Week 4 at AFHSC

I realized today that it's been a few weeks since I've updated anything, so here goes. Things are going well at the Armed Forces Health Surveillance Center. I got data on hospitalizations for poisoning at the end of the second week, so I've been spending my time since then staring at numbers and analyzing data.

To do all this analyzing, I'm using a statistical software called STATA (I don't know what, if anything, it stands for). I used STATA last year in school (yay for flashbacks to Epi 3...), so I'm somewhat familiar with it, which is good, since we're getting our STATA review tomorrow. Yeah, about two weeks later than I needed, but whatever.

I spent most of my first day with the data playing with the software, trying to remember simple commands and trying to figure out why I couldn't get anything to work the way I wanted it to (I eventually figured it out), and then the next few days doing some more complicated analyses. Since then, I've been working on more complicated analyses and putting my presentation together.

My project is actually in two parts: the first part is to describe who has been hospitalized for poisonings (both drug overdose and toxic exposures, such as to petroleum or lead); the second part is to figure out which poisonings were intentional, and what the differences are between those who purposely poisoned themselves and those who didn't. The first part was easy enough; there are a few simple commands (that I had to do over and over again) to do all the descriptive epidemiology, but the second part required much more thought (and probably isn't all that accurate).

As far as describing who in the military has been hospitalized for poisonings, there have been almost 15,000 over ten years. There are some minor fluctuations from year to year, but for the most part, the rate has been fairly constant. While there were more men (because the military has more men), the rate was higher for women. The rates are also highest for the lowest ages (17-19), lowest ranks (E1-E4), those in the Army (because we're Army strong...?),  least education, never married, and white (although the differences in races were pretty small).

With the second part--figuring out which poisonings were intentional--I used a few different things. The first are that there are certain diagnostic codes that can be used to say that a hospitalization was due to suicide attempt. The second is that there was a paper a few years ago that used a combination of psychiatric diagnoses within six months of the hospitalization to say that it was likely intentional. They did this in a civilian population, though, which has different baseline rates of psychiatric diagnoses than military populations.

Long story short, according to my calculations, 63% of all hospitalizations for poisoning in the military over the last ten years have been intentional. Risk factors include being female, in the Army (again, we're Army strong), multiple deployments, being married (yes, married people are at a higher risk of trying to poison themselves), and working in healthcare. Protective factors--those that make people less likely to try to poison themselves--are age over 40, increasing rank, and being in the Air Force or Marine Corps.

So, it's been a lot of analyses and a lot of math over the last few weeks, but I actually have some results to present, so that's a good thing. Pretty much, all I have left for the next two and a half weeks is to do my presentation and write my paper. Fun and exciting, I know.

First week at AFHSC

Last week was my first of six weeks at the Armed Forces Health Surveillance Center (AFHSC--don't try to say it as a word; it's not one of those kinds of acronyms. Just the letters). I wish I could say I accomplished a lot, but that wouldn't be entirely true. I do have a project, so that's a start (and honestly, all anyone ever accomplishes in the first week).

My original idea for a project came from my surgeon friends, who have said that they've noticed different rates of mucor infections in war wounded between Walter Reed and Bethesda, suggesting that maybe there's a difference in either the conditions the Army and Marine Corps are fighting in, or there's a difference in care. (Mucor, by the way, is an invasive fungal infection that's pretty rare and very bad). Well, difference in rates between the two hospitals or not, there haven't been enough cases in the last ten years to do any sort of analysis. So that idea was scrapped.

I didn't really have any back-up plans, so my project mentors suggested that I read through the Medical Surveillance Monthly Report (http://www.afhsc.mil/msmr?clear), which is the military's version of CDC's Morbidity and Mortality Weekly Report. Well, I didn't see too much exciting, but I did notice that they always clumped injuries and poisonings together, and while injuries have been a big priority, nobody's ever done an analysis of poisonings. So that's what I'm doing. I'm going to do an analysis of who has the highest rates of being hospitalized for poisonings (of both medical and non-medical types), looking at age, sex, race, branch of military service, rank, education level, and marital status (and maybe more categories; I don't remember).

We also found an article from the civilian medical literature that described how you can estimate which injuries and poisonings are intentional (ie, suicide attempt), using the type of injury/poisoning (all poisonings fit this category) and certain psych diagnoses within 180 days of being hospitalized. So we're going to be looking at psych diagnoses before poisonings, to estimate which ones were intentional and which were not.

At least, that's the plan. My request for data just went in today, so we'll see if I get any usable data from any of that.

As if I didn't have enough to do with that project, my project proposal that I presented for my degree is just getting started (yes, I was supposed to have this done before finishing my degree...). At this point, we're still at the stage where we contact people and beg them to participate in the study. There are over 200 people on the list, and we've gotten (wait for it...) one set of surveys back. Yes, one. So part of my job is to find a way to reach the ones we haven't to also beg them to join. It's all sorts of fun. At least it's not very intellectually challenging. Just time consuming. It's great fun.

AFHSC and serum repository

Yesterday we had a tour of the Armed Forces Health Surveillance Center (AFHSC) and the serum repository. The serum repository is the largest one in the world, containing almost 60 million blood samples, the blood that's left over every time the DoD draws blood for a routine HIV test. So three of those samples in the repository are from me.

They have all sorts of fun toys in there, to make dealing with that many blood samples manageable, including one that pipettes blood into vials and unscrews tube tops. Here's a video, if you want to watch how it works:

And in case you can't visualize 60 million blood samples, here's the view in one of 7 freezers (at -30 degrees C), each of which is about 7000 square feet.

And down the aisle:

After the tour of the serum repository, we had a three hour epidemiology review, which was all sorts of fun (not really). That's what we were doing when the earthquake happened. Unfortunately, it only rescued us from about two minutes of reviewing (enough time to leave the conference room, confirm that the world wasn't coming to an end, and return). Here's what the white board looked like at one point:

I start at AFHSC full-time on Monday (hopefully without the epidemiology reviews). While there, I'll do a surveillance project on a disease of military interest. My surgeon friends tell me that they're seeing a lot of war-wounded patients with invasive fungal infections of the wounds, and for some reason, the patients at Walter Reed do worse than the patients at Bethesda, even though Bethesda gets more patients with this type of infection. I'm hoping to do an analysis of how patients do based on which service (Army, Navy, Marine Corps, Air Force) and where in Afghanistan the patients were when wounded. We'll see if that's deemed a good project or not.

Goodbye, Kenya

 I've been back from Kenya for a few days now, procrastinating about posting my last few pictures onto the blog. The last couple of days in Malindi were pretty low-key. On Thursday, we took the German medical students out to lunch at the Hilton. The one on the right, Maria (who is actually Norwegian, but goes to school in Germany), ran the 5K as part of the marathon on Saturday (day after I left) and placed third for women. Apparently, there was a girl about 10 years old who showed up for that run in ballet slippers. Dr. Childs told Maria she had to beat the girl, and she did--just barely. Even Kenyan children are good runners.

The girls were quite a hit with the children at the Hilton.

Here's a random picture of the waiting area of the outpatient clinics at the hospital:

Friday I packed up my belongings (which reminds me... I still need to fumigate my duffle bag, my laundry smelled that bad) and attempted to check out of the hotel, but they told me that their credit card machine was down (whether it was or not, I don't know), so they told me to go to the ATM. Well, my government credit card only lets me pull $600/month out in cash, which wouldn't cover the 95000 KSH hotel bill (about $1000), and the ATM that took my personal debit card wasn't working, so I had to take my personal credit card to the bank with my passport to pull the cash out. Long and frustrating story short, two hours later I had the cash to check out of the hotel, and then it was time to head to the airport.

This was the plane that carried me from Malindi to Nairobi, the first of four flights until I landed at Reagan. I had a very long layover in Nairobi (almost eight hours), so I spent some of that time in one of COL Coldren's favorite bars, The Pub (it's at the airport). He discovered that bar when he was in Kenya as a preventive medicine resident and had a long lay-over in Nairobi, so I kept alive the tradition of preventive medicine residents working on data at The Pub while waiting for the next flight.

After Nairobi was Amsterdam, then Detroit (where I again confirmed that the entire state of Michigan is worthless... no USO, no free wifi, and bad cell phone reception in the airport), and then it was back to DCA. I had from Saturday afternoon until Monday morning to recover, and then it was into WRAIR at 7:30 to officially begin my third year of residency. I have a week of in-processing and administrative stuff, and then begin at the Armed Forces Health Surveillance Center (AFHSC) next Monday.

Slaughterhouse and spraying

I said I was doing things by alliteration, so today I had to visit the slaughterhouse and then spray for bugs. It only makes sense.

My day got a very early start this morning... 0100, to be exactly, when my alarm went off, telling me to get out of bed and get dressed to visit the slaughterhouse for a meat inspection. We arrived around 0130, and then the veterinarian and public health officer showed us around the place, to the lariage, where the animals are waiting to be taken toward the slaughter, and then to the stunning pen, where they shoot them with a bolt gun prior to slaughter. Once stunned, the necks are cut for slaughter, and after they've stopped thrashing around, the heads and hooves are removed, and then they're ready to go.

This is what the slaughterhouse looks like when they're almost done with the slaughter. They usually do between 20-30 cattle a night, and because everything's done by hand, they wait until they've slaughtered all of them before moving on to the next step. They slaughter goats and sheep here, too, but we only saw the cattle slaughter (no pigs; that's against Muslim regulations, to slaughter them at the same facility. I don't know where they slaughter pigs around here, but they do have pork, so it must be somewhere).

This was the part that was most impressive to me, how quickly they got that hide off the cow. Everything's done by hand, and it was less than five minutes of skinning, and it was done perfectly. No meat on the hide, no holes, just one big piece of cow hide. They remove the gastrointestinal tract and reproductive tract at this step, too.

Unfortunately, I was apparently not supposed to be taking pictures, so I don't have any pictures of the actual meat inspection, which is what I was there for. They inspect the head and the carcass separately (since the head had been removed already). They're supposedly arranged so head 1 belongs to carcass 1, which matches with hide 1 and intestines 1 and hooves 1, but the vet says that there's often quite a lot of mix-up.

For both the head and the carcass, there are three main steps: visualization, palpation, and incision. For the head, that's visual inspection to make sure there's no bleeding or bruising and everything looks symmetric. Then the muscles, tongue, and lymph nodes are palpated. Finally, the tongue and masseter muscles (open and close the jaw) are incised, to look for cysts (parasites) and abscesses (bacteria). None of the heads had anything wrong with them.

Next is the inspection of the carcass, and before, it's visualization, palpation, and incision. Again, what they're looking for is signs of bruising, bleeding, signs that good with poor bleeding of the animal during slaughter, and infection, with either parasites or bacteria. The kidneys, liver, lungs, and hind leg are all incised. In the liver, they're looking for liver flukes (which aren't found much in this part of Kenya, due to the proximity of salt water; liver flukes like fresh water) and echinococcus, another parasite. They also look for echinococcus in the lungs, and in the actual meat, they're looking for tapeworm cysts. The animals we inspected all passed.

So after getting a little bit more sleep, I was back in the hospital and back in the public health department. There were reports of cockroaches in the newborn unit (which we verified). Cockroaches themselves aren't vectors, but can carry bacteria on their legs. Besides, they're gross, and where there are cockroaches, other bugs will follow. Since we didn't want to be spraying preemies and otherwise sick babies with insecticides, we had to have them remove all babies (and most of the stuff) from the unit before we could begin, and then stay outside for another four hours. All sorts of fun. Unfortunately, it wasn't possible to move everyone out of the maternity building (where the newborn unit), so we couldn't spray the whole building. The spraying remains in the room for several months, but the rest of the building will probably soon have a bug problem. Oh, well. Maybe then they'll consider moving their patients.

Tomorrow is my official last day in the hospital, but I probably won't do much, and I definitely won't stay past lunch (I'll probably leave much before that). There are still a few more things I need to buy for people, and I'm down to only coins, so I hope the ATMs are more cooperative tomorrow morning than they were this afternoon (the one ATM that took MasterCard decided that it doesn't like MasterCard, and my back-up ATM card is my government credit card for travel, which was maxed out on cash withdrawals, but is being paid today).

Almost home!

Gongoni and Mambrui

Today I got to see where Malindi District Hospital incinerates its waste, since their waste incinerator was vandalized and is non-operational. There are two facilities with identical incinerators (more of the work of the United States Marine Corps) about 15 kilometers up the road toward Lamu, Gongoni and Mambrui. We took the waste to Gongoni today (they alternate between the two).

Here's a picture of the incinerator, which they use to incinerate sharps waste (glass bottles, needles, etc):

The incinerator was built in May 2010, when the Marine Corps essentially went down the coast of Kenya and built one for every hospital and clinic, but as you can see in the picture, the concrete can't hold up to the heat of the incinerator. It's still operational, but I can't help but wonder how much longer it will be so. I wonder who I should contact from the Marines to inform them of this problem, so they can improve on the design in the future.

Unfortunately, the incinerator is only for sharps containers. The rest of the infectious waste produced at the hospital is incinerated in the incredibly high-tech incinerator pictured above: a hole in the ground. Obviously, this is not an ideal situation for anyone (it can't reach the heat necessary for proper incineration and to prevent the formation of dioxins, which are carcinogenic), but as far as I know, nobody's doing anything to rectify the situation.

The new "incinerator" that will be going in at Malindi isn't actually an incinerator at all, but an autoclave, followed by a grinder. This will sterilize all infectious wastes (sharps and non-sharps) and then grind it to a course powder for disposal. Since nothing is burning, there's no smoke, so no concerns of carcinogens, which means that it doesn't have to be set away from where people live/work/play/etc, which is what the WHO recommends (I think the distance is 50-150 meters, depending on the climate conditions of the area).

This is Mambrui Dispensary, which is the other site they use for incineration. We didn't burn anything there today (I'm really not sure why we made that side trip, actually). Just a little bit about the different terms: there are six levels of government health care in Kenya. Level 1 is the community health workers. Level 2 is the dispensaries, which have a head nursing officer (I don't think they have a clinical officer), delivery room, maybe one or two rooms for inpatient care, and a consultation room. They have a pharmacy and vaccine clinic as well, but the only vaccines they do are the routine pediatric vaccines. Level 3 is a health clinic (such as Gongoni), which has at least one clinical officer, more inpatient wards, etc, etc. Levels 1-3 are run by the Ministry of Public Health and Sanitation. Levels 4-6 are run by the Ministry of Health, and these are the hospitals of increasing size (district, provincial, and national). So, Malindi District Hospital is a level 4 facility, and the dispensaries and health clinics in the district fall under it, even though they're run by two different ministries of the government. Confused yet?

Random picture of the day: Salt farm. Yes, they farm salt here.

Sunday and Monday

I realized last night as I was in bed that I didn't write an entry. Oops.

Not much exciting happened on Sunday. I woke up, went running at the gym (where it was already hot and humid despite showing up when the gym opened at 7), and then lounged around the hotel until it was time to do some souvenir shopping. I went to the tourist market (yes, it's called the tourist market), and had the 'help' of a local, which mostly meant he shooed me past shops until we got to ones that belonged to his friends who would offer me 'good prices'. Whatever. All the shops had pretty much the same stuff, so I wasn't missing anything.

Random shot of children near the tourist market:

Yesterday the Casualty department (like an emergency department) opened for business. Well, it opened; I don't know if they got any business yesterday. When I was there in the morning, the nurses were doing inventory and making sure all the keys to all the rooms worked (they didn't). Here's what the resuscitation room looks like:

Not a bad facility, all things considered. They have one portable x-ray, a portable ultrasound, monitors for vital signs, and a defibrillator (which nobody knows how to use). It's too bad I'll be leaving in a few days; it would be interesting to see how works with patients.

That's me and Katana, the public health officer. Yes, it's centered funny because I'm not very good at using the timer on my camera.

After opening the Casualty department and doing the walk-through, I was surprised by the next assignment: to teach a group of secondary school students the basics of HIV/AIDS. I was told that this is what we were going to be doing about five minutes before we headed over there to do it. I'm not sure exactly what the students are being trained for, but it's a week-long course over HIV/AIDS, either to be peer educators at their schools or to do VCT (voluntary counseling and testing).

So we went over there, and after the standard couple of hours of introductions, ice breakers, and the students going over their expectations of the course (all of which was in English, out of consideration for me... makes me feel a bit ignorant, that these kids know at least three languages fluently, and I only know one), it was my turn. Since they're going to have a lot of sessions about some of the nitty-gritty details, I just wanted to go over the basics, so I started asking what they knew about HIV/AIDS. Some of them had a fairly broad base of knowledge, others not so much. Here was the list they came up with:

-HIV stands for Human Immunodeficiency Virus
-There is no cure for HIV
-HIV causes AIDS
-HIV can be prevented
-You can't tell if someone has HIV just by looking at them

We then went through how HIV is transmitted, which turned into a session about facts and myths of HIV transmission. Some myths I had to dispel include that you can get HIV through a person's sweat or sharing a toothbrush. They also had questions about a few things I didn't know about, such as whether HIV can be transmitted by traditional circumcisions or wife inheritance, so they had to explain those to me. In traditional circumcision, you'd have a group of boys or girls (yes, there are places in Kenya where they do female circumcision) and they'd all get circumcised at the same time, one after the other, with the same tools. I said that that would be possible to transmit HIV in that case, but apparently the Ministry of Public Health and Sanitation beat me to that: they've done quite a lot of teaching to the villages on this, and now most will sterilize the instruments in the fire between 'patients' or use new ones with each circumcision. Good to know.

Wife inheritance is that when a husband dies, the brother inherits the wife to take care of, and often that inheritance includes expectations that she would perform all wifely duties. Obviously, if the husband had died of AIDS, that's not going to be a good thing. So I said yes, HIV can be transmitted that way, which is why it's important to educate people that you should always know a person's HIV status before having sex with them, even if it is a new spouse. Obviously, empowerment of the women to be able to say no to having a new husband would be the ideal situation, but baby steps.

In all, despite the zero prep time, it went pretty well. The students seemed to follow what I was saying and had good questions, so I'm sure the rest of their week will go well. I just don't know what role I have in the rest of that week.

Scuba and snakes

I've decided to do the rest of my experiences in Kenya by alliteration. Today is scuba and snakes, tomorrow will be running and...rest? Rum? Rainbows? Just kidding, even though my two experiences today really were scuba diving and seeing a snake farm.

I went diving out of Malindi Marine Park this morning with Blue Fin Diving on two sites, Tewa and Papa. The website even provides maps of the dive sites:

They were pretty good dives with reasonably good visibility and a lot of fish and octopi to see (and, at Papa, a large turtle). It was a pretty large group I went diving with (and all Italian...), but they had a lot of dive masters and split us up into small groups, so it was manageable.

After I was done diving, I went out to Watamu to meet up with Dr. Childs for lunch and to head out to Bio-Ken snake farm. But first we had lunch at Ocean Sports Resort, where we had to put up with terrible views like this:

Bio-Ken (http://bio-ken.com/) is a snake farm and research center, with many different missions, including milking snakes for venom to be sent off to India and used to make anti-venoms. I was under the impression before I went that they make the anti-venoms there, but it's too large and expensive of a venture that involves, among other things, injecting horses with increasing amounts of venom until they make antibodies against it.



This is a green mamba, which is one of the most poisonous snakes in Kenya and one that they harvest the venom from. The distribution of the green mamba in Kenya is the light blue and yellow:

We're obviously in the yellow. There's a lot of other cool stuff on the website, if you're interested in learning about snakes and snakebites. Probably wouldn't be very helpful with American snake bites, though (other than the general info on taking care of snake bites: don't apply tourniquets, keep the patient calm, etc).

That was pretty much my day. Tomorrow I'm going to try to get some running in in the morning (before the gym gets ridiculously hot), and then we'll see what happens after that.

Medical examinations and the falconry

 Yesterday and today, I spent a good portion of the day doing medical examinations of the food handlers at two local resorts (Blu Key and Coral Key, owned by the same outfit). "Medical examination" is probably a bit generous of a term for what we did: we collected urine and stool samples and checked them for urinary tract infections and parasite infections, a process that every food handler goes through semi-annually to keep his or her food handler license. We did detect a few probable urinary tract infections (hard to be definitive when the only thing you're using is microscopy), but no parasite infections. I was quite surprised (and a little disappointed, to be honest) at the lack of parasites, until the public health officer I was working with informed me that food handlers are routinely dewormed. Here are a few things that we were looking for:

 Hookworm eggs

 Ascaris egg (roundworm)

 Schistosomiasis egg

Actually, we did a schistosome egg today, but that was in an unrelated patient. But yes, I did spend most of my afternoon dealing with shit. During spring quarter of my master's, I took a class on medical parasitology (worst class ever, by the way), and every Friday afternoon, when everyone just wanted to go home and take a nap, we had parasitology lab, which consisted of us looking at slides of stool samples, trying to find parasites. So every Friday during lunch, I ended online conversations with Brad by saying, "Well, time for me to look at shit under a microscope." It became a bit of a joke for everyone in the class.

But back to the story... everyone passed their "medical examinations" and got their certificates to continue working as food handlers for another six months, and I wrapped up another week of work at Malindi District Hospital (only one week to go until I'm heading home!) After finishing at the hospital (and Dr. Childs finishing his first class of almost-ATLS), we decided to hit the town. Nothing terribly exciting: we went to the Malindi Falconry, which is more of a zoo than just a Falconry. Here's some of what we saw:

Giant, ancient turtle (the guide said he was 118 years old). He liked to be petted, so I petted him for a bit (it's like a leathery dog), but apparently he took a liking to me and started following me around. I was a little weirded out, but not too worried. I'm pretty sure I can outrun him.

Monitor lizard.

Green mambas. These are very poisonous and are found in Kenya (along with black mambas and a couple of other venomous snakes)

And, of course, falcons, which we got to play with. Not really; we just got to hold them, but that was kinda fun, too.

Finally, we had dinner at the Malindi Sea Fishing Club, where they have displayed Kenya's first grander (fish weighing over 1000 pounds). This sailfish (swordfish to us Americans) weighed in at 1250 pounds. It's quite large. There was a cricket game on the television, which I still do not understand at all, despite the fact that we were there watching for an hour and a half.

Tomorrow begins the last weekend in Kenya, and I'm going to be starting it off with a nice and relaxing scuba dive off the Malindi Marine Park :)

Teaching and training

Today was more of the same, unfortunately (or fortunately, I haven't quite decided yet). I'm again in public health, so I spent time with Katana on his weekly disease surveillance reports, which have to be submitted up to the next level. He gets reports from the local clinics (35 or so of them, I think they said), and then puts that all together to submit up to the district public health officer, who submits them up to the province, then to Nairobi, etc. What he usually does is count them all up by hand and submit it that way, so I introduced him to Excel, which will do the summations and keeps everything in a pretty handy place for the future. I've never taught anyone how to use Excel before, so it was a little interesting to see all the things that I do without thinking (like making the columns fit the headings), from the point of view of someone who doesn't know much about the program. I did teach him the basics and how to do summations, but that was about it. I also had to teach him how to save websites into his favorites... The things we take for granted having grown up with computers, I guess.

After that, I got a call that there was a post-mortem (an autopsy) that was about to start, and since I was interested in that process, I went over to the morgue/funeral home for that. Sadly, it was an 11-year-old girl who had been hit by a bus. She was missing the back of her skull and almost all of her brain, so cause of death was pretty obvious, but they still did an internal examination to get a full list of injuries for the police report. One main difference between autopsies here and in the States is that in Malindi, they don't have trained pathologists, so they don't do histology (looking at tissues under a microscope). For cases such as this one, with obvious cause of death, looking at the tissues isn't really all that necessary anyway, but if there's a question of cause of death, or if there's something that needs to be looked at to determine if it's cancer, the tissues get sent down to Mombasa, about 3-4 hour drive down the coast. Not nearly as streamlined of a process as what I'm accustomed to.

Following that, I decided to check out how the trauma training was going. Dr. Childs was using ATLS presentations, which was good, in that they cover the standard of care for trauma treatment, but also a bit difficult, in that Malindi doesn't have a lot of the resources that are needed for standard of care. It's an interesting balance, to present what is right but at the same time teach them what to do in their situations. There's a group of German med students who are the hospital for a month who were also attending the training, so I got to chat with them for a few minutes about school and what they were hoping to accomplish on this rotation.

Tomorrow, I think I'm going with the district public health officer to inspect some of the clinics, but I haven't heard from Jeremy, so I don't know what time I'm supposed to be at the hospital to leave. This could be interesting...