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.