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.