Destiny disrupted

"Gossip, stories, jokes, rumors, historical impressions, religious mythologies, products, and other detritus of culture flow along with traders, travelers, and conquerors. Trade and travel routes thus function like capillaries, carrying civilizational blood. Societies permeated by a network of such capillaries are apt to become characters in one another's narratives, even if they disagree about who the good guys and the bad guys are."

from Destiny Disrupted by Tamim Ansary.

Quote from a book I'm currently reading about the history of Islam. Pretty good read. I like the way the author puts words together. I'm about to get to my favorite part where the Mongols come through raping and pillaging (OK, I did just read historical fiction about that so I'm intrigued to see how a Muslim historian describes those events).

Coalition forces have been in this country since 2001 and will be here until...pick a date. I wonder what lasting mark we will make on this country. How much of our detritus of culture will remain after we're gone? From a medical standpoint, we're providing care to local nationals that is light years ahead of what they've ever experienced. This is both a blessing and a curse. On the blessing side, we're able to save people who would have otherwise certainly died. On the curse side, we save them and leave them with chronic medical problems that require years and years of follow-on care, care that is likely not available. Hmmmmm, is that really saving them? Likewise, we try to teach them how to use the latest and greatest technology (OK, not latest and greatest by US standards, but certainly by local standards), with the knowledge that they don't possess the same technology. Or if they do, they probably don't have the service contracts to keep it running. Example, we're being asked to teach them how to read CTs. There is only one, yes 1, CT scanner in this country that is not owned by coalition forces. Perhaps if we spent more time on simple sanitation and preventive medicine issues...ahhh, but those decisions are not for me to make.

Switching topics. Got some spectacular pictures from home this week of the snowstorm in Virginia Beach. An unexpected snowstorm is one of those happenings that brings a smile to kid's faces like few other things. This also fits into my appreciation of seasons. The changes in the weather both mark the passage of time and give us more appreciation for the surprises of nature. Ruth's profile picture on Facebook is beautiful. Beautiful wife, beautiful kids. I wish I was there.

Day after day of sunny weather here. I'd settle for a snowstorm. That being said we did have thunderstorms and hail last week. Of course we also had more rocket attacks last week. I don't like those kinds of things falling from the sky.

Greater love...

A young Marine. Dressed in full body armor. The sheer randomness of shrapnel from a suicide bomber means that somehow several pieces managed to go into unprotected areas of his neck and shoulders, and most damaging, under his helmet into his brain. Bleeding in his neck and shoulders, bleeding and swelling his brain. CPR is being performed as he is wheeled into our OR. Through the work of the surgeons and myself we stop the bleeding in his neck and shoulders. The neurosurgeon steps in and does his part. It's out of our hands and we step back to see what happens. The simple question is this: is the damage to his brain too severe? By damage, I mean from the shrapnel itself as well as the secondary injury to a brain that occurs when you require CPR (because the brain does not receive as much oxygen in that situation). Things do not go well overnight. Swelling in the brain progresses. He is put on a medevac plane home. It is highly unlikely that he will survive. The hope: he can make it home for his family and organ donation.

I have the organ donation block checked on my driver's license. I've never really given it much thought. Now the goal of our medical system is to keep this Marine alive so through his death others can live. I don't know how much organ recipients know about the donors. In this case, I hope they are told the full story. I hope they know that some young man left home to go fight in a war so that they could "sleep peacefully in their beds at night because rough men stand ready to do violence on their behalf." And because he did that, because he made the ultimate sacrifice, they are the ones who benefit. I also hope they know that there are people all along the medical chain who really wish it had not come to this. I am sure they have a serious need for the organs they will receive, yet all of us would rather he kept them. If you haven't figured it out yet, we don't like failing. It hurts. I know, it pales in comparison to the pain his family will experience, but nonetheless, it hurts.

Where have I heard this story before? Oh yeah:

Greater love hath no man than this, that a man lay down his life for his friends.

John 15:13

Dorsett, success and strange times.

The week started by getting our New Year's card in the mail. Wonderful pictures of the family, including a picture of Naomi and Dorsett, the dog we lost last year. Most people know that was a big loss for us. So, here I am far from home, thinking about that dog and I'm reminded of the following piece from a book I read right before we put him to sleep. The book is written from the dog's perspective and is highly recommended if you are a dog person. Be forewarned, you may cry.

“In Mongolia, when a dog dies, he is buried high in the hills so people cannot walk on his grave. The dog's master whispers into the dog's ear his wishes that the dog will return as a man in his next life. Then his tail is cut off and put beneath his head, and a piece of meat or fat is placed in his mouth to sustain his soul on its journey; before he is reincarnated, the dog's soul is freed to travel the land, to run across the high desert plains for as long as it would like.

I learned that from a program on the National Geographic channel, so I believe it is true. Not all dogs return as men, they say; only those who are ready.

I am ready.”

From "The Art of Racing in the Rain" by Garth Stein

On to other things. I wrote sometime ago about the little girl who had lost one leg after stepping on a landmine and her family was really hoping we could save the other leg because a female in Afghanistan missing both legs is absolutely shunned (as opposed to the relative shunned world they normally live in!). Well, she came back recently sporting her new prosthetic and was able to walk a few steps without support. The fact that her other leg was able to be saved is a direct reflection of our orthopedic doctors and hospital staff. This is one of those success stories that doesn't end up on the news. If winning wars like this is about changing the minds of individuals, we can only hope this made a small impact. Regardless of the outcome of this war, this will always be a success.

It's a beautiful January day. You and your friends are hanging out trying on the latest in suicide bomber vest technology...and it accidentally blows ups. 8 injured. 2 severely. Those 2 come to our hospital. Well, if this isn't one of those ethical dilemmas that you talk about in basic med school ethics...OK, we never really covered this situation. This is a little different from the injured Taliban that we take care of when they are injured in combat. These guys were planning to die anyway, while hoping to take some of us with them, and now we're supposed to save them? From the medical standpoint, the right answer is what we did - treat them and try to help them. From the military standpoint, we should have just left them out on the tarmac to die, and part of me wanted to do that...because once they enter our hospital we are required to care for them. Yet, also from the military and public standpoint, we are obliged to treat them lest the Taliban propaganda machine turn this into a story of how the American medical system is killing them. What a strange situation.

2010

A new year. Finally get to turn the page on my calendar that I bought at the Canadian exchange. The picture above is the first image on this calendar. If you're looking for heroes from this war, I'll always cast a vote for the medics that fly into hostile territory, often under fire, to bring back the wounded. They do everything in their capacity to keep the person alive in the hopes that if they can do that, then we can do the rest. Many times they are right and we can save the person. Sometimes we can't. When we can't, while we all feel loss and hurt, which is a combination of feelings stemming from hating to see another young person killed and also from the simple fact that the vast majority of us in this line of work really don't like to fail, I suspect that the medics feel the loss in a much more visceral fashion. They've just put their life on the line to rescue a soldier from the field...they did their part...sometimes our part is not enough.

My business has been picking up. Have got to do arteriograms on severely injured people recently, both for diagnostic purposes (to aid the surgeon in planning their procedure once they know the artertial system looks like) and interventional purposes: stopping bleeding. The two most recent: one of the bad guys shot in the leg with arterial bleeding - found the source and placed some tiny coils in the artery to stop the bleeding. The second: one of our guys with a traumatic aneurysm (actual term: pseudoaneurysm; let me explain, no there is too much, let me sum up. Oh, never mind, too much medical info) of his vertebral artery (one of the arteries that goes to the brain) from a piece of grenade shrapnel. The aneurysm ruptured during the case with expected bleeding and racing hearts (ours and his!). I coil embolized it in a short period of time and he did well. His CT the next morning showed that his brain looks normal and he'll likely be fine. Time will tell.

So here's the thing, the chance for me to be over here doing good work comes at the expense of life and limb of our young men and women. I believe that is the definition of a mixed blessing. I expect I'll have more chances to practice my trade over the next several months as the surge rolls in. I pray that we are able to do enough. Time will tell.