30 August 2007

Putting the practice on ice

This picture was taken during an operation I did a while back in the nursery intensive care unit. The operation was fixing a birth defect in a baby boy. I got to know his parents before he was born, because they had learned about his birth defect during an ultrasound. They were worried but hopeful. In addition to the little preparations all parents make, they also prepared for the worries and stresses of medical treatment. They were calm, far calmer than I could have been. I heard about the research they done and learned their depth of knowledge about their child's condition, and learned their calm was not born of ignorance of the risks.

When their baby was born, he was cared for by the newborn specialists. His birth defect affected his lungs, and he required assistance from a machine to breathe. After the initial days of adjustment had passed, he was ready for his operation. That brings us to the picture above. The baby is covered with blue sterile sheets. Under that, a machine breathes for him through a tube. The newborn specialist nurses and doctors give him medications to keep him sleeping during surgery.

I wear sterile gloves and sterile waterproof gown. On my head is a surgical cap that one of the nurses made. It has stars on the cuff and tiny hearts on a red background. She is a trauma nurse, and she sold the caps to raise money for cab fare to give to trauma victims who need to get home. I also wear surgical telescopes that magnify an area five inches across, two and a half times larger. Over these I wear a fiberoptic spotlight. The hole I made for the operation is about three and a half inches across. It is completely hidden behind my hand and skinny fingers. The assistant surgeon holds the edge of the wound open as I tie a knot in a stitch through fragile tissues in the baby's chest.

I look at this picture and I can distinctly see the view through the telescopes. I rember the feel of the tissue and the way I had to adjust the repair to make it fit his individual body. When I see this picture I know I'll never quit because I couldn't find anything else that feels quite like it. I worried about this boy. He stayed in the hospital several months, and even needed another operation. He came to visit me a few months ago and was chubby and beautiful with wonderful blond hair. He held onto his mother and peered around my office with bright curious blue eyes. She and her husband must have seen this outcome long before I did and were right to be calm. I don't know which brought me more happiness, performing the intricate operation or seeing him so strong and well after passing the initial speed bumps.

Two days ago I did my last sheduled operation before my departure. It was a quick simple operation on a vigorous school age boy. I knew his parents well because I had taken care of one of their other children previously. I was please to see him eating well and enjoying cartoons the day after surgery. It has been hard to close up my practice. For weeks I have been referring requests for surgery to a civilian pediatric surgeon because I ran out of available operating room time weeks ago. I am taking care of a baby in the nursery intensive care unit and I will have to turn his care over to a visiting doctor. He is well on his way to recovery, but I want to see him the day he is well enough to leave and his proud parents carry him to the elevator. I think it is tougher because I am a solo pratitioner. If I had a partner, I think it would be easier to keep the office open and reassure parents: "Don't worry, my partner will see you in two weeks to make sure the incision is healing well." Even though the doctor who will cover me is one I know well and trust completely with my patients, it hasn't felt responsible to do a major operation when I won't be there to try and pick up the pieces if there is a complication.

I will be changing gears soon. The surgery at the combat hospital is completely different. The patients are much bigger. The wounds are larger. The urgency is greater and the pace is quicker. Even the children we treat come to us needing rapid control of life-threatening injuries and clensing of multiple wounds with removal of destroyed flesh. It is important work and the chance to make an immediate difference in another's life in the here and now. But I know I won't feel guilty when I long to return to the delicate measured pace of operations in the newborn intensive care unit.

It is late. I have taken far too much time tonight installing the garbage disposal under the kitchen sink. To paraphrase They Might be Giants; now I'm even older, now I'm even older, and now I'm older still. (listen here) Sweet dreams.


27 August 2007

Blowing Paint off the List

I’m finding it easier to write again, or rather, tougher to stop writing and sleep. The first time I deployed, writing was my answer to insomnia. When I couldn’t sleep, I would write until the sun came up and it was time to go back to the hospital. I don’t think that was a formula for coherent expression, but it helped me get the most abrasive stuff out of my head.
We have a list of things to do before I leave. For example, I just got a gorgeous olive green suit from my sweetie, and I really have to make it down to the Nordstrom’s to have it tailored. Trouble is, the suit is one of too many things on the list, and the time just keeps getting shorter. The suit is in danger of getting shelved (hung?) until I get back. Just yesterday, installing lattice around the base of the deck slipped off the list for good. There are too many more important things that have bubbled up higher on the list. Today I toured the house with a ladder and a pocket full of nine volt batteries and changed out all the old batteries in the smoke alarms Our smoke alarms are wired together, so when one goes off, they all do. Unfortunately, when one has a dead battery, they all start chirping every 20 seconds in unison. It is a mystery to me why this is absolutely required to happen around three in the morning. Since they all wail distress together, it is a bug-hunt to discover which one has drained its battery. It is a wonderful way to wake up the family in the middle of the night. If I can prevent that fun from occurring while I’m away, I will feel comforted that one small annoyance has been eliminated. I probably threw away a handful of batteries with a good couple of month’s juice in them today, but it was worth it to have that petite worry off the list.
The list isn’t all chores. A few weeks ago, B. asked me if he could try his hand at paintball and I told him we would before I left. The first day of school is mere hours away so I thought it would make for a perfect way to blow off some steam before settling in to studies. As it turned out, it was a also a well-needed release for me to let fly a couple hundred rounds of paint.
It took some time to find the range because every ranch looks to be the same rock studded ridge rolling with scrubby trees. We rented our equipment, bought our paint, and attentively soaked up our safety briefing. The other participants were mostly teenagers, walking from course to course, wearing paint-spattered oversized camouflage and black outfits while toting shiny air-powered paintball markers. There were some dads on the field, and some moms at picnic tables with stacks of sandwiches, but a quick glance told me that if I wasn’t the oldest there, I sure was a prime contender.

Yellow-clad referees started each battle and we quickly took cover to fire from behind stacks of tires and clumps of trees. I crawled through a dry creek bed fighting off a phalanx of fire ants and took out a sniper only to be lit up by a 10-year-old who spattered me with a burst of three rounds of pink paint. The second game we played was Iraqis and Americans on the Fort Bagdad course. The referees asked for seven volunteers to play Iraqis holding the fort and the remainder played Americans with the objective of storming the fort. I suppose seventeen years of combat in the Gulf has given Cowboys and Indians a new name. The fort was taken quickly.
B. and I stuck together and were teammates for each game. He covered me well when I ran. We both were sweaty and dirty and laughed at danger.
As we drove back into town with the air streaming through the open Jeep, I was glad that we had picked this item on the list. It was worth far more bruises and ant bites that we ever could have gotten.

25 August 2007

Skinny me

I never seem to be able to put on weight. Odd statement I know, but truth is, I'm a skinny guy, sort of a dark-haired, big-nosed scarecrow of a medium tall drink of water. I could pack away pancakes, buiscuits, gravy, and three meats for a month of breakfasts and not gain more than five pounds. I don't say it to brag, I know it is true because that is what I ate last deployment. In fact, I ate four meals a day (blessed be midnight chow!) and didn't change shape too much. Maybe it is the Mediterranean genes, perhaps a tapeworm. I don't know, but the point is, I'm a stick.

In the military, among other things, our corporation measures and regulates our fitness. For the Air Force, that means waistline, calesthenics and a timed run. After your vital statistics are fed into a double secret Price Waterhouse Oscar night formula, (test yourself!) the result is used to determine if you must be on a regimented exercise program, in fact, it is monitored exercise if you really tip the scales.

I tested in December. Then, in an effort to foster some comraderie, our flight of surgeons tested as many of us as we could gather together again in April. I'll pause to mention at this point that I'm falling apart. I could blame kids (there's some damage!) or perhaps a surgical oncology rotation when the 12-hour operations day after day left me limping home. Perhaps a marathon or two too many pushed my knees over the edge. Truth be told, I'm just getting old. (Heavens, no!) However, in spite of this state of shambling decrepitude, I passed these two recent fitness tests with a result of Excellent, as I always have. After willingly enduring the masochism of a surgery residency, forcing yourself through a mile and a half run and a few push-ups is a cake walk. It doesn't hurt that I get a big boost in my score because the formula unfairly rewards me for having the tiniest waist in the county.

So it came as quite a surprise to me that I had to fitness test again for deployment, to see if I needed to be on weight management program. The response came too fast; I couldn't repress it, "Why?" Never ask why, it betrays a blind belief that there is somewhere a hidden nugget of rationality. The answer was, they didn't know if my fitness test results would be valid for the full duration of my deployment. This time, I checked my instincts, and just scheduled a fitness test.

The next day, at 0-dark-thirty, I find myself driving in to the Warhawk Gym in my high-reflective Air Force Physical Training Uniform. After giving my tester fifteen minutes for the no-show, I return to the hospital and find him. (No aspersions here, he was helping another troop through an emergency.) As I'm on deployment time, it's well accepted that these deployment preparation tasks take precedence over other duties, so I was in no rush. I had asked him, could I fitness test in my armor? Armor is personal protective equipment weighing approximately 35 pounds, gear that I will wear for the majority of my waking hours during my tour. No I couldn't. Again, too fast, I let it slip, "Why?" The answer was that it was too hot out. I could get hurt. Sure, we have had some 95 deg days here. And even though the sun had just risen, it was already 82 deg, even with a light cool rain falling. Consider for a moment that it was 132 deg in the area of responsibility yesterday. I have been jogging in this armor for a week so it isn't such a shock to wear it when I get there. Once again, that was an argument based on logic, and had no place here.

Without the armor, I literally felt the weight lifted. I felt like Baron von Munchausen's runner with his weights removed. He hit the stopwatch and I was running! I was a running fool. I sleep easily knowing that I have once again escaped weight management. Even with creaky cartilege and a crusty attitude, it would seem that I am fit to fight.

Be well and enjoy the company of those you love.


23 August 2007


Salute, originally uploaded by ccoppola@pol.net.

For those about to read, we salute you!

Italian Proverb: It is impossible to love and to part.

How do you prepare to be apart?

I mentioned before that it’s important not to let thinking about time apart ruin the time together. Surgeons aren’t the only ones with a long schedule, but I think it is important that we learn that lesson early. This was especially true during training. The hours were so long, sometimes as much as 120 hours a week at the hospital. Mind you, there are only 168 hours in each week, if you haven’t done that math yourself. Surgeons all have. At least married ones have. It is important not to screw up those precious hours at home. Sleep isn’t as important, but it does intrude involuntarily. I have fallen asleep in the strangest places: in the car, at the dinner table, and, yes, on the toilet! Fortunately, life is better now as an attending surgeon.

I used to ruin my vacations because I would spend the first few days worrying about how the crew covering my patients was sure to screw up what I had done. The last few days I would anticipate and gear myself up mentally for getting back into the fray. That left few days of relaxation and enjoyment with family. Nowadays, if I’m home, I’ve forgotten the hospital. I don’t leave the hospital unless I’m satisfied things are the best I can leave them, and then once out the door, I don’t worry myself until it’s time to drive back in, or they call me with a disaster. (To be honest, I’d like to believe that, but it is too deep in my nature not to obsess about a child who is not yet out of the woods.) The change in attitude has made me a better person.

But now, with a longer separation looming, it isn’t quite possible to completely ignore it. Sure we are preparing. Besides the training that I suspect will not be useful to me (e.g. If numerous people around you are salivating excessively and vomiting, consider the presence of a nerve gas agent) there are some tasks that do feel are necessary. We are putting our financial affairs in order, I’ve made sure that the will is up to date, and my family has several phone numbers to call when it is difficult to get an urgent pediatrician office visit at the base.

We are also looking forward to upcoming events. Yesterday we celebrated G’s birthday. It was a wild affair at the bowling alley with cake, pizza, fake moustaches, and stray bowling balls launched from shoulder height. It was a great time and sweet to see him with his classmates. The funny thing is, it wasn’t his birthday yesterday, and it isn’t even his birth month. Is it better to celebrate his birthday on a day as fake as the moustaches? I think so, because I would rather be here for the party! G thinks so, because that means presents come early! He is trying to convince us that he is already a year older since we have had his party. I suspect it might have something to do with the fact that his allowance is tied to his age. We are toying with the idea of celebrating some other holidays before I take off.

I’ve heard of other families creating a photo stand-up decoy of the deployed member. They take the decoy with them on trips and include it in family photos. I’m all for anything that make it easier for the children. But it seems like a hollow replacement to me (what a conceited statement: How could I ever be replaced!) I was touched by journalist Alison’ Buckholtz’s essay on the topic. She described how the presence of a cardboard cutout facsimile of her husband scraped the painful nerves of her longing for her actual husband. I hope to think that I’m wise enough to accept that different people will respond better to different means of coping. It’s that way in surgery, not everyone responds the same to each operation.

I shouldn’t write when I’m in a foul mood. It comes out too melancholy. At least Doonsbury can still make me laugh at the absurdity of the situation. Friends, enjoy life and have fun with your loved ones around you!

At your service,


21 August 2007

A quite surprising expert qualification in pistol

Here is my target for the pistol range. Lots of
scatter there, but I met the main goal: do it good enough so that you don't have to
do it again. Similar to the usual goal. Get the piece of paper signed, make a copy,
turn it in.

Air Force Training, Sir!

Hi Friends,

As I wind down my practice preparing for my second trip to the sandbox, I’m impressed with the amount of training we all undergo, willing or not. Perhaps most dramatic is our weapons training. Last time I went I trained using a 9mm handgun, much as I did when I had my initial officer indoctrination course (yes, that’s what’s it’s called.) However for this tour of duty, I also trained using an automatic field rifle. I’ve always maintained that I was already far too dangerous with a scalpel. It was not prudent to add to that by putting firearms in my hands. I suppose the principles behind weapons trainings for doctors is that we all are warriors when we go to war, no matter what our job. However, it gets complicated when you consider the Geneva conventions rules for medical personnel. As long as I only use my weapon to defend myself or my patient, I am within my restrictions as a physician. I suppose that makes innate sense to me. My goals in going away are few: to stay true to my principles, give the best care to my patients, and return home to my family. Fortunately, there are very few scenarios in which those goals would require a gun.

Weapons training was very interesting, if nothing else. The classroom instructors were civilians who rattled off the parts of the weapon and the method of disassembly with a rehearsed patter that clearly had been given to tens of thousands before us. Range activity was conducted strictly and safely, partially allaying my fears from being in the company of several hundred trainees with live ammunition in their weapons. After classroom training it was time to test for qualification on the range. We were assigned a weapon and a shooting position; I got lucky number 13. We filed out to the stalls and of course down the entire line, mine was the only bay with an inch of muddy water puddled on the cement. As instructions blared over the loudspeaker, we fired rounds from different field positions, of course including a flat prone position. I suppose I was getting the fullest experience, shooting out of a muddy hole. In the end I was able to qualify as an expert in pistol and rifle, not a welcome achievement for one sworn to protect life. It just wasn’t very fun to handle these weapons after fighting day after day on my last deployment to fix the damage they caused. Expert wasn’t very hard, but after struggling to put sutures into two millimeter blood vessels, a five inch disc on sheet of construction paper looked as big as the moon. Imagining a living breathing head or chest is another thing entirely.

The past few weeks have been a long goat rope of trips to offices, supply depots, and training sites. We sit in classrooms to hear about preparing our wills or free babysitting and oil changes for our spouse. I have completed mysterious forms that I have never heard of with mysterious cryptic alphabet soup names. It all has an inevitable Catch-22 air of absurdity about it. There was a blank spot on my checklist for Medical Unit Readiness Training. “But, Sir, I have completed Medical Unit Readiness Training three times already. Also, I did deploy to the hospital before, which was sort of like four months straight of Medical Unit Readiness Training, except it wasn’t training.”  That didn’t change the fact that my Medical Unit Readiness Training certificate would expire three days before I am scheduled to return from this deployment. Yes, I would have to do it again. At least the cadre for medical unit training was a great group with whom to work. It was easy enough to turn off my pager and my mind for a few days to play soldier on the training grounds.

It has been troubling to me to put my surgical practice on hold and cancel clinics and operations. However, since I am a solo practitioner, the start of deployment will be a disruption in the care I provide. Fortunately, I have the gracious help of another military pediatric surgeon who will relocate here while I am away and the help of civilian colleagues in town to bridge the gap. It is hard to operate on children and meet expectant parents whose unborn babies will need surgery in the future, and know that I will not be seeing the outcome over the following months. Tougher still is to not ruin this time with my family with a frantic desire to make the remaining moments count.

Hope you all are well, and I’ll talk to you soon!

Warm regards,