Afghanistan-ER Postings

Curmudgeon’s Wastebasket—Afghanistan-ER Postings

http://curmudgeonspoubelle.blogspot.com/

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).

 .

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.”

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.”

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.”

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.”

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.”

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.”

Debunking the Program-of-the-Month Myth

“This is what you and I were talking about four years ago—before the Kaizen Curmudgeon blog even existed: ‘Jaded Julie announces to everyone within earshot, “I’ve seen them all—Total Quality Management, Quality Circles, Baldrige, ISO 9000. We tried them, spent a lot of money, management lost interest, and they went away. They were all just the program of the month, like this new Lean stuff. It will go away too.” '

“To which I responded, ‘No, Jaded Julie, you’re wrong (mostly). Lean is not the program of the month, and it has worked too well to simply ‘go away.’ Here are the facts:

· All of the programs that you listed came from a common origin, W. Edwards Deming’s principles of driving out fear, employee empowerment, studying and improving processes, and reducing waste.

· The programs had many elements in common, such as people working together in teams.

· Over time, the programs evolved, became more sophisticated, and were given new names.

· Programs came and went because they were mismanaged. On this point you were correct, Julie: Management often lost interest before the programs could pay off.’ “

“You’re right, Curmudge. I was too quick to criticize; I’ve learned a lot in the past four years. Lean has been working well for us, and it has become widely used in health care organizations. But what are some of the other current programs? When I encounter them in my reading, I want to know what the author is talking about. However, it’s my guess that success doesn’t depend so much on the program itself but on how vigorously it is implemented.”

“Let’s start with an old name, Gemba Kaizen . Although this is the predecessor of Lean, the name is a trademark and is not used very much. Among the principles of Gemba Kaizen are management’s role in upholding standardization, focusing on the process, analyzing process data, establishing and implementing countermeasures, following PDCA cycles, revising standards, and policy deployment.”

“That sounds a lot like Lean. Because it is Lean’s predecessor, that should be no surprise. Lean has also strengthened the emphasis on housekeeping (5S), process analysis using value stream mapping, and A3 problem solving.”

“Most of what we have discussed can also be found in Six Sigma, where their project elements include Define-Measure-Analyze-Improve-Control. In addition, there is emphasis on process control, statistical design and analysis of experiments, and training of project leadership (black belt and green belt).”

“I assume, Curmudge, that you are going to mention the Institute for Healthcare Improvement’s (IHI) Model for Improvement.”

“IHI is sort of like a supermarket; if you need something, they are likely to have it. In this case, IHI can provide a lot of guidance as well as tools for improving a process. Principal elements in their Model for Improvement include: Forming the Team, Setting the Aim, Establishing Measures, Selecting Changes, Testing Changes using plan-do-study-act cycles, Implementing Changes, and Spreading Changes. A newer IHI tool is their Improvement Map .”

“Although the Improvement Map is free of charge, Curmudge, I understand that its use requires installation of Microsoft Silverlight software.”

“Here’s an improvement program—also fairly new—that comes from The Dartmouth Institute for Health Policy and Clinical Practice. It’s called Clinical Microsystems. To me, it looks like a highly structured, Lean-like approach to process improvement with preprinted documentation. The microsystem is ‘your unit,’ and it is defined as ‘the place where patients, families, and care teams meet.’ For people in the unit, job #1 is to provide care, and job #2 is to improve care. Steps on their Improvement Ramp include: Assessment of the unit, Theme (identified in the assessment), Global and Specific Aims (specific numeric goals), Ideas for Change, and then Plan-Do-Study-Act cycles. The organization provides so-called Greenbooks for applying these steps to specific units within a hospital (Inpatient Units, Emergency Department, etc.).”

“As you suggested, Curmudge, these programs—the old as well as the new—have a lot of features in common. So tell me, how does the newcomer decide which of these she will propose to her organization?”

“Jaded Julie, although we favor Lean and call it the Affinity Performance Excellence System, one does not need to be a purist. Pick and choose what might work best in your organization or unit. And feel free to supplement from the works of Quint Studer (Hardwiring Excellence) and James C. Hunter (Servant Leadership).”

“When we wrote much of this four years ago, we were contemplating changing my name to Enthusiastic Emily. Whatever came of that?”

“Jaded Julie, it will never happen. Your name has become a household word, or at least a hospital-wide word. You will no longer be jaded when I am no longer a curmudgeon.”

Afghanistan ER--Firefight

“Hey, Curmudge. We haven’t heard from Mack recently. Is the war in Afghanistan over?”

“Don’t I wish, Julie? Mack was in the States for a mid-deployment leave, but he’s back over there now. He copied me on this note to a friend:

‘Hi Rich,
It's been a decent week here. We had a ground assault mission three days ago; was nice because it was only one day. We left at 0400, got back at 19, in time for hot chow. The purpose was to hunt for bunkers and weapons/explosive caches. We found a lot of stuff and blew it all up. In the afternoon we got into a rather large firefight. The Taliban were actually hitting with more than their usual accuracy, meaning they were hitting the grape rows in front of us. We fired a ton of ammo, not really sure if we hit anyone, but certainly stopped their shooting. What the enemy usually does is fire on us for a short period of time, then simply break contact and disappear in the grape rows. They usually shoot from buildings like houses or grape huts but not for long. If they did we would get a bead on them and destroy them. They are usually not very accurate; their plan is to get us to pursue and lead us through fields where they have planted IEDs. We don't usually go for that anymore. The best part of this day was that no one stepped on an IED or got hurt. I'm all scuffed up from crawling over 5-foot high walls, etc. and destroyed a set of ACU pants. I'm certainly the oldest one out here, at age 49. Most everyone is in their 20s.
Mack’”

“It probably doesn’t make Mack feel any better to remember that he was an infantry platoon leader (prior to med school) before some of the younger soldiers were born.”

“Julie, if Mack slows up the troops any—and he probably doesn’t, I’ll bet they are still glad to have ‘The Doc’ come along with them.”

Afghanistan ER

“Hi, Curmudge. I see that Mack copied you on a note to one of his medical colleagues.”

“Right, Jaded Julie. When you read the note, it will be evident that it could only be fully understood by another Army emergency medicine doc who had served in combat. When I asked Mack about some of the terms, he dictated a rather cursory glossary (below). Here’s the note:

‘Hi Ian,
Had a terrible air assault day before yesterday, very dangerous area. One person killed by IED. Also Local National blown up accidentally by our APOB while we were trying to breach through really dangerous IED seeded area. Even though they did the whole procedure to warn the locals and clear everyone out. It was after dark when we crossed after the explosion, the people up front found a guy on the road, huge facial wounds but alive and struggling. I put in a tibial IO, (I carry the mini-drill in my Aid Bag). Hit him with IV Ketamine (in spite of the head wound. I heard that increased ICP with Ketamine was not really borne out by literature. Also only thing I had to adequately sedate him for any extended time). Also used some Versed. Did a cric, balloon failed so exchanged it for new tube over a stylet. Ran 2 Hextends IO for the crappy radial pulse. The guys used their Tac lights on their M-4s for light. Set up hasty LZ and evacd him. Guy made it back to the Role III alive; they did labs, CT scan, everything. He had a brainstem bleed and a depressed skull fracture, so they withdrew care and he died. My two medics and I were covered with blood. Several of us fell into a creek trying to get back to the exfil LZ so had to wait for 3 hours in the freezing cold while wet. We were in PZ posture in the dark; the Chinook almost landed on us. Whole planeload had to dive off 6-foot embankment to keep from being dismembered by the bird, then crawl up the sides of the ditch and run for the helicopter. Still scratched and sore from that.
Anyway, that's my world for the last 3 days. Take care—Mack’”

“Gosh, Curmudge, every note from Mack further strengthens my belief that war is Hell.”

“I believe most everyone can get that impression without the glossary, but here it is anyway:

IED—improvised explosive device
APOB—chain of explosives fired several hundred yards ahead of advancing troops to explode IEDs
IO—intraosseous. An ‘IV’ into a bone instead of a vein.
Ketamine and Versed—anesthetics
ICP—intracranial pressure
Cric—cricothyroidotomy; an incision in the front of the neck to establish an airway
Hextend—colloidal plasma volume expander
Tac lights—very bright, focused, visible light source mounted on weapon
Role III—advanced medical care. A battalion aid station is Role I.
Exfil LZ—helicopter landing zone to extract troops at end of mission
PZ posture—troops lined up in Pickup Zone in order of entry into helicopter”

“The glossary improves my understanding, Curmudge, but it doesn’t assuage my feelings one bit.”

“As always, Julie, you’ve got that right.”

Afghanistan ER

“Hi, Jaded Julie. Mack copied me on his exchange of Christmas notes with his friends, Ernie and Susan. You might find them interesting. Here’s the note that Ernie and Susan sent to him:

‘Christmas Day is just about done where you are, and the grandchildren here are already winding down - all the Santa gifts are opened and being played with. But we wanted to wish you a very merry Christmas and lift you up with a prayer that 2011 will be a year of much more peace - for you in particular and for all of us in general.’”

“It sounds like a classical, peaceful American Christmas, Curmudge.”

“This is Mack’s response:

‘Dear Ernie and Susan,
Christmas has been pretty nice. Today was a nice, quiet day. Just got a cold so spent a few hours napping at the house. The whole camp has had it; I'm like the last one to get it. Just got back from screening a detainee tonight. Christmas Eve was a little more exciting. I was eating lunch when one of my medics ran in the chow hall and told me we had traumas coming. Apparently one of the good Afghanis in a nearby village was the victim of a Taliban motorcycle drive-by. Shot in the chest, head and leg. His cousin brought him to right outside our FOB, with the guy in the back of a minivan. Stokes, one of my medics, and I took the little ambulance and had a hair-raising ride to the gate. Blood everywhere. The van was outside the gate on the highway since they couldn't come in. We drove through the gate onto the highway, usually a no-no since the Ford has no armor (and we were in T-shirts!!) The Ford does have a siren loud enough to peel paint, however.

I had the Afghanis in the van lay the guy by the side of the road and I did a "cric", which is a surgical airway where I cut a hole in his throat and put in a breathing tube, right there on the road. Fortunately no snipers. We put the guy in our ambulance and took him back to the aid station. Unfortunately he died; had a pulse of something like 29 when we got him on the table, but I think we got some I/O points with the local population for trying.

We had a beautiful candlelight Christmas Eve service in the chapel (tent) last night. I played the piano for it like I do for most of the church services.

Today Major General Terry (RC South Commander) flew in to visit everyone for Christmas. We enjoyed meeting him very much.

Anyway, I'm guessing you guys had a pretty nice Christmas Eve service at church. Feel free to read this letter at Sunday School if you want, so they know we had a good Christmas as well. Stay in touch and God bless. -----Mack.’”

“Curmudge, the FOB (Forward Operating Base) must be a fortified island of relative safety amid a sea of anarchy. So why am I shuddering? Maybe if I put on a warmer sweater…”

Afghanistan ER

“Good morning, Jaded Julie. You may be interested in the news bulletin (below) that I saw on the Web yesterday:

‘Six American soldiers were killed and more than a dozen American and Afghan troops were wounded on Sunday morning when a van packed with explosives was detonated at a new jointly operated outpost in southern Afghanistan. The soldiers were inside a small mud-walled building near the village of Sangsar, north of the Arghandab River, when the bomber drove up to one of the walls and exploded his charge around 9 a.m. The explosion blasted a hole in the thick wall, causing the roof to collapse on the soldiers inside. Others quickly arrived and clawed and pulled at the waist-deep rubble to free the buried troops. The building had been occupied by the Americans and Afghans for only a few days, an American official said, and was beside a narrow road. It was not immediately clear how the van managed to get so close without being challenged or stopped.’”

“Doesn’t sound good, Curmudge. We’ve heard about mud-walled buildings before. Did you send a note to Mack asking about it?”

“I did, and here is his reply:

‘Yes, that suicide bomber was for us. It occurred on Sunday morning at a small outpost, happened to one of our platoons, one that I have been out with a number of times and been at the exact same type of outpost with. Good I wasn't killed in a blast, but frustrating that I wasn't close enough to do anything to help. I was sent out there quite quickly by the command, but when I got there, all the dead and worst injured had been already evacuated. They were just digging through the rubble; I took care of a couple of Afghan Army folks. I've been busy checking out the remaining folks here, also there is a huge emotional toll since 6 guys were killed like that. Been busy, up until 0200 last night just talking to distraught guys.
Jim Slone, my PA, has gone on leave, so I can't really leave the Aid Station on base to go on missions, since we have to have at least one care provider on hand.’”

“My feelings are a mixture of thankfulness and rage, Curmudge.”

“Mine also, Julie. Mack said that with winter coming on, the Taliban chiefs will sit at home by the fire in the security of Pakistan and send out the young jihadis to become martyrs. I guess he’s right.”

Afghanistan ER

“Here’s Mack’s latest note, Julie. I’ll read it to you:

‘We did have a huge Thanksgiving dinner. I literally ate too much. Our mission that you mentioned was successful in that we accomplished what we set out to do. We went into one of the worst Taliban areas, found improvised explosive and burned and blew it up. We also found a Taliban Aid Station and burned it down. The real sad thing was that the other platoon was moving and an Afghani soldier moved off the cleared path and stepped on an IED, blew both his legs off, also injured an interpreter. Some of our guys were carrying him to the helicopter and the enemy apparently had a buried remote-controlled IED ready. When the stretcher bearers passed over it, they blew it up, killing two of our guys, injuring several more, and of course killing the Afghan guy on the stretcher. I was six hundred meters away with the other platoon and couldn't go help them since all the ground between us was not cleared and likely seeded with plenty more explosive devices. It was extraordinarily frustrating to not be able to help. Everyone was furious and despondent at the end of an otherwise tactically very successful mission. Memorial service was yesterday.

We are in our new Aid Station, which was just completed. It is beautiful and three times as large as our old one in the old stone Afghan building. The new place is by the helicopter landing zone; can be windy at times. Also too close to the trash burn pit, and I am lobbying hard to get the burn pit moved. Anyway, after I got back from the mission I pretty much just slept all day while the medics moved everything from the old building (none of them were out on the mission like I was). It was sometimes exhausting out in the field, climbing over the stone walls in the grape fields with full packs, weapons, etc.’”

“Golly, Curmudge, it must be awfully depressing for the troops and for the folks back home at Fort Campbell for the battalion to be losing at least two soldiers per week to IEDs.”

“Julie, I seem to recall reading about medieval times when battles were stopped to allow the wounded to be removed from the field. I guess now we are fighting an even more primitive civilization.”

“Civilization? Aren’t these the guys who condemn women to death by stoning?”

Afghanistan ER

“Another note from Mack. It’s rather short:

‘Pretty busy over here; lost some guys to a suicide bomber in the field. These were guys I had just been on the same mission with for 6 days. Then I went back in to check up on things at the aid station. Next day, guys I was just walking with out there were blown to bits by a s_ _ _-a_ _ with an explosive vest. Also three injured. I can't stand the fact that I was with them; then the moment I leave to go back here to work, this thing happens. Memorial service tomorrow.’”

“Do you have any comments, Curmudge?”

“Nothing that isn’t profane, Julie.”

Afghanistan ER

“Well, Curmudge, after spending the past couple of days thinking about Mack’s letter in our last posting, do you feel any better?”

“I don’t feel better, Jaded Julie, but I understand better. Mack is living out his belief that wounded soldiers should receive the best medical care available at the point of injury. And he has determined that he will be available. As long as he has a good PA back in the aid station, Mack will practice battlefield medicine literally in the field. He may be setting a new standard for infantry battalion surgeons.”

“I can just hear the platoon sergeant announcing, ‘Listen up, guys. I have some good news and some bad news. The good news is that the doc is going with us on this mission. The bad news is that that means our platoon has the toughest assignment and we are the most likely to sustain casualties.’”

“Let’s hope the good news outweighs the bad and that the bad news doesn’t actually occur.”

“But Curmudge, isn’t a physician too valuable to go out into the field like Mack does?”

“I’m sure, Julie, that every parent feels that way about their 20-year old rifleman son.”

“Mack said that he and the medics carry M-4’s and act like riflemen until someone is wounded. I thought that medical personnel were noncombatants and had red crosses on their helmets.”

“That was another war, Julie. To the Taliban, a red cross—especially a cross—would look just like a bull’s-eye.”

“Curmudge, wouldn’t a physician feel out of his element in the field carrying a rifle along with his aid bag?”

“That might be true for a lot of docs, but not Mack. When he first went on active duty in the mid-1980’s, he was an infantry platoon leader. That was before a lot of today’s young soldiers were born.”

“Finally Curmudge, do you still get that knot in the pit of your stomach when you read notes from Mack?”

“It’s there all the time, Julie, and it will remain there for the next several months.”

Afghanistan ER

“Curmudge, a few weeks ago, on October 11, you shared a note from Mack describing injuries that he and the troops sustained from improvised explosive devices (IEDs).”

“Right, Julie. It brought the war in Afghanistan awfully close to home. He recently provided more details about the mission in a letter to an old friend from Appleton. Mack sent me a copy; I’ll read part of it:

‘Dear Joe,

The last 5 months have been quite an adventure. It would take quite a while to detail everything, and I can tell you stories on end if you are interested. I will tell you about the mission where the IED attack happened. To start with, I am a ‘battalion surgeon’ in an infantry battalion. The term ‘surgeon’ in this case, means the chief medical officer for a military unit as opposed to being a surgeon who takes out gall bladders, etc. As you know, my specialty is Emergency Medicine, i.e. working in an ER.

I have gone on all the major offensives/missions. What happens is I usually go with whichever platoon or company looks like they will encounter the most resistance and have the greatest potential for casualties. I carry an M-4 (it's a shortened M-16 with a collapsible stock like the riflemen carry) and function pretty much like a rifleman the way the medics do until something happens. There is a combat medic in each platoon and I "plus up" the given platoon in these situations.

This particular mission was a Clear and Hold, where we move through the countryside, clearing houses/ compounds to ensure no enemy there and identify/destroy any IEDs that are found. The second evening we were settling down to eat a meal and sleep when the radio call came in that one of the guys in the next platoon over had stepped on an IED and had lost a leg. I ran with the company commander who was with our platoon up to the area where they were, (a grape field). The guy was pretty messed up, one leg gone, open pelvic fracture, severe rectal and pelvic injuries. The medics and I got the guy stabilized and we called in a helicopter to fly him out. We were somewhat shaken up by what had happened to him. I went back to my platoon and we went to sleep. The next morning we were to move to a new compound (Afghani houses, or compounds are mud-walled courtyards with individual rooms built into the walls as opposed to the whole building having a roof like an American house), and we packed up and moved to the place. It had been searched to ensure no bombs were rigged or anything. We had just moved inside when the first bomb went off. It was about 15 feet from me, but it was inside the foyer and I was just around a corner so that protected me from shrapnel. In the explosion guys were thrown through the air, lots of smoke, etc. and lots of confusion. I was checking out the guy who landed right in front of me; then people started shouting that someone was badly injured. I yelled that everybody who could walk should go toward the walls and bring the badly injured to the middle.

We were working on this guy who had shrapnel to his face, legs, etc, left middle finger partly blown off, fragments in right elbow, etc. in the middle of the courtyard when the second bomb went off along the wall. My medic and I fell across the guy to keep the dirt chunks/ fragments, etc from falling on him, then got him wrapped up to fly out. Because of the concussion there was an increasing number of people vomiting, losing balance, etc. I sent out 5 on the first helo, then 12 on the next one. We sent out some more on a convoy that brought the battalion commander to the scene later. By this time the platoon was not really combat effective, so the rest of us flew out late that night on a Blackhawk. My medics at the base camp with my PA checked the remainder of the people out including me. I just had a headache and jaw ache the next day, then pretty much felt back to normal aided by my pounding max doses of Tylenol. My parents did get a call the next morning from Fort Campbell saying I had had a mild ‘TBI’, but fortunately I had e-mailed my dad late the night before so he know I was still coherent.

I hope that wasn't too laborious a read. This week has been somewhat difficult as we lost two guys who were killed outright by IEDs. My PA and my medics and I were in the Aid Station three nights ago when the locals brought in two girls (age 4 and 7) who had been badly burned in a gasoline explosion. Apparently the parents had bought what they thought was diesel fuel but turned out to be gasoline for their heater. When they filled it and lit it, Boom! Burns about 80-90% of bodies. We intubated the kids, dressed the burns, and flew them out. Apparently they both died the next day, judged by the hospital to be not survivable burns, changed to comfort care only.

I should be home next spring/summer and certainly plan to stop to see you the next time I'm in Wisconsin.

Take care---Mack’”

“What’s the lesson, Curmudge? It sounds as if the good guys took it on the chin.”

“Julie, when I read this, my only feeling is the knot growing in the pit of my stomach. Let’s think about Mack’s letter and talk more about it in a few days.”

Afghanistan ER

“Hey, Curmudge, has Mack recovered from the concussion he received from the IED blasts?”

“His email notes seem pretty normal, Jaded Julie. A few headaches, but none of the more serious symptoms that one expects from traumatic brain injuries. He has been back ‘home’ at the forward operating base (FOB) for the past few days, but living there is not especially easy.”

“I understand that the Americans share the FOB with British and Afghan soldiers, and that the sanitary conditions are not the best.”

“Here’s what he says, Julie, in his latest note:

‘Do you really think I haven't been ‘encouraging’ these people to improve the Porta-Potties? We've been doing everything we can, including trying to restrict as many as we can for US and British use only. This was determined to be ‘discriminatory’ to the ANA, so they are back to dive-bombing the latrines. They actually stand up on the toilet seats and let it go, and if things don't quite fall into the hole, oh well. The struggle is ongoing.’”

“Do you recall, Curmudge, our writing about sanitation in Third World countries back on March 3? If 40% of the world’s population don’t have any toilet facilities, there are a lot of people out there who might not know how to use them if they had them.”

“And a couple of years ago on May 8, 2008 in Kaizen Curmudgeon we talked about how a leadership culture change sometimes involves learning things that seem unnatural, like potty training for young children. So there in Afghanistan the culture change is more than like potty training, it is potty training.”

Afghanistan ER

“Another note from Mack, Jaded Julie. I am at a loss for words, so I’ll just read his:

‘Hi, everyone,

This weekend was quite eventful. I was in a double IED blast. We were in a compound and there were two houseborne IEDs that went off, first one about 15 feet away from me; then while we were taking care of the guy hurt worst in that one, a second bomb went off. I just got done being checked out in the Aid Station at Howz-E-Madad. Only a little sore, have a mandatory 24 hour rest period that we do for soldiers who have been in IED or bomb attacks as part of the mTBI (mild traumatic brain injury) policy for prevention of worsening, etc.

I had been on this patrol mission since Thursday. Last night a guy stepped on an IED, lost his leg but also had terrible pelvic injuries; we did all we could do for him, (treating him in a grape field). He had two surgeries today, I think, and is on a flight to Germany. I already had a pretty depleted Aid Bag today when the IEDs blew up; now it's completely trashed as are my clothes and everything. I still have someone's blood on me; it took forever to get everyone flown out and I finally got a helicopter ride back here about 10 PM or so. I am going to leave the bloody stuff in front of the house and go take a shower.

Take care and stay in touch----Mack’

After reading this, I sent him a note suggesting that this might be a good time to revisit the concept of a board-certified physician going on patrols.”

“You can already guess his reply, Curmudge. He will probably say that the horrible wounds suffered by the troops make it all the more essential that he be there. If it hadn’t been for Mack and his medics, the soldier who lost his leg would have died right there in the grape vineyard.”

Afghanistan ER

“Hey, Curmudge, it looks as if you have another note from Mack.”

“It’s pretty short, Julie, and is mostly a thank-you note to his brother. Here, I’ll read it to you:

‘Thanks so much for the last package. I've been doing a lot of field time with this big thing you've probably seen in the news.... Would've been downright unhealthy without all the wet wipes, toilet paper, Gatorade, and of course, the cookies for morale and a break from just straight MRE's (field rations). Very interesting and slightly precarious last several days. Last night I was on the ground 400 meters from a kinetic strike (F-16 making two runs dropping a two-thousand pound bomb each time). Most terrifying explosion I've ever experienced and I think the rest of the group felt pretty much the same.’”

“Not anything about emergency medicine in this one, Curmudge. Let’s assume that’s good news.”

“As much as I appreciate getting these notes, they always leave me a bit shaken. At least this time it was the enemy on the receiving end. Nevertheless, I’m reminded of how much danger the troops—even the medical personnel—are in.”

Afghanistan ER

“Hey, Julie, Mack has been ‘out of the office’ for several days and just sent this note:

‘I was just on a 10 day mission. Was projected to be pretty dangerous with lots of casualties, but didn't turn out too bad. I did have one scary patient where I put in a chest tube in a partially-built guard tower. Whole thing was pretty exhausting. I did wade across the Argandab River during our "push." You should look that one up, since this is apparently a pretty notable river here.

We have another mission coming up very soon, (sooner than I would have wanted for rest purposes). By the way, please send another roll of duct tape (not for medical use).’”

“I think I understand what an Afghanistan emergency room is, Curmudge. It’s any place where a wounded soldier needs the urgent care of a physician.”

“Perhaps Mack’s team should adopt the motto, ‘The best of care anywhere. Literally, anywhere.'”