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.

A few thoughts on 9/11

As nothing terribly note-worthy happened at work today, I thought I'd dedicate this post to a few of my random thoughts.

Seven years ago, I was an 18-year-old college freshman, one month into what would become an eight-year stint in a state 2500 miles away from the town I grew up in. In the morning of Tuesday, September 11, 2001, I was in General Chemistry lab, oxidizing magnesium to form magnesium oxide. When I finished the assigned exercise and wrote it up in my nifty little lab book, I headed back to the dorms, where I was intercepted by one of my friends, who told me that we were under attack, that two airplanes had flown into the World Trade Center. Not believing at first, I joined the masses of people watching CNN, still not quite believing that this was real. Classes were cancelled for that afternoon (not that I had one anyway), and roughly half of the students and professors gathered in the Campus Green for prayers and discussions about what was happening.

Not long ago, Mom and I talked about how long it would take before all but a studious few forgot the significance of September 11. I said it would be less than a generation; after all, how many people today know the significance of December 7? If it is someday declared a national holiday, how long would it be before it was only known as a day off work or school? If it doesn't become a holiday, who would remember it at all?

I don't think it's going to take a generation for us as a nation to forget. Here I am, on active duty in DC for the month, and there is little indication that today is any different than any other. Yesterday, I overheard LTC Cavicchia talking about the invitation-only dedication at the Pentagon; even then, her primary concern was how the traffic would be around the Pentagon, as roads will be closed for the event. This morning, I had gone on a run and gotten dressed for the day while watching the news, and the first I even realized the date was when I checked my watch to figure out how long it would be before I get my next paycheck. I went to work at an Army base, and the only thing that was different was that half of the parking lot around the commissary was closed for a parking-lot sale tomorrow.

I'm not saying that our lives haven't changed in seven years; they certainly have, but in most cases, we've grown accustomed to them. Security changes at airports, once seeming so strict, are now commonplace. Going to war seemed like such a big deal at the time, but we have grown accustomed to seeing troops going off to Iraq or Afghanistan, and now the talk in the Army medical community is not "if I'm deployed...", but "when I'm deployed..." Gas prices have certainly gone up, but how much of that has to do with conflicts in the Middle East and how much is the natural course of things is unknown.

I did not join the Army as a result of the events of Sept. 11, 2001, but I know people--doctors--who did, who saw what happened and swore that they would do their part in making sure that nothing like that happens again. For them, this was a life-changing event, and they will never forget. Can the rest of us say the same?

Navy ports

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

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

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

By the way, here's WRAIR.

Life in Preventive Medicine

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

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

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

Field trip

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

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

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

More stories about coins

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

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

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

Deployment Health Surveillance

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

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

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

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

In-processing at WRAIR

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Getting a week's worth of errands ran in 3 days

In case you couldn't tell from the title, it's been a fairly hectic couple of days, but nothing all that blog-worthy. After dropping Mom off at the airport on Wednesday, it's been pretty much nothing but trying to get everything that needs to be done in person in Ohio (which is quite a lot) done before I leave for DC.

On Thursday, I had my meeting with Dr. Para, one of the Infectious Diseases specialists I worked with on that rotation, about the letter of recommendation he's writing for me. The meeting went fairly well, and he suggested I ask Dr. Schlesinger, the chair of the Infectious Disease division, for another letter, since I did research with him the summer between my first and second year. Unfortunately, Dr. Schlesinger wasn't in the office for these few days, so I handled all that via email (I think that's how Dr. Schlesinger prefers to work, anyway). So now that's taken care of, and I have four letter writers (which is the minimum), so I'm good in that regard.

So then I spent some time cleaning the apartment before my optometry appointment that afternoon (yay for new contacts), and then a mandatory med 4 meeting, which was mostly about reducing infection by washing our hands, and increasing patient satisfaction and stuff like that. The patient satisfaction stuff was based on survey results, which are the least reliable source of data, so I spent most of that meeting trying to distract myself from jumping up and telling them that those numbers mean nothing. But they did give us all-important business cards to give to our patients (which I will not do, in case you're wondering). Here's what it looks like:

After that meeting was the first Military Medicine Interest Group meeting, which got a lot more people than we were expecting (but we had enough food for everyone, so it was all good). I think we answered a lot of people's questions, and that's always the goal. It's strange to be a fourth year now and be the authority on all these things, instead of being the one asking the questions, like I was a couple of years ago.

Yesterday was more of the same. I went to Target to print pictures of MMIG members in uniform doing all sorts of military medicine-type stuff for our display case (it has to be updated every year at the beginning of the year; we just put up new pictures each time), then I had my travel appointment at the Health Center for my Papua New Guinea trip. I only had to educate the nurse practitioner on one thing, mostly because I didn't give her a chance to get it wrong on anything else--I told her what medications I would like and which vaccinations I need. The one thing she didn't get was terminal prophylaxis for maleria, which is when you take a treatment dose of a medicine that kills the liver form of the disease after returning from a long trip (defined by LTC as >4 weeks), to prevent relapse. She had never heard of it, and had to talk to the doctor, who agreed with me. Unfortunately, they don't carry that drug in the pharmacy, and I only get insurance in that pharmacy, so that's going to be expensive.

After that was more running around getting stuff taken care of, such as turning in receipts for reimbursements and taking some old study books to the "book closet" to be used in a book sale (it's a bit like selling books to a used book store). Then Jeff, Adrienne's fiancee, came into town and took us out to dinner, and fun was had by all.