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.