Death

Death is a personal journey. It's a trip we all know we must take, but one that we don't necessarily want to take right now. When it comes time to take that journey, I hope that I have the strength and courage to take it with such grace as my brother, Jim, and his now deceased wife, Lara. Lara, if you remember my last post from 5 months ago, was diagnosed with a primary brain cancer, glioblastoma multiforme, while they were on their boat sailing around the world. That was 5 months ago. On Thanksgiving Day she left us for a much, much better place.

I am putting this in writing because I want readers to know what I think of my brother. Her journey, tragic and horrible, was short and she is now in Heaven. Jim and his wonderful daughters now have the hard road ahead of finding their way without their wonderful friend, wife, and mother.

I sent this book excerpt to Jim early on. It is from "Mortal Lessons" by Richard Selzer:

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I stand by the bed where a young woman lies, her face postoperative, her mouth twisted in palsy, clownish. A tiny twig of the facial nerve, the one to the muscles of her mouth had been severed. She will be thus from now on. The surgeon had followed with religious fervor the curve of her flesh; I promise you that. Nevertheless, to remove the tumor in her cheek, I had cut the little nerve.

Her young husband is in the room. He stands on the opposite of the bed, and together they seem to dwell in the evening lamplight, isolated from me, private. Who are they, I ask myself, he and this wry-mouth I have made, who gaze at and touch each other so generously, greedily? The young woman speaks.

"Will my mouth always be like this?" she asks.

"Yes," I say, "it will. It is because the nerve was cut."

She nods, and is silent. But the young man smiles.

"I like it," he says. "It is kind of cute."

All at once, I know who he is. I understand, and I lower my gaze. One is not bold in an encounter with a god. Unmindful, he bends to kiss her crooked mouth, and I so close I can see how he twists his own lips to accommodate to hers, to show her that their kiss still works. I remember that the gods appeared in ancient Greece as mortals, and I hold my breath and let the wonder in.

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Revelation 21: 4-5

And God will wipe away every tear from their eyes; there shall be no more death, nor sorrow, nor crying. There shall be no more pain, for the former things have passed away. Then He who sat on the throne said, "Behold, I make all things new."

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To my friend and brother, Jim, we only know a portion of your pain. You have the full measure of our love and respect. It is not enough. I'm sorry.

I hold my breath and let the wonder in.

The final post

I've got my things I'm good to go.

You'll meet me at the terminal.

Just one more plane ride and it's done.

....with apologies to Jack's Mannequin, "Bruised"

And you know it's time to go,

Through the wind and driving dust

Across the fields of mourning

Light in the distance.

And you hunger for the time

Time to heal, desire, time

And your earth moves beneath

Your own dream landscape.

Oh don't sorrow, no, don't weep

For tonight, at last

I am coming home

I am coming home.

....with apologies to U2, "A sort of homecoming"

"We all went up to Gettysburg, the summer of '63: and some of us came back from there: and that's all except the details. " Captain Praxiteles Swan, Confederate States Army

“It is not within our power to forget or gloss over circumstances which we believe to be evil…They tear at us, buffet us, goad us, scorch us, stifle us — and you tell us to forget about them?” Cicero

"The disparity between what we are told or what we believe about war and war itself is so vast that those who come back, like Lefèvre, are often rendered speechless. What do you say to those who advocate war as an instrument to liberate the women of Afghanistan or bring democracy to Iraq? How do you tell them what war is like? How do you explain that the very proposition of war as an instrument of virtue is absurd? How do you cope with memories of children bleeding to death with bits of iron fragments peppered throughout their small bodies? How do you speak of war without tears? " From The Photographer by Emmanuel Guibert.

I've been gone from home for almost 10 months. 10 final thoughts.

1. I went to Kandahar in 2009-2010. I saw many horrible things. I saw many good things. I will never forget this place.

2. Simply put, this has been the most professionally rewarding experience of my life.

3. Simply put, I would gladly accept a less rewarding experience for just one less injured soldier or child.

4. Jonah: 1278 days old. Naomi: 2235 days old. Deployment: 284 days. I've been gone for 22% of Jonah's life and 13% of Naomi's life. I know many have done more. I hope I can make it up to Jonah and Naomi.

5. Most people here are more affected when someone from their own country is injured or killed. When a child is injured or killed, everybody hurts.

6. I've been through the move from our old tent/plywood hospital to a new brick and mortar building. I liked the old tent/plywood hospital. Better sense of community in it. It felt like being in a war zone.

7. To the families of the wounded: We did everything we could. You have the hard job ahead of you of helping your soldier heal. I wish you well.

8. To the families of the dead: We did everything we could. Your soldier received the best care possible. We treated them as we would our own son or daughter. I can't begin to imagine your pain. I am so sorry.

9. If you are reading this, the odds are that you are sitting at home in the States in the air conditioning. Perhaps your biggest concern today was that when the trash was picked up they spilled some debris on the ground and you have to go pick it up. We're better than this. Consider giving to the following organizations: www.homesforourtroops.org, www.uso.org, www.specialops.org, www.operationhomefront.net, www.fisherhouse.org.

10. I can envision getting off the plane and seeing Ruth, Naomi and Jonah. Chills go through my body as I think about it. I want to laugh, I want to cry, I want to hug them all at once. I want to be whole again.

Final surreal moment from this deployment:

I was in the operating room the other night working on a patient. The surgeons had done a herculean effort to save this young man who had been grievously injured by an IED. He was still bleeding and had a very tenuous grasp on life. I was doing my part with my wires and catheters stopping internal bleeding in his pelvis. His injuries were too severe and he died. At the exact same time, on the other side of the world, a team of surgeons had their hands and instruments inside the brain of my sister-in-law removing a malignant tumor. She has a rough road ahead of her. I don't think it is possible to pray enough.

So, there you have it. Thanks for reading. Thanks for the support that you've given me and more importantly, the support you've given Ruth, Naomi and Jonah. I am blessed.

"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."

Two more.

Two more posts. I think that's about all I've got left in me. Here's what I've come to realize after being here for almost 9 months: the rawness of emotion that I felt with the early deaths that I witnessed has passed. That's not right or wrong, its just reality. They say time heals all wounds, but in maintaining a theme I've struck on before, this wound shouldn't heal. The fact is this: young men and women are dying everyday in a country that many in America have trouble finding on a map, and the vast majority of Americans are neither engaged in this war personally or emotionally. The only time it really breaks into their consciousness is when U.S. troops do something that, by today's warfare standards, is considered wrong.

If 9/11 was really the earth-shattering event that we thought, then this war would be on the front page everyday until it was over. Yes, 9/11 was an earth-shattering event for us, but as with everything, the rawness of emotion that we felt at the time has passed. What are we left with? We're left with a war where the deaths come in ones and twos. When you have that kind of war for 9 years, then the nation loses interest. And in a democracy like ours, when the nation loses interest, you know the poll-bound politicians aren't far behind.

I watched some more young men die this week. Their deaths will raise the interest in their hometowns for a period time. Then, as it always happens, the interest will fade and their families will be left to pick up the pieces.

I'm fortunate. In the supposedly apolitical field of medicine, my job over here is very easy. Take care of patients and get them home safely. But I'll admit, as I come to the end of my deployment, as I think back on what I've seen over here, as I look on yet another shattered body (whether or not he survives), I wonder is it worth it? Are we winning? I'm not even sure what constitutes "winning" in this war. I think that the job we are doing over here, in our hospital, is the most important job in Navy Medicine today. I am thankful for the opportunity and thankful that we've been able to make a difference in so many people's lives. But, my God, at what cost???

Memorial Day.

A day for barbeques, picnics, and family fun. Too often that seems to be the only connection people have to this holiday, oh yeah, and it's the unofficial start of summer. A little bit of history:

Memorial Day was officially proclaimed on 5 May 1868 by General John Logan, national commander of the Grand Army of the Republic, in his General Order No. 11, and was first observed on 30 May 1868, when flowers were placed on the graves of Union and Confederate soldiers at Arlington National Cemetery.

When I lived in DC I would periodically make trips to Arlington National Cemetery to visit my grandfather's gravesite. If you have never been to that cemetery, I strongly recommend it. It's a place of history, a place of remembrance, and a very sobering reminder of the cost of war.

Approximately 12% of the total U.S. population served in World War II. Less than 1% of the total U.S. population has served in these two wars which have lasted twice as long as World War II. I don't say this to encourage everyone to join the military, because I'll admit, I'm ambivalent about my own kids joining the military. I say this to make the point that these wars, despite their length, are not felt as personally as previous conflicts.

I think they need to be felt personally, and I'll admit, that's part of my reason for writing this blog. Almost 5500 young men and women have died since the start of these conflicts. Thousands more have been severely injured. I've, unfortunately, seen my fair share. I've also seen my fair share of young children who have been severely injured or killed. And when I say young children, yes, I'm talking about little Afghani kids who were in the wrong place at the wrong time. Realistically, I'm at the age where I could be a father to the young U.S. troops who are injured or killed. These are kids, all of them.

We send them out as soldiers to do the bidding of our government, and I see them come into the hospital as kids. Scared, injured, bleeding kids. Kids peering up from their stretcher and trying to see their friend, calling out his name, wondering if he made it when the IED went off. Kids that are hoping and praying that they aren't the guest of honor at the next Memorial Day. And for every kid, there is a family back home, hoping and praying that they are never handed a folded flag. I cannot express how impressed I am with those kids. Words fail me.

So, I hope, that as you enjoy the unofficial start of summer, that you also take a moment and remember these kids, Americans, Afghanis, all of them.

Back to reality.

Is there ever a good time to die? I'm sure everyone has different opinions on that, but I know this, I'm thankful that my Aunt Nina died while I was home on leave. That sounds weird to say and it feels weird to write. Here's the basics - diagnosed with Parkinson's disease in 1985, former book editor at Newsday in New York, and more recently editor of Book World for the Washington Post. Incredibly sharp, witty, and more importantly, family. Ours is a family of readers, and she took it and ran with it. She'd been ill for years and in hospice since February. She took a turn for the worse the Monday after I got home, and then died on Thursday morning, May 6th, the day before here 70th birthday. I was hoping to be able to see her. I was not successful, arriving in DC hours after she died. However, that being said, I was able to be there for the funeral. I was able to see family. I was able to tell my daughter about her. I was able to see many great pictures of her life, which included great pictures from my grandparent's place, Mill Point, in North Carolina.

Life and timing are never perfect. There's never a perfect time to buy a home, never a perfect time to go back to school, never a perfect time to have a baby. This was pretty good timing.

So, I left home on a Monday morning around 8 a.m. and arrived back at KAF at 3 a.m. on Thursday. It was a long trip, but if you have a good book (as my Aunt would agree) then it makes travel much more palatable.

I get back to work which feels a bit like having my parole revoked...not that I know anything about that. When I started writing this a couple of days ago we were up to our ears in the final stages of the move into the new hospital. As of today, we moved into the new hospital. After the fun and games last night (type Kandahar Attack May 2010 in google and see what pops up), it is nice to be in a brick&mortar hospital that is rated as a bunker. While the leap in technology and facilities is amazing, I did like the tent/plywood hospital.

The best part about returning to Kandahar is without a doubt the fact that I have now entered the final stage of this deployment. The final stage that will end with another really long plane ride, followed by goofy giggles, grins and hugs from Naomi, Jonah and Ruth...and a bitter dog who wonders why she has to give up part of the bed. I can't wait!

Brief respite.

A perk of being deployed for over 270 days is that you get to take a couple weeks of leave. So, with the knowledge that time is scarce, here are a couple of thoughts/observations from my time at home.

1) 5+ hour flights jammed knee to knee on a C130 in body armor makes routine flights on airlines seem like flying 1^st class!

2) The fatigue and disorientation of 2+ days of flying is quickly wiped away by the look of wonder and joy on Naomi and Jonah’s faces.

3) For as long as I live, I will never forget the look on the kids’ faces when I came off the plane.

4) The first morning at home, I got up with the kids and let Ruth sleep. Naomi asked where Mommy was and I told her she deserved to sleep in after 7 months. Naomi’s reply: “But Mother’s Day isn’t until next week!”

5) The reintegration back into homelife happens pretty quickly. I’m already crossing things off the “To-do list.”

6) Washington, DC, is still one of my favorite cities. I’m glad we had the opportunity to share it with our kids.

7) Jonah gets it now. He gets that deployment means Daddy is gone for a long period of time. He doesn’t want me to go back to “Scanistan.” I don’t blame him.

8) If everything happens for a reason, then the reason I took leave at this time was to be back in the States so I could attend my Aunt Nina’s memorial service. I missed seeing her alive by hours. Damn.

9) I feel rather disconnected from the war after just a couple of weeks. It’s not a bad feeling, just weird. I’m guessing not much will have changed when I get back.

10) Ruth still seems sane after 7 months with the kids by herself. I’m not sure I would fare as well.

11) Our dog, Lilly, is underwhelmed with having to share the bed with me.

My next post will be back in Afghanistan. About 2 months after that I should be home. Naomi gets it. I hope Jonah understands.

Swim.

You gotta swim
Through nights that won't end
Swim for your families
Your lovers your sisters
And brothers and friends
Yeah you've gotta swim
Through wars without cause
Swim for the lost politicians
Who don't see their greed as a flaw

The currents will pull us
Away from our love
Just keep your head above

---from "Swim" by Jack's Mannequin

I listen to my ipod a lot. At the gym. Sitting at the flight line reading a book. While dictating reports on CTs and x-rays. I can think of many songs and how they weave themselves into the story of my life. This is one of the songs that will remind me of this deployment.

Is this a war without cause? While I certainly agree that there are many lost politicians who don't see their greed as a flaw, I'm not sure about the preceding line. What determines the cause of a war? Is it the words of the lost politicians? Is it the general will of the people? Is it the headlines?

My perspective on this war is skewed. I see the broken and battered bodies of the soldiers and civilians (and occasionally the bad guys) who were in the wrong place at the wrong time. Many of the civilians we see are not injured as a direct result of the war, but the severity of their injuries is such that we are trying to help them...to improve relationships. That is my take on this war. We are here to improve relationships. Our goal in helping the severely injured soldier is to get him (or her, though that is uncommon) home, so he can continue the relationships of his life. We understand that some of the soldiers will get home and then die due to the severity of their injuries. But, if we can help them get home, they then have the chance to see family. They have the chance to see the son or daughter who was born after they deployed. They have the chance to seek the comfort that comes from holding hands with loved ones.

We treat the injured civilians as our own. We give them care that is completely unheard of in this country. If by doing that, we can get the 2 year-old (who looks so much like Jonah that I just want to hug him and never let him go) back to his village and his family where he can hopefully have what passes for a normal life in this country, then we're improving relationships.

Think what you will about this war. For me, the cause is improving relationships. I've seen enough death here to last a long time. I'm more interested in the lives that we help. Maybe, just maybe, we can improve a few relationships over here that will pay off in the long run. If we don't, we know that we tried. You can define victory in many ways. I'll settle for a definition that includes being able to get severely injured young men and women back home.

For 209 days the currents have been pulling me away from my family. Next week, volcano* permitting, I'll be going home for 2 weeks, then it's back here for another 6-8 weeks and I'm done. I can't wait!

*speaking of volcanoes, Michael Crichton's book "State of Fear" dealt with ecoterrorists triggering natural disasters to make their points. I wonder if the Taliban is responsible for the volcano??? ;-)

Family ties.

Main Entry: ¹val·ue

Pronunciation: \ˈval-(ˌ)yü\

Function: noun

Etymology: Middle English, worth, high quality, from Anglo-French, from Vulgar Latin *valuta, from feminine of*valutus, past participle of Latin valēre to be of worth, be strong — more at wield

Date: 14th century

1 : a fair return or equivalent in goods, services, or money for something exchanged
2 : the monetary worth of something : market price
3 : relative worth, utility, or importance

Definition number 3: relative worth, utility or importance.

This is a story that has nothing to do with this war. You can have any number of opinions about the Iraq war. But most people will agree that the country that harbored Al Qaeda was the right country to invade post-9/11. Many people will also agree that we need to make this country a functioning country so that it won't become a future refuge for terrorists. Our success or failure over here has nothing to do with this story, or does it?

What is a life worth? The answer will depend on who is answering the question. We, in the U.S. place a very high value on life. Most of us will agree that we will do almost anything for our children and our families. They are precious, it is as simple as that. I think we also define our worth by how well we take care of our families.

So, a local woman and her two children are on their way to get vaccines. They are hit by a car. Some reports say intentionally. She suffered a broken femur. Her baby was tossed and ended up in a water-filled culvert. She suffered a severe head injury. Her toddler suffered a severe head injury and pulmonary injury. The baby died in our hospital that same day. The toddler died the next day. The mother did fine with her broken leg. She did fine if you consider that her husband was quoted as saying, "If my favorite daughter dies (the toddler), then the mother dies." She did fine while she was in our hospital. We can't keep her forever. She is discharged to a civilian hospital and her waiting husband.

This is insight into a culture that I don't understand. Your two children are killed in a hit&run and you are mad at the mother, your wife, for taking them to get vaccines? While I understand that we are not trying to create a little America over here, I also recognize that there are some deep-seated cultural beliefs that may directly conflict with our goals over here. This family and this story is not even directly related to the war...it's just that we happen to be seeing it because we're here. It's a part of the culture I could do without.

I turned 44 today. This is the first time that Ruth and I have been apart for this long. I hope it is the last, but I recognize that when you wear the uniform of the country, then the chance for deployment is always there. It is part of who we are. I am proud to be over here doing my job. I am thankful for the opportunity to serve. It has always been my opinion that if you are willing to accept a paycheck from the U.S. government then you have to be willing to go when asked. Those that balk at that service and seek to get out of it do not deserve the honor of wearing a uniform. Their actions directly impact the lives of others. Those selfish actions result in sacrifice on the parts of others. My sacrifices are small when I compare them to the sacrifices of the young men and women we see in our hospital. As I've said before, we owe them all the respect and help that we can give. As I've also said before, I hope that by doing what I'm doing, maybe, just maybe, Jonah and Naomi will never have to experience this. I value them too much.

Paul Harvey.

Now for the rest of the story.

Many of you have probably read the WSJ article. If not, here's the link:

http://online.wsj.com/article/SB10001424052748704655004575114623837930294.html?mod=WSJASIA_hpp_MIDDLEThirdNews#articleTabs%3Darticle

As always there is more to the story than can be captured in an article. I thought I'd provide some of that background. I will try to explain things as much as possible in laymen's terms.

From a professional perspective it was a great day. There was a patient who had been shot in the legs and I came from one OR where I stopped some arterial bleeding in his leg to the other OR where the patient mentioned in the story was on the table. From a surgical perspective, operations in the junctional areas (e.g, the base of the neck, the groin) can be challenging because to operate on a blood vessel you need to gain proximal control of the vessel...which in the neck area can mean removing the clavicle and sometimes cracking the chest. So, if we were able to treat this via an endovascular approach (meaning through the blood vessel directly with catheters) then we could spare this patient a rather involved surgery in an area with an artery that we know is damaged, which increases the risk.

So, I insert a catheter into the right common femoral artery (right groin) and manipulate it up through the aorta into the right vertebral artery, at the base of his neck. I inject contrast (also called dye) which is visible on fluoroscopy - realtime xray. We then are able to see the arterial injury which is called a pseudoaneurysm, meaning injury to the arterial wall which is bulging outwards. Unfortunately what we also see is some blood clot in the artery past the pseudoaneurysm, meaning, closer to the brain. This, as you may imagine, is problematic because any manipulations we do, either surgical or endovascular, carry the risk of dislodging the clot and sending it to the brain.

At this point, we actually took a brief break for all parties involved (me, the general surgeon, and the trauma surgeon) to call a colleague. We all had our own professional opinion of how to handle the case, but I'll admit, based on the blood clot that we saw, we wanted to make sure we were doing the right thing. So, after phone consultation, we all came to the same decision that the best option was to place small metal coils in the artery to stop the flow in it. I considered placing a stent across the injured area, but in my mind that had a higher risk of dislodging the clot since I would have to get a larger sheath (tube) into his neck through which to deploy the stent.

I walked back into the OR, saying a brief prayer, something to the effect of "Oh, God, please help me not to kill this guy." So, I advance the wire through the catheter just a bit more so I can advance the catheter just a bit more into the damaged artery. I need to get the catheter just a bit more into the vertebral artery so I can safely deploy the coils. The goal of coil embolization is to stop the blood flow in the place you want to by safe and proper placement of the coils in the exact spot...meaning, you really don't want to have a coil accidentally end up in the wrong spot, thereby stopping blood flow in a different place, because you didn't have the catheter placed exactly in the right spot. That is considered bad form. When I did that, I just had the sense that the wire and catheter didn't move exactly where or how I thought they should. You have to remember, I'm looking at a 2-D image of a 3-D structure and a lot of what we do is mental extrapolation from the 2-D image to a 3-D image in our head as we try to move wires and catheters through arteries. So, I removed the wire and injected a little bit of contrast to opacify the artery, and sure enough, the pseudoaneurysm had burst. I will say that at this time several things happened in the OR: 1) Everyone's heart rate shot up!
2) The surgeons prepped for possible emergent surgery 3) The trauma surgeon uttered what is now a rather famous line at our hospital: "Coil the motherf@#k#r!!!!" 4) So, I did...in rather expeditious fashion. The bleeding stopped. The vessel thrombosed. The patient was medevac'd out the next day.

And now you know the rest of the story.

Good day.

Tired.

I wish that for one magic hour on a summer's evening, a weary nation would pause and reflect, and each man and woman would remember how the world once looked and smelled and felt and how nice it was to draw such supreme comfort and security by the simple act of putting one's hand into the hand of a father or mother.

--The Gold Coast by Nelson DeMille

I like this quote. While written in a fiction book years ago, it certainly seems to fit now. I read it and I want to hold Naomi and Jonah's hands so bad that it hurts. I want to pick them up and squeeze them tightly and let them know that I love them and I hope and pray that they never have to leave home for months on end because of war. I don't know how this war will end. I hope that we will leave this country better than we found it. I hope that we, as a country, will have learned something about ourselves and our place in the world.

I will not digress into too much politics here, but here is something else that I hope we learn as a country (and this applies to almost any issue of the day: war, taxes, health care reform): I hope we can come to some sort of understanding that just because someone is from a different political party does not automatically mean that their opinions are wrong. If you work on the assumption that every word coming from opposite side of the political aisle is false or designed to harm America, then your natural response will be to get your hackles up and attack when they say something. I'm a radiologist. I make my living by discerning between a multitude of shades of gray on images. Guess what...that's what life and politics is like. Nothing is ever as black and white as the different political parties would have you believe. The fringes of the parties would have you believe that...but they are fringes for a reason. Unfortunately, it's the fringes that yell the loudest and get the most air time because sensationalism sells.

Politics and the incessant bickering that goes with it makes me tired. I get tired of how worked up people get about it. No one seems to get that worked up by the fact that we've been at war for over 8 years, 5400+ dead, thousands more injured. Yet, people would rather yell and scream about how the other political party is evil and anti-American and those are the more benign terms.

OK, I digressed into politics. But for me, that's not what is important. Here's what is important: I want to see my kids. I want to hear them giggle and laugh. I want to hold their hands. I want to hear our dog snore. I want to be a family again.

Terror Alert.

I'll admit, some of the topics I write about aren't cheerful. The lyrics from "Sunday, Bloody, Sunday" by U2 were stuck in my head recently: "I can't believe the news today, Oh I can't close my eyes and make it go away." All that being said, all it takes is looking at the beautiful photo collages that the Gibbons family sent me to make me smile.

So, in the spirit of smiling and happy thoughts, I pass along the following response to a recent terror alert. This information was given to me by one of my Australian colleagues, so it's got to be true.

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The British are feeling the pinch in relation to recent terrorist threats in Islamabad and have raised their security level from "Miffed" to "Peeved." Soon, though, security levels may be raised yet again to "Irritated" or even "A Bit Cross." Brits have not been "A Bit Cross" since the blitz in 1940 when tea supplies all but ran out. Terrorists have been re-categorized from "Tiresome" to a "Bloody Nuisance." The last time the British issued a "Bloody Nuisance" warning level was during the great fire of 1666.

The French government announced yesterday that it has raised its terror alert level from "Run" to "Hide." The only two higher levels in France are "Surrender" and "Collaborate." The rise was precipitated by a recent fire that destroyed France's white flag factory, effectively paralyzing the country's military capability.

It's not only the French who are on a heightened level of alert. Italy has increased the alert level from "Shout loudly and excitedly" to "Elaborate Military Posturing." Two more levels remain: "Ineffective Combat Operations" and "Change Sides."

The Germans also increased their alert state from "Disdainful Arrogance" to "Dress in Uniform and Sing Marching Songs." They also have two higher levels: "Invade a Neighbor" and "Lose."

Belgians, on the other hand, are all on holiday as usual, and the only threat they are worried about is NATO pulling out of Brussels.

The Spanish are all excited to see their new submarines ready to deploy. These beautifully designed subs have glass bottoms so the new Spanish navy can get a really good look at the old Spanish navy.

Americans, meanwhile, are carrying out pre-emptive strikes on all of their allies, just in case.

New Zealand has also raised its security levels from "baaa" to "BAAAA!" Due to continuing defense cutbacks (the air force being a squadron of teenagers flying paper airplanes and the navy some toy boats in the Prime Minister's bath), New Zealand has only one more level of escalation, which is "Shoot, I hope Australia will come and rescue us." In the event of invasion, New Zealanders will be asked to gather together in a strategic defensive position, called Bondi.

Australia, meanwhile, has raised its security level from "No worries" to "She'll be right, mate." Three more escalation levels remain: "Crikey!", "I think we'll need to cancel the barbie this weekend" and "The barbie is cancelled". There has not been a situation yet that has warranted the use of the final escalation level.

End of message. End of broadcast.

Playing God.

So I ask you; when someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn't miscarry or that their daughter doesn't bleed to death or that their mother doesn't suffer acute neural trama from postoperative shock, who do you think they're praying to? Now, go ahead and read your Bible, Dennis, and you go to your church, and, with any luck, you might win the annual raffle, but if you're looking for God, he was in operating room number two on November 17, and he doesn't like to be second guessed. You ask me if I have a God complex. Let me tell you something: I am God.

--from the movie, "Malice"

I am going to tread very gently around this topic. There are many things I want to say about this subject but because of where I am and the uniform I wear, I cannot. I will simply say this: None of us here like playing God. It is not something we take lightly. But sometimes, yes, sometimes we have to do things for the greater good. Our medical system does not always mesh with the local medical system. That is reality and that is out of our control. When we have to make hard decisions regarding patient care, know this, it hurts and we hurt. It just sucks.

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Onto less troubling topics.

I had the absolute joy this week of learning to play a new sport: Cricket. Some of our Australian counterparts brought out a portable pitch and all the equipment and then I think they mostly laughed at the antics of the silly Americans. There are many people here that say that was one of the most fun days they've had on deployment. Funny thing, I think back to playing Ultimate in Philly at the Edge and seeing the Cricket match going on next to us. I have most of the rules down now, if I ever make it back there then at least I can watch them play and understand what's going on! It really was a blast! And then to top it all off, the Aussies invited us over to their compound for a BBQ on Saturday night. Hey Ruth, maybe we should move to Australia!

Speaking of Ultimate, played another good game of it today. It was made all the more enjoyable by the chance meeting of a Canadian who clearly has played. The game becomes much easier when you have someone else who knows what they are doing. OK, and it also helps us win. And, as anyone who knows me and my slightly competitive nature, winning beats losing.

Here's what I'm going to miss at home: Naomi losing her first (and maybe more) tooth. Of course, if Ruth has her way they will all stay in until I come home. I've commented before on the magic that is Skype - well now I'm hoping I get to see a tooth come out on Skype! I try to get Naomi to wiggle her teeth for me which usually results in lots of giggling from Naomi and Jonah! The laughter of a child is tonic for whatever ails you. I could listen to Naomi and Jonah giggle forever. It makes my heart happy.

Rage, rage

Do not go gentle into that good night

by Dylan Thomas

Do not go gentle into that good night,

Old age should burn and rave at close of day;

Rage, rage against the dying of the light.

Though wise men at their end know dark is right,

Because their words had forked no lightning they

Do not go gentle into that good night.

Good men, the last wave by, crying how bright

Their frail deeds might have danced in a green bay,

Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,

And learn, too late, they grieved it on its way,

Do not go gentle into that good night.

Grave men, near death, who see with blinding sight

Blind eyes could blaze like meteors and be gay, 

Rage, rage against the dying of the light.

And you, my father, there on the sad height,

Curse, bless, me now with your fierce tears, I pray.

Do not go gentle into that good night.

Rage, rage against the dying of the light. 

This poem was read to us at morning report by one of our departing British doctors, Dr. Richard Cantelo. There is something about the reading of a poem (with a fine British accent) that speaks of fighting against death in a war zone, where young men and women do die, that is so incredibly moving. I've seen a heart that was not beating for several seconds suddenly start. We've all seen patients with injuries that at first blush seem incompatible with life, only to watch the patient "rage, rage against the dying of the light." As I said in my last post, it is awe-inspiring. I hope and pray that those young men and women who do succeed in raging against the dying of the light, continue raging because many of them will need every bit of emotional strength they can muster as they continue the healing process. I hope and pray that they have the support systems in place to help them and their families. We, as a military and as a country, owe them that.

The days are getting longer. The mornings aren't so cold. I love spring. I love the grass and little flowers that are trying to grow in a dusty, unfriendly environment. I love that it is March. Because if it is March then that means NCAA conference tournaments followed by March Madness. Not sure that there is a more perfect sporting event. This will be the first time in decades that I will not be watching many of the games live. I'll manage, but not sure the anxiety and excitement will transmit in quite the same fashion with the automatic 30 second refresh on the ESPN home page!

With spring comes rain. With rain comes mud and puddles. With puddles (or as we affectionately call it, Lake Kandahar) comes the opportunity to skip stones. It's the little things in life...