ACPM 2013: Day 2

Today was a lighter day than yesterday, mostly because I didn't want to go to the all-afternoon session on reducing childhood obesity among Latino children in Arizona (crazy, I know, since that's usually my area of interest in tropical medicine...).

The day started with a 4ish mile trail run, starting at 6am. As I joked to my former program director (also running), I don't know who did the risk assessment for that exercise, but whoever it was should clearly be fired. Running on trails before the sun comes up (and in the cold--I think it was about 38 this morning) was not a very good idea. We did get to watch the sunrise over the mountains as we ran, though, which is always one of my favorite sights.

Once we had breakfast and got cleaned up, it was time for the first plenary session, which I think was misadvertised. The lecture was called Population Health, but I kept waiting for him to stop talking about primary care and start talking about population health, which he never really did. The second session was equally disappointing. It was about vaccine updates, which last year was a very good talk, going into all of the recommended changes to the vaccines and vaccine schedules from the CDC and why they made those changes. Maybe there just weren't very many changes and they had to fill the time with something else; I don't know.

After that was my break in the afternoon (see above comments about not going to the thing about obese children), which I used to fill out questionnaires and quizzes to get credit for the hours I'm here. Then we had the last session, which was about the future of preventive medicine. They had some interesting ideas, but none of them were all that applicable to preventive medicine in the Army.

Tomorrow's my presentation, so I hope I'm prepared!

ACPM 2013, Day 1

Yesterday I flew into Phoenix, Arizona for the American College of Preventive Conference. Sadly, with all of the budget stuff that's going on in Congress right now, the Army doesn't have the money to pay for me to attend, but since it is my specialty's conference, and I'm presenting on Saturday, I forked over my own money to come. And it's ACPM, which I've been attending since I was a med student.

The day started with hitting an overcrowded gym (preventive medicine types like exercising) before I grabbed breakfast and hit the registration table, getting my first-ever "ACPM Member" badge (instead of Med Student Section or Resident Physician Member badge). The opening plenary speaker today, the editor-in-chief of the American Journal of Preventive Medicine, talked about the health care system (a popular topic at these meetings). Specifically, he talked about the fact that it isn't a system; it's a bunch of people doing whatever they want and ignoring the other pieces of the puzzle. He compared it a construction company that built houses by telling everyone to do what they usually do and giving nobody blueprints, which I thought was an interesting (but probably apt) comparison. These kinds of fractures, in his opinion, are what is driving up the cost of healthcare so much in this country, and changes that we're making (like Obamacare) are the same as rearranging the deck chairs on the Titanic while it's sinking. He said we need to be more like engineers, who actually think about systems as a whole, and if we did that, we would not only be more efficient (and therefore cost-efficient) at providing healthcare, but better at it, too.

The next session I went to I fully expected to be bored during. It was titled: "Linking Primary Care and Public Health: Where Are We?" I expected it to be about lifestyle medicine--talking to people about what they eat and how they need to exercise. I was pleasantly surprised to find that it was more about how primary care uses what we find in public health to do primary care better. One speaker, the health commissioner for Georgia, used the example of infant mortality, which was much higher in Georgia that most other states. They looked into what was causing infant mortality in Georgia and elsewhere, found out how to impact the most common causes, and implemented them. As a result, infant mortality dropped.

I think my favorite session today was the keynote speaker, former U.S. Surgeon General Richard Carmona, who was Surgeon General from 2002-2006. He talked about the plague of politics on science and medicine and how whenever politics gets involved in science, everyone loses. He used specific examples, both from his own term as Surgeon General, such as fighting with the Bush administration about how abstinence only sex education has no science behind it because it doesn't work, and older examples, going all the way back to the bubonic plague outbreak in San Francisco at the turn of the twentieth century, when the public health commissioner of San Francisco (or California, I'm not sure) wanted to quarantine ships coming into harbor, and the state of California disagreed because they thought it would ruin tourism and trade. That one went all the way up to the president, who sided with the medical people, which led to the end of the outbreak. The point that he really drove home is that, while the Surgeon General is a political appointee, he can't be the physician of the president or the party that put him into office; he has to be the physician of the United States, and to do that, he has to follow only the science, and not the politics that tries to get involved in it. He was an amazing speaker and brought the entire audience to our feet when he was done.

After a few more sessions in the afternoon, we had the med student/resident/young physician happy hour, which was "light appetizers" (which I ate enough of to count as a full dinner) and then preventive medicine trivia, which my team won. I even got a prize: MRSA and a CDC mug. I don't know why the picture is sideways.

ASTMH: Day 3 (I think)

If today is Tuesday, than it's the official third day of the ASTMH conference (and yes, it's all run together that much that I no longer know). The day started with the first session at 8, just like yesterday. I attended the session on non-malaria fever in Africa, thinking it might be applicable to my job, but that might have been a mistake. I don't know if it was that I was so tired from the night before or if the speakers were just that non-engaging, but I found myself falling asleep during the presentations. I actually stood up during the last presentation, which was on a new algorithm for treating pediatric fever, because I actually wanted to stay awake to hear what she had to say. It was a really good presentation; her group had gone through and tested a lot of children (I forget the number) who came into the hospital with either fever, cough, or diarrhea, and then went back and correlated the signs and symptoms at presentation to what they actually had (malaria, pneumonia, dysentery, etc). They came up with a new algorithm for evaluating children that, when used properly, reduced the number of kids given antimalarials or antibiotics who didn't really need them. Pretty powerful stuff, if they can get wide-spread use of the new algorithm.

The second session I went to was also on global health, and wasn't really that great. Each session had multiple speakers, and the one I wanted to hear was about training community health workers on proper diagnosis and treatment of kids (a lot of the same stuff as the session before). However, the presenter didn't really discuss what the teaching was, just that it didn't work very well. Oh, well. At least I get continuing education credit for being there.

The best session all day was the lunch session on tropical medicine in temperate climates. It's a session given every year by the people at the London School of Tropical Medicine, because they have an entire ward of the hospital for tropical medicine. This year's cases were loa loa (African eye worm), West African trypanosomiasis (African Sleeping Sickness), and adverse reactions to malaria medications. Just for something to gross you out, here's a picture of loa loa:

Yes, that is a worm in a person's eye. It's gross (all pictures of eyes are gross), but the patient was properly diagnosed and treated and is now doing well (at least, that's what the doctors making the presentation tell me).

Tomorrow is my poster presentation on my dengue project, so I hope that goes well. After I'm done standing by my poster, I'm packing up my stuff and then heading for the airport, because it'll be time for me to go back to Savannah and work for a couple of days before I leave for Tanzania to climb Mt. Kilimanjaro (should be a good time).

Exploring Atlanta and Beginning ASTMH

Yesterday we didn't have any obligations at the conference until the opening plenary session in the evening, so I decided to explore. I have been to Atlanta before, but the most recent time was in 2004, when I was at Emory doing research for the summer. That was obviously a long time ago, so I had a lot of exploring to do. I started the day by sleeping in (it was, after all, Sunday, and I had taken a pretty big exam the morning before), and then headed down to the Underground Atlanta area (less than a mile from my hotel) to take an electric car tour. It was pretty similar to the trolley tours in Savannah, only without the on-and-off that the Savannah trolleys offer (to allow you to explore on your own between stories from the tour guides). I did learn a lot about the downtown Atlanta area, though, including some of the history of the King family as we drove by the house where MLK, Jr was born and the church where he would occasionally preach. I also learned what this is. Any guesses?

It's actually a holding cell (I know, right?). Back in the day (before 1905 or so), this part of Atlanta (Inman Park) was pretty far away from the city proper, so when someone had committed a crime, they would lock him into this tiny little cell and turn on the light on the top, so the paddywagon knew to come pick him up and take him to jail. Well, Atlanta gets hot in the summer, and after enough people died in these, they decided that maybe it wasn't the best way to hold prisoners until they could be taken to jail.

After the tour, one of my classmates from last year and I explored World of Coke, because it's free with a military ID. I wouldn't recommend it to anyone who has to pay. Completely not worth it. We did like this picture of a WWII Army nurse, though:

Last night was the opening plenary, by the CEO of Save the Children, Carolyn Miles, pictured below (pic from the internet):

It actually wasn't the best speech ever, but it wasn't bad. I think the problem was that she's a business-type person, speaking to an entire room of people who study tropical diseases about why children are important and why studying the diseases that kill them is important. I think we got that message already.

Today I started the day with clinical updates from the last year in malaria, dengue, yellow fever, and TB. The malaria updates were very well done and very helpful, but the other presenters of the other three diseases spent too much time going over the history of their respective diseases and not enough time talking about updates. After that session was a talk on tropical dermatology, which made me feel good about myself and my ability to recognize pictures of rashes. Of course, it's the same 100 pictures used for the same diseases, so whether I'm just recognizing the pictures or if I understand the rashes or not is another issue entirely. Here's one of the pictures I saw a lot of in my tropical medicine studying:

This is chromoblastomycosis, and if I didn't know better, I'd swear it was the only picture of this disease, for how often it's used. Anyway, after tropical derm was lunch/clinical cases, which was about echinococcus and given by a completely uninteresting speaker, so my friend and I left early for our midday break, which I spent going on a short run (3ish miles). Then we returned for more clinical updates from the CDC, and then it was time to break for the evening for drinks and pizza. I forget the name of the restaurant, but it was delicious. And I got to do a lot of networking, which is always helpful.

Tomorrow will be more of the same (as far as the lectures, not the exploring of Atlanta). Hopefully I learn something applicable to my new job.

CTropMed Exam

Well, this morning was the moment of truth: the last test of the foreseeable future (assuming I passed both the Preventive Medicine boards and this one), the ASTMH Certification of Knowledge in Tropical Medicine exam. Here's what I was using to study:

Yes, this is a very large stack of flashcards. I went through all of the lectures from Principles and Practice of Tropical Medicine (the most intense course I had during my MTM&H coursework) and turned every bacteria, virus, fungus, parasite, and miscellaneous disease into a flashcard. It's pretty much all I've been doing for the last month, but I think it paid off, because I was feeling pretty confident during the exam. From the conversations of my classmates who went through it with me, that wasn't a universal feeling.

The exam was 200 multiple-choice questions in 4 hours (I didn't take the whole time), paper and pencil (which was also strange, since I hadn't had a non-computerized exam since the MCAT). Most of the questions were infectious disease, but there were also some on travel medicine and I think five questions on epidemiology/biostats (which were all ridiculously easy). There were a few that were "guess what I'm thinking" type questions, and a few that I could swear had a few right answers to chose from, but it all, wasn't too bad. I would give an example if I could remember any verbatim (and if it weren't against the rules to post such things on the internet).

After the exam, those of us who did the course together all went out for lunch, and then some had to leave to catch flights back to their respective locations (since the conference isn't funded for DoD, most people decided not to stay; I'm paying for it out of pocket). Those of us who are staying went back to the hotel to crash before we went out for dinner. It was a pretty fun group, and aside from that inconvenient little test, was a pretty fun day.

And here's a random picture of looking up in my hotel from the lobby. Yes, it's very tall.

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.

ACPM 2012

I spent Tuesday through Sunday in Orlando for the 2012 conference of the American College of Preventive Medicine, which has been a combination of a lot of fun and a lot of work (well, as much work as sitting in rooms in a conference center is).

The conference started on Wednesday (Tuesday was just a travel day) with a session on health economics and cost-effective analyses (yes, it was as exciting as it sounds). Thursday was a very long day, with a run in the morning before breakfast (a little more than 4 miles through Downtown Disney and surrounding areas), followed by sessions all day, poster presentation in the evening, and one more session that ended at 9:30. Long day. Here's a (not great) picture of my poster:

Friday was a slightly shorter day, mostly because I didn't see anything interesting to go to for one of the sessions and I decided to take a nap instead. The day also ended earlier, with the last session ending at 4:30 and my fellow residents and I deciding to go out to Universal City Walk for dinner afterwards. There were some big-name restaurants there, but it being a Friday night, the wait at some was rather ridiculous. We tried to go to Emeril's, but when they told us it was a 2-2.5 hour wait, we decided to hit Hard Rock Cafe instead. And because it was Hard Rock, we went to the store, where Derek decided to model the merchandise:

Saturday morning started with a long run, again through Downtown Disney and around the golf course. I actually got lost around the golf course, which made for a nice run, and amazingly enough, I made it back to the hotel with almost exactly the right mileage for the run (six miles). Here was my course:

Most of the sessions on Saturday (at least, most I attended) were part of the Uniformed Service Academy of Preventive Medicine offerings, which included a business meeting (terribly exciting), followed by a session on measuring behavioral health in the Army, then a session on vaccine surveillance in the military. In the evening was the awards banquet, which was a dress-up event. Derek and Raul only kinda understand the concept of dressing up:

Derek ended up getting an award for his oral presentation on degenerative disc disease, so we're very proud of him.

In all, it was a good conference, and I hope that next year I'm not too busy with work to go again.

ASTMH

This past week, I was hanging out in Philadelphia for the American Society of Tropical Medicine and Hygiene conference. It was pouring rain, but since the conference was indoors, that wasn't really that big of a deal (until my deputy program director insisted I go play tourist, but I'm getting ahead of myself).

The conference started on Sunday night with a student and trainee reception, which wasn't terribly exciting, but it did include free appetizers and wine. I got to talk to a couple of medical students, grad students, and people applying for medical school about the things that they've done and want to do, so that was pretty neat. After that was the first plenary session, which was mostly focused on how global aid is dropping and the impacts that will have on global health and disease prevention and treatment.

Monday started the endless series of sessions, each an hour and forty-five minutes long and consisting of a series of speakers, each talking for fifteen to twenty-five minutes. I went to sessions on a variety of topics, from dengue (since I'm doing my residency project on it) to global health, clinical sessions, and neglected tropical diseases. I actually really enjoyed the sessions on neglected tropical diseases (which are diseases that only affect the poorest of the poor and don't have a lot of research dollars associated with them). Of these diseases, there are a few that the WHO is slated for elimination or eradication.

Let me back up to explain the difference between those terms: elimination is the cessation of transmission in a given geographical area. For example, polio has been eradicated in the Americas. Eradication means that there is no more transmission anywhere in the world. The only disease that has been eradicated is smallpox. The next step, after eradication, is extinction, meaning that there is no more anywhere, and no diseases fall under that definition, including smallpox (there are still lab samples and who-knows-what from the former Soviet Union).

So, back to what I was saying. There are four diseases that the WHO wants to eliminate/eradicate by 2015 (yes, it's coming up quick). One is trachoma, which is the number one cause of blindness from an infectious disease worldwide. I would include a picture, but pictures of eyes gross even me out. It's actually a Chlamydia bacteria that infects the eyelids, causing scarring that scratches the eye and leads to blindness. The treatment (before one is completely blind) is surgery and antibiotics (azithromycin). The prevention is facial hygiene and clean water. Another is onchoceriasis, also known as River Blindness. This is slated for elimination from the Americas by 2015. They'll focus on eradication at some other point.

As you can see, they're close to elimination in the Americas, and there's still a lot of work to be done in Africa. It's a parasitic infection that causes (wait for it...) blindness, and is transmitted by the bite of a black fly.

Number three is lymphatic filariasis, also known as Elephantitis. Here's an illustration (less gross that way):

It's also caused by a parasite, which blocks lymphatic flow, causing backup and the swelling, like in the picture.

The final one is Chagas Disease, which only occurs in the Americas:

Once again, caused by a parasite, transmitted either by the bite of a kissing bug or from mother to child. There's much less transmission from bug bites now, but there's still quite a lot from mother to child or from blood transfusions.

That was a lot more about that than I anticipated writing. Anyway, that was my Monday and Tuesday, and then on Wednesday, it was sessions in the morning and playing tourist in the afternoon. The hotel was only about half a mile from Independence Park, with the Liberty Bell and Independence Hall. Unfortunately, it was pouring rain, so I was quite soaked, but fortunately, it being a Wednesday afternoon and with that weather, I didn't have to deal with large crowds. Here are some pictures:

Inside Independence Hall, where the Continental Congress met and discussed both the Declaration of Independence and the Constitution. The chair in the middle was where George Washington sat when they approved the Constitution.

Liberty Bell. I wasn't all that impressed.

And the outside of Independence Hall. And yes, there's construction going on. And yes, it was really raining.

Next week, back to clinic.