31 January 2008
Just got word from one of my bros that he has arrived safely at Balad. The duty has passed to him and his crew, and I'm sure that they will give the troops the finest surgical care anywhere in the world. It feels a little strange because we were on the surgical team together in 2005. After four months working at the hospital in Balad day after day, I began to get the erroneous impression that the place would fall over if I wasn't there to help. But the medical corps is bigger than this one little troop and I know that it will carry on just fine.
Tomorrow I head back to work at my hospital in Texas. Reconstitution time has gone by so quickly and I could use more and more! Most of all I have loved spending every day with M., eating, shopping, or just hanging out together at home. I already know that there is a toddler waiting for me in the intensive care unit who may need surgery. I have to complete the shift from combat support surgeon to pediatric surgeon because there will be babies depending on me. All I can promise is that I will try.
30 January 2008
This is just a short post to say thank you. Thank you to everyone who has bought the book. With the recent royalties received, we have been able to go to over $1000 donated to Fisher House. It's a small amount, maybe not as much as Garry Trudeau or Denzel Washington have given, but if that little sum helps even one family of a wounded soldier, it is worth it. A special thank you from me because the timing is so helpful. After coming home from deployment where I help troops every day in a concrete way, I always feel a little troubled that I am suddenly doing nothing for injured troops. Giving royalties to Fisher House makes me feel like we are doing our small part.
Anyone wishing to give directly can find options at http://www.fisherhouse.org/
29 January 2008
I am a longtime fan of the work of Garry Trudeau. When I was just a toddler, he was documenting the Viet Nam war and the reaction on college campuses. A few years later I read a collection of his wartime comics and I was amazed how the characters came to life. Zonker's slacker Zen approach to life and B.D.'s intensity as he wore his football helmet in Viet Nam after enlisting made these real characters who grew and changed through their experiences.
Trudeau has been a staunch supporter of veterans. He has met with troops and written their stories. He has donated royalties from "The Long Road Home" and "The War Within" to Fisher House. These two books tell the story of B.D. fight to live after losing a leg to an RPG and his subsequent battle with PTSD. He has also worked to help Disabled American Veterans and hosts a forum for milbloggers called the Sandbox.
In the past three months, the daily Doonesbury cartoon strip has been relating the story of Toggle, a specialist injured by VBID in Iraq. Toggle is introduced as the soldier who programs other troops' iPods before they go out on a mission.
(Source: Doonesbury, Trudeau, 2007)
He injects his own personality and individuality into his duty as a deployed troop.
He may bend a rule or two, but he is all about the mission.
Last month, Toggle's HMMWV is hit by a VBID.
He suffers an eye injury and a brain injury causing aphasia. He is evacuated home in a C-17 through Landstuhl to Andrews.
Trudeau knows details of our pipeline home for the injured that one could have only gained by being there.
When Toggle arrives at Andrews, he is met by B.D., who feels a need to be at his side, in spite of, or perhaps even because of his own struggle with PTSD after his own injury.
I know that Toggle isn't real, but I read in him so many young men and women we launched from Balad with high hopes that they would find a future life of recovery and happiness. Perhaps he seems so real because Trudeau has come in contact with so many troops fighting to get their lives back after injury. I don't think I'll know how it turned out for thousands of the troops I sent home. I'm hoping that Toggle does okay. Maybe if he can make it, the ones I knew did too.
27 January 2008
I received many responses after airing my poor attempt to honor the memory of two fallen soldiers.
My bro, Ted, told me that his station had recently interviewed the families of Blair Emery and Joel House last week.
I wish I could have been more successful at expressing the depth of sadness, loss, and anger I feel considering these young lives cut short. But I don’t forget that it is not my opinion or assessment that matters; it is the effect on their families that matters. I hope that I get that across.
But as I often do, I find that when I have failed to make my words carry the depth of truth, there is someone else out there who has succeeded. I was referred to SSGT Tristan Ruark’s blog, “Angry American” by Laurel of Books for Soldiers who was such a staunch supporter while I was in Balad, and continue to support many troops who are still over there.
He is a squad leader serving in Iraq. He tells us of the life and death of Duncan Crookston, one of his troops.
And here see SSGT Ruark with his family on his R&R
Read about the first year of his current deployment.
Mind you, I’ve traveled there and back and he still has a spell to go. I’m glad he is accelerating
toward the day he journeys home. I think that you will find SSGT Ruark’s blog incredibly engaging as I did, reading page after page. I echo his feelings about a Christmas spent apart from family:
It was great to see another troop who marveled at the surprise of snow in Iraq.
Lastly, with apologies to those who won’t appreciate the scatological nature of this post, I was baffled, amazed and thoroughly impressed with another troop who shares my practical attention to the deuce but has reached a tactical level far above my simple plan of “number two walks”.
I may no longer be able to give you a view on life in Iraq, but he is definitely someone who can.
26 January 2008
I only got to see life within the rarified confines of Balad airbase, and once the 86th CSH in Baghdad, so this is a perspective of Iraq I did not have. I will say that I heard some of my patients say things very similar to those portrayed in the clips.
Clip 1: Ambulance pickup at a market after a suicide bombing
Clip 2: Introduction in the hospital
I think that the clips were filmed in 2007. Hopefully we see less of thes attacks as time goes by. In the first clip when I heard the line "Only the children playing outside." I could feel a sense of a parent's worry for their own children above one's own safety, yet also a feeling of guilt in knowing they were someone's children.
Today, a friend sent me an article about Sgt. Blair Emery from USAToday. He died 30 NOV 2007 in Iraq. When his body came through the hospital, news that a troop had died spread through the staff like a bitter chill that was unwelcome, but you couldn't help but feel deep in your bones. The next morning his name was on the list of Significant Incident Reports. Then he was gone. His body was flown to Dover for processing. We had other patients to care for coming in the door every day. Even if we were able to put Blair's death out of our minds, there were more deaths to chill our spirits again.
Now that I'm home, war casualties are no longer in my hands. But my connection to them continues. Just as I will be linked to the little girl S. whom we helped after her gunshot wound, I will be linked to those who lost their lives while in Iraq while my fate was to carry mine home.
I can't say that it is a welcome experience to learn more about Sgt. Emery and his neighbor from Lee, Maine, Joel House, who died a few months before. It actually makes me angry to think of a life with broad potential cut short. But it is the right thing to learn more about him. We couldn't do anything to undo the damage caused by the explosion under his HMMWV, but we can do him the honor of recognizing he was an individual, and remembering him as we go forward. My deployment may be done but that duty will continue.
24 January 2008
21 January 2008
A friend just told me that it must be nice to be back in the routine of the mundane. He is absolutely right. There is slim chance that I will encounter either a mortar attack or an amputated limb in my daily circles. That in itself is a comfort, beyond the big comfort of being back with my family. I still find myself tracking in a few habits. I keep pulling on my boots whenever I prepare to leave the house. Nothing else seems comfortable. It is really hard to choose clothes, now that I have a choice. A few days ago, M. and I were in the HEB supermarket. (that's "Henry Edward Butt's supermarket" for you Northerners, but they also claim that the acronym stands for "Here Everything's Better. Wow, I'm calling people Northerners.) Anyway, one of the forklifts started backing up, and I swear, the backup alarm sounds just like the incoming mortar/rocket fire klaxxon on the base. Did I blog this already? I can't remember. I almost hit the deck, but when I didn't hear the command post's robot lady voice shouting "Take cover! Take cover! Take cover!" I knew I was okay.
I've forgot to mention two very important reunions. First off is our pooch L. He grew to 50 pounds while I was away, M. said that he had calmed down a lot since I deployed, but that all changed when he saw me. Since I'm the one who chases him around the deck (sometimes in play, other times not!) he immediately started baiting me to get me to take up pursuit. Yesterday the boys and I brought the dog to the Martin Luther King, Jr. Day walk in San Antonio (the nation's biggest!) You would have thought that he was the first standard poodle to ever grace San Antonio. He was a hit. People were asking to come up and pet him. I lost count of how many people videoed him on their cell phones. Some people knew what he was, but the usual response was "It looks like a poodle, but it's so big!" I just replied "Thank you." If I knew that he was going to get so much attention, I might have cleaned the food that was hanging off his jowls. Some people remarked that it was surprising to see a man (and my three little men) out walking around with a poodle, because it has some feminine connotations. I pointed out that that connotation may be true, but it was countered by the fact that he was black, which was such a cool color. To this most people would respond by saying "Amen to that!" or cheering.
The boys had fun, even in the rain, or perhaps because of it. People were very friendly and the spirit of brotherhood was clear on the faces of all the people we met. We attended a celebration in a park at the end of the walk. There were educational booths and a program of speeches, poetry, and song. The boys liked the booths with the freebies best. When the Star Spangled Banner was sung, I had tears in my eyes. It was the first time I had heard it since returning to American soil. It was followed by the pledge of allegiance to the flag and the pledge of allegiance to the Texan flag. I met some Veterans for Peace, and I thanked them for speaking up for us. I was happily impressed that all three of my boys had heard about Martin Luther King, Jr. the week before in school.
My other reunion was with my new baby, my 4-door Jeep Wrangler. It was hard being so far from it in Iraq, and watching all those HMMWV's running around the base. M. started it for me once or twice, and let me hear the enfine over the phone once. Just before I got home, she made sure that the insurance was restarted. I brought it in for a recall reprogramming of the brake software. Sitting there in the service waiting room is something that would usually annoy me, but I appreciated the calm and quiet of a return to the mundane. It's been great getting back behind the wheel. However, I still haven't lost my Balad habit of driving over curbs when I want to get somewhere. Bring on summer, I can't wait to get my top off!
20 January 2008
One of the best parts about getting home is that I can look back and be thankful for all the wonderful people who helped get me through it all.
I appreciate all that you all did for me with kind messages, care packages, prayers, or even just sharing a laugh or a tear when I needed to. As I've said before, writing here has been my way to clear my mind of the thoughts of mass destruction that would linger after seeing the pain and tragedy that war causes on a personal level.
One of my favorite crutches in Balad was a good movie. It was great to turn down the lights and get transported to a dreamworld of magic for an hour and a half. That was an hour and a half when I forgot the worries of the hospital and I wasn't in Balad anymore. It was something that I could share with buddies from the hospital. M. and I would try to watch the same movies on different continents so we could chat about them. It wasn't the same as sharing a piece of pie and coffee together in a diner after a movie, but it did make me feel like my honey was close to me. I'm indebted to L. from Books for Soldiers for sending us so many movies on our wish list.
One of the greatest privileges of being an officer was the luxury of some private time. It was a huge help in recharging the batteries to have even a few hours alone to just sip hot chocolate, gnaw on jerky, and write some letters alone. I could have gotten by without it, but I'm sure that I would have been a lot more annoying to be around.
Of course I never would have made it without my crew in the hospital. We worked like a Rugby scrum, all leaning in together, holding each other up, and pushing a hell of a lot harder than any of us could have done alone. I especially appreciate the B.A.D.A.S.S. surgeons, past and present, who made for a great team to whom I could tag off care on any patient, no matter how critical, and leave the hospital confident that they would be getting a level of care that was equal, or likely better than I could have given myself. Family dinner with them the nights I could make it made me feel the bond of a band of brothers, which is more powerful than the depressing enormity and banality of war's mechanized cruelty.
It is hard to imagine life at war without the easy access we had to the Internet. Emails to my family in Texas as well as my brothers, sister, and parents always gave me the courage to carry on. The Internet was also a way to try to keep abreast of current events and the global picture of progress in Iraq, or an outside view of the personal tragedies we were witnessing from our vantage here at the hospital. The 'net also provided much needed entertainment in the form of little videos like this one and this one(warning, profanity!!) Through blogging, I got to meet some amazing other bloggers. One in particular I would like to mention is Emergency Emm. Many times her blog brought me humor or indignation, exactly when they were appropriate. It amazes me that someone so young has already figured out when to crush the grapes of life for fine wine and when to crush them for vinegar. I suppose it comes from the extremes of human behavior you see as an EMT.
Also, and I have to mention this for anyone who might have an upcoming deployment, it was essential to do some sort of physical training. There was no other way to keep the mental and physical balanced (or survive the onslaught of cholesterol laden food at the DFACs!) Everyone had a program of some sort that they followed. I did my fencing stretches, lifted, and swam. I ran outside about 75 miles total before the burn pit smog and my borderline cartilege got the best of me. Now the challenge is to keep up good habits at home!
Most of all, what got me through the night was dreams of returning home. To me that home is a United States of America where my children are safe from random violence and constitutionally protected from leaders who try to force their own religious or ideological agenda on the people. It is a place where each citizen has an equal say in our government, and the right to speak out against our leaders' actions is protected. But at the heart of it all, most important were dreams of being warm in the hearth and hearts of M. and my boys again. That promise could have gotten me through far worse than the simple inconveniences I was asked to tolerate in the service of our great nation.
19 January 2008
19 JAN 2008 It's a Wonderful War!
With all due apologies to Frank Capra, I would like to present our take on his timeless classic "It's a Wonderful Life!" that we filmed at the hospital just before Christmas. It is a little late in the season to be unveiling this ten minute atrocity, but I just didn't have to bandwidth to post it until now. Some of you have seen this already, but you many not have seen the bloopers reel at the end of the movie. So without further ado, here is our treatise on the importance of each and every life at the Air Force Theater Hospital!
Here is a great article from John Camp of the MinnPost who visited the hospital last week. The best of the article talks about my friend Public Affairs Officer D. who has taken countless visitors through the hospital. He's not assigned to the hospital, but he might as well be, he's always there. When he is not escorting reporters as part of his official duties, he's staffing the ED and helipad as a volunteer to help out. He gave the staff a real boost by arranging to get everyone a scrub top and backpack with the DAV and hospital logo on them. Back home he works for Disabled American Veterans. He won't have the problem that I had last time. When I got home, I felt like I went from doing a good job supporting the troops to instantly doing nothing for them.
Now if I can only figure out how to stop waking up at 0430 every morning...
18 January 2008
17 January 2008
16 January 2008
Hi friends! I've finally found a quiet comfortable spot to rest on my way home. Since I've got nothing to do but rest and wait for air travel, I thought it was a good chance to tell you a little bit about the road that got me here. I feel like I'm at a pit stop for the night on "The Amazing Race." It is wonderful to be here, but I won't have won until I get home to M!
I started thinking about redeployment the day I found out I was going to be deployed! I did do my best over there, every day, even if I was grumpy many of them. I know the work I did in Balad will probably be the most important work I ever do in my career, but not for an instant did I forget that I belonged home with my family.
Through most of the deployment, I had not been assigned a replacement. This can be a bit unnerving, since without a replacement, I don't go home! Our command section assured me that one would be assigned. "Don't worry, trust the military". Eventuallyone was assigned, and it was a huge relief. However I was assigned one person as my unit number replacement, a different person as my functional replacement, and even a third person as my housing replacement. What really mattered, as far as wounded patients and I were concerned, was that my functional replacement arrived so that someone would be doing the work. He showed up around 8 JAN and I promptly trained him up. As far as the military was concerned, I couldn't leave until I had a crossover period with my unit number replacement, so it took a letter from our commander to get permission to leave.
As soon as that was done, I quickly received a reservation via email for a flight from a US city to my home on a commercial airline on a specific flight. A little while later, I got an email telling me that I was on a military flight out of the middle east to the US, but the window of uncertainty was within five days. And then finally after a few more days of waiting, I was told that I had a spot on the chalk leaving Balad for Qatar, just after midnight on 13 JAN. Funny how starting the journey, just getting out of Balad was the most uncertain part and the last to be arranged.
I passed my weapon on to the armory early, because after all it wasn't much use to me as a doctor. I cleaned my hooch and had it inspected, and with out my inspection stamp, I wouldn't be able to leave Balad! I had a nice last family dinner with the crew of surgeons, and they saw me off to the rally point for our chalk at housing.
Halfway to Qatar we had to make the stop in Kuwait I told you about to pick up the congressman. It was so freezing waiting thos hours with the back of the plane open. Eventually we got wheels up and made it to Qatar. When we landed in Qatar, we lined up in a cold rain to wait for the chance to turn in our body armor and chem gear. At our arrival briefing, we were first greeted with the unpleasant news that our exit from the Middle East had been slipped back a day. The ground crew had us unload our luggage into a bin. When it turned out to be the wrong bin, we had to move it to another. We immigrated to Qatar under the variably watchful eyes of Qatari officials wearing a blend of uniforms and civilian clothes. On rare occasions, they made a thorough scan of a troops DVD case to be sure that no porn was entering Qatar.
The two days at Qatar passed quickly because I spent them either eating, drinking our rationed three drinks/day or sleeping. Especially sleeping. The barracks were a good friend of mine. On the third day, we were told to show up between 1400 and 2000 for a 2am flight out of the middle east. Again we checked out of housing and got together at the terminal. A friend and I called Delta to change our flight once in the US, since we would miss our original reservation now that our flight had slipped back a day. We needed a stamp from the military staff, and also from the Qatari nationals who were emigrating us from the country. When the Qatari office closed because the official went for dinner, we were told that we could get both stamps from the military staff. I almost asked why we couldn't always get both stamps from the military staff, but then I remembered where I was.
After we had all been checked in and settled into the most painful metal terminal chairs known to man, the terminal staff chose to inform us that our plane had been stuck in Ireland for hours due to a hydraulic problem and our mission was again pushed back. Since a new day was coming, some troops decided to re-immigrate to Qatar to get the next calendar day's ration of three drinks. Eventually we were told that plane was on it's way. I got back on the phone with Delta to again push my domestic flight back to accomodate this newly annouced delay. All through the crowded tiny terminal, troops played cards, watched bad movies, or spread out their Goretex parkas on the dusty floor to sleep. The terminal staff commandeered waiting troops and handed them brooms to clean the terminal so they had something to do while they waited.
As dawn arrived, so did our DC-10. I can't remember the last time I rode a DC-10. Oh yeah, it was the last time I deployed. The military uses civilian contracts to move the bulk of troops around the world. The contracts are taken up by providers such as "World Airways" and "Omni Air International" that don't exist as options to civilians travelers. They have also done away with any amenities that might appeal to civilian travelers. They use aging airplanes and an interesting blend of flight attendants who are just starting or about to end their career.
With the plane on the flight line, the terminal staff lined us all up and moved us to a different building with the same cruel chairs to wait for another 45 minutes. They picked out some passenges to load the baggage and weapons onto the plane. Eventually, they let us cross the windy tarmac in the dull grey morning light of Qatar to board the plane via an aluminum stairway.
Once aboard the plane, we were promptly yelled at by corpulent, troll-like, homuncular flight attendants. They alternately barked "Sit Down" and "Move to the back faster" in loud grating ogre-ish voices. It was too absurd to take seriously. I was reminded of the bank robbers in "Raising Arizona" who shouted "Freeze, Drop to the ground!" The old timer replied "If'n I freeze, I can't rightly drop to the ground." The passenger seats had been reconfigured so tightly together to accommodate more bodies, that only Smurfs could have sat in them comfortably. We had been living out of bags for 72 hours. Some couldn't fit their massive back packs in either the overhead bins or under our feet. While one flight attendant attempted to close a hopelessly overstuffed bin, several other attendents would scream at the troops in her vicinity to get up and help her. Those who were tricked into rising from their seats to assist were promptly snarled at by the first attendant to "Sit Back Down!" I wondered if Bush would be leaving the Middle East on the same flight as us.
We learned as we waited for this flight that our first stop would be Kuwait. Yes, Kuwait, where we had just been three days before. We were headed back closer to Iraq. No reason was given, but I'll admit, by this time I've sipped the Kool-Aid enough that I no longer expect explanations for such things. So as we sat crammed buttock to buttock with our brothers-in-arms, we lifted off the runway and winged our way back to Kuwait. We glance out the window at the pallid sky and lifeless landscape and smiled. No matter how rocky, this was the road home.
14 January 2008
Well, I'm in a plane terminal, and I'm waiting around, using my pack as a pillow, so it must be good! There's a well loved computer station so I thought it was a good chance to say hi. Now years of desert dust and hundreds of thousands of troops who have passed through here have taken their toll on the spot. The keyboard sticks a little. In particular, the shift and the space keys stick. At least they aren't keys I use that often??!!
It is good to be moving, and by moving, I mean hurry up and waiting! just having the dream of a flight is enough right now. it is hard to be in limbo, not having a job to do, an djust waiting for a trip across the sky to the one i love.
have to tell you a wonderful story about the big heart beating in the chest of every troop I know. one of my troops recently had a death in the family. By recently , i mean she found out yesterday. She is in our chalk, but for some reason, she got booked on a flight two days late rthan us. She and i came to the terminal earlier today, and made our pitch to get her on an earlier flight. There were no spots available, we needed CEnTAF aproval, there would have to be a REd Cross letter, blah, blah, blah! After we got off the phone, A Sergeant who had over heard our conversation told us to come around the desk an dhe would see what he could do. he calle da friend, who called afriend, and magically a seat appeared on the flight. It was such a sweek, kindhearte dact, and that sort of desire to go beyond the call of duty is something i have seen many times. The big SYSTEm is very cold and uncaring to troops, but each airman serving as a cog in the machine has a family, and i have often seen people reach out to give a stranger a boost when they need it most.
Today I said goodbye to my temporary barracks. It is a large canvas over aluminum shelter that sleeps about 80 men. The temperature was right so i have no complaints. But around shower time, that place is as busy as a bus terminal with people coming and going to the Caddilacs.
Well, i guess i'll check the status board again, might have changed in the past half hour. knock on wood for me, if this flight slips, it's back to the barracks!!
13 January 2008
I hope that this letter from the road finds you well. Well, what can I say, my long awaited journey home has finally started! now I will be anticipating the long-awaited end of my journey home! I made it as far as (redacted) in the wee hours this morning. The plane ride was cramped, frigid, and noisy. (And I loved it!!) We tacked on an additional three hours on our trip because we had to pick up Distinguished Visitor (redacted) in (redacted) and waited on the runway for quite a while waiting for their motorcade to show up. But no complaints today!
This is the Middle East I remember from my first visit three years ago! It is rainy, cold, barren, and there are ankle deep puddles everywhere. It is so odd to see everyone walking around in either DCU's (desert camouflage uniform) or PTU's (physical training uniform.) It is like we are two mutually exclusive teams on a big muddy playing field.
My last few hours at Balad were typical to the very end. I finished a case about three hours before my assembly time for departure. Yesterday morning I took a nice shower, and put on clean undergarments because I knew I would be steaming in them for quite a while before I had a cozy place to change. Then, of course, a fresh pediatric trauma arrives and I head into the OR to sweat for three hours while we clean and dress wounds. I walked out of that case soaked through. Good thing they don't have any freshness requirement to get on a military transport.
After the operation I said goodbye to some of the staff, and patient families with whom I had become close. It was very sad to part with these friends whose lives I'd shared for a good long while. But there was no hesitation as I began my journey. The sweetest person of all is waiting for me at the end!
We rounded up the available surgeons for family dinner. The Czar Car was loaded especially full since we had more personnel around than usual with replacements. For my last meal in Balad, I tried the fried pork chops, with a side of brown stuff and rice. A little of the new, a little of the old. The pork chops were a nauseating slap to the taste buds and ensured that my stomach would carry no lingering longing for the high cuisine of DFAC 3. I had failed to follow the sage advice of the departing troop: try nothing new in the last month of deployment. Stay with your routine, it got you that far.
I loaded up my massive rolling contractor's trunk, otherwise know as the coffin (since I could fit in it if I ever needed to return as cargo, not passenger.) We cruised to the PAX terminal, and after an extensive luggage and body cavity search courtesy of the fine sailors of Navy customs, we were on our way! The only thing consfiscated from me was my wood. I was bringing home a 2x4 from the destroyed old hospital because personnel back home wanted a piece to construct a legacy plaque. Unfortunately, the USDA forbids it because some pests can piggy back on wood. Fortunately, they only arrest you for smuggling porn, firearms, and alcohol, so I was allowed to continue with my chalk.
So I've been up 24 hours, but I'm on new turf. The biscuits and gravy taste just as good here as they did back at Balad. In fact, they taste a wee bit better because they are a wee bit closer to home! Time for a shower and a nap, and then it's back to the classic military pastime: hurry up and wait.
Be well, Friends!
12 January 2008
It is amazing how every new day brings a new experience. As I walk through my paces here, I feel like it is just more of the same, but every new patient experience or visit with tactical forces is a new world so far from my quiet little practice back home.
Just now I finished a burn operation on a 10-year-old boy. He was so calm and brave in the emergency department before we sedated him for surgery. He and his father had been in town when a VBIED (vehicle borne improvised explosive device) exploded next to them. I examined him and found a whitish silver pallor to his skin. I have seen patients burned with white phosphorus, or "Willy Peter" as the the troops call it, and it is dangerous because it continues to burn int the tissue until you cut every trace of it away. But this was different. I rubbed it and a little came off on my finger. It was silver paint. I went to talk to the boy's father. His sweater and sandals were covered with the same silver paint. He said that when the truck detonated, there was an expanding cloud of silver that emanated from it. Everything around it had been coated. We washed the boy's burns, removed fragments of metal from his face and legs, and dressed his wounds. Our Ophthalmologist C. looked in his eyes and Otorhinolaryngologist R. (or for those of you who don't want to say Otorhinolaryngologist, Head-Hole Doctor R.) looked in his breathing and swallowing tubes to see if there was any injury.
After that I visited a little girl recovering on our ward. She is the one who was shot in the neck three years ago and developed an abnormal artery in her neck. Two days ago, the high-tech equipment we had been waiting for so that we could fix this vessel, finally arrived. I got to witness amazing work by Vascular Surgeon M. and Radiologist B. in the OR yesterday. Here is this girl with a rare complicated problem caused by an injury long ago, and they were heroic in their efforts to give her some remedy. The problem is an AVF (arterio-venous fistula) where the trauma causes an abnormal bridge between two vessels. Because it was partially in her brain, it was an extremely complicated case. In an incredible exercise of modern surgical care, Vascular Surgeon M. and Radiologist B. performed a delicate procedure using long tubes and wires in the blood vessels to eliminate this AVF. There is no where in Iraq where this procedure is available except now and here in Balad. The girl's father had been trying to get to Jordan but had been unable to obtain the money or visa necessary to go. He had been trying to get his daughter help for three years. It is incredibly generous and exemplary that my colleagues would take her case.
I tagged along in the OR as go-fer on the case. I watched in wonder as they worked the delicate catheters through the blood vessels. Some features of the girl's problem made this case extremely difficult and the work took nearly six hours. Both of the doctors had been working on trauma victims tirelessly the night before and could just as well have been resting in their hooches. It was almost like watching Nintendo as they made deft movements of the catheters and watched the progress on the TV screens of the fluoroscopy X-ray machine. The little girl has been waiting for the devices to arrive and has been in our hospital for a while. She has become a whiz at Wii bowling and can beat me easily. I can't wait until she is back on her feet and well enough to play again. When I saw her today, she was up and out of bed, but still a little sore. You can imagine that six hours of surgery can do that to a person! But if I know kids, she will bounce back, and even faster than an adult would.
We had a visit from a troop that is special to one of our staff members. Physical Therapist S. has a son who is in an Army unit to the (redacted) of us. He was on base to pick up a new tactical vehicle for his squadron. It is called a MRAP (Mine Resistant, Ambush Protected) vehicle. This particular model is a RG-31 Caiman. It is an incredibly well protected six-wheeled vehicle. Thick plates of steel protect the hull, and the hull is shaped with a V at the bottom to deflect the blast from IED's. It is much more protective than an HMMWV when faced with a deadly IED. I have treated patients who drove over massive IED's in an MRAP and suffered nothing more that bruises. They showed me pictures of the scent. The Hull had been separated from the frame, and the engine had been blown out of the forward compartment. But since the hull had not been breached, they were safe inside.
Physical Therapist S.'s son took us for a ride around base. The RG-31 has a gun turret for defense. It has 360-degree protection when the weapon is inserted into the crease. The driver is high above the road. In the cockpit, there is a screen with Blue Force Tracker, a system for telling the crew where they are, where all friendly forces, and any where any known enemy forces are. They can communicate across the whole network of forces in the area. the rear is a spacious cabin with crew seats and a reinforced swing out door.
As safe as they are, the troops told us that they like it best when they can dismount and get out to do their job. They said that the vehicle is so intimidating that enemy forces flee into houses when they see them. They have to get out and go house to house to capture enemy fighters in the area. They are in more danger once they exit, but these young men told me that they feel that their excellent training and equipment still gives them a huge advantage in a person to person confrontation. Recently, their squadron lost (redacted) young men. I was incredibly impressed that these young war fighters were still so strong-willed and dedicated, even in the face of this recent tragic loss. I was struck with an impressive level of professionalism that belied their young age. America's best are giving their best each and every day over here.
I got my mug on the Internet at the MinnPost.com. It can be found in a good slide show here. One of their writers, whose pen name is John Sheldon, visited to write about the troops. He got to see a lot of the activity on the base including in the hospital.
Well it is time to hunt for some dinner. I'm following that old deer path of work, eat, sleep. Even had some Congressmen come through here today, but that changed nothing about the wounded or the work. Hope you all are well at home and hope to see you soon. There is so much to tell that I feel I could go on non-stop.
11 January 2008
10 January 2008
Ah yes, midnight in the Wounded Warrior computer lounge. My fingers again caress the familiar keyboard, because there is nothing else in the hospital that they ought to be caressing! I'm smiling because I know that no matter what they do to me, they can't stop the clock! There is also ample reason to smile today because we were fortunate to see very few wounded pass through our doors in need of comfort and care. After reporting my list of patients from my 24-hr shift, I attended to the needs of a sweaty body that had been in the same clothes for 24 hours, and made a deep dive for slumber land. My friend Laparoscopic Surgeon S. knocked on my door to tell me that yet another little child needed a tracheostomy. I returned to the hospital to give him a secure tube for breathing and a tube for feeding. His skull was fractured in an explosion a few days ago and he is still in a coma. Don't any of you count him out. It is a great gift of nature that children have great chances to recover from head injuries. We'll be watching him for good things.
As the article reports, British officials have identified 18 soldiers and 6 contractors from the UK who have received blood using a technique called fresh whole blood transfusion. As this is a topic with which I have much experience through my two deployments, I'm happy to provide my thoughts (which of course are mine and not in any way to be construed as official Department of Defense communication.) I have no contact or specific knowledge of the 24 individuals involved, but I can speak in general about the technique. If you have no interest in blood transfusion or if you wish to be awake three minutes from now, STOP HERE!
One of the deadliest killers of our injured troops, as well as civilians, in the theater of war is exsanguinating hemorrhage. This fancy term means that all of a person's blood came out of them, and they died. It is nothing new to the war in Iraq, it has been a threat to soldiers in the line of fire probably as long as men have taken to the activity of killing each other. War has been a cruel but efficient teacher, and we have adopted techniques to try and keep these injured individuals alive after they have suffered bleeding wounds. One of the best methods, an old one, is to place a tight tourniquet on the limbs of the injured to stop the leakage of blood until they come to the care of a surgeon. Another which has proved so effective, and allowed us to save many a troop who might not have made it home otherwise, is placing a surgeon in the theater of war, and quickly transporting the injured troop to that surgeon's operating table. But even with quick surgery, we cannot keep a body alive if it has been emptied of blood. Blood lets the body move oxygen to all its parts, and blood transfusion gives this ability back to an injured person. Banked blood is blood that has been collected before the injury, is tested, stored, and is then available when the injured need it. Fresh whole blood is collected from a donor at the time of injury and is given to the person needing it at that moment.
So why would we use fresh whole blood? It has some benefits and some risks. First of all, when there is an overwhelming onslaught of wounded, we run out of blood in the blood bank and have no other choice. Secondly, when a person has lost a very large amount of blood, giving them banked blood restores the volume to their veins, but doesn't provide all of the ingredients in blood. Stored blood loses tiny cells called platelets that help stop up leaks in injured arteries. Stored blood is also missing some of the proteins in blood that help form a healthy blood clot, like a person would need to stop a nose bleed. As stored blood gets older, the cells start to break and they release high levels of potassium which can be harmful to a person's heart rhythm if levels in the body get too high. Also, stored blood has a chemical called EDTA added to it to reduce the level of calcium, which can cause the stored blood to clot in the bag. This ETDA can cause a person's calcium level to drop after a large transfusion. These aspects of stored blood probably don't matter if a person only receives a small transfusion. However, if they receive large volumes of blood as high as the person's whole body content of blood, or even greater, these abnormal levels of platelets and minerals can become dangerous.
Some of these deficits of whole blood can be compensated for, such as giving a person a matching transfusion of plasma or isolated platelets for each transfusion of blood the receive. But some facilities that store blood may not also store components such as plasma or platelets. They require a colder freezer and a more complicated method of collection, called apheresis.
When I worked in Balad in 2005, we gave fresh whole blood many times. Often were the times that we received numerous casualties in quick succession and depleted our blood bank. At that time, our tent hospital did not have the capability for platelet apheresis and was dependent upon delivery of platelets that had to be ordered from another hospital in the country. For these reasons, we called for rapid donations of fresh whole blood many times, and I believed that we saved lives that otherwise we couldn't have been saved. In fact, after returning home after my last deployment, I was able to meet a troop to whom I had donated a unit of blood. His arm had been nearly torn off in a vehicle crash and he had lost a terrible amount of blood. My colleague Vascular surgeon T. reconnected the severed blood vessels in his arm in a precise and painstaking operation. When the call came for blood, I answered with other troops and we rolled up our sleeves. This reservoir of blood in the veins of the men and women working on this base is referred to as the "walking blood bank". If the call for donation goes out, I know that we will have more volunteers than we need in a matter of minutes. I know that to be true because twice on this 2007-2008 deployment that call has gone out. It is far less frequent than my previous deployment because several factors have changed. Thankfully, we see the occurrence of an overwhelming mass casualty event far less frequently this time. We are nearly always able to keep ahead of the demand for transfusion in our blood bank. Secondly, we now have the ability to perform apheresis on site, which allows us to treat people who are short not just on blood but also on the platelets that help them stop the bleeding.
As I mentioned, there are risks. One risk is that a person will get blood that does not match their type. For this reason we test blood for a match against the wounded before it is given. When circumstances are too dire to wait for that, we give "universal donor" blood of type O negative, which is accepted by all blood types. There is a risk of getting an infection (HIV, hepatitis, Human lymphocyte virus) from a transfusion. For banked blood, the blood has been tested for infection before it is released for use. When life-threatening situations require the speed, volume, and component content of fresh whole blood, there isn't the luxury of holding out on the dying person until the tests are done. We do however take measures to reduce the risk as much as possible. First off, all military members in this theater of war have been tested yearly for HIV infection and have been immunized against hepatitis B. At the time of fresh whole blood donation, donors answer health risk questions to exclude those whose circumstances put them at risk for undiagnosed infection. This questionnaire is subject to honesty, but it is still a powerful method of selecting a potentially safer donor pool. When a troop donates blood, test specimens are collected at the same time. For every donor, a rapid 20 minute test for HIV, hepatitis B, and hepatitis C infection is performed. Often this test is complete before the blood gets to the patient. For every donor, test specimens are sent to the US Army Blood program for definitive testing. All results are reported to our hospital. Additionally, our hospital will track any recipient of whole blood, regardless of their nationality to monitor for complication.
So you can see that we take the safety of whole blood transfusion very seriously, as we do all of the therapies we offer at our little hospital. It is a dreadful responsibility to know that the decisions we make here may determine the difference between life and death. It gives me a sense of pride and honor to be part of a broad and varied team of professionals who take this responsibility to heart every day. I've listed below a few more in depth resources below if you aren't completely sick of the topic!
Be well, and keep an eye out for me! I've reached the point in the rotation where I refuse to do anything new. If I've come this far running over my familiar, well-travelled deer paths, there is no way I'm going to change now!
Here is a quick PowerPoint presentation by Rice that illustrates some of the motivation for whole blood transfusion in the battle environment.
An extremely informative paper on the use of fresh whole blood transfusion in Operation Iraqi Freedom by trauma surgeon Dr. Holcomb and colleagues.
A more up to date article (abstract only) by my friend and colleague, Dr. Spinella.
09 January 2008
10 JAN 2007 A fistful of dinar
It’s the wee hours of my waning call night. Soon I’ll get the list of new admissions from Patient Administration and I’ll be able to prepare my morning clinical openers talk for the boss. I’ve had a bit of a breather since midnight. I lay down on the couch in the swamp for a while and drifted off as “Donnie Brasco” played on the TV. So far it has been a reasonable call day as call days go. During daylight hours we were running around like chicken heads because there was a rush of casualties. We finally got them squared away. After that we could resume the scheduled operations for the day, and I finished the last one at 2200. Forget about it!
We are training one of the newly arrived surgeons. He has jumped in with both feet and had already scrubbed into a case about four hours after his plane touched down. I worked with Surgeon J. a few years ago when he was a resident. He is such an even-tempered and solid guy that I know he is going to be a great asset to the patients here. He seems to have blended into the rhythm of round, operate, and eat. Two nights ago, we piled into the back of the Czar Car together for his first family dinner. As we passed by landmarks in the fading twilight, we pointed out where he could swim in Indoor Pool or work out at Old Man Gym. It was good to let him know that there are activities to do here that help keep a body sane in between the riots in the hospital.
We were called to the ER to treat two trauma codes early this morning. An Iraqi couple who had been injured together were brought to us by Blackhawk helicopter. The woman was moaning in pain and curled on one side to favor her right leg. She had been hit by two bullets. One had ripped a chunk of flesh from the meat over her scapula, and the other had torn a hole through the inside surface of her thigh. The wound in her thigh was covered by a thin bridge of skin. When I looked through the hole, I could see the bed under her through her leg. We ran tests to be sure she did not have internal bleeding or injured arteries, and inserted a breathing tube. I washed the small splinters of metal and fibers of clothing from her wounds. She had also cut her hands and feet when she was hurt. Perhaps she was knocked over by the impact of the bullets. There was a mixture of blood and mud driven deep into the wound on the sole of her right foot. The nurses and I used a motorized sprayer to slowly wash all the bloody mud out of her foot.
The man that came with her had holes in all of his limbs. His skin color was a lifeless purplish grey. The medics had been performing CPR as they flew him to us. As soon as they had rolled his NATO gurney into the trauma bay, we took over the chest compressions and puffs of air into the lungs. We intubated him and made sure that his lungs weren’t collapsed. We checked to see if his heart was leaking blood into the sac that surrounds it. We checked for any electrical activity with the electrocardiogram. We looked for any motion of the heart muscle with the ultrasound. We felt for pulses, listened for breath’s movement of air and watched for any muscle reflexes. There were no signs of life. We stopped pushing on his chest and let him finish dying. In his pocket was a thick stack of Iraqi 250 dinar bills, stained with his blood. They were locked away with his other belongings.
The woman with whom he came has not regained consciousness yet. She is still sedated after her surgery. I don’t know what relationship exists between them. When she is awake enough, one of us will have to tell her that her companion is dead.
Later several troops were transported to our hospital. Their injuries resulted from an explosion. When they all arrived at once, our ER was flooded with personnel responding to the call for help. Each patient had several doctors, nurses, and techs working on them. I even saw volunteers from other areas on base such as Security Forces or the flight line that were spending their off-duty downtime in the hospital trying to help an injured troop. The troops were quickly triaged and the ones who needed it were spirited off to the OR.
I spoke with one of the injured men while we were waiting for the CT scan machine to be free for him. He described the explosion to me. He said that one of his fellows had his legs broken by debris. He said that they were “twisted like spaghetti” and the most disgusting thing he had ever seen. I asked him the name of the person whose legs were broken. I was surprised to hear that it was the man two beds over, on whom I had just been working. I had splinted his broken legs, and I distinctly remember thinking that his legs looked great, and I was relieved that the breaks weren’t as severe as most I see. I was relieved to see that there were pink wiggling toes below those broken bones, not just a bloody stump with a shard of bone sticking out where a foot was supposed to be. I realized that my perspective has been changed by conveyer belt that has been dumping multitudes of injured men and woman at our door. My definition of what looks disgusting has been drastically changed.
Eager to get back to boo-boos,