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.  

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.

MCBC: Day One of Bio

Today was the first day of Medical Management of Biological Casualties, or the "B" part of MCBC, at USAMRIID (which is a much nicer drive from my place than Aberdeen Proving Grounds). They starting things off with a running start, and then it kept on going until they set us free around 5.

Just a bit of a brief overview, the first documented case of biological warfare in history was back in 1346, when plague corpses were launched over the city walls of Kaffa. Whether or not this contributed to the fall of Kaffa is unknown; chances are, the rats (which don't really respect city walls) were going to cause an outbreak of plague around that time anyway.

The US did have an offensive biowarfare program, from 1943-1969 (which was three years before the Bioweapons Convention ban). Most of the agents we produced were aimed at disrupting the food supply instead of killing people, such as diseases against cattle and crops (we did produce anthrax, botulinum toxin, tularemia, and others, though). In 1969, President Nixon ended the program and ordered all stockpiles removed. Three years later, as I said, was the Bioweapons Convention, which was ratified by over 100 countries (including the USSR, which blatantly ignored the fact that they said they weren't going to produce or stock offensive biological weapons, and stockpiled a few hundred tons of smallpox, anthrax, and other scary stuff).

The rest of the day was going over specific select agents. A select agent is one that we think can be used for biological terror or warfare. They're cheap or easy to obtain, easy and inexpensive to produce, easy to deliver, difficult to detect, cause a large of casualties, and cause widespread fear and terror. The ones we had lectures on today were anthrax, tularemia, plague, brucellosis, Q fever, and agriculture agents.

We finished with a lecture on the epidemiology of bioterrorism, which gets to the question of, how do you know if an outbreak is natural or intentional? There are 11 clues that something might be an intentional attack:
1) Highly unusual event with an unexpected number of casualties. For example, 751 cases of salmonella in one month in one county in Oregon is very unusual (in the case of the Rajneeshee salad bar debacle).
2) Higher morbidity or mortality than expected. This would make you think that something might have been modified in a lab.
3) Unusual disease. When West Nile Virus appeared in New York in 1999, it had never been seen in the States before, and this made people suspect that it was some sort of biological attack (it wasn't).
4) Point source outbreak
5) Lower attack rates in protected populations
6) Multiple or serial epidemics
7) Dead animals of multiple species
8) Reverse or simultaneous spread between animals and humans. Usually human disease follows animal disease, so if it happens the other way around, that's a little bit suspicious.
9) Usual manifestation of disease. 95% of anthrax is cutaneous, so if there's a lot of inhalational anthrax and not very much cutaneous, that might mean that somebody released aerosolized anthrax.
10) Downwind plume pattern. This was seen after the accidental release of aerosolized anthrax from an anthrax factory in Sverdlosk
11) Direct evidence. This is rare, but was seen with the 2001 anthrax letters (they included a letter saying exactly what it was).

It was a long day with a lot of information thrown at us (most of which was a review). Now I'm heading off to bed so I can do it all over again tomorrow.

MCBC: Happy Halfway!

Today we finished the chemical portion of the Medical Management of Chemical and Biological Casualties. We started the day with the most exciting part, the field training exercise (which, in military speak, is FTX). 

The FTX was actually in two parts. In the first part, we had twelve of our classmates dressed up and acting as casualties, and we each had to triage them. That was hard enough, but we were doing it in MOPP 4, which made it intellectually and physically challenging. I don't know what MOPP stands for (and I don't know anyone who does, except maybe Wikipedia), but here's a diagram of what the MOPP levels are:

MOPP gear is designed to protect against a chemical or biological attack, so obviously, the overgarment doesn't breath all that well. Fortunately, we were allowed to wear our PT uniforms under it instead of field gear (as demonstrated in the MOPP 0 column), and the weather was pretty mild, so it wasn't terribly uncomfortable. 

The second part of the FTX was to break into groups and go over decontamination and treatment of chemical casualties, while in MOPP 4. Decontamination isn't an easy process; done right, it takes about 20 minutes to completely decontaminate a casualty. Here's a picture (from the Internet, not my course):

As you can see, the people doing the decontamination are also in MOPP 4, which makes things a bit difficult (it is not easy to cut through a MOPP suit while wearing thick gloves). Also, during the 20 minutes a patient is being decontaminated, he isn't really available for medical treatment, so you have to make sure everyone who goes through decontamination is stable enough to last 20 minutes without care. We also practiced things like intubating patients (well, dummies), starting IVs, and giving injections of atropine (for nerve agent exposures), while wearing MOPP 4 (and I'm not great at the first two without MOPP gear). 

After that, we did some after action reports to discuss the course, and then they set us free (at 5). Tomorrow begins the bio portion, which I'm really looking forward to (mostly because it'll be a review and I'll get to feel really smart). 

Medical Management of Chemical and Biological Casualties (MCBC) Course

Starting yesterday, ridiculously early in the morning, I got up to drive to Aberdeen Proving Ground for the first half of the Medical Management of Chemical and Biological Casualties course, or MCBC. The course is three days of chemical warfare at the United States Army Medical Research Institute for Chemical Defense (USAMRICD, and no, I don't know how to pronounce that acronym), followed by three days of biologic agents at the United State Army Medical Research Institute of Infectious Disease (USAMRIID, which is pronounced u-sam-rid) at Ft. Detrick.

I was kinda dreading the chemical half of the course, because chemical agents aren't nearly as exciting as bioterrorism, but it's been pretty interesting so far. We started with a lecture on the history of using chemicals in warfare, which began with the Chinese using arsenic smoke to suppress peasant revolts, back in 1000 BC. Way to be innovators, China.

Modern use of chemical warfare really began with WWI, and it was the Germans who started it. A chemical engineer, Fritz Haber, masterminded the use of chlorine gas at Ypres (1915), and at the end of the battle, there were 800 fatalities from chlorine gas and over 10,000 Allies injured. Chlorine gas was effective, until the Allies started getting good at making gas masks (by the time the US joined the war, we had it figured out). Chlorine, like the other pulmonary chemical warfare agents, doesn't have a specific antidote; treatment is pretty much just getting to an ICU for monitoring and intubation.

Here's a picture of a WWI gassing:

The next class of chemical warfare agents we talked about was the blood agents, of which cyanide is the typical example. It was also used in WWI, but by the French. Unfortunately, like many things done by the French, it was pretty ineffective. Cyanide is lighter than air, so it didn't do a very good job of getting down into the German trenches. However, by WWII, the Japanese and Germans both figured out how to use it (mainly, by using it indoors). The gas Vyklon B in concentration camp gas chambers is a cyanide gas. Unlike chlorine, there is an antidote to cyanide--inhaled amyl nitrite, IV sodium nitrite, and IV sodium thiosulfate. You have to work fast, though, because about three minutes after a inhaled cyanide attack, your casualty is going to be dead.

The cyanide turned the walls of the concentration camp gas chambers a bit blue. Here's a picture:

The next to make it into the game was the blistering agents, such as mustards and Lewisite. They were first used (by the Germans) in July 1917, because the Allies had figured out the gas mask issue. Just like it sounds, these cause blisters on the skin. They didn't kill too many people, but they did take people out of the fight for quite a long time (average convalescence time was 42 days). Many of the casualties thought that they were blind, due to the swelling around the eyes, but the actual numbers of people who went blind from mustards was pretty low. The treatment for these is immediate decontamination (in the first few minutes after exposure, before it completely goes into the skin), and then burn treatments for blisters, including skin grafts, if necessary.

Here's a picture from Bari, Italy, where an American ship filled with containers of Lewisite was blown up by the Germans in 1943. There were a lot of civilian and military casualties, made worse by the fact that they wrapped everyone in blankets, which were also contaminated with Lewisite.

The most recent addition to the arsenal of chemical warfare agents is the nerve agents, first used in battle by Iraq during the Iraq-Iran war in 1980 (and we wonder why we thought Iraq had unconventional weapons...). Most of the nerve agents were developed by (drumroll, please...) Germany, and thus have codes of GA, GB, GD, and GF (no idea what happened to GC or GE), which correspond to tabun, sarin, and soman (GF doesn't have a name, as far as I know). VX is also in this category. Like cyanide, these will kill you pretty quickly if you don't treat. The antidote is atropine, 2-PAM chloride, and diazapam (Valium) for seizures. We have autoinjectors for these that an exposed soldier can give to himself or a buddy in the case of an attack. Here's what the autoinjectors look like:

And in case you don't remember VX from the movie The Rock, here's a reminder:

After all those lectures, we practiced putting on our chemical protective gear and gas masks in preparation of our casualty exercise tomorrow. No, this isn't me.

Last Day of the TB Course

Today was the last day of the Denver TB Course (in case you couldn't tell from the title of the post). Most of the lectures today were about non-tuberculous Mycobacteria, or NTM. These are bacteria that are related to TB, but a little bit different, and so they cause a little bit different kind of disease. They're also usually more difficult to treat, sometimes requiring medication for years to a lifetime, sometimes requiring surgery. Fortunately, they are also a lot less likely to affect people who are otherwise healthy. Most people who get NTM infections have other diseases, such as HIV, cystic fibrosis, diabetes, cancer, or other diseases that require steroid medication. That isn't to say that otherwise healthy people can't get NTM infections, it's just more rare.

That being said, because TB is becoming so rare in the United States (and chronic diseases are becoming more common), most of the Mycobacteria in the US is actually NTM.

We also talked about multi-drug resistant TB (MDR) and extensively drug resistant TB (XDR), which are becoming increasingly common around the world (remember the report in the news a few years ago of the guy who flew all over the place with TB? He had MDR, and ended up at National Jewish). MDR and XDR are increasing around the world in large part because people don't completely treat their TB infections. It's a long course of a lot of medications--a typical TB infection in the lungs requires two months of taking four drugs, followed by four months of two drugs--and while the WHO calls for all of that to be directly observed therapy (DOT) to make sure that all of the doses are taken, resource-limited countries aren't all that great at always doing it. People who take the medicines for a short time and then stop, or take some medicines but stop others, increase their chances of ending up with a drug-resistant form of TB that is very difficult to treat.

In all, the TB course was pretty valuable and I feel like I learned a lot that will help me in the future. There was some stuff that isn't necessarily relevant for a preventive medicine physician (if I get a person with MDR-TB, I'm not going to be treating him or her; I'm going to be calling my friendly infectious disease physician and handing the case over), but it was still interesting. So you can rest assured that your tax dollars went to a good place (at least this once).

Not quite timely, but still appropriate:

TB Course, Days 2 and 3

I realized this morning that I forgot to write about my day at the TB course yesterday. Oops. So today's entry will serve for both days. First of all, here's a picture of National Jewish Hospital back when it opened as a TB sanitarium in 1899:

Yesterday was a mix of helpful and not helpful information, which mostly means things I will need to know as a preventive medicine physician and things I don't need to know. How to screen people for latent TB is something that I need to know, because that's something that preventive medicine physicians do. Here's the reason why:

 

What this says is that if you have 100 people who are exposed to TB, 70 will be fine and 30 will become infected, which is known as latent TB infection. Since TB is such a slow-growing bacteria, for 27 of those, the infection will always be latent and they will never have active TB. For the remaining 3, half will have disease within two years, and the other half will have disease later in life (okay, bad example, since you can't have half a person, but you get the idea). The point of treating people with latent TB is to reduce their risk of having active disease in their lifetime from roughly 10% to less than 1%.

And this is how you screen someone for latent TB. When you have a person at high risk, such as someone born outside of the US or someone who has been around someone with active TB, you do either a TB skin test, which is also known as a PPD; or a blood test (IGRA, or immunoglobulin release assay). If that comes back positive, you do a chest x-ray to look for active TB. If the chest x-ray is abnormal, you probably end up treating for active TB, but if it's normal, they're said to have latent TB. And again, the reason why we treat people with latent TB is to reduce their risk of progression from 10% in their lifetime to less than 1%.

That was a good deal of yesterday and a bit of today. Today we also did a workshop for TB outbreak investigations, which was interesting, because there's a change I'll be in charge of one of those someday. It was kinda a good feeling that I got during this workshop, because I felt like I had a better handle on the situation than most people in my group, which makes me think that if I have to do that someday, that maybe I won't mess it up too bad.

Here's a parting thought for tonight, from the CDC doctor who was sent to Colorado to close their sanitariums and ended up staying for the rest of his life:

Denver TB Course

As seems to be the trend for this year, I'm again away from DC, this time to Denver for the Denver TB Course at National Jewish Hospital. Here's a picture of the building the course is in:

This is the 49th year of the TB course at National Jewish, which established itself as a TB mecca of knowledge, so to speak, back in the days of sanitariums. What I didn't realize until the History of TB lecture today is that the practice of sanitariums started in Europe, in the Alps, around 1865. In the States, it started in the Adirondacks in 1884 with Trudeau (the great-great-grandfather of the comic strip artist, I believe), a physician in New York, who was diagnosed with TB. At the time, that was pretty much a death sentence, as they didn't yet have antibiotics to treat it. So he left his practice and went up the Adirondacks to relax, and his symptoms improved. They thought it was the elevation. Well, since the Adirondacks are pretty miserable for most of the year, and the Rockies are fairly nice, the practice of traveling to sanitariums moved from upstate New York to Colorado. More people traveled to Colorado for TB treatment than to strike it rich at the gold rush.

After our History of TB lecture, most of the lectures were introductory, covering topics such as transmission, immunology, diagnostics, and chest x-ray findings. Most of it was pretty dull, actually, although I did pick up a few pointers in the x-ray lecture. I'm hoping tomorrow will be more exciting. We'll be discussing some challenging cases that they've seen here at National Jewish, than latent TB infection (which is pretty much all preventive medicine physicians deal with, in terms of TB), and more about treatments and drugs. Should be a good time.