Kandahar 17

It’s finally gotten chilly here, particularly in the mornings and evenings, although you can still walk around during mid-day in shorts and a t-shirt if you’re not a wuss. One benefit is that most of the Taliban flies have died or hibernated or whatever it is they do when it gets cold. This is a good thing for them because I’ve developed some sweet ninja skills in killing them. I don’t even use a fly-swatter anymore, just my hat. If I ever find myself stranded, I’ll have enough fly protein on the top of it to sustain me for at least a few days.

Despite the fair number of mortars launched at the base since I arrived here in July – though they’ve also thankfully really decreased now that it’s gotten colder and the traditional fighting season is over – I don’t think there have been any serious injuries from them on the base. Correlation is not causation, of course; my arrival here did not miraculously stop all mortar-related injuries. But the previous crew were in dining facilities when mortars happened to hit ... twice. Although one of the mortars didn't actually explode, it struck and killed a woman. The other one did explode and the doc here before me had to stick a needle in a kid's chest to decompress his lung right there on the dining facility floor. I’ve only seen a few people for mortar-related issues; more often than not the effects were more psychological than physical.

Traumatic brain injuries (TBI) have become a hot topic in our current conflicts. A mild TBI is a fancy term for a concussion. Better equipment, primarily in the form of IBA (interceptor battle armor, or “battle rattle”), and expeditious medical evacuation are probably keeping more kids alive than previously. Instead of dying from bleeding, they end up suffering from TBIs and as amputees. The ubiquitous use of IEDs instead of more “traditional” shoot-outs, as well as riding in armored vehicles, also puts them at higher risk for TBI.

Newer, better equipment can make a difference.

Blast injuries are divided into four classes: primary, secondary, tertiary, and quaternary. Primary blast injures are due to high pressure air waves, or shock waves, that affect parts of your body that are exposed directly to air, primarily your ears, lungs, and hollow organs of the gastrointestinal tract (thanks, Wikipedia). These shock waves often don’t leave any external marks, but they can blow out ear drums and bruise your lungs so that they fill with blood and/or excess fluid and can no longer exchange oxygen and carbon dioxide normally (that’s sort of important). This is called “blast lung” and is the primary cause of death among people who initially survive an explosion. It's sort of like drowning.

Secondary blast injuries are due to shrapnel that penetrates and damages someone’s body. Obvious enough. Tertiary injuries are due to the blast wind that throws a person against solid objects; the sudden deceleration causes injuries, including coup contrecoup injuries, which is the underlying source of TBIs; in other words, your brain bounces back and forth in your relatively solid skull and gets bruised. It’s science. It's inertia. The quaternary injuries are the olio (I recently learned that word from doing the crossword puzzle – it refers to a Spanish stew containing a hodgepodge of ingredients, kind of like Hairy Buffalo punch) of other injuries that occur, including flash burns and psychiatric injuries, e.g., PTSD. As I mentioned before, the psychiatric issues are the ones that I mostly deal with.

Coup contrecoup mechanism of injury, a.k.a. trying to reason with a stubborn Master Sergeant.

TBIs usually occur to our guys when they’re thrown against a hard surface, like the ground or a wall, or from getting bounced around into the heavily reinforced surfaces of the armored vehicles they operate. And although better helmets prevent direct penetration of projectiles into a kid’s head, they act like the body of a bell, which makes the kid’s head (and brain) like the bell clapper. I rode in a Humvee the other day, and I can tell you that everything about that vehicle was squat, heavy, and thick; and those are considered “lightly armored.” I almost gave myself a hernia trying to open and close the door. Because they’re heavy … and because I’m old.

They call it "getting your bell rung" for a reason.

Concussions have become an important topic in sports as well. The NFL, shamefully, has only recently taken some steps to acknowledge and address the problem after years of denying it and presenting “evidence” to the contrary (some doctors were collaborators in this denial, unfortunately). Three hockey enforcers all recently died (two thought to be secondary to suicide and one to an overdose of alcohol and pain-killers), and fighting in hockey may now come under greater scrutiny and hopefully be banned.

An autopsy of one guy’s brain showed that it had changes similar to a much older and demented person, which is a common theme with many former contact sport athletes who’ve had their brains posthumously examined. A recent study suggested that even heading a soccer ball too much can cause measurable changes in cognitive function, particularly with attention, concentration, and memory; during residency one of our radiologists had a small brain bleed from heading a ball while playing non-competitively. There is some discussion “out there” about the death of football, particularly for young kids since their brains are still developing and potentially much more vulnerable.

It’s scary stuff. And it’s not even that you have to have full blown concussions. The syndrome is being called CTE, or chronic traumatic encephalopathy, and it involves multiple, repetitive occurrences of someone’s brain being sloshed around in and colliding against their own skull. The best recognized example is that of the “punch-drunk” boxer, the fancy name being “demenita pugilistica.” Malcolm Gladwell wrote an interesting article that I read a few years ago that does a good job explaining the situation. Worth the read:

http://www.newyorker.com/reporting/2009/10/19/091019fa_fact_gladwell

On the one hand, I saw a kid who was about 20 meters away from where one mortar burst not too long ago. He and a buddy hit the ground just in time and were mostly unhurt – a few scrapes and a little bit of ringing in their ears was all – but their truck had pieces of shrapnel all through it. He came in because someone told him that he had to, and because it’s part of the MACE requirements (Military Acute Concussion Exam). This is a standardized exam, mandatory for anyone within 50 meters of an explosion or who has any loss or alteration of consciousness due to one. This kid was fine and he handled it all pretty well.

One guy in our clinic had quite a bit of difficulty sleeping for a while after one of them landed a few hundred yards from our compound; he otherwise comes across as a pretty grizzled Master Sergeant type. Another girl I saw had some very mild barotrauma (pressure injury) to her ear drum. She was driving outside with the window slightly rolled down when the vehicle-born IED I mentioned a while back went off. Kind of freak thing, though, cause she was really nowhere near the actual explosion. But mostly it just scared her and I listened to her cry for a little while as she told me about it.

Another guy I saw was nowhere near that very same shell that tore up that other kid’s truck, but he just happened to be outside playing basketball when it hit, and it was really loud. I went through the whole question and exam thing with him, but there really wasn’t anything obviously wrong. I asked some more questions about how he was managing it mentally and emotionally. After some hem-hawing, he finally explained that what concerned him most was that he was talking with his wife later that same evening. Apparently, she Skypes “provocatively” with him, and he couldn’t get an erection. And that’s what really freaked him out – his boner wasn’t working and he was worried about whether things would be functioning correctly when he returned home in a few weeks.

I told him that particular effect is probably part of his acute reaction to stress, that the "fight or flight" response shuts down some of the body's less essential functions to immediate survival. I then reassured him that I thought things would probably go back to normal soon and he should be just fine when he gets home. I’ve seen him around the compound a few times since and he reported that things have "straightened out" for him.

In fact, more guys I’ve seen have been concerned not about "rising to the occasion," but rather they've worried about "leaving the party early." I remember one guy in Korea who told me that it would be almost a year since he was with his wife and he didn’t want to be a “two-pump chump” when they had sex for the first time after his return. Apparently antidepressant medications can help with that, but a medication we use for pain, called Tramadol, can apparently increase a fellow’s stamina by up to 7 times.

I learned this from a urologist with whom I was working one day during residency. He was very excited about the results of a study he just read. He asked me several times if I’d write him a script for his “knee pain"; more like his "wee-knee" (I know, not quite as bad as the “punch-uate” pun, but still pretty bad). I assured him that, for all intents and purposes, 35 seconds (5 sec x 7) probably wouldn’t make an appreciable difference for his wife.

Maybe the strangest request for boner pills occurred last year when I saw a guy asking for a refill on Levitra. He came in just before leaving to return to the the States, so I asked why he waited until the last minute to make an appointment. He explained that he was going on emergency leave. He only just found out that morning about a family member who passed away, and he was leaving later that evening to arrive and attend the funeral. Boner pills for a funeral?

Chazz Reinhold: Grief is nature's most powerful aphrodisiac.

John Beckwith: I crashed a funeral today ... It wasn't my idea, I was basically dragged to it ... I went with Chazz who you forgot to tell me is totally insane. He also might be a genius because it actually does work. He's cleaning up.

I can’t say that the explosions and alarms have really bothered me all that much. I certainly haven’t lost any sleep perseverating about them. This is not because I’m particularly brave – I assure you I’m not. Rather, and I know I’ve told many of you this, I think it’s because after I got hit by that car on my bike a few years ago, I’ve convinced myself that I can be hurt, but that I cannot die.

I know, right?! That doesn’t sound crazy at all.

Kandahar 16

I posted a response I wrote to the Stars and Stripes about how I think that for-profit centers of “higher” education like DeVry and University of Phoenix aren’t doing anyone any favors: neither tax-payers, who ultimately pay for the GI Bill programs, nor the former and current military people who use that benefit for their education. Turns out that the Air Force’s educational programs aren’t really helping anyone, either.

There are different “schools” that one is supposed to complete while one has various ranks in order to qualify for promotion: SOS – Squadron Officer School – for Captains, ACSC – Air Command and Staff College – for Majors, and AWC – Air War College – for Lieutenant Colonels. Doctors don’t really need to do any of these unless they want to get promoted to a full-bird Colonel; we get more or less automatic promotion to LtCol unless we intentionally kill someone or sleep with enlisted chicks. And get caught. Some people have expressed resentment about this; I tell them that medical school, residency, and continuing medical education total way more time spent studying than most other military members will ever do, and are much more useful. Also, I’m paid to be a doctor, not an officer.

"Physicians in the Air Force take this course of study from Air University when they attain the rank of Major."
The answer, Mr. Connery?

One of the nurses here is currently taking ACSC, “a 10-month, 34-semester-hour resident course at Air University ... geared toward teaching the skills necessary to conduct air and space operations in support of a joint campaign ... Graduates can earn a master’s degree.” She stopped by one evening and asked me if I’d look over a paper she wrote for a class in which she is currently enrolled. I agreed.

Although I’m picky about grammar, I can excuse it if the content of what someone writes is interesting or matters. I mean, Dad can’t punch-uate his way out of a wet paper bag (worst pun ever?), but that’s OK because I usually have some interest in what he writes. And, quite frankly, he's my Dad and I actually think it's kind of cute.

In residency, I worked with a student who was really great; maybe the best medical student with whom I’d ever worked. When I went over a discharge summary one morning with her, there were quite a few mistakes. Further along, she pointed out that she’d spelled “caroted” instead of “carotid.” “Yeh,” I said. “You’re not too great with the spelling are you?”

“No," she answered. "Not really. I’m dyslexic.”

So yes, I felt a little bit bad about that one. But like I said, the content was good, so that's OK. This nurse’s paper? POSSIBLY THE WORST THING I’D EVER READ THAT WAS WRITTEN BY AN ADULT! I honestly think a not particularly gifted fourth of fifth grader could have written/copied from the internet a more coherent and interesting paper. It was something about the Civil War and river battles and ramparts high up on the banks from which the one side fired down on the other and how the leaders of the South weren’t very good and that’s why they lost; therefore, good leaders are important. The end.

Even with the numerous grammatical and style/content changes I made - the hard copy she gave me looked like a candy cane after I finished going over it with my red marking pen - it was still a woeful effort, and that’s being generous. A few days later I ran into her again. She thanked me for the help and then told me excitedly that she got an “A”. A little part of me died upon hearing that. There cannot be a just god in the heavens if this woman earned even a passing grade.


They say that Chuck Norris’s tears can cure cancer; unfortunately, he’s never cried. This woman’s paper would be that cure if Chuck read it. And remember that this course “can earn a master’s degree.” Sad. Sad. Sad.

And for the medical nerds out there:

Kandahar 15

The upstairs MWR (morale, welfare and recreation) room is right next to the chaplain’s office, which is convenient because the chaplain always has snacks. They receive box upon box of goodies sent over from people in the States. There are usually some cards from some second-grade classroom of students. I just go there for the sugary goodies, though. I randomly received a care package the other day from little kids and Girl Scouts, etc. My favorite part was the card from some kid named Juan that said, “I will prey for you.” Coincidentally, I received five boxes from my own mother last week, but all they contained were old magazines, medical junk mail, and a couple of Pez dispensers. Thanks, Mom.

Happy hunting, Juan! Now learn to spell ... and get off my lawn!

I have a small stash of goodies in the office, and if he sees something he likes, Joe occasionally asks me where I got it. I usually reply that I “stole it from the chaplain.” It’s not true, but it sounds scandalous. It’s almost as fun, though equally false, as telling others that “I stole the wig in that picture from some woman being treated in the cancer clinic.” Or, “Punching whiny little kids breathless in the solar plexus keeps them still long enough for you to perform a good ear exam.” What can I say? It’s fun to pretend to hate little kids:

“Dear God, make them all better or make them all die; either way, it’s not my problem.”
(Prayer of the Pediatrics Intern – Lance McAdams, 2007, UC Davis)

Yes, I’m most definitely going to hell.

So I was digging through this big plastic container full of candy the other day, taking out the Butterfingers, Baby Ruths, Reese’s Peanut Butter Cups, and Milky Ways, when the new chaplain walked in. He started some small talk, and I indulged. We talked about life at Kandahar, where to eat, what to do. He asked what books I’ve read recently, and I mentioned that I’d read an interesting book about Afghanistan’s cultural and political history.

He then asked me whether the stories about homosexuality between men and boys are true. I told him I didn’t know much – not exactly a topic I’m personally all that interested in – but, I’d read and heard a little about it, as well as about practices in other cultures where young boys/men live with an older man for some time before they get married. These relationships sometimes have a sexual component to them.

We talked about how American men are definitely less touchy-feely between each other, as a general rule, than men in other parts of the world. Here in Afghanistan, grown-ass men walk hand-in-hand and arm-in-arm all the time. My friend, Charla, works with the ANA (Afghan National Army), and tells me how it makes the US soldiers a little uncomfortable, but they have one day a week on which they allow the hugging and holding of hands. In her words:

Man love Thursdays. It's the day before Jumaa (Holy Day), so they sin and ask for forgiveness the next day. They're practically Catholic! The Afghans hold hands and hug each other all the time, but when the coalition guys do it and aren't called gay is on Thursdays. The Navy guys are the exception...

I also explained to him that my friend, Shane, told me how he’d seen security camera tapes at the base where he was stationed observing Afghan guys making sweet, bleating love to their goats while keeping watch over their flocks by night. And no kidding, on the front page of the Stars and Stripes, below the fold, I saw an article titled, “Sex with animals still not OK for US military.” I mean, I’d expect to see a story header like that from The Onion, not a military-affiliated newspaper. "And just in case you weren’t sure, bestiality is still illegal in the US military ... Pentagon officials say the deletion of bestiality is a legal technicality and does not represent any fundamental change in the military’s moral code for servicemen (and service animals).” Glad we got that sorted out.

You can put lipstick on a dog ...

... but it's still a dog. *

So the chaplain gave me this look like he was disgusted, and while I clearly think man-boy and man-Labradoodle relationships are wrong, I added that it’s not like Afghans have a monopoly on the man-boy love thing; there are very recent examples of it in the US, e.g., the Penn State scandal with Jerry Sandusky. This is probably the best article I read about it – the author puts all of it into perspective very well:

http://www.grantland.com/story/_/id/7233704/the-brutal-truth-penn-state

I stopped there, but considered whether to rehash the Catholic church’s embarrassingly notorious past, and present for that matter, problems with sexual abuse, but decided not to mention that to Father Close.

After a brief, slightly awkward pause, during which I suspected he might have been thinking about more or less the same thing, I said, “Nice chat, Father. Gotta go.” And left.

* No Maggie Gyllenhaals were harmed in the making of this update.

Kandahar 14

It’s been a week, or two, I guess. Maybe three. At this point, who really knows. Every day blends into the next and you sort of lose track of time when there aren’t really identifying characteristics to discriminate one day from the next. Josh asked me to describe what it’s like to spend the holidays deployed. In two words - it sucks. The caveat, though, is that every day here sucks.

Every day is Groundhog’s Day, in the Bill Murray movie sense. I hear my alarm, press snooze, hear Joe’s alarm, he presses snooze. I eventually wake up, go to the gym, shower and shave, go to lunch, sit around in the MWR (morale and welfare room) and tool around on the computer, dress for work, go to the clinic, BS with Joe for a while, see some patients, go back to the gym and run a bit, then shower again, get dinner, eat at the clinic, see a few more patients, go back to the room, answer a few of Joe’s questions (I think he really misses pre-sleep pillow talk with his wife but I draw the line at just talking), go to bed. Sleep. Wake up. Repeat.

Careful! The Afghan groundhogs are most likely rabid.

You become a creature of habit and routine because there’s nothing else to do. Very occasionally something will break a small bit of the monotony: a good-looking girl wearing black stretchy workout pants at the gym, fish and chips day with mushy peas (better than it sounds) at the dining facility, the occasional interesting patient, rain, a tour of one of the airframes on base, birthday dinner and ice cream cake. We’re talking extremely small “victories.”

On the holidays some of the dining facilities will cater to that day. So there was turkey and ham and stuffing on Thanksgiving. Our compound, Camp Losano, had dessert for Air Force people and they showed a movie outside on a makeshift screen. I was working, so I didn’t hang out. As an aside, they sometimes hook up an X-Box and hold video game football tournaments and invite whoever wants to do so to come and watch and cheer -- I cannot think of anything more boring and pointless. “Hey guyth, you wanna thee my thweet Madden thkillth?” Wait, you mean how quickly you can punch buttons with your fingers and thumbs on a plastic controller? Wow. That sounds great, but no thanks. I'd rather just go back to my room and pass a kidney stone.

On 9/11 Outback Steakhouse provided dinner, which was far and away the best meal we’ve had here, although it’s not my first choice when I’m back in the States. The lines on the special meal days are usually ridiculously long, though the worst lines are at the British dining facility when they hold Indian night once a month or so. Every single southeast Asian TCN on base (and there are a lot of them) comes, not to mention plenty of the white people who like Indian food (or just need that small break in the monotony), and it can easily take 30 minutes to get out of there, whereas usually if it takes more than 5-10 minutes you’re taking your time.

I still spend a lot of time at the gym, and try not to waste it only listening to Rihanna. Between her own stuff, and working with everyone from Eminem to Sean Paul, she’s EVERYWHERE! I re-subscribed to The Economist a while back and got the audio word-for-word edition where professionals read the entire week’s contents, all 8-9 hours of it. It’s great, especially when I discovered that the iPod Nano has a feature that lets you play podcasts at 2x speed.

I thought that I’d have to listen and think twice as fast, and maybe I'd get headaches or have seizures, but turns out it doesn’t work that way. You just sort of let your brain do all the work for you and it takes almost no effort at all. It took a little getting used to, but now I can’t listen to podcasts any other way. Regular speed now is like watching erosion or listening to some patients as the recount every single detail of what’s bothering them. Excruciatingly slow. So slow, in fact, you start thinking about other things and miss the point entirely. It doesn’t work so well to listen to podcasts on the spin bike, though – you have to have music for that, and that’s where Rihanna enters the picture. No way around it.

Marc, a Belgian guy, started coming to the Canadian gym a few weeks ago. He teaches spin back home and is keen to keep up his skills, so he leads a class most mornings. Nice enough guy. His voice is, um .... let’s just say that it projects well. “FEEL ... YOUR ... RESISTANCE!” --- “KEEP CLIMBING!” --- “GET READY FOR SOME HANGING!” (Hanging is nothing more sinister than leaning over your handlebars but moving back as far as you can on the bike without actually sitting on the seat).

Writing it out in all caps makes me picture a little Hitler in spandex lederhosen on a spin bike. Not sure what that’s all about, and not that anything about the Nazis was all that funny, but that might be an amusing SNL skit – Hitler leading spin class, or Zumba. Who knows, maybe some yoga: “NOW VEE VILL PERFORM ZEE DOWNVARD HUND!” Now that I think about it, Marc also does this thing where he puts one hand up in the air when he does countdowns in order to get your attention and then direct you to the next move on the bike; kind of looks like a “Sieg heil!” I’m just sayin’.

HANDS AT POZITION VUN!

I could do without the whole situation of hanging out with a bunch of sweaty European dudes in spandex, especially the part where we stand around in a circle and group stretch afterwards. Not that we stretch each other, just that we stretch individually but at the same time. I usually pass and spend some more time on the bike. Otherwise, it’s OK. Marc wants to meet up when we’re both back in Europe and do some real biking. Belgium is right next door to Germany, so maybe I will – I pass through a chunk of it every time I head down towards Griff’s place near Ramstein.

Unfortunately, the Canadians have officially left and they’ve closed off their gym for a week or so before the US takes over and reopens it. I don’t like the spin bikes over at the NATO gym, and it’s a 10-minute walk to get there. I know, wah wah! They held a farewell 5k run a few weeks ago. On 4 October 2009, I ran a 5k in Kunsan, came in second, and the title of a post afterwards read, “15 years too old, 15 pounds too fat, and 4 seconds too slow.” This time I was “8 years too old, 15 pounds lighter, but still ½ second too slow.” In all fairness, the fastest guys on base ran in a half-marathon the day before, skipped this one, and so the competition was weak, to say the least.

Still, I was able to stay within 30-40 meters of the first two guys for most of the race, realized I still felt OK with a few hundred meters to go, so made a push for it; passed the second guy, then closed in on the first. With 20 meters to go, I was right on the leader and made a last push for it, then the @&#damn bastard moved over just enough to cut me off and then elbowed me, almost knocking me into some orange cones funneling runners into the finish line.

I'm sharpening my elbows and bringing a knife to the fight next time, A-hole!

I’m over it. But still, pretty lame. He denied it, of course. Acted like he didn’t even know he’d run into me. Whatever. It’s a stupid race in a stupid war zone. It wasn’t even about winning, it's just about catching that one last person in front of you; those of you who have run races know what I’m talking about. Anyways, I finished in 17.36, about a minute faster than the previous one I ran here a month ago. I always have to qualify things by remembering that I have a brother who ran in the Olympics. Still, not horrible for an old man who hardly runs anymore. Not carrying an extra 15 libbies doesn't hurt.

Kandahar 13

In regards to Dorie Mattson’s opinion piece, “Military students thrive in, enhance the classroom”. In her essay about teaching for the University of Phoenix, Ms. Mattson says all the right things about our military members, legitimizes herself by pointing to her own family military heritage, quotes St. Colin Powell (the patron saint of the post-9/11 military), and even goes Biblical by quoting St. Peter himself. Well done.

http://www.stripes.com/military-students-thrive-in-enhance-the-classroom-1.160468

Although some of the initial calculations may have been off when the story first broke, the fact remains that for-profit universities are absorbing huge amounts of US tax-payers’ money from the GI Bill; generally, they are not giving our active duty members and veterans very good educations.

No serious employer in a serious profession takes the University of Phoenix, DeVry University, or any of the others of their ilk, seriously. End of story. And that’s bad news for our veterans who are trying, and failing, to find work after finishing service in the military (also a frequent topic in recent news).

http://www.stripes.com/news/senators-blast-rise-in-gi-bill-funds-going-to-for-profit-colleges-1.155864

http://www.stripes.com/news/senate-officials-acknowledge-error-that-inflated-gi-bill-money-to-for-profit-schools-1.160028

http://ap.stripes.com/dynamic/stories/U/US_OBAMA_VETERANS?SITE=DCSAS&SECTION=HOME&TEMPLATE=DEFAULT&CTIME=2011-11-12-06-04-45

While Ms. Mattson is ostensibly sincere in her praise for the active duty and former military members she teaches, I still find her essay to be little more than a glorified promotion for for-profit “higher” education. I find it disturbing and a disservice to military members that your newspaper continues to publish such pandering opinion pieces (of garbage) from people associated with these education corporations (particularly the piece by a former general officer who is employed by them). Not to be outdone, allow me to quote St. Matthew as it relates to the topic: “Beware of false prophets, which come to you in sheep’s clothing, but inwardly they are ravening wolves.”

Kandahar 12

I've discussed, ad infinitum and nauseum, the extensive uniform rules in a previous post. Each of the US services has its unique patterns and patches, and within each service there are multiple other uniforms for whatever purpose, real or imagined, they supposedly need them. It seems there are almost as many reasons for the many uniform variations as their are reasons for fun runs, although I have yet to see a pink camouflage "breast cancer awareness" uniform. But it's coming. Trust me. Everyone loves boobies.

Madam, I salute you!

Each country also has its own unique uniforms. The French, in particular, have “fashionably-cut” uniforms, which flatter some of their female troops’ ass-sets; however, I could do without the “no-secrets” fit on the dudes. “Uh, iz dat a saucisson in your pokette or ahr you zhust happy to see moi?” And their flightline mechanics can wear a variation with shorts, which just looks - and I intend this only with love and no disrespect - totally gay.

Gay or French, you ask? ... Oui!

Brian Montenegro told me about his semester at sea during college when the group went to a bath-house in France somewhere, if I remember correctly. There was a statue of a guy with his junk on full display. The guide at the bath-house tells the group, “Uh, probably you noteeced ‘dere iz a penis on dee wall.” Then proceeded to assure them that, “'Deez iz not pornography ... uh, deez iz art!” It’s funny because they’re French.


One of the flight docs here has a similar problem with his flight suit uniform, which is basically just a onesy with a zipper in the front and some other cargo pockets. His just fits way more snugly than it should. He also wears dark-rimmed glasses and looks like he could be Harry’s long-lost Muggle brother, so Joe and I have decided to call him Henry Potter. Or “Hank” for short. His real name is Jason, but who cares? Not my problem. Henry Potter will just have to do.

The British troops probably have the best uniforms, and they wear them with great aplomb. The Canadian guys call the Brits “the Beatles” because they saunter around with their fashionably-shaggy haircuts, long sideburns, designer sunglasses worn on their heads, and often wear their uniforms without undershirts. These are all acts that go against the Hammurabian code ("eye for an eye, tooth for a tooth") of proper military grooming and uniform wear which most of the rest of us follow, and which would probably result in punishment just as severe if we were caught in defiance of it. There aren’t as many of the British troops who are as “royal family” looking as I suspected, by which I mean to say that they don’t look nearly as inbred nor appear to generally have the poor dental hygiene we Americans typically assume about our English counterparts.

Kandahar 11

I missed a couple of now-obvious ones in the last update. When describing bathroom noises, I might have mentioned “Colonel Colon” playing his “booty flute.” Also should have added something like “snag yourself in the nostrils when wiping out the hostiles.” And, I should have said that, after my friend’s husband took a hit off his asthma inhaler, they continued make “sweet, wheezy love” instead of “sweet, sweet love.”

It wasn’t Lawrence this time that made the loud booming noise that shook the building and startled all of us a few weeks ago – it was a vehicle-born IED (improvised explosive device), basically a truck with a couple hundred pounds of explosive mixed in a tank, that a couple of insurgents drove up to the outer barrier of the base and set off. It was pretty impressive; shook lots of buildings on base and created a mini-mushroom cloud. No one was actually able to get onto the base, but things locked down for a couple of hours, people had to actually put on their body armor and patrol the compound, and we had to post guards at the entry points to all the buildings.

Later that night, a guy from EOD (Explosive Ordinance Disposal) came to the clinic because of an ingrown toenail. For some reason the power was out, so we were sitting out front, just talking. It actually would have been a nice night to just BS if we weren’t in a combat zone and all. I told him we’d wait a few minutes to see whether the power would come back on, but worst case, we could try removing it by flashlight.

When others inquire what EOD does, he asks whether they’ve ever seen The Hurt Locker (which could be a euphemism for soo many things, e.g., the cramped bathroom stalls in our living quarters). If so, he tells them that it’s sort of like that, but without the Tim-Cruise-in-Top-Gun maverick cowboy antics. In fact, one guy I spoke to told me that any EOD who acted like that probably wouldn’t last very long, either from blowing himself up dead or the other guys in the squad putting an end to that kind of reckless behavior pretty quick. He spoke pretty nonchalantly about having seen and knowing guys who’ve gotten hurt or killed by IEDs. It’s part of the job, I guess. One of those things you just get used to.

The defining feature of this war, really, is the ubiquitous use of IEDs. Sure, there are some complex attacks against bases – coordinated assaults where multiple insurgents try to breach security and hit high-value targets, e.g., like the VBIED the other day - but these tend to be the exception. There was another attack not too long ago on the FOB not far from KAF where they keep fuel supplies. And while there are more than a few of these, most of the attacks on US/coalition forces are by IEDs.

IEDs have become especially effective since troops have been encouraged to patrol on foot. Foot patrols are seen as more compatible with the “winning hearts and minds” strategy than driving around in Humvees, or perched high atop an MRAP (Mine Resistant Ambush Protected) vehicle, looking down on the locals. Unfortunately, the trade-off for trying to win hearts and minds has been the loss of arms, legs, and genitalia; and I’m not being facetious. There was an article in a recent Stars and Stripes (military newspaper that is surprisingly much less biased than I would have imagined) about how kids are getting their testicles blown off, damaged beyond repair, or else having them removed during the resuscitation/stabilization process when they arrive at the surgical units on bases.

I asked a surgical nurse who I recently met about it, and she said that there has been some serious discussion about this specific issue. There’s a question of whether the military should start offering sperm banking services; at the very least, whether they should counsel the kids, who will potentially be going out on patrols and be exposed to IEDs, about whether they have plans to have children, and, if so, giving them information on sperm-banks.

The insurgents come up with all kinds of ways to kill people dead with IEDs. Recently, they’ve put them into turbans and have killed Afghan government officials as well as another very popular and respected leader who many thought could have been instrumental in brokering some new, more peaceful equilibrium in the situation here. They’ve been using young children as well, brainwashing them, which is very not cool.

A few weeks ago, an Afghan woman, apparently legitimately injured in some sort of vehicular accident, was brought onto base and taken to the hospital. When someone noticed wires among her clothing, they did a more thorough search and found she had an explosive vest strapped to her body; fortunately, they were able to disable it safely. I don’t know whether the vehicular accident was opportunistic for some nearby insurgents who happened to be in the vicinity, or whether they caused the accident with the express intent of turning her into a suicide bomber.

The article went on to say that there are a lot of these kids who say they’d rather lose an arm or leg than lose their “third leg”; in 2010 almost 10% of casualties in Afghanistan had genitourinary injuries. It’s become enough of a concern that these kids are being supplied undergarments made from heavy silk (and there’s a design underway that also integrates Kevlar).

Is that an M-16 in your bomb panties or are you just happy to see me?

These ballistic boxers are supposed to provide additional groin and femoral artery protection against IED blasts, and some patrol leaders have started checking to make sure their guys are wearing them before they head out. Some guys apparently call them their “bomb panties.” The tagline for one of the products goes: Protection for your privates, both literally and figuratively.

Kandahar 10

Saw another guy from security forces in my clinic the other day, so I asked for an update. He had some interesting stories to tell. He does a bit of traffic-related stuff here and there (says they caught someone doing 65mph and the max speed limit is 40kph, or about 25mph), but tries to avoid that as much as possible; much more interested in doing base security, snagging bad guys and all. As I mentioned previously, there's a lot of contraband, so he catches plenty of people with alcohol, primarily contractors.

There are drugs as well, and he busted a tent full of Army guys one night who were smoking Spice ("They'll let anyone in the Army," in his words). Spice is an umbrella term for various synthetic canniboids, chemicals related to THC, the psychoactive substance in marijuana. It doesn't show up on routine drug screens, and apparently the K9s either can't or are not trained sufficiently to sniff it out. It's garnered quite a bit of attention over the past few years and initially was sold legally in smoke shops, though it has since been ubiquitously controlled and/or banned internationally. He said he found 7-8 lbs of the stuff, which suggested they were probably trying to distribute it.

He randomly goes to the dining facilities where many of the TCNs (third-country nationals) usually eat. They conduct line-ups and random searches at that time in addition to the other more targeted searches they perform based on intel received. Occasionally, they've found TCNs with components to construct IEDs and every so often there are reports of suicide vests; fortunately, none of them have been used. Every now and then they'll confiscate USBs and cell phones, too, which the TCNs are not supposed to have with them. Someone will use a camera to take photos or video of whatever it may be they or others might want to know (the flight line is a definite "no pictures" zone), and then they transfer it to the USB in order to smuggle it off base since it's much easier to hide a USB drive than a camera.

Vehicles go missing at times, usually the Gators, little open-aired gas-powered golf cart like utility vehicles. Whoever steals them will paint them a different color, and although sometimes they find them and return them to their original owners, often they simply disappear. Other larger vehicles - work trucks with hoists and even heavy machinery - have been driven right off base and sold in downtown Kandahar. Some of these vehicles cost over $100,000 and are sold for $10-20,000. Apparently they just drive right through the front gate and no one stops them.

If you know what to look for or who to ask, there is a bustling prostitution industry going on as well. Some of the women who work as vendors at the boardwalk are from the Philippines and Kyrgyzstan, and I guess there are some military women who occasionally offer their services as well. The vendorettes make something like $500 per month, but can pick up an extra couple of hundred bucks a week for a few minutes of extra work, or seconds, depending on the guy's stamina, I guess. As an aside, and speaking of stamina, I had a friend back in Boston who told us that her husband sometimes had to stop and take a couple of hits off his asthma inhaler before he was able to continue with their sweet sweet lovemaking. That should be a scene in an R-rated comedy if it isn't already.

Anyway, he told me that one girl lost her job and had to head back home. Airport security inspected her things and found $50,000 in cash in her luggage. I wonder whether she wasn't transporting money related to other illicit on-goings for other people, but she said it was all from prostituting herself. I'm no mathlete, but even if she was charging $200 per poke (probably a generous estimate), that would be 250 pokes; if she gave any discounts or "Buy 4 Get One Free” coupons, that number goes up even more. That's a lot of pelvic exertion. Hope she's keeping up with her Kegels.

This guy says he loves his job. "It's my favorite deployment by far. It’s like the Wild West out here." I admit that I live in my own head a lot - I'm the guy with his nose stuck in a Kindle, reading while walking to and from the dining facilities, boardwalk, etc. - so I'm usually not up on a lot of the gossip that goes on wherever it is I work. But, that we don't hear about most of this stuff that goes on suggests that these guys are doing their jobs fairly well, and I respect them for it.

I have my own struggle for survival going on every day – me vs. the Taliban flies. I hate those little effers. They sneak into our clinic and seem to congregate in the office I share with Joe. They're not like our American flies, either, and not just because they don't speak any English. American flies are, well, more like Americans - pretty content to just hang around your food, get fat, and then develop diabetes and die. The Taliban flies are wily and wiry. They buzz around your head and bite at you. I swear they've declared jihad on my face and the back of my head. I've become pretty handy with the fly-swatter.

And speaking of pesky bloodsuckers – contractors. I'm not a very big fan. They've been on our compound over the past couple of weeks. The American contractors mostly just stand around and watch while the TCNs do all the work - electrical wiring, new lighting, and cleaning air-conditioning filters. I saw one guy in our computer room for hours many days, drinking coffee and surfing the internet, and it seems they’re always on break. One morning I was "minding my own business" in one of the bathroom stalls and the door opens. Whatever - it's a communal male bathroom, no big deal. Then a female voice asks, "Is anyone in here?" - Um ... yes. - "Oh, well why didn't you say something?" and she headed back out.

Why didn’t I say anything?! Who says anything every time a public bathroom door opens – or ever, for that matter? I don't know how it works in female restrooms, but there are rules when more than one guy is in a male bathroom at the same time: for instance, no using the urinal just adjacent to another guy if it's possible to leave one open (only possible if there are three or more urinals); keep your conversation to a minimum - a simple "Sup?" with a slight head tilt/chin lift will usually more than suffice; and, as with gorillas, use extreme caution with making prolonged direct eye contact as it can be interpreted as a sign of overt aggression. The only people who tend to break these rules are drunks at a bar or club and “anti-homosexual” Republican congressmen in airport bathrooms. Just saying.

Keep direct eye contact to a minimum

And we certainly don't announce ourselves every time someone opens the door. I have to work with these people – I don't want them to know it was me blowing out my bowels on the toilet bowl, and vice versa. I don’t need to know that General Johnson or Colonel Smith was the guy in the stall next to me making noises from his “bum trumpet”, his “stench French horn”, his “ass saxophone” - you get the picture – noises so unearthly that they strain (no pun intended) the limits of what should be physical possibly. Really it comes down to a matter of maintaining proper military respect, bearing, customs, and courtesies.

In college one morning I dreamt about being back home. I was hanging out with Megan (my little sister), who plays the violin. I asked her to play something for me. She at first refused, telling me that she wasn’t any good, but I continued to encourage her to play something, anything. She finally relented, picked up her violin, then proceeded to strum a note on one of the strings. Duh-duh. The string was a little out of tune, so she told me she had to adjust it, and so she kept playing that one note over and over. Duh-duh. Duh-duh. Finally, I came out of my sleep and realized I was a dreaming; I also heard once again the sound of that un-tuned string – duh-duh – and at that time realized that my roommate was farting in his sleep across the room.

So I finished up my "morning chores" and walked out and past this woman, who was standing outside the door, leaning against the railing at the top of the stairs. She is a prime example of a "booty-do." If you don’t know, a booty-do is a woman who's so fat that her stomach sticks out more than her booty-do. The male counterpart is, of course, the dickie-do; not such a rare creature anymore, this species is so fat that he can't look down and see his own wiener (that’s my one allowed wiener reference for this update). I didn't say anything to her as I passed and walked down the stairs, but I heard her say "Hey baby!", and then she must have puckered her lips because I heard her make a kissing sound. Gross.

Since we're talking about the bathroom, the JAG here (his name is Lance), stopped by the other day to ask us some questions about sanitation and hygiene; specifically, they pertained to the implications of someone peeing in a water bottle at night in their room and then throwing those urine-filled bottles away the next morning in the bathroom garbage can. Yes, this is actually happening. And it's not a phenomenon isolated to a single pod. It’s not like our sleeping areas are located a couple of hundred yards away from the toilets, or it's freezing cold outside, or there are rabid animals prowling about (just rabid Taliban flies). Not that any of those situations would make it OK, but I might sympathize a little. Every single row and every single floor of our living pods has its own bathroom and shower room. If you're sleeping at the other end of the pod away from the bathroom, you might have to walk 20 yards to reach it, if that. Joe had to go to the commanders’ meeting and brief them about this. Most of them just started laughing and couldn’t believe it, either.

So accessibility is pretty good, but one problem once you reach the bathrooms is that the stalls are really narrow and short, not leaving a whole lot of room to maneuver. I don't know whether they were made for Chinese people, or just made in China, but it's a very tight fit in there. If I’m in there for more than a few minutes, my patellofemoral syndrome (runner’s knee) starts acting up a little. We usually call it the “theater sign” because your knee will ache if you’re sitting in a cramped movie theater seat, but I think the “Chinese torture chamber sign” works, too.

I’ve never had this particular conversation, but I’m assuming I’m like most people who like a little leg room when casting out one’s digestive demons. Being scrunched up prevents one from being able to relax all those pelvic floor muscles and associated sphincters in order to allow easy passage of one’s “dark passenger” (that’s a Dexter reference for those of you who watch). Tell me if I’m wrong about this, but I don’t think so.

Another problem is that there's very little head room in front of you. This makes maneuvering yourself onto, and off from, the toilet seats a bit challenging. One's natural inclination is to bend forward a bit to counterbalance and control one's downward momentum onto the toilet seat; likewise, it helps to have a little momentum, by throwing your head forward, when you stand up. But, with the door so close, you end up hitting your head on it, or you have to try and dead-lift squat yourself up from the toilet seat. This is especially precarious if you've been sitting there for a while, your leg falls asleep, and isn't back to full functioning.

And forget about it if you have your uniform and weapon with you. It’s a nightmare trying to take off my gun harness and uniform top and hang them up. Listen, I’m trying to take my talents to South Beach, not play a game of Twister. And while I don’t think “pooping dog” is the name for any real yoga pose, I’m pretty sure I’ve performed it and maybe even mastered it by now.

Things become especially dangerous because of hook-hangers on the doors. Not only do you run the risk hitting your head on the door, but also possibly poking out your eye-hole while tidying up your pie-hole; you know, jabbing yourself in the ear-hole while digging around in your rear-hole; hooking yourself in the mouth while cleaning up the dirty South. You get the picture. It does make it easier to maneuver if you leave the door open a bit when you sit, then close it once you get settled, as well as opening it again when you have to stand up to wipe. But, then you run the risk of someone opening the main door and catching you in a somewhat compromising position, which I'm sure violates some of those bathroom rules I mentioned earlier.

Kandahar 9

Manas is the base in Kyrgyzstan through which most troops on their way to and from Afghanistan pass. There are huge sleeping tents, dining facilities, gyms, a few restaurants, and a bar at which you can get your 2 cans of beer or glasses of wine per day. This is kind of a big deal since Afghanistan is a dry country. I’ve heard all kinds of stories about things people try to do to get alcohol to Afghanistan (and I mentioned a few previously). I heard a story about a guy who was having vanilla extract sent because it had just enough alcohol to hold off his withdrawal symptoms. There are similar stories about people drinking mouthwash.

I saw on the History channel one time a show about bootlegging, and they talked about what the “proof” on a liquor bottle means. During British Empire times, sailors were sometimes paid their wages in rum. To make sure that the rum wasn’t watered down, they would prove its potency by sprinkling gunpowder into the rum, then attempt to light it. If the gunpowder ignited, then the rum’s alcohol percent by volume was at least 57% or so. In the US nowadays, the proof is basically just twice the alcohol by volume. In general, any liquor above 40% alcohol by volume should light on fire.


I don't have a lot of experience with lighting alcohol on fire, but one time I thought it’d be an interesting experiment to spray a few pumps of hair spray, which has alcohol in it, on my arm and light it. Do not try this at home. I thought it’d just burn off real quick and no real harm, but I can say that, actually, it burns really hot. I may or may not have ran around the apartment screaming like a little girl and maybe got a little nauseated by the smell of burnt hair. During residency we went without the alcohol gel sanitizer in our exam rooms for a month or so because they originally placed the dispensers near the rooms’ light switches, which turns out is a pretty serious fire hazard. The gel in Purell or other alcohol-based hand sanitizer is about 62% alcohol by volume.

So apparently there was a guy last week, passing through Manas, who doused his hands with hand sanitizer before leaving the building he was in. Usually the alcohol evaporates quickly, especially if you just use the little amount that it usually requires to do the job; if you wave your hands around in the air, it can speed up the evaporation process. This guy didn’t do either and instead went immediately over to a nearby smoke pit where he attempted to light a cigarette; instead, he lit the alcohol on both hands on fire, sustaining 2nd and 3rd degree burns to his appendages. That’s one way to get an immediate ticket back home …. but, I don’t smoke. I think he deserves at least an Honorable Mention nomination for a Darwin Award.

Kandahar 8

Mostly the same old same old here. About 3.5 months to go, which is 3.5 months too many. I did receive a call from my replacement, which was a little bit of a boon to my spirits. My tentative date of departure from here is January 5, 2012. I don’t count down or mark calendars, but I think that puts me at just over a hundred days left. We get 2 weeks of rest and relaxation (R&R) after we return, and I plan on going snowboarding in Austria and/or Switzerland and/or France and/or all of the above for two weeks when I get back. If anyone wants to come to Europe at that time for some serious shredding the pow-gnar, let me know.

I strained my back about two or three weeks ago doing some lunge-reach exercise with kettle bells. Locked me up pretty good. I’d sort of tweaked it a bit before that but was able to continue doing my regular workout stuff, but that didn’t allow it to get better and set me up for pulling a muscle or two a few days later. Joe told me I should rest for a week or two, and I listened a little bit. I mean, I stopped doing any lifting or pushups or pull-ups, but I got on the spin bikes and have been doing that every day for at least an hour or two. My back feels a lot better, and I’ve lost another 4-5 lbs. The upside, my abs stick out a little bit (or my belly sticks out less – same difference in my book); the downside, as my face has gotten a little thinner, my ears stick out even more. Not a good look for me.

I arrived at work the other day and only one other person was there – our supply person, who’s not a medical technician. I asked her where everyone ran off to, and she replied that they had just left for the Canadian gym. Someone ran into the clinic a few minutes earlier asking for medical help. They thought someone at the gym was having a seizure. I missed most of it, but apparently when Joe and the techs arrived, the woman was on the ground, gasping irregularly, and nonresponsive. Joe thought he lost her pulse, so gave her some mouth-to-mouth and they did some chest compressions.

By the time I arrived, the EMTs were there and had placed EKG pads on her. She had a pulse so they were just bagging her as some of the gasping breathing persisted. Joe told me that one of her eyes deviated out to the side. Apparently, the woman is a 33 year old American contract worker. She had diabetes and it hasn’t been well controlled, though she works out regularly. As it turns out, her blood sugar was fine when they checked it. We found out later that she had a hemorrhagic stroke, a brain bleed. I asked someone who works at the hospital and they think she died after they transported her out of here, but that's still unconfirmed.

Speaking of people who have recently died, there was also a soldier who recently died back in the States after he'd just returned from Afghanistan. Rabies will kill you dead without getting treatment. Guaranteed. Apparently, he'd been bitten by an animal while deployed, but apparently didn't tell anyone, which is obviously a bad idea. Now it's a "priority issue" for everyone because, of course, it has to look like we're all taking this very seriously. And it's not that I don't think rabies is serious, but everyone who in-processes here is warned that rabies is endemic to Afghanistan, so don't touch any animals. It seems like common sense. And it's one guy who wasn't very smart, but was very unlucky. That doesn't make it a high-priority issue (I still say that not getting your limbs blown off and/or killed dead by an IED still ranks as the highest priority issue here), but it does make it a seemingly extra-important issue because it was in the press.

Anyway, back to brains bleeding. I remember being in medical school and our team had an 18 year old patient who had a stroke. The kid was 6’5” or so and had a scholarship to play baseball in college – the “All-American” kid, everything going for him. He was working out one day lifting weights, next thing he knows his head hurts and he can’t move half his body. He’d ruptured a congenital aneurysm, or a blood vessel that has weak walls and sort of balloons out until it breaks. Scary to think about, that you might have a ticking time bomb in your head that could go off at any moment. I think that would be a hard thing for anyone, but particularly for people who are especially active.

Griff and I went skiing in Korea last year, and afterwards we were watching a movie called “Murderball”. It’s a documentary about a wheelchair rugby team. As they introduce the team members, they tell each guy’s story about how he became a quadriplegic. Some of the guys had freak accidents while biking or whatever, and in an instant could no longer properly control (to varying degrees) their bodies from the neck down. Well, after less than 15 minutes of hearing those guys tell their stories, and thinking about a few of the accidents I’ve had riding mountain bikes, I had a visceral reaction to it - literally felt sick to my stomach and became so depressed and scared that I had to turn it off. Really.

I remember talking to Mom years ago and she mentioned that she’d taken Maddy to the vet and had her put down. She had those horrible allergies and nothing was really working to relieve her symptoms. I asked her, facetiously, “How would like it if your children put you under for having allergies?” She answered, in Grandma Etta fashion, something like, “If I’m old and as miserable as that dog was, I’d do it myself.”

Old and allergies are one thing, and probably not justifiable reasons for putting your parents to sleep ("probably" being the operative word, though I'm open to debate), but I'm not sure how I would feel about being paralyzed from the neck down. My instant reaction is to say, “Just put me out of my misery.” Don't think I’d want to live like that. I mean, Christopher Reeves was inspiring and all to lots of people, but I don’t think I want to go through all of that. Plus, he was wealthy and famous and probably received extremely exceptional attention because of his celebrity and advocacy. I seriously doubt most quadriplegics have those kinds of resources available to them or get that amount of attention. I guess you can’t really know how you’d feel and respond except in the unfortunate case that it happens to you.

As you may have heard, the military quietly suspended the “Don’t Ask Don’t Tell” policy about homosexuals serving openly in the military. And while I absolutely agree that it was a way overdue policy change, I am still not gay, so this isn’t a coming out announcement. I know, I know. I’m a fabulous, nearly 36 year old male, not horrible looking, smart, fairly athletic, EXTREMELY charming, goes on hiking and camping trips with his buddy with the creepy mustache named “Griff”, hasn’t brought home a woman to meet the family, and is still single. I also know that Bill asked my buddy, Brian, whether he suspected I might be gay as we were traveling through Nebraska and stayed at their place on our way to California to start our respective residencies back when. So I get it. But that doesn't mean I'm gay; it just means that maybe I'm awful and girls don't like me, and that I'm a menace to society.

"USA! USA! US ... HEY there big guy!"

I do, however, find my job has me talking about and touching other men’s genitalia way more than I’d prefer; and I’d prefer not-at-all. I often tell people that my job isn’t all glamour and call-room hookups with naughty nurses. Sometimes I say, when someone asks about what I do, that I stick my fingers in people’s butts. For money. It’s part of my job, and it’s not all that great. Trust me.

Coincidentally, just the other day I had another man's penis in my double-gloved hands, freezing off little cauliflower clusters of genital warts. He explained to me that part of the reason he waited so long to be seen for this issue was that he was nervous and embarrassed that, when at "parade rest", his wiener is kind of small. So I proceeded to reassure him that there are men who are "show-ers" and those who are "grow-ers."

In a cold room, and at their smallest, the "show-ers" would seem to have the longer penises, but the "show-ers" don't get much longer when they get an erection. It’s basically “what you see is what you get.” On the other hand, the "grow-ers" are guys who are smaller when flaccid, but then get considerably larger when they're tumescent, i.e. sometimes big things come in little packages, no pun intended. All the while, I methodically applied a freezing solution to his phallus flower garden. Fortunately, nothing I did to the guy allowed us to find out how much of a "grow-er" he is, although I suppose applying a freezing cold applicator to his genitals might have had some beneficial effect to that end as well, thank goodness.

Also had a guy come in for breast tenderness just under his nipple. I stood behind him, with his shirt off, rubbing both his nipples (cause you have to compare the affected and non-affected side, after all) and said, "I really hope no one barges in on us right now. That would be some awkward explaining to do." Then I had to tell him that, unfortunately, I probably ought to examine his balls (breast masses can sometimes be associated with testicular masses). Sometimes I think I’m way underpaid for the crap I have to do.

And then there was one of the Canadian guys who works at the gym. He came up to me one day while I was on the spin bike, asking what hours I work at the clinic, and if he could stop by to chat. Most of the time when people want to “ask you a question” in private, it really means “I think there’s something wrong with my balls and/or wiener.” In Gono-Korea, we saw a lot of STDs. When guys would come to morning sick call with those types of complaints, the euphemism was “foot problem,” as in “Doc! There’s something wrong with my foot – my wiener is dripping all over it.”

Anyway, the Canadian guy thinks he got herpes from a girl he’s been sleeping with. He was telling me all about these painful bumps/sores that he has on the inside of his foreskin. I sat and answered his questions for the better part of an hour. At the end of our conversation, I told him that was way more time than I ever wanted to spend talking about his junk; and I'd prefer not-at-all. A few days later he gave me one of the better designed t-shirts from the Canadian Air Force run. And as I’ve said before, it’s all about the t-shirts. And donuts.

And then there are all the people with gastrointestinal issues. I admit, after I had those two weeks of diarrhea after returning from Nepal (during which time I was wearing sweatpants to bed in case I farted and shat myself in my sleep), I don’t have a lot of sympathy for people who come in and tell me they’ve had non-bloody, non-fever, non-cramping diarrhea since “this morning.” One guy came in complaining of blood in his stool (from hemorrhoids). He was thoughtful enough to take a picture with his iPhone and show it to me. Um ... thanks? People get pretty freaked out when they see blood in the toilet, so I usually reassure them that even a tiny bit of blood in the toilet bowel can make it look like a battle scene from "Braveheart" in there, or the opening beach scene in "Saving Private Ryan." I sometimes wonder what they do with those pictures afterwards. Hopefully they refrain from posting it to their Facebook page, though I wouldn’t put it past some of them: “Sergeant Johnson … had blood in his poop today! OMG! LOL! BRBPR!!*”

*(BRBPR = bright red blood per rectum)

I saw a girl the other night who was complaining of being really nauseous and vomiting several times before she arrived to see me. We've been seeing a good bit of gastroenteritis lately. I can't say whether it's something going around or not, but when you have lots of people working and eating in close proximity, and who maybe don't wash their hands as diligently as they should, it can obviously be passed around. I had her lay down in order to exam her abdomen (which wasn't overly concerning, though she was a bit tender over her stomach), but I guess that sitting her up made her a little dizzy and ratcheted up her nausea. She told me she needed to throw up, so I grabbed the garbage can. When I got it up by her face, she let go a salvo of yellow-green liquid vomit without any chunks. I held the garbage can and rubbed her back while she let it all out. I asked if she'd eating a yellow piece of candy, and she says she had an apple Jolly Rancher (or a Jolly Rogers, as Dad would say).

After she recovered, she asked, "How can you just stand there so calmly and rub my back while I'm puking right in front of you?" I don't know. It's like lots of other slightly unpleasant things that you just get used to, like changing baby diapers, or eating vegetables. Yeh. Kind of like that. I remember watching a friend get his ingrown toenail cut out in Lithuania, and I almost passed out then, but now I rip out toenails all the time.

I didn't always have even that much fortitude when it comes to vomit. The very first patient I worked with as a medical student had end stage liver disease (drugs and alcohol will do that), and he ended up dying; not a great start to my career. I went in one morning to round on him, and he was more disoriented and out of it than usual. As a brand-new medical student on my rotations, I wanted to be very thorough, so I made sure that I sat him up so that I could really get a good listen to his lungs, though it was probably unnecessary.

He didn't react to all the moving around so well, however, and he started gagging and dry heaving. That can be bad enough to witness as it is, but when you're right next to this guy who already smells sick and you're hearing the gagging amplified through your stethoscope ... ugh. That's when I got grossed out and had to make a quick run for the bathroom. At that time I learned from experience that bananas do indeed taste more or less the same coming back up as they do going down. My friend, Brian, laughed at me when I first told him, but then he was almost offended that it happened. He said something like, "A doctor puking because a patient grosses him out? That makes no sense! That's like a lawyer who doesn't know how to lie." I guess I've grown a little since then, and I don't mean that in the "grow-er" vs. "show-er" sense.

Kandahar 7

Reader response from recent update:

Hey Stupid-

Here's an idea for you. Don't go in the air unless absolutely necessary. Anything in the air is a target. Remember the little story I told you about the bird:

Once upon a time there was a non-conforming sparrow, who decided not to fly south for the winter. However, soon the weather turned so cold that he reluctantly started to fly south. In a short time ice began to form on his wings, and he fell into a barn yard, and almost froze to death.

A cow passed by and crapped on the little bird. The sparrow thought this was his end. But instead, the manure warmed him and defrosted his wings.

Warm and happy, able to breathe he started to sing. Just then a large cat came by and, hearing the chirping, investigated the sound. The cat cleared away the manure, found the chirping bird and promptly ate him up.

The moral of the story:
1. Everyone who shits on you is not necessarily your enemy.
2. Everyone who gets you out of the shit is not necessarily your friend.
3. If you are warm and happy in a pile of shit - keep your mouth shut.

KAF is your little warm and "happy" pile of shit for another 4 months. No need to go flying around.

Thank you Reader X. Sage advice. Got a kick from the “Hey Stupid-“ opening.

I ran a 5k last weekend for something or another cause. I don't know which one. It doesn’t even matter; I just do it for the t-shirts and Tim Horton's donuts at the end. Yes, the Canadians have a Tim Horton's at their compound, which is conveniently located right next to ours. The donuts are delicious, though I only get them on days when I have to work the entire day and feel sorry for myself. I ran an 18.30. In my defense, my legs were really sore from spinning, I couldn’t fall asleep until after 2am the night before, the race started at 6am and I didn’t warm up or anything, and I’m getting old and slow. There’s another one this weekend for wounded Canadian Army midgets. Or something like that. Like I said: t-shirts and donuts.

Oh Canada! ... Oh My! Canada!

So, I'm the clinic OIC here: officer in charge. There are only two of us officers in the clinic. Joe is a Major, so he obviously outranks me, but his duty is sort of the chief medical officer on base for the Air Force (even though Magnum is a LtCol, his duties have him off just working with the flyers). In effect, Joe has really been the OIC of the clinic. He's here in the mornings and early afternoons, when most of the "action" goes on. He also has been seen as the point of contact for leadership since he has to go to meetings with them every day. He occcasionally tells me, "Hey man, you're the OIC. I don't mean to step on our toes or anything." I tell him I appreciate his concern and then nothing really changes. All of that is absolutely fine by me. Every once and I while I order him, in the name of the clinic OIC, to get out of the clinic when his shift is over rather than hanging around, but he doesn't really listen.

Joe’s a nice guy, and we get along. He kind of reminds me of my friend, Brian Montenegro - Latino ancestry, but kind of really “white.” I don’t know, he just eats sandwiches all the time, married a white women, and likes top-40s pop music (don't worry Brian, I won't tell about the time I came home from the hospital and found a Celine Dion CD in the stereo that definitely did not belong to me). SSgt Williams, one of our techs, tells him that he’s qualified to be a school teacher because he has a notebook butt and pencil legs. He has a bit of an angry streak, though, and prefers to nip things in the bud if anyone gives him any attitude; has a little bit of “tough guy” in him.

I end up playing the peacemaker and the one to whom people come to complain or vent their frustrations. It’s not my forte, but I try to seem like I’m listening. I usually give some relatively vague feedback about how I can see some validity in every party’s concern in whatever the dispute might be, give some generic exhortation for patience to see whether things don’t work themselves out, and suggest that different people have different styles of communicating, but we all need to try and communicate better regardless. That kind of stuff. And usually the knots do unravel and things are fine again. We’re not that busy, and there are only eight of us working in the clinic, five of us who are directly involved in patient care. Things are really not all that difficult or stressful, though, and so I don't get why there's any drama in the first place.

It could be worse, though, so I guess I'll shut my mouth now about my pile of shit here.

Kandahar 6

Joe has been excited about getting me on one of the aerovac flights here in country. Aerovac is basically medical transportation for wounded kids or others with medical issues that need more workup than we have the capabilities to perform here at KAF; we also call them "bandage flights." So the other night, he sends one of the techs from the clinic to find me at around 9pm. I was a little worried that something was really wrong, but Joe tells me that they have a bandage flight the next morning and one of the patients needs a medical escort, which I can do even though I'm not a flight doctor (though I'm probably still overqualified - they usually they send a nurse). The guy's condition wasn't real serious or anything, and more than anything, it was an excuse to get me on a flight. So I said OK and left to get things ready for the next morning.

Show time is 2 hours before the flight is supposed to leave, even though I just ended up sitting around with one of the other flight docs talking for an hour and 50 minutes. The guy I was escorting was a 40-something year old Army troop who was complaining of chest pain. He maybe had some minor abnormalities on an echocardiogram, and the cardiologist at our hospital didn't have some of the equipment to do more sophisticated testing, but which they do have up at Bagram, which is where we would be going.

Another 2-3 guys with relatively minor injuries were also loaded up into the C130. They've outfitted them so that stretchers with patients can be stacked up inside. The C130s have been around forever, and have been the work horse cargo airframe for the Air Force for relatively short distance transport. They're propeller driven and the trip is noisy and often bumpy.

C130 Hercules

We first headed over to another nearby FOB (forward operating base) and there picked up another couple of patients, one of them attended to by the CCAT team: critical care air transport. Those patients are usually very seriously injured and they're intubated and on a ventilator. We took off again from there and then flew up to Bagram, which is located up farther north and is nestled in on three sides by mountains. I'd heard about that and was actually hoping to have a clear view, but it rained all morning, the first rain I've seen in two months, which was actually a welcome change.

The nurse on the flight told me that I should hop off in Bagram and stick around with the patient. The C130 would be going back to another FOB, then return back to Bagram before we'd fly back to KAF and hopefully be back around 230-300pm, about the time I start work at the clinic. The lesson as always: don't listen to nurses. If the cardiologist decided the guy needed still more workup, he'd be sent on to Landstuhl, Germany, in which case I wouldn't be going with him; on the other hand, if he was cleared to return to duty, he wouldn't need me to fly back with him because he would have been declared healthy.

I did get to eat lunch there, and they have real Baskin Robbins ice cream there. I had two bowls of caramel and pralines for lunch, and it was delicious. I know I have an ice cream eating problem (actually, I have no problem eating it, I have difficultly stopping myself from finishing the carton in one sitting), but I haven’t had any since I first arrived here at KAF. We have soft serve here at KAF, but it's horrible - the flavors are off. And the irony isn't completely lost on me that I'm complaining about having ice cream in the middle of a third-world wasteland in the middle of a war zone.

As it turns out, the weather caused some trouble for the airframe on which I originally flew, so they had to divert back to KAF, stranding me in Bagram. Luckily, with Joe's help and some persistence, I was able to arrange a way back; the passenger terminal initially told me that there wouldn't be another flight until the next evening. The lesson as always: don't listen to those people ... or nurses. I talked to another senior enlisted lady, who was really helpful. I explained that I'm one of the two doctors that takes care of all the Air Force peole down at KAF. Fortunately, an Air National Guard C27, sort of a "shortbus" version of the C130, out of Mansfield, Ohio, landed in the early afternoon and allowed me and a couple of other guys trying to get back to Kandahar to travel back with them.

We first had to fly to another FOB and pick up some Army general. We were supposed to be there for 20 minutes or so, but it ended up being almost an hour. That's how it goes with those guys. When he asks, "Hey boys! Am I late?" the answer is, "No Sir! We arrived extra early." Anyway, this FOB was in the middle of nowhere and was the one I mentioned before that is currently under construction, by all appearances fairly recently begun. We're talking still-open trenches and recently poured concrete block to support fence poles. As I've said before, for a conflict that's supposed to winding down (MISSION ACCOMPLISHED) it seems curious that there are currently brand new bases going up.

It ended up being a really long day. Woke up around 4am and didn't get back until almost 9pm. I'm glad I went and experienced it, and I'm glad that it made Joe happy to make that happen for me. The reality is that it wasn't really all that great, and not just because I was stranded. I mean, it's not really all that much better than flying on any other sort of transport or commercial aircraft except that maybe you have a little more leg room. But, there was no one bringing me little snacks or drinks. I guess I'd go again, but it's not something that I'm just dying to try once or twice a week like some of the other flight docs here. While I was talking to Joe on the phone, trying to figure a way back, I actually heard myself say, "You know, I just want to get back to Kandahar." Hearing myself say that, and maybe even meaning it, was by far the most distressing part of the day.