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The Edge of Summer

The sun has been shining, the grass is green, and summer is in the air. We're still in that magical window when it's nice to be outside for most of the day without fear of withering from the heat. The press of the last few months is just about to see its release. I've got a long weekend and then I take my board exam next Tuesday. I feel pretty confident about my readiness, but I'll still crack the books daily til Tuesday. 

The transition to fee basis at work has essentially completed and my schedule has normalized itself for the most part. It's really nice to have a three day workweek at the most. It's funny how quickly that became the norm for me. The default schedule should be three days for three weeks and then a week off. I'm working half as much and bringing home more than double my Federal pay (with consideration for no increase to my pension and no 401K matching).  It's really the perfect work scenario for me and my capabilities. I can complete exams more thoroughly and faster than any of the people I have worked with so far. I'm sure there are others like me out there, but we all have a fairly unique skill set that gives us distinct advantage over other examiners. Nearly thirty years of continual Federal service including the twenty three years of active duty has definitely paid off in my current job.

I haven't really been able to settle in and take advantage yet because the last few months were occupied with the end of the Berklee semester and then the beginning preparations for the board exam. Thankfully, the board schedule is transitioning to a ten year cycle after this.  My goal is that by the time I take the next board, we'll have paid off this house, built or bought our house in the country and I'll be well ensconced in my bespoken home studio.  That mostly depends on a steady state for my current work situation. I'm relatively confident that the C&P program in general won't go anywhere soon, and I'm mostly optimistic that the role of the examiner will stay the same as well. The prevalence of laziness, incompetence, and ambivalence in the Federal service actually plays to my advantage. There's no shortage of work for me, and this allows me to maximize my time/salary in a way that's really unmatched anywhere else in the job market that I know of. 

I am being sorely tested...

by all involved parties. First we get smoked by our walkins today (3x the usual number) and then our staff is doing their best to give the exponentially enlarging snowball an extra kick before it gets to me. I love the fact that people who are not ultimately responsible to care for a patient are more than willing to sign them in when they don't have an appointment since it's my responsibility to take care of them. Soon I will be in a job that doesn't have walkins and I won't have subordinate personnel who can arbitrarily add to my workload.

Being a provider with a schedule of patients is an occupational experience that most people don't comprehend. When you have a schedule, you are locked into that schedule. Your day is dictated by the schedule and you must stick to it or suffer complaints and backlash from patients and staff alike. As a provider I accept this, because it's what I get paid to do. Where I get really frustrated is when other people through ambivalence, naivete or outright intention add to or otherwise complicate my schedule. I don't mind a busy, fully booked schedule. The busier I am at work, the faster the day goes by. I pride myself on staying ahead of my schedule, finishing my notes in a timely manner, and getting all the time sensitive issues handled as soon as safely possible. When it's up to me, this is very rarely a problem. The only time I typically fall behind is through the action or inaction of others.

Today we had 15 people signed in for sick call, and we only have 90 minutes to see them before appointments start. The frustrating thing is that most of these people don't truly have acute medical issues. Most of our sick call patients are here because they don't want to wait for an appointment, or they are trying to get out of work. Rarely do I see a patient on sick call that I think "It's good you came in when you did, because this was a serious issue". Most of the time I think "Why would anyone ever seek medical treatment for this issue?" This gets back to my fundamental problem with most clinic visits by soldiers which is that they get free healthcare and have the secondary gain of time away from work, duty modification, etc.

The NCOs responsible for triaging the acute patients are not very good at what they do. They have a tendency to not want to enforce sick call complaints to acute only, and if the patient argues with them or insists on being seen, they sign them in. Military patients essentially have no negative reinforcement system for spurious complaints. The worst thing that happens to them is being told they are normal or their issue doesn't require any more workup or treatment. Even in those cases, they were at least able to get out of pt and work for a few hours. Patients can no-show, malinger, drug seek, or engage in a multitude of fraudulent or exaggerative behaviors and they very rarely get held accountable. This is one of the reasons I have sought employment elsewhere. The secondary gain issue is fairly common with the normal active duty population, but it's the modus operandi of the meb patient. I don't know how any competent provider with military experience could tolerate long term employment with this population. "Never has so much been done for so few who are so less deserving" - this should be the clinic motto. I find myself less and less proud to be an American citizen and retired soldier the more of these types of patients I am exposed to. There is a significant portion of the young population who look at the world as a set of entitlements with no requirement to work or produce for those entitlements.

I'm rambling now. Rant over. I expect my relative attitude will improve here shortly.

3 clinic days left...

and then hopefully <1 day of clearing. Not that I'm counting. The realtor should be coming over later today to take pictures of our house and then hopefully get it listed here in the next few days. We're going to be taking it somewhat in the shorts since we've only lived here two years and the market is pretty flat (better than most other places, though). We've accepted the loss because of all the positive reasons for the move and job change. It's also taught us a bit about the home buying/selling process.

We're Coming Home

I received the offer via HR over the phone, and although it will mean a modest pay cut from my current wage it's still more than I was expecting the VA to offer. I accepted and the paperwork train is leaving the station. I'll have loads of credentialing fun as well as the requisite physical and security checks in the coming weeks. Not to mention dealing with the fall out of my departure from my current position.

Well I'm working here in Jackhole town...

And the "soldiers" are trying to bring me down
and it's getting very hard to stay-ay-ay-ay-ay-ay
and I'm stuck right here in jackhole town...

the "brave" lament their lot in life
they've had to deal with all this pain and strife
even though they've not deployed a day-ay-ay-ay-ay-ay-ay
just another day in jackhole town

the "intrepid" need their MRIs,
percocet and duty day profiles
why was my sergeant so mean today-ay-ay-ay-ay-ay
and I'm dying here in jackhole town

Every "fighter" has a pretty good shot
To get as much as the other "hero" got
They never sacrificed in the first place
"Heroes" throw the flag in our face, oh oh oh.

it doesn't matter if you lie
we just don't want to make you cry
soon or late you'll get your way-ay-ay-ay-ay-ay
when your a citizen of jackhole town

The return of the tubular…

Our favorite thoracic shrapnel patient returned after about a month in the hospital for a check up.  He is the patient that I put the chest tube in and then shamelessly hammed it up for the after picture. He is doing very well with no residual pain or loss of pulmonary function.  The scar is still impressive enough for him to get sympathy dates, though. Not sure if he's tried it yet. 

Chest Tube after web

A really bad 24 hours…

We lost our civilian doctor, Dr. Rahullah who had been an integral part of our clinic here. He is on my left, explaining the patient’s prognosis to her father. He apparently was killed because of an inter-family rivalry although that isn’t confirmed. He was a man who had risen so far above his upbringing and spent seven years of his life in medical school and had been working in our clinic for less than a year. As unique as doctors are in the states, they are even more special here in Afghanistan. This is a typical outcome for those who put their lives on the line to help the people of Afghanistan.


Is that a tube in your chest…

or are you just happy to see me?  A couple of action shots of a guy who had what was apparently a shrapnel wound to his posterior thorax that resulted in a hemopneumothorax (blood and air in the chest cavity, compressing the lung).  We started an IV, gave him some pain meds & antibiotics, and I placed the chest tube seen here.  We evacuated him to our forward surgical team and he's doing well according to reports.  Yeah, I don't exactly look professional in that first shot, but we tend to joke around a lot during traumas, especially after we have stabilized the patient and know that they're going to do alright. 

I had assisted with a few of these during PA school, but this was the first trauma patient that actually needed a chest tube that I put in myself. During OIF 1 we just never got anyone with penetrating chest trauma that really needed a chest tube.  It's surprising just how hard you actually have to push to penetrate the pleural lining, but it's very obvious once you do. After penetrating and opening the hole up with hemostats there is a great rush of air (in the case of a pneumothorax) and blood (if there's a hemothorax as well) and the patient usually immediately begins to breathe easier, which this one did.  That also explains the last picture (I probably needed a face shield). I'm sure I'll get several more under my belt before I'm done here.

More action photos…

These are 3 pictures from when I tapped a kid's knee last week. The first is me prepping the knee, then it's me and SPC Strain not posing, and finally Dr. Paresh Patel (the battalion surgeon and an ER doc by trade) also not posing. The tap was negative so we ended up just treating him for an overlying cellulitis that resolved after a few days.

The vacant stare and protruding tongue are products of Ketamine, an anesthetic agent that works very well for short procedures. We have to use it fairly often for young children because they get so distressed by the environment and the procedures we perform here.  We use local anesthetics first, but they usually still get very upset by the process so we often sedate them.  These kids get what I call the "Ketamine Stare" where they lay with their eyes open staring, but they are unaware of what's going on. I put on a little Pink Floyd first and with the Ketamine onboard, send them to the Dark Side of the Moon.

A new month

It's now September, so another calendar month is gone by.  August was a fairly good month in retrospect. I left Jalalabad on August 6th and came to FOB Blessing which has turned out to be a positive change in most aspects. I'm pretty happy with the living arrangements, and I have settled into a comfortable routine here.

In the last month I have seen more serious trauma than I saw during my whole OIF deployment. That statement must be qualified by the fact that we didn't have a steady supply of local nationals that we were seeing and Iraq hadn't really heated up yet during my time there.  After four years in Occupational Medicine I was feeling pretty rusty on trauma management, but just a few weeks here can knock a lot of rust off. Yesterday, I placed a chest tube in a local national that was hit by shrapnel and then we evacuated him to Jalalabad for further care.

Things to look forward to in the next month include the completion (hopefully) of the new dining facility which will result in the relocation of the MWR facility to the former mess hall area (which will allow more room) and possibly a small PX being put into the previous MWR facility. September and October are still fairly busy from an operational standpoint, so we will probably continue to get a steady flow of trauma patients.


The Zen Masters of Afghanistan…

or ninjas, or firewalkers, or whatever other badass pain insensate icon you can compare to these kids. Here’s a couple more of our stalwart local patients.

The little boy with the interesting headgear and gator (it was raining and we needed to keep the dressing dry) was hit on the top of the head with an axe, according to the story we got. Luckily, it must have been a very lightweight axe as it only penetrated the skin and didn’t reach the bone. He was completely lucid and not showing any neurological defects during the hour he was with us. I threw some stitches in and off he went. He got the gator because he sat there as stoic as a supreme court judge the whole time without complaining or moving. Yeah, these kids are tough. We still get the occasional hysterical screaming kid, but we get more of these kids with zen like patience and bearing.

The little girl behind the old man lost her right eye and suffered shrapnel wounds to her face and leg. I treated and stabilized her initially and then we evacuated her to the forward surgical team where she stayed for a few days. She is on a list to get a replacement eye prosthetic (glass, I think) which will probably be performed in Kabul when it eventually happens. She was another monk like patient; she cried a little bit but otherwise didn’t squirm or fidget during the whole process of cleaning up her wounds and bandaging them. Normally we would have sedated her, but since she had head trauma, we couldn’t give her anything that would cloud her clinical picture.

She’s too young to realize the magnitude of her loss, but the day this picture was taken (about 10 days after the event) she was smiling and playing with her sister and responding to me when I talked to her.

The toughest kids in the world

These children in Afghanistan have a very hard life by any standard, especially by Western standards. Almost daily we are seeing children with significant burns, blunt and penetrating trauma, or infections that have progressed much farther than they would in the US. This little girl is about 3 years old and she was burnt when she apparently knocked over a boiling tea kettle. She was brought in about 12 hours after it happened. We sedated her and cleaned up her burn and dressed it. We arranged for her transfer to a burn center in Kabul and she flew out yesterday. She'll probably do okay in the long run, but it's hard to see these kids going through all the suffering they do when some simple safety measures could prevent these accidents.

I’m in demand…

This is a picture of the front door to the aid station at Camp Blessing.

I’ve been in Afghanistan for about five weeks now, the last two at a new base with a different battalion after one of my peers had to be replaced. I was moved to one of the infantry battalions at Camp Blessing, which is in a more remote and contentious area in A-stan. I actually find the life here much preferable to the last place I was at (Jalalabad). The weather here is a bit cooler, the aid station we occupy is a permanent cement structure that keeps the temperature cooler and more stable around the clock, and everything that I would need to do is within about 300 meters walking distance (aid station, dining facility, gym, laundry, bathroom). We see mostly local national children here and we get to do surgical procedures mostly on a daily basis. Lots of abscesses and skin infections with the occasional trauma thrown in. In the two weeks I have been here, we have had two mascals (more patients than we can treat at one time) although in both cases there were only two “serious” patients so both the doc and myself were able to manage them within our scope. We’ve intubated four patients, and put in four chest tubes (one guy got two). We’ve seen everything from shrapnel, to GSW (gunshot wounds) to MVAs (motor vehicle accidents).

We also see alot of kids with burns and other questionable blunt trauma injuries. It’s not uncommon for children here to be running around open fires with cookpots full of boiling water and other dangerous substances. Safety practices are essentially non existent so we see alot of stuff you wouldn’t see in the states. Personal hygiene is also not a priority here so we see alot of infections that wouldn’t normally occur in the US. I wouldn’t have thought it, but I find the work here quite agreeable. I normally prefer the steadiness of occupational medicine but there is definitely a different vibe to seeing people with true objective illness and injury as opposed to the typical sick call patient we see in the US. When you see a 6 month old kid with an eyelid full of pus the size of a golfball, it’s not even a question as to whether or not they deserve your attention. So many of the problems here are correctable with an intervention or two so it’s much more satisfying when you treat them and then see them get better. And they are almost universally appreciative for the help.

This is opposed to the typical soldier on sick call who has some sort of minor musculoskeletal issue that will only get better with time and a small amount of effort/common sense on the soldier’s part (which is often lacking). There are plans to get a new PA to replace the one that left and theoretically that would mean I get sent back where I was, but I am beginning to think it would be better to remain here. The work is real, the living is better, and time is going by faster while I’m here. Time will tell.

The first few weeks…

are now gone by. I am currently in Jalalabad, Afghanistan working out of a consolidated treatment facility colocated with a forward surgical team. We have moved two different times already, and are due to move again when they finish building new housing and a clinic. That’s due to happen in Sep/Oct but I will probably miss it as I am getting ready to backfill for a provider from an infantry unit that is being sent back to the states. Hopefully I will still have connectivity where I’m going, but I won’t know until I get there. I intend to upload some photos and video when I get the chance.