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.
Friday, May 28, 2010
Friday, May 21, 2010
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.
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.
Tuesday, May 18, 2010
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.
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.
Thursday, May 13, 2010
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.
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.
Thursday, May 6, 2010
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.
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.
Saturday, May 1, 2010
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.
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.
Subscribe to:
Posts (Atom)