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A: Dr. Tucker: There are currently five active duty allergists (three on East coast and two on West coast) covering three regions in the U.S. I am the specialty leader for Navy allergy at this time. We also have one second year fellow and two first year fellows in training. Currently we have two allergists who had trained through the Army at Walter Reed and one through the Air Force at Wilford Hall. The remaining two Navy allergists had done civilian fellowship programs. Q: What is a typical day like for you? A: Dr. Tucker: At this time, there are two Navy allergists on deployment in Afghanistan--myself and Dr. Kaplan. A third Navy allergist is set to join us in Afghanistan in the coming weeks. We are all being deployed as general medical officers. This means that we see any medical ailment that may come through the medical tent. This could be upper respiratory infections, backaches, ankle sprains, lacerations, depression or unknown rashes. We also come across some unusual cases. I have seen people with situs inversus, cardiomyopathy, seizures, peripheral neuropathies, knife wounds and gun shot wounds. The other portion of my day involves teaching the corpsmen (Navy medical techs) in triage, mass casualty situations, physical examination and sickcall screening skills. Dr. Kaplan: I would add vaccine administration - by the time I am done here we will have administered over 2000 vaccines (H1N1/Seasonal flu/Anthrax and typhoid). Q: How has your allergy/immunology training helped you to be prepared to practice in a foreign combat setting? A: Dr. Tucker: I believe that any training one has is beneficial training. My allergy/immunology training has come in handy on occasion. The first two patients I saw out here were previously undiagnosed asthma and seasonal allergic rhinitis. I was surprised how much irritant induced bronchospasm I was seeing when we first arrived. There are a lot of people with history of mild intermittent asthma as teenagers who have been totally asymptomatic while in the military, but started to have respiratory symptoms shortly after arriving. They responded to SABAs or in some cases to ICS/LABA combinations. I attribute a lot of their symptoms on the fine dust that seems is a constant hazard out here. We have also seen plenty of urticaria, eczema and other rashes. My most interesting allergy case thus far is a 23 year old female who has had three episodes of anaphylaxis with running within three hours of eating (otherwise no issues with exercise). I suspect food associated exercise-induced anaphylaxis. I even performed a treadmill challenge 90 minutes after eating the suspected food, but she had no symptoms. A: Dr. Kaplan: Patch testing with the TRUE TEST would be very easy to do and if I was planning on staying here long term I would consider ordering the kits. They do need to be kept cold - I do patch testing routinely at Bethesda - several patients per month. Plus, it's easy to teach to Family physicians and other primary care providers. With a little practice, interpretation is not very difficult. I have seen several cases of eczema, which is a problem out here given the inability to adequately "soak and seal". In addition, to the Army AID station where I work as the sole practitioner, there is another AID station here at Leatherneck with primary care doctors who have been caring for the Marines. These other physicians have been referring to me allergy/immunology cases. One particularly memorable case was a 19 year old female Marine with eight episodes of urticaria/ angioedema who will likely be following up with Dr. Tucker later this spring when she returns to the West Coast. Additionally, I have been serving as a consultant at the Role III hospital at Camp Bastion for inpatients with allergy/immunology issues. Here I have had the opportunity to help provide care for the European patients with allergic diseases. Several years ago, there was an article published in the Journal of the American Medical Association (JAMA) by our Army colleagues about acute eosinophilic pneumonia (AEP) occurring frequently in new tobacco users in Iraq. They suspected that dust in the air in conjunction with smoking were important risk factors for the development of AEP. There has been one case over here at Camp Leatherneck that I am aware of, and I am cautiously looking out for other cases as the chance for sandstorms increase this spring and early summer. Q: What special needs does practicing in this setting present, compared to practicing at a base in the US? A: Dr. Tucker: In an allergy sense, we are extremely limited. I have no standardized way of testing individuals to common allergens. I have no patch testing capability at this time. I have no data on local allergens (there are very few Afghanistan physicians and I very much doubt that there is anyone with training in allergy outside the military allergist currently deployed here). I have no spirometry. Q: Are you seeing Hymenoptera anaphylaxis and what happens if someone experiences anaphylaxis? Rush Immunotherapy? A: Dr. Tucker: There is a native large black ant that is seen in the summer and fall, but is not to be found in the winter. I have not had any unexplained anaphylaxis which would make we weary of hymenoptera anaphylaxis. I have also not seen any flying hymenoptera. Dr. Kaplan: I have only seen flies and one little spider (which is now dead). No hymenoptera here in the desert of Helmand Province--perhaps in other parts of Afghanistan where the vegetation is different. Mosquitoes will be prevalent in the spring and summer - I am expecting to see patients with large local reactions presenting complaining of an "allergic reaction" to mosquitoes. Q: What causes of allergic contact dermatitis are you identifying? A: Dr. Tucker: The most common allergic or irritant contact dermatitis that I have seen is to jet fuel or other greases/petroleum products that are used on vehicles or aircraft. I have had one person who seemed to be having a contact reaction to her uniform and another to her bra. Q: Have you seen any unusual food allergies because of the diet differences? A: Dr. Tucker: The majority of the military personnel eat at either American or British chow halls that serve typical dishes of that country. Thus, we are not seeing any unusual food allergies. Q: Have you had a chance to meet any native practicing allergists? If yes, are there differences in practicing? A: Dr. Tucker: It is rare to find a trained Afghanistan physician much less a practicing allergist. We are also assigned specifically to this base and thus do not travel abroad. <back>
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