 By the sixth week of basic training, 90% of these men could be carriers of meningococcal disease. Under the physical and mental stresses to which these men will be subjected, it is not unreasonable to assume that about 50% will contract an upper respiratory infection. The peak of this type of disease will be reached during the third through the sixth weeks of basic training. The period when the greatest amount of stress is felt. For a very few of the more than 20,000 basic trainees on this post, the combination of stress, URI, and more stress will result in meningococcal disease. This can be a rapidly progressive disease unless it is diagnosed early and treated intensively. The commanding officer is as acutely aware of the medical problems of his post as is the chief medical officer. If the surgeon can show him a way to reduce the length of hospital stay, the severity of debilitating infection, and mortality from things like meningococcal disease, the commander will become an active and dedicated member of the preventive medicine team. Further, he will provide the means for involving all of the training command in this effort. There is no currently effective prophylaxis for meningococcal infection, but the disease can be controlled in part by reducing the incidence of URI in the recruit population. That is why the preventive medicine team must consist of the training battalion commanders and their cadre, as well as the commanding general, post surgeon, and preventive medicine officers. When the commanding officer makes it clear that without physical well-being there is no combat effectiveness, preventive medicine achieves a new dimension. This is part of the preventive medicine program. At this post, it ranges from provisions for indoor training activities during severe weather to assuring a minimum of 72 square feet of living space for every recruit in every barracks room. Buses are often employed to transport troops to training areas three miles or more from their battalion areas. This eliminates the unnecessary marching that leaves recruits tired before a training session even begins. It is frequently among the hardest working that URI will develop, go untreated, and later open the way for meningococcal disease. Experience at this post has shown that reducing physical stress by curtailing exposure and overexertion helps cut the incidence and severity of URI. Simultaneously, meningococcal disease is reduced without reflecting on the proficiency of training received. Effective reduction can take place too by taking steps to ameliorate the more extreme climatic conditions of cold and heat. Breaks like this are valuable too in reducing the stress of training. Warming tents, appropriate clothing, and shade also help the trainee pursue his work in better physical condition. By employing specific measures to reduce stress, and by actively encouraging all recruits to seek medical attention at the first sign of sickness, a definitive program of meningococcal disease control can be instituted. Successful early diagnosis, the first part of the program, means that every man responsible for recruit training must also share the responsibility for recruit health. Cadry will have to be schooled in the signs and symptoms of the disease, and encouraged to develop an attitude of concern for the men who complain of not feeling well. The barracks room is where recruits drop the pressures of a day's training, where there is time to prepare for the next day, relax, gather new strength for the challenge ahead. It is also the place where the personal problems often bubble to the surface after being submerged for a day. Early signs of sickness may appear anytime, anywhere of course, but here is where they can be easily discovered by an alert soldier. Millets, muscle aches, sore throat, fever or chills are symptoms of many things. They may indicate nothing more than a viral infection, but they might also be the precursors of meningococcal infection. A soldier exhibiting any of these symptoms, particularly after the second week of training, should not be left to look after himself. When an NCO discovers one of his men in this condition, he must make it his responsibility to see that the man is seen by a doctor. There can be no delay in getting to the hospital emergency room. This is not the time to wait for an ambulance or bus. If this recruit is developing a meningococcal infection, time is one of the few aids the medical team can have. A suspected case of meningococcal disease is an emergency and must be treated as one, because the onset of the disease can be quite sudden. The patient may become unconscious within minutes after arrival, even though no indication of this is present at the time of admission. For this reason, a history must be taken right away. Of prime importance in this history are allergenic reactions to penicillin, and the present whereabouts of the parents, wife or other next of kin. It may be days before these patients are conscious again, and contact between doctor and the patient's relatives is a vital part of this program. Not all meningococcal infections will show up without warning in the barracks. It can easily be hidden in the prodromal stage by a simple virus. Men reporting on sick call with symptoms of upper respiratory infection must not be sent back to the barracks for self-treatment, as has sometimes been the practice in the past. Examination by a doctor in a dispensary may often reveal more definite indications. Patiki eye on the mucosal surfaces and on the conjunctiva is a classic sign of meningococcal disease. In some cases, they may even appear over the trunk and extremities. Another classic sign is nuchal rigidity. Any complaints involving this symptom require immediate attention. One technique useful in following the progress of this disease is circling of all hemorrhagic spots on the body each time the patient is examined. In this way, new patiki eye will be more apparent. Patiki eye alone, of course, do not constitute a positive diagnosis. Usually, patients who are admitted to the hospital for treatment of URI will be in the ward when meningococcal infection manifests itself. Nurses and corpsmen on these wars are trained to watch all patients for the cardinal signs, high fever unresponsive to usual measures, nuchal rigidity or meningismus, skin lesions, increasing lethargy or changes in the patient's personality. Sudden long outburst of profanity, for instance, have proven a good indicator of meningococcal disease. While no single sign is adequate for a positive diagnosis, any one of them is enough to warrant moving a patient to the special intensive care unit established for meningococcal infection. Here, the patient is examined again to give the medical team an up-to-the-minute picture of the suspected case. Diagnostic tests must be started as soon as the patient arrives. Spinal fluid and patikial smears are taken along with other samples. These must be done rapidly so that therapy can be started even before a positive diagnosis is reached. If tests prove negative, therapy can be stopped. But if meningococcal disease is present, much time will have been gained. Every member of the medical team has been trained in the special requirements of the disease. Every piece of equipment, every necessary form and therapeutic agent that could have even remote use is ready and accessible. Following the lumbar puncture, two blood cultures are drawn. The CBC and blood sugar analysis are used for comparison with the spinal fluid. If these studies are made as a matter of course on all patients admitted through the emergency room, or URI ward, diagnosis will be that much advanced in time. IV tubes for fluids and penicillin are placed as soon as the samples are drawn. Tubes must be flexible and well secured to prevent the patient pulling them out or causing them to break off. In patients with this disease, the blood will often show a leukocytosis 15,000 or greater. This contrast with a lower count in patients with a viral infection or its appearance with a negative throat and clear chest picture are good indicators of a positive diagnosis. Media for culturing spinal fluid and blood should be warmed in a body temperature water bath before inoculation. Cold media will slow culture growth and even kill certain organisms entirely. The same temperature, 35 to 37 degrees centigrade, should also be maintained for the specimens using an incubator if necessary. Spinal fluid may be normal in many patients seen early in the disease even though a culture is positive. A typical spinal fluid will be cloudy with leukocytes numbering hundreds or thousands, an elevated protein and diminished or absent glucose. The diagnostician must analyze and compare all of the tests before drawing a definitive conclusion. Operator, this is Dr. Dempsey. I'm calling from extension 2049. Yes, I'd like Russellville, Kentucky. That's area code. When a positive diagnosis of meningococcal disease is ascertained, the attending physician can then turn his attention for a few minutes from patient to parent. Hello, Mrs. Poole. Yes, this is Dr. Dempsey. I'm with the hospital where your son James is taking his basic training. Yes. We have James in the hospital now, Mrs. Poole, to treat a condition which is just developed. And I wanted to get an idea of the family medical history. Yes. How is your health, first of all? Because the news is serious and because it is often late at night, the doctor is trying first to determine how the person on the other end will take the news. If the first person the doctor speaks with indicates a weak heart or similar condition, he will ask to speak with another member of the family. I see. Well, Mrs. Poole, James has developed a bloodstream infection. If the diagnosis is meningitis, of course, the doctor will say so. And while his condition is serious and there is real danger, we have had lots of experience with this disease and have been getting good results. We have the best there is in the way of drugs and equipment. Our staff will spare no effort to assure Jimmy the best possible care. The doctor then asked that the parents come to the hospital to see their son. If necessary, he tells them the local Red Cross chapter will help them make arrangements for the trip. The local chapter, of course, will have been informed of the situation by the post-Red Cross office and instructed to come to the family's aid if necessary. Less than half an hour posted mission. All tests can be completed and intravenous penicillin started. Now, routine care must follow a specific plan. Most important in this is observation. But voltage. This is a disease that can take a fatal turn in a matter of minutes. The disease is not highly contagious and strict isolation is unnecessary. In this unit, four patients can be cared for simultaneously, making constant observation feasible. Each patient may show different signs depending on stage and type of infection present. There are actually three forms the infection may take. Bacteremia or bloodstream infection. The more familiar meningitis. And finally, a combination of the two. Bacteremia is most common. These patients exhibit the classic patechiae, high fever, and nuclear rigidity. On set is extremely rapid, often a matter of minutes, during which the patient can develop hypotension and die. For this reason, vital signs must be checked every 15 minutes for the first 24 to 48 hours of hospitalization. And as indicated thereafter. A cardiac monitor is used in patients with Bacteremia. This gives the doctor adequate warning of the presence of any significant arrhythmia, and allows prompt therapy to be started for this complication too. An additional significant measurement is the sensual venous pressure. It can be measured by a monitor connected to a catheter placed in a large vein. By charting the venous and arterial pressures on a 15-minute basis, a picture can be developed that will show the patient's condition relative to shock. By following changes in these measurements, shock can be anticipated and prevented. Thus, supportive therapy can be given early, lessening the likelihood of a fatal outcome. Urinary flow is another sensitive indicator of cardiovascular status. A decreased urinary flow in the face of adequate intake may precede clinical shock. The presence of meningococcus in the spinal fluid presents the classic picture of meningitis. Because meningio involvement is frequently underway before organisms are easily demonstrable in the spinal fluid, penicillin must be started as soon as the blood cultures have been obtained. Two million units every two hours will produce an adequate cerebrospinal fluid level for treatment of this disease. This therapy should be for 10 days. Progress of meningitis is marked as the patient becomes comatose. He will frequently become violent and must be restrained. In this form of the disease, the fatal complication is caused by failure of the CNS cardio respiratory centers. Again, time can be the deciding factor. No patient with meningitis should be left unattended even for 30 seconds until the convalescent period begins. Respiratory difficulty begins suddenly and can end a patient's life the same way. Emergency equipment placed within arms reach before any difficulty develops can bridge the critical seconds between life and death. Standard equipment including resuscitation devices and endotracheal tubes must be available. In addition, a tracheostomy tray is prepared and ready should the failure not respond to the other emergency measures. When a patient's parents arrive at the hospital, they are met by one of the post red cross workers. The attending physician now extends his care to include them, meeting with them before they see their son. The doctor first assures them that although seriously ill, their son is making satisfactory progress and should soon be fully recovered and return to training. The parents must be prepared for their son's appearance. With IV tubes, catheters and restraining straps, a patient could increase the anxieties of relatives visiting for the first time. Two, the doctor must be able to answer the questions parents always have, to reassure them that everything possible is being done, to ease their minds and to lay their fears. While the parents are visitors to the hospital, every effort should be made by the training command as well as the medical staff to ensure a good relationship. They should be given an opportunity to eat in their son's mess hall. Later on they can visit his living quarters. Introductions to his officers, NCOs and fellow recruits will further serve to remove any doubts about the adequacy of their son's care and treatment as a member of the armed forces. Most convincing, of course, will be the fact of their son's return to duty after his convalescent leave. Meningococcal infections can be treated successfully without residual effects, provided the cases are diagnosed early and subjected to intensive therapy. Observation of training and trainees by medical and training officers will point up areas needing changes to protect the recruit population. With the active sponsorship of the entire chain of command, a program of early diagnosis of suspected cases of meningococcal infection can be instituted. Every commander, every NCO must be assigned the responsibility, along with the medical personnel in the dispensaries, as well as the hospital. The training program for new recruits has an inherent part. Stress, physical and psychological pressures that are different and more concentrated than those normally found in civilian life. Upper respiratory infection and the associated stress-related complications like meningococcal disease are a natural result of severe environmental and occupational changes necessarily imposed on men new to military life. While there is no certain prophylaxis for meningococcal infection, stress can be reduced, environment controlled, and URIs treated as a serious threat. All of these will in turn reduce the incidence of meningococcal disease. This is a disease where time is one of the most critical factors. Time to institute treatment, time to take heroic life-saving steps when seconds mean life. If the signs are disregarded or the importance of immediate intensive treatment not recognized, meningococcal disease will progress to a fatal conclusion. Early diagnosis and intensive treatment is the only successful defense. It is the only protection against this enemy for those who will protect us from our nation's enemies.