Happily Ever After*

(*Please allow 90 to 120 days for the "Happily" part to kick in before calling to check on the status of your order. No refunds.)

This will probably be my last post, if not one of them. The "Isosceles Triangle" is now only a couple of miles on each side, and only during the day when Autumn and/or I are at work! I think OIT was a great idea and Autumn and I have given serious thought to a few suggestions that we should make a book out of it for posterity. Hopefully we figure out a good way to archive it so it does not fall into the pit of time, and if we do it right, we can probably open it up and read it from time to time.

I have tried to keep what I share happy and positive, not to create some sort of rosy illusion, but because most of my posts would look like this if I didn't:

"I came off another self-imposed 16 hour day today and had a terrible workout. I tried to call Autumn but no one around the phone knew where she was, and I didn't bother leaving a message I knew wouldn't get to her in a reasonable amount of time. I guess it's just another Monday. The network change we have been planning for two weeks seemed to work at first, but ended up failing sometime after I left. The redundant link stayed up, but I do not know what to try next, so I guess it's time to prepare for a few days of frustrating and embarrassing briefings while we beat our heads against the wall thinking. It sure would have been nice to be able to take an engineering-level class on this equipment, but what did I expect when we did not know the mission we trained for was not the mission we would end up doing? Only six more days until my next down day, large pizza, and sleep sweet sleep."

A couple of those posts and we might as well shade the Isosceles Triangle a nice, creamed-pinto-bean beige to represent the feelings of frustration, apathy, and regret. No, I thought it best to take the gems from the year, dust them off, and share them with everyone so the interesting parts of life are immortalized and the daily drudge fades.

So, I'm not going to sift through and find the "things worth remembering" in this post. It is not because I am not so far away or because there is nothing interesting to tell, but here at the end of the journey, I find that the interesting parts contain a measure of frustration, apathy, regret, and even pain. Omitting this would make my contributions a pleasantly incomplete story, and that is something I might regret when I read this on the eve of my next deployment. Epilogues aren't always the neat little bow on the outside of a wrapped present, right?

So what have I been doing and what has happened to me since I last posted?

I made it back from where I came. Redeployment was everything the experienced guys told us it would be, though there is no way to fully articulate just how excruciatingly slow everything moves when you are trying to leave. Someone, somewhere, at some time in the past has done every self-destructive thing imaginable during redeployment, so there is a briefing, pamphlet, form, or counseling session to cover the Army's butt on it. We sat through briefings where we were told to be careful what ATM we use to withdraw money, don't drink excessively, be patient when you reintegrate with your friends and family - all reasonable so far. However, we were also shotgunned through anti-suicide briefings, at least 4 that included the speaker saying he/she was pleased to be the one to inform us we have benefits under the VA as combat veterans now, and a briefing to synchronize us filling out our travel vouchers (Government version of a commercial expense report for business travel) which ended up being reconvened two more times. I can say it was at least not as bad as mobilizing on the front end of the deployment, where we were "trained" in automatic weapons fired from moving vehicles and how to speak Arabic. I am sure if you are reading this you also read Autumn's account of how she orchestrated a trip for her, Matt, and a bunch of my friends to come to my welcome home ceremony - that was something I did not expect and that no one told me would happen ... !









I got a tattoo. My brother, Charles, and I had been talking about it for a long time, and we decided to get the same tattoo in the same place - a cool design from a Japanese cartoon on the top left of the chest. I don't know if I would have had any more or less inhibition had I not just come back from deployment, but certainly not being able to fulfill our plans while I was away made it all the more satisfying when we finally got it done. Two months after getting it, I can still say I like it, so at least I'm not looking up laser removal clinics. The design we chose has meaning to us on many levels, though I won't detail it all here.





I joined the Regular Army. I am now stationed at Fort Bliss, just like Autumn, and it's almost like we have regular jobs with the same company (commercial company, that is). She has been on travel for a few days, but before she left, we had lunch 3 of the previous 7 days, and we bring Matt to see each other briefly at work on days when one works and the other does not. I make less money, and I am certainly working a lot less without having to manage both my Army career and my full-time civilian career. I am sad I am not working with John Lagozzino and Bob Randolph at GDIT right now, but living in El Paso would prohibit that anyway. We have a few years left here and I want to make the most of it - what I was really going for was what Autumn and I had in high school, which was separate academic careers on the same campus with some of the same activities. I used to play practical jokes on her, surprise her, and generally do things you do to a girl when you like her. When I was working my civilian job in Virginia, I was a one hour drive (each way) from where Autumn was, if she was at the closest hospital! Forget lunch, let alone kindling our respective inner teenagers!





I said goodbye ... again. I left good friends in Delaware, Virginia, and Maryland when I left for Iraq, but it was not reconnecting when I got back that was really goodbye. It's hard for me to say goodbye (silently or otherwise), but harder for me to correspond, as I am sure everyone will agree I am probably one of the worst correspondents this side of three degrees of separation. I will miss my friends, but I would rather say goodbye and remember the relationships as happy than watch them suffocate as I try haplessly to keep frequent communication alive. I did this when I left Hong Kong in 1989, Glendora in 1993, Claremont in 1997, Ithaca in 2001, Georgia in 2007, and probably El Paso in 2012. My memories are strewn with the remnants of old friends the way they were when I last saw them, if not with faces, at least the essence. Lots of things remind me of people I used to know, and who I suppose used to know me. It makes me feel lonely and apprehensive about making new friends.

I have been replaced. Before I left Iraq, I discovered that while Autumn and I had not kept in touch as often as we both would have liked, she found friends with whom she continues to keep in touch in both the medical and the Special Forces communities. That is not a bad thing (I found good friends serving in Iraq), but Autumn has made it clear to me that given a choice of communicating with them or communicating with me on virtually every topic, she is, for the time being, more comfortable communicating with them. I know this because I asked her "not to choose them over me again" now that we're both back, and she not only didn't say "Ok, yes, I won't", she said "it's going to take some time, and you will just have to live with it". So I am living with it, we have a big pink elephant in the corner, and maybe someday I will find I am #1 in her life again. We have talked about it once since she told me to suck it up, and it was a good conversation, but I am still mourning the loss of our intimacy and intensely resentful and jealous of the people who have seemingly replaced me.

I reconnected with my son. I just finished building him a playset that he really likes - the kind with a slide and swings, a climbing wall, a net, and even a little ship steering wheel, and also the kind he used all summer at his cousins' houses. I can be the only one in the room and he is good with it, he smiles when I come in from work, and I can take him on errands without it being a huge cryfest. Those things were not true the few weeks after I got home, and I thought the alienation would never subside, but it has. We are currently working on him letting me put him to bed, which requires a vanishing act by Loretta and/or Autumn at bedtime so I am seemingly the only one around. I guess if dad is a distant 3rd, and he's the only one there, it's ok for him to read books, sing nursery rhymes, and sleep on the floor next to the bed until sleep comes. All in good time, I suppose - something I have a little more faith in now.











I think that about covers it. Hopefully the asterisk on "Happily Ever After" comes down sooner rather than later, but for now, it's a good start with a way to go.

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. :-)