Wednesday, January 22, 2014

Afghanistan-ER Postings


Curmudgeon’s Wastebasket—Afghanistan-ER Postings



Posting Date
Subtitle
8/11/10
A doc in the field?
9/15/10
Incoming!
9/24/10
The best of care anywhere.
10/04/10
Support from the air.
10/11/10
The IED blasts, concussion, someone else’s blood.
10/18/10
Afghanistan Porta-Potties.
11/15/10
I carry an M-4, more on IED blasts, burned kids.
11/17/10
Good news and bad news.
11/22/10
Suicide bomber.
11/30/10
Deaths from IED’s, the Taliban aid station.
12/14/10
Van packed with explosives.
12/29/10
Christmas, the Taliban get a “good guy.”
1/25/11
Head wound, note to another doc.
2/24/11
Firefight.
4/25/11
Village with lots of little alleys.
5/04/11
The mountain.
6/13/11
Mack is back.

Use of the Blog Archive to access a Curmudgeon’s Wastebasket posting: Links to all postings are available via the Blog Archive in the right margin of each posting.  But to use it one has to know when the subject of interest was posted, as in the table above.  In the Blog Archive one clicks on the year and then the month of posting.  Titles of each of that month’s postings appear, and they are links to the posting with that title.  After one finds a subject of interest, he/she goes to the Blog Archive in the right margin of any posting and clicks on year, month, and title (link).
 .

Sunday, April 1, 2012

Physicians as Artists

“Did you know, Julie, that Dr. Brent James and Dr. Jay Kaplan have characterized physicians as artists or craftsmen?”

“That sounds like a compliment, Curmudge. To me, a painting or sculpture is the product of the brain and hand of a single individual, and those I’ve seen in Chicago appear to have been done by artists with great talent.”

“But remember, Julie, that every artist and original work of art is unique, and only the best works are hung in museums. Does that suggest what James and Kaplan had in mind when they depicted physicians as artists and craftsmen?”

“Surprise, Old Man! I’ve done my homework. As James said, ‘We continue to rely on the "craft of medicine", in which each physician practices as an independent expert—in the face of huge clinical uncertainty (lack of clinical knowledge; rapidly increasing amount of medical knowledge; continued reliance on subjective judgment; and limitations of the expert mind when making complex decisions.).’ Results of physician ‘artistry’ include: ‘Well-documented massive variation in practice based on local medical myths, high rates of inappropriate care, and unacceptable rates of preventable care-associated patient injury and death.’ “

“Of course, I wouldn’t mind being treated by a Michelangelo-quality physician-artist if I had an obscure, hard-to-diagnose ailment. Maybe even several of them if I were at the Mayo Clinic. However, as Levy has stated, ‘the vast majority of medical care is not complex; it calls for standardization, adoption of protocols, and scientific experiments of process improvement to modify those protocols to enhance care and reduce harm.’ “

“Curmudge, this is what I see as the problem. Physicians of the past and present were trained to be artists. That sort of training is likely to be insufficient for the future. That’s a problem that you and I can’t solve, but we’ll share with our readers whatever we can learn from the experts.”

“Back on February 16 in Kaizen Curmudgeon we quoted Brent James’s proposed countermeasure, but there is more to be said about a path forward. We’ll continue our discussion next time.”

Wednesday, December 14, 2011

The Last Christmas

“You’re always bah-humbuggy during the holidays, Curmudge. Why’s that?”

“Holidays are an awful lot of work, Julie. But they’ve always been more work for Mrs. Curmudgeon than for me. She worked harder than Santa Claus, but I was just a helpful elf.”

“How so, Rudolph? Did it have something to do with her profession as a church organist - choir director?”

“It had everything to do with it, Julie. Choir rehearsals began in October for the major Advent oratorio. But the efforts didn’t begin to get intense until December. Then we had to decorate the house for holiday entertaining. A tree inside and on the porch, figurines all over the place, and more greenery than a national forest. If all of the candles had been lighted, the house might have burned down.”

“Thank goodness it didn’t. So when did all the entertaining occur?”

“It began with a small dinner party for my long-ago professional colleagues and their spouses. We were a fairly subdued bunch, as you’d expect from chemists, but it took a while to straighten the house after they left.”

"I know the next event—the big oratorio with festival choir and orchestra. Remember last year’s awful snowstorm on Saturday? On Sunday there were more singers in the choir than people in the congregation.”

“Traditionally, we held the big choir Christmas party on the following Wednesday evening. That was the main reason for all the decorations in the house. The night before was spent making 80 or so ‘Aunt Lucy’s ham-and-cheese sandwiches’ to be served at the party. The usual beverage of choice was ‘Ethel’s punch’ that I concocted.”

“Of course, all of the parties included caroling around the grand piano. One year, even one of your friends with Alzheimer’s sang.”

"That’s right, Julie. With 40-50 people, the house was filled to overflowing. You can imagine the cleanup job after everyone left. At noon on the following day, Mrs. Curmudgeon’s colleagues from church came for lunch. Then a week later we did the full-house thing over again for another circle of friends.”

“Golly, Curmudge, with the parties and great music, I’ll bet that everyone had a wonderful time. It’s pretty evident that Mrs. Curmudgeon loved good friends as much as she loved good music. But I must admit that the whole effort sounds exhausting.”

“It certainly was. During one of our late-night cleanups, I commented to Mrs. Curmudgeon, ‘I hope we won’t be doing many more of these.’ It was not my intent to be prophetic. However, Mrs. Curmudgeon must have sensed more clearly than I that her interstitial lung disease was worsening and that these parties might be the last.”

“And finally Christmas arrived—along with pneumonia.”

"Mrs. Curmudgeon had to play three church services on Christmas Eve. It was quite a struggle for her to climb the 32 steps to the organ loft. Her breathing was labored…as if she were climbing to the top of Mount Everest. By the time the final service was over, it was Christmas Morning. She came down from the loft completely exhausted, and three weeks later, she died.”

“Curmudge, it sounds as if you helped everyone else to have a merry Christmas. Perhaps you and Mrs. Curmudgeon had a good time mostly because everyone else did.”

“Julie, she made great music and hosted holiday parties for about 40 years. In years past when people would ask when Mrs. Curmudgeon planned to retire, her answer was an emphatic, ‘Never.’ She would go on to explain that she hoped to flop dead on the organ console. She came close.”

Saturday, November 19, 2011

Return to our Roots

“Listen up, Julie. We may be returning to our roots.”

“If you think that’s going to make you any younger, Curmudge, you’ll be disappointed.”

“I mean our blogs, Kaizen Curmudgeon and Curmudgeon’s Wastebasket. Remember how Kaizen Curmudgeon began in May 2007. Our intent was to document the progress of our Lean transformation at Affinity. Although we couldn’t always focus on Affinity, we were able to limit ourselves to Lean and its required leadership. We maintained that through the middle of October 2008. Then our anticipated local contributions failed to materialize. While waiting, we expanded our scope further into health care and leadership topics that might be of interest to our readers. We are still waiting and writing about topics from the literature that our readers might not otherwise encounter.”

“In those early days, Curmudge, draft postings that were rejected by our reviewers were, literally, dumped into your wastebasket. Then in January 2010 we formalized your trash can into a new blog, Curmudgeon’s Wastebasket. During the last half of 2010 and the first part of 2011, Wastebasket was populated by e-mails describing emergency medicine as practiced on the battlefields of Afghanistan. Since then, that blog has been relatively dormant.”

“Dormant no longer, Julie. It has been suggested that we return Kaizen Curmudgeon to its roots and limit it to discussions of Lean at Affinity. Most future discussions of other topics formerly posted in Kaizen Curmudgeon will be posted here in Curmudgeon’s Wastebasket.”

“Wow, Curmudge. Think of all the topics our Kaizen Curmudgeon readers would have missed if this limitation had been in place for the past three years: Patient Safety, Mistakes, Checklists, Amazing Devices, Evidence-Based Medicine, The Crystal Ball, The Laboratory, Sepsis, Primary Care Medicine, and more.”

“One might call missing those postings unintended consequences. So geht es im Leben.”

“You meant to say, ‘such is life,’ Curmudge. Postings on Kaizen Curmudgeon will quite likely become less frequent. Our new path forward will require more effort, but we’ll make the best of it.”

"As usual, Jaded Julie, you’ve got that right.”

Monday, June 13, 2011

Afghanistan ER--Mack Is Back

“Hey, Jaded Julie, Mack is back safe and sound.”

“Hooray! We’ve been waiting a whole year for that to happen. Does that mean that we won’t have any more postings with the Afghanistan ER title?”

“I don’t know. He was planning to accompany the troops on at least two more missions before the end of their deployment, and I haven’t heard anything about them. Perhaps he’ll have something to say when I see him in about a week.”

“Curmudge, I’m concerned about how the transition will be for one coming from the horrors of war back to the relatively peaceful U.S. No more patients with legs blown off and ghastly pelvic wounds. No more wearing a uniform soaked with (other people’s) blood. No more wondering if your next step will be your last.”

“It will certainly be a relief, but probably much more. We tend to think that to a physician it’s all in a day’s work, but they can’t avoid being affected by what they are seeing and doing day after day.”

“Do you suppose that it might be somewhat like grieving, where one’s sense of loss—and possibly in Mack’s case, outrage—will subside over time?”

“A big similarity will likely be that although images of persons and events will fade, a portion will be indelibly etched in some far corner of one’s mind. Apparently that has been the case with veterans of World War II. The rate-limiting step in healing is how long it takes for one’s mind to accept that what once was reality is no longer the case.”

“Interesting thoughts, Curmudge. They remind me of the Kaizen Curmudgeon blog where we often discuss topics about which you know little or nothing.”

Wednesday, May 4, 2011

Afghanistan ER--The Mountain

“Listen up, Jaded Julie. Mack copied me on a note that he sent to some of his Army friends.

‘Hi, everyone,

I just heard about Bin Laden's untimely death. Thanks for all the well-wishes and kind words. Sunday and Monday I was on an air assault mission. Yesterday, I was sleeping in the strong point and guys started talking about it. I guess the news was put on the tactical radio net. I was half asleep, thought I had just imagined it, but later when I woke up, I found out it was true. I think he was mainly a symbol, a coward who has just been hiding for the last ten years, so I don't know how this will change our fight over here.

Last two days were pretty tough; mission was up in the mountains. Saturday, some of one of the platoons was up on this mountain, a piece of rock about four-1/2 stories above the rest of the area. Anti-personnel mine blew the right leg off one of the guys, right at mid thigh. The temperature was about 98 degrees. I had to run (or as close to that as I could manage) about 500 meters through uncleared terrain with a guy in front of me with a Vallin (mine detector) and one of the squad leaders, climbing over walls and cutting through compounds. Then one of my medics and I had to claw our way to the top of this thing to take care of him. A proverbial nightmare!

The whole time the helo was saying over the radio that they were almost out of fuel and were going to have to turn back if we didn't get him down to the bottom in minutes. The Fast-One failed to fire its needle; never had that happen before. Eddie was conscious, but I could barely feel a radial pulse. So I decided to go for the second IV and try to get the other unit of Hextend on board and also do some IV morphine because he was in so much pain. Never had a lousy IV start give me so much anxiety! The first responders had done an excellent job on the tourniquet, as high on the thigh as this was; but there was so much oozing we kept adding combat gauze and more pressure dressings. All in this little spot on top of this damn dirty rock.

We had to lower the guy over the side and practically skate him down on a Fox litter. IVs both pulled out by the time we reached bottom, but got what we needed in. I thought we were going to lose him; but they told me last night he's alive, has had a surgery or two, and I think he's on his way to Landstuhl.

The exertion of the whole thing was horrible. I had a weapon, full aid bag, and also was carrying 7 liters of water because of the heat. I felt like the climb was going to do me in, especially with me being twice the age as everyone else. Anyway, I got back to the FOB last night, am lying low today. Have about 3-4 days until next mission. (I can't believe with less than a month until we actually fly home that we are still at this horrendous op tempo!)

Forgive me for unloading this war story. I'm not including my civilian friends that won't understand anything anyway. Take care and please stay in touch.—Mack’


“Curmudge, just hearing the story makes me feel exhausted.”

“When we lived in Washington State, Mack and I would speed-hike up mountains in the Columbia River Gorge. But then we were 20 years younger.”

“And no one’s life depended on how soon you got to the top.”

Monday, April 25, 2011

Afghanistan ER

“Hey Curmudge, I understand that Mack’s battalion is located in a new forward operating base.”

“It doesn’t sound much better than the old one, Jaded Julie. I just received this e-mail from him wishing a Happy Easter to friends and family:

‘Hi, everyone,

Happy Easter. I hope that everyone’s enjoying the day. I went on a raid today, actually flew out at about 0200 this morning. I think it was one of the most sinister places in this country I’ve been. A village with lots of little alleys and roads with walls on both sides. There were snipers taking shots at times during the day. One of the engineers got shot through both thighs; one of my medics and I took care of him. They may have hit the femoral vein, but I think he’ll be OK. Happened just as the sun was coming up. It was horrendously hard to carry him out of there to the helo, since the fields around the village were flooded in some places. Afghanistan is the #1 heroin-producing country in the world, and every square foot of ground in this part of the country is covered with poppy plants about to be harvested. We captured four guys who were making IEDs and explosives. Late in the afternoon, maybe an hour before we were getting ready to fly out of there, everyone was sitting up against a wall. Some of the guys were starting to clear the PZ for the flights out, when the enemy cut loose with five minutes of machine gun fire. Since we were behind the wall, no one got hit or anything. It was steaming hot all day, and everyone brought as much water as they could carry; but we were almost running out by the time we got out of there. Now I’m back in my hooch listening to “The Time Warp” from the Rocky Horror Picture Show and checking e-mail. About to get midnight chow. Please stay in touch because I’ve really enjoyed hearing from you while over here. Take care—Mack.’ “

“Curmudge, your grim countenance tells me that that wasn’t the kind of Easter you were expecting Mack to have.”

“You’ve got that right, Julie. I had Easter dinner with friends in a restaurant that was hosting a lot of noisy, seemingly carefree young people. I find the contrast between their Easter and Mack’s Easter disturbing.”