Microbiology in a Combat Support Hospital

Microbiology in a Combat
Support Hospital - Tikrit, Iraq
CPT Frank Erfurth, PhD
United States Army Medical Service Corp
Dwight D. Eisenhower Army Medical Center
Fort Gordon, GA
Overview
•Environment
•Microbiology in Theater
•My Lab
•Lessons Learned
21st Combat Support Hospital
Deployed as the General Lab Officer
COB Speicher, Tikrit Iraq
January 2010 – December 2010
COB Speicher, formerly Sahra Airfield
Northwest of the City
TIKRIT
Northern point of the “Sunni Triangle”
Still functioning Tikrit Teaching Hospital
Tikrit, Iraq
• Outside of a small zone around the Tigris
River, mostly sand*
• 4 months >100°F
MAY
97°F
JUN
106°F
JUL
111°F
AUG
111°F
SEP
102°F
• 2010 had two weeks in August with
temperatures spiking near 130°F daily
OCT
90°F
Sand Storm
Levels of Army Medical Care
• LEVEL I
Front Line Medics
• LEVEL II
FST Teams
• LEVEL III
CSH
• LEVEL IV
Medical Care Outside the Combat Zone
• LEVEL V
Army MedCen
Levels of Army Medical Care
• LEVEL I
Front Line Medics
• LEVEL II
FST Teams
• LEVEL III+
CSH
• LEVEL IV
Medical Care Outside the Combat Zone
• LEVEL V
Army MedCen
Deployed as GLO 21st CSH
• Deployed as a General Lab Officer with Specialization
in Microbiology
• CSH Laboratories includes Blood Bank, Hematology,
Chemistry, Urinalysis, Special Chemistry and
Microbiology in 3 ISOs
• Coulter, Piccolos, ISTATs, Vitros, Autoscan, BacT,
Incubator, 2 Microscopes, Basic LF Hood,
3 Centrifuges, Plasma Thawer, Freezers and
Refrigerators
• Treat Soldiers, Contractors, Third Country Nationals,
Iraqi Civilians
Deployed as GLO 21st CSH
• Deployed as a General Lab Officer with Specialization
in Microbiology
• CSH Laboratories includes Blood Bank, Hematology,
Chemistry, Urinalysis, Special Chemistry and
Microbiology in 3 ISOs
• Coulter, Piccolos, ISTATs, Vitros, Autoscan, BacT,
Incubator, 2 Microscopes, Basic LF Hood,
2 Centrifuges, Plasma Thawer, Freezers and
Refrigerators
• Treat Soldiers, Contractors, Third Country Nationals,
Iraqi Police and Civilians
Chemistry ISO
Micro ISO
January 15, 2010 – December 21, 2010
•21845 Individual
Laboratory Tests
•Only a little over 600
Micro Tests
Lessons Learned
Lessons Learned
• Improvisation is an important tool for any
scientist in an austere environment
Leishmaniasis
• Endemic to any river adjacent area in
Iraq
• Samples to Walter Reed Army Institute
of Research
• Saw 0 cases contracted in Tikrit in 2010
• Tested four wounds which were
recurring rashes irritated by scratching
Malaria
• Endemic to the region
• Saw only two cases of Malaria
in one year (both imported)
Malaria
A. The BinaxNow Rapid Malaria Assay reporting 3 lines: positive control, T1 and T2, indicating an
infection with Plasmodium Falciparum alone or mixed with other Plasmodium species. B. A
trophozoite in a erythrocyte. C. A trophozoite in an acanthocyte (spiculated RBC). D. Two cells with
trophocytes and a gametocyte.
Lessons Learned
• Improvisation is an important tool for any
scientist in an austere environment
• Just because you are looking for it doesn’t
mean you will find it
Bacterial Resistance
• Itinerant population
– Soldiers who are coming and going on
missions
– Contactors whose health problems may
send them back to their home countries
– Locals who may or may not be allowed to
return for additional medical attention
• Unconventional use of antibiotics
CSH Relocation
• Moved 2 miles up the road
• OR, EMT & ICU moved from hard
stand buildings (brick and wood) into
temper (tents)
• First two cases in OR micro found
pseudomonas and acinetobacter
Dehydration
• The majority of Micro testing was from urine
samples (371)
• Urine culture was a reflexed test in the chain:
– Urinalysis (cloudy, blood, leukocytes)
– Microscopic (bacteria 1+, RBC 1+, WBC)
– Urine Culture
• Test strip specific gravity (correlated with
refractometer data) > 1.030 in 76 of urine
cultures
Lessons Learned
• Improvisation is an important tool for any
scientist in an austere environment
• Just because you are looking for it doesn’t
mean you will find it
• Microbiology is IMPORTANT
Identification Without Alcohol
• Siemens Autoscan VP requires
alcohol reconstitution of reagent
• In Lieu of reagent ran testing without
VP well and looked at results (pos &
neg) and correlated with colony
morphology and clinical
manifestation
Identification of No Bacteria
• Refrigeration temperature
easy to maintain
• Subzero not difficult
• Room temperature most
difficult
Identification of No Bacteria
• Found that growth well Pos, all
other wells Neg = acinetobacter
• Colony morphology and growth
identical to very slow growing,
susceptible enterobactericeae
species
Lessons Learned
• Improvisation is an important tool for any
scientist
• Just because you are looking for it doesn’t
mean you will find it
• Microbiology is IMPORTANT
• Overreliance on equipment can be
problematic
21st CSH Laboratory Team
Thank You