Sunday, September 5, 2010

Home At Last

Chevy Chase, MD

I have now been home nearly two days.  It seems like a blur, but it is glorious.

The remainder of the trip home was as circuitous and tedious as I imagined it would be.  We took two large buses with the complement of our crew to somewhere near Kuwait City, then boarded smaller "Scooby Vans," as they call them there, loaded to the brim with our seabags and trunks.  We dispersed to the various  terminals, having been warned to be diligent with our luggage and to not allow the "smurfs" - aggressive baggage handlers dressed in outlandish blue outfits - touch our stuff.  Unfortunately, in dispersing so quickly into the insanely busy Kuwait airport, we were denied one last goodbye with our colleagues who were not on our specific planes.  We waited in interminable lines just to check our bags in, but finally, at midnight, were able to board our first leg to Frankfurt.

Once in Frankfurt we managed to find our way to our connecting terminal - not an easy task as only the terminal and building were being flashed on the screen 6 hours prior to our flight taking off.  A small group of folks heading to DC and Norfolk managed to come together for a real beer at 8am Frankfurt time.  NA beer was now a thing of the past.

Nine hours later, over twenty four hours since I left Kuwait, I arrived at Dulles International's customs terminal.  The customs agent, a pleasant lady of a certain age, thanked me for my service and then asked me how long I was staying in country.  I was briefly stunned - did you really have to ask?  Indefinitely was all I could muster.
Even Mr. Clean welcomes me home

I spilled out into the terminal with the rest of the non-military folks.  I saw my daughters and my wife, holding US flags and carrying a big sign welcoming me home.  Home at last!

In seven and a half months I have tended to many victims of war and their traumatic injuries, lived through a continuum of insanely hot days, and bonded with a tight knit group of friends and colleagues.  These things remain at the fore of my mind.  My reintegration into "normalcy" seems to be going well thus far - I have not figuratively kicked the cat, nor do I intend to.  But I will not be able to shake the memories, good and bad, of what has transpired over these many months.
In Frankfurt - one last gathering with friends and colleagues

Thank you for following along, occasionally commenting, and always offering words of support.  I look forward to reuniting with you readers, colleagues, and friends.

Dona Nobis Pacem,


Thursday, September 2, 2010

Warrior Transition Program

Camp Arifjan, Kuwait

We are decompressing.  That is the buzzword, decompressing, what we are told we should be doing.  Camp Arifjan is the pivot point out of theater.  We turn in our weapons, our seabags full of army accoutrements, and we receive a handful of lectures telling us how we might better re-integrate into the lives we left nearly eight months ago.

A lot has happened in those eight months.  I was just showing some photos to a colleague of mine who is stationed here in Kuwait.  It's hard to believe all that happened in Kandahar and Fort Lewis.

Checking the flight schedule: flights are assigned seemingly at random
The photos are difficult to look at for a variety of reasons:  I did document some grisly things, learning tools for those who will come to Kandahar after me.  I documented some enroute care missions, some mass casualties, and other photos of the frenetic day's events at the ROLE-3.  I took photos of many friends and colleagues, many who have already departed the Warrior Transition Program for points around the globe.  It still excites me to look at the photos, but I also get a pit in my stomach.  I think this is the crux of the challenge of returning home:  I am excited at the prospect of seeing my family and friends, but I will miss so much of what I left behind - the colleagues, friendships, excitement of the day to day rhythms of the ROLE-3.  Of course there are things I wish to never experience again as well.  The sight of mangled bodies and parentless children, the smell of an IED blast victim, the unsavory sight of flesh ripped off bone.  This bouillabaisse of emotion is apparently what plays tricks on the minds of folks returning home.

Playing Taboo in the 'Decompression Tent' -
yes it is really called that.
A friend told me recently that after he went through WTP after returning from Iraq on his last deployment, he was told that as long as the house was still standing or not in foreclosure, that he wasn't divorced, and that all his kids were healthy then it was a good deployment.  Who should care about anything else?  That is truly dumbing it down but the point is well taken.

My friend Chris donned his Afghan outfit for one of the briefs -
 we had been told that uniform regulations were relaxed
to accommodate our decompression after all.
After we turned in our weapons, holsters, chemical and biologic warfare gear, and so on, we were addressed by the command's chaplains.  We were told over and over that only a small handful of us could be identified as needing psychologic care now, but that in three to six months roughly 20% would need it in some capacity.  We were given pointers on how to reintegrate back into our families and jobs.   It was fairly basic information.   Don't kick the cat.  Don't 'take charge' of your family like your infantry platoon.  Expect weirdness in how you interact with your family - that is natural.  I have some insight into all this, having had a father who went on numerous deployments as a career Naval Surface Warfare Officer.  I remember him coming home to a hippy son - me - and telling me to get my butt to the the barber toute suite.  I remember thinking, who is this guy again?   My teenage self thought, I've been the man of the house for the past 6 months.  Fortunately I don't have any teens waiting for me at home, not yet anyway.

Our chaplain told us that a Vietnam vet once told him that his transition home was far too quick: that one day he was in the jungle and two days later he was sitting in his living room at home wondering what had just happened.  The chaplain reminded us that in WWII troops coming back from the Pacific would take roughly 50 days to get home, 50 days to absorb losses of their friends and to contemplate on what had just happened.  I do believe that WTP is designed for us to spend about five days doing nothing, so that we aren't like the Vietnam vet wondering what just hit us.

There are a few diversions here - a tent with video games, internet access, and a a movie theater.  On the other side of base there is a pool.  All water here on base is virtually scalding, to include the pool.  That's a slight exaggeration (although "cold" shower water at any time of day is far hotter than any water coming from a water heater).  We had a pool party the other night (still no beer here!) in which we refreshed in the 91 degree water.  It was a form of decompression, I recognized that.  It was fun albeit not so refreshing.

See you on the next deployment (?)
The last two days have been interrupted by our pack leaving, breaking up in ten to fifteen person increments.  Most of us are leaving by commercial airways, which disappoints me.  In my mind's eye I witnessed us being reunited as a group with our families at some DC airport.  I believe I will be arriving with a group of five or so, at midday tomorrow.  I am thrilled thinking about it, but the emotional cocktail still sticks in my throat.

Monday, August 30, 2010

The Longest Goodbye

31 August 2010

Camp Arifjan, Kuwait

Once the new crew was in place following the change of command, we old timers began to feel "old and in the way."  Perhaps I am projecting.  Our whole lives for the past six months have revolved around what goes on in the hospital.  I for one had a hard time staying away, which resulted in more than once observation "'re not gone yet."

Unfortunately we couldn't beam ourselves out of Kandahar.  The course of events leading to our C-17 flight out of theater was long and convoluted, in classic Navy style.  First we had to get our rooms into inspection-ready condition, and move into a large tent, with over 200 of our closest friends.  Many folks had already moved into the tent by the time I got there.  The first night they experienced a too-close-for-comfort rocket attack in which one person insisted he saw the contrail of the rocket cast light over the top of the tent.  The unexploded warhead was found wedged between two Texas barriers the next day.  Part of the rocket disabled a C-17 on the tarmac, piercing one of its tailfins.

Odd tent decorations
Moving in and out of any facility is not easy.  We are all carrying at least 80 lbs of combat equipment that we have never used - chemical-biological warfare gear, cold weather gear, various tools and garb that had been given to us in Fort Lewis.  I personally had two full seabags, a stuffed-to-the-brim rucksack, and a carry-on, plus my flack jacket and helmet.  I packed relatively light.

One Last Coffee on the Boardwalk
The tent was completely full.  I had a top rack that was not fit for sleeping, even if I could ignore the snoring, joking, bed creaking, and so on.  My bed listed at about 20 degrees.  I took another night of ICU call so I could sleep in the hospital.  The next two nights I crashed on an ICU bed in the corner, and a cot in a distant office, respectively.  Some relished the summer camp feel of the tents but I was more concerned at this point in getting some end of deployment sleep, well-deserved if I may say so myself.

On Friday night, we were feted by one of our friends who works with the special forces.  He got his hands on some local Afghani food - rice with raisins, a chick pea stew, and some dubious-looking goat meat.  After we feasted on the tasty local meal one of the special forces docs honored myself and two others with their unit coin, for taking great care of their fallen comrades.  It was touching.

Waiting in the terminal
That night I had an interesting conversation with a psychologist who was assigned to the special forces.  She had extensive experience with folks "redeploying home" (the unfortunate Army term for going home).  She told me that most folks get annoyed at little things they see on a day to day basis.  For example, one might be at a restaurant where a patron makes a big fuss that his hamburger is taking so long.  The redeployer will get disproportionately angry at this kind of scene - he or she will have seen so much truly worth getting irritated at (wounded soldiers, amputations, broken children) that this will just set the person off.  She strongly suggested that we get together with other folks with whom we had deployed, to reminisce with someone who "gets it."

Inside the C-17
After our final goodbyes with the comrades that had joined us halfway through our "roto," (the ones we remained close to, as the new guys continued to marvel that we were "still here?" more than a week after the change of command), we finally lugged our gear once more to the outgoing passenger terminal.  We boarded buses leading us to two enormous C-17s, the kind I watched take off nearly every day from the flightline.  They are gargantuan up close, and impossibly big from the inside.  We were allowed to take off our flak once seated, though many kept them on for the entire four hour flight.  No peanuts or ginger ale on this flight - it was all business.  Within minutes of being seated we were taking off much too steeply for FAA regulations.  I knew from many nights on the flightline over NA beers and cigars that our tail lights were extinguished as soon as wheels were off the deck - a tactical takeoff.

All grins
We arrived in Kuwait at Ali Asalem, a military terminal two hours by bus away from our Warrior Transition Program destination.  We were led, bleary eyed but happy, to our tents.  Our long route home had begun in earnest.

Wednesday, August 25, 2010

Last Call

25 August 2010

Kandahar, Afghanistan

I had my last overnight call in the ROLE-3 last night.  There have been a lot of bittersweet "lasts" lately.

We played our last hockey match on Monday.  Steve, our neurosurgeon, even played with broken ribs - from our hockey match the previous week. He said he just couldn't miss the occasion.  We showed up in particular for Tracy, our Canadian "mayor of Kandahar."  She is an ICU and trauma bay nurse who is pleasantly gregarious, seems to know everyone, and who has had a habit of getting us onto the hockey rink even when we might want to be sleeping after a night of call.  Unfortunately on this day Tracy learned she was going home a day early.  She was noticeably angry at the screw up: apparently someone had known about it for 3 weeks but hadn't bothered to tell her until the day before.

At Tracy's farewell lunch

Tracy couldn't play hockey on Monday as she had to pack and get ready to leave this place.  It's a common theme - as much as one wants to get the hell out of here and back to a normal bed, a reasonable temperature, green grass, a cold beer - I could go on - one feels the gravitational pull of a tight knit group of friends and colleagues that one really doesn't want to leave behind.  As Tracy told me, where else are you going to find a group that is so close, a group that shares tragedy in the horrible things we see, but also a group that gets together daily to break bread, play sports, drink yet another NA beer, or generally goof off (probably in an effort to forget the terrible things)?  Many of these events occur on the same day.  At home we have colleagues and may occasionally get together, but it takes effort, and it may take weeks of coordination to make a get-together happen.  Here at KAF we all have a shared set of intense experiences, see each other every day, live in the same dorm... and we have become like a family after six months together.  If you haven't been here it is difficult to relate.

On the day Tracy left we took her out to Echoes, the Dutch cafe with the cartoonishly rude staff.  We ate together for one last time with our personal live wire, Tracy.  When it was time to say good bye she was crying.  We have made tentative reunion plans but we know it will never be the same.

We have been experiencing a region-wide dust storm the past couple of days.  It is more dangerous to fly missions in the dust, so many of our patients that would normally be transferred by helo are grounded at the various forward operating bases located close by, attended to by lower echelons of care.  At about midnight last night I received the page that 8 were inbound by Stryker or MRAP - vehicles used to carry troops around the countryside and armored to withstand IED blasts.  We assembled at just before 1am to meet the hoard.  After waiting an hour we were told that the patients wouldn't arrive for yet another hour, and that we would be paged again.

Our last cigar night?

I slept for that hour and dreamt about being a soldier in a ground war, being shot at over and over, with no place to take cover.  I awoke, troubled and a little nauseated.  I was thankful that I was only dreaming about being shot at, lying in a bed.  Our patients, who finally arrived at half past 3am, were in fact being shot at in some miserable landscape several hours away by vehicle.  When they finally arrived at ROLE-3, they had been traveling for hours in a hot and cramped vehicle.

Dropping off patients by vehicle, outside the trauma bay doors

They could have easily hit an IED on the way here.  One of the wounded had his foot blown off.  A young Afghan boy had somehow arrived with the group of soldiers, having fallen into a well (our third such victim in the past 3 months).  Amazingly, only the boy ended up in the ICU.  It was a strange way to end up my six months of call here.  Is there some metaphor concerning falling into a well I am missing?

By morning I was wondering if the nightmares of being shot at were something I should be concerned about.  Today I do not feel emotionally wounded after what I have seen.  We have been told that the medical professionals who rotate in a hospital like the ROLE-3, and who have seen horrible things, occasionally have PTSD or PTSD-like illnesses upon their return home.  From what I have been told, it is most often worst for the nurses, and most easily tolerated by the surgeons who operate and perhaps see the most carnage.  I know it has been hard on some.

The Commanding Officer being awarded the Boatswain's Pipe after the Change of Command ceremony

Today is the day of the Change of Command.  At today's morning report I witnessed some tears shed by those who are turning over the reigns to the new crew.  I think the tears were a combination of exhaustion, joy in surviving, and joy in knowing we made a difference to scores of people, both Coalition soldiers and Afghan citizens.  Our chief of trauma reviewed the numbers of people we had treated, the units of blood we transfused, the hundreds of orthopedic surgeries performed - many representing amputations, and other data.  When the numbers scrolled across the screen I think it sunk in for all of us present:  we put a lot of energy, effort, emotional toil... and on occasion, tears, into what we have accomplished and to what we have witnessed.  It is no surprise to me that tears were shed this morning.

Incidentally we have another evolution to complete before going home designed to deal with these issues that many will carry back with them.  It's called the Warrior Transition Program, which takes place in Kuwait.  I understand it must be done and it probably is useful for some.  I will be so preoccupied with thinking about getting home by that point I have to wonder if I can pay attention.

The Change of Command started at 10:30 this morning.  As we were still under a cloud of dust, it was mercifully cool by Kandahar standards.  After the benedictions, speeches, salutes and the final handing over of the flag, I got to shake the skipper's hand.  I am sure I saw a tear in his eye too.

Sunday, August 22, 2010

Heart and Mind

22 Aug 2010

Kandahar, Afghanistan

We recently had a child in the ICU who had an IED fragment traverse through his frontal lobe of his brain. He had a pleasant, white bearded grandfather who spent hour after hour at the bedside of his grandson, coaxing him toward recovery.  Grandfather knew a bit of English, which is very atypical here.  At one point we proposed a plan for the child in which he would have a catheter placed in one of the ventricles of the brain, tunneled via subcutaneous tissue, and placed into the abdomen.  This life-saving procedure, called a ventriculo-peritoneal shunt, or "VP shunt,"would drain the excess spinal fluid that accumulated in the brain.  The only problem is that we could not do this procedure here as we did not have the shunts.  Because of our often suboptimal supply system, it could be weeks before we could get a shunt to Kandahar.  We proposed sending the child to Pakistan to have the procedure done there.  Grandfather stated bluntly to our neurosurgeon, "Why would I besmirch your name by sending my child there?"  He further explained that he felt our surgeon had saved his grandson's life up to this point, and he was confident the boy would ultimately get better based on interventions up to that point.  He felt the need to tell us that Americans are beloved by him, and throughout his village.  It would be a sad day indeed, when we leave.  We wryly noted later that we had won over one heart and one mind in the grandfather.  Incidentally, the boy did get better, and was determined not to need the VP shunt after all.

Yesterday I went with three other docs and our translator back to Camp Hero, likely my last visit there.  I had a sack of toys yet to give away to the kids that folks had sent me.  After visiting the children's ward and handing out the toys, I rejoined our surgeons in the OR.  Two patients had been prepped for surgery and our surgeons were essentially training their surgeons on some relatively complex procedures.  The first involved a patient whom we had cared for at the ROLE-3.  He had had his arm nearly blown off by an IED.  The hand was still viable but the flesh on the forearm and around the elbow had been largely been blown off.  In order to allow the remaining tissue to heal enough to take a skin graft, our surgeons had sewn his arm into his abdomen.  Our surgeons were cleaning up the now immobilized arm.  This is a fairly amazing procedure as far as I am concerned.

Sign at the entrance to the Camp Hero Operating Room - unnecessary in the US.

I looked over to the OR table 6 feet away with another patient being attended to by one of the Afghan anesthesiologists.  He was using his bare hands to start an IV, going to various sites on the patient's arm without using alcohol to clean the patient's dirty arms.  So in adjacent beds I was witnessing  third world medicine being practiced next to state-of-the-art medicine in the arm-to-abdomen patient.

Our surgeons scrubbed into three procedures yesterday before we were called back to the ROLE-3: an 18 month old child had a fragment from an IED penetrate her posterior skull, and as we would soon find out, was still lodged in her brain.  The mother had died in the IED blast.  Another heart and mind to be won in this 18 month old child.

Thursday, August 19, 2010

Lines On My Face

19 August 2010

Kandahar, Afghanistan

I was up at 3am this morning getting numbers for ICU rounds, having just left the trauma bay after a quasi-mass casualty.  We had been paged a little earlier - 7 patients inbound from another helicopter crash. Again it was a CH-47 Chinook, a school bus with rotors.  It had crash landed and flipped over.    The text message gave us a 3 minute warning, which is virtually unheard of.  Seven inbound patients means you activate at least five trauma teams, each comprised of 5 or so people, most sleeping at the NATO barracks a half mile away.  No way they are going to make it in three minutes, so we cobbled together three teams and waited for the onslaught.

MRAP convoy with a device designed to defeat the IED at the front. 

As fortune would dictate we ended up treating 7 "walking wounded" - incredible.  I watched as the trauma team members sleep-walked into the trauma bay just before the victims.  No one was even remotely excited.  In my mind I compared this scene to the one in which we treated five or so soldiers who were in a V-22 Osprey crash, our first mass casualty, last March.  At that time you could smell the tension, and see it on everyone's face.  Even though this turned out to be more of a false alarm early this morning I knew that things will soon be different when the new crew takes over in a few days.

Not able to sleep after our faux-MASCAL, I now gather the numbers and data that begin to roll in on our patients in the unit at this early hour - dozens of labs, hourly urine output tallies, heart rates, blood pressures, intracranial pressures on our head gunshot victims, ventilator statistics, arterial blood gas measurements, and so on.  Each patient's data tells a story of what happened that shift, that day.  Are they trending toward the better or the worse?  Does anyone need blood or plasma this morning?  Can I pull the breathing tube out of their throats?  Must I put another invasive catheter into one of their veins or arteries to get even more information?

We have a theme going this past couple of weeks in terms of patient make-up: neonates and young children; the usual census of gunshot wounds to the head with swollen brains and parts of craniums surgically removed to allow the brain to swell even more; and Afghan and Coalition soldiers with gunshot wounds to the jaw, making their mandibles look like cracked eggshells.  The latter group generally gets their jaws wired shut and breathing tubes subsequently placed via their nares into their tracheas.  Getting these folks off the vent here has been problematic as a handful of them have aspirated or vomited, necessitating that we emergently take the wire cutters taped to the foot of the bed to snip those wires and quickly get a breathing tube through their oropharynxes into their tracheas.  That's not a pleasant situation.

Poster in the ICU made by my colleague Corey's wife reminding us that 'kids aren't just little adults.'

I grow frustrated at the seemingly never-ending stream of young boys and girls that wind up in our ICU.  I had no idea it was going to be like this when I came out here.  We pronounced another young boy dead in the trauma bay yesterday, a victim of an rocket propelled grenade (RPG) attack.  We presently have two young boys in the ICU with gunshot wounds to the backs of their heads.  They may do reasonably well in the long run, maybe only paralysis to part of their body, or difficulties comprehending what one says.  Even though they likely would have died if they hadn't been diverted our way, it is still such a tragedy.  Someone asked me recently, do people target these children?  It's a sickening thought.  We have always assumed that they are caught in the crossfire.  But why would a child be playing in an area where people are shooting RPGs at one another?  Wouldn't one run as fast as one could in the other direction?  Or perhaps that explains why our two boys have wounds to the backs of their heads.  We just never know.

In the past week we have had two infants, one 4 months old who had a bad pneumonia, and one 2 days old, who had been breech and delivered via C-section at one of our local FOBs.  They should both survive.  What kind of Afghanistan will they grow up in?

Sign at the inner wire.

We are lucky to have my colleague, Jon, who is a Pediatric Intensivist.  He has taught me via the school of hard knocks how to treat critically ill babies and children.  I'm no expert, trust me.  But I am now PALS (Peds Advanced Life Support) qualified, have run a handful of codes on babies, and have put in numerous invasive catheters on young children.  I think I have at least a part of a pediatric internship under my belt at this point.  And I am sure I have seen the dark underbelly of what happens to some children in this particular world - babies scalded in milk, young children and babies run off the road and into canals by Taliban, spinal cords of young boys and girls transected by wayward bullets - or worse, intentionally directed ones.   I just want to get home to hug my girls and not think about this stuff for a long while.

Today I ran into two women I had trained with back in January at Fort Lewis.  I noticed that one of them looked markedly older.  I wonder about the lines on my face, the extra grey hair I have "earned," the ever-receding hair line.  I look in the mirror and only see the Afghan weathered red face, but I am sure I looked older to these women after only six months.

Monday, August 16, 2010


Kandahar, Afghanistan

It must be graduation week, or at least it feels that way.  There is a giddy atmosphere that seems to permeate everything we do.  Morning rounds have become impromptu comedy routines.  If I am reading that last sentence and not writing it I would probably be put off somewhat.  When we round in the ICU for example, there are several people who may be in a "guarded" condition, others are trauma victims being being actively resuscitated or who have just come out of the OR with open abdomens or limbs missing.  Still others may have devastating head injuries, and we are waiting for them to "declare" themselves as there may be nothing we can actively do to save their lives or restore neurologic function.  How can one be silly or make jokes in this environment?  One can, trust me.  We don't poke fun of patients and they are not the objects of jokes.  But there are usually several situations each day that beg to be lampooned, and I feel that it is a defense mechanism to deal with what we see daily.

A few months ago I ordered a "travel gnome" to lighten up the mood every so often.  I have taken the gnome to various places around the base and have gotten dozens of people to pose with it.  It's an automatic mood-loosener.  Everyone needs a gnome or a gnome surrogate around here.

On Sunday we had our one and only sanctioned BBQ of the tour.  Back in the days before General McCrystal the various units on post, to include the Role-3, would have a monthly BBQ to get the command together, hand out awards, and generally promote good morale.  McCrystal nixed the monthly BBQ and allowed each unit one every six months.  Our other parties - the goat-kebob luau and the pool party were financed through various fund raisers - selling t-shirts, ball caps and such.  Our officially sanctioned BBQ had a theme - the 1980s.  Now it's pretty hard to go to the Thrift Store to buy costumes and such, but where there is a will, there's a way.  The best costume came from my ICU colleague, Corey, and his roommate, Joe.  They fashioned a Devo outfit out of parts from the ICU and OR.  The highlight of the evening was when Corey received his end-of-tour award - in his Devo outfit.  Classic.

Corey got his award a day early because he left today for Kuwait.  My numerical relief arrived four days ago, allowing one ICU watchstander to head home a couple of weeks early.  It is a bittersweet parting for me as Corey and I climbed aboard a plane on January 26th to begin this odyssey.  But I'm glad he will be home soon.

The International Security Assistance Force Medal that we all receive.  All are awarded 3 unit awards including the ISAF award, and many will receive a personal award such as a Navy and Marine Corps Commendation medal.  That's a lot of "chest candy" for one deployment...

Our flight schedule was posted yesterday.  We move into tents next week and then board planes for Kuwait between 27 and 29 August.  There are but two big events left: the mass arrival of our replacements and the Change of Command ceremony, where we officially hand the torch to our reliefs.  We are giddy.