Epiblogue

The trip home from Al Udeid was more comfortable than the C-130 heated-tin-can run through Iraq, but no less tiring.  We stopped 3 times during the 26 hours from Al Udeid to BWI, and I slept for 6 hours at a local hotel prior to the flight home to San Antonio the next morning.  [Here's a shout-out to American Airlines which put me in First Class on both connections from BWI to San Antonio.  That was an unexpected and much appreciated treat].  Alas, I arrived to a smiling family, and have enjoyed the reunion with them since.

The day after coming home, I was at the pool with my kids and ran into an older gentleman who works there.  He welcomed me home, and then commented on the "mess over there" and "how screwed up those people are."  I took that as a queue: "Yes," I said, baiting, "after we bombed there water purification systems and power plants, they have become a bit surly."  This is not what he was intimating, and as he looked away, and his expression changed from an approximation of admiration to a suggestion of disgust, he then pointedly asked me if they weren't surly before we got there.  Ever since the crusades, there has been a mutual, generalized mistrust between muslims and christians, so I guess I couldn't find this surprising.

Whether or not it was a mistake to go into Iraq as we did - this is a much more difficult query than most people tend to make of it, given modern history in this area of the world - it is undeniable that our tactics for the invasion were imprecise and not pristine.  As has been said many times, we overplanned for the warriors, and underplanned for the civilians.  And worse, we were ill prepared for interloping Jihadis who, cleverly, and obviously in retrospect, ensnared our focus and drew us to unavoidable civilian casualties (ie. al qaeda mortar rounds launched from schoolyards, mosques and markets toward American troops), and the societal costs of the destruction to the infrastructure.  Whereas a bunker may have served as one of Saddam's hiding places, it was not on the night dozens of women and children were inside of it taking refuge from fighting in the streets, when heavy ordinance came down upon them.  These are the casualties of war, but in an offensive, these deaths appear reckless to residents who lose a child, wife, or sister, and then join a terrorist insurgency, which became the great thorn in the heel of OIF.  I talked to many Iraqi who did not become insurgents, but who became disillusioned with us after these types of things occurred, and after the years of frustration with inconsistent basic services due to the lingering insecurity generated by the terrorists.  They wanted us to leave.  But as the security has improved, inroads (albeit, just inroads at this point) have been made for repair of much of what they were accustomed to in Iraq: first-world medical care, a vibrant economy, an admirable secular educational system, and reliable utilities.

I always knew that caring for wounded American and coalition troops would be fulfilling, but this is where my experience taking care of HNs became the pleasant surprise of my time in Iraq.  We saved countless Iraqi civilians and many children who would otherwise be dead, and each husband, wife or parent returns home with their child with a new view of Americans.  A bilingual Iraqi physician told me that prior to meeting us, these Iraqis know only George H. Bush, who they perceive as abandoning them, George W. Bush, who they perceive as destroying Iraqi society in the quest to rid the world of Saddam Hussein, and US Marines, the tip of our spear, and the deadly edge of our sword.  According to this physician, we change the way they view us: the real Americans, a representation of the compassion and industry present in our general populace.  People are people.  These people suffer the same human frailties and greatness, and they got to see this from us - fighting sleep on call in the middle of the night, losing patience and yelling at a nurse, life saving surgeries and medicines.  I am contented to have helped to save a few, and improve a few of these lives, and in the process provided more glue for these folks to put their country back together.  I hope that the person who hasn't been over there and prone to make poolside comments about those people keeps these things in mind.



It has been a uniquely flattering to hear nice things from so many strangers who read this blog; I guess they are all within 2-3 degrees of Kevin Bacon, but friends of friends of friends are people I don't know, and bearing witness to power of the internet in this fashion, and knowing the anecdotes reached people has been a special experience for me.  The blog became a chore on occasion, and I often lacked the inspiration I needed to deftly pluck out a captivating story.  Thank you for allowing me some elbow room in this regard.  My goals were accomplished:  1) to tell the story to non-military Americans of the day to day life for Americans deployed in the AOR - not the glory or gratuitousness draped across the marines in the HBO specials, but rather the basic sustenance for those most resembling regular folks back home; 2) to remind folks back home that despite the news, that the war is still on (even now - with withdrawal of the last of combat troops - our military members are not in a safe place); 3) to pass the time - I learned a few things about myself in this process, and found it a fine catharsis and release valve for banalities of daily deployed life for a dust-stomping oncologist.

So, thank you for reading, thank you for your encouragement, and thank you for remembering our military in a time when it is easy to forget what they are out there doing for you.

Moonscape

Al Udeid would not be a bad place to be deployed if you had a domicile which was not a tent and the weather was like February year round.  The last time I was here the air was relatively dry, the evenings were cool, and the days were blue skied; hot in the sun, temperate in the shade.  The endless white rubble known as Qatar is not so merciful in the summer months.  The only ones outside at noon are madmen and Englishmen, as many an Indian has said.

For these few days in Qatar, I have adjusted my schedule, both in deference to the CST which I will soon be rejoining, and, more importantly, at the moment, as a strategy to deal with the heat.  I sleep through breakfast and lunch, sit in the Chaplain's makeshift living room (an air conditioned lounge that has wireless internet) until the sun goes down.  Then it is time to make the 1/2 mile trek to the dining facility.  Here I am again today: bloggin', email'n, surfin', and readin' the news.

The heat here is worse than Iraq.  The temperature is not as high, but the humidity is much higher, and when it is 110 and humid, it sits on you like a full length hot towel.  You feel like the cheese in a burrito.  One can really understand the dish-dash-ah and the gutrah - the long white cloak and headdress, respectively - worn by the locals.  I guess every place has a less pleasant/unpleasant season.  The 6 months of nasty heat here seems inequitable share of nasty - like an Alaskan winter.

It is a shame to be stuck in this Haji Grand Central Station for over a week (combining time here on the way to and from Iraq) and be unable to get to Doha which is less than an hour drive.  Doha is home to a million people.  Curiously, most of them are expatriates; a larger portion of whom are laborers from South Asia.  The middle east is so different from what we are used to in the US or Europe.  It would be interesting to walk around and see how things are done.  Under different circumstances, I wouldn't mind seeing Doha, as well as Abu Dhabi and Dubai, which are the principalities of the UAE.  That said, I don't see a dedicated trip for the this purpose in my near future.

Alas, here I sit.  Alone in the desert, waiting to come home.  Interesting how the military creates such intense desire for a 22 hour flight with 5 layovers.

There has to be a better way to do this

The best thing about yesterday is that I don't have to live it twice.

I climbed out of bed at 0300 to clean my CHU, and make final preparations to leave with a show time of 0700.  In the military, there are flight times and show times.  Flight times are just as you would imagine, they are times of the flights.  The show times are anywhere from 3-4 hours prior to the flight, and if you don't make arrive for the show time, you lose your ticket - it is given to a standby customer.  (This is just like commercial air travel, except that Delta doesn't give away your ticket until you "no-show" at the boarding call.)  The 1100 flight was delayed, however, until 1545.  So, I sauntered about the base until the new show time of 1245.  I then lugged my gear - 125lbs of my belongings, 70lbs of battle armor and kevlar helmet, and 50lbs of chem gear - to the meeting spot, where we proceeded to tag and load our bags and take the bus to the terminal 1/2 mile away.  

I thought our trip from my base to Al Udeid would consist of the 2+ hour flight over 1000+ kilometers of desert packed into the Air Force's favorite tin can: the C-130 Hercules.  I was overly optimistic.  Clad in 

IBA and helmets, 40 of us, packed tightly as cigarettes in their case, made our way north 300-400km to Kirkuk, where we dropped off 6 and picked up 13 soldiers and airmen, back down to Baghdad where we dropped off 10 more, changed pilot crews and added some cargo, and then, finally, south to Al Udeid, Qatar.  The 4x4000hp Allison Korean War era engines buzzed as a mammoth wasp for the entirety of our 3 legged, 5 hour voyage.  The blessing of our delay left us landing on our desert peninsula within the Persian gulf at 2130, mercifully, after the setting sun.

Soaked through our undergarments and battle-ready burlap-canvas camouflage (ie. ABUs), we sat through an hour of briefings, dropped our checked luggage in a bin, lugged our the remainder of our gear through customs, dropped off chem gear and IBA, and then waited in the steamy night for a bus to the transient housing office.  My psychologist colonel friend had a driver taking him to the DV (distinguished visitor) housing unit, so I caught a break, skipped the bus, and hitched a ride with him.  My attempts to hole up in DV quarters posing as his aide-de-camp were apparently more transparent than I had guessed, so I was curtly shipped back to second class.  I shrugged, picked up linens, and walked 1/4 mile to a 45 person tent filled mostly with hygiene-challenged 18-25 year old soldiers that smells like 3 day worn sweaty socks dipped in a septic tank and left to dry on a line.  But at least the air was cool in this tent, so I stripped off my saline-laden stink, took a deep breath, and re-dressed in shorts and a t-shirt.

I walked another 1/4 mile to the bar, had three glasses of water and a Guinness.  All is forgiven.  Counting down hours until commercial air takes me north and west from here.  

Leave no trace

When it is 130 degrees Farenheit with 8% humidity, you need to drink your water.  This is the desert, so water is brought into the base from elsewhere.  I cannot tell exactly where it comes from, but given the risks of terrorists poisioning our water, I am sure it is not from the local spickets.  Drinking water arrives in stacked plastic-wrapped pallets of 1L water bottles, which are subdivided into cases of 12 bottles.  These pallets are deposited around the bases, and the water warms in the sun extracting whoknowswhat from the polyethylene terephthalate bottles.  The plastic bottletops twist open without the characteristic release of tension and snap which we have all grow so accostumed to in the US.  They say the water bottles are not recycled, but who knows why they don't have that seal.  (Knowing how many people urinate in these bottles, I want to believe that they are never reused).

The bottles end up in the trash, along with everything else; the cardboard boxes, the styrofoam trays on which I eat, at least, 2 of my daily meals, the mounds of paper, the expired food, all go into the trash, and all of it is burned.  In reality, I have thrown out more in the past 6 months than I have in 6 years at home where I recycle with abandon, separate all types of refuse, and make all efforts to wash and reuse those items which can be reused.  Military discipline (and martial law) assure there is no litter in sight, but the garbage cans do fill. 

Preparing to pack my things, I gave a pair of tennis shoes to the Pakistani janitor, a rug to the Indian who drives the floor cleaning Zamboni, and old towels and hangers to my partners - there seems no reason to carry these things across the pond, and they should be able to use them.  This is not reaching my goals for stewardship, but cuts down on the garbage.

Recycling and stewardship have become a tertiary priority, a statement of volunteerism, and they are quickly set aside when the burden grows elsewhere - I even notice this at home where we are less dedicated to composting or separating recycleable goods with 3 children to care for, than we were by ourselves before them - and, here in a deployed setting where environmental considerations are a luxury which seem to impede the mission.  When will our jobs of stewards of this planet become mandatory?  When will the pursuit of oil and wealth be secondary to the impact on the surroundings, as in the case of the BP oil spill in the Gulf?  Do we have to sully the entire planet and render all environments toxic before we place stewardship higher on the moral standard?

The military has its objectives, it just seems that we can accomplish the mission in a way that doesn't leave what we are fighting for so stained from the battle.

Drawdown of military medicine

Six months ago, the plans for the drawdown of military, and civilian support, personnel in Iraq were public knowledge.  Reduction of military force by 50% in September 2010, and removal of all troops, with exception of training operations and diplomatic missions by September 2011; or something approximating that, anyway.

Most active duty troops are relatively young and healthy, but the sheer number of folks here leads to the statistical inevitability of strokes, heart attacks, seizures and what-ails-you walking through our door.  These cases have previously been dispersed among the many hospitals and small clinics throughout the country.  This year, we expected to see an up-tick in the number of medical admissions when the peripheral bases started to close this summer.  What we did not expect was the simultaneous increase in violence - or at least the perception of such - as there are diminishing number of facilities prepared to care for trauma patients.  In addition, the young surgical crew here is hungry, and doing far more elective cases than the previous group. 

So, these have all led to a significant increase in business, decrease in sleep, and mild regret among my colleagues as to my departure - or at least the departure of my work.  The hospital's first priority is to care for the trauma of US soldiers, and that mission will be met.  The elective procedures may start going away, and that will provide more time for the surgeons to care for trauma victims, but other services we provide are not as elastic.  The care of host nationals (HNs), for example, is, in part a humanitarian effort to win the hearts and minds of those in the areas around us.  The choice of which of the patients are chosen to receive care here, however, is somewhat arbitrary.  People will be happy when we discharge the 21 month old boy who has been here for 1 month in the hospital, a most certain rescue from death from his burns.  People are less pleased when Command accepts a terrorist with a gunshot wound over a infant with a simply reversible birth defect at the gate.  Compounding this, recently, our follow-up clinics have been canceled, so once a HN patient is discharged from the hospital, they are on their own for follow up medical care.  I liken this to dropping off an individual on a deserted island with a laptop and a cell phone.  The medical infrastrucure in Iraq simply is not mature enough, or hasn't rebuilt enough, to handle complications or complete staged procedures for complex patients.  Nonetheless, this is all part of the plan to slowly remove ourselves, and any dependence on us, from inside of Iraq.

Planning for removal of 100,000 troops and 100,000 contracted support personnel is based on some known variables, and it must remain mutable for those unpredictable surprises.  We are counting, or at least hoping for less violence during the drawdown.  For the sake of the care of the troops, if nothing else, let's hope this is an accurate assumption.

Eatin' up, with my bad self

For months, I avoided soul food night specials at the DFAC and chose, instead, a bowl of cereal or pop tarts.  The macaroni and cheese was served in cut blocks as the pasta had melted into itself.  The "fry" on the fried chicken seemed much greater in mass than the "chicken" of fried chicken.  The vegetables?  Overcooked, and molten, indistigunshed.

As of late, however, Sunday night has become a culinary delight.  I never seem to remember it ahead of time, but when I walk down to the DFAC, and discover that it's SOUL FOOD NIGHT, well, I am a happy man.  Tonight, I eschewed the ribs and macaroni and cheese delicacies, and, instead, partook in the gumbo - which, as a charming mix of shrimp and left over chicken curry adorned with plump pieces of floating hotdogs, may not rate as 'Nawlins finest, but makes a nice dish, all the better mixed up with cornbread, and washed down with sweet tea.  The larger portion on my plate was collard greens, without the pork parts, and a heaping mound of blackeyed peas.  I used to consider this the penance for the sins of the "gumbo mash" described above, but my vegetarian wife will be happy to know that I now enjoy these as much.  (The better to wish in the next New Year, I suppose).

Honestly, the food here is tremendous.  We are blessed to have hot food, and people who cook it for us.  There are no MREs, and the dreaded constipation that accompanies it.  There are many selections, and frankly, some of the food is tasty.  I am always amazed at how they are able to offer these gargantuan trays of fresh fruits and vegetables to thousands of soldiers in the middle of a dust bowl; especially, considering that the food is brought from all parts of the world, all of which are more than 1000 kilometers away.  The dishes all have a little taste of the sub-continent, and I am happy to leave this behind, but that is more to escape routine and a welcome of choice, not for lack of quality.

Really, this is a far cry from anything in deployed settings in the past wars, and you do find yourself a bit guilt-ridden with complaining about a shortage of Diet Coke or Honeynut Cheerios, having Pepsi Light and Total, to suffice.  If anything, though, you recall the cornicopia available to most Americans, at any time of the day, and truly appreciate that remarkable convenience.  Gulitily, I am looking forward to this in a major way.  In the meantime, however, this white boy is digging his curry-chicken gumbo mash with a large side of greens. - vinegar and hot sauce at the ready.

Shorttiming

Going home soon.  There is not much time left for me in this accursed country, but the hands of the clock have slowed; they are my never boiling watched pot.  When your tour is measured in weeks or days, you can realistically cross days out on the calendar without worrying of running out of ink.  This doesn't make sense to me as I will just spend more time staring at the calendar.

My children may not be stopped from this, but they are weary of the weight of our separation, and the younger ones have started to wonder if I am every returning.  School has been out, but my wife has maintained a routine, for her own sanity, and their benefit.  Surely, they remain occupied for most of their day.  Perhaps my arrival home will be noted with a shrug, or less, by my sons, who have lived without me for longer than they can remember.  I hope and believe that this will not be the case.

The crews here have changed over.  Those who saw me come in, and showed me the ropes have returned home.  I talk of February and rain here, and the those newly deposited into this stink are disbelieveing, as if they are things of another epoch.  Strangely, the contractors from the sub-continent, while always polite and professional, have lately started to afford a familiarity of mutual respect.  They don't check my ID at the gate when they see my face; I am served my usual breakfast off the buffet by issuing a smile and without uttering a word; they even bring me curry sometimes to my office.

Let the outprocessing scavenger hunt begin...  ...oh, gladly.   More on this later.

Incoming

The sound of the klaxon is unlike any other siren.  The grating, repetitive hum drills to the primal, and the response is subconscious and automatic:  a reflexive flop, and quick acquiantence between man and dirt.  The low frequency horn forever symbolizes urgency and danger.  As the wounded appear here with all matter of fragments blown into them, the response to the klaxon is visceral in everyone. 


Usually, the incoming mortar is thrwarted with the eyes in the sky and the guys with long hair and thick necks and sharp knives.  But when the wind thickens the air with dust, and surveillence becomes difficult, the klaxon will sound and send everyone to the ground.  Sometimes defense missles shoot the mortar round out of the sky, sometimes it is a dud, and occasionally, it lands somewhere on this vast base stirring up the air, and shaking the ground. 

Incoming fire of real consequence may not be common, but the sirens and announcements are.  The base is well fortified and protected, but the enemy fervent and tireless.  I have read (and this is common knowledge, not OPSEC) that al-Qaeda in Iraq has become more clever, and no longer places mortars in the fields around us themselves.  Instead, they pay impoverished farmers to place "packages" in their fields, or, they have been known to place a mortar round frozen in a block of ice in the apeture of a launcher, whereas it may launch hours later after melting away the ice in the hot sun, and subsequently falling into its launching barrel.  These tricks have low specificity, and limited payload, but are very difficult to prevent, thus, they harass us, and require vigilence to monitor and contain.  More importantly, they generate fear and we expend more resources to account for them - and this is the terrorist victory difficult for us to deny, at home or abroad.

Of the many rounds which never detonate, EOD teams are quick to disassemble those warheads, but, in place of the klaxon, the loudspeakers issue instructions and caution - another auditory stimulus unique to a war zone.  "THERE HAS BEEN AN INDIRECT FIRE ATTACK..."  The klaxon and the intercom, like cordite and decay for the olfactory, are the indeliable sounds of Iraq; so askew from home, so poignantly descriptive of war.

Vigil

It has been a few years since I spent the entirety of a day and a night at the bedside of one patient.  I did have to admit a handful of other patients with trauma and other injuries, but the surgeons did the lion's share of that care, and as I wrote the physician orders and interviewed them in the ICU, I was just meters away, and even then, only intermittently, from Mahmoud (not his real name), my 17 month patient with burns from his face to his feet. 

This toddler was brought to the base gate in the arms of his sobbing father one week ago.  The boy reached for his meal cup on the edge of the counter in the kitchen, but this familiar thermos was filled with boiling water which his mother had just poured in while preparing his breakfast.  Why his cup with scalding water was within his reach is something I cannot understand, and a question his parents will probably never be able to answer. 

Mamhoud's mother, 9 months pregnant with the next child, has not seen Mahmoud since he came to the hospital where his burns, not unexpectedly, expanded, as he developed, also not unexpectedly, a severe infection, which leaves him now intubated, flirting with death.  I had to explain, through an interpreter, how Mamhoud is very ill and may die as a complication of his burns to his father and uncle; the mortality of this severe of a burn in the United States   "But this is why we brought him here," they say, incredulously.  Knowingly, they say, "He would die at the [Iraqi] hospital," and indeed, death was certain at the local Iraqi hospital where they have no capacity to offer this level of care.  That is the my solace - that this child would be dead without me - in practicing outside of the scope of my own practice; a specialized profession in the care of adults.  We are taught from very early in medical education, the ethical dilemnas and the hard and fast rules.  In the US, you practice in the scope of your care or you lose your license.  The lines are blurry, sometimes, but surgeons don't do psychiatry, obstetricians don't do cardiology, and adult medical subspecialists don't take care of children.  The exigent circumstances which leave this child dead without me, and the fact that providing critical medical care with the resources available is something a "reasonable person with my skill set would set forth to do" in this environment, make this ok.  This is what I tell myself, and what the lawyers say.

That doesn't mean that you when you perform outside of your arena you don't second guess all of you decisions.  In 24 hours, I wrote over 100 orders on this child, maximizing his physiology.  I watched his bell rise, the movements of his fingers, the eletrocardiographic tracings all the while titrating his ventilator settings, and massaging his hemodynamics.  And each decision I made, unmade and re-made in tragic inefficiency, to avoid errors I am so much more likely to make in him than I would in an adult. 

In this vigil, I watched this boy, equal in age to my youngest son, and the more I stared at him or listened to his breath sounds, or readjusted his dozens of invasive tubes and lines, the clearer the evolution of his pathophysiology became to me.  Like a hidden puzzle in the Sunday comics, the pathology revealed itself to the patient observer.  As Sir William Osler noted over a century ago, the bedside vigil embodies the essence of what it means to be a physician.

No fireworks

We hope that the 4th of July comes and goes without exploding projectiles.  The smells of cordite and grilled brats serve well back in the 50 Free, but you do not want to smell sulfur here.  Indeed, this will be my first 4th of July without fireworks (the DFAC did have Independence Day placemats today), but I can reflect on the notion of independence in a different light; from the perspective of the Iraqi. 

Often people consider Bedouin tribesmen when then think of Arabs.  They imagine camel-riding theives wrapped in linen headdresses.  This, or Saudi Shieks inspecting rows of Rolls-Royces.  The society built upon mesopotamian oil money under Saddam, however, was wealthy, educated, and secular. The rich history of the fertile cresent with the layers of influence imparted by the Ottomans, and then the British, and dozens of conquerers before, imparted wisdom and provided a rich foundation for prosperty and growth.  Of course, modern Iraq self-destructed under the militaristic build-up and subsequent hemorrhage of the Iran-Iraq War.  The desperate recovery attempts by the Ba'athists after this culminated in OEF; this much and the rest has been the evening news for the past 10 years.

The brain drain began in the 1980s, at the first signs of the disintegration of Iraq as resources were siphoned toward imperialistic desires within greater Persia, but accelerated after Desert Storm, and then skyrocketed with OEF in 2003.  Once the infrastructure completely collapsed, with safety in doubt, there was not reason for anyone with means to remain.  Like Dr. Fajal, they left anyway they could, as refugees, or, if lucky, as emigrants.  What remained was a country without its wisdom.  The average aged male in Iraq was 18 in 2005; only now is that figure starting to rise as ex-patriots return, and as the violence quells, letting the citizens live longer. 

So, as this country searches for identity, it looks for its own independence; not just the democratic process which allows them to vote leaders among themselves, but the independence from international welfare; and not only self-sufficiency, but ascendancy into a leading nation as expected inheritance for those of Mesopotamia.  This ambition is the expectation of the young Iraqi men I have met, but it represents an independence I will likely never live to see.

Law of averages

I met a brigade commander last night who came in to see his soldier in the ICU.  He had traveled from a base over an hour away, and was anxious for a status update, and report on the progress of his care.  The answers were not what he wanted.  No pupillary reflex.  No corneal reflex.  No muscle tone.  No gag reflex.  Most likely, his trooper was brain dead.

The man was crushed, in a work-related accident, by a falling steel panel.  The piece which trapped him to the ground required a forklift to move, and 15 minutes afterwards, the man was without a pulse and in cardiac arrest.  His heart was recalibrated with eletricity, chest compressions and delivery of oxygen, but the tell-tale signs of his anoxia were present already, even by the team of EMTs providing his care.  Fifteen minutes without oxygen to your brain is not survivable.

The Commander said that support brigade suffered no battlefield deaths during his deployment of nearly a year, but two accidental work-related deaths.  This is not clumsiness - in fact, very much the contrary, as there could have been many more in the thousands of munition transfers, movements of heavy machinery, and preparation of heavy equipment for the infantry forces if not for their training and safety precautions - but instead the unavoidable, statistical reality of unpreventable accidents; and the more dangerous the job, the greater that reality.

I cannot help but think, however, of dying via an accident here as less palatable than the same thing happening at home (or a battlefield injury here).  Men fight in war, and some die there; this is an ending of honor, and a risk these men, and their families, understand from the outset.  When we leave home to fight, however, we cannot oblige (nor accept) an early departure from this world for the mundane and unworthy poor stroke of luck.  A cracked head on a waxed floor.  A wet finger and an ungrounded light switch.  Complications from a severe pneumonia.  These things happen all over the world, so they happen here too.  If there still 100,000 troops, and 100,000 contractors in Iraq, it is simply a law of averages that bad things will happen to some of these people.  Location, is everything, however, and going down in a hostile country, 8,000 miles from home in the care of strangers is not how anyone envisons their end.

-------------
[FWIW - The DoD takes pride in the manner by which family is notified, and the means by which these family are brought to see injured family members at the first possibly opportunity.  Usually, this means Germany, east coast US, or England, as family cannot be flown into the AOR.  We make every effort possible to maximize the physiology of these patients with non-survivable injury, so that they can survive long enough for family to see them at these locations, and possibly even serve as organ donors.  We cannot predict how all patients will do, but most can be supported by vasoactive pharmaceuticals long enough to get out of the AOR via emergent air evacuation.  Sometimes, we are wrong, families wait in Germany, but patients never alive, dying on the plane, or to Dover AFB, in Delaware as HR (human remains).  This is uncommon, but can happen, and is part of the risk taken in an aggressive approach to getting patients and families together.  It just makes the accidental non-battlefield death that much harder for family]. 

A refugee radiologist: perspective for the apathetic, Part II

...cont.
So, in Syria for a day, and needing to decide whether to leave to Libya by nightfall, Dr. Fajal and his family had a decision to make:  were they to make the relatively simple move to Libya, and start a new life there under another dictator, or were they to stow up in Syria, weigh their options and make the more difficult, costly travel to the United States.  Dr. Fajal's son did not want to leave Saddam's Iraq to be part of Qadaffi's dominion, and pushed the family to make the trip to the States.

Months later, the family was settled in New England, and though Dr. Fajal spoke English and was a practicing physician in Iraq, there are very few reciprocal agreements with respect to medical training and licensing in the United States, and in order to function as a radiologist in the US, he would be required to pass all USMLE tests, and attend another residency in an accredited US radiology residency program.  It is hard for people to conceive the difficulty - hubris aside - of going back and completing a 5 year residency after 20 years in practice.  Even if Dr. Fajal could find quick placement into an American residency, and this is not likely given the competitive nature of the field, and the protracted process for selection of residents, he would have to pay back loans for his travel to the US, and support his wife and children on a resident's salary; all while he was required to work 80 hours per week for 5 years before he could re-establish a practice in the States.  This in mind, he chose the pragmatic approach.  A local community college offered an ultrasonography certification after 6 months, and given his experience with ultrasound over 20 years of practice in Iraq, he pursued this option; the quickest and easiest route to a paycheck; the paycheck which would put food on the table, pay rent, and settle debts for the travel to the US.  Each of his children, at the appropriate age and schooling, worked themselves to support the family. His son worked with the electric company, and each of the daughters worked in retail shops, in addition to their studies.  Each payday, the children brought their checks to their parents to budget and disperse as necessary.  They became citizens in the US.

His son has completed his education, and is a practicing chemical engineer.  His daughters, however, are still in college, and the debt from their cumulative education exceeds what he could afford as an ultrasonographer.  To that end, Dr. Fajal traveled back to Iraq, now as a emissary from the US, to function as a discharge planner, in a contract position.  As I have alluded to earlier in these blogs, these contract positions in Iraq pay exceedingly high salaries, give the danger implicit in being here, so Dr. Fajal, though functioning, again, far below his aptitude and training, can garner the salary necessary to pay his childrens' tuition.  This all comes with a price:  he has been here since 2008, away from his wife, and children.

People like Dr. Fajal inspire us to be better, to try harder.  They conquer obstacles that most of us cannot imagine.  He humbly completes his duties with grace, and is a fantastic "over-asset" to have (imagine having Itzhak Perlman to provide violin lessons to your children) here.  Hearing his story reminds me of the fragility of my material life, and serves as a reminder of the value, and integrity, of work.  My children need to know about his life, and hopefully, they will remember his story. 

Supposedly, necessity is the mother of invention, and suffering the fuel of ambition.  Here's to faith that we can teach the lessons from another's hardship, and avoid the apathetic timbre resonating among so many of our own.

A refugee radiologist: perspective for the apathetic, Part I

As a parent, I want nothing more than the health and happiness of my children.  I do not want them to suffer.  I want to give them more than was given to me, which was more than was given my father, and so forth.  I also want them to understand the value of work, and the virtue of self-preservation.  I want them to be happy, but I do not want them to be apathetic; I want them engaged in their lives.  Nothing engenders responsibility and ambition like suffering and necessity, so how do I teach well-fed children to be hungry, without taking away their bread?  I find this to be the modern American paradox.  How can we develop entrepreneurs and inventors who grow up in the age of Paris Hilton?

It takes discipline, undoubtedly.  I am optimistic I can lead my boys by words and examples, but I stole these lessons; some them from Dr. Fajal.  Yesterday's post tells of this work to place HCN (host country nationals) after their discharge from the hospital.  I did not, however, allude to the path that led him back to Iraq, as an American contract worker.  I decided to provide a drastically truncated narrative of this road over the next 2 blogs... 

In 1998 when the strains of the western embargo on Saddam's Iraq revealed a hopeless future for those wise enough to see it, and brave enough to act on it, Dr. Fajal and his wife made the decision to leave Baghdad.  He could not emigrate, sell his home and more to Jordan or Egypt as any Ba'athist intelligence officials who sensed this plan would seize his assets and confine him, or worse.  He knew his family's departure would have to be surreptitious; that he would leave his life as a prominent physician, all of his extended family and friends, his home and his assets, with the exception of what could be carried on his back.  His children went to school and returned with news from their father that they were leaving within the hour to go on a vacation to Jordan.  They packed accordingly for a week's vacation to Jordan.

They ultimately arrived in Turkey, north of Kurdistan, knowing no Turks or Turkish, without work or a place to stay.  Dr. Fajal and his family lived on savings as he took menial jobs to help supplement expenses during the next several months for their asylum application to be processed.  At the end of 8 months an order for deportation arrived, and the family had six days to determine where they would pick up and settle.  They applied for asylum in Syria, but as the border was closed, they had to await for approval from the Syrian embassy in Ankara.  On the last day prior to their ominous deportation back to Iraq, they received permission from the Syrians, and made their way toward Damascus.  

They arrived in the Syrian coastal city of Banayas on the day of the monthly ship to Libya.  His family had to make a decision just then: were they to emigrate to Libya, or make attempts to reach America... (to be continued tomorrow)

Disposition

Providing a disposition for American patients going home with an injury is pretty simple.  We communicate with the flight surgeon, they arrange for a plane, and off he (or she) goes.  Discharging third country national (TCN) contractors is a little more challenging, but there is a discharge team here to help communicate with the contracting company to arrange for the patient's transport to where ever they may be going.  These patients then go on to heal in the country where they have their further therapy, or back in their home country.

The quandry comes with host nationals (HNs) - Iraqis.  Most of the Iraqi patients we see here are victims of IED blasts or local children suffering severe burns.  They often stay in the hospital for months - we may delay this to provide the best salvage possibility - but eventually, they have to leave the hospital, and they will need to be cared for by someone.  Another person will need to help them change dressings, dress and wash themselves, and often help them toilet or change their ostomy bags.  This in a country that doesn't stock ostomy bags at the local bazaar.  In this wasteland deplete of long term rehabilitation facilities, and families without the knack or funds to care for these people, we have lost more than one patient to dehydration, starvation, infection, or depression after discharging them from here.  But you cannot keep them here forever; they need to re-enter their lives.  Dr. Fajal (not his real name) is the person who shows them how to live on their own after their accidents.  Within the HN cultural context, he explains to families how to provide this care, he arranges communication between the patient with his or her family (not as routine as you may think as HNs are not let onto this base very easily), and ultimately arranges for transportation of the patient back to their home - or, if necessary, a local hospital for further staged care. 

Dr. Fajal works in this role as contract discharge planner for an American company, as a fluent Arabic, English, Turkish, Farsi-speaking specialist who gave up his career in medicine in his escape from a bankrupt Iraq under Saddam.  In his escape, he spent years as a refugee, before settling in the United States, where he acquired an ultrasonographer license after taking some basic courses, to provide for his teenage children.  The United States which did not allow his medical degree or post graduate training; the United States which decimated the remaining infrastructure of Saddam's Iraq; and, ironically, given the hazard of the job, the United States which now provides him a professional man's salary for assisting in providing a disposition to these HNs.  This is an amazing individual.

More on him later.

Smile for the Cameras

Volcanogate ended, and the cumulative Iraq-Afghanistan trauma melange ceased to exist in my ICU.  After the subsequent VBIED from the Iranian border, we still had the less common Iraq traumas come through several times a week, and an assortment of contractors and active duty patients with new heart attacks and strokes.  The unit had been more sparse, though, and this had afforded me a chance to take a deep breath and relax a little. 

Then we had a high level Iraqi minister coming for a visit, so there the brass wanted to fill up the hospital with Iraqis.  Thus, the policies which have taken been molded over the past several years on which host country nationals we see - and which we don't - were put to the screws.  Somehow, the reins loosened, and we had a ward full of host country nationals, just so the Iraqi minister could see a ward full of Iraqis.  There are still 8 HCNs (host country nationals) here.

We recently had the surgeon general, and then the chief of the air force stopping by as well.  There were several announcements about the incoming visits, biographies circulated, and then the requisite instruction to "clean up your area" followed by a command inspection. 

With a culture so well suited and steeped in the punative, I don't suppose I can blame commanders for wanting to avoid hearing about unsatisfactory behavior or demeanor of those under their command, by those higher up the food chain than themselves.  By the same token, however, it seems antithetical that the highest leaders of any organization the size of the military would have any concern or time with pedantry, but, rather, instead hope to discover a sense of the true uncensored sentiment of those in their charge.

Purple hearts

The division commander, Major General C, came to present our young injured troops with purple hearts in the hospital last week.  These were the boys injured in the VBIED whom I previous wrote about previously (see "Weeping heart").  None of the physical injuries sustained in the attack will leave these soldiers permanently disabled, though they lost 2 close friends, and the screening from the trauma incidentally found 2 advanced tumors in 2 separate soldiers.  For this they have the psychological burden of thte attack, and foul luck.

In the tiny hospital ward, a dozen or so Army Rangers packed in between we medical personnel to take part in a ceremony to award the purple hearts.  Purple hearts are for soldiers injured in the field of battle and represent one of the oldest awards given by the military - dating back to the American Revolution.  It was somber, and a sobering 5 minutes for each of the injured.  These were granted by the general along with meritious service medals, so the whole thing took close to 45 minutes.  As I stood among the Rangers and the other physicians and nurses listening to the citations being read, my spine stiffened with a sense of the honor shared among these men, and the privilege of their witness. 

I can also attest that I am pleased to know that these are the special operations guys - the guys who go deep into enemy lines.  I am not a small man, but each one of these hulking masses stood 2-4 inches higher than me, with the breadth of their shoulders equal to mine plus me sideways, while maintaining a similar waistline.  It was as though I was wandering amidst a crowd on a planet with a different species of humanoids.  Each one of them appeared to be capable and proficient with snapping men's necks between their thumbs and forefingers.  They are well disciplined and professional, but their anger after this cowardly attack has tightened their resolve, and focused them in their pursuit.  I am glad that they are on my side, and I fear for our enemies.

My day

16.43	Weeks
115	Days
2,755.23	Hours
165,314.00	Minutes
9,918,840	Seconds

I have been here for a while.  Not that I am counting, but it appears to be approximately 9.9 million seconds...  ...or so.  I have talked before about the folks who have been out hre multiple times for 12-15 months at time, and put this, and my paltry 6 month deployment, in perspective with the boys from both World War I and II who slept in foxholes for 3 years with no word from home.  That doesn't mean that I cannot look forward to going home, and it won't stop me from counting down days remaining - now that I am well past the 1/2 way point.

I am careful not to wish my life away, however, and continue to soak every bit of goodness from being here.  Ironically, this is probably the best Father's Day I have had.  Near midnight, I received and opened a wonderful package from my sons.  It was filled with snacks, and pictures with them clad in homemade t-shirts that read: "My Dad Rocks."  They sent to me life-size silhouettes of themselves - each of them inches taller, with bigger feet than when I departed.  There were handwritten notes.  One in cursive from the eldest, the first multiple sentence letter ever from the 5 year old.  They aren't so good on the telephone, but it nice to see they remember me, and sort-of appreciate me. 

When you are away from what you love most, you can appreciate the magnitude of your affections.  Absence may or may not make the heart grow fonder, but it clearly provides a higher altitude view.

Saint-sational entertainment, for who?

This picture is a little larger than usual for obvious reasons.  In the middle my friend Brett, a nurse anesthestist friend who comes from the Bayou.  This is not a headliner, as far as the USO is concerned, but I think Brett was quite pleased to have his team represented here.  [If you haven't met a "Who dat?" t-shirt-clad cajun, you have yet to meet a rabid football fan].  So all right!  Glad that the Saintsations made it by!  (I hope that they were wearing sunscreen).

The attempts by the USO to keep the deployed entertained and happy, and the generosity of different entertainers is laudible.  I missed the cast from the Sons of Anarchy, with great dismay, as I would have like to share a near beer with them - one guy who came, Kim Coats, plays a complete psychopath, so I was interested in what he was like in real life.  Zac Brown Band came also, and they recently released a video filmed here in Iraq.  Most of the footage is from here at my hospital and base (http://www.cmt.com/videos/zac-brown-band/522070/free.jhtml). 

You might think that visiting dignitaries would spend time with the brass, but the cheerleaders and actors would be led to the young enlisted to meet and enjoy.  You would be thinking wrong.  In fact, for reasons not clear, the people in charge - the commanders and senior NCOs - are the ones giving the cheerleaders the tours of the hospital.  In all actuality, it is a little embarassing that the guy in charge is spending his time showing the cheerleaders what an ER looks like, when that task would be the envy of any 25 year-old sergeant.  You will have to trust me on this (I do not have bandwith available to prove it), but there are pictures, on the hospital servers of the Command or 40-something superintendents getting chummy with every actor, singer or Hooters girl who has passed through this place.  The worker bees are in the hive collecting honey.

I am just glad the Captain Brett got to meet his Saintsations.  But I wouldn't expect a cajun to tolerate otherwise.

Ziggaurat-tten

I will likely never see the true ziggaurat of Ur, the site of the most well preserved remaining Mesopotamian pyramid of the Sumerians from nearly 5000 years ago.  This is one of the things, if things were different, I would like to see in Iraq.  I fear that this will not be a peaceful place to visit as a tourist for many years, if ever, and possibly not in my lifetime.  [So sad that this is true for the large majority of this part of the world].  Alas, 20th-century ziggaurats within the walls of this base will have to suffice.

For reasons mysterious to me, a French company, contracted by the Iraqi military, built several bunkers shaped liked ziggaurats around the base (maybe the French were clairvoyant and preparing for Desert Storm which they supported).  Some of these bunkers are simple 2-3 rooms structures with air handling systems.  Others, are much more complex with dozens of connecting tunnels and rooms (see above left).  Unfortunately, for Sadaam, the bunkers were able to be busted after all (see above right), so these are essentially non-functional piles of bricks and twisted metal littering the base - and the country, as I understand.  From the pictures, it is also clear to see the thousands of circulating dust particles reflecting the flash of the camera (see below left).  Big explosion followed by 7 years of no air handling in this dessicated wasteland equals a real pulmonary workout - masks recommended.

Walking through this eerie, man-made underground maze was exhilirating.  It felt as though we were driving a submarine through the wreckage of the Titanic for the first time, complete with equal amounts of debris and filth; though, realistically, nothing could be farther from the truth, it was fun to be exploring, unraveling a mystery, and imagining, in our minds, what happened in these places before the war.

Carpe diem

Doing your job while deployed to Iraq has challenges in its own right, many of which I have discussed in this forum previously.  Most people take their down time; however, work out, sleep or watch TV.  There are few folks here who really seem to carpe their diems.  I suppose this is true of any place.  The vast majority of us develop at least some sense of complacency, and choose to idle our remaining waking hours, and stretch out our non-waking hours.  Still, a small minority will strive to make the most of every minute of their days, sucking every drop of life from the cup. 

The differences here are striking insofar, as the experience is finite.  The time in this very odd life circumstance is, for many of us non-professional soldier types, fleeting and unique.  In addition, we practically live on top of one another here; we eat together, share showers, work together.  It is simple to notice those who color outside of the lines, and use more than the standard palette, so to speak.  In fact, the military is probably one of the less forgiving institutions with regard to nonconformity, so creativity comes with a price.

But for those who are creative, there are wonderful myriad adventures afoot in a new or rebuilding country.  One of my colleagues and friends, not unlike many young physicians recently emerging from a decade or more of self-imposed scholastic asceticism, suffers from an impressive cultural naiveté.  I truly respect this person; however, for aggressively seeking exposure to what there is here to see.  This physician sought out and befriended special operations troops, helicopter pilots, infantry command, and a variety of contract workers.  There were times at the firing range, the helicopter rides over Baghdad, an opportunity to drive a tank, and made to order food in the back kitchens of the dining hall; a doctor, who otherwise was never required to leave the hospital (with exception to tending to personal duties, etc), developed alliances, yet more, friendships, with folks who most of us would never have the opportunity to know, much less summon the courage to pursue.

I really want to drive a tank too.

Weeping heart

I have been told that this war is over by many people here and back home.  On the muslim holy day, Friday, a platoon of American soldiers were lured to investigate a bogus grenade threat in northeastern Iraq.  When they went to re-enter their vehicles and return to their rally point, a suicide bomber drove a car full of explosives into them, killing 2 Rangers, 2 Iraqi civilians, and injuring dozens.  Seven of those injured from the targeted platoon came to our trauma center.  All seven are alive, and they will all leave this hospital without unrecoverable injuries, and with all 4 limbs.

We cared for the troops, several of whom ambled, with lemon-sized shrapnel in their legs after the explosion, as much as 50 yards from where they were targeted to the transport along tortuous, crowded city streets, and back to a safe landing area for their helicopter.  Once on the Blackhawk, they were kept warm, resuscitated, and bandaged or torniqueted as necessary. They arrived to our ER where 50 waiting doctors, nurses, and techs were arranged in 7 physician-run patient care areas.  The platoon leader, a 30 year old lieutenant, was triaged to me.  I quickly assessed him; all the while he screamed, not for pain, but in anguish for what he knew were his lost soldiers, and in desperation for the wounded aside him.  


Calming him with talk, morphine, and ultimately, a stern order, I was then able to glean the story related above in which some devious assassin set a trap and killed our soldiers in a war that is supposed to be over.  It took me a moment to suppress my anger and gather myself after this.  Yet, I continued with his assessment, and organizing the efforts of my team in his care.  I shot lidocaine into a dozen wounds in his legs, carefully excised, and then filled a specimen cup with shrapnel.  He will recover fully from this and his significant, but relatively simple, orthopedic injuries; barring any findings on film that were unforseen on his exam, he would have escaped this tragedy unscathed, at least physically.  Wickedly, fate revealed a tumor in his brain, incidentally found on the CT, and compounding the anxiety of the day.


Our surgeons spent the night repairing a mangled arm of the most sick individual.  His radial artery was severed, and the trauma surgeon was, amazingly, able to harvest the saphenous vein (much like a cardiothoracic surgeon would for a bypass), and use it as a vein graft for the decimated radial artery.  We spent the better part of the day completing his resuscitation, and controlling his pain.  He was extubated, clear to his surroundings, moving his injured hand, anxious to hear of his brothers.  With pride and ease, I was able to tell him of his 6 healed, and healthy comrades.  Watching his eyes when I told him of the others who had fallen, tore away at my own soul, as my heart weeped inside my chest for those we lost after a war had supposedly ended.

Weakness of the notsoyoungman

I have it in my mind that deploying to a war zone is easier for a young man that an old man, or at least, a not so young man, as it is.  The duties of a husband and father are springs not yet sprung in the mind of a young man; nor are the concerns with the daily life, health, virtue and development of those children and wife.  The body of a young man abounds without the arthritides he later gains.  Rising after quick restful sleep, the young man needs no respite, stands for the physical challenges, and consumes, digests and evacuates in near involuntary routine.  The not so young man must strategize water consumption to avoid otherwise nighttime prostatic spasms and subsequent trips to the loo, and deviates from his set cuisine at his own peril given the unpredictable effects on his bowels.  That he thinks of bowels makes him different that the young man.

The young man is likely less aware of the ways of the world, and more accustomed to following directions without fully comprehending the import or the consequences.  To the young man, time is infinite, and spending it directionless without purpose is of little regret or concern.  The not so young man is less generous with his most valuable depleting resource.  The not so young man knows the absurdity, inequity, and unkind face of war.  The young man speaks in platitudes, and has a clear dictum on the purpose of his service.

The young man lacks wisdom and insight to put inconveniences and suffering in perspective.  He lacks the capacity to compartmentalize properly the intellect and the emotion.  He can become weary with personal investment in things outside of his control.  But still, a young man can be more content to waste his time, is less aware that he is wasting it, and is more steadfast in the clarity of his work.

Dust

This is an old picture, but it is better than the ones I took when this happened this week.  Sandstorms may be predictable, but not be me, or anyone I know here.  The limits of prediction tend to be as the photographer in this picture: “Oh shit; will you look at that!  Let’s take a picture.  Now let’s run inside.”  Sometimes, this happens when you sleep, and you wake up and notice no sunlight coming from underneath your door; an opaque thickness to the air, and layer of dust on your nose.  This dusty fog may linger for weeks, I am told.  It does provide a reprieve from the heat (by blocking the sun); at the cost of pulmonary detriment.

When you do emerge from your hootch in the morning, you sense you are stepping into the post-apocalypse.  The air is thick, and visibility is limited to a few hundred yards.  The sun is nowhere in sight, but the enveloping orange hue belies it.  Every structure and vehicle is under a layer of dust, as if blanket by snow after a midnight dusting.  This morning, I dirtied by hands and then my slacks jumping aboard my bicycle.  The crackle of the gravel beneath the  wheels is the only sound.  The dirt in the air seems to absorb sound and lead to an eerie silience.

I just peaked out the door, however, and relished a view of the sun and cumulus clouds; a sign that the dust is settled, the wind in down, and the air is clean – or as clean as it gets, anyway.

Relative scarcity

I cannot complain about deployments amidst helicopter pilots here for their 5^th 12-15 month tour in the past 8 years.  That said, that is the nature of being a helicopter pilot.  They are most valuable to the world – as helicopter pilots – in this war in the middle east.  Back in the states, they may be in demand to shuttle a CEO from Manhattan to JFK, or to help fire jumpers in the west, but here, they save lives daily, and provide essential transportation services where there are no roads, roads are unsafe, or roads to sanctuary are too long.  Likewise, the trauma or orthopedic surgeons are the war-theater rock stars.  They are in demand all over, but here, at least when the violence was greater, they operated here more frequently and to greater effect than ever before in history.

By contrast, the nature of my job is to diagnosis and treat malignant blood disorders.  Since most of the diseases I care for occur in less than 1:10,000 people, I almost never make a new diagnosis here in theater.  More importantly, and to the point, the capacity to confirm diagnosis through laboratory methods, and initiate treatment is only available at higher levels of care, for obvious reasons, and there is no intent to have me here to perform this role.  In the States, I am one of 3 people who do what I do in the Department of Defense, servicing all active duty and beneficiaries via TriCare, while here, I serve as a hospitalist, just as every other medical subspecialist and general internist who comes here.  That doesn’t diminish the gravity of our jobs here, or take away from the value of care provided by hospitalists whatsoever.  In fact, if anything, it emphasizes the value of their inpatient critical care skills, which, for me, required some dusting and freshening prior to re-use.  It rather emphasizes the nature of deployment patterns and violations of the laws of supply and demand, or scarcity, in the military, or at least, in the medical corps, in order to acheive parity.

In order to keep sending the much needed critical care specialists, they send me to pretend to be one.  In addition, I am pretending to be a pediatrician right now.  [God forbid we get another obstetric case (had an etopic pregancy months ago dealt with by the general surgeons)].  The parity principle is fair in some ways, but then again, those who chose to train in trauma surgery or critical care in the military should have known what they were in for, no?  Interestingly, the parity principle is commonly violated by those puppeteers who steer we pawns around the globe.  The USAF, for example, never deploys radiation oncologists or dermatologists, and just recently started deploying pediatricians.  I fail to see how a dermatologist has less to offer burn patients than I do, especially, those trained in plastic surgery techniques.

Again, the glass is half full; it could be worse.  The urgent care clinic across the street is manned by my army colleagues to help the family practitioners: a neonatologist, a rheumatologist, a pediatric neurosurgeon, and an infectious disease specialist.  If you have MD after your name, the army does not see a difference among you.

June 06 - 66 years later

The USAF deployments used to be 3-4 months.  As the Army was sending people here for 12-18 months at a time, the USAF changed policy and lengthened deployments to 6-12 months (just in time for  my deployment), and the Army, ever for the sake of parity, diminished 15-18 month deployments in favor of 12 month stints. 

For 3 months, you can hold your breath.  To be sure, it is a long time to be without the people who love you, and away from life as usual, but it is not so long that a seamless transition back into that life cannot occur. Life here is so different in every way - hiking to a shower, walking everywhere, wearing the proper uniform, dealing with the threats and stresses of a war zone – and 4-6 weeks quickly fly by before anything becomes rote and a real rhythm is maintained.  Most anyone can muddle through the 4-6 weeks that remain prior to the 1-2 weeks spent preparing for the voyage home.

Six months is different.  Seasons change.  The rains come and go.  And the fog quickly dissipates revealing the exotic, mundane; the weeks and months then progress with a rhythm of life, not an escapade, but a regular life.  Sometimes I wake up in a cold sweat after dreaming that my boys have grown to men in my absence.  It is not missing a t-ball game, but rather, watching, as if through a kaleidoscope, your son learning how to throw a ball from his friend’s father - a surrogate guide through a boy’s rites of passage.

My doubts aside, those on multiple tours contend that there are many opportunities to atone for these fatherly absences.  Those sent here for a year or more, however, put this contention in doubt.  When you receive orders to come to Iraq or Afghanistan for a year, you are picking up and moving your residence, no matter what they tell you.  Active units involved in military operations may work constantly to keep their war machines humming along, and months pass quickly given the greatest distraction of self-preservation.  As if they were frozen in suspended animation traveling at warp speed to and from another galaxy, in cliché Star Trek fashion, they return home to find life has continued without them, and they are not as they perceive - hours or days - but months and years removed those they left behind. 

The permanence of these moves is magnified at the close of a war or during a lull, when the work does not fill waking moments, and the mind is filled with the pedantry of which I have spent months discussing in this blog.  I am not sure how a man, or woman, returns to regular life after spending a year here.  It is completely humbling to consider this in the context of D-Day, which 66 years ago today marked the beginning of what was 18 months, or more, away from home, in deplorable conditions amidst countless deaths and decay. 

Ticket to ride

The key to getting out of here, is the arrival of your replacement.  There is always some planned overlap for you to show that person where the bathroom is, how to say "peace be onto you" in Arabic, and how to get the Indian kitchen staff to deliver you extra curry chicken.  By design, this overlap is not long, however, as every day 2 people are here in one spot, the government pays double.  Though the government is paying double to have 2 people doing one job here, the 3-4 day planned overlap sometimes becomes 2-3 weeks, just because the document that defines the logistics of the handoff slid off someone's desk or is buried under some folders.

In the medical group, as in many, there is one extremely powerful person, a tech sergeant, named Sergeant Lola Jones (not her real name), whose sole job is to manage those logistics.  As there is no train station or commerical aircraft, the monopoly by which you are extracted from Iraq is the USAF - and when it comes to getting out of here, Lola is the USAF.  She decides who is on which plane, which poor souls have to travel back through Qatar on the way to the states, and which are flown directly to Germany or England prior to heading home.  She controls the issue of the tickets, and, as it is rumored, has a secret rolodex of the logistic and aircraft contacts who actually move military members around the world.  Colonels can be jackasses, and Lola still gives them the expedient travel, as the fallout from angry colonels is not worth the hassle otherwise.  The rest of us, however, better be nice to Lola.  Be nice, or spend 2 extra weeks in a tent in 130F in Qatar; and we (below colonel) just cannot make significant enough waves in the tub to save Lola's revenge.

In the military you never want to be the ranter-and-raver as this will assure you get precisely the opposite of what you seek, if, for no other reason, than spite; and because you have pissed off a person who has the power to screw you.  Though passively allowing life to happen can lead to extraordinary opportunity in the military, I don't recommend this approach, either, as no one is really vested in your interests, and you may get looked over. 

Instead, the tried and true approach is to subtlely remind Lola that, 1) you exist, 2) she likes you.  I have learned this lesson the hard way, and have been smiling at Lola every day since I got here.  I even brought her some ice cream when the doctors did our part on "staff appreciation day" (otherwise, of course, this would have been saccharin and over-the-top).  It is my hope that this capital is gaining interest, and my flight out is easy and smooth.  In the meantime, it is damn entertaining to watch officer after officer stomp down the hall and raise hell after Lola gives them little daggers.

Lemonade and chicken salad

Our pediatrician has left the premises.  Her tour has ended, and leadership has decided not to replace her with another pediatrician.  In fact, this decision was made in haste last week, and the pediatrician previously planning on coming over was told to unpack his bags, as he was staying stateside.  As our troops and the contractors are big people, the decision to send home the keeper of the little people seemed prudent. 

Then there is the matter of goodwill.  Or, rather, the political capital our military may aim to gain by providing care to the surrounding community, which, as one may gather, includes children.  Children in auto accidents, children burned in fires, children with risk to life, limb or eyesight.  Now, there are not many children who find their way into our hospital, but there are some, and typically, these are burn victims who end up on service for months at a time.  Luckily, the surgeons known how to care for burns in children.  The problem is these patients get infections, and develop acute medical issues.  And who is to care for this?  Not the surgeons.  Children receive medicine in weight-based formulas.  They do not suffer from diseases of wear - coronary disease, emphysema, diabetes (at least adult-onset diabetes) - but, their physiology and psychology are just different.  Metabolism.  Growth plates.  Communication.  Fear.  Together, we are a team of "adult doctors" who will care for these children who have no pediatrician. 

George Annas recently wrote an article in the New England Journal of Medicine concluding, "...the medical standard of care...  ...can be understood as doing what you can under the circumstances, with the patient's informed consent.  The standard of care is the same in sickness and in health and in emergencies."  I would like to think that taking care of children in this setting is doing just that: making lemonade. 

The impossibility that has been reckoned on physicians in this situation, however, in which mutually exclusive sentiments are pursued - operating a Level I trauma center, and maintaining the 'status' of this capability, while simultaneously trimming down essential personnel  from the roster - is the heart of the frustration.  Meet irrational demands to do the impossible. This is a recurring theme in the military which I will be quite glad to leave behind. 

Pediatrics is a separate residency training I gladly avoided for a reason.  Now that we have sick children here, I will do my best to care for them, and will in the future when they come in to the hospital - I will make chicken salad.  That does not mean, however, that I approve of another chicken shit policy.

Hot wheels!

The dust quickly joins with bicycle grease to form an unpleasant grit with each rotation of the pedals. Riding on loose gravel at low speeds is recipe for capsizing; zipping through the layers of unsettled rock at high speeds denotes wanton disregard for exposed skin.  Tires become flat soon after every weeklong search for a working bicycle pump.  And still, possession of a bike is elevation to Iraq nirvana.  The heat, a little less hot with a breeze on a bike; the mile ride to the BX, a simple jaunt on two wheels.  The late night call to the hospital - diminished to a few breaths, pedaling in the night.

With the exception of a few long term American contractors who spend the money to bring Trek, Specialized or Gary Fisher mountain bikes, most of the bikes are cheaply made knock-offs with a very limited shelf life. The BX does sell very overpriced, low quality knock-offs, but the majority of the two wheeled fleet here is from the recycle market (and usually, just 2-3 recycles before the desert does them in).  Anyway, as part of some unwritten, and frustrating, rule, bicycles (as well as other accoutrement) are handed down from replacement to replacement.  That is to say, when the pharmacist leaves, he betroths his goodies to the next pharmacist; when the orthopedic surgeon leaves, he betroths his Iraqi belongings to the next orthopedic surgeon.  Even my buddy the radiologist didn't offer my his mini-fridge (a prized possession) as he was passing it to the next radiologist coming here - who he barely knows!  Needless to say, I am not part of a rich tradition of inheritance here, and breaking into the nepotistic black market is not child's play.

First, I tried the public announcement - an advertisement: "Man seeking bicycle."  This returned only greedy offers from charlatans to sell bikes for $100-150 which they themselves were given by their predecessors, gratis, as part of the heretofore mentioned nepotistic inheritance practices.  Every subsequent attempt to find a bicycle after this was met with some variation of this response: "Sorry man, I am saving mine for my replacement."

So, it is, the sweetness of now finally having acquired my own wheels - along with headlamps and repaired bicycle helmet (which reads in big black letters over duct tape: "Combat Oncologist") - all divined for a handshake alone from a generous realist who has similar opinions of the bicycle hand-me-down cliques.

With aplomb, I ride through the HMMWVs (humvees) and MRAPs, over curves and into the sea of dust and unsecured rocks.  I avoid the 20 miles of perimeter road for the random peashots that may come from outside the wire; but the protected guts of the installation are mine to roam.  At least until the bike gets stolen, and passed down through another set of undeserving replacements.

Memories

I sent a 24 year old home on the ventilator last night.  He has a ball bearing in his cervical spine, and no ability to breath on his own.  He will likely die within the year, with injury worse, and resources less, than Christopher Reeves. 

A young woman's neck was ripped open by rocket frag, and she died in the emergency room a couple of months ago.  Another was shot in the base of the skull and died in the OR in heroic attempts to put his brain back together.  A young man who was rescussitated with 10 hours of abdominal surgery and 20 units of transfused blood was found brain dead from the closed-head-injury not noticed until the aforementioned surgery was complete, and the head was scanned.

Post-call, I had the day off to go exercise, sit in the sun, read a book, watch a movie; a juxtaposition, on the day to remember these, and the countless others who died, and continue to die, here, and in Afghanistan.

Memorial day had always been a day of historical references: broken black and white film of bombers over Germany, the famous flag-raising photo from Iwo Jima, a video clip of a man running through the bush, and rapid fire of Viet Cong to an evacuation Huey in a jungle clearing.  During the OIF/OEF there have been clips of rehabing amputees or kevlar-laden soldiers and laughing arab children, fading to a longitudinal, diagonal view of headstones at Arlington or Normandy all to the backdrop of America the Beautiful. 

I lost a handful of acquaintances and friends over the past few years to the wars, and I do think of them on days of remembrance, but their passings were sterile and distant, despite surely shocking and painful.  Memorial Day will be a time I will remember the smell of burnt flesh and blood, the high-pitched steady ping of the heart monitor reading asystole, the silent ceremony for placement of the folded flag upon the chest of the HR (human remains) before zipping up the black rubber bag.  The dominant images in my mind, and the most poingant memories will be of those who were carried into the hospital with life already all but gone, those I pronounced dead, those I struggled to heal, but failed.  For those, I salute.

Tarred and feathered

I am officially off of the nightshift, ready to rejoin the living!  So, in the morning on my post-call day off, I showered at the hospital and began my walk into the day.  Quickly, I generated a reasonable sweat in the 95 degree morning air under my all-season wear ABUs (Airman Battle Uniform = USAF for camouflage).  I was swimming through and tasting the dust within the thick air; the opaqueness of which explains why I walked around a corner, downwind - a very steady, fierce wind - from the poop truck which was vacuuming its targeted contents, while another South Asian contractor power-washed the innards of one of the many PortAJons littering the base.  The fetid mist ricocheted onto what had now developed into an adhesive slurry of perspiration and dust coating my exposed skin. 

I have been tarred and feathered, Iraqi style.

Tomorrow will be better.

Lucky Joe

The overhead intercom announced "Trauma times one to the ER.  Trauma times one to the ER."  Shortly thereafter, and prior to the arrival of the pending "GSW to the face," there were 15 docs, nurses, and technicians geared and gloved up awaiting the helicopter. 

As the Blackhawk landed outside the door on the helipad, everyone assumed their positions:  ER doc to the head of the bed, the surgeon and I at the foot, the nurses and respiratory technicians on each side awaiting or gun shot victim.  Then, nonchalantly, the medic from the helicopter walks through the door aside a man with a bandage around his head, and a large compress of gauze held into place against his left cheek. 

Someone ran around the corner to grab a bed - for this patient did not come in on a gurney or litter as per normal, but walked in, on his own accord.  We waited for the bed, and in those few seconds, the ER physician and he had the following conversation:

ER MD:  How are you?
Patient:  Shitty.  My face hurts.
ER MD: What happened?
Patient: I got shot in the face.
ER MD:  Did you lose consciousness or fall?
Patient: No.

The bed arrived, and the patient, again, who walked into the ER holding his face as if he had a toothache, was layed supine where a complete survey of his body was done in less than 1 minute.  His pants were cut off, though he walked into the ER, as soon as he layed down.  He was examined, radiographs and blood samples were taken.  He had a rectal exam, and something close to the following ensued:

Patient: Why are you checking my rectum?
ER MD: This is part of what we do in the evaluation of trauma patients.
Patient: Yeah, but I just got shot in the face.  Not in the butt.
ER MD: I understand, it will only take a minute.

It turns out that a sniper had shot this young man but only entered the left side of his cheek, with the bullet lodging in his sternocleidomastoid on the same size.  He is a lucky Joe.  So, we often get these patients from the front lines with no real background story, and there has to be a systematic approach to trauma patients, in order to avoid missing things that are catastrophic if not attended to. 

That said, this is pretty absurd.  And damn funny.

Run, Forrest

We run for different reasons, but anyone who spends any appreciable time running stops, at some point, and asks, "why am I running?"  Forrest Gump ran a few thousand miles before it occured to him that his means had no end, and in the end, he did not understand the means.  Haruki Murakami wrote a book about the less obvious utility of running - Things I think about when I think about running, averring the clearness of thought, and tranquility his daily run has brought to him.  Clearly, running is more about getting from one place to another quickly.

Maintaining the mental and physical stamina to continue running through the parenting years (also the career building years) is undeniably difficult, and in the case of the author, was a failure.  From marathons and sixty miles on my feet a week, to arthritis and sixty miles of driving a day.  Being here has allowed me an unfettered opportunity to slowly overcome the orthopedic ravages and sloth and return to Murakami's running zen.  This is an exaggeration.

However, there is no beer here (at least no quality beer with alcohol), you walk everywhere, and, most importantly, there is nothing else to do, except exercise.  [The list of leisure activities has been well vetted on a previous blog: exercise, reading, movies].  So, outside of the 60 hours a week that I am at my job - and the slowing pace of incoming traumas has allowed for this working pace since I have been here - there is always time to exercise.  Admist the weight training that the rickety shoulders and knees tolerate, I am on the treadmill, and slowly reducing the spare tire (have gone from p195/75 R16 to p185/65 R14 thus far), and my R-Zen is on the horizon.

Even when you have accepted your fate in this minimum security prison (see previous blog), and you have agreed to make the best of your sentence, ennui looms large (btw-can ennui loom?  or be large? ??).  This is not a unique phenomenon, or a surprise, I guess, as this is the military.  There are, however, nearly weekly 5k running races (universally won by one of the east African gazelle contractors here on base) with hundreds of entrants, sometimes thousands.  Maybe they just want the T-shirt, but I think that they are looking for  clear minds and their own R-Zen(s).