30 November 2007

1 DEC 2007 Precision

1 DEC 2007 Precision

He said he was an Al Jazeera photojournalist. But today in the age of YouTube and podcasts, who isn't? The troop guarding him said that he was speaking in English until the medics at the aid station intubated him.  He was one of a group of (redacted) injured men. Their injuries were varied and severe. Shrapnel had been driven into internal organs, perforating small bowel, blood vessels, gall bladder, pancreas, liver. Chest tubes distributed among their bodies drained blood and air into collection resevoirs. Eyes were punctured with small shards of metal and genitals were torn by metal fragments. They all required surgery. They were in trouble in the ER with dropping temperatures and abnormal laboratory values. With each new x-ray we performed it seemed like we found a new fragment and concommitant injury. In the operating room, we worked in teams of two, tagging off between specialties. Once work was finished on the belly, work would begin on the eye, and so on. Our assembled team of specialists each leant a degree of precision that would be hard to find elsewhere in the region. When time became crucial, we actually moved the operating table over and worked with two patients in the same room simutaneously. Legend has it that every time we operate with two patients in the same room, an angel gets its wings. As each operation finished, the bandaged men with tubes emerging from every orifice were rolled into the intensive care unit for expert monitoring of their recovery.

I cannot say it frequently enough; I can only trust the events that happen within the walls of this hospital, before my own eyes. "Trust no one" is the mantra of the paranoid surgeon. I double check everyone and triple check myself. Everything that occurs outside of the hospital I consider to be rumors and lies. All I can be sure of is that the Blackhawks land, and the helipad crew unloads the patients. Still, the story told by the troops who accompanied the injured men was pretty clear and convincing. The troops were patrolling in a (redacted) helcopter to the (redacted) of (redacted). The group of men we treated were on a lookout position on the ground. One of the men fired a rocket-propelled grenade at the helicopter while a companion of his recorded it with a video camera. The unguided RPG missed the helicopter by a mile. The helicopter deftly maneuvered to direct its arsenal at the men, and fired a precisely accurate (redacted) at the attackers' position. The threat was neutralized immediately. The troops quickly called in a dustoff. The medics rapidly transported the injured men to lifesaving care.

Of course I asked, in the interest of obtaining a thorough history of the mechanics of the traumatic event, but the video recording was not available.

Doing our best over here,


McGyvered fender

McGyvered fender, originally uploaded by ccoppola@pol.net.

How I keep the mud from splashing up my back: coathangers, duct tape and
orthoglass <>

Santa wears a reflective belt

Santa wears a reflective belt. Check the stash! <>

28 November 2007

29 NOV 2007 Going Home

29 NOV 2007 Going Home
Every day after rounds our hospital has discharge planning rounds. A small group meets in the conference room in the command building. It is attended by some of the nurses who tell the group what progress the patients are making. Representatives of the medical evacuation team come to get some estimates of how many will be requiring a flight to the hospital in Germany or elsewhere. One of the staff in the patient movement office joins in to let us know what assets are available to fly where. The hospital representative from the Iraq Army, Captain H., and our liaison to the Iraqi healthcare system, Doctor A., join to coordinate transfer efforts. The person presiding over this meeting is our chief of staff, Gastroenterologist B. Each day, they hear the condition of every patient in the hospital. They consider how close each one is to leaving the hospital, and what their destination will be when they depart.

For a month now, we have had a small boy named S. living in our hospital. He is nine-years-old, and he is a real charmer. He has had all of the nurses catering to him, and he spends the day playing with them and sitting in their laps. Sometime he and translator N. toured around the hallways and perimeter of the hospital, N. wearing his tattered NY Yankees cap, and S. wearing his plain blue one. S. slept in a mattress that the nurses placed on the ground. This was because he liked to get up in the night and wander over to the nurses’ desk or the ward television. With the mattress on the ground, he wasn’t going to fall climbing over the rails of a hospital bed. Next to his bed was a pile of toys and stuffed animals donated from people back home.

I met S. about a month ago when he was flown to the hospital by a Blackhawk helicopter. He had been injured when an explosion threw fragments into his face and neck. I cut open his windpipe and placed a tracheostomy tube so he could breath. Maxillofacial surgeon W. spent nearly the entire night washing and repairing the many cuts on his face. He quickly recovered. He was able to breathe well through his mouth and I removed the tracheostomy tube. His body quickly healed the hole in the front of his neck. He had trouble seeing at first because of the abrasions across the surface of his eyes. But with the help of antibiotic ointments he quickly regained clear sight. He was silent at first, and very fearful of any men in the hospital. He would cling to the female nurses and bury his face in their chests. Bit by bit, he became more outgoing, and began to speak and play with the hospital staff.

We didn’t know where any of S.’s family was. We thought that his mother had been killed in the attack. His family had recently moved in Iraq due to conflict. The military medical aid station that had sent him in to us had no contact information. We had been faced with dislocated children in the hospital before. With the disorganization in the country, it is always had to know what is truth and what is rumor. There had been cases of people attempting to remove children who were not theirs from the hospital. We had to be very careful since their lives and futures were in our hands.

Chief of staff B. had been making inquiries and sending email ever since S. was admitted to the hospital. Finally he had some response as one of his counterparts in a different province of Iraq said that he was in contact with a mother who was looking for a son who fitted S.’s description. They arranged for her to visit our hospital. She brought with her an older son. As soon as S. saw them, he immediately recognized his mother and brother. He ran to them. The tears in S.’s mother’s eyes told us all we needed to know. His big brother gave him a warm embrace. This reunited family headed out of the hospital to the helipad for their trip home. We were somewhat saddened to see our little friend go, but that feeling was completely overwhelmed by the satisfaction of seeing him reunited with the people who love him.

27 November 2007

28 NOV 2007 Deployment at the movies

28 NOV 2007 Deployment at the movies
I got up a little early today. I am giving grand rounds later, so maybe I am a little nervous. I’ll be talking about a specialized procedure we do for children at my hospital in Texas called ECMO. It stands for extracorporeal membrane oxygenation which is a long way of saying “artificial lung”. Our team in Texas is special because we can take care of a baby using this artificial lung and fly him or her anywhere in the world with Air Force planes. We can fly to a baby in need anywhere in the world, I can do the operation to connect them to the artificial lung, and then we can fly them back to our newborn intensive care unit in Texas. This is good because US troops and their families are stationed all over the world, sometimes far from the advanced medical care available in the United States. I’ve spoken about it before, so the talk should go fine.

There is a subject I’ve been thinking about for a long time over here, and I’ve wanted to write about it. It’s pretty important and I’ve been waiting until I had enough time to give it the attention it deserves. The subject is movies during deployment. They are such a big part of our experience. Movies provide that temporary distraction from the troubles we face. They give a moment in the dark to ease the burden of being far from family. They make us laugh and get us pumped up for the mission. Everyone with whom I’ve come in contact in Balad has had at least a mild interest in movies. We bring them from home and watch them on laptop computers as we wait in airports. We trade them and get together in the Swamp after dinner to watch together. We browse the Haji mart for pirated copies of new films and boxed sets that exist nowhere else like “Brad Pitt Super Golden 12 Movies in One.”  We monitor the weekly announcement of the theater schedule, and plan our dinners around new releases. We quote favorite lines to each other as we operate on soldiers late into the night.

Movies are a popular deployment pastime for the same reason they were popular during World War II. They provide a quick emotional boost that is sorely needed in troubling times. We can’t make the war over, but we can escape for a moment. What surprises me is that the most popular deployment movies are war-themed movies. The question surfaces: Why would we want to take a break from the war by watching a war? I think the answer is that Hollywood so glamorizes war that it becomes something exhilarating and sexy. This is far removed from the boredom and dustiness that is the reality of our war. So war in the movies still provides a break from the war that crawls by our eyes, day in and day out. In an attempt to inform you, or maybe just to entertain myself, I have ventured to give an answer to the query: “What is the best deployment movie?”

I have to take a moment here to state the obvious; these observations are of course based on my personal preferences. I’m bound to throw in a movie that you don’t like and omit one that you adore. The choices wouldn’t be the same for a different troop. I’m sure a woman would come up with a different list. A Soldier in Baghdad would be sure to prefer a different spread of movies than a doctor in Balad. However, I know from many conversations on the base and from the cheers of troops in the theater some of the basics that hold appeal out here. I’ve also left out some of my favorites at home that just aren’t deployment movies. I’ve mentioned before that there is a danger of my running on for far too long. So, if you don’t feel like putting up with the blabber, I’ve finished this post with a few top 10 lists that should cut to the chase.

I’ll start by discussing genre. We’ve already brought up the popularity of the war movie. One of the best examples of this is “Full Metal Jacket”. Kubrick does such an amazing job showing first the training of a Marine, then combat in Viet Nam. Every troop can quote a few lines to dress down their buddies drill sergeant style: “Only two things come from Texas…”. Many amazing Viet Nam movies have come out, perhaps out of our collective desire to exorcise the national pain felt through that experience. “Apocalypse Now” is a beautiful journey into the unknown heart of darkness in the Vietnamese jungle. In “Good Morning, Viet Nam” Robin William’s portrayal of Adrian Cronauer mixes humor and horror in response to the absurdities and atrocities of war. It seems that each war has its representative movies. The pain and heroism of World War I can be seen in “All Quiet on the Western Front”, which brings out the humanist antiwar sentiment of the Remarque novel,  and “The Lost Batallion” in which Rick Schroder does a great job of demonstrating how unlikely leaders and regular guys can discover that they are stronger than they expected. World War II inspired many contemporary and current works such as “Saving Private Ryan”, with shocking realism, “Catch 22”, a humorous pacifist piece marked by style of the sixties and the “Band of Brothers” series, which develops characters so real you feel you grew up with them. The attack on Pearl Harbor alone has been chronicled in films like “In Harm’s Way”, which showcases an aging but powerful John Wayne and “Pearl Harbor”, which is a pretty face showcase but also delivers stunning panoramic scenes. I see the Korean War through the lens of “M*A*S*H.” Episodes of the television serial that followed were more a part of my medical education than microbiology or pathophysiology. The grit and frustration of the First Gulf War are so well portrayed in “Jarhead” even though it leaves out a few sordid details from the book. “Three Kings” is great more as a caper than as an accurate portrayal of war in the Middle East. Even small conflicts like Granada have their movies with “Hamburger Hill” with a gristly Clint Eastwood, and “Blackhawk Down” a vivid and guttural expression of the disappointing loss in Somalia as well as a premonition of war in the streets of Baghdad and Fallujah. A worthy standout from ancient war is “The 300” which bears the marks of its graphic novel roots in the depiction of an outnumbered Spartan force. It will be interesting to see what movies come of our war, but movies like “The Kingdom” with very hot Jennifer Garner are a prediction of a focus on conflict with cultural differences and how far we can break the rules before we lose ourselves.

War movies are a special sub-genre of action movies. Action moves are great for deployment. We want the explosions and car chases. It is all about distraction from the drab slog of life over here. One could use the term “guy movies”, but I know from discussions with women over here that lady troops want the same thing.  Perhaps they also want to watch “She’s All That”, but it doesn’t subtract from the unisex appeal of the action movie.

A good example of the action movie would be every installment of the “Die Hard” oeuvre. Bruce Willis’ John McClane gets more beat up and bloody than any action hero and keeps going. The Die Hard movies are also great representatives of the buddy movie device, even though in the first “Die Hard” Bruce Willis doesn’t meet his buddy until the end of the movie. The Die Hard movies also provide some of the most intense villains around starting with Alan Rickman’s Hans. Another great action hero is Arnold Schwartzenegger. The “Terminator” movies provide great fights, plenty of firepower, and very quotable lines. Since Schwartzenegger is the Governator now, it is questionable if he will be providing more deployment material. Steven Segal has an excellent supply of kick-ass action movies, doubtless the best example for deployment being “Under Siege”. He is a deadly military member (albeit a sailor), he takes on traitors and mercenaries trying to steal nuclear warheads and the movie contains one of the most gratuitous nude scenes when a Playmate pops out of the cake oblivious to the warfare around her. No listing of tough guys would be complete without mentioning Chuck Norris, since when he does a push-up, he doesn’t go up, the world goes down. And we cannot forget that “Charlie’s Angels” are far tougher than all of us, and totally hot, to boot.

Gangster and crime films can also deliver a momentary thrill during deployment. The Godfather has set a standard that has been deliciously reworked in “Scarface”. “New Jack City” is a masterful period piece in which director Mario Van Peebles captures the drug wars whose effects I saw as a medical student in the ER in Baltimore. Wesley Snipes as Nino Brown is the perfect villain that we just might secretly want to be. “Cool Hand Luke” and “Shawshank Redemption” bear mention as deployment films because we can relate to the idea of an imprisoned population doing their best to retain their individuality. I haven’t attempted to eat 50 eggs, but I can attest that drinking a cold beer after a hard day’s work makes me feel like a man, or at least drinking a cold near-beer after a hard day’s work makes me feel like a near-man. Clint Eastwood’s “Dirty Harry” is the unforgiving law-giver that treats civilian crime with the intensity of a personal war, even though “a man’s got to know his limitations.”

A classic action genre very appropriate for deployment is the kung fu movie. Sonny Chiba’s “Street Fighter” movies are a great place to start along with Bruce Lee’s “Enter the Dragon”. There are modern versions with Chow Yun Fat’s “Bulletproof Monk” which carries the tradition of simplistic plot development and the indoctrination of a skillful beginner, but adds the modern dressings of special effects and girl on girl fighting. There are great precursor films such as the Samurai classic “The Seven Samurai” by Kurosawa which has defined so many standards such as the villagers in need, the assembly and training of an A-team against incredible odds, and visuals such as horsemen cresting the horizon of a hill. Quentin Tarantino can take me away from this world of dust with the enthralling story, dialogue, and fight scenes in “Kill Bill”. “The Matrix” series has a strong foundation in martial arts, yet its special effects, concepts, and the science fiction world it creates make it a great crossover choice, although the high concept on the meaning of the universe does fizzle out a bit by “Matrix Revolutions”.

Sci-Fi movies are great for deployment because they produce bigger and badder villains to defeat. The “Alien” has had many a troop rooting for Sigourney Weaver to kick some alien butt, especially in “Aliens” with the military landing party. “AVP” brings together two great deployment movie syndicates by pitting the aliens against the “Predator”, cool for gadgets that I’m sure will be part of our future force arsenal. Harrison Ford is king of good deployment fare since we all would want to be Han Solo in the “Star Wars” movies, and he was cool incarnate as Decker in “Blade Runner”. In “The Fifth Element” director Luc Besson couples Bruce Willis with sexy Milla Jojovich and you can branch from each of these individuals to other key deployment films. Horror films can make for good deployment fare if they move fast and it doesn’t hurt to have a voluptuous leading lady like Salma Hayek in the gun-heavy vampire-fest “From Dusk to Dawn.”

A great source of heroes and stories for deployment are western movies. First and foremost must be the Sergio Leone “A Fistful of Dollars” spaghetti western series. Clint Eastwood as the man with no name is strong, silent, and unpredictable. You never know when he is going to turn on his compadres or ride back into town. A bizarre addition to the group is “You Better Duck, Sucker”, also known as “A Fistful of Dynamite” which pairs an Irish terrorist and a Mexican bandit in the aid of a populist revolution. Robert Rodriguez has brought the man with no name to a new stylish level, though he is a bit more altruistic in the “El Mariachi” trilogy.

Another action genre that provides good distraction is spy movies. Of course the classics are the James Bond movies. I think that history has proved that there is no Bond better than Sean Connery, and basically any movie he is in is a good on deployment. A great update of the spy movie is the “Bourne Identity” series with Matt Damon’s renegade search for the bad guys and his memory. The “Mission Impossible” movies are a little too slick for us troops to completely identify with Tom Cruise as he effortlessly jet sets around the globe.

The next great collection of movies that that get us through deployment are comedies. We are not talking romantic comedy here; I mean sloppy slapstick lowbrow comedy. In fact, “The Three Stooges” are great deployment fare, and I’m going to have to make sure I secure the collection we have in the Swamp for New Year’s Eve. The best modern inheritor of this tradition is the Farrelly Brothers, with “Something About Mary” being a great demonstration of the ability to push past the limits of taste to hilarity. “Shallow Hal” does a great job of illustrating the irony of inner beauty and also includes the mayhem of Jack Black, a deployment movie hero. I’d ignore a mortar attack to continue laughing through “Dumb and Dumber”. Of course classics like “Animal House” will always deliver and I think the hospital group before us actually had a toga party. What the heck, we have enough sheets. Bill Murray rules in “Caddyshack”, and not just because he is a Viet Nam veteran. In “Stripes” he gives the Man the treatment that we all wish we could. And if I haven’t told you yet, let me say it now clearly, deployment is and always will be “Groundhog Day.”

The last films I’ll mention are our personal favorites. Each of us has a favorite film in our heart that will bring us back to home and the ones we love. I can’t wait until I watch “Moonstruck” again with the right person. The film might be a family tradition, or a holiday special. Some celebrate Christmas with “It’s a Wonderful Life” and others favor the new classic “A Christmas Story”. A favorite movie might bring back a first date, or raucous nights with high school friends or fraternity brothers. Favorite films not only distract us from grind of life over here, but also take us on a brief journey of longing and love for that somewhere else we would rather be.

Top 10 Deployment Leading Men: So many to mention here, that it seems there should be an honorable mention, at least for the comedy heroes. We wish we could be as cool and tough as these guys.

    1. Tom Hanks
    2. Sean Connery
    3. John Wayne
    4. Harrison Ford
    5. Bruce Willis
    6. Bill Murray
    7. Matt Damon
    8. Clint Eastwood
    9. Steven Segal
    10. Wesley Snipes

Top 10 Deployment Leading Ladies: We like leading ladies hot, but these women can also give a beating, even after they have taken a beating.

    1. Uma Thurman
    2. Sigourney Weaver
    3. Natalie Portman
    4. Milla Jojovich
    5. Jennifer Garner
    6. Lucy Liu
    7. Linda Hamilton
    8. Selma Hayek
    9. Darryl Hannah
    10. Drew Barrymore

Top 10 Deployment Directors: Of course incomplete, but these directors know how to deliver a heart pounding dose of action and occasional sex appeal.

    1. Stanley Kubrick
    2. Sergio Leone
    3. Akira Kurasawa
    4. Quentin Tarantino
    5. Francis Ford Coppola
    6. John McTiernan
    7. Mario Van Peebles
    8. The Farrelly Brothers
    9. Robert Rodriguez
    10. Luc Besson

Top 10 deployment movies: I know there will be major disagreement here. Well guess what, you can write your own dang blog! Aw, c’mon back, I didn’t mean it. You can comment here or email the one you think I’ve left off.

    1. Full Metal Jacket
    2. Saving Private Ryan
    3. Groundhog Day
    4. A Fistful of Dollars
    5. The Seven Samurai
    6. Die Hard
    7. Apocalypse Now
    8. The Matrix
    9. Cool Hand Luke
    10. Caddyshack

26 November 2007

27 NOV 2007 Twizzlers and jerky

27 NOV 2007 Twizzlers and jerky
It’s 0300 again, my usual time to write. Here I am, typing away, fueled on midnight snacks of Twizzlers and beef jerky. When my call night finished, one of the ICU crew wanted to observe surgery. It is always encouraging to see someone from one part of the hospital interested in what happens in the other parts. She takes care of severely injured postoperative patients every day and wanted to see what happens to her patients before they arrived in the ICU. We were operating again on the Iraqi policeman who had been injured in the IED attack. His first operation had been fast, designed to identify the organs hurt by the fragments, remove the injured portion of the colon without reconnecting it, then quickly got him to the ICU to be resuscitated. Today Surgical oncologist J. and I were closing his belly and giving him a colostomy so his colon could work.

The nurses taught our visitor how to scrub and got her gowned for surgery. As tired as I was from the call night, it was worth staying to see someone who was observing surgery for the first time. In her eyes, the internal organs were something mysterious and new. She remarked that the man’s insides looked so healthy and new. They didn’t seem to be affected very much by the shrapnel that had passed through his belly. The policeman was only 19-years-old. She was fascinated by the way everything seemed so orderly and calm within the sterile square cordoned off by the blue surgical drapes.

I couldn’t help but think of the first time I had been in surgery. I watched J. Alex Haller, a pediatric surgeon in Baltimore. It was my second day of medical school. When I told my advisor that I wanted to be a pediatric surgeon, he brought me right to Dr. Haller’s office. Dr. Haller happened to be heading to the operating room and asked me to come along. He was fixing a teenage boy’s chest. The boy had a condition where his chest was caved in from the front like a funnel. I watched in wonder as Dr. Haller broke down the deformed supports of his breastplate bit by bit  and reconstructed it into a naturally rounded shape. I remember how warm the boy’s moving heart felt. Even though the shape of his ribs was deformed, it was amazing to see the way the muscle and fat was so perfectly and smoothly joined to the cartilage and bone. It was a wonder that in a world of such disorder, such an incredible machine could be formed. The boy did well. He was sore and bruised after surgery and stayed in the hospital about a week. He and his parents were so pleased with the new shape of his chest. As sore as he was, the boy smiled broadly and thanked Dr. Haller.

We surgeons do some violent things to the body. We push it to the limits of what it can take. No recess or corner is sacred. After injuries, we work frantically to stop bleeding and salvage destroyed tissue and form. Under our knives, the secret cavities of the chest and belly are laid open to the light, their mysteries exposed. We must work carefully, cutting this part, and sparing that one. We use scalpels, scissors and heat to divide and eliminate tissue, then use sutures, pins, and glue to reconstruct them. But in the end, all our meddling is worthless if the healing powers of the body are not there to continue the work after surgery. With tiny machines beyond our finest skill, the body works secretly to repair the insults of trauma and the surgeon. We merely start the process and then step back in the hopes that the extraordinary processes of the body can take over.

It doesn’t take witnessing this miracle through the wide eyes of a neophyte to remind me that I am privileged to walk in this temple. I am amazed every time I see a person’s eyes flutter open after surgery. It’s amazing what a body can do with air, water, Twizzlers, and jerky.

25 November 2007

25 NOV 2007 I can almost taste home

25 NOV 2007 I can almost taste home

Well, soon after I last wrote, I went to the hospital. It was freezing! It was probably 50 deg, but it felt like the arctic on my bare legs as I biked into the hospital compound. I met up with Surgeons J. and S. who were on call. Soon after, a helicopter landed, delivering a young US contractor who had been blown up in an IED attack. Our combat medical system is set up in levels. This man had gotten Level 1 care right at the scene of the attack. His buddies and the responding medics placed tourniquets and bandages. Then he was moved to a Level 2 hospital for an emergency surgery. Surgeons stopped his bleeding and replaced an injured artery in his leg with a temporary plastic tube. Following this, he was quickly moved to our Level three hospital. We were able to examine him head to toe, check his body for hidden fragments with a CT scan, and perform specialized surgery. I helped Thoracic surgeon J. repair the injured artery in his leg with a piece of his own vein taken out of the other leg. This vein will become a living replacement for the artery and can last for years, unlike the temporary plastic tube. The repair was tenuous, because the vein in that leg had been mangled in the course of his injury. The blood had an easy way into his leg, but it was difficult for blood to get out. All the tiny veins in his leg would have to gradually grow to replace the job of the central one that had been injured.

After this operation I got a few hours sleep before my call day started. I began the day by working on one patient to place a surgical breathing tube through the skin of his neck, called a tracheostomy, and a surgical feeding tube through the skin of his belly, called a gastrostomy. He had a serious head injury and had not regained consciousness for more than a week. It was only 0900 when the first new traumas began coming in. Three young Iraqi policemen had been attacked using an IED. They were each peppered with small and large fragments of metal. One had a fracture through his skull, another had fragments in his shoulder, and the third had fragments breaking his arm and leg on one side as well as entering holes in his flank. In the operating room, we removed many of these fragments. Some looked like large metal ball bearings, others were rectangular chunks of iron. Some of the fragments buried in his arm were wrapped in little packets of his uniform that had been forced into his flesh, like the filter on a teabag. One of the fragments in his arm was a metal hook from a shower curtain. The IEDs are packed with all sorts of projectiles intended to do harm. He still has his arm and his leg, but both are supported with external braces of metal pins and graphite rods which looks like the scaffolding on an old building.

The rest of the day had been relatively slow paced. I had to have my pistol inspected. A defect was detected in some of the M9 handguns issued to officers. When the slide is racked, this defect causes the weapon to come off safe by itself. The security forces Arms Marshall was very professional as he checked our guns one by one. We stood in a line with our weapons tucked into holsters or the waistbands of our scrubs. After my weapon was checked, I received another piece of paperwork. Paperwork is a real favorite of the military.

Laparoscopic surgeon S. organized a barbecue tonight. We pulled together food from the PX, the dining facilities, and some bratwurst we had been saving since the last delivery from Germany. In the cold night air, it felt good to huddle around the flames leaping as the grease dripped off sizzling burgers into the coals. We used an improvised surgical device to flip burgers since we didn't have a spatula. The freshly grilled burgers were a great taste of home. As we sat around the PLX chomping on hamburgers and bratwurst, we could have imagined that we were back home in our backyards. Only the supposed beers we drank were non-alcoholic and our wives and children where not gathered around us.

After dinner, I finished "The Kitchen God's Wife" and watched a few episodes of "The Family Guy" saved on the morale drive. I scored a great comforter from the ER and curled up on the couch in the PLX for a midnight nap. One of the nurses woke me to come see a patient on the ward. He was having trouble breathing. He was a detainee, and a few weeks ago he lost one of his arms and legs when he was struck with a missile. He has gone through numerous operations and was fighting off an infection. When he is up to speaking, he often remarks that he will shoot us all. He is under constant guard and is kept blindfolded. I listened to his breaths using a stethoscope the nurse handed me. I sat him up and tapped his back to try and dislodge phlegm that might be clogging his airways. I needed the interpreter to tell me the word for cough. I asked what word I could use in Arabic for "Mister" since we were not supposed to ask the patient his name. I had thought that "Sayed" which means "Sir" would work, but the interpreter said to use "Ente" which means "you". I got the ICU doctor to look him over with me. Hopefully we won't have to use a breathing tube tonight, because he has a better chance of warding off pneumonia if he can continue breathing on his own and trying to cough. The nurses looking after him will keep a close eye on him and make sure he gets the best care possible.

24 November 2007

24 NOV No easy fix

24 NOV 2007 No quick fix
Today I felt about as useless as an anus on my elbow. After duties, around 1400, I returned to my hooch and just passed out cold. I have been fighting a little fever and haven’t been able to get a solid chunk of sleep. Last night I tried several times to rest, but alternated between kicking the sheets off for feeling too hot and sweaty, and shivering in long johns even with the covers pulled up and the combination air conditioning/heating unit blowing like a hair dryer. Eventually I gave up and read Marine Mike Hodgins account of his reconnaissance work in Viet Nam.

After climbing into bed this afternoon, apparently I slept through an Alarm Red for an indirect fire attack. I missed the klaxon and the All Clear. When I didn’t report in for accountability, the command section sent someone looking for me. The female sergeant and airman who knocked on the door of my hooch had a chuckle when I staggered out in my boxer shorts and mumbled my name as I squinted in the afternoon sun.

I’m feeling a lot better now after being comatose for the evening. Having a cold over here showed me one of the brief shining moments when it is so easy to be deployed. When I wanted a decongestant and pain reliever, I stopped by the pharmacy. There were no forms, no fees, and no wait. Pharmacist P. just tossed me a pack of Sudafed and a bottle of ibuprofen. It’s in the spirit of “three hots and a cot” where the military just provides anything you might need while you are stuck over here. In my case it’s sometimes four hots since I’ve been known to draw midnight chow.

The hospital has seeing business like a big city ER back home. Last night, we had more patients injured in car crashes than from battle injuries. As has been the trend, most of the patients were Iraqis, one a child who sustained a head injury in a fall. It is good to provide this much needed and appreciated help, but someday, the Iraqi healthcare system is going to have to suffice. Doubtless, they are struggling with shortfalls in personnel, supplies, electricity, water, and security. As long as our hospitals are here, they provide a crutch on which the domestic system is willing to lean. At some point we have to let the Iraqi system stand on its own. Back in the United States, if we had a free alternative hospital that would take care of our sickest patients, even we would take advantage of that option. Since that outlet doesn’t exist for us back home, we do our best to take care of patients with the resources we have.

I have been able to find out a little about the system of healthcare financing in Iraq from an Iraqi soldier who works in the hospital. He is a liaison to the hospital who helps get Iraqi soldiers back where they belong after they have been treated here, as well as directing their pay in the proper direction. He explained to me that the Ministry of Health, like other governmental bodies in Iraq, has a central office in Baghdad, then a branch for each of the provinces in Iraq. There are no taxes levied against citizens in Iraq. The money to run the government comes from oil sales, but mostly from foreign financial aid, the majority of which comes from the US. Each Ministry gets its budget, and then the ministry is responsible for supplying the provincial offices. The Ministry of Health in Baghdad electronically transmits money to the bank accounts of each of the provincial offices. The provincial minister of health is responsible for running and supplying healthcare needs in their region with that budget.

It’s not surprising that there can be problems with this system. I remember the last time I was here, in 2005, the local hospital in Balad had depleted their supply budget in March. They could no longer buy bandages. Each week, Iraqi Doctor O. would visit our hospital and drive off base with a big box of donated bandages. I have seen Iraqi patients come to us wearing soiled towels around their colostomies because there were no colostomy bags available. Emergency medical needs can overwhelm the hospitals quickly. Elective care is often only available to those who can afford to pay for it up front. Security is also a problem. I read in the Brookings Report that of the 34,000 doctors in Iraq before 2003, approximately 17,000 had fled the country and 2,000 had been killed. That chilling statistic certainly tells me that I have very little to complain about when I consider the challenges that Iraqi doctors face every day. It is so good and rewarding to care for Iraqis in our hospital every day. But I have sinking feeling that we are only seeing a tiny fraction of the many who fall through the cracks in Iraqi healthcare. It reminds me that lawmakers have the potential to save far more lives than doctors.

I did do one operation today. Laparoscopic surgeon S. and I used a laparoscope to evacuate a collection of pus from the belly of a US troop. About a week ago, I took out his appendix. He never felt quite right after surgery and didn’t regain his appetite. Day by day, he felt worse and then he developed a high fever. We did a CT scan on him and found the liquid collection of pus in his belly was interfering with his intestines. After removing the pus, we left a soft rubber tube hanging out of his skin to allow any further infection to escape. He will be evacuated from the country to continue his recovery. I hope that things turn around for him now. We do so many appendectomies in which people recovery nearly immediately, that it is easy to take it for granted as a mild illness. Before the advent of surgery, appendicitis was considered a death sentence in nearly every patient who suffered from it. Every once in a while, a challenging case comes along that reminds us what a potentially serious illness it can be.

Well I’ve heard a bunch of helicopters land as I’ve written, so it is probably worth checking to see if I can be any use to my partners, especially since I was so useless today! I am going to try and get a little more rest before morning because tomorrow I start a 24-hour on-call shift.

I miss you and I can’t wait to get home.

22 November 2007

Helipad football

Helipad football, originally uploaded by ccoppola@pol.net.

Helipad football <>

Thanksgiving on the roof

Thanksgiving on the roof, originally uploaded by ccoppola@pol.net.

Thanksgiving on the roof <hospital.JPG>>

22 NOV 2007 Thanksgiving

22 NOV 2007 Thanksgiving
A holiday in military life can be quite an adventure, for lack of a better word. I’ve had my share of holidays apart due to overnight call shifts in different hospitals during residency. But a call night was different. There was always the promise of heading home the next day after operations and rounds were done. Family was only a short drive away. If I was lucky, there wouldn’t be too many traumas, and M. would bring the boys in so we could dine together. We would see what was being offered in the cafeteria, or M. would bring food from home in Tupperware containers for us to reheat in the call room microwave. The boys loved the novelty of cafeteria food and enjoyed watching a video in the call room or climbing on the sculptures in the lobby. They would create murals on any available surface with the dry erase markers. Even though I couldn’t leave the hospital, it was a treat just to be together. We would hope that there would be no emergencies while they visited. The nurses would try to keep things quiet for a few hours so we could enjoy a protected moment together. After they had left to go home, I felt like I could face any challenge through any sleepless night.

Over here, there are so many of us together, but apart from our families. We may be missing our spouses and kids, but we do have each other’s company. It seems like people have been planning Thanksgiving in Iraq activities for weeks. There were USO shows for the troops. Yesterday Aaron Tippen gave a show in the Sustainer Theater. He has visited the troops in Iraq for the past three Thanksgivings. That is an impressive dedication to show his appreciation. Maybe next Thanksgiving, he won’t have to come over. Before his show, he visited injured soldiers in the hospital and gave them all autographed pictures. He also gave one to S., the little Iraqi boy whose face had been injured in a blast. He even gave one to the Iraqi policeman who was in a coma. Today there was a USO review which included Cuban model sensation Mayra Veronica! I didn’t make it to the show, so I don’t know what she did. I guess she modeled. Maybe she brought cigars.

The chow halls have been decorated from floor to ceiling with crepe paper, banners, and fold-out turkeys. DFAC three had a nice mural of a horn o’ plenty superimposed on a US flag. They had all the classics on the menu: boneless turkey roll, stuffing, ham with pineapples, roast beast, and potatoes. After dinner there were tasty treats with pumpkin pie, pecan pie, and ice cream. The dinner was filling, nutritious, but it wasn’t in danger of eclipsing dinner back home. What made the dinner special was the time shared with my military family. We are all in the same boat together. We work so hard side by side each day; it was good to share a moment of rest.

The hospital was abuzz with excitement over the first annual Turkey Bowl touch football tournament. Each section of the hospital had put together a team. The day was cool and clear, bright sun shining down on the helipad from blue skies. Those who weren’t on a team turned out to watch and cheer. The competition was fierce. Surgeon and tech, nurse and administrator, all turned in their A-game. Once during the maatches, we had to clear the helipad to let two Blackhawks land to drop off casualties. One team went inside to perform an amputation while the others returned to football. The elimination tree grew thinner as teams advanced. In the end, the ER team took home the trophy. The surgeons delivered an admirable performance for fourth place. Surprisingly there were no major injuries to report.

I missed the first part of the games because I was working on a four-month-old child who had come in the night before. He had pneumonia and was having difficulty breathing. We started him on antibiotics, but he lost his only IV. After the nurses tried to find a good vein, they called me. He was a handsome little guy with olive skin, long eyelashes over brown eyes, and a tuft of dark hair on his round head. I could see by the needle holes that most locations had already been tried. After getting translator J. to explain things to his father, I gathered what I needed and placed a central line, a long soft IV in a large vein. It took quite a while to find the vein because he had become dehydrated. He cried, and it was hard on his father. His father had to step out of the intensive care unit for part of the time. Eventually, I got the IV in place. One of the nurses wrapped the boy in a soft blanket and fed him a bottle. He smiled a bit then went to sleep. His father was relieved.

After the game, we climbed onto the roof of the hospital. Some of the guys lit up cigars. We shared stories about our usual Thanksgiving traditions. The midafternoon sun shone down on us and from time to time Blackhawks would land. I drifted off to sleep fat on turkey roll and egg nog. Later on when I knew it was late enough that the sun had risen in Texas, I called home. To hear M.’s voice and my children’s’ laughter was the best part of the day. I was truly thankful.

21 November 2007

The Turkey Team pre Thanksgiving injury check

The Turkey Team pre Thanksgiving injury check

Standing by his newest command, the SEW VEIN II in the DFAC I

Standing by his newest command, the SEW VEIN II in DFAC I

21 NOV 2007 Sleepless in Balad

21 NOV 2007 Sleepless in Balad
So here I am, in my cave, drinking chai, and watching “Sleepless in Seattle” on the TV. Isn’t this what chicks do? No matter, just being motionless for a spell is enough for me at the moment.

Post call is good, as long as things are cool enough that you get to leave the hospital. Last night finished up a little wild. The elderly woman who had been shot through the pelvis had a difficult night. Raw edges of broken bone tend to ooze blood. Throughout the night, ICU doctor V. watched her like a hawk, giving her transfusions, measuring her urine. He came to get me around dawn because he wasn’t happy with her blood pressure. We stood together at her bedside, like we had several times that evening. We reviewed her vital signs and the trends of her laboratory tests. She had held her own, but it was time to take a look in her belly again to see what disaster might be brewing there. The OR crew opened up a room for me. I removed the bloodied gauze we had packed into her the night before. There was some bleeding, but all in all, she was doing better than I thought she would. Thoracic surgeon J. took over from me to place new gauze and a dressing so that I could present the night’s patients to our commander.

Some US troops had come to us with broken bones and shrapnel wounds. They worked in a base to the (redacted). They had been working on a bulldozer crew, when a rocket streaked in and blew up next to them. One troop had his jaw broken open. The broken bone already had metal support bars in it from a previous injury to his jaw. The others had shrapnel buried in various locations in their body. We x-rayed them, operated on them, and by dawn they were winging their way north in a C-17 to the regional evacuation hospital in Germany. They will undergo other operations, perhaps in Germany, or perhaps in Washington DC. Two British troops who had been killed in a helicopter fire stopped here briefly. Their remains were flown home to their families.

After my duties were done, I changed into my uniform. I shrugged on my individual body armor, strapped on my M9, and headed out to get my flu shot waiver at the clinic. Back at the hooch, I decided to put my head down and suddenly it was 1500. Unfortunately I woke up in Balad again, but at least I was well rested. I did laundry, cleaned the hooch, and met up with the surgeons for family dinner. Laparoscopic surgeon S. had set up a golf ball net on the roof and they were driving balls. We headed out to the helipad to run some plays in preparation for the hospital flag football tournament tomorrow. Besides a pulled hamstring and some scrapes, we escaped relatively unscathed. It was seafood night, so even Ophthalmologist B. made sure that he made it on time for the Czar Car ride. The Kellog Brown and Root contractors from around the Indian Ocean were working overtime to decorate for Thanksgiving. They had constructed a miniature yacht in DFAC 1. I took a picture of Vascular surgeon M. in front of it. The boat can be his command since he is a former Marine and has boat back home.  After dinner, I stopped by the Air Force recreation center to say hi to the ER staff taking salsa lessons, and then walked to the gym to work out. Sometimes I wonder if this base is really in a war zone.

Now it is 0300, Happy Thanksgiving to you all! Well there goes Meg Ryan, running to the Empire State Building to Find Tom Hanks. First time I saw this, I couldn’t understand why Bill Pullman wasn’t pissed. Then I realized that he knew the last thing he needed was a lady who was crazy insane for Tom Hanks. Nothing can stand in the way of two meant to be together. Nothing here can. Nothing here will. As the credits roll, two F-16’s and a Predator take off and fly overhead.

20 November 2007

ready to go home

ready to go home, originally uploaded by ccoppola@pol.net.

ready to go home

20 NOV 2007 Trying not to spill my latte

20 NOV 2007 Trying not to spill my latte

Man, I don’t know what it is; I just can’t hit my groove tonight. I’ve got no interest in eating, sleeping, watching a movie, or much else. I am on call, so it’s not like I could go anywhere, even if there was anywhere to go. I sat and stared at a group of empty chairs for half an hour. I read a SPIN magazine cover to cover because I could reach it without getting up. (I am actually interested to hear the Hives new album now; perhaps it has been lifted for the morale drive already) I’ve been told by three people today that I’m the only surgeon left who hasn’t gotten the flu shot. Guess I didn’t get the memo about the TPS report cover sheets. I don’t think Ali Baba is worried about his flu shot. I catch myself thinking that at least it would be interesting if a trauma came in. I can’t believe that I would actually appreciate a moment’s reprieve from my dysphoria because another human being had been injured. Disgusting.  


I took care of an old lady who got shot in the belly today. She was so thin and frail. I don’t know how old she actually was, but she looked to be about 170 or 180. Her eyes were sunken and I could see the curve of her eye sockets under paper-thin skin. The muscles from the base of her ears to her collar bones were raised up from the surrounding tissue like the number “11”. Either she hasn’t been able to find food or something inside is consuming her. She grunted softly with each breath. On her belly was a small red hole with a thin black burned rim where the bullet had entered her body. When we turned her over, we found some of her intestines hanging out of a hole that had been blasted through her tailbone as the bullet exited her body. We washed the blood out of her belly, removed the damaged intestine, and left sterile gauze and towels packed in her belly to control the bleeding from the splintered bone. Tomorrow we’ll operate again to try to reconstruct the separated lengths of her intestines. Why are people shooting old ladies?


Today we were able to send home a little boy and his father. The boy had a bandage on his chin and the father was favoring his left leg with the aid of crutches. They both had recovered from their injuries quickly. A few days ago, Al Qaeda fighters attacked a police outpost near their house. After killing the officers, they sprayed the surrounding family homes with bullets. The father leapt onto his son to protect him. The boy was shot once in the chin and the father was shot in the back of his thigh. He saved his son’s life. Before the Al Qaeda fighters left, they put a few of the bodies in a nearby building, opened a propane tank, and rigged the door to spark when opened. A responding policeman was burned when he opened the door to retrieve the bodies of his colleagues and the gas ignited. His burns were minor and didn’t require more than topical treatment.


Sorry I’ve nothing but ugliness to offer tonight. Rather than go on, I’ve provided “The top 50 reasons you know you are at Balad” which was sent by a friend. If you don’t get some of them, ask anyone who has ever been here for more than a day.


Sunny days,




(Author: Unknown)



TOP 50






  1. …. watching porn means catching Desperate Housewives on AFN
  2. …. you run in terror from a controlled detonation your first week then stand in the open

      and watch real mortars landing yards away a month later. 

  1. …. the most intimate contact you've had in months is with the shower curtain in the Cadillac.
  2. …. winning a dodge ball tournament is like winning the World Series or the Super Bowl
  3. …. your most successful pick up line is "I've got a vehicle".
  4. …..You’d trade a month’s per diem for an empty dryer that works
  5. …..All the Air Force people look like glow in the dark power rangers and you can’t see the army folks.
  6. .… your 6:00 am wakeup call is “Boom….Alarm Red, Alarm Red, Alarm Red”
  7. …. “We are U ready” is proper English
  8. …. they actually give the Air Force weapons
  9. …. you give directions using bunker murals
  10. …..you realize AAFES is there own country, and can print their own money.
  11. ….. The amount of sand in you’re boots is only surpassed by the amount in you’re nose.
  12. …… the F-16 wakeup call sounds like its coming from your wall locker.
  13. ….. KBR provides free purple tie-die t-shirts and short sleeve DCU service after each washing
  14. …..Something as simple as taking a shower or going to the bathroom at 2:00 in the morning requires preparation equal to the Apollo moon landing.
  15. ….. the Texas Style Brisket is not from Texas , is not brisket and has no style.
  16. ….. you are more worried about your socks showing while in PT gear then getting hit by a mortar.
  17. ….you are watching a “chick-flick” with 300 guys with machine guns.
  18. …you start sending out care packages to needy friends back home because you’ve received too many
  19. …..You attend several Services’ theme parties but you’re always in PT gear or DCUs!
  20. …your internet connection is twice as slow as your old dial-up connection back home
  21. …you’re lying under your bed in IBE saying to your spouse, “No, nothing exciting happened today” and you mean it
  22. ….You can buy vehicles from AAFES but paper towels are no where to be found.
  23. ….You use the term “War is hell” in the DFAC while watching a movie on the big screen TV and eating Steak, Lobster and Baskin-Robbins ice cream
  24. …. You know Army TOA is really code-word for “hold on to your stuff”
  25. …. Your lunch leftovers are covered with crème sauce and raisons and magically becomes the “dinner surprise”
  26.  …..You live in gated community and your home is still a trailer
  27.  ….your idea of PT is that morning sprint to the porta-john.
  28.  …. your idea of a road trip is going to the west side PX.
  29. ….your roommate drops his boot and you drive for cover
  30.  ….You are caught way over the speed limit and you are going 22MPH
  31.  ….Your helmet is referred to as a, “Combat cup holder”
  32.   …. incoming mortar fire at 0630 is your wake up call for morning chow
  33.  …. You’re idea of a night on the town is going to DFAC 4
  34.  ….. the Cadillac you are sitting in is not a car!
  35.  ….  DWI means driving while inhaling
  36.   …. the grass is always greener but you still wouldn’t want to be on that side of the fence.
  37.   ….. Dusting the furniture has a whole new meaning.
  38.   ….. ”Pimp my ride” means putting doors on your Hummer!”
  39.  …. “Your Cadillac seats are porcelain instead of leather”
  40.  …. U2 is hitting the charts again
  41.  ….  you start using Alarm Red as a reason why you didn’t you’re your wife/husband!
  42.  …. You put tick marks on your boonie cap to mark the number of Alarm Reds.
  43.  …. you buy a new PT shirt to update your wardrobe
  44. …. The local community holds fireworks displays everyday in your honor
  45.  …. Driving over curbs seems totally natural
  46.  …. The outcome of the war hinges on how you wear your reflective belt
  47.  …. you see a guy in full battle gear driving a humvee trying not to spill his latte’
  48.  …. It feels normal to dry your hands at the DFAC on toilet paper

Along the wire

Along the wire, originally uploaded by ccoppola@pol.net.

Along the wire

20 NOV 2007 Remembering Mary

20 NOV 2007 Goodbye Mary


While I’m in , I’m continuing work on my MBA. I have been enrolled in a distance learning program with Norwich University in Vermont for about a year now. Those who love me have asked me “Why would you do that to yourself?” I’ll agree that I probably have enough to do as it is, and scheduling sleep for me would be a better choice. So the answer to their question is “because I’m an idiot.” Our Wing Commander, Brigadier General Field spoke to us all in the first week of our deployment. He urged us to find some way to improve ourselves over the course of our tour. It didn’t matter if it was physical training, personal reading, music, or progress on a degree like I am doing, but he didn’t want us to finish this experience without taking advantage of the chance to leave the Area of Responsibility a little wiser. It’s true, time I would usually spend just living and loving in the presence of my family is many empty hours each day. Completing my MBA assignments is a wonderful way to keep my aging brain from going to rot. There is another reason I’m taking the course. I paid $1000 into the Montgomery GI Bill plan. There was no way I was going to leave that money on the table. MGIB is paying about $12,000 of my $18,000 yearly tuition. So again, countrymen, citizens, taxpayers, as your humble government servant, I say thank you.


Norwich University is an incredible institution. It is the country’s first military academy. Growing up in New England , we were within close striking distance. One of my best friends from home and high school graduated in the corps of cadets, artillery. It has a proud patriot and frontier tradition that has been honed by years of experience and weathering the Vermont winters. It was head and shoulders above my other choices for an online MBA. I’ve never set foot on campus, but I feel as much pride as if I was living there. I have met wonderful classmates and professors from across the country. Many have prior or current military experience. We each bring our own individual geographic and political differences. Such are Americans. I enjoy our discussions and relish the hard work accomplished together on our group studies. It has been a logistic challenge to coordinate group marketing presentations on TIVO and other companies with conference calls transmitted from satellites across broadly separated global time zones.


One of my classmates was Mary. She was born in the Midwest, and through family, school and career had eventually migrated to New England . She was an active team member in a brokerage firm and was taking the MBA course to be even better. Mary had a wonderful family and was enjoying raising two beautiful school age daughters with her loving husband. Our little cadre of students all started about the same time. We exchanged bios as well as photographs of family and pets. We shared exciting personal news and rooted for our home teams. Much of our discussion was centered on our case studies, but the social discussions have been just as lively. It was easy to see Mary’s enthusiasm for life in her communication. She always would be just as happy to hear good news as to receive it. She could quickly identify with experiences from any of our classmates, and always had a sense of optimism and enthusiasm. You could almost hear the excitement in her voice when she would bring a new idea to the forum.


A few days ago, Mary died. She is younger than me, and I’m way too young to be dying. Her children were the same age as my two youngest, and they are way too young to be without their mother. She broke a bone and needed surgery. During her recovery, a blood clot formed and traveled to her lungs, stopping her heart. Young as she was, the paramedics that rescued her were able to bring her back. Too much damage had been done and she only lasted a few days longer in the intensive care unit. I never met Mary in person, but her online presence was so lively that I feel as if we shared a real classroom, not a virtual one. This world of telecommuting and electronic communication is so strange, when we humans are built to work side by side. But it didn’t matter that we had never shaken hands or met eyes, I felt like I knew Mary as a person and a classmate. I still see her online posts in our discussion space and messages from her husband come through in her name. Her death is a shocking and tragic loss. I cannot begin to imagine the hole left behind for her husband and daughters. She was such a great heartwarming and human presence online; it is no doubt that she greatly influenced the lives she touched in person. It is my strongest wish that they find the comfort and support they need to carry on. We who live must dust off, pick up our feet, and continue to make steps. There are no appropriate words, no easy explanations. Perhaps the best we can do is something close to our Norwich University motto, “I will try.”

19 November 2007

Running the bunker

Running the bunker, originally uploaded by ccoppola@pol.net.

running the bunker

Family dinner at DFAC 3

Family dinner at DFAC 3, originally uploaded by ccoppola@pol.net.

Family dinner at DFAC 3

19 NOV 2007 Hold fast

19 NOV 2007 Hold fast

Happy Birthday P.! I miss you a lot, brother. I wish I was back home with you. We could go visit the reservation and trow some numbers. I'm so proud of you and all that you do for your family and your students. We'll have good time when I come visit. Maybe we can even see if Captain Tom's boat is available this summer.

Balad hasn't changed much . The past week has been cool and clear. I've been told by my father that I have my grandparents' genes in me. Of course I do, but it should come as no suprise that I plan to explain this in great detail. My grandparents exhibited a strong characteristic that could be equally and accurately described as resolve and stubborness. My mother inherited the same character, and apparently so have I. This family trait is demonstrated in fierce adherance to one's impressions formed when interacting with another individual. For family and friends, this is an undying and generous loyalty, but if you cross her she will remember it forever! She knows it is true. I really am much the same way. It is pretty hard to convince me to give up a point once I've adopted it.

Our commanders have decided that we will wear an official physical training uniform whenever we are not in our desert camaflage uniform or airman battle uniform. The PTU is a heather grey polyester T-shirt with a stylized reflective eagle on the front and the back. The shorts are dark blue nylon mini seventies Bruce Jenner shorts that come up on the side of the thigh and have reflective chevrons. There are a slew of other regulations related to armbands, headbands, socks, sneakers, hats, ipods, headphones and what not. The PTU is reasonably priced, even though the PX only has sizes petite and XXXL left at this point. For cooler weather, there is a matching track suit, of the swish swish friction between the legs nylon variety. This is not reasonably priced, in my opinion. Of course you have to take into account my background. At the beginning of each school year, my mother used to take us to Bob's Discount Clothing in Middletown where you could get a perfectly good sweatsuit for six dollars. You know the one: comfortable thick cotton with the double stripe in opposing color down the legs and sleeves, drawstring hoodie on the top, and a pocket sewn on the front where your hands come together in the middle. I may not be able to find one for $6 anymore, but I am not going to spend seventeen times as much on one I don't like! I don't know if the enlisted corps gets a uniform allowance to buy theirs, but I hope they do. I realize whenever I talk about money, I have to make sure you all know that I understand that doctors in the military are paid so much more than just about every one else. It would be insulting for me to bring up woes about money when I have it so much easier than many around me. The point is not the money, the point is that I'm being told to buy something I don't like for more than it is worth. It is not to wear for my job or during performance of official duties, but to wear during my non-working hours. There is no way that is going to happen. I will wear my skimpy polyester 70's Air Force PTU, dreamed up by some fashion sadist whose company was paid far too much for the consultation, but I will not buy the optional track suit. I will lose toes to frostbite before I do that! Therein lies the proof that I am my mother's son.

So we ride to dinner together each night in the back of the pickup truck. The sun sets before we head off for the several mile trip to the DFAC across base. The landscape of central Iraq is dry hard-packed ground with groves of scrubby trees. It is dry, and once the sun is down, the heat quickly flees the earth. As the truck traverses the base at 30 mph, a brisk breeze flows over the cab and chills us a little in the short trip, me more than most because I am not wearing my overpriced windbreaker, and I'm a pretty skinny poke to start with. I prefer the ride in the bed of the truck rather than the cab, because the open breeze gives me a brief nightly reminder of hauling down the highways of San Antonio with the top off the Jeep and the stars overhead. Usually the moon hasn't risen by the time we head for dinner, but we can often see Venus, and Mars. Tonight Mars rides high, a glaring yellow red speck ruling over us from afar. I may shiver a bit, but I am warmed by the smoulder of my bitterness and refusal to submit.

Just when I complain that I have seen every variety of brown stuff on rice that the DFAC has to offer, they go and surprise me with something new! Tonight our trip to DFAC 3 was rewarded with bountiful food service trays of sweet and savory chop pork barbecue. The main line attendant asked me twice if I really wanted turkey cutlet, shredded Buffalo chicken, and the barbecue pork. With an only mildly stale bun and some jalapenos, I was tearing into a darn good BBQ pork sandwich! With a nice Dixie cup of sweet tea, I could close my eyes and practically imagine that I was in Richmond at Bills. 

Now I don't want to even get into the whole Texas barbecue thing with my dear, dear brothers and sisters in the Republic of Texas. Come on, do you really want me comparing something that Haliburton froze some where in New Jersey, shipped across the Atlantic and trucked up from Kuwait to anything served in our Lone Star State? Let me leave it at the fact that I had my first pork sandwich in Richmond, and perhaps that was a safer gradual entry for a boy from Connecticut than to dive right into the heart of Texas. I will tell you that Texas certainly did kick my tail a few years later when I foolishly entered a jalapeno eating contest after my training on Medina base annex in San Antonio. When I say kick my tail, I mean literally: those of you who have suffered the same fate won't need a detailed description. I had never before seen peppers the size of pears they were pulling out of the giant food supply cans. I did manage to cram 11 down my protesting gullet in a minute, only to be beaten by a girl from a girl from Brownsville who ate 12 without shedding a tear. 

Have I illustrated the stubborness well enough yet? It may carry a little suffering to cling unflinchingly, perhaps unreasonably, to a position, but my mother couldn't have given me a better gift.

18 November 2007

18 NOV 2007 Just keep swimming

18 NOV 2007 Just keep swimming

I got a good start to the day. Sunday is our one different day. We don't have our usual morning clinical openers, and we start the day's operations an hour later. I got up early to run five miles with Gastroenterologist B. He keeps a pretty good pace, but I was able to huff and puff along well enough to keep up. It is so much better to run with someone else! In my world, successful running is all about distraction, not focus. The more I can be distracted from the road, my joints, my muscles, the air, the better. Most of all, I need to be distracted from the most obvious question of all, "Why am I running?" Running on a track starts to get painful, and with every successive loop past the exit, I am more prone to come to my senses and walk off. A treadmill is right out. Even headphones can only distract me momentarily from the glaring fact that I am going nowhere. So a good outdoor run with sights thumping slowly by and spectators in cars for whom to perform is acceptable, but chit chat with a running partner is best of all. I know that there are runners out there who focus, count heartbeats, and beep their stopwatches on at the start of the run. They live for the run and want to immerse themselves in the sensation of running, eager to beat a personal best. I just want to get to the finish with a strong enough stride left to be proud and no one left behind. I would annoy the heck out of you with my chatter, if you were an intense runner.

Got to work and I had two cases to tackle. Washing out a man's leg, after he had been bitten by a dog, and washing out another man's leg that had been shot by with an AK-47. It was pretty much the same operation twice. With due deference to those who love their doggy kisses, the bullets were cleaner than the dog's mouth, unless of course the shooter was using his AK rounds to clean his anus. Due to this difference, I planned to staple closed the wound for the man who was shot and to leave the dog bite open so I wouldn't be trapping mouth and snout bacteria under the skin. Then we could continue to wash it every day.

Before I had a chance to start, a trauma code was called. I kept the OR ready in case this new patient needed an operation. He did. He was an insurgent who had taken M4 rounds to the chest and the belly. The hole is his belly would spout blood in a fountain the width of my index finger about four inches high whenever the dressing was removed. He was trucked on into the operating room double-time as soon as a breathing tube was in his throat. Two of my partners scrubbed to open him up while I flitted around the operating table making some final preparations. I helped one of our medics get a tube into his right chest. As soon as the tube was pushed through the muscle holding two adjacent ribs together, about a liter of blood jumped out of his chest and onto the floor. I got his arms out at right angles to his body on boards and splashed a bottle of antiseptic iodine over his body from the chin to the knees. I tipped his operating table head down to help the little blood he had remaining in his veins to rush to his brain to keep it alive. My partners rapidly sliced a wide incision to open him up and pack his belly full of bulky white gauze to try and stop the bleeding with pressure. In the time it took for me to scrub in and join them, they had already opened the chest to find even more blood. By this time his heart had stopped because it was so empty it had nothing left to pump. He had already received several bags of donated blood pushed into the large IV's in his neck and his chest, but it was rushing out of the holes in his large blood vessels as quickly as it went in. We had called for a whole blood drive and donors were lining up. We pumped his heart using our hands directly. I placed one hand under his heart and one over it, holding my hands like I was praying, but sideways, with his heart between. I squeezed and released in a quick rhythm as the anesthesiologists pumped oxygen into his injured lungs and loaded him up with blood and powerful stimulants. The muscle of his heart began to quiver in an ineffective shimmy of disorganized action. We used electric paddles that looked like serving spoons to shock all of the muscle cells into the same cadence. Even after shocking his heart multiple times and pumping in quarts of blood, we could not get his heart to beat. We let him go.

Whatever this man was doing, it caused our troops to take him down hard. The second these well-trained professional troops had incapacitated him with well placed rifle wounds intended to kill, they immediately initiated efforts to save his life. They brought him to us. From the moment this man was unloaded on the helipad to the moment of his death in the OR with a puddle of blood all around, our crew worked as hard to save him as if he had been one of our own. It was a bad, bad way to start the day. We closed the long incisions on his chest and belly with thick nylon stitches. I couldn't decipher the Arabic character tattoos on his shoulder and forearm, but it must have been a statement of someone or something he believed in. Maybe it referenced a woman, or was a religious statement of belief. Perhaps it was the insignia of his organization. We lifted his thin body into a zippered black bag.

After the blood was mopped up, we proceeded with my two leg operations. They went well. I was in my hooch getting dressed to go workout, when I got the page from Colorectal surgeon J. to report to the ER. We had received a new casualty, an Iraqi Army officer. An IED had blown off his left arm and sent shrapnel throughout his body. He was blown up head to toe. First he was taken to an Iraqi aid station. They applied a tourniquet to his arm and sent him to one of our other combat support hospitals to the north. They opened his chest and belly, controlled his bleeding, and then sent him on to us for further care. When we received him, he was only five hours out from his injury and had already undergone an operation. After ensuring that his vital signs were stable, we used the CT scan to check his entire body for any remaining injuries. The CT scanner showed us that he had a nail in his brain and another in his large intestine. So just two hours after his last operation, he went back under the knife. I washed him head to toe with hydrogen peroxide to remove the dried blood and dirt from hundreds of small scrapes and punctures on all three of his remaining limbs. While Ophthalmologist B. removed his eye that had been pulverized by flying debris, Surgical oncologist J. and I reopened his belly. Things looked good in there. Healthy pink intestines without any leakage or unhealthy swelling lay nestled in a fatty padding. It took two full courses of running our fingers the entire seven feet of his large and small intestine to finally find the nail. The nail was a short roofing nail with a broad head. It had entered the colon point first, plugging it shut like a nail you might run over with your tire. The nail head was hidden in a little tuft of fat and no bowel movement had leaked out of the colon. We removed the nail, cleaned the wound of dead tissue, and closed it securely. It was very rewarding to find and fix that injury. A wound like that untreated would begin to leak stool and might have become a widespread or lethal infection. The officer is strong and recovering in our intensive care unit.

It might not seem immediately obvious how a nail got stuck in his colon. The bombs used by the insurgents against human targets are packed with nails, nuts, bolts, ball bearings, scrap metal, marbles, glass and anything else that might cause some damage. When the explosive detonates, it sends a spray of these lethal missiles into anyone unlucky enough to be nearby, soldier, civilian, or child. In suicide bombings, parts of the suicide bomber can become projectiles. I've removed bits of exploded suicide bomber arm and leg bone from the wounds of those injured in an attack. I’ve met an Israeli surgeon who removed a suicide bomber's tooth from the neck of a young lady. He also has seen cases where the bomber’s hepatitis or HIV infection was transmitted to a victim. They are a crude but devastating tool of violence.

So now I wipe the blood from my sneakers, breath deeply a lungful of Balad dust and eau de burn pit, and leave the hospital to work out. I think I'll go to the recreation center to see the salsa lessons. Maybe that will distract me enough so I can just keep swimming, just keep swimming. I hope I haven't annoyed you with my chatter.