Life After Afghanistan - My Dog Maddy!

We have now been at war in Afghanistan for over 9 years. It is officially the longest war in our history. Vietnam clearly was longer and bloodier, but it was not always called a war for whatever reason. So, what affect does war have on a country? Thousands of miles away from the bombs and the blasts, there are profound consequences here in America. When even one service member deploys, it touches so many people. Entire communities pray every day for safe and speedy returns. The families go through a range of emotions. It puts tremendous strain on our military back home. I see spouses and kids every day in our clinic who have a range of issues that are undoubtedly related to the war. There are kids acting out, spouses who cannot sleep, and extramarital affairs. It is not pretty. We have programs in place to help. But, many times really nothing can help. And, when the deployer returns things will never quite be the same. In my own life I have experienced this in a way that I did not anticipate at all. Enter my dog Maddy. Let me explain.



In August of 2009 I adopted Maddy. She was a rescue dog that I met at a charity event. She came right up to me with a friendly greeting and the rest is history. Maddy is a yellow labrador retriever who has been through a lot. Apparently she was rescued some time ago when she was quite emaciated. In fact, Maddy had delievered a litter of puppies and was found laying down with all her puppies surrounding her. Her left side was literally stuck to sizzling hot black asphault. She was peeled off the ground and taken in for treatment. This left her with a permanent spot on her left side that will never grow fur completely. All of her puppies died. She spent the next 6 months living in various households as the rescue organization attempted to find a suitable owner. Her health was in peril. Maddy had heartworms which left untreated can be fatal. It is an expensive and long treatment to eradicate the heartworms. This was left for the new owner which of course is me.



The very first night that Maddy stayed at my home it was apparent that she had major issues. She began scratching herself vigorously. It was out of control. I attempted to console her to no avail. She actually scratched so much that a nipple bled. Wow. I took Maddy to the vet a few days later. The intitial bill was $500 and she came home on 6 medications. Her skin was in horrible shape. She needed heartworm treatment ASAP. Nevertheless, we bonded quickly. It is hard not to love Maddy. She is great around people. She comes right up to you and puts her face in your lap. Then she lays down on her back begging for a belly rub. She has an almost insatiable need for affection. Eventually Maddy began the extensive heartworm eradication. She had a section of her fur shaved off and was injected with powerful medications once a month for several months. Over the course of about 6 months the worms were slowly eliminated.



In December 2009 I deployed to Afghanistan. Maddy once again had to adapt to a new caregiver. I had made arrangements for a live in pet sitter so that she could stay in the same home. I thought this would make it a lot easier for her but that was not the case. Maddy's caregiver Jessica told me little about what was going on back in Charleston. That was a blessing because I needed to be focused 100% on my work at Bagram. My sister Annie took care of Maddy a lot as well. She also kept any details about Maddy to herself. Fast forward to July 2010 . I was home and at first everything seemed okay with Maddy. Then, the attacks started. She would go into attack mode anytime another dog was spotted. There are tons of dogs in the neighborhood. It made walks with her absolutely miserable. She would be bucking like a bronco, barking up a storm, and foaming at the mouth. It was embarrassing. Then one day it really got out of hand. Maddy spotted a golden retriever, got off the leash, and made a bee line for the other dog. She attacked the other dog. I actually had to run over and tackle Maddy to get her away. This was BAD!

So, I hired a dog trainer. Over the course of the next 2 months, I learned a lot about handling dogs. Maddy is in fact trainable. We went to public areas and attempted to socialize her. It was often painful. Progress was slow. Maddy would show glimpses of good behavior, then revert back to the bucking bronco on the next walk. It was frustrating. I actually thought about not only getting rid of her, but having her put to sleep. You would understand if you saw these outbursts. After several months, Maddy graduated from dog training school. Her prize was a small stuffed goat to chew. Graduation did not in any way mean that she was all better. In fact, it is still a struggle today. Every day I have to walk her with caution. I give her positive feedback as much as possible. Spending a lot of time with her seems to help. Exercising her for about an hour a day is key. When she gets excited, then we run which seems to calm her fairly well. Maddy has a lot of room for improvement. Progress is slow, but there is hope. If I can get her to get along well with other dogs it will be one of my biggest accomplishments in life. No kidding.

I did not in any way anticipate that my deployment would affect my dog as much as much as it did. Unbelievable. Maddy is a great dog overall. She has so much to offer. I look forward to seeing her every time I come home. Yep, that's corny but true. You would understand if you met her. She is very lovable. But, this whole thing has been harder than I ever expected. I guess even our pets have a hard time with deployments!

Life After Afghanistan - America is Beautiful!

Yes, THE BLOG IS BACK! Why? Simply stated, the deployment experience lives on... even after you are back home safely... sleeping in your own bed again... reunited with your dog... on vacation in great places... laughing with friends and family... swimming in the ocean... or just back in normal routine of everyday life.

It has been 3 months since I arrived back on American soil the evening of July 2nd. It was an amazing feeling to be home again after a long, tough deployment. The ephoria of being home wore off in three or four weeks. I was then left to process all that happened in Afghanistan. As much as I would like to forget about it all, that's impossible. My two deployments are now a part of me forever. As I write this, not even one fiber of my being wants to return to Afghanistan in this lifetime. Who want want to go back to that war torn country when you live in America?

In the last few months I have been able to see and do a lot. It has solidified the fact that we live in an amazing country. In July I took a trip to San Francisco. Wow, what a fabulous city! I met up with my friend Mona there. She is a dynamic person that I met while living in Nebraska. We had an absolute blast touring and experiencing all that San Fran has to offer. The scenery along the coast really is "breathtaking". That's the first time I've ever used that word to describe something! Of course, I ran the San Francisco Half Marathon for fun. It actually went over The Golden Gate Bridge. Not your average Sunday morning run for sure! Perhaps the best experience in San Francisco was something completely random. Mona and I were walking back to our hotel when we came upon a crowd. There was music blasting. People were dancing. Essentially, it was a spontaneous dance party right in front of city hall. It was the most eclectic group of people I have ever seen all having a blast right in the middle of the city. Nobody cared. It was just pure fun. The cops drove by and told everyone to have a good time. So, here was a group of total strangers from all walks of life who were able to spontaneously come together. I was astounded. None of the people wanted to kill anyone. There was no hatred. Politics did not matter. It was just pure fun. The war seemed a million miles away for me.

In September I was able to take another cool trip, this time to Seattle. I went with my good friend Jeremy from Charleston. We went there to experience the northwest, to take in the sights, and to get away from our busy lives. It was an action packed vacation. We started by going to the top of the Space Needle. We finished by taking in a college football game between my team Nebraska and the University of Washington. In between we went kayacking on Lake Union with the Seattle skyline at our backs, travelled up to see the surprisingly cosmepolitan metropolis of Vancouver, and did white water rafting in the mountains. Mostly though we explored the interesting city of Seattle. The neighborhoods have so much character. The layout of the city is unique with Elliot Bay, Puget Sound, and 3 lakes dividing up the city. The air is fresh and cool. On a sunny day, it is definitely one of the most beautiful places in the USA. The sun was shining at Husky Stadium as we watched my Nebraska Cornhuskers pile on the touchdowns against the University of Washington. The only thing that reminded me of the war that day was the fly over of fighter jets, and those thoughts were fleeting. I was in heaven that day.

On top of these vacations, I get to live in the crown jewel of the south. Living in Charleston is a little slice of paradise. I never get tired of strolling through the historic district. The ocean is always refreshing here. The people are friendly. I live in Mount Pleasant which often is called Mount Perfect. Need I say more? My summer in Charleston was filled with family visits and reconnecting with friends here. My parents both came for nice visits. And, over Labor day weekend we were able to have 5 of the 6 Hayes siblings and 9 of the 12 nieces and nephews all here for the weekend. We had a blast together. There were Hayes kids running all over the beach. We all visited my sister Annie at her art booth in the Charleston market one night. My 12 year old nephew Joe got to meet his first ever bachelorette party while we were downtown that night. The photo of that is priceless and is currently displayed on my refrigerator. Good times.

After 6 months in a dusty, smelly, dry, nasty place... well, anything would seem better than Afghanistan. Americans often overlook the fact that we live in a vast country with so many interesting things to see and do. I hope to never take our country for granted again. After all, America is Beautiful!

Never Forget

After working harder than I ever have for six months in Afghanistan, I am now enjoying some much needed vacation time. Home feels the same in many ways. My dog still loves me. The ocean is still refreshing. Charleston is still a fabulous place to live. Nevertheless, everything seems different as well. I am enjoying the little things in life a lot more. Things like a hot shower, quiet nights, and a comfortable bed are more appreciated now. I am more grateful for our country. We truly have more blessings than most of us can imagine. I am also trying to live in the moment. However, more often than not my time in Afghanistan is on my mind. It was an unforgettable, life changing experience for many reasons.

Who could forget the 19th of May? At 3 in the morning I was sleeping in the on call room when I was awakened by BOOM, BOOM, BOOM. We were told to get our weapons and stay put in our duty sections. As we huddled together in the hospital, the fighting seemed like it was just outside the door. Apache helicoptors were hovering above us and were raining rounds down on the base perimeter. The army took position with their armored vehicles and quickly gained firepower superiory. The firefight lasted maybe an hour although it seemed much longer. 20 terrorists attacked our base that night with a myriad of weapons. None of them survived. They managed to kill one person and wound 5 others. Their actions put our base into lockdown for several days. Security was increased. Several of my colleagues were shaken by this experience and would not sleep well for the remainder of the deployment.

Who could forget our six year old patient with brain trauma? Modaser sustained an injury to the right side of his head. He was a victim of war related violence. He was also one of the cutest and most entertaining kids you ever want to meet. His hospital course was complicated by an infection that required long term antibiotics. He actually had a wound vacuum on his head. Modaser also had neurological damage which caused his right leg to not work properly. No problem. His solution was to simply walk more. Modaser did countless laps around the hospital. His walking improved greatly over weeks. His infection eventually was eradicated. He was quiet at first, but then he came out of his shell big time. Modaser had the great gift of gab. He would talk practically non-stop in his native tongue. Then, he would smile and laugh. Modaser single handedly raised the morale of our staff every day. I hope that he is safe in his village right now and that he is able to help his country become a better place.

Who could forget the baby faced marine with the leg amputation and the open abdomen? He spent several weeks guarding a prisoner who was hospitalized. His unit had captured the suspected terrorist. He was a nice kid that was well liked by everyone. Eventually, the prisoner left the hospital and the baby faced marine returned to Helmand Province. This is one of the most dangerous places on earth right now. Shortly after leaving us, he returned as a critical trauma patient. It was so difficult for us to see someone we actually knew get torn up by yet another IED blast. It was hard to stomach even looking at him as he lay motionless on a ventilator in the ICU. He was stabilized and sent on to Germany. His wounds will likely heal, but he will never be the same.

Who could forget working with extraordinary people? Dr. Mike Greene became my closest friend in Afghanistan. We both did our residency in Family Medicine at the University of Nebraska and Offutt Air Force Base. Mike was two years behind me in his training. He was an intern when I was the chief resident of the program. We barely knew each other then. But now we have shared a difficult experience together. Mike is very dedicated to his work. He showed up every day to see his patients at oh dark zero. I would make it in at oh dark thirty. He always went the extra mile even when the sheer number of patients was practically unmanageable. We often needed time away from the hospital just to talk about the insanity of it all. We leaned on one another to make it through the deployment. His work ethic, patience, and integrity inspired me every day to be a better doctor.

There are certain experiences in life that shape us. Some even change us for the better. Many of the events of the past 6 months are burned into my brain. My world view has changed. The little things in life are more important now. The small stuff is not as stressful now. I feel very grateful for my many blessings. Friends and family matter more than ever before. I am more connected with my spiritual side. I want these feelings to stay with me indefinitely. Without a doubt, life goes on after Afghanistan. It is important to compartmentalize the memories in order to move forward. But, I hope to never forget all that happened. I hope to never forget how it felt to take care of the wounded. I hope to never forget all the people that prayed for us. I hope to never forget those that were severely injured. I hope to never forget the hard work of the troops. I hope to never forget those that paid the ultimate sacrifice. I hope to never forget those that are serving our country at home and abroad. I hope to never forget all the difficult lessons that I learned serving our country.

Coming Home

Military travel is almost always long and arduous. The trip home from Afghanistan certainly qualified as such. I spent 3 relatively peaceful days in Kyrgystan at Manas Air Base. It was absolutely necessary to have some down time before the long trip home. To the credit of the military, they have built in this time at Manas as part of the deployment. I felt a lot of the deployment tension easing over those 72 hours. It was fun to shoot the breeze with people and have some laughs. I was able to hang out with my good friend Geoff Cooper. He is a family doctor I know from residency who was deployed to Manas. His time there was very different than mine at Bagram. Horseback riding and kayaking are just a few of the things the folks at Manas are able to do in their time there. Now that is what I call a good deployment! Before leaving Manas, I was able to get a fabulous back massage from a local lady named Lena. It cost me $10 for 30 minutes. I tipped her $15 which apparently is a lot of money there. Lena gave me a kiss on the cheek. Oh Lena! I felt the best I had in probably a year.

The trip home began abruptly. We had a show time at the terminal of approximately 0500. But, 130 marines had a different agenda. A small group of us Air Force guys were sharing a tent with these fine gentlemen. At 0230 their sergeants began screaming at the top of their lungs. The lights were turned on and chaos ensued. Apparently, it was important for them to act like they were in Times Square at this crazy hour. There was no reason for this at all because they were not getting on the same plane as us and to my knowledge there were no other planes taking off that morning. Oh well. I thought about pulling rank on one of their sergeants. But, the fact that they had a plethora of semi automatic weapons readily available was the deciding factor. I kept my mouth shut up, packed up, and left with the rest of the Air Force guys.

Our first stop on the way home was in Turkey at Incirlik Air Base. We were there for a few hours refueling and picking up more passengers. The summer is a busy time for moving in the military. Various families joined us on the way to the states. We were able to eat some turkish food there which was nice. My belly was full as we headed off to Germany. The flight across Europe was pretty easy. I could not help but notice green trees as far as the eye could see as we descended into Ramstein Air Base. This is something none of us had seen for months. The stay at Ramstein was a bit odd. We were allowed to stroll through the terminal for about 10 minutes. Then we had to hurry up and get back in line. It was yet another security screening. Our identification was checked about a half dozen times. The German security agent took away my deoderant because it was 4 ounces. It was the only way for me to control the overwhelming body odor that happens on a transcontinental flight. Too bad for the passenger next to me! We were then quarantined like animals in a large room for 2 hours which is standard procedure for some reason. A large amount of families also joined us for this flight. Screaming babies were abundant.

The flight across the Atlantic was smooth. However, about 5 hours into the trip I noticed a woman in distress at the front of the plane. I approached her and immediately noticed her gravid uterus. She stated calmly that she was contracting every 2 minutes! What? Excuse me? Holy -----!!!!! This is not a trauma patient I told myself as I tried to remember what to do with a contracting 34 week pregnant lady. After all, it had been over 3 years since I delivered a baby. 6 months of shattered bones, amputated limbs, and open abdomens had not prepared me for this. I asked her a few questions. Luckily, she did not have any major abnormalities that were red flags for disaster. The head flight attendant then asked me point blank if we needed to divert the aircraft to Nova Scotia. After all, we were still over the Atlantic! 250 people wanted to get home that day. I was not about to stop this unless absolutely necessary. My answer was no. We had several other family doctors on the plane to help with this crazy situation. Also, we had a labor and delivery nurse named Lieutenant D whom I worked with for the past 6 months at Bagram. She had not dealt with a pregnant patient in a long time. Now was her chance.

Lieutenant D had the patient lay down and drink lots of water. She was able to calm the patient in a way that I could not. 30 minutes later the patient was still contracting every 2 minutes. I suggested checking her cervix for dilation. Lieutenant D talked me out of it. Her instincts told her that this would pass. She was 100% correct. As we descended into Baltimore, the contractions slowed down to every 5 minutes. Our 34 week pregnant patient was feeling good. There would be no delivery at 30,000 feet! Crisis averted. The plane landed. The paramedics came to the gate. The patient was immediately taken to the hospital. I proceeded to baggage claim thanking the good lord the entire way.

Arriving back in the United States of America after a deployment is an amazing feeling. Euphoria is the best word to describe it. I had to stay the night in Baltimore which was fine by me. I took multiple showers in my sparkling bathroom, had a belgium waffle for breakfast, and went for a jog through a suburb of Baltimore. It was relaxing. By mid morning I was ready to continue on to my home in Charleston. I could not help but notice the busy people at the airport talking on their cell phones and rushing through the day. They were all blistfully unaware that I was on my way home from the most difficult experience of my professional life. After the plane landed in Charleston, I walked slowly through the terminal. My knees were weak as I hugged my sister Annie. There was a group of my friends and colleagues there to welcome me home. It was emotional. It felt great to be home again after this long deployment. I felt immensely grateful. Coming home after a long deployment is like nothing else.

Decompression

Making it out of Afghanistan is a great feeling. Most people feel very relieved to be leaving a war zone. It does not matter that the military flights are always uncomfortable. We are packed in there like sardines. Wearing body armor makes it worse. Some people even have to fly back with caskets of fallen service members on the same plane. That's sobering to say the least. But, it is worth it to leave a war torn country. Our first stop out of Afghanistan is in another one of the "Stans"- Kygystan to be exact. This is a former soviet republic that is now an independent country. It has been in the news for several months due to civil unrest. It's unstable, but for now we have a base here that serves as the transit center to and from Afghanistan.

When the relief of leaving Bagram wears off, people generally have a lot of different emotions. For me, it is simply mental exhaustion. I just want to vegetate watching movies and doing other mindless things. There is a certain amount of hypervigilance about safety that goes along with being deployed. Even at a large base like Bagram, you have to be on guard. You learn to sleep with F-16's roaring through the sky and explosions off in the distance. Now, we understand the phrase that the "silence is deafening". It is strange to have pure silence although those moments are few here given that I am sleeping in a tent with 130 marines. We all need time to process everything that happened on our deployments. This will take weeks. For some it will take months. For others they may never reconcile what happened. My 130 marine roommates definitely had a very different experience than me. It all needs to be compartmentalized to a degree to return to normalcy.

Enough with the psycho babble... LET'S PARTY!!! That is exactly what is happening here in Kygystan. This base has all sorts of amenities to keep us occupied. The average stay here is about 72 hours. Having a little fun is important. There is a cool hangout here called "Pete's Place". It is located in the middle of the base. It has a large deck, pool tables, a stage for entertainment, and of course a bar. Everyone is allowed 2 alcoholic beverages a day. People let loose. The young nurses from Bagram have been severely tipsy on 2 beers. Nice. Karaoke was the center attraction one night. I thought about singing a Neil Diamond song, then thought the better of it. Last night there was music provided by the local Kygystans. It was really entertaining. They played some interesting instruments which rang out some American songs for everyone to sing along. The ladies had elaborate costumes for some exotic dancing which was quite a sight for many sore eyes. A good time was had by all.

In the next 48-72 hours I will be back in my close to the beach condo in Charleston. There will be a reunion with my dog Maddy. I cannot wait to jump in the ocean. Taking a nap on the sofa sounds fabulous. Lounging at the pool while catching some strong South Carolina sun is a must. Seeing friends and family again will be a lot of fun. When the dust settles, another deployment will be in the books. Then, the process will continue on with some serious decompression.

The Best People

In the past week, a wave of new doctors, nurses, and medics arrived here at Bagram. These are our much anticipated "replacements". I am sure the group with is filled with plenty of talented people. There are not many things that I will miss about this deployment. But, I have met many outstanding people that I will always remember. Some of them set themselves apart in my mind.

How about Airmen Chris? He is a physical therapy assistant who was assigned to the hospital ward and intensive care unit. His job involved working with very sick patients every day. He would help intubated patients move their arms and legs. He would walk patients with amputations and shattered bones. He would take patients outside who had not seen the light of day in weeks. He did this all with a smile, a great sense of humor, and an infectious laugh. Airmen Chris is planning to get a masters in physical therapy. I have no doubt he will be highly successful.

Then there is Sergeant Jen in the ER. She is a positive, upbeat person who embraced her job as a medic. She was clearly a valuable member of the emergency room team. She worked on countless trauma patients. Sergeant Jen would disconnect the patients from the myriad of medical equipment they are attached to upon arrival and then help resuscitate them. Doing this expeditiously is very important as many of these patients need blood transfusions and surgery not later but NOW. One day I found out that Sergeant Jen will be starting medical school this summer. It did not surprise me one bit. What did surprise me was learning that she is a ivy league graduate from the University of Pennsylvania... she is smarter than all of us!

Nurse Laura volunteered to come to Afghanistan leaving behind a nice life in California. She is a member of the Air Force Reserves and was assigned to work in the Contingency Air Stage Facility (CASF). This is essentially a large tent behind the hospital that houses patients awaiting a medical flight to Germany. The CASF staff takes care of these patients, but they also serve as the staff to plan the flights to Germany. The CASF staff has moved up to 60 patients on one flight. That's amazing! Nurse Laura impressed me in many ways, but mostly because she helps the patients feel like human beings. The patients are often very affected by their war experience. They need someone to talk to about their lives. Nurse Laura gets to know them on a personal level. Often, she takes them to the coffee shop or to the dining facility. This helps them transition back to normalcy. She and the rest of the CASF staff help the troops to be regular people again.

Not all surgeons are created equal. Right away when I met Surgeon Todd he was different. He was soft spoken and friendly. He seemed to set everyone at ease in tense situations. As a vascular surgeon, he is a highly trained professional who repairs blood vessels for a living. He once helped reattach an amputated arm. That's intense! I enjoyed working with him because he was down to earth and humble. These are rare qualities in surgeons. But, Surgeon Todd also was assertive when he needed to be. At a meeting one of our commanders gave the doctors a lecture about how it was important to ALWAYS be nice to the nurses and medics. Surgeon Todd disagreed. He stated that sometimes people need to be told exactly what to do. When they make the same mistake repeatedly, then yelling at them is okay. After all, we are in the military and our mission is about saving lives.

Colonel Joe the dermatologist is well known in the Army medical world. You would never know this talking to him because he seems like a regular guy. But, he was instrumental in bringing a dermatologist to the Iraq War after soldiers started showing up by the dozen with nasty skin lesions from Leishmaniasis. This is a skin disease caused by camel spider bites. It can leave disfiguring scars. Colonel Joe has now deployed 3 times. He is a great dermatologist. The only requirement for a referral to him is that the patient has skin! He stays in fine shape by running almost every morning at dawn. When he was running one morning, a group of females yelled "NICE BUTT" as they drove by in their armored vehicle. Colonel Joe took it in stride. After all, he is the coolest colonel I know.

I have met so many good people here at Bagram that it would be difficult to mention them all. In my experience, it is the people that make or break a situation. I was able to get through this deployment because of the people here. And, the best people are the ones that made an impression on me that will last well beyond the confines of Bagram.

Perspective

Last week a meeting was called at the hospital for all the soon to be departing personnel. We were told that we would all need to move out of our living quarters and that our replacements were due soon. For various reasons we would be housed in several different tents and temporary places near the hospital. In the event of a mass casualty event, we were all needed. Space has become a major problem here at Bagram with the Afghan Surge well underway. Some of us were asked to live in the hospital. I was mandated to live in the clinic. Tonight will be my sixth night sleeping on a procedure table. It is designed for minor procedures such as mole removals and toenail extractions. Instead, it is my bed for the foreseeable future. Toxic is the best way to describe me ever since this turn of events. I have been complaining constantly about this terrible situation. After all, how can the United States Air Force treat a doctor like this? This is a gross injustice of immense proportions, right? ABSOLUTELY NOT!

Recently, I learned that rank and titles do not matter when it comes to our space problem. Our head nurse who is a colonel is also living in her office. She is sleeping on a cot. The pharmacy supervisor who is a master sergeant is sleeping in the pharmacy. The head radiology technician is assigned to live in the radiology department. This is reality. There are definitely worse places to be. One morning not too long ago some soldiers were spotted sleeping on litters (aka stretchers) next to their armored vehicles. This was in an open space just a hundred meters from the hospital. That's rough. How about our soldiers who are in harm's way at this very moment in time? How about the Afghans who live in mud huts just outside the fence line of our base?

A few of my frieends and I recently watched the movie "The Pursuit of Happyness". It is a good movie about man who overcame incredible odds to make it big. It shows a little glimpse of what it is like to be homeless and to have almost nothing. The movie got me thinking about my situation and how pathetic it is for me to complain. Then, my friend Dr. Mike told me a little of his life story. You see, Dr. Mike was on food stamps for the first year of medical school. He has lived through some very tough times. He and his wife dropped out of high school after having their first child. Mike then graduated in his high school's vocational program. His wife earned a GED. The next decade was struggle. His wife worked the night shift at Wal Mart. Dr. Mike worked as a short order cook. They took college classes and slowly made their way through school. Mike had to donate plasma for money to help pay the bills. At one point, their apartment building burned down and they lost everything. They even lost their car. He rode the bus to school for 2 years at Syracuse University. It was never easy. They lived on $7,000 during Mike's first year of medical school. Then, Mike was awarded an Air Force scholarship. Life got better for his family. And, the Air Force gained an outstanding individual. The rest is history. It has been a pleasure to serve with Dr. Mike here in Afghanistan. He has inspired me to be a better person.

Some time in the near future we all will be home sleeping in our own beds. It will be a great feeling. When the euphoria of being home wears off, hopefully we will all appreciate the little things in life a little more. I can handle sleeping on a procedure table even if I know that someone had a large wart cut off on there the other day. At least I am not out in the cold or the heat for that matter. I guess a little persective goes a long way.

Too Hard or Too Easy

Several weeks ago I made the decision to move from working in the hospital to the clinic. For five months I was a "hospitalist". I only did inpatient care of our hospitalized patients. It was a great experience in many ways, one that I will never forget. But, there are no days off in the hospital here. I was going nuts. 157 days in a row of seeing blown up people has a tendency to do that! One of the family doctors working in the clinic wanted to get some hospital experience. There was a small window of opportunity to make a change, and we took it.

For the past several weeks I have been spending my days in the comfortable confines of the The Outpatient Clinic. They actually made me the boss as well. The hours are set. There are few surprises in the workload. The pace is very reasonable. And, I actually had a day off as well which was amazing. Nevertheless, there are still plenty of challenges even away from all the trauma patients. To be a good clinician in the outpatient world you must be efficient. Nobody likes a doctor who runs behind schedule constantly. It makes everyone irritable including the staff and the patients. Do you ever remember waiting a long time at a doctor's office? It is not the most pleasant of experiences. The bottom line is that as a doctor you have to do the best you can to get people in and out of there. It can make for a real grind especially in a high pressure clinic.

Our clinic here is far from high pressure. But, we do get patients referred to us from all over Afghanistan. It can be interesting at times. Recently, there was a patient I thought had a rare condition called occipital neuralgia. I injected some medication over a nerve on his scalp. It relieved the headaches he had been having for 3 weeks within a few hours. Several days later he is still headache free. Now the patient thinks I am REALLY smart which obviously is not the case. For every good case that we have like this, there are at least 3 bad cases. What I mean by this is that other doctors and physician assistants "dump" patients on us. When the patient becomes too difficult to figure out, they send them to us. When the patient has an alterior motive, they send them to us. When the patient is drug seeking (they want morphine), they send them to us. When it becomes TOO HARD to do the right thing, they send them to us!

It is easy to give someone a hundred morphine tablets when their back hurts. It is easy to make up a diagnosis when the patient demands an answer. It is easy to order a test instead of telling the patient that you do not think anything is wrong. It is easy to prescribe antidepressants instead of taking time to find out more about why the patient is crying. And... it is TOO EASY to send the patient to another doctor when they are too sick or too broken to serve in a war zone and their commander wants "boots on the ground". After all, the pentagon is very concerned about how many troops are here. Thus, commanders do not necessarily care if a soldier is healthy enough to do a job because the mission comes first.

This is what we deal with every day in the clinic. It is not glamorous. It is not exciting. Actually, it is frustrating as heck. But, it is a job that has to be done. Nobody will ever give me a medal for filing the most paperwork to send sick and broken troops home. The exact opposite of that is true. Nevertheless, I was taught in my training to be an advocate for the patient no matter what. In the end it is very difficult to do what is the right thing instead of avoiding what is TOO HARD or doing what is TOO EASY.

GO BIG RED!!!

One of the ways that people cope on deployments is to compartmentalize. You simply stop thinking about certain aspects of your life. Your life back home is so far away that you will drive yourself nuts if you do not put it on the shelf for a while. For me this has meant forgetting about laying on the beach in Charleston, walking my dog around the community pond, or taking a road trip down to Kiawah Island. But, now I am getting close to leaving Afghanistan. Life back home does not seem so far away. I can start thinking about better days ahead.

For as long as I can remember, sports have been an important part of my life. My earliest memory is getting my picture taken as a 3 year old with a baseball cap on and a wiffle ball bat in my hands. I can recall clearly watching sports practically non stop as a kid. New Year's Day 1984 was a marathon of college football for me. I sat in our TV room and watched 3 football games in a row. The last game was one of the greatest games in college football history. It was the 1984 Orange Bowl between the Nebraska Cornhuskers and the Miami Hurricanes. The game ended just before midnight when Nebraska went for a game winning 2 point conversion and were denied. Miami won the game 31 to 30. They were crowned national champions. Bernie Kozar was Miami's quarterback. He was only a freshman at the time. Of course, he would later become a hero in my hometown as the quarterback of the Cleveland Browns.

Fast forward to 2004. I was a first year resident (intern) at the University of Nebraska Medical Center. I was living among countless diehard fans of the aforementioned Nebraska Cornhuskers. They call it Husker Nation. Late in the fall that year, I obtained 2 tickets to a Nebraska football game. I invited my good friend Allen. He was nine years old at the time. I was serving as his "big brother". We made our way to Lincoln and found our seats high up in the 72nd row. The wind was howling. Allen became uncomfortable and scared. He was quite upset. We left our seats and went down to ground level. Allen asked me, "Why don't we just get another seat?" My reply was something like, "Buddy, this stadium has been sold out since 1962! There are no other seats." We were standing there and Allen began to cry. I did not know what to do. Out of nowhere an usher approached me and asked me what the problem was. I explained the situation. He said that perhaps he could find a solution to our dilemma. He lead us through the crowd, talked to a few people, and the next thing I know we were sitting at field level right behind the end zone! It was incredible. At halftime this same usher found us and led us through the stadium. He took us on a tour of the locker room and weight room. He then showed us the trophy cases including the National Championship and Heisman Trophies. Our day was complete. I became a Husker fan for life.

On Friday it was announced that the University of Nebraska would be joining the Big Ten Conference. Are you kidding me? I am so fired up!!! It will be fabulous to see the Huskers play the Ohio State Buckeyes in Columbus some day soon. I cannot wait for the Huskers to dominate Michigan in the big house. It will be a blast when Nebraska plays Iowa. My nephew Joe is a die hard OSU fan. Let the trash talking begin! My good friends Brad Meyer and Drew Porter are big supporters of their alma mater, the University of Iowa. They both met their wives in Iowa City. We will have fun tailgating in Lincoln together. Geoff Cooper loves his Penn State Nittany Lions. A trip to see a football game in State College, Pennsylvania is a must now. I get excited just thinking about all this. Good times are ahead. Afghanistan will be in the rear view mirror soon. I will come home a changed man for sure. This was a life changing experience. But, very little can change the core of one's personality. After all, I came out of the womb a sports fanatic. So, the news of Nebraska joining the Big Ten is music to my ears.

GO BIG RED!!! (By the way, the N on the Husker football helmet stands for Knowledge)

The W

For the first five months of my deployment I worked exclusively in the hospital on the Intensive Care Ward. (I recently moved to the clinic which I will explain later) It's commonly referred to as the ICW or simply The W. I am not sure if there is a place quite like it anywhere else. I have never heard of a section of the hospital being called an intensive care ward. But, here at Bagram it makes sense. The patients on The W are very sick. Essentially, when patients in the Intensive Care Unit come off a ventilator (breathing machine) they are sent to The W. They arrive with jaws wired shut, tracheostomies in place, bowels in discontinuity, limbs amputated, wound vacuums in place, chest tubes on suction, drains in the belly, and external fixators holding bones together. Simply stated, these are complicated, sick patients who are recovering from horrific injuries.


The work done every day on The W is outstanding. It is always busy. There is a constant flow of injured Afghans. And, almost every day a group of American and coalition patients are loaded onto litters and transported out of the hospital onto planes to leave Afghanistan. The hospital beds fill up again in a matter of hours and the entire process begins again. There is rarely a reprive from this. The staff has to be ready to work hard at all times. This can be a real grind to say the least. All of us have felt it. And, each of us has needed to lean on others to survive and stay sane.

The staff I worked with on The W was diverse. There was a large group from Nellis Air Force Base (AFB) in Las Vegas. Travis AFB in northern California is the home station for many others. The nurse manager is from Shaw AFB just up the road from my home station of Charleston AFB in South Carolina. One of our doctors was an Army internist from Heidelburg, Germany. Another doctor is stationed in Japan. Other places represented include Seymour-Johnson AFB in North Carolina, Andrews AFB in Maryland, and Lackland AFB in Texas. We cannot forget our medic from the Idaho Air National Guard as well. I am sure that I have forgotten someone.

On the whole, the staff is quite young with ages mostly in the twenties and some in the thirties. I bet there were a few fortysomethings as well! Some were quite experienced while others are just beginning their careers. Several nurses work on maternity wards back home. Others work in post anesthesia care units and emergency rooms. A few come from clinics much like the one I work at in Charleston. The bottom line is that almost none of us had seen anything like what we have here at Bagram. It was certainly a shock for many of us. The learning curve was steep. Yet, everyone stepped up to the challenge. We did things that we never expected to do and acquired knowledge in areas that will only help us in the long run.

Without a doubt, The W has made its mark. We shined when both the President of the United States and the President of Afghanistan visited us this year. More importantly, we impacted the lives of a heck of a lot of patients. The work is definitely something to remember. But, work is merely one aspect of life. In the end, it is the people that made up The W that really matter.

Living and Dying with Dignity

In the summer of 2009, an Afghan local national (civilian) was shot in the abdomen. He was transported to Bagram for life saving treatment. He likely would have died had he not been brought here. His abdomen was opened, the bowel injuries were sutured together, and he was given an ostomy (bag for collecting stool). His intestines were left in discontinuity. The plan was for him to return months later for his bowels to be sewn back together. Similar patients present to our hospital nearly every day. However, this particular patient was destined to become one that most of us will never forget. He would get many nicknames during his stay. I will simply refer to him as Mr. G. He was a middle aged man with a large family, nine children and a wife to be exact. He maintained a long black beard. He was quite thin and short like many Afghans. Mr. G was pleasant, easy going, and likeable.

This past January, Mr. G was admitted to the hospital to have his ostomy bag removed, a hernia repaired, and his bowels to definitively repaired. My good friend Dr. Mike Greene was his attending physician. The operation went as planned. Mr. G spent the next few days recovering. All seemed well. Dr. Greene prepared his discharge papers. Mr G was set to leave, but then we noticed a foul smelling discharge coming from his incision. It was feces. Mr G had developed a dreaded enterocutaneous fistula. What the heck is that you ask? Well, essentially it was a tract from his bowel to his skin. Fistulas are a rare complication of any surgery. It is the body's response to the trauma of surgery. I do not claim to be a fistula expert. In fact, Mr G's fistula was the first I had ever seen. I hope I do not ever see another one.

It is difficult to summarize what happened in the next 140 days of Mr G's hospitalization. I'll do my best. The irony of a fistula is that it was caused by surgery and by doing more surgery you can actually cause more fistulas. One fistula is bad enough. You do not want more! So, we had to calmly wait to see if Mr G's fistula would heal. The output of feces needed to be controlled to avoid infections. Mr G was not allowed to eat. We started him on Total Parenteral Nutrition (TPN). This is basically an entire day of nutrition in one bag that is given intravenously. His bowels needed to rest in order to have any chance of the fistula closing. TPN is labor intenstive for the pharmacy and it is very expensive. The cost would make the hair on the back of your neck stand on end. At any rate, the fistula was given time to heal. Weeks turned into months. The darn fistula just would not heal. The surgeons were chomping at the bit to do something about it. After all, a chance to cut is a chance to cure... except in the case of fistulas!


Mr. G eventually did go back to surgery. In fact, he had over 50 trips to the operating room. Our team of excellent surgeons did everything they could to find a solution. His abdominal musculature was removed and thrown into the bucket. This left him with the grand canyon of all abdominal wounds. It was not pretty. In addition to his fistula, Mr G had numerous complications. One of the main risks of giving TPN is infection because it has to be given through a large IV inserted in the chest or neck. Mr G developed overwhelming blood infections that made him critically ill not once but actually 6 TIMES! I am not exaggerating. He was put on a ventilator (breathing machine) for prolonged periods of time. We treated him with the best medications known to man. He always pulled through. Simply stated, Mr. G is a survivor. One night I was on call and we had a power outage in the hospital at 3 in the morning. The patients in the intensive care unit were prioritized because their ventilators had no power. Mr G was considered a low priority. I walked into the ICU and Mr. G was breathing on his own despite the fact that his endotracheal tube (breathing tube) was still in place. It was like breathing through a straw and he was doing it no problem. We took out the breathing tube because he obviously did not need any help breathing. He left the ICU later than day and was back to his normal self. The legend of Mr. G grew larger.

As the weeks passed, the surgeons kept trying all sorts of different ideas. Unfortunately, nothing worked. He had 5 skin grafts done to close his abdomen all of which failed. After over 4 months taking care of Mr G, my colleague Dr. Greene needed a break. I became the attending physician for Mr. G. It was clear to me that we were reaching a crossroads. An incredible amount of resources has been used in his care. Mr. G had been on an emotional roller coaster. So, Mr. G and I had a frank discussion through the interpreter. I told him that he was in charge of his health care, not the doctors. I told him that he needed to do what was best for him and his family. It was important to say this to him because in Afghanistan people will do whatever doctors say. They do not question us. I let Mr G think about this for several days. Then, one morning with his father by his side Mr. G informed me that he wanted to leave the hospital. Enough was enough. We began to make arrangements for this to happen. However, there was not agreement among the doctors about what was best for Mr. G. In the meantime, Mr G became critically ill once again. I was called to his bedside during the night because he had a fever of 105. He once again has bacteria in his blood. He went back to the ICU. Those of us that had taken care of Mr G for over 4 months were disgusted. It was difficult to see him so sick once again. But, Mr. G survived this trip to the ICU yet again. He was back to his normal self in 3 days. After all, Mr G is the ultimate survivor.

Several days later, Mr G was lead out of the hospital in a wheelchair. It was early in the morning on a clear day. I pulled a wagon full of medical supplies for him. We loaded him onto the ambulance for the short ride to the base entry control point for his release. The ambulance doors were closed. Mr. G waved good bye. Some tears were shed as they drove away. His fate was now out of our hands. He was scheduled for a follow up appointment at our hospital. I doubt he will be back. In fact, he may not even be alive today as I write this. One thing I know for sure is that Mr. G is either living or dying with dignity.

The Trauma Czar

Christmas Day 2009 was my first exposure to how life would be for the next 6 months here at Bagram. I had arrived the previous day and had settled into my living quarters. I made my way over to the hospital for morning rounds which start at 0630. In medicine, ,making "rounds" means many things. Generally, it means that you are going around seeing your patients in the hopsital. Rounds at Craig Joint Theater Hospital was unlike anything I had ever seen in my career. First off, most of the professional staff was present. Getting a couple dozen doctors from various specialties all together at the same time is unheard of at most hospitals. Then, I was introduced to "The Trauma Czar". This position is held by someone trained in trauma surgery. l will call him the TC.


It was apparent from the very first moment that the TC was a dictator when it came to patient care here. He ruled with an iron fist. Rounds would start off with a review of recent x-rays, proceed to the Intensive Care Unit (ICU), then finish up in the Intensive Care Ward(ICW). The TC was in complete control the entire time. Doctors who were experienced and competent would report an update on each patient. Ultimately, the TC would decide on a plan of care. Often this would involve him telling various surgeons and doctors what they needed to do. This is not a common practice at a normal hospital. I was shocked to see this happening. Doctors have big egos and plenty of pride. Being told what to do is a major slap in the face. The TC did not care at all about hurting anyone's feelings. You had to have thick skin around this man. After all, there is no crying at a military trauma hospital in the middle of a war zone dammit! Why did the TC act this way? Months later I came to understand that he felt 100% responsible for every patient that came through our doors. Whether this was self imposed pressure or whether it was reality is debatable.


The TC was perhaps even more authoritative in the trauma bay, aka the "Trauma Hot Box" (THB). Our trauma patients would be brought into the ER and then were assessed in the THB. A plethora of people would be present at these resuscitations. Often, the TC would tell everyone to, "Shut up, be quiet, and do your job". Another signature statement was, "If you are not needed here, GET OUT!" When a patient was unstable and needed interventions right away, the TC would step up his game even higher. Orders were barked out firmly such as, "Transfuse a six pack of platelets NOW" or "Put in a right chest tube NOW." In time everyone knew their job in the THB. There was very little ambiguity. This was definitely a good thing because few of us had ever seen anything like the horrifying injuries that we see here routinely.

The TC was an equal opportunity offender. It did not matter if you were a full bird colonel or an airman first class. If the TC thought you did something wrong, he would be in your face. The TC was a major, the same rank that I was promoted to just a month ago. In many ways, to see him going off on colonels was highly amusing. I could never pull that off like he did. It was refreshing to a certain degree. In this situation, experience and training trumped rank and time in service. That's appropriate considering that the stakes here are so high. We are in the business of saving life, limb, and eyesight.

My description of the TC probably makes him seem like a first class you know what. But, I think it is important to realize what was motivating this man. Simply stated, the TC's primary goal was providing world class health care. He wanted to do what was right for the patient. He treated all the patients the same whether they were an American general or a young Afghan policemen. Human life is the same across the board, right? The TC also took into account what was the best thing for the military. For example, if a soldier wanted to stay here in Afghanistan (a clear sign to me of insanity) but he could not do his job due to an injury, well, he was on the way home. The TC angered a lot of people by doing this, but in the end it is the right thing to do. After all, what happens when the person with a bad back comes under mortar fire and cannot get to a bunker fast enough? Is it okay to send someone back to duty who needs mind altering medications to numb pain? These are difficult questions. But, the TC made the answer clear. If there was any doubt at all, the patient was getting on a plane out of Afghanistan.

I worked with this TC for 20 weeks. I came to understand a lot of things about him. One morning he took a few minutes to go out of his way to thank me and my colleague Mike Greene for our work in the hospital. It was sincere. He felt we worked hard for the right reasons. We simply wanted to do what was best for our patients even if it was not easy. That's why I think the TC respected us. And, his dedication to the patients and our country is why I respect him. About 10 days ago the TC left Afghanistan and was replaced by another trauma surgeon. The TC is now home in Texas enjoying life. He is probably spending a lot of time on his boat which he talked about frequently. He is back at home with his family where he deserves to be. If the TC ever reads this, I want him to know one thing. Thank you Dr. John Bini for all that you did every day here.

Change

I have worked 149 consecutive days on this deployment. I will not have a day off until I leave Bagram. God willing that will be around the end of June. This is just the way it is. There is nothing I can do about it except press on until the end. We all have become quite comfortable with our jobs here despite the human carnage surrounding us. Routine has kept us all sane. We work. We eat. We exercise. We sleep. There is little else to do. It has become predictable which is important when you are in the middle of an unpredictable war zone. However, in the last week or so most of the surgeons and all of the emergency room doctors have been replaced. We are all trying to put names to faces now. More importantly, we are all scrambling trying to deal with all the CHANGE that has been thrust upon us with this new wave of doctors. It has been painful to say the least. Our routine has been turned upside down.

For the last 5 months, the hospital has functioned based on an early rounding time of 0630. I would see my patients on my own from 0530 to 0630. Then, the professional staff would meet to see all the patients together and come up with comprehensive care plans. The surgeons would start operating around 0800. It was not easy to be coherent at that early hour, but after a while everyone became accustomed to it. One week ago all of this changed. The new boss (aka trauma czar) decided that starting things later would be better. We are now meeting at 0800 or 0830. The intention is to make things a little easier on us. It seems like a good idea. The problem is that routines have been established and many of us are not happy to have it all changed when the end of our deployment is in sight. Oh well, we will get over it.

Another issue is that there is a lot of confusion over who is responsible for what. Our roles were clearly delineated with the previous group. Everyone knew what they were supposed to do and where they needed to be even if you did not like it. In a crazy place like our hospital, it really helped us all stay focused on providing excellent care to our patients. That is what truly matters. In my first 5 months here, only 2 injuries were missed on our entire populatione of trauma patients. We had over 600 trauma patients admitted to the hospital. That's an amazing record. It is a tribute to the organization and the redundancy of the system. A systematic approach is absolutely essential in trauma patients. It is even more important in our patients because they sustain all kinds of atypical injuries from these powerful blasts. In the last week or so, there have been several near misses. The problems were corrected before they could lead to any adverse outcomes. But, the potential is there for patient care to suffer. It has been difficult for us all who have been here since December to see all this happening.

Change in life is inevitable. The previous group of surgeons and ER doctors had to leave. Their work here was complete. People are always coming and going whether that be here at a busy military trauma hospital or back home in any workplace. An important principle for new leaders to understand is that too much change is not good. There needs to be a balance. Right now we are slowly finding that balance again after some drastic changes. We will all get through it. I just wish it did not have to be this way. Nevertheless, embracing the change going forward is probably the best solution.

Is there hope for Afghanistan?

Most Americans are consumed with their daily lives. We live in a busy society. Our schedules are packed with things to do and places to go. It is so easy to get caught up in all this. I am no different even here in Afghanistan. There are days when the drama of the hospital keeps my attention constantly. One way that I have been able to stay in tune with the world is by reading the military paper called "Stars and Stripes". It's a daily publication here in the middle east for deployed military members. It has a lot of great articles every day. Some are done by active duty military writers and others are from various papers back home. There is a lot of good information about what is truly going on here in Afghanistan.

Last month was the first time that the Department of Defense spent more money here in Afghanistan versus Iraq. The total cost of the Iraq War to date is in the ballpark of $690 billion dollars. Afghanistan has cost the taxpayers $190 billion. I cannot fathom that amount of money. At the peak of the Iraq surge, I believe we had about 150,000 troops in Iraq. The American death toll in Iraq is approaching 5,000. This summer we will have approximately 100,000 troops in Afghanistan for the surge here. The current death toll here is 983. I am sure we will top 1,000 before I leave especially with an offensive on Kandahar on the horizon. The numbers are a small part of the story. The human factor is much more important. Certainly there has been incredible suffering for so many people from both of these wars. God willing I be home in July having spent a year of my life here. My sacrifices pale in comparison to so many.

Discussing money and death tolls undoubtedly begs the question of whether or not all of this is worth it. Many would argue that it is not. They have strong arguments. I have friends that have been in the most dangerous and the poorest areas of Afghanistan. It is not pretty. This is a desolate country full of uneducated people. That's the truth. A good friend of mine, Brent Barnstuble, who is a doctor spent 9 months in Zabol Province, Afghanistan on a provisional recontruction team (PRT). Essentially, they were there to help build the infastructure of Afghanistan which by the way is one of the poorest countries in the world. Brent was in dangerous situations daily. He saw poverty, incompetence, and corruption up close. To this day he cannot understand why he was sent there and feels strongly that very little good came of his team's work. Brent could have easily been killed at any time. That's reality. My friend is one of the best people I know. I am confident that Brent did everything he could to complete the mission. But, was there really any chance of success in Zabol Province? PRT's exist because the mission is "nation building". This is a concept that many people believe is not realistic in Afghanistan.

Counterinsurgency is another strategy being employed here in Afghanistan. It was used in Iraq. Essentially it involves working with the people of Afghanistan to fight back at those who want to kill. Winning "hearts and minds" is something that is talked about all the time. An article that I read recently stated that the think tanks at the Pentagon are becoming increasingly skeptical of this strategy in Afghanistan. Many say it is too costly and takes too long. We have been in Afghanistan for almost 9 years. Progress has been slow to say the least. I saw this reality with my own eyes every single day of my previous deployment. The pentagon is now considering a new idea which is "counterinurgency light". This involves the use of special forces, the CIA, air strikes, etc to wage the war here. Army brigades would stay home. Thousands of marines would no longer be in southern Afghanistan on patrol. It's definitely an interesting concept in my opinion.

In the last 24 hours there has been several large scale attacks in places previously thought to be secure. It is scary to say the least. Events like these always shake our confidence in this war. We have 44 countries in the coalition here trying to help Afghanistan become a better place. We all want the world to be a safer due to our efforts here. Nevertheless, Afghanistan is a complicated country. We face very difficult challenges here many of which may be insurmountable. I would definitely like to see my Afghan friends have a better life. Reality is that I will leave here wondering if there really is any hope for Afghanistan.

The Nurses and Medics

The nurses and the medics here at Bagram had their week in the sun this past week with Nurse/Medic Appreciation Week. It was well deserved. We had a 5K run on Saturday morning which was a big success. The sun was shining and there was a nice turnout. We delayed the start of the work day so that everyone could run. Of course, the nurses and medics did most of the leg work (no pun intended) for the race. All the doctors did was place 3 people in the top 6 finishers! It was a well organized race which I am sure took a lot of time and effort. The next big event was an ice cream social. Again, it was organized by the nurses and medics. But, the doctors including myself got dressed up in hats and beard nets (just like the locals in our cafeterias) and we served out the ice cream. I must say that it takes a fair amount of strength to scoop out rock hard ice cream. My forearms were burning in 10 minutes and I was done! They had a slide show of pictures from our deployment which lasted like 20 minutes. It was nice to see everyone together for some good clean fun. Lastly, we had a pancake breakfast. Fresh pancakes really hit the spot. I had a stack of four of them. As you might expect, this event too was organized by the nurses and medics. Obviously, the docs are a bunch of moochers and slackers!

Without a doubt, our nurses and medics do some extraordinary work. They are the one "in the trenches". Every single person in our hospital has an important job. The medic who sees that a wound is bleeding through the bandages 6 hours after surgery may actually save a limb. The nurse who notices the slow decline of a patient's eating may prompt tube feeds which can help heal wounds faster. This saves time, money, and effort. The lab tech who prioritizes the tests that are ordered then calls immediately when an abnormality is noted may in fact help initiate a life sustaining intervention. So, it all matters and we are only successful if everyone does their job to the best of their ability.

Some of the medics and nurses go above and beyond the call of duty. The other day I was out running when I noticed that one of our medics had taken one of our sickest patients outside for some fresh air (that's relative here in Afghanistan) and a little sunshine. This took quite a bit of effort to get the patient ready to leave his room with his multiple intravenous lines and tubes in various body cavities. But, doing this was probably the most therapeutic intervention this patient had in a while. I cannot imagine what it must be like to be stuck in an intensive care bed for weeks to months. Another example of extraordinary care occurred several months ago. One of our nurses took it upon herself to give a patient a hair cut right in the middle of the ward. He was a young Afghan National Army soldier with a severely injured leg. She took out the clippers and buzzed that hair off his head giving him a pretty good looking crew cut. The patient was beaming for the rest of the day. Next thing we knew this same patient was playing with a whoopee cushion and making all the other Afghans laugh. It was hilarious. A simple haircut seems small, but in reality it made a major difference for that patient.

I could go on and on with similar examples of the impact our nurses and medics have each day. But, maybe I should simply thank them more often. Maybe I could be a little less cranky at 0300 when they call with a question. Maybe I could give better explanations when we are at the bedside examinating a patient. Clearly, the nurses and medics deserve all that and more.

Membership has its privileges...

It seems like my blog has focused on the challenges and obstacles here in Afghanistan more than anything else. It is important in my mind to have a realistic view of what is going on here. But, sometimes this approach can breed little else besides negativity. I have discussed the finances of the war, compassion fatigue, medical treatment of prisoners, the devastating injuries caused by IED's, the insanse work pace here etc. BLAH, BLAH, BLAH! Let's focus on the positive for a while because being in the military has definite benefits.


When I return to Charleston in July, I will have one year to go on my Air Force commitment. More importantly, I will have NINETY FOUR days of vacation. Outstanding! Let's party! How is this possible? Well, the whopping number is due to 2 deployments in 3 years along with working in a clinic that seems to always be limiting time off due to staffing issues. At any rate, I have earned this time and I plan to make the most of it. It will be the year of 4 day weekends baby! Invite me to visit and chances are that I will BE THERE. It's exciting just thinking about it all. European travel to Germany and Italy... here I come. Whitewater Rafting... let's do it. Nebraska versus Washington on the gridiron in Seattle... Go Big Red. We get 30 days of "leave" every year in the military. You just cannot beat that. Also, there is the option of traveling military air basically for free. This is called "taking a hop". Military planes are flying all over the world every day. As an active duty member, you can show up and get on a flight on a space available basis. Why not take advantage of this? I will.

There is a certain amount of adventure associated with being in the military. My brother Chris is also in the Air Force. He has four kids and a wife. They have lived overseas for six years. His kids have seen and done things that most people never get to do. They have been to live performances in London, climbed on Roman ruins in Turkey, eaten amazing food in Spain, and gone on school field trips to Germany. These are enlightening experiences. Being a "military brat" can be pretty cool. My own military career has also allowed me to do things I never would have expected. On a rainy night in Kansas, I was at the trigger of 50 calibur machine gun during my training with the Army for my deployment in 2008. That was kind of insane actually. Later than year I went swimming in the Persian Gulf during my "R and R". Not many Americans can say that they have been on a beach so hot that it would cause first degree burns of your feet within minutes. The heat in Qatar was so oppressive that the Persian Gulf's water temperature was 90 degrees! Another highlight was a mountain climbing expedition outside Kabul on my last deployment. It was a beautiful fall morning. I went climbing with a group of Polish soldiers including a great guy named "Polish Mike". By the time we reached the top of the 8,000 foot peak, several other groups had also ascended up the mountain. It was an international party up there with Germans, Danish, Afghans, French, and Americans. I'll never forget that.

But, by far the best part of the military is the people. Everywhere I go and everything I do is with some of the highest calibur people you ever want to meet. Here at Bagram, it is no different. I treated a general one night who had been deployed 5 times. He had back pain from spending hours that day in 50 pounds of body armor sitting Indian style while meeting with Afghan village elders. Helping him feel even a little better was the least I could do. Being deployed 5 times is incomprehensible to me. That's the definition of service before self. During my residency at Offutt Air Force Base, I became quite close with my classmates. We were there for 3 years training to be good family doctors. Our class developed a very strong bond. This past September we were able to get together for a memorable vacation in South Carolina. My friends came from all over the country. There were 14 of us there which included 7 kids under the age of 4. Of course, my dog Maddy was there too. We rented a giant beach house on the Atlantic just 5 miles from my pad. It was a blast to be with everyone again. We commisurated about all of work related issues. We talked about the wars and aired our opinions openly. We relaxed in the hot tub and pool. We enjoyed the beach every day. The kids had tons of fun. A good time was had by all. That's comraderie at its finest.

So, here I am in Afghanistan for the second time. I could go on and on about how difficult it is. However, tonight I choose to embrace the positives. When I stop to think for a while, it is easy to see that military membership has its privileges.

Diagnosis: Compassion Fatigue

Last Wednesday morning was a particularly busy morning. By the time 0900 rolled around, I had already seen 9 patients, rounded on them with the rest of the staff, and then discharged five of them. Of course, there was a lot of drama involved. One of the patients was a two star general in the Afghan National Army (ANA). His staff was anxious for him to leave and they seemed to think that the discharge process occurs with the snap of a finger. I wish that was the case. Two of my discharges that morning were American contractors that basically should never have entered a war zone. One was 78 years old on 14 medications who presented with chest pain. I am sorry my friend, but this is not the VA! The other one was 62 admitted to the hospital for a possible seizure or mini-stroke. Neither of these patients wanted to leave Afghanistan to obtain medical treatment consistent with the standard of care in the western world. After all, they make a small fortune here off the US government. I have seen this scenario play out several times before. I have learned to simply ask the patient straight out if they want to go to Germany for further treatment or not. The 78 year old reluctantly agreed. The 62 year decided that money was more important than his health. He signed a letter written by me stating that he understood fully that he could have a stroke and die in Afghanistan. Thi is called leaving "against medical advice" or AMA. It does not bother me too much anymore when patients do not follow our recommendations. After all, it is their body and it is their life.

Nevertheless, these interactions all put together left me exasperated. I went to the gym that afternoon to work out some of my aggression. 18 plus weeks working every single day was wearing me down for sure. Maybe I just needed to throw some weights around for a while. So, THERE I WAS on the bench press when it hit me. I realized what was really going on with me which is a very real phenomenon in medicine known as compassion fatigue. Simply stated, this is when a healthcare provider temporarily has lost much of his or her ability to provide compassionate care. The cause is usually an overwhelming workload or prolonged exposure to difficult situations. Here at Bagram we have both of these on a regular basis. As I continued to tone my pectorals via the butterfly curl, the thought occured to me that most of our staff probably carries the diagnosis of compassion fatigue as well. Let me give you an example of how this occurs.


Several months ago an Afghan patient whom I'll refer to as Ralph (not his real name but close enough) was transferred to the ward from the Intensive Care Unit. He was under my care for the next 8 weeks. Ralph had been hit by a car sustaining muliple facial fractures, a broken arm, and a broken leg. His jaw was wired shut and an artificial breathing tube was placed into his neck called a tracheostomy. Thus, he could not talk and he could not eat. It was a difficult situation to say the least. In addition, Ralph had a VERY low pain tolerace. He called out for pain medication constantly. He would wave his hand in the this distinctive limp wristed motion and then cry out in his high pitched voice. It did not take long for us to realize that Ralph could handle quantities of morphine that would permanently disable the respirations of an average human being. The problem was that Ralph had many reasons to have pain. After all, he was in the category of "All Blowsed Up" as our orthopedists like to say. In addition, he had parasites in his guts which we realized when he passed a foot long worm in his diarrhea one day. (I am NOT making this up) Ralph would become hysterical after surgery. One day our anesthesiologist was tired of it all. He gave Ralph massive quantities of pain medications, barbiturates, and sedatives. Ralph was not heard from for about 2 days, but then he was back with a vengeance. The calling out was incessant and unstoppable. It got to the point where there was almost no way to tell if the man really had a problem or not. This continued for weeks. We gave him a pain pump called Patient Controlled Analgesia (PCA) which usually does the trick for just about anyone. Not Ralph. I mentioned that Ralph had his jaw wired shut due to a broken mandible. It was supposed to be in place for 6 weeks. In the event of profuse vomiting which could cause him to choke to death, wire cutters were left at his bedside to cut the jaw wires. They were only to be used in an emergency. Well, one afternoon Ralph cut his own wires and then he tried to tell us that it was an accident. Ridiculous! In addition to his pain issues, Ralph also had several serious complications as he recovered from getting hit by a car. I'll spare you the details of all that. Several weeks ago the day finally came when Ralph was discharged. Fittingly, he asked for morphine as he was wheeled out the door!

To be completely honest, Ralph sucked the life out of me. He did the same thing to several of our nurses. These are good people who would react with justified anger because his wants and desires were just so out of proportion to what is realistic. When you have a patient like this in addition to all the stressors of dealing with blown up Americans and foreign patients with major communication barriers, it simply becomes overwhelming. We are all doing the best we can at this point. Everyone has their own coping mechanism. My colleague Dr. Mike Greene keeps his head down and ignores people. My style is a bit more flamboyant. In the end, we all need to dig very deep to make it through this. I do not think there is a a perfect solution to any of this other than taking it one day at a time.

Special Forces

The other day I was able to witness the interrogation of an Enemy of Peace (EOP), aka prisoner. He had been shot in the left leg taking a large chunk out of his thigh in the process. So, he was in the hospital on the ward in stable condition. A member of special forces(SF) appeared to do the interview. My role was to do a brief exam before and after the interrogation to document that no abuse occured. The SF guy was dressed in civilian clothes with a beard. He had on hiking shoes, jeans, and a button down short sleeve shirt. This is normal. Outside the wire (off base), the SF guys wear uniforms without name tags from what I understand. Inside the wire (on base), they dress casually. With the beards and all, it is actually not too difficult to pick them out of a crowd. I am told beards are worn to help garner respect with the locals. The EOP also had a beard and was probably in his twenties. He was actually one of the healthiest appearing EOP's that I have seen.

The interrogation was actually quite professional. There was no waterboarding! It was simply 45 minutes of questions about the EOP's background then specifics about the events leading up to his capture. Voices were never raised. Some of the conversation went something like this:

SF guy: Why were you shooting at us?
EOP: I was not shooting.
SF guy: But, we saw you shooting. Where did you get the weapon?
EOP: I did not have a weapon.
SF guy: But, we saw you shooting. Why did you try to run away?
EOP: I did not try to run away.
SF guy: But, we captured you when you were running away shooting at us with a weapon.
EOP: (silence)

The SF guy took extensive notes. No threats were made. It was simply information gathering. Today, the aforementioned EOP left the hospital for the detainment facility.

I have had several other interactions with SF all of which were curious. After a firefight in Kabul, a group of SF guys were helicoptered to our hospital. They all walked in under their own power. They did not want pain medicine. The first thing they asked is when they could leave and go back to the fight. I told one of them, "Dude, you just had a grenade blow up near your face!" He was taken for an eye exam and passed with flying colors. I would not be surprised if he ate a roast beef sandwich then immediately left the wire to meet up again with his SF brethren. Another had minor injuries from a blast. He also was able to leave the hospital that day. But, the thing that was the most remarkable about it all was that a large group from the SF community came to the hospital to check on the guys. It was kind of a circus outside the trauma hot box. SF has their own doctors apparently. I had to explain what was going to on to several of them to report up their chain of command. There was tremendous concern for the well being of their men. I have not seen any other unit, platoon, squad, brigade, task force, or whatever have such an impressive response. SF is clearly tight knit.

Not too long ago an SF guy was admitted to the ward for low back pain under the care of one of my colleagues. Low back pain is one of the most common complaints in primary care. It almost invariably will get better no matter what the medical provider does for the patient. So, I was exceedingly unimpressed to have a low back pain patient in the hospital. The patient received large amounts of pain medicine. As it turns out, I happen to be the only doctor on base that does back adjustments due to my background in osteopathic medicine. (On several occasions I have been paged to crack the backs of high ranking military officials. It's kind of annoying actually.) I did a minor back adjustment for the SF guy right there in his hospital bed. It did make him feel better temporarily, but his pain persisted. The next day the SF guy was flown to Germany for further testing. To me, this was ridiculous which I happened to mention to one of the SF doctors. Fast forward a month or so when I was approached in the emergency room by this same SF doctor. She ran up to me and yelled, "THE GUY HAD A TUMOR!" Excuse me. Yep, the SF guy's pain was caused by a tumor on his spinal cord. I felt like an idiot. I told her she had every right to get in my face and say "I told you so", but she did not. Instead she explained to me that SF guys do not complain and they do not lay in bed. When one of them does this, something very serious must be wrong. Fortunately, the tumor turned out to be benign (non-cancerous).

Without a doubt, SF is a unique subset of the military. I am told that we are not supposed to know what they really do out there. They are on the front lines here in Afghanistan. The commander of this war, General McCrystal, has a SF background. He has made many changes in our counterinsurgency strategy here. From what I understand, the military is relying more and more on SF in this increasingly complicated war. We will definitely continue to see SF guys within the walls of our trauma hospital. Perhaps my approach will be a little different the next time I encounter one of these characters.

Major Mid Life Crisis

At the ripe age of 34, I am noticing some disturbing trends and changes in me. Physically, things are going downhill. For example, I have been sick with the common cold twice since getting deployed. During my twenties, I hardly ever got sick. Now, I have to be very mindful of the limitations of my body when it is fighting a virus. Going out for a 5 mile run after a 10-12 hour work day is just not in the cards anymore. It frustrates me. This is normal I guess but it does not make it okay. During the month of March, I attempted to grow a mustache to celebrate the military tradition of "Mustache March". However, hair seems to be growing in all the wrong places now that I am thirtysomething. I wanted hair on my brow. Instead, ear hair is proliferating out of control! What is up with that? When I go to the barber, they offer me a trim of my ear hair and I actually really need it. Ridiculous! I won't even go into details on the hair growth in other areas other than to say that I am seriously considering investing in a device known as "The Manscaper" (patent pending). I saw this online at target.com. It costs $39.95.


My interests are definitely changing. I am reading for pleasure more than I ever have before. I now prefer a good book over a movie. I have seen 3 or 4 movies since getting to Afghanistan, but I have read at least 6-8 books. This is surely a sign that I am OLD. It seems that the older I get, the qwirkier I become. I actually got up at 0430 the other day and went for a run before work. And, I even enjoyed it! That's kind of sick. I used to think that this group of "old guys" here that goes out for a long run at 0500 on Sundays was absolutely nuts. Now, I am strongly considering joining them. Also, my moodiness is becoming legendary on the hospital ward. I can get cranky in a heartbeat. Don't even think about talking to me before I have had my morning cup of coffee because you just might get your head biten off. The nurses think I need an infusion of continuous intravenous lithium to combat the bipolar behavior. When I am in a good mood, I agree with them. But, catch me in a bad mood and you can kiss my #$%^!


Then, the other day it became readily apparent that I am truly in a mid life crisis. THERE I WAS, holding my right hand in the air uttering the words, "...I will defend the constitution against all enemies, both foreign and domestic." That is correct, the Department of the Air Force promoted me to the rank of MAJOR! There are now oak leaves on my collar instead of bars. I had gotten so used to those Captain's bars, but I am not sad to see them go. After the ceremony, I proudly walked down the street sporting my new rank. I saw a lowly Captain out of the corner of my eye. It felt good for him to render a salute to me. I thought to myself, "Heck yeah Captain, give me the respect." By the way, he was a chaplain but I did not care. I will probably get over this relative power high when Major responsibility is thrust upon me. Doing performance reports and scolding people does not sound all the appealing. But, it brings to light a much bigger issue. Am I ready to give up the military life? When I get home there will be one year left on my committment. I have now been in the Air Force for 10 years. There have been good days and bad days. Without a doubt, these 6 month vacations to Afghanistan have got to stop! But, am I ready to move on and be a civilian? I will be contemplating this question going forward. It is my Major Mid Life Crisis.

Aerovac

The name of the game in wartime medicine is air evacuation, otherwise known at aerovac. This is what allows us to keep people alive and to manage the constant flow of wounded warriors. In the year 2010, this is a rather elaborate process that has been perfected in many ways. Approximately 98% of soldiers injured in combat can be saved if they make it to a forward medical facility in a timely manner. We are a tertiary care facility at Bagram. The patients from all over Afghanistan are funneled here before leaving the country. If the patient has a surgical problem, chances are a surgery has been done at a forward surgical hospital to stabilize the injury. They come here and have more surgery. We have a lot of capabilities here, but also many limitations. For this reason, we must move our coaliton patients quickly out of our facility to Landstuhl Regional Medical Center in Germany.

A week ago the volcano in Iceland erupted and the aerovac system was thrown into chaos. Little did any of us know that mother nature above the arctic circle would affect us here in Afghanistan. Suddenly our well oiled machine was brought to grinding halt. No flights were allowed in or out of Germany. What on earth would we do with our coalition patients? The already high stress levels within the walls of our hospital soared to a new level. We were forced to set up cots in between the beds in order to make room for all the patients. There was literally about 3 feet from one patient to the next. Keeping them all straight in my mind was a challenge. I pride myself on knowing my patient's names and their stories. The numbers forced me to remember them simply as a diagnosis such as "right pneumothorax and axillary soft tissue injury" or "traumatic brain injury with L5 compression fracture". We have all been doing the best we can, but the tension has been rising. I have to admit that this does not bring out the best in me. Others are in the same boat.

I know very little about aviation or the operational air force. But, I am familiar with the phrase, "Flexibility is the key to Air Power." This has become rather apparent to us all in the last week. As people all over Europe were struggling to get from point A to point B, our aerovac system needed to find new routes as well. We had to think long and hard before putting certain patients on planes not knowing exactly how long it would be before they could have surgery again. Our most critical patients simply had to stay with us. Each day new ideas were coming forth on how we should handle this crisis. How about flights all the way to San Antonio? What about a stop over in Kuwait? Could the plane just stop to refuel in southern Europe before going all the way to DC? I am sure many hours were spent by higher headquarters wrestling with these questions.

To the relief of our entire medical staff, a workable solution has been found. There happens to be another theater of operations directly on the way back to the states. We still have many assets and a rather large foot print in Iraq. Why not utilize our medical facilities there? That is exactly what is happening. So, one of my patients caught wind of all this. He absolutely could not believe that after being blown up in Afghanistan, the next time he would see the light of day he would be back in Iraq! It is kind of insane, but for the time being it is the best that we can do. I'm just happy that we can all get a little more sleep now. More importanly, aerovac will be getting our patients home in 48-72 hours despite volcanic activity in Iceland.

Special People

Morning rounds today started off with a little something special. Sundays are a day to sleep in of course. We start our rounds at 0730. (that's "sleeping in" for us medical folks!) This is when the inpatient doctors like myself get together with the surgeons, the pharmacist, the physical therapist, the lab manager, etc to see our patients one by one together as a team.

The military has a lot of quality people. We are a voluntary service. This attracts a certain kind of person. Over my ten years in the service, I have met countless military members. Most of them are at baseline solid citizens. Some of them are exceptional people. One such person is known as "Super Girl". She is a medic who works in the intensive care unit. Today she had something to say on her last day of work here. It was rather remarkable for her to stand up in front of our entire team and read the following:

A Special Kind of Person...

(A special dedication to all who served with me @ Bagram AF, Afghanistan Dec 2-Apr 21, 2010)

It takes a special kind of person... to think of someone else,
It takes a special kind of person... to put SERVICE before SELF.

It takes a special kind of person... to wear our blues and greens,
It takes a special kind of person... to work together as a team.

It takes a special kind of person... to handle all the stress,
It takes a special kind of person... to put forth their very BEST.

It takes a special kind of person... to look our enemy in the face,
It takes a special kind of person... to medically take care of them, especially at this place.

It takes a special kind of person... to makes the decision that we do,
It takes a special kind of person... to follow through and through.

It takes a special kind of person... to give medical attention and care,
It takes a special kind of person... even though life sometimes isn't fair.

It takes a special kind of person... to work long hours every day,
It takes a special kind of person... to accept the challenge, even without the pay.

It takes a special kind of person... to deal with the blood, guts, and tears,
It takes a special kind of person... to ease somebody's pain and take away their fears.

It takes a special kind of person... to help our soldiers, sailors, and airmen to get better,
It takes a special kind of person... one fight, one mission... we all work together.

I salute you fellow co-workers, for everything you've done...
You've helped me make a difference, in my deployment #1.



Written from the heart - SSgt Andrea' Mosca

Return to Duty

During this deployment, I have witnessed countless Purple Heart ceremonies. Usually a general and his entourage come to the hospital to honor the wounded warrior. They will march into the hospital ward and spend a few minutes with each soldier or airman. It's a nice touch. A few nights ago we had 5 Purple Hearts awarded. I had admitted all 5 of these patients in the wee hours of the previous night. The group had been out and about in Afghanistan when their vehicle was hit with a rocket propelled grenade. I do not know much more than that. We try to respect the privacy of our patients here allowing them time to process what has happened. Sometimes they will talk openly about a firefight or an explosion. Most of the time they just want to sleep. This is rather obvious when the entire medical staff does hospital rounds together at 0630 every morning. The patients will often just pull the sheets over their heads and try to ignore us all. There is no need to bother them at this point. The thing they need the most is time away from the insanity of war.

But let's get back to my 5 patients from the other evening. The general entered the ward with a slew of support staff. He offered some words to each soldier before the following was read aloud, "This is to certify that the President of the United States awards the Purple Heart to Staff Sergeant ______ for wounds received in combat on 12 April 2010." The declaration goes on to say that the Purple Heart was first given out by General George Washington. These ceremonies are important moments for our troops. I have yet to get tired of seeing one of our wounded warriors be recognized. If I am present when a patient of mine receives the Purple Heart, the emotions are strong.


It is not uncommon for patients to come to our hospital after an IED attack (and they are definitely attacks when you consider the intent of the terrorist is to kill), get a full battery of tests, and then be deemed "Return to Duty". Essentially, the patient does not have any major injuries that require surgery. However, this is not to say that the effects of the attack are not profound. There is a term from years ago, shell shocked, which goes a long way in describing these patients. In the year 2010, we call it combat stress. Whatever you want to call it, the bottom line is that the mental strain of war has made its mark. After all, just being in a combat zone is beyond the normal human experience.

4 out of my 5 patients from earlier this week did not need surgery or long term therapy. They did not need to be hospitalized from a purely medical standpoint. But, we kept them there for a day anyway. The old adage of "three hots and a cot" still rings true. It is generally accepted in military medicine that getting these soldiers back to the fight is actually the best thing for them. I agree with this to a certain extent. I do not rush these patients back out to their forward operating bases. To me, being in a life threatening situation then being flown to a hospital for a full medical work up warrants some time off for pete's sake! This is where my training in Family Medicine comes in handy. We are trained to be advocates for our patients. So, my patients get a letter stating that they should be on convalesence for 72 hours and we make arrangements for them to stay near the hospital for that time. This seems like a reasonable compromise to me whether they are a special forces guy who is gung ho or an infantryman who is scared out of his mind.

Dollars and Sense?

Money makes the world go round, right? With that in mind, I think it is important to stop and think a little bit about the cost of war. Before even considering the human suffering and the tragic loss of life, the cash that it takes to wage war is staggering. As I ate my bagel this morning and thought about the day's plan for my patients, I realized that each bite and every spread of cream cheese cost the U.S. government several dollars. How do I know this you ask? Well, last week a friend who works in logistics informed me that every warm meal I eat here in Afghanistan costs $30. A company called Fluor runs the food service. They charge the U.S. government $30 every single time an ID card is scanned on the way into the dining facility. Last week I stopped to get a cup of coffee at the dining facility on my way home from picking up my laundry. My ID card was scanned, thus, our government paid $30 for my cup of coffee. I had no idea it was the most expensive coffee I have ever had. After all, not even a quadruple latte vanilla swirl expresso with whipped cream and a cherry on top at Starbucks costs that much!



There are many government vehicles here at Bagram. I only need to walk a hundred yards from my B-Hut to see a long line of MRAP's (Mine Resistant Ambush Protected). These are the hulking four wheelers that cost one million dollars to build. They are manufactured in my home of Charleston among other places. I often see them driven on the Air Force Base in Charleston before they are loaded on a C-17 and flown to the middle east. They are so big that only 2 of them fit on the world's best cargo plane. MRAP's carry about a dozen people. The whole point of the vehicle is to save lives. Are MRAP's truly "mine resistant"? Absolutely not. We see patients with devastating injuries every day here who are victims of IED blasts while in MRAP's. This is because the terrorists are always one step ahead of us. The main road at Bagram is often gridlocked with MRAP's trying to get to their destination or leave the base for a mission. They get maybe 5 miles to the gallon of gas. I am told that the price of gas here is quite high. When you figure the cost of shipping to this land locked country, a gallon of gas can cost as much as $30. It's right up there with my cup of coffee in the dining facility the other day! Can you imagine how much it costs just for fuel alone when a convoy of MRAP's goes out on a mission and is gone for hours to days?



Several weeks ago I was able to go on a tour of the F-15 fighter jets that we have here at Bagram. We were able to meet the pilots, learn a lot about their jobs, and then of course get to see the F-15 up close. These are $55 million dollar planes that were designed in the 1970's. According to "Biff" the pilot, these are the best planes on the globe. "Biff" gave us a run down on the capabilities of these birds. His enthusiasm was contagious. He showed us the missiles that are used in close air support strikes on suspected terrorists. These cost about $55,000 a piece and they pack quite a pop. If you think the fuel for MRAP's is expensive, well, it's nothing compared to the jet fuel used for th F-15. At any given time, two F-15 crews are "on alert" for emergency missions. Their goal is to provide an air strike anywhere in their region within 15 minutes of receiving the call. This correlates with approximately how long the average soldier's ammunition will last in an intense firefight. On any given day, F-15's can be heard taking off at all hours of the day. Their roar is deafening.


The cost of running the hospital here is also quite astounding. We have 2 Afghan patients that have been hospitalized for almost my entire deployment. Both have been in the intensive care unit for weeks at a time. Both have undergone many procedures and operations. They have wounds that may never heal. Even if they do miraculously get better and walk out the door, they will be subject to the limitations of the Afghan medical system. In short, I am not even sure you could call it a medical system. The main military hospital in Kabul does not have the most basic of medications. They do not have antibiotic ointment. They do not even provide food for their patients. There is no such thing as a nursing home in Afghanistan. The medical costs for the prolonged hospitalization of both of the aforementioned patients easily exceeds a million dollars. Actually, it is probably several million dollars. The argument could be made that neither of these patients should have received the care that they did given that they have very little chance of being okay once they leave our doors. These are the hard decisions that often are not made in the heat of the moment. We as health care providers want everyone to be okay. But, it does not work that way. Forging ahead with the care of these patients essentially is making the decision to spend thousands if not millions of dollars. I wish I could say that these are the only Afghan patients I have seen in this type of situation at our hospital. If I did say that, I would be flat out lying.

I could go on and on with examples of costs that will make your head spin. Maybe this is information that the American people really should not know about it. You can go about your life blistfully unaware of all this. But for me, it really begs the question of whether or not all these dollars make any sense???