Archive for February, 2011
Soldier of the Year 2011
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Sailors’ ship deploys to fight pirates
Long Co. men on aircraft carrier during hijackers’ capture
Mike Riddle
Coastal Courier correspondent
riddle4news@yahoo.com
February 25, 2011
x3Cpx3ETwo former Long County High School students, Trevor Ribal and Eric Boyd, were on board the USS Enterprise aircraft carrier earlier this week when the U.S. military took down a group of Somali pirates who hijacked a yacht and killed four Americans. The 15 captured pirates and the bodies of the Americans are headed to the United States on the USS Enterprise, ABCnews.com reported.x3Cbr /x3EAccording to Associated Press reports, the Somali pirates hijacked the S/V Quest, a privately owned vessel, last Friday and took the four Americans onboard hostage. The four were identified as Jean and Scott Adam of California, who owned the yacht, and Phyllis Macay and Bob Riggle, who were from Seattle. The Adams had been sailing around the world on their boat since 2004. x3Cbr /x3EAfter the yacht was taken over by hijackers, four Navy ships, including the Enterprise, were sent to the S/V Questx26rsquox3Bs location off the coast of east Africa to monitor the piratesx26rsquox3B actions. Reports indicate that on Tuesday, shots were heard coming from the Quest followed by the pirates firing a rocketx2Dpropelled grenade at one of the ships tailing it, the USS Sterett. The shot missed the ship and Navy seamen overtook the Quest, killing two pirates and taking 15 into custody. Two other pirates were found dead on the yacht, but their cause of death has not been determined.x3Cbr /x3EKelly Clary, Trevor Ribalx26rsquox3Bs mother, talked about the dangers faced by her son and fellow seaman Boyd.x3Cbr /x3Ex26ldquox3BThey are performing a mission that us as citizens need not know. We just need to remember that the military is a very important part of our safety in this world. Ix26rsquox3Bm glad that they were where they could help in this current situation,x26rdquox3B Clary said.x3Cbr /x3EThe proud mom also said shex26rsquox3Bs happy her son chose to serve the nation. x26ldquox3BI love that hex26rsquox3Bs involved in keeping this country safe for usx3B these days you never know what can happen,x26rdquox3B she said.x3Cbr /x3EClary acknowledges that military assignments can be dangerous, but she knows deployed men and women are wellx2Dtrained.x3Cbr /x3Ex26ldquox3BThese sailors are well aware of the risks in other parts of the world. They are trained to deal with those risks and keep themselves and us safe back home,x26rdquox3B she said. x26ldquox3BSometimes things happen that are out of anyonex26rsquox3Bs control. I send wishes of safety and support to my sailors on the USS Enterprise.x26rdquox3Bx3Cbr /x3ERibal is an electronics technician and Boyd is an operations specialistx3B both men hold the rank of petty officer 3. Boyd graduated from LCHS in 2004 and Ribal graduated in 2006. As crew members on the USS Enterprisex26rsquox3Bs 21st mission, the two have been to Turkey and Portugal during the shipx26rsquox3Bs deployment to the Mediterranean Sea.x3C/px3Ex0Dx0Ax3Cpx3Ex26nbspx3Bx3C/px3E
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Two former Long County High School students, Trevor Ribal and Eric Boyd, were on board the USS Enterprise aircraft carrier earlier this week when the U.S. military took down a group of Somali pirates who hijacked a yacht and killed four Americans. The 15 captured pirates and the bodies of the Americans are headed to the United States on the USS Enterprise, ABCnews.com reported.
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General issues apology
Admits soldier’s escape was result of ‘incorrect transport’
Denise Etheridge
detheridge@coastalcourier.com
912x2D876x2D0156
February 25, 2011
x3Cpx3E3rd Infantry Division deputy commander Brig. Gen. Jeffrey Phillips released the following apologetic statement Wednesday evening, following media inquiries into how alleged rapist Pvt. Daniel Brazelton managed to escape military custody.x3Cbr /x3EBrazelton, 20, of the 3rd Battalion, 15th Infantry Regiment, was apprehended Feb. 18 by the Daytona Beach Police Department in Holly Hill, Fla., according to a news release from Fort Stewart public affairs. Brazelton is wanted for the alleged sexual assault of a 15x2Dyearx2Dold Los Angeles County girl.x3Cbr /x3EBrazeltonx26rsquox3Bs escape Feb. 11 from a van on Airport Road prompted a nationwide manhunt. The soldier reportedly exited the van and ran to a treeline while he was being returned to the Liberty County jail following a medical appointment for an unnamed condition on Fort Stewart.x3Cbr /x3Ex26ldquox3BAs the acting senior commander at Fort Stewart, I apologize to the community and to the alleged victim for Pvt. Daniel Brazeltonx26rsquox3Bs escape from military custody,x26rdquox3B Phillips said in a news release. x26ldquox3BAll aspects of Pvt. Brazeltonx26rsquox3Bs escape, including any potential assistance he may have received, will be thoroughly explored by a U.S. Army Criminal Investigation Command independent investigation now underway. Because of that investigation, many details cannot be shared at this time. CID has been actively involved since this case began, immediately launching its investigation, together with local and federal agencies, to find and apprehend Pvt. Brazelton.x3Cbr /x3Ex26ldquox3BFort Stewartx2DHunter Army Airfield has a policy dictating how soldiers in custody are transported,x26rdquox3B the general continued. x26ldquox3BWe are determining the quality of that policyx26rsquox3Bs implementation in this case. So far, we have identified some deficiencies, which we are correcting. We have clarified with local law enforcement agencies that all future prisoner transport requests will be coordinated through our law enforcement officials and will only involve military police in the actual transport. In the case of Pvt. Brazelton, he was incorrectly transported by soldiers from his unit without coordination through appropriate military police authorities.x26nbspx3B x3Cbr /x3Ex26ldquox3BI reiterate how sorry we are to the community and the alleged victim who has suffered so much,x26rdquox3B Phillips said. x26ldquox3BWe will do everything possible to prevent such avoidable incidents in the future.x26rdquox3Bx3Cbr /x3EIn an anonymous ex2Dmail sent Wednesday to the Courier, a tipster claimed Brazelton was in the company of a soldier or exx2Dsoldier. This information could not be confirmed.x3Cbr /x3Ex26ldquox3BAs for the status of a soldier (AWOL, deserter, active duty, etc.) CID would not be the appropriate agency to provide information on that question,x26rdquox3B CID spokesman Chris Grey said in an ex2Dmail Wednesday. x26ldquox3BAs for your remaining questions, we have an ongoing investigation and to protect the integrity of that investigation, we are not releasing any details of the case at this time.x26rdquox3Bx3Cbr /x3ESgt. Brian Hudson with the Los Angeles County Sheriffx26rsquox3Bs Departmentx26rsquox3Bs Special Victims Bureau said in a phone interview Wednesday he knew nothing about a second soldier.x3Cbr /x3EHudson said Brazelton still is being held at the Volusia County, Fla., jail awaiting extradition to California. The LA detective said LACSD officers will fly to Florida to accompany Brazelton back to California. Any questions about the soldierx26rsquox3Bs escape would have to be referred to the Army, he said.x3C/px3E
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Denise Etheridge
3rd Infantry Division deputy commander Brig. Gen. Jeffrey Phillips released the following apologetic statement Wednesday evening, following media inquiries into how alleged rapist Pvt. Daniel Brazelton managed to escape military custody.
Brazelton, 20, of the 3rd Battalion, 15th Infantry Regiment, was apprehended Feb. 18 by the Daytona Beach Police Department in Holly Hill, Fla., according to a news release from Fort Stewart public affairs. Brazelton is wanted for the alleged sexual assault of a 15-year-old Los Angeles County girl.
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Article source: http://beta.coastalcourier.com/section/35/article/29231/
Diagnosis/Definition
Neuromusculoskeletal conditions relating to the spine and/or its immediate adjacent articulations including:
- Spinal articulations and attachments
- Sacroiliac joints
- Rib attachments to spine and sternum
- Clavicles
- Scapulae
- Temporomandibular joints
Initial Diagnosis and Management
When the PCM believes that x-rays or another diagnostic tool would be helpful in visualizing an injured area, he/she should order these studies so they will be available at the time of consultation. If ordering spinal x-rays, please specify that they should be taken weight bearing.
Ongoing Management and Objectives
- To evaluate patients with acute or chronic spinal injuries primarily to the axial skeleton, adjacent articulations and intrinsic support elements.
- To assist these patients in attaining and sustaining maximum recovery by employing standard, conservative, spinal manipulation techniques.
- To employ various in-clinic adjunctive therapies to support and enhance the results of spinal manipulation.
- To educate patients in techniques to maintain improvement and prevent reinjury. These include visual, verbal, written and demonstration-performance techniques.
- To refer patients to other health specialties for laboratory, radiographic studies, education, consultation, or evaluation as necessary.
Indications for Specialty Care Referral
Note: Only active duty service members can be seen at this time. NO EXCEPTIONS. (Service members arriving from or departing for a combat zone have priority. We may not treat individuals seeking maintenance or wellness levels of care, (i.e., one visit per month, etc.) or chiropractic therapy to sustain a recovery. The patient must be willing to work as a team with the chiropractor to maximize recovery potential; this includes keeping established appointments.)
Conditions that can benefit from chiropractic treatment:
o Myofascial pain
o Neck pain, stiffness or spasms
o Back pain, stiffness or spasms
o Tension headaches
o Sciatica
o General joint stiffness due to DDD/DJD
o Spinal sprain/strain injuries
o Bulging disks (no prolapse)
Conditions considered cautionary for spinal manipulation:
o Severe calcification of carotid or vertebral arteries
o Bone weakening conditions (osteoporosis, osteopenia, and osteomalacia)
o Severe encroachment of the neural foramina (congenital/degenerative)
o Recent fracture (within the last six weeks)
o Cancer
o Infection
o Any rapidly progressing neurological deficit
o Certain rheumatologic/connective tissue disorders (e.g., RA, Ehlers Danlos)
- Cautionary conditions are evaluated on a case-by-case basis. A patient may have one of the conditions, such as carotid calcification, but could still be a candidate for mid or low back adjustment. Similarly, someone with severe osteoporosis could benefit from low force pressure point techniques.
- If you are uncertain as to whether a patient in the cautionary category would benefit from a course of chiropractic treatment, contact the chiropractic clinic 435-5617.
- Recent (acute) injuries, defined as having occurred within the prior six weeks.
- Chronic conditions, defined as neuromusculoskeletal injuries over six weeks old, and the patient has not been previously seen at this chiropractic center for the condition.
- Chronic conditions seen previously at this chiropractic center that have, in the medical opinion of the PCM, been significantly reaggravated in a new episode, not simply worsening from a withdrawal of chiropractic treatment.
- The chiropractic clinic is not an emergent care center; emergency cases should be referred to the Emergency Room or other appropriate immediate or urgent care clinic.
- Submit all consultations as “routine” but in one of the following two categories: Acute or Chronic
- Please do not make simultaneous referrals to physical therapy and the chiropractic clinic for the same condition; instead, refer to the clinic you believe most appropriate.
Criteria for Return to Primary Care
Patients who either did not respond or were discharged as having reached maximum recovery.
Diagnosis/Definition
- A tympanic membrane perforation represents a hole in the eardrum establishing a communication between the middle and external ear.
- There are two general types, which are distinguished by the area of the eardrum involved. A central perforation (most common) can involve any portion of the drum as long as a portion of the tympanic membrane surrounds the hole. A marginal perforation involves the edge of the eardrum (tympanic annulus).
- A tympanic membrane perforation must be distinguished from a retraction pocket, which is typically an involution of a portion of the intact tympanic membrane and can be a harbinger of cholesteatoma.
- Treatment of central and marginal perforations is the same.
Initial Diagnosis and Management
- History: Key factors to elicit in the history include the etiology of the perforation, the duration of the perforation, and associated symptoms including hearing loss, otorrhea, vertigo, and tinnitus. Common etiologies include acute or chronic infection, eustachian tube dysfunction, trauma, and previous ear surgery (including PE tube placement). Typically, tympanic membrane perforations heal on their own over the course of 1-4 months, especially if they developed from an acute process. Chronic disease is more likely to require intervention.
- Physical: The physical exam should confirm the existence of a perforation vs. a retraction pocket, as well as describe the perforation’s size and location. The size is given as a percentage of the drum surface, and the location describes the quadrant of the drum. For example: a 25% central perforation in the anterior inferior quadrant. On pneumotoscopy the TM will not move if there is a perforation. If there is movement, the diagnosis of a TM retraction should be suspected. An examination of the middle ear mucosa should be performed through the perforation to document any pathology (cholesteatoma, infection, etc). Typically with an infection there will be discharge visible in the external ear and the mucosa will look pale and friable. Rinne & Weber tests are always indicated with a 512Hz tuning fork to document hearing loss.
- Ancillary Tests: An audiogram should be obtained to document and quantify any hearing loss. This is especially important in the trauma setting as well as in chronic infection.
- Initial Management: Management strategies are initially focused on the etiology. Traumatic perforations should NOT be treated prophylactically with ear drops. Acute and/or chronic infections as well as eustachian tube dysfunction should be treated medically. The majority of tympanic perforations undergo spontaneous closure with conservative care. Patients should be instructed to keep water out of the ear during healing especially during bathing and swimming. Patients may use a large cotton ball saturated with vaseline (petrolatum) jelly placed onto the outer ear opening to prevent water from entering the ear.
Ongoing Management and Objectives
Ongoing management should focus on prevention of infection and documentation of spontaneous perforation closure.
Indications for Specialty Care Referral
- An audiogram showing conductive hearing loss associated with a TM perforation.
- Traumatic perforation with any of the following: flap of TM into middle ear, vertigo, or suspected sensorineural hearing loss. Call ENT Clinic and refer immediately.
- Recurrent middle ear infections associated with a TM perforation.
- Patient desires to participate in water activities AND surgical correction with an otherwise stable perforation without infection or hearing loss.
Criteria for Return to Primary Care
Resolution of the problem by medical or surgical therapy
Diagnosis/Definition
The palatine tonsils are paired lymphatic structures located in the oropharynx and have a physiologic role in antigen processing and immune surveillance. The histologic structure of the tonsils is closely related to this immunologic function. There are no afferent lymphatics, however there are numerous crypts that provide an access port for inhaled and swallowed antigens. The adenoid pad is a midline structure similar to the tonsils in function and histology. Both are part of Waldeyer’s ring, which is completed by the lingual tonsils at the base of the tongue. Pathology of the tonsils and adenoid most commonly involves infection and/or hyperplasia. Patients can complain of recurrent sore throat, halitosis, or purulent rhinorrhea due to infection, or airway problems such as loud snoring, mouth breathing, and voice abnormalities due to increased size of these organs. The definition of recurrent adenotonsillitis is a patient with 3 or more infections per year despite adequate medical therapy. Chronic adenotonsillitis is defined as a patient with persistent symptoms for greater than 3 months despite adequate medical therapy.
Initial Diagnosis and Management
- History: The diagnosis of adenotonsillar disease is easily made on history and physical exam. Pertinent historical data include the presence of fever, severity of discomfort, history of otitis, previous infections, missed school or work, antecedent therapy, and culture results. For obstructive patients, documentation should include any mouth breathing, dysphagia, growth chart statistics, chronic rhinorrhea, sleep apnea symptoms, snoring, bedwetting, and malocclusion. Patients who complain of recent onset of odynophagia, neck pain, and voice change should be suspect for peritonsillar abscess.
- Physical Examination: The physical exam should include a description of the tonsils, including the size, presence of exudate or cryptic debris, and any asymmetry. The palate should be examined for symmetrical contraction with vocalization. The absence of this symmetry, along with trismus, drooling, and voice changes are possible signs of peritonsillar abscess and should be documented. Any rhinorrhea should be noted, as should any cervical lymphadenopathy.
- Ancillary Tests:
- Throat culture
- Monospot as appropriate
- CBC
- X-ray of adenoid bed as appropriate (lateral soft tissue of the neck)
- Initial Management: The initial management of adenotonsillitis is the institution of appropriate medical therapy. This includes adequate hydration and pain relief as well as antibiotic coverage if indicated (Refer to the Sanford Antimicrobial Handbook). If a peritonsillar abscess (See Physical Examination Section for physical signs ) is suspected, referral to ENT by contacting the ENT Clinic during duty hours or the ENT resident on call after duty hours. Nasal steroids may help reduce adenoidal hypotrophy.
Ongoing Management and Objectives
Relief of symptoms.
Indications for Specialty Care Referral
- Recurrent infection: three or more infections of tonsils and/or adenoids per year despite adequate therapy.
- Hypertrophy causing upper airway obstruction, severe dysphagia or sleep disorders. For adults, if their tonsils are very large (4+) and they symptomatically are obstructing, a sleep study may not be necessary before ENT referral.
- Hypertrophy causing dental malocclusion or adversely affecting oro-facial growth documented by orthodontist.
- Suspected peritonsillar abscess.
- Persistent foul taste or breath due to chronic tonsillitis not responsive to medical therapy.
- Chronic adenotonsillitis not responding to beta-lactamase resistant antibiotics.- Unilateral tonsillar hypertrophy.
- Unilateral tonsillar hypertrophy.
- Any other symptom or clinical findings that are of concern by the referring provider.
Criteria for Return to Primary Care
Resolution of the problem by medical or surgical therapy.
Diagnosis/Definition
- Approximately 4-7% of the population has a palpable thyroid nodule found on physical examination.
- Due to the increase in neck imaging with various modalities, many non-palpable nodules are being discovered.
- Most thyroid nodules are benign and can be treated conservatively with suppression, observation or aspiration of simple cystic lesions.
- Thyroid nodules can be cystic, solid or mixed.
- Solid lesions are malignant in approximately 21% while cystic and mixed lesions are malignant in 7% and 12% respectively.
Initial Diagnosis and Management
- History: Thyroid nodules can be found in patients of any age. The age of the patient and the sex are relevant factors in determining risk of malignancy. The history should evaluate for symptoms of hypo or hyperthyroidism. Other important historical facts include voice changes, dysphagia, aspiration symptoms, cachexia, weight loss, prior history of radiation therapy, and failure of suppression therapy.
- Physical Examination: The physical exam should focus on the thyroid gland and the surrounding lymph nodes. The overall size and consistency of the gland as well as the number and size of the thyroid nodules should be evaluated. A thorough examination of the neck for evidence of cervical lymphadenopathy should be performed.
- Ancillary Tests: TSH and an ultrasound for non-palpable nodules.
Ongoing Management and Objectives
- Thyroid nodules require evaluation to determine the potential for malignancy.
- The nodules that are confirmed to be malignant or indeterminate lesions require surgical resection.
Indications for Specialty Care Referral
- Thyroid nodules over 10 mm in diameter or with concerning findings on imaging should be referred to ENT, General Surgery or Endocrinology for fine needle aspiration.
- Thyroid nodules that have grown significantly in size should be referred.
- Nuclear medicine thyroid scans are NOT indicated to evaluate a nodule, unless the patient is hyperthyroid.
- An large thyroid gland from goiter or large nodule suspected of causing airway compression or dysphagia should be referred.
- A hyperthyroid patient with a hot nodule (autonomous, “toxic”) may be cured by thyroid lobectomy and should be referred.
Criteria for Return to Primary Care
The patient will be followed by the respective specialty care clinic until the nodule has been treated surgically and the patient is recovered or until the nodule is determined to be benign.
Diagnosis/Definition
- Sinusitis is defined as an infection of the paranasal sinuses, typically secondary to obstruction of normal sinus outflow.
- The obstruction can be either mucosal (i.e. edema due to allergy, URI, irritants etc) or bony (i.e. anatomical narrowing due to trauma, polyps etc) or a combination of both.
- Treatment is designed to relieve the obstruction and eradicate the infection.
- Chronic sinusitis refers to the persistence of symptoms despite adequate medical therapy for over 3 months.
Initial Diagnosis and Management
- History: Pertinent historical data include the duration of symptoms and previous treatment, history of prior episodes, and complaints of nasal obstruction, anosmia, facial or dental pain, rhinorrhea (clear, mucoid or purulent), post nasal drip, and visual changes. Documentation of any facial trauma and allergy history should also be done.
- Physical: Physical findings should note any rhinorrhea, septal deviation, nasal polyps, facial tenderness or asymmetry, post nasal drainage, and turbinate hypertrophy pre and post decongestant treatment.
- Additional studies: Plain film X-rays are discouraged in the acute sinusitis setting because they rarely add useful information. A CT scan of the sinuses is indicated after a second, 3-week trial of antibiotics with recurrent or unresolved symptoms or if there are concerns for impending complications from acute sinusitis (orbital cellulitis, facial cellulitis, etc.).
- Initial management: For acute sinusitis, a 2-week course of first line antibiotic therapy (refer to the Sanford Antimicrobial Handbook) is indicated. This is supplemented with nasal saline rinses and topical nasal decongestant therapy for 3-5 days. The use of mucolytics (guaifenesin), oral decongestants, antihistamines, and nasal steroids are dictated by the patient’s history. For recurrent or unresolved symptoms, a second line antibiotic is used for no less than 3 weeks, and nasal steroid therapy is instituted. A CT scan is obtained after this therapy for recurrent or persistent symptoms, preferably waiting at least 2 weeks after finishing therapy to allow time for edema to further resolve. For recurrent sinusitis (4 or more episodes in 12 months) despite maximal medical therapy, a sinus CT scan is indicated.
Ongoing Management and Objectives
Prevention and control of further infections.
Indications for Specialty Care Referral
- Sinusitis unresponsive to medical therapy after a 3 week trial of a second line agent and a full course of nasal steroid therapy with evidence of disease on the sinus CT scan.
- Recurrent sinusitis – 3 or more episodes in a 6 month period despite adequate medical treatment as outlined above and evidence of disease on the sinus CT scan.
- Patient with known immune compromise or ciliary motility problem.
- Orbital or cranial complications of sinus infections.
- Recurrent nasal polyps unresponsive to medical therapy and evidence of disease on the sinus CT scan.
- Any evidence of tumor noted on exam or CT.
Criteria for Return to Primary Care
Resolution or control of the problem by appropriate medical or surgical therapy.
