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Milnet.ca Medic Q&A

mariomike

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Activated said:
I know what I want to be! A Paramedic! I just have problems planning out my future education after high school and if I should join the Army Reserve...

Here is some info:
http://www.torontoems.ca/main-site/careers/becom-medic.html
Don't get any demerit points on your driver's licence!
You may also want to consider becoming a dispatcher. It's clean, inside work with no heavy lifting.
http://www.torontoems.ca/main-site/careers/dispatch-opportunities.html
 
I

IIMedicII

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Ok, im not 100% sure how the East does things, but here in Alberta you are not just a Paramedic
We have three "levels" of training EMR (Emergency Medical Responder), EMT (Emergency Medical Technician), and EMT-P (Emergency Medical Technologist- Paramedic)
Now Im no expert, but personally, Im on my way to hopefully becoming an EMT-P (start my EMT in Sept) but i would say go and take the basic emergency medical course offered.
Reserve MedTech positions are pretty competative nowadays, so having as much "outside" training you can is definitally a boost.
Also, ALOT of people think they want to be in EMS but find as soon as they get into the workplace it isnt for them, so instead of wasting $40,000 on schooling, and commiting to the Forces, only to find your not that into it.  Why not spend $1000 (tops) and see if its really for you...then once finished, toss in an application if you really do enjoy it, and go from there.

PS. And if you aleast have a clue what your doing, it will make fitting in with the rest of the MedTechs alot easier

just my 2cents
 

GDawg

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Is information about diagnosing and treating leishmaniasis shared throughout the CF medical system domestically?

This disease can go undetected for months after you've been back in Canada.
 

Gunner98

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Leishmaniasis is discussed in the CF Health Risk Assessment for Afg:

http://www.forces.gc.ca/health-sante/wn-qn/adv-avi/op-athena-eng.asp

It is also widely discussed in World Health Organization site:

www.who.int/topics/leishmaniasis/en/
 

GDawg

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Frostnipped Elf said:
Leishmaniasis is discussed in the CF Health Risk Assessment for Afg:

http://www.forces.gc.ca/health-sante/wn-qn/adv-avi/op-athena-eng.asp

It is also widely discussed in World Health Organization site:

www.who.int/topics/leishmaniasis/en/

I've seen all that. What I am wondering is if our military doctors, especially the ones working domestically are actually trained to recognize this disease? Are they able to perform tests to determine the exact type and would they have drugs on hand, or have expedient access to drugs to treat this disease? Any idea on what the statistics are on how many soldiers have gotten Leishmaniasis on deployments?

 

PMedMoe

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GDawg said:
I've seen all that. What I am wondering is if our military doctors, especially the ones working domestically are actually trained to recognize this disease? Are they able to perform tests to determine the exact type and would they have drugs on hand, or have expedient access to drugs to treat this disease? Any idea on what the statistics are on how many soldiers have gotten Leishmaniasis on deployments?

I'm thinking the docs are not specifically trained to recognize the disease but it is something they should take into consideration if they know of the member's deployment and/or travel history. 
Tests, I have no idea, that would be the lab. 
Access to treatment drugs?  Yes, not sure about how "expedient" it is but they are available. 
Stats, again, no idea but I wonder how many of the soldiers who have leishmaniasis or malaria, actually treated their uniforms with permethrin pouch and used their DEET 24/7?
 

dangerboy

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When I returned from TF 3-06 I had a growth on my wrist which would not go away, I did not pay to much attention to it until I had a medical where I showed it to the PA. As a couple of members of my Sect had been diagnosed with Leishmaniasis I was booked an appointment, they removed it using something that looked like a "hole punch" and sent the specimen away to be tested. Thankfully the test came back negiative.

This occurred at CFB Shilo, so I think that no mater where you go they can do tests. 
 

GDawg

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I'm asking because I have it, and no one had the slightest clue what it was. I was sent to a dermatologist and its now the problem of the civilian medical authorities.
 

Armymedic

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As a student PA, I can say we had a few slides on recognizing and treating the parasite during that specific portion of the course.

As for the doctors employed by the CF, any military MOs should be aware of it, civilian MDs might not be. But if you were consulted to a dermatologist (see final line below), then I would say your treatment is well under way. It is not an easy thing to recognize nor treat.

For the unwashed, here is the entry for Leishmaniasis in the Current Consult Medicine 2007 edition avail through StatRef!.

Leishmaniasis

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Four clinical syndromes occur
    - Visceral leishmaniasis (kala azar)
    - Cutaneous leishmaniasis
    - Mucocutaneous leishmaniasis (espundia)
    - Diffuse cutaneous leishmaniasis

GENERAL CONSIDERATIONS

• Two species of sand flies transmit infection
    - Phlebotomus (Old World leishmaniasis)
    - Lutzomyia (New World leishmaniasis)
• Transmission
    - Sand flies feed on wild animal reservoir (eg, rodents, marsupials) and domestic dogs and then bite humans
    - Kala azar is transmitted directly from humans to humans
• Leishmaniae life cycles have two distinct forms
    - In mammalian hosts, the parasite is in its amastigote form (Leishman-Donovan bodies, 2-5 μm) in mononuclear phagocytes
    - The sand flies ingest the parasitized cells when they feed on an infected host
    - In the sand fly vector, the parasite converts to, multiplies, and is then transmitted during feeding as a flaggellated extracellular promastigote (10-15 μm)
• There is overlap between the four clinical syndromes, and each syndrome is caused by more than one species
• Leishmania results in lifelong latent infection
• Cutaneous and visceral leishmaniasis have occurred in US military after exposure in Afghanistan and Iraq
• Leishmaniae can become opportunistic pathogens through reactivation or new infection
• In southern Europe, ~5% of people with AIDS have coinfections
• Diffuse cutaneous leishmaniasis
    - State of deficient cell-mediated immunity
    - Causative organisms: L mexicana complex (New World) and L aethiopica(Old World)

DEMOGRAPHICS

• In tropical and temperate zones, ~12 million persons are infected with leishmaniasis
• 1.5-2.0 million new cases occur yearly
• > 1 million are cutaneous and 500,000 visceral disease
• Approximately 50% are in children

CLINICAL FINDINGS

SYMPTOMS AND SIGNS

• Severity of infection ranges from subclinical (self-curing or easily treated cutaneous lesions) to persistent, disfiguring cutaneous and mucocutaneous lesions to potentially fatal visceral disease
• See Leishmaniasis, Visceral (Kala Azar)
• See Leishmaniasis, Cutaneous
• See Leishmaniasis, Mucocutaneous
• Diffuse cutaneous leishmaniasis
    - There are widespread, leprosy-like skin lesions
    - Skin lesions are generally progressive and refractory to treatment
• In patients with AIDS who have coinfection with Leishmania, splenomegaly may not occur in visceral disease

DIAGNOSIS

LABORATORY TESTS

• Definitive diagnosis is established by finding
    - Intracellular nonflagellated amastigote
        ◊ In Giemsa-stained biopsies from skin, mucosa, liver, or lymph nodes
        ◊ From splenic aspirates (most sensitive site, but risky procedure), bone marrow, or lymph nodes
    - Flagellated promastigote in culture of these tissues (requires up to 21 days)
• Occasionally, the organisms are seen in mononuclear cells of buffy coat Giemsa-stained smears
• In patients with AIDS, diagnostic criteria may be altered (Leishmania antibodies become undetectable; splenomegaly may not occur in visceral disease)
• Golden hamster or BALB/c mouse inoculation of the nose, footpad, or tail base may be used (requires 2-12 weeks of observation)
• Polymerase chain reaction has up to 100% specificity and sensitivity
• Species identification is by molecular, isoenzyme, and monoclonal antibody methods
• Serologic tests (ELISA, indirect fluorescent antibody, direct agglutination) and the leishmanin (Montenegro) skin test (not licensed in the United States) may facilitate diagnosis, but none is sensitive or specific enough to be used alone, to speciate, or to distinguish current from past infection

DIAGNOSTIC PROCEDURES

• Skin lesion specimens should be obtained through intact skin (cleansed with 70% alcohol) at a raised edge of an ulcer margin
    - Can use local anesthesia
    - To obtain tissue fluid for staining, press blood out of the site with two fingers, incise a 3-mm slit, and then scrape with the blade
• When doing a biopsy, an impression smear is made, a portion is macerated for culture, and the remainder is reserved for pathologic sections. For needle aspiration, sterile preservative-free saline is inserted with a 23- to 27-gauge needle; the aspirate is then cytospun at 800 × g for 5 min

TREATMENT

• See Leishmaniasis, Visceral (Kala Azar)
• See Leishmaniasis, Cutaneous
• See Leishmaniasis, Mucocutaneous

MEDICATIONS

• The drug of choice is sodium stibogluconate or meglumine antimoniate; resistance and treatment failures are increasing
• Generic sodium stibogluconate is as effective and safe as Pentostam
    - Start with 200-mg Sb test dose followed by 20 mg Sb/kg/d (IV preferable to IM)
• Meglumine antimoniate (85 mg Sb/mL) is equal in efficacy and toxicity in equivalent Sb doses (20 mg Sb/kg/d)
• The drug is given QD
    - 28 days for visceral and mucocutaneous leishmaniasis
    - 20 days for cutaneous leishmaniasis
    - Longer courses are indicated in regions where there is resistance
    - Side effects likely to appear with cumulative doses
• Common side effects
    - Gastrointestinal symptoms
    - Fatigue, fever
    - Myalgia, arthralgia
    - Phlebitis, rash
• Rare side effects
    - Hemolytic anemia
    - Hepatitis, pancreatitis
    - Renal and heart damage
• Therapy is discontinued if the following occur
    - Aminotransferases 3-4 times normal levels
    - Significant arrhythmias
    - Corrected QT intervals > 0.50 s or concave ST segments
• Relapses should be treated at the same dose for at least twice the previous duration
• In the United States, only stibogluconate is available (obtain from the Parasitic Drug Service, Centers for Disease Control and Prevention, Atlanta, GA 30333 404-639-3670)
• Second-line drugs are amphotericin B and pentamidine

Amphotericin B

• Visceral leishmaniasis
    - AmBisome 3 mg/kg/d (parenteral) on days 1-5, 14, and 21; may be repeated
    - Dosage for immunoincompetent persons is 4 mg/kg/d on days 1-5, 10, 17, 24, 31, and 38
    - There may be comparable effectiveness with cumulative doses of 3.75 or 7.5 mg/kg, given in five divided doses, over 5 days
• Conventional amphotericin B deoxycholate 1 mg/kg daily by slow infusion (4-6 hours) for 20 days (used in India)

Pentamidine isethionate

• Pentamidine isethionate, 2-4 mg/kg IM (preferable) or IV, QD or QOD (15 doses for visceral and 4 doses for cutaneous leishmaniasis)
• For some forms of visceral leishmaniasis, repeat treatment may be necessary using up to twice the dose, but resistance may persist

Paromomycin (aminosidine)

• Cutaneous leishmaniasis: topical application in various formulations has variable success that differs by region
• One ointment is paromomycin 15%/methylbenzethonium chloride 12% in soft paraffin, applied BID for 15 days; skin reactions may occur. The ointment cannot be used in regions of mucocutaneous leishmaniasis as it does not prevent metastatic disease
• For refractory visceral leishmaniasis, parenteral paromomycin is promising, but may cause renal or otic toxicity

Miltefosine

• Oral drug; approved in India for treatment of visceral leishmaniasis
• Daily dose is 2.5 mg/kg in two divided doses for 4 weeks (95% cure rates)
• Promising efficacy for cutaneous leishmaniasis
• Side effects: vomiting (40%), diarrhea (20%), occasional transient elevations of aminotransferases and creatinine
• It cannot be used in pregnancy due to teratogenic potential

OUTCOME

FOLLOW-UP

• Patients should be monitored weekly for the first 3 weeks and twice weekly thereafter by serum chemistries, complete blood cell counts, and electrocardiography

PREVENTION

• Sand fly habitats are warm, humid, dark microclimates, including rodent burrows, rock piles, or tree holes; these are often in sylvatic areas near forests or semiarid ecosystems
• Peridomestic sand flies are found on debris close to buildings
• Biting is generally at twilight or at night but may occur in shaded areas during the day
• Partial protection is from permethrin applied to clothing, DEET repellent, avoidance of endemic areas (especially at night), use of mosquito coils, and use of fine-mesh insecticide-impregnated nets for sleeping (may be too warm for tropical use)

WHEN TO REFER

• All patients should be referred to a clinician with expertise in this disease
 

GDawg

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SFB, well done to you! I am glad its covered in CF medical training.

I've got Miltefosine from Germany, not cheap, the CF would do better to buy it straight from the Red Crescent in theatre  ;D

We'll see how she goes, I still need to get the blood work done for monitoring purposes.

It would be a shame if someone out there slipped through the cracks and had their Leishmania go visceral. My perspective is a bit jaded but the system needs to warn those returning from deployment to be vigilant for these sorts of problems because they can pop up months, even years after you're home.

 

Armymedic

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GDawg said:
My perspective is a bit jaded but the system needs to warn those returning from deployment to be vigilant for these sorts of problems because they can pop up months, even years after you're home.

Sorry I can't resist this slam:

They do warn, but only the ones who actually remain awake for the entire PMed predeployment briefing actually hear it.
 

GDawg

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I vaguely recall pre-deployment medical briefs, and I do not recall a post deployment medical brief...
 

bang

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Four quick questions:

1)  You are a reservist with a Tcat.  Does it expire on its own?

(Unrelated with the first)

2)  In the civilian system, if you are given a diagnoses or have been treated in a mediocre or poor fashion that makes you uncomfortable with the doctor, you can switch to a different doctor.  In the regular force or when you are on class C, are you entitled to a different MO or NCM as designated by a senior MO?

If so... 
Did I miss it on the QR&Os or DAODs

Or is it on the a unsuperseeded CFAO, which would not be online for the short term?

Thanks
 

PMedMoe

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1)  No.  TCats do not "expire" on their own.  You must see a doctor again and be declared fit, usually by having a full medical.

2)  Yes, you do have the option to see another doctor but be prepared to wait and possibly to explain why you want a different MO.  I'm more curious about the wording of your query.  Was the doctor unprofessional?  If so, there are means to report them.  Or did you get a diagnosis you don't agree with?
 

Gunner98

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CFHS Patient's Rights and Responsibilities

As a patient, you can expect to:
• Be treated with respect at all times
• Have the privacy of your health information respected
• Be involved in decisions about your care and treatment
• Include you family members in decisions about your care where appropriate
• Be fully informed about all aspects of your care
• See a physician, should you desire
• Know who is providing you with care
• Request a second opinion, should you desire
• Have your religious and cultural beliefs respected
• Be treated in the official language of your choice
• Have access to your health records
• Have a second medical staff member, of your gender, present during an examination or treatment, where appropriate.

As your care providers, we expect you to:
• Communicate openly and honestly with your health care providers about your health concerns
• Raise any concerns about care with your health care providers
• Participate actively in decisions about your care
• Carry out treatment recommendations
• Attend all scheduled appointments
• Treat your health care providers with respect
• Inform your direct supervisor of your medical employment limitations
• Utilize CF medical facilities whenever possible
• Inform CF medical authorities of any medical care received outside CF facilities

CFP 154 Chapter 3 http://www.forces.gc.ca/health-sante/pd/cfp-pfc-154/CH-3-eng.asp

Temporary Grading
9. Occasionally, it becomes necessary to temporarily lower one or more factors of the medical category. The validity of such temporary reductions shall not exceed six (6) months, but a temporary category may be renewed once (i.e., maximum 12 months temporary medical category status). This time frame should allow an accurate estimate/assessment of prognosis for almost any medical condition. As soon as the member's condition is stable or is not expected to significantly improve in the foreseeable future, a permanent category should be assigned, even before the end of the 12-month period of temporary category. A statement regarding prognosis shall be made in Section 3 of the CF 2033 and Section 2 of the CF 2088 at the earliest reasonable time. In the rare case where additional temporary status beyond 12 months may be warranted for extenuating circumstances, the case must be reviewed by D Med Pol Standards.


 

bang

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Thanks, that was educational. 

Number two does not involve me, so I will keep that one down.  Thanks especially for the sources.

Correction - however I was wondering if there was an online source for the rights and responsibilities that would make it the word of law?  If not, is there something that makes this the word of law at all?

Thanks again


Bang
 

mariomike

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If you enjoy Paramedic Q and A's, here is something from my old "Dr God" aka Base Hospital. It is civvy, but may be relevant to the CF.
http://socpc.ca/paramedic_resource_manual.html
 

Gunner98

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Bang said:
Correction - however I was wondering if there was an online source for the rights and responsibilities that would make it the word of law?  If not, is there something that makes this the word of law at all?

Thanks again

Bang

This is an excerpt from a CFHS glossy policy handout available at every clinic in the CF.  One online Internet source for this document is at CF Health Services Centre Ottawa: www.forces.gc.ca/health-sante/cfhsco.../con-eng-eng.asp
 

PMedMoe

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Try this one:

Patients Right to Privacy Protection and Choice of Physician

Right to Choice of Physician

7. Patients should be advised that they have a choice of physician, within the available resources at the unit or the base, and that choice is to be respected whenever feasible.

Emphasis mine.  For example, if you were in Alert, where there is no MO, only a PA, you obviously wouldn't have a choice.

 
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