DRC, Day 9: Back in Kinshasa

Today was a ridiculously long day.

                

Like every day, I went for my run in the morning, and then we had breakfast, etc before heading back up to Kitona. The only thing on the schedule was doing an outbrief of MAJ Lang’s public health findings before we headed back to Muanda to change and get ready for our flight. We ended up getting to BG Moustafa’s office before he did, so MAJ Lang and I decided to swing by the hospital and thank BG Amisi for his time as well. Unfortunately, we also got there before he did. He showed up a few minutes later, did an “inspection of the troops” (which I had never seen before, but involved a lot of medical officers standing around looking bored before he arrived). We had just enough time to thank him and whatnot, and then it was back to BG Moustafa’s office.

The doctors lined up for inspection

                

MAJ Lang did the outbrief, which included some good things he saw (not much) and then then top three “easy fixes” of his findings, which was to add faucets to the water pipes to keep them from running constantly and drain the pool to decrease the standing water (and thus, mosquito breeding sites); add water treatment to the water distribution (not really an easy fix, but still important); and fix spacing of latrines, trash, and kitchens in the recruit areas. I’m pretty sure none of these will actually happen, because BG Moustafa nodded and said that none of this was a surprise to him, and he had submitted it up to Kinshasa in the past, and nothing was ever changed.

MAJ Lang briefing BG Moustafa

                

In other words, he didn’t want to take responsibility for the problems.

                

After that, we headed back, changed, finished packing, and then headed to the airport to wait for our flight back to Kinshasa. LTC McCullough gave me a coin, which is kinda about time, since it was my third trip in working for him. Whatever. It was nice anyway.

                

The flight was uneventful, and then we were back in the O’Costelo for another two nights. The next large group of travelers (nine of them) was also there, in preparation for flying out to Muanda tomorrow, and the whole bunch of us went out for dinner. I probably should have stayed at the hotel and ordered a croquet monsieur (grilled cheese sandwich), because after a week in Muanda, I had forgotten how loud people can be, especially a group that large of people who were jetlagged (and therefore a little punch-drunk) and excited to be in the Congo. It was so ridiculously loud, and I just wanted to get out of there. My introvert alarms were all going off, and there was nothing I could do about it.

Shrimp

              

The shrimp was good, though.

                

The worst part was probably the civil affairs guys from USARAF, because they were acting like incredibly pretentious jerks all night, and sadly, that reminded me a lot of having to go back to work and deal with the pretentious jerks who make my life miserable there. I don’t know what it is about these civil affairs guys sometimes, but it just drove me crazy, and I wasn’t the only one. MAJ Lang was pretty frustrated by it, too, and when I told him that that was a little bit like what my life was like at Ft. Stewart, he said he understood why I’m so eager to be in the office as little as possible.

                

Ugh. Makes me really hope the job at USAMRIID at Ft. Detrick can be mine next year.

DRC, Day 6: Going into the Weekend

Yay! It’s Friday! The last day before the weekend…in a town where there’s nothing to do… Oh, well.

                

We got an early start to the day to go to the women’s sensing session, which was actually pretty well attended, with about 43 female soldiers, officers, and police. It's a very civil affairs thing, and it was facilitated by a woman from Dyncorp, which is doing the civil military operations training during the exercise as well. She had the women go around the room and ask what they did in the FARDC (or police). There were quite a few nurses and nursing students, but a lot from the “regular army” as well. Then she asked the reasons for joining the military, which is pretty similar to why people join the military in the States—no money for education, hope to get training, want to serve/defend the country, etc. The last question was about what they hoped to get out of joining the military and what they still hoped to accomplish, and that opened up the floodgates. Almost universally, they said that the opportunities for the good training—English language training, computers, etc—was always given to the men, because they assume the women would mess it up. They said they aren’t treated as equals, there’s nobody to help with the childcare when they’re at work, nobody respects them, and on and one. They said it’s a problem with the leadership, that the views of women in the military come from the top down.

During the sensing session

After

                

This was confirmed when, after the sensing session when we were getting a picture, the general drove up, saw that the sensing session had already happened, and told me that I should work with the women to teach them how to be better soldiers, because they all think they’re there to “service the men.” I really didn’t know what to say, but it definitely made me believe the women who said that they get no respect from the leadership.

Talking to BG Moustafa

                

After we were done with that, we all headed to Banana Naval Base (where the Congo meets the Atlantic), to give the Navy doctors a chance to shake hands with the navy people (the navy that has no boats…), and then the Navy doctors hopped on the Kin-Avia flight back to Kinshasa, while MAJ Lang and I get to suffer through a weekend in Muanda with nothing to do. It’s really not fair, but I guess that’s life. What I’m really bummed out about is that I’ve now been to DRC three times, and I still haven’t seen the bonobos (apes that are only found in DRC; there’s a reserve about an hour outside Kinshasa). I’m sure they’ll find something for us to do in Muanda… or I’ll just take a lot of naps and do a lot of reading. One of those, I’m sure.

6-11-13: Last Day at the Hospital

Today was the last day in the hospital, which was good. I think I’ve seen just about as much of that place as I can handle. For now, anyway.

                

There was some initial confusion about which doctors the three physicians were going to work with, with Dr. Patrick being in surgery and nobody really that trilled about working with the triage physician. Finally, Dr. Lesho bit the bullet and went with the triage doctor, and both Dr. Mann and I worked with the pediatrician. Since there weren’t any patients waiting to be seen, we went upstairs for rounds and saw the kids on the inpatient wards.

                

After rounds, I worked with my translator on my presentation about HIV in the US Military, and then it was time for a tour of the nursing school. It’s a military nursing school, with most of the students in the military, and a few civilians who pay tuition. We actually interrupted their finals, which I felt a little bad about.

The group outside the nursing school

The school itself wasn’t too bad, although outdated. They actually still have an iron lung in the clinical simulation center, which has got to be the oldest one still around. I don’t know if it’s still operational or not; somehow, I wouldn’t be surprised.

Iron Lung

After the tour of the nursing school was lunch, and then we had the last day of academics. We had two lectures on blood security and blood transfusions, one about the program and stats at Kitona, and one from LTC Cannon about WHO standards. I was actually surprised at how robust the program is here—they don’t pay anyone for donations, which is good, and test every unit of blood for HIV, syphilis, hepatitis B, and hepatitis C. It’s not nearly as many as we test in the States, but it meets WHO recommendations, which is always good. They do have a strange policy where they only transfuse matched blood—an A patient will only get A blood, etc. I feel sorry for their AB patients. There aren’t many of us out there.

                

The third lecture was about sexually transmitted diseases at Kitona, and then I wrapped up academics with my presentation about HIV in our military. It actually started an argument between the hospital commander and the deputy commander of Kitona Base, who was there to present the completion ceremonies. The hospital commander asked why all the recruits at Kitona didn’t get tested when they joined, the way our recruits do (and according to DRC policy, as we learned yesterday during academics), and the general said that it’s the hospital commander’s responsibility to do it. There were angry words flying around in French all over the place, but hopefully they’ll figure something out to get the testing done.

My presentation on HIV in the US Military

After the awards ceremony (read: speeches and certificates), we headed back to the hotel, and then down to New Cliffs restaurant (our usual dinner place) for a final Muanda dinner. We invited our translators and the hospital commander, and hired a music/dance group. It was a lot of fun to hear and see traditional music and dances from Bas Congo, and everyone got up on the dance floor at least once. Yes, even me, but I really hope there are no pictures of this out there.

Dancing

I gave Lt. Olivier, my translator, a gift at the end of the night: my Army Medical Department regimental crest. I brought it with the intention of giving it to the doctor I worked with, but I didn’t end up forming any sort of bond with any of the doctors, and Olivier and I got to know each other fairly well. I told him that it was what American Army doctors wore on their uniforms, and after translating for me all week, he was practically a doctor and should have it. I think he appreciated it.

Tomorrow we fly back to Kinshasa, and then there’s a couple of days of stuff that we have to do for the embassy before we head home on Friday night.

Final group picture in front of the hospital

6-10-13: Back to the Hospital

We were back at the hospital today for our second to last day of clinical and academics at Kitona. Like Saturday, we physicians rotated physicians to work with. I took the pediatrician, Dr. Lesho worked with the triage doctor who doesn’t like anyone, and Dr. Mann (the pediatrician) went to internal medicine.

                

Pediatrics clinic was slow today, so we ended up going up to the pediatrics ward for rounds. Most of the cases were simple malaria (well, simple for them), but there was one boy who’s pretty sick. He’s had swollen lymph nodes, a cough, lack of appetite, and swollen legs for about a month. I’m thinking it might be TB, but with three primary sites (lymph nodes, lungs, and possibly kidneys), which would be unusual, unless he has HIV, and the mother won’t consent to an HIV test. Dr. Mann thinks it might be Burkitt’s lymphoma, a cancer caused by EBV, the same virus that causes mono.

                

The issue about HIV testing came up in academics this afternoon as well. In DRC, you have to “opt in” for testing, which means that a doctor can recommend that you go for counseling and testing, but can’t order the test for you. This is the system that the US used to have, before we went to “opt out”, which means that a doctor can order an HIV test for you, unless you specifically state that you don’t want it done. The problem (especially in Africa), is that if you have an opt in program, people can chose not to opt in (and usually they chose this because they’re afraid it will be positive), and then continue living life as if they’re negative, continuing to spread HIV. You’re not going to be able to fight HIV until you have the ability to get people who are HIV+ the education and treatment they need.

                

We also had a lecture on antibiotic stewardship by Dr. Lesho, who works in the wound infection division at WRAIR. The lecture was a bit too technical, especially when working through a translator who doesn’t know medical terminology, but the point was sound. Since they can’t do culture and test for which antibiotics a bacteria is susceptible to, the doctors in Kitona tend to prescribe anything and everything for any complaint, and often for longer treatment courses than necessary. For example, every patient (outpatient, inpatient, etc) gets a urinalysis, even if they don’t have any urinary symptoms (which they usually don’t). Because hygiene is an issue, and I doubt they know how to do clean-catch urine collections, there’s a lot of background bacteria. In the U.S., you don’t treat bacteria in the urine if there are no symptoms, unless it’s in a pregnant woman. Here, however, if they find evidence of bacteria, they’ll treat with 7 days of ciprofloxacin (an antibiotic). In the States, that would be a 3 day course of antibiotics. This kind of over treatment and over-lengthened treatment increases antibiotic resistant bacteria, which is a huge problem everywhere.

                

Tomorrow is going to be our last day of clinicals and academics. It’s also a surgery day, so there probably won’t be much going on clinically. I might watch a surgery or two. The academics will be long; we’ll finish up the HIV lectures, and then we have a presentation of certificates to the DRC participants, and then we have an after-action report. It should be interesting.

Random picture of the group from cultural day

6-7-13: Malaria Day

Today was actually a pretty frustrating day… Well, at least the morning was.

                

The plan from yesterday was that we would try to switch off to different departments, to see different parts of the hospital and get a more rounded experience. To be honest, for as much as I hate rounding, I was hoping to do internal medicine rounds, because I feel like there’s more opportunity for teaching during rounds than while seeing clinic with the same triage doctor, who doesn’t seem to understand that he’s doing things wrong. Unfortunately, they weren’t prepared for that, so we decided to continue with the plan for today, and our logistics support would talk to the hospital commander about us seeing different things tomorrow.

                

We shall see.

                

So I went to triage with the same doctor, and the first thing we did was see a patient on the wards who came in the night before. Her eyes were very yellow (from jaundice) and her belly was very extended (from ascites). However, the doctor said that it was from a perforation in the intestines, and the air from the intestines was making her belly big. I tried to explain that we see that finding in patients with liver failure, and that the yellow eyes and extended belly are both probably from the liver. I was about to suggest that they look for different causes of liver failure—viral hepatitis, yellow fever, liver parasites—but he remained sure that the belly extension was from a perforated intestine.

                

Sigh.

                

We went back down to triage and continued seeing patients. One had a very swollen neck, which started about five days ago as an earache. If it had been slower than that, I would have thought it was TB in the lymph nodes (more common in the Pacific Islands than Africa, but still happens in Africa), but with such a quick onset, I narrowed my differential to mumps, an ear infection that infected the bones, or a dental abscess. I had my otoscope (to look in the ears), and there was no sign of an ear infection, but when I looked in his mouth, the back teeth looked a bit suspect. This led me toward dental abscess, which apparently the doctor agreed with, because we walked the patient to dental. The dentist decided that he should be put on antibiotics until the swelling went down, and then he would remove the tooth. That made sense, because I don’t think the dental clinic has general anesthesia, and it would have been too painful for him to open his mouth all the way for the surgery under local anesthesia. However, what I don’t agree with was that the doctor discharged him home with oral antibiotics. With his mouth so swollen, I don’t know that he can swallow pills, and his throat was swollen that he was struggling to breath. When you have to work so hard to breath, you can’t always keep it up forever, and eventually you’ll stop. I hope that doesn’t happen.

                

There was another patient with fever and a negative malaria blood smear, so I tried using that as a teaching point about infections that aren’t malaria, but also cause fever. I might as well have been talking to a brick wall. Both the military doctor and the junior doctor in the room insisted that fever is always malaria. When I tried pointing out that mild dengue looks like malaria, they said that dengue looks like ebola. I agreed that severe dengue looks like ebola, but mild dengue looks like malaria, and they said that dengue is not nearby. I informed them that Cabinda (the piece of Angola north of the Congo River) has dengue, and that that’s very close to Bas-Congo (the region of DRC we’re in), but they said no, that dengue was in Sudan and malaria was in DRC.

                

Clearly I wasn’t going to get through to them.

                

Lunch break was at noon, and then we had academics in the afternoon. The topic today was malaria, so I wanted the DRC physicians from Kinshasa to give their presentations on malaria, followed by COL Lesho, one of our teammembers, to present infections other than malaria (dengue, chikungunya, typhoid) last. However, they’re so eager to have us talk that they had him go first, and he was a bit awkward with the translator, taking almost an hour. That only left an hour for the DRC physicians to talk about their malaria programs, which wasn’t enough time. We’ll have to finish that tomorrow.

COL Lesho's lecture

What we did learn about malaria in DRC was interesting, though. There are no parts in DRC that are not endemic for malaria, and everywhere accepts it as a fact of life. DRC accounts for 11% of all malaria infections in the world, and is one of five countries that makes up more than 50% of all world-wide infections. Forty percent of childhood (<5 50="" all="" and="" are="" big="" doctor="" during="" for="" malaria.="" malaria="" numbers.="" of="" old="" p="" pregnancy="" so="" those="" visits="" years="">

                

Nationally, the country has programs for treatment and prevention; sadly, I can tell you from working in clinic that the treatment programs are not followed. All clinical malaria (fever + any other symptom) is supposed to be confirmed by blood smear before treatment, but all “clinical malaria” (any fever) is treated as malaria, regardless of what the blood smear says. So everyone is getting medication that they probably don’t need, and everyone is ignoring other causes of fever. I also asked what percentage of the population is using bed nets (one of their interventions), and was told “everyone”. Everyone in DRC gets free bed nets—insecticide-treated bed nets are distributed free of charge—but as far as usage? Nobody knows, because nobody asks.

                

Mosquito net sign

It’s very frustrating for me, a physician who was trained in evidence-based medicine and in tropical medicine, to go to a place where evidence is disregarded, where national and WHO guidelines are ignored, and where the physicians on the ground aren’t interested in learning from outside physicians. It makes me wonder why we’re here at all, working side-by-side with physicians who ignore our “helpful hints” and are only giving lectures to the upper-level policy makers, all of whom already know what we’re teaching.

                

I’m probably not going to give this experience a high rating.

6-6-13: Day 2 of Clinicals, Day 1 of Academics

Today was day two in the hospital, and things went pretty similar to day one. I talked to the DRC physician I’m working with before the first patient this morning, and said that I’m okay doing physical exams, but what I wanted to do was discuss what he thought the diagnosis would be and differences between symptoms in DRC and the US. However, what ended up happening was pretty much the same as yesterday. He would pretty much do a full history, full lab work, and physical exam on every patient, which is not standard operating procedures in my clinic. If I do a physical exam (which our veterinarian will tell you is hit or miss), I only examine the areas in question—if you’re complaining of shoulder pain, I’ll look at your shoulder, but don’t expect me to press on your abdomen. If you’re complaining of shoulder pain, I’ll ask you about your shoulder, what the pain is like, and how long it has been hurting. And I’ll only order labs if you look like you have an infection or if you need your cholesterol checked.

                

I did have some opportunity for teaching, or training, or whatever you want to call it: there was a man around 70 years old who came in for difficulty rising from a chair and inability to see out of one eye, and I pulled out my ophthalmoscope (to look in the eyes) and showed the DRC physician and the doctor-in-training (graduated medical school and here for additional training before he goes out into independent practice) how to use an ophthalmoscope to look into the eye. Anyway, he was completely blind out of that eye, and the pupil didn’t even change with light, which is a bad sign. I’m pretty sure he had a stroke, and possibly has Parkinson’s, but neither of which is treatable in DRC, so there really wasn’t much to do.

The second case where I got to be an expert was the last case of the morning, an obese women (yes, they do exist in Africa) with abdominal pain. I’m pretty sure she has gallbladder problems, and talked the doctor into sending her for an abdominal ultrasound to look at her liver and gallbladder. I also identified that her skin was darker in her skin folds (neck, armpits, stomach rolls) and pointed out that that is usually a sign of diabetes in the States, and maybe we should check her blood sugar. So they did. I don’t know the results yet.

Over lunch, our team conferred about things we had seen over the morning and what we wanted to do for academics. We have a pediatrics infectious disease physician, adult ID physician, me, a public health nurse, and a lab officer. The peds ID doc saw clinic and then rounded in the pediatrics ward, but both the adult ID doc and I just saw clinic, and would both be interested in seeing rounds. Hopefully tomorrow. Honestly, I think the public health nurse is having the best time and seeing the most things. Yesterday she went over the tuberculosis surveillance program and other surveillance programs, and today she rounded with the nurses on the internal medicine wards. The lab officer, who was requested to help them with the blood bank program and with SOPs in the lab, today tried to talk to them about quality control and calibrating equipment, but didn’t really get far. The idea of having quality control is fairly foreign to them.

                

After lunch was academics, and today was the first real day of academics. We got an overview of the hospital, which I had heard in March but the rest of the team hadn’t. The hospital commander ended up giving more of an explanation of the health zone and the six included health areas, which was good, because that was stuff that I hadn’t heard before. After that, I gave an overview of prevention of cholera, and then the academics concluded with the hospital commander with discussing the cholera epidemic that happened from January 2012-February 2013. In the 12 months of the outbreak, there were 226 cholera patients in the Kitona Health Zone area, with 4 deaths, and no cases among health care workers. Everything they had done was textbook; in the lecture I gave about preventing cholera during an outbreak, there were ten points that I had mentioned, and they did all ten of them during that outbreak. There were questions from both the DRC physicians and our team asking if we had coordinated the lectures, but we hadn’t. They had done everything that well.

Setting up for academics

COL Amisi Okito, the hospital commander, speaking about the 2012 cholera outbreak

I’m hoping to round with the internal medicine team tomorrow, which I think will be more interesting than clinic, and possibly have more opportunities for teaching. We shall see how things develop.  

6-5-13: Getting Started

Today was our first day working at Kitona Referral Hospital, which was nerve-wracking in its own right. It means that the MEDRETE has officially started, and there’s nothing we can do about it now.

For the mornings, we’re paired up with DRC military physicians, to see patients with them. My physician partner is the equivalent to a first lieutenant (one rank behind me), but he’s older. He also has a wife and five kids in Kinshasa, which came up in conversation before our first patient arrived.

                

We spent more time on the first patient than we should have, given how many patients we had to go through. I think maybe the physician I’m partnered with was unsure about my level of education or what my role is, because he explained things in much more detail than necessary, instructing me on listening to heart and lung sounds (medical student-level instruction). I didn’t say anything, but I should have, because it made things drag on much more than necessary and didn’t really accomplish anything. Tomorrow, I’m going to tell him that I’m okay on physical exam, and what I really want to do while we’re working together is talk about what he thinks the diagnosis is and why, and from there, to discuss the differences (or similarities) between those symptoms in the States and in DRC. I guess we’ll see if I have enough of a backbone to do that tomorrow.

                

The first case was interesting, though. It was a young man, maybe 23, a college student with pain with urination. My immediate thought was chlamydia or gonorrhea, both sexually transmitted diseases. However, the physician I was working with didn’t ask anything about sexual history (beyond “are you married?”), and definitely didn’t ask the “men, women, or both?” question that I was taught in medical school. He was leaning much more toward a urinary tract infection, which is fairly rare in grown men in the US, outside of some other medical problem (HIV, cancer, etc) or men who have sex with men. However, he said that UTIs are common in men in DRC, due to poor hygiene, poor sanitation, and relative dehydration.

                

The rest of the morning was fairly routine cases, and then it was time to break for lunch (me, not the DRC physician… they don’t eat as many meals as we do and don’t mind working through the day). In the afternoon, we were supposed to have didactics, but there was such an influx of patients from the community that none of the DRC military physicians were able to get away. We found out afterwards that that was because there was a message that went out on the radio saying that the Americans would be here and would be giving out free medical care.

In other words, the exact opposite message that we wanted to go out, which was that we would be training in public health and infectious disease along with the DRC military physicians.

                

Instead of doing academics, we hammered out a schedule for the week we’ll be here, with what we’re going to talk about on any given day, and then it was time to go back to the hotel. This morning, the hotel manager told our logistics people that they don’t have enough money to keep taking care of us (electricity, food, etc) for eight days, especially with the list of needed repairs that we gave them (showers not working, AC out, etc). We gave them one night pay each ($100 x 10 people) to help out before we checked out. When we got back from the hotel, we found that they had repaired all the plumbing issues we brought to their attention (for example, the switch deciding shower or bath in my shower was broken, causing there to be a slight trickle of water from both) had been repaired, and they had moved everyone who’s AC was broken into new rooms.

Landscaping at the Prosper, new since March

Apparently, when you give money to a business in the developing world, they reinvest it in their business, instead of just lining somebody’s pocket, as usually happens in the State. It was nice to see a hotel operating to provide hotel services, and not just a profit.

                

Well, it was a long day, and after waiting far too long for our food at the restaurant (as usual), I’m ready for bed. I hope tomorrow goes smoothly.

Dinner tonight: lobster :)

6-4-13: Back in Muanda

After getting into the hotel in Kinshasa late(ish) last night (around 9), I had a late dinner and then went to bed in preparation for getting up early to go running before we had to head to Muanda in the morning to begin the MEDRETE. As it turned out, I didn’t go running (the alarm went off and I disregarded it), but I was ready for the flight to Muanda.

View from the Fleuve in the morning

The flight was the same as last time—small prop plane, a little warm, stops in Matadi and Boma—before we landed in Muanda around noon. We loaded up the rental cars (and by cars, I mean Toyota Highlanders), dealt with the usual drama associated with traveling in developing countries, and made our way to the hotel. Fortunately, the advance team was already on site and had ordered our lunches ahead of time, so we only had to wait about 30 minutes before we got to eat.

View of Kitona Base, from above.

Around 2 pm, we headed back to Kitona Base, to meet with the hospital commander and a few representatives of the medical department of the Ministry of Health, who had traveled from Kinshasa. We hammered out the final details in preparation for tomorrow (which I still think will be a disaster) and then called it a day and headed back to the hotel.

We’re staying at the Hotel Prosper this time, which is different from my hotel when we were here in March (I was staying at the Eunice). The rooms aren’t as nice, the air conditioning doesn’t work as well, and as of yet, I still don’t have running water. This will make returning from my run tomorrow interesting, I’m sure.

My room in the Prosper, complete with sequined pillowcases

We had a meeting of the medical personnel right after we got back from the hotel, to hammer out who’s giving what presentations during the academic portions of the mission. We’re going to be working closely with the physicians in the morning, seeing patients while paired one on one with the DRC military physicians, and then the afternoons will be spent in academics, some of which will be given by us, and some by DRC physicians. I still don’t know exactly what I’ll be talking about, but a couple of the other physicians came with canned presentations that will work nicely.

               

It’ll be interesting, let’s just put it that way.

                

The day wrapped up with dinner at New Cliffs, which we ate at before (as it’s one of three restaurants in the whole town), and like before, it was a 2.5-3 hour wait before we got food. We did get to see the sun set over the Atlantic Ocean, so that was kinda neat, but really, we were hungry.

Watching the sun set from the beach by the New Cliffs

Tomorrow, after a short run in the morning with a few of my teammates, it’ll be the first day of the mission. Should be interesting.

Getting Ready to Leave Again

Tomorrow I'm taking off for Democratic Republic of Congo again, so why I even bothered to go to work is beyond me. Especially because I was on the only one there.

It didn't take me long to finish the few things I needed to do for travel before I went (printing off my official orders, attempting to check-in for my flight only to be told that I have to check-in in person because I'm flying internationally), and then I moved onto the things I knew I needed to do before heading out for two weeks (putting in medication refills, making sure orders were in the computer, etc). All in all, most of the work day was pretty boring, but at least it was quiet, since I had the office to myself.

The one point I had today where I actually got to feel productive was when one of the medics for A Co came in to ask me to look over his medical threat brief for Lesotho. He's not going to Lesotho, but two of his team members are, and it's always the responsibility of the medic to put together a "okay, here's what this country has and here's how you can avoid getting sick" brief. We have a template of the brief that they should give on the medical section website, so they just fill in/delete as needed for the country (for example, Lesotho doesn't have yellow fever or malaria, so you don't need slides for either of those). Unfortunately, he didn't remember that we had a template, so he tried to reinvent the wheel.

For the most part, it wasn't too bad. There were a few things he went into too much detail about--he had a slide about the symptoms and treatment of hepatitis A, when all he really needed to say is 'hepatitis A is transmitted by food and water, and you're vaccinated against it--and a few things he didn't go into enough detail about--what to do about jet lag, how to be safe while traveling, etc. So we went through the template presentation and filled it out for Lesotho, discussing things along the way, such as which vaccines they needed and which they didn't. The medics are all pretty sharp, and this one was no exemption, so he picked up on the stuff pretty quickly. It's still hard for me to remember that they don't have the same training in travel medicine as I do, however, so sometimes I have to stop myself in midst of technical explanations about proper dosing of malaria medications and remind myself to stick to the things they need to know.

Anyway, so that was my bit of excitement for the day. Once we were done discussing Lesotho (and discussing his future career plans), I called it a day (because there was nobody around to tell me I couldn't), put a message on my white board saying that I'm out until 17 June, and headed home to pack/procrastinate about packing. Because honestly, I hate packing and I wish I could pay someone to do it for me.

Out in the Field

Despite my best intentions, I've been neglecting the blog world. Sorry about that. I can't decide if it's that I've been too busy or that things are too routine. Let's just go with that I'm too lazy.

A few weeks ago, though, we did something out of the routine--we went out the field! Kinda. Alpha Company had their Culminating Exercise, which is when they go to a simulated village, in this case in Mali, and demonstrate that they learned something in all of their training.

In theory, anyway.

The week started with the firing range and mass casualty situations, which were to assess how well the medics could triage and determine who to treat first. Overall, they didn't do too well. One medic spent all of her time on a head casualty that should have been triaged as "expectant" (as in, expectant to die). Another went straight to the first casualty and didn't look any further. In other words, we have some work to do.

On days 2-4, they were out in the simulated village in "Mali" (really a remote corner of Ft. Stewart). I got to play a doctor with MSF (Medecines Sans Frontieres, or Doctors Without Borders), which has a very strict "we don't work with the military--any military" policy, so I played that to the best of my abilities. This is me yelling at one of the team leaders (my friend Dan) for their actions throughout the village and how we just wanted them to leave.

The other two officers in my office, MAJ Greifenstein, the environmental science officer (in red) and CPT Avriette, the veterinarian (the girl) also got to play parts, both as USAID scientists (he a soil science, she a vet... we were really imaginative). In the course of playing a soil scientist, Griff was digging holes, and instead of the teams asking him what he was doing (which they were supposed to do), they reported him for burying land mines and declared entire roads off-limits. Not quite the reaction we were going for.

In all, it was a fun week in the field (because, well, we weren't in the office), but the teams have a lot to learn about operating in Africa. Maybe I have an advantage, because I've only been on "peacetime missions" and no deployments to Iraq or Afghanistan. I don't really have a combat mindset, but all the team members have been deployed in combat situations, and that's what they revert to when they think of going overseas. As I've said in multiple conversations to multiple people, Africa is not Iraq or Afghanistan. Not only that, but civil affairs shouldn't be about combat. It's not about going into a village with weapons, ready to shoot the bad guys. It's about getting to know people and winning trust, and not assuming that there's a bad guy behind every door.

It's a work in progress, I guess.

More Medic Training and Some Random Musings

I actually started to write this post on Friday, but then I realized that I didn't have everything I needed to write it. By that I mean the link to the article I wrote... Keep reading and that will make more sense.

Before I left for ACPM, we had Dr. Likita Aminu from the CDC come over to talk to the medics about hepatitis. Dr. Aminu is originally from Nigeria, and met LTC Gardner in December at an African culture event in Savannah. Because LTC Gardner can talk anyone into anything (he is, without exaggeration, the type who would be able to sell ice to Eskimos if he wanted), Dr. Aminu agreed to chat with the medics. Since he had done research on hepatitis in the Coastal Region of Georgia (where we live), and hepatitis is an issue in Africa, that's what he talked about.

And here's the link to the article I wrote about the training:

http://www.stewart.army.mil/homepage/news/news8.asp

Now onto my random musings. For the second half of last week, I was in a pretty annoyed mood. I think it started on Wednesday, when we had a Command and Staff meeting. Command and Staff is pretty awful to begin with--each of the staff sections talks about what's going on in that section. It's great if you really care about how many humvees are due to be serviced or whose evaluations are due. If you don't, it's about an hour and a half of torture. Well, because the conference room table is only so large, I don't have a seat at the table, but I do have a slide (as in, one PowerPoint slide) to brief, and that's the medical readiness of each of the companies. To make an already long story somewhat shorter, before the meeting started, I was trying to find the right chair to pull into the corner of the room, the entire time thinking, "I went to four years of medical school and three years of residency for this?" Yes, a bit egotistical, perhaps, but that is what I was thinking.

I think part of that was the fact that I was just at a conference, hanging out with the people I used to work with, which was a nice little reminder of how well I used to have it. In residency, my only obligations were to learn as much preventive medicine as possible (and stay up to date with all my Army required trainings, of course). Now, I see routine complaints (boring), track who is due for which vaccines or blood work (boring), and only rarely get to do anything preventive medicine or tropical medicine related (yay!).

I guess the point of that is, going to such conferences remind me that I do like the Army, but that I think I'll be happier if I leave FORSCOM and go back to MEDCOM, where doctors typically get to do what they're trained to do.

We'll see what happens.

Training the Medics

Yes, it's been a while since I've last the blog... Sorry. I wish I could say a lot has happened since my last post, but sadly, that's not really true. It's pretty much the same thing on a daily basis: work-out, go to work, go home, sit on the couch, go to bed, repeat. With the occasional variation for a weekend.

So I'll write about what's been occupying my time at work: how to train the medics.

We have about 25 junior medics (private first class-corporal), all of which are very bright, for junior medics. They were recruited for civil affairs by being at the top of their classes during Advanced Individual Training (AIT); once selected for civil affairs, they completed a seven week CAMS course (Civil Affairs Medical Specialist), which went over basic preventive medicine, environmental science, and veterinary medicine. More than half of them have gone to a paramedic course and are now certified paramedics. They're great at trauma care; unfortunately for that, most of what the medics are probably going to be encountering in Africa is going to be tropical medicine and not trauma.

Fortunately, I happen to be a little bit good at tropical medicine (and that's not just me saying that... The American Society of Tropical Medicine and Hygiene agrees, and gave me a certificate saying it).

So between the environmental science officer, the vet, and myself, we came up with the perfect (okay, not perfect, but decently good) training plan, with two hours lectures once a week, on Wednesdays from 2-4 pm. We presented this to the company commanders, but sadly, the presentation did not go as planned. The company commanders were concerned that we were trying to tell them what to do with their people, and told us that they'll get back to us with a plan for how they want us to train their medics.

That was over a month ago. Still no word on what that plan is.

In the meantime, we've been doing what we can to "unofficially" train the medics. I put "unofficially" in quotes, because everything is, actually, official (we keep careful records, because the medics need a certain number of hours of training a year to maintain their certifications), but just not without the approval and/or knowledge of the company commanders. Through the super-secret sergeant channels (that's what I call how all of the non-commissioned officers get things done), the senior medics who work in the aid station contact the senior medics in the company and tell them that we're going to do training, and if their junior medics are free, that they're welcome to attend. For unofficial training, we've so far done "stump the professor", where the medics asked me any question they had about diseases in Africa (on which they stumped me on one disease--guinea worm), and practicing inserting IVs, which Mary, the vet, ran (she even brought in her dog so the medics could practice on the dog as well as each other). Both went very well.

We've also had official trainings, which so far has consisted of one guest speaker, a Nigerian-born physician from the CDC. He came in to talk about his research on hepatitis that he's done in the Coastal Region of Georgia, and compared that to hepatitis trends around the world. Some of the statistics were a bit pedestrian, but overall, the medics were very attentive throughout and asked some good questions, so I'm proud of them. We have another presentation scheduled for a couple of weeks from now, when the dermatologist from Ft. Stewart is going to talk about tropical dermatology. Should be a good presentation.

Long story less long, training the medics to know what they need to know about tropical medicine, before they go to Africa, isn't easy, but we're finding a way to make it work.

Back at Work

Because our battalion is still getting started as far as missions, I was fortunate enough to be able to escape for two weeks of leave for Christmas and New Year's. I started with a week in Everett at Alex and Allison's house with the family, with a side trip over the mountains to Moses Lake for a day to see Papa and the cousins and their families.

Mountains. Aren't they pretty?

For the second week, I hopped over to the other Washington (D.C., that is) for some time with my friends. My friend Jen (the one I went to Kilimanjaro with) broke her leg, so it was a pretty low-key stay. She invited some friends over for New Year's Eve; it was good to get to hang out with them again.

Unfortunately, on New Year's Day, I boarded a plane back down to Savannah, because on the 2nd, I had to be back at work. Fortunately, most of the battalion was still on leave, so I had the office to myself and was able to be pretty productive. I didn't end up missing much while I was gone (like I said, there's not much in terms of missions), so it took me surprisingly very little time to get caught up.

I think things are going to start picking up pretty quickly, so now's the time to get as prepared as possible, and hopefully we'll be ready when it's time for the first team to be out the door.

Change of Command, Staff Assistance Visit, and Board Exam Results

The last two days have been pretty busy for the medical section of the 82nd Civil Affairs Battalion. We started our day yesterday with a Staff Assistance Visit (SAV) from our parent brigade, the 85th CA Brigade. I think the original plan was that all of our counterparts would come over from Ft. Hood, but in the end, it was just the brigade veterinarian and environmental science officer (so, my counterpart wasn't there). The vet, who is the head of the med section at brigade, explained to us things that he expected from us and updated us on live tissue training (LTT).

To back up for a second, LTT is essentially doing trauma training on animals, in order to prepare Soldiers to do trauma care on Soldiers in combat situations. To explain what happens in very simple terms, a goat will be shot and then it'll be up to the Soldiers to keep it alive for, say, four hours. This is done throughout the Army, but usually just for medics and just before deployment to Afghanistan. In the Special Forces community, where much of our leadership is coming from, all of the team members participate, because they operate in small teams (like we do), and if something happens to their one medic, the other team members need to know what to do. Summing up many months of discussions and requests, the battalion wants us to do LTT. Well, getting permission to do that isn't nearly that easy. The brigade vet explained the process that's going to happen, which is going to involve paperwork sent up the Pentagon and probably three + years of work in progress. In other words, not the answer we would have liked, but we finally have an answer when people ask.

After a couple of hours of meeting with them, we had a change of command ceremony for Headquarters and Headquarters Company (HHC). Since I am in HHC, I should have been in the formation, but because of our SAV, we didn't have time to rehearse, so we just watched (actually, our command sergeant major told us to sit in the second row of the VIP section, so that was kinda nice). It was ridiculously cold (our only cold day; it went back up to the mid-60s today), so I was glad to be able to sit and wear my fleece jacket, instead of standing at attention in formation.

Here's the outgoing company commander, CPT Scott Cummings, pass off the guidon (the flag) to LTC Gardner to signify handing over his command:

And below is LTC Gardner handing the guidon off to MAJ Will Richardson, the new HHC Commander.

I had never seen a change of command ceremony before, so it was interesting to see. And I'm happy for both Scott, who gets to move to B Company to be a team leader, and MAJ Richardson, who is going to be bringing his civil affairs expertise to the company command.

After all that, I finally had a little bit of time to do my job (imagine that), and then our counterparts from brigade wanted to go out in Savannah. MAJ Escajeda, the environmental science officer, had been stationed at Ft. Stewart before, so she knows Savannah. We went to Pirate's House for dinner (great food) and then did a hearse ghost tour just for fun. It was all very hokie, but we did get to hear some stories, like the involvement of the Candler Hospital in the yellow fever outbreaks in the 1800s and during the Civil War. And it's supposedly haunted, but we didn't see any ghosts. Just a really old hospital (the oldest in Georgia and the second oldest in the country, according to our tour guide).

It was quite a night out (I got home at 1 this morning), and then I had clinic this morning (ugh). When I got home, though, I had some good news waiting for me in my mailbox: I passed my board exam! It was a pretty poorly written exam, but apparently everyone who took it felt the same way, because I finished the two pieces of the test at the 95th and 98th percentiles. The certification lasts for 10 years, so I am done taking exams until 2022. That's certainly a relief!

APFT and Preparing for Yet Another Exam

Even though the rest of the Army does the APFT (Army Physical Fitness Test) in April and October, we just got around to doing ours on Wednesday (November 6). Better late than never. Now, this brings up a fun fact about coastal Georgia: it gets cold in the mornings in November. Not the kind of bone-piercing, dry cold that I grew up with. No, this is wet cold that you breathe into your lungs and it just kinda stays there, all cold. So even though the thermometer said 42, I was bundled up like it was far below freezing (or maybe the South has just made me weak).

Despite the cold (and a fair amount of whining by yours truly), I managed to do this on the APFT:

That's a 308/300, or better than what the Army considers to be prime fitness (it'll be recorded as a 300 in my records; just like there's no such thing as an A+, there's no such thing as better than the maximum score). Since our brigade command sergeant major (highest enlisted Soldier in the brigade) was here from Ft. Hood, my perfect score got me one of these:

This is our brigade coin, which I was supposed to be awarded during morning formation yesterday. Unfortunately, when they called my name, I wasn't there, because I was at the hospital seeing one of our Soldiers. He had an ACL repair last week and ended up developing a clot (DVT, or deep vein thrombosis) in his leg, which traveled to his lung (forming a pulmonary embolus, or PE). He's doing fine now, but he's been in and out of the ER since the day after his surgery. He first went in with shortness of breath and a CT (cat scan) was negative for PE. So he was sent home; four days later, he was again short of breath, and this time, they did find a clot in his lungs. It wasn't large, but they did admit him for observation and to teach him how to take the medications to treat it (one week of a blood-thinner shot and six months of a blood-thinner pill). Unfortunately, the day after he was discharged from the hospital, he was back in the ER. He followed up with the orthopedic surgeon who did his ACL repair and ended up coughing up a little blood, which freaked out the surgeon and he called for an ambulance. Again, he's fine. I explained to him that while he's on these blood thinners, he might cough up a little blood every once in a while, or he might get nosebleeds, or might bruise easily, and unless he's actively bleeding, there's no need for alarm.

The biggest learning experience of this (for me) was learning how to be an intermediate between the doctors at the hospital and the Soldiers and officers of my battalion. I obviously speak 'doctor', but this Soldier doesn't, and neither does his company commander or first sergeant. They're understandably protective of their Soldier and were very upset about all of this back-and-forth to the ER, thinking that it meant that he wasn't getting adequate care from the hospital. So I talked to his doctors, found out the whole story, and explained things to the Soldier, his commander, and his first sergeant in a way that (I hope) calmed everyone down.

Of course, after all of this, I hopped on a plane for Atlanta (okay, there was some time between; I finished up the workday yesterday, went home, studied, got up this morning, went running, gave blood, and then hopped on a plane for Atlanta), because I have my Certification of Knowledge in Tropical Medicine exam tomorrow, the first activity of American Society of Tropical Medicine and Hygiene. Since arriving at the hotel, all I've done is sit and go through my flashcards (I'll put up a picture of the stack of flashcards tomorrow, if I remember). I did have a nice view, though:

I'm on the 23rd floor of the Atlanta Marriott Marquis, which is downtown (and only a couple of blocks from a MARTA station, so I didn't have to spring for a cab from the airport). After my exam tomorrow (if I have any energy) and all day Sunday, I'm going to explore Atlanta, since I haven't been here (airport doesn't count) since my summer at Emory in college (2004... Man, time flies). And then I'll be spending my time conferencing and preparing for my presentation. More about that later.

Activation, Triathlons, Medical Evaluation Boards, and Everything In Between

Yes, it's been a while since I've updated. A very long while. I could say I've been busy, but really, I think I've just been lazy. Here are some of the things that have happened since my last post:

1) The 82nd Civil Affairs Battalion was activated on 27 September 2012. The week leading up to the activation, we had rehearsals almost every day, which was tedious, but there were still some good times:

This was one of the rehearsals, obviously. I don't know what led to this; I just walked up as they were doing pushups, so I figured it was as good a time as any to take pictures.

And this is 2LT Alex Sasseman, the Adjuvant General (officer in charge of personnel). She had the delightful job of running in front of formation at the sound of the Adjuvant's Call, so that was actually quite a bit of running in the course of all of those rehearsals.

This was after the activation, when LTC Gardner (in the middle) cut the cake with his Zulu sword.

2) Triathlons. I ended up doing two triathlons this summer, one on the beach on Hilton Head Island and one in Florida at Amelia Island. The one on Hilton Head was actually pretty difficult, because not only was everything on the beach (including the bike), but it was August and very hot and sunny. The one at Amelia Island ended up not being a triathlon (they cancelled the swim due to riptides), but was still a good race. I ended up winning the military division for the sprint distance (16 mile bike and 3 mile run). I also did a 2.5 mile ocean swim in Jacksonville, FL and a few runs, the most recent of which was the Rock n Roll Half Marathon through downtown Savannah yesterday (I started too fast in efforts of finishing under 2 hours and ended up dying around mile 8, coming in at 2:21. I'll try not to repeat that mistake at my next half in December).

This was at the costume run the Friday before Halloween. I had to buy the red running shoes special for the costume.

3) Medical Evaluation Boards (MEB). This is not fun. As part of the "post tax", as LTC Gardner calls it, once a week I see soldiers from the Military Police in clinic to determine if they need to go to the MEB. These are soldiers who have been on limited duty profiles for an extended period of time and aren't making any recovery (or not enough). For some, it's just a matter of writing a referral to see a specialist (orthopedics, neurology, etc). For others, it's time for a long conversation about not being fit for the Army any more. It's not as simple as writing the referral for the MEB, unfortunately. The entire process takes anywhere from 6-12 months and involves many meetings and evaluations from people from the Army and the VA and likely more that I'm forgetting. I have no idea how many of the people I refer will actually be found to be not fit for duty, but this is what I do.

4) Parents came to visit. We explored Savannah, went hiking in a state park, Jekyll Island, and went up to Charleston, SC and Ft. Sumter. It was good to have them here (even though my guest bed didn't arrive until after they left).

5) Disney World. It's the most magical place on Earth. Need I say more?

6) Firing range. For three days last month, I got to hang out with the team leaders and senior NCOs from Alpha Company at the firing range. It wasn't much fun, but I did qualify on both the M4 (rifle) and M9 (pistol).

And I got a little burned by some ejected brass. Like I said, not much fun.

I think that's about it. I'll try not to let it be another three-ish months before I update next.