Update from the ACPM conference

So I was going to write about significant events for each day of the ACPM (American College of Preventive Medicine) conference, but I got too lazy. Here's significant events of the first two days:

1) Met my new residency director. LTC Cersovsky, the current WRAIR residency director, will be getting promoted (as happens in the Army) sometime this year, so MAJ Mancuso will be taking over. I got to meet him, and everyone who has worked with him says he's a really nice guy and very smart, so that'll be a good experience.

2) Met another OSU alum in Army preventive medicine. MAJ Schnabel is a 2002 OSU College of Medicine alum who is currently the director of the Global Emerging Infection Surveillance at the Army's research facility in Kenya. He has done some pretty exciting things with disease surveillance in Africa, which really makes me want to have his job someday. He now makes five OSU alums/future alums I know in preventive medicine in the Army (one resident at Madigan, one resident at WRAIR, a staff member at WRAIR, him, and me). Pretty impressive for a school that doesn't emphasize preventive medicine in the curriculum at all.

3) Impressed the MSS (Medical Student Section). We had our annual MSS meeting this morning, and the members who were there seemed rather impressed with stories from PNG. One of the girls had done some public health work in Tanzania and also sees herself doing a lot of international medicine in her career, so we had a very long talk about that while socializing tonight.

4) Discovered that I get to add another publication to my CV. The project I worked with at WRAIR during my preventive medicine month has been made into a poster (CPT Ahluwalia, the resident--and OSU alum--I worked with that month will be presenting).

5) Been invited to join in another research project. Another WRAIR resident (CPT Manos) invited me to join in a project that involved WRAMC interns (of which I will be next year). It'll probably lead to a publication in a few years.

6) Been welcomed to the RPS (Resident Physician Section). CPT Ahluwalia is the RPS president, and I think he's grooming me to follow in his footsteps (being as I'm a fellow WRAIR Buckeye and all), so he's been taking care of me during the conference and talked me into coming to the RPS meeting and is trying to get me to run for an officer position (as an intern!). He's also been trying to convince me to go to Johns Hopkins for my MPH, which is what he did.

7) Networking, networking, networking! I'm meeting so many interesting people with very interesting careers in the field, and I'm getting very excited about the possible things that I can do, both in the military and if I decide to leave when my commitment is up (in eight years).

So far, it's a really great conference, and I'm looking forward to learning more tomorrow. As for now, it's time for bed.

Match results!

The military match results came in this morning at 0600 EST. I have, obviously, been looking forward to this moment for months, if not years. Here it is:

Walter Reed Army Institute of Research preventive and occupational medicine residency class of 2013

Yay! That was my first choice and I'm quite thrilled with the results. Tonight is our post-match Military Medicine Interest Group meeting, so I'll find out how my military classmates did and where they'll be going.

Anyway, here's my schedule for the next four years:

July 2009-June 2010: transition year internship at Walter Reed Army Medical Center
July 2010-June 2011: Master's of Tropical Medicine and Hygiene (or Master's of Public Health) at the Uniformed Services University of Health Sciences (or, if I get an MPH, at Johns Hopkins University)
July 2011-June 2012: Preventive Medicine practicum year at Walter Reed Army Institute of Research
July 2012-June 2013: Occupational Medicine practicum year at the USUHS

I don't know how they expect me to do work today. I'm too excited!

Epi chiefs meeting and out-processing

There wasn't a whole lot for me to do today, so I sat in on the epi chiefs meeting at AFHSC (Armed Forces Health Surveillance Center), which is a biweekly phone conference of the epidemiology chiefs around the world--WRAIR, CHPPM (Center of Health Promotion and Preventive Medicine), USAFSAM (United States Air Force School of Aerospace Medicine), LRMC (Landstuhl Regional Medical Center), Madigan, Coast Guard, Navy/Marines Medical Command, and some other groups that I didn't catch. Anyway, a lot of time was spent talking about screening blood for Chagas disease (don't ask) before we actually got to the epidemiology part of things. There are a couple of outbreaks/clusters out there, which I found interesting, but we didn't have much time to get into them. And of course, both of the residents who were there had to leave for other meetings before this one was over, leaving me with a bunch of colonels and retired colonels to discuss the cases after the conference.

After the epi chiefs meeting was a quick lunch before I headed back to WRAIR to out-process, which consists of walking around gathering signatures--again--before turning in my badge and driving away. It was very sad, but with any luck, I'll be back here.

One of my friends from Officer Basic, Emily, is in town doing general surgery at WRAMC. Since she's on a surgery rotation, and studying for USMLE Step 2 CS, she's been ridiculously busy, so tonight was the first time she had free for dinner. It was good to see her again and talk about where everyone is applying for residencies. She's hoping to match in general surgery at WRAMC, so maybe we'll get to be interns together next year (and both so stressed we'll still never see each other... such is life).

Patient interview and journal club

Today we finally got to do our first patient interview. One of the patients is still in the hospital (actually, being transferred to the VA tomorrow, so our timing is excellent), so we got permission from the doctors taking care of him and went in to talk to him using the questionnaire that we've spent the last three weeks perfecting.

In the course of the interview, we discovered that this patient isn't quite like the others in our cluster of patients. For one, his symptoms were very sudden--he was found down in his barracks in Afghanistan and MEDEVACed to Landstuhl in Germany before being transferred to Walter Reed. Also, Stars and Stripes has already published what everyone believes to be the cause of his symptoms. Here's a link to the article:

http://www.stripes.com/article.asp?section=104&article=64432&archive=true

Well, we went through the entire interview anyway, and with any luck, the other patients in our cohort will get their interviews soon--we sent the questionnaire to the preventive medicine docs at Madigan, where two of the patients are now, and we're hoping they'll get those back to us fairly soon. With any luck, we'll find something publishable. Or, we can do what LTC Cersovsky and Dr. Scoville (the civilian epidemiologist) did a couple of years ago: publish in JAMA that they did an epidemiologic investigation of Acute Eosinophilic Pneumonia, and couldn't figure out what causes it.

That was our morning. In the afternoon we had journal club, this week's topic being rabies. I was assigned to discuss treatment of active rabies as well as to present the case of rabies being transmitted by organ transplantation. For anyone who watches Scrubs, that really did happen; they based the episode off the real-life events. It was actually a really fun journal club, because the second hour was spent discussing some cases that MAJ Soltis invented, most of which started along the lines of "That ER resident who has been calling you about possible rabies exposures all week calls you at 0300 to ask you what to do in the case of the...".

After journal club I had my evaluation session with MAJ Soltis. She said that I did such a good job, she's going to push for me to match wherever she's going to be next year. Seeing as she's trying to get sent back to Madigan, I don't know if that's such a good thing or not...

Interviews and evaluations

Since LTC Cersovsky is going on leave tomorrow, we did my residency interview (part 2?) and rotation evaluations today. The interview was pretty routine stuff... why are you interested in preventive medicine, which program are you ranking (which, technically, they can't ask, but everyone does anyway), do you have any questions for us. The one question I had was, how many people are applying for preliminary preventive medicine interns? There are four positions each year in the Army, two at WRAIR and two at Madigan. The answer? Two that LTC Cersovsky knows of :) That greatly increases my chances of matching at WRAIR and makes me happy.

As far as the evaluations, the whole thing is laughable. It's a standard evaluation form from OSU, which has nothing to do with preventive medicine--most of the questions are in regards to my clinical skills, which, well, doesn't really happen in this rotation. So he just marked "expected level" (which is the highest choice) on each of them. For comments: "Very strong performance. Would be a pleasure to have you train with us in the future." :) That also makes me happy. Now we just wait and see what happens in three months for the military match.

Journal club and more paperwork

Today was a bit of a wasted day, unfortunately. MAJ Soltis was going to go over vaccination principles with CPT Lee and me this morning; unfortunately, she found out at the last minute that she had mandatory training all morning, and essentially told us to make ourselves scarce, our we might get roped into it as well. So I spent the morning going over our patient records again, trying to figure out if there's something I missed the first time (nothing jumped out at me).

Right before CPT Lee had to leave to go to clinic at WRAIR (as a doctor, not a patient), MAJ Soltis gave us the guidelines to write an executive summary (EXSUM), which is a fifteen line brief for commanders, usually generals, who know nothing about medicine. So we put down some stuff about what we've found so far ("since 8 JUL, five soldiers have been evacuated from Iraq and Afghanistan and hospitalized at Walter Reed Army Medical Center..."), and then CPT Lee took off and I ate my lunch.

This afternoon was journal club, which was a make-up from last week's journal club, when we didn't have a computer. So I sat through seven presentations about DA PAM 40-11, and then gave my own presentation on the last four chapters. It was fairly mind-numbing.

LTC Cersovsky, MAJ Soltis, CPT Ahluwalia, CPT Lee, and I (I must say, it's getting a bit old being the most junior officer around; everyone else is two ranks above me) discussed the 5th draft of the patient questionnaire as well as the EXSUM. We found only a few minor changes to make to the questionnaire, so I'm hoping that the 6th draft will be the last. The EXSUM, however, didn't fare so well. MAJ Soltis said it wasn't bad for a first EXSUM either CPT Lee or myself has written, but you know whenever someone says that it's not bad for a first try that they really mean that it's absolutely terrible. And it was. I think the only words from the first draft that will make it to the second will be "five patients", "Iraq and Afghanistan", and "Walter Reed Army Medical Center". Oh, well. I'm here to learn, right?

I got an email from the Army's First Year Graduate Medical Education (FYGME) coordinator (the person overseeing the Army Match for residencies) reminding us that we have less than a month until the 15 October deadline to get our applications. As if I really needed the reminder.

Field trip

Today MAJ Soltis took CPT Lee and myself on a field trip to Ft. Myer, VA for travel clinic at Rader Clinic (which is actually on Henderson Hall, the Marines side of things). It was a nice drive through Rock Creek Park and the George Washington Parkway to get there.

Here's a picture of Rader clinic, obviously without the shadowy dead guy in the foreground. I actually didn't see this part of the building--we came in through the back.

CPT Lee handled the first two patients, mother and daughter going to China, and then MAJ Soltis gave the couple needing the waivers for the yellow vaccine their paperwork. Then my first patient didn't show, so we took a long shopping/lunch break. The PX (actually MCX--Marine Corps eXchange) at Henderson Hall is probably the nicest one I've ever seen. If most PXes are like Wal-Mart, this one is Macy's. Then we dined at the Marine Club for lunch before coming back for my afternoon patients, husband and wife going on a cruise in the Caribbean and up the Amazon river. The wife is a microbiologist, so she has had pretty much every vaccine known to man; the husband is retired Air Force, so he also had every vaccine known to man--in 1969. Needless to say, he needed a few boosters. So we talked to them and got everything squared away for their trip (and did a lot of small talk in the process), and then headed back to WRAIR, where we were sent home after being assigned our homework--the first four chapters of the CDC's Pink Book (vaccine handbook).

I had a good time at travel clinic, and I feel like I learned a good deal--it was different enough from travel clinic at Madigan that I can't exactly say it was the same experience. Plus, it's always nice to have a change of scenery.

Paperwork

In case you did not already know this, let me tell you what practicing medicine is: paperwork. Paperwork done by people with way too much education, but still paperwork.

This morning, CPT Lee and I got in early to do some (guess what) paperwork on our patients for travel clinic tomorrow. This entailed getting on the travax website (no, I'm not giving you a link, because it's a subscription service and you need a password), putting in the itinerary, and figuring out what vaccines and medications our patients will need. Then we looked up contraindications to vaccines and medications to make sure our patients could take them, and checked for drug interactions between what we want to give them and what they're already taking.

After that, we headed for the preventive medicine department meeting, where we heard about the various projects going on and updated everyone as to our own project. That was a little intimidating--I'm the most junior person there, both in age and rank, talking about a project that involves training I haven't had yet.

And then it was more paperwork. Everyone working on my project got together and went over the patient questionnaire I've been working on for the last week (we're on our fifth draft now), reorganizing the questions and trying to make things as clear as possible. The purpose of the questionnaire is to use it to guide patient interviews, so we can figure out what kinds of exposures our patients had, such as taking body-building supplements or working with heavy metals, and determining if the patients have the same or similar exposures. Right now, we're assuming that this is related to supplement use, so if we can get evidence of this, we're hoping we can use that get the PXes to stop carrying them.

While we were doing that, we were also coming up with a clear case definition, and using that definition to determine how common this is in the Army. We keep having to come up with more and more specific definitions, trying to get the numbers down to something reasonable. The last time we ran a query based on our case definition, we found more than five hundred cases in the last year. Obviously, that would be too many to give everyone the questionnaire, so we're trying to make it more specific and getting a better count of exactly what we're looking for.

And then more paperwork. Tomorrow, we have a couple coming into travel clinic that who will be going on a cruise. Technically, they need yellow fever vaccines, but they're both too old and too sick to take it, so we drafted vaccine waivers for the respective customs agencies, citing various studies that have shown that giving the vaccine would be bad.

We went over some more stuff for travel clinic, and then it was time for CPT Lee's phone interview with LTC Wiesen at Madigan (she's switching to preventive medicine, so she has to apply for both positions, Madigan and WRAIR), so I took off so she could do that. Fortunately, I'm all done with interviews, so all that's left is collecting letter's of recommendation (all four have been requested, I'm just waiting for them to come in) and then I can submit my application.

Navy ports

No, I did not actually visit a Navy port. I'm referring to an entirely different kind of port.

After a morning spent learning more about preventive medicine from LTC Cavicchia, we broke for lunch and reconviened in the PM conference room for journal club. I was assigned chapter 8-11 of DA PAM (Department of the Army Pamphlet) 40-11 to present, and when I got to the room with about two minutes to spare before 1300, I was told that the computer didn't have internet access, and it being a government computer, I couldn't use my unencrypted thumb drive (doing so would scramble the drive and make it useless), so I had to borrow one from a resident, run down to the library (conference room is on the third floor, library is on the first--and on the opposite end of the building), get to my email, and get the powerpoint onto the thumb drive before walking briskly back to the conference room. When I arrived, the computer screen was blank. Apparently, this government computer wasn't encrypted, so when one of the residents tried to download his presentation from his encrypted drive, he ended up crashing the computer and his (likely expensive) government-issued encrypted thumb drive. So we got a new computer, which had internet access, but when LTC Cersovsky tried accessing the network, nothing happened. By the way, it's now 1330, and then there's a fire drill. So it's 1400 by the time we get back into the conference room and LTC Cersovsky calls the help desk. They arrive, he explains the problem, that we can't get onto the network, and they look at it and say, "Oh, that's a Navy port." You see, WRAIR is not just WRAIR--it's also NMRC (Navy Medical Research Center). And apparently, the Navy and Army networks don't get along, and you can only access the Army network from an Army port, and the Navy network from a Navy port. Needless to say, the presentations on DA PAM 40-11 didn't happen today, and "Navy port" is the new joke of WRAIR preventive medicine.

Tomorrow, CPT Lee and I are going to AFHSC (Armed Forces Health Surveillance Center) to try to figure out the background rates the condition that we're investigating. After all, if ten soldiers a month end up hospitalized for this, than what we're seeing is hardly an outbreak, and that will be that. LTC Cersovsky is pretty sure that's not the case.

By the way, here's WRAIR.

Life in Preventive Medicine

This morning CPT Lee (internal medicine intern on a preventive medicine rotation) and I were educated as to the work of a preventive medicine doc by MAJ Soltis. We learned about medical threat briefs, outbreak investigation, redeployment medical briefs, and what PM docs do when deployed. She was in Afghanistan in 2006 with the 10th Mountain Division, so she gave us a little presentation about what that was like. She was the only PM doc in all of Afghanistan, so a lot of things fell to her. She was in charge of the influenza vaccination program in country (everyone in the military must get a flu shot every year, even while deployed); that year, 82.5% of soldiers in Afghanistan got a flu shot (that's a very high number, by the way). She also made recommendations regarding malaria prophylaxis, including changing medications when necessary; did weekly casualty briefs; gave redeployment briefs three times every week for a year; and was the go-to person for possible outbreak investigation and immunization needs. It actually sounded like a lot of fun.

Anyway, after that, CPT Lee and I were sent to WRAMC to look up the patients in our "outbreak" and get all their in-patient data, which you can only do on-site (outpatient data is on AHLTA and can be accessed on any computer in the world with AHLTA access). That ended up taking longer than we thought, and we didn't get out of there until about 6:00, by far my latest night on this rotation to date. I'm hoping we got all the relevant data we needed, and we don't have to go back. It took us about 45 minutes to get to the hospital, even though WRAMC is only about a mile from WRAIR (we found out later that President Bush was visiting, which always does funny things to traffic and security).

Tomorrow, our education on PM continues, as LTC Cavicchia (another OSU alum, by the way), the Chief of Epidemiology and Disease Control at WRAIR, tells us about her job.

Field trip

It was back to work at WRAIR today to get started on my epidemiological project, which involved coming and going to many of the various military medical facilities in the DC area--with my CAC scanned at each location. Big brother is watching. Here was the day (I would include a map, but that seems like way too much work):

-Arrive at WRAIR, do some background work on LTC Cersovsky's computer
-To USUHS (Uniformed Services University of Health Sciences) for the Preventive Medicine Interest Group meeting (the PM docs were there to give advice/tell stories. I was there for free food).
-Back to WRAIR for more background work
-To Walter Reed to meet with the doctors who reported the outbreak/cluster to USACHPPM (United States Army Center for Health Promotion and Preventive Medicine). While there, we learned that one patient is still at Reed, two are at Madigan, one is somewhere in Texas, and one is in locations unknown. Also, the doctors are going to look through their recent cases to see if any others fit this pattern.
-Back to WRAIR at the end of the day

All in all, it was a good day. I'm really excited about this investigation, regardless of what comes of it. I'm less excited about my presentation on DA pamphlet 40-11: Preventive Medicine on chapters 8-11 on Wednesday.

More stories about coins

Last night, I went out for drinks with my friend Sunil, who is now a surgical intern at Bethesda (note: never go out for drinks with a sailor when you have to get up the next morning to listen to a briefing... ugh). Anyway, he's on a urology rotation right now, and had a fairly entertaining story about commander's coins (see my post on June 25), so I thought I'd share it.

The other day, one of his last patients for the day was a Vice Admiral (equivalent to a Lt. General; 3 stars). So he takes the history and does the general physical exam, and then because he's on urology, did a prostate check (digital rectal exam, or DRE), and then sent the patient out the waiting room while he finished his note or something. A couple of minutes later, he goes out to retrieve the patient, and the waiting room is empty. The receptionist said she thought he was done with the patient, so she sent him on his way. So Sunil had to go up to Executive Health and figure out how to track down this three-star admiral and finally gets a hold of him on his cell phone (he was still on base at the commissary or something), and asks him to come back to the clinic so they can finish the appointment. So the admiral comes back, they finish the appointment, and then they shake hands at the end. Sunil said he felt something round and hard in his hand; sure enough, he had gotten a coin, which he described as "very shiny, with three stars prominently displayed." At this, I had to laugh--that must have been a really good DRE to get a coin out of it!

Other than that, it's been a pretty boring since my last post. I went up to Baltimore this morning for the last part of the Deployment Health Surveillance workshop and then came back to the hotel to do a literature search related to the epidemiological investigation I've been assigned to work on this month.

Deployment Health Surveillance

This morning I drove from Bethesda up to Baltimore (well, BWI) for the Deployment Health Surveillance workshop. There's quite a bit of traffic in the DC area, but fortunately for me, it was going the other way--people trying to get into DC in the morning, and out in the afternoon.

The content of the workshop hasn't been cleared for the public, so I can't say anything about what I learned today, but I can say it was a perfect example of the "death by PowerPoint" that the Army seems so fond of, and full of acronyms I didn't know (in other words, even if it was cleared for the public, I really wouldn't be able to tell you much about it). And tomorrow, I get to go back up to Baltimore to do it again.

LTC Cersovsky decided on a project for me--an active Army epidemiological investigation! Since it is an active investigation, I can't tell you what it is (that's part HIPAA and part the Army being all secretive about the troops). I'm really excited to be working on an active investigation, even though it isn't related to infectious diseases, and this should result in a publication for me.

Anyway, sorry about everything being all shrouded in mystery and whatnot. Depending on what I end up doing within the field of Army preventive medicine, that might become a regular occurrence.

In-processing at WRAIR

Today was my first day at Walter Reed Army Institute of Research, which will hereafter be referred to simply at WRAIR (pronounced "rare"). This is not the hospital Walter Reed (the one in the news a couple of years ago). That is Walter Reed Army Medical Center (WRAMC). Two completely different entities with the same name. Welcome to the Army.

Today was in-processing, which is a fun (sarcasm) process that one must go through whenever reporting to a new location/duty station. Since WRAIR is a research facility with stuff that can kill a person, the place is locked down as tight as Ft. Knox, requiring one to jump through several hoops to be approved to enter the building. Here was my day:

1) 0805: Arrive at Walter Reed Annex. To get through the gate, I had to show my CAC (Common Access Card; my Army ID) and rental agreement to my car. Fortunately, I didn't have to have my car searched.

2)0810: Enter WRAIR (Building 503). In case you couldn't tell, the parking lot is a good distance from the building. To get in, my bag was searched and I had to go through a metal detector. Then, I had to hand over my driver's license, get a "Vistor: Escort Required" badge, and call LTC Cersovsky.

3) 0815ish: LTC Cersovsky comes down, rolls his eyes at my "Escort Required" badge, and sends me to Building 500 to get my in-processing packet, and tells me to get back before the safety briefing at 0845.

4) 0818-0835: Personnel office in Building 500, where they debate what kind of in-processing packet to give me (which was the wrong one, according to LTC Cersovsky). Then, realizing the time, they quickly send me back to 503 for the safety briefing.

5) 0838: Return to 503, once again having my bag scanned (no metal detector required, thanks to the "Escort Required" badge). Call LTC Cersovsky to escort me down the hall for the safety briefing.

6) 0845: Safety briefing, get that signed off on the in-processing packet. Call LTC Cersovsky again to escort me from the safety briefing back to the door.

7) 0900ish: back to 500 to get checked through base security.

8) 0945: after a really long time having my orders pored through, my background check examined, the paperwork filled out for a visitor's pass, and the picture taken, they realize I'm still missing signatures in my in-processing packet and send me back to 503.

9) 0948: Bag gets checked again, LTC Cersovsky called again to escort me up to the Preventive Medicine residency area to get more signatures on the packet (remember, it's the wrong packet, so these signatures aren't really required, but the badge people won't give me a badge until the paperwork I'm given is complete.

10) 1015: Back to Building 500, this time with more signatures. Finally get my badge. As you can see, they misspelled my name.

11) 1020: Back to WRAIR (Building 503) to meet with LTC Cersovsky about my expectations for the rotation. Bag gets scanned again, but no phone call necessary, thanks to the badge.

12) 1050: LTC Cersovsky has to head out to Bethesda for some inspection, and sends me back to 500 to get everything at personnel squared away, then tells me I can take off for the day once that is complete.

13) 1110: Personnel finds one line that isn't signed to their satisfaction, and sends me back to 503 to have that corrected and faxed to them.

14) 1115: Bag gets scanned again on the way in, form gets signed and faxed. I stop by the resident's office to chat with CAP Ahluwalia, who is an OSU alum (2006). Get invited to lunch in about an hour (so much for going home early). Head down to the library to check email and waste an hour without annoying the residents (the rotation is still young; there's plenty of time left to get on their nerves).

15) 1200: Lunch. Well, more accurately, I go back up to the resident's office and socialize for about half an hour, then we head out to Subway, which is located next to one of the most sketchy commissaries I've ever seen, on another part of the annex. We're still on base, but have to exit the WRAIR gates, which are open during the day and locked to card access in the off-hours. In other words, there are two layers of gates around WRAIR; the base gates and the WRAIR gates.

16) 1315: Leave for the day (I won't be leaving this early on a regular basis, in case you're wondering).

So there you have it; all of that walking back and forth between buildings and going through security and calling for an escort, just so I can be around for four weeks doing epidemiology research.