Periodic Health Assessment

Today was a meeting of the Joint Preventive Medicine Policy Group (another acronym: JPMPG, pronounced jip-em-pig), which is a group of preventive medicine people from all of the services (Army, Navy, Air Force, Coast Guard, sometimes foreign militaries, etc), and the topic of the meeting was the periodic health assessment.

The periodic health assessment is done by each of the services, but each one is different, which in today's fairly integrated military, makes things a bit difficult. There's an online portion that each service member completes on his/her own time, and then there's a face-to-face with a medical provider (doc, PA, NP, etc). The problem comes in for the face-to-face... if a sailor goes to an Army clinic to do the PHA, there's no guarantee that that Army doc knows how to do a Navy PHA (or even knows which computer program to use). For the record, I don't know how to do Navy or Air Force PHAs, nor do I know what programs they use. As you can figure, that creates some problems on joint bases.

So the purpose of the meeting (which extends into tomorrow, but I won't be going to, because I'll be at WRAIR for didactics), is to figure out 1) what the purpose of the PHA is (that's an entirely different conversation, which I won't get into); 2) if the multiple different PHAs can be standardized into one form; and 3) what that might look like.

Easier said than done. There's a lot more to policy than meets the eye.

Proponency Office for Preventive Medicine at the Office of the Surgeon General

That's where I'm rotating now (today was the first day). Or, because the military likes acronyms the way normal people like breathing, POPM/OTSG (which we just call POPM, pronounced pop-'em).

To put it (very) simply, POPM is where medical policy in the Army comes from. Whenever there's a question about the way things are done in the Army medical department (AMEDD, back to the acronym thing), it goes to POPM, they check the research and what the civilian side and other services are doing and get the opinions of subject matter experts, and then make policy. Yes, that was very simplified.

Today I spent the morning doing the standard for a new rotation: in-processing. Fortunately, every Army prev med resident as rotated through POPM since 2008, so they know what they're doing (which is impressive; usually when someone should know better, they act as if it's never been done before and the wheel needs to be reinvented). Then the afternoon was taken by a teleconference about the new regulation for the Army program, which mostly turned into public health nurses bashing just about everyone else (including prev med docs). That took over three hours, and when it was done, they sent me home, because the snow was falling pretty heavily (not sticking, but still falling). Unfortunately, people around here become idiots on the road when there's weather involved (and I mean any weather... snow, rain, sunshine, hurricane, earthquake...). It's a little more than 15 miles from work to home, and it took me almost two and a half hours. I was not happy with that commute.

Whitman-Walker and Travel Clinics

In trying to stay up to date on the blogging, I'm writing about yesterday's and today's clinics. I was going to write yesterday, but I decided to go out to dinner with friends instead.

Yesterday I was at Whitman-Walker Clinic, which started as a HIV/AIDS clinic in DC and is now mostly primary care for HIV-positive patients (among other things, but the primary care in HIV patients is what we do). Every three months, the patients come in for blood work, including a full chemistry panel, blood count, HIV viral lode, and CD4 count (the white blood cells that HIV attacks). Twice a year they also get blood work for hepatitis B and C and syphilis.

All the patients I saw yesterday are doing very well, as far as their HIV. In fact, for all of them, that was the least of their complaints. One recently had a heart attack, one was recently diagnosed with diabetes and colon cancer, and one fell and hurt his shoulder (there were others, too, but I don't remember if they had any complaints). I wonder if the people who started HIV care thirty years ago imagined that the disease would be so manageable that chronic diseases would be more of a concern than the HIV.

That was yesterday. Today was travel clinic at Ft. Myer. I had four patients, three different trips (the middle two patients were a husband and wife traveling together). Here's where they're going and what I did:

Tanzania:

The first patient is going on a two-week safari in Tanzania. She got a yellow fever vaccine (there's no yellow fever in Tanzania, but there is in Kenya and she has a connecting flight. Tanzania requires official WHO documentation of a yellow fever vaccine for everyone coming from Kenya) and a bunch of other vaccines, including typhoid, meningococcus, hepatitis A and B, polio, and flu. She also got a prescription for doxycycline for malaria prophylaxis (the map above is the malaria map, so you can see that it's everywhere) and prescriptions for Immodium and ciprofloxacin for traveler's diarrhea. I also discussed with her safe food and water, insect avoidance (wear DEET, sleep under mosquito nets, etc), avoiding animals (because they all have rabies), and standard safety information and how to register her trip with the State Department (so they know she's there if anything happens).

Southeast Asia:

The couple traveling together is a retired lieutenant colonel and his wife, going on a two week cruise to Southeast Asia. They needed surprisingly little for their trip. Both needed two shots--typhoid for both, influenza for him and pneumococcal for her--and I gave them prescriptions for traveler's diarrhea, but there's no malaria in any of the cities where they're stopping, so they didn't need anything for that. I did give them some DEET, because there is dengue, and the mosquitoes that carry dengue bite during the day, which is when they're going to be off the ship.

Eritrea:

My final patient was born in Eritrea and lived there until she was 13. This is her first time going back; she's going to visit friends and family for two months. She's mostly going to be in the capital, Asmara, where there is no malaria (the white spot in the middle of the map). Since she is planning on visiting people outside (in the giant red areas), we discussed malaria prophylaxis. There were a few choices: no prophylaxis, a few short courses of prophylaxis just for when she's outside Asmara, or prophylaxis the whole time. She decided on prophylaxis the whole time, so I prescribed mefloquine, since it's only once a week. She also needed a couple of shots--typhoid, flu, and polio. There's no yellow fever in Eritrea, so she didn't need that. I also gave her a few courses of Immodium and cipro in case of diarrhea, and we discussed the standard safety things and travel insurance and whatnot.

Not a bad two days. In other news, I have a couple of presents under my tree, so that makes me happy :)

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.

Clinic, Week 2

I meant to write this while at work on Friday, and then yesterday during my day of doing absolutely nothing (no, really--I woke up, went on a run, and then only got off my couch to get food. It was kinda glorious). But I didn't, so I'm writing on Sunday night.

So here's how this past week of clinic work went:

Monday: No clinic (my preceptor at Whitman-Walker was still on vacation from Thanksgiving). So I sat at WRAIR and worked on work. And went to a two hour long safety briefing, which was incredibly boring, even with the company of my two fellow residents.

Tuesday: Travel clinic at Ft. Myer. I actually had patients! It was a lot of fun (and actually fairly busy). I had a retiree who is now a consultant who will be going to Afghanistan for twelve months, so he got a couple of vaccines and a year's prescription of doxycycline, which is an antibiotic that is also used as an antimalarial. He'll have to get a two-week prescription for primaquine, another antimalarial, to take when he gets back. The next patient was another retiree, going to Ghana for his mother-in-law's funeral. He's been out of the service for almost twenty years, and despite still having family (well, family he married into) in Ghana, he has never been to Africa, so he got quite a few vaccines, and also a prescription for antimalarials (Malarone, in his case, which is a drug with very few side effects but a pretty high price tag), as well as all sorts of counseling about how to take care of himself while he's traveling. Patient number three is a dependent (meaning she was never in the military, but her husband was) who was born and raised in El Salvador and is going back for Christmas. El Salvador does have malaria, but not much, so I gave her some bottles of bug lotion with DEET and told her to be careful going out at night (which is when the malaria mosquitoes bite), but she didn't need any medications. She did need a couple of vaccines, though, which we were more than happy to provide. The final patients were a family (mother and three kids under 10) who were going to Bahrain to visit the husband/father, who is stationed there temporarily. Bahrain is a pretty safe place, when it comes to diseases, so all they needed were typhoid shots and prescriptions for antibiotics in case they get diarrhea, and they were good to go. No malaria there.

Moral of the story: whenever you're traveling to the developing world, go see a doctor. You're probably going to need a few shots and drugs before you go.

Wednesday: This was supposed to be prev med clinic at Bethesda (excuse me... Walter Reed National Military Medical Center), but instead, we had a talk about the embassy bombing in Nairobi in 1998, by the doctor who was in charge of the research lab then (she is now retired but still working for the Army). It was a really interesting talk, if for no other fact than to demonstrate how far we've come as a military when it comes to treating and evacuating casualties from big, traumatic events. And this bombing was a big, traumatic event--there were around 400 killed and 1200 injured.

Thursday: TB clinic at Montgomery County. This was, well, not what I expected. I pretty much just observed while the medical director saw patients. The first was an elderly woman who recently immigrated from China and had a positive TB skin test and x-rays that looked like she had TB in the past. She never had any sort of treatment, so she was given a prescription for four months of isoniazid and rifampin (two drugs that are used to treat latent, or inactive, TB), and then a whole bunch of counseling on why it was important. The next few patients were all follow-ups who have active TB and come into the clinic once a month to check on the symptoms, see how they're progressing, and so on and so forth.

Friday: No clinic (there's never clinic on Friday). I finalized my orders for attending the American Society of Tropical Medicine and Hygiene conference in Philadelphia (where I am right at this moment) and did some mandatory online training, and that was about it.

So now I'm in Philly, with one day of the ASTMH conference down and four to go (it's a pretty long conference). I'm not presenting anything, just going to the sessions and, I hope, learning stuff. We'll see how that goes.

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.

Remembrance Day

Today I went up to Gettysburg with Melanie and her roommate Amy for Remembrance Day. We tagged along with the Norwich DC Alumni Association (where Melanie got her Master's). Although it was cold, it was a really good experience, which included a tour by a Norwich alum who teaches at the Army War College and is obviously quite knowledgeable about military history. We were also joined by a group of Marine recruits from the Yorktown area who were brought by their recruiters to Gettysburg and ended up joining our group.

We ended the tour at the cemetery at Gettysburg, which was decorated for the occasion:

Our tour leader read through the names of the Vermont fallen (Norwich is in Vermont) and we left flags at their gravestones. What really impressed me was that those Marine recruits (mostly high school seniors or recent graduates) not only stayed with us for this, but were at the first of the line to take flags. I was very impressed with how respectful they were of everything, and told that to their recruiters. They're going to be fine Marines.

Smallpox Vaccine Clinic

About a week and a half ago (hey, I'm a little proud of myself for only being a week and a half behind), I arrived early at Ft. Meade to attend smallpox vaccine clinic. Since smallpox vaccine isn't exactly routine, there's quite a lot of screening and education that goes along with it.

The education begins at 0630, with a CDC video about why we vaccinate against smallpox (since it's been, you know, eradicated and whatnot), how to vaccinate, and some of the risks. Quite frankly, I thought it was a bit too technical for the average audience (medical information for patients should be below the eighth grade level) and quite boring. It wouldn't be a bad video for doctors, nurses, and the techs who are administering the vaccine, but they need something better for the vaccinees. And something made in this century.

That took about 45 minutes, and then it was into the exam room to screen patients for vaccination. It's a very risk-averse environment, and there a lot of contraindications. Overall, the risk of infection is only theoretical--terrorists might have smallpox, but we have no proof of that. So if someone has a slightly increased risk of having an adverse effect from the vaccine, we're not going to give it. Some of the contraindications of vaccinating are skin problems (eczema, psoriasis, severe acne, etc) or skin problems in any close contacts (family members). This is why:

This is eczema vaccinatum and the result of someone with eczema being in contact with the vaccinia virus. People with intact skin will only get vaccinia at the sit of innoculation (the hands of milkmaids in the good old days, the right deltoids of vaccinees today), but people with such skin problems can get cowpox (vaccinia) everywhere. And it's quite serious.

Anyway, other contraindications of smallpox vaccination are dry eyes (because people with dry eyes rub them, and getting vaccinia in the eyes would be bad), immunosuppression (from HIV or certain medications), close contact with infants younger than 12 months, having another live virus vaccination within the last four weeks (such as FluMist), and certain heart problems, since smallpox vaccination can cause heart problems in even healthy people. Of the three people in vaccination clinic when I was there, only got vaccinated. Of the other two, one had FluMist the week before, and the other had both close contact with an infant and severe acne. Interestingly, the one who did get vaccinated was born outside the United States and had a BCG vaccination at birth (to protect against TB) and scar from that. Little known fact: according to the WHO, the BCG vaccine is given in the left deltoid, and the smallpox vaccine on the right, because they leave identical scars. By having it standardized back in the days when many people got both, you could tell who had had what.

I did watch the tech do the vaccination (he made me stand on the other side of the room, since I haven't been vaccinated). It looks kinda like this:

This is the only vaccine that uses a bifurcated needle. How it's done is that the needle is dipped into the vaccine so it leaves a small drop between the two prongs. Then, using the hand technique demonstrated here, the arm is stabbed with the needle fifteen times quickly, deep enough to leave a drop of blood. The site is then covered with a piece of gauze and the vaccinee is given instructions on how to care for the vaccination site. If everything goes right, the site should look like this:

And then it leaves a small, permanent scar. Quite enjoyable. Can't wait for mine (sarcasm).

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.

Poisoning project

I'm actually starting on my second week at Ft. Meade, which means I've really procrastinated about summing up my AFHSC rotation. As I mentioned before, my project was on poisoning hospitalizations in the military from 2001-2010, figuring out which of those were intentional, and finding risk factors of intentional poisoning compared to those that are unintentional. Here's what we got for total numbers:

I also looked into what people were being poisoned with. The top contenders are pain medications and psych medications (surprise, surprise).

The next part was to look into which hospitalizations were intentional. For this, I used an algorithm that was published in the civilian medical literature that looks into certain psych diagnoses during the hospitalization for poisoning. Surprisingly enough, despite the increases in psych diagnoses in the military over the last ten years, the percentage of poisonings that were intentional has remained fairly constant (with a very slight increase).

Risk factors for intentional poisonings were drug (medication) overdoses, being female, married, black, a recruit, in the Navy, and multiple deployments. Protective factors are age over 40, currently being deployed, being in the Marine Corps, and increasing rank (which goes along with being older).

I presented that about a week and a half ago and got a fairly good reception. Previous residents were only on that rotation for four weeks, instead of the six that I (and my fellow residents) have, so I was able to do more analysis than they were accustomed to seeing. All in all, it was a good rotation and a good refresher on the epidemiology. I'm still trying to get in the swing of my current rotation (preventive medicine department at Ft. Meade). I hope this one ends up being a good learning experience as well.