6-5-13: Getting Started

Today was our first day working at Kitona Referral Hospital, which was nerve-wracking in its own right. It means that the MEDRETE has officially started, and there’s nothing we can do about it now.

For the mornings, we’re paired up with DRC military physicians, to see patients with them. My physician partner is the equivalent to a first lieutenant (one rank behind me), but he’s older. He also has a wife and five kids in Kinshasa, which came up in conversation before our first patient arrived.

                

We spent more time on the first patient than we should have, given how many patients we had to go through. I think maybe the physician I’m partnered with was unsure about my level of education or what my role is, because he explained things in much more detail than necessary, instructing me on listening to heart and lung sounds (medical student-level instruction). I didn’t say anything, but I should have, because it made things drag on much more than necessary and didn’t really accomplish anything. Tomorrow, I’m going to tell him that I’m okay on physical exam, and what I really want to do while we’re working together is talk about what he thinks the diagnosis is and why, and from there, to discuss the differences (or similarities) between those symptoms in the States and in DRC. I guess we’ll see if I have enough of a backbone to do that tomorrow.

                

The first case was interesting, though. It was a young man, maybe 23, a college student with pain with urination. My immediate thought was chlamydia or gonorrhea, both sexually transmitted diseases. However, the physician I was working with didn’t ask anything about sexual history (beyond “are you married?”), and definitely didn’t ask the “men, women, or both?” question that I was taught in medical school. He was leaning much more toward a urinary tract infection, which is fairly rare in grown men in the US, outside of some other medical problem (HIV, cancer, etc) or men who have sex with men. However, he said that UTIs are common in men in DRC, due to poor hygiene, poor sanitation, and relative dehydration.

                

The rest of the morning was fairly routine cases, and then it was time to break for lunch (me, not the DRC physician… they don’t eat as many meals as we do and don’t mind working through the day). In the afternoon, we were supposed to have didactics, but there was such an influx of patients from the community that none of the DRC military physicians were able to get away. We found out afterwards that that was because there was a message that went out on the radio saying that the Americans would be here and would be giving out free medical care.

In other words, the exact opposite message that we wanted to go out, which was that we would be training in public health and infectious disease along with the DRC military physicians.

                

Instead of doing academics, we hammered out a schedule for the week we’ll be here, with what we’re going to talk about on any given day, and then it was time to go back to the hotel. This morning, the hotel manager told our logistics people that they don’t have enough money to keep taking care of us (electricity, food, etc) for eight days, especially with the list of needed repairs that we gave them (showers not working, AC out, etc). We gave them one night pay each ($100 x 10 people) to help out before we checked out. When we got back from the hotel, we found that they had repaired all the plumbing issues we brought to their attention (for example, the switch deciding shower or bath in my shower was broken, causing there to be a slight trickle of water from both) had been repaired, and they had moved everyone who’s AC was broken into new rooms.

Landscaping at the Prosper, new since March

Apparently, when you give money to a business in the developing world, they reinvest it in their business, instead of just lining somebody’s pocket, as usually happens in the State. It was nice to see a hotel operating to provide hotel services, and not just a profit.

                

Well, it was a long day, and after waiting far too long for our food at the restaurant (as usual), I’m ready for bed. I hope tomorrow goes smoothly.

Dinner tonight: lobster :)

6-4-13: Back in Muanda

After getting into the hotel in Kinshasa late(ish) last night (around 9), I had a late dinner and then went to bed in preparation for getting up early to go running before we had to head to Muanda in the morning to begin the MEDRETE. As it turned out, I didn’t go running (the alarm went off and I disregarded it), but I was ready for the flight to Muanda.

View from the Fleuve in the morning

The flight was the same as last time—small prop plane, a little warm, stops in Matadi and Boma—before we landed in Muanda around noon. We loaded up the rental cars (and by cars, I mean Toyota Highlanders), dealt with the usual drama associated with traveling in developing countries, and made our way to the hotel. Fortunately, the advance team was already on site and had ordered our lunches ahead of time, so we only had to wait about 30 minutes before we got to eat.

View of Kitona Base, from above.

Around 2 pm, we headed back to Kitona Base, to meet with the hospital commander and a few representatives of the medical department of the Ministry of Health, who had traveled from Kinshasa. We hammered out the final details in preparation for tomorrow (which I still think will be a disaster) and then called it a day and headed back to the hotel.

We’re staying at the Hotel Prosper this time, which is different from my hotel when we were here in March (I was staying at the Eunice). The rooms aren’t as nice, the air conditioning doesn’t work as well, and as of yet, I still don’t have running water. This will make returning from my run tomorrow interesting, I’m sure.

My room in the Prosper, complete with sequined pillowcases

We had a meeting of the medical personnel right after we got back from the hotel, to hammer out who’s giving what presentations during the academic portions of the mission. We’re going to be working closely with the physicians in the morning, seeing patients while paired one on one with the DRC military physicians, and then the afternoons will be spent in academics, some of which will be given by us, and some by DRC physicians. I still don’t know exactly what I’ll be talking about, but a couple of the other physicians came with canned presentations that will work nicely.

               

It’ll be interesting, let’s just put it that way.

                

The day wrapped up with dinner at New Cliffs, which we ate at before (as it’s one of three restaurants in the whole town), and like before, it was a 2.5-3 hour wait before we got food. We did get to see the sun set over the Atlantic Ocean, so that was kinda neat, but really, we were hungry.

Watching the sun set from the beach by the New Cliffs

Tomorrow, after a short run in the morning with a few of my teammates, it’ll be the first day of the mission. Should be interesting.

Stranded in Brussels

Well, the inevitable has finally happened. After years of traveling to remote and exotic locations, I finally had a missed connection on a flight that happens once a day, stranding me in a foreign city.

Fortunately, it was a foreign city I've never been to, so once I calmed myself down, it was actually a win.

Yesterday started pretty much the same as any traveling Saturday. I had done most of my packing Friday night (translation: I grumbled about packing and procrastinated until I finally got around to putting some clothes in a duffle bag hours after I should have), so after my run in the morning, all I had left was my carry-on stuff and then I was good to go to the airport.

I was flying United from Savannah to Chicago, and again from Chicago to Brussels, but then I switching to Brussels Airlines. It's still a Star Alliance partner (yay for frequent flier miles... I'm going for gold), but I wasn't able to print off my boarding pass in Savannah due to the airline change. I didn't think much of it, figuring I would have plenty of time when I got to Brussels.

Wrong.

The weather in Chicago was pretty terrible, which delayed us about two hours. We made up some of the time in flight, but in all, my comfortable two hour lay-over was reduced to 25 minutes, which is never comfortable, especially when 1) flying internationally; 2) connecting in an airport I'm not familiar with; 3) in a country where I don't speak the language; and 4) I don't have a boarding pass yet. So nope. Didn't make the connection.

And there's one flight a day down to Kinshasa.

Fortunately, United/Brussels Air/Star Alliance/some unknown benefactor put me up in the Sheraton (on airport grounds) and gave me meal vouchers for lunch, dinner, and breakfast tomorrow. After having to forcibly calm myself down (because honestly, what good does getting angry/frustrated get? They're not going to create more flights out of thin air), I got a shower and free lunch and decided that there's no point in spending my free day in Belgium cooped up in the hotel. So I got on the train and headed down into the city and walked around a bit, taking some pictures.

Playing with the panoramic feature on my iPhone while standing in the middle of Grand Place

It's a chocolate museum. Because, well, it's Belgium and they do that here

I saw the chocolate museum, which was actually pretty interesting. It went into the history of chocolate and how it's made, and then there was a demonstration (and treats). The demonstrator gave one line in French and then repeated the line in English. After a couple of trips to Africa, I've forgotten how well people in Europe speak English.

Belgian waffle with chocolate and banana

 And, of course, when in Belgium, you have to have a Belgian waffle. At least, that's what I told myself. It was very tasty... Much better than Belgian waffles I've had in the States.

So that was my day in Brussels. It's now 6 pm local time and I'm fading fast, so I'll probably be getting dinner soon and then going to bed, keeping my fingers crossed that the plane leaving for Kinshasa tomorrow is on-time (even though, realistically, I'll settle for it landing at any time, as long as it lands).

Getting Ready to Leave Again

Tomorrow I'm taking off for Democratic Republic of Congo again, so why I even bothered to go to work is beyond me. Especially because I was on the only one there.

It didn't take me long to finish the few things I needed to do for travel before I went (printing off my official orders, attempting to check-in for my flight only to be told that I have to check-in in person because I'm flying internationally), and then I moved onto the things I knew I needed to do before heading out for two weeks (putting in medication refills, making sure orders were in the computer, etc). All in all, most of the work day was pretty boring, but at least it was quiet, since I had the office to myself.

The one point I had today where I actually got to feel productive was when one of the medics for A Co came in to ask me to look over his medical threat brief for Lesotho. He's not going to Lesotho, but two of his team members are, and it's always the responsibility of the medic to put together a "okay, here's what this country has and here's how you can avoid getting sick" brief. We have a template of the brief that they should give on the medical section website, so they just fill in/delete as needed for the country (for example, Lesotho doesn't have yellow fever or malaria, so you don't need slides for either of those). Unfortunately, he didn't remember that we had a template, so he tried to reinvent the wheel.

For the most part, it wasn't too bad. There were a few things he went into too much detail about--he had a slide about the symptoms and treatment of hepatitis A, when all he really needed to say is 'hepatitis A is transmitted by food and water, and you're vaccinated against it--and a few things he didn't go into enough detail about--what to do about jet lag, how to be safe while traveling, etc. So we went through the template presentation and filled it out for Lesotho, discussing things along the way, such as which vaccines they needed and which they didn't. The medics are all pretty sharp, and this one was no exemption, so he picked up on the stuff pretty quickly. It's still hard for me to remember that they don't have the same training in travel medicine as I do, however, so sometimes I have to stop myself in midst of technical explanations about proper dosing of malaria medications and remind myself to stick to the things they need to know.

Anyway, so that was my bit of excitement for the day. Once we were done discussing Lesotho (and discussing his future career plans), I called it a day (because there was nobody around to tell me I couldn't), put a message on my white board saying that I'm out until 17 June, and headed home to pack/procrastinate about packing. Because honestly, I hate packing and I wish I could pay someone to do it for me.

Out in the Field

Despite my best intentions, I've been neglecting the blog world. Sorry about that. I can't decide if it's that I've been too busy or that things are too routine. Let's just go with that I'm too lazy.

A few weeks ago, though, we did something out of the routine--we went out the field! Kinda. Alpha Company had their Culminating Exercise, which is when they go to a simulated village, in this case in Mali, and demonstrate that they learned something in all of their training.

In theory, anyway.

The week started with the firing range and mass casualty situations, which were to assess how well the medics could triage and determine who to treat first. Overall, they didn't do too well. One medic spent all of her time on a head casualty that should have been triaged as "expectant" (as in, expectant to die). Another went straight to the first casualty and didn't look any further. In other words, we have some work to do.

On days 2-4, they were out in the simulated village in "Mali" (really a remote corner of Ft. Stewart). I got to play a doctor with MSF (Medecines Sans Frontieres, or Doctors Without Borders), which has a very strict "we don't work with the military--any military" policy, so I played that to the best of my abilities. This is me yelling at one of the team leaders (my friend Dan) for their actions throughout the village and how we just wanted them to leave.

The other two officers in my office, MAJ Greifenstein, the environmental science officer (in red) and CPT Avriette, the veterinarian (the girl) also got to play parts, both as USAID scientists (he a soil science, she a vet... we were really imaginative). In the course of playing a soil scientist, Griff was digging holes, and instead of the teams asking him what he was doing (which they were supposed to do), they reported him for burying land mines and declared entire roads off-limits. Not quite the reaction we were going for.

In all, it was a fun week in the field (because, well, we weren't in the office), but the teams have a lot to learn about operating in Africa. Maybe I have an advantage, because I've only been on "peacetime missions" and no deployments to Iraq or Afghanistan. I don't really have a combat mindset, but all the team members have been deployed in combat situations, and that's what they revert to when they think of going overseas. As I've said in multiple conversations to multiple people, Africa is not Iraq or Afghanistan. Not only that, but civil affairs shouldn't be about combat. It's not about going into a village with weapons, ready to shoot the bad guys. It's about getting to know people and winning trust, and not assuming that there's a bad guy behind every door.

It's a work in progress, I guess.

Democratic Republic of Congo, Day 4

This was our last morning in Muanda, which was a good thing. I was getting a bit tired of that place (which is probably going to make it hard to go back in June…). I did finally get to go running, though; the Defense Intelligence Agency (DIA) major went running yesterday morning, so I asked him if I could go running with him today. We did about 3 miles in 30 minutes, which wasn’t bad, considering the heat, humidity, and poor conditions of the road. I’m excited about getting to go running along the Congo River in Kinshasa tomorrow morning (even though it’ll be early).

The main road in Muanda and where we went running

The flight from Muanda to Kinshasa is the same plane that does the reverse trip (makes sense), which means it doesn’t leave until the afternoon, after the plane gets into Muanda and the crew gets a couple of hours to rest. So we spent the time in the morning hanging out the lobby of the hotel, with its spotty air conditioning, planning the details of the MEDRETE in June. It’s going to be four physicians—me, two adult infectious disease physicians, and one pediatrics infectious disease physician—as well as a laboratory tech who knows blood safety, and three support/security personnel from USARAF. In addition, we’ll also have five Congalese translators, because the doctors at Kitona don’t speak much (if any) English, and the American doctors probably (in my case, definitely) don’t speak much French. The Embassy has already identified two of those translators; I hope they find another three by June and that they know medical speak well enough to translate it.

In all, the mission will be 11 days, but with travel time to and from Muanda, there will only be eight days on the ground, seven of which are working days (they only have one doctor on call on Sundays and don’t see any new patients). On those days, we’ll have physicians paired up (one Congalese, one American) seeing patients as the Congalese normally do in the mornings. Then, in the afternoons, we’ll be having “summit meetings”, which will be discussions about programs that the DRC Ministry of Defense and Ministry of Health has for HIV, malaria, and TB, as well as the American doctors explaining our programs for these (well, for the ones we have programs for) and going over WHO guidelines for diagnosis and treatment. I think the lab tech will just be doing similar things with the lab personnel, in terms of teaching and learning (learning how to read malaria slides, teaching about blood safety, etc).

Finally, noon rolled around and we piled in the rental cars and headed for the Muande airport, where we again loaded a tiny little plane that stopped at the same places as on the way there before depositing us in Kinshasa. The embassy cars met us there and loaded us up to the Fleuve hotel, where we got reliable air conditioning, hot showers, and good food we didn’t have to wait three hours for. It was nice.

The Congo, from the air

Back at Ndolo airport, after spending two hours on the hottest plane in existance

The view from my 17th floor room at the Fleuve

Democratic Republic of Congo, Day 3

Today I actually got to sleep in until I woke up on my own, which is always a nice experience. Granted, I woke up on my own around 6am when breakfast wouldn’t be served until 7:30, but beggars can’t be choosers.

Because nobody had done a recon of Muanda, the town that we’re in, nor had I heard from anyone how safe it is/isn’t, I didn’t plan on going for a run in the morning (and it’s never a really good idea for a white woman to be running through the streets of Africa by herself), which was too bad, because one of the majors ended up going for run at 6, right around the time that I was awake anyway. Oh, well. We’re already planning on going running together tomorrow.

After breakfast, the day started by driving to Kitona Base. Our first meeting was with the deputy base commander and commander of the infantry, a brigadier general (one star). He claimed to already know what we were going to be doing for the mission, but then when we brought up medical stuff, he seemed surprised and said that that was out of his lane. He proceeded to take us to the infantry school and give us a presentation there, which we calmly listened to before insisting that we go to the hospital so we can actually do what we had planned on doing.

Shiny new infantry school buildings, courtesy of EUSEC (EU military, kinda)

The hospital commander, a colonel (not sure if that’s equivalent to our colonel or lieutenant colonel; he didn’t give a card), briefly explained his hospital to us: the Hospital Militaire de Reference de Kitona is a referral hospital, a tertiary care facility for the Kitona region (the DRC equivalent of, say, Brooke Army Medical Center in Texas—not the national-level military hospital, but the largest one in the area). Unlike our military hospitals, though, the population seen by the hospital in Kitona is about 40% military and 60% military, which is pretty normal for DRC. There are four military physicians, each of which is a general practitioner, who sees patients in all four departments of the hospital—medicine, pediatrics, OB/GYN, and surgery. On Mondays, Wednesdays, Thursdays, and Saturdays, the physicians see consultations, which means two of the physicians see outpatients and two manage the wards. On Tuesdays and Fridays, two will do surgeries and the other two manage the wards. On Sundays there is one physician on call. For each patient who comes in (about 50-60/day), they will be seen by the registrar, then triaged by a nurse before being seen by the consulting physician. It actually seems to be a pretty efficient system that is working well for them.

The hospital on Kitona Base

The majority of the patients are there for infectious diseases—malaria, TB, HIV, diarrheal diseases, etc. This is actually exactly what we’re looking for, for our Medical Readiness Training Exercise  (MEDRETE) in June. The goal of the MEDRETE is to train U.S. military physicians in tropical diseases and public health, while doing good things that will (with any luck) have a lasting impact in Africa. We still have some discussing to do, as far as how many physicians we can bring on this mission, but I think it’s going to be a go. Which means I’ll be back in the DRC, at Kitona Base, in June. 

Democratic Republic of Congo, Day 2

Today started way, way too early, with my alarm going off at 4:30 so I could get ready and check out of the room a little after 5, because at 6, an embassy car came to pick us up to take us to Ndojo airport, the domestic airport in Kinshasa. We were going to Muanda to evaluate the hospital at Kitona Base.

Our chariot awaits

Not unexpectedly (as I have spent some time in the developing world), the plane that was headed toward Muanda took off late. We thought we were leaving at 9; it was closer to 10. It was a situation pretty similar to what I experienced in Papua New Guinea: one small plane (maybe 18 seats?) that made a few stops before it got to where I wanted to get off. DRC was pretty, from the air. Because there’s so little development, everything is all green and full of rainforests, without even roads to interfere with the landscape once you got away from the cities.

The view from above

It was around noon when we landed, and then we had to go through some rigamarole with the passports (why they were checking passports on a domestic flight is beyond me) and luggage, but finally we were able to step out of the grass hut that makes up the airport and into the air conditioned rental cars (complete with drivers) to take us to the hotel. Because the entire city of Muanda is lacking any real-sized hotels, our group is split up between two hotels. I think I’m in the nicer one, but that’s not saying much.

By the time we sat down for lunch (at the hotel’s restaurant), we had already missed our scheduled meeting with the commander of Kitona Base, which was pretty much all we had scheduled for the day. So instead of doing anything meaningful, we did “familiarization activities”, which consisted of scoping out restaurant where we could eat, seeing the beach (since Muanda is on the tiny stretch of Atlantic coastline that DRC has), and traveling the road from Muanda to Kitona Base. It’s a very, very bad road (“unimproved” was how I was told to describe it), and the mission planner is definitely not excited about the idea of a MEDRETE team driving that twice a day for two weeks. More if they don’t have food available on base. It was bad enough that the car I was in got a flat, which always makes for some entertaining pictures.

Fixing the flat

So that was today. Not much meaningful happened, unfortunately. Tomorrow we’re supposed to meet with the deputy base commander (word is the base commander is in the east of the country somewhere) and then visit the hospital to see if there is anything worthwhile there. Pretty much, unless they have really cool diseases and a staff that is really interested in learning about public healthy, we’re probably going to recommend that the MEDRETE not happen. Because it’s really not worth $150,000+ of the taxpayers’ dollars to go on a mission where nobody learned anything and the local Ministry of Defense couldn’t care less.

Democratic Republic of Congo, Day 1

I'm a few days late in posting, but rest assured, I did write this post on the day it should have been published (which in this case was Monday, March 11). Here it is:

After a long day of traveling yesterday, we arrived in Kinshasa around 10 pm local time. By the time we got to the hotel (which is very nice, by the way), it was almost midnight, and I went to bed right away. Because I was tired from a very long day of traveling.

My room in the Flueve Hotel

Today started by formally signing into the embassy and receiving the RSO (Regional Security Office) brief. Since it is the Democratic Republic of Congo and there are a number of security concerns, we listened carefully for anything of note. Before the mission, we received a warning of anticipated protests at the return of the defeated presidential candidate (who declares that he was actually the winner and has a following that does the same), but that didn’t happen. What we did note was that police officers are known to be corrupt, believed to be due to low pay and low training, and are to be avoided at all costs, as all they usually want from westerners is bribe money. We also learned that photography was illegal until recently, and still is in and around government facilities, and is still frowned upon, so if I don’t give very good pictures from this trip, that’s why.

The first real meeting of the day was with the AFRICOM training advisor and the Deputy Chief of Mission, where we learned that the Ministry of Defense (MOD) is not organized well, but the medical corps is better than most departments within the MOD. The key issues all revolve around logistics, because things are too expensive, too difficult to get out of Kinshasa (due to lack of roads in most of the country), and hoarding is an issue.

Following the embassy, we headed out to the MOD, where we first met with COL Kambale, the Director of Military Cooperation. He didn’t have too much to offer. The second meeting was with COL Louis Kakudji Ilunga, MD, the Deputy Surgeon General. He identified four disease surveillance programs within the MOD: malaria, HIV, TB, and cardiovascular disease. I don’t know how robust these programs are (with the exception of the HIV program, which is funded, monitored, and run by US DoD programs), but if the MEDRETE happens, these will be the areas that we focus on. Pretty much, all I learned is that their disease surveillance is low, consisting of monthly reports of disease counts. This doesn’t really mean much, because I don’t think that they follow trends or even take into account denominator data of the overall population (troops, dependents, etc) who are at risk.

The final meeting of the day was with the medical director of Clinique Kinoise, the first public hospital in DRC, built after independence in 1966. It is currently in very poor shape, with a roof with structural problems, electricity that is unreliable, and no running water. It is a 300 bed facility with 4 ORs, but there are around 3 surgeries/week, approx. 10 inpatients currently, and an average of 15 patients seen in the outpatient clinics daily. The medical director does have grand plans for the hospital, all of which would require significant donor equipment and funds, and is unlikely to be maintainable without significant outside assistance. It is unlikely that we will use this at the clinical site for the MEDRETE, because there’s really not much to see or do, with such a low patient count.

Clinique Kinoise. Lovely, isn't it? Oh, and there's no elevator, in case you were wondering.

In all, pretty long and exhausting day, and I was glad to be able to get back to the hotel to go for a run (on the treadmill) and sit by the pool to work on my sunburn (because it would be embarrassing if I returned to Savannah without any color to me).

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.