Friday, April 30, 2010

Braumatic Train Injury

Accessibility and affordability of extra-durable alloys conceived over the past several decades have change warfare, and the pattern of injuries we see in war.  Flak jackets and Kevlar helmets are relatively impenetrable to small arms fire or small fragments from IEDs.  High velocity rounds will go right through a Kevlar helmet, and we have seen a patient with an AK-47 round lodged in the middle of her brain - and it will likely stay there for the rest of her life.  Likewise, direct hits from explosive devices of nearly any kind are mostly fatal from despite these protections. 

In general, there are more survivors, or rather, survivors per servicemember attacked, then there were in conflicts as recent at Vietnam.  This is largely due to improved protective devices (eg, armored vehicles, kevlar helmets, flak vests) quick access to medical care.  Tactical superiority plays a role, but in Iraq and Afghanistan, the guerrilla warfare and use of suicide bombings have negated much of the conventional military advantage.  Unfortunately, explosions which would have killed servicemen in the past now leave many with amputations, and many more with traumatic brain injury (TBI) and secondary, or coexistent post-traumatic stress disorder (PTSD).  The DoD has made large investments in medical personnel and research in this area, but the treatment of TBI is still underdeveloped.

We have several patients in the hospital at any one time with TBI. Usually, this is from proximity to an explosion, but can be vehicular accidents, falls, or brawls.  We are largely not equipped to handle these patients here, and they are sometimes the toughest patients to properly classify.  For example, while it is quite clear that patients who have brain surgery for a concussive injury and subsequent brain swelling are to be stabilized, and then sent home, and patients with mild/distant exposure to explosives who do not suffer concussions and pass a TBI screening test should be able to stay in theater; it is difficult, however, to discern how to triage those in the middle.  There are always soldiers who have a concussion and clear post-concussive anxiety who plead to stay here with their squad.  And for each of these, there is another with no concussion who seems fine and pleads to leave (this includes malingerers, and there are some of those too).  It is not an easy judgment call; determining who should be sent home for priority medical care, and who is fit to return to duty.

The other night, I think that we saw the results of one who slipped through the cracks.  This gentleman was 40 feet from a rocket blast, and though he had no clear injuries (behind the wall), he was shaking like a leaf and had a massive headache.  His CT was normal, and brain was not bruised, but it turns out that he has a history of PTSD, and related headaches, from exposure to another explosion in an earlier deployment.  After years of behavioral therapy he somehow garnered approval to return to theater, and then he gets hit again.  His nerves were fried, and one could see months and years of work unraveling. 

He insisted on returning to his unit.  He wasn't my patient, so it wasn't my decision - though it never really is the doctor's decision, as the commanding officer makes the final call - but I do wonder if something else is going to happen to him, or that he'll go unhinged if/when it does.  We have to do better with this here, and when he returns to the US, and is expected to hold down an honest job, and get along with others in a world surreal to his own.

Thursday, April 29, 2010


Bob Hope don't come around much anymore.

No, there are traveling entertainers, of one variety or another, but haven't seen the big names around here.  Since arriving, Bad Company, the Zac Brown Band, somebody-Whorley, 1/2 of the cast from a TBN show about motorcycle ganges, and "The World's Fastest Rapper" have made their appearances.  This is a picture of the Hooters girls. [Note their variable reactions to the skull trauma on the scanner].  They were quite popular, as were the Dallas Cheerleaders

The USO started off the morale campaign for soldiers, deployed, and otherwise, in 1941, and is probably most famous for the Camp Shows they sponsored to back defenses in the Pacific and Europe in WWII.  Now their reach has grown to include access to communication back home, and ocassional sundries (ice cream, shaving kits, dog tags for kids, etc).  They even sponsor a program at the hospital where they will record a DVD of the deployed parent reading a book for their children.  I did this once, but I over-zealously attempted to read too much at a time  (the final chapter of the Percy Jackson book we were reading together).  My ambition left the kids with a video the top of my head as I tried to read the final 25 pages before my time in the video booth expired.  Live and learn. 

The USO started things in partnership with the DoD, and now the DoD has it's own section called the MWR which stands for Morale, Welfare and Recreation.  So, there is an entire DoD mini-budget for gyms, movies, concerts, computer access to augment that which was the backbone of the USO.  As I connect to the internet daily from this MWR computer to write my blog, check email or connect with family on Skype, I am definitely benefiting from the resource.  And again, I am humbled by the set of tools, psychological distractions, as they are, which those before me had to suffer this (and worse) same warish banality.

Wednesday, April 28, 2010

Me myself and I

Young people are spoiled.  Spoiled by the lack of responsibility, boundless energy, and the naivete to venture boldly down any given path.  The aged are spoiled with wisdom, avoiding futile forays, and handling responsibility efficiently, which is necessary given the lack of energy.  Its too bad you cannot get these life advantages in tandem.

Starting a family and then working to support them is sacrificing selfishness.  It is well worth what is given up, but it is easy to forget defining characteristics, habits, and interests of the man alone. 

I communcate with my family daily; usually by email, often by telephone, and sometimes by videoconferencing (Skype).  This still leaves, what seems to me, anyway, an enormous amount of time to spend by myself.  Reading comic books, writing poetry, mastering Kung Fu, collecting scorpions, whathaveyou.  Some people make new friends, and spend their waking moments drinking coffee in the company of their new D-BFF (deployed-BFF).  In these 4 decades though, I have made plenty of friends, and right now, I prefer to spend time with myself - the me that I haven't seen much of since the 10 years of medical training and kids started.  And in between private attempts to impersonate Dave Matthews on the Persian guitar I have (so far) commondeered, or mastering the eagle pose during my late night physical fitness, there is (perhaps, dangerously) sufficient introspection time, during which I have drawn through 2 or 3 steno pads a complex soup of matrices, lists, ideas and doodles. 

That is the way deployment to this place is, at least if you can keep your head square.  You work like mad.  To exhaustion.  You see things that will destroy your faith in humanity, if you let them.  But you don't because you cannot.  So, you compartmentalize the horror.  Leave that when you go home to your trailer.  Take the time you have with yourself and capitilze on the beauty of life.  Buff and polish your body and soul, you must.  Use the terrible suffering you witness to give the relative ease of your life perspective and lead you to greatness.  That, or kick back with your D-BFF.

Tuesday, April 27, 2010

Watch your 6

The sign seems stupid.  If it were in your neighborhood, it would be guilded and a little overbearing.  It has amazing power here.   Very simple, it states, alone on the side of the road: "Complacency Kills." 

Unfortunately/fortunately, there is no conventionality to this war.  The evil hajis just launch rockets into the air and run--for they certainly cannot maintain any position and have hopes to continue breathing--hoping they land on someone's head.  Most of the time, they miss the heads and just make a bang.  Once in a while they reach the statistically inevitability, as that room of chimpanzees typing Shakespeare, and someone walks under a falling ordinance.  The bastards do this to the good hajis, and they do this to us.  There are well-fortified, usually permanent structure bases, like here.  And there are easy targets; isolated, undermanned FOBs (forward operating bases).  This is entirely a guess, as I have no official knowledge of this either way, but I gather these are lower-yield, easier targets lacking much of the high-tech capacity to quickly hunt down the would-be murderer(s).

We get trauma triplets flown in here at a steady, but random pace.  Always 3.  Your guess is as good as mine as to the consistency of this phenomenon.  One patient either dead, or near dead with fatal injuries, the next with completely recoverable soft tissue shrapnel injuries, and a third, perhaps with a concussion, otherwise, esssentially, untouched, but suffering from PTSD, regret and denial, and most poignantly, a sense of responsibility failed.  What do you say to the 19 yo kid who in the midst of a chuckle, took a bite out of his burrito, while, in great non sequitur, the exploding fragment ripped through the neck of his dining companion; and who then, futilely, but determinedly, held this young carotid together with his hands, as he became soaked with the fleeting life of the other?  We had another RPG meal-time attack come in the other night.  The surgeons spent all night repairing the mascerated young sargeant as his 2 comrades waited in angst.  And after expending the reserves of the blood bank, and satisfied with establishing normal blood pressure and heart rate, they then declared him stable enough to have a CT scan of his brain.  Unfortunately, the talking and purposeful movements the patient made prior to the surgery belied the nonrecoverable fatal brain injury which only now became evident on film. 

This is the only way the terrorists can operate, as we whip them on every "conventional" level, but it is cowardly nonetheless.  Cowardice and desperation go hand-in-hand and lead to these essentially unpredictable, and unpreventable actions.  We have safeguards to prevent all that we can:  mortar shields, communication systems, air defense and surveillance.  All of this is what limits the effectiveness of their cowardly cunning.  Any target cannot prevent all that is viciously random in this nature, however, so we must remain vigilant.  Analagously, in the US:  wear your seatbelt, and watch where go at night.  Complacency kills, so watching my 6, best as I can.

Sunday, April 25, 2010

Near but so far beer

I like my beer.  At some point, likely during gustatory nerve-washing in college, I developed a taste for the stuff, and now, I do enjoy a cold one as much as anybody.  Beers of all kinds have their place, but I favor the ice-cold-pilsner-served-up-with-pizza-beer, and, most preciously, the rich-snack-in-itself-porter/stout (preferably imbibed in a tall, walnut booth within a dim bar accompanied by one who has an equal appreciation of that moment).  So, I guess I miss beer, and I miss the beer-experience.

We do a fair assortment of non-alcoholic beverage here.  The hospital DFAC even offers something from Germany called Astra, which is completely detestable, and gold-labeled Coors, which is tolerable when taken immediately from the freezer where it must reside for at least 20-30 minutes.  These "beers" are free.  The BX about 1 mile from where I work and sleep has the finest selection to include Lowenbrau and Becks.  If you are going to drink near-beer here, those are undeniably the best, and can be had for $1 a piece.  [I usually buy no more than a six pack at a time as I have to walk with it for a mile, and access to a refrigerator only at work].

There is a pizza trailer/restaurant called Ciano's, which serves mediocre pizza, and unsavory Italian food (though I have a high standard), and if you coordinate things properly, you can enjoy a cool pauci-Lowenbrau with some passable pizza.  If you close your eyes, you can imagine that you are back in the US, but the hordes of M-16 toting soldiers eating their own personal 8 slices decked out in full battle gear belies this mirage quickly.  Plus, there is no warm-fuzzys after this near beer.  That is the near beer-experience

I am a scientist but unfamiliar with the chemistry involved in making beer without alcohol.  It likely is not very difficult, but there is just something wrong about removing the fermentation of dextrose from the final product.  More is lost than just the alcohol content.  The taste suffers, but powerfully (and strangely) the experience is diminished.  And maybe this is psychological, and I still drink it.  That is what we have.

Saturday, April 24, 2010


The terrorists are typically not smart.  However, they are, by and large, devious.  They make their own improvised explosive devices with with whatever they can find around the cave.  Nuts, screws, bolts, springs, knife blades, pens.  Sometimes, when they are feeling particularly sinister, they sautee their frickasee in cow dung or human feces and dirt in the hopes that wounds will become infected and the injury, thus, more severe.

This picture from a radiograph of one of our patients shows a bolt lodged adjacent his R maxilla (upper jaw/face).  I am sure if there were a little more force, it would have traveled through the maxilla, and likely into the brain.  This is a recent wound, and he was transported quickly to the US after stabilization, so it is tough to tell if this was a septic explosive device or

not - his infections, and he likely has them brewing, are yet to come. 

This reminds me: the surgical paradigms here are thus altered to account for this kind of nonsense.  Trauma patients from auto wrecks in the US, for example, have entirely different injury patterns and are not taken back to the OR for the large number of repeat washings as they need to be here.  This took me some getting used to.  Just imagine the ballistics.  With a projectile, meant to explode and inflict damage hits the ground, the wall, the roof of a structure, there are various perimeters, roughly circular, which define the injuries to be expected.  In a car wreck, the force is pretty well vectored one direction - thus, people looking at a car driving away from them into something are much less likely to become injured than people watching a car driving toward them into something.  Follows the laws of physics, but not something you typically think about in daily care of patients in a civil society.  I quickly assimilated into the habit of counting bullet holes and matching wounds.  When I take care of leukemia patients, I rarely think of these types of things.

Friday, April 23, 2010

Grand central horror

The battle injuries in Iraq come less frequently, thankfully, than they used to come.  There are still plenty of IEDs, snipers, and injuries from accidents (see Thursday's blog); more than any of us would like to see.  Nonetheless, there is no denying that the bulk of the battle injuries come from Afghanistan, just as CNN reports.  During Volcanogate 2010, we have been the epicenter for all patient traffic to the United States from both Iraq and Afghanistan.  Everyone going out has been through this facility, and now that the volcano dust is diminished, we are shipping out the backlog of folks from throughout the AOR to LRMC (Landstuhl Army Regional Medical Center).

We had a medic who was shot in the head while tending to a soldier who sustained a minor injury.  When he arrived, he looked as though his brain would herniate, and he would die.  He had a revision craniectomy, and his CT improved, while he showed complete normal function of both hands and feet, and normal speech.  Another young man fell prey to an IED and lost both of his legs and most of his fingers.  His inhalation injury, incurred from inhaling the burning of his own flesh and surroundings, bought him intubation, but he answered my questions appropriately, blinking and nodding his head, and giving a thumb up.  These were the more severe, but we had dozens come through, most of them giving a thumb up, if they had one to give.

We have launched several missions with planes filled with patients bound for the states.  All CCAT teams based in Germany were here to assist with evacuation, and we were able to move patients smoothly back to the States.  Now with the shorter flight to Germany now back open again, the CCATTs have scaled back and the mission frequency has diminished. We are, however, still full of patients.  Sick ones.  I am anxious for the pending mission to get these boys home, or one step closer to it, and out of limbo, where resources are rationed, manpower is relatively fixed, and it is starting to get hot.

Wednesday, April 21, 2010

Wear your seatbelt

Most non-physicians can tell this is the profile of a head and neck, and likewise see the injury here.  This was from a gentleman who will never walk again after a truck in which he was riding shotgun went end-over in an "Iraqi pothole."  He might have walked away from this if he was wearing his seatbelt.

There are various bad-guy induced trauma injuries, and those are horrible.  We are still in a war of sorts here, however, and we expect and are built for those type of injuries.  With so many people over here, we are bound to see accidents; stupid moves as I recently described in a blog, and a melange of bad choices and luck.   Surely, this guy's 6th vertebrae would be where it is supposed to be if he had not ridden in that truck.  If he had been wearing his seatbelt, he may have walked away.  Who knows?

I might save this to show my boys when they start driving.

Tuesday, April 20, 2010

Moovies Moovies Moovies

War has changed.  Cigarettes and girly mags have been replaced by digital media as the commodity of choice.  Again, what I am doing is far from what the marines do in a new conflict or army guys on the front lines, so the aforementioned may have maintained their value there.  But behind the wire, where power is pretty much constant, thanks to the legions of generators clicking 24/7 in several veritable power-fields around base, laptops are ubiquitous, and the portable hard drives are replete with thousands of movies produced in the past 20 years.

When you are within a minimum security prison, there is not much to do.  Excursions involve walking to the BX, working out, and going to eat (and the Cadillacs).  So, you end up watching lots of movies.  The military encourages this, and even provides several public HDs full of movies.  I reckon it is part of the plan to keep the natives from getting restless.  If you are not working or working out, they want your eyes on the tube, sedated.  And while it is less true in a deployed environs in which the best view stations are procured at the expense of individuals (see Man Cave Part I from March), the military has gone on a wide-screen television Blitzkrieg buying spree back in the states.  Again, part of the hypnosis, I gather.

To that end: Once, while preparing for the deployment I was on one of my 27 trips to the comic-ironically named, Readiness office, completing my 3 page scavenger hunt, and I decided that they sure had a lot of TVs down there.  I counted 33 people working in the department, and I counted 27 televisions.  All of them were larger than 40" or larger.  Surely, some of them are necessary for presentations, and whatnot, but 27?  I cannot imagine that tax dollars to keep Airman Snuffy and Private Duffy entertained with Oprah while they work is within the best interests of national security.

Anyway, there are a veritable cornucopia of movies available here on HDs.  I have seen far too many to count, but I have also read 11 novels.  I have not done as well keeping up with my reading in medical journals, but have done more pleasure reading than I have since pre-children.   The remainder of my free time not in the gym, writing blogs, or reading is spent keeping up with my beautiful wife and kids.  So, the time away from them, while impossibly painful, is passing.  I am nearly half-way done with my 6mo, and have caught up on all of the pop-culture (and other) I have missed being a busy physician and father back home.  Maybe this will help me to avoid watching my boys roll their eyes when I try to be suave.  Actually, probably not.

Monday, April 19, 2010

Volcano surge

We are insignificant beings. 

With all of the technology, capability and resources at the disposal of the military, our entire program of shuttling patients from theater to the US changed overnight with the middle earth exhalation from an Icelandic mountaintop.  The ash which turns to glass when heated within a turbine jet engine has grounded not only passenger flights across Europe, but all of the military flights.  There is word today of an F-18 test mission today over Northern Germany which left turbines encased in ash-glass, so apparently, it is still a problem, though the flying ban is supposed to lift imminently.

We have significant trauma surgery capability here at this theater hospital, but there are limits to what we can do when these surgery patients get infected or become chronic medical patients.  We have very little capability to care for medical intensive care patients, and no capability to care for cancer, to my chagrin.  Thus, anyone who we don't see going back to work within 2 weeks, we send up the road for a higher level of care.  Most of the similar flights from Afghanistan go directly to Germany, north of Iran over Russian airspace.  The flights from Iraq mostly come from here, over Turkey and southeastern Europe to the same destination.  Patients can get everything they need in Germany, but we send them home to DC or San Antonio from there, when they are stable and/or they are requiring chronic medical care (e.g. a new leukemia patient requiring months of chemotherapy, or an amputee requiring rehabilitation). 

With VolcanoGate 2010, all of the flights must now go directly to the United States.  This has put an enormous strain on the air-evacuation system, and made our base the center of the AOR evac universe.  All of the flights out of Afghanistan cannot fly north of Iran any longer, so they fly south of Iran to us.  We cumulatively send our Iraqi evacuees and Afghan evacuues on flights that go directly to the United States.  Recall that distances from Old World to New World are significantly longer as you move closer to the equator; that is, the flights which steer south of the Icelandic dust over Europe to go the US are 21-27 hours long.  This usually means that 2 separate crews are needed for each flight.  So, taxpayer, I am not sure on the math, but there is some serious costs incurred enacting "plan B" during a volcano eruption. 

Seriously ill patients are tended to via CCATT - critical care air transport teams.  These include a physician, usually an anesthesiologist or pulmonologist, a nurse, and a respiratory technician.  Though each of these flights back to the US is filled with AE (air evacuation) patients, most of them are either ambulatory (e.g. digit amputation) or low resource (e.g. stable patient with foot ulcer) not requiring CCATT.  My ICU patients do, however, and even the evacuation of 3 ICU patients at a time via CCATT is not a small thing.  There are many wires, and IV lines, and tubes with which to contend.  The most complicated issue is switching of ventilators, as all of the CCATT patients travel with the Uni-vent Eagle 754 compact portable ventilator, not the plug-in 5ft  models at the bedside.

Tonight, I have 3 of them coming from Afghanistan, and 4 of them going out 2 hours later to the US.  They are due to arrive within ten minutes, so adios, for now.

Sunday, April 18, 2010

Hey, y'all, watch this!

I got this picture from It is part of an article done on the Seminole Alligator wrestling festival.

It was not taken in Iraq. but it reminded me of some the acts of stupidity I have grown accostumed to seeing. 

We have treated several tragedies which involve some level of stupidy; head injuries from 1) on-concrete-tackle-football-player, and 2) an assortment of roll over accidents with a vehicle racing theme (generally, not a good idea in recently bombed place where roads average one studio apartment sized defect per mile, there are no lane markers or street lights).  There have been suicide attempt plummets from just 3 stories high, and one poor soul who tried by taking a bottle of laxatives. 

In the ICU, the humor in stupidity-accidents is shrouded with horror.  If they are here, they were exceedingly stupid, or, more often, exceedlingly unlucky, and perhaps a little foolish.  The ER gets much better stupid stories.  The guy who shot his buddy witha pellet gun in the butt while looking to shoot the birds (too keep them off the flight line).  The Colonel who busted his face when he passed out on the treadmill (ok, not so stupid, but funny nonetheless to see the man with full birds on this shoulders and no front tooth).  The car wreck from the "bright shine of the reflective belt [of the person walking in front of the car]." The plethora of ankle twists and broken fingers from the soccer games played with basketballs on the 2ft elevated basketball court (!!??!?!).  And of course, you will recall the story I told a few weeks ago about the dog suit and the K9 unit...   ...well, one of the ER docs broker her clavicle, while in the suit, after being slung to the ground by the 75lb German shepard. 

There is one young man who had come back with testicular pain 2 weeks in a row (from excessive masturbation) in efforts to see the lovely female urologist.  Between his visits, our replacement/new physician-o-male-hardware is sure to perform a not too gentle rectal exam to reduce this and similar visits.  So far he has successfully reduced this recidivism.

Stupid things happen everywhere, but the seriousness of this place makes the absurdity so much more poignant.  So, we have no alligator mouths in which to thrust our heads, but you can get a rise for much less than that around here.

Saturday, April 17, 2010

More on fried chitlins

I have already confessed my professional ineptitude for dealing with pedi-burns (burned children).  Luckily, we have one pediatrician and one pediatric anesthesiologist deployed here, so they do most of this care, but I do ocassionally get called, and have to break out the calculator...   ..."80mcg/kg for first 10kg, then 5mcg per each 5kg, and pt is, how many kgs?" 

I am happy to report two more relative success stories from facial burns in kids who would have died if for not the American medical support provided them. 

One 18 month-old child had 2nd and 3rd degree face burns, but because of the accompanying inhalation injuries, was intubated for 18 days, and even survived a respiratory code and flatline.  He is extubated and smiling, his wounds are healing, and though he may have some slight scarring at the areas of deepest burning, he will recover nicely, and his small scars may actually provide him masculine ruggedness as he ages.  His largest advantage, beside his medical care, is his mother, who, despite her full headdress and inconveniences of modesty, has slept by his side every night for nearly 3 weeks.  I wondered for a while why his father or others didn't come to replace the mother, and it was suggested recently that they were not welcome.  Indeed, it could have been that they were not allowed to come see the boy while he is on base as they are known to be affiliated with bad guys, or were bad guys themselves.  The mother was allowed visitation, and I know nothing of her beliefs or intentions, but know her gratitude and manners are replete.  Perhaps the outcome of this child will turn some hearts and change some minds, and there will be less bad guys to deliver AK-47 rounds to the heads of 29 year old women the day prior to their birthdays, as happened last week.  [Sending this soldier home 3 weeks prior to her scheduled departure was bitterly ironic].

The other small child with facial burns will have some unsightly scars after a hot oil spill, but she will survive, and soon she will leave the hospital to join her family.  Her mother has never visited for reasons I do not know, and her father, or the man who claimed to be her father, is no longer allowed to visit her, given solicitious and improper behavior he exhibited on his initial visit.  [I was tending to a patient's wound and looked up to see him curiously peering in the wound with a smirk on his face, as if to say, "That SUCKS for that guy!"  He was also found propositioning the nurses - that didn't go over well].  I wonder how she will fare.  The young man I described above will grown in a family that loves him.  I am unsure if he will grow to be a man who loves or hates America, but he will grow to be a man.  This girl, I fear, has a less certain fate, not due to her wounds from the fire, but perhaps from the wounds already imprinted in her mind, and the environment she will return to for the final stages of her recovery.  Do girls with dozens of siblings and half-siblings from one father who has multiple wives receive support she needs to completely recover?  If she does, what happens to young women with scars on their faces who come from families like hers, here in this chaos?

Caring for individuals who have homes to return to in the United States evokes different emotions, but never regret.  We are used to a social structure that has evolved to assist the wounded and ill.  One cannot help to wonder, however, the fates of these local nationals, when it is time for them to go home.  Is Iraqi society prepared to handle them?  Will their family be able to provide what they need?  Paralyzed or severely injuried Iraqi patients released from military hospitals have been know to show up in the Tigris days after discharge; cooly dispatched of by cruel, or maybe just realisitic families who have to ration resources carefully.  The thought of discharging a child like this, and hearing of her found dead in a ditch or river evokes indescribable rage.

As a physician, however, you must handle that what is your charge, and can do only what you are meant to do - in your training, and in your position; you have to compartmentalize.  As a military physician, you must do so within the context of the mission.  There is frustration when the mission changes on the whimsy of a bureaucrat up the chain, but discipline to the mission keeps things together - or that, at least, is what I try to tell myself.

Friday, April 16, 2010

Burn baby burn

The wind is a savior.  The sulfur and carbon dust blow with the wind, and any point lateral or upwind of the Burn Pit can enjoy a day of clean breathing.  On still days, the burning refuse eminates in all directions from the pit, and fills each of the lungs which breathe it, twenty thousand of times per day.  These lungs, like the filters on the air conditioners and the screens on the windows, are painted with the visible contents of the air.  The molten and aerosolized rubber, heated and gaseous deposits of countless ploymers, and the pungent essence of the charred methane of human waste, create a noxious olfactory cacophony.

At my current, location, the largest of the burn pits - an open air 10 acre ignited waste dump - has been replaced by more sanitary means of disposing of waste.  But for years, this was assumed the most efficient, feasible means to be rid of garbage in this war zone where priorities for strategic control and security outweighed what was considered a nuisance smell.  Clearly, the burning and susequent inhalation of carcinogens and pulmonary toxins is more than a nuisance, and it may be that these pits increased the risk of a variety of maladies in our soldiers. 

Indeed, soldiers in the area have claimed exposure-associated illnesses ranging from lung fibrosis to emphysema to cancers of all types, first when Saddam set fire to oil geysers in his 1990-91 retreat from Kuwait, then with the invasion of Iraq in 2003, and since then on fixed installations which developed burn pits.  The difficulty is delineating causation and coincidence as the inhaled toxins are known to be dangerous in a dose-dependent fashion, and exposures are extremely variable depending on the jobs we have in theatre.  For example, it may be easier for a young corporal who dumped garbage and lit it on fire to make the case for a VA claim, than it would be for Predator pilot working from an underground climate controlled room.  Regardless, this is causing big problems for the government as the number of claims has risen, and the evidence of causation is really mounting.  There is a good NYT article on the subject - the link is here:

Interestingly, the DoD has repeatedly claimed lack that these burn pits are safe.  As the NYT article ponits out, however, the internal studies were done in settings bound to bias against causation (rainy days, etc).  This is very disappointing, and has to make one wonder.  It is as though we are revisiting the Vietnam:Agent Orange episode all over again.  Ultimately, the government will likely end up spending more money caring for the veterans who became ill in theater, than it would have spent to create safer incineration/waste removal practices in the first place.  This time, however, the VA will pay, and not the DoD.  Interesting.

Thursday, April 15, 2010

Freudian Blogonimity

[Brief diversion from the mission for below philosophizing]

To previous followers and commenters, and recently, to you, R.P, E.E. and P.W., thank you for your lovely emails - your notes warm my cardiac cockles.

To the rest of you:  thank you for your patronage.  But who are you and are you really out there?  That is the problem with a blog, isn't it.  You aren't writing a column for a newpaper that gets circulated to so-and-so many individuals.  You are not writing a novel which you can pick up at Barnes and Noble, and by law of the direct mail, will sell at least 1% of the copies printed, to someone who may read it.  Someone curious.  Or foolish.  When you write a blog, your Id is scribbling, your Ego is editing, and your Superego is publishing on the ethereal Matrix, disguising the product of the Others in such manner making their labor superfluous and invisible.  Sure, under Idian pressure, the Ego negotiates with the Superego, and the invisibile is visible, for a handful, a select few - in the form of the code to an otherwise random, impossibly located corner of the Matrix.  Otherwise, really, how many eons would it take a room of chimpanzees to type, and therefore instruct their internet browser to go to :

I digress.

Blogging is lonely business.  After nearly two decades of email, one becomes, or I have become, conditioned to know the internet as a social tool, and another means of dialogue.  Never blogged before.  Blogging ain't like that.  Just monologue.  Or soliloquy.  Or drivel.  Let me just leave it there.

Wednesday, April 14, 2010

The bell curve blues

One of the perks of this job is that I get to wear my pajamas at work.  Nothing is more comfortable than a set of cool, thin cotton scrubs and a well ventilated clog shoe.  Unless, the scrubs don't fit.  The medium scrub pants make me look like I am trying out for the BeeGees.  The extra-large pants always seem to invite a comment from one of the nurses, though they will do in a pinch, you cannot see my shoes when I wear them, like a Franciscan monk, or Dopey the dwarf.  The medium shirt just doesn't work.  I do an unconscious Hulk impression, ripping the shirt in half as I bend over to examine a patient.  The extra large shirt's v-neck nearly bottoms out just above my belly button, so it is equally ridiculous.  You may ask. "But, where have the size large all gone?"  And I will answer, as you may guess, that size large is the size occupied by about 75% of all of the people here, but not proportionally represented in the clothery. 

When it comes to the scrubs, they represent a largess of donated, or, frankly, stolen, surgical attire.  They have various stamps of ownership from around the world's hospitals.  The other day, my tunic said, Sacred Heart, and on my fanny read, Property of the US Government (so true, indeed).  But due to some atrocious miscalculation, there are the same number of extra small scrubs as there are size large.  My friend, the Lilliputian pediatrician comes with smart new color of perfectly tailored scrubs daily.  Today, in order to find a garment that fit, I had to endure a chartreuse tunic with white tulips. 

As per standard ethos in the military, there is a unofficial "workaround" for this.  I was informed by a veteran of 5 months here, that due to the difficulty of finding scrubs, she just takes 3 sets that fit her when she finds them (mind you, a large woman), and rotates them through her own laundry, thereby keeping herself flush with well fitting attire, and leaving me in chartreuse.  This is where the saying, "If you cannot beat 'em, join 'em," comes from because fixing this is just not worth the clear discontent I would cause.

Take that and think of the clothing sales at our little Iraqi BX.  They sell PT gear here - which is good, as with the heat, you wear 2 sets a day, and no matter who you speak to prior to coming, you never bring enough of those T shirts.  Unfortunately, they haven't had one large t-shirt there in my 12 stops since arriving.  There are, however, several bins of 4XXXX large.  I mean, is there anyone actually that big in the military at all?  How about throwing a bone to all of the people who sit on the fat part of the bell curve?

Tuesday, April 13, 2010

The nose knows

When they first came here in 2003, the base was basic.  It was founded at a previous military training site of Saddam's, but had to be greatly expanded.  The living quarters to support the vast numbers of troops here had to be constructed.  For months, human excrement was removed via burning (by the lowest ranking), and they lived in tents with the ants and scorpions, before semi-permanent facilities were brought in and constructed.  All of this is chronicled well by photos and video.  The whooping of the Chinooks and Blackhawks, crescendoing thunder of the F16, and the churning of MRAP convoys live on, but I imagine the war orchestra once included far more fortondoando, back in the day. 

But one thing you just have to imagine is the smell.  The sulfuric bouquet of cordite and burning rubber still remains, but to a much lesser degree since closing the "burn pit" (more on this at a later date).  The greatest sensory change over the past decade has got to be olfactory, not just the carbon-stained outside air, but the air inside a tent or building or vehicle or aircraft.  And this, likely due to the genesis of showers.  In 2003, the men-and they mostly were men-didn't really take too many showers.  Washing was brid-bath style, and on ocassion, via the sun-warmed shower bag.  The 15 gallon transparent bags of water drained to gravity and served as makeshift showers, and still do, at forward locales.  The sun would warm the water during the day, and depending on the time of year, become too hot by early afternoon, and they chill again to near freezing by dawn.  This meant a rush for a limited supply of suitable water between 1000-1300.  I reckon many a stinky soldier.

The Cadillacs have come and we are now on version 2.0, or something.  There are separate shower and toilet stalls.  There are actually hot water heaters, so thre is usually hot water.  Sometimes, there is even some water pressure.  I only have to walk 50 yards or so myself, but some folks walk 300 yards.  Just as with the toilets, you find a favorite shower, and you find yourself going to that shower only.  Maybe you like the way the curtain hangs, the situation of the stall, or perhaps the hooks outside the curtain for your things.  It doesn't matter what it is, but something about that particular shower captures you.  I have a specific advantage insofar as i work in the hospital, which has probably the most Western version of a shower around.  The water pressure is good, the water is always hot, and the walls and floor and clean tile; not the thin mold-ridden composite plastic that lines the semi-private Cadillac stalls.  This huge advantage is a reminder of home, and does make things more comfortable.  The humanity of a hot shower is only obvious to he who lacks it.

The mortars do not fly as they did, and the burning has near ceased.  The crops grow, again, around the outside of the wire, exchanges exchanging carbon gases for new oxygen.  But not long ago, the bombs fell, and burned, plumbing was a luxury, not commonplace, and hygiene standards rose to a much lower threshold than they do now.  Take all of this and compound with necrotic rotting flesh, months of standing water and excrement, and just imagine what the trenches of Avingon or Gallipoli smelled like.  It is merciful that visual and audio war history are so much easier to comprehend than olfactory accounts.

Monday, April 12, 2010

One is the loneliest number

Schizoid personal disorder afflicts a small number of people who most aptly can be described as "comfortably alone."  For whatever reason, these people see no need to form relationships with other people.  Perhaps, they are most entertained by themselves and that is enough.  Most of us, however, are social animals; we need to interact with other human beings.  And that is the base of it.  We really need more than that.  Affirmation, reciprocal love and concern, and ultimately, a complex interdependency with another soul.  I am surrounded by people all of the time here.  [There aren't too many places to be alone - outside of the Cadillacs].  Most all of them were strangers when I arrived here, and now most are friends and pleasant acquaintences.  I am interacting with people because I don't have a choice: I cannot be schizoid here, even if I had that propensity.  Schizoids in the military have holed themselves in offices or are off crawling through caves by themselves.  They just aren't - or shouldn't be - working in the hospital.

Despite these forced interactions, and elective ones we may or may not subsequently seek, near all of us lack the companionship of our partners - unless (and this is rare) they are deployed here with us.  Now, lacking this partner implies having one, of course.  There are hundreds, dare say thousands, of young men and women here living their single years.  They don't have the emotional self-defense mechanisms that their wiser sisters and brothers have, but they haven't left behind a sizeable chunk of their -ness either.  Perhaps, it is the parallel growth of emotional strength with ensconcement of another into our deeper Qi which allows us to be here and perservere without our Other.  I don't know.  Loneliness is not about being alone anymore, it is about being without One.  In this minimum security prison of mine where there are always a dozen people with nothing to do, happy to do something with you, seclusion is fleeting and exasperatingly seldom.  But loneliness is pervasive.  Despite the marvels of technology, phone calls and letters, I miss her touch, and sharing our life.  I long for my Other.

Tragedy is a potent accelerant of perspective, however.  The loneliness while germane to this time, is finite.  She will wait for me, and I will come home.

On the contrary, tonight, I watched a 20 year old boy die.  Someone shot him in the head with a high caliber rifle, and the only reason his heart was still beating was that his skull was, for the most part explosively removed, giving his brain a decompression recompense, thereby preventing the brain from squeezing down into the neck as it swelled.  He was brought here from a local hospital for neurosurgery he was too far gone to receive.  But we had him then; ventilated, complete with the accoutrement of the fated, too far gone to send from where he came.  If his family could be found, they would never get through the security here to see him before he died.  We would never find them anyway.  I hope he was already running through Paradise with his 72 virgins, and didn't have to feel the loneliness I felt for him.

Sunday, April 11, 2010

Dear Iraq: Be grateful

We are leaving.  I promise that is the plan.  But first, we will try to leave you with security you need to avoid devolution in anarchy.  Your police force was largely illiterate, wiith little or no knowledge of weaponary, and no knowledge of the laws of civilized nations beyond what is in the old testament or Koran.  Our citizens have paid to clothe them, train them, and provide them a salary with which they can feed their families. 

For reasons right or wrong, we removed a bloodthirsty dictator, and, in good faith provided the framework for an egaltarian society.  The man who used poison gas against thousands of his own people is now dead by trial and sentencing of your judicial respresentatives.  The progeny of these people can now vote in a representative democracy, and their voices can be heard, as can the majority Shia who were shackled by the Ba'athists. 

The stars of the previous Iraqi society have left Iraq under tyranny, but many return to build upon the ancient stones of thousands of years of productive peoples.  The infrastructure so damaged by Saddam, and then by the US military in its attempt to rid the world of his tyranny, has been costly, but the rebuilding effort has been mammoth.  Retarding renewal of a great nation via the guerrila warfare and terrorism, a small minority of Iraqi citizens, and jihadist recruits have and continue to kill for a purpose which is becoming more and more unclear. 

When the cover of the newspaper has photos of burning effigy of American leaders and an angry crowd in Baghdad on the day of several recent bombings, I am dismayed.  Is that fire different than that which melted the flesh of the young Iraqi children we now care for here?  Why must embassies of peacemakers be bombed?  Why must young soldiers be kidnapped?  The overall sentiment in Afghanistan and here in Iraq favors hastening of the removal of American forces.  Personally, I am more than happy to oblige in leaving this dusty hell-hole, but I also understand the long-term price to pay if we leave you in the hands of the Taliban and Muqtada al Sadr, respectively.  And thus, I remain here under the orders of our President.  But when in history has a conquerer, no matter the legitimacy of their conquest, acted more benevolently with concern for the vanquished?  Having learned a lesson after WWI, the allies after WWII were not even such benefactors to the losing Germans.  And that was a war between armies of nations, not upon innnocent civilians. 

I am not a historical scholar.  I am not a politician, or military commander.  I am just a doctor.  I am here caring for your (and our) injured and ill.  And all of the rest of us are here doing a job to help you as well - building your roads, designing your electrical grids, teaching your police.  Just be grateful for that.  I don't have to hear it.  I don't need the edification.   But don't curse my ancestors, and wish me ill.  Don't kidnap my brothers to torture, humiliate and kill them.  Just respect, to some degree, your benefactors; be thankful in your heart, thankful for our sacrifices to help you.

Saturday, April 10, 2010

Curry makes the meal

Food is readily available, free, for the most part germ free, and a far cry from the MREs others have to endure.  I shant complain.  I would be remiss, however, if I did not make some observations of the deployment cuisine. I have previously mentioned the curry fajitas on Tuesday, but may not have noted the preceding cumin-laden kung pao chicken on Monday, or the Indian-spiced steak on Wednesday.  Oh, and Thursday is Indian night.  You can always get a salad or soup if you tire from the Aruvedic churnas.  Be forewarned, however, the salad is sprayed with a sulfa-containing preservative, and some people ain't quite right for a week after the salad - probably those with sulfa allergies.  So far, I have been unaffected, which I can also say with regard to my forays into the fruit tray, which is, honestly, as good as what you would get at the Fresh Market.  Mangos from Kenya, Syrian pears, and avocados and onions from who knows where are highlights from the DFAC (dining facility).  It is a marvel of logistics that anyone can arrange to feed thousands of voracious soldiers in a war zone with anything but prepackaged meals, let alone fresh perishibles. 

Recently, I have taken advantage of a healthy collection of cereals, and seem to eat cereal or pop tarts twice a day.  The resourceful radiologists also help keep the menu more diverse as they seem to have daily shipments of blue corn chips, wasabi almonds, albacore in salt water, or other delicacy foreign, and are generous to share. 

We also have 2 restaurants on base.  You have to pay for this food, but it is a change in ambience from the routine of the DFAC.  Ciano's is like a Iraqi Sbarro's.  The pizza is better, but nothing to cherish.  They have tasty coffee.  The other eatery is called Sami's Turkish Cafe.  This place is adorned with middle eastern decor - kilims, brass pounded reliefs of one mosque or another, and some belly dancing music - but has pressboard tables, plastic chairs and peeling linoleum floor reminiscent of a branch of Napa Auto Parts or the DMV.  They also serve pizza, and one of the great debates across we deployed concerns the relative merits of Sami's and Ciano's 'Za.  Frankly, it is like comparing K-Mart and Walmart

I prefer Sami's not because of the pizza, but rather the small array of Turkish cuisine.  Tonight, I had what I was told was lamb.  It was decent, not great, but, importantly, tasted like something you would cook at home, rather than something defrosted or mass produced.  I sat on the hospital roof by myself and ate my lamb tava watching the sunset, imagining I was somewhere else.

Friday, April 9, 2010

Unapproved bodily fluids

So which bodily fluids are unapproved for the toilet, anyway? 

During my active duty tenure, I try to take pictures of signs like this that I see.  I can share a few others soon.  One favorite is the one that says, "Iraqi free zone," and points left toward a landfill.  With all of the rules we have, it seems like they should require all of the sign writers to pass some kind of written english competency test.  In addition, they should at least do their homework as to which part of the law they are referencing.  Article 78 in the UCMJ concerns violations as an "accessory after the fact" so flushing unapproved bodily fluids is likely not punishable by the UCMJ, at least not under Article 78.  It is funny how the world, this world, at least, is so punitive.  Are we supposed to shudder in our boots when we see, "Punishable under Article ____ in the UCMJ?"  That is like saying, "Punishable under page 4 of the constitution."  The acronym "UCMJ" just carries such foreboding power among we Pavlovian dogs for reasons we can only explain as conditioning.

I had once noticed a funny sign in the military advertising a talk for a gastroenterologist entitled, "The History of the GI Tract."  Seriously.  Really.  This compendium of mastication, digestion and elimination, given by a senior colonel who had risen to his rank by virture of the military's loss of his competition over 25 years, was accompanied by several email reminders of his visit complete with the requisite warning of required faculty attendence...  ...or what?  We would not be present to heckle him?

Anyway, sometimes it is like being Hogan or one of his Heroes, not held by the Germans, but rather in the captivity of the Literalists and syncophants.  Find levity where you can get it.

Thursday, April 8, 2010

Fly me to the moon

The military's air evacuation system is multifaceted and complex.  I am more of the end user.

For instance: Infantry gets shot.  BattleBuddies carry guy to bunker and triage him.  Helicopter (or truck, then helicopter) brings him to the local hospital or medical unit.  Guy gets stabilized as best as possible.  Helicopter or small plane brings guy here.  Guy gets more stabilized.  Guy gets sent to US via Germany.

As a small and compact, but true Level I trauma center, we are prepared to do a variety of things here which include vascular, neurological, urological, orthopedic, ophthamologic and head and neck surgery.  We are not a multifaceted medical facility, however, insofar as we do not have a catheterization laboratory, dialysis, chemotherapy or endoscopy.  This is by design and for obvious reasons, but as one can imagine, it limits what we can do for the ill surgery patients, and obviates definitive care for the medical patients.  For example, there is no heart surgeon or stent-placing cardiologist to rescue a patient in cardiac shock after a heart attack.  We maximize medical managment, package, and ship.  As a service to the many contractors in theater, the military provides medical care and transportation, for an undisclosed and negotiated contract, to ill service members.  This seems like the right thing to do for the multinational work force that supports the military.  As I have discussed previously, it is neither safe to send most of the individuals to local hospitals where they may be perceived as complicit with imperialists by the Bad Guys, nor is it a standard of medical care that Americans are prepared to accept, given the departure of senior physicians and scientists and a now fledgling medical education system.  Recall, however, that there are 100,000 contractors in the AOR.  Most companies do not screen deployed individuals as does the military; ergo, the 58 yo smoker with diabetic-foot who presents to our ER in sepsis.  As the planned withdrawal ensues, and the smaller bases close, we are all curious as to what will happen to these individual who are placed throughout the country.  Will they all come here?  Anyway, that is not the point of this piece, and I will save room to debate that another day.

More interesting at the moment, is the evacuation of patients, at least from the end use perspective.  We provide definitive therapy (ie, sewing up bowel in a IED victim, neurosurgery from gunshot wound--or soccer ball as shared earlier--or antibiotics, vasopressive agents and supportive care in the patients with severe infection and sepsis), and often, just stabilize patients (eg nitroglycerin drip, morphine and aspirin for a patient with a new heart attack) for the 5 hour flight to Landshtuhl Medical Center (LRMC) in Germany.  American military all go this route, eventually, on their way back to the states.  American contractors most often use the same channel.  The non-American contractors, however, are usually sent at the expense of their contracting agency to some place closer, and in this part of the world, that means Kuwait, Saudi, Egypt or Jordan, which are replete with excellent physicians and facilities.  [I understand the Emirates are also well equipped, but are likely too expense.  Given the price of a night at Dubai's Grand Hyatt (starting at $960, I can understand this].

Ideally, the contract agency is suppose to arrange for pick up of the patient at the US Air base.  As can be imagined, however, it doesn't always go so smooth.  With Germany, it is really easy as there one hospital and a set of people who know the rules and each other.  When contractors are ferried around the region, however, it is not uncommon for the plane to arrive without a proper hand-off of the baton.  Meaning, of course, that the transporting military team is not met with the reception promised them by the contractor.

Most people aren't malicious, and this is usually due to a miscommunication, but this can lead to less than desirable situations.  Take for instance, the other night, when I sent the intubated Asian stroke patient to Kuwait with the CCATT (critical care air transport team) team.  The contracting agency had arranged for transportation to a civilian hospital to be ready at the terminal when the CCATT arrived.  Well, the ambulance wasn't there, the hospital, 45 minutes away, had no room and had never heard of the patient.  The CCATT team, being medical people and doing what was right for the patient, brought the patient to appropriate care.  Clearly, however, not the role of military folk, and an example of how if you offer the contracting agencies a nibble, they bite off your finger.  I can imagine this scenario repeating itself, potentially putting uniformed military medical personnel, without a security detail, at risk and the expense of the tax payer.  Let's hope not. 

Wednesday, April 7, 2010

Muddrops keep falling on my head

We are a bit north of Egypt, so perhaps the plagues are coming out of order.  That, or today was not arrival of the 9th plague of darkness, but rather just a prelude to the 2nd plague of frogs, the river (Tigris) having already turned 'red with blood' over the past several years.

"This is what the great LORD says: Let my people go, so that they may worship me. If you refuse to let them go, I will plague your whole country with frogs. The Nile will teem with frogs. They will come up into your palace and your bedroom and onto your bed, into the houses of your officials and on your people, and into your ovens and kneading troughs. The frogs will go up on you and your people and all your officials." 

That sounds about as scary as frogs can possibly sound, and I have yet to see amphibians, but this storm was unlike anything I have seen before in the States or elsewhere.  From the afternoon heat, an amorphorous orange haze arose without warning from the desert and occluded the sun.  Before this picture was taken, I was squinting behind sunglasses.  As it darkened, I started to take them off were it not for the gale which brought dust of that foreboding cloud slamming into all crevices and apetures, cornea included.  I cursed.  I cursed the military for bringing me here, this wasteland which is my current home, and then the gods.  Despite the curse, however, my wish for some accompanying rain to put down this thick air, was granted. 

This odd rain was not a refreshing sprinkle.  It was more like the splatter of water you might feel standing next to a puddle when a bus drives by you.

The rain actually came down in the form of mud - admixing with the fine cloud of airborne earth.  Though it may be hard to tell, this picture is a uniform decorated with mud drops.  Muddrops.  These muddrops showed up right after my shower.

Tuesday, April 6, 2010

Fits with Fitness

Residing in a minimum security prison means that your the meals are the same - curry fajitas every Monday for us - the library is stocked only with books you can buy at truck stops, and there is plenty of time, and incentive, to get in shape.  Superior fitness make walking on the loose gravel, which has been poured everywhere to lessen the muddy mess on the rare ocassion of rain, smooth sailing.  When you perform those walks in 125 degrees with 55lbs of battle armor and a weapon, fitness is a necessity.  I do a lot less of that than, say, the infantry and civil engineers around here, but even the hopelessly slothful see direct gain from a daily run and few push ups in a place where going to work and eating means walking no less than 1 mile per day minimum. 

Exercise is like tobacco abuse.  I am not sure anyone has tried to make this analogy before, but here it goes.  Like smoking, exercise is not pleasant when you start.  Sometimes you do it to look cool, or fit in with everyone else.  Before you know it, you are really liking it, and find it part of your day, using it more and more to quell emotional toil and anxious thoughts.  In essence, it takes more and more of it to feel satisfied.  Then you have a day without it, and you feel incomplete.  You become anxious, and your mind races.  Perhaps, there may even be some nausea; your body just does not feel right without it.  Then, after sometime without it, it is hard to imagine starting it again given the unpleasantness experienced with the first start.  Well, this is problem a description of any addiction, but as I am in another hate phase of my love-hate (bolded as more 40-60% type of balance) relationship with exercise, I liken it most to tobacco: socially pervasive and insidious, bitterly seductive, and ultimately, unforgiving for misgivings. (The analogy totally breaks down here, of course, as exercise is something you would want to start again, and tobacco, ideally, is not.  Not to mention that, though I may be idealistic, I would like to think that a lifelong devotion to physical fitness would lead to agile octagenary, not portable oxygen and lung neoplasm).

There is another aspect of exercise which is particular nasty.  That is, sometimes, no matter how hard you try, no matter what your mental and emotional dedication, the body doesn't cooperate.  This is especially cruel given the direct relationship that exists between injuries, and a general crescendoing recognition of the emotional/psychological devotion to exercise necessary with age, not just to be buff, but to get through the day - no matter the motive.

I continue to my Sisyphusian quest, only venially daunted, always looking for ways to improve efficiency.  And here, with 80% of the population between 18-28 years old, Narcissus need not look far for self-appointed gurus.  There are those who prescribe to the standard lifting programs or daily running/swimming.  We have dozens of spin classes - predominantly attended by women and old farts, not mutually exclusive.  P90x is a video series all loaded up on PCs connected to big screen televisions in the gym - aerobics for the 21st century.  And then there is CrossFit.  Some of the first people I met here - all 8-15 years younger - raved about this, so I gave it a try.  I come to find out that this a little like a cult, at least over here.  But what the hell, I will not fall prey to a cult, and was interested.  The concept of the program is to incorporate aerobic activity with weight lifting with a variety of exercises to create muscle confusion and maximize an intense workout in a short period of time - this was just the get-fit-quick-scheme I was looking for. 

I tried it, I was exhausted.  I walked funny for a couple of weeks, but thought it was as good a way to spend an hour getting fit during the day as any, and was actually starting to feel strongish.  Of course, my soreness relented just in time for me to throw out my back doing a dead lift.  Please don't ask me to explain what this is or why the hell I was doing it.  Needless to say, the 28 year old CrossFit CoolAid dispenser had insisted I do an exercise I hadn't done in 20 years, and I acquiesced.  It hurt.  Perhaps, after a few months of lean living, I will again be ready to give this routine a try.  Until then, I am sticking to water aerobics and watching Oprah while on the recumbent bicycle.  No shame in that, right?

Monday, April 5, 2010

Law of diminishing providers

Easter was my first break from the daily blogging.  I would like to say this is due to my devotion, and I decided to take a day of rest, but I would be exaggerating.  The truth is, after Jesus died for our sins, people started trying to die here, in force.  After the weeks of boredom with intermittent hysteria, the past several days have been more of a prolonged hysteria, just now settling to flatuent murmur.  This week: burned babies, heart attacks, 3, yes three, projectile-in-brain traumas - all of whom survived, without serious deficit (well, one is blind in one eye, and one cannot move his left arm) thanks to the swift handling of our adroit neurosurgeon. [See - some of our counterparts in Afghanistan actually just removed a live round from a patients head].

I just described some trauma, but the majority of what we are starting to see now, in the setting of relative peace after the election of Alawi, are non-traumatic injuries and illnesses:  heart attacks, meningitis, cellulitis, strokes, etc. etc.   With over 100,000 troops, and 100,000 contractors in Iraq, we are statistically destined to see a proportion of these types of cases, with the remaining being seen at small FOBs (foward operating bases) throughout the country.  As has been publically disclosed, with the post-election drawdown, the expectation is to close all of these FOBs, and exit the theater via a handful of larger bases.  If the convoys of servicemen leaving these FOBs are attacked, there may be considerably more trauma at the hospitals which remain; read: us.  But even in the best case scenario, with no attacks, we will start to see a much larger proportion of injuries and illnesses that any town of 200,000 people might see. 

The draw-down has also meant shrinking assets and space, not just personnel.  So, now that can potentially be seeing considerably more patients, we have 1/2 the space for ICU patients, 1/2 the space for regular ward patients, and 1/2 the staff to care for them.  This is very much likely. 

No surprise to anyone, but everything in the government moves slow, and the changing of missions in the medical corps are no exception.  As we see little of these cases now, we generously care for all active duty, most contractors, and assortments of HCN (host country nationals).  As the volume increases, the mission will have to change, or we will just not have the beds available for American soldiers when we need them.  Think of it this way: the Iraqi health care system is in shambles, and the best care in the country right now is likely here at this theater hospital (scary thought).  Baghdad is a city of over 10 million people, and most of the sick ones would come here if they could.

I am a worker bee, and have no effective role in defining policy.  We have, however, been sending feedback  up river.  Let's just hope and pray that the those mining the locks haven't gone out for a 2 hour lunch. - this is a little peak at our cozy hospital ward, busy even at 0300.

Saturday, April 3, 2010

The Omega Pu Fraternity

This is my current sentiment, though I cannot claim the wit of this graffiti.

The thinly veiled roll of posterior torture in the form of lowest bidder industrial-strength adsorbent "sanitary paper" does encourage, however,  a foray into the territorial behavior of the military man (for reasons which will become obvious if they are not already, I cannot comment knowledge of analogous regressions committed by the fairer sex).

I haven't been counting porcelain "omegas" - rather plastic ones, or, often, the spaces between 2x4s, here in the sandbox - but, by rough estimation, the number of rectums (not counting the colostomies at my workplace) here at this enclave outnumbers thrones by more than 20:1.  I am sure someone in the Pentagon working for the 3-star in charge of logistics has actuarially prepared for this type of derriere:throne ratio by carefully calculating the number of minutes spent per soldier performing the base act of ridding of undigestables.  (Never mind, that the waves of curry fajita induced dysentery are both unpredictable in scope and severity of those affected - beyond the scope of all ninja actuary - like Josh Worsham or Frank Houghton).

Anyway, there is always an available, relatively sanitary place to get down to business.  But among men, at least, this is not the point.  For these most private of moments, the king needs to be atop his own throne.  Just imagine the scandal of violating this privacy to be atop the throne of another king!  In anything by the most dire of emergencies, this, among men, is a deplorable act of humiliation.  In Iraq dust-camp, we make adjustments, but the territorial lines, make no mistake, have been drawn - like the tape around Les Nesman's office he imagined in Cincinnati - and woe be it to he found in the stall of the king.

This brings me to an experience had the other day in the nearby Cadillac (though I am still unclear of the origin of this name for the W/C trailer, I am starting to suspect that it is a ironically applied compliment of sorts, to this 20th century improvement over the Turkish toilets endured by those before me).  I was near the end of time in my personal claustrophobia-inducing plywood box, when there was an attempt to open, then a loud bang on the door.  This was followed by and urgent, "Hurry up, I have to go," uttered in a deep voice owned by someone very capable of just removing the plywood door off the hinges.  After recovering from the initial shock of having my entitled-field-grade-officer-personal-space invaded, I remembered that there were 5 other empty stalls when I entered the one I was currently occupying -  given the picture above this is the one I have come to prefer.

"Try another one," I simply said.

"But I use this one!" he unrelentingly replied.

I thought about this for a minute.  Now, I am not one to prescribe entirely to the king:throne subculture described above, but I admit, unabashedly, that the concept is not foreign.  An attachment to any particular commode has its roots in learned behavior.  As a child myself, I witnessed that a good number of those in my father's family, only would concede to conduct said business via a "foreign toliet" in a complete emergency.  One of my best friends from college, to this day (as far as I know), still insists on being completely naked, not even with socks, to perform the act.  !?!

So it is, not out of fear of the hulking M-16 carrying, walking bicep behind the door, but out of respect and perhaps a bit of empathy, for the man and the psychologic quagmire had immersed himself into, that I quickly completed my business, and egressed.

I could see him scowl in the mirror while I washed my hands.  He didn't even say thank you.

Friday, April 2, 2010

Burnt Childs

In my practice, I care for adults.  Occasionally, I will see a 17yo and treat them like adults (much like the State of Texas chooses to do with slightly underage criminals), with adult medicine and therapy.  I never, however, manage the medical care of childly children, as in the ones who drink milk from a bottle, carry around a "lovey" or eat Goldfish crackers.  If children were really sick, it broke my heart to deal with them, otherwise, their parents broke my will and patience.  So, early in medical school, I knew that though I love children, I don't want to be their doctor.  

During stem cell transplantation, many patients develop GVHD (graft vs host disease), which is, essentially, an immunologically mediated burn caused by donor lymphocytes which recognize the host tissues (skin, liver, GI tract) as foreign and attack.  However, my exposure to burns in my earlier training consisted of the more traditional skin charring secondary to fire, and I didn't really enjoy this type of medicine at all.  The patients were disfigured, and the collateral damage of terrible, and sadly, often intentional, accidents.  They required their rooms to be intolerably hot while they healed given loss of skin and inability to regulate body temperature, and had frequent dressing changes with wet sloughed skin stuck ingloriously to each petroleum laden cloth.  More than one of the patients with burns I cared for as a medical student blew themselves up by lighting a cigarette while receiving oxygen.  Oxygen is flammable. And, hey, aren't you needing oxygen to breathe as your lungs were ruined by smoking?  [This calls into question Darwin's meaning of "survival of the fittest," and usually led to horrible facial and airway burns].  But I digress.

The burns I have seen here are awful, and not, in fact Darwinian, but rather, most often involving chidren.  The stories are not pleasant: big sibling pushed 3yo into fire, 17 mo boy walks into stove, or 3 yo girl pulled hot oil onto her face.  Here in Iraq, as in much of the 3rd world, the cooking is done often, not in conventional electric ovens, but rather over a fire in an open pit.  In addition, while the epidemiology is not clear, there is clearly an unacceptably high rate of child abuse, and some of these pediatric burns are via hot oil punishment from troubled parents.  Education is the best means to limit this, and improved means of cooking ( are coming, but both egalitarian rights are still farther up the hierarchy of needs than, "security", "food", and "shelter", all of which are just starting to solidify.

Oy!  Children and burns - this is not what I thought I would be doing; so heartbreaking.

At least I don't have to work in the STD clinic.

Thursday, April 1, 2010

Negative reinforcement and punishment

The First Sargeant for our Wing (think army = brigade) is not the most senior NCO (non-commissioned officer); the more senior NCOs occupy the positions of "Chief" or squadron superintendents - this roughly means that they have their own pick up trucks to get around base, and represent our squads at morale events such as fun runs, live music performances or award ceremonies.  These most senior NCOs would never want to be the First Shirt because this job is a mix of hall monitor, risk manager, and narc.  Our First Shirt has to present for the Prosecution in all UCMJ violations (and GO1B violations), minor disciplinary infractions, and has to, on behalf of the Commander, set the tone with regard to enforcement of the rules. 

One of the particularly notorious and unpalatable faces of the First Shirt is that of clothing inspector.  There are certain ways to way the different uniforms (the camoflauge, the PT gear, etc), and clearly, there are always people pushing the limits, but the twice weekly reminders of nuances of uniform compliance are tedious, at best.  With the warmer weather here, and I am sure this is a recurring theme, a few young soldier/soldierettes strip down to the bare essentials on the roofs of their work places for some sun.  No one would know that Private Jones was baring all, but the Victoria Secret, on the roof.  No one, except, that is, one of the helicopter pilots who fly the Blackhawks and Chinooks overhead in scores every afternoon.  Does Private Jones think that all helicopter pilots and passengers will remain silent on this violation? 

So, in typical rant to the lowest common denominator, my e-mailbox, and everyone else's is filled with reminders of expected behavior and attire.  The letter from the First Shirt on behalf of the Commander, the forward of the FS's letter from the Commander to all personnel endorsing said note; and then, a compendium of syncophants to follow.  Got it.  Will tuck in my shirt, and will be sure not to roll cigarettes in the sleeves.  This is the tact to change behavior in the military.  It is entirely punative, and directed like shotgun fire into a flock of ducks.  In this analogy, I am minding his own business on the periphery, receiving contaminant buck shot from the proverbial Dick Cheney.  Another reason to wonder as to why we have trouble retaining skilled people in the military.