Gents,
I have no dog in this fight so I'm staying out of it, but I'm LEARNING a great deal.

I'm unfamiliar with the AO so that is one reason I've stayed out of this, but one thing did initially pop in my head when Pt. #1 presented and then #2 and #3 showed up, as Brush as asked/pointed out, what are the different mold(s) that you deal with there?

I know this is probably not along the lines that Trapper is going, but could the mold(s), if any present, help facilitate the S&S seen?

OK, so we have an early stage bacterial meningitis outbreak and this is going to escalate rapidly. Immediately start Antibiotic therapy. Two most likely causative pathogens - N. meningitidis (Gram neg) and S. pneumoniae (Gram pos). S. pneumoniae is most common in young adults. Rx: 3rd generation cephalosporin (Ceftriaxone or Cefotaxime 2g IV bid). Because of the high probability of S. pneumoniae as the causative agent and S. pneumoniae can be beta-lactamase producers, Vancomycin is indicated (20 mg/kg IV bid).

As I posted earlier-

Just for fun let's say the NG unit is a Company size unit at this remote FOB. Let's also assume the AO is hot and Medevac may be days away. Intel reports a large Taliban force is on the move towards the FOB. You may be able to get a resupply dropped in, but the window for that is closing fast. You need to quickly assess the medical situation and request any resupply that you might need within the hour.

So, What supplies do you request? (A personal supply of Dexedrine might not be a bad idea 'cause you are not going to get much sleep for a while :D)
Do you consider prophylactic antibiotics for everyone?
What is the longer term containment/treatment plan?
What procedures do you implement to get ahead of this outbreak?
What are the recommendations to the Team Sergeant/Team Leader.
What do you recommend to the NG CO?
What effect can this medical emergency have on the tactical situation?

FWIW, I apologize if I threw anyone by not pointing out that the headache was more prominent in cases 2 & 3! I should have been a little more clear in discussing the differences between the first case and the later cases.

What about 1Gm rocephin IM bid, sucks but less exposure and more mobile force. But vanc is only good po for cdiff so they need the IV anyway. Or maybe Subq? You can leave a Subq button in for days. Connect and disconnect easily. Just an idea.

Good ideas, but you have 3 different groups to deal with: (1) 3 patients with active disease. No question these 3 need IV Rocephin and Vancomycin; (2) an exposed population and lets say that is the 20-30 guys that slept in crowded quarters when the AC was out; and (3) the rest of the NG company that are possible exposures. Brush Okie mentioned decontamination procedures. What about quarantine proceedures: Who? How? I agree with the reticence for prophylactic antibiotics, but in this case it would be warranted. Who should receive prophylactic antibiotics? What? Dosage and dosing regimen?

The tactical situation has dramatically changed now. The NG company has just, in effect, sustained 20%-30% casualties and is no longer an effective combat ready unit. The likelihood of a major engagement with an equivalent sized enemy force is imminent. The NG CO is not going to like this assessment. He may be in denial when you inform him of this ugly fact. How do respond to that possibility?

Up to now your Team has just been co-located at the FOB with the NG company. Does this situation change that dynamic? Remember your an Special Forces A-Team. How can your Team change the dynamic and avert a pending disaster?

No one has mentioned the Junior medic on the Team. What should he be doing?

I realize that this is a medical thread and this started out as a medical scenario, but the situations we face as SF medics and the problems we have to solve when on an operational mission rarely, if ever, compartmentalize into problems that are solely medical in nature.

No one has mentioned anything related to stockpiling medical supplies that would be useful when there are combat casualties. Your supplies were sufficient for your Team. That is no longer the situation is it?

Well sure as sugar you have been exposed. If the jr or sr is the other medic, you segregate him and the team members not exposed. Get them off the base. They can conduct patrols in relation to finding and trying to fix this Taliban element before it attacks the compound and you're fighting with a sick NG company.

Quarantine the 30 exposed in the tight element and treat with IV Gorillacilli (I took cefoxitan with me on all my deployments but only like 25 viles, that's enough for combat wounds but would only last for about 8 hours with this problem. Make sure you have your mannitol handy (unless there is something better now). Separate the platoons and have platoon medics monitor closely. No contact between platoons. Emphasize the importance of this platoon quarantine. Put the quarantine guys back in the building and make this your home for the next week. The rest of the NG guys go on the perimeter and/or local patrols.

No way you're going to treat an entire 120 man inf company (plus SF team with ANA) prophylacticly. There won't be enough drugs in country but I would order them up just in case. Order up a doctor and/or pa and the med sustainment officer ( I think those guys do PM and infectious disease stuff). Order up PPE masks for everyone in the camp. You might look gay but you'll be able to fight when the time comes.

You've done this before haven't ya? :lifter

IMO this is the most important thing to do given the situation.

This is priority action #2 IMO.

That's #3.

And that's #4

Ladies and gentlemen you have just had a short tutorial on combat medicine SF style. What, XSFmedic, Ender18d, and Miclo18d have shown you are couple of key points that are emphasized in our training. (1) Limit your Hx and PE to a few key points (3-4). I had this Dx with Patient #1. (2) Speed is your friend - Act -don't second guess yourself. (3) Work with what you have, improvise if necessary. (4) SA is essential. Medical emergencies in a combat environment require decisions that take into account the tactical situation. Plan accordingly.

The actions implemented by Miclo18d would have averted a much a larger disaster IMO. It is very likely that the increased patrolling and your Team out of the FOB would have located the Taliban and dissuaded them from their present intention.

So, this raises another question in my mind. Does anyone think that the pending attack on the FOB and the emergence of bacterial meningitis in NG troops was a coincidence? With that question in mind, what would be some things that you would consider in the AAR?

I don't mean to extend this thread beyond it's usefulness in this forum, but that question just occurred to me as this scenario unfolded and I thought it might be an interesting discussion topic.

Something to consider, especially for the line medics, is that my plan is really about common sense if you know what you're dealing with. How do you know what you're dealing with? You start with medical intelligence. You do IPB on illnesses in your AOR just like you would for enemy forces. What diseases are prevelant? What is your biggest threat to your smallest based on occurrence and danger (malaria, TB, TYPH, cholera, leishmaniasis, EEE, mgc, etc. what are S/Sx for each? Prophylaxis? Tx? Preventive Med for each or for all.

The first thing the 18Ds did when we got to a base, especially early on (02-03) was the PM plan for the base. Piss tubes, shit burning details, potable water sources, other water sources, showers, hygiene areas, food areas, etc. we had a platoon plus of 82d on the base with us and Afghan militia (before the ANA). They all had to know the PM plan. My second tour PM was much more established on many of the big bases but was still important. History has always been: more soldiers die from disease than combat. We are always 1 step out from that postulate! This scenario helps drive the point home.

Interestingly enough, I saw some afghans with TB and lots with leish. For US troops it was diarrhea and oddly enough on my team I had 2 cases of appendicitis within a month of each other. I always wondered if there is a slight chance of an endemic element to that. I'm sure lowered immune systems and strange diets and other things like that were causative, but 2 cases a month apart was like, scary!

Back to the scenario. Keep your plan simple. As Doc Illinois pointed out, MGC doesn't spread like Ebola, so your quarantine can be limited and simple, but use the PPE. We have a case here in my county in FL where an elementary aged kid died in 24 hours and they had his daycare closed for 1 day.

The plt segregation was so that you can monitor the platoons and if you see cases pop up you have limited the exposure to the other platoons. My general thought was that the platoons would be on the perimeter and you keep them there until the threat is reduced (enemy AND illness). Think 33-50% security in Ranger school. You have basically triaged the entire camp to expectant (probably exposed) to routine (unlikely exposed).

The team off the base keeps their exposure down and they're more likely to whip the living tar out of the enemy force than a battalion of NG (no offense meant here, just being realistic). SF teams roll with CCT, just a fact of life here.

In my other post I did forget to order up supportive care measures in case any of your exposed guys go south on you. You're going to need some ACLS stuff just in case.

I'll step back and let some others throw in some pointers.

That was a very interesting "case study". Very thought provoking. Thanks for the lesson.

NCIS Episode on Tue. 12/17
 

Anyone catch the last episode of NCIS on Tuesday 12/17? If not and you have cable that allows you to watch previous episodes, it would be interesting to watch in light of this thread.

See if you can pick up any medical discrepancies. Hint: Look for the slide showing the presumptive causative bacterium, later look for the picture of the rash, both of which were in the background while Gibbs and the team were discussing this outbreak. Then listen for the CDCs diagnosis towards the end of the episode.