Driver's Training

Today started out pretty rough. I was up all night at the bedside of an 8 yo local national boy who's pick-up soccer game had been interrupted by a rocket attack. He came in from Asadabad after an operation which removed part of his colon and part of his small intestine in addition to correcting his pelvic fracture; when he arrived, he had an open abdomen and, while stable, was quite sick. He ended up going to the OR overnight, but even afterward required constant resuscitation. Ultimately, he ended up getting about 15 doses of blood products, but he was clinically better in the morning than when he arrived last night.

When I left the hospital, I was exhausted, and ended up sleeping until I had to report for training on the MRAP. As some of you may know, MRAP stands for "Mine Resistant, Ambush Protected" - it's the type of vehicle used here in Afghanistan for convoy missions (including patient evacuations). There are several different types of MRAPs, but the one I rode in could be configured to seat up to 8 passengers, or 1 litter patient plus 4 walking patients. It has a turret at the top for a gunner as well. It's a pretty complicated vehicle, much more complex than the humvees of the past. For example, it has a hydraulic back door which will take your fingers clean off if you're not careful! It has an intercom system, a fire retardant system, and a music system - just kidding, no music, although we were able to connect our iPod to the intercom to play music through our headsets. :) These little buggers cost around $500,000 each, but the advantage is that (according to my NCOIC) no one has ever died in an MRAP. It's a small price to pay for the security of the troops.


We got to the other side of the base, and the NCOIC asked if we wanted to drive. Eek! At first, I thought he was kidding, but ..... no, he was serious. So I got behind the wheel of thd 36,000-pound beast, and drove up and down hills and through a dust storm. The vehicle doesn't accelerate very well, but it does stop (almost) on a dime. I was surprised how easy it was to drive, considering its hefty size and shape. It was really pretty fun!

When It Rains, It Pours

I posted a couple months ago about how mail works over here in Iraq, which is really a "best effort" extension of how it works back home; the military post offices here collect mail from us and inject it into the mail system at home, and from there we wait the requisite time for delivery. Priority Mail, for instance, takes 2-3 days normally, so if we use it over here, it is however long it takes to get to the US, plus that 2 or 3 days. Getting mail from the US to here works the same way, only in reverse, with mail addressed to my ZIP first getting delivered to the Army, then flown here by them or a contractor on a best effort basis.

I mention all of this because I got four packages today, some of which have postmarks from two weeks ago!!

So, without further ado, the first package I got was:


Shoelaces. I opened this one on the spot at our supply office, since I got an email that an order came in. Yes, I really got a plastic envelope with two sets of shoelaces in them (bootlaces to be more precise). The Army set up this system to replace uniform-related stuff in country that wears out and ... (ok, I think no one cares about the shoe/boot laces).

I took the laces and went back to my housing unit, where I discovered my roommate, Bob, had picked up my mail for me - the other three packages, which I did not know were waiting for me at this point. He reminded me as I gleefully started cutting them open that he recently carried a large metal pole for some distance, which was currently providing us Internet (I knew I would not live that one down for a while ...). I assured him that if these were what I thought they were, I could repay him in spades!

So, the second package was:




SALSA!!! Yes, like the "precious" One Ring from Tolkien's classic, I knew it immediately when I saw the lids of the iconic jars Tonya picked in which to "can" them. I spent a few minutes telling Bob the importance of what I held in my hand, the history behind Tolteca, and how I could not get this salsa even when I was in Maryland. I guess if you are outside of driving distance from Tolteca, you might as well be on the moon if you are trying to get salsa there. Yet, here was a jar, in my hand.




The verdict: it was still good! Obviously, I did not have a reference dish of salsa to do a more scientific comparison, but really, it tasted great. I guess I don't necessarily want to know if there's supposed to be a difference when you perform the canning process if I can't tell as I'm devouring it. Still not convinced himself, Bob took a taste:


... and score another one with the broad side of the chalk for Tonya and Tolteca (but I'm still not forgiven for the metal pole incident). In all, she sent 12 of the jars, which hold a reasonable sitting's worth of salsa (probably about 2 dishes in the restaurant), and rationing it out I go through about a half-jar at a time.

The third package was another bag of chips from Tonya, pictured to the left in the next photo. That brings my stock to three bags, which each supposedly have around 220 chips.

The fourth package was yet another huge surprise ... a birthday party kit from Kathy!


Yes, that is a cake in the middle of the box, and the jar to the lower left is frosting. There are a couple of containers of "drizzle" in there too, which I guess is supposed to go on top of the frosting from what I read of the instructions. There are plates, candles, and little confetti, all emphasizing that it will be the "Big 3-0" for me in a couple of days. I'm leaving it as sealed as I can until Friday, when I will decorate a little, borrow a lighter from the smokers next door, and do a field-expedient birthday celebration!

One of the best parts of the kit was the DVD with pictures of Kathy and Matt making the cake - there are a few pictures of John feeding Matt lunch and getting him ready for the hard afternoon of quality testing (what other expertise does a guy with cheeks like that have?), then the lunacy of baking a cake with a 17-month old is chronicled in a series of pictures of Kathy and Matt working at the island in her kitchen. There were about a dozen prints, which I taped to the wall by some of the other pictures.

There were also Kathy's classic baked goodies in with the kit, which did not make it quite as unscathed as the cake and the salsa:


The Oatmeal Carmelitas on the top shelf and the Poppy Seed Bread on the bottom right didn't get mushed, they got baked more! It has been around 105-110 here for the past week or so, and the postmarks on the boxes indicate they've spent at least two in transit. I didn't see anything wrong with the OCs or the bread, so I put them in the fridge to firm up a bit. Bob thinks that aside from sticking to the bag a bit, they're going to make good midnight snacks (we are flush with things like microwave popcorn and small candies, but these are a meal!). The Pumpkin Bread on the lower left made it just fine, albeit a bit warm, so it's going in the fridge for a bit too.

Whew! What a great birthday I'm going to have in a few days!! Thanks Tonya and Kathy!

P.S. By the way, thanks for making the runs to the Post Office, John ... I noticed the customs forms mostly seem to have your name on them!

One Jar of Salsa Short of a Fiesta

I got a box in the mail today from Tonya ... no description of the contents ... they were obviously well-padded ...


... but not salsa :(

Maybe a month ago, Tonya posted a shocking but fake account of my favorite restaurant in the world burning down. I usually read the OIT blog entries with great interest, but that day I read with disbelief until the punch line at the bottom. She was then gracious enough to reveal she planned to can some salsa (one of the reasons La Tolteca is at the top of my list) and send it.

I had such high hopes this would be "the package"! I knew the cilantro and onion-flavored nectar of the gods (Tolteca salsa) was on its way, and I overlooked the rather even weight of the box in my zeal to open it. With Tonya's return address on it, it could only have been one of two things: chips or salsa.

Knowing Tonya, that means the next one is probably going to be a cylindrically-shaped rock, well wrapped, and in a box just big enough for a couple jars of salsa. It's the box after that which will make all the waiting worth it!

(Thanks for the chips, Tonya; they're sealed until the main event!)

Chasing the Jackal

I can Skype.

I've actually waited about four months to say that! I finally got an antenna rig for the one ISP on Camp Victory, "Jackal", that allows you to use programs like Skype, BitTorrent, online gaming, and some other less savory yet high-demand online services. The one that I had been using, "Magic Island" or "MIT" (Magic Island Technologies), worked much like you might use a hotspot in a Starbucks - they have wireless access points all over the place, and if you are close enough to one, you connect, pay, and surf. The trouble is, MIT is in bed with the military, and it polices what you do on the network. In the case of the less savory things you can do online, it is to be expected, but they also cut off Skype, gaming, and other fairly benign things in the name of security and conservation of bandwidth. Despite this odious policy, since you don't need a crazy antenna to get their service, they get a lot of users who aren't willing to go on an epic quest to connect.

The antennas are available as they come into country, and you have to sign up with Jackal before they will order one. For $150 ($75 deposit, $75 for the antenna to keep as long as you need), you get on a waiting list that is at least a month long. When it comes in, you have to find some kind of mast, pole, or long piece of wood to mount it on, then set it up to point to one of several Jackal motherships. I was able to get one secondhand for $100 (but it's not eligible to be returned for its deposit ...), complete with a sturdy metal mast and a fairly long cable. I thought the guy who sold it to me lived only a couple housing units down from mine, so I asked my roommate Bob to pick it up for me on his day off - the guy selling it was trying to get out of Dodge quick (no pun intended - I live in a housing area called "Dodge City North"). It turned out he lived more like 20 housing units away. It'll take a few more weeks to live that one down.

Hopefully I can start getting into the weekly Skype routine everyone has been running for several months now!

Of course, pictures always help ... here are some of the install:

This is the antenna itself, known as a "Subscriber Unit" (it's WiMax technology). The guy who sold it to me gave me the metal pipe it is attached to as well.

We set it up to lean against the 12-foot concrete walls that surround our housing unit (bottom right). I used nylon cord to attach it to the concrete wall; there are a couple of rebar loops built into the wall to allow forklifts to manipulate it.

There wasn't much room between the wall and the housing unit for me, let alone the ladder ... oh well, war is hell.

Bob, watching me risk my life on the ladder from the ground, still not amused about having to carry the immense metal pole a quarter mile (or more)!

That's it! We ran the cord from the wall (in the background) to our window, and we got unrestricted Internet!

Stamina

Tuesday's Playdate...

Aunt Tonya has the stamina of a marathon runner. She decided to have all 4 cousins over all day. First, she woke at dawn for the excursion to pick up Matt, who I heard slept in the carseat.

The kids played with balloons and toys in the morning and about 10AM were hungry for lunch (getting up at dawn throws your schedule off). Then we had a painting party at Aunt Tonya's - thank goodness Uncle Michael was willing to do the clean up! The girls had the hang of painting down. They made a tic-tac-toe board, hopscotch, painted their footprints, you name it. Zach pretty much ate the paint (safe) and Matt got painted by everyone (particularly Aunt Shannon). I love the look of green toes on a toddler!

Matt was a little monkey and climbed the play equipment even using the big kid rungs as opposed to the easier, larger wooden steps. He went down the slide forwards, backwards, side-ways... And he enjoyed playing in the gravel, putting it in buckets.

The water table and pool were a big hit and helped expedite kid clean-up. Ashley and Kate took turns spraying each other and Zach pretty much had a temper tantrum. Not sure why he was so fussy but he does have molars coming in... Aunt Tonya organized, refereed everything and cleaned up. Like I said, she had more stamina than I could muster. Then it was baths, snack time, quiet time with cartoons and naps.

The girls have the largest playroon I've ever seen despite the fact that the toys had recently been culled and donated (but don't tell the girls they're missing anything!). Of course the playroom was fun for all the kids including the teeter-totter - even Aunt Shannon had a ride!

Fajitas were made for dinner complete with La Tolteca salsa. It goes without saying that everyone enjoyed it (except Zach who was still fussy and refused to eat). Grandpa Frank, Tita Loretta and Uncle Michael joined the kids for dinner. After dinner included climbing up and down the stairs, get to the landing and turn around again. Amazing what will entertain toddlers and the big kids cheered them on.

I was wiped out but Aunt Tonya still had the stamina to clean up and serve desert. Kate made special homemade vanilla ice cream with fresh berries. It was a hit. Zach was fading fast so we had to give hugs and kisses and get out of there. But I'm sure Matt hung out for a little longer to climb up the stairs some more and play with the girls' toys. Grandpa Frank and Tita Loretta took him back to Glendora for bed.

It was a great day but a tiring one. Remind me not to have another kid any time soon! Zach is all I can handle for now...

Pictures can be viewed here:
http://picasaweb.google.com/mtsadsad/PaintingParty?feat=email#5335164775680663842

Zoo Crew, Part Deux

Seems like Matt is becoming an expert on the attractions at the LA Zoo...

Uncle Chuck took the boys for a field trip. His post is coming soon with many funny antics.

Pictures of the trip can be viewed here:

http://share.shutterfly.com/share/received/detail.sfly?sid=0AcuWzZy0aMmT3A&imageIndex=1&fid=4c3a55354713283b

Fighting for Life

Yesterday was a rough day at Craig Joint Theater Hospital in Bagram. Just after lunch, we were barraged with 6 trauma patients, 2 of which were critically injured and went to the operating room immediately. (Their injuries ranged from a severe pelvic fracture with broken bones in both feet to a simple head laceration; I orchestrated the resuscitation on a mid-level patient, one with a spinal fracture.) Before we could even get all the patients out of the ER and onto the ward, there was a 2-soldier trauma and another 4-soldier trauma. All but 1 of the 12 trauma patients were Americans. Thankfully, all of the soldiers survived the night, and all of them that require transport will be in Germany by tomorrow.

The pace at the hospital has been picking up, which is to be expected during the summer months here in Afghanistan. Last year, there were around 240 surgeries in the month of April, 280 in May, and 300 in June. (That's a whopping 10 surgeries per day!) I would anticipate that with the new troop surge, we might even surpass these numbers in the summer of 2009.

In thinking of yesterday's trauma patients, I remembered a documentary which was screened for USUHS students and faculty in the spring of 2007. It's title is "Fighting for Life", and James and I went to the screening and the reception that followed. We both agreed that the film was superb, and I will even admit to shedding a tear or two. It tells the stories of doctors, nurses, and patients at the combat support hospital in Balad, Iraq, and in the case of the patients, follows their stories to Germany and to the United States as they are treated for their wounds.

When I initially saw the film, I never imagined that I would be one of the physicians caring for these wounded troops. I'm not sure why - I was a 2nd year resident at the time, and it should have been obvious that I would be deployed in the next few years. But I guess I was so emotionally caught up in the film that I didn't see myself in that role.

I would recommend the film to anyone interested in the life of a physician in a war zone, anyone interested in military medicine or medicine in general, or anyone supporting a soldier, sailor, airman, or marine in the current world conflicts in Iraq and Afghanistan. It is truly enlightening.

The documentary has been available in limited release in movie theaters around the country, but next weekend, for the first time it will be broadcast on national television. For most, it will be on PBS between May 23 and May 26th. (In southern California, it will be on channel 28 [PBS] on Saturday, 5/23, at 10PM; in Phoenix, it will run on Sunday, 5/24, at 10:30PM.) It will also be available after the TV broadcast for purchase on VHS and DVD.

Find out more about the movie and find your local listings here.

These are some snapshots from the film:

Tolteca's Revenge

By now, you know about James' obsession with this little family-owned Mexican restaurant in Azusa. You also probably read Tonya's account of the fake Tolteca Fire and her idea about canning their ultimate delicacy: salsa. (Or read about it here.) The canning apparently has been accomplished, but at quite a price! All I have to say is this: Tonya, when you reported that a fire had destroyed James' beloved restaurant, the Gods were out to get you!

Enjoy Tonya's recent email to James and me:

Primary Issue: We have a flat of canned salsa packaged and ready to be mailed. Will send ASAP. This is my first attempt at canning so if any jar arrives broken, cracked or leaking or if the seal does not pop when opened - the jar must be discarded. Enjoy!

Secondary Issue: I went to get the salsa after dropping Matt at home. Pulled up to the building and what do I see? The building is closed, abandoned and tagged beyond belief. It has been closed for so long that the only word that remains on the window is "closed". There rain, wind and taggers have eradicated the rest of the message. The interior is gutted. Weeds grow through the cement cracks. My only thought: OMG! I am sitting in a traffic lane not moving until a car horn behind me brings me back to my senses. Pull the car around the one-way block and park in front of the building. Now, I have my second thought: I was just kidding....Really, it was just a joke. It's my turn to breath, just breath and start problem solving. First step is calling information and see if there is a new number. I get the telephone number that actually connects and I breath in relief. Now on to the next set of problems: Kate is muddy and crabby. Ash is sleeping and covered in sticky strawberry juice. We are in Glendora. It's already late afternoon with rush-hour traffic. Mom is coming in two hours for dinner and to help me with canning. I will be driving to the new location that is who knows where.

Man answers the phone and I confirm that this is the same Tolteca that was located on Azusa Ave. Ask him to give me directions from the old location and tell him that I have a pen and paper ready. He laughs and laughs. I know that I'm doomed - he's going to tell that the new location is in Palm Springs, San Diego, Barstow or some other unreachable location at this hour. Then he gives me the instructions: Look up the road 100 yards on the left. You will see the 10ft tall letters spelling "Tolteca" in bold print. Parking is under the sign.

Touche'.

Here is the sign with the 10-foot tall letters. Hard to miss, eh?

The two pictures that follow depict two recent exploits at Tolteca. The first (with James in uniform) was taken immediately upon his arrival for R&R - it was the first place he wanted to go! The following picture was taken the last time James and I went to Tolteca, and it was the first visit that Zach and Matt made there together.

Learn more about Tolteca's rich history and glorious food. Or, check out pictures of the beautiful new location that Tonya had difficulty finding! Next time she goes there, perhaps she'd like some driving directions?

Caper at Vons Supermarket

This recent story was relayed orally by Matt's Grandpa Frank via skype session. I asked him to put the shenanigans on paper for all to enjoy!!

Matthew is strong for his age. One learns this when trying to pry his hand off something he doesn't want to give up. The grip he musters when climbing things is particularly impressive. Most impressive is his recent Caper at Vons Supermarket.

Matthew and I have a daily patrol involving a number of routes and places that need checking. We now have a coterie of dog friends, shop keepers, joggers, relatives with offices downtown, and those who ooh and ahh over Matt's classic looks and cheerfulness. Our favorite place is the supermarket, because their shelves have a lot of interesting stuff.

So there we were, tooling down aisles looking for some action when the pickle section appeared. I thought I might want some dill pickles, so I parked Matt and his stroller immediately across the aisle near the mayonnaise. Over the years I have developed a number of defensive protocols, one of which led me to place Matt a good 12 inches from the jars of mayonnaise. This put them barely within his reach. In any case they were too large and too heavy for him to get off the shelf. I felt it was safe to turn my back while I scanned the pickle offerings.

I decided against the pickles and turned to the stroller. There was Matthew, about to put his finger in an opened jar of mayonnaise! I reached with all my considerable swiftness for his hand, and got it just before his finger sullied the mayonnaise. He looked up at me with an expression of alarm, and I'm sure he was thinking, 'Get your own jar of mayonnaise.' In restoring the lid to it's rightful position, I noticed that to remove the lid one had to break a fairly thick plastic neck ring. The bottle was heavy, as expected, and the lid quite large in relation to his hand size. I think one really had to be there to appreciate the strength needed to do what Matthew did.

There have been other supermarket adventures. Matthew likes to have items he can stash around himself in the stroller. Hence, we usually get an orange and apple to carry around while we are in the store. The apple quickly gets a battle scarred look, as Matthew leisurely nibbles at the shiny red skin. The other day we got a large acorn squash and a small watermelon at the same time. After a while, Matthew began to feel crowded and he threw the squash out. On picking it up, I noticed a slight split, so we had to buy it. No real problem, as Tita used it to make her legendary 'squash and chicken' dish. I managed to get the watermelon just before it met the same fate.

On another occasion Matthew got hold of two string beans. When we got to the checkout counter, one bean had been badly wounded and the other showed signs of bite marks. The manager graciously did not charge us for these items.

Further additions to Matthew's second year resume' will be reported as they happen.

Thanks, Frank, for this addition to our ever-growing blog!

Happy Mother's Day!

Hi Mommy~
Happy Mothers Day!
I LOVE YOU.

Happy Cinco de Mayo

Cinco de Mayo was celebrated by picking strawberries at Cal Poly Pomona. The university (Uncle Chuck's alma mater) has a large U-Pick strawberry field that welcomes kids and parents (or aunts) to pick the berries.

Zach and Matt spent most of the time running in the mud and eating berries and dirt. Kate and Ashley understood the concept a little better and actually picked large, sweet RED strawberries. Turns out some were small and green but we picked those too!

After the strawberry picking was farm races. We ran up and down the fields getting dirty and sweaty. Matt enjoyed crawling up and down the stairs. He is becoming really mobile. He has great dexterity and said "up" when he went up the stairs.

By this time everyone was hungry despite eating half the strawberries we picked. Totaling $10 worth of berries for young Uncle James to eat! We corraled the kids and managed to escape the heat at Chick-Fil-A. This is a local fast food chain one step above McDonalds. They offer nutritious chicken selections that are a little less greasy than most fast food. The kids seemed to enjoy their nuggets. Which were scarfed before rushing off to the play place. Kate and Ashley climbed on all the equipment including the windy slides. Matt was able to climb up and down the big kid stairs and spent the entire afternoon navigating the equipment with speed and a HUGE smile. Both aunts even climbed up to chase him! And Zach had fun in the toddler area looking at himself in the wacky mirror and playing with the beads.

Matt says too many words now to count and uses them all in the correct context. He has definitely bonded with Aunt Tonya and wants her in his sight at all times. Especially in the busy restaurant. But as long as she is near he is extremely happy and willing to participate in just about anything. We couldn't wipe the grin off his face until he finally fell asleep on the car ride home!

It was a great day and so much fun spending time with this brood. I think its highlight of the week. Certainly the kids seem to enjoy it even if the moms are a bit exhausted.

Thanks to Aunt Tonya who documented the day with pictures you can view here:

http://picasaweb.google.com/mtsadsad/StrawberryFieldsForever?feat=email#5332475317634800546

Zachary's First Birthday

The cousins helped Zachary celebrate his first birthday. All his friends and family met at the local park for a full day of fun consisting of jumping in the bounce-n-slide that Daddy bought, a Transformers pinata full of candy, birthday cake, more sugar, more sugar, presents and the taco lady! While it wasn't La Tolteca, fresh made tacos certainly hit the spot.


Matt really enjoyed himself on the slide and swings at the park. He was full of energy and ran the length of the park atleast twice with Loretta tailing him. Ashley really whacked the pinata and was able to collect an entire bag full of candy. Kate made fast friends with the other kids and was a great helper with Zach. I wonder if Kate thinks Zach actually belongs to her now? And Michael (without Tonya who was working) looked a little frazzled keeping up with two wild girls.


Zach had a great nap that morning and was wide-eyed throughout the whole day. He allowed everyone to hold and kiss him despite Dad's worries of swine flu. And Zach certainly enjoyed his birthday cake.

James' Lolo and Lola (Grandpa and Grandma) really enjoyed spending time with Matt. Lola said (with accent) "Oooh my! He is a big strong boy!" He almost weighs as much as Lola... well not quite! :) Actually they said he was so beautiful and hope to spend more time with him very soon.

Here are more pictures of the whole day:
http://zacharysfirstbirthday.shutterfly.com

"Freedom don't come free"

"And I will always do my duty, no matter what the price,
I've counted up the cost, I know the sacrifice,
Oh, and I don't want to die for you,
But if dying's asked of me,
I'll bear that cross with honor,
'Cause freedom don't come free.

I'm an American soldier, an American,
Beside my brothers and my sisters I will proudly take a stand,
When liberty's in jeopardy I will always do what's right,
I'm out here on the front lines, sleep in peace tonight."

-Toby Keith, "American Soldier"

Last night I chose to attend a ceremony which I hope never to attend again. It's called a "Fallen Comrade Ceremony", and it takes place on Bagram whenever a US or allied troop is killed in Afghanistan. Most of the deceased are transported by ground to Bagram then flown to the US, and therefore a Fallen Comrade Ceremony occurs here for every soldier killed anywhere in Afghanistan.

The first notice we get of the ceremony is electronic: there is generally an email sent to our Afghan email account announcing the timeline of the ceremony. Before the ceremony begins, the "giant voice" on the loudspeakers across base direct all available personnel to line up, in ACU uniform, on Disney Drive (the main drag through Bagram). Hundreds - perhaps thousands - of soldiers from a variety of countries line the several-mile route and stand silently at parade rest awaiting the commencement of the ceremony.

I was at the very end of the parade route, so I waited about 30-45 minutes for the procession to arrive in my area. There were several large police vehicles at the head of the procession, followed by two pick-up-style humvees carrying two caskets draped in American flags. Each casket had 8 pallbearer escorts at its side. We snapped to attention and rendered a deliberate salute as the caskets passed, then performed an about-face (a formal 180-degree turn) in order to return to our duty locations. It was a solemn and respectful tribute to two US servicemembers who gave their lives so that we may all experience and enjoy freedom.

It also reminded me that this is a war zone, and that people die in war zones. Almost every day, I see severely injured US and allied troops in the hospital, but I have yet to see a soldier die within our walls. (We do everything humanly possible to transport the patient back to Germany where their families are able to see them before they die.) There is certainly a considerable amount of morbidity associated with the injuries suffered by these servicemembers, but the mortality of this 21st-century war is diminutive relative to the injuries sustained; the percent of soldiers who die from their wounds is also far smaller in OIF/OEF in comparison to prior wars like Vietnam and WWII. Since essentially no US or allied soldiers die within our facility, it's easy to assume that the pall of death is absent from this war. However, the more and more frequent Fallen Comrade Ceremonies lately prove that soldiers DO die on the battlefields of Afghanistan before tertiary medical care can be rendered. The ceremonies thereby serve as a reminder to all soldiers that our line of work - no matter how safe or mundane it might seem - is quite dangerous and requires constant vigilence. Clearly, freedom is not free.

Dr. Richards, the "little sister"

Most days at the hospital I feel like everyone's "little sister". There are a lot of very specialized doctors here, and most of the doctors are much older because they underwent more years of training than I did. For example, the pediatric neurosurgeon was in residency and fellowship for ~10 years, and the adult cardiologist was in residency and fellowship for 6 years; my 3 years of residency pale in comparison. While many of my counterparts are recently graduated from fellowship, most have more experience than I do, both in medicine and in wartime medicine. There are only three other docs at my level of experience (two internal medicine and one family physician), and of course they are all assigned to the hospital in the capacity for which they trained. I, on the other hand, am assigned as a general medical officer, a term for a doc of any training who is placed in a position to take care of soldiers. (GMOs do not exist in the Air Force - all USAF docs are assigned to a position in their specialty, whereas even the most specialized Army docs may be assigned as GMOs.) So not only am I less trained than many of my counterparts, but I also am tenuously assigned to the hospital in a catch-all slot - a slot which may be moved at any time to another facility likely to be far less comfortable and far less safe.

All of this contributes to something of an inferiority complex. Everyone else seems to be an expert in their field, while I am a relatively new pediatrician who has primarily been taking care of adults while at Bagram. It is constantly uncomfortable as I struggle to gain the knowledge that the adult docs have spent years upon years learning. Caring for pediatric patients is somewhat different in that I am more capable than the adult docs, but I still rank a distant 4th out of the 4 pediatrics-specialized docs (there is a peds neurosurgeon, a peds surgeon, and a peds ID doc here with me). All in all, there is very little here in which I might be considered an "expert", and I feel that I must always prove my worth in order to be "allowed" to stay at Bagram.

The one (and probably only) thing that I know more about than any of the other docs is newborn medicine. Of course, the other peds docs have done some newborn/neonatal care, but none have cared for new babies as much I have in the past year. (In fact, all I have done since graduation from residency last July is staff the newborn nursery!) Of course, we don't see many newborns in our hospital, so the fact that I can competently care for them is somewhat moot.

Or at least it was moot, until the newborn with the omphalocele was admitted a few days ago. (Read about the circumstances of the admission and his first days in our facility here.)

The pediatric surgeon has been running the show as far as surgical care is concerned, like when to decompress the belly and when to allow the baby to feed. (I completely defer to her for these types of issues, for she has far more experience with babies that have abdominal wounds.) Where I have been able to contribute most is in the area of nutrition for this small baby. We all knew that we would be unable to feed the baby formula or milk for a while after his surgery, and had discussed during his admission the probability of needing IV nutrition (also called TPN, or total parenteral nutrition). Unlike adults and older kids, small babies shouldn't go for days without some sort of nutrition, so when I heard this kid was coming to us, I immediately got to work on a TPN plan.

TPN hasn't been run in this facility for months and months; in fact, no one can even remember the last time a patient received TPN in our hospital. Understandably, there was a fair amount riding on the results of this "TPN trial", and I knew it wouldn't be easy given the lack of pediatric/neonatal resources in the hospital. All we have on the shelf is adult pre-mixed TPN, which has inappropriate amounts of nutrients for neonates. I gathered all of the information from the pharmacy about the pre-mixed TPN and vitamin/mineral solutions and set to work developing a plan. I estimate that it took 30-40 hours to investigate all of the neonatal nutritional requirements and determine if the TPN would even be safe, and an additional few hours to make the TPN the most nutritious possible given the child's clinical condition. Once I had a plan, I discussed it with a neonatal fellow at Bethesda Naval Hospital, who in turn passed it along to their pediatric pharmacist for review. We started the TPN yesterday through an IV running into the jugular vein.

Because of this child's blood sugar requirements, we actually have four solutions running into the vein: the TPN (which is 10% dextrose), some additional sugar water (25% dextrose), some additional sterile water without dextrose, and the fat concoction. It's a very complicated setup which requires vigilence on the parts of the doctors, the nurses, and the pharmacists simultaneously in order to NOT kill the patient.

The first test was the blood sugar: would the four solutions be able to keep a steady blood sugar in the baby? After the TPN started, we checked blood sugars every hour or two, and they remained quite stable. (Today I had to switch around the rates of the sugar-containing solutions a bit, but really it was a small bump in the road and has corrected easily.) This morning was the bigger and more important test: would the solutions provide the appropriate electrolytes for the baby? I nearly let out a scream of joy when I saw that the baby's blood labs this morning were completely normal! The TPN had worked!

This is the first time I have actually felt competent in something since I arrived in Afghanistan. I don't think any of my colleagues know exactly how much work went into developing TPN for this little one, nor just how complicated the plan is (I had to explain to the DCCS - a full-bird colonel and my ultimate boss - why the kid couldn't be transferred to the step-down unit today, and it was a mouthful). Nobody has been patting me on the back; I assure you that I will get no accolades for this achievement. But that's OK with me. It's enough just to see the baby thriving, breathing on his own, and taking a little bit of formula by mouth. :-)