Sometimes we cry.

"In times of war, you often hear leaders-Christian, Jewish, and Muslim-saying, 'God is on ourside.' But that isn't true. In war, God is on the side of refugees, widows, and orphans."

--from "Three Cups of Tea" by Greg Mortenson.

12/24 - Kids either playing with things they shouldn't be or in the wrong place at the wrong time. Bullets and hand grenades always win.

12/25 - Kids working in their garden. Turns out IED makers like to hide their toys in a variety of places so they aren't caught with the evidence. IED vs. kids...guess what wins?

12/25 - IED vs. soldier. We're pretty good. We win more than we lose. Sometimes we lose. Sometimes we cry. Merry Christmas.

12/26 - Kid vs. car...car wins. IED vs. multiple. Another bad day.

12/27 - Cleaning your personnel weapon is sometimes fraught with danger. Being a bad guy is also fraught with danger.

12/28 - Quiet day...just one limb.

12/29 - Quiet day...just one shot.

12/30 - Read the newspaper. All hell broke loose. We're still pretty good. We still win more than we lose. Sometimes we lose. Sometimes we cry. Happy New Year.

Back to the opening quote. After this week, there are some more people that need to have God on their side.

Christmas Eve in Kandahar

The past 48 hours have brought any number of reminders of how often things can go dramatically wrong for people in this war, be they soldiers or civilians. I think of my kids and the building excitement for them as Christmas is hours away. Then I think of what I'm doing and seeing over here. Two different worlds. I'm glad they are safe with Ruth. OK, I told Ruth I would be more upbeat in this posting…so here goes.

A favorite quote by Albert Einstein: “You can live your life in two ways: As if everything is a miracle or nothing is a miracle. ” I first came across this quote when Ruth was pregnant with Jonah and we were dealing with some abnormal lab tests/ultrasound and the very real chance that Jonah might have a terminal congenital condition. Jonah, as you know, is fine and I'll take that miracle.

I look at our two wonderful kids, Naomi and Jonah, and relish in their enjoyment of life and all it's miracles. They know I like birds, so they take pleasure in pointing out birds to me. I saw a great blue heron fly across the runway at Kandahar a couple of weeks ago. My first thought was of the kids and how they would know exactly what it was and my enjoyment at seeing the bird was made special by the brief connection I felt with them over the miles. I saw a little yellow flower growing in this very dusty, bleak place and knew that if Naomi saw it, she would want to pick it and give it to Ruth. I'm not sure where I'm going with this, I guess this is just my way of trying to stay connected with the kids over the miles. For those with kids - watch them grow and learn and tell me it's not a miracle. OK, I know, sometimes it's a miracle that we don't sell them off...but that's still a miracle!

So, here I am in the middle of a war, trying to see the miracles in everyday life. From a medical standpoint I offer up two numbers. In the current conflicts, the survival rate of wounded in action is just shy of 90%. In World War II, the survival rate of wounded in action was just shy of 70%. Many, many injured soldiers and civilians are alive because of the miracles worked by their fellow soldiers, medics, techs, nurses and doctors.

In the Battle of Flanders in the winter of 1914, the allies and the Germans had an impromptu truce on Christmas Eve. They exchanged gifts, sang songs, buried their dead, and briefly put aside the horror around them. That won't happen here, but I can hope and pray that we're able to continue to do our part in this war by creating miracles with the patients that we see.

On this side of the world, it's only a couple of hours until we celebrate the miracle of Christmas. My hope is that you and your family have a wonderful Christmas. Celebrate it with laughter. Celebrate it with egg nog. Celebrate it with gifts. Celebrate it by remembering the miracle that happened over 2000 years ago in Bethlehem. Hug and kiss your family and friends. If you see my kids, give them a hug and kiss for me. Let them know that Daddy is doing something important and misses them. And it goes without saying, I miss Ruth.

Perspective.

A young African-American male, in the prime of his life and career, dies. Everyone talks about what a good person he was. Tears are shed.

No, I'm not talking about Chris Henry, troubled wide receiver for the Cincinnati Bengals, who died this week while involved in a dispute with his fiance. I'm not talking about a young man with a history of clashes with the law, who was seemingly turning his life around. I'm not talking about a man who will be honored for the rest of the season by his teammates with his number on their helmets. That man will be honored by the media, sportscasters and newspaper writers. They will talk about what a good father he was and what a tragedy it is that his children lost their father days before Christmas.

Yes, it is a tragedy. But what I'm talking about is any number of young soldiers who die in war. The number currently stands at 4,373 in Iraq and 857 in Afghanistan. Take those numbers and multiply them by 2-8 (or more) for the number of people directly affected by their deaths.

Yet those deaths will receive less coverage than the death of one NFL star. This makes me sad.

On a somewhat related note of things that make me sad (actually, appalled is a better word), I still can't believe I read the article correctly about the Republicans trying to filibuster a defense spending bill to hold up the health care debate. A defense spending bill. Money for armored vehicles that protect against IEDs, money for salaries of soldiers, sailors and marines in harm's way. Hmmmmm, seems they might need some health care to reattach the nose they just cut off to spite their face. To quote my oldest brother, "A pox on both their houses."

OK, Christmas is just around the corner, I'll be more upbeat next time.

Unintended consequences.

The unintended consequences of war. Local national driving his car, hits an IED. Brought to our hospital in bad, bad shape. The list of injuries: intracranial bleeding, broken jaw, skull base fracture, broken scapulae, broken left arm, left pneumothorax, splenic injury, pelvic fracture with significant internal bleeding, shattered left femur, left below knee amputation, penetrating injury to the right leg with no pulse.

He receives the full court press. Intubation, left chest tube, multiple catheters to deliver fluids and blood products. Full body CT scan and then rushed to the OR because we're losing the battle.

Try to visualize the activity level in a small OR with this patient. Two anesthesiologists, two general surgeons, two orthopedic surgeons, one interventional radiologist and one general radiologist, one OR nurse, two OR techs, one radiology tech, all engaged in a battle against time. The anesthesiologists are keeping the patient breathing and pumping blood products into him as fast as they can. The general surgeons are opening his abdomen to look for the source of bleeding. The orthopedic surgeon is completing the amputation to his lower leg and trying to stop the bleeding from that side. As they are doing this, I'm putting a catheter into his femoral artery to evaluate his arteries in his right leg and then look at the arteries in his pelvis to potentially stop internal bleeding.

In the best of situations, all of these individual pieces of this operation are complex and deserving of special focus and attention. This is not the best of situations. We're trying to do this simultaneously in a small OR on a critically injured patient. In this patient's case, this was the proverbial dance with death. Death won.

This is not the kind of work that I did in residency and fellowship. It's hard to train for this kind of trauma because we don't see this kind of trauma in the U.S. That being said, I love what we're doing here.

I fully expect that as the surge happens this kind of trauma will happen more frequently. It's a rather simple concept, put more people into harm's way, more will get injured. Funny thing, most people agree that putting more troops into the fight is the right thing to do. If that's the case, then why is it that fewer than 1% of all Americans are involved in this war?

“It must be laid down as a primary position and the basis of our system, that every citizen who enjoys the protection of a free government owes not only a proportion of his property, but even his personal service to the defense of it.” George Washington, in a letter to Alexander Hamilton, 2 May 1783.

Hearts and minds.

Thanksgiving has come and gone and all of a sudden it's the first week of December. Work has slowed, but we're managing to find ways to stay busy. Currently working on an article about patterns of injuries in tactical vehicles. Debating on doing an article on the increased incidence of appendicitis in areas with high levels of dust/pollution. I thought this was kind of novel...only to find that someone else has already reported on this idea.

Interesting story. There was a local national who was injured in an IED attack. He had been hired by a U.S. contracting firm as a translator for our troops. So, he's injured pretty severely, and unfortunately for him, his contract stated that if he was injured then all pay and benefits (including medical care after he leaves our hospital) stopped! There aren't many good things I have to say for that contracting company, or the rules that are in place that allow them to set up these contracts with local nationals. Translators for the U.S. receive death threats and occasionally disappear. They are serving a vital role and the way we take care of them is to stop all pay and benefits if they are injured while working with our troops! Yet another recruiting tool for the Taliban. Unbelievable.

Speaking of the Taliban. Colonel Sir Francis Younghusband, one of the British players in the Great Game in this region at the turn of the 20th century (see "The Great Game" by Peter Hopkirk for some interesting reading), after the British expedition into Tibet in 1903-1904, noted that wounded Tibetan soldiers wondered, "why we should try to take their lives one day and try to save them the next." Nothing has really changed (both with respect to that aspect of warfare, at least from our side) and on a bigger scale with regards to different countries fighting in and around Afghanistan.

Regarding the easier to tackle subject: providing medical care for someone who seconds before was trying to kill one of our soldiers. It's not as hard as it might seem. I am in the business of helping people. I am not in the business of playing judge and jury with someone's life because I don't like what they have done. I will leave that to the people that handle weapons for a living. That is not to say that I don't understand some of the feelings of frustration expressed by some of our troops when they bring in an injured enemy combatant. To quote a soldier who had just been in a firefight and brought in an injured enemy combatant, "I hope he f@#$ing dies!" I can't do that. That's the proverbial slippery slope for doctors. If I go down that path, where do I stop? I will say that we are much more emotionally involved with the injured U.S. and coalition forces. Simply put, it hurts to see them torn up.

All that being said, injured enemy combatants get the best care we can provide while they are here. Not sure what happens when they leave our care. Suffice it to say that receiving care in an Afghan hospital is of questionable quality. The U.S. and coalition forces receive top notch care here and then depending on the severity of their injuries, they are often out of the country in less than a day for definitive care in Germany and the U.S. (or respective countries). It really is an amazing system with amazing results.

Do I believe that the Taliban will provide the same care for captured U.S. forces? No, and that's even if they had the capability to provide that kind of care. We are a different people and society. We need to remember those differences.

Happy Thanksgiving!

"No human counsel hath devised, nor hath any mortal hand worked out these great things. They are the gracious gifts of the most high God, who while dealing with us in anger for our sins, hath nevertheless remembered mercy.

It has seemed to me fit and proper that they should be solemnly, reverently, and gratefully acknowledged as with one heart and one voice by the whole American people. I do, therefore, invite my fellow-citizens in every part of the United States, and also those who are at sea and those who are sojourning in foreign lands, to set apart and observe the last Thursday of November next as a day of thanksgiving and praise to our beneficent Father who dwelleth in the heavens.

... commend to his tender care all those who have become widows, orphans, mourners, or sufferers in the lamentable civil strife in which we are unavoidably engaged..." A. Lincoln, 1863, on the declaration of Thanksgiving Day.

OK, it's no surprise, President Lincoln could write better than I ever will, so I thought it fitting to include a bit of the text from his declaration when Thanksgiving was made a national holiday. Hmmmmm, he made that declaration while we were engaged in the Civil War.

So, here are some things I'm thankful for while "sojourning in foreign lands."

I'm thankful for a wonderful family. Ruth, Naomi, and Jonah bring an indescribable joy to my life. Sometimes when I'm skyping with them, I don't really want to talk, I just want to watch them move and talk and laugh. I already daydream about our reunion and getting tackled by Naomi and Jonah and rolling around on the floor with them. I'm thankful for Ruth. She keeps the family running when I'm there and even more so when I'm gone. To quote Jack Nicholson, she "makes me want to be a better man."

I'm thankful for friends and family. I'll admit, I'm not the best at keeping in touch. But the memories of times spent with friends and family are precious to me. I look forward to making more.

I'm thankful for our dog, Lilly. Many of you know that we had to put our first dog, Dorsett, to sleep this year. That is a loss that I still feel. For those of you that are dog people, you know that you can't replace a dog. But if you're lucky, you get a new dog who is a new friend and that makes you happy. I'm happy.

Finally, I'm thankful for the opportunity to serve. The military serves a vital role for our nation. Part of that role involves sending young men and women into harm's way to do a job that is sometimes unpopular. If they are going to get injured in some corner of a foreign field (with apologies to Rupert Brooke), then they deserve the best care they can get and that is what we are giving them.

"For peace in our hearts, for peace in our homes, for friends and family. For life and for love, for work and for play, let us pray to the Lord, let us pray to the Lord."

Combat Radiologist

For those who say we never touch patients. For those who say we sit in dark rooms and look at pictures because we're afraid of patients, I offer the following story.

The medevac report comes in. IED attack on an armored vehicle. CPR is being performed in the helicopter.

The patient is brought off the helicopter. He's pale, very pale, the kind of pale that comes from significant blood loss. He's not breathing on his own. He's missing most of his right leg below the knee. He has a large gash on his upper inside thigh. He has a tourniquet on the same leg.

He's rushed into the OR. I put the ultrasound probe on his chest to look for any cardiac activity. I look again. There is none. It's over. Young 20s. Gone. We cover him with a blanket. My eyes briefly water. I move on.

I'm not afraid to touch patients. I don't sit in the dark and look at pictures because I'm afraid of patients. Sometimes I'd rather sit in the dark because I know what I'm going to see, and it's not going to be pretty.

I saw his casket loaded onto a C-130 the next day for the flight home. His casket will be met by his wife and new baby. His wife will now mourn the loss of her second husband. Her first husband was killed in Iraq. She celebrated her birthday on the day he was killed.

Welcome to Afghanistan.

I've been here for three weeks. In that time I've seen more amputations and traumatic death than in the 14 years since I started medical school. I watched a soldier cry today as he awoke from anesthesia to find that he now missing his left foot after stepping on a mine. I briefly thought to myself that he's lucky that he's only missing a part of one limb, why's he crying? He's otherwise uninjured. These thoughts were quickly replaced with feelings of shame. How can I think those things? Apparently I can. And it only took three weeks.

In the practice of medicine we often find ourselves developing attitudes about patients and diseases that the average person would find abhorrent. We're supposed to be better than this, but we're also human.

The patients I see are making a sacrifice that is completely foreign to the vast majority of Americans. They deserve the best we can give them, in actions and thoughts. I give them my best with my actions. For a couple seconds I didn't give them my best with my thoughts. It won't happen again. I'm sorry.

No title

I'm stuck. I don't have a title. Now what do I do?

Are you ready...more of the same. Work didn't change. The pattern continues. Quiet during the day, picks up around dinner time. I would say that bothers me because I want to get home in time for supper...but that's not true here.

This was the week of the random single piece of shrapnel or single bullet causing devastating injuries. This was also the week of looking at a CT in a patient who came in for kidney stones and diagnosing lymphoma in him.

I managed to Skype with my oldest brother, Jim, while he sat on his boat in Cabo, Mexico. Aahhh, the beauty of technology. He asked how the war was going? From my view through the wrong end of a telescope it's going fine. People get injured. We take care of them. If they're well enough, they go back to their units. If not, they get a long plane ride home and try to rebuild their lives. Are we making a difference? Yeah, we are, for the individual. Jim's response to my rambling, "Isn't war all about what happens between individuals?" or words to that effect. Yeah, I guess it is. I can't control what happens in DC, Kabul, or some lonely road where someone waits to blow someone up. I can only control what happens in my little part of the hospital and try to make a difference for them.

Speaking of war and individuals. This was also the week of a nutjob wearing an Army uniform and killing 13 people because he was a little distressed about getting deployed. Oh yeah, in case you didn't hear he is also a psychiatrist and graduated 2 years after me from the same med school. No, I didn't know him. We'll hear stories and theories over the next weeks/months/years about he was a victim, a terrorist, oppressed, etc. Cut the crap. He was and is a murderer. No more, no less.

On a more upbeat note. This was also the week of multiple trips to the British dining facility for the curry bar!!! And there was much rejoicing. They also have soft serve ice cream on Mondays, Wednesdays, and Fridays! And there was even more rejoicing.

Saw some amazing pictures from home. Pictures of a guy jetskiing in front of our house from the flooding from the nor'easter! Fortunately Ruth and the kids were safe and dry (except for some water damage in the sunroom). I have not seen rain since we left the States. It's fun talking with the kids on Skype - they mostly view it as a time to jump around like crazy in front of the camera. I miss them.

Groundhog Day

I've been here for just over two weeks and am settling into a schedule. I'm alternating 24 hour shifts at the hospital, starting at noon each day. I'm trying to hit the gym at least 2 out of every 3 days. Meals are at one of 5 dining facilities. Went to the British one tonight which was a big hit because they have a curry bar! Had some excellent lamb curry. Had a fun discussion with one of our Australian doctors about why cake with sauce is called pudding, and pudding is called custard, and fries are called chips and so on. This discussion on food also had to get around to that dessert I saw the other day at one of the dining facilities called (and this is the polite name) "Spotted Richard." Hmmmmmm.

It has been relatively quiet at the hospital for the past two days. I took a tour of the new hospital which will open sometime next year. It is going to be a monumental upgrade from the collection of huts/tents we're in now. The panoramic photo is from the roof of the new hospital. Our current hospital is in the foreground bottom left of the photo.

One of the saddest things I've seen so far is the cute as a button 11 year-old girl who stepped on a landmine (remnants from when the Soviets were here). She lost one leg below the knee and the other leg, while saved, has some pretty extensive damage. She has no family except for her uncle. He's asked us to do everything we can to save her other leg because "No Afghan male will marry a woman missing both legs."

Currently working on clinical practice guidelines regarding the use of interventional radiology in theater. We're breaking new ground here and a lot of what we're doing is trying to educate the various physicians about the capabilities that we have here and how it can play a role in the management of battlefield trauma.

Tomorrow is Veteran's Day (or Remembrance Day for our Canadian friends). These long-running conflicts have increased the number of veterans in the U.S., many of them with visible injuries, just as many (or possibly more) with injuries not readily detected. Say thanks to one of them. Say a prayer for them and their families. Don't wait for Memorial Day to think of the ones who didn't make it home alive.

Kandahar, Afghanistan

We arrived here at around 3 a.m. last Tuesday after a nice flight from Kuwait in a C-17. The base is a sprawling mixture of tents, modular living units, more tents, concrete blast barriers and buildings of different sizes and shapes. There are a few paved roads and the rest are dirt roads. Dust is a common theme here with a constant low-level haze at ground level. We can see some small mountains to the north, otherwise, all I see is the base and more buildings. The weather is basically sunny and up to mid 70s during the day and down in the 40s at night. I'm told that winters get cold and also rainy. Great...can't wait to see what kind of a mudpit this place becomes!

Since this is a NATO base, there are a multitude of uniforms, flags, and languages. It's sort of a game to try to figure out who's who in the zoo. I'm working in a hospital that is a mixture of small connected portable buildings and some

tents. The hospital is staffed by the U.S. Navy, Canadians, and Dutch. I have one 16-slice CT scanner, a couple of ultrasounds, plain-film x-ray, and a C-arm in the OR that I use for interventional cases. My IR supplies are currently in a variety of boxes in various rooms and one of my first orders of business is to consolidate and inventory the supplies. We will be staffed with two radiologists, myself and a general radiologist.

So, as in many things, the job can be slow at times, but when it picks up, it is frightening. I've seen multiple traumas already and I'm pleased to say that we do a good job with them. The injuries are not the kind that you see in the U.S., and we should all be thankful for that. So often as radiologists we are too far removed from the actual patient, but I'm very happy to be in the trauma bays when the patients roll in because it makes imaging easier when I have a sense of what has happened to the patient.

Living arrangements: I'm in what is effectively a small college dorm room. I share the room with Jon Gibbons, an anesthesiologist and med school classmate. We have real beds and internet in the room. Life could be so much worse so there is really nothing to complain about from that aspect. We have a nice gym outside our door and are in walking distance to most of the base amenities, including multiple dining facilities (and they have helpful handwashing stations inside of them!) Speaking of the internet - this is a dramatic quality of life issue. I'm able to skype and call (via magicjack) from my room!

So, there you have it. A brief intro to Kandahar. Not too exciting, I know. More to follow.

The Udari Range Experience

To get the full training experience, I just got back from 3 days, and 2 lovely nights, in the desert just a few miles south of the Iraqi border. We were organized into groups of about 35 people and we slept & had classes in the same room. There were no showers, no running water, and meals consisted of MREs (meals ready to eat). Of course, as my brother, Jim, says, the term "meals ready to eat" consists of three lies. They are neither meals, nor are they ready, nor should they be eaten.

The training consisted of more classes on convoy operations, more classes and experience in close-quarters marksmanship (think shooting while walking in a line just past the shoulder of the person in front of you), and more Humvee convoy training with explosions and people shooting tracers around us.

The training was good, but I'm not sure I needed to be sequestered in the desert to get the experience. The most important learning points were situational awareness and good communications, points that apply in every aspect of life.

Here's what else we learned: take a group of people that you've never met (OK, I do know a couple of them from med school, prior training) and put them into close quarters for a period of time and you really learn about personalities. You quickly

learn who is reliable, selfish, selfless, insecure, obnoxious, etc. This is not an officer/enlisted or male/female issue. This is an issue that crosses those lines and I think that much of it comes from how they were raised. I remember my Dad saying that the most important thing in marriage is that the two people are courteous to each other. That also applies in close quarter living. I never cease to be amazed at how self-centered people can be. Sigh.

First stop

We made it to Kuwait after a very long flight from Columbia, SC with only one stop. After weeks in an Army training environment, I was more than pleased to get on the Boeing 767 to find that Commanders and above get to sit in first class! We're here for briefs, acclimatization, and more range training (convoy training and shooting). Now, where we're staying is relatively desolate...and the range is supposed to be even more desolate. I say relatively desolate, because, really how desolate can a place be with wireless internet and a 24 hours/day Starbucks!

Most of our spare time is spent contacting family, working out, and hanging out at the USO making free phone calls to the U.S. The USO also has this wonderful service where they will record you on a DVD reading books to your kids, and then package up the same books and DVD and mail them to your kids for free. Shameless plug, if you have some extra money and want to give it to a good cause, strongly consider the USO. They provide a priceless service!

Have been able to talk with Jonah and Naomi pretty regularly. Jonah's been missing me a bit and all the technology in the world doesn't make "Daddy, come home soon" any easier to hear. I was talking with the kids on Skype tonight (I'm 7 hours ahead of the east coast) and it was obviously dark where I was and still daylight in Virginia Beach. Naomi asked the obvious question when she realized it was dark, "How did the day go so fast where you are?" I wish you could hug your kids through Skype.

Politics...because I had to get to it at some point. The reality of the war and possible 40,000 troop surge becomes all the more real when you are one short flight away from being in-country. Funny, we sit in the U.S. and interpret the news of the war through a certain set of filters. We criticize leaders as we sip our cup of coffee and opine about what should or shouldn't be done. Put on body armor and carry a weapon (and I'm a doctor for crying out loud!) and see how that may change the filters that you use for interpretation.

Packing bags

Leaving the U.S. on Saturday for a very long flight. Doing all the appropriate long-flight prep which mostly consists of making sure I have adequate reading material and that my ipod is fully loaded and charged. I also bought an adapter for my ipod that lets me recharge it with AAA batteries. Two seabags, one rucksack, one carry-on backpack. Probably around 200 pounds of stuff. Where's a sherpa when you need one?

Funny letter from my wife mentioning that our daughter was surprised to see my wife working with tools (replacing curtain rods)...b/c that was something that Daddy does.

I think I'm ready (both mentally and physically) to get this show on the road. Game on.

Two weeks after the first post and I'm finally finding some time to write again. Limitations on writing include being tired, poor internet connectivity, and so on. In the past two weeks I've qualified on the M16, M9 (9 mm Beretta), fired hundreds of rounds out of those weapons and different automatic weapons. We've ridden in Humvees, practiced egressing from a rolled over Humvee, eaten lots of mediocre food, and made new friends. A few more days of training and then we ship out. I've also developed a new appreciation for the life of the average soldier. In general, I don't think we give them enough credit for what they do or how hard the job can be.

I'm lucky that I've been able to talk with my family every night, a luxury that will be going away shortly. My kids wonder why I wear funny clothes (they rarely see me in uniform, much less combat gear). I miss them dearly.

And so it begins

"I am a stranger in a strange land. I've left behind my home and kin. I am an alien. I am unwanted, and there is no one to take me in. Who will befriend me? Who will defend me? Who will extend me an open hand? Who'll stand beside me? Who'll walk before me? For I'm a stranger in this land."

These lyrics, from "I am a stranger" by Ken Medema (based on Exodus 2:22) seem kind of fitting as I set off for Afghanistan. I'm currently undergoing some Army training and these lyrics also apply in this setting.

I'm an interventional radiologist and I have a particular set of skills that lend themselves to the combat setting. My thoughts in this blog will try to capture some of what I'm experiencing.

My first thought:

I miss my wife and kids and look forward to our reunion.