Defense Occupational and Environmental Health Surveillance Course

For the last couple of days, we've been up at Ft. Meade for a three-day course on Defense Occupational and Environmental Health Surveillance, or DOEHS. The main purpose of the course is to teach us, as preventive medicine physicians, what the other members of the preventive medicine team do, both while deployed and in garrison. 

The preventive medicine team, in addition to the PM physician, includes environmental science officers, environmental science engineers, entomologists, industrial hygienists, and a slew of others, included enlisted preventive medicine techs and environmental science techs. We started the course with a "where do they go when they're deployed?" talk, which goes something like this:

Level 1: Each Company has a field sanitation team, which is two enlisted soldiers who, as an additional duty, are responsible for field sanitation (latrines, bug spraying, etc). Since this is an additional duty, nobody wants to do it, and is sometimes (but not supposed to be) given as punishment. 

Level 2: Each Battalion (which has ~5 companies) has a PM detachment, with one junior (2LT or 1LT) environmental science officer and one junior (private-specialist) environmental science or PM tech. 

Level 3: Each Division has a PM physician as a consultant to the Division Surgeon. In addition, there's a PM team, roughly 5x the size of a Battalion-level team.

Level 4: Area Medical Laboratories. There were two, but one was just deactivated. These are complete and completely deployable labs, with almost the capabilities of public health labs in the States. When they deploy, they have a total of 43 people, 19 officers (including 1 PM physician) and 24 enlisteds.

Level 5: Public Health Command, at Aberdeen Proving Ground. That's the definitive authority for everything public health/preventive medicine in the Army.

The confusing part comes when you start to consider who answers to whom. It would make sense to put the Battalion PM assets under the command of the Division PM assets, but this isn't true. The Battalion PM assets fall within the Battalion, and thus, the Division PM doc doesn't have the ability to directly ask the Battalion PM to do something.

It's the Army. It's sometimes a little confusing.

Today we focused more on what people are actually doing while deployed. We learned about the equipment that the enlisted techs use on their inspections. Here are some pictures:

Above is a rucksack with everything a PM or environmental science tech needs to do an assessment of a forward operating base. It's actually quite amazing all the stuff the pack contains, and it still weighs ~35 pounds.

This is a kit to test untreated water; for example, if they're evaluating a lake or river to use as source for a water treatment facility. To give you a sense of scale, everything's packed inside a cooler. All of the testing is done at Public Health Command; they send the cooler, the techs fill the bottles according to instructions, and then send it back for testing. The whole process takes around 6 weeks.

Tomorrow we're going to hear from the other sections. Although this won't be as pertinent to my first assignment with civil affairs, there will be other deployments in the future, so I should try to keep this all in mind.

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.

Poisoning project

I'm actually starting on my second week at Ft. Meade, which means I've really procrastinated about summing up my AFHSC rotation. As I mentioned before, my project was on poisoning hospitalizations in the military from 2001-2010, figuring out which of those were intentional, and finding risk factors of intentional poisoning compared to those that are unintentional. Here's what we got for total numbers:

I also looked into what people were being poisoned with. The top contenders are pain medications and psych medications (surprise, surprise).

The next part was to look into which hospitalizations were intentional. For this, I used an algorithm that was published in the civilian medical literature that looks into certain psych diagnoses during the hospitalization for poisoning. Surprisingly enough, despite the increases in psych diagnoses in the military over the last ten years, the percentage of poisonings that were intentional has remained fairly constant (with a very slight increase).

Risk factors for intentional poisonings were drug (medication) overdoses, being female, married, black, a recruit, in the Navy, and multiple deployments. Protective factors are age over 40, currently being deployed, being in the Marine Corps, and increasing rank (which goes along with being older).

I presented that about a week and a half ago and got a fairly good reception. Previous residents were only on that rotation for four weeks, instead of the six that I (and my fellow residents) have, so I was able to do more analysis than they were accustomed to seeing. All in all, it was a good rotation and a good refresher on the epidemiology. I'm still trying to get in the swing of my current rotation (preventive medicine department at Ft. Meade). I hope this one ends up being a good learning experience as well.