Friday, September 24, 2010

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.'”

Wednesday, September 15, 2010

Afghanistan ER

“Hey, Curmudge, I see that Mack copied you on another email to his friends. It appears that he only writes to them when something exciting has happened.”

“Exciting isn’t the right word, Jaded Julie. This time it was tragic. I’ll read part of what he wrote:


‘Hi, everyone,

Hope your Labor Day holiday was good. Ours over here got pretty tumultuous. We were sitting down to a special Labor Day dinner they had in the mess tent when the word came that incoming (fire) was expected. I had to leave half my dinner behind as everyone had to go to bunkers, etc. A mortar hit a Hesco (barrier wall) and bounced into a bunker. It blew up at head height right in the middle of a group of American contractors that worked with us. It was the worst mass-casualty event I've ever been involved with. People lying all over the place with terrible head injuries gurgling blood etc. Two died within the hour, then one more died the next morning at the hospital where we had flown him. (I tried as much as I could to help him.) Several more still in bad condition. It's taken a couple of days to just clean the blood off ourselves and the equipment. Still getting more incoming, lots of time in body armor. Our morale is very good, including mine (so far). I have a tiny ‘cottage’ that one of my medics and I built so I don’t have to sleep in a tent all winter. I’ll try to send a picture of it. I can say that I own property in Afghanistan, albeit in an unsafe neighborhood. Anyway, we’ve got a burned baby coming in. Gotta go--Mack.’”

“Curmudge, it sounds as if on Labor Day the term ‘triage’ reverted back to its original meaning.”

“The training of the whole medical team undoubtedly kicked in; but after things settled down, all of them—Mack, his PA, and especially the young enlisted medics—must have realized what an emotional experience their first mass-casualty event had been.”

Wednesday, August 11, 2010

Afghanistan ER

“Hey Curmudge. I see that you received a note from Mack.”

“Right Jaded Julie. He copied me on an email sent to several of his friends here in the States.”

“I understand that he is a battalion surgeon in Afghanistan.”

“That’s his title. Actually he is an emergency medicine physician. Would you like me to read part of his note? Here it is:

‘Just wanted to say hi. Pretty exciting last several days. My medics and I have taken care of a lot of people, 49 traumas in 2 months. Mostly Afghanis, (Military and civilians including kids). Took care of a 5 year-old boy with gunshot wound to head, very serious, flew him out stable. We've saved a lot of lives. Yesterday I was on a patrol and we got ambushed and had half-hour firefight. No one of us hurt. The Kiowas (helicopters) came in to shoot them up. I played guitar in the chapel service last Sunday…’“

“One question, Curmudge. What was a board-certified physician doing on a patrol?”

“It must have been a slow day back at the battalion aid station. He undoubtedly left his PA in charge.”

“Curmudge, is there a lesson in this story?”

“I hope so, Julie. There in the midst of a war and a dusty, almost Biblical setting, they are achieving the basic goal of medicine everywhere. As Mack said, ‘We’ve saved a lot of lives.’”

Wednesday, April 14, 2010

When Education Becomes Indoctrination

“Curmudge, our topic for today looks rather ominous. Perhaps we should start with an example. Our last discussion ended with the males of the village acquiring enough education to build systems for providing clean water and basic sanitation. Then what?”

“In their madrasa the boys undoubtedly learn reading and writing. However, if their teacher is an Islamic radical, he may also be indoctrinating them with the belief that the United States is the ‘Great Satan’ that must be destroyed by people achieving ‘martyrdom.’”

“So Curmudge, in our eyes these so-called ‘martyrs’ become murderers and suicide bombers by blowing themselves and innocent people to bits. It doesn’t do much good for these people to grow up with clean water and sanitation if their ultimate desire is to be dead before they’re old enough to grow a beard.”

“It’s even worse, Jaded Julie, when a whole nation becomes indoctrinated. Sixty-five years ago (I was 11 years old) American civilians viewed Japanese kamikaze pilots as a small group of deranged zealots willing to crash their planes onto American ships off Okinawa. Only slightly later did we learn that the whole Japanese nation had been brain-washed into believing that Americans were a sub-human race to be resisted unto death. This was clearly demonstrated by Okinawan civilians jumping to their death off high cliffs before the advancing Americans.”

“I can understand the history, Curmudge, but their psychology blows my mind. I hope the Islamic terrorists possess the only remaining vestige of such a warped mindset.”

“Unfortunately it’s not true, Julie. The modern-day North Koreans have been propagandized in much the same way as the World War II Japanese. The North Korean educational system teaches a belief in the unique moral superiority of the Korean race (1); Americans are depicted as an inherently evil race and sketched as jackals with paws and snouts.”

“Golly Curmudge, that would seem unbelievable except that it has been pounded into the minds of North Korean children for the past forty years.”

“There’s more. ‘They are also told that the South Korean masses, for all their material comfort, are ashamed of being under the thumb of the Yankees and yearn to live under Kim Jong-Il.’ The propaganda apparatus continues to assure the North Korean people that their economic sacrifices (over a
million starved to death in the 1990’s) are essential to support their ‘military first’ regime and protect them from the Yankees.”

“If we didn’t know authoritatively that all this is the truth, it would seem like some sort of diabolical fairy tale. How will this situation end?”

“For our purpose, Julie, we can conclude that education can be a force for good; but when it becomes propaganda, it can become unspeakably evil. History is full of additional examples. For North Korea, the end game is a total unknown. Watch out for further writings by B. R. Myers to keep up to date on the situation (2). However if you want to sleep well at night, read medieval novels by Ken Follett.”

(1) Myers, B.R. The Cleanest Race: How North Koreans See Themselves—and Why It Matters. Available from Amazon.com. See also review by William Alexander.
(2) Myers, B.R. North Korea on the Edge.
http://online.wsj.com/article/SB10001424052748704100604575145672974954144.html?KEYWORDS=BR+Myers

Wednesday, April 7, 2010

Will education be the key to the Third World's health problems?

“Curmudge, it’s hard for me to forget about the problems of that Third World country that was our imaginary destination a few weeks ago. Wouldn’t the people’s lives be better if they could somehow get an education?”

“Jaded Julie, it depends on their culture and ultimately, on their government. With their hanging latrine, the people we visited were already one rung up on the sanitation ladder. I’m sure you recall that 2.6 billion people don’t even have a basic latrine, and many of those folks might not even appreciate the value of one. So the first step in education would be to put sanitation in the mindset of the populace.”

“What about formal education like reading and writing?”

“The dominant belief in some cultures is that women should not be educated. So in those locations at least half of their intellectual capital is wasted. Fortunately those children who are able to attend school will eventually be able to interact with their government and nongovernmental organizations (NGOs) to learn about developing clean water systems and basic sanitary facilities.”

“So, Curmudge, how might they obtain clean water?”

“It depends on the locale. They might dig a well or collect rainwater. Even in the U.S., my mother and her sisters used water from the rain barrel to wash their hair; it was softer than the spring water that they drank. Surface water in the Third World would have to be purified to make it safe. That could be done inexpensively by filtration through a
ceramic cone or treatment with Clorox or similar chemicals. A solar still should be adequate to produce drinking water for a small family.”

“What about sanitation? There must be something for undeveloped countries that is better than that hanging latrine that we saw.”

“There are several systems, Julie, including composting pit latrines and their commercial version, the
Ecosan waterless toilet. We needn’t discuss operational details other than to say that they are simple and should be inexpensive. I’ve seen these, fitted with solar panels, in national parks in the U.S.”

“We’ve done it, Curmudge. We’ve solved the water and sanitation problems of the Third World, at least theoretically. So everyone should live happily ever after.”

“It’s not necessarily so, Jaded Julie. Governments or ethnic groups can come along and turn everything we’ve said on its head. We’ll talk about that next time. You won’t like the story.”

Wednesday, March 31, 2010

Governments and Health in the Third World

“Curmudge, do you recall our imaginary visit a few weeks ago to that Third World village where the people had such poor health and sanitation? I suspect that those people’s sorry situation is duplicated in many locations throughout the Third World. What’s the root cause of their plight?”

“In my opinion, Jaded Julie, the root cause is poor government. I’ve heard it said that in the U.S. one gets rich and then goes into politics; in the Third World one goes into politics and then gets rich. In these countries, graft is rampant. When the developed world sends (lends?) money to Third World countries, it often ends up in the pockets of the leaders and their cronies. These folks don’t seem to believe that a government should exist for the benefit of its people.”

“Citizens of Third World countries often do quite well if they are able to emigrate to a developed country. What is their country of origin lacking that prevents their ‘pulling themselves up by their bootstraps’ back home?”

“For the most part, the countries of the world that are the most poverty ridden are those without democratic governments that foster free markets. This is documented by
studies published by the World Bank. At the bottom of the ease-of-business scale are those little countries of Africa that would be difficult to find even on an up-to-date map. The vast majority of the populations of these same countries live in poverty.”

“That must mean, Curmudge, that the countries in which the citizens prosper are those in which it is easy to do business.”

“Exactly. At the top of the ease-of-doing-business scale are Singapore, New Zealand, Hong Kong, and the U.S. in that order. The World Bank’s criteria include: starting a business, dealing with licenses, hiring and firing workers, registering property, getting credit, protecting investors, paying taxes, trading across borders, enforcing contracts, and closing a business. We know intuitively that most of these conditions are favorable in the countries of the developed world.”

“I saw you reading an
article by Steve Forbes in which he elaborated on some of these criteria.”

“According to Forbes, the rule of law that we enjoy in the U.S. is essential. Commercial contracts must be respected by everyone, including government bureaucrats, and government cannot seize your property or nationalize your business. ‘Low tax rates on income, profits and capital gains foster more risk-taking and higher growth, bringing about a richer economy with a higher standard of living—along with higher government revenues.’”

“Curmudge, some people don’t believe what Forbes said about lower tax rates bringing a higher standard of living and, at the same time, higher government revenues.”

“Forbes’ statement is undoubtedly based on the
Laffer curve. Although it is somewhat controversial, the political philosophy of those who totally reject it appears to have blinded them to the realities of history. Speaking of history, the concept of the Laffer curve has been around since the 14th century.”

“So back to those impoverished folks in the Third World village we visited a few weeks ago. We could help that single village by sending our own resources, but what can be done to assist the whole poverty-ridden nation?”

“If the source of poverty is despotic leadership, Julie, one solution might be regime change. The feasibility of that depends on the relative strength and determination of the regime and of the people. Peaceful change came to the former Soviet–bloc countries in 1989-90 because virtually all of the citizens participated in peaceful demonstrations that the communist leaders were unwilling to suppress violently. Elsewhere, regime change has not occurred because despotic leaders were willing to put down unrest irrespective of the cost.”

“I have the feeling that today’s discussion might end on a discouraging word, Curmudge. If they don’t get a democratic, somewhat benevolent government, the folks we visited may have to put up with their polluted water and hanging toilet for a long time.”

“They are not the only people with concerns, Julie. Even people in developed countries have to work hard to keep their standard of living from being eroded by their government. To quote
Thomas Paine, ‘The greatest tyrannies are always perpetrated in the name of the noblest causes.’"

Thursday, March 25, 2010

Cultures--Bad and Good

“Curmudge, I believe that you’ve felt that one of the best aspects of the Lean culture was its respect for people.”

“Right, Jaded Julie. Although I always enjoyed my work, I now realize that I often worked in a poor cultural environment. I guess I was just stoic and didn’t know any better. Fortunately, there were other places where the culture was extraordinary.”

“We can learn from experiences that were bad as well as from those that were good. Let’s start with the bad ones. Can you give some examples?”

“The company’s culture was great until the founders retired. The new CEO was from Chicago, so he moved corporate headquarters there (at great expense). As I recall, the building had five stories; the top floor was for the exclusive use of the top executives and their administrative assistants. Whenever I met with my boss, her assistant would escort me from the third floor; the elevator door wouldn’t open at the fifth floor for mere peasants. When one stepped out of the elevator, you faced a life-size stylized horse which likely cost much more than a real one. If the horse could have talked, it would have announced, ‘You are now in executive country.’ The art work on my boss’s office walls was exquisite. It had to be because it was inspected periodically by the ‘picture police.’”

“To say the least, the corporate culture doesn’t sound very egalitarian. You once told me that it wasn’t so much the executive floor that bothered you; it was the political stratification that seemed to be palpable throughout the whole building.”

“That’s for sure, Julie. Corporate royalty had an executive dining room on the top floor and a garage beneath the building for their company-owned cars. Fortunately, some of the perquisites trickled down to the lower floors. Managers had offices with a window, and directors had corner offices. Others, like me, had cubicles in the middle of a big room. I was grateful that because my regular location was here in the Fox Valley, I only visited corporate headquarters occasionally for meetings.”

“Although the whole situation sounds pretty dismal, were there other aspects of the culture that really got your goat?”

“There sure were. Another location of the company had layoffs that occurred in waves. During one of these periods, when the P.A. system summoned a person to report to Human Resources, it usually meant that his job had been eliminated. In addition, when I read the company’s annual report, I learned that they paid more for the executives’ golf club memberships than they paid me in salary. I remain perplexed at the top-level executives’ apparent disinterest in how the company’s venomous culture impacted the rest of their employees.”

“Wow, Curmudge! Your experience with medieval management must have been a real downer.”

“There are more examples, but perhaps not quite as egregious. Many years ago in a different organization, a new president was hired from a university in the South. Despite the organization’s extraordinary culture, he made no attempt to understand it or to build upon it. It was his way or the highway, and most staff members—including me—chose the highway.”

“I hope, Curmudge, that these truly bad experiences were matched by some that were truly good.”

“We’ll talk about those soon in
Kaizen Curmudgeon, Julie.”