ACPM 2013: Day 2

Today was a lighter day than yesterday, mostly because I didn't want to go to the all-afternoon session on reducing childhood obesity among Latino children in Arizona (crazy, I know, since that's usually my area of interest in tropical medicine...).

The day started with a 4ish mile trail run, starting at 6am. As I joked to my former program director (also running), I don't know who did the risk assessment for that exercise, but whoever it was should clearly be fired. Running on trails before the sun comes up (and in the cold--I think it was about 38 this morning) was not a very good idea. We did get to watch the sunrise over the mountains as we ran, though, which is always one of my favorite sights.

Once we had breakfast and got cleaned up, it was time for the first plenary session, which I think was misadvertised. The lecture was called Population Health, but I kept waiting for him to stop talking about primary care and start talking about population health, which he never really did. The second session was equally disappointing. It was about vaccine updates, which last year was a very good talk, going into all of the recommended changes to the vaccines and vaccine schedules from the CDC and why they made those changes. Maybe there just weren't very many changes and they had to fill the time with something else; I don't know.

After that was my break in the afternoon (see above comments about not going to the thing about obese children), which I used to fill out questionnaires and quizzes to get credit for the hours I'm here. Then we had the last session, which was about the future of preventive medicine. They had some interesting ideas, but none of them were all that applicable to preventive medicine in the Army.

Tomorrow's my presentation, so I hope I'm prepared!

ACPM 2013, Day 1

Yesterday I flew into Phoenix, Arizona for the American College of Preventive Conference. Sadly, with all of the budget stuff that's going on in Congress right now, the Army doesn't have the money to pay for me to attend, but since it is my specialty's conference, and I'm presenting on Saturday, I forked over my own money to come. And it's ACPM, which I've been attending since I was a med student.

The day started with hitting an overcrowded gym (preventive medicine types like exercising) before I grabbed breakfast and hit the registration table, getting my first-ever "ACPM Member" badge (instead of Med Student Section or Resident Physician Member badge). The opening plenary speaker today, the editor-in-chief of the American Journal of Preventive Medicine, talked about the health care system (a popular topic at these meetings). Specifically, he talked about the fact that it isn't a system; it's a bunch of people doing whatever they want and ignoring the other pieces of the puzzle. He compared it a construction company that built houses by telling everyone to do what they usually do and giving nobody blueprints, which I thought was an interesting (but probably apt) comparison. These kinds of fractures, in his opinion, are what is driving up the cost of healthcare so much in this country, and changes that we're making (like Obamacare) are the same as rearranging the deck chairs on the Titanic while it's sinking. He said we need to be more like engineers, who actually think about systems as a whole, and if we did that, we would not only be more efficient (and therefore cost-efficient) at providing healthcare, but better at it, too.

The next session I went to I fully expected to be bored during. It was titled: "Linking Primary Care and Public Health: Where Are We?" I expected it to be about lifestyle medicine--talking to people about what they eat and how they need to exercise. I was pleasantly surprised to find that it was more about how primary care uses what we find in public health to do primary care better. One speaker, the health commissioner for Georgia, used the example of infant mortality, which was much higher in Georgia that most other states. They looked into what was causing infant mortality in Georgia and elsewhere, found out how to impact the most common causes, and implemented them. As a result, infant mortality dropped.

I think my favorite session today was the keynote speaker, former U.S. Surgeon General Richard Carmona, who was Surgeon General from 2002-2006. He talked about the plague of politics on science and medicine and how whenever politics gets involved in science, everyone loses. He used specific examples, both from his own term as Surgeon General, such as fighting with the Bush administration about how abstinence only sex education has no science behind it because it doesn't work, and older examples, going all the way back to the bubonic plague outbreak in San Francisco at the turn of the twentieth century, when the public health commissioner of San Francisco (or California, I'm not sure) wanted to quarantine ships coming into harbor, and the state of California disagreed because they thought it would ruin tourism and trade. That one went all the way up to the president, who sided with the medical people, which led to the end of the outbreak. The point that he really drove home is that, while the Surgeon General is a political appointee, he can't be the physician of the president or the party that put him into office; he has to be the physician of the United States, and to do that, he has to follow only the science, and not the politics that tries to get involved in it. He was an amazing speaker and brought the entire audience to our feet when he was done.

After a few more sessions in the afternoon, we had the med student/resident/young physician happy hour, which was "light appetizers" (which I ate enough of to count as a full dinner) and then preventive medicine trivia, which my team won. I even got a prize: MRSA and a CDC mug. I don't know why the picture is sideways.

Training the Medics

Yes, it's been a while since I've last the blog... Sorry. I wish I could say a lot has happened since my last post, but sadly, that's not really true. It's pretty much the same thing on a daily basis: work-out, go to work, go home, sit on the couch, go to bed, repeat. With the occasional variation for a weekend.

So I'll write about what's been occupying my time at work: how to train the medics.

We have about 25 junior medics (private first class-corporal), all of which are very bright, for junior medics. They were recruited for civil affairs by being at the top of their classes during Advanced Individual Training (AIT); once selected for civil affairs, they completed a seven week CAMS course (Civil Affairs Medical Specialist), which went over basic preventive medicine, environmental science, and veterinary medicine. More than half of them have gone to a paramedic course and are now certified paramedics. They're great at trauma care; unfortunately for that, most of what the medics are probably going to be encountering in Africa is going to be tropical medicine and not trauma.

Fortunately, I happen to be a little bit good at tropical medicine (and that's not just me saying that... The American Society of Tropical Medicine and Hygiene agrees, and gave me a certificate saying it).

So between the environmental science officer, the vet, and myself, we came up with the perfect (okay, not perfect, but decently good) training plan, with two hours lectures once a week, on Wednesdays from 2-4 pm. We presented this to the company commanders, but sadly, the presentation did not go as planned. The company commanders were concerned that we were trying to tell them what to do with their people, and told us that they'll get back to us with a plan for how they want us to train their medics.

That was over a month ago. Still no word on what that plan is.

In the meantime, we've been doing what we can to "unofficially" train the medics. I put "unofficially" in quotes, because everything is, actually, official (we keep careful records, because the medics need a certain number of hours of training a year to maintain their certifications), but just not without the approval and/or knowledge of the company commanders. Through the super-secret sergeant channels (that's what I call how all of the non-commissioned officers get things done), the senior medics who work in the aid station contact the senior medics in the company and tell them that we're going to do training, and if their junior medics are free, that they're welcome to attend. For unofficial training, we've so far done "stump the professor", where the medics asked me any question they had about diseases in Africa (on which they stumped me on one disease--guinea worm), and practicing inserting IVs, which Mary, the vet, ran (she even brought in her dog so the medics could practice on the dog as well as each other). Both went very well.

We've also had official trainings, which so far has consisted of one guest speaker, a Nigerian-born physician from the CDC. He came in to talk about his research on hepatitis that he's done in the Coastal Region of Georgia, and compared that to hepatitis trends around the world. Some of the statistics were a bit pedestrian, but overall, the medics were very attentive throughout and asked some good questions, so I'm proud of them. We have another presentation scheduled for a couple of weeks from now, when the dermatologist from Ft. Stewart is going to talk about tropical dermatology. Should be a good presentation.

Long story less long, training the medics to know what they need to know about tropical medicine, before they go to Africa, isn't easy, but we're finding a way to make it work.

Back at Work

Because our battalion is still getting started as far as missions, I was fortunate enough to be able to escape for two weeks of leave for Christmas and New Year's. I started with a week in Everett at Alex and Allison's house with the family, with a side trip over the mountains to Moses Lake for a day to see Papa and the cousins and their families.

Mountains. Aren't they pretty?

For the second week, I hopped over to the other Washington (D.C., that is) for some time with my friends. My friend Jen (the one I went to Kilimanjaro with) broke her leg, so it was a pretty low-key stay. She invited some friends over for New Year's Eve; it was good to get to hang out with them again.

Unfortunately, on New Year's Day, I boarded a plane back down to Savannah, because on the 2nd, I had to be back at work. Fortunately, most of the battalion was still on leave, so I had the office to myself and was able to be pretty productive. I didn't end up missing much while I was gone (like I said, there's not much in terms of missions), so it took me surprisingly very little time to get caught up.

I think things are going to start picking up pretty quickly, so now's the time to get as prepared as possible, and hopefully we'll be ready when it's time for the first team to be out the door.

Change of Command, Staff Assistance Visit, and Board Exam Results

The last two days have been pretty busy for the medical section of the 82nd Civil Affairs Battalion. We started our day yesterday with a Staff Assistance Visit (SAV) from our parent brigade, the 85th CA Brigade. I think the original plan was that all of our counterparts would come over from Ft. Hood, but in the end, it was just the brigade veterinarian and environmental science officer (so, my counterpart wasn't there). The vet, who is the head of the med section at brigade, explained to us things that he expected from us and updated us on live tissue training (LTT).

To back up for a second, LTT is essentially doing trauma training on animals, in order to prepare Soldiers to do trauma care on Soldiers in combat situations. To explain what happens in very simple terms, a goat will be shot and then it'll be up to the Soldiers to keep it alive for, say, four hours. This is done throughout the Army, but usually just for medics and just before deployment to Afghanistan. In the Special Forces community, where much of our leadership is coming from, all of the team members participate, because they operate in small teams (like we do), and if something happens to their one medic, the other team members need to know what to do. Summing up many months of discussions and requests, the battalion wants us to do LTT. Well, getting permission to do that isn't nearly that easy. The brigade vet explained the process that's going to happen, which is going to involve paperwork sent up the Pentagon and probably three + years of work in progress. In other words, not the answer we would have liked, but we finally have an answer when people ask.

After a couple of hours of meeting with them, we had a change of command ceremony for Headquarters and Headquarters Company (HHC). Since I am in HHC, I should have been in the formation, but because of our SAV, we didn't have time to rehearse, so we just watched (actually, our command sergeant major told us to sit in the second row of the VIP section, so that was kinda nice). It was ridiculously cold (our only cold day; it went back up to the mid-60s today), so I was glad to be able to sit and wear my fleece jacket, instead of standing at attention in formation.

Here's the outgoing company commander, CPT Scott Cummings, pass off the guidon (the flag) to LTC Gardner to signify handing over his command:

And below is LTC Gardner handing the guidon off to MAJ Will Richardson, the new HHC Commander.

I had never seen a change of command ceremony before, so it was interesting to see. And I'm happy for both Scott, who gets to move to B Company to be a team leader, and MAJ Richardson, who is going to be bringing his civil affairs expertise to the company command.

After all that, I finally had a little bit of time to do my job (imagine that), and then our counterparts from brigade wanted to go out in Savannah. MAJ Escajeda, the environmental science officer, had been stationed at Ft. Stewart before, so she knows Savannah. We went to Pirate's House for dinner (great food) and then did a hearse ghost tour just for fun. It was all very hokie, but we did get to hear some stories, like the involvement of the Candler Hospital in the yellow fever outbreaks in the 1800s and during the Civil War. And it's supposedly haunted, but we didn't see any ghosts. Just a really old hospital (the oldest in Georgia and the second oldest in the country, according to our tour guide).

It was quite a night out (I got home at 1 this morning), and then I had clinic this morning (ugh). When I got home, though, I had some good news waiting for me in my mailbox: I passed my board exam! It was a pretty poorly written exam, but apparently everyone who took it felt the same way, because I finished the two pieces of the test at the 95th and 98th percentiles. The certification lasts for 10 years, so I am done taking exams until 2022. That's certainly a relief!

Kili Trek Day 5: Horombo to Marangu Gate (And Back to the Hotel)

Yesterday we completed our trek with a 19 km hike down from Horombo to the Marangu gate; it was a lot easier headed down than it was going up. We were all exhausted and focused on getting back to the hotel, so there was very little chit chat and hardly any stopping to take pictures. Just hiking.

Me right before we began the trek back toward the gate. I quickly shed the fleece once we started hiking.

When we made it to the bottom, we had all sorts of people trying to sell us things; when we were out of money, they turned to bartering and asking for our hiking stuff. I ended up trading my headlamp for a Mt. Kilimanjaro tee-shirt (not a fair trade, I know, but whatever), but I drew the line at trading my sunglasses. Jen ended up giving up her water bottles, camelback, and head lamp for a tee-shirt, two wooden animals, and some artwork. I don't know what the guys bartering at the bottom do with hiking gear; I'm sure they sell it to the guides and porters.

After a ride back to the hotel, we got our certificates saying that we made it to the top (yay!) and then we finally got to shower and get dressed in clothes that hand't been up and down a mountain. We also got to deal with whole issue of tipping, which was actually much more complicated than it should have been. The website for our tour group suggested $200-$250 per hiker, but then when they broke it down by how much each person got, it didn't add up. After trying to finagle it for a while, we just gave up and gave our guide the whole bit and asked him to split it up amongst himself, the assistant guides, the cook, waiter, and porters. He seems honest; hopefully he is and will split it up properly.

With our certificates saying that we made it up to Uhuru Peak.

Jen and Angie took off this morning for Nairobi to meet up with the Romanians and go on safari; Kevin and I are currently sitting in the courtyard of the hotel watching the groups about to take off for the trek and judging them. One couple showed up with none of the right stuff; fortunately, the gear rental place in the hotel will square them away for that, but can't really do anything about how out of shape the woman appears to be. Another woman is wearing denim shorts and a daypack without any structure to it. The only group we're confident about is two Indian guys who live in Kenya and have climbed Mt. Kenya. They'll make it to the top.

In all, it was a good experience to have, but I wish I had prepared more, especially for summit day. But I made it, and I'll always be able to say I made it, so that's something.

Random picture of Jen and me

Kili Trek Day 4: Kibo to Uhuru to Kibo to Horombo

Today was one of the longest and definitely the hardest day ever. After three days of relatively mild hiking, we were woken up at 10 pm to begin our preparations for summiting. Unfortunately, there was some excitement in our hut around the same time, when the Czech hiker who had been with us along the way had a seizure and began vomiting in his bed. Once he came to, we gave him some Diamox and explained to him and his guide that he shouldn't ascend to the summit; however, it was ultimately his decision, and he decided to go up. He did make it up (it took a while), and made it back, so I guess it all worked out in the end.

We finally hit the trail around 11:40, all bundled up and with our headlamps on. Although they tell us that the ascent is at night so we can see the sunrise from the top of the mountain, we decided when we saw the trail at the descent that it was to keep us from freaking out. It was a pretty shear face with a lot of switchbacks, and we went very, very slow. Before my Garmin watch died due to the cold, we had gone 1.66 miles in three hours. Forward progress, sure, but slow.

What the hike looked like, with the headlamps.

I did not feel well during the summit ascent, pretty much from the beginning. In addition to being cold, I was feeling really nauseated and concentrating on not throwing up. As we got closer to the top, I also started to feel really sleepy, to the point that when we reached Gilman's Peak, I sat down and promptly fell asleep. Fortunately, the guide woke me up right away, gave me the fleece sweatshirt he was wearing and some hot water, and I was feeling much better. Which was good, because I was contemplating asking one of the three guides to take me down, and that would have been disappointing.

From Gilman's Peak, it was another hour and a half hike (fortunately, mostly flat with an overall 100m increase in elevation) to Uhuru Summit. Angie was almost as cold as I was (only without the hypothermic need to sleep), so she refused to stop when Kevin and Jen requested breaks. I stuck with her, because I didn't want to stop, either, and we were the first two from our group to reach the summit sign. Unfortunately, in the pictures, I was still wearing the oversized fleece sweatshirt instead of my purple coat, but whatever. I made it, and that's all that matters. It took about 7 hours to make it up (it's supposed to be a 5.6 hour climb).

After Jen and Kevin arrived, we took group pictures and then we were out, because it was cold (our guide said -20C). 

Our group at the top

Angie and I again stuck together with one of the guides and ended up being the first group to summit to make it back to Kibo (2 hours down). 

Looking down at Kibo on our way down

Looking up from the bottom of the hill we "skied" down (if you can see the dark  lines, that's where we stirred up the sand)

It had warmed up once the sun came up, so it wasn't too bad by the time we made it back, but our room in the hut was still cold (go figure), so after we shed our hiking boots, we crawled into our sleeping bags to take naps. Kevin came back about 15 minutes later, and Jen about ten minutes after that. And then they fed us breakfast and allowed us to sleep until it was time to pack our bags before lunch, and after lunch, we headed out to return to Horombo, and make the return trek in two hours and fifteen minutes (compared to the four and a half it took us to get there).

We hung out with the Romanians through tea time and dinner, and then got our brief for tomorrow. We'll wake up around 6:30, breakfast at 7, and then headed toward the Marangu gate around 8. We'll stop for a hot lunch at Mandara hut (where we stayed the first night of the trek), and then continue on to the gate. Should be about 19 kilometers, which is nothing to the 35 we did today (13 up the mountain and 13 down, then nine to Horombo). And it doesn't involve summiting the tallest peak in Africa.

When we arrived at Horombo, we were the old and wide returning hikers we so admired two days ago, and we had flocks of questioning Americans wanting to know how it was. When I said it was, no joke, the hardest thing I had ever done, one of the girls (who is from North Carolina) asked if we did much hiking in the States. My response was that I hadn't done anything like this. They asked us if what we were wearing then (which was our heavy hiking pants and long sleeved undershirts +/- fleece sweatshirts) was what we wore to the summit, and we laughed and said no, and explained how cold we were in what we had been wearing (heavy hiking pants over base layer, two pairs of socks, base layer on top, followed by fleece, down jackets, and rain gear), and one girl actually said, "Oh. I brought yoga pants and leggings." This tells me a multitude of things: 1) She's not forwarding thinking enough to Google "packing list Mt. Kilimanjaro"; 2) She never went into an outfitters store (REI, North Face, Columbia, etc) and said "I'm going to be climbing Mt. Kilimanjaro, what do I need?"; and 3) Their guides don't care about their success rates enough to ask them about their gear and get them rental stuff from Moshi before they took off. Which is surprising, because I'm pretty sure a guide gets hired based on his success rate.

Silly Americans.

Sunrise over the glacier

Panoramic view from the summit

Kili Trek Day 3: Horombo to Kibo

It's 1:10 pm right now, and I've already had a challenging day.

We set out from Horombo around 8:30, right behind two very large groups of Swiss tourists who are doing the six day trek (extra day at Horombo for acclimatization). Unfortunately, they were older than our group of twenty- and thirty-somethings, so we were stuck dragging behind them until we finally found a place to pass them.

The summit and the Swiss group we were trying to get around

We made the transition from moorland to alpine desert, and it was quite the transition. There weren't exactly tall trees in the moorland, but then there was nothing in the alpine desert taller than some tufts of grass that were maybe 8-10 inches tall. And then the grass was gone, too. At least we still had rocks.

The last water point on the trek. After this, it was too high for water. Our porters carried  60 liters of water up for drinking and cooking.

Kibo, where we are now, is 4750m, which makes it the highest I've ever been, and I'm feeling pretty good. A little short of breath when I walk around, but otherwise okay. No headaches or vision problems or other symptoms of altitude sickness, so I guess my medication really is working (despite the claims of the Romanian mountain climber that it doesn't do anything).

Kibo Hut. Very high and very cold.

We're going to be having lunch soon, and then we get a brief nap before it's time to bundle up again and go on another acclimatization hike. Our guide said it'll be about 45 minutes total, which will be good, because we'll be taking off around midnight to begin the trip up to the summit.

View from the acclimatization hike

Day 3 of the hike, according to my Garmin

Kili Trek Day 2: Mandara to Horombo

Happy Thanksgiving! Actually, I didn't realize it was Thanksgiving (or Thursday) until Jen asked if it was, and after some thinking, I agreed she was right.

I didn't sleep well last night (time zone differences + sharing a hut with three other people + uncomfortable mattress, etc), so I was already awake for the 6:30 wake up call this morning. After a large breakfast (porridge, eggs, cheese, sausage, and toast), we finished packing up our gear and headed out toward the next stop. The first part of the hike was the same route as the one we took last night, but this time, the clouds hadn't come in yet and we could see the summit. It seemed very high up and very far away, and was actually a little discouraging.

Heading out

The summit

Since we are now in the moorlands (think desert but a little bit more green), there was less stopping for pictures, so we kept a pretty good pace, even though the vast majority of the hiking was uphill (a total of 1000m elevation climb, so, yeah). We saw quite a few hikers going down from the summit, some of which I was thinking, "If he could make it, there's no reason why I can't."

We were getting a little bit nervous when we passed what we thought was the halfway point (they told us we had 11.8 km of hiking, so roughly 7.2 miles), without stopping for lunch. Granted, it was still early in the day, and I was still really full from that large breakfast, but when they tell us we are stopping halfway and we pass the 4.5 mile point without stopping, you're going to make us nervous. When we did finally stop, they explained it wasn't really the halfway point, so we were all relieved (especially Kevin, who had already drained his Camelback). Jen took a nap during lunch and ended up losing her sunglasses; unfortunately, she didn't realize it until we were almost at the huts. No more sunglasses for Jen this trip.

The last picture of Jen with her sunglasses

We ended up hitting Horombo huts at 7.1 miles by my Garmin (I was a bit slow to hit the start button after each time we paused, so I think that's my fault). This place is much busier than the last. It's a stop on the way up and way down on our route, as well as on the way down for other routes, so there were lots of people. You could really tell the difference between coming and going; those who summited today were exhausted but thrilled to be done for the day (it's a pretty long day, as I'll probably be discussing on Saturday), and those of us who hadn't were just cold and nervous.

Horombo huts, 12340 ft

After washing up and having tea, we set out for Zebra Rock, which was 3.4 km way, with about a 300m rise. 

Zebra Rocks. Because they're all striped and everything.

This is part of how our guide acclimatizes us to increasing elevation; at each stop, we go up a little bit more, then head back. In total for the day, it was around 11.5 miles and 1300 elevation gain (the last bit to Zebra Rock wasn't recorded, since I dropped off my Garmin at the the office for charging (for $5).

Dinner tonight was crepes (which they called pancakes), beef kabobs, rice, and vegetable sauce, and then we had our brief for tomorrow's hike. We're going about 9.3 km and another 1000m elevation gain to Kibo huts, reaching there around lunchtime (where we'll have a hot lunch--yay!), then we get a brief nap, acclimatization hike, and then another brief nap before we wake up at midnight to begin the trek up to the summit. Good times. Hopefully I don't freeze, because it is pretty cold up here.

Day 2 of hiking, according to my Garmin

Kili Trek Day 1: Marangu Gate to Mandara Huts

Day one of the hike is now behind us! After a pretty rocky night of sleep (I blame jet lag) we got up to finish packing, loaded our gear into the bus, and headed to the Marangu gate. It was about an hour drive from the hotel to the gate, giving us a glimpse of the Tanzanian landscape.

View of Mt. Kilimanjaro from the hotel immediately before heading out.

We had to register at the gate before we could get started, and then we waited for our guide to check in and get the crew ready (in addition to the guide, we have two assistant guides, a cook, and eight porters to carry our gear). 

Stops along the way on the Marangu route, with elevations and estimated time of hiking. Estimations were all lies.

While we waited, we wandered around the area before the gate and saw the plaque commemorating the first European to reach the summit. There was also a plaque for his guide and porters, which was nice. I asked our guide if anyone knew who the first person was to reach the summit; he said that the local tribe used to go up there to hunt. I don't know if they summited or just got close (I can't imagine we'll see a lot of big game at 20,000 ft), but since the first European had guides and porters, somebody obviously knew the way.

Hans Meyer

Plaque to the guides and porters of Meyer's trek

The first part of our hike was nice. It was in the rainforest, but we didn't get rain and it wasn't too humid. I started the hike with a sun hat and using poles, but the hat got too hot and I still haven't really figured out the point of the poles, so I didn't use them for long. Anyway, we went nice and slow, reaching our spot for lunch around 1 (with frequent stops to take pictures).

Starting the trek. Don't I look all official and whatnot?

We started to exit the rainforest in the second half of the hike, and started to see monkeys, which were fun. We stopped for about fifteen minutes at one point to watch them and take pictures.

Monkey. Isn't it cute?

We reached Mandara huts in the afternoon and had a brief tea break before we headed out to a crater to take some pictures. 

Mandara Huts, 2720 meters

We did see into Kenya, but unfortunately, it was too cloudy to see the summit. Our guide says maybe tomorrow. 

Looking into Kenya

Then it was back for dinner (and by now it was getting cold outside) which was potato and cucumber soup, fried fish, potatoes, vegetables, and bananas. It was quite good. We hung out in the dinner hut for a while talking and getting the brief for tomorrow, but then it started to rain, so we all decided it was time for bed (it's 8 pm as I'm writing this). Here's the overview of the day's hike, according to my GPS watch:

In all, a good day, and I'm really looking forward to continuing the hike tomorrow.