Tuesday, March 30, 2010

Supporting supporters

A long term occupying force requires considerable infrastructure.  After a critical mass, the mission-executers (combat infantry, pilots, intelligence) develop a more indeliable footprint, and caring for basic needs requires a large support structure.  The critical mass was reached year ago here, and the majority of the thousands on this base support essential missions, rather than execute them.  As I have described, we have a fixed wall (and mortar-shield roof) hospital, and there are similarly robust edifices throughout the base.  Ultimately, everything supports the Mission, but they don't send me out to get bad guys - I just fix up the good guys who get hurt rustling up the bad guys.  Or at least that has been the modus operandi.

For better or worse, however, the Mission is a moving target.  Drawing down essential staff to care for injured good guys is reactionary, not simultaneous.  Over a certain period of time, less of the good guys are hurt rustling up bad guys, or there are less bad guys, or we just get better at wrapping up insurgents casualty-free.  So over this time, the medical corps has been drawing down the staff in the AOR (http://en.wikipedia.org/wiki/Area_of_responsibility) because there is less trauma - again, a good thing.  During this same time period, however, the FOBs (forward operating bases) have been closing or losing capability, so we are seeing a larger and larger percentage of patients with non-traumatic illnesses and injuries here at the trauma hospital who would normally be treated within or closer to their FOB.  As most of the active duty force are put through extensive screening prior to arriving in the AOR, and held to high physical standards, there are, proportionally, only a small number of illness among them.  There are, however, a rising number of  non-traumatic illnesses among the less (non) extensively screened, and woefully less fit civilian contractors who are among us.  Clearly, some of these contractors are the young Shri Lankans or Malaysias employed to do non-skilled labor by the large contracting firms (see early post - Outsourced), but it seems like the majority are the chronically ill, and medically mal-managed westerners.  I recently was consulted, for example, on a 50yo security forces contractor (yes, he carries a loaded gun), who was thought to have a stroke, and was brought here from Baghdad via helicopter for evaluation.  It turns out that the US Army spent these resources for an improperly screened, chronically ill man in the setting of drug overdose due to self-medication of his relapsing migratory polyneuropathy which he acquired years prior via infectious Rickettsial disease (eg Lyme disease, erlichiosis, etc).  Why someone on narcotics with chronic pain and polyneuropathy is working security in theatre carrying a gun is a mystery to me.

In my world, this is a recurring theme, and we care for patients without prejudice.  I sense, however, that it is a harbinger for the scrutinous debates next to come:  what personnel services are contracting agencies really responsible to provide for the contracted price; what does the government provide?  what is the absolute basement threshhold necessary for individuals to be allowed into the AOR?  And ultimately, are the contractors here to support us, or quixotically, are we now supporting them?

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