The goat

Sunday 31 January 2010

I suppose I should provide some follow-up on the surgeon/patient. He ended up recovering quite nicely at BAF for 2 days, without surgery. He has been sent to Germany for a few weeks of observation to ensure that he doesn’t develop any delayed complications as he is posted in a location where it would take a while for him to reach medical care. Outside of his own, that is. I fully expect that he will be assertive enough to play salmon, swimming upstream against the normal patient flow and make it back to theater.

Yesterday at about 3:30, as I was dutifully and happily working on the transition brief for my replacement, my vascular surgeon friend walked in and told me that a patient had arrived with a gunshot would to the back of the neck and that the bullet was lodged in the soft tissues of his neck. He told me not to worry, though, that they could handle it.

“You just like to turn the bovie (electrocautery) up really high and dig right down to it, right? I mean, it’s just the neck- there’s nothing to hurt in there.”

My keen sense of observation and his half-smirk told me he was just getting my goat, but I was surprised at how quickly he was able to find the soft spots. I guess I’m not as subtle and mysterious as I had hoped. As he walked to the OR, I chased him down the hallway muttering profound things like, “Come on, I mean… no…you can’t…you have to approach…fine.”

The case was actually fun and not very technically demanding. I was able to dig the fragment out from the deep neck musculature quite easily and nothing important had been injured. The whole thing only took about 15 minutes, including my running commentary to the anesthesia team about the incredible degree of difficulty of this case and that only 3 surgeons in the world could pull this off. All of which was totally untrue, as confirmed when the anesthesiologist said that he had seen zits that were more difficult to get out. I think this is a conspiracy.

After the case, I walked into OR #2, where my buddy was doing an intricate vascular repair with a graft to the posterior tibial artery on a patient who had been shot through the lower leg. He had also, incidentally, been shot through the back and stomach, so the general surgeons were doing a laparotomy at the same time.

I asked him if he needed any help as I had recently read that the leg bone is indeed connected to the foot bone and I’d be happy to talk him through it. It’s just the leg, after all, there’s nothing important in there, right? He asked me how my zit went.

Something

Saturday 23 January 2010

I ran into one of my favorite people yesterday in the smoke shack on the roof, an Air Force vascular surgeon who was intently examining his cigar and immediately said to me in an exasperated tone as I entered our little Shangri La, “You Army guys are something.” I could sense that he wasn’t exactly complimenting me, so I inquired as to the inspiration for this sudden realization. He told me that one of our FOB’s was rocketed yesterday, injuring several medical personnel. One of the casualties was a general surgeon, who was then flown here on a medevac flight for treatment. The surgeon actually walked off of the helicopter and into the trauma room, saying loudly “Where’s the latrine?” As he walked out of the bathroom, he then exclaimed, ”There. Now there’s no need for a foley (catheter).”

After agreeing to finally lay down and get examined, the “patient” said “I’ve already explored the wound- there’s no intraperitoneal injury.” My friend inquired how the surgeon had managed to explore his own wound, upon which he replied, “With my finger.” Some eyebrows were raised, but the patient did agree to undergo imaging (x-ray and CT) studies, which actually showed that he had free air in his belly. This finding indicated that he did indeed have some shrapnel that entered his abdominal cavity, necessitating a laparotomy- a surgery to explore the abdomen and remove the shrapnel. After my friend reviewed the films with him and briefly discussed the procedure, with which both surgeons were of course familiar and which was completely necessary, the patient said, “No.”

“No?”

The patient said that he had no fevers and didn’t want to have surgery or be air-evacuated to Germany. He wanted to be observed for 48 hours, and if he didn’t develop peritonitis (an infected abdomen), he wanted to go back to his FOB and get back to work.

Funny enough, noone has ever said “no” here before. I won’t go into the medical details of the situation, but the request was risky, unusual, and caused a bit of head-scratching on the part of my friend and our entire medical command structure.

I’ll let you know how it turns out.

The arena

Tuesday 20 January 2010

I am back at BAF and ran into some of my surgeon friends who were stationed at FOB Ghazni and FOB Salerno (Khost Province). They’re on their way back home and fly out tomorrow. Both groups mentioned that in a strange way, they are kind of disappointed and a bit sad to be leaving. After referring them for immediate cognitive testing and a neuropsych evaluation, I found out that they had been happy with their deployments and universally had very rewarding experiences. One of the surgeons, interestingly, reportedly left FOB Salerno in tears. Part of their melancholy is no doubt associated with the fact that they’re actually on the way home. I still have about 6 weeks left to go and am trying to just keep up the pace and finish strong. Once I let myself really start thinking about home, I’m afraid that time will start to slow. I’m not quite ready to reflect back just yet- there are too many hours and miles between me and Kailua.

While I have very little access or time for media, even I have heard about the recent tragedy in Haiti. I’ve also heard about some of the frustration with the slowness of relief efforts. I am acutely aware of the challenges of providing humanitarian relief in austere environments and was at first frustrated by the critical nature of some reports. Then I thought, how American of us to just assume that of course we would come to the aid of another country and that of course we should be rapid and effective. What other nation expects and demands such perfectly executed compassion? Ultimately, that is likely a good thing and I guess that’s why we are who we are. Before I came to that realization, however, one of my favorite quotes regarding the difference between doers and critics came to mind:

"It is not the critic who counts: not the man who points out how the strong man stumbles or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood, who strives valiantly, who errs and comes up short again and again, because there is no effort without error or shortcoming, but who knows the great enthusiasms, the great devotions, who spends himself for a worthy cause; who, at the best, knows, in the end, the triumph of high achievement, and who, at the worst, if he fails, at least he fails while daring greatly, so that his place shall never be with those cold and timid souls who knew neither victory nor defeat."

-Teddy Roosevelt

I suspect that my departing friends must be feeling the satisfaction of leaving the arena with their heads held high.

tulips

Sunday 17 January 2010

I’m currently at Kandahar Air Field (KAF), which is a NATO base in Southern Afghanistan. The weather has been warm (in the 60’s during the day), a blessed relief from the cold of northern and eastern Afghanistan. Since it’s a NATO base, the majority of people at Kandahar are actually not from the U.S., which is also an interesting distraction. Aside from the Tim Horton’s donut shop (which I will not discuss as I’ve just barely come to terms with my gluttony-inspired self-loathing), the most amazing thing about KAF is the NATO gym. It’s run by a civilian company from Amsterdam, and it is the cleanest place I’ve been in 5 months. It very much resembles a health club back home with music playing and weight machines- strikingly different form the Army gym tent at Bagram. I had previously heard that you actually have to change into clean shoes when you get into the gym, which is a problem for me, because I just don’t have anything clean. As I approached the European front desk worker/receptionist, he looked down his nose at me with a pinched expression, as if he had just discovered a worm in one of the tulips in his windmill garden. I can understand Serge’s shock (I’m assuming his name is Serge, though it could just as easily have been Tomas or Sven) at my appearance. I was wearing my stretched, stained workout uniform and shorts with my combat boots, since I don’t have one clean pair of running shoes let alone two that would allow a change. I’m fairly sure that he gagged when he saw my running shoes. I hadn’t noticed until then that my formerly grey New Balance 990’s are now black, cracked, and surrounded by a Pigpen-like cloud/aura/entitiy that is part dust, part stench.

He felt compelled at that point to state, “Ze purpose of ze shoo shange policy ees to shange from derty to clean, not derty to dertier.”

Got it, Sven, it is what it is. I’ll try not to touch anything and I won’t even comment on the Enya CD you just put in. Deal?

He let me in and dove straight for the hand gel. Anyway, they had soccer playing on the TV’s, though thankfully the sound didn’t quite overpower the Enya. Ugh. I did notice a short piece on BBC about Prince William. He was standing in a Royal Air Force uniform along with his father, who was in his Royal Navy uniform. I’m assuming Prince William must have completed some sort of military training. I recall vaguely that his little brother is doing something with the Royal Marines. Though I suspect that neither of them will be dropping 20 pounds with their brethren in Helmand Province or nearly freezing to death along the border of Pakistan, I think it’s neat that they get a little taste of military life.

I will admit to watching a bit of the soccer, since they weren’t showing the NFL playoff games. I know that I am shallow, biased, and woefully underexposed, but I can’t help myself- I just don’t understand the attraction to soccer. I mean, when the players get blazing mad at one another, they run up and kick each other, much like the young girls did on my schoolhouse playground. While I can shamefully admit that those kicks did actually sometimes hurt, I just don’t get it. We were taught as youngsters playing baseball that if you get hit by a pitch, jog nonchalantly to first base as if nothing happened, though it may feel like you just ruptured your spleen. Your teammates would be yelling “Don’t rub it” as you trotted down the first base line. In football, you’re taught to “play through the pain,” or “grin and bear it.” Soccer players, however, seem to suffer an epileptic fit when another player actually happens to graze them, flopping on the ground like a dying fish.

I am happy to report, though, that Chelsea beat Ulster (or Unger or something like that) 7-1. Tomas was ecstatic.

Resolution

Sunday 3 January 2010

New Year’s Eve and Day came and went with barely a notice. Christmas was recognizable because of the holiday lights hanging inside b-huts, barracks, and in the hospital- the multi-colored kind we keep strung up all year in Hawaii. Christmas trees of different sizes were visible here and there, mostly small ones shipped from home with a handful of token ornaments, infinitely more poignant and profound in their sincerity and simplicity. New Year’s, however, was pretty much ignored. I spent the morning of New Year’s Day with the smell of my daughter’s hair, the squeeze of my son’s tight hug, the feeling of a tender kiss on New Year’s eve somewhere in the back of my mind. The rest of me spent the morning of New Year’s Day in OR #3, operating on a 13 year-old Afghan child that I had seen out in a village when I was on a medical outreach mission. He had a tumor working its way out through the skin of his face, so I did a parotidectomy and neck dissection to remove the tumor. It was nice to be doing head and neck surgery again, rather than trauma surgery or combat trauma research work. Mostly, I guess I was relieved by how much I enjoyed the case. I see it as proof that I will eventually be able to return home to my normal life, finding it fulfilling and well, normal. I’ve only been gone for five months, but it seems strange to imagine a world without the constant sound of helicopters, the smell of outdoor toiletry, the vista of haze and opacity that lurks and obscures.

The real heroes of that case were the guys who went back out to the village to find the child and bring him in. Their daily courage is awe-inspiring. Maybe even more than them, though, I admire the boy. He is a 13 year-old villager who showed up at the hospital to see me with no escort outside of a commando that he didn’t know. I can’t imagine what he must have been thinking and feeling as we walked to the CT scanner, not understanding the language of anyone around him, in an environment that must seem so utterly incomprehensible. Through an interpreter, I explained the scan and the upcoming surgery, and he neither blinked nor flinched. An impassive nod was his sign of assent. One of the commandos was able to track down an older brother who serves as his guardian and has stayed with him since the surgery.

I just checked on him this afternoon and he is doing fine. I have always enjoyed rounding on my patients alone. The patients tend to be more relaxed, I’m less rushed and distracted, and it allows for real communication, even when we don’t speak the same language. When I’m alone, I can sometimes hear my former patients that I carry around with me- the successes and the failures. They remind me of my strengths, my weaknesses. They sometimes scold, sometimes applaud, often remind me of things that I should have remembered but seem to have forgotten, and constantly point out that they will always be there, patiently waiting for me to be quiet and wise enough to listen.