid fever, mononucleosis, malaria.  You Giemsa stain her blood smears but you do not identify any ring-like Plasmodium parasites that would suggest malaria. You initiate intravenous fluids and antipyretics. Over the next hours Solyna develops hypothermia, severe abdominal pain, decreased mental status, and bleeding from her gums and nose. You now suspect dengue – an arbovirus infection. Which ONE of the following is a characteristic of severe dengue fever?


A  Leukocytosis with increased band forms

B  Increased urinary output

C  Abnormal vascular permeability with spontaneous bleeding

D  Predictable improvement in response to gamma globulin infusion

E  Decreasing hematocrit


This case requires careful attention to detail in the history and physical exam. The correct answer is C. Key criteria for diagnosis of severe dengue fever are abnormal vascular permeability with spontaneous bleeding, fever, and low platelet count. Leukopenia (low white blood cell count), increasing hematocrit, and decreased urinary output commonly accompany severe dengue fever. Gamma globulin is of no therapeutic benefit.


Practicing in the absence of comprehensive laboratory testing, advanced imaging, and specialty consultations provokes understandable anxiety in most medical care professionals. But you can learn to provide quality care within such parameters, especially when you develop such skills under the watchful attention of an experience supervisor. INMED International Medicine, Nursing and Public Health Training Sites are designed to assist you in developing such prized, life-saving skills.


How Skilled Are You To Care For “The Least Of These”?

April 1st, 2023 by INMED
Posted in INMED Action Steps For You|


Last Sunday, many readers of this blog commemorated the historic entrance of Christ into the city of Jerusalem. During those ensuing days, Christ spoke passionately about eternity’s most compelling truths. He knew that within a few precious days he would be arrested, tortured, executed – and then return once again to physical life. Of what did Christ speak? Matthew 25 records a particularly compelling theme: care we show towards those in need:


“Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’ “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you drink, stranger and invite you in, needing clothes and clothe you, sick or in prison and go to visit you?’ “The King will reply, ‘Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.’


How skilled are you at caring for such people; those who are poor, homeless, minorities, refugees, or victims of disaster or war? INMED’s richest skill advancement opportunity begins on June 7-8 with full day courses in Ultrasound, OB Ultrasound, Helping Babies Breathe (HBB), Essential Care for Every Baby, Helping Mothers Survive, and Hands-On Skills for Low-Resource Healthcare. Stay on location on June 9-10 for the 18th annual Humanitarian Health Conference to connect with professionals of the same mind. Use coupon code “equip15″ to enjoy a 15% discount. First-time undergraduate and medical students use coupon code “connect2023″ to register for just $30. (Please register using your school-issued email address)


During these precious days preceding Easter celebration, let’s dwell again upon eternity’s most compelling truths. How we treat those in need indeed has eternal consequences. Let us double our commitment to provide care with kindness and excellence.


Who Is The Most Famous Musician In International Health?

March 17th, 2023 by Nicholas Comninellis
Posted in International Health News & Inspiration|


Albert Schweitzer is one of international health’s most fascinating personalities. Born in on the border between France and Germany in 1875, by age 30 Schweitzer distinguished himself with advanced accomplishments in theology, philosophy and music. Most notably, Schweitzer transposed Bach’s renowned compositions from orchestra to organ, and traveled throughout Europe with the Paris Bach Society performing to considerable acclaim.


At the age of 30, Schweitzer received an appeal from Paris Missionary Society for a physician to serve in west Africa. One biographer documents what happened next: “Amid a hail of protests from his friends, family and colleagues, Schweitzer resigned his post and re-entered the university as a student in a three-year course towards the degree of Doctorate in Medicine… He planned to spread the Gospel by the example of his Christian labor of healing…”



Over the next 50 years – including a period being interned during World War I – Albert Schweitzer lived in what became of the nation of Gabon, West Africa. His autobiography is filled with accounts of caring for Africans who suffered from dysentery, malaria, sleeping sickness, leprosy, poisonings, and surgical emergencies. Throughout these decades, Dr. Schweitzer continued to compose works of theology and philosophy, most notably The Quest of the Historical Jesus (a rebuttal against growing liberal interpretation of scripture) and  literary works expanding the principle of Reverence for Life – for which he was recognized with the 1952 Nobel peace prize. For visitors to his remote hospital he also regularly entertained through organ recitals well into the nights.


50,000 Deaths in Turkey-Syria Earthquake – Immediate and Long-Term Response

March 3rd, 2023 by Nicholas Comninellis
Posted in Disaster Management|


The earth would occasionally rumble under my feet as a child living with my grandmother in Greece. We ran outside of her brick home; fearful it would collapse and kill us. One month ago, just 400 miles away in Turkey and Syria, earthquakes did indeed collapse thousands of homes, instantly killing 50,000 people – the same number of US soldiers who perished in the Vietnam War. The extent of this tragedy is almost unimaginable, and 1 million people are now homeless.


How shall we – people who enjoy relative affluence – respond to this catastrophe? In the coming weeks and months, survivors will be afflicted with hunger, cold exposure, unsafe drinking water, contagious diseases, and marked depression and anxiety. In the short term. your immediate donation of time or treasure to a reputable relief organization is especially strategic. INMED highly recommends Heart-to-Heart International (HHI), headquartered in greater Kansas City. At this moment, HHI is distributing trauma emergency surgery kits, deploying stand-alone portable medical trauma clinics, and sending the most-needed medicines and supplies, including analgesic medications, bandages, and crutches. You can also meet HHI staff in-person at the Humanitarian Health Conference on June 9-10.


In the long-term, how can we support sustainable infrastructures that will both prevent and more effectively respond to upcoming cataclysmic disasters? This broad question requires answers from multiple disciplines, including construction, governance, law-enforcement, and public safety. Within the discipline of healthcare education, professionals must be better equipped with critical disaster response and prevention skills – INMED’s particular forte. Each major INMED education program includes Disaster Management coaching.


Next time the ground rumbles, waters rise, tempest blows, or fires encroach may we all be well equipped for immediate and long-term response.


Jimmy Carter, Guinea Worm, and Human Disease Eradication

February 17th, 2023 by Nicholas Comninellis
Posted in International Public Health|

Last week, Jimmy Carter – 39th US President 1977-1981 – entered hospice care at age 98. Post-presidency, Carter focused his energies on distinguished humanitarian pursuits: launching Habitat for Humanity, negotiating cessation of international conflicts, instructing biblical truths, and leading the march to eradicate a human infection.


Dracunculiasis, or Guinea worm infection, is a parasitic disease acquired by humans who drink water contaminated with its eggs. Within the human intestine, these eggs develop into adult worms about 1 m (3 feet!) long that penetrate the intestine and begin migrating through the body until they reach the skin. Once the parasite detects water nearby, it begins to emerge through the skin inflicting unrelenting, debilitating pain upon the sufferer.



No successful medication, vaccine, or other treatment has been discovered. Management of this disease remains the same as it has for millennia: raping the emerging worm on a stick and slowly extracted over a period of weeks.


In the 1980s, about 3.5 million new cases were reported in eastern, central, and western Africa – primarily in the countries of Ethiopia, South Sudan, Angola, Mali, Chad, and Cameron. It occurs mainly within very low-income communities where water and sanitation infrastructure are undeveloped.



In 1986, a coalition of international partners, including the World Health Organization and the Carter Center, began a systematic program to both track the occurrences of the disease and educate communities regarding prevention. Effective prevention efforts include provision of safe drinking water, application of approved chemical agents to kill the parasite in contaminated water, and educating Community members to properly dispose of fish guts which breaks transmission of the parasite eggs.


So successful has been these efforts worldwide trust 25 cases were reported in 2016 and only 10 cases in 2021. Successful eradication of Guinea worm would be only the second time in history – following smallpox eradication – that a human infection has been entirely eliminated. A distinguished pursuit indeed!

Dental Care in Kenya by Caren Abraham – INMED Grad in Action

February 3rd, 2023 by Nicholas Comninellis
Posted in INMED Grads In Action|

“Over the last year and one-half I have set foot in four continents, been a part of five conferences, lost a few team mates, welcomed others, and spoken languages I haven’t used in years. Captured below is a summary of the last few months in pictures. May you be blessed to see what the Lord is doing around the world!” – The words of Caren Abraham, DDS. In 2015, Caren began studying at INMED, and in 2019 earned the INMED Professional Diploma in International Medicine and Public Health (DIMPH) which included her supervised dental care service-learning experience in East Africa.



Caren continues, “Thank you to each one of you for upholding me in your constant prayers. Behind these highlights have been many challenges, but God has watched over me through them all. I pray that these photos give you a glimpse into the work that is happening on our side of the globe and help you know that your prayers and financial investment are not in vain.”


Caren is preparing to move back to Kenya to continue providing long-term dental care. Contact Caren Abraham at [email protected].

Present Your Poster at the Humanitarian Health Conference!

January 20th, 2023 by Nicholas Comninellis
Posted in International Public Health|


What great advances in international health have resulted from research? Measles vaccine, HIV drugs, malaria bed nets, tobacco controls, basic newborn resuscitation, to name a few. But profound international health challenges remain that can only be vanquished through continued scientific investigation. Some of these challenges include the quests for more effective tuberculosis vaccines, successful cardiovascular polypill, low-cost cancer treatments, and road trauma prevention.


The Humanitarian Health Conference, June 9-10 in Kansas City, is an opportunity for students and researchers of all experience levels to share their insights to an altruistic audience. We invite Poster Presentation subjects in three categories: global health education, research or innovation, and case study. For examples, please view the 2022 Poster Presentation Participants and Award Recipients. That’s right, awards and cash prizes for the premier poster presentations! More importantly, poster presentations can expand your professional network and advance your career qualifications. Please view the Poster Presentation Information and submit by May 25, 2023.


What great advances in international health are just over the horizon? Participating in the Humanitarian Health Conference is an ideal opportunity to contribute to the science, increase your healthcare skills, connect with volunteer organizations, and ultimately to advance the welfare of all humankind.


Who Has The Very BEST Healthcare?

January 6th, 2023 by Nicholas Comninellis
Posted in International Public Health|


This provocative question evokes sentiments of national pride, social justice, and personal experiences. It’s also a pivotal question, influencing the design and resources for healthcare. A compelling follow up to “Who has the very best healthcare?” is to clarify, “By what criteria shall we judge quality of healthcare?” Consider the following benchmarks:


  • Cost. Health expenditures per capita loosely correlates with quality of healthcare. United States: $11,800 per person, Canada: $5,800, Chile: $2,400, Turkey: $1,300, Ghana $221
  • Health Outcomes. Commonly used measures include life expectancy, child mortality, and years of potential life lost. Life expectancy in the US: 79, Canada: 83, Chile: 80, Turkey: 78, Ghana: 63.
  • Compassion. Authorities broadly agree on the essential nature of compassion in healthcare. Yet scholarly research has yet to identify an acceptable objective measure.


Compassion is a virtue better observed or experienced than quantified. Muhammad is a 13-year-old in the nation of Ghana, west Africa. For months he has suffered from severe scabies, an infestation of the skin causing relentless itching, weight loss, cellulitis and sepsis. See the above left photo. The volunteer physician caring for him in Ghana, Burton Adrian, is a graduate of the INMED Master’s Degree in International Health. Dr. Adrian made the diagnosis, and upon discovering that the needed medication was not available, he searched the country to locate it. Muhammad’s photo on the right was taken two months after treatment.


“Who has the very best healthcare?” Those who receive it with compassion! On Fri-Sat, June 9-10, INMED is hosting hundreds of professionals like Burton Adrian at the 2023 Humanitarian Health Conference. This gathering will increase knowledge and skill surrounding diseases connected with poverty, community health and development, and career decision making. Moreover, the 2023 Humanitarian Health Conference could be your very best opportunity to talk together with inspiring colleagues, whose priority is health care infused with compassion.


Can You Solve This Case Of Tropical Fever?

December 23rd, 2022 by Nicholas Comninellis
Posted in Low-Resource Healthcare Pearls|



Maria, the seven-year-old girl in this photo, presents to you at the Clinical Evangelica Morava on the remote western coast of Honduras. Her parents explain that five days ago she suddenly developed fever, vomiting, severe headache, and pain on moving her eyes. Several other children in the neighborhood have been similarly ill since the onset of the rainy season with its customary heat and mosquitoes.


On physical examination you note that Maria is lethargic, has generalized lymph node enlargement with clear lungs and a slow heart rate relative to her fever of 39 degrees. She has a fine rash on her extremities. You quickly perform thick and thin blood smears with Giemsa stain, but you do not identify any ring-like Plasmodium parasites within red blood cells that would suggest malaria.


Your initial differential diagnosis is broad: influenza, dengue, typhoid fever, mononucleosis, malaria with negative blood smear. You initiate intravenous fluids and antipyretics. Over the next hours Maria develops hypothermia, severe abdominal pain, persistent vomiting, decreased mental status, and bleeding from her gums and nose. You now suspect the Maria is suffering from dengue – an arbovirus infection.


Which ONE of the following is a characteristic of severe dengue fever?


A. Leukocytosis with increased band forms
B. Increased urinary output
C. Abnormal vascular permeability with spontaneous bleeding
D. Predictable improvement in response to gamma globulin infusion
E. Decreasing hematocrit


Explanation: Abnormal vascular permeability with spontaneous bleeding, fever, and low platelet count are key criteria for diagnosis of severe dengue fever. Leukopenia (low white blood cell count), increasing hematocrit, and decreased urinary output commonly accompany severe dengue fever. Gamma globulin is of no therapeutic benefit. The correct answer is C.


You continue to treat Maria’s hypotension and shock, taking care to not administer aspirin or nonsteriodal anti-inflammatory drugs (NSAIDs) as they may increase bleeding tendency. Vitamin K supplementation may be useful given her coagulopathy, but the Clinica has none in stock. Meanwhile, Maria’s parents politely but persistently press you for information about her illness.


Of the following statements about dengue fever which ONE is NOT true?


A. Dengue vaccine is indicated for administration to people living in regions with high mosquito density.

B. The vector for dengue is the Aedes aegypti mosquito.

C. Dengue most commonly occurs in Southeast Asia and Latin America.

D. Treatment is essentially supportive with particular attention to hemodynamic status.

E. Infection may progress to complications that include hemorrhage and shock.


Explanation: WHO recommends the dengue vaccine CYD-TDV for people ages 9 to 45—only in geographic settings with a high burden of dengue disease and only be given to persons with confirmed prior dengue virus infection. The vector for dengue virus is the Aedes aegypti mosquito, which feeds during the early morning and late afternoon. The mosquito is adapted to the human habitat, often bites indoors, and breeds in small quantities of water. Dengue is distributed throughout the tropics, causing sporadic cases or large epidemics, especially in Southeast Asia and Latin America. Commonly recognized complications include thrombocytopenia, bleeding, and hypovolemia. Treatment is supportive, with particular attention to hematocrit, blood pressure and urine output, and adequate hydration. The correct answer is A.



World Health Organization. Dengue and severe dengue. Accessed January 1, 2023.


Dengue fever is a classic disease of poverty – one associated with insects and poor housing, and one that calls for broad social development as well as medical interventions. The heartening response of many to Maria’s illness is to offer their personal time and talent to protect those like her. Together let’s continue to emphasize interventions that empower marginalized communities to combat poverty and to care for their own.


WHY Did Jesus Come?

December 9th, 2022 by Nicholas Comninellis
Posted in International Health News & Inspiration|


At Christmas time we focus most on the details of Jesus Christ’s birth: the prophecies, star, virgin mother, impoverished setting, jubilant angels, and frightened shepherds. These indeed are intriguing and worthy of celebration. But let’s look deeper beyond the details of how Jesus came and inquire why Jesus came.


Jesus’ contemporaries largely hoped and anticipated that he would be their liberator from the oppression of harsh Roman rule. They expected Jesus and his followers would win political power and rule by decree. Similar sentiments exist even into today. But look carefully into the public statements of Jesus, recorded by the four independent authors of the Gospels, and the purpose of coming described by Jesus himself appears markedly different:



Rather than rule by way of might, Jesus advocated humble service to one another. Mark 10:42-45 declares, “Whosoever wishes to be great among you shall be your servant, and whoever wishes to be first among you shall be slave of all.” What an extraordinary contrast to the hierarchical and dictatorial structures that characterize most human societies. Jesus advocates a polar opposite definition of power (leading by example) and greatness (humility in service to one another). Many INMED grads continue to prioritize this modality of service towards humanity.


Jesus closes this short discourse with another profound statement: “For even the Son of Man (his title) did not come to be served but to serve, and to give his life a ransom for many.” What compelled Christ to come and give his life was not simply to model a lifestyle, but also to redeem the sin of humankind. For deep dive into this greater purpose, read Jesus’ explanation documented in John chapter 3.