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.

Memories

I sent a 24 year old home on the ventilator last night.  He has a ball bearing in his cervical spine, and no ability to breath on his own.  He will likely die within the year, with injury worse, and resources less, than Christopher Reeves. 

A young woman's neck was ripped open by rocket frag, and she died in the emergency room a couple of months ago.  Another was shot in the base of the skull and died in the OR in heroic attempts to put his brain back together.  A young man who was rescussitated with 10 hours of abdominal surgery and 20 units of transfused blood was found brain dead from the closed-head-injury not noticed until the aforementioned surgery was complete, and the head was scanned.

Post-call, I had the day off to go exercise, sit in the sun, read a book, watch a movie; a juxtaposition, on the day to remember these, and the countless others who died, and continue to die, here, and in Afghanistan.

Memorial day had always been a day of historical references: broken black and white film of bombers over Germany, the famous flag-raising photo from Iwo Jima, a video clip of a man running through the bush, and rapid fire of Viet Cong to an evacuation Huey in a jungle clearing.  During the OIF/OEF there have been clips of rehabing amputees or kevlar-laden soldiers and laughing arab children, fading to a longitudinal, diagonal view of headstones at Arlington or Normandy all to the backdrop of America the Beautiful. 

I lost a handful of acquaintances and friends over the past few years to the wars, and I do think of them on days of remembrance, but their passings were sterile and distant, despite surely shocking and painful.  Memorial Day will be a time I will remember the smell of burnt flesh and blood, the high-pitched steady ping of the heart monitor reading asystole, the silent ceremony for placement of the folded flag upon the chest of the HR (human remains) before zipping up the black rubber bag.  The dominant images in my mind, and the most poingant memories will be of those who were carried into the hospital with life already all but gone, those I pronounced dead, those I struggled to heal, but failed.  For those, I salute.

Tarred and feathered

I am officially off of the nightshift, ready to rejoin the living!  So, in the morning on my post-call day off, I showered at the hospital and began my walk into the day.  Quickly, I generated a reasonable sweat in the 95 degree morning air under my all-season wear ABUs (Airman Battle Uniform = USAF for camouflage).  I was swimming through and tasting the dust within the thick air; the opaqueness of which explains why I walked around a corner, downwind - a very steady, fierce wind - from the poop truck which was vacuuming its targeted contents, while another South Asian contractor power-washed the innards of one of the many PortAJons littering the base.  The fetid mist ricocheted onto what had now developed into an adhesive slurry of perspiration and dust coating my exposed skin. 

I have been tarred and feathered, Iraqi style.

Tomorrow will be better.

Lucky Joe

The overhead intercom announced "Trauma times one to the ER.  Trauma times one to the ER."  Shortly thereafter, and prior to the arrival of the pending "GSW to the face," there were 15 docs, nurses, and technicians geared and gloved up awaiting the helicopter. 

As the Blackhawk landed outside the door on the helipad, everyone assumed their positions:  ER doc to the head of the bed, the surgeon and I at the foot, the nurses and respiratory technicians on each side awaiting or gun shot victim.  Then, nonchalantly, the medic from the helicopter walks through the door aside a man with a bandage around his head, and a large compress of gauze held into place against his left cheek. 

Someone ran around the corner to grab a bed - for this patient did not come in on a gurney or litter as per normal, but walked in, on his own accord.  We waited for the bed, and in those few seconds, the ER physician and he had the following conversation:

ER MD:  How are you?
Patient:  Shitty.  My face hurts.
ER MD: What happened?
Patient: I got shot in the face.
ER MD:  Did you lose consciousness or fall?
Patient: No.

The bed arrived, and the patient, again, who walked into the ER holding his face as if he had a toothache, was layed supine where a complete survey of his body was done in less than 1 minute.  His pants were cut off, though he walked into the ER, as soon as he layed down.  He was examined, radiographs and blood samples were taken.  He had a rectal exam, and something close to the following ensued:

Patient: Why are you checking my rectum?
ER MD: This is part of what we do in the evaluation of trauma patients.
Patient: Yeah, but I just got shot in the face.  Not in the butt.
ER MD: I understand, it will only take a minute.

It turns out that a sniper had shot this young man but only entered the left side of his cheek, with the bullet lodging in his sternocleidomastoid on the same size.  He is a lucky Joe.  So, we often get these patients from the front lines with no real background story, and there has to be a systematic approach to trauma patients, in order to avoid missing things that are catastrophic if not attended to. 

That said, this is pretty absurd.  And damn funny.

Run, Forrest

We run for different reasons, but anyone who spends any appreciable time running stops, at some point, and asks, "why am I running?"  Forrest Gump ran a few thousand miles before it occured to him that his means had no end, and in the end, he did not understand the means.  Haruki Murakami wrote a book about the less obvious utility of running - Things I think about when I think about running, averring the clearness of thought, and tranquility his daily run has brought to him.  Clearly, running is more about getting from one place to another quickly.

Maintaining the mental and physical stamina to continue running through the parenting years (also the career building years) is undeniably difficult, and in the case of the author, was a failure.  From marathons and sixty miles on my feet a week, to arthritis and sixty miles of driving a day.  Being here has allowed me an unfettered opportunity to slowly overcome the orthopedic ravages and sloth and return to Murakami's running zen.  This is an exaggeration.

However, there is no beer here (at least no quality beer with alcohol), you walk everywhere, and, most importantly, there is nothing else to do, except exercise.  [The list of leisure activities has been well vetted on a previous blog: exercise, reading, movies].  So, outside of the 60 hours a week that I am at my job - and the slowing pace of incoming traumas has allowed for this working pace since I have been here - there is always time to exercise.  Admist the weight training that the rickety shoulders and knees tolerate, I am on the treadmill, and slowly reducing the spare tire (have gone from p195/75 R16 to p185/65 R14 thus far), and my R-Zen is on the horizon.

Even when you have accepted your fate in this minimum security prison (see previous blog), and you have agreed to make the best of your sentence, ennui looms large (btw-can ennui loom?  or be large? ??).  This is not a unique phenomenon, or a surprise, I guess, as this is the military.  There are, however, nearly weekly 5k running races (universally won by one of the east African gazelle contractors here on base) with hundreds of entrants, sometimes thousands.  Maybe they just want the T-shirt, but I think that they are looking for  clear minds and their own R-Zen(s).