First week of clinic

Monday began my first week of clinic, and it being a short week, there wasn't really a lot happening. Here's what I had:

Monday afternoon: Whitman-Walker Clinic (http://www.whitman-walker.org/). It was pretty much the first HIV/AIDS clinic in DC, and continues to serve that function (and others). I'm working with the medical director, who sees about half of the time (doing medical director stuff the other half), mostly doing HIV primary care. Patients come in every three months and have labwork done to check CD4 counts (white blood cells targeted by HIV), HIV viral lode, full chemistry panel and liver function tests, and to screen for syphilis, TB, hepatitis B, and hepatitis C. My job on Monday was to go in, chat with the patient, find out how they were doing and if they were having any affects from their medications, go over their labwork, and to do a quick physical exam. I saw three patients, and all three of them were doing well, so that's obviously the ideal.

Tuesday morning: This is supposed to be travel clinic at Rader Clinic on Ft. Myer. However, I found out after driving down there that my one patient cancelled that morning. So then it was a drive back up to WRAIR to get some other work done. Here's what my drive looked like that day:

And then back home from WRAIR (C to A) at the end of the day. Obviously.

Wednesday afternoon: This was supposed to preventive medicine clinic at Walter Reed National Military Medical Center (formally known as National Naval Medical Center, or just Bethesda). However, just like on Tuesday, there were no patients, so I got to spend the afternoon sitting on my couch, making phone calls for my concussion study.

And speaking of the concussion study, I've made it all the way through the list of people I needed to contact (235 soldiers). Of those, we have 11 subjects who sent their surveys back completed, 75 surveys that have been mailed and are awaiting return, 6 declines, 60 who have changed their phone numbers/email addresses and we couldn't get hold of, and 83 voicemail messages that I still have to follow-up on. Guess what I'll be doing tomorrow?

More clinic next week. Maybe I'll actually have patients to see.

Remembrance Day

Today I went up to Gettysburg with Melanie and her roommate Amy for Remembrance Day. We tagged along with the Norwich DC Alumni Association (where Melanie got her Master's). Although it was cold, it was a really good experience, which included a tour by a Norwich alum who teaches at the Army War College and is obviously quite knowledgeable about military history. We were also joined by a group of Marine recruits from the Yorktown area who were brought by their recruiters to Gettysburg and ended up joining our group.

We ended the tour at the cemetery at Gettysburg, which was decorated for the occasion:

Our tour leader read through the names of the Vermont fallen (Norwich is in Vermont) and we left flags at their gravestones. What really impressed me was that those Marine recruits (mostly high school seniors or recent graduates) not only stayed with us for this, but were at the first of the line to take flags. I was very impressed with how respectful they were of everything, and told that to their recruiters. They're going to be fine Marines.

Smallpox Vaccine Clinic

About a week and a half ago (hey, I'm a little proud of myself for only being a week and a half behind), I arrived early at Ft. Meade to attend smallpox vaccine clinic. Since smallpox vaccine isn't exactly routine, there's quite a lot of screening and education that goes along with it.

The education begins at 0630, with a CDC video about why we vaccinate against smallpox (since it's been, you know, eradicated and whatnot), how to vaccinate, and some of the risks. Quite frankly, I thought it was a bit too technical for the average audience (medical information for patients should be below the eighth grade level) and quite boring. It wouldn't be a bad video for doctors, nurses, and the techs who are administering the vaccine, but they need something better for the vaccinees. And something made in this century.

That took about 45 minutes, and then it was into the exam room to screen patients for vaccination. It's a very risk-averse environment, and there a lot of contraindications. Overall, the risk of infection is only theoretical--terrorists might have smallpox, but we have no proof of that. So if someone has a slightly increased risk of having an adverse effect from the vaccine, we're not going to give it. Some of the contraindications of vaccinating are skin problems (eczema, psoriasis, severe acne, etc) or skin problems in any close contacts (family members). This is why:

This is eczema vaccinatum and the result of someone with eczema being in contact with the vaccinia virus. People with intact skin will only get vaccinia at the sit of innoculation (the hands of milkmaids in the good old days, the right deltoids of vaccinees today), but people with such skin problems can get cowpox (vaccinia) everywhere. And it's quite serious.

Anyway, other contraindications of smallpox vaccination are dry eyes (because people with dry eyes rub them, and getting vaccinia in the eyes would be bad), immunosuppression (from HIV or certain medications), close contact with infants younger than 12 months, having another live virus vaccination within the last four weeks (such as FluMist), and certain heart problems, since smallpox vaccination can cause heart problems in even healthy people. Of the three people in vaccination clinic when I was there, only got vaccinated. Of the other two, one had FluMist the week before, and the other had both close contact with an infant and severe acne. Interestingly, the one who did get vaccinated was born outside the United States and had a BCG vaccination at birth (to protect against TB) and scar from that. Little known fact: according to the WHO, the BCG vaccine is given in the left deltoid, and the smallpox vaccine on the right, because they leave identical scars. By having it standardized back in the days when many people got both, you could tell who had had what.

I did watch the tech do the vaccination (he made me stand on the other side of the room, since I haven't been vaccinated). It looks kinda like this:

This is the only vaccine that uses a bifurcated needle. How it's done is that the needle is dipped into the vaccine so it leaves a small drop between the two prongs. Then, using the hand technique demonstrated here, the arm is stabbed with the needle fifteen times quickly, deep enough to leave a drop of blood. The site is then covered with a piece of gauze and the vaccinee is given instructions on how to care for the vaccination site. If everything goes right, the site should look like this:

And then it leaves a small, permanent scar. Quite enjoyable. Can't wait for mine (sarcasm).

Ft. Meade Preventive Medicine

I've been rotating in the preventive medicine department at Ft. Meade for a little over four weeks now, and have just been procrastinating pretty bad about writing about it. So here's finally a blog entry about the wonderfulness of Ft. Meade.

First of all, there's the drive, which is the map above. It's 33 miles, according to GoogleMaps, which doesn't seem like a lot, until you factor in DC-area traffic. Fortunately, most people are coming into DC in the morning and leaving in the afternoon, and I'm doing the opposite, so it only takes about 50 minutes to go those 33 miles. It's still far too much time in the car, and even with buying gas on base (usually a few cents/gallon cheaper than outside the base), it's pretty expensive.

My schedule's been a little erratic for this rotation; I'll try to simplify it as much as possible:

Monday and Tuesday: Occupational medicine clinic (ugh). This is mostly pre-employment physicals for jobs around base, such as child care, firefighters, and hazardous material handlers (there were a few other jobs, but you get the idea). We also do pre-deployment physicals for Army civilians who are deploying, which is something fairly new at this clinic. Because they haven't been doing it very long, they don't have a protocol for it, so things are pretty chaotic, and it's a ton of work. It takes quite a lot to be able to say, "okay, you're healthy enough to deploy. Go forth, have fun, and make lots and lots of money."

Wednesday: Fortunately, I get to go to WRAIR for didactics on Wednesdays (six mile drive instead of 33). Last week we were learning about recruit medicine and went down to Quantico to do sick call for the Marine Corps Officer Candidate School. That was pretty fun, but I am glad I'm not a Marine. There's something about not being allowed personal pronouns that I don't think I'd deal with very well ("This candidate's leg has been hurting since yesterday" is how they say that their leg hurts).

Thursday: Random other clinical stuff at Ft. Meade, including more of the pre-deployment physicals, travel clinic, and work injuries. I do love travel clinic, that's for sure.

Friday: My preceptor's admin day, so I usually tag along with the Environmental Health tech to do inspections. There are quite a few places on base that need to be inspected monthly, including all of the kitchens (such as the dining facility, Club Meade, the golf course, bowling alley, child care kitchens, etc), the child care centers themselves, the pool, and home-based day care centers (of which there are about 40 on base; four or so will be inspected monthly, at random). There are also places that have to be inspected quarterly, including the barber shop and the gym. Quite a lot of stuff on base that has to be inspected.

And then I have weekends off, which is nice. My summer/fall running season ended on Sunday with the Marine Corps 10K, so now I have the weekends to be a bit more lazy. Well, this weekend, the parents are coming into town, so I'll have to keep them entertained, but other than that, a bit lazy in general.