their stories

IMG_0843 Uncle sm.jpg


He arrived in the clinic on a NATO stretcher, a collapsible green mesh-and-metal contraption that rolls on bicycle wheels. The soft, grey-beard smile he offered with a hand over his heart didn’t match the bandages and splints on his legs. An AK-47 round, 7.62 caliber or “Seven-six-two” in military lingo, had entered his left leg a third of the way down his shin, pulverizing part of his tibia before exiting just below his knee. The damage, however, continued, as the bullet tore apart into the copper jacket and steel core, both penetrating his right thigh, where they lodged in the muscle. No major blood vessels were cut, so he did not bleed to death right away. Instead, the wound remained contaminated until he came to our clinic. Often in Afghanistan, the exposed, contaminated bone becomes infected, chronically draining pus, weakening, finally requiring an amputation.

Nobody, nowhere, wants a leg amputated. I guess I thought before coming here that amputation must be a part of life in Afghanistan, where the Soviets carpeted the countryside with air-dropped mines in an attempt to “depopulate,” and thus subjugate, the rural areas. I thought that a country that had been at war, on and off, for thirty years, would be more accepting of this sort of deformity and disability. I could not have been farther from the truth. I have regularly been told by patients, “I would rather die than have my leg cut off.”

So as we looked at this man we called “Uncle,” we made some plans to try to save his leg. His diabetes would not be our friend in this endeavor, making wound healing that much more difficult. But after some planning, several returns to the operating room for scheduled “washouts,” and cleaning away dead or contaminated tissue, we fixed his bone with a titanium rod and covered the hole in the bone with half of his calf muscle. Two weeks or so in the hospital, and he went home, his diabetes and congestive heart failure under some reasonable control. Was it worth it?

When any patient here is recovering from illness, hospitalization, or surgery, their friend and relatives come for a visit. They sip shin chai, green tea, and chat about their host’s recent illness. I think it is a universal that people love to talk about their bouts with illness. What’s more, spin-girai, or “grey-beards”, like Uncle are important men, wise men, tribal elders. A lot of people come to visit them. I mean, a WHOLE lot. By his estimate, around six hundred people came to visit the first day. The second day was expected to exceed a thousand visitors, to pay their respects to the elder. Every one of them got to hear his story and see his leg. So was it worth it? I’d say it was effort well-spent.

Motorcycle Man
One patient, who also had a bad leg fracture from a motorcycle crash, now well-healed, told us what he had thought of the Americans before his stay at our hospital. "They told me the Americans will cut off your arms and legs just for practice," he said. Again, the specter of amputation looms in the collective consciousness. There are no services for amputees, no rehabilitation, no handicapped ramps, no accomodations. Prosthetic limbs are few and precious. The prosthetic hospital in Kabul is very busy and overwhelmed, we are told by some patients. Furthermore, the trip can be dangerous.

Another patient, from an area rife with the insurgency, related his story of seeking care at Salerno. "I asked my mullah [religious leader] if I could go to the American hospital." The mullah, a Taliban stooge, consulted his handlers. He returned to the patient with the news: "They said they would prefer that you go somewhere else, but if you can't get the treatment you need anywhere else, you can go to the Americans." We joked for a couple of weeks that we were now on the "Preferred Network Provider" list for TalibanCare.

my afghanistan reading list

Several of my colleagues here have asked me for the names and authors of the best books I’ve come across about Afghanistan, so I thought maybe more people would benefit from reading some of these works. Each one is a little different. Some are more geopolitical; others are a very human look at life in this country; still others focus on military operations since the beginning of OEF.

I have to say, in general, folks back home are very generous with care packages for the troops, with more candy than anyone here can eat, notes, cards, toiletries, and paperback novels. My only wish would be for more of the sorts of books I list below to be ubiquitous in Afghanistan and Iraq. Unfortunately, despite “Commanders’ Recommended Reading Lists”, most people serving here have very little idea of the culture, history, or politics of the region that they spend six or twelve months in. That is at best a lost opportunity; at worst, it can be a fatal misstep for a mission or a planned operation.

I would welcome your comments or additions to this list.

Best Human Perspective

Sarah Chayes, The Punishment of Virtue: Inside Afghanistan after the Fall of the Taliban (Penguin Books, 2007)

I read Ms Chayes' book in 2007, before my Iraq deployment, and found myself wishing I was coming to Afghanistan. Her love for the Pashtun tribespeople is evident, and she paints a wonderful picture of fragrant orchards, mild nights, tasty fruits and nuts, and meaningful relationships. These pleasant memories of Kandahar are scattered amid the backdrop of a disturbingly confused reconstruction strategy carried out by DoD, USAID, NGOs, and international donors.

Best Current-Events Landscape (tie)

Seth G. Jones, In the Graveyard of Empires: America’s War in Afghanistan (W.W. Norton, 2009)

RAND Corporation analyst Jones does a succinct job of laying out the relevant regional history, the current players, and the sticky issues confronting the international community as reconstruction and counterinsurgency efforts progress in Afghanistan. The most telling part of Mr Jones’ book comes early on: he reminds the readers that the average duration of successful counterinsurgency operations is 14 years. And the amount of money required per capita? FAR higher than what has been invested or even committed in Afghanistan.

Ahmed Rashid, Descent into Chaos (Viking Adult, 2008)

An accomplished author of multiple books about the region, Pakistan-born journalist Ahmed Rashid spends a good deal of time explaining the complex relations between India, Pakistan, and Afghanistan, and how this affects everything we do in the region. You can’t understand one without the other. He also unfolds the story of the insurgent groups, including Al Qaeda, Taliban, Haqqani Network, and TTP (Pakistani Taliban).

Best Military Ops Account

Sean Naylor, Not a Good Day to Die: The Untold Story of Operation Anaconda (Berkley Trade, 2006)

Naylor, a seasoned war journalist, delves deep into the details in this book about an early 2002 operation in the Shah-i-khot Valley, a few dozen miles from where I’m writing. The details of military machinations ring true, from the detailed preparations of the special operators, to the “war-by-video-teleconference” mentality of some of the senior leadership. The special forces units pull off some pretty heroic feats, despite inadequate support from some of their leadership. An insightful look at how military ops are planned, executed, and susceptible to flawed communication.

Best Page-Turner

Marcus Luttrell, Lone Survivor: The Eyewitness Account of Operation Redwing and the Lost Heroes of SEAL Team 10 (Little, Brown, and Co., 2007)

Luttrell describes the training that goes into being a Navy SEAL, and later in the book one appreciates why exactly these tough young men are made to endure extreme hardship, sleeplessness, and physical punishment: because a SEAL instructor may not be the scariest challenge one ever has to face. Luttrell and his team get caught in an ambush in eastern Afghanistan, and his brave companions are killed, one by one, until he is finally the only one living. He makes it to a nearby Pashtun village, where he is cared for and protected until he can make it back to safety. A remarkable account.

The One I Can’t NOT Mention

Greg Mortensen, Stones into Schools: Promoting Peace with Books, not Bombs, in Afghanistan and Pakistan (Viking Adult, 2009)

This follow-up to Three Cups of Tea carries Greg Mortensen’s story of school-building from Northern Pakistan into eastern Afghanistan, from Kandahar to Khost, Nuristan to Badakhshan. While education is not the sole solution to some of the problems in this region, it is a good start. In fact, it is THE start. Uneducated people are people easily led by demagogues and extremist ideology. The Central Asia Institute has begun to do what we should have done when the USSR collapsed: build schools to give the Afghan people a future.

photos from the fob

Here are a few photos of life on the FOB.

One of the 155mm guns is named after a...er...performer in Wilmington.One of the 155mm guns is named after a...er...performer in Wilmington.

The surgeons of Salerno (that is a really good name for an opera, by the way).The surgeons of Salerno (that is a really good name for an opera, by the way).

Home sweet home.Home sweet home.

A foggy morning after a rainy day.A foggy morning after a rainy day.

seatbelts and snakes

Well, it's been raining for the better part of a day here in Khost... just when I thought it was always sunny and warm here. In any case, it gives me a chance to sit and write a little. I have a couple of anecdotes worth sharing from the FOB Salerno hospital.

A few days back, we got what seemed to be our third or fourth motor vehicle rollover incident involving Afghan National Army (ANA) troops. "Jeez," someone said, "somebody needs to teach these guys how to drive!" "I'd be happy if they just started wearing seatbelts," someone else chimed in, bad motor vehicle crashes being notorious for causing severe head trauma, organ injury, and fractures in the improperly restrained. One of our interpreters turned around with an incredulous look.

"Seatbelts? Only suicide bombers wear seatbelts!"

...apparently so they don't lose nerve at the last minute and change their mind? It turns out that this Afghan man had been in several rollover car crashes, emerging from each without serious injury, but he still refused to wear a seatbelt. One time, he said, the police had stopped him, pointing their weapons at him and saying "Who are you? Who are you? Why are you wearing a seatbelt?" So much for a seatbelt-centered injury prevention campaign here.

snake in the sleeve
One of my Pashto language teachers related a Pashtun proverb to me:

"Mar ta pa lastoonike zay ma warkawa."

"Don't let a snake make its home in your sleeve."

Apart from the wisdom of its literal meaning, the symbolism is significant in this part of the world. The snake could be a Jordanian doctor allowed easy access to the inner circle of the CIA on a FOB in Khost. Or the snake could be Jalaluddin Haqqani, the Pakistani ISI's pet that has come back to bite them. The snake could be Lashkar-e-Tayyaba, cultivated to wage war in Jammu and Kashmir but who end up causing an international terror incident in Mumbai as they spiral out of control.

The proverb is particularly meaningful here and now, and the warning is clear: snakes bite. Be careful who you allow close to you.



I have had the privilege of getting to know more about my hosts here in Khost, Afghanistan. The Pashtun tribes are one of the oldest people-groups on earth, having lived in these mountains, the Hindu Kush, for about 6,000 years. I have undertaken (call me crazy) to learn to speak Pashto (also called Pashtu or Pakhto). Pashto is a pretty simple language, full of words for things like home, relatives, livestock, work, land, and seasons. On the other hand, almost all words for things mechanical and modern are borrowed, from English, Farsi, or Arabic. Car: motar. Cellphone: mobil. Driver: driwar.

The “Pashtun Belt” is the homeland of many Pashtuns, straddling the Afghan-Pakistan border, a mostly mountainous area, reaching from Badakhshan in the north to the border with Balochistan in the south, and westward to Herat. The arbitrary line separating Afghanistan from Pakistan was drawn up by Sir Henry Mortimer Durand in 1893 as an agreement separating Afghanistan (in which Russia had some interest) from British colonial India. Afghans generally, and Pashtuns particularly, do not recognize the international border between Afghanistan and Pakistan.

One of the more fascinating parts of Pashtun culture is the code of tribal laws and customs, called Pashtunwali. I do not claim to be an expert in this, but this is some of what I’ve learned in my Pashto language and culture class. What follows is a summary of the laws that have governed these tribes for millenia. They have never been conquered. The Pashtuns have intermittently (and reservedly) acquiesced to a centralized government, but Pashtunwali is the law written in their hearts, as it were. Pashtunwali isn’t a written code; it is passed as oral tradition, from father to son.

Melmastia (Hospitality)

Pashtuns are, like most middle-eastern people, welcoming and generous to a fault. Guests in a home will usually be offered snacks like nuts, chai (green tea), dates, raisins, or bread. I can hardly visit the bazaar to buy a scarf or a bracelet without sitting down to share a cup of chai and a bit of candy. It seems to carry more meaning than just niceties, though. Being the “guest” of a tribe or family obligates them to protect and share. This may progress to an extreme, even to the point of providing protection to one’s enemies or to a fugitive. Many have interpreted the “settling” of al Qaeda and other extremist elements in the Pashtun belt in light of melmastia, suggesting that some Pashtun tribes reluctantly but resignedly continue to host these groups.

Badal (Revenge)

Injury or insults to another’s honor are avenged by the males of the tribe. There is no “statute of limitations” on this. Vengeance will be sought, whether in one day or one year or 1,000 years. Problems arise when the “settling of the score” is not perceived by both parties to be just. Other provisions of Pashtunwali then must take effect for a blood feud to end.

Nanawati (Forgiveness / Asylum)

This is a fairly complex idea I still have trouble getting my head around. The word carries the idea of “entrance”, as in, entering another’s home for protection. It can mean asking for protection from one’s enemies. This usually involves some payment, such as the slaughter of a goat, cow, or sheep in front of the protector’s house. The petitioner humbles himself in this way before the protector, who then is obligated to go to extreme lengths to render assistance, protection, or hospitality to the petitioner. This could be used in cases of accidental wrongful death of a child or relative, or with long-standing feuds in which one party accepts the humility of asking for forgiveness.

Jirga (Assembly)

The assembly of tribal elders (masharan) is the ultimate tribal judicial authority in matters of law. The lashkar (tribal militia) is the force which carries out the decisions of the jirga. Not surprisingly, the traditional jirga is an all-male affair. (The parliamentary system of modern Afghanistan uses the traditional language to describe their legislative houses, the Meshrano Jirga and the Wolesi Jirga being the upper and lower houses, respectively. They do, and must by law, include women.) A Loya Jirga, or grand assembly, was called to form the new constitutional government of Afghanistan.

Nagha (Tribal fine)

The jirga may impose a fine on a guilty party, both as punishment for the offender, and as satisfaction for the victim.

Badragha (Tribal escort)

If a tribe guarantees safe passage through an area, they are obligated by oath to uphold that committment and ensure that no harm befalls the travelers.

Lokhay Warkawal (see below)

Another fairly nuanced topic that I don’t completely understand, this literally means “giving or lending of the pots.” Depending on who I talk to, it could signify providing a sort of housewarming for a newly married couple, a taking of a collection, or going to extreme lengths to protect someone from enemies. How does this all fit together? My theory is this: the down-and-out, the utterly destitute, the one who has nothing and can offer nothing, is most in need of defense and restoration. For that individual, we should go to extraordinary lengths.

Hasaya (Neighbor)

A foreigner or group of foreigners may request asylum or alliance with their Pashtun hosts, and any aggression against the hasaya is interpreted as aggression against the host.

So there are most of the prominent concepts of Pashtunwali. The Pashtun culture has governed itself for thousands of years (even before Islam) based on ideas of hospitality and protection, revenge and forgiveness, and the wisdom of elders.

outrage, please?

As we shared a meal the other day, my Afghan friend, who deplores the violence and killings that have wracked his country, reminded us of one of the suras in Q'uran, the oft-debated sura 5:32 - "...if anyone killed a person...it would be as if he killed all humankind; and if anyone saved a life, it would be as if he saved the life of all humankind". Regardless of the interpretations of various scholars, many muslims believe it at face value: Saving life is a virtue; taking it is a vice. I asked my Afghan friend, "Do your mullahs speak out against violence like suicide bombings?"

He shook his head, dejected. "Our mullahs are weak. They are corrupt. They get pay and nice gifts from violent people. And the people here are uneducated country people. They listen only to mullah."

We talked about how that in times of crisis and necessary change in our country, it was often religious leaders who served as the conscience of the country, leading us to what we ought to do. Where is the Rev. Martin Luther King, Jr. of the Muslim world? Where are the outraged mullahs who condemn violence? Where is the courageous one? Not a word. Not a peep.

I found this article on life in Khost online. It's worth a read.

the inferno

I haven't written, you will notice, in some time. If you have followed the news and know the pace of a Combat Support Hospital (CSH, pronounced "cash"), you will know that we have had it up to our eyeballs. I don't think anything I experienced in Balad rivaled this in intensity and duration.

The news accounts of the various happenings can be found here in the LA Times and here on Yahoo!, among other places. I've included some excerpts here from my journal to relate a little of what we experienced starting on December 30th. I've edited some for operational security, but almost all of the details can be found online.

“The gym at [Forward Operating Base] Chapman just got a direct mortar hit,” they said, walking down the hall toward us. “We’re getting an unknown number of casualties.” A chill went through us; it could just as well have happened here, the gym being a frequent afternoon ritual for many. I changed into scrubs and donned a burnt-orange surgical cap and made my way to the trauma room. Long shadows and late-afternoon orange light filtered in through the open hospital door. “At least its not cold,” I thought, since hypothermia can be deadly for a trauma victim.

More of the story filtered in: a suicide bomber had struck at Chapman, and we were told to prepare for at least 6 casualties. Little clusters of medics formed around each trauma bed. Lab techs, pharmacy techs, respiratory therapists all went through their paces in preparation, automatic, efficient. One of the bearded special operator medics who we saw frequently while working out quietly showed up, donned latex gloves, and went to the hospital ward to make beds and check supplies, doing the unglamorous and critically important.

And then they were here. Choppers landing. Dust. Noise. Fading daylight. The first two casualties roll in, Dr. N and I taking them and starting our assessment. “What’s your name?” "Do you have medical problems?" "No." "Ever had surgery?" "Appendix," he rasps through gritted teeth. The automatic questions to ask in the conscious patient, the need-to-knows, just in case they’re in no condition for us to ask them later.

I just then hear our internist Dr. L, “Josh, she’s got a chest wound.” I turn to see them rushing a stretcher in, the girl on it no more than 25, it seems. I see my own daughters and out of my mind goes all the data and MASCAL triage resource-allocation wisdom. “She’s somebody’s daughter,” I think. I HAVE to do something, anything, to give her a chance. The pea-sized hole in the middle of her chest disguises a larger injury inside. “I need a thoracotomy set!” Starting CPR. At the head of the bed I see a familiar face, a paramedic. “Can you get an ET tube in her?” He can, and does. I'm handed a knife and K is standing beside me opening the thoracotomy set. Slicing through smooth white skin, muscle, rib. A finger into the chest cavity, then it is open. One of our NCOs is beside me, cranking open the retractor. Feeling the empty and motionless heart, the empty, collapsed aorta, my own heart sinks. My index finger, feeling, nudging the pleural membrane away from the aorta enough to slide a clamp across. Squeezing, pumping the heart. “Epi!” I call. Someone hands it over. Sliding the long needle into the ventricle, emptying the full syringe into the heart. Squeezing, pumping. The flight doc is across from me, putting a chest tube in. Bright red blood, lots of it, spills out into the tube. I extend the incision and I reach up to the upper chest, where a shredded mass of vein and artery tell me that I’m out of options.

Dr. L reaches me then. “I’ve got two belly wounds out here. Can you salvage her?” I shake my head. We’re done. “Does anyone know her name?” I ask. She’s somebody’s daughter.

I reach the next one, scanning and assessing the injuries, taking it in within seconds: neck swollen with two gaping wounds, abdomen with a pea-sized wound, but distended, tourniquet on one leg with a big wound below it. We move to the OR. CRNA M and I hear gurgling from the mouth with each breath given. “I don’t think the airway is in.” He slides the “scope” in to find gaping wounds on either side of the airway. Sgt M hands me a knife and within seconds we have a tube into the trachea, through the neck just below the mangled larynx. I reassess, and by now there is no pulse. I press an ultrasound probe over the heart, and mine sinks once again when I see no motion. I look again at the neck wounds, the abdominal wounds, the leg wounds, and for the second time in minutes I again realize that I can’t fix this. “What good is a surgeon that can’t fix people?” I think to myself. On to the ones that I can help.

Dr. L comes and finds me, telling me about one in the “overflow hut” with a possible vascular injury and a tourniquet on his leg. I walk out into the cold air and to the hut, where the temperature hovers around 50 degrees inside – potentially deadly for a trauma victim. The special ops doctor has assessed him, but I have to find some people to draw blood for labs. I send him along to the CT scanner.

I walk to the ward to find another young man with a complex leg injury. I look over his CT scans and realize he has a penetrating brain injury – pieces of shrapnel have penetrated his skull and lodged in his brain. He’s doing remarkably well for that, awake and alert. I decide he needs a neurosurgeon more than he needs me. I talk to him quickly, explaining that he has a brain injury, and that it will be necessary to intubate him, inserting a breathing tube in his throat to protect his airway in case he loses consciousness during the hour-long flight to Bagram. He would be dead if that happened, because a maneuver as complex as putting a breathing tube into the airway is next to impossible in a dark, cramped, noisy, rattling, moving helicopter. He makes a face when I tell him that he likely won’t remember anything more until he is stateside. “Don’t worry,” I reassure him. “You’re entering the best worldwide system of trauma care ever. They’ll take care of you.”

I join our orthopod, Dr. C, in the operating room, as be begins stabilizing the fractures on the young man from the overflow hut. Drills, pins, bars, erector-set-like, his leg re-assumes the form it was meant to have. And then slicing, red, the muscle bulges and swells out as we free it from its fascia straightjacket, no longer dying in the strangling tight compartment.

We've barely started that when I am called across the room to join Dr. N at the other operating table. "There is a lot of bleeding from the leg here." I lend an extra pair of hands as she and I isolate the wound to the big vein in the thigh. We elect to tie it off rather than repair it. Life preservers, not swimming lessons.

...and so on, for ten days. Most of it is a blur to me now. I don't even really have pictures to post; we didn't stop to take any. Sleeping when we could, stubbly faces, sweat-soaked scrubs. Grabbing the occasional bowl of cereal or cold food from the chow hall. Popsicles. Crack-sickles, we call them. Little frozen bits of sugar and water never tasted so good as they do between surgeries in an 85-degree operating room.

And now I'm going to get a bit of that precious commodity, sleep.

christmas on the FOB


Think about how you celebrate Christmas. “Ahh,” you say, brimming with nostalgia, murmuring sweet nothings about lights, gifts, trees, family, warmth, food, crackling fireplaces, homemade hot cocoa, and ...oh, yeah, Jesus.

Now imagine Christmas without family. No tree or crackling fireplace. A few strings of lonely lights. Gifts wrapped with care by the US Postal Service may or may not have arrived in time. Swiss Miss cocoa, with little undissolved chunks. And although Kellogg, Brown, and Root did their dead-level best to truck in a good attempt at a feast via Karachi through the Khyber Pass or the Chaman crossing, it doesn’t exactly do justice to Mom’s sweet potatoes, Dad’s turkey-carving, or my wife’s pie and homemade cranberry dressing.

I’m not complaining - I really did have a good Christmas. But the stripped-down version helped bring into sharp focus what we celebrate. It’s the Christ-Mass. We met on Christmas Eve in the little FOB chapel for carols, readings from the gospels, and the completion of the Advent wreath, the lighting of the Christ candle, and from it, all of our candles. “In Him was life, and the life was the light of mankind.” Standing room only. Pretty awesome.

On Christmas morning, we got up to perform that peculiar American holiday activity: group endurance sports! The 4.25 mile Christmas morning FOB run included standout participants such as Santa Claus and two jogging penguins. It was below freezing at the starting line, but was still well-attended. I grabbed a quick shower and opened my gifts from Mom (thanks for the comforter and dark chocolate, Mom!), then joined my hospital compatriots for Christmas dinner.

After a postprandial nap, Dr. L and I strolled around the FOB doing some sightseeing. We found the 155-mm howitzer crew, who showed us the “gun” and the 95-pound high explosive shells. Talk about modern warfare...no more compasses and plotting and angle calculations. With the coordinates calculated by compters, these babies can lob that shell like Roger Clemens hitting you in the head with a baseball from a mile away...every ten seconds! I don’t know what the qualifications are for that crew, but they clearly have much bigger biceps than me, as heavy as those shells are.

After a quick supper (leftovers from lunch, just like back home!) I headed to my Pashto class, a free Army educational offering at the learning center here. Our (Muslim) instructor graciously began, “Merry Christmas to you all. I understand that this is a holiday that you would like to spend with your families, but you’re not able to be with them today because you are here helping our government, and so I thank you for that.” Then we dove into how to tell time, names for family members, and an explanation of Muslim holidays. "Six-thirty." "Spagh niemay baje." Right now I’ve got enough on my hands just getting the spoken language down. I’ll tackle the written Arabic script if I ever attain some level of speaking proficiency.

And that’s my Christmas. Hope yours was well.

residency blues

One of the problems that Afghanistan faces is a devastating educational void. It is hard to overemphasize how pervasive this is. Three quarters of adults here are illiterate, according to "official estimates", which are essentially numbers plucked from thin air. BEFORE the Soviet invasion in 1979, 11% of adults surveyed were literate (18% of men and 3% of women). In some rural areas, female literacy approached zero. Now fast-forward through thirty years of war and disruption, and the estimates are not encouraging. Dr. Y, my Pashto tutor, has a phrase that is one of my favorites, "That is a good Pashto word...but nobody understands it." I can't say I'm a "surgeon"; I have to say I'm "a doctor who cuts", so the local (rural) population can understand. What would have been the outcome, do you think, had we invested a small fraction of the support we previously sent to the mujahedin to instead build schools and educational systems in Afghanistan after we used this country as our proxy battleground in the Cold War?

You see how important the work of those like Greg Mortensen is. Three Cups of Tea is a must-read. It's the best non-fiction book I've read this year. Read it and give it away. If you're looking for that perfect Christmas present for me, send the just-published sequel.

Many Afghans who have completed higher education have done so in Pakistan, the UK, or the USA. Most doctors here are on par with a pre-medical or medical student back home, and lack basic sterile supplies or modern textbooks. Pirated pharmaceuticals are plentiful in pharmacies, but the knowledge of how to use them is not as plentiful. Most dismal of all is the "get mine" attitude we see in the communities here. I think after thirty years of war, people cease to think in terms of community service, social capital, or whatever you choose to call that conscientious behavior that sees beyond the next dollar or afghan. "Get what you can now, because who knows what will happen tomorrow." When I ask if the provincial health clinic meets the health needs of the populace, I am told that most of the doctors see the free clinic as a means of recruiting patients to their "private clinics," where they will charge an exorbitant fee for their service. Predator or practitioner?

Thanks to the hard work of some of my predecessors, Dr. Fenton, Dr. Kam, and others, a stable "mini-residency" program in surgical care has been established and formalized here at the Salerno hospital. In six to twelve weeks, we try to impart some of the basics of surgical technique and patient care to our Afghan partners. We teach, we laugh, we prod, we sometimes scold. Of course, the raw recruits vary widely in educational level and motivation, and the hospital volume of local patients is erratic, but slow times are ripe opportunities for lectures and skills training. Injured coalition troops are an opportunity for them to observe us, their mentors, doing the things that we teach them about. Ill and injured local nationals provide an opportunity for them to put it all into practice under our supervision. Will they emerge from the mini-residency at the same level as my residents back home? By no means. But they will be better prepared than they were at the start. And hopefully, somewhere along the way, they will see that the calling to practice medicine is more than just a way to "get mine."

things that go "boom" in the night

This morning as I tried to wring the last hour out of my night's sleep, tossing and turning through malaria-medicine-altered dreams, I awoke for good when the GIANT VOICE started talking.

No, I'm not psychotic - the FOB has a loudspeaker system for times when a large number of people have to be notified of something quickly. "BEEP BEEP" said the GIANT VOICE. "ATTENTION ON THE FOB. ATTENTION ON THE FOB..." Then came the calls for the Quick Reaction Force (QRF), followed moments later by the call for the medevac flight teams.

...followed (predictably) minutes later by the call for the trauma team. I was already getting dressed, and came to the hospital to see what was inbound. This was the reason for the friendly wakeup call. We worked for several hours on a soldier who had something that looked like a large framing nail driven through his neck by the blast, lacerating the jugular vein, passing right behind the throat, and missing both of his carotid arteries by millimeters. After dissecting out all the vital structures that we could access, we...held our breath and pulled the twisted shard of metal out. No bleeding...good. Not so good was the injury that appeared to have severed all the blood vessels supplying his leg below the knee. We managed to thread a tiny plastic tube, a "shunt", into the cut ends of one of his leg arteries to keep his leg and foot alive until he goes to Bagram, where my colleagues worked on him later today.

Every couple of minutes as I write, I just about wet my pants when the FOB's howitzers erupt with a BOOM so loud it sounds like it's outside your door. They tend to choose bedtime for the fireworks show. I don't know who they're shooting at (could be anyone within 15 miles or so, I think), but it's not going to turn out well for the guy on the other end.

This article from the Washington Post is a super followup to my last post. You can't ask for a better outcome than to see an airman's smiling face on the Post's website.

I'll start accompanying the posts with pictures when I get my camera. It should be here soon, so long as no one along the mail route gets a hankering to have their very own Canon Digital Elph.

Khushpah Waladeh. Have a good night.

catching up


Well, I've been here about three weeks already, and I'm just getting the blog going, but here's a brief synopsis:

A hop, skip, and a jump got me here, spanning only 7 days: San Antonio, Baltimore, Germany, Turkey, Kyrgyzstan, Bagram Air Field, then a bumpy ride on a Short TakeOff and Landing (STOL) plane, and here I was, on the gravel runway of a little place called Forward Operating Base (FOB) Salerno. All the PAX terminals in all the world look the same; my travel needs no more description.

Dr. L, the orthopaedic surgeon, and I arrived together and joined a great team of talented and dedicated people here at the Salerno Hospital. Some are doing the same jobs as back home; some are Army reservists who back home are students, foundry workers, salespeople. A reporter from Wisconsin visited recently and did a series of articles (here, here, and here) profiling the hospital personnel, many of whom are from Wisconsin and Minnesota.

It's been great working with the team in the OR here; it seems like us "new guys" have slid in seamlessly with this hardworking crew. One early case reinforces with me not just how talented the crew manning this hospital is, but how much has been built and invested in a system that cares for injured troops and local civilians in a way that is absolutely world-class.

An airman came to our hospital from a nearby FOB after having been shot at close range by a military rifle. Two small puncture wounds on the back gave way to two large holes on the front of his abdomen, the "exit wounds" through which some of his intestine was protruding. As we quickly assessed him, his vital signs began the march into hemorrhagic shock. Without any further ado, he was brought into the operating room, where we spent about two hours stabilizing his injuries, which were numerous. Perhaps the worst was a gash through the head of the pancreas, with several lacerations of the duodenum, the portion of the small intestine that curls around the pancreas. As we worked, we called for a "whole blood drive," since he needed blood and coagulation factors that were in desperately short supply. The message went out to the entire FOB over the loudspeaker, and I later heard that a line of fifty to one hundred people of the blood type announced formed in minutes outside the hospital. That made me proud to be serving with these Americans.

The airman went on to have two more surgeries in the next 48 hours, at Bagram and Germany, before arriving in the USA. That lifesaving system, a globe-spanning chain of trauma care, is greater than the sum of its fallible human parts. It is no accident, but rather, credit is due in large part to the efforts of great Americans like Don Jenkins, John Holcomb, Jay Johannigman, Donald Trunkey, and others who recognized the need, not just for well-trained people, but for a reliable system that meets the needs of our injured troops.

i'm baaaack!

Oh, where does the time go? Well, with wife, kids, work, house, church, deployment, and running, well...the time goes pretty much anywhere but blogging.

But that's about to change!

...Because here in the Afghan mountains, I am the new proud owner of...FREE TIME! Not always, but way more than I'm used to. So, in the spirit of Steve-O's recent blogging exploits, I will carry on the proud tradition of the Salerno blog.

And even though the Air Force public relations spin doctors get fits of belching heartburn when they read it...I'm the new Air Force general surgeon at FOB Salerno.

More to come soon...

rodeo, VBIEDs, and other life in the grinder

Wow, it's been a long time since I posted. My regrets.... Here's what has been going on here.

The Rodeo
The first annual Balad Rodeo went down a couple of weeks ago. My buddy Andy was the mastermind behind this event, which ballooned from a little hospital get-together to a big freakin' deal! Donated prizes poured in from back home, to the consternation of those concerned about the appearance of solicitation of gifts from civilian enterprises. The planning got pretty intense as the Rodeo neared, and Andy bent but didn't break under the stress of the monster he had created! The day of the rodeo was beautiful, and hundreds of people came out for burgers and 'dogs, (plastic) calf-roping, bull-riding,
Guitar-Hero-ing, and two-stepping. There was a float parade, a hot-dog eating contest, lots of country music, visits by the general and some medal of honor winners, and a rodeo clown contest. The Mustache March competition concluded; unfortunately, the closest I got to a trophy was as runner-up for "Most Robust." The 'stache got shaved on the last day of March, never to return (at least until next March...). I got to stop by the Rodeo a few times, although as the surgeon of the day on call, I was in and out of the hospital, seeing a few injured troops or Iraqis, then making the surreal journey outside to clowns and barrel-racing. Only in Balad...

The last few days have brought us a dozen or so pretty severely injured national patients, many of them from this incident. You just shake your head every now and then at what suffering some will inflict on their fellow human beings, without remorse. This VBIED (Vehicle-Borne Improvised Explosive Device), or car-bomb, was detonated in front of a crowded Baqouba restaurant, killing scores of men, women, and children. The pattern of injuries is gruesome, too, with a combination of fragment peppering and full-thickness burns. Given the number tallies on CNN, I think one of my Iraqi colleagues in Baqouba is pretty busy himself with more of the injured victims.

The Grinder
The number and severity of injured victims has given birth to the name we affectionately call the Balad Theater Hospital, "The Grinder." It just seems to keep rolling along, inexorable, feeding in the worst of the blown up/shot/burned, churning out discharges at the other end, patched and sutured up, quite a bit the worse for wear, like a humming, eerily efficient machine. It's a privilege we have to be able to serve in this way, especially with the amazing team we have here, but it does wear you down sometimes.

The end is near!
In just a couple of weeks, the first of our rotation will be departing. Others of us have to wait a little longer, but my, how the time has flown! It would be hard to imagine a better surgical experience for a newly minted general surgeon than to come here. I thanked one of my mentors while he visited a couple of weeks ago for the opportunity to come here, to join the ranks of the Balad Association of Doctors Anaconda Surgical Society. The acronym should be self-evident.

on call at AFTH

I'm the SOD (Surgeon Of the Day) on call tonight here at the Air Force Theater Hospital, and it's just after 1:15 AM. We've just "tucked in" two injured US troops who came from Baghdad, which is sort of a nightly occurrence. One of them had to go back to the OR on arrival here. I can't believe it's been two weeks since I last posted...sorry. It's been a little busier here lately, with lots of Iraqi thoracoabdominal injuries and our fair share of postoperative complications.

Thank the Lord for small victories. And really shout your thanks when you get big victories! We had two of those this week. The first one, who we call Lazarus, is a young man who walked out of the hospital (on crutches) this week after being shot in the groin and bouncing between Iraqi hospitals before being sent to us. The typically courteous referral letter from the Iraqi surgeon, written in both Arabic and English, starts out: "Dear Dr., Kindly I refer to you young male present with bullet injury..." His gunshot destroyed the junction of some important vessels in his groin (probably the same constellation of injuries as this guy) and he was so near death that most of us had never seen someone so physiologically deranged "come back to life." Thus the nom de guerre, Lazarus. (Briefly, for you trauma guys, pH 6.72, BE < -30) Our senior surgeon, the czar, remarked on the phone to me when I called him in the middle of the night, "He's a dead man. Oh, well, I'll come on in." So after a two week hospital stay, we didn't hesitate to snap a photo to remember Lazarus by.

The other big victory is happening as I write. Little 2 1/2-year old M, whose name and face I cannot show due to security concerns for his Shia family, has been with us for going on two months. He was badly burned over 45% of his body with an burn injury to his lung as well. One outgoing surgeon remarked, "You'll probably spend all your resources on him for two weeks, and then he'll die." Eight weeks later, with all his burns skin-grafted and healed, he's due to get on a plane in a couple of hours to fly to the a Shriner's Hospital in the US for rehab and likely some additional surgeries. It's really a tribute to the dedicated USAF and Army personnel here who labored over him for those two months that he is alive today. I hope to hear great things from this young man one day. I blinked back some misty eyes when his mother told me, "I will tell him about you every day that he grows up so that he does not forget."

The other thing you may notice in some of these pictures is the atrocity between my upper lip and nose. That's right, folks, it's "Mustache March" here at the AFTH. I started a bit late, but I'm catching up. It takes a dedicated team to grow mustaches for a month, but we're a crack unit, and victory will be had. And then, on the last day of March, there will be a shaving such as the world has never seen.

Thanks to all for your care packages (wow! there must not be any PowerBars left in Virginia!), and especially for the notes and emails. Your care for us is much appreciated. Two months down, two to go!

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