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.