More Medic Training and Some Random Musings

I actually started to write this post on Friday, but then I realized that I didn't have everything I needed to write it. By that I mean the link to the article I wrote... Keep reading and that will make more sense.

Before I left for ACPM, we had Dr. Likita Aminu from the CDC come over to talk to the medics about hepatitis. Dr. Aminu is originally from Nigeria, and met LTC Gardner in December at an African culture event in Savannah. Because LTC Gardner can talk anyone into anything (he is, without exaggeration, the type who would be able to sell ice to Eskimos if he wanted), Dr. Aminu agreed to chat with the medics. Since he had done research on hepatitis in the Coastal Region of Georgia (where we live), and hepatitis is an issue in Africa, that's what he talked about.

And here's the link to the article I wrote about the training:

http://www.stewart.army.mil/homepage/news/news8.asp

Now onto my random musings. For the second half of last week, I was in a pretty annoyed mood. I think it started on Wednesday, when we had a Command and Staff meeting. Command and Staff is pretty awful to begin with--each of the staff sections talks about what's going on in that section. It's great if you really care about how many humvees are due to be serviced or whose evaluations are due. If you don't, it's about an hour and a half of torture. Well, because the conference room table is only so large, I don't have a seat at the table, but I do have a slide (as in, one PowerPoint slide) to brief, and that's the medical readiness of each of the companies. To make an already long story somewhat shorter, before the meeting started, I was trying to find the right chair to pull into the corner of the room, the entire time thinking, "I went to four years of medical school and three years of residency for this?" Yes, a bit egotistical, perhaps, but that is what I was thinking.

I think part of that was the fact that I was just at a conference, hanging out with the people I used to work with, which was a nice little reminder of how well I used to have it. In residency, my only obligations were to learn as much preventive medicine as possible (and stay up to date with all my Army required trainings, of course). Now, I see routine complaints (boring), track who is due for which vaccines or blood work (boring), and only rarely get to do anything preventive medicine or tropical medicine related (yay!).

I guess the point of that is, going to such conferences remind me that I do like the Army, but that I think I'll be happier if I leave FORSCOM and go back to MEDCOM, where doctors typically get to do what they're trained to do.

We'll see what happens.

Training the Medics

Yes, it's been a while since I've last the blog... Sorry. I wish I could say a lot has happened since my last post, but sadly, that's not really true. It's pretty much the same thing on a daily basis: work-out, go to work, go home, sit on the couch, go to bed, repeat. With the occasional variation for a weekend.

So I'll write about what's been occupying my time at work: how to train the medics.

We have about 25 junior medics (private first class-corporal), all of which are very bright, for junior medics. They were recruited for civil affairs by being at the top of their classes during Advanced Individual Training (AIT); once selected for civil affairs, they completed a seven week CAMS course (Civil Affairs Medical Specialist), which went over basic preventive medicine, environmental science, and veterinary medicine. More than half of them have gone to a paramedic course and are now certified paramedics. They're great at trauma care; unfortunately for that, most of what the medics are probably going to be encountering in Africa is going to be tropical medicine and not trauma.

Fortunately, I happen to be a little bit good at tropical medicine (and that's not just me saying that... The American Society of Tropical Medicine and Hygiene agrees, and gave me a certificate saying it).

So between the environmental science officer, the vet, and myself, we came up with the perfect (okay, not perfect, but decently good) training plan, with two hours lectures once a week, on Wednesdays from 2-4 pm. We presented this to the company commanders, but sadly, the presentation did not go as planned. The company commanders were concerned that we were trying to tell them what to do with their people, and told us that they'll get back to us with a plan for how they want us to train their medics.

That was over a month ago. Still no word on what that plan is.

In the meantime, we've been doing what we can to "unofficially" train the medics. I put "unofficially" in quotes, because everything is, actually, official (we keep careful records, because the medics need a certain number of hours of training a year to maintain their certifications), but just not without the approval and/or knowledge of the company commanders. Through the super-secret sergeant channels (that's what I call how all of the non-commissioned officers get things done), the senior medics who work in the aid station contact the senior medics in the company and tell them that we're going to do training, and if their junior medics are free, that they're welcome to attend. For unofficial training, we've so far done "stump the professor", where the medics asked me any question they had about diseases in Africa (on which they stumped me on one disease--guinea worm), and practicing inserting IVs, which Mary, the vet, ran (she even brought in her dog so the medics could practice on the dog as well as each other). Both went very well.

We've also had official trainings, which so far has consisted of one guest speaker, a Nigerian-born physician from the CDC. He came in to talk about his research on hepatitis that he's done in the Coastal Region of Georgia, and compared that to hepatitis trends around the world. Some of the statistics were a bit pedestrian, but overall, the medics were very attentive throughout and asked some good questions, so I'm proud of them. We have another presentation scheduled for a couple of weeks from now, when the dermatologist from Ft. Stewart is going to talk about tropical dermatology. Should be a good presentation.

Long story less long, training the medics to know what they need to know about tropical medicine, before they go to Africa, isn't easy, but we're finding a way to make it work.

Teaching and training

Today was more of the same, unfortunately (or fortunately, I haven't quite decided yet). I'm again in public health, so I spent time with Katana on his weekly disease surveillance reports, which have to be submitted up to the next level. He gets reports from the local clinics (35 or so of them, I think they said), and then puts that all together to submit up to the district public health officer, who submits them up to the province, then to Nairobi, etc. What he usually does is count them all up by hand and submit it that way, so I introduced him to Excel, which will do the summations and keeps everything in a pretty handy place for the future. I've never taught anyone how to use Excel before, so it was a little interesting to see all the things that I do without thinking (like making the columns fit the headings), from the point of view of someone who doesn't know much about the program. I did teach him the basics and how to do summations, but that was about it. I also had to teach him how to save websites into his favorites... The things we take for granted having grown up with computers, I guess.

After that, I got a call that there was a post-mortem (an autopsy) that was about to start, and since I was interested in that process, I went over to the morgue/funeral home for that. Sadly, it was an 11-year-old girl who had been hit by a bus. She was missing the back of her skull and almost all of her brain, so cause of death was pretty obvious, but they still did an internal examination to get a full list of injuries for the police report. One main difference between autopsies here and in the States is that in Malindi, they don't have trained pathologists, so they don't do histology (looking at tissues under a microscope). For cases such as this one, with obvious cause of death, looking at the tissues isn't really all that necessary anyway, but if there's a question of cause of death, or if there's something that needs to be looked at to determine if it's cancer, the tissues get sent down to Mombasa, about 3-4 hour drive down the coast. Not nearly as streamlined of a process as what I'm accustomed to.

Following that, I decided to check out how the trauma training was going. Dr. Childs was using ATLS presentations, which was good, in that they cover the standard of care for trauma treatment, but also a bit difficult, in that Malindi doesn't have a lot of the resources that are needed for standard of care. It's an interesting balance, to present what is right but at the same time teach them what to do in their situations. There's a group of German med students who are the hospital for a month who were also attending the training, so I got to chat with them for a few minutes about school and what they were hoping to accomplish on this rotation.

Tomorrow, I think I'm going with the district public health officer to inspect some of the clinics, but I haven't heard from Jeremy, so I don't know what time I'm supposed to be at the hospital to leave. This could be interesting...

More training

This time, the training isn't for me. Yay!

I started the day in the public health office, where we did active surveillance for polio and measles. This involves going to the outpatient physiotherapy and occupational therapy logs, and checking the diagnoses to make sure nothing sounds like "acute flaccid paralysis" (which is polio), and then going to the pediatrics ward and making sure nothing looks like "fever and a rash" (which could be measles). It would also be possible for acute flaccid paralysis to be the inpatient peds ward, but we didn't see that (or fever and a rash). This is good, because with the two cases of neonatal tetanus from before, Malindi District Hospital already has enough to report to the WHO.

That didn't take too long, so I was off to do more preventive medicine-type things, which was seeing how their vaccination clinic worked and what exactly happened in the family planning clinic. The vaccination clinic was interesting, just because there's so much logistics that we don't usually think about. Cold chain is very important, especially for the measles vaccine; if the vial gets to warm, it's useless (and no, I don't know what that magic number is). So they have the stocks of the vaccines in a freezer, which is only opened twice a day, once in the morning to remove what would be needed for the day, and once the evening, to return anything that wasn't used. The vials that are going to outlying clinics were placed in a cooler and packed with freezer packs (the fake ice stuff usually used in coolers). Those that were going to the vaccination clinic at MDH were placed in a fridge in the clinic, except what they needed at the moment, which was kept in a cooler with the freezer packs. Whenever that cooler was emptied, they opened the freezer to get more. It was somewhat complicated, but it works, which is the most important part.

"Family planning" is the PC term for birth control. I haven't seen the actually study that says this, so I don't know if it's true, but according to COL Coldren, women in Kenya seek family planning after they already have a kid. Men want it before they have a kid, but once they have one, they want more, so they don't want family planning anymore. Sometimes this means there's a little bit of sneakiness on the part of a wife, who will go in for Depo-Provera shots (birth control shots) when she has to go to the clinic for her baby's shots. From what I saw, Depo is the birth control of choice here, because it's cheap (70 KSH a shot, which is about $0.80) and you only have to think about it once every three months. Family planning is offered to anyone who wants it, but from what I saw, it's usually women who already have at least one kid and are trying to space kids out, which is good.

And now back to the title of the post. Today a trauma surgeon and Navy reservist arrived to provide training in care for trauma patients (this is his annual two weeks of active duty time... talk about having a hard life). His original plan was to do Advanced Trauma Life Support (ATLS) training, which is a 2.5 day training back in the States (I did it during C4, during intern year). Well, ATLS requires all sorts of skills demonstrations that they just don't have here, so his plan is to use a lot of the ATLS lectures and just teach whatever skills he can manage to teach, given the resources of the hospital. This training was requested by Dr. Buni, the medical superintendent, because they're opening up a Casualty ward (essentially an ER), and he wants to make sure he has medical officers and clinical officers who know what they're doing in it. It's going to be a busy two weeks for Dr. Childs, given that he has to make up some aspects of the course and given that there are about 50 people who want/need training. I'll drop in on some of the lessons, to see how the training goes and offer my assistance if he needs it.

After work, I lounged around for a bit before heading over to the gym and putting in some treadmill time (ugh). It's not exactly fun (in fact, compared to doing some real running, it's pretty much torture), but it has to be done. In a little less than two weeks, I'll be back home and will get to do all the running I can handle (hopefully without ending up in a fracture boot this time...)