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!

Bailey K. Ashford and Robert A. Phillips Research Awards

Last week I ended up spending more time than I would have liked at Walter Reed National Military Medical Center, because on Monday and Wednesday, I was competing for the two research awards at the hospital the Bailey K. Ashford Award and Robert A. Phillips Award. It was the first year that preventive medicine residents from WRAIR were allowed to compete, so I submitted my abstract on poisoning hospitalizations that I did at AFHSC several months ago, and was selected as a finalist for both.

Here's a picture of Bailey K. Ashford. He was an Army physician in the Spanish American War. After the war, he was sent to Puerto Rico to command the medical department troops (which today would a job given to a Medical Service Corps officer, not a doctor, because it's a pretty thankless job and kinda like herding cats. We don't listen to directions well). While he was there, he noticed that the Puerto Ricans were not only shorter than Americans, but that most of them were anemic. This led him to discovering a new species of hookworm and spent a year working on treating around 300,000 Puerto Ricans, reducing the death rate from anemia by 90% on the island. After this, he established the Puerto Rican Institute of Tropical Medicine and Hygiene, which is now part of the University of Puerto Rico School of Medicine. 

And this is Robert A. Phillips. He was a Navy physician and served in the Naval Reserves during WWII. In 1945-46, he was sent to Cairo to study typhus and ended up establishing the US Navy Medical Research Unit #3 (NAMRU-3), which is still there today. His first big assignment as the commanding officer of NAMRU-3 was a cholera outbreak in Egypt. In that outbreak, his research on cholera and treatment made him pretty much the world expert in it until he died in 1976.

In the good old days of the National Capital Region, when the Army had Walter Reed and the Navy had Bethesda, these were two separate competitions (Bailey K. Ashford at Walter Reed and Robert A. Phillips at Navy), and the two had nothing to do with each other. Four years ago, however, we all had to learn how to play well together, and both competitions were open to residents and fellows from either service. The main difference is that Bailey K. Ashford is for graduating residents, and Robert A. Phillips is for any resident. So there was quite a lot of overlap in the people competing for these awards, including me.

I didn't get the Robert A. Phillips award--it went to an Army orthopedic surgery resident who came up with a new system of classifying lumbosacral fractures--and the Bailey K. Ashford won't be announced until residency graduation in June, but I'm not exactly holding my breath. These are clinical research awards, which judges who are clinicians, and these people rarely consider epidemiology to be clinical research. Whatever. I was just happy that I was selected to be a finalist in both, because that meant that: a) someone recognizes the value of epidemiologic research; and/or b) someone thought my research was interesting enough that they wanted to hear me talk about it. And it got me out of clinic for two days, which is always a plus.

First week of clinic

Monday began my first week of clinic, and it being a short week, there wasn't really a lot happening. Here's what I had:

Monday afternoon: Whitman-Walker Clinic (http://www.whitman-walker.org/). It was pretty much the first HIV/AIDS clinic in DC, and continues to serve that function (and others). I'm working with the medical director, who sees about half of the time (doing medical director stuff the other half), mostly doing HIV primary care. Patients come in every three months and have labwork done to check CD4 counts (white blood cells targeted by HIV), HIV viral lode, full chemistry panel and liver function tests, and to screen for syphilis, TB, hepatitis B, and hepatitis C. My job on Monday was to go in, chat with the patient, find out how they were doing and if they were having any affects from their medications, go over their labwork, and to do a quick physical exam. I saw three patients, and all three of them were doing well, so that's obviously the ideal.

Tuesday morning: This is supposed to be travel clinic at Rader Clinic on Ft. Myer. However, I found out after driving down there that my one patient cancelled that morning. So then it was a drive back up to WRAIR to get some other work done. Here's what my drive looked like that day:

And then back home from WRAIR (C to A) at the end of the day. Obviously.

Wednesday afternoon: This was supposed to preventive medicine clinic at Walter Reed National Military Medical Center (formally known as National Naval Medical Center, or just Bethesda). However, just like on Tuesday, there were no patients, so I got to spend the afternoon sitting on my couch, making phone calls for my concussion study.

And speaking of the concussion study, I've made it all the way through the list of people I needed to contact (235 soldiers). Of those, we have 11 subjects who sent their surveys back completed, 75 surveys that have been mailed and are awaiting return, 6 declines, 60 who have changed their phone numbers/email addresses and we couldn't get hold of, and 83 voicemail messages that I still have to follow-up on. Guess what I'll be doing tomorrow?

More clinic next week. Maybe I'll actually have patients to see.

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.

Visas and burgundy passports (or, visas in burgundy passports)

For everyone who doesn't know what's going on (a group that may include my parents, as they never seem to know what I'm up to, whether I tell them or not), I am taking off for Peru in two days (Sunday, 21 Feb), for three weeks of tropical medicine research.

The DoD (Department of Defense, for the less acronym-inclined) has several domestic and overseas laboratories--one owned by the Air Force, a few by the Navy, and most by the Army--which collectively make up GEIS, or Global Emerging Infection Surveillance. The overarching command, if one could even use that word, is in the DC area, which meant that I got to rub some high-ranking elbows, impressive them with my CV and career goals, and convince them that it's in their best interests to pay for me to go to one of these labs. Peru was chosen because three weeks is a bit short for a research rotation, and since it's in the same time zone as DC, I won't be losing any time to jetlag.

This whole process, of convincing people to let me go and to pay for me to go (two different groups--one to let me go, one to pay for it), started in August, and I got final authorization (ironically, from the 'let me go' group; the 'pay for it' group had already given the thumbs up) much later than that, after months of stubbornly not letting them say no.

Now that that was taken care of... Believe it or not, foreign countries aren't always glad to see active duty military personnel arrive on their soil, regardless of their reasons for being there, so all sorts of country clearance and theater clearance (theater being theater of operations, which in this case is SOUTHCOM--Southern Command) and things going through diplomatic channels and taking forever. The process to get my official (burgundy) passport started... well, I don't remember when it started, but the passport was issued on 11 Jan. Then I needed an official visa to go with the official passport, which requires a resolution signed by the president of Peru, which just came through on Wednesday (so yes, the president of Peru gave me personal permission to enter the country). So I went to the Peruvian Embassy on Wednesday for the visa, and was told that I needed a letter, on letterhead, from my command. Just showing them my orders wasn't good enough. I emailed my program director (who is not technically my commanding officer, but I prefer to leave my commanding officer out of as much as possible, because he loses things. Like leave papers.) and asked her to write the letter, which she did. So I brought all that stuff back again today and dropped it off, and was told to pick up the passport at 5.

Long story slightly less-long: after three trips onto what is technically Peruvian soil, I now have a visa in my burgundy passport.

And assuming no more freak snow storms close Reagan National Airport, come Sunday, I'll have a stamp in my burgundy passport as well.

In case you were wondering how an official passport is different than a normal passport:

This is not my actual passport, just a picture I shamelessly copied from Google. As you can see, it's not blue, it has the word 'OFFICIAL' on it (which blue passports do not), and that little electronic-chip looking thing on the bottom means that there are electronics embedded in the passport.

Anyway, assuming I don't get too lazy while I'm gone, and assuming I have adequate internet connections, stay tuned for tales from the southern hemisphere (it's barely the southern hemisphere, but it counts).

4 star coins and the light at the end of the tunnel

For those of you who read my Facebook status update, you know that I now have coin from a four star general. Here it is:

And now story time. There is a lieutenant colonel in the room across from the MICU workstation. He was hit by an IED in Afghanistan (I believe... he's a SICU patient, so I don't know much about him). It's pretty rare that someone that highly ranked gets himself blown up (he was a Ranger or Special Forces or something), so he's gotten quite a lot of attention. I have now seen the Secretary of the Army and more stars than I can count. Anyway, on Monday morning, I was writing down lab values on my patients, and when I looked up from my computer, I saw stars. A line of four of them, right down the front of this man's uniform. He thanked us for all that we're doing to care for all of our patients, and then gave us coins.

As far as the light at the end of the tunnel, I had lunch yesterday with my future residency director, just to check in and see how my first month of internship is going and give me more information about the residency. Let's just say that I was really excited about what is to come. It really was a nice reminder that all of this being on call every third night and rounding for six hours thing doesn't go on forever.

I can't wait for next year.

Last day of the ACPM conference

Today was the final day of ACPM 2009, which was a bit sad. It was fun hanging out with medical students and doctors who have the same feelings on medical careers as I do (even if they are all bleeding-heart liberals who think that Obama is the savior of the known universe). Anyway, here's a brief run-down of the day (and I'll try to explain acronyms and abbreviations better):

1) One last breakfast with the MSS (Medical Student Section)

2) Listening to the explanation of Healthy Americans 2020, which is a repackaging of Healthy Americans 2010. Nothing's really changed. Pretty boring session.

3) Argued with some administrators/test-writers of the USMLE (United States Medical Licensing Exam; the Board exams) about public health and preventive medicine questions in the multiple-choice and standardized-patient portions of the exam. LTC (Lieutenant Colonel) Cavicchia (one of the OSU alums in preventive medicine) was taking my side, so I guess I wasn't too far off.

4) Lunch (not that exciting)

5) Great careers in preventive medicine-public sector session. This is where the CDC, Army docs, and state/county public health directors talked about their careers. Some of them were pretty impressive. CPT (Captain) Ahluwalia and I were essentially planning out the timelines of our careers (when he would take over from the current Army director at the Global Emerging Infections System and when I would take over from him, etc). I hope it works out that way!

6) Preventive Medicine challenges in Iraq and Afghanistan session. Needless to say, this one was geared toward the Uniformed Services Academy of Preventive Medicine (of which I am the lowest ranked member!)

7) Wrote a speech at the last minute for the awards banquet, and then gave it in front of all these impressive preventive medicine physicians, including my future residency director. Well, they said I did a good job, so I guess that's all that matters. And no, I didn't win an award, I was giving them--I was announcing the winners of the Future Leaders in Preventive Medicine grant, which is what paid for the other medical students to come (I was paid for by being a med student section officer).

Anyway, tomorrow morning it's off to the airport to try to get on an earlier flight on standby. Either way, I'll be home tomorrow.

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.

Why adults need vaccines

Just as a warning... I'm getting on soapbox here. As a future preventive medicine physician, there are few things that I deem more important than vaccines, and few things more frustrating than seeing patients with vaccine-preventable illnesses. Despite what Hollywood mothers like Jenny McCarthy would have you believe, there is no link to vaccines and deafness or autism.

Anyway, we had two 22-year-olds come in yesterday during my shift with pertussis (whooping cough). It was a classic story for both of them, with a barking cough that comes in paroxysms (intense, uncontrollable, painful coughing for a few minutes, followed by a few hours of feeling perfectly fine, followed by more uncontrollable coughing for a few minutes). So we took throat cultures and wrote them prescriptions for azithromycin (Zithromax, or Z-pack), and then I had a little chat with them about their vaccinations, which, of course, neither of them knew. Before a couple of years ago, kids got the DTaP vaccine, which is diphtheria, tetanus, and acellular pertussis, and then adults got a booster of Td (tetanus and diphtheria) every ten years after that. However, the CDC started to notice that whooping cough was coming back, especially in adults who had gotten the full DTaP series as kids, so they changed the recommendation for adults to get Tdap (yes, the capitalization is important, but I won't bore you with the explanation) as one of their tetanus boosters.

Fortunately (?) for me, I needed a tetanus booster as part of my pre-travel vaccines, so I got my Tdap less than a month ago, which meant I "won" the debate about who got to see these two patients. When I presented my history and physical to one of the attendings, he rolled his eyes and went off on his soapbox about vaccines. Apparently, his sister-in-law is one of the Jenny McCarthy-type mothers who think vaccines will kill their children, so his nieces and nephews aren't vaccinated. Last year, the whole family had whooping cough.

So, in conclusion, GET YOUR VACCINES! If it has been more than ten years since your last tetanus booster, go see your doctor and get a Tdap, because enough people have gotten lax about that that whooping cough is coming back, and there's no need for that, since we have a vaccine that works.

Okay, stepping off my soapbox now. In happier news, they finally posted my grades from my two preventive medicine rotations, and I got honors in both :) They also upgraded my overall ratings, so I'm now a "very good" medical student, not just a "good" one. So I'm average to above average again.

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.