I recently came across this and have to say I love the name!
This is basically blood transfusion given by combat paramedics and aeromedical retrieval teams, for use with wounded soldiers.
For those of you who have not heard of Blackwater…You should. Blackwater was one of the most prolific, controversial and effective private military security companies in the world. While the company has morphed several times and now has re-named and re-branded, the name Blackwater lives on.
The Blackwater Tactical Weekly is their online journal that focuses on issues pertaining to Private Military and Security work. I am very happy to contribute to their work and discus medical issues faced by the private military contractor.
The first article can be found here and discusses one of my favorite topics, Malaria.
We are very proud of a recent article in Robb Report Magazine that examined adventure travel and how people can stay healthy overseas. This article looked at Adventure Doc’s services and specifically focused on a challenging expedition we provided medical support for, two years prior.
Tropical medicine, international health and diseases of poverty all go together…we should know this by now. A new drug to combat Multi-Drug Resistant Tuberculosis (MDRTB) recently got United States Food and Drug Administration (FDA) approval. A relatively unbiased and superficial article about the new drug can be found here:
A press release from MSF/Doctors Without Borders can be read here: http://www.doctorswithoutborders.org/press/release.cfm?id=6519&cat=press-release
Why we need to know TB management in remote and international settings
Working in international and remote settings, I often care for both imports and locals. Contractors, ex-patriots, visitors, etc are the people that bring me there. Providing care for the local patient population is often done for a variety of reasons ranging from public health control and generating “good will” to the fact that they are employed by another entity. Screening and managing tuberculosis is a skill that is often overlooked by the docs and paramedics who work in these settings. Sure we are good at malaria, trauma and managing high blood pressure…We need to be good at this too!
Condition: A mycobacterial disease that is common in developing nations. 70% of disease effects the lungs while 30% is extra-pulmonary. This disease has made a recent “comeback” with immunocompromised states caused by HIV/AIDS.
Infectious Agent: Mycobacterium Tuberculosis complex consisting of Mycobacterium tuberculosis, M. africanum and M. canettii. This is an Acid fast bacillus.
Signs and Symptoms: Fatigue, fevers, night sweats, hemoptysis and sputum producing cough, weight loss
Diagnosis: A PPD (purified protein derivative) and/or chest x-ray are commonly used tools to diagnose. The PPD is also known as a Mantoux skin test. Positive skin tests should be followed with a chest x-ray. The skin test is “read” 48-72 hours after the subcutaneous injection is given and examined for induration/swelling. Positive results range from 5-15 mm in size. More on test interpretation can be found here from the CDC: http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm . False positives are common.
Transmission: Exposure to TB in aerosolized respiratory droplets (1-5 microns in diameter); Health care workers are at high risk
Treatment: For most susceptible cases a 4 drug cocktail of Isoniazid, Rifampin, Pyrazinamide and Ethambutol is used for the first two months of treatment then just Isonaziad and Rifampin for 4 months. A total of 6 months of treatment is advised and should be tailored to sputum culture results and sensitivity. I remember this because TB effects your RESPIratory tract (Rifampin, Ethambutol, Streptomycin, Pyrazinamide and Isoniazid)
Prevention: Strict control of positive and suspected cases, Directly Observed Therapy (DOT) to ensure patients take medication, approved face masks to prevent droplet inhalation
Epidemiology: Found worldwide, the disease is associated more with poverty and immunocompromised persons.
As doctors and paramedics working in areas where TB is possible, we need to promptly identify and treat this illness, we need to know how to administer a PPD and read it. Most people are comfortable with giving a sub-cutaneous injection but here is an expert video from the CDC on how to do it. This is a multi-part series and I have linked to the injection section of the video although viewing them all is a great idea as there is a lot of good education, review and information in all the sections.
Providing medical care in a remote or austere location means you have to know a lot about many different things. Often we get focused on trauma, common infectious diseases and basic primary care. I hope this review made us more ready to recognize, diagnose and treat TB.
Condition: Infection by a parasitic worm that often causes lymph-edema in the lower extremities
Infectious Agent: Lymphatic filariasis is caused by Wuchereria bancrofti; Brugia malayi and B. timori. All of these are filarial nematodes.
Signs and Symptoms: Most infections are asymptomatic. As the worms mature they may progressively block lymph channels in the lower extremities, scrotum, arms or breasts. This causes the resultant back-up of lymph and presentation of elephantiasis. Secondary skin infections in these effected areas are also common.
Diagnosis: The standard diagnosis is through a blood smear that demonstrates microfilariae under microscopy. The highest concentrations of microfilariae are seen in peripheral blood at nighttime hours and specimens should be drawn between 10PM and 2AM.
Transmission: The bite of infected mosquitoes such as Aedes, Culex, Anopheles and Mansonia species
Treatment: Diethylcarbamazine (DEC) is the drug of choice for travelers with these infections. Although ivermectin does kill microfilariae it has no effect on adult worms. Once elephantiasis has developed there is no corrective methods to reveres the course. Surgical excision of the filarial worms only result in scarring of the lymph channels and worsening the blockage. Local wound care of the effected region is important including hygiene and infection control.
Prevention: Protective measures include mosquito bite prevention such as long sleeves, pants, bed nets, permethrin treated clothing and DEET 30-35% insect repellent.
Epidemiology: This effects approximately 120 million people worldwide. Lymphatic filariasis is seen in Sub-Saharan Africa, Egypt, Southern Asia, Pacific Islands, Brazil, Haiti and the Dominican Republic. Short term travelers to these regions are at low risk for infection. Travelers in these regions for extended periods of time (>3 months) and are intensively exposed to mosquitoes are considered to be at a higher risk for infection.
We have recently been experimenting with publishing our own weekly newsletter on travel and expedition medicine. We are publishing it via twitter, as well. Too follow our account on twitter visit us @AdventureDoc
Our expedition and travel medicine weekly can be seen here: http://paper.li/AdventureDoc/1324446220
It will be growing so please keep checking back!
A lot of people have asked me what it is like to be a “remote site” doctor or about providing medical care to expeditions or groups in “far away locations”. The glamorous sounding job of “expedition doctor” is not always what is sounds like. Here is what a typical contract or service is like, from my point of view. Obviously, each job is different but there are a few common threads:
Pre trip phase and packing
Packing the tools of my trade: stethoscope, ent kit, a few favorite medical books, Kindle with the rest of my medical books, iPad with pharmocopeia, more medical text books and reference material. This all depends on what gear is already on hand at the destination. Sometimes I have to bring a whole medical kit with diagnostics, medicines or even a portable hospital with me! Generally I bring my personal items that are customized and just the way I like them. The books are noted and highlighted and the ebooks are noted and bookmarked for rapid reference.
Packing things to entertain me such as a kindle with my RYP books, pleasure reading (non-fiction), iPad loaded with music and movies, iPod loaded with music, external hard drive loaded with movies, lap top, work out mat, etc. I also never forget my power-monkey charger for those power outages in the middle of my 212th time viewing Indiana Jones III.
Packing clothes for the area and I generally work in the tropics or desert. This means lots of shorts, sandals, scrubs, ex officio shirts, running gear, one pair of boots and a dress outfit in case I need to meet important people…I have yet to wear this outfit though. On duty I generally wear an ex offico style shirt and cargo pants with a few IV kits, tourniquets and medicine vials stuffed into the pockets. If I have to go into the field with a smaller team I carry my shoulder bag or backpack filled with doctor like stuff including saline, clotting agents, antibiotics, tourniquets, etc. I also wear a vest sometimes…yes I am AM that guy but screw it…the vest holds a lot of stuff and does not interfere with a back pack and still gives easy access to items.
Take a plane from my home town to the capital city of where I am going. This generally involves several airports, layovers and an unavoidable overnight in a “hotel near the airport”.
From capital city x,y,z I usually take a crappy plane, often a prop plane or rotary wing to the site. This can often be the most hazardous part of the trip!
Finally I arrive in the camp/area/clinic and find my quarters and work area.
Settling in phase
I usually end up staying in con-ex boxes, mobile homes, trailers or tent structures. Some have a/c and some do not. Most are filthy and very lived in, complete with body hair from others scattered everywhere, dirty dishes, moldy food in the fridge (if I have one) and the first goal is to clean up the area. I usually bring my own sleep sack/bivy so I avoid scabies and bed bugs and do not have to deal with yucky, stained sheets. I do not unpack my suitcase and bags unless I am there for more than one month and can clean the drawers/chests out.
Meeting people I will be working with for the assignment is always interesting. There is a lot of ego measuring, posturing and trying to show off without actually being nasty about it. I try to be nice and say a lot of “I hope you guys just keep me out of trouble” and “let me know if I am making any mistakes”. The nurses and other staff are trying to figure out if I am a complete idiot or going to work out ok. This usually takes a few weeks to sort out. There is the type that wants to tell you how great they are, the type that kisses your ass and the type that is too lazy to care.
Getting down to work
The first few days are generally spent trying to tread water and not screw up too bad. Lots of new paperwork, forms and “the way we do things here” stuff. I also love the “I am not sure how you do it where you are from but we do this this way, here”. Learning from others, being nice and still having to lead the team is a fine art I am still mastering.
Clinic from 9am to 12:00
The usual gambit of injuries and illness depending on the area and people I am covering. Miners get respiratory complaints, sore muscles and twisted ankles and knees. Shooters get sore shoulders from weight workouts, twisted ankles and knees and everybody gets flu like illnesses and vomiting/diarrhea. The trick is to plow through the mundane crap each day and not miss the important red flags. That vomiting and stomach pain is probably gastroenteritis but it could also be a gallbladder or gi bleed. Staying vigilant when you repeat the same stuff every day is difficult some times.nthe morning also has the sick bay commandos looking for excuse notes and a day off work.
Clinic from 14:00-16:00
Same thing. I also usually see the chronic illness patients in the afternoon to make sure their blood pressure is not too high and they take their medicines Ike they should.
A few days per week I also have to do some public health duties like checking water supply, the kitchen and food storage. This is generally done after clinic and involves a mountian of paperwork and being a hard-ass about temperatures of food storage, parts per million of chlorine and other safety issues that make me quite unpopular some times.
My personal time
After 4pm I am usually done unless there is a problem. I am on call 24/7 for emergencies. The 57 year old guy that never takes his blood pressure meds, has horrible cholesterol, is 50 pounds overweight and smokes a pack a day usually has his chest pain episode around my dinner time. The guy that is not paying attention gets his fingers cut off around 2 am on night shift. Night time is generally when “badness” happens. A lot of times it is just being on standby in the clinic and then giving everybody a once over when they get back to the area. Still, it is nerve wracking, involves geting up out of bed and getting ready to work.
During “my time” I generally read, study or watch movies on the lap top or tv if I have one in my little shack. Even if their is tv there are never any good channels and knight rider in Arabic is just not that fun to watch. Working out in your trailer and not leaving the compound can be challenging. I do alot of calesthenics, pushups and the like. I always tend to make friends with the people I am working with. This means I worry about them when they are on a particularly dangerous outing, getting far from camp or I get a radio call that someone is coming into the clinic with “a problem”. Classic worrying mother syndrome!
If I get really beat-up at night with calls, sick visits or trauma, I cancel the clinic in the following morning to sleep in. Once per week or so I also give a lecture to the crews about some first aid topics, disease background or hygiene. I also try to give a lecture to the nurses at least once per week on an interesting case or point of learning such as physical exam or laboraty test interpretation.
Food can be challenging. Generally there is a base kitchen and a few freezer/fridge boxes in the camps. They are stocked with frozen meats, little airline sized condiments and sometimes fresh veggies if you get there quick enough and before everybody else. Generally I cook my own food if I have a kitchen in my trailer and if not I am at the mercy of the cooks. The food is ok, not great but not crap either. Some contracts give me a credit to spend at a local commissary store to get some luxury items like coca cola, yoghurt and a frozen pizza. Pasta and hamburgers are mainstays along with lunch meats and cheeses. Bottle water is the only way to go, mixers such as Gatorade or emergen-c help change the taste of crappy water.
The next day I head back to clinic, and this cycle repeats itself everyday for the duration of the job. What sticks out the most is a lot of boredom, watching crappy movies in a sweaty box called my house, the same boring food over and over and the people I meet. There is the occasional moment or two of sheer terror when there is a sick patient or bad trauma and we are trying to stabalize and coordinate an evacuation.
This is is…lather, rinse and repeat until the job is over.
Of note, this was written late one night while I was waiting for lab results on a patient on Mornington Island off the Coast of Queensland, Australia.
Condition: A diarrheal illness resulting from parasitic infection
Infectious Agent: Giardia intestinalis, a protozoan parasite
Signs and Symptoms: Symptoms can range from aysmptomatic to a variety of gastrointestinal complaints including diarrhea, abdominal cramping, bloating, fatigue, flatulence and nausea. Diarrhea is classically foul smelling and greasy. Symptoms generally present 1-2 weeks after exposure and are generally self limiting after 2-4 weeks.
Diagnosis: Giardia cysts or trophs are not always seen in the stool of infected patients. Examining up to three stool samples over several days can increase investigative power.
Transmission: Ingestion of fecally contaminated food or water including water swallowed while swimming; contact with fecally contaminated surfaces such as diaper changes, caring for an infected person or sexual contact.
Treatment: Metronidazole, tinidazole, nitazoxanide and furazolidone are drugs known to have efficacy against Giardia. Because of the difficulty of definitive diagnosis, empiric treatment can be started in patients with appropriate symptoms and history.
Prevention: Travelers should follow strict food and water precautions. There is no vaccine or role for preventative antibiotics.
Epidemiology: Found worldwide, the risk of Giardia infection increases with duration of travel. Roughly 31 of 1,000 travelers seeking medical care are diagnosed with giardia. This is most commonly seen in travelers from South Asia, Middle East and South America although it has been in seen in travelers from all regions of the world. Long-term travelers (>6 months) have a much higher incidence than shorter-term travelers. In Nepal, Giardia is found in 10% of stool samples from patients with complaints of diarrhea.
We have decided to start using some of the work that has been put into some of our education modules, traveler/patient hand-outs and internal training material here on the blog. So there is going to be a new feature of a brief examination of a disease, condition or piece on travel health a lot more frequently. To get this started I have selected Amebiasis mainly because it starts with the letter “A”.
Condition: A parasitic infection that often affects the gastro-intestinal tract causing diarrhea; may spread to other organs of the body (liver) to form abscesses
Infectious Agent: Entamoeba histolytica, a protozoan parasite
Signs and Symptoms: Crampy, water and sometimes bloody diarrhea; weight loss; 1/3 of patients have a fever; asymptomatic infections may be seen
Diagnosis: PCR testing is standard; microscopically indistinguishable from E. dispar which is non-pathogenic
Transmission: Fecal-oral route such as eating or drinking fecally contaminated products
Treatment: Metronidazole followed by iodoquinol or paromomycin
Prevention: Food and water precautions including ice and frequent handwashings; avoidance of fecal exposure during sexual activity; there is no vaccine against amebiasis and prophylactic medicine is not advised
Epidemiology: Found worldwide, especially in the tropics; more common in areas of poor sanitation; most commonly seen in travelers returning from South America, South Asia and the Middle East; Long-term travelers (>6 months) are considered higher risk than shorter-term travelers; only 10-20% of infected patients become symptomatic
When talking about preventing malaria it is first important to understand a few basics about the disease. First, malaria is a global killer with around 1,000,000 million deaths per year. Half of the world’s population lives in a malaria risk zone (3.3 billion people). There are an estimated 250 million cases of malaria each year.
Malaria Basics: A parasitic disease that is spread by infected mosquitoes; Malaria is characterized by fevers, fatigue and muscle aches. As the disease progresses enlargement of the liver and spleen can occur, along with a yellowing of the skin and eyes. Malaria is both treatable and preventable.
Species: There are four main species of malaria parasites: Plasmodium Vivax, P. Falciparum, P. Malariae and P. Ovale. Plasmodium Falciparum is considered the worst and most drug resistent.
Location: Malaria is found in virtually every tropical location on the planet, especially at lower elevations
Talking abot how to prevent malaria is a complex matter. An easy way to remember malaria prevention is the A-B-C-D approach
B: Bite Prevention
D: Diagnose early
Awareness is simply realizing that you are entering a malaria zone and are at risk for the illness. In addition, it is wise to know a bit about the disease including signs and symptoms.
Bite prevention centers around the concept that if you are not getting bit, you are not getting sick. The ways to avoid getting bit is to wear long sleeves, long pants and make use of insect repellent. 30-35% concentrations of DEET should be applied to your skin and permethrin should be applied to your clothing. Avoid being outside during peak mosquito biting times such as dusk to dawn. If needed, sleep under a mosquito net.
Chemoprophylaxis means taking a medication to avoid getting sick. For malaria, there are four main types of medications to prevent illness.
Chloroquine-Taken weekly; start 1-2 weeks before entering area and take 4 weeks after leaving
Doxycycline-Taken daily; start 1-2 weeks before entering area and take 4 weeks after leaving
Mefloquine (Larium)-Taken weekly; start 1 week before entering area and take 4 weeks after leaving
Atovaquone/Proguanil (Malarone)-Taken daily; start 1-2 days before entering area and take 7 days after leaving
Diagnosis early means that if you have a fever in a malaria zone it should be treated as malaria until proven otherwise. Do not delay diagnosis and visit a qualified health care provider as soon as you suspect malaria. Travelers can get malaria even when taking their medicines.
Coming up in May of this year, the Internaional Society of Travel Medicine is having their annual conference. This year’s location is Boston. This is also the time when health care providers sit the exam for their “Certificate in Travel Health“. This is what I am planning to do, in a few more months. I am in the process of preparing for the exam and I thought I would share some of the textbooks I am using. These books are constantly open and I am reviewing information from them on a regular basis.