Activation, Triathlons, Medical Evaluation Boards, and Everything In Between

Yes, it's been a while since I've updated. A very long while. I could say I've been busy, but really, I think I've just been lazy. Here are some of the things that have happened since my last post:

1) The 82nd Civil Affairs Battalion was activated on 27 September 2012. The week leading up to the activation, we had rehearsals almost every day, which was tedious, but there were still some good times:

This was one of the rehearsals, obviously. I don't know what led to this; I just walked up as they were doing pushups, so I figured it was as good a time as any to take pictures.

And this is 2LT Alex Sasseman, the Adjuvant General (officer in charge of personnel). She had the delightful job of running in front of formation at the sound of the Adjuvant's Call, so that was actually quite a bit of running in the course of all of those rehearsals.

This was after the activation, when LTC Gardner (in the middle) cut the cake with his Zulu sword.

2) Triathlons. I ended up doing two triathlons this summer, one on the beach on Hilton Head Island and one in Florida at Amelia Island. The one on Hilton Head was actually pretty difficult, because not only was everything on the beach (including the bike), but it was August and very hot and sunny. The one at Amelia Island ended up not being a triathlon (they cancelled the swim due to riptides), but was still a good race. I ended up winning the military division for the sprint distance (16 mile bike and 3 mile run). I also did a 2.5 mile ocean swim in Jacksonville, FL and a few runs, the most recent of which was the Rock n Roll Half Marathon through downtown Savannah yesterday (I started too fast in efforts of finishing under 2 hours and ended up dying around mile 8, coming in at 2:21. I'll try not to repeat that mistake at my next half in December).

This was at the costume run the Friday before Halloween. I had to buy the red running shoes special for the costume.

3) Medical Evaluation Boards (MEB). This is not fun. As part of the "post tax", as LTC Gardner calls it, once a week I see soldiers from the Military Police in clinic to determine if they need to go to the MEB. These are soldiers who have been on limited duty profiles for an extended period of time and aren't making any recovery (or not enough). For some, it's just a matter of writing a referral to see a specialist (orthopedics, neurology, etc). For others, it's time for a long conversation about not being fit for the Army any more. It's not as simple as writing the referral for the MEB, unfortunately. The entire process takes anywhere from 6-12 months and involves many meetings and evaluations from people from the Army and the VA and likely more that I'm forgetting. I have no idea how many of the people I refer will actually be found to be not fit for duty, but this is what I do.

4) Parents came to visit. We explored Savannah, went hiking in a state park, Jekyll Island, and went up to Charleston, SC and Ft. Sumter. It was good to have them here (even though my guest bed didn't arrive until after they left).

5) Disney World. It's the most magical place on Earth. Need I say more?

6) Firing range. For three days last month, I got to hang out with the team leaders and senior NCOs from Alpha Company at the firing range. It wasn't much fun, but I did qualify on both the M4 (rifle) and M9 (pistol).

And I got a little burned by some ejected brass. Like I said, not much fun.

I think that's about it. I'll try not to let it be another three-ish months before I update next.

Slowly Settling In

Progress is being made in getting me settled into my new job (yay, progress!). I have an office now. It's nothing exciting yet:

We're supposed to get some fresh paint in the next couple of days, and it's still undetermined if anything will be done about the flooring (rumor is, the tiles have asbestos, so they might have to stay put). We have some furniture waiting to be moved in, once the painting is done, and then really, all I'll need is a computer. There will be an "after" picture, at some point.

I do finally have access to AHLTA, the DoD's electronic medical record. That just came through today, so I was pretty excited about that. Even though I won't be able to get it installed on my office computer (you have to be on the medical department's network, and my new job isn't), I will be able to access it remotely from my office, once my application to do so is approved. Again, with any luck, that won't be too long.

I also swung by the division surgeon's office today. The division surgeon is the top medical person in the 3rd Infantry Division (the division at Ft. Stewart). My battalion isn't technically part of 3ID, but since we're located on the same base, we fall under them in some respects. One of those is an agreement that all medical providers in the division put in some time at the Troop Medical Clinic (TMC). This is kinda a hairy point, as I'm not technically part of the division, but common belief (not held by me) is that this applies to me as well. So I talked to the division surgeon and explained that patient care is actually a very small part of my job, and the number of hours they were asking was not in alignment with how much time I should be spending on care. She then asked for my full job description, so now I'm roped into giving a presentation to her on Thursday about my roles and responsibilities as the physician in a civil affairs battalion. Much fun. I'm hoping I do a good enough job that I can convince her to let me out of time spent at the TMC, without having to involve higher-ups to pull any influence. Fingers crossed.

Getting Work Done, and Taking a Break

I've been a bit lax about updates, but to catch you up, I finished in-processing, both for Ft. Stewart and the battalion (yes, there was a separate in-processing for the battalion, but it was easy and only took about an hour).

Friday was my first full day, and since then, I've been working(ish). The unit does PT together every morning, which is a completely foreign concept to me (I'm used to working out by myself). So Friday morning, I joined in for PT with some of the other officers. We ran about three miles in a park not far from where I live, which was nice, because it meant I got to go home and shower and change, instead of sharing a locker room with about 100 other girls.

I still don't have full computer access, either at the battalion or at the hospital. I don't mind so much at the battalion; as long as I can get on a computer, I'm happy. The hospital, on the other hand, controls whether or not I can do work. So I've been spending a lot of time going back and forth between my battalion headquarters and the hospital (where I'm using a computer in the preventive medicine department). It's a couple of miles across post, so all I've really been doing since Friday is going between office and car and office and so on and so forth. I think I made the round trip three times today.

I tried to do PT with the battalion on Monday morning as well (after doing a whole lot of nothing all weekend), but got caught in traffic and ended up arriving 45 minutes late. And I thought I left the traffic behind in DC (I found out later yesterday that there was an accident, which tends to slow things down on a two-lane highway). So I went running on a treadmill at the gym yesterday morning instead (and then dealt with the whole shower/locker room situation) before spending the morning at the hospital working on getting computer access. Great fun.

The day started early this morning, when I drove to Hunter Army Air Field (subordinate base in Savannah) to do PT with the junior medics. They're taking a paramedic course in Savannah, so it's easier for them to work out at Hunter instead of Ft. Stewart. After that was back to Ft. Stewart, to continue trying to get stuff down without a computer (seriously, how did people do it?!?). People are starting to come to me with medical questions, which I can't really do anything about. I can't practice medicine, because I don't have a clinic, computer access, or credentials; and because I don't have computer access, I can't write referrals for them to see anyone else. With any luck, this will all be over soon and I'll be doing real work.

Until then, I have ten days of vacation, because that's what the Army does when you move somewhere and haven't figured out your job yet. Immediately gives you a vacation.

Days 3 and 4 of In-processing: Almost Done

I realized this morning that I forgot to write a post about yesterday. Sorry about that. I'll try to combine the experience with today's experience.

Yesterday I did not go in for PT at 0600, choosing to go running at home instead. I was going to go running outside, but ultimately, unfamiliar neighborhood, lack of sidewalks, prior to sunrise, and lack of streetlights lead me to believe that that not be the best idea ever. I found a place on base today where I'm going to try running tomorrow, but I digress.

The day really started at 0845, when I arrived at the room where we would spend the morning. Even though they told us 0845, nothing really started until 0915, and that wasn't much. We turned in our dental records (exciting), our medical records (I didn't turn mine in, because I don't see the point), and then finance came to have us fill in forms to get our housing pay changed to Ft. Stewart (good-bye, getting paid to live around DC) and fill out our travel forms to get reimbursed for moving. Sounds simple enough, but you would think it was rocket science for all the questions it generated.

After lunch was when the VIPs (me and a few others) were separated from the normal people. We were given four tasks to go through: dental for an exam and x-rays, even though I just had an exam and x-rays at Walter Reed last month; medical, to confirm that I am up-to-date on vaccinations (which I am; that's kinda my job); behavioral health, to confirm that I'm not [too] crazy to be in the Army; and personnel, where I changed my address and made sure my life insurance when somewhere (have fun, parents). Then I was given four more tasks to complete in the next five days. I knocked out two of them yesterday (the museum of the 3rd Infantry Division and the Education Center). The other two will take the next two days, because they both happen at the same time daily.

This morning, I opted for the Central Issue Facility, where I was given almost $5000 worth of Army gear (not to keep for myself) that I will probably never use. At every step, they seemed really surprised that I hadn't been issued any gear before. That's what happens when you spend your time at a base that only has a hospital (and no troops). Nobody gives you anything. So now I have a trunk full of cold weather gear, Kevlar helmet, sleeping bag, rucksack, etc, etc. Tomorrow morning will be the safety brief, and then I'll be done in-processing on post.


Since I finished at CIF around 1100, I headed over to the battalion office to check in and see if there's anything they could do for me (or I for them, even though I can't really do anything yet). While I was there I took a lovely picture of the sign:

They're getting me set up on getting email and whatnot, which is about all they can do until I actually get an office. I also stopped by the hospital to see about getting computer access, because I can't really be a doctor until I have access to the DoD's EMR. With any luck, that'll happen soon.

Day 2 of In-Processing: Continuing to Make Progress

Today was my second day of in-processing, which is actually my official "day zero". It didn't make much sense to me, either.

After getting up early to make it to PT on time, I was again stuck in the "no decals" lane at the main gate, because I still don't have decals on my car (I now have a temporary pass, which is the best I can do until I have my Washington registration and plates, but that's another story). What nobody bothered to tell me, however, is that it takes about 45 minutes to get through the "no decals" lane around 0600. I didn't make it on base until 0630, half an hour after when I thought PT was supposed to start. Turns out, 0600 is the time for formation; PT itself doesn't start until 0645. So I didn't miss anything (except a good workout, because you can't get that at group PT 95% of the time).

I finished PT, showered, got dressed, and returned to the Marne Reception Center to find one of my classmates from my MPH sitting there. After the initial "What are you doing here?!?" greetings, I noticed he had the patch for the 85th CA Battalion on his arm (see Friday's post), and was able to put two and two together and realized that he's the environmental science officer for the battalion. So I do know someone at Ft. Stewart (and even in my battalion!) after all.

Since he was just signing in today, his "day one" is Wednesday, and since he's a major, he doesn't have to work at getting on the VIP list, so he's not even coming in tomorrow. For today, though, we stuck together to get our cars registered (which is where I got my temporary pass) and go to finance, where I turned in my paperwork to get paid for my partial do-it-yourself move (meaning I put a bunch of stuff in my car and drove it south). Then we grabbed lunch and he headed back home, I got official word that I'm a VIP (yay for no group PT tomorrow!), and then headed over to the hospital to do the in-processing that's not a part of the overall in-processing.

I won't be working at the hospital, since I'll be working in the battalion, but the hospital has to keep my credentials and give me access to the computer systems and whatnot. Turns out, though, that while we were able to get my credentials file started, Walter Reed still hasn't send over my residency file (let me put on my surprised face...). We got that going, but I won't be able to request access to the electronic medical records or my work email until I'm done in-processing to Ft. Stewart.

That taken care of, I headed home and got my paperwork ready for tomorrow, my "day one" of in-processing (only three work days into the process). What do I have to look forward to tomorrow? Endless lectures. Including one on preventive medicine. I wonder if they'll let me give that one.

In-processing to Ft. Stewart, Day 1

Today was my first day of in-processing at Ft. Stewart in anticipation of starting my new job as the battalion surgeon with the 82nd Civil Affairs Battalion. In true in-processing fashion, it was not all smooth sailing. Let's start from the top:

I arrived at the gate at around 0745 this morning, only to be told that, while the DC area no longer used military decals on the cars, Ft. Stewart still does. Since DC doesn't have decals, I don't have any on my new car, which meant that I had to go to the main gate to go through a full inspection before I could get on base.

Even with that, I still arrived at Marne Reception Center, where all new arrivals sign in, around 0800, only to discover that I forgot my leave form. I thought it was still in a folder in the trunk of my car, but it wasn't. So I tried calling WRAIR to see if they could fax a copy over; unfortunately, the sergeant seemed to be incapable of operating a fax machine, because despite multiple claims of faxing it over, no copies ever arrived. So I drove home (about a 35 minute drive), found the pile of papers that included my leave form, and drove back to sign in. Success.

I was supposed to go to a safety brief at 1530, but instead, I was rescued by MAJ Ellis, the chief of preventive medicine at Ft. Stewart (everyone in PM knows everyone else, it seems). He took me to find my battalion, which after a few wrong turns, we did. There's a pretty sign in front of the building and everything (I didn't get a picture of it, but I will). The battalion commander is at a training course, so he wasn't available, but a few of the senior non-commissioned officers were there. They welcomed me to the battalion, which included giving me the proper left shoulder patch for my uniform:

So I am now officially part of civil affairs, and no longer part of MEDCOM (Medical Command). The fifteen minutes I spent with the two NCOs were probably the only useful fifteen minutes in my entire day. They explained who has arrived thus far (the battalion won't be officially stood up until September), what my job will be (I'll be in charge of the medical shop for the battalion, which includes me, a vet, an environmental science officer, medical logistician, and a slew of medics of various ranks and training), and where my office will probably be. I didn't see my office, but I am excited about the idea of having an office. Of course, as one of the NCOs pointed out, having an office means people know how to find you.

In all, a long and trying day, with a rewarding few minutes at the end. Compared to most in-processing activities, the rewarding few minutes at the end made it almost worthwhile.

Next step... PT at 0600 on Monday. Fun.

Defense Occupational and Environmental Health Surveillance Course

For the last couple of days, we've been up at Ft. Meade for a three-day course on Defense Occupational and Environmental Health Surveillance, or DOEHS. The main purpose of the course is to teach us, as preventive medicine physicians, what the other members of the preventive medicine team do, both while deployed and in garrison. 

The preventive medicine team, in addition to the PM physician, includes environmental science officers, environmental science engineers, entomologists, industrial hygienists, and a slew of others, included enlisted preventive medicine techs and environmental science techs. We started the course with a "where do they go when they're deployed?" talk, which goes something like this:

Level 1: Each Company has a field sanitation team, which is two enlisted soldiers who, as an additional duty, are responsible for field sanitation (latrines, bug spraying, etc). Since this is an additional duty, nobody wants to do it, and is sometimes (but not supposed to be) given as punishment. 

Level 2: Each Battalion (which has ~5 companies) has a PM detachment, with one junior (2LT or 1LT) environmental science officer and one junior (private-specialist) environmental science or PM tech. 

Level 3: Each Division has a PM physician as a consultant to the Division Surgeon. In addition, there's a PM team, roughly 5x the size of a Battalion-level team.

Level 4: Area Medical Laboratories. There were two, but one was just deactivated. These are complete and completely deployable labs, with almost the capabilities of public health labs in the States. When they deploy, they have a total of 43 people, 19 officers (including 1 PM physician) and 24 enlisteds.

Level 5: Public Health Command, at Aberdeen Proving Ground. That's the definitive authority for everything public health/preventive medicine in the Army.

The confusing part comes when you start to consider who answers to whom. It would make sense to put the Battalion PM assets under the command of the Division PM assets, but this isn't true. The Battalion PM assets fall within the Battalion, and thus, the Division PM doc doesn't have the ability to directly ask the Battalion PM to do something.

It's the Army. It's sometimes a little confusing.

Today we focused more on what people are actually doing while deployed. We learned about the equipment that the enlisted techs use on their inspections. Here are some pictures:

Above is a rucksack with everything a PM or environmental science tech needs to do an assessment of a forward operating base. It's actually quite amazing all the stuff the pack contains, and it still weighs ~35 pounds.

This is a kit to test untreated water; for example, if they're evaluating a lake or river to use as source for a water treatment facility. To give you a sense of scale, everything's packed inside a cooler. All of the testing is done at Public Health Command; they send the cooler, the techs fill the bottles according to instructions, and then send it back for testing. The whole process takes around 6 weeks.

Tomorrow we're going to hear from the other sections. Although this won't be as pertinent to my first assignment with civil affairs, there will be other deployments in the future, so I should try to keep this all in mind.

MCBC: Day One of Bio

Today was the first day of Medical Management of Biological Casualties, or the "B" part of MCBC, at USAMRIID (which is a much nicer drive from my place than Aberdeen Proving Grounds). They starting things off with a running start, and then it kept on going until they set us free around 5.

Just a bit of a brief overview, the first documented case of biological warfare in history was back in 1346, when plague corpses were launched over the city walls of Kaffa. Whether or not this contributed to the fall of Kaffa is unknown; chances are, the rats (which don't really respect city walls) were going to cause an outbreak of plague around that time anyway.

The US did have an offensive biowarfare program, from 1943-1969 (which was three years before the Bioweapons Convention ban). Most of the agents we produced were aimed at disrupting the food supply instead of killing people, such as diseases against cattle and crops (we did produce anthrax, botulinum toxin, tularemia, and others, though). In 1969, President Nixon ended the program and ordered all stockpiles removed. Three years later, as I said, was the Bioweapons Convention, which was ratified by over 100 countries (including the USSR, which blatantly ignored the fact that they said they weren't going to produce or stock offensive biological weapons, and stockpiled a few hundred tons of smallpox, anthrax, and other scary stuff).

The rest of the day was going over specific select agents. A select agent is one that we think can be used for biological terror or warfare. They're cheap or easy to obtain, easy and inexpensive to produce, easy to deliver, difficult to detect, cause a large of casualties, and cause widespread fear and terror. The ones we had lectures on today were anthrax, tularemia, plague, brucellosis, Q fever, and agriculture agents.

We finished with a lecture on the epidemiology of bioterrorism, which gets to the question of, how do you know if an outbreak is natural or intentional? There are 11 clues that something might be an intentional attack:
1) Highly unusual event with an unexpected number of casualties. For example, 751 cases of salmonella in one month in one county in Oregon is very unusual (in the case of the Rajneeshee salad bar debacle).
2) Higher morbidity or mortality than expected. This would make you think that something might have been modified in a lab.
3) Unusual disease. When West Nile Virus appeared in New York in 1999, it had never been seen in the States before, and this made people suspect that it was some sort of biological attack (it wasn't).
4) Point source outbreak
5) Lower attack rates in protected populations
6) Multiple or serial epidemics
7) Dead animals of multiple species
8) Reverse or simultaneous spread between animals and humans. Usually human disease follows animal disease, so if it happens the other way around, that's a little bit suspicious.
9) Usual manifestation of disease. 95% of anthrax is cutaneous, so if there's a lot of inhalational anthrax and not very much cutaneous, that might mean that somebody released aerosolized anthrax.
10) Downwind plume pattern. This was seen after the accidental release of aerosolized anthrax from an anthrax factory in Sverdlosk
11) Direct evidence. This is rare, but was seen with the 2001 anthrax letters (they included a letter saying exactly what it was).

It was a long day with a lot of information thrown at us (most of which was a review). Now I'm heading off to bed so I can do it all over again tomorrow.

MCBC: Happy Halfway!

Today we finished the chemical portion of the Medical Management of Chemical and Biological Casualties. We started the day with the most exciting part, the field training exercise (which, in military speak, is FTX). 

The FTX was actually in two parts. In the first part, we had twelve of our classmates dressed up and acting as casualties, and we each had to triage them. That was hard enough, but we were doing it in MOPP 4, which made it intellectually and physically challenging. I don't know what MOPP stands for (and I don't know anyone who does, except maybe Wikipedia), but here's a diagram of what the MOPP levels are:

MOPP gear is designed to protect against a chemical or biological attack, so obviously, the overgarment doesn't breath all that well. Fortunately, we were allowed to wear our PT uniforms under it instead of field gear (as demonstrated in the MOPP 0 column), and the weather was pretty mild, so it wasn't terribly uncomfortable. 

The second part of the FTX was to break into groups and go over decontamination and treatment of chemical casualties, while in MOPP 4. Decontamination isn't an easy process; done right, it takes about 20 minutes to completely decontaminate a casualty. Here's a picture (from the Internet, not my course):

As you can see, the people doing the decontamination are also in MOPP 4, which makes things a bit difficult (it is not easy to cut through a MOPP suit while wearing thick gloves). Also, during the 20 minutes a patient is being decontaminated, he isn't really available for medical treatment, so you have to make sure everyone who goes through decontamination is stable enough to last 20 minutes without care. We also practiced things like intubating patients (well, dummies), starting IVs, and giving injections of atropine (for nerve agent exposures), while wearing MOPP 4 (and I'm not great at the first two without MOPP gear). 

After that, we did some after action reports to discuss the course, and then they set us free (at 5). Tomorrow begins the bio portion, which I'm really looking forward to (mostly because it'll be a review and I'll get to feel really smart). 

Medical Management of Chemical and Biological Casualties (MCBC) Course

Starting yesterday, ridiculously early in the morning, I got up to drive to Aberdeen Proving Ground for the first half of the Medical Management of Chemical and Biological Casualties course, or MCBC. The course is three days of chemical warfare at the United States Army Medical Research Institute for Chemical Defense (USAMRICD, and no, I don't know how to pronounce that acronym), followed by three days of biologic agents at the United State Army Medical Research Institute of Infectious Disease (USAMRIID, which is pronounced u-sam-rid) at Ft. Detrick.

I was kinda dreading the chemical half of the course, because chemical agents aren't nearly as exciting as bioterrorism, but it's been pretty interesting so far. We started with a lecture on the history of using chemicals in warfare, which began with the Chinese using arsenic smoke to suppress peasant revolts, back in 1000 BC. Way to be innovators, China.

Modern use of chemical warfare really began with WWI, and it was the Germans who started it. A chemical engineer, Fritz Haber, masterminded the use of chlorine gas at Ypres (1915), and at the end of the battle, there were 800 fatalities from chlorine gas and over 10,000 Allies injured. Chlorine gas was effective, until the Allies started getting good at making gas masks (by the time the US joined the war, we had it figured out). Chlorine, like the other pulmonary chemical warfare agents, doesn't have a specific antidote; treatment is pretty much just getting to an ICU for monitoring and intubation.

Here's a picture of a WWI gassing:

The next class of chemical warfare agents we talked about was the blood agents, of which cyanide is the typical example. It was also used in WWI, but by the French. Unfortunately, like many things done by the French, it was pretty ineffective. Cyanide is lighter than air, so it didn't do a very good job of getting down into the German trenches. However, by WWII, the Japanese and Germans both figured out how to use it (mainly, by using it indoors). The gas Vyklon B in concentration camp gas chambers is a cyanide gas. Unlike chlorine, there is an antidote to cyanide--inhaled amyl nitrite, IV sodium nitrite, and IV sodium thiosulfate. You have to work fast, though, because about three minutes after a inhaled cyanide attack, your casualty is going to be dead.

The cyanide turned the walls of the concentration camp gas chambers a bit blue. Here's a picture:

The next to make it into the game was the blistering agents, such as mustards and Lewisite. They were first used (by the Germans) in July 1917, because the Allies had figured out the gas mask issue. Just like it sounds, these cause blisters on the skin. They didn't kill too many people, but they did take people out of the fight for quite a long time (average convalescence time was 42 days). Many of the casualties thought that they were blind, due to the swelling around the eyes, but the actual numbers of people who went blind from mustards was pretty low. The treatment for these is immediate decontamination (in the first few minutes after exposure, before it completely goes into the skin), and then burn treatments for blisters, including skin grafts, if necessary.

Here's a picture from Bari, Italy, where an American ship filled with containers of Lewisite was blown up by the Germans in 1943. There were a lot of civilian and military casualties, made worse by the fact that they wrapped everyone in blankets, which were also contaminated with Lewisite.

The most recent addition to the arsenal of chemical warfare agents is the nerve agents, first used in battle by Iraq during the Iraq-Iran war in 1980 (and we wonder why we thought Iraq had unconventional weapons...). Most of the nerve agents were developed by (drumroll, please...) Germany, and thus have codes of GA, GB, GD, and GF (no idea what happened to GC or GE), which correspond to tabun, sarin, and soman (GF doesn't have a name, as far as I know). VX is also in this category. Like cyanide, these will kill you pretty quickly if you don't treat. The antidote is atropine, 2-PAM chloride, and diazapam (Valium) for seizures. We have autoinjectors for these that an exposed soldier can give to himself or a buddy in the case of an attack. Here's what the autoinjectors look like:

And in case you don't remember VX from the movie The Rock, here's a reminder:

After all those lectures, we practiced putting on our chemical protective gear and gas masks in preparation of our casualty exercise tomorrow. No, this isn't me.