A refugee radiologist: perspective for the apathetic, Part II

...cont.
So, in Syria for a day, and needing to decide whether to leave to Libya by nightfall, Dr. Fajal and his family had a decision to make:  were they to make the relatively simple move to Libya, and start a new life there under another dictator, or were they to stow up in Syria, weigh their options and make the more difficult, costly travel to the United States.  Dr. Fajal's son did not want to leave Saddam's Iraq to be part of Qadaffi's dominion, and pushed the family to make the trip to the States.

Months later, the family was settled in New England, and though Dr. Fajal spoke English and was a practicing physician in Iraq, there are very few reciprocal agreements with respect to medical training and licensing in the United States, and in order to function as a radiologist in the US, he would be required to pass all USMLE tests, and attend another residency in an accredited US radiology residency program.  It is hard for people to conceive the difficulty - hubris aside - of going back and completing a 5 year residency after 20 years in practice.  Even if Dr. Fajal could find quick placement into an American residency, and this is not likely given the competitive nature of the field, and the protracted process for selection of residents, he would have to pay back loans for his travel to the US, and support his wife and children on a resident's salary; all while he was required to work 80 hours per week for 5 years before he could re-establish a practice in the States.  This in mind, he chose the pragmatic approach.  A local community college offered an ultrasonography certification after 6 months, and given his experience with ultrasound over 20 years of practice in Iraq, he pursued this option; the quickest and easiest route to a paycheck; the paycheck which would put food on the table, pay rent, and settle debts for the travel to the US.  Each of his children, at the appropriate age and schooling, worked themselves to support the family. His son worked with the electric company, and each of the daughters worked in retail shops, in addition to their studies.  Each payday, the children brought their checks to their parents to budget and disperse as necessary.  They became citizens in the US.

His son has completed his education, and is a practicing chemical engineer.  His daughters, however, are still in college, and the debt from their cumulative education exceeds what he could afford as an ultrasonographer.  To that end, Dr. Fajal traveled back to Iraq, now as a emissary from the US, to function as a discharge planner, in a contract position.  As I have alluded to earlier in these blogs, these contract positions in Iraq pay exceedingly high salaries, give the danger implicit in being here, so Dr. Fajal, though functioning, again, far below his aptitude and training, can garner the salary necessary to pay his childrens' tuition.  This all comes with a price:  he has been here since 2008, away from his wife, and children.

People like Dr. Fajal inspire us to be better, to try harder.  They conquer obstacles that most of us cannot imagine.  He humbly completes his duties with grace, and is a fantastic "over-asset" to have (imagine having Itzhak Perlman to provide violin lessons to your children) here.  Hearing his story reminds me of the fragility of my material life, and serves as a reminder of the value, and integrity, of work.  My children need to know about his life, and hopefully, they will remember his story. 

Supposedly, necessity is the mother of invention, and suffering the fuel of ambition.  Here's to faith that we can teach the lessons from another's hardship, and avoid the apathetic timbre resonating among so many of our own.

A refugee radiologist: perspective for the apathetic, Part I

As a parent, I want nothing more than the health and happiness of my children.  I do not want them to suffer.  I want to give them more than was given to me, which was more than was given my father, and so forth.  I also want them to understand the value of work, and the virtue of self-preservation.  I want them to be happy, but I do not want them to be apathetic; I want them engaged in their lives.  Nothing engenders responsibility and ambition like suffering and necessity, so how do I teach well-fed children to be hungry, without taking away their bread?  I find this to be the modern American paradox.  How can we develop entrepreneurs and inventors who grow up in the age of Paris Hilton?

It takes discipline, undoubtedly.  I am optimistic I can lead my boys by words and examples, but I stole these lessons; some them from Dr. Fajal.  Yesterday's post tells of this work to place HCN (host country nationals) after their discharge from the hospital.  I did not, however, allude to the path that led him back to Iraq, as an American contract worker.  I decided to provide a drastically truncated narrative of this road over the next 2 blogs... 

In 1998 when the strains of the western embargo on Saddam's Iraq revealed a hopeless future for those wise enough to see it, and brave enough to act on it, Dr. Fajal and his wife made the decision to leave Baghdad.  He could not emigrate, sell his home and more to Jordan or Egypt as any Ba'athist intelligence officials who sensed this plan would seize his assets and confine him, or worse.  He knew his family's departure would have to be surreptitious; that he would leave his life as a prominent physician, all of his extended family and friends, his home and his assets, with the exception of what could be carried on his back.  His children went to school and returned with news from their father that they were leaving within the hour to go on a vacation to Jordan.  They packed accordingly for a week's vacation to Jordan.

They ultimately arrived in Turkey, north of Kurdistan, knowing no Turks or Turkish, without work or a place to stay.  Dr. Fajal and his family lived on savings as he took menial jobs to help supplement expenses during the next several months for their asylum application to be processed.  At the end of 8 months an order for deportation arrived, and the family had six days to determine where they would pick up and settle.  They applied for asylum in Syria, but as the border was closed, they had to await for approval from the Syrian embassy in Ankara.  On the last day prior to their ominous deportation back to Iraq, they received permission from the Syrians, and made their way toward Damascus.  

They arrived in the Syrian coastal city of Banayas on the day of the monthly ship to Libya.  His family had to make a decision just then: were they to emigrate to Libya, or make attempts to reach America... (to be continued tomorrow)

Disposition

Providing a disposition for American patients going home with an injury is pretty simple.  We communicate with the flight surgeon, they arrange for a plane, and off he (or she) goes.  Discharging third country national (TCN) contractors is a little more challenging, but there is a discharge team here to help communicate with the contracting company to arrange for the patient's transport to where ever they may be going.  These patients then go on to heal in the country where they have their further therapy, or back in their home country.

The quandry comes with host nationals (HNs) - Iraqis.  Most of the Iraqi patients we see here are victims of IED blasts or local children suffering severe burns.  They often stay in the hospital for months - we may delay this to provide the best salvage possibility - but eventually, they have to leave the hospital, and they will need to be cared for by someone.  Another person will need to help them change dressings, dress and wash themselves, and often help them toilet or change their ostomy bags.  This in a country that doesn't stock ostomy bags at the local bazaar.  In this wasteland deplete of long term rehabilitation facilities, and families without the knack or funds to care for these people, we have lost more than one patient to dehydration, starvation, infection, or depression after discharging them from here.  But you cannot keep them here forever; they need to re-enter their lives.  Dr. Fajal (not his real name) is the person who shows them how to live on their own after their accidents.  Within the HN cultural context, he explains to families how to provide this care, he arranges communication between the patient with his or her family (not as routine as you may think as HNs are not let onto this base very easily), and ultimately arranges for transportation of the patient back to their home - or, if necessary, a local hospital for further staged care. 

Dr. Fajal works in this role as contract discharge planner for an American company, as a fluent Arabic, English, Turkish, Farsi-speaking specialist who gave up his career in medicine in his escape from a bankrupt Iraq under Saddam.  In his escape, he spent years as a refugee, before settling in the United States, where he acquired an ultrasonographer license after taking some basic courses, to provide for his teenage children.  The United States which did not allow his medical degree or post graduate training; the United States which decimated the remaining infrastructure of Saddam's Iraq; and, ironically, given the hazard of the job, the United States which now provides him a professional man's salary for assisting in providing a disposition to these HNs.  This is an amazing individual.

More on him later.

Smile for the Cameras

Volcanogate ended, and the cumulative Iraq-Afghanistan trauma melange ceased to exist in my ICU.  After the subsequent VBIED from the Iranian border, we still had the less common Iraq traumas come through several times a week, and an assortment of contractors and active duty patients with new heart attacks and strokes.  The unit had been more sparse, though, and this had afforded me a chance to take a deep breath and relax a little. 

Then we had a high level Iraqi minister coming for a visit, so there the brass wanted to fill up the hospital with Iraqis.  Thus, the policies which have taken been molded over the past several years on which host country nationals we see - and which we don't - were put to the screws.  Somehow, the reins loosened, and we had a ward full of host country nationals, just so the Iraqi minister could see a ward full of Iraqis.  There are still 8 HCNs (host country nationals) here.

We recently had the surgeon general, and then the chief of the air force stopping by as well.  There were several announcements about the incoming visits, biographies circulated, and then the requisite instruction to "clean up your area" followed by a command inspection. 

With a culture so well suited and steeped in the punative, I don't suppose I can blame commanders for wanting to avoid hearing about unsatisfactory behavior or demeanor of those under their command, by those higher up the food chain than themselves.  By the same token, however, it seems antithetical that the highest leaders of any organization the size of the military would have any concern or time with pedantry, but, rather, instead hope to discover a sense of the true uncensored sentiment of those in their charge.

Purple hearts

The division commander, Major General C, came to present our young injured troops with purple hearts in the hospital last week.  These were the boys injured in the VBIED whom I previous wrote about previously (see "Weeping heart").  None of the physical injuries sustained in the attack will leave these soldiers permanently disabled, though they lost 2 close friends, and the screening from the trauma incidentally found 2 advanced tumors in 2 separate soldiers.  For this they have the psychological burden of thte attack, and foul luck.

In the tiny hospital ward, a dozen or so Army Rangers packed in between we medical personnel to take part in a ceremony to award the purple hearts.  Purple hearts are for soldiers injured in the field of battle and represent one of the oldest awards given by the military - dating back to the American Revolution.  It was somber, and a sobering 5 minutes for each of the injured.  These were granted by the general along with meritious service medals, so the whole thing took close to 45 minutes.  As I stood among the Rangers and the other physicians and nurses listening to the citations being read, my spine stiffened with a sense of the honor shared among these men, and the privilege of their witness. 

I can also attest that I am pleased to know that these are the special operations guys - the guys who go deep into enemy lines.  I am not a small man, but each one of these hulking masses stood 2-4 inches higher than me, with the breadth of their shoulders equal to mine plus me sideways, while maintaining a similar waistline.  It was as though I was wandering amidst a crowd on a planet with a different species of humanoids.  Each one of them appeared to be capable and proficient with snapping men's necks between their thumbs and forefingers.  They are well disciplined and professional, but their anger after this cowardly attack has tightened their resolve, and focused them in their pursuit.  I am glad that they are on my side, and I fear for our enemies.

My day

16.43	Weeks
115	Days
2,755.23	Hours
165,314.00	Minutes
9,918,840	Seconds

I have been here for a while.  Not that I am counting, but it appears to be approximately 9.9 million seconds...  ...or so.  I have talked before about the folks who have been out hre multiple times for 12-15 months at time, and put this, and my paltry 6 month deployment, in perspective with the boys from both World War I and II who slept in foxholes for 3 years with no word from home.  That doesn't mean that I cannot look forward to going home, and it won't stop me from counting down days remaining - now that I am well past the 1/2 way point.

I am careful not to wish my life away, however, and continue to soak every bit of goodness from being here.  Ironically, this is probably the best Father's Day I have had.  Near midnight, I received and opened a wonderful package from my sons.  It was filled with snacks, and pictures with them clad in homemade t-shirts that read: "My Dad Rocks."  They sent to me life-size silhouettes of themselves - each of them inches taller, with bigger feet than when I departed.  There were handwritten notes.  One in cursive from the eldest, the first multiple sentence letter ever from the 5 year old.  They aren't so good on the telephone, but it nice to see they remember me, and sort-of appreciate me. 

When you are away from what you love most, you can appreciate the magnitude of your affections.  Absence may or may not make the heart grow fonder, but it clearly provides a higher altitude view.

Saint-sational entertainment, for who?

This picture is a little larger than usual for obvious reasons.  In the middle my friend Brett, a nurse anesthestist friend who comes from the Bayou.  This is not a headliner, as far as the USO is concerned, but I think Brett was quite pleased to have his team represented here.  [If you haven't met a "Who dat?" t-shirt-clad cajun, you have yet to meet a rabid football fan].  So all right!  Glad that the Saintsations made it by!  (I hope that they were wearing sunscreen).

The attempts by the USO to keep the deployed entertained and happy, and the generosity of different entertainers is laudible.  I missed the cast from the Sons of Anarchy, with great dismay, as I would have like to share a near beer with them - one guy who came, Kim Coats, plays a complete psychopath, so I was interested in what he was like in real life.  Zac Brown Band came also, and they recently released a video filmed here in Iraq.  Most of the footage is from here at my hospital and base (http://www.cmt.com/videos/zac-brown-band/522070/free.jhtml). 

You might think that visiting dignitaries would spend time with the brass, but the cheerleaders and actors would be led to the young enlisted to meet and enjoy.  You would be thinking wrong.  In fact, for reasons not clear, the people in charge - the commanders and senior NCOs - are the ones giving the cheerleaders the tours of the hospital.  In all actuality, it is a little embarassing that the guy in charge is spending his time showing the cheerleaders what an ER looks like, when that task would be the envy of any 25 year-old sergeant.  You will have to trust me on this (I do not have bandwith available to prove it), but there are pictures, on the hospital servers of the Command or 40-something superintendents getting chummy with every actor, singer or Hooters girl who has passed through this place.  The worker bees are in the hive collecting honey.

I am just glad the Captain Brett got to meet his Saintsations.  But I wouldn't expect a cajun to tolerate otherwise.

Ziggaurat-tten

I will likely never see the true ziggaurat of Ur, the site of the most well preserved remaining Mesopotamian pyramid of the Sumerians from nearly 5000 years ago.  This is one of the things, if things were different, I would like to see in Iraq.  I fear that this will not be a peaceful place to visit as a tourist for many years, if ever, and possibly not in my lifetime.  [So sad that this is true for the large majority of this part of the world].  Alas, 20th-century ziggaurats within the walls of this base will have to suffice.

For reasons mysterious to me, a French company, contracted by the Iraqi military, built several bunkers shaped liked ziggaurats around the base (maybe the French were clairvoyant and preparing for Desert Storm which they supported).  Some of these bunkers are simple 2-3 rooms structures with air handling systems.  Others, are much more complex with dozens of connecting tunnels and rooms (see above left).  Unfortunately, for Sadaam, the bunkers were able to be busted after all (see above right), so these are essentially non-functional piles of bricks and twisted metal littering the base - and the country, as I understand.  From the pictures, it is also clear to see the thousands of circulating dust particles reflecting the flash of the camera (see below left).  Big explosion followed by 7 years of no air handling in this dessicated wasteland equals a real pulmonary workout - masks recommended.

Walking through this eerie, man-made underground maze was exhilirating.  It felt as though we were driving a submarine through the wreckage of the Titanic for the first time, complete with equal amounts of debris and filth; though, realistically, nothing could be farther from the truth, it was fun to be exploring, unraveling a mystery, and imagining, in our minds, what happened in these places before the war.

Carpe diem

Doing your job while deployed to Iraq has challenges in its own right, many of which I have discussed in this forum previously.  Most people take their down time; however, work out, sleep or watch TV.  There are few folks here who really seem to carpe their diems.  I suppose this is true of any place.  The vast majority of us develop at least some sense of complacency, and choose to idle our remaining waking hours, and stretch out our non-waking hours.  Still, a small minority will strive to make the most of every minute of their days, sucking every drop of life from the cup. 

The differences here are striking insofar, as the experience is finite.  The time in this very odd life circumstance is, for many of us non-professional soldier types, fleeting and unique.  In addition, we practically live on top of one another here; we eat together, share showers, work together.  It is simple to notice those who color outside of the lines, and use more than the standard palette, so to speak.  In fact, the military is probably one of the less forgiving institutions with regard to nonconformity, so creativity comes with a price.

But for those who are creative, there are wonderful myriad adventures afoot in a new or rebuilding country.  One of my colleagues and friends, not unlike many young physicians recently emerging from a decade or more of self-imposed scholastic asceticism, suffers from an impressive cultural naiveté.  I truly respect this person; however, for aggressively seeking exposure to what there is here to see.  This physician sought out and befriended special operations troops, helicopter pilots, infantry command, and a variety of contract workers.  There were times at the firing range, the helicopter rides over Baghdad, an opportunity to drive a tank, and made to order food in the back kitchens of the dining hall; a doctor, who otherwise was never required to leave the hospital (with exception to tending to personal duties, etc), developed alliances, yet more, friendships, with folks who most of us would never have the opportunity to know, much less summon the courage to pursue.

I really want to drive a tank too.

Weeping heart

I have been told that this war is over by many people here and back home.  On the muslim holy day, Friday, a platoon of American soldiers were lured to investigate a bogus grenade threat in northeastern Iraq.  When they went to re-enter their vehicles and return to their rally point, a suicide bomber drove a car full of explosives into them, killing 2 Rangers, 2 Iraqi civilians, and injuring dozens.  Seven of those injured from the targeted platoon came to our trauma center.  All seven are alive, and they will all leave this hospital without unrecoverable injuries, and with all 4 limbs.

We cared for the troops, several of whom ambled, with lemon-sized shrapnel in their legs after the explosion, as much as 50 yards from where they were targeted to the transport along tortuous, crowded city streets, and back to a safe landing area for their helicopter.  Once on the Blackhawk, they were kept warm, resuscitated, and bandaged or torniqueted as necessary. They arrived to our ER where 50 waiting doctors, nurses, and techs were arranged in 7 physician-run patient care areas.  The platoon leader, a 30 year old lieutenant, was triaged to me.  I quickly assessed him; all the while he screamed, not for pain, but in anguish for what he knew were his lost soldiers, and in desperation for the wounded aside him.  


Calming him with talk, morphine, and ultimately, a stern order, I was then able to glean the story related above in which some devious assassin set a trap and killed our soldiers in a war that is supposed to be over.  It took me a moment to suppress my anger and gather myself after this.  Yet, I continued with his assessment, and organizing the efforts of my team in his care.  I shot lidocaine into a dozen wounds in his legs, carefully excised, and then filled a specimen cup with shrapnel.  He will recover fully from this and his significant, but relatively simple, orthopedic injuries; barring any findings on film that were unforseen on his exam, he would have escaped this tragedy unscathed, at least physically.  Wickedly, fate revealed a tumor in his brain, incidentally found on the CT, and compounding the anxiety of the day.


Our surgeons spent the night repairing a mangled arm of the most sick individual.  His radial artery was severed, and the trauma surgeon was, amazingly, able to harvest the saphenous vein (much like a cardiothoracic surgeon would for a bypass), and use it as a vein graft for the decimated radial artery.  We spent the better part of the day completing his resuscitation, and controlling his pain.  He was extubated, clear to his surroundings, moving his injured hand, anxious to hear of his brothers.  With pride and ease, I was able to tell him of his 6 healed, and healthy comrades.  Watching his eyes when I told him of the others who had fallen, tore away at my own soul, as my heart weeped inside my chest for those we lost after a war had supposedly ended.

Weakness of the notsoyoungman

I have it in my mind that deploying to a war zone is easier for a young man that an old man, or at least, a not so young man, as it is.  The duties of a husband and father are springs not yet sprung in the mind of a young man; nor are the concerns with the daily life, health, virtue and development of those children and wife.  The body of a young man abounds without the arthritides he later gains.  Rising after quick restful sleep, the young man needs no respite, stands for the physical challenges, and consumes, digests and evacuates in near involuntary routine.  The not so young man must strategize water consumption to avoid otherwise nighttime prostatic spasms and subsequent trips to the loo, and deviates from his set cuisine at his own peril given the unpredictable effects on his bowels.  That he thinks of bowels makes him different that the young man.

The young man is likely less aware of the ways of the world, and more accustomed to following directions without fully comprehending the import or the consequences.  To the young man, time is infinite, and spending it directionless without purpose is of little regret or concern.  The not so young man is less generous with his most valuable depleting resource.  The not so young man knows the absurdity, inequity, and unkind face of war.  The young man speaks in platitudes, and has a clear dictum on the purpose of his service.

The young man lacks wisdom and insight to put inconveniences and suffering in perspective.  He lacks the capacity to compartmentalize properly the intellect and the emotion.  He can become weary with personal investment in things outside of his control.  But still, a young man can be more content to waste his time, is less aware that he is wasting it, and is more steadfast in the clarity of his work.

Dust

This is an old picture, but it is better than the ones I took when this happened this week.  Sandstorms may be predictable, but not be me, or anyone I know here.  The limits of prediction tend to be as the photographer in this picture: “Oh shit; will you look at that!  Let’s take a picture.  Now let’s run inside.”  Sometimes, this happens when you sleep, and you wake up and notice no sunlight coming from underneath your door; an opaque thickness to the air, and layer of dust on your nose.  This dusty fog may linger for weeks, I am told.  It does provide a reprieve from the heat (by blocking the sun); at the cost of pulmonary detriment.

When you do emerge from your hootch in the morning, you sense you are stepping into the post-apocalypse.  The air is thick, and visibility is limited to a few hundred yards.  The sun is nowhere in sight, but the enveloping orange hue belies it.  Every structure and vehicle is under a layer of dust, as if blanket by snow after a midnight dusting.  This morning, I dirtied by hands and then my slacks jumping aboard my bicycle.  The crackle of the gravel beneath the  wheels is the only sound.  The dirt in the air seems to absorb sound and lead to an eerie silience.

I just peaked out the door, however, and relished a view of the sun and cumulus clouds; a sign that the dust is settled, the wind in down, and the air is clean – or as clean as it gets, anyway.

Relative scarcity

I cannot complain about deployments amidst helicopter pilots here for their 5^th 12-15 month tour in the past 8 years.  That said, that is the nature of being a helicopter pilot.  They are most valuable to the world – as helicopter pilots – in this war in the middle east.  Back in the states, they may be in demand to shuttle a CEO from Manhattan to JFK, or to help fire jumpers in the west, but here, they save lives daily, and provide essential transportation services where there are no roads, roads are unsafe, or roads to sanctuary are too long.  Likewise, the trauma or orthopedic surgeons are the war-theater rock stars.  They are in demand all over, but here, at least when the violence was greater, they operated here more frequently and to greater effect than ever before in history.

By contrast, the nature of my job is to diagnosis and treat malignant blood disorders.  Since most of the diseases I care for occur in less than 1:10,000 people, I almost never make a new diagnosis here in theater.  More importantly, and to the point, the capacity to confirm diagnosis through laboratory methods, and initiate treatment is only available at higher levels of care, for obvious reasons, and there is no intent to have me here to perform this role.  In the States, I am one of 3 people who do what I do in the Department of Defense, servicing all active duty and beneficiaries via TriCare, while here, I serve as a hospitalist, just as every other medical subspecialist and general internist who comes here.  That doesn’t diminish the gravity of our jobs here, or take away from the value of care provided by hospitalists whatsoever.  In fact, if anything, it emphasizes the value of their inpatient critical care skills, which, for me, required some dusting and freshening prior to re-use.  It rather emphasizes the nature of deployment patterns and violations of the laws of supply and demand, or scarcity, in the military, or at least, in the medical corps, in order to acheive parity.

In order to keep sending the much needed critical care specialists, they send me to pretend to be one.  In addition, I am pretending to be a pediatrician right now.  [God forbid we get another obstetric case (had an etopic pregancy months ago dealt with by the general surgeons)].  The parity principle is fair in some ways, but then again, those who chose to train in trauma surgery or critical care in the military should have known what they were in for, no?  Interestingly, the parity principle is commonly violated by those puppeteers who steer we pawns around the globe.  The USAF, for example, never deploys radiation oncologists or dermatologists, and just recently started deploying pediatricians.  I fail to see how a dermatologist has less to offer burn patients than I do, especially, those trained in plastic surgery techniques.

Again, the glass is half full; it could be worse.  The urgent care clinic across the street is manned by my army colleagues to help the family practitioners: a neonatologist, a rheumatologist, a pediatric neurosurgeon, and an infectious disease specialist.  If you have MD after your name, the army does not see a difference among you.

June 06 - 66 years later

The USAF deployments used to be 3-4 months.  As the Army was sending people here for 12-18 months at a time, the USAF changed policy and lengthened deployments to 6-12 months (just in time for  my deployment), and the Army, ever for the sake of parity, diminished 15-18 month deployments in favor of 12 month stints. 

For 3 months, you can hold your breath.  To be sure, it is a long time to be without the people who love you, and away from life as usual, but it is not so long that a seamless transition back into that life cannot occur. Life here is so different in every way - hiking to a shower, walking everywhere, wearing the proper uniform, dealing with the threats and stresses of a war zone – and 4-6 weeks quickly fly by before anything becomes rote and a real rhythm is maintained.  Most anyone can muddle through the 4-6 weeks that remain prior to the 1-2 weeks spent preparing for the voyage home.

Six months is different.  Seasons change.  The rains come and go.  And the fog quickly dissipates revealing the exotic, mundane; the weeks and months then progress with a rhythm of life, not an escapade, but a regular life.  Sometimes I wake up in a cold sweat after dreaming that my boys have grown to men in my absence.  It is not missing a t-ball game, but rather, watching, as if through a kaleidoscope, your son learning how to throw a ball from his friend’s father - a surrogate guide through a boy’s rites of passage.

My doubts aside, those on multiple tours contend that there are many opportunities to atone for these fatherly absences.  Those sent here for a year or more, however, put this contention in doubt.  When you receive orders to come to Iraq or Afghanistan for a year, you are picking up and moving your residence, no matter what they tell you.  Active units involved in military operations may work constantly to keep their war machines humming along, and months pass quickly given the greatest distraction of self-preservation.  As if they were frozen in suspended animation traveling at warp speed to and from another galaxy, in cliché Star Trek fashion, they return home to find life has continued without them, and they are not as they perceive - hours or days - but months and years removed those they left behind. 

The permanence of these moves is magnified at the close of a war or during a lull, when the work does not fill waking moments, and the mind is filled with the pedantry of which I have spent months discussing in this blog.  I am not sure how a man, or woman, returns to regular life after spending a year here.  It is completely humbling to consider this in the context of D-Day, which 66 years ago today marked the beginning of what was 18 months, or more, away from home, in deplorable conditions amidst countless deaths and decay. 

Ticket to ride

The key to getting out of here, is the arrival of your replacement.  There is always some planned overlap for you to show that person where the bathroom is, how to say "peace be onto you" in Arabic, and how to get the Indian kitchen staff to deliver you extra curry chicken.  By design, this overlap is not long, however, as every day 2 people are here in one spot, the government pays double.  Though the government is paying double to have 2 people doing one job here, the 3-4 day planned overlap sometimes becomes 2-3 weeks, just because the document that defines the logistics of the handoff slid off someone's desk or is buried under some folders.

In the medical group, as in many, there is one extremely powerful person, a tech sergeant, named Sergeant Lola Jones (not her real name), whose sole job is to manage those logistics.  As there is no train station or commerical aircraft, the monopoly by which you are extracted from Iraq is the USAF - and when it comes to getting out of here, Lola is the USAF.  She decides who is on which plane, which poor souls have to travel back through Qatar on the way to the states, and which are flown directly to Germany or England prior to heading home.  She controls the issue of the tickets, and, as it is rumored, has a secret rolodex of the logistic and aircraft contacts who actually move military members around the world.  Colonels can be jackasses, and Lola still gives them the expedient travel, as the fallout from angry colonels is not worth the hassle otherwise.  The rest of us, however, better be nice to Lola.  Be nice, or spend 2 extra weeks in a tent in 130F in Qatar; and we (below colonel) just cannot make significant enough waves in the tub to save Lola's revenge.

In the military you never want to be the ranter-and-raver as this will assure you get precisely the opposite of what you seek, if, for no other reason, than spite; and because you have pissed off a person who has the power to screw you.  Though passively allowing life to happen can lead to extraordinary opportunity in the military, I don't recommend this approach, either, as no one is really vested in your interests, and you may get looked over. 

Instead, the tried and true approach is to subtlely remind Lola that, 1) you exist, 2) she likes you.  I have learned this lesson the hard way, and have been smiling at Lola every day since I got here.  I even brought her some ice cream when the doctors did our part on "staff appreciation day" (otherwise, of course, this would have been saccharin and over-the-top).  It is my hope that this capital is gaining interest, and my flight out is easy and smooth.  In the meantime, it is damn entertaining to watch officer after officer stomp down the hall and raise hell after Lola gives them little daggers.

Lemonade and chicken salad

Our pediatrician has left the premises.  Her tour has ended, and leadership has decided not to replace her with another pediatrician.  In fact, this decision was made in haste last week, and the pediatrician previously planning on coming over was told to unpack his bags, as he was staying stateside.  As our troops and the contractors are big people, the decision to send home the keeper of the little people seemed prudent. 

Then there is the matter of goodwill.  Or, rather, the political capital our military may aim to gain by providing care to the surrounding community, which, as one may gather, includes children.  Children in auto accidents, children burned in fires, children with risk to life, limb or eyesight.  Now, there are not many children who find their way into our hospital, but there are some, and typically, these are burn victims who end up on service for months at a time.  Luckily, the surgeons known how to care for burns in children.  The problem is these patients get infections, and develop acute medical issues.  And who is to care for this?  Not the surgeons.  Children receive medicine in weight-based formulas.  They do not suffer from diseases of wear - coronary disease, emphysema, diabetes (at least adult-onset diabetes) - but, their physiology and psychology are just different.  Metabolism.  Growth plates.  Communication.  Fear.  Together, we are a team of "adult doctors" who will care for these children who have no pediatrician. 

George Annas recently wrote an article in the New England Journal of Medicine concluding, "...the medical standard of care...  ...can be understood as doing what you can under the circumstances, with the patient's informed consent.  The standard of care is the same in sickness and in health and in emergencies."  I would like to think that taking care of children in this setting is doing just that: making lemonade. 

The impossibility that has been reckoned on physicians in this situation, however, in which mutually exclusive sentiments are pursued - operating a Level I trauma center, and maintaining the 'status' of this capability, while simultaneously trimming down essential personnel  from the roster - is the heart of the frustration.  Meet irrational demands to do the impossible. This is a recurring theme in the military which I will be quite glad to leave behind. 

Pediatrics is a separate residency training I gladly avoided for a reason.  Now that we have sick children here, I will do my best to care for them, and will in the future when they come in to the hospital - I will make chicken salad.  That does not mean, however, that I approve of another chicken shit policy.

Hot wheels!

The dust quickly joins with bicycle grease to form an unpleasant grit with each rotation of the pedals. Riding on loose gravel at low speeds is recipe for capsizing; zipping through the layers of unsettled rock at high speeds denotes wanton disregard for exposed skin.  Tires become flat soon after every weeklong search for a working bicycle pump.  And still, possession of a bike is elevation to Iraq nirvana.  The heat, a little less hot with a breeze on a bike; the mile ride to the BX, a simple jaunt on two wheels.  The late night call to the hospital - diminished to a few breaths, pedaling in the night.

With the exception of a few long term American contractors who spend the money to bring Trek, Specialized or Gary Fisher mountain bikes, most of the bikes are cheaply made knock-offs with a very limited shelf life. The BX does sell very overpriced, low quality knock-offs, but the majority of the two wheeled fleet here is from the recycle market (and usually, just 2-3 recycles before the desert does them in).  Anyway, as part of some unwritten, and frustrating, rule, bicycles (as well as other accoutrement) are handed down from replacement to replacement.  That is to say, when the pharmacist leaves, he betroths his goodies to the next pharmacist; when the orthopedic surgeon leaves, he betroths his Iraqi belongings to the next orthopedic surgeon.  Even my buddy the radiologist didn't offer my his mini-fridge (a prized possession) as he was passing it to the next radiologist coming here - who he barely knows!  Needless to say, I am not part of a rich tradition of inheritance here, and breaking into the nepotistic black market is not child's play.

First, I tried the public announcement - an advertisement: "Man seeking bicycle."  This returned only greedy offers from charlatans to sell bikes for $100-150 which they themselves were given by their predecessors, gratis, as part of the heretofore mentioned nepotistic inheritance practices.  Every subsequent attempt to find a bicycle after this was met with some variation of this response: "Sorry man, I am saving mine for my replacement."

So, it is, the sweetness of now finally having acquired my own wheels - along with headlamps and repaired bicycle helmet (which reads in big black letters over duct tape: "Combat Oncologist") - all divined for a handshake alone from a generous realist who has similar opinions of the bicycle hand-me-down cliques.

With aplomb, I ride through the HMMWVs (humvees) and MRAPs, over curves and into the sea of dust and unsecured rocks.  I avoid the 20 miles of perimeter road for the random peashots that may come from outside the wire; but the protected guts of the installation are mine to roam.  At least until the bike gets stolen, and passed down through another set of undeserving replacements.