First week of clinic

Monday began my first week of clinic, and it being a short week, there wasn't really a lot happening. Here's what I had:

Monday afternoon: Whitman-Walker Clinic (http://www.whitman-walker.org/). It was pretty much the first HIV/AIDS clinic in DC, and continues to serve that function (and others). I'm working with the medical director, who sees about half of the time (doing medical director stuff the other half), mostly doing HIV primary care. Patients come in every three months and have labwork done to check CD4 counts (white blood cells targeted by HIV), HIV viral lode, full chemistry panel and liver function tests, and to screen for syphilis, TB, hepatitis B, and hepatitis C. My job on Monday was to go in, chat with the patient, find out how they were doing and if they were having any affects from their medications, go over their labwork, and to do a quick physical exam. I saw three patients, and all three of them were doing well, so that's obviously the ideal.

Tuesday morning: This is supposed to be travel clinic at Rader Clinic on Ft. Myer. However, I found out after driving down there that my one patient cancelled that morning. So then it was a drive back up to WRAIR to get some other work done. Here's what my drive looked like that day:

And then back home from WRAIR (C to A) at the end of the day. Obviously.

Wednesday afternoon: This was supposed to preventive medicine clinic at Walter Reed National Military Medical Center (formally known as National Naval Medical Center, or just Bethesda). However, just like on Tuesday, there were no patients, so I got to spend the afternoon sitting on my couch, making phone calls for my concussion study.

And speaking of the concussion study, I've made it all the way through the list of people I needed to contact (235 soldiers). Of those, we have 11 subjects who sent their surveys back completed, 75 surveys that have been mailed and are awaiting return, 6 declines, 60 who have changed their phone numbers/email addresses and we couldn't get hold of, and 83 voicemail messages that I still have to follow-up on. Guess what I'll be doing tomorrow?

More clinic next week. Maybe I'll actually have patients to see.

Remembrance Day

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

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

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

Smallpox Vaccine Clinic

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

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

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

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

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

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

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

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

Ft. Meade Preventive Medicine

I've been rotating in the preventive medicine department at Ft. Meade for a little over four weeks now, and have just been procrastinating pretty bad about writing about it. So here's finally a blog entry about the wonderfulness of Ft. Meade.

First of all, there's the drive, which is the map above. It's 33 miles, according to GoogleMaps, which doesn't seem like a lot, until you factor in DC-area traffic. Fortunately, most people are coming into DC in the morning and leaving in the afternoon, and I'm doing the opposite, so it only takes about 50 minutes to go those 33 miles. It's still far too much time in the car, and even with buying gas on base (usually a few cents/gallon cheaper than outside the base), it's pretty expensive.

My schedule's been a little erratic for this rotation; I'll try to simplify it as much as possible:

Monday and Tuesday: Occupational medicine clinic (ugh). This is mostly pre-employment physicals for jobs around base, such as child care, firefighters, and hazardous material handlers (there were a few other jobs, but you get the idea). We also do pre-deployment physicals for Army civilians who are deploying, which is something fairly new at this clinic. Because they haven't been doing it very long, they don't have a protocol for it, so things are pretty chaotic, and it's a ton of work. It takes quite a lot to be able to say, "okay, you're healthy enough to deploy. Go forth, have fun, and make lots and lots of money."

Wednesday: Fortunately, I get to go to WRAIR for didactics on Wednesdays (six mile drive instead of 33). Last week we were learning about recruit medicine and went down to Quantico to do sick call for the Marine Corps Officer Candidate School. That was pretty fun, but I am glad I'm not a Marine. There's something about not being allowed personal pronouns that I don't think I'd deal with very well ("This candidate's leg has been hurting since yesterday" is how they say that their leg hurts).

Thursday: Random other clinical stuff at Ft. Meade, including more of the pre-deployment physicals, travel clinic, and work injuries. I do love travel clinic, that's for sure.

Friday: My preceptor's admin day, so I usually tag along with the Environmental Health tech to do inspections. There are quite a few places on base that need to be inspected monthly, including all of the kitchens (such as the dining facility, Club Meade, the golf course, bowling alley, child care kitchens, etc), the child care centers themselves, the pool, and home-based day care centers (of which there are about 40 on base; four or so will be inspected monthly, at random). There are also places that have to be inspected quarterly, including the barber shop and the gym. Quite a lot of stuff on base that has to be inspected.

And then I have weekends off, which is nice. My summer/fall running season ended on Sunday with the Marine Corps 10K, so now I have the weekends to be a bit more lazy. Well, this weekend, the parents are coming into town, so I'll have to keep them entertained, but other than that, a bit lazy in general.

Poisoning project

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

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

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

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

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

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!