Monday, May 31, 2010

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Memorial day had always been a day of historical references: broken black and white film of bombers over Germany, the famous flag-raising photo from Iwo Jima, a video clip of a man running through the bush, and rapid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.

Saturday, May 29, 2010

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.

Wednesday, May 26, 2010

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.

Tuesday, May 25, 2010

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).

Sunday, May 23, 2010

Power up

The hallways in the hospital have been dark tonight.  Air conditioners are turned warmer (or off).  The base stopped carrying the AFN (Air Force Network).  There was an initial request to reduce power consumption, followed by a second, more forceful message which basically said, "if you don't, we're gonna 'insert-punative-action-here'."  Just like anywhere else in the world, people are very slow to voluntarily reduce their power consumption.  If they weren't we would not be talking about global warming as much as we are.

The military, is a dictatorship, however, and punative actions happen regularly to meet demands.  Often the demands are mutually exclusive; for example, "double your output, and half your work force."  In this case, continued power consumption at the rate the base was using was not commensurate with the amount of fuel left to burn.  So, when everyone (not me, as I avoided doing my laundry and wore dirty clothes to save warming wash water and powering a dryer) ignored the warnings, the electricity nazis sprang into action.  Some Army battalion commanders just shut off the power, making surly infantrymen even more so.  Granted, that was an easy fix, albeit Draconian when the temperatures are over 110 degrees.  The kindler, gentler Air Force commanders have assigned squandron superintendents to reduce consumption, in a more nuanced fashion.  This explains why only the emergency lighting is turned on right now in the hospital.  It also explains why the hospital is 28 degrees Celsius.  This is ok when you are dressed in scrubs.  The fevering patients are not pleased, however.  [It is striking that everyone of the 200+ CPUs in the hospital are cooking all night, even though only about 20 need to stay on for the nightshift.  The hilarity of this was not lost on this author who was told by the "systems" people (see tomorrow's blog) that shutting down the CPUs was a bad idea as the network links would be irrevocably lost.  Why, you may ask, would a network connection be forever lost because the computers shut down and turn back on in the morning?  They couldn't explain this to me].

I digress.  Power has been spotty, except for mission-essential (weapons systems, hospital, planes), due to this shortage, but not bad overall.  Again, nothing to complain of in the scheme of things.   It does make one wonder why we don't have an overabudance of solar power given the abundance sun here, but I guess for the same reason Arizona isn't off the grid.

Saturday, May 22, 2010

Life, limb or eyesight

Friday is the Muslim holy day.  On May 21st, it was a pleasant evening in Khalis, and a crowd of locals were relaxing outside of a coffee shop in the busy market, enjoying the change in weather.  A vehicle containing an improvised explosive device exploded in front of this crowd, and destroyed many shops.  The blast killed 30 people, and left another 4-5 dozen injured. 

As this town less is than 15 minutes from here, we started to receive report that the bulk of the seriously injured patients were on their way here.  This caused an initial panic, and in the end we only received 2 of these patients, one who had minor injuries, and ther other, who came to our ER pulseless, had his leg amputated, but who is now eating breakfast and happy to be living.  There were rumors that the road and bridge over the Tigris from Khalis to this base was blocked - presumably, by terrorists - but I have no idea of whether or not this was the case. 

Given the quality of care we have provided for many Iraqi citizens here, we have daily requests from outside of the gate for admittance and care at our Joint Theater Hospital.  Obviously, we are not set up to become a local trauma hospital (or community hospital for that matter) for ill and injured Iraqis, but the policy, as stated by people above me who make policy, is to accept only patients from the community who arrive at the gate with risk to life, limb or eyesight.  The same day as the aforementioned bombing, for example, a head-on collision just in front of the base led to 5 trauma patients (all of who survived, and 3 of whom have already been discharged) come in to our ER simultaneously. 

The "life, limb or eyesight" policy has its holes, but does, at least, provide some humanitarian assistance to truly urgently ill patients.  It is a tough call for a 20 year old Army medic to make, however, with only a walkie-talkie to the ER to help sort through information.  Head-on collisions, for example, are particularly dangerous, and lead to high-impact low-survivability trauma, so taking these 5 patients from the accident, when only 2 of them really ended-up having urgent needs, is acceptable.  There are those who try to game the system, as you might imagine.  Patients are sometimes driven to the gate, unloaded from a still-moving vehicle (sometimes supine from a pick up truck), as the delivery vehicle speeds away.  When this happens, the patient often has IVs and a name bracelet from another local hospital.    We do what we can for these people, but you can imagine how this makes steam come out of my bosses ears.

And it can lead to confusion.  A young burn victim who alights himself making a bomb gets free admittance and care, but an infant with a potentially fixable birth-defect, may be denied and returned to the hands of a sobbing mother, destined to go without a life-saving (eventually) procedure.  Children with cleft lips are turned away, even as our head and neck surgeon has no planned cases.  Though all of these decisions are made through reason, and with the best interests at heart, many people - outside of the gate, and within the hospital - cannot reconcile these decisions.  Sometimes, it is the greatest challenge to win hearts and minds.

Thursday, May 20, 2010

Generally speaking

One of the benefits of working nights means that you aren't around during the day.  Particularly, here, that means you miss the Dallas Cheerleaders or Hooters girls when they come through, but you also miss the visits from the DVs.  Distinguished Visitors (DVs) are the military equivalents of VIPs, and they often are not distinguished, but they are almost always General grade officers in the military, or civilian equivalents.

We have had Iraqi and American legislators, governors, heads of agencies (eg. Red Cross) and all of the paparazzi-worthy military (eg the guys you see on the evening news).  This week General Green, the 3-star general in charge of the USAF Medical Corps paid us a visit.  He is supposedly a nice guy, and approachable enough.  I have heard different things of General Odierno, the head of the military in Iraq, who was due this week also, but canceled do to something, undeniably more important.  I lack firsthand experience with any of these people because I come to work at night.

The funny thing about their visits, however, lies in the preparation dedicated to each of their visits.  The "Bio" or CV for each DV comes via email to the whole installation prior to their visit.  If the DV is important enough, we are usually also sent instructions on how to act with a reminder to hold our backs particularly straight, and have our desks particularly orderly.  There is a literal red carpet that sometimes comes out (though I have not seen this here in the AOR) - as if they came to receive their Oscars - and their are near life-size portraits of these individuals on placards at entrances to the building.  Each duty section selects a particularly spiffy, well-put-together individual to give a prepared 30-60 speech about the capability of their duty section; "Our patient wards include 20 beds with the capability to expand to 40 beds in the event of a mass casualty..."  Laughing, visibly, within the line of site of these individuals during their sermons is considered poor form.

And then, there is the entourage.  The aide-de-camp, the public affairs official, the body guard(s); the more important the DV, the larger the entourage.  This gaggle always includes the local commander, or in the case of the less important DVs, the vice commander.  Rounding out the entourage are the chief master sergeant (top enlisted person) and the local superintendents (the top enlisted persons aside of the chief - whose jobs are most amorphous), and a token soldier, seaman or airman who either suffered a battle injury, earned the Medal of Honor, or represents an underrepresented ethnic group.  Sometimes, the Chief gets lucky and finds someone who can be all 3.

Monday, May 17, 2010

Me me me

One thing about deployed life that is difficult for the many single people here to understand is that it is, ironically, an unbelievable selfish time.  Our military is a volunteer service, and we all know that being sent away to one shithole or another is part of the job - the part that feels less voluntary, and indeed is almost entirely involuntary, is the particular shithole to which one is sent, and, of course, the time, length and particulars of internment to said shithole; not to mention the politics and obscured path to righteousness among many of the more recent military forays.

I digress; the point at hand is that when you are on your deployment, your primary, and near solitary non-work focus is upon yourself.  Surely, some deployments are more mission intensive than others; the mission consumes all of the waking time for some of our forward deployed troops.  Away from the front lines, there is time away from work, and it is not spent cooking, cleaning, caring for children or parents, and commuting from one place to another.  Commuting, at least for me, and the majority of the 20 thousand people here, involves a negligible period of time, and usually serves the added advantage of loosening up my legs for the self-indulgent body sculpting which is soon to ensue.  The clothes are washed for free by a service provided by the government - they even fold your socks - and the food is hot and cooked 4 times a day.

After work in the morning, I go to the gym, and have nearly broken 20 minutes for a 5k run - the fastest I have run since high school - and the spare tire is gone.  I have read several novels. Daily, I complete my (near daily) blog, play guitar, and spend time writing letters or emailing my family.  I have watched nearly 4 seasons of the Sopranos, both seasons of Rome, all episodes of It's Always Sunny in Philadelphia, all three seasons of Californication (all of which I recommend), and about 30 movies.  [I have commented previously on the volume of digital media here, and it really is dumbfounding the amount of digital media is made available to us, whether purposely, as designed by Uncle Sam to keep the masses docile and sane, or via an accident perpetrated by the ease and infectivity of digital media sharing]. 

And not all of this is on my time off, as such would be impossible.  On slow nights at work - as is the nature of trauma, we wax and wane between frenetic and comotose - I accomplish a grand majority of the movie watching (see Man Cave from March blog), blogging, and guitar playing.  Now, quixotically, and very ironically due to the consolidation on base, I have a larger office, and a 'man cave' of my very own (see forthcoming blog: Man Cave III).

When I tell my wife these things (maybe I shouldn't?), she sometimes rolls her eyes, and this reminds me of how she, as did I prior to coming here, has very little time that is her own and for her own enrichment.  Parenting is its own joy and reward, do not mistake me, but raising 3 boys leaves little time to play guitar, go to the gym or wax poetic.

So, in my final stage of grief [see blog Being here (and too much philosophy)] - acceptance - I am "looking at the bright side."  And so the irony of an act of patriotism - selflessness, embodied - has rewarded me with a sabbatical from selflessness.  This is a free pass to do the introspection many middle-aged (am I really that, now?) American men need to a divorce and a Porsche to accomplish.  Ok, it is dangerous, uncomfortable (often, though not always), and most importantly, a previously unperceivable sacrifice to miss the lives of my wife and children.  But...    ...the glass is half full.

Saturday, May 15, 2010

The beauty of a clean day

The yellowing sky to the east, with fading stars and the moon above were the first clues the dust was down.  Quickly, the rising star of ours heats the cool night air, and the convection currents stretch the rare, singular portion of the day, that, when the sky is clear and the lungs are not full of dirt, elicits rare smiles, deep inspirations and peaceful sighs from lone soldiers off to eat or come to work, the marching batallions still cool in the full gear which will cause them to sweat liters later in the day, and the legions of drivers, windows-down, contently moving their jeep, truck or tank down the road.  But today's mission will not be in blindness of sand, and, given the cooler morning air and clear sky, will surely include an enjoyable shaded moment for lunch or rest in the afternoon.  A quick rain brought the dirt from the air back to where it belonged, but before this, the monochromatism of the landscape was startling.  Contrast was absent, and visibility severely diminished.  There was no whipping, conical sand gales, but the dryness, and the steady breeze had erased all but a small fraction of the landscape's palatte.  Each breath led to a cough or sneeze full of its contents.  The windows of all vehicles were opaque, as if painted to be so.  Air intake fans had, and still do, deposit daily coatings to everything that is inside. 

So, I aim for a quick sleep, after only 13 hours of the past 84 spent in slumber, so that I can take a late afternoon walk, to where (well, there is no where to go), I am not sure; but to walk and breathe clear air while the birds are awake, the palm leaves still rustle, and life is vibrant - and not toilsome, beneath a merciless hot, and dirty fog - prior to my 12 nightime hours inside the hospital.

Thursday, May 13, 2010

Hot stuff

I woke up at 1845 today.  The sun was nearly down, and the sky was darkening.  It was 105 degrees.

I lamented on the crack in my Anesthesiologist friend's new glasses.  She said they spontaneously broke in the sun while walking to lunch.

Scorpions sweat here.

When I told a colleague that I was scheduled to go to Iraq this year, I asked him how hot it was in the summer.  Both of us were in San Antonio, and had suffered a particularly blistering summer together there.  He had returned a year ago from a deployment to Iraq himself.  "San Antonio," he said with a smirk, "is a memory of winter for you."  I laughed.  He couldn't be serious.

The main question I have is to how this could be the part of the world (not Italy, not Hawaii) that people have been fighting over for the past 5000 years?  Is it the monochromatic landscape?  The camels?  The fun loving Sh'ria law?  No, it must be the climate.   But its a dry heat.

Well, not really, yet.  Apparently, once the rain stops, sometime around now, it doesn't rain again until the fall, and as it heats up the humidity starts to drop.  Right now, it is 110, and still a little humid, since it rained a week ago, or so.  I understand that once the puddles are all gone, the air dries out and the temperature rises.  to 130 or so.  As the temperature is rising here, schedules need to be adjusted to accordingly.  I am planning for this, and aiming to spend as much of the day from 0900-0500 within air conditioning as possible.  And I will try not to burn my scalp.

Wednesday, May 12, 2010

Operation Proper Exit

Wounded soldiers are stabilized here, and sent on their way as soon as it a plane is available and it is safe to fly home.  Over the past decade, most of these patients have spent time in Germany as a secondary triage point on their way to the states.  The majority of their recoveries, however, have been in the States, and usually, in DC or San Antonio.  Wounded warrior rehabilitation takes place for months after amputation and wound healing are complete. 

With this in mind, the time that most of these individuals spend in our hospital is a blur.  They remember images, pain, confusion, but have no tacit string of memories.  And this is what they have told me first hand when they return.  To help soldiers deal with the psychological damage they endure with war injuries, Operation Proper Exit, the brainchild of soldiers themselves, and now executed by Rick Kell and his relief organization Troops First, brings wounded OIF soldiers back to the theater in order to provide these men and women an opportunity for closure and emotional healing.  One of their stops is our hospital, and I have had the opportunity to meet these people who are 2-5 years down the road from their injuries.  All 16 of the last group to come through walked into the ICU, but 15/16 had prostheses, and a few had 3 artificial limbs hidden by their baggy uniform. 

The project is designed for the soliders who were injuried, but has the unexpected, and welcome benefit of adding to the care of our current soldiers who are still dealing with the acute aspects of the injury.  Most of the more ill patients are not in a position to greet these physically-righted, as best as possible, returning soldiers, but most are, and seem to appreciate them.  A brotherhood within a brotherhood, are the injured from war.

Monday, May 10, 2010

Nurses

The nurses caring for the very ill here come from all walks of medical life; the ER, the ICU, specialty outpatient clinics, and even neonatology.  They bring diverse sets of skills and experiences, and have diverse range of aptitudes.  This is true anywhere, but magnified in a situation where the staff is generated collectively from hospitals all over the country, and really, the world.

There is one nurse who works in the ER, and moonlights in a catheterization laboratory.  She is reasonably skillful, but has an exagerated sense of her own skills, and commonly questions orders from all of the physicians.  A quest for edification or education is fine, but it becomes tiresome to explain alternative ways to do things right to someone who seems to have been trained in a singular, but apparently superlative fashion. It is worth noting that being awake and alert in the ICU is enough to drive anyone bonkers.  After asking this nurse to provide the alert and non-sedated Iraqi patients with some kind of Arabic media (TV, magazines, etc) for the past several days without a response, I decided to write my request as an order in the chart.  She didn't like this, and thought it was patronizing.  My retaliatory order was: "Please make balloon animals for patient."  She didn't like that either.

Another of my nurses clearly graduated at the top of her class, though this could not have been more than 3-4 years ago, as she looks no older than 25.  She is demure, and keeps away from some of the more outspoken of the staff (see above), and spends her time reading or providing extra comforts of some kinds to the patients.  As I was coming in to work the other day, she was walking toward me, on her way home with fresh tears in her eyes.  Apparently, a young soldier charge or hers tried to hang himself with his IV tubing when she walked around the corner for some supplies.  This was averted, and obviously awful.  The dayshift carbon-copy of the RN in the previous paragraph saw this as an opportunity to disgrace her, by filing the infamous "incident report," (of which there is likely one being generate in my file for the balloon animal comment in the medical record).  My young friend, blaming herself for this misgiving and near tragedy, had the compound guilt of underperformance or making a near disastrous error (walking away from bedside for 5 minutes?) in the face of a senior, and markedly inferior, nurse.

It really is like General Hospital minus the sex.  Politics and drama.

When people ask me what I actually do here, my response is that I do very little, but write a lot of orders which other people execute, and for these nurses and technicians who clean, maintain, and comfort these patients; who administer medicines, shepherd through rehabilitation, and organize important medical documentation, I am grateful to thee.  For those of you who go the extra mile in care of your charge: I am inspired.

Sunday, May 9, 2010

BOOM!

There is not much to do around here, but when you are in a deployed environment there is a real opportunity to see all of the myriad things the war machine does in theater.  When times are slow, all of us supply a tour for other military who are here, but just do a different type of job; I have had 2 F-16 pilots shadow me during my shift thus far.  Last week I was the highlight of my deployment. 

After obtaining eye protection from the OR, and ear protection and some gloves from the helicopter pad, I boarded a MRAP and made my way to the home of the EOD (explosive and ordinance disposal) squadron about 1 mile away.  From there, we traveled with our EOD crew onto the flight line.  We stopped multiple times for FOD removal, and once for a landing F-16.  On the far side of the runways there was a big open space and a large concrete bunker. 

We parked adjacent to this bunker, and made our way, in small groups to 5 separate piles of ordinance, each with its own EOD instructor and large pile of C4.  The mission of the day's controlled detonation was to destroy - read: incinerate - these materials.  We were each given a stick of C4 plastic explosive, and tasked with designing C4 squirrels, balls, hearts or whatever the imagination led one to ply with the doughy explosive.  Afterwards we staked the C4 around these expired munitions and enemy UXOs (unidenified ordinances), careful to assure that all of the C4 touched itself in order guarantee ignition of all of the explosive.  I learned, among many other things, that C4, while explosive and powerful, was actually quite stable, and if not ignited directly via a power source or through direct contact with other previously lit C4, may not explode at all, even at the high temperatures of the blast.  This was deemed quite undesirable of a result for the EOD experts as it may end up mandating that they search the blast radius for pieces of unexploded C4, which they obviously could not just leave lying around the flight line.

After the C4 was packed around each of the piles of munitions, the non-EOD "tourists" were escorted back to the bunker, while the experts placed the blasting caps, and ran over 100yds of wire back to the bunker where we all anxiously awaited.  I was lucky enough to get to pull the lynch pin when the time came, and watch, in less than a second's time, a large explosion down range, followed nearly simultaneously with a thunderous boom, and subsequent smell of cordite.  [Video and still photos pending].

When I returned  to the hospital from my "field trip" to the controlled detonation, I was sad to know that a contractor, new to our base, jumped into a ditch when he heard the explosion as he had thought we were under attack.  He was in the ER, safe from major injury, but undergoing a scalp repair from the gash served to him from the rock at the bottom of the ditch. This is not the way I aim to create business!

Saturday, May 8, 2010

Being here [and too much philosophy]

The distaste, wonder and pungent idiosyncrasity lasted for a month or so.  The subsequent month was spent establishing routine and interweaving into the system while attempting to improve the status quo.  At this point, I am just here, living.  I previously wrote of itinerate nature of this place.  The perspective I mentioned, only tangentially, was that of the (dis)affected new old guard.  Seeing people go has been a delight in some cases, and sad in others; however, the replacements have invisibly slid into place during the rejoice, or lamentation, over the departure of the old old guard.  Now, nearly half of the people I am working with have been here for a shorter duration than I have.  The tenor has changed; as so change policies, practice, and positions.

So that is another aspect of being here: its inherent mutability.  Establishing, and re-establishing schedules and routines, fine tuning policies and compromising with a new wisdom from alternative background and style.  Going from newbee to the new old guard.  And part of this moniker comes with acceptance.

Just as Dr. Elisabeth K├╝bler-Ross' described stages of grief, the deployed soldier goes through a similar experiences.  The shock is over, as is the anger, despair, and bargaining.  A year, or even a half of a year is just too long to hold your breath or thrashing in battle.  Now, it is acceptance.  There is nowhere to go, and you have to live your life, no matter the current situation, as it is.  My family adapting to being without me, and me, reciprocally, finding ways to live, with the exception of brief communications home, as an island.  After 15 years with Kristina, it is hard to be an island - albeit with internet access - again.  Melodrama, but it is what it is, and it is part of being here.

Thursday, May 6, 2010

Another homage to India...

They say that the caste system in Inda is a thing of the past.  It is tough to judge the voracity of this claim in the United States, where most of the Indian immigrants, historically, have been those of means, and heavily weighted of the Brahman caste - whether Gujarati, Bengali, or Punjabi.  Most of the custodial work and service jobs here are conducted by some of the middle and lower eschelons of southwest Asia - not local Central Asians, for concerns of safety. 

Many of the folks have been here for 5 years and never been home.  They mop floors and clean the hospital for low wages, but the contracts are always vast improvements on their home salaries, were they to have them, and they eat for free here.  I am not sure of the arrangement they have made for lodging, but I hope it is reasonable.  All said, they make their nest eggs here, and send most of it home to children they never see for years at a time.  Like sailors of the old age, or soldiers gone for a decade of battle, their lives are made away, to make better lives for their own at home.

Funny thing happens, however, when the simple Sri Lankan who mops the floor meets the Indian-American physician working here, seemingly the owner of the American dream.  These workers maintain decorum and great respect for all of us, but they tend to keep a professional distance from me and most of the white/black/hispanic Americans.  My Indian-American physician friends, however, they approach with a keen sense of brotherhood, or adoring-younger-brotherhood, if you will.  They bring nightly curry dishes to these folks, and constantly ask what special favors can be done for them.  They treat them respectfully, even honorifically.  They provide easy access to the kitchen and supplies. Most curiously, they rely on their higher society Indian-American brethren for advice, and respect their words for true finality. 

We had a contractor recently in the hospital for a heart condition, and I spent 2 days working with him, and explaining the disposition to he and his friend and boss, another Indian man, Rakesh, who had been dutifully at his bedside.  Not 30 minutes after my last and most complete debriefing, one for which I was particularly proud of the logic and efficiency by which I had made a plan clear to the patient, I found Rakesh speaking with my Indian American physician friend and colleague.  I found that curious, but was on my way to some other task so did not inquire just then.  Before I had an opportunity to ask him why he was talking with the radiologist (after all, he had no radiographic studies at all), I had the chance of walking past a group of the Indian custodians talking together in mixed Hindi and English.  All I could make out, at the end of a busy conversation was, "...and Dr. Raj will take care of this problem." 

Speaking to my radiologist friend Raj later in the day, I was told that one of the custodians had brought Rakesh to him in order to get his care expedited as best as possible.  At first I was incredulous, and a bit miffed, that I was circumvented on the disposition of my patient, and this man thought that the radiologist who is completely disconnected from this part of the patient care process could make it happen more efficiently or quicker. 

I am not sure if this is a vestige from the caste system.  And it does remind me of the way things work in New York City, especially among more recent immigrants, where the only way to get things done is to "know some guy."  All I know for sure is that my buddy the radiologist is like a king to them.

Wednesday, May 5, 2010

Fod glorious FOD

If you haven't been in, or associated with the military, you probably have never heard of FOD.  But anywhere there are jet planes, and specifically, in dusty deployed locations, FOD  (foreign objects and debris) is a big deal.  The little pebbles and gravel which account for the great majority of the open spaces, roads and walkways around here are serious hazards for jet engines that can suck in the FOD when revving up for take off.  The F-16s, of which there is a squad here, are particularly susceptible given the large thrust - ergo vacuum with respect to FOD - and short distance to the ground where the FOD lies.  This is such a costly problem that there are people who write newsletters on FOD...  ...really: http://www.fodnews.com/article0r.html

Approaching the flight line, and everytime after re-entry into the flight line, the wheels of the vehicle driving on the line need to be checked for pebbles and dirt between the treads.  There are even special FOD tools, which look like dull box knives, made specifically for digging the FOD out of the tires.  On really muddy days there are pressure washers to remove large amounts of mud and stones. 

This seems like such a low tech problem for such a high tech piece of machinery, and it reminds me that our fancy technology's survival is fragile.  Volcano dust or dirt runways can ground American's air fleet.  Maybe there is wisdom to hanging on to some low-tech options to survive the natural disasters, EMPs or defense computer hackers.

Tuesday, May 4, 2010

Inglourious Basterds

When the war began, and for some time after, the mission was to establish control of the country and neutralize the Ba'ath loyalists and insurgents.  As US and coalition military bases grew to support this mission, they increasingly became targets for the enemy, and defenses were constructed appropriately.  Fire upon the installations was retalliated against many fold, and the culprits were captured and held as enemy combatants, or tried by military tribunals and sentenced accordingly.  Abu Ghraib and Guantanamo Bay hit the headlines and things changed.  The capture, confinement and care, and rendition, if applicable, of these types of criminals is now done in concert with defense forces of the host nation - both here and in Afghanistan.  This means more paperwork, more legality, less efficiency, in the hopes that civil liberties - whatever of those are deserved by a terrorist - remain intact. 

Uncommon are the top eschelon, coordinated military attacks against our installations.  The import and movement of the weapons systems necessary to carry out these attacks has become extremely difficult, and the value of personnel capable of manning these complex systems have made attacks of this type very high risk.  Instead, as alluded to earlier, single agents, armed with RPGs or small portable mortars sneak up to the fences, fire when in range, and slink back through the fields and disappear within the adjacent hamlets and cities.  Our surveillance must be able to see these people on heat maps or in real time video.  But in this era of extrication from Babylon, in which we must promote goodwill and avoid collateral injury and death at great cost, and when we must respect the autonomy of the host civil defences, the apprehension of these terrorists is never simple.

Politically speaking, coordination with Iraqi military and police is necessary to make our departure as seemless as possible, though this adds such inefficiency and bureaucracy.  [Nevermind the estimates you read in Newsweek that 10% of the Iraqi military is working for al Qaeda in Iraq].  If, and this is a big "IF", the scoundrel is captured, there is the question of rendition.  If American soldiers are injuried, or intended to be so by these attacks, logically, these terrorists should be turned over to Americans.  It is not so simple here in this amorphous grey area (the mounting responsibility handed to the host nation as we leave this shithole behind).  If the perpetrator is caught, his fate is determined by politics, not law. And if he is injured, he is treated for his wounds, here, without prejudice for his safety and for safekeeping.

I claim no firsthand knowledge of this scenario, but can imagine that actions as a physician here have brought life back to men, at one time or another, who may have wantonly launched those aimless RPG in hopes they would land atop the heads of some unprepared American soldier.  We care for this person, free of bias;  we also fix his chronic problems - a inguinal hernia, perhaps his cataracts - and we send him back to Baghdad where he may or may not stand trial among his peers for the launched RPG which deviously,and with cowardice, crashed upon 3 - and they always come in 3's - of my Sisters and Brothers.  One who would be gone, one who would be maimed, and the other psychologically wrecked as a witness.

Monday, May 3, 2010

Musical Chairs

Unlike normal jobs, military jobs almost always have finite timelines.  It is rare that anyone stays in the military in the same location for their entire career.  This quality is hyperbolized in the deployed environment where no one stays for more than 12-15 months, and most everyone is only here for 3-6 months.  To ebb the tide of constant orienting and for other reasons, most folks come and go on certain calendar rotational blocks.  A small minority arrive between the blocks - most likely to avoid having entirely new staff at the same time.

We recently said goodbye to a large group of people in the hospital who were making their long trek back home.  Some were going through Germany, some through Ireland, but almost all through some staging area outside of war theater, but within the AOR, namely, Kuwait, Qatar, or Saudi.  Special forces guys fly in and out of all kinds of places, but they don't count.  I am talking about the regular rank-and-file; the massive support for the warriors and peacekeepers.  For them, no one seems to know what is going on, and you must just take deep breaths and exercise your patience.  Keeping the flight manifests secret until just prior to the take off is probably in the best interests of security, and allows for execution of last minute operations (e.g. we lost one plane on the way here because a General and his staff absconded with it for reasons unmentioned).  It does however engender a copious amount of distrust and cynicism to the system which mercilessly holds your metaphorical testicles at its whimsy. 

So, this new batch of folks rotating in have the same smirk, and dark ovals under the eyes which I, and many before me, have worn after finally arriving here.  [Funny psychology: 10 days of thankless, tortuous travel, makes you start to pine for a bed, and a semi-permanent shed within which to store your gear, even if the stopping place must be this kind of purgatory].  They tell similar stories of flights delays 7 times, flooded tents with rats, and customs agents who took DVDs or electronic devices.  These people also breathe fresh air into the place.  The last set of new people then become the veterans to show the new set of new people the ropes, and in the manner of impermenance, redesign some aspect of the ropes to their liking.  They come with fresh personalities and idiosyncrasies.  And out go those which they replace. 

There is nothing like shared suffering to solidify a friendship, like the weld of lead and nickel under smelt; and similarly, not much time does it take to get to know someone fairly well, and truly feel loss when they rotate back home.  You feel sadness to go on while they return, but gladness for them to leave this behind them.  In the same way, proximity magnifies misery, and these close quarters intensify the polarity of the same idiosyncrases which repel us, in human nature.  For these people, there is opposite sentiment of rejoice at their departures and jealousy that they have completed their sentence, albeit, at times, dishonorably or with rancor.  We are just glad to see them go.

Saturday, May 1, 2010

Parcel posts

With the rise of email, and mail carrier competition, the USPS has had a rough few years.  It seems that people are always complaining about the Postal Service.  But, as I sit hear eating the sun dried tomatoes my mother sent to me 5 days ago from south Florida, I cannot help but marvel.  It is nothing short of amazing that for $12.50, my family can send a 20lb package 7,000 miles in less than a week's time.  Even if the USPS has strategic disadvantages to UPS and FedEx in the states or in the civilian world, their service to APO has been worth my tax dollars.

Mailing things from here is a little more complicated, belabored, and certainly not as quick and efficient.  The prices are the same, and altogether reasonable.  I have to trapse to the post office about a mile away from where I stay.  (This usually involves borrowing someone's dolly or the squadron van, during the daylight hours-my sleep time-that the base post office remains open).  All parcels are inspected carefully prior to mailing, a fact I find interesting in its own right.  One could easily mail uninspected contraband into this place, but not so easily get it out.  What are they searching for, one might ask?  The list of prohibited items is tiresomely long and includes the usual suspects (porn, food, knives, guns, relics, etc).  Mainly though:  war trophies, and flammable objects.  The latter is clear, the former less so.  I am sure no one was frisking Vietnam veterans as they left theater for Vietkong daggers or ordinance shells.  Maybe they should have been; however, and now, they aim to prevent such loot hoarding.  Some of this is clearly ridiculous, and you can see why they have the rule.  For example, there was one guy who tried to send home an aerated cage with a pet scorpion he found in the desert.  Alternatively, there are a few other things which seem more innocuous.  One of the surgeons has a 3 inch piece of shrapnel he took out of someone's back that he wants to bring home and use for teaching purposes.  That seems reasonable enough, to me, anyway.

When I arrived here in February I came through Qatar (the hottest place on earth) where we remained after our charter flight from Ireland for 5 days.  It was 90 degrees Farenheit, and from that point forward during this transit, I was a real beast of burden carrying 130lbs of gear, while wearing a 20lb helmet and 40lb IBA vest - all with the thick USAF ABUs.  My current plan is to leave here during the end of summer when temperatures in Qatar approach 140 degrees Farenheit with humidity of near 90% given the surrounding Persian Gulf.  My goal is shed as much gear as I can prior to this, even if it is at my personal expense via the USPS.  Once I am on the charter plane out of Qatar, I can rest easy with my satchel and trust in baggage handlers.  Until then, I am my own mule, so the goal is to keep it light.  Thank you, USPS.