Democratic Republic of Congo, Day 4

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

The main road in Muanda and where we went running

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

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

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

The Congo, from the air

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

The view from my 17th floor room at the Fleuve

Democratic Republic of Congo, Day 3

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

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

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

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

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

The hospital on Kitona Base

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

Democratic Republic of Congo, Day 2

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

Our chariot awaits

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

The view from above

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

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

Fixing the flat

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

Democratic Republic of Congo, Day 1

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

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

My room in the Flueve Hotel

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

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

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

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

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

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

More Medic Training and Some Random Musings

I actually started to write this post on Friday, but then I realized that I didn't have everything I needed to write it. By that I mean the link to the article I wrote... Keep reading and that will make more sense.

Before I left for ACPM, we had Dr. Likita Aminu from the CDC come over to talk to the medics about hepatitis. Dr. Aminu is originally from Nigeria, and met LTC Gardner in December at an African culture event in Savannah. Because LTC Gardner can talk anyone into anything (he is, without exaggeration, the type who would be able to sell ice to Eskimos if he wanted), Dr. Aminu agreed to chat with the medics. Since he had done research on hepatitis in the Coastal Region of Georgia (where we live), and hepatitis is an issue in Africa, that's what he talked about.

And here's the link to the article I wrote about the training:

http://www.stewart.army.mil/homepage/news/news8.asp

Now onto my random musings. For the second half of last week, I was in a pretty annoyed mood. I think it started on Wednesday, when we had a Command and Staff meeting. Command and Staff is pretty awful to begin with--each of the staff sections talks about what's going on in that section. It's great if you really care about how many humvees are due to be serviced or whose evaluations are due. If you don't, it's about an hour and a half of torture. Well, because the conference room table is only so large, I don't have a seat at the table, but I do have a slide (as in, one PowerPoint slide) to brief, and that's the medical readiness of each of the companies. To make an already long story somewhat shorter, before the meeting started, I was trying to find the right chair to pull into the corner of the room, the entire time thinking, "I went to four years of medical school and three years of residency for this?" Yes, a bit egotistical, perhaps, but that is what I was thinking.

I think part of that was the fact that I was just at a conference, hanging out with the people I used to work with, which was a nice little reminder of how well I used to have it. In residency, my only obligations were to learn as much preventive medicine as possible (and stay up to date with all my Army required trainings, of course). Now, I see routine complaints (boring), track who is due for which vaccines or blood work (boring), and only rarely get to do anything preventive medicine or tropical medicine related (yay!).

I guess the point of that is, going to such conferences remind me that I do like the Army, but that I think I'll be happier if I leave FORSCOM and go back to MEDCOM, where doctors typically get to do what they're trained to do.

We'll see what happens.

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!