Lessons of a Scorpio

The following is copied from a website which discusses astrological signs. I had a discussion at the end of my deployment about "what it means to be a scorpio", and subsequently did some self-analysis and self-reflection which resulted in the musings of this post.

* The red text was generated by me; the black text originates from http://zodiac-signs-astrology.com/zodiac-signs/scorpio.htm.

Scorpio and Independence:

Scorpios are fiercely independent. They are able to accomplish anything they put their mind to and they won't give up. They are perfectly suited to being on their own. They are not social butterflies like some other zodiac signs and some actually prefer to live on their own that way there is never any issue about who controls what at home, as they like to be in control.

I have, in the past, been a control freak. Deployments in the Army don’t particularly agree with control freaks, since so many details of a deployment are outside of the individual soldier’s control. For example, it took me 10 days to get across the Atlantic to Afghanistan, and 2 days to travel a few hundred miles to FB Lilley. When I was at ROTC Advanced Camp in 2000, I hated the fact that I didn’t have any control over my own schedule, my own personal space, my own food, or anything else for that matter. But I think I relaxed considerably during my deployment to Afghanistan. I’m not sure why, but I’m not so severe of a control freak anymore (at least so far during my transition; this may change!). Perhaps the Army has beaten it out of me. More likely, though, is that I have learned to put time, effort, and passion into the things which will make a difference in my life or the lives of others … and not allow less important things to get to me. My mother has always told me not to allow things outside of my control to “rent space in my head”; I think I am now finally taking that excellent advice to heart.

Scorpio and Friendship:

Relationships with Scorpio are always complicated; just like the person, their relationships are a series of extremes, and they can even be downright moody for no apparent reason. Scorpios are known for their possessiveness and jealousy but on the other hand, they are extremely loyal. They will always remember a kind gesture forever and repay it. Any kind selfless gesture done to a Scorpio will gain trust and respect which is extremely important to them in any relationship, either romantic or not.

Yes, I can be moody for no apparent reason (or, there might be an apparent reason, as those of you who have had the pleasure of dealing with me when I’m hungry have seen). Although I’m not as possessive or jealous as this description might suggest, the narrative is absolutely accurate in reference to my fierce loyal streak. For example, the SF guys at Lilley took good care of me when I joined them in June, and as a result, I vowed to repay them in some way. I settled on becoming something of a liaison in Bagram, helping them to obtain supplies and equipment that they otherwise might not be able to obtain. After my second (very eventful) trip to Lilley, my loyalty and respect for them knows no bounds.

Scorpio and Careers:

Scorpios make excellent doctors, surgeons, scientists and leaders; they are perfectly suited to any form of business that makes a difference in the world, that greatly impacts people and society. Most importantly, Scorpio has to be in a power position: this is why these careers are suited to the Scorpio. They all demand one person in supreme control giving orders and leading a unit of people or practices.

“Impacting people and society” wasn’t necessarily a priority of mine prior to my little vacation in Afghanistan; however, I now realize that “impacting people and society” is, quite simply and accurately, what I enjoyed so much about the deployment. One of my goals has been to make a difference, and in Afghanistan the opportunities to improve the lives of Afghans abound. (I suppose this makes logical sense, for Afghanistan is a third-world country with many societal, governmental, health, and cultural challenges, all of which provide opportunities for intervention and improvement.)

Whether my mission is caring for the children of soldiers who put themselves in harm’s way (i.e. my mission in the states) or caring for the soldiers themselves (i.e. my mission this summer in Afghanistan), all I really want to do is make a difference in somebody’s life every day. My own personal satisfaction is derived from making these small differences in people’s lives, and I am repaid with smiles of appreciation from parents, honest words of thanks from downrange soldiers, and the personal knowledge that I have made the world just a little bit better. I don’t need “stuff” or “things” in return for caring for those who serve this great country – generally their appreciation is payment enough.

Scorpio and Temperament:

Scorpios are extremely ambitious, persistent and determined … and a Scorpio never gives up - they are absolutely determined to reach their goal. The key to their success is flexibility. They are able to re-survey a situation and take a different approach if necessary. This makes them very adaptable and versatile.

The unknown has always been frightening to me; as a self-proclaimed sufferer of OCD (or OCPD), I like not only knowledge of the future, but also some element of control over it. Afghanistan certainly changed my comfort level with regard to the unknown; many aspects of my life were unknown while working at the Bagram hospital. For example, while I would usually know the overnight call schedule in advance, I would never know whether I would admit 2 patients overnight, or admit 22 patients overnight, whether I would get a full nights’ sleep or never see the call room at all. Furthermore, while Bagram was probably the safest base in Afghanistan, the base was attacked with indirect fire several times while I was stationed there; certainly the rocket attacks could never be predicted and we could never be fully prepared. Some soldiers constantly worry about being attacked while in the theater of operations; I was not one of these soldiers. I had to let go of my fear of the unknown – otherwise it would eat me alive, constantly occupy my thoughts, and ultimately compromise patient care.

Scorpios are excellent at restoring order to a chaotic situation and they are just as capable of manipulating for their own greed and benefit. The un-evolved Scorpio is a very dangerous person because they use their powers to benefit only them and step on other people in order to satisfy their own greed.

If there’s anything I have learned during this deployment, it’s that “restoring order to a chaotic situation” is not only an ability of mine, but it is also something I whole-heartedly enjoy. While I have always enjoyed the career fields that involve creating order from disorder (e.g. ICU, emergency medicine), I chose pediatrics because I absolutely love and enjoy caring for children. (Now that I have had some experience taking care of adults again, I am even more committed to pediatric medicine and even more convinced that my choice of patient demographic was correct so many years ago.) I enjoy kids, but I also enjoy the adrenaline rush of an ED code or the chaos of the delivery room when a newborn refuses to take her first breath. Thus I feel that I am at a crossroads: I would like to continue to take care of kids (at least some of the time), but I would also like to participate regularly in the forcible regulation of pandemonium.

There are many options, some of which are plausible and some of which are not. These options include emergency medicine (which would require a 4-year residency in emergency medicine), pediatric emergency medicine (which would require a 3-year peds ER fellowship, which might or might not be supported by the Army), civil affairs doc (who mostly do public health types of missions), SF group surgeon (which would require me to go to Airborne school at the minimum, and would require a complete change of focus to tactical and field medicine), and operational billet (like battalion surgeon or flight surgeon; both positions would require me to give up pediatric medicine).

So where does this leave me? Where am I headed in life with these recent career aspirations? What will the Army allow, and what might be best for my family? These are all questions which demand an answer sooner rather than later. Given that I am now working in emergency medicine and loving it, I think I have a respectable starting point to build these career changes …

Scorpio Deep Inside:

Scorpio is the most misunderstood of all astrology signs. They are all about intensity and contradictions. They like to be aware of a situation and always know what's going on, figuring this out with their probing mind … They are very capable of hiding their true feelings and motivations, as they often have ulterior motives or a hidden agenda.

Scorpios are very emotional. Compared with other signs, their emotions are intensified - both good and bad. Negative emotions of jealousy and resentment are hallmarks of this turbulent astrology sign. On the other hand, Scorpios are well known for their forceful and powerful drive to succeed and their amazing dedication. Scorpios are constantly trying to understand their emotions through finding a deeper purpose in life.

I am far more emotional than I was 6 months ago. I have seen ample death, devastation, passion, poise, tyranny, selfishness, and loyalty during this time. All these emotions were so vivid, unadulterated, and raw that they could never be duplicated. Although I did not experience all of these emotions myself, I was given the opportunity to experience them with and through others; these shared experiences have given me food for thought about the deeper callings in my life and career. This self-reflection – which has been evident on our blog in posts like “Transitions” and “Fear is the best motivator” – is strong evidence of my scorpio tendencies.

Scorpios have a fear of failure that they keep hidden extremely well. Should their confrontation not be successful, or their career fail, they will simply use their adaptive skill to quickly change course and leave the bad experience behind. Do not ever expect them to fess up or share their failure, though, because this shows signs of weakness.

I have often said that I have a primal fear of failure. Nobody really sees this fear; I purposefully camouflage it within a fragile shell of confidence and poise. I know that I have defects in my medical and Army knowledge like everyone else; therefore, I am constantly questioning my understanding of military medicine, and ultimately trying to improve my fund of knowledge. Unlike many docs, I am comfortable with my shortcomings, and do not hesitate to ask for help when patient care hangs in the balance. (Patients come first, far before my fear of failure or concern about the appearance of ignorance.) I don’t let everyone know that I’m not a confident person on the inside – after all, would you like to take your kids to a pediatrician who didn’t sound self-assured? I keep a confident front because I’m supposed to, and it engenders trust from my patients; however, deep down inside I have issues with self-confidence that stem from a deep-seated fear of failure.

Scorpios are very weary about trusting anyone; a person needs to gain their trust but once all the 'trust tests' have been passed, Scorpio loves deeply and intensely. Underneath the cool exterior, energies and emotions are constantly flowing but the Scorpio channels it into useful activities, hobbies, relationships or a career. This is never apparent to the outside observer but knowing this fact explains why Scorpios are so passionate … Scorpios have powerful instincts and they trust their own gut feeling.

It has taken me a long time and much experience to trust my gut. In medicine, I can walk into a waiting room and identify a child who might not be very sick at the moment, but who will in short order become quite ill. Most of the time, I cannot identify anything about the child that gives me this gut feeling; his vital signs, appearance, lung sounds, etc might be completely normal when I first examine him. But when my gut tells me something is awry, I have learned to listen and trust these feelings, even if they do not seem to make sense at the time.

During my deployment, I have learned to trust my gut in more diverse scenarios. For example, after my downrange mission the SF team at Fire Base Lilley was preparing for an outside-the-wire mission (as they do almost daily), but when I got word of the mission, I expressed to one of the team members my gut-wrenching conjecture that something was about to go terribly wrong. We discussed his process for casualty notification (read: notification of family and friends in the event of his death), and because he trusted my gut, he offered to stay at Lilley within the wire while the rest of the team completed the outside-the-wire mission. Of course, I told him that he had to go – his team could not afford NOT to have him – but that he should be very, very careful and tell the rest of the team to do the same. I wasn’t sure why, but I was nearly in tears telling him about my intuition/superstition/gut feeling. Ultimately, I was relieved to learn that the mission had been cancelled; only then was I able to sleep soundly.

The ongoing lesson in life for those born under the Scorpio zodiac sign is to channel their powerful energy into positive goals and not succumb to the darker forces in life (e.g. manipulation and greed). They will then have great success in life and have a clean, happy conscience and a circle of friends they can trust and hold dear to them.

Scorpio in a Nutshell:

Scorpio is the astrology sign of extremes and intensity. Scorpios are very deep, intense people; there is always more then meets the eye. They present a cool, detached and unemotional air to the world yet lying underneath is tremendous power, extreme strength, intense passion and a strong will and a persistent drive. Scorpios have a very penetrative mind; do not be surprised if they ask questions, as they are trying to delve deeper and figure things out. They always want to know why, where and any other possible detail they can possibly know. Scorpios are weary of the games that other people try to play and they are very aware when they are being manipulated. Scorpios tend to dominate and control anyone that lets them. The person that a Scorpio respects and holds close to them is treated with amazing kindness, loyalty and generosity. On the outside, a Scorpio has great secretiveness and mystery. This magnetically draws people to them. They are known to be controlling and overly ambitious - they need control in order to feel safe.

Extension explanation ... or lack thereof

I think there's a lot of confusion out there about my potential deployment extension; everyone seems to think that I AM being extended, and that I am UPSET about that fact. This perception is, in fact, completely opposite the truth.

BLUF: I AM NOT being extended, and I AM UPSET about that.

Why, you ask? Why in the world would I request to extend my tour and be separated from my son longer than necessary? And why am I disheartened about the refusal of my command to authorize the extension?

There are many details at play here; the situation is not as clean-cut and simple as it may seem at first glance. I requested an extension for only 4 weeks, and there was a unique and specific purpose for the request: I wanted to synchronize my return to the states with James' return. Why is this important? Well, there are 3 possible scenarios if I return to the US a month before he does:

(1) I return to the states, go immediately to California, grab a Uhaul and move Matt back to El Paso in a leisurely fashion, and go back to work after 3-4 weeks of leave .... right when James is returning from Iraq. So as he takes his post-deployment leave, I will have already returned to the daily grind, and we won't have much time off together.

(2) I return to the states, go back to work immediately (leaving Matt in California), and take my leave when James returns. Thus, we would be able to take leave together and reintegrate as a family without the stress of work. On the other hand, let me ask this question: for you moms out there, after a 6-month separation of 7500 miles from your toddler, could you possibly leave your son 700 miles away while you calmly return to work? Out of the question. Absolutely.

(3) I return to the states, go immediately to California, pack up and move Matt to El Paso as expeditiously as possible, and get back to work as soon as possible in order to "save" 1-2 weeks of leave for a family vacation when James returns. This will require me to hurry through the reintroductions to my family in California and Arizona, something which I have no desire to do after 6 months in a combat zone.

So my reasons for extending were not the "typical" reasons, like personal need to continue work in Afghanistan, fulfillment from the job, increased pay and benefits during deployment, avoidance of reintegration or other situations at home, or buying cheap gifts for everyone. I simply wanted to avoid the chaos of moving Matt to Texas and taking leave without James' presence and assistance.

Weeks and weeks ago, I submitted the request for extension, and I learned 36 hours ago that my request was declined by my command at Ft. Bliss. The reason I was given was that I didn't have "a valid reason" for the extension. You can probably imagine how that response made me feel. Apparently, bringing my family together after a year of worldwide separation isn't important enough to the powers-that-be.

With this news, I now have a lot of work to do in my 24 days left in Afghanistan. I have packing, shopping, outprocessing, and planning for my redeployment to do in addition to my regular duties on the ward and in the clinic. And that feels like a humongeous burden at the moment. (I suppose I have now been thrown into the final stage of deployment, called the "11 month slump", complete with anxiety and exhaustion.)

I know everything will turn out OK; I know that I have the support of my family and friends in this process; I know that I have managed to have one of the best deployments that the Army Medical Department has to offer. But it's still hard. And I still worry.

5 weeks on Facebook

I didn't post much on the blog in June, but I did post on Facebook almost daily. Facebook is a new addiction of mine, and it's pretty quick since I only have to post a few words or a sentence at a time! For those of you who have not seen the Facebook posts, I have pasted them below so you can see what June was all about for me. NOTE: there are some posts below which refer to a Facebook quiz I took, such as "What do your eyes say about you?" or "Which time era are you from?" I have included both the quiz results and my comments about the quiz.

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Autumn Richards is thinking about just how lucky I am to be stationed at a relatively large, relatively safe base in Afghanistan. Other soldiers are far less fortunate - they make do with minimal amenities and maximal safety risk. They are truly amazing and are the heroes of this war.
June 1 at 9:39pm

*Editorial comment: I wrote this during my first day at Fire Base Lilley, after I had snooped around enough to understand the differences between Bagram and Lilley.

Autumn Richards is thinking about the flight medics here in Afghanistan and how difficult a job they have at the point of injury, en route, and during offload. Today I have gained a different perspective of the challenges of their job.
June 2 at 7:38pm

*Editorial comment: I wrote this the day I cared for a patient blown up by an IED. In a moment my perspective had changed.

Autumn Richards is thinking about a favorite Bon Jovi song: “It's my life/ It's now or never/ I ain't gonna live forever/ I just want to live while I'm alive”
June 2 at 10:34pm

Autumn Richards is wondering how a long hard night of Rock Band resulted in a blood blister on her right thumb ....
June 5 at 12:07am

Autumn Richards is listening to Sting from a delta's computer ....
June 7 at 10:30am

Autumn Richards is (for a change) NOT sad about NOT getting off the ground today!
June 7 at 3:26pm

*Editorial comment: Our planned return to Bagram was delayed by one day - usually I would complain about NOT getting to fly!

Autumn Richards has a tummy full of king crab legs and na'an bread! Planning to have a banana split and play some Rock Band later ... hopefully with less "non-battle injury" than last time!
June 7 at 8:54pm

*Editorial comment: I was quite fortunate to enjoy the crab legs and na'an as a result of the canceled flight....

Autumn Richards can't get Madonna's "Like a Prayer" out of my mind....
June 7 at 10:46pm

Autumn Richards is back at Bagram after an 8-day trip to Fire Base Lilley, 4 miles from the Pakistan border in southeast Afghanistan. The trip was the highlight of my deployment so far!
June 8 at 1:36pm

*Editorial comment: This was my first announcement that I had been somewhere other than Bagram. The FaceBook community thought I was kidding!

Autumn Richards is trying to unpack in complete silence and near darkness .... and is getting frustrated.
June 8 at 6:01pm

Autumn Richards is ready for a nap after chasing PTT values all night in a patient on a heparin drip.
June 10 at 8:19am

Autumn Richards is still tired after sleeping for several hours this morning. Perhaps another nap is in order ......
June 10 at 2:43pm

Autumn Richards can't breathe.
June 10 at 7:33pm

*Editorial comment: I wrote this after finding out that one of my best friends at Bagram had been hand-picked to join the General's staff at ISAF headquarters in Kabul. I felt like the bottom had dropped out of my world.

Autumn Richards feels somewhat better after a decent night's sleep.
June 11 at 5:57am

Autumn Richards just returned from a 2-hour coffee date with a friend .... it was almost like home!
June 11 at 7:58pm

*Editorial comment: We talked about everything from home remodeling to weekend activities while sitting in the coffee shop. I felt like a regular person for a few hours.

Autumn Richards is reminded of the old adage that "people you deploy with are your friends forever." Here's to forever!
June 12 at 1:30am

*Editorial comment: Around this time, I began to realize that this deployment will create memories and friends that last a lifetime.

Autumn Richards is working on getting some much-needed supplies and books down to the medics who protected me last week.
June 12 at 10:06am

*Editorial comment: I have pretty much made it my life's mission to send supplies downrange to the medics at Lilley. They deserve only the best.

Autumn Richards is pretty excited to have a local cell phone! (For those of you in theater, the number is Roshan 079-353-1511 ... call me!)
June 12 at 1:33pm

Autumn Richards is quite annoyed that the Department of Defense hired the lowest bidder to provide mattresses and bed frames to deployed troops.
June 13 at 8:46am

Autumn Richards just took the most luxurious combat shower ever using Origins gingersnap body cleanser. :-)
June 13 at 5:54pm

*Editorial comment: The body cleanser was a gift from some dear old friends in the DC area. I actually felt feminine afterwards!

Autumn Richards is addicted to coffee in Bagram....
June 14 at 12:21am

Autumn Richards was introduced to deep-fried french toast at the North DFAC today. :) I have been avoiding it for 16 weeks .... but now it will have to become a weekly routine!
June 14 at 9:33am

Autumn Richards hates hates HATES the act of putting clean sheet on her bed, but loves loves LOVES the way they feel!
June 14 at 4:35pm

Autumn Richards: On the one hand, yes I have worked hard to get where I am today. On the other hand, I am so fortunate to have a fabulous family, safe deployment, indoor plumbing, and awesome friends! So no, maybe I'm not spoiled in the traditional material sense, but there is very little in my life that I would change.

Autumn has taken the Are you spoiled? quiz.

According to quiz analysis, Autumn is 11% spoiled!

You are definitely not spoiled. You've worked hard for what you have.

Down to earth and grounded, you don't need a lot to make you happy.

June 14 at 4:51pm

Autumn Richards can't wait for her massage this evening.
June 15 at 2:39pm

Autumn Richards is going to be super sore tomorrow thanks to yoga this evening......
June 16 at 10:13pm

*Editorial comment: My first yoga experience was somewhat painful, but since then it has been pure bliss.

Autumn Richards nearly forgot that she needed to put on a "real" uniform this morning.
June 17 at 6:55am

Autumn Richards needs a few moments to cool off after being accused of "not being able to handle" clinic. If I had access to alcohol, now would be the time to chug it .....
June 17 at 6:45pm

*Editorial comment: One of the LtCol's in clinic was appalled when a patient was waiting to be seen at 5 pm. Little did she know that two patients checked in just before we closed and hadn't been waiting all day!

Autumn Richards is annoyed that her entire drugstore.com shopping cart has somehow been lost in cyberspace.
June 17 at 8:32pm

Autumn Richards has decided that the MRAP must be the most awesome vehicle known to man! Bulletproof, mineproof, soundproof, light disciplined and very heavy, it's almost impossible to be killed in one!
June 18 at 2:19am

*Editorial comment: I wrote this post after taking a night ride in an MRAP with music blaring (inside) and night vision turned on!

Autumn Richards should really go to bed.
June 20 at 1:41am

Autumn Richards is very proud of all the medical graduates out there. To those graduating from residency and fellowship: congratulations!
June 20 at 1:42am

Autumn Richards is putting on mega sunscreen. The sun at 5000 feet can be a killer!
June 20 at 10:51am

Autumn Richards probably shouldn't be awake.
June 21 at 4:22am

*Editorial comment: This was the night of the mortar attacks which killed 2 soldiers at Bagram. It was a very long night for all of us. See the full post here.

Autumn Richards had forgotten how nice it is to work out early in the mornings!
June 22 at 6:56am

Autumn Richards found grass today. In Bagram, Afghanistan. About 20 square feet of it. My feet were very happy and are requesting that I return tonight.
June 23 at 3:04pm

*Editorial comment: I enjoyed coffee on our "lawn" with a friend this evening .... almost like I would in the states.

Autumn Richards must get to bed for her early-morning workout tomorrow.....
June 24 at 10:56pm

Autumn Richards is wondering why suddenly there are many, many new Air Force duffel bags stacked in her already-squished dorm room. More importantly, she wondering how they ended up on her desk, her armoire, and her chair ..... six to a room is NOT going to be fun, even for a few days.
June 25 at 5:09pm

Autumn Richards is now happy to return to her room really late and find 4 sleeping roommates and a relatively clean 5 x 10 living area!
June 25 at 11:16pm

Autumn Richards is going to avoid the hospital LIKE THE PLAGUE over the next few days while the new airmen move in and the old ones redeploy. It's such a disaster to have twice the number of people fighting for the showers and the dining hall, plus teaching all the newbies the ins and outs of BAF life. Please save me!
June 27 at 12:22am

*Editorial comment: see the full post here.

Autumn Richards has enjoyed checking out the Victoria's Secret semi-annual sale.
June 27 at 2:27am

Autumn Richards is pretty concerned about Matt's recent speech eval. Trying to manage developmental delay from Iraq and Afghanistan is nearly impossible. :(
June 27 at 11:47am

Autumn Richards spent a day at the Bagram spa getting a mani, pedi, and massage.
June 27 at 4:48pm

Autumn Richards slept through breakfast this morning. Instead, she enjoyed omelettes and french toast at midnight chow!
June 28 at 1:23am

*Editorial comment: I slept through breakfast because I had the day off. Really! It was my second day off here at Bagram, and it made me feel like a real person again.

Autumn Richards just got involved in a massive clinic waterfight. We started with syringes, then progressed to water balloons and, finally, 20 oz water bottles. I can't say that I won the fight ..... but I can say that it was quite fun! :)
June 28 at 12:37pm

Autumn Richards: Remember this one? "A whole new world/A new fantastic point of view/No one to tell us no/Or where to go/Or say we're only dreaming....." It applies.
June 28 at 9:36pm

Autumn Richards is going to sleep early tonight.
June 29 at 10:17pm

Autumn Richards apparently looks like a "naughty librarian" (according to her yoga instructor). Not sure if that's a good or a bad thing. Please comment.
June 30 at 10:19pm

*Editorial comment: The general consensus from the Facebook crowd is that I was being hit on!

Autumn Richards: Check out this video ... I think everyone's seen the story, but I just encountered the video for the first time!

US docs save burned girl, 8, victim of Afghan war
Source: www3.signonsandiego.com

Autumn Richards was having a "skinny" day until her company commander pissed her off and the cookies and milk came a callin'.....
July 1 at 9:50pm

*Editorial comment: My CO just can't understand that certain medical conditions - combined with the 5000-foot altitude - just don't mix with Army physical training. I wept several tears this night and was very, very angry.

Autumn Richards can't wait to try the new clothes that arrived in the mail from Victoria Secret today .....
July 2 at 10:47pm

Autumn Richards definitely shouldn't be awake at 2 am Bagram time. But Matthew is worth it!
July 3 at 2:30am

*Editorial comment: I got up at 2 am Bagram time in order to participate in the social services evaluation for Matt's speech therapy. Although it was the middle of my night, I was so glad I did it!

Autumn Richards is headed to the gym then to cover the ward for the afternoon. The new call schedule is quite confusing. I can't say that I'm all that excited about taking care of inpatient big people!
July 3 at 9:52am

Autumn Richards had the best workout in a month or more!
July 3 at 12:20pm

Autumn Richards: This is not exactly what I was expecting. At some times of my life, I have been exactly the OPPOSITE of Mod New York: homely, nerdy, reserved, careful, and risk-averse. There have also been (relatively few) moments in which I have fit this era well: OBC ('nuf said), Ft. Benning for the rugby national finals, San Diego with Philla for the kidney conference, the past few weeks here in Bagram .... I think maybe I need to find a happy medium between the homely, sweet, innocent, intelligent pediatrician and the rambunctious, rule-breaking, energetic, adrenaline-junkie wild child!

Autumn took the What Era Should You Time Travel To? quiz and the result is Mid-Century Mod New York

You like things simple and fun. Bold and daring, you don't hide how you feel, so you're a natural born leader. You love music and good times with your friends, especially nights out on the town! You want a no-fuss life style that is also totally chic. Going wild is your specialty and you love to be the center of attention, so why not go to the center of fashion and good-times: New York City! Better yet, slip in with the hip crowd, play it up in the latest pop fashions, and savor the British Invasion! It's artsy, suave, sexy, and totally you, baby! Boys, bring on the Beatles and ladies wiggle into your Twiggy mini dresses because Mid-Century Mod NYC is calling!

July 3 at 10:08 pm

Autumn Richards: Now that's more like it!

Autumn took the What do Your Eyes Say About You? quiz and the result is: Boldness.

When people look into your eyes, they can see that you're an energetic, happy, and cheerful person. You're outgoing and fun, and love to make new friends. You're not afraid to speak your mind, and you never stop laughing! People realize that you're a bouncy, loud person, that can sometimes be obnoxious, just by looking into your eyes. They can see that you're a unique, stylish, and one-of-a-kind individual. You're independent, and you don't let anybody get in your way.

July 3 at 9:55 pm

Autumn Richards is planning to nap today and admit patients all night. We had somewhere around 25-30 admissions yesterday .... and it doesn't seem to be slowing down anytime soon thanks to the continued surge in Southern Afghanistan. :(
July 5 at 10:05 am

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:

"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. :-)

Egyptian Liberation, omphalocele, and Toby Keith

You must know I've been busy since it's been 9 days since I've blogged!

I have done some interesting things in the past 9 days. For one thing, I went to the Sinai Liberation Day Celebration put on by the Egyptian forces on base. There were, of course, welcome remarks from the Egyptian commander, the posting of the colors, etc, and also a video depicting the importance of the holiday in their culture. Then came the main feature: the food! There was grilled eggplant, rice and chicken, fried cheese, and - of course - rice pudding made with rose water. It was certainly a nice departure from the same-old-same-old in the military DFACs. After dinner, the dancing started. It was hilarious! Almost all of the Egyptian military members are male, so "dancing" essentially consisted of the men standing in a circle and gyrating. Eventually some females joined them, and we laughed even harder.

A few days later, I got a page while I was running around the hospital, and it was the commander wanting to know if we could take care of a one-day old baby with an omphalocele, a birth defect in which various abdominal contents are sticking out of the belly button. It took some thinking and some discussion, but the peds surgeon, the other pediatrician, the commander and I decided that we had the resources to care for this baby.

Meanwhile, I prepared for the concert event of the spring: TOBY KEITH!! His band came by the hospital during the day, and I was fortunate to speak for quite a while with the bass player. The concert was in a large tent which surprisingly had great acoustics. Although he only played for an hour (he had been to 15 bases in 5 days, so he was probably pretty tired), we got to hear all the good songs, like "Beer for my Horses" and "The Angry American" (I wasn't leaving until I heard the latter song!). It was a little surreal, because for a few moments I actually forgot I was in Afghanistan. But then I would look around at the weapons slung around everyone's shoulders and waists .... and I would remember that this is a war zone. All in all, the concert was the social highlight of my two months at Bagram. My friend took some pictures, and I'll post them when I can.

I went back to the hospital after the concert and found the baby in the OR. The surgeon feared strangulation of the bowel, so she decided to operate immediately. I sent the other pediatrician home and waited for the surgery to conclude. I ended up waiting until 12 or 1 am, and the patient came out of the O.R. very unstable. The surgery had gone well, but his electrolytes and blood sugar were totally out of whack (for you medical folk: his initial glucose was 617 by one accucheck and 430 by the other). The surgeon and I sat at his bedside all night monitoring his condition, and by morning I felt as if I had been hit by a truck.

I completely lost the entire next day, as I was napping and covering the peds inpatients as best I could while Rob (the other pediatrician) saw the outpatients. Luckily, I went to sleep early that night because we got two additional admissions overnight who would require my full attention the following day. Rob and I are basically running a PICU with 5 patients, and we also have 2 patients on the ward (one of which was only moved there to free up a bed .... she's the girl with the devastating burns, and she really belongs in the ICU). In fact, we have more patients than the adult service has! At one point, we had 4 intubated patients and one marginal, recently-extubated patient .... so let's just say that we are very busy with some pretty sick kids. I am happy to report, though, that tonight all of the patients are off their breathing machines (including the baby) and their clinical conditions have stabilized.

The Message Bean

I got some good news about a week ago - from a bean plant:

The bean plant

"A what?" you ask? Yes, I didn't type that incorrectly. It was somehow written on the side of a bean seed, so when the bean sprouted, it exposed the text. I started watering it about three weeks ago, and it took around a week for the sprout to break ground, then a day or two for the husk to show with the message. Here's me with my new bean plant (it still brightens up the Engineering area even after it's delivered its message):


So this blog entry has actually been about 4 months in the making. Tita, Autumn and Matt sent me this bean plant back in December, when it was pretty cold out here, so I left the plant in the shipping materials (a can with a removable top) for a warmer time. After I had been back from leave for about a month, I stumbled on it, and eventually made it into work carrying it in my cargo pocket. It did really well under the fluorescent lights and the indoor air, which is a bit warm now despite the air conditioning. It's only the beginning of the heat - it's rumored to reach 120 degrees out here, which is basically like Palm Springs if it were on another planet.

The bean plant has garnered quite a following in the office, being the only real plant there. There are people (of course), rats, roaches, and various insects, but this is really the only plant. The first encounter with someone usually involves the bean's backstory, and I get a rash of daily status seekers, all looking it over to see if it has been attacked by insects, burned by the nearby copier, or even some who wonder if it is still there (I think they're plotting its doom). In any case, I'm sure going to miss it when it's gone. I guess I know how Tom Hanks felt about that volleyball in "Castaway" ...

Oh yeah, the message. Tita, Autumn and Matt wanted to let me know: "I love you"!

The power of family

I have always known that family was important. But I didn't know that here in Afghanistan, family is not just important, but it is crucial for the survival of children in the hospital. Not that our nurses and doctors are incapable of taking care of children; it's just that kids heal so much better when their families are present.

The 5 year old little girl with the penetrating head trauma has been in the hospital for several weeks now, and she has been getting feedings through a tube inserted into her nose. We have been trying endlessly to get her to take feeds by mouth, offering everything from applesauce to yogurt to milkshakes. Not only would she take nothing, but she would spit out the semi-solid food in disgust. She would not sip from a straw, and the only way we could get her to take any liquid was by squirting it into her mouth using a syringe. In her case, there are three reasons why she might not be eating:

(1) she's not hungry - this seems possible given that she's getting tube feeds and therefore her stomach is rarely empty

(2) she cannot eat - this doesn't seem likely given the location of her injury and the fact that she is able to swallow her own secretions

(3) she doesn't like the food - always a concern with these Afghan children; their diet is very different from the "typical" American diet we offer them in the hospital

We tried to "fix" problems #1 and #3 as best we could by offering her a wide variety of foods and slowing down her tube feeds to attempt to artifically create some hunger. But all of our efforts were to no avail; she still would only take a few ounces of liquid per day, nowhere near as much as she would need to in order to maintain her hydration and nutrition. A few days ago, it seemed that we had met an impasse.

Meanwhile, a few days ago, her uncle (who had been her guardian since a few days after the injury) needed to return home to take care of some personal matters. She was far less happy during his absence, and did not want to interact as much with the nurses. She no longer spoke or played. However, everything turned around once her uncle returned last night.

When he walked onto the ward and saw her sitting up in a chair (almost) by herself, he literally started crying. She had made a ton of progress in her rehabilitation since he last saw her. She was returned to her bed with her uncle at her side, and a few hours later the nurse went to check on her. Would you believe that there was an empty box of juice on her tray? When questioned, the uncle stated that she took the entire box - and she drank it by the straw! She was provided with a nutritional shake and a half banana, and with some help from her uncle, she took those too! Amazing.

This morning when I saw her, she was eating yogurt from a spoon. It was quite a happy sight, with her opening her mouth for more food and her uncle shoveling the yogurt in. (The trauma surgeon said that it reminded him of a little bird opening its mouth for food.) She will be transferred to a Red Cross rehab hospital today, and will follow up as an outpatient next week in order to track her weight, blood protein level, neurologic status, etc.

Thank goodness for happy endings!

IED vs. chocolate bunny

Happy Easter!!

I have been waiting for this holiday to tell you the story of the chocolate bunny on my desk in the clinic, and after that perhaps you will understand the nature of this post.

Since I started work here at Bagram, there has been a slightly eaten chocolate Easter bunny on my desk. The face is bitten off, and someone had also taken a bite out of its ear. After seeing quite a few IED blasts come through the ER and onto the ICU, I couldn't help but think that my little bunny had - before I arrived, of course - suffered an IED blast. I mentioned this to one of my colleagues, and it has since become quite a joke in the clinic. Numerous patients have asked about the bunny, and I tell them that he was hit with an IED. It gets the conversation started, to say the least!

IED blast injuries are very common in theater, both for the bad guys (who often present with bilateral hand amputations and facial injuries after the blast has gone off unexpectedly) and the good guys (who are often tr avelling in a vehicle when hit by an IED near the road). Since we are the referral center for nearly all med-evac flights in Afghanistan, we see a large majority of these blast injuries on our ward and ICU. The ubiquitous nature of IED blasts makes them, at times, a source of jokes and laughs. This does not mean that the health care providers take them any less seriously; the jokes and laughs are just how we survive the day-to-day grind of caring for patients with devastating injuries.

With that small introduction, I would like to provide you with my first attempt at composing Easter songs. (Well, I didn't really compose them, but rather modified them for my current situation.) I encourage you to sing them out loud, as the beats and rhymes will make more sense that way. There is a glossary of terms and acronyms at the end of the songs for those civilians who might not be familiar with the verbiage.


Sung to the tune of "Peter Cottontail"

Here comes Peter Combat-tail
Rollin' down the convoy trail,
MRAP, HMMWV,
Better look both ways!

Wearin' all the bad-ass gear,
Minus one chocolate ear,
Helmet, M9,
Better stay away!

Takin' out the Taliban,
Knowin’ soon they'll be gone,
C4, grenade,
Soon enough you'll pay!

Teachin' all the girls and boys,
IEDs are never toys,
CCAT, dust-off,
Need them both someday!


Sung to the tune of “I’m a Little Teapot”

I'm a little bunny missin' my face.
My ear was blown off without a trace.
When I see an I.E.D
My tail does shake!
And then, of course,
A bite it takes!!!


Sung to the tune of “London Bridge”

Bunny has no face at all,
face at all, face at all.
Bunny has no face at all,
Left I.B.A.

His ear was blown off Easter Day,
Easter Day, Easter Day.
His ear was blown off Easter Day,
By I.E.D.


Glossary:

MRAP - Mine Resistant Ambush Protected (a type of wheeled vehicle used for mine sweeping)
HMMWV - High Mobility Multipurpose Wheeled Vehicle (a military Hummer)
CCAT - Critical Care Air Transport Team
IED - Improvised Explosive Device
IBA - Individual Body Armor
Dust-off - Slang term referring to the medevac hangar

(Some of you only thought I was crazy. Now you know for sure!)

Great day

I had a great day today! But since it's 10:04 pm and I'm due back at the hospital at 5:30 am, I'll be brief by summarizing the events of the day:

(1) Slept well last night. Got up and rounded on my few pediatric patients with a positive outlook on the day.
(2) Attended rounds with the team. Helped put in a central venous catheter with one of the surgeons. She walked me through it so that if I ever had to do it on my own ....
(3) Went to the OR with one of the patients. Did the intubation, then scrubbed in for the case. The surgeons let me participate!
(4) Finally ate some breakfast - cinnamon raisin bagel with a mocha latte (=coffee with hot chocolate). Didn't get around to eating the remaining breakfast - hard boiled eggs and pear.
(5) Spent a considerable amount of time trying to figure out if my patient with the amputation has neuropathic (aka "phantom") pain. Once I determined that her pain likely is neuropathic, I spent a considerable amount of time learning how to treat it. Once I had gained that knowledge, I spent a considerable amount of time figuring out if we - given our limited pediatric pharmacy resources - even can treat it. Turns out that we can. Wrote the order.
(6) Saw a medic from my unit for chronic cough. The CO had sent her to me because she didn't feel that she was treated appropriately in the outpatient clinic. Looked at her XR and gave recommendations.
(7) Tried three time to put a feeding tube down the patient with the amputation. Had to have four people hold her down in the process. Two-year olds have mighty strength when they think that you're going to hurt them!
(8) Gathered various fruits for the patient since her tube feeds do not have enough daily fiber. Was able to locate and cut up green apples, pears, plums, dried cranberries, raisins, prunes, and dried blueberries. Served them all to the patient and implored her brother to help her eat some of it.
(9) Talked for about an hour to the PA who first treated with patient with the penetrating head injury. He was doing a routine humanitarian mission in the area when a local Afghan man brought the patient to him. He had a minimal medic bag, but was able to intubate and stabilize her before the flight medics arrived to bring the patient to the hospital. It was an amazing story and I very much enjoyed hearing it from the horse's mouth.
(10) Made some uber-ramen for dinner. I had to put it into three cups for microwaving because I couldn't find a bowl big enough!
(11) Called the pediatric neurosurgeon when one of the patient's ventricular drains began to leak (a ventricular drain is a pop-off mechanism so that some of the spinal fluid will drain off if the pressure in the head gets too high). Assisted in fixing the drain.
(12) Went back to the little girl with the amputation to find that she had eaten almost an entire pear, half an apple, and two prunes. Success!
(13) Checked the orders for all of the patients for morning labs. Don't want to miss anything or draw any labs that are unnecessary. Checked in with all of the nurses in the process (a habit I got into as a resident; I found that if I checked in with the nurses before going to bed, I could avoid getting paged overnight ....).
(14) Returned back to the barracks for a very quick combat shower and to hit the sack.

So that was my day! It was more busy than the average (mostly because I made it that way) but very rewarding and even fun!

Makeup

Just a quick anecdote that I thought you might enjoy...

This morning, the nurse taking care of the 8-year-old with burns was putting bacitracin over her eye wounds and some chapstick on her lips to keep them from drying out. The little girl started saying something in her native language, so the nurse got an interpreter. She was saying that she wanted more "makeup"! This entire time, when we have been putting bacitracin and chapstick on her, she thought we were putting on makeup to make her beautiful. And in a way, we ARE putting that stuff on her face to make her beautiful. She will be beautiful once again when her wounds have healed. :)

She also requested some "sparkles", which are (apparently) an eye makeup used by Afghan women. I'll see if I can find some at the Haji market on base ...

Happy National Doctors' Day!!

Happy National Doctor's Day!! There was a great surprise from the nursing and support staff in celebration of National Doctor's Day: a BBQ lunch. And not just any BBQ ..... they coerced the flight doctors (who accompany patients to Germany every other day on med'evacs) to pick up some authentic German food from the Ramstein commissary. So there was real bratwurst, sauerkraut, cabbage, and real cheese (not the processed kind) for lunch!

During the BBQ, the winners of the "March Mustache Madness" competition were announced. We knew that Dr. Morgan (ENT surgeon) and Chief Coyle (Vet Tech) were at the top of the list, and we all rushed around this morning submitting our final votes. (Votes each cost $1.) Chief Coyle has had a mustache since 1992, and Dr. Morgan started growing his just a month ago. The winner has the "opportunity" to keep his mustache throughout the month of April, while all of the other men in the competition will be required to shave their faces completely by tomorrow. By a mere 10-vote margin, Dr. Morgan won the competition. Which means that Chief Coyle will have a bare face tomorrow ....



Overall, the competition garnered almost $600. Half of the earnings will be given to our young patient, Nasi, who is being transferred to a US hospital for further care. The remainder of the cash will go into the "morale fund" to pay for future parties and BBQs.

(Yes, these really are the things that keep us busy during deployment!)

Symbiosis

I was on call today in the ICU, and it was quite the busy day. First thing this morning, the 8 year old with burns was extubated and taken off the breathing machine. We had the translator at the bedside so that we could tell her what we were planning to do. Like a champ, she coughed when we pulled out the tube, and continued to cough some more to get the phlegm out of her airways. She did better than most of the adults I have seen extubated! She is a strong, strong little girl, and that has helped her tremendously as she rehabilitates in the ICU. She has had skin grafts to the 40% of her body that was burned, so now essentially her entire body is a huge sore (the 60% of her body which was not burned was harvested so that we could cover the 40% which was burned). Despite 5 trips to the OR, painful dressing changes, and a very different environment than she's used to, she has done beautifully thus far. She has a long road ahead of her (on the order of months, not weeks) which will likely include dozens of visits to the OR, but ultimately I think that she will survive.

In addition to taking care of her, I had two admissions today. One was a simple pre-admission for a 4-year-old boy who will undergo surgery in the morning. (He had an abdominal surgery about a year ago, and the pediatric surgeon will do the second and final stage of the procedure tomorrow morning. In the interim, he has nearly doubled his weight, going from 8 kg to 15 kg. He has also gained the strength to walk on his own!) The second admission took me somewhat by surprise: she is a 2-year-old girl transferred to us from a US hospital in eastern Afghanistan. She was struck by a tactical vehicle two days ago, and underwent surgery at that time to repair her left arm, which was broken in several places. She was transferred today for continued surgical care. Her arm was a deep purplish-blue color, and her hand was ice cold. We could not locate pulses at her elbow or her wrist. She was whisked to the CT scanner, then to the OR, where the surgeons attempted to repair her vasculature to restore blood flow to her hand. As of this writing, we do not know if the surgery was successful; a shunt was placed into the artery at her elbow to keep it open and flowing, and they are planning for another OR trip in a few hours to see if the shunt remains patent. If it does not work, an amputation is in her future.

I heard a very disturbing story when discussing this child with the ICU nurses. Most of them have been at Bagram for several months, and they have seen an endless stream of children come through the doors after losing a confrontation with a tactical vehicle. Rumor has it that families will actually throw their children in front of oncoming US traffic, since the US provides not only medical care but also a stipend to local Afghans injured in the course of this war. (I do not know if the stipend is provided on a one-time or recurring basis.) Apparently, the populace here is so desperate that they would sacrifice their most vulnerable assets - their children - in exchange for US dollars. I find this rumor appalling, but unfortunately believable considering the abject poverty of this country. I will attempt to confirm or deny this theory in the coming days.

Despite the horror of this rumor, my heart has been bouyed by the response of the staff to our little pediatric ward. There are four total patients now: I've already discussed the 8-year-old girl with burns, the 4-year-old going to surgery, and the 2-year-old girl with the mangled arm. The fourth patient is a 2-year-old who has been living in the hospital for a year now after suffering an injury to her esophagus and trachea. She swallowed a watch battery which eroded through these internal structures, and she now has a tracheostomy tube in her neck. She cannot go home with a trach since it requires a suction machine, but her family does not have electricity. She is known as the "Queen of the Hospital" and literally runs around smiling and waving at everybody. She even knows where the snacks are kept in the doc box! All of the hospital staff know Nasi, and we just can't help but smile when she toddles by. The same is true of the little girl with burns - you can't imagine the outpouring of support she has received from all over the base. The medics who picked her up initially from her destroyed home have visited several times; the daughters of one of the nurses drew her pictures for her hospital room then scanned and emailed them; every day I find new stuffed animals on her bed. (She's got quite a collection!)

Our little peds ward is unlike any other place in the hospital. It's known as the place where patients get better, and more importantly, it's the place where we can watch patients get better. With few exceptions, patients fall into one of four categories: (1) US and coalition troops, who are stabilized and air evac'ed to Germany; (2) Afghan soldiers and policemen, who are stabilized and returned to their local hospital; (3) enemy combatants, who are stabilized and returned to the internee facility on base; and (4) pediatric patients, who have the opportunity to stay in the hospital until they are ready for discharge to home. My patients are the only ones that we, as the staff, get to see through the entire course of their illness. We watch with heavy hearts as they suffer despite our best efforts, but then we rejoice when they improve and are able to go home to their families. As a result, we rally around these sick and injured Afghan children. Maybe we rally around them because they remind us of our own little ones at home; maybe we rally to temporarily forget the death and destruction facing us daily. In any case, it seems that we need them just as much as they need us. We treat their pain, help control their anxiety, and feed and bathe them, and in return they provide us with moments of hope, love, and happiness. And nothing could be more important than that!