Paddling in

Thursday 26 November 2009

It has been a nice Thanksgiving here in Afghanistan, cool and blessedly clear. The snow line is moving down the mountains and I suspect will hit us any day now. People here have two main ways of dealing with holidays. Some prefer to pretend that the holiday doesn’t exist. “Just 1 out of 180, man” is what many say, meaning that it’s just another day of deployment and one more closer to going home. I’ve opted to try to make the best of it, ate some turkey in the chow hall, and my team took turns talking about their favorite Thanksgiving traditions. I detailed how excellent the waves have been on the Windward side of Oahu on every Thanksgiving weekend for the past 8 years and how nice it is to paddle out from my neighborhood into clean, peeling, reef-break waves. After recounting this story, though, I suddenly realized that the best part was actually paddling in, knowing what and who was waiting for me on shore. That’s what I’m really thankful for.

I am going to spend some time with a Polish military unit in the near future. That’s kind of exciting for me, given my Polish heritage. My great-grandfather was apparently in the Polish cavalry, so it’s kind of neat for there to be another Sniezek working with the Polish Army again, 100 years later. I’ve actually been thinking of my Polish roots, lately, hoping that somewhere buried in my genetic code lies an improved tolerance of this cold weather. After all, my name means "snow" in Polish. Eight years in Hawaii has made me pretty soft.

Happy Thanksgiving to my family and friends. You don’t know it, but you just spent a Thanksgiving with me in Afghanistan.

RIP-TOA

Sunday 22 November 2009

It’s kind of a dusty and dreary Sunday here in Bagram. Or “Runday” as my roommate refers to it, since we usually run our 8 mile loop around the perimeter of the base on Sunday mornings. The air is so full of dust and pollution, today, that the mountains are not visible at all. During the run, somewhere in the midst of a skeptical diatribe that I was delivering and both of us were largely ignoring, my roommate commented that in 20 years, people will be skiing in those mountains. I wittily replied, “What mountains?” Well, it seemed funnier at the time since we were both pretty high from the carbon monoxide being spewed in the exhaust fumes of the jingo trucks passing us on the dusty road.

We had a large turnover of the surgeons last week. The Army calls it a RIP-TOA, for relief in place/transfer of authority. The old crew of surgeons redeployed and the new group just arrived. Being slightly more than half way through my deployment afforded me a somewhat objective perspective to the experience. The guys leaving tried hard (some harder than others) not to gloat or expose their glee at heading home. The new guys were pretty bleary-eyed from the jetlag and bothered by the incessant hacks emanating from their still healthy lungs and airways, not yet compensated to the filth in the air here. Their first real day on the job, we had 13 casualties arrive simultaneously. Welcome to Bagram. The Taliban shot RPG’s and rifles into a bazaar not far from Bagram that happened to be crowded with children at the time. Four of the victims were under ten, and there were several teenagers, as well. While you tend to adapt to anything, even war casualties, seeing children that have been victimized by war wounds is unnatural and haunting. Their little bodies in our trauma room and ICU beds is a sight that I won’t soon forget.

The new team did well and provided great care. One week later, the glazed looks of trepidation are gone, the coughs are resolving, and they appear to have settled into the rhythm of life here. The witty comments and bits of laughter have even returned to rounds, an excellent sign. Like their upper airways, they're adjusting to the grit of deployment. Hard to believe that in about three months, it will be time for my RIP/TOA. I’ll have to remember not to appear gleeful.

Good news- the inauguration went off a few days ago without any major violence or incidents. Everyone was pretty anxious about what would happen. Good cause for Thanksgiving.

Ashtrays and mice

Wednesday 11 November 2009

Unfortunately, there was an accident yesterday just outside of the wire at the 8^th FST involving some ANA (Afghan National Army) soldiers. The details of the story were recounted to me last night by the FST Commander. The ANA is actually very well respected by coalition troops. They form the lead and tail elements of many patrols and we treat more ANA casualties than Americans or NATO forces. They are a tough lot with their own idiosyncracies, like everyone else. At any rate, five ANA soldiers were apparently in a bunker when one of them threw a cigarette butt down and ignited a fire, cooking off an RPG, which ignited several other RPG’s, injuring all five. There is certainly no humor in that, but after operating on the guys, the surgeons starting passing around a hat for the “ANA ashtray fund.” Pretty good stuff.

I had the pleasure last week of eating an Afghan meal prepared and served by some of the Afghani interpreters who accompany the local outreach efforts. It was certainly the best meal I have had in many months and amazingly, all courses were prepared over one small field stove. There were several curries with potatoes, a long grain rice, and local bread. They also served a tabouli-like salad with spicy peppers. The food was excellent, but the company was even better. I really like the Afghan people who I have met. I suppose I expected most Afghanis to be stoic and stolid, similar to the folks I’ve interacted with in Ladakh and Kashmir, but the Afghanis are more apt to smile, laugh, tease, and joke. Granted, the sample is a bit skewed because these interpreters have a fair amount of interaction with Americans, so they tend to adopt some of our habits and mannerisms, but they have an innate happiness that pleasantly surprised me. Rather than being destroyed by the centuries of war and suffering experienced by their nation, most are generally upbeat, generous, and gracious. The Afghanis who work in the laundry tent are equally as pleasant. About once per week or so, they hide a rubber mouse between the pages of the sign-in book and laugh hysterically when I, or anyone else, looks shocked as it is discovered. Kind of like playing 'pull my finger', the joke just never seems to get old. People are resilient.

Bagram skyline

Here's the Bagram skyline. It's not Manhattan, but I think the backdrop of the Hindu Kush mountains edges out the East River. Cold winds blew in from the North today and cleared the air. I hadn't realized that the mountains are snow-covered until I walked out of my barracks this morning. We've been blanketed in dust for the past three months. It's getting down to 18 degrees tonight. Winter is finally here. Also, for those who haven't seen one, that's an MRAP (mine resistant armored personnel carrier) on the right. My prediction is that we're going to start hearing a lot about these vehicles in about 12 months or so. If you double click on the photo, you can get a better sense of just how stunning the mountains are. Who knew?

Any Given Sunday

Sunday 8 November 2009

It is a beautiful Sunday morning here at Bagram with a cool breeze and light, sprinkling rain. This is only our third rain in the past three months and it is certainly welcome. When I walked out of the hospital last night, a general surgeon I passed saw the rain and said, “Wow, isn’t it beautiful.” It was dark and all you could really see were little muddy puddles, but I know what he meant. The rain helps to clean the dust out of the air. Soon after it stopped raining this morning, however, the passing MRAP’s stirred up clouds of dust that returned me to the atmospheric reality of life at Bagram. Despite three semesters of college physics, I’m not exactly sure how a road can be muddy and dusty at the same time. This is a miraculous place.

Instead of operating this morning, I was “excused” out of the OR by the other Head & Neck Surgeon here at Bagram. We did a pretty challenging mandibular and facial reconstruction yesterday on an ANA patient who had been shot in the jaw. It was the third patient we had treated with a similar injury in the past three days, so he told me to take off and do something “Sunday-like.” Besides, the case was “only” a tracheotomy, maxillary-mandibuar fixation, and repair of a facial Leforte I fracture. Rather commonplace in these environs, and he could certainly handle it without me. So, instead of operating, I went on an 8 mile, muddy, grunge-run. If you would have told me 5 months ago that I would elect to go on an 8-mile run as a form of relaxation, I would never have believed you.

I have posted a link to a series of pictures compiled by CNBC. The pictures show trauma patients being treated at the 8^th FST (forward surgical team). The 8^th FST is based out of Hawaii and is comprised of nurses and techs stationed at either Schofield Barracks or Tripler. I have had the fortune to spend some time with this unit at their FOB (forward operating base) and it was memorable. The pictures portray some of the feelings, emotions, intensity, and blessing of spending time in our medical units here in Afghanistan far better than words ever could. They also show one of the most intense experiences encountered by the health care providers at the 8^th. They were forced to treat one of their own medics who suffered an IED blast while riding in an MRAP on a mission outside the wire. This would be akin to treating one of your own family members, as the bonds that are formed in this environment are often stronger than a traditional co-worker relationship. I should also mention that the two surgeons mentioned in the article have since redeployed, and the senior surgeon at the FST is now a recently-graduated, former general surgery resident from Tripler. Those of you at Tripler who know him should be proud- he has done some amazing work.

One of my favorite memories of this deployment is sitting next to a bonfire comprised of burning wooden pallets, smoking a cigar with the nurses and surgeons of the 8^th right in front of the hospital tent shown in one of the pictures. As we smoked, UAV’s and helicopters buzzed overhead and 155 mm howitzers would occasionally be fired from the artillery battery not far from the tents. I asked one of the surgeons if it was wise to light a bonfire at night since no other lights were allowed at night at the FOB due to Taliban activity in the region. He responded that “sitting next to a target is the safest place to be. Their aim sucks.”

http://www.msnbc.msn.com/id/33305590/ns/news-picture_stories/displaymode/1247/?beginSlide=1

Bagram is kind of a-flutter today because the FOX Sunday NFL pre-game show is being televised from here this evening. Terry Bradshaw, Howie Long, Jimmy Johnson, and crew are roaming around, signing autographs, and taking pictures. Actually, they’re not roaming around, but they’re here, and I'm glad. It provides a welcome distraction, if even for a little while, and it’s just nice to know that this place will be remembered by some of the millions of Americans sitting on their couches, watching Sunday football. As they should. That’s why we’re here.

All in

Tuesday 3 November 2009

Since I’ve been deployed for roughly three months, now, and had the opportunity to watch and read some of the media coverage about Afghanistan during my recent trip to Iraq (I frankly haven’t had adequate time or internet access to follow the news prior to that trip), I feel as though I should share some thoughts on the reality of the situation here in Afghanistan with my family and friends.

My thoughts and opinions are based on personal observations, military briefs to which I have had access (though I obviously won’t discuss secret or classified information), and reading some insightful comments from people such as David Brooks of the New York Times. I am a physician, not a politician, so my interests are more aligned toward the delivery of health care than the trend of politics. I will also try to distinguish between facts and my perceptions. My intent is to share these perceptions, not initiate a political debate.

Who are the bad guys?

The enemies of peace in Afghanistan consist of a loose and fluid group comprised of the Taliban (religious extremists from Afghanistan and/or Pakistan), members of Al Qaeda from nations such as Chechnya, various tribes who are paid or incentivized to attack the Coalition or Afghan government, and individuals who are coerced or paid to perform violent acts. The numbers and allegiances are constantly changing, which is why it’s impossible to distinguish, separate, or even quantify this group at any point in time. There is no underlying or unifying philosophy or mantra of this disparate group, and their goals are not always aligned. The one thing that they have in common is a willingness to randomly attack the Afghan govt, coalition forces, or their own people in order to preclude a representative government and personal freedoms such as the education of women or religious tolerance.

Who are the good guys?

The Afghan National Army (ANA), Afghan National Police (ANP), and Coalition Forces (68k or so US forces and various NATO troops). Only about 20% of US forces are actual combat soldiers, the rest are support troops. After the US, the largest percentage is from the UK and Poland. I believe that there are approximately 30+k NATO/UN troops. Afghanistan is roughly the size of Texas.

What is GEN McChrystal’s plan?

GEN McChrystal’s military career has predominately been spent with Special Operations and covert military units. Interestingly, he feels that success in Afghanistan cannot be achieved solely with military technology such as unmanned drones or special ops forces. He feels that a successful counter-insurgency strategy needs to focus on the protection of the majority of the populus rather than focusing on killing the bad guys. In fact, he has forbidden the use of large bombs that may be effective but have an increased likelihood of inflicting collateral casualties. That is logical and easy to digest from a couch back in the States, but the decision to place your soldiers, your brothers, at higher risk of injury or death in order to prevent theoretical collateral damage is brave and profound.

Essentially, the GEN sees a race or competition between the govt/coalition and the bad guys. The coalition is trying to build infrastructure and essential services that will potentially allow a representative government and society to be established, while the bad guys are trying to destroy infrastructure, government, and commerce. It’s always easier to destroy than to build, so the race is actually defined by which side can win the faith and commitment of the majority of the population. This is the essence of a successful counter-insurgency strategy. Unfortunately, protecting all major population centers, roads (there is only one main road in the country, but it is extremely long), and infrastructure requires a lot of soldiers and skill. There currently aren’t enough ANA, ANP, or coalition forces to adequately protect the important stuff, when the bad guys have the advantage of attacking anywhere, at any time, and having any violence reported in the media as a failure of governance.

What do I think we should do?

The previous discussion is fact rather than opinion. Here is my opinion. While I generally support compromise and it is my instinct to build a consensus when resolving a conflict, this is one case where only the extremes offer an adequate solution. I think that we either need to fully commit to a comprehensive counter-insurgency strategy that will require tens of thousands more American soldiers, trainers, aggressive civil infrastructure efforts, and years of commitment, or we need to totally pull out. There is no adequate compromise or middle path. I wish there were. That’s what we’re doing now, merely treading water. Everyone over here is just desperate for a decision, and all are hedging their bets- the Afghan govt, the populus, and the US military. We all need to know what the stakes are, and I believe all is depending on the level of commitment that President Obama is willing to make. Locals, and some allies, are not willing to fully commit until they confirm the level of US commitment.

Honestly, I don’t feel passionately about which path is chosen, though I do feel that more troops are required if it is our goal to provide enough security for a more representative and stable government and society to be established, with the marginalization of the violent and extremist minority. That is how I would define success, and NATO, the UN, and most Afghanis agree. The most important thing, though, is just that A decision is made, one that is definitive and unequivocal. This is not a time or situation where half-measures are adequate.