31 December 2007


Smokin <<Smokin.jpg>>

It all checks out

It all checks out
<<It all checks out.jpg>>

Securing the gibs

30 December 2007

30 DEC 2007 So many holes

30 DEC 2007 So many holes

Today was pleasant and calm. I biked to the hospital under a steely grey sky. My little friend with the back burn was scheduled for a check of her dressing. To avoid any pain, she was given a sedative that relaxed her and prevented her from remembering any of the procedure. I removed her dressings and took out all the steel staples holding the artificial skin to her back. The wound had dried up well and the artificial skin was sticking like shrink wrap. Even the deeper burn on her hand was starting to look cleaner. Her father has been doing a good job keeping the burn clean, though she protests loudly every time her hand iswashed.

After dressing the wounds on her back and hand, we turned our attention to her face. The burns there were very mild, but had some scabs that were peeling off and sticking to her long fine hair. She hadn't been able to to bathe because I kept the dressing on her back for a few days. her hair was dirty and tangled. After scrubbing the burns on her face to remove the yellow scabs, the nurses helped me wash her hair. I only have sons, and don't know a thing about taking care of little girls' hair. I learned that a brush is better than a comb for getting out tangles. We were able to give her a good shampoo with the medical soap. After de-tangling her hair, we used some kiwi lime conditioner to repair the breaks and split ends and give her hair a luminous bounce. After a good rinse, one of the nurses braided her hair and we wrapped her head in a towel to dry. I swear, Jack Twist, it seemed more like a salon than an operating room this morning.

I found the father of the girl surrounded by other Iraqi men, talking on the ward. I brought him to his daughter. I learned that this man works as a (redacted) in the (redacted.) He spoke excellent English and after I assured him that his daughter had fared well in surgery, we discussed other common issues. As they live close by, I should be able to send her home for the rest of her recovery nestled in the heart of her family, returning occasionally for clinic visits. I'm optimistic that the scars will be reasonable.

After this I wandered around the hospital, an idle soul. Up on the roof I found OR Nurse R. and Vascular Surgeon M. working on OR#5. I joined in to lend a hand and all my cares just drifted right into space. I drilled hole after hole and it was a very satisfying release. I was smart enough to wear my safety goggles. No one wants a pediatric surgeon who looks like a pirate. The wiring is coming along nicely for a TV, refrigerator, ceiling fans, and music system. What a shame it will be to leave..............NOT!

In the afternoon I wandered back to the OR and found Urologist S. rebuilding a little boy's urinary tube. It had been injured when he was treated for shrapnel wounds this summer. For the past five months, he had been peeing through a tube that came out of his belly. After Urologist S. used a telescope and an x-ray to find the blocked area of his urinary tube, I acted as assistant while he and Urologist J. carefully removed the blockage and reconstructed the delicate tube. He will need time to heal, but it is great that there is the possibility that he may urinate the normal way in the future.

We definitely feel a decreased number of wounded coming to visit us, especially among US troops. Here's hoping that this good trend continues.

Be well,


29 December 2007

29 DEC 2007 No surprises

I was asked a few questions after my last posts, and I thought I'd share them here:

Q: Would you have any suggestions about what those of us who can't bring steaks to you could do to show our support and concern?

A: As for what to do for us, honestly, we do have every convenience we could ask for on this base. There are many organizations that help to get care packages and supplies to troops who are in rougher conditions than I am. As for me, simply an email of support and good wishes is enough to let me know that I am remembered and brighten my day a little! As an American, I think the best thing you can do for the troops is to honor them by exercising your freedoms, being sure that the no one, including our government, takes them away, and speaking up to make your opinion known to fellow citizens and leaders. Lastly, if you are so inclined, you could consider helping out with a very important cause: injured and disabled veterans. Fisher House Foundation ( http://www.fisherhouse.org ) gets an A rating as a charity because nearly 100% of their funds get put to use. It doesn't maintain a large balance of idle unspent funds and has an extremely low ratio of funds spent on fundraising.

Q: It's good that you were able to use the supplies meant for the boy - do you have enough supplies for all the burn victims? What would have happened to the girl if you didn't have the supplies left over from the boy? Just curious.

A: We do have enough supplies for burn victims. We are responsible for many US troops who are in the area, so we have to be sure that we have a stockpile ready for large numbers of casualties at any time. If any supplies get depleted, we have an incredibly strong supply chain that could replenish us in a short time. Burn care is very resource intensive, both emotionally and with regard to supplies. However, there are many, many ways to treat a burn, and in this situation it seemed like I would save this little girl some pain and suffering by using the artificial skin that we happened to have available. If it hadn't been there, we would have found a different way to care for her.

Q: We don't do burns where I am at so it's good to know about the artificial skin. Is it Alloderm or something else?

A: There is such a variety of products available for burns. I have used Alloderm (cell-reduced cadaver skin) in the past, but in this case I used Biobrane (collagen protein coated silicone/nylon mesh) to cover her burns. The burn is a multiple attack: there is the stress from the insult of the thermal trauma, there is the presence of dead tissue that needs removal, and then there is the breech in the skin's defenses against heat loss, moisture leakage, and infection. All of these problems must be dealt with. A skin replacement can temporarily do the jobs that the missing skin has left untended. The skin replacement will cover the bare area until new skin grows or is grafted in from another part of the body by a surgeon.

29 DEC 2007 No surprises

Today again started cold, but ended up a very mild afternoon. Much of the OR staff migrated to the roof to enjoy the sinking sun, have a drink, or puff on a cigar. The rooftop lounge is nearly complete and bears the initial coats of paint and varnish. We have been meaning to rig up a slingshot for some time. Today I tried to fashion one with a long elastic strip called an Esmarch's bandage. Freidrich von Esmarch designed it in the 19th century to help control blood loss during battlefield amputations. Fortunately, we haven't had to do an amputation for a few days, so I decided to put one to a different use in a purely scientific interest in ballistics. I was able to fling an orange, but no further than 40 feet or so because it kept rolling out of the strip of bandage when released. I'll have to add a pocket sling to the middle or switch to the traditional slingshot of two passes of surgical tubing. If I can get enough distance, I might even be able to hit my hooch from the hospital. This is what happens when a surgeon doesn't have a trauma victim on whom to operate. I'm thankful for these moments when we aren't seeing a tide of casualties roll in. I got to enjoy a good phone call with my parents.

The girl with the burns on her back is doing well. The nurses have done a wonderful job of teaching her father to change the dressing on her hand. She does wail so for that small dressing so I'm glad that the artificial skin on her back can sit there undisturbed for a while. I'm always so impressed when parents can participate in the care of their own children. I would be so timid if I had to use any of my skills on my own children. I just think that my worry would overcome my reason. M. would probably handle it much better than me! Once my son had a laceration on his ankle that I closed up with some butterfly strips. It was a little scratch, and he stayed so calm for me while I applied them. Still, I was anxious and relieved when it was over. It is just harder on my own child to distill off the worry and reach the calm place I need to do the best job.
About two weeks ago, I operated on a boy who had been injured by an explosion in his back yard. We had operated to remove his injured intestines, but as he healed he became blocked up by internal scars. His intestines have finally begun working again. He is able to eat and is making healthy bowel movements in his colostomy bag. Now that he can get good nutrition and hydration, he is up and about, behaving like a normal 12-year-old boy. He is kicking the butts of the translators and nurses on the Wii video game that is on the ward. Soon he should be able to return home to his family. It is such a relief to see the body's natural healing accelerate and take over all of the functions that it should.

I helped on one operation this morning. It turned out to be a surprise and exciting. If you are familiar with the inside of an operating room, you know that both of those terms are unwelcome. It is best when surgery is scheduled and boring. Boring surgery is good surgery. A man who had received shrapnel wounds to both his legs was going to the operating room to have his wounds washed out. Orthopedic PA J. asked me to take a look at his tracheostomy site, which was bleeding a little. Orthopedic Surgeon H. also said to stop by because the man just looked a little funny. He couldn't put his finger on it, but you have to learn to trust those instincts that something is wrong. It is like Spidey-sense. It starts tingling when something is askew, even before you can really identify it. I washed his trach site and we replaced the tube through his neck with a breathing tube through his mouth. I saw some signs of infection and cauterized a few spots that oozed, but thankfully there wasn't damage to the large vein that runs through that area.

I had finished my part and we were about to prepare the patient for the cleansing of his wounds when Anesthesiologist C. noticed that his heart rhythm wasn't normal. His heart rate had accelerated to faster than normal, and the electrical pattern was strained. Anesthesiologist C. gave him more oxygen, and I kept a finger on the pulse in his neck to see how well the heart was doing its job of pumping the blood around with the impediment of this abnormal rhythm. The pulse was fast, but present. We gave some medications to stabilize the electrical activity of the heart, and prepared for any emergency. As we waited, I noticed that the pulse weakened, became irregular, and then disappeared altogether. I started compressing the man's chest with the heels of my hands while Anesthesiologist C. timed breaths of oxygen-laden air. O.R. Nurse R. applied the electrical defibrillator paddles to the man's chest and shocked him after ensuring that all staff had dropped contact with the table to avoid being zapped. His arms jerked forward. His heart took on a new rhythm of disorganized flopping of the heart muscle. We gave doses of emergency medications to try and ameliorate any mineral deficiencies and continued the CPR. Again we shocked him at a higher energy level and his heart rhythm abruptly reverted to a quick but normal pattern of pumping. I felt his neck and found a bounding pulse. We got some blood tests, and abandoned the operation to return the man to the intensive care unit. I'm sure this little episode has thrown the man's system for a loop. But since he has survived, now we have the luxury of methodically discovering why it happened and making sure that it doesn't happen again. I'm so lucky that I get to be part of this expert team. Everyone moved together on instinct like a finely-meshed machine. I'm sure that this man is still alive because of their smooth expertise.

As usual, my thoughts often turn to the next meal. It is the fortune of our little band to ring in the New Year together here in Balad. Last night, two little piggies arrived from Germany. They will be roasting on a spit behind our hospital as the clock chimes midnight. We ran into some trouble when one of the aircrews refused to fly a pig to a Muslim country. We had to gently remind them that our DFACs on base serve bacon, sausage, ham, pork chops, deviled ham, pork tenderloin, chopped pork, pork ribs, pork barbecue, and pork Mongolian barbecue, so it probably wouldn't make the sky fall. I've signed up for a watch to hand-crank the spit near the end of the 24 hour roasting because It is my suspicion that there will be some prime pig-pickin' to be had at that hour. A chef has to make sure and check the meal! Mmm.

Love life, be mello, and have fun!


28 December 2007

Cooks from the Valley

Cooks from the Valley, originally uploaded by ccoppola@pol.net.

Cooks from the Valley

28 DEC 2007 Sinking my teeth in

28 DEC 2007 Sinking my teeth in

I slept hard today. After morning clinical openers, I cleaned up a little business, changed back into DCU's and biked back to the hooch. It was so cold that my fingers hurt in the wind. By the time I got back to the hooch, they were cold and white. Guess it wasn't so silly after all for the military to send me here with big puffy gloves! Rather than cut through the barriers, hop the curb, then pop over the water supply hoses, I opted to take the long way around to the parking lot behind our housing pod. It was too cold to risk ditching my bike like I do some mornings. After being on call for a 24-hour shift, several bodily functions start to get a little finicky. My right eye starts to twitch. It makes me look like a maniac who is just barely holding back an outburst. It makes for great conversations with concerned parents. I actually appreciate those who ask so that I can reassure them that I'm not crazed. After a night on call, my body loses all ability to regulate temperature. I become like a poikilothermic lizard, normalizing temperature with the environment around me. Often post-call you can find me trudging around the hospital in long johns or with a wool blanket draped over my shoulders like Pancho Villa. And lastly, my balance can suffer a bit. This can add some much needed excitement to a boring bike ride out of the hospital compound.

Surprisingly, I know from numerous experiences that after being up all night, I am easily able to operate for another 12 hours straight. That's just what residency drills into you. Tires as you are, you focus on the red patch of flesh bounded by a blue square of sterile towels and do your job. It is a matter of focusing on the need at hand, and ignoring the external distractions as well as the internal distractions. I wouldn't continue to be a surgeon if I wasn't able to turn in the goods after a night awake.

There wasn't much surgery to do last night, but there were some patients to get admitted, herd through tests, and tuck away for the night. And of course midnight chow couldn't be neglected. I did have a chance to sleep for about two hours, but they were not well spent. Rather than sleep out in the open at the PLX, I opted for the surgeons' call room. Sleeping out in the open is convenient. If the ER or ward staff has a question, they just nudge you awake, you answer the question, and you get back to sleep without even moving more than eyelids and mouth. But it does have it's disadvantages. The PLX couch is bound in non-breathable pleather so you usually wake up stuck to it with a layer of sweat. Also it has a few crossmembers that can bite into the spine. The distance between the armrests is slightly smaller than my six-foot height, so I have to curl up a little to fit. The other option is to put my head up on the armrest, but that gaurantees a crick in the neck for later. Lastly, since the PLX is a high traffic open area, there is the risk of a public display of snoring, pants handwarming, or morning wood if I should happen to sleep that deeply. Friend are always happy to record the moment with some candid photography. Fortunately any shame or modesty I used to have atrophied long ago.

Probably for the heat and the dark, I chose the call room last night, and made the best of it. I failed to get restful sleep and woke from my two hour nap with an awful headache. Unfortunately the drains in the call room bathroom were emiting a foul miasma of sewer gas that was slowly asphyxiating me. I'm sure I lost some more of the precious few viable brain cells I have left. Through some feat of plumbing incompetence, our drains cannot maintain adequate water in the stink traps, so whatever waste we send downstream continues to send us vapors to maintain itself in our memories. I'd even rank it a notch worse than the burn pit odor. Worst part is, I'm sure that smell impregnates itself into my clothing and hair the way the formaldehyde would mark me as unclean during my gross anatomy classes back in medical school.

So back in the hooch, I awoke after a comatose nap. I was very thankful for my handy-dandy combination air conditioner and heater unit through the wall of my little half-trailer. It blew away like a hair dryer, blasting my cave with a dry warm breeze. I awoke to find that it was the afternoon. There was the faint aroma of good food wafting in on the heated wind. I showered, donned my PTU's and biked back to the hospital. There I found that a little crew had come from California to brighten our evening with a steak dinner. They were the Cooks from the Valley from Bakersfield California, and they had brought 500 steaks to the hospital for us. they had a long half-barrel barbecue blazing, and the succulent dead cow flesh was sizzling and spitting on the grate. In addition to the hospital patients and staff, we had invited the many troops on base who would give up their off-duty free time to volunteer at the hospital loading and unloading the injured from the dustoff Blackhawks that land on our helipad. It was the best meal I had eaten in months! The fat juicy steak on my plate was kept company by a big baked potato with sour cream and butter, baked beans and a salad. I spoke with the chef who told me that their restaurant had gone to many bases in the US and abroad to feed the troops a special meal. They had even been to Guantanamo, Cuba. They were just fellow citizens who wanted to show the troops that they were remembered and appreciated. Speaking for this one individual well-fed troop here, I can tell you that they succeeded.

We have a friendly little visitor to our hospital that I admitted last night. She is a seven-year-old girl, and a helicopter brought her from another military hospital in the country last night. A friend of mine, Pediatric Pulmonologist A. contacted me last week about her from his base. Three years ago, she had been shot in the neck when she got caught in the cross fire. The bulled lodged near her spine and caused an abnormal connection between the artery and vein in her neck. It creates a constant buzzing vibration in her neck and sometimes aches. Her hands tire easily and there is the chance that this blood vessel could create a blood clot in her neck. For three years, her father has gone from hospital to hospital looking for help. I told my friend that he could send the girl to us and we would try to help. She has a beautiful smiling face, dark eyes, and long curly black hair. She sat calmly and sweetly while we examined her and started an IV catheter in her arm. Her father is a friendly man and speaks near-perfect English. He told me that he had studied in a sports college in Baghdad before the war. He had majored in futbol until he hurt his knee, then he switched to volleyball because he didn't have to cover as much distance. After the war he has worked guarding the border. Whenever he wasn't working, he searched for someone to help his daughter. He has an amazing thick black walrus moustache of which I was very envious!

His daughter had a complicated abnormality of her artery. It is very close to her brain, and I don't know if we are going to be able to do anything for her. I was very fortunate to have the good help of Vascular Surgeon M. Over the past few months I have come to know regard him as one of the most skillful people I know with delicate care of blood vessel illnesses. He is doing everything he can to try and come up with a plan to help this girl. If there is a way to do it, I know he will find it.

It seems that I escaped major punishment even though I tempted the fates by calling the shift last night quiet. It is such good news to see statistics that violence is decreasing in Iraq. I hope that this is a sign that a combination of our policy and efforts on the part of concerned citizens across Iraq refusing to allow troublemakers to maim and kill are starting to make a difference. How good it would be to have our little hospital become obsolete. I can only wish for such a feat.
Be well. Don't worry about us, we'll keep working hard, and at least for the moment we have a good dinner in our bellies!


27 December 2007

Hi Friends.

It has been a quiet call night so far. Any of you in medicine know that we are afraid of using the all-destructive "Q" word. Any mention of the fact that there hasn't been a deluge of new patients is simply inviting the trauma gods to instantly send a busload of cracked up hemophiliacs your way. So I have thrown all caution to the wind by starting this letter with a sentence containing the word quiet.

This morning, I operated on the girl who had been scalded on Christmas Day. She certainly wasn't the first burn I had seen, and I have seen this pattern of burn hundreds of times back in the US. Her father told us that she had been in the kitchen when it happened. Many of the homes around our base are one or two room dwellings. There is a common room where the cooking is done. Often the stove is unprotected, and some even cook indoors over a small fire. The family had a small stove, and there was a kettle of burning water on it. The little girl, backed into the stove, and knocked the kettle onto herself.

Her burns weren't deep, but I am sure that they felt raw. It's a fact that full-thickness burns, that kill the skin all the way through to the fat, hurt less in the beginning because the pain nerves have been destroyed. A partial thickness burn stings, because the nerves are still alive. When she arrived, she was cleaned in the ER with a little bit of sedative to calm her.

I arrived this morning just before the first cases in the OR were about to start. I saw the girl's number on the schedule. Our trauma czar had visited her the night before. She was having a lot of pain whenever the nurses cleaned her wounds, and he wanted her to have her burns cleaned in the operating room. That way, she could be knocked out and not feel it at all. The anesthetist brought the girl to the room and medicated her. After her breathing was regulated and she lay still, we removed all of her dressings. I took several of the stiff brushes that we use to clean our hands before surgery, and soaked them in warm water. We each took an area, and began scrubbing her burns. The bristles removed the thin yellow slime that had started to develop over her burns. After that was gone, we scrubbed deeper, bringing small pinpoints of blood to the injured skin. This rough treatment was to be sure that the skin was alive and also to remove any dead material that bacteria could feast on. It made me cringe to imagine how it would have felt if she was awake. When her shoulders were done, we turned her over on her stomach and cleaned the burn on her back the same way.

After washing and drying her skin, I applied a temporary artificial skin over her burns. I had ordered it a month ago for a burned boy who had died. We all had struggled to keep him alive. His infection became too much and had spread through his body. He was too far gone to benefit from the high-tech artificial skin, but it would help this girl. I stapled it in place and wrapped her body in gauze. After the gauze covered her chest and arms like a mummy, I stretched an elastic netting over her torso to hold the wappings on. Then we let her wake up. She showed us she was alive with a strong yell. We gave her some pain medicine, but what she was really yelling for was her Dad. We reunited them in the intensive care unit, and she calmed some. The best part about the artificial skin is that it will stay on her for a week or two. We don't have to subject her to painful dressing changes and washings every day.

The other surgeons and I loitered around the PLX, like firemen waiting for a fire. As my day to go home to M. glimmers like a star low on the horizon, I am getting antsy to leave. I think that I'm a little more touchy than usual. It was tougher today to control my outbursts on my political opinions and frustrations with the slow pace of progress. I wasn't alone in harboring a strong opinion. Like sharks to chum, my surgeon friends all chimed into the discussion with opinions that covered the full spectrum. If only we were Congress, the war would have been solved today!

As the evening wore on, we received a few patients from other bases. Two men came to us who had sustained sports injuries bad enough for them to need evacuation out of the country. Amazing! Both were in some discomfort. We medicated them to ease their pain, and got them ready for the next flight out.

Hope to talk to you again soon!


26 December 2007

26 DEC 2007 Tween Calls

26 DEC 2007 Tween Calls

Yesterday I was backup call (and did nearly nothing, shhhhh!) Tomorrow I have my 24 hour shift on duty in the hospital. Today was calm. I started the day by putting a feeding tube in a baby who had been shot in the head. He has been in our hospital almost a week. The day he arrived, Neurosurgeon M. removed part of his skull and controlled the bleeding in his brain. He removed the bullet. He washed the brain gently. He reattached the panel of skull he had removed with short braces and screws. He left a tube in the brain to drain excess fluid and measure the pressure. That makes it sound like mechanic's work. It actually sounds more mechanical than what I do, and he's a brain surgeon! It may be fluids and screws, but yes, it is brain surgery. It's amazing what they do. The baby has survived this week, but still is deeply sedated. He's not quite in a coma, because when his sedation is lightened, he becomes upset and moves around in a disoriented fashion. This is good, because it means that part of his brain is alive. This is bad, because the agitation makes the pressure in his brain rise to a dangerous level. Time and gentle nursing is what he needs most.

A few days ago I put a breathing tube through the front of his windpipe. That day he was swollen tight and shiny. Today I was happy to see that he had regained some of his babyish features. His is such a sweet face. Little mouth and nose resting under long dark curly eyelashes. He will look a lot better running around than he will motionless in a hospital crib, sprouting tubes from every orifice.

In the OR, I made a cut in his belly, found the stomach, and sewed in a soft rubber tube. He will receive his food this way until he is awake enough to use his mouth to eat. Back home I use a tube the size of a pencil, but today I put a tube the size of my thumb into this baby's belly. It is hard to get the medical nutrition formulas here in Iraq. We give the families a supply when they leave our hospital, but once that is gone, it's gone! They have to blend food and force it through the tube with a syringe. A common combination that delivers great protein is egg, honey, and milk. Early on, we used our usual petite tubes, and they quickly clogged when the patients left the hospital. A clogged tube is a useless tube. It is no better than a handle. We learned to use the biggest tubes available so that they would stay open long time.

I worry for this boy. Of course it is my most earnest hope that the pressure in his brain stabilizes and he begins to cry and play like he should. But my visions of his future are darkened by paranoid thoughts of paralysis, brain damage, and pneumonia. I don't know the future so all we can do is carry on and hope for the best. I hope that I am being my usual pessimist self.

The operation went smoothly. Instead of the usual Balad closure of a row of steel staples resembling railroad ties, I closed his skin with delicate transparent thread that will dissolve in two weeks and a thin layer of surgical superglue. He won't need to have any staples removed or any bandages stripped off. It was probably a meaningless gesture, but it gave me comfort to remove one tiny discomfort from his future, and also gave me a transient flash of my usual techniques back home. My mother sent me a card that read "We give comfort, and receive comfort...sometimes at the same time." Story of my life. In fact, I think I have received far more in my meager service of the ill than I could return if I had several lifetimes.

After surgery, I accomplished yet another check box on my out-processing checklist! What an accomplishment for the day! Redeployment is a still (redacted) off, but we have to start early on our checklists! And to think, it feels like I just completed my in-processing checklist! Come to think of it, I'm not absolutely for positive that I actually completed every item on my pre-deployment checklist. What me worry, I seem to have gotten here okay. Shall I share one of the items on my out-processing checklist? Well if the mundane hasn't scared you off yet, this won't either! I was checked off by the library as not having any overdue materials. Since I had never been to the library before, it took me a while to find it before I could get my proof that I wasn't hoarding items from a library I had never visited. Ditto for the Supply Department and the Vehicle Maintenance Center. I was being signed off as having no maintenance deficits on a vehicle that I did not have. Did that mean that I had missed the chance to have a vehicle? I'm going to be pretty pissed if I could have been tooling around base with GI Joe and Combat Barbie in my very own Jeep all this time! Here is the item I want to check off: hauling my sorry carcass onto that plane about to taxi down the flight line. Done and Done!

Being 'tween calls, is a precarious predicament. You want to do something, so you don't feel like you have no life outside the hospital, but you don't want to push it too hard or you will be dragging keyster on call the next day. Back in residency, I was scheduled to be on call every other night for a majority of the nine years I trained. If you waited for a break in the action, you would never ever have a fun night. My usual choice was to stay up too late and reanimate my zombie corpse with beau coup coffee the next morning. So today I went and worked out, picked up clean laundry, dropped off a package at the post office, checked the shelves at the PX to make sure the same old scheiss was there, and biked around base. What a wild and crazy guy, no!? When I ran out of exciting errands, I returned to the hospital like a moth to the flame.

A seven-year-old girl had fallen off a roof. She fell nine feet and passed out for half an hour. Her uncle brought her to the gate. I don't know why her parents didn't bring her. Maybe they are dead. I hope not. Her uncle hadn't seen her fall and didn't know for sure what had happened. She was screaming her head off. This was a good sound. There is no sound more beautiful than someone else's child screaming. You need oxygen in your lungs to scream. She was pissed off that we had a collar around her neck to protect it. You need oxygen in your brain to be pissed off. She had a black eye, and just as this predicted, she had a mild fracture of her skull. In addition to the lungs and vocal cords, it seemed that everything else was working too. This was very reassuring. This was the kind of trauma that we didn't even need to go to war to see. And best of all, there didn't seem to be any serious damage. Neurosurgeon M. and Ophthalmologist J. didn't think she would need any surgery; only ice and Tylenol. It was a relief to us all. Eventually we got her settled close to her uncle and she was able to calm down.

I had seen this injury before. Years ago, one of my fraternity brothers suffered something similar when he was demonstrating the forward flip he could do off the front hall stairwell. He did it, but the slate floor in the foyer seemed to win. He went on to graduate college, if that is any measure of brain function. In addition to the ice and Tylenol, he needed to sober up, but he was going to do that with or without a head injury. At least for a little while. How similar are the inebriated and children! Both share poor judgement, top heavy gait disturbance, and annoying noises. It is like alcohol is a temporary fountain of youth! Even though my nights with heavy drinking buddies are largely over, I get to relive those days through my children!

But to move on, we are in a war, and head bonks aren't the only trauma we see. Late in the day on Christmas, a woman and child were brought to our hospital. They were taken from a car stopped by coalition forces. The driver of the car had given chase, and when the car was disabled, fled on foot. As the coalition forces closed in, the primary target detonated a suicide device he was wearing. The woman and child were brought to us. The woman will be detained elsewhere after her limb injury is treated. The child is uninjured. I don't know where he will go.

I wonder, will I see worse tomorrow? I've given up believing that I can't.


Christmas Dinner on the roof

Christmas Dinner on the roof <>

Lance, Kid, Robin, Miss, and Lewis

Lance, Kid, Robin, Miss, and Lewis <>

Santa visits the hospital

Santa visits the hospital <>

25 December 2007

25 DEC 2007 Bahu dores

25 DEC 2007 Bahu dores

Christmas in Iraq came bright and clear. I'm back on my bike after a short break and trucked in today. Like a bad, bad safety pup I forgot my helmet, but wore my green tuke (The PX was all out of regulation black). The morning started full of cheer. I wrote a letter to my sister, and that made me think how lucky I was to have such wonderful people in my life. I had been so cynical and disappointed about spending Christmas here that when the day actually arrived, it felt far better than I had imagined.

There were several maintenance operations to do, so I signed on for two. After changing into scrubs, I played Santa's elf. A friend's wife had sent me his gift in the mail a few weeks ago, so I placed it in his stocking, and asked the chief of the OR to direct him to the stocking when he came in. After my improvised Christmas device had been set, I hit OR 4 to wash out burns and shrapnel wounds on all five of a man's extremities. Once his wounds were dressed, I switched to OR 1 where Colorectal Surgeon J. and I reconnected a man's intestines then washed the stumps where his legs used to be. Every time we moved him, we found more wounds so I ended up stripping burned skin off his back, cleaning the wound over a broken bone on his right arm, and washing a small puncture on his right. He did well.

After surgery, I found that my elf efforts had paid off, and my buddy was quite surprised. It was good to be a part of that. It helped make the day seem a little like Christmas.

We had another football tournement on the helipad, but by the time I got out of the OR, the surgeon team had already been double eliminated! Besides some lost skin and an Achilles strain, there wasn't too much damage. We all loaded up at the DFAC and headed to the rooftop lounge to enjoy Christmas dinner together. The day had started around 40deg but the direct sun made it much warmer on the roof at noon. We sat at picnic tables and reclined on the chaise lounges. The new OR5 on the roof even has a breakfast nook!

The beef here has broken my heart time and time again, so I thought I would never risk my emotions anew. However, the prime rib looked so tender and succulent, that I decided to be a cockeyed optimist and throw caution to the wind. Boy was I happy I had. The Balad roast beast was the best I had ever tasted here, and only about one third gristle. I've looked at prime rib from both sides now. The tiny shrimps in the shrimp cocktail were a nice touch. They made me think of finishing shrimp leftovers from the big Christmas Eve seafood dinner back home. We laughed at movie quotes and some bedded down their meals with a cigar. A thin column of black smoke rose straight up from the burn pit in the clear still air and didn't molest us. We were well fed and in good company.

I got to catch a movie with Nurse R. He and I went to see Beowulf with digital Angelina Jolie. She was just like a Barbie Doll, but evil. Is that redundant? We laughed that we would remember Christmas 2007 by that movie. Amazingly, the tales of his Italian Christmas dinners back in Pittsburgh actually outdid mine. When he described how he and his father would make their own sausage, I hailed his victory.

Back at the hospital, two children presented to the ER. One had shrapnel wounds to his head and bleeding in his brain. He was hustled off to the OR for a marathon with the neurosurgeons, ophthalmalogists, and craniofacial surgeons. Another girl came to the gate after a kettle of boiling water spilled down her back and arms. She screamed as we held her down to start an IV catheter and scrubbed off the yellow sagging blisters of burned skin. I swirled a bottle of water outside the OR and watched my Christmas cheer dissolve.

I got to wish M. and the boys a Merry Christmas. They were very good and let her sleep all the way until 0700! I got to hear the tale of each gift opened and how many parts they had put together. The dog threw up on the floor. I could close my eyes and I was there. But only until I hung up the phone. At least I didn't have to clean up after the dog! I'll be happy when I do.

Merry Christmas, Enjoy the ones you love.

24 December 2007

Airman's Memorial to fallen members of the 332 AEW Tuskegee Airmen (detail)

Airman's Memorial to fallen members of the 332 AEW Tuskegee Airmen
(detail) <>

The Airman's Memorial to fallen members of the 332 AEW Tuskegee Airmen

The Airman's Memorial to fallen members of the 332 AEW Tuskegee Airmen

23 December 2007

24 DEC 2007 Santa is cleared for landing

24 DEC 2007 Santa, you are cleared for landing

There are may tiny cultural differences that remind us that even though we are essentially the same, we become the products of our own society's mannerisms. Beyond language and gesture, there are the little nuances like how close to stand to each other and how long to make eye contact. Our new indoor hospital, (to differentiate it from the old tent hospital) was built by a contractor that uses Turkish labor as well as machinery and resources brought in from Turkey. In addition to the contract to build the place, they also are charged with maintaining and cleaning the structure. There is a good bustle of activity in recent weeks because they are laboriously adding a structural security feature which is a (redacted.) This is a bit awkward, because the hospital is already built and in use.The current construction involves breaking down certain parts and working around the beehive of activity in what is probably the most busy trauma-only hospital in the world. From time to time, we have to shut down sections of the hospital or go without running water. All told, it is far less interruption in essential infrastructure than most Iraqis have to put up with. Our power source is nearly continuous, and we have loads of bottled water for the times that the tap is turned off.

The Turks who clean the hospital are very friendly. They use very little English, but are quick to give a warm salutation. They will occasionally comment on an interesting poster or scrub top, but mostly keep to themselves, socially. They are remarkably adamant about completing their cleaning duties. If you are using a computer to enter patient notes, and they are cleaning the room, they will roust you from your seat to clean under the desk. They won't take no for an answer. Even if you stand your ground and refuse to move, they will meticulously clean every available space around your feet and the base of the chair. They work the mop between the legs of the chair and between your boots. In our changing room, they asked us to keep our boots off the floor. Each day they would pile them into boxes on top of the benches. We would have to sort through the boxes of nearly identical boots to find a good match. When that didn't deter us from leaving our boots under the lockers, they hid some of the boots on top of the lockers or behind the laundry basket. Once Laparoscopic Surgeon S.'s boots were even found marked with a big black capital T on the to of each boot! It has proved costly to keep boots on the ground.They are in for a nasty surprise when the mud comes.

Our DFAC is staffed by very friendly workers contracted by KBR from India, Indonesia, and other places. They smile broadly as they scoop brown stuff on rice into our plates. They never mind if we want an extra helping of wings. The other day as my eye traveled down the cafeteria line, it was arrested by the sight of circular pads fried in a crispy batter.

I asked if they were eggplant.
"No." came the answer.
"Well what are they?" I inquired.
"Chicken." I was told with a smile.
Sure, a little chicken patty sounded good, so I took the plunge.

From the first bite, I knew something was rotten in Denmark. This was too soft and grey to be chicken. I sliced the patty in half, expecting to find the answer. However, the dull granular cut surface of the mystery foodstuff didn't betray its secrets. I delved further and peeled off the batter. There I found the offensive surface of one of yesterday's hamburger patties, complete with grill marks. I had been stuck with a refurbished dinner. In spite of the $36 per meal fee our government is paying, they had been forced to recycle patties, and hide their shame in a crispy coating of fried bread crumbs and oil. I had been bamboozled! They moved the headstones, but they didn't move the bodies!

That dinner turned out to be soup and salad night for me.

Our part-time contractor, and sometimes Vascular Surgeon, M. has gotten the new rooftop lounge "OR #5" wired with electricity. Tonight it will be lit with strings of over sized multicolored Christmas lights, signalling Santa in for a landing on the helipad. I hope that we have been nice! It's hard to get naughty when your sweetie is so far away.

Be well, and a peaceful Christmas Eve to you all.

Your friend,


23 DEC 2007 B.A.D.A.S.S. cap

This will have to be my Christmas Card this year since I'm flying solo over here. Maybe I can photoshop the family in. Here is our operating room Christmas tree, and I'm sporting my B.A.D.A.S.S. (Balad Association of Doctors, Anaconda Surgical Society) cap.

Merry Christmas and Happy New Year!
Mahalo to friends for visiting!

22 December 2007

22 DEC 2007 Rollin' with the homies

22 DEC 2007 Rollin' with my homies

It's amazing how I get to meet shot up Iraqis from all walks of life here in the hospital. Today I treated a 30-year-old man who is a soldier and a seven-year-old boy who just plays. Both got shot.
The soldier was in our local province. He took some small arms fire and felt a burning pain across his chest for a moment. He had some blood on his uniform and could tell he was shot. He put on a bandage and hopped a ride with one of his buddies into a base. When they peeled off his uniform, he had a hole in his chest that went from his neck to the top of his shoulder. You could have fit a Subway 12-incher in there. His ribcage was still there, but his right collarbone was shattered. Shiny white pieces of it poked out of the wound like dinosaur bones at Peabody Museum. He was pretty comfortable, just didn't want to use his right arm. I was impressed. We got some tests, and then operated on him to remove shards of bone and dead muscle. He was very calm and thankful as he woke up after surgery. He, Translator A., and I had a very nice conversation. Almost as if we had just finished an elective operation he had requested. In two days I will close his wound. Even though his arm will be in a sling for a couple of months, he should get everything back. A few inches to the right, I never would have met him.

The boy was playing with friends. They heard gunfire afar off. the boy suddenly fell. His playmates ran for help. When the adults arrived, he was on the ground. There was no one with a gun to be seen. He was in an Iraqi hospital for two days. His uncle came with him to our hospital. He told us that today that Americans had said that he would be better off at the American hospital. So they came to see us. The boy was confused and thrashed about. Our neurosurgeon removed the bullet from his brain. I hope he will live. If he survived for two days with a bullet in his brain, I can imagine that he is rather tough!

The boy who was shot two days ago is hanging in there. Today I operated on him to put a breathing tube in his throat. He was all puffed up from his head to his hips. It is odd how extremely sick people seem to look more alike than they do their kin. His swollen skin was shiny, and his tongue protruded from between his teeth. His short neck was spongy with fluid and his chin almost touched his chest. He had lost all of the curves and features in his face. Still, when I prepared him for surgery, he fought me with his hands until the medicine took effect. I liked seeing that sign of life. You have to be alive to be pissed off. I hope he hangs in there.
The injured soldiers left. The seriously injured ones including the troop with the self-inflicted injury were evacuated out of the country. As I was entering the hospital yesterday, two young soldiers saluted me. I recognized at once that they were two of the men who had been involved in the suicide bomber attack. They were looking strong. They had lost a leader in the attack. I thanked them for their hard work and asked them if they were feeling well. The were calm and answered to the affirmative, but their expressions were non-committal. Imagine that, going back to war and they were the lucky ones.
I do wish that the self-injurious troop gets good help. This war is a grinder, and some nuts get torn up in it. How bleak it must be to get so lost that the only choice seems to be to hurt yourself. We have to look out for each other. I'm sure the troop's battle buddy is wondering if there was something that could have done to have prevented this. We have a far less stressful job here in the hospital. Still, it has made me look around at my friends and wonder if I have been doing my duty well enough to look out for them. We came together, we're going home together.
It has been hectic, but from time to time there is a break in the clouds and a ray of sunshine beams through. Be well, dear ones. I can't wait to get home to you.

20 December 2007

21 DEC 2007 Suicide Bombing

21 DEC 2007 Suicide Bombing

It’s a little after midnight, and I’m spent. I’ve operated for about 18 hours today. We had a sudden rush of patients after a suicide bombing in a city near us. http://www.abcnews.go.com/International/wireStory?id=4032612 We received several injured US troops, and they had us busy in the OR for a while. I also helped put an IV in to a baby who had been shot in the head. How did it happen? All I was told was that it was an accident. There are no accidents. Another troop was treated for intentionally hurting himself. He said he only wounded himself because he couldn’t drum up the nerve to kill himself. He was waiting in line for the OR, surrounded by the other troops who had been wounded while patrolling. Later when he was tucked into the ward after surgery, the commander visited the other troops to give them their Purple Hearts. They all have a period of recovery ahead of them.

Earlier in the morning, today, there was a USO Christmas concert featuring Kid Rock, Robin Williams, Lance Armstrong, Miss USA Rachel Smith, Lewis Black, and others. The morning started out quite cold. I was wishing I had worn my gloves as I walked into the hospital. By the time the show started, the sun had taken a little of the chill out of the air. Unfortunately I missed the show because I was operating on the little boy who had to be brought back to our hospital after he had vomiting at home. As people heal, they form scare, inside and out. For him, his internal scars had caused a blockage of his intestine. We had to operate to release those scars so his intestines would work again.

A few of the surgeons made the show, and they said that it was a good time. They were surprised to see that Robin Williams joined Kid Rock for one of his encores to play the harmonica. This crew is doing eight shows in six days. They have quite a busy schedule. They got stuck on one base because of bad weather and had to sleep in barracks. All the men ended up in one tent while Miss USA had her own. Apparently Lance Armstrong related that Robin Williams and Kid Rock snore. Kid Rock retorted that Lance was flatulent in his sleep, but he expressed it in more colorful verbiage. They all agreed that Robin Williams was the hairiest man they had ever seen. They haven’t met my friend M. from back home!

I’m sorry that I missed the show, but I know I wouldn’t have enjoyed it knowing that the boy was waiting for his surgery. Some of the celebrity visitors to our base tour the hospital, but they were moving too fast today to stop. A few of the wounded soldiers who were well enough to make the trip were bussed to the stadium, so that was good.

Well, it’s nice to take a break, but that’s about all I’ve got. I think that some Pringles, Gatorade and more cowbell will be just the prescription I need. Take care, sleep tight.


19 December 2007

Our Santa on the roof of the hospital rides a hospital and is visible from space

Our Santa on the roof of the hospital rides a hospital and is visible
from space <>

Would you trust this doctor?

Would you trust this doctor? <>

18 December 2007

18 DEC 2007 Livin' FOBulous

18 DEC 2007 Livin’ FOBulous

Happy Birthday, M.!!! I love you. I wish I was there with you. Hopefully I get a chance to call later. I’ll try to call you later. Fortunately I realized that it was far too early to call, and didn’t mark your birthday by rousting you at the crack of dawn.

Today has been good. What a load of clean up operations we have to do from our surge of patients two days ago! Fortunately, after this round, most of them will be well enough to leave. The wounds from this war are usually high energy tissue damage. AK-47 and M-16 rounds enter the body through a small hole. When they leave the body, they blast out a large crater of tissue. As they travel through the body, it isn’t just the path of the bullet that is injured. There is a cone-shaped shock wave of damage that destroys flesh, even if the tissue isn’t blown away. We learned early that it is important to cut away a large diameter of tissue, otherwise gangrene sets into the dead tissue left behind. We almost never close wounds the day they were made. Instead, we bring patients back to the OR every other day and wash and trim their wounds. After a few trips, they are usually clean and healthy enough to be closed. Some have such huge holes in their body that we need skin grafts to cover the damage.

IED wounds are even worse. The fragments go everywhere. They drive in dirt, river pebbles, and bits of uniform. Even on the fourth or fifth washout we are still finding pockets of sand at the edges of the wound. It’s amazing that people survive it at all.

After helping with the maintenance operations, I attended clinic. The man with seventeen children had brought in his daughter. (Yes, since I had seen him last, one of his wives had delivered another one.) The child was doing wonderfully. She cried a little when I took out her staples, but we got through it together by counting staples. I can only count to ten in Arabic, so we had to start over before getting to eleven. Unfortunately, her father told us that her brother wasn’t doing as well. He was vomiting at home and couldn’t keep anything down. We sent him off to bring the boy back to the gate. Hopefully he gets back before it closes for the day.

I also saw two burned patients. One was the little boy who fell into the pot of boiling water in his kitchen. His chubby cheeks told of how well he had been eating. When I saw him last, six weeks ago, he still had many open spots on his burns that bled when the dressings were changed. This time his skin was completely healed over. The pigment was even starting to return to the areas that were burned and the sites of skin graft harvest. He walked upright and smiled. (Except, of course, he screamed like crazy when I was examining him. He screamed the entire time until his clothes were back on!) He even had a stylish new haircut. He wanted to see Doctor J., one of the nurses on the ward who took care of him during his long hospital stay. I carried him over on my shoulders. He was met with much cooing and cuddling. I don’t get that reception when I visit the ward alone. He asked if he could have a soccer ball, and people came out of the woodwork to give him balls and toys. He left with a bag full of three balls and two toy cars.

The third patient I saw was a little girl who was burned a year ago. She was playing with some children in the street. There was a bonfire. She got too close and her clothes caught on fire. No adults were around, so she ran all the way home with her clothes still burning. She stayed at our old tent hospital for three months. Her family member had been trying to get her in the gate to see us. Since the girl didn’t have an appointment, the family member had been frustrated. This person has been a valuable source of information to the quiet professionals who keep our part of the country safe. The information this person provides had produced many valuable leads. The quiet professionals personally escorted the two of them to our hospital. They asked me to please see her, as a favor to this person who had been so helpful in the fight. I examined her burns. She had been burned from the hips down. She had healed remarkably. The skin had been harvested from her belly, back, and buttocks to cover her burns. These sites were also healthy and supple. The family member asked me if she would always have the scars. I told her that she would, but that as long as she ran, played, and ate well, her legs would work. I told him that it had been my experience that usually burned children are better able to accept the appearance of their burn scars than their parents are. I told the family member that it was essential that the girl be encouraged fully participate in life. I hope this helped, but it will probably take time to prove to the family member that this little girl is able to overcome the history of her injury. I don’t ask parents to believe my prediction, it is fine for them to just wait and see, and believe me after it happens.

I’m still waiting for the boy to be readmitted to the hospital. Since he also had a bladder injury from the explosion in his back yard, Urologist S. will see him too. It is a comfort to know that I am surrounded by such highly skilled professionals, like Urologist S. I am so lucky to have the resources of a clean modern hospital and such dedicated fellow Airmen. I really am livin’ FOBulous in this bitch.

16 December 2007

17 DEC 2007 Feast or famine

17 DEC 2007 Feast or famine

A couple of days ago, we had some distinguished visitors. They were congressmen and governors, visiting from the US. Each had a tour of the hospital at some point on their agendas. Their visit occurred during a calm spell, so the hospital was pretty empty. Most of our patients were Iraqi. In fact, there was only one American patient, a man who was being treated for testicle pain. Through the day, each visitor touring the hospital would be paraded by this unlucky man. Of course every one of them had to ask the question. “What are you in for?” When the answer came, it was embarrassing for both parties. That poor troop will think twice about coming back to our hospital. He probably thinks that the government is keeping pretty close tabs on the budget for military medical care.

It is my turn as SOD today. It’s a Sunday, so I squeaked in an extra hour of sleep and got a good shower. We had the usual roster of maintenance operations to do: wash out abdomen, close wound, replace drain, etc… We were only on to the second case in each room when the fresh traumas came to the door.

“Trauma code in ER, times (redacted)” the announcement sounded overhead. Three waves of patients came at intervals of about 45 minutes. When they had all arrived, we had a healthy burden of patients, all fresh traumas from the field. They numbered in the double digits, but never to the point that we were overwhelmed and had to activate the Mass Casualty recall. Except for one US soldier who had been injured when a concrete block fell on his head, these individuals were all Iraqi Civilians from a nearby province. They had all been injured in the same village.

Our translators spoke for them. We removed tourniquets and examined wounds; we sent them for CT scans. One man was shot through his chest. Another had a broken bone on three of his four limbs. Another had holes in his colon and small bowel. Nearly all of them needed an operation. We worked together to find every last injury. They were sorted according to most life-threatening, and given an order in which to proceed to the operating room. We operated on three patients at once for about 18 hours straight. Everyone pitched in. There were strange parings. Neurosurgeons worked with orthopedic surgeons. Thoracic surgeons worked with urologists. When there were multiple limbs injured, we each took a limb and washed until all the wounds were cleaned and dressed.

One of our translators, N., used to travel with a unit that patrolled outside the wire. He said that Al Qaeda knew that it was outgunned by US forces, so they would adjust their tactics. They would not directly engage US troops. They would wait until soldiers had left an area, then attack anyone who was in the open, be they civilian or military. He said that Al Qaeda would attack with continuous small arms fire and grenades. It seemed that they were attacking in waves, with one wave reloading while another was emptying their magazines on full auto. He said that it was impossible for anyone to move while they were attacking. They didn’t care who they shot; men, women, and children were targeted equally. It was always hard to know when an attack was coming, because the Al Qaeda fighters wore the same garb as civilians. After the attack, those who were not neutralized would blend back into the population. I told him I was happy he was working in the hospital, and no longer going outside the wire.

The attack today that brought us so many patients was directed against a concerned citizens’ group. They had rejected Al Queda from their village. They said that Al Queda had been driven out of a neighboring area. As the Al Queda fighters fled, they entered the village. The people we were treating told the translators that the Al Queda fighters had opened fire on a crowded public area. There was no warning of the attack. They were shooting indiscriminately. The men told us that they hit adults and children. We did not receive any children at the hospital.  All the children shot in the village died on the scene.

After midnight, I received a few last patients. One was an Iraqi man who had fallen off his motorcycle. He didn’t know where he was and made some very confused comments. Some things are the same no matter where you go. Another was an Iraqi highway patrolman whose car was blown up. So we had CHiPs and Walker, Texas Ranger. The last operation I did for the night was to clean to wounds of a soldier injured by an IED. He had lost one of his legs and injured his testicles. Another hospital had operated on him, but he still had a lot of dead skin and muscle that needed to be removed. We dressed his wounds, and he is safely on his way to Germany.

14 December 2007

There are days when the world just doesn’t seem to work right. The little girl I was taking care of with the gunshot wound to the abdomen died this afternoon at 1700. I’m still at a loss to understand how she died, or even the fact that she is gone at all. She was improving. She made it through the night and was stronger when the morning came. I operated again and reconnected her intestines. I was able to close her belly and get her back to the ICU. I showed her mother the surgical wounds and explained what each tube was for. The girl was breathing well. When she heard her mother’s voice, she opened her eyes and seemed to recognize her. It was a big step forward to have her belly closed again. I allowed a glimmer of hope that she might soon be breathing on her own.

I returned to the OR to work on a middle-aged woman who has large wounds across her buttocks, abdomen, and back from gunshot wounds. She has been in the hospital a few weeks. It was amazing she was still alive with what she has gone through. She was injured at a security checkpoint. As she approached it, she didn’t stop at the no-fire line. When the guards fired a warning shot, she accelerated, and the soldiers fired to stop the car. It seemed like all of us had operated on her at some point during her stay. I trimmed dead tissue from her wounds and sewed her muscle back together.

Before I finished the operation, I was called emergently to the ICU. The little girl had lost her heart rate. None of the doctors or nurses could figure it out. As we gave her CPR, we checked her breathing tube, her intravenous catheters and her medications. We looked for bleeding and collapse of her lungs. For a time that seemed like an eternity, we tried every option we had to attempt to restart her heart. I didn’t want to give up. She wasn’t supposed to be dying. She had made it through the most dangerous period. This was such an unanticipated and tragic turn of events. Eventually, I had to stop our efforts and declare her dead. As I did the final examination to look for any residual sign of life, I looked at her swollen eyes and purple lips. The team around me was in shock, but I knew they were looking to me because she was my patient. There was nothing I could say to them, so I thanked them for doing everything they had done to help the girl.

Two translators were waiting with the girl’s mother in the boarders’ room. Translator N. told her the low news I carried while translator M. hugged the mother and let her cry on her shoulder.  Yesterday her husband died of gunshot wounds, and now I was telling her that her daughter was dead. The nurses and Colorectal Surgeon J. helped me clean the girl’s body, wrap her in a white sheet, and bring her to her mother to hold. I said my peace, answered her questions as best I could, and went back to the operating room.  I go on, but ask myself, how can I?

Later that night, I wait for the helicopters to liftoff the helipad. I cross the helipad and enter the compound of the old hospital. I pass by the ruins of the tents, just a few frames, canvas and sandbags. I climb to the roof of the old Swamp and gaze out over the wire. The lights of Balad blink in the distance as deuce and a half trucks drive by on Victory Loop. I let Iraq know what I think of it.

13 December 2007

13 DEC Early to rise

13 DEC Early to rise

I got enough rest yesterday in spits and spats. I snuck off for an afternoon nap. I racked in my hooch to the tunes from the Eric Clapton Crosswoods Festival. I returned to the hospital in the afternoon then headed back to the hooch around midnight. Just as I was opening my door, a formation of (redacted) Blackhawks and (redacted) Chinook helicopters flew overhead in a great hurry. They Chinooks really shake the joint as their double rotors beat out a deep bass tone that seems to be oozing up from the very earth.

I'm glad that I stole those extra hours of sleep because I was paged in emergently in the wee hours. When my pager went off, not only did I have the annoying daily disorientation of not knowing where I was, but I also didn't know if it was an emergent page or just the morning wakey wakey. Finally after fumbling in the dark I got the display to glow green and it showed me the code to proceed immediately to the ER.

I biked in wearing an assortment of PT gear and a sleep shirt, complete with helmet and reflective belt. I found Surgical Oncologist J. in the PLX waiting for me. He told me that he had called me in to take care of a three-year-old girl who had been shot in the belly. Her intestines were hanging out. The girl was one of (redacted) children who had been transported to our hospital. Some of our quiet professionals had raided the home of an insurgent in the city of (redacted). When the man shot at them, they returned fire. Unfortunately children in his home and a neighbor's home were wounded in the melee.

The child was waiting for me in the OR. We worked together for a few minutes to be sure we had the catheters we needed in veins, artery, and bladder. Each of us took a limb and hunted until we struck a vessel with a needle and were rewarded with a flash of red blood. Colorectal Surgeon J. and I opened her belly, removed the wounded, leaking pieces of intestine, and washed out the stool that had spilled around her internal organs. We left a large sterile dressing on her open belly and moved her to the ICU. Her mother squeezed my hand and held it to her face as she cried. She asked me if her only daughter would live. I could feel the warm moisture of her tears on the back of my hand. I told her I didn't know but I would try my best. I told one of my boys was about the same age. I took her to visit her daughter. She kissed her daughter's face before we had to take her away to the waiting area so the nurses could clean the child and arrange all of the tubes and wires she needed.

After we operated on all the children and dressed their wounds, we sat around drinking coffee and watching Arnold Schwarzenegger in "The Running Man." There had been an interruption of email contact. When it was reestablished this morning, a whole bunch of messages came in together. I read my emails while the movie played in the background. A short time into the movie, we were called back for fresh trauma victims in the ER. Men had been blown up by an IED. They had tourniquets on their limbs and there was strikethrough of blood on the many dressings wound around them. We prepared them for surgery.

Each new injured child I see seems to rip the scab off a wound in my heart that won't let me rest. Today a boy came to the gate of our base. His parents were seeking entrance so he could get medical care. He had been run over by a truck a couple of months ago. He had been treated at an Iraqi hospital in the city of (redacted). He had pins in his body to stabilize his broken bones, and a colostomy so he could poop into bag on the skin of his belly. Since the operation, he had withered to an emaciated shadow of the boy he had been. Open wounds festered on his back an heels. His parents had grown frustrated with the Iraqi health care system and wanted us to care for him. I turned him away. We exist to provide immediate care after a trauma. This poor boy was at the stage at which we would send him to an Iraqi hospital for his long recovery. There was nothing we could offer him. It felt like crap to turn his family away. It was a bad day to be a kid in Iraq.

Tomorrow I'll operate on the girl again. We'll get up like we do every morning, ready for the newly injured who make it to our door.


12 December 2007

12 DEC 2007 Trimming the trees

12 DEC 2007 Trimming the trees

Well it is another cool clear day in Balad. I wore my long johns under my uniform for the bike ride into work today. The hospital is warm and toasty. We control the temperature in the brick and mortar hospital so much better than we used to in the old tent hospital. This is the kind of day where I would have worn my watch cap and insulated sleep shirt all night long in the hospital. The sky is clear. The only break in the morning pinks and blues was the column of dingy gray smoke rising from the burn pit. The recently concluded environmental found that the burn pit is releasing dioxin into the air. Shame it is upwind from the hospital, but guess they just wanted the particles to act as an irritant to help my post op patients cough more vigorously and expand thier lungs after surgery.

Colorectal Surgeon J. gave a nice grand rounds presentation on rectal pain in the combat environment this morning. In my opinion, the whole deployment is one big pain in the rectum! I've really enjoyed operating with Colorectal Surgeon J. Since he focuses on one specific body part in his stateside mission, he has a high degree of expertise and has taught me a few new tricks in the operating room. He had a big finish with the "Ode to the Colorectal Surgeon"

The brother and sister recovering from shrapnel injuries have made the push and are ready to go home today. Their mother joined their father to bring them home. OB/GYN nurse C. toured the hospital with the girl in tow to say goodbye to everyone who helped take care of her. It may not have been as extravagant as the West Haven "Festival of Lights", but we entertained her briefly with a performance by all of the mechanical Christmas toys in the menagerie at the surgeon's desk. She had been a very worried little girl most of her stay, with furrowed brow and scowling eyes. Yesterday we got her to smile with a nice pink unicorn sent to me by my boy R.'s class. We got a good laugh or two out of her with the dancing musical toys. Just to avoid an international incident, we kept the marching mechanical pig that oinks jingle bells behind the desk.

OB/GYN nurse C. told me she was bringing the girl around because she thought it was so rewarding for the hospital staff to see a young patient recovered to health after surviving such a harrowing ordeal. Just that day she had performed an ultrasound on a woman who was in her middle trimester of pregnancy. It made her happy to see the healthy unborn baby, and it gave her a little flash of her job back home to help keep her going. Her mission in Balad is to care for the many postoperative patients who need numerous complicated wound treatments and medications. It can seem like a endless assembly line in that ward. New patients arrive from the intensive care unit and operating room as fast as others are shipped out in ambulances to the airfield or the gate.

The pregnant woman is being treated for cuts to her face and scrapes to her eye. Her daughter is still in the intensive care unite, on a ventilator. The girl had fragments and bleeding in her brain. She required an emergency operation to take off part of her skull and evacuate the blood clots and destroyed pieces of brain. When her sedating medication levels drop, she wiggles her hands and feet some. This gives us hope that her brain will work well enough for her to wake up. We shall see, but I never count a kid out, after having seen them come back from what I thought would be devastating injuries.

The pregnant woman's husband and son are still at (redacted) hospital. According to the last word we have received, they are alive. The story of how they were injured was very disappointing to me. About a week ago, I read that some Iraqi refugees in Syria were returning to Baghdad. There are abut 2.4 million Iraqis that have fled Iraq since the war began, and there are anywhere from 1-2.2 million that have fled their homes, but are still in the country. Since the surge in US troops, there has been a decrease in violence in Baghdad. On a local note, we have seen an increase in incidents in the (redacted) province, which feeds our hospital more directly, but we are pleased to see that the overall numbers of injured have steadily declined since summer. This decrease in violence has been great news to those who fled Baghdad to Syria, and many board busses for the trip back to Baghdad. The pregnant woman and her family were on one of those busses. Now I have to insert here that all the mysterious stories I hear about how injuries occurred outside my hospital are about as trustworthy as all of the "Sumdood jumped me" stories I hear back home. But the story she told was this. The bus approached a security checkpoint improperly and the guards opened fire with machine guns. What a shock it must have been to have finally gotten up the nerve to return home, then have the journey interrupted when they wrere nearly there.

Christmas approaches. I've seen all sorts of pieces of flair througout the hospital. Last night I went to the OR core to pick up some equipment. I found the night crew making Christmas hats with glue and glitter. I couldn't resist the temptation and stopped to make a B.A.D.A.S.S. Christmas cap with a big gold peace symbol. There are trees popping up all over the hospital. My boy R.'s class sent me a whole bunch of beautiful construction paper trees with shiny foil stars. They make the surgeon's desk look very festive. The treatment facility where my sister A. works got together and sent a boxful of decorations including oversize multi-colored Christmas lights. They are going to adorn the new rooftop lounge so we will be well visible from the dustoff landing pattern. It's going to look like Christmas in East Haven! As for Christmas dinner, I can only imagine what mass-produced freeze-dried concoction is ominously trucking it's way here on the road from Kuwait. Make mine Who-hash, please.

Peace and mistletoe,


10 December 2007

10 DEC Enough to eat

10 DEC Enough to eat

There are a few children who are side by side in our hospital ward. I think it is good that they have each other. It must be frightening being in a big hospital with lots of people who are bigger than you and don't speak your language. Add to that the pain and discomfort of recovering from surgery and it must be a terrible experience. It might take away a little of the terror to see that there are some other children around who are going through it too. Maybe if they see someone else getting better, they will be able believe that they can get better too.

We are treating one boy who was shot through the heart a few days ago. Kind of reminds you of the Bon Jovi song. Thoracic Surgeon J. did an amazing job repairing the two holes in his heart. After a few days in the ICU, he has grown strong enough to make it to the patient ward. He has had all of his tubes removed and is able to walk around. We are encouraging him to eat a little better so that he has enough protein to heal. His older brother, who is an adult, was also injured in the same suicide bomber attack. His older brother has been hanging out in front of the wide screen TV on the patient ward, watching movies. Translator N., a young man who goes around in distressed jeans and a Yankees hat, is our resident style advisor and picks out all the cool movies for the patients. They boy whose chest is healing asked us today why he couldn't hang out with his brother and watch TV. This sounded familiar! It's not fair! I want what my brother has! Of course we could move him into a chair by the TV. A friend from home sent some wonderful plush teddy bears that were perfect for cuddling. One of them had a heart sewn on his chest with broad stitches. It was perfect for the boy. I gave it to him and pointed to the stitching on the heart. He looked, then pointed to the incision healing on his own chest and took the bear with a smile. When I left the ward he was clutching the bear tightly to his chest as one of the nurses started a IV in his arm. With a little luck, both he and his brother should be ready to head home soon.

A boy we treated a few months ago for a gunshot wound to his aorta has come back. He was very seriously ill and we didn't think he would make it. He fought off infection after infection and went to the operating room for procedures more than ten times. Eventually he was well enough to head home. His mother took him home. Our translator M. tells us that the region of the country in which he lives has a reputation. The people there are proud to think of themselves as simple farmers. They do not value education so much as the ability to successfully farm the fields. They are also known to be quick to fight in defense of their opinion, right or wrong. This description reminds me of a few places in the US. Translator M. told me the story of one of his friends who was from that region. He was the only one in his family to go to college. Upon returning home, he saw his brother driving a truck of grapes to sell at the market. The two men recognized each other and stopped their vehicles to talk. The brother returning from college told his brother who farmed that the grapes looked excellent. He responded by thanking him and said that he was happy to see that he was home from school so he could help on the farm. They said goodbye, and as the farmer was climbing back in his truck, he noticed his brother taking some grapes to eat. He told him to put them back because they were the best grapes and they needed to stay on the top to make the produce look valuable. The student said that the least he could do was to give his brother returning home some of his delicious grapes. The argument elevated and the brothers ended up drawing guns and shooting each other. The student died.

The boy we are treating is one of six children. In addition to caring for her children, his mother works in the fields. When she brought the boy back to us, he had lost nearly 20 pounds and was skin over bones. He tried to eat, but would throw up what ever he put in his mouth. He told us that he didn't want to live because he would never be well enough to work. His mother said that she wanted her son to be well, but she understood her son's point of view. He is 11 years old. After a long time talking, they both agreed to come into the hospital to try. We admitted the boy to our hospital. After staying a few days, the mother returned home to care for her other children. She visits as often as she can. It is difficult to feed him. He has many internal scars so his digestion is poor. When we feed him with a tube, he cries piteously about the pain in his nose and pulls the tube out. An infection in his belly had eroded through the skin and some of the food he eats leaks out with his digestive juices. We try to feed him more, but then he leaks more. He won't heal the hole in his belly until he gets more nutrition. It is a tough predicament. He used to cry a lot when he was in a room of his own. Now that he is in the company of other children, he seems to show a little more interest in his world. It is frightening to look upon him and see the bones of his skull and each of his ribs starkly outlined under his paper-thin skin. I'm very worried for him and it will be a challenge to keep him from starving to death. We have to start first by helping him find the will to live, and I hope that the children around him will teach him that lesson better than we have been able.

Also on our ward are the two children who were injured when an explosive was detonated in their back yard. They are a brother and sister, and they are neck and neck in the race to see who gets better first. Each morning we round on first the girl and next the boy. Their father sits between them and smiles as he listens intently to our conversation and then turns to the translator. Each morning he thanks us in English. He seems so calm, but then again, he has 16 children so probably very little fazes him! Both children are taking small bites of food. So far I thin the sister is winning, but really likes to lay in bed all day so her brother may still have a shot.

Tonight has been calm so far. Two men came to us, both shot in the head. One lived and one didn't. After dinner I went with one of the quiet professionals to the range and shot at steel targets in the dark. How different their job is from mine. How similar is the feedback loop from eye to hand to target and back to eye. We'll both work hard at what we were trained to do.

Good night,


09 December 2007

9 DEC 2007 I'll wait to go home

9 DEC 2007 I'll wait to go home

Well it's evening. We've returned from family dinner. There was such total crap for dinner tonight. I'm sure the troops who are outside the wire would laugh to hear me complain. I expect that a hot dinner in a warm enclosed DFAC is a sight better than an MRE in a tent. But with that frame of reference aside, I am sick of every variety of gray meat and brown stuff on rice they have to offer here in Mortaritaville. The shaved beef raised the spirits with an appearance that deceptively promises the makings of a nice Philly cheese steak. Time and time again I have been fooled by this temptress only to have my heart broken again when I try to chew through an unpalatable mass of gristle that was discarded when they trimmed someone else's cut of meat. The fried cabbage hurt me enough at lunchtime that I wasn't ready for another round. Good thing I have a fan in my hooch. The prime rib was neither. I settled for a plate of potatoes and pasta. Up yours, Atkins, you carbastard! It turned out to be egg noodles with tomato soup. What they lacked in spices they compensated for by overcooking the noodles. Good thing we are paying KBR $36 a head for this fare.

The DFAC was not without a healthy dose of atmosphere. The line attendants all greeted us with friendly smiles. They were more than happy to scoop us massive servings of the hot food. I can complain about the quality, but how can I stay mad when they ladle on more than a bear could eat? And of course wartime dining wouldn't be complete without decorations. The Thanksgiving turkeys are down and the effigies of Christ carved out of vegetables have yet to go up, but there is an impressive model of the Taj Mahal. I think it might be a southwest Asian version of a gingerbread house. How long does it take to build a five foot tall model of the Taj Mahal? I'm not sure, but they probably let the pasta boil away to mush the whole time they were constructing it. I think the model might be edible. It is even wired with small colored lights. Does the real Taj Mahal have lights in the windows? I think that a few of the DFAC staff might possible live inside of it. I hope they don't serve it to us on Christmas.

So after a satisfying dinner which I followed with a dessert of complaining, I returned to the hospital with the crew to see what the helicopters had brought us. It was only the CSH run, transferring American patients from the hospital in (redacted) so they could be staged here for aeromedical evacuation out of the country. So I settled into the Wounded Warrior Lounge to use the computer.

My thoughts stray from my postprandial agita and self-pitying to two of my colleagues who headed home early from deployment. Both were members of the hospital staff. One suffered an injury. He was in incredible pain and had trouble walking. After examinations and x-rays, one of our specialists started him on medication. He continued to work through it all. Even though he couldn't take care of patients in his condition, he continued to fulfill his administrative duties and hammered out an incredible amount of paperwork that otherwise would have been sloughed off to someone else at the last minute. He was biding his time and waiting to get better because he didn't want to leave us a man short. I think that every one of us told him to pack up and get himself home before he was finally convinced to leave. I just didn't think that he would be able to recover here, especially not with the pace of work he was keeping. I know him well, and frankly it didn't surprise me to see him working so hard. He has an incredible work ethic and I don't think I've seen him complain once here or at our home station.

Another troop who left is someone whom I've gotten to know here for the first time. He has a great sense of humor and always has a positive attitude. He is one of the senior leaders in our hospital. Even when I'm in a particularly irritated mood he can usually get me to laugh. He received word that one of his loved ones would need to undergo treatment for a newly-diagnosed illness. He delegated his duties that he couldn't simply complete before leaving, and made the trip home to the person who needed him. To his expressed intention to return quickly to help us, we all told him to not come back. We certainly do benefit from his hard work here and need him in a generic sense, but it is so much more important that he go home and stay home. He is needed much more specifically there. I do miss him because he certainly lightened up the place a bit. I didn't get to give him my good wishes and encouragement before he left, but he and his family are in my thoughts. I sincerely hope that all is resolved safely and smoothly.

So it ain't so bad to be stuck here for the full deployment when you consider the greater scheme of things. I'll be very pleased to do my time and come home in good health to a family that is doing well. I wish the best for both of my friends who headed home early.

Love life and have fun,