Six months ago, the plans for the drawdown of military, and civilian support, personnel in Iraq were public knowledge. Reduction of military force by 50% in September 2010, and removal of all troops, with exception of training operations and diplomatic missions by September 2011; or something approximating that, anyway.
Most active duty troops are relatively young and healthy, but the sheer number of folks here leads to the statistical inevitability of strokes, heart attacks, seizures and what-ails-you walking through our door. These cases have previously been dispersed among the many hospitals and small clinics throughout the country. This year, we expected to see an up-tick in the number of medical admissions when the peripheral bases started to close this summer. What we did not expect was the simultaneous increase in violence - or at least the perception of such - as there are diminishing number of facilities prepared to care for trauma patients. In addition, the young surgical crew here is hungry, and doing far more elective cases than the previous group.
So, these have all led to a significant increase in business, decrease in sleep, and mild regret among my colleagues as to my departure - or at least the departure of my work. The hospital's first priority is to care for the trauma of US soldiers, and that mission will be met. The elective procedures may start going away, and that will provide more time for the surgeons to care for trauma victims, but other services we provide are not as elastic. The care of host nationals (HNs), for example, is, in part a humanitarian effort to win the hearts and minds of those in the areas around us. The choice of which of the patients are chosen to receive care here, however, is somewhat arbitrary. People will be happy when we discharge the 21 month old boy who has been here for 1 month in the hospital, a most certain rescue from death from his burns. People are less pleased when Command accepts a terrorist with a gunshot wound over a infant with a simply reversible birth defect at the gate. Compounding this, recently, our follow-up clinics have been canceled, so once a HN patient is discharged from the hospital, they are on their own for follow up medical care. I liken this to dropping off an individual on a deserted island with a laptop and a cell phone. The medical infrastrucure in Iraq simply is not mature enough, or hasn't rebuilt enough, to handle complications or complete staged procedures for complex patients. Nonetheless, this is all part of the plan to slowly remove ourselves, and any dependence on us, from inside of Iraq.
Planning for removal of 100,000 troops and 100,000 contracted support personnel is based on some known variables, and it must remain mutable for those unpredictable surprises. We are counting, or at least hoping for less violence during the drawdown. For the sake of the care of the troops, if nothing else, let's hope this is an accurate assumption.
Saturday, July 24, 2010
Sunday, July 18, 2010
Eatin' up, with my bad self
For months, I avoided soul food night specials at the DFAC and chose, instead, a bowl of cereal or pop tarts. The macaroni and cheese was served in cut blocks as the pasta had melted into itself. The "fry" on the fried chicken seemed much greater in mass than the "chicken" of fried chicken. The vegetables? Overcooked, and molten, indistigunshed.
As of late, however, Sunday night has become a culinary delight. I never seem to remember it ahead of time, but when I walk down to the DFAC, and discover that it's SOUL FOOD NIGHT, well, I am a happy man. Tonight, I eschewed the ribs and macaroni and cheese delicacies, and, instead, partook in the gumbo - which, as a charming mix of shrimp and left over chicken curry adorned with plump pieces of floating hotdogs, may not rate as 'Nawlins finest, but makes a nice dish, all the better mixed up with cornbread, and washed down with sweet tea. The larger portion on my plate was collard greens, without the pork parts, and a heaping mound of blackeyed peas. I used to consider this the penance for the sins of the "gumbo mash" described above, but my vegetarian wife will be happy to know that I now enjoy these as much. (The better to wish in the next New Year, I suppose).
Honestly, the food here is tremendous. We are blessed to have hot food, and people who cook it for us. There are no MREs, and the dreaded constipation that accompanies it. There are many selections, and frankly, some of the food is tasty. I am always amazed at how they are able to offer these gargantuan trays of fresh fruits and vegetables to thousands of soldiers in the middle of a dust bowl; especially, considering that the food is brought from all parts of the world, all of which are more than 1000 kilometers away. The dishes all have a little taste of the sub-continent, and I am happy to leave this behind, but that is more to escape routine and a welcome of choice, not for lack of quality.
Really, this is a far cry from anything in deployed settings in the past wars, and you do find yourself a bit guilt-ridden with complaining about a shortage of Diet Coke or Honeynut Cheerios, having Pepsi Light and Total, to suffice. If anything, though, you recall the cornicopia available to most Americans, at any time of the day, and truly appreciate that remarkable convenience. Gulitily, I am looking forward to this in a major way. In the meantime, however, this white boy is digging his curry-chicken gumbo mash with a large side of greens. - vinegar and hot sauce at the ready.
As of late, however, Sunday night has become a culinary delight. I never seem to remember it ahead of time, but when I walk down to the DFAC, and discover that it's SOUL FOOD NIGHT, well, I am a happy man. Tonight, I eschewed the ribs and macaroni and cheese delicacies, and, instead, partook in the gumbo - which, as a charming mix of shrimp and left over chicken curry adorned with plump pieces of floating hotdogs, may not rate as 'Nawlins finest, but makes a nice dish, all the better mixed up with cornbread, and washed down with sweet tea. The larger portion on my plate was collard greens, without the pork parts, and a heaping mound of blackeyed peas. I used to consider this the penance for the sins of the "gumbo mash" described above, but my vegetarian wife will be happy to know that I now enjoy these as much. (The better to wish in the next New Year, I suppose).
Honestly, the food here is tremendous. We are blessed to have hot food, and people who cook it for us. There are no MREs, and the dreaded constipation that accompanies it. There are many selections, and frankly, some of the food is tasty. I am always amazed at how they are able to offer these gargantuan trays of fresh fruits and vegetables to thousands of soldiers in the middle of a dust bowl; especially, considering that the food is brought from all parts of the world, all of which are more than 1000 kilometers away. The dishes all have a little taste of the sub-continent, and I am happy to leave this behind, but that is more to escape routine and a welcome of choice, not for lack of quality.
Really, this is a far cry from anything in deployed settings in the past wars, and you do find yourself a bit guilt-ridden with complaining about a shortage of Diet Coke or Honeynut Cheerios, having Pepsi Light and Total, to suffice. If anything, though, you recall the cornicopia available to most Americans, at any time of the day, and truly appreciate that remarkable convenience. Gulitily, I am looking forward to this in a major way. In the meantime, however, this white boy is digging his curry-chicken gumbo mash with a large side of greens. - vinegar and hot sauce at the ready.
Saturday, July 10, 2010
Shorttiming
Going home soon. There is not much time left for me in this accursed country, but the hands of the clock have slowed; they are my never boiling watched pot. When your tour is measured in weeks or days, you can realistically cross days out on the calendar without worrying of running out of ink. This doesn't make sense to me as I will just spend more time staring at the calendar.
My children may not be stopped from this, but they are weary of the weight of our separation, and the younger ones have started to wonder if I am every returning. School has been out, but my wife has maintained a routine, for her own sanity, and their benefit. Surely, they remain occupied for most of their day. Perhaps my arrival home will be noted with a shrug, or less, by my sons, who have lived without me for longer than they can remember. I hope and believe that this will not be the case.
The crews here have changed over. Those who saw me come in, and showed me the ropes have returned home. I talk of February and rain here, and the those newly deposited into this stink are disbelieveing, as if they are things of another epoch. Strangely, the contractors from the sub-continent, while always polite and professional, have lately started to afford a familiarity of mutual respect. They don't check my ID at the gate when they see my face; I am served my usual breakfast off the buffet by issuing a smile and without uttering a word; they even bring me curry sometimes to my office.
Let the outprocessing scavenger hunt begin... ...oh, gladly. More on this later.
Thursday, July 8, 2010
Incoming
The sound of the klaxon is unlike any other siren. The grating, repetitive hum drills to the primal, and the response is subconscious and automatic: a reflexive flop, and quick acquiantence between man and dirt. The low frequency horn forever symbolizes urgency and danger. As the wounded appear here with all matter of fragments blown into them, the response to the klaxon is visceral in everyone.
Usually, the incoming mortar is thrwarted with the eyes in the sky and the guys with long hair and thick necks and sharp knives. But when the wind thickens the air with dust, and surveillence becomes difficult, the klaxon will sound and send everyone to the ground. Sometimes defense missles shoot the mortar round out of the sky, sometimes it is a dud, and occasionally, it lands somewhere on this vast base stirring up the air, and shaking the ground.
Incoming fire of real consequence may not be common, but the sirens and announcements are. The base is well fortified and protected, but the enemy fervent and tireless. I have read (and this is common knowledge, not OPSEC) that al-Qaeda in Iraq has become more clever, and no longer places mortars in the fields around us themselves. Instead, they pay impoverished farmers to place "packages" in their fields, or, they have been known to place a mortar round frozen in a block of ice in the apeture of a launcher, whereas it may launch hours later after melting away the ice in the hot sun, and subsequently falling into its launching barrel. These tricks have low specificity, and limited payload, but are very difficult to prevent, thus, they harass us, and require vigilence to monitor and contain. More importantly, they generate fear and we expend more resources to account for them - and this is the terrorist victory difficult for us to deny, at home or abroad.
Usually, the incoming mortar is thrwarted with the eyes in the sky and the guys with long hair and thick necks and sharp knives. But when the wind thickens the air with dust, and surveillence becomes difficult, the klaxon will sound and send everyone to the ground. Sometimes defense missles shoot the mortar round out of the sky, sometimes it is a dud, and occasionally, it lands somewhere on this vast base stirring up the air, and shaking the ground.
Incoming fire of real consequence may not be common, but the sirens and announcements are. The base is well fortified and protected, but the enemy fervent and tireless. I have read (and this is common knowledge, not OPSEC) that al-Qaeda in Iraq has become more clever, and no longer places mortars in the fields around us themselves. Instead, they pay impoverished farmers to place "packages" in their fields, or, they have been known to place a mortar round frozen in a block of ice in the apeture of a launcher, whereas it may launch hours later after melting away the ice in the hot sun, and subsequently falling into its launching barrel. These tricks have low specificity, and limited payload, but are very difficult to prevent, thus, they harass us, and require vigilence to monitor and contain. More importantly, they generate fear and we expend more resources to account for them - and this is the terrorist victory difficult for us to deny, at home or abroad.
Of the many rounds which never detonate, EOD teams are quick to disassemble those warheads, but, in place of the klaxon, the loudspeakers issue instructions and caution - another auditory stimulus unique to a war zone. "THERE HAS BEEN AN INDIRECT FIRE ATTACK..." The klaxon and the intercom, like cordite and decay for the olfactory, are the indeliable sounds of Iraq; so askew from home, so poignantly descriptive of war.
Tuesday, July 6, 2010
Vigil
It has been a few years since I spent the entirety of a day and a night at the bedside of one patient. I did have to admit a handful of other patients with trauma and other injuries, but the surgeons did the lion's share of that care, and as I wrote the physician orders and interviewed them in the ICU, I was just meters away, and even then, only intermittently, from Mahmoud (not his real name), my 17 month patient with burns from his face to his feet.
This toddler was brought to the base gate in the arms of his sobbing father one week ago. The boy reached for his meal cup on the edge of the counter in the kitchen, but this familiar thermos was filled with boiling water which his mother had just poured in while preparing his breakfast. Why his cup with scalding water was within his reach is something I cannot understand, and a question his parents will probably never be able to answer.
Mamhoud's mother, 9 months pregnant with the next child, has not seen Mahmoud since he came to the hospital where his burns, not unexpectedly, expanded, as he developed, also not unexpectedly, a severe infection, which leaves him now intubated, flirting with death. I had to explain, through an interpreter, how Mamhoud is very ill and may die as a complication of his burns to his father and uncle; the mortality of this severe of a burn in the United States "But this is why we brought him here," they say, incredulously. Knowingly, they say, "He would die at the [Iraqi] hospital," and indeed, death was certain at the local Iraqi hospital where they have no capacity to offer this level of care. That is the my solace - that this child would be dead without me - in practicing outside of the scope of my own practice; a specialized profession in the care of adults. We are taught from very early in medical education, the ethical dilemnas and the hard and fast rules. In the US, you practice in the scope of your care or you lose your license. The lines are blurry, sometimes, but surgeons don't do psychiatry, obstetricians don't do cardiology, and adult medical subspecialists don't take care of children. The exigent circumstances which leave this child dead without me, and the fact that providing critical medical care with the resources available is something a "reasonable person with my skill set would set forth to do" in this environment, make this ok. This is what I tell myself, and what the lawyers say.
That doesn't mean that you when you perform outside of your arena you don't second guess all of you decisions. In 24 hours, I wrote over 100 orders on this child, maximizing his physiology. I watched his bell rise, the movements of his fingers, the eletrocardiographic tracings all the while titrating his ventilator settings, and massaging his hemodynamics. And each decision I made, unmade and re-made in tragic inefficiency, to avoid errors I am so much more likely to make in him than I would in an adult.
In this vigil, I watched this boy, equal in age to my youngest son, and the more I stared at him or listened to his breath sounds, or readjusted his dozens of invasive tubes and lines, the clearer the evolution of his pathophysiology became to me. Like a hidden puzzle in the Sunday comics, the pathology revealed itself to the patient observer. As Sir William Osler noted over a century ago, the bedside vigil embodies the essence of what it means to be a physician.
This toddler was brought to the base gate in the arms of his sobbing father one week ago. The boy reached for his meal cup on the edge of the counter in the kitchen, but this familiar thermos was filled with boiling water which his mother had just poured in while preparing his breakfast. Why his cup with scalding water was within his reach is something I cannot understand, and a question his parents will probably never be able to answer.
Mamhoud's mother, 9 months pregnant with the next child, has not seen Mahmoud since he came to the hospital where his burns, not unexpectedly, expanded, as he developed, also not unexpectedly, a severe infection, which leaves him now intubated, flirting with death. I had to explain, through an interpreter, how Mamhoud is very ill and may die as a complication of his burns to his father and uncle; the mortality of this severe of a burn in the United States "But this is why we brought him here," they say, incredulously. Knowingly, they say, "He would die at the [Iraqi] hospital," and indeed, death was certain at the local Iraqi hospital where they have no capacity to offer this level of care. That is the my solace - that this child would be dead without me - in practicing outside of the scope of my own practice; a specialized profession in the care of adults. We are taught from very early in medical education, the ethical dilemnas and the hard and fast rules. In the US, you practice in the scope of your care or you lose your license. The lines are blurry, sometimes, but surgeons don't do psychiatry, obstetricians don't do cardiology, and adult medical subspecialists don't take care of children. The exigent circumstances which leave this child dead without me, and the fact that providing critical medical care with the resources available is something a "reasonable person with my skill set would set forth to do" in this environment, make this ok. This is what I tell myself, and what the lawyers say.
That doesn't mean that you when you perform outside of your arena you don't second guess all of you decisions. In 24 hours, I wrote over 100 orders on this child, maximizing his physiology. I watched his bell rise, the movements of his fingers, the eletrocardiographic tracings all the while titrating his ventilator settings, and massaging his hemodynamics. And each decision I made, unmade and re-made in tragic inefficiency, to avoid errors I am so much more likely to make in him than I would in an adult.
In this vigil, I watched this boy, equal in age to my youngest son, and the more I stared at him or listened to his breath sounds, or readjusted his dozens of invasive tubes and lines, the clearer the evolution of his pathophysiology became to me. Like a hidden puzzle in the Sunday comics, the pathology revealed itself to the patient observer. As Sir William Osler noted over a century ago, the bedside vigil embodies the essence of what it means to be a physician.
Sunday, July 4, 2010
No fireworks
We hope that the 4th of July comes and goes without exploding projectiles. The smells of cordite and grilled brats serve well back in the 50 Free, but you do not want to smell sulfur here. Indeed, this will be my first 4th of July without fireworks (the DFAC did have Independence Day placemats today), but I can reflect on the notion of independence in a different light; from the perspective of the Iraqi.
Often people consider Bedouin tribesmen when then think of Arabs. They imagine camel-riding theives wrapped in linen headdresses. This, or Saudi Shieks inspecting rows of Rolls-Royces. The society built upon mesopotamian oil money under Saddam, however, was wealthy, educated, and secular. The rich history of the fertile cresent with the layers of influence imparted by the Ottomans, and then the British, and dozens of conquerers before, imparted wisdom and provided a rich foundation for prosperty and growth. Of course, modern Iraq self-destructed under the militaristic build-up and subsequent hemorrhage of the Iran-Iraq War. The desperate recovery attempts by the Ba'athists after this culminated in OEF; this much and the rest has been the evening news for the past 10 years.
The brain drain began in the 1980s, at the first signs of the disintegration of Iraq as resources were siphoned toward imperialistic desires within greater Persia, but accelerated after Desert Storm, and then skyrocketed with OEF in 2003. Once the infrastructure completely collapsed, with safety in doubt, there was not reason for anyone with means to remain. Like Dr. Fajal, they left anyway they could, as refugees, or, if lucky, as emigrants. What remained was a country without its wisdom. The average aged male in Iraq was 18 in 2005; only now is that figure starting to rise as ex-patriots return, and as the violence quells, letting the citizens live longer.
So, as this country searches for identity, it looks for its own independence; not just the democratic process which allows them to vote leaders among themselves, but the independence from international welfare; and not only self-sufficiency, but ascendancy into a leading nation as expected inheritance for those of Mesopotamia. This ambition is the expectation of the young Iraqi men I have met, but it represents an independence I will likely never live to see.
Often people consider Bedouin tribesmen when then think of Arabs. They imagine camel-riding theives wrapped in linen headdresses. This, or Saudi Shieks inspecting rows of Rolls-Royces. The society built upon mesopotamian oil money under Saddam, however, was wealthy, educated, and secular. The rich history of the fertile cresent with the layers of influence imparted by the Ottomans, and then the British, and dozens of conquerers before, imparted wisdom and provided a rich foundation for prosperty and growth. Of course, modern Iraq self-destructed under the militaristic build-up and subsequent hemorrhage of the Iran-Iraq War. The desperate recovery attempts by the Ba'athists after this culminated in OEF; this much and the rest has been the evening news for the past 10 years.
The brain drain began in the 1980s, at the first signs of the disintegration of Iraq as resources were siphoned toward imperialistic desires within greater Persia, but accelerated after Desert Storm, and then skyrocketed with OEF in 2003. Once the infrastructure completely collapsed, with safety in doubt, there was not reason for anyone with means to remain. Like Dr. Fajal, they left anyway they could, as refugees, or, if lucky, as emigrants. What remained was a country without its wisdom. The average aged male in Iraq was 18 in 2005; only now is that figure starting to rise as ex-patriots return, and as the violence quells, letting the citizens live longer.
So, as this country searches for identity, it looks for its own independence; not just the democratic process which allows them to vote leaders among themselves, but the independence from international welfare; and not only self-sufficiency, but ascendancy into a leading nation as expected inheritance for those of Mesopotamia. This ambition is the expectation of the young Iraqi men I have met, but it represents an independence I will likely never live to see.
Friday, July 2, 2010
Law of averages
I met a brigade commander last night who came in to see his soldier in the ICU. He had traveled from a base over an hour away, and was anxious for a status update, and report on the progress of his care. The answers were not what he wanted. No pupillary reflex. No corneal reflex. No muscle tone. No gag reflex. Most likely, his trooper was brain dead.
The man was crushed, in a work-related accident, by a falling steel panel. The piece which trapped him to the ground required a forklift to move, and 15 minutes afterwards, the man was without a pulse and in cardiac arrest. His heart was recalibrated with eletricity, chest compressions and delivery of oxygen, but the tell-tale signs of his anoxia were present already, even by the team of EMTs providing his care. Fifteen minutes without oxygen to your brain is not survivable.
The Commander said that support brigade suffered no battlefield deaths during his deployment of nearly a year, but two accidental work-related deaths. This is not clumsiness - in fact, very much the contrary, as there could have been many more in the thousands of munition transfers, movements of heavy machinery, and preparation of heavy equipment for the infantry forces if not for their training and safety precautions - but instead the unavoidable, statistical reality of unpreventable accidents; and the more dangerous the job, the greater that reality.
I cannot help but think, however, of dying via an accident here as less palatable than the same thing happening at home (or a battlefield injury here). Men fight in war, and some die there; this is an ending of honor, and a risk these men, and their families, understand from the outset. When we leave home to fight, however, we cannot oblige (nor accept) an early departure from this world for the mundane and unworthy poor stroke of luck. A cracked head on a waxed floor. A wet finger and an ungrounded light switch. Complications from a severe pneumonia. These things happen all over the world, so they happen here too. If there still 100,000 troops, and 100,000 contractors in Iraq, it is simply a law of averages that bad things will happen to some of these people. Location, is everything, however, and going down in a hostile country, 8,000 miles from home in the care of strangers is not how anyone envisons their end.
-------------
[FWIW - The DoD takes pride in the manner by which family is notified, and the means by which these family are brought to see injured family members at the first possibly opportunity. Usually, this means Germany, east coast US, or England, as family cannot be flown into the AOR. We make every effort possible to maximize the physiology of these patients with non-survivable injury, so that they can survive long enough for family to see them at these locations, and possibly even serve as organ donors. We cannot predict how all patients will do, but most can be supported by vasoactive pharmaceuticals long enough to get out of the AOR via emergent air evacuation. Sometimes, we are wrong, families wait in Germany, but patients never alive, dying on the plane, or to Dover AFB, in Delaware as HR (human remains). This is uncommon, but can happen, and is part of the risk taken in an aggressive approach to getting patients and families together. It just makes the accidental non-battlefield death that much harder for family].
The man was crushed, in a work-related accident, by a falling steel panel. The piece which trapped him to the ground required a forklift to move, and 15 minutes afterwards, the man was without a pulse and in cardiac arrest. His heart was recalibrated with eletricity, chest compressions and delivery of oxygen, but the tell-tale signs of his anoxia were present already, even by the team of EMTs providing his care. Fifteen minutes without oxygen to your brain is not survivable.
The Commander said that support brigade suffered no battlefield deaths during his deployment of nearly a year, but two accidental work-related deaths. This is not clumsiness - in fact, very much the contrary, as there could have been many more in the thousands of munition transfers, movements of heavy machinery, and preparation of heavy equipment for the infantry forces if not for their training and safety precautions - but instead the unavoidable, statistical reality of unpreventable accidents; and the more dangerous the job, the greater that reality.
I cannot help but think, however, of dying via an accident here as less palatable than the same thing happening at home (or a battlefield injury here). Men fight in war, and some die there; this is an ending of honor, and a risk these men, and their families, understand from the outset. When we leave home to fight, however, we cannot oblige (nor accept) an early departure from this world for the mundane and unworthy poor stroke of luck. A cracked head on a waxed floor. A wet finger and an ungrounded light switch. Complications from a severe pneumonia. These things happen all over the world, so they happen here too. If there still 100,000 troops, and 100,000 contractors in Iraq, it is simply a law of averages that bad things will happen to some of these people. Location, is everything, however, and going down in a hostile country, 8,000 miles from home in the care of strangers is not how anyone envisons their end.
-------------
[FWIW - The DoD takes pride in the manner by which family is notified, and the means by which these family are brought to see injured family members at the first possibly opportunity. Usually, this means Germany, east coast US, or England, as family cannot be flown into the AOR. We make every effort possible to maximize the physiology of these patients with non-survivable injury, so that they can survive long enough for family to see them at these locations, and possibly even serve as organ donors. We cannot predict how all patients will do, but most can be supported by vasoactive pharmaceuticals long enough to get out of the AOR via emergent air evacuation. Sometimes, we are wrong, families wait in Germany, but patients never alive, dying on the plane, or to Dover AFB, in Delaware as HR (human remains). This is uncommon, but can happen, and is part of the risk taken in an aggressive approach to getting patients and families together. It just makes the accidental non-battlefield death that much harder for family].
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