Say what?

This is the backside of an F16, the teeth in the local air-to-air defense here.  Several times a day, a pair of these monsters take off and run off somewhere to do something.  We are in a combat zone, and they take off with fire - afterburners on - and everyone on base, and for miles around can see it and knows it. 

The sound is deafening.  It is a crescendoing thunder which rattles the windows, shakes the doors, and culminates in - depending on your distance from the flight line - profound ear pain, prior to decrescendoing as it pulls miles above and away from us.  I have grown to learn why I have so many deaf retirees in my clinic back in San Antonio.  Now, those on the flight line have fancy ear protection and often have their hearing screened to prevent a mirroring debt to the one we now pay.  I can imagine that the first days of the modern fighter at the end of Vietnam left many without this sense.

When I sleep during the day, the earplugs and rain machine usually prevent me from waking from the avionic earthquake, but this is undoubtedly a learned response, for the daily sorties woke me up for the first month I was here.  Lack of good plugs or the white noise, however, and I cannot be deep enough into REM to avoid return to consciousness, immediate panic as the uncertainty of my surroundings, and then a minimum of 30 minutes of recovery from the catecholimine storm prior to return to slumber. 

I have been told by the more savvy flight buffs that this noise is but a pleasant hum compared to some of the USAF's arsenal.  The F15, for example, has not one, but two Pratt & Whitney F100 turbofans and F229 afterburners.  Double the auditory fun?  I am not sure, but clearly louder; as is the B1, and F18.  Some claim the low roar of the cargo planes - the C5 and ANT 225 - do the most damage, but the pure noise acceleration from zero of the fighters is the most shocking to me.  [Imagine the splendor of a seaside mountain in Patagoina as more impressive to behold than a taller Himalayan giant arising from hills already elevated over 4,000 meters].

Supporting supporters

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

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

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

Double secret probation

The UCMJ, or Uniform Code of Military Justice, describes crimes and the punishments for those crimes for individuals within the military.  For the most part, it differs little from any State legal system as lying is bad, stealing is worse, and maiming and killing is worst.  There are some crimes unique to the military.  It is, for example, not only morally abhorrent, but illegal, in the military to commit adultery.  Fraternization implies socializing between enlisted and officers in the casual sense, but within the UCMJ, it defines career ending romantic relationships between and officer and an enlisted member.  Bouncing on either of these legal trampolines will land stiff penalties, often a court martial and prison sentence.  Some of the emboldened deployed take the chance, and hence the genesis of the General Order 1b.  I am not sure of the exact wording, but this edict essentially bans alcohol, porn, or visitation into the room of someone of the opposite sex in the deployed setting, and the penalty is steep.  I guess if you don't go to the room of someone of the opposite sex, it is less comfortable to commit adultery or fraternize.  The unattached, young virile population must adhere to the same rules, probably to limit war zone pregnancies and the spread of venereal disease.    The army doesn't like venereal disease either, but this is only a USAF order, not DoD-wide.  The army permits co-visitation, which makes things very confusing in a joint service base like this.  You can imagine the scenarios the command has to adjudicate.  In case you have a poor imagination, a USAF female was recently caught in an army uniform in efforts to take advantage of the more lax army co-visitation policy.  This wasn't very smart:  she violated GO1B, and she fraudulently misrepresented herself; double whammy.
Violations of GO1B are nearly always grounds for an Article 15, which is just shy of a court marshall, and can be a de facto career stopper for lifelong military.  If violations also involve adultery or fraternization, a court martial is likely.  Outside of this, or felonious acts which would otherwise lead you to prison in civilian life, it is hard to get into real trouble.  I am not sure how the system was created, but unless you really fly off the handle and do something ridiculous, it usually take a long history of underperformance and several minor violations to lead to a letter of counseling. and several letters of counseling to lead to a letter of admonishment.  Get a few of those in your file, and you may get a letter of reprimand, and that could lead to an Article 15.  Mind you, underperformance without a serious of minor violations does not get punished.  In fact, it usually leads to promotion - ascension by attrition.

http://www.youtube.com/watch?v=vVO4BSqXTig

Avoid the Turret

Everybody knows what a humvee is.  Hummer may be out of business, but guys drive those puppies around every city and most towns.  I even saw one in southern California with the plates that read: "TRMN8OR" - not sure if that belonged to the 'Governator' or not; the windows were darkly tinted. 

Here we have tricked out humvees complete with armor and a 50 caliber machine gun in a turret up on top.  The guy up there has an obvious job, with clear appeal to 20 year old infantrymen.  Most of the time, however, these guns have the safety on, and fingers off the trigger.  The guy just sits up there with his IBA (individual body armor - kevlar flak jacket) and 20lb helmet, looking lean and mean.  Also here, however, most of the roads are unpaved or riddled with defects, and the dust swirls without notice in the eyes of the pilot of any vehicle.  So, accidents happen.  Vehicles roll off the road, skid in mud, and send passengers flying when hitting the potholes. 

The particular unenvious position to occupy when any of these missteps occurs is in the turret.  One might think that in the 8th year of the war, these vehicular outcroppings would be lined with titanium, and giant hydraulic shocks.  Alas, the brave, and likely unaware young man manning the big gun has but a seat belt and an alloy cage fencing around him.  In the handful of humvee accidents I have seen, via IED or weather or bad road, the man in the turret is usually the one with the short stick.  Head injuries, pulmonary contusions, abdominal trauma, and likely (though I have not seen, thankfully) decapitation are all in the litany of 'turreter dings.' 

Dangerous jobs in the military usually come as advertised.  Guys who deal with explosives understand that explosives can explode.  Those who fly fighters realize they are traveling at the speed of sound 6 miles from the surface of the earth, and that it ain't without risk.  Anyone who carries a loaded gun in a war zone knows they can also be shot.  But unexpected injuries and deaths, or those which occur in cases which equipment is judged to be suboptimum are particular regrettable.  During the past 10 years, body armor and vehicle armor has improved greatly - the MRAP (mine resistant ambush protected vehicles) one of the more well known advances (http://defense-update.com/products/m/mrap.htm).  I think we still have progress to make.

Patriot

A young staff sargeant works for a friend of mine here.  He is not outstanding, but clearly competent in what he does.  His wit is sharp, and he is friendly enough.  The captivating thing about him, though, is his courage.  Jabar was born in the US to strict muslim parents from Pakistan.  After education in the states, and against their wishes, he joined the military medical service corp.  With no wife or children, and a first-generation loyalty to his country, he volunteered for deployment to war in either Afghanistan or Iraq. His parents forbade this, and thus, he never told them to where he was sent.  He has been here for months, and his life is here.  He has virtually no contact with home, and his parents, with whom he has not spoken in months, think he is somewhere in the far east without the capacity to call or email.  His love and respect for his parents, and his devotion to his nation mutually exist in his heart.

Wild, wild, [middle] East

The secular Shia presidential candidate, Ayad Allawi, won a contested election and the results were announced today.  Apparently, many were pleased; hence the celebratory gunfire - Calamity Jane Style - and subsequent falling-bullet calamities.  And, likewise, some were not - hence the non-accidental bombings and the IED blasts which brought a score to our ER tonight, and killed hundreds throughout the country. I will report on the details of this when the dust settles.

You cannot win over here.  The Sunni win, the Shia bomb.  The Shia win the Sunni bomb.  I have no interest in making an opinion as to the rightful heir of the caliphate from the Prophet; I simply do not know the history well enough to gather a guess.  The blood shed after this schism in Islam, however, cannot be within the designs of the Great Prophet.  Likely, this is no different than saying blood shed between Roman Catholics and Eastern Orthodox Catholics cannot be part of Jesus' plan to love thy neighbor.  Shit happens.


But celebratory fire?  In the States, this may imply a yule log, or sparklers on the Fourth of July.  Here, well, it is the Wild, Wild East, and we scream and point our AK-47s to the air for jollies.  From the door of the hospital, you could hear the gunfire from outside the wire.  I stayed inside (under the mortar shield).

 

Miserable melodrama

Juxtapose this!

After some email traffic, and today's experiences, I feel that I need to make a correction.  The description of OR5 from yesterday, and the earlier entry (Man Cave I) may provide an inappropriate illusion of comfort here in Sandland.  These are examples of the ingenuity of some of my colleagues which has provided refuge, and solace in what otherwise amounts imposed confinement.  There are efforts to enrich the experience, and provide minor conveniences.  The reality, however, is that I am here, forbidden to leave our 10 square mile pile of dirt, away for my youngest son's first words, my eldest son's 9th birthday, and the other's entire first t-ball season.  I am here expected to work as I did in my 5th of my 10yrs of post-graduate training, while my laboratory and practice sit in limbo.  I knew all of this when I took the oath, and received my orders, but the worst part is that on days like today, I question the merits of the sacrifice.

I have commented that small patient volume and subsequent boredom roughly translates to less attacks by insurgents throughout Iraq, and thus, less injured soldiers.  This is a likely correlative; so, in this way, boredom is a blessing.  But boredom also breeds discontent (e.g. 'Idle time is the devil's workshop'), and, perhaps, a bit of overly aggressive introspection.  After approximately a month here, you start to see the true colors of people you work with every day.  Some remain vibrant, and cheerful, and allying yourself among these optimists, while keeping your mind at work, is of great value.  Others are dark, miserably unhappy, self-interested and self-aggrandizing individuals.  Sharing air with the latter has a profound effect on the psyche and is not counterbalanced by the former.  [I would liken this imbalance to the far deeper amount of guilt felt after losing at the casino than the joy after winning equal amounts].  Such is the psychology in the communal human experience, I guess, but this is magnified when you cannot get away from people here...   ...or on an island with no departing ferrys...   ...or in prison.

I have daily interactions with an individual who edifies a particularly dangerous combination of attributes:  arrogance, power, and incompetence.  With a humble father, and a decade of post-graduate training filled with reminders of any slight deficiencies, I realized early the true virtue of humility.  It should not amaze me that some people never make that discovery.  They ascend their respective food chains, usually through attrition, and often avarice, and defeat the potential strength and symbiosis of the team they lead by ostensibly refusing to yield authority to make any single decision.  They alienate themselves, fail to realize the attributes of their team members, and develop defensive postures which expand exponentially until they commit errors too egregious to be ignored, or suffer at the hands of a mutiny.  I would prefer to let people like this live out their days ignorantly.  But, in medicine, I egregious errors lead to death, and so, by virtue, one must intervene when it appears inevitable.  This pending confrontation I see is unpleasant at best, but at its worst, in the context of confinement, isolation from family, and the reality of an eroding career 7000 miles away, misery.

Man Cave: Part 2

Surgeons are good for something.  Long ago, when there were few colonels here, fewer rules, and people's time was occupied with taking care of patients, and not inspecting uniforms or developing new protocols, a little construction project was undertaken.  In between the traumas, the first few groups of surgeons here somehow commondeered some extra lumber, tools and some hardware, and built this outdoor mancave affectionately known here as OR5.  On the roof of the hospital, there is a place to get away, smoke a cigar, inhale the diesel fuel, and thanks to another clever radiologist, go to the driving range.  The cargo net capturing the golf balls 3 yrds from the tee makes all of my shots seem true.  I am starting to like golf again.  At least until I throw out my back.


.

Salutations

Few people know this about me, but when I was a young boy, I slit my wrist in the bathtub.  After watching Rocky in the theatre, I returned to the home of my mother's parents where I took a bath prior to bed - my parents were in the city to see Evita on broadway.  After washing my hair (distant fond memory), I re-enacted spars between the fantasy Italian hero and his opponent and Billy Dee Williams' Apollo Creed.  My poor choice was relegating the glass shampoo bottle (yup, they used to have those) as Apollo Creed.  I lost.  The slight scar on my medial wrist is hard to discern from the natural creases in the skin, and as my hand always seemed to work fine, this was a 30 year old injury without apparent consequence other than the anxiety caused to my grandmother when she walked in to see her only (then) grandson in a pool of bloody water.  [For the record, my grandmother, mother of 6, grandmother of 15, and great-grandmother of 3 turns 90 this year - no worse for that wear].

Then I went to officer training about 10 years ago, and realized an otherwise unnoticeable defect: an ulnar palsy which prohibits me from adducting my 5th finger when my hand is extended flat, as might be necessary in, say, a salute.  In fact, my first attempts at a salute in officer training were met with extreme derision as my pinky flared apart from my hand as if I were mockingly imitating Liberace, or the Scarlet Pimpernel, making a joke of the ancient military tradition.  In fact, I had no such intent, I simply couldn't move my pinky.  After a fine time inhaling the spittle and halitosis of a young diminutive Lieutenant with penis envy and anger management problems, a sympathetic Master Sargeant garnered the attention of the Major in charge who soon discovered the truth behind my disability.  He taped my 4th and 5th fingers together, and typed a letter - signed by the he, the commander - for me to carry with me at all times, declaring my permission to use tape on my fingers.  During the training, with or without the tape, I learned a few little tricks to hide this embarassing salute faux pas, and eventually, found a way to form a respectable salute, sans splint.  I also learned during this time the rules of engagment when it came to saluting.  You salute outside, not inside.  You salute all high ranking officers, but not enlisted NCOs.  You return salute, but not when in your presence is an individual of a higher rank; he or she has that honor.  You salute when walking and approaching at 180 degrees, not if passing, on a bicycle, driving a car, or carrying large objects - all for obvious reasons.  At my job in the states, I walk into the building before most are there, and leave after most are gone.  There is no saluting inside, and when I go home and on weekends, I don't wear my uniform. 

Here in theatre, you always wear your uniform, and the salute can become a little bit like a Monty Python skit mixed with "Who's on First" from Abbot and Costello.  Sometimes, when I go to the cafeteria, if I time it wrong, I end up return saluting 50-60, or more, young troops, as if I were a marionette being jerked to order on a timer.  I have to really be on my toes, as intermixed in these salute offerers is the occassional colonel.  And for they the roles are reversed; this is the custom, and I am accepting of that.

The more interesting or difficult quandry comes when faced with the non-saluting troop.  Though we are implored by the senior NCOs and officers to dress down approaching troops who fail to adhere to this tradition, I usually don't say too much.  I rationalize that they didn't see me, weren't paying attention, or what have you.  There is a rare particular impudence in a young airman as I come bee-bopping along with my medical insignia in clear view, and for integrity, and to avoid being observed ignoring this rudeness, I should speak up.  Indeed, I did today.  After eye contact, and what I thought was a smirk, with no salute, I called a yound staff sargeant to the carpet.  For reasons not quite clear to me, I stopped, incredulous of my self, and called for him.  I quoted Band of Brothers and told him how one "salutes the rank, not the man." (Lord knows where that came from!?!?!)  As he curtly threw up a lackadasical salute, a senior master sargeant who apparently knew this individual appeared beside me, and proceeded to provide this poor bastard with a high tonal expression of his dissatisfaction in his military bearing.  (Imagine getting the riot act from your Momma in front of all of your high school friends at the movie theatre.  Now imagine you were naked.  This is what I saw in his eyes).  

Some military tradition and discipline is difficult to reckon for a physician; it can run counter to the way we think and are trained.  Hawkeye Pierce didn't help with the sterotype, and this is nothing like M*A*S*H here.  But as did Hawkeye, modern day military physicians tend to philosophize the absurdity of this war, and some of the things that we do in the military.  As with caring for patients, we ultimately are concerned with "Why."

How do you say "FUBAR" in Arabic?

During each shift, we enjoy the luxury of having 2 Arabic interpreters to help us communicate with our Iraqi patients.  Some of these interpreters are American citizens, perhaps Iraqi Christians who emigrated under during the Iran-Iraq war in the 1980s, or Shia escaping discrimination and harassment at the hands of the Ba'athists. A number of our interpreters are Iraqi citizens, and the remainder are active duty military members who speak Arabic as a native tongue or studied it for this precise purpose at the Defense Language Institute (DLI) in Monterey, California.  Near all of these individuals share one thing - in addition to their mastery of Arabic - however, insofar as they previously did something else for a living.

For one of the interpreters, this offered an opportunity to escape the hijab (veil worn by women in Islamic nations) after her university education was interrupted at the end of Sadaam's reign.  Another is a contractor from Dearborn, Michigan, home of the largest Iraqi-American community, here to make 3x the money he can make doing anything else.  He is a young man with education and skill, raised within a wealthy, family who was working as a merchant in the shop owned by his expatriated family.  In the ICU, we also have the luxury of speaking to our patients through translators who also happen to be physicians.  One of these physicians joined the US Army upon naturalization, and is now a corporal serving under the American doctors here as a translator.  He is active duty with a family back in the United States, and filled with joy to be working outside of his field, below his level of education, for a $25,000 salary buttressed only slightly with his deployment hazard pays. 

Without any tone of bitterness, he affably describes the long road ahead of him to return to medicine as a physician in the United States.  Though he completed his medical training and was practicing in Iraq prior to the war, he will be required to gain admittance to a full American residency training program, and this, only after passing the 3 part USMLE test which American doctors normally take after their 1st and 3rd years of medical school, and complete after their internship in order to practice medicine in the United States.  Given his commitment to military service as a translator, this will take him 5 years at minimum, and possibly more.  Nonetheless, he is happy for the opportunity. 

Though he and other Iraqi physicians who now work to relay my messages to any Arabic speaking patients, live on Post, they often travel to clinics outside the gate, and previously had gone with special operations units on goodwill missions, or, in some cases, in terrorist search missions.  Now they are mostly at the hospital, working in the ICU, but they say living outside the wire within the local population would be suicide.  The resistance sees these individuals as traitors, and American sympathizers, and several of them have been brutalized, beheaded and defiled in unspeakable ways. 

The history of violence under Sadaam and then in the anarchy that ensued after the invasion, has left Iraq similar to a large Lebannon or Palestine - deplete of professionals, victim of a massive brain-drain.  Those with opportunity, whether actively pursued and harassed, or just seeing the writing on the wall, have fled this chaos to protect themselves in their family.  They left for nearby, stable regimes (Jordan, Egypt), Europe or the United States.  The result is a populace replete with uneducated leaders, grand fodder for religious fanaticism, and a vacuum of educators to give the swelling mass of youth skills with which to busy their lives.  In medicine, I see this first hand, when, after caring for the traumatic injuries of Iraqi soldiers, we have no outlet of suitable rehabilitative care.  These patients, often now without a leg or use of half of their bodies, are left to the mercy and devices of their families.  There is no Center for the Intrepid  (http://www.fallenheroesfund.org/About-IFHF/Fund-History/The-Center-for-the-Intrepid.aspx) in Iraq.  If patients are deemed too ill or injured, their families may just dump them into the Tigris days after release from our care. 

How do you go about fixing this problem?  The prevailing answer is:  the youth.  New leadership is stressing education and making some strides.  But just like with the stories you hear back home of a rag-tag Iraqi police force, the medical corps has its challenges.  In a country of 30 million people, the need for medical professionals is dire.  It is hoped that ensuing political stability can ensure safety for those from around the world still willing to come here and help.  Regardless, it will be a long road.

25 going on 40

In efforts to assimilate among the legions of the fit and ripped here, I have been soaking through PT gear twice a day for nearly a month.  For some reason, I don't feel as good (or look as good) as I thought that I should at this point in the venture.  Part of this routine includes a daily class led by a likely unqualified, but unimaginably confident modern day Hercules-Bruce Jenner hybrid.  The class is named "crossfit" as it aims to capitalize on "muscle confusion"- the act of performing a variety of different exercises which allow specific muscle groups rest, while the demand on the cardiovascular system persists - to lead to aerobic fitness and anabolism, simultaneously. Most of the time, there is also a good deal of "Michael confusion," but I get along, despite my abhorrence of doing maneuvers with names like, "squat," "clean-and-jerk," and, "dead lift."  After the first couple of weeks, I was even starting to walk normal again. 

This holiday from orthopaedic purgatory expired a few days ago, however, at the hands of the aforementioned maneuvers.  The coup de grace was the aforementioned, and aptly named, "dead lift." Now you may say that I had this coming, but my grace period from my last old-guy injury had given me a sense of security and confidence.  I looked in the mirror, and started to see just another, albeit balder and chubbier, 25 year old stud.  Indeed, when H.B.Jenner decided our workout would be low repetition with "maximum weight" in the dead lift, I could have ran away, or coolly slipped out the back door.  But I stayed, and endured, possibly deserved, the guitar string snaps which were the cacophony of ripping muscle fibers in my lower back, followed by spasm, and what has been 3 days of ibuprofen, ice, stretching and cursing.

Not as bad as it could have been.  Now, I am on the mend.  Doing fine. 

I will remember this, and act my age, for at least...   ...a few months.   

Care to share (confess) your last auto-overestimation?

How will King Soloman divide this child?

Dedicated to W.B.

There are 100,000 US troops still in Iraq.  By August 31st, the military has been mandated to have no more than 50,000 troops in country.  This number will be diminished to a few essential personnel only by January 2011.  Despite what you may think, I am not invited into the inner sanctum with the general officers to decide which battalion stays here, which regimen goes home or which unit is disassembled.  In fact, I do not even have any insight into how the leadership plans to reduce the medical corps in this country - I just know that we are "drawing down." 

The precise means by which this is done in the medical corps presents some interesting challenges.  Perhaps there are 300 equally trained nurses in theatre, so cutting this down to 150 RNs by this summer would likely be an easy strategic decision.  If the military fields 3 neurosurgeons in all of Iraq, however, and you reduce that number to 1 or 2 (?1.5?) neurosurgeons, how do you choose where to stash that(those) asset(s)?  We have a wonderful, if not politically poignant, Texan neurosurgeon here (look for an entire dedicated to this friend of mine in the near future) at our hospital.  Most days, there are no neurosurgical patients for him to see.  He has minimal clinical responsibilities, and he hasn't operated in a few weeks.  For this reason, in the context of a "draw down," there had been grumbling as to the wisdom of stationing this physician here. 

The other night we had a young man who reported to the ER after, of all things, heading a soccer ball, and becoming lethargic and dizzy.  The CT of his brain showed a large subdural hematoma (SDH) which was causing mass effect (pressure pushing the normal brain aside), and evidence of "hyperacute bleeding" - a sign that the bleeding was still occuring and compounding the swelling.  I must admit, neither I nor any of the other staff physicians here have seen this injury occur from a soccer ball before, but the fact remains that the chance of this young man surviving without an immediate craniotomy, decompression and evacuation of the blood, was very low.  Travel to the nearest neurosurgeon aside from our hospital would take at least 3 hours, and altitude changes with air travel may accentuate the brain injury.  Alas, our trusty neurosurgeon quickly mobilized the OR staff, expertly removed this clot from this young man's brain, and thereby saved his life. 

My recurring theme:  in a war zone, boredom is your friend.  But as the boy scouts say: Be prepared; you never know when you will need a brain surgeon.

Relative relatives: Those walking before us.

I have seen 8 of those 15 American deaths - or at least post-mortem - since I have been in theatre.  In 2007, during the equivalent to the month I have been over here, I would likely have seen ten times as many dead soldiers, 10 times 10 times as many amputees, and 10 times 10 times 10 as many who left this place without the naivete with which they arrived, and burdened now instead with endless, unwelcome nightmares.  The 3 suicide attempts we have seen this past week may have numbered 30 or more; and far more of them were "successful".

I have written, with levity, about day to day life on this blog several times - and will continue to do so.  Some of this reflects ways that we entertain ourselves during downtime, and it may even reflect some of the boredom we now experience.  As I have previously mentioned, however, I am happy to be bored given the alternative.  In the past, quick passage of time over here meant doctors were busy caring for injured patients; the clock ticks slower now, but this sacrifice for boredom-away from family and career-I make gladly.  True, tens of thousands of troops are still here, in harms way (truthfully, I am near the rear of this installment), as the walk behind the talk, and when most Americans debate the wisdom of international entanglements over wine and cheese, they need to remember those walking that walk.  Further, they, and we still here walking, need to know that since 2003, the walk has changed.

Everything is relative.  The marines who first arrived in the desert in the late hot spring of 2003 called this place "The Suck."  I think that it is still an appropriate moniker, but I also know that there is not a marine alive who would not scoff, and many who would deride me, for such the damning of my air conditioned "Single-wide Shangra la."  They did not have air conditioning, they were saddled with gear to establish their camps - often over 100lbs per person - they took daily hostile fire, all while donning a plastic chem warfare suit, which we call MOPP gear.  They defecated in the grass and ate once daily MREs.  The first medics may have been behind this line, but not far behind, and they endured austere conditions beyond what I can imagine, taking many casualties.

The marines, in particular, and the medical corps have a very healthy mutual respect each realizing the impossibility of doing each others' jobs, each in awe of the execution of the respective skill set in a coordinated well-fashioned machine (eg - a field hospital contructed in 72 hours for stabilization of battlefield trauma or a marine unit taking a stratgeic post from 10 times as many well-armed enemy soldiers, in order to secure safety for 1000 non-combatants).  Fittingly, these marines, the army infantry and the special operations troops I meet, remind me, most often, without uttering a word, of the relative comfort I now enjoy.  They edify my respect and humility for those on the rocky road before it was paved.  With great humility, today I honor those here before me.  Thank you: to all of those who made it so I could be bored.

Dirty dust

This is supposed to be a trauma hospital.  We see our share, though thankfully, far less than we used to see here earlier in the war.  People do get sick wherever they are, however, and if they're sick enough, and they are in Iraq, they evenutally find their way here.  I should qualify that statement, as all sick Iraqis obviously don't end up here.  This is meant to say, all US military, any coalition military as per host country (some countries fly their patients home or to other nearby bases), contract workers (depending on where they are injured, and what is their country of origin - American and British contractors all end up coming here), and Iraqi military, police, or civilians who are approved for treatment here on a case by case basis (more on this arbitrary process in a blog tbd).

The sick huddled masses yearning to receive ICU medical treatment include routine pneumonia, heart attack and pyelonephritis patients.  They also include a handful who fall victim to nasty arthropods, an occassional stroke patient - including the 22 yo boy I cared for last night - and a surprisingly high number of pneumonitides.  Some military colleagues of mine published a manuscript describing a series of patients in the New England Journal of Medicine a couple of years ago noting the increased rate of acute eosinophilic pneumonitis among otherwise young, healthy soldiers here in Iraq.  This is a inflammatory reaction which causes lung damage, usually at the prompting of an allergen.  These patients typically increased or started smoking cigarettes in theatre, and developed acute shortness of breath imediately after a dust storm, implying some allergen in the dust, and a baseline lung inflammation due to new or increased smoking.  This shortness of breath came with hypoxia - an inability to deliver oxygen to the tissues - terrible lung inflammation on radiographic studies, often intubation and ventilatory support, and sometime death.  Interestingly, we have seen a handful of these patients here in central Iraq, and a number sent here via helicopter or airplane transport from surrounding areas.  We treat them with steroids - not anabolic steroids, but anti-inflammation steroids - and try to send these patients to a higher level of care as we can.  [This involves the USAF's critical care air transport team CCATT, and I will write more details on this fascinating subculture within military medicine on a later blog].

Perhaps the eons old tradition of the Kafiyah (or Bedouin headdress) has a purpose beyond fashion.  I did not get a camoflauge military-issue Kafiyah, but I may fashion my own for the next dust storm that comes this way.  Maybe I will get one at the Haji-mart!

Éirinn go brách!

Guinness really does taste better in Ireland.  I can attest to that.  For me, however, the Goodness was enhanced by the recognition that it would be my last beer, or last one with alcohol in it, at least, for 6 months.  I drank it slow in the lounge at Shannon International Airport on the way over to Babylon as my poor Army comrades cursed my name (Army allows no alcohol in uniform while traveling - not so in the USAF; what great parity!). 

To my great surprise, KBR actually stocks this place full of a variety of non-alcoholic beers, some of which don't taste so bad.  Though I am working out twice a day (see yesterday's post), I am still having a nightly beer or two with a plenty of courtesy carbohydrates, and hence maintaining my doughy mid-section (chicks dig it).  Tonight was a special occassion worthy of celebration.  There was an evil humor circulating that the command was going to allow one real beer to all active duty here.  Rumor, indeed.  We celebrated St. Paddy's our own way, however, with some near-beers and green food coloring - the only way I get to drink beer in the ICU, I guess.  There was even some contractor that they dressed up like a leprechaun.  My jovial staff cheered and laughed, but I excused myself to my melancholy rather than face a sober, politically correct leprechaun and beer without alcohol.  Apologies to the Irish, within and outside of my ancestry, for such bastardization.  Such is life in Babylon.

Military unique curriculum

In the spirit of cross-training the leaders of tomorrow, the military promotes continuing education of all kinds.  One particular brand of education I prefer is the "exchange program" between divisions and job types.  We give a few helicopter pilots a tour of the hospital, and a week later, a few of our guys are up in a whirlybird staring down at the Tigris.  "Medics to Maintenance" was just launched by a senior NCO who has a friend on the F16 maintenance line.  This involves letting us work on F16 engines.  [Now, I haven't done this yet, but I gather that there is no way in hell that they will let any doctor near a 23 million dollar propulsion system with a socket wrench.  Regardless, it seems like a fun opportunity.]

You would think that working 6 days a week, you would have to plan your off time carefully, as it would soon evaporate.  That said, imagine your life without having to do laundry, wash dishes or cook.  Expunge memory of trips to the grocery store or mall, and imagine life which did not require driving a vehicle at all.  Turns out, absence of all of these, and singular care of your person - here, you only have responsibility for yourself, not your family; small bits of time during the work day to send email and write letters to spouse and children compared to major focus of your day at home - allow for enormous, comparative, amount of time with which to busy yourself.  In the past 10 years, work and family have been my only priorities.  Limit my work to shifts, take away the day-to-day hands-on fathering responsibilities, contract out my daily chores; and voila! time to kill.

You can only read so many novels and work out so many hours a day.  Indeed, we watch movies (see Man Cave I blog earlier), and sit up in OR5 and smoke cigars while waxing poetic under the stars (pending Man Cave II), but, alas there is still time to procure military unique curriculum with our bretheren who have have much cooler jobs:  pilots, explosion guys (I hear that they let you blow stuff up with C4), tactical warfare folks in special ops (I am getting to old for this), and of course, our friendly bomb-sniffing K9 unit.  With the killer dog, tonight was strictly observational for me, but I found that I just couldn't look away from this demonstration.  So cool. 
http://www.youtube.com/user/savona007?feature=mhw4

Now, do you get to do this at your office?

Outsourced

I paid $4 for a haircut.  Since I haven't paid anyone to cut my hair over a decade, I am unclear on what I should be paying, but that seemed more than fair.  The Malaysian who made me handsome even rubbed my head after the buzz.  What a deal.

After I was awoken at 11am (recall that I work the night shift) by the South African electrician vieing to tend to my wall unit HVAC, I bought coffee from a Sri Lankan, laundry soap from an Indian, and walked through "the Haji mart" where certifiable, or at least well-connected, Iraqis hawked pirated copies of any imaginable digital media to GIs for prices I am certain are reasonable.  This worked up an appetite, so I went to the DFAC (cafeteria) for dinner; I was allowed entrance by the Ugandan security guard. 

Most of the foreign service contracts are direct or subcontracts from companies like Halliburton or KBR which make the business of taking care of deployed soldiers their business.  They made the argument years ago that they could do this more expertly and more efficiently than the military could with its own personnel, and further, that doing this would free up more military personnel to do the things military personnel do (I don't think that this includes writing blogs).  Built into that bottom line is the cost of labor, and many skilled workers and white collar contractors are American, British, or Australian.  These contractors are paid the astronomical wages you have read about in the news, some for jobs you should think would exist.  A "crew supervisor" in Qatar and I got to talking as I was waiting to take my shower as the Cadillac (read: fancy outhouse), and she explained to me the meaning of her solid red shirt.  While a crew of emaciated Pakistani custodians cleaned and stocked the Cadillac, she, and others in Red, stood arms crossed "supervising" the crews.  This involved more of the same for 4-5 hours a day, driving a pick up truck full of these custodians from Cadillac to Cadillac - all of this for six figures in wages.  What a steal for your tax dollars.

By comparison, personnel from poorer Africa and Asian countries make pennies on those dollars, as my Ugandan friend Joseph (I will call him Joseph) tells me, they are also paid with reference to their host-country standards.  If the median income is $75/month in Sierra Leone, and and SLese workers are paid (?)$150/mo, they are happy and the contractor is happy.  Some of these pay structures seem inequitable, however, when all of the contractors are living together on the base, and not thousands of miles away at their respective coutnries.  Shouldn't these individuals be paid to scale of their jobs (ie. military pay), rather than by their origins?  Joseph is content and providing well for a large extended family back home.  He was vetted, and never served in the LRA.  So maybe he is paid enough.  I am just not sure I have the right answer, but I guess it would be nice to know that Joseph and the remainder of the Ugandan security detail, befit with locked-and-loaded M16s, had high rates of job satisfaction.

Very bad luck

There is no fighting fate.  How else can you explain this?

Three army soldiers were walking to the chow hall in a base north of here.  They walked toward the tent to receive their food, and mortar rained with a few feet of where they were standing.  They were all knocked to the ground.  One soldier had a bruised back from a piece of random shrapnel, and another had a piece of molten metal sorn into the soft tissue of his neck, but centimeters away from all of the many important anatomic structures in the neck.  Stunned, they both rose, shellshocked, but conscious, and otherwise, unscathed.  The third soldier remained on the ground, I imagine, gasping for air that could not travel from her nose to her lungs as her trachea no longer connected the two.  She was tended to quickly, and rapidly lost blood from a severed carotid artery.  She was recussitated as well as possible in a helicopter in route here, and after 40 minutes of aggressive support she and her comrades arrived.  She was unconscious and ashen.  Her monitor indicated asystole - flat line.  Her pupils were dilated and fixed. This was determined after 5 minutes of additional CPR in the emergency department, while the other victims, destined for purple hearts and trips out of the sand, sat with catotonic glazes as they watched their friend and sister in arms slip away.

The Commander and chaplain led a respectful quick memorial in the ER prior to sending remains out on another flight.  But then came questions:  How did one soldier die, and two other escape nearly unscathed?  What if they left for chow five minutes later?  Why did they stop and talk to that other soldier, delaying their walk?  Where would that mortar have landed if the wind weren't blowing that night?  These questions run through the minds of the surviving soldiers, undoubtedly, and will haunt them.  A palpable sadness accompanies this type of tragedy, much as if a person walks into a hold up at a 7-11 or is struck by lightening.  But as with these other examples, the randomness of this strikes me most poignantly. It makes you wonder as to how preventable this was, and how much it was destined.  Unlike the other examples, however, it was fated only when this soldier volunteered to come to Iraq, at the tail end of an absurd war which has a beginning we cannot see.  

Man Cave: Part I

Dedicated to A.R. and R.T.

Men need a sanctuary.  It need not be grand, ornate or even pleasant.  It must however, be free of the ettique expected , and a clear escape from outside of said cave.  Sometimes this a place to sip a fine bourbon or smoke a cigar, put golf balls on a strip of astroturf, or roast meat over an open fire.  As one might imagine, we lack all beverages of interest deployed in this muslim country, and procuring meat to grill is not a simple task.  However, we do have radiologists.

As you may imagine, the radiologist is the king of the man cave: he has disposable income to spend on toys, technical know-how on how to best integrate these toys, flexible schedule to enjoy these toys, and an epicurian appreciation of the man cave.  Additionally, and importantly, the radiologist is alloted dedicated, non-shared space, even in the most austere environs, for the hardware necessary, and the privacy and shelter from sunlight to perform their job: to read films in the dark.  As my luck would have it, I am here with two radiologist, man cave kings, and this has eased the adjustment, added levity, and provided, at times, a sanctuary.  In between trauma calls, and when things are slow, there are movies on our 96 inch projection screen.  We even secured some paint and a roller to rid the wall (screen) of imperfections and improve the viewing.  My sense is that this will not last long as when word gets out that anyone is having fun in the military, someone ends it.  In the meantime, however, I have a few friends in the darkroom - we are looking forward to watching March Madness on 24hour tape delay...   ...don't tell me what happens!!!

Wolf in Sheep's Clothing?

An elderly Iraqi man - by nature of living his decades in this part of the world, elderly - had cardiac arrest on post some time ago.  He received prompt medical attention in the field, and was rescusitated and stabilized here in the hospital.  Since then, did very well, and was only here for monitoring and medical management awaiting plans to send him to more definitive care out of theater - perhaps Egypt, Jordan or Europe.  In the meantime, I saw him daily, on social calls.  His broken English professesions were always complimentary, and his mannerisms defferential.  He thanked me profusely during each of our conversations twice every shift.  This man could be a grandfather, and this was the persona he portrayed; kind, humble, and patient.
     As per usual, days after the arrival of a patient, intelligence starts to filter down to the medical team.  This patient happened to be a senior military officer in the Ba'athist regime of Sadaam Hussein.  Who knows the extent to which Sadaam produced or planned to produce weapons of mass destruction.  But the brutality of the regime was beyond debate.  Recent Iraqi history is rife with evidence of genocide with the Kurds, and torture and murder of political prisoners. So the question here is:  to what degree was this patient, the man I have helped to keep alive and stabilize, complicit in crimes against humanity? How am I to know?  Clearly, the depths of duplicity within some of those I have already treated is beyond my perception.  I know of one terrorist already who we saved, and who initially told me through an interpreter that he was shot by "terrorists" - the definition of that term is, I suppose, subjective. 
     Physicians are trained to diagnose, triage, and treat.  Over the years, we recognize behavioral characteristics and physical and psychological signs which belie patient history, and some degree, intent.  We are not professionals of the spycraft, however, and do not have particularly good eyes to decipher the clues or misdirections of the cunning and evil among some of those we heal.  Often, we are surprised to learn the true nature or history of those for whom we care.  International Law teaches us that we must treat all patients - US soldiers, civilians, or terrorists - with equal skill and efficiency.  But the law cannot regulate the heart and soul devoted to a patient.  So perhaps for the sake of the law, and for parity, it is best that intelligence comes to us post hoc. 
     Recall GWB's deck of cards - Sadaam as the Ace of Spades?  A few cards off that deck have rolled through here American medical facilities here.  We have fixed many of them so that they survived to stand trial for unimaginable crimes.  This, after "Shock and Awe" and the sequela aimed to take most of them out.  Absurd, isn't it.

Things we do well.

The military screws things up, for sure.  There are a ton of inefficiencies.  It is impressive, however, to see what we do in a combat zone.  This is particularly true among the actual warfighting units, which in the air force consist of the planes, the guys who fly them, and the people that support them directly. In the medical corps, it is the building of a flexible/modular hospital to meet needs over time.  The hospital I am working in here is built on top of one of Sadaam's prior medical facilities (there are rumors about the basement - more on this later).  It is nothing grand, but has air conditioning, indoor plumbing, and for the most part feels like a real hospital.  (Importantly, it is also the best place on base to get a shower).  I have attached a youTube video to give some perspective. 

http://www.youtube.com/watch?v=qR1C9t2eBio

For security reasons, videos cannot show everything, but as you can see, there have been some dramatic improvement since the modular "tent" hospital at the beginning of the war.  The intent is to give this hospital back to the Iraqis, so it was always intended to be a permanent fixture.  Even on my days off, I spend most of my waking time here as it is truly the most comforable place on the base.  It has plumbing and electricity akin to what we find at home, and has few windows, so sometimes I can forget I am in Iraq, at least for a few hours when I come here.  Most importantly, it has the most reliable internet connection with which to publish my blog!

I prefer boredom

There were 8 intubated people in the ICU last week, and then there was 1.  One patient, 4 nurses, 4 techs, and me covering the night shift.  So, during the shift, I caught up on email, read my book, watched 3 hours of season 7 of 24 (crazy addictive), and now I write the blog.  The trauma business is quite unpredictable, however, so who knows when we will be stretched thin again.  I sent a young private to Germany the other night on a CCATT (critical care air transport team) mission.  He was driving his humvee in Baghdad, and ran over an IED (improvised explosive device).  The passengers in the humvee had concussions and minor lacerations, but were otherwise fine.  He was not so lucky.  His sacrum was fractured.  He was eviscerated.  All of the soft tissue between his lumbar spine and his upper thigh was missing.  His bladder was ruptured.  The surgeons made his bowel continuous again (they sewed up the loose ends in the OR), placed an ostomy as his perineum was without skin, and not suited for normal defecation, and packed his posterior wounds with wet dressings.  I provided him with antibiotics and proper nutrition and fluids, and maximized his pulmonary ventilatory settings, and when stabilized, we sent him to a higher level of care in Germany.  His spine was intact, and his thorax and brain were clear of injury.  The injuries to his abdomen and soft tissue, however, have disfigured him permanently, committed him to many surgeries to come (flaps, grafts, cosmesis, etc), and he will likely have chronic pain and secondary psychological trauma.  I was glad to see him stabilized and sent to Germany.  Yet, a 3 year old with 3rd degree burns over more than 1/2 of her body remains.

The less business here, the better.  Boredom means less trauma.

I see you...

So, I woke up around 4pm today, which marks the second day in a row I have gotten 8 hours of sleep.  After not sleeping more than 4 hours nightly for a few weeks adjusting to the night shift, this was a relief.  After waking, I decided to do my laundry.  You can drop it off, and KBR will do it for you, but that takes 3 days, and I was plum out of skibbies.  So, I elected to do it myself.
      I haven't bought Tide laundry detergent in a while, but the 1L bottle I bought was $9.75.  That seems expensive - funny how you can get some things cheap here, but other simple items cost a fortune.  Anyway, I had to walk a little farther to a functioning laundry as the one within my housing sector had a fire last night.  (I heard something about poor wiring, too much lint, and canvas tent). After finishing my laundry, I began the walk back to my "hootch", and realized it was dark and I was without the required reflective belt.
      In dim light hours, active duty members are required to wear reflective belts.  If they have backpacks, their backpacks need reflective belts also.  The army requires reflective belts anytime they wear PT gear - this explains why there is so much reflection of light in the weight room, and watching a basketball game on the court under the lights is little distracting.  So, the air force has the wisdom to note that reflective gear is probably only useful at night, but the army has the forethought to know that if you are wearing your reflective gear, then you don't have to rush home at dusk like Cinderella and her pumpkin chariot at midnight.  Alas, I completed the laundry and stepped out the tent, into the darkness sans belt.  One sargeant approached me to say, "Sir, you are not wearing your reflective belt," to which I replied, "then how did you see me?"  He was unamused, but it helped ease my anxiety that I was out of uniform on the remainder of the walk back to my luxury quarters.
     Like most things in the military, the reflective belt makes sense, on a population-based analysis.  Sure, if we put everyone in reflective belts, then we will reduce auto-pedestrian accidents by 25%.  Perhaps, we just altered natural selection, and saved ignorant people who put themselves in front of vehicles (?)  Yes, I wear my reflective belt as I am told, and I don't think that it is that big of a deal in it of itself.  It is the cumulative requirements of things that I need to have on my person when I leave my hovel to go to work that chafes me.  At home this consisted of: wallet, beeper, keys, cell phone +/- briefcase.  When I came to the military, it was: wallet, beeper, keys, cell phone, badges, hat, and remembering which day of the week to wear which uniform.  Here, I have wallet, beeper, keys, badges, gun, reflective belt, hat +/- extra uniform and shoes.  The nurses think it is funny that I never remember all of these items.  Don't even get me started about the 9mm I am packing.  see: http://www.youtube.com/watch?v=R7U38QCRMVw

Mortar walls and Mudcon

Behind those 12ft concrete walls are the temporary homes of the many soldiers, airman, and seamen here.  You may notices that there is no concrete barrier roof.  So, if we were to have mortar attacks, you are supposed to run to the bunkers.  There is one just to the left of this compound.  I live about 100 paces away from "R" pod, but they pretty much look the same.

The rain is now starting to lighten up, which is good, as it has been a muddy mess.  Turns out that central Iraq looks more like south Texas than the Sahara.  When it rains, there's mud.  On my way here, I was in Qatar for nearly a week waiting for a flight.  When it rains there, there's wet sand.   Anyway, as it takes 1-2 minutes to put on your boots, the mud is a pain.  The command issues "mudcon" alerts, and you have to carry spare shoes if you want access to buildings such as the dining hall (known here as the D-FAC), the hospital, or the gym - pretty much the only places I go.  I know I will yearn to return to the rainy days in July when it is 128 degrees Fahrenheit.

Housing for field grade officers is nothing to complain about.  I am quite comfortable, and do not have to share my little box with anyone.  Colonels have wet trailers (connect to a bathroom) - that would be nice - but I still have to walk to the "cadillac" (WC).  That is not a big deal, except during serious "mudcons" in the middle of the night.  I will write a post later on some of the creative alternatives I have heard of or seen here - people are funny.

Confessions of Blogvirgin

I apologize for the delay.  My goal was to have this up and running by now, but I have been a bit handicapped by my internet connection, the lack of knowledge on how to set up a blog (amazing how I have gone from technically savvy to incompetent with regards to computer programming over the past twenty years - blogger does everything for you, as it turns out), and, most importantly, lack of sleep.  I have finally adjusted from CST to LAT (local arab time), and working nights, and things should be good to go now.

The world is beautiful - even parts of Iraq, I guess - but truly, most beauty comes from the relationships you have.  And my life is filled with beauty.  So, during these several months of my deployment, I hope that I can keep up with you even though most of those who read this  are 7000-10000 miles away.



A few notes.
The security around here is not subtle, and though there are myriad blogs and youTube videos published of this place, I am betting that some are violations of operational security (OPSEC).   Thus, in interest of staying out of jail, my posts will be delayed by 24-48hrs.  Likewise, I will post some pictures, but not too much detail as a lot of this stuff is "off limits."  Albeit, this is a ironic as you can see all the buildings on google.earth, but, I digress.  The blog is open to whoever wants to post, but I can also receive email at savona007@gmail.com if you want to have a private conversation.