Goodbye, Iquitos. Hello, Lima

Yesterday I said good-bye to Iquitos, but not before managing to get a picture of the lovely traffic I had been dealing with for the last several days. Those three-wheeled motorcycles are called 'motokars', and they're what serves as taxis in Iquitos. It seems like half of the population makes a living by driving the other half around. And in case you're wondering, the lines on the road are just for decoration. They don't correspond to any sort of order when it comes to driving. So when you combine a bunch of motokars and motorcycles and a few random cars, you'd pretty much have to have a death wish to drive in Iquitos.

I landed in Lima around 8 pm last night, and made it to my hotel a bit before 10 (between baggage claim and the taxi ride, that's pretty much how long it took). Anyway, I'm on the twentieth floor, with a great view of Miraflores (the touristy district in Lima) from my window.

Anyone who's been to Europe will appreciate this. Many European countries have decorated animal statues around town for one reason or another. Well, in Lima, they have cows. I have several pictures that'll make it to Facebook sooner or later, but here's one of them.

I spent my morning doing some souvenir shopping in the Indian Market, where I confirmed my horrible haggling skills, and then spent the afternoon in Larcomer, which is essentially a mall in Miraflores. There's also a gold museum in Larcomer (Oro del Peru), which has some pretty interesting stuff about the history of Peru and gold and silver artifacts. Here's a map of what the first Spanish explorers thought Latin America looked like.

A popular activity in Miraflores seems to be hang-gliding. Looks like fun, if you ask me, but here's a picture from Larcomer at sunset of some of the hang-gliders over the ocean.

Boat rides and malaria slides

Well, I figured now was as good of time as any to give you some pictures. This first one is the lab where I've been "working" for the last couple of days, NMRCD-Peru, Iquitos Laboratory.

And here's the picture of catching mosquitoes that I promised you yesterday. It's essentially a low-powered vacuum that sucks up mosquitoes and captures them live in a little cup, to be taken back to the lab to be counted and later processed.

Okay. So now what I did yesterday. The day started with arriving at the lab for what I thought was a lecture about malaria in the Iquitos area. What ended up happening was a boat ride to Padre Cocha, a village up a river that feeds into the Amazon. And no, nobody speaks English in Padre Cocha, including the microbiologists who study the blood smears to diagnose malaria. I did learn, mostly through pictures and hand gestures and whatnot (actually, a lot of science-type words are the same in any language), how to tell the difference between the different forms of malaria (P. falciprum and P.vivax) on a blood smear, and the research projects that they're doing on length of treatment for each of those infections. Of the two blood smears we had to look at for that day, one was positive for vivax, and the other was negative for any form of malaria.

Before leaving Padre Cocha to head back into Iquitos, we stopped by a butterfly farm/animal rescue, which is run by an Austrian woman who speaks no fewer than four languages (she was giving the tour simultaneously in Spanish, English, French, and German). They have there a boa constrictor, a few parrots (or similar large, brightly-colored bird), a couple of crocodiles that found their way in, a river manatee, a few monkeys, and a jaguar. The jaguar apparently costs about 1000 soles a week (about $350) to feed, because they only eat raw meat. Although the primary mission of this animal rescue is to return animals to health and find a place to release them into the wild, that isn't possible with this one, because it has completely lost its fear of people (and releasing a large cat that eats raw meat and isn't afraid of people into the wild is bound to result in a few people being eaten). So they keep it, which is rather expensive, and the reason why they didn't want to take any felines in the first place.

So, that was the morning yesterday. Then, after lunch, I went with some of the lab employees (and an entomology grad student from UC-Davis who essentially served as my translator) to see a patient with dengue. Very interesting, but didn't look like much fun. I've been staring at my mosquito bites ever since, hoping that none of them were carrying dengue. Guess we'll find out in 4-10 days...

Counting mosquitoes

Yesterday was my first day of doing 'work' in Iquitos, and let me tell you, doing work in a city where English speakers are very few and far between is not easy.

I started the day by going to IVITA (and no, I have no idea what that stands for, and it's probably in Spanish anyway), where they have mosquito experiment huts. These are similar (and yet different) from the huts that Walter Reed and the rest of the yellow fever commission used way back in the day to demonstrate that yellow fever was transmitted by mosquitoes: you have a sealed hut (sealed with mosquito net, not completely sealed from the elements; I think you'd suffocate) and people and mosquitoes inside. In the yellow fever commission days, they'd leave the people exposed to the mosquitoes and see what happens. In these huts, the person is under mosquito netting most of the time and is just there to observe the mosquitoes. The five huts all have different experiments, but the one I saw had different panels of cloth hanging on the walls, soaked with different concentrations of permithrin, an insect-repellent for cloth and clothing (not for skin). The mosquitoes are counted every hour to see how many land on the various panels, in efforts of determining the concentration that should be used in real life.

Anyway, after IVITA, they took me to the cemetery, where a group of entomologists (people who study bugs) were catching mosquitoes. No, this does not entail running around with a jar trying to catch them--they have these little vacuum mosquito-sucker things with enough vacuum to collect the mosquitoes, without destroying them. Since most people are 'buried' in crypts, they just run these vacuum things over the crypts and collect what they collect. I have a picture on my camera; I'll try to get it up soon.

After that was lunch, which was chicken noodle soup and a pasta with a pesto-like sauce and chicken (really good, but rather heavy for such a hot and humid day), and then it was back to the lab to count the mosquitoes that were collected. The joke about prev med docs, especially the ones who specialize in tropical medicine (like I will someday), is that we go to exotic locations and count mosquitoes--and that's exactly what I did. I learned how to differentiate between the three species of mosquitoes around here and tell the difference between the males and females, because only the females bite, and only Aedes aegypti carries dengue in these parts (malaria is carried by Anopheles mosquitoes, which are found in rural areas, not cities).

And that was the end of my work day, at which point I did my homework of occupational health questions (today I get to have blood drawn... fun, fun!), took a nap, and went out for fast-food chicken with plantain chips to eat while watching TV (something that the other American researchers here do every week). And then I went to bed, went running this morning at a soccer stadium, and am now ready for another day of work.

Writing from Iquitos

Well, I made it to Iquitos last night, after a long day in Lima, and will be heading out into the field in ten or so minutes, so this'll be quick.

Yesterday was a lot of in-processing type activities and in-briefing type activities, where they make sure everything is squared away with my itinerary and teaching me about the various labs. And asking multiple times if I speak Spanish, because apparently, no one outside of people who work for NMRCD seem to know English.

I did get a chance to go over to the medical school in Lima for a lecture the commander of NMRCD (a Navy commander) was giving on viral gastroenteritis for the Gorgas tropical medicine course, which is an international course for doctors who want to learn more about tropical medicine (and, fortunately, the course is in English). There wasn't really anything new in the lecture, but it was a nice review. Then it was back to NMRCD, lunch, more in-processing/in-briefing, and then a taxi ride to the airport to fly to Iquitos.

I'm staying at NMRCD's guesthouse, which is pretty nice--not as nice as my hotel room in Lima, but with electricity, AC, and internet (obviously), which makes it nicer than my accomodations in PNG. I am on my own for food, so we'll see how that goes.

Today I'm off to a cemetery to catch mosquitos, and then in the afternoon, testing them for dengue. Should be interesting...

On my way to Peru

This was written yesterday while I was on the plane. If I have internet in Iquitos tonight, I'll post for today.

And we’re off. Well, I’m off, and quite a few of my closest friends, all crammed into a plane I wasn’t supposed to be on.

So, things didn’t exactly go off to a smooth start today. Concerned that there might be travel problems (thinking about the last time the government bought my plane tickets, when I went to C4 in October and arrived at the airport at 0430 to find that the tickets hadn’t been purchased), I left home on the Metro at 0900 for a 1245 flight, got to Reagan a little before 1000.

And, surprise, surprise, the tickets hadn’t been purchased yet.

Unfortunately, it wasn’t as easy of a fix as it was last time. There’s all sorts of bad weather at Dallas/Ft. Worth, so the emergency line at Carlson-Wagonlit was quite busy. After being on hold for forty minutes, I was told that they didn’t have a copy of the authorization from the WRAMC travel office (just like last time), so I faxed the orders and called back. After another thirty-five minutes on hold, they told me of all sorts of other problems with the orders. Long story short, after spending more than two hours with my phone against my ear, I missed the opportunity to get on the flight I was supposed to be on, and ended up on a flight on Delta (instead of American) arriving two hours later. Unfortunately, the people in Lima had already arranged for me to be picked up at the airport when I arrived, and although I emailed them about the change as soon as I could, I don’t know if anyone was checking email today to get the message.

Guess I’ll find out soon enough.

I’m actually not in Peru yet—just off the coast of Colombia, according to the in-flight map, at 2115—forty-five minutes until I’m supposed to be landing in Peru, and two hours and forty-five minutes until I do.

Unsurprisingly, all of this stuff not going well put me in a rather bad mood (and I can see my parents feigning shock at that—‘what? Lisa not taking two hours of things not going the way they were supposed to, followed by a change in travel plans, well?’), which got me started on the “what am I doing and why am I doing it?” line of thought. I’m going to a country where I don’t speak the language, re-writing all sorts of internship rules while doing so, to research diseases that I find very interesting, but have little more than a passing knowledge of. Oh, and I’m doing this alone (at least until I get to the lab tomorrow morning), and I don’t know if I’m going to have a ride from the airport to the hotel or not.

And I spent six months working on making this happen. What was I thinking?

I’m sure that I’m just inventing all sorts of problems in my head and unnecessarily stressing myself out. After all, I’ve done this before—I landed at the airport in Papua New Guinea in pretty much the same state of mind and with the same uncertainty of the plans, and I ended up where I needed to be without any problems.

According to the flight information screen, two hours and nineteen minutes until arrival.

Visas and burgundy passports (or, visas in burgundy passports)

For everyone who doesn't know what's going on (a group that may include my parents, as they never seem to know what I'm up to, whether I tell them or not), I am taking off for Peru in two days (Sunday, 21 Feb), for three weeks of tropical medicine research.

The DoD (Department of Defense, for the less acronym-inclined) has several domestic and overseas laboratories--one owned by the Air Force, a few by the Navy, and most by the Army--which collectively make up GEIS, or Global Emerging Infection Surveillance. The overarching command, if one could even use that word, is in the DC area, which meant that I got to rub some high-ranking elbows, impressive them with my CV and career goals, and convince them that it's in their best interests to pay for me to go to one of these labs. Peru was chosen because three weeks is a bit short for a research rotation, and since it's in the same time zone as DC, I won't be losing any time to jetlag.

This whole process, of convincing people to let me go and to pay for me to go (two different groups--one to let me go, one to pay for it), started in August, and I got final authorization (ironically, from the 'let me go' group; the 'pay for it' group had already given the thumbs up) much later than that, after months of stubbornly not letting them say no.

Now that that was taken care of... Believe it or not, foreign countries aren't always glad to see active duty military personnel arrive on their soil, regardless of their reasons for being there, so all sorts of country clearance and theater clearance (theater being theater of operations, which in this case is SOUTHCOM--Southern Command) and things going through diplomatic channels and taking forever. The process to get my official (burgundy) passport started... well, I don't remember when it started, but the passport was issued on 11 Jan. Then I needed an official visa to go with the official passport, which requires a resolution signed by the president of Peru, which just came through on Wednesday (so yes, the president of Peru gave me personal permission to enter the country). So I went to the Peruvian Embassy on Wednesday for the visa, and was told that I needed a letter, on letterhead, from my command. Just showing them my orders wasn't good enough. I emailed my program director (who is not technically my commanding officer, but I prefer to leave my commanding officer out of as much as possible, because he loses things. Like leave papers.) and asked her to write the letter, which she did. So I brought all that stuff back again today and dropped it off, and was told to pick up the passport at 5.

Long story slightly less-long: after three trips onto what is technically Peruvian soil, I now have a visa in my burgundy passport.

And assuming no more freak snow storms close Reagan National Airport, come Sunday, I'll have a stamp in my burgundy passport as well.

In case you were wondering how an official passport is different than a normal passport:

This is not my actual passport, just a picture I shamelessly copied from Google. As you can see, it's not blue, it has the word 'OFFICIAL' on it (which blue passports do not), and that little electronic-chip looking thing on the bottom means that there are electronics embedded in the passport.

Anyway, assuming I don't get too lazy while I'm gone, and assuming I have adequate internet connections, stay tuned for tales from the southern hemisphere (it's barely the southern hemisphere, but it counts).

Snow emergency

Yes, that's right: a snow emergency. For the second time this year (well, fiscal year, I suppose, since the first time was in 2009), the metropolitan DC area is in a state of snow emergency.

I'm not talking about 'ooh, look how scared the people are when snow starts falling'. This is 'huh. Didn't realize so much snow can fall in less than 24 hours. And why isn't it stopping?'

Just like last time (which was going on as I was flying to Washington for Christmas), we did have plenty of advance warning, which meant that starting on Tuesday, we were getting emails at work telling us how to prepare for the weather, reminding us that doctors are 'essential personnel' and thus may be snowed into the hospital, and discussions about closing clinics early on Friday.

I had business to do at Walter Reed yesterday morning (I'm currently on a rotation at NNMC), so I drove over early in order to take care of it before all the weather stuff started, and at that time (about 0630), there were already plows and salting trucks parked off the shoulder of the Beltway, on standby for when the snow started. Well, I got everything taken care of I needed to (I hope, anyway), and was again on the road, to head back home, around 0930. Fortunately, still no snow. I parked my car in my building's parking garage and then headed to the Metro station to go over to NNMC for work. I intentionally wore my Gor-Tex boots, knowing that the above-ground Metro stations (in other words, everything on my side of the Medical Center stop) close when there's more than eight inches of snow on the ground, and I figured if I had to walk home through the snow (it's only four miles), I should probably make sure my feet would be warm and dry as I did so.

The snow started around 1000, and I sent my med student home (something I really don't have the authority to do, but whatever), so he wouldn't get snowed in (doctors are essential personnel, med students are not). I tried to get all of my work done in a pretty efficient manner, so I could also get out at a reasonable time. Although I am 'essential', I wasn't scheduled to work over the weekend anyway, so getting snowed out of the hospital wouldn't cause any disruption of patient care. I wrapped everything up around 1400 and headed out, when the Metro was still open (I contemplated walking anyway, just for the experience, but having a cold, soaking wet beret on is never a pleasant thing). And then I proceeded to sit on the couch and watch the snow fall.

So now it's Saturday, and while I haven't been outside to verify this, the the news says that Rockville, MD has gotten more than eighteen inches, with another five to eight to fall throughout the day today. It's a little insane. The power was flickering last night, but it's holding strong so far today, so at least I know I have heat (and TV, and internet...)

Anyway, here are some pictures. Sorry about the low quality; they were taken on my phone through my window.

This is from last night, when it had already been snowing for ten or so hours.

And this is what I woke up to this morning. Don't know if you can tell or not, but there's a road at the bottom of the picture, Rockville Pike, which is a pretty major street. Other than the plows, I have seen one car on it this morning. It's a little insane.

I'm glad I had to go grocery shopping on Thursday anyway, because I'm pretty sure the state of panic translates to empty shelves in the stores (assuming the commissary is even still open in this mess).

Should be interesting to see if this clears enough for me to Metro to work on Monday, or if I'll be hoofing those four miles through the snow after all.

Infectious Disease Consults and More Tests

On Tuesday (seeing as Monday was a holiday), I spent one day on the Infectious Disease Consult service at National Naval Medical Center (Bethesda). Then I had two days of incredibly fun testing: USMLE Step 3.

The United States Medical Licensing Exam has three steps: Step 1 is between the second and third years of medical school, Step 2 (which itself has two parts, CS and CK) is at some point before medical school graduation (I did mine July 2008), and Step 3, which is sometime after graduating medical school and before becoming a licensed physician (for most people, during internship).

Like Step 1 and Step 2 CK, Step 3 started with a seemingly endless series of multiple-choice questions on the computer. That was day one. Then, on day two, more multiple-choice, and then patient simulations--ridiculous cases on the computer where real time and case time aren't the same. It's really confusing to try to explain how it works, so we'll stick with, it was strange.

And now, I have to wait six weeks until I find out if I passed or not.

Anyway, I returned to the Infectious Disease service today (in my Class B uniform, because I forgot to wash my ACUs... I discovered today why I haven't worn those uniform shoes since the first time I wore them. My feet are killing me). Anyway, on Fridays, its all the same on consult services. Realizing that consultants don't do much on weekends, all of the primary services (the doctors on the wards, the ones writing the orders) will put in any consults that might need to happen in the next three days. So, on pulmonary services, it's "patient has lungs, please evaluate and treat", and on ID, I guess it would be "patient once complained of having a fever, please evaluate and treat". So we got a few consults like that.

The first one was "patient had a fever, chest x-ray looks like pneumonia, please assist with antibiotic treatment." This is actually pretty simple: you open the books to 'Hospital Acquired Pneumonia' and pick the antibiotics listed; then, when the bacterial cultures grow (usually takes 2-3 days), you figure out exactly which antibiotic is best, so you take them from getting two or three antibiotics, down to just one. So our recommendations were, "Continue antibiotic regimen, when culture and sensitivity returns, tailor antibiotics as necessary." Pretty simple.

The next one went to the med student (pretty similar to that one), and the one after that was mine. It was a little old lady with multiple cancers (colon, lung, esophageal...) and something on her chest CT. So we pretty much just gave advice about what they should test for.

And then we wrote our notes and went home (where I finally got to take those shoes off). Time for a nap.

Rehab consult service

Yes, I realize that it's been a long time since my last post (sorry). Since returning to DC from Christmas, I had two more weeks in the PM&R clinic, and then a week of the PM&R consult service, which I'm on this week (tomorrow is the last day).

For the most part, the consult service is pretty slow. Almost everyone who comes in from Iraq or Afghanistan gets a consult, for either amputations or traumatic brain injury, but most of those don't go onto the in-patient PM&R service--they either don't need in-patient rehab, or they need a service we don't offer (ie, blind rehab), or they want to go somewhere closer to home/family. And even for the ones who do eventually come to the rehab service, they don't need to be followed all that closely until all of their surgeries and whatnot are done.

I've seen a patient a day since starting on the consult service. The first patient was hit by an IED (improvised explosive device) in Afghanistan, with his injuries almost entirely on his face. He lost one eye in the explosion, and had a piece of shrapnel lodged in the other, and is now completely blind (at twenty-two years old). Once his facial injuries heal a bit more (he also has his jaw wired shut), he'll probably be going to the VA rehab hospital in Palo Alto, CA, which is the VA's center for blind rehab.

My patient on Tuesday was actually a patient I had seen in amputee clinic before Christmas. His leg was amputated below the knee about seven months ago in Afghanistan, and was readmitted to the hospital on Monday for a revision of the residual limb (the stump, in colloquial terms), because he was having difficulties getting a good fit with his prosthesis. The ortho team didn't really need to consult us, since he is already established with all the amputee services (physical and occupational therapy, prosthetic fittings, etc), so I pretty much just went in and chatted with him and told him that after ortho is done with him, that he'll just go back to the Mologne House (essentially a hotel on base where all the rehab patients stay until they can go home) and keep coming back to the hospital every day for his physical therapy, just like he had been doing. That was no surprise to him, because he was pretty much expecting that to be the case.

Yesterday's patient was another one that they didn't really need to be consulting us for, a patient with a mild traumatic brain injury who wanted to do his rehab at the Richmond VA hospital, because it was closer to home. So we said sure, sounds like a good idea, and left it to the trauma team to arrange the hospital-to-hospital transfer. I think they were just trying to get us to take him on the PM&R service so we'd have to do that work for them.

Today's patient was one in which they jumped the gun a little bit in consulting PM&R. After an IED blast in Afghanistan, he essentially only injured his right hand (which is, unfortunately, his dominant hand) and ended up with a lot of fractures and an amputation of his middle finger. The trauma service wanted to know if he had any sort of nerve injuries, but with his hand in a splint and all sorts of pins in his bones and broken tendons, there's no way that we could do a decent neuro exam on the hand. So after chatting with him for a few minutes, we said continue the course, and after all of his surgeries are done and the hardware is removed and the bones are healed, we'll follow up with him as an outpatient (so, after he's discharged) to do a full exam and look for any sorts of neurologic deficits, but he definitely doesn't need inpatient rehab for that.

Another patient I saw, who was actually not a consult patient but one from amputee clinic, was readmitted to the hospital today for a wound infection on his residual limb. He just had his amputation about three weeks ago, after trying to save his leg for about a year, and just has not had much luck with it. I saw him yesterday, as well as last week, in amputee clinic, and he just fits the description of bad things happening to good people. But he's really upbeat about things, and his wife (who is also in the Army and works in personnel at Walter Reed) has a good sense of humor and I think keeps things in perspective for him. I ran into them as they were checking in for him to be admitted (getting a wash-out procedure tomorrow) and wished them luck. I'll probably swing by tomorrow after his surgery to see how he's feeling.

So I spend most of my time studying for the boards (USMLE Step 3 is next week) and spending a few of my eight or so hours at work looking up these guys' complete medical histories and figuring out exactly where all of their injuries were and what kinds of surgeries they had had done. I have to say, after doing PM&R here and doing it at OSU, that it's much more rewarding (and interesting) to do it in a military setting.

Traumatic Brain Injury Clinic

Yesterday was my first day of PM&R (Physical Medicine and Rehabilitation; or Plenty of Money and Relaxation :) ), which is a nice change after four weeks on the medicine wards.

Every Tuesday morning in the PM&R clinic is TBI clinic--traumatic brain injury. When I did PM&R as a med student last March, I was on the TBI service and did a 1/2 day a week in TBI clinic, but today was completely different than that, because TBI in the military is completely different from TBI in the civilian world. Most of the patients I saw back at OSU were there as a result of drunken stupidity, which is most definitely not the case with the patients I saw today.

The first patient was an infantry specialist (gunner on an MRAP) who literally just got in from Afghanistan (he was on the Friday MEDEVAC). On Sept. 11 of this year, his MRAP was hit by an IED, and he ended up with a concussion that left him with persistent migraine headaches (nausea, vomiting, sensitivity to light, the whole bit). He ended up going to one of the field hospitals and got a CT, which didn't really show anything. He kept telling everyone that he felt better so he could go back to his unit, despite the fact that he was still having the headaches. After a few more concussions, it got to the point that his unit's medic realized that he wasn't fine, despite his insistence otherwise. It took the medic pointing out that a gunner who couldn't concentrate on his job was putting his unit at risk to get him to agree to be evacuated from theater for further evaluation.

It really puts things in perspective--here was a guy who was being fired at on a regular basis, who felt terrible on a daily basis, and didn't want to leave his job.

While the PM&R resident I was working with went to fetch the social worker, I chatted with him about his military history. His contract is up in a year and a half, and after that, he wants to go to OCS (Officer Candidate School) to become an infantry officer. Right now, he's still having headaches, and is having difficulty concentrating and sleeping. I really hope he gets back to where he was before these IED blasts.

The other two patients I saw had been established with the TBI clinic for awhile--one had a gunshot wound to the head and is almost back to where he was before he was shot, and the other was another IED blast, who now has some personality changes, problems with his memory, and pretty severe depression.

So like I said, traumatic brain injury in the Army is completely different than traumatic brain injury in the civilian world.

And tomorrow... amputation clinic.