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.