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.

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.

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.

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.

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.

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[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]. 

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.